Pelvic fracture

Pelvic fractures most often occur in patients with multiple trauma caused by impact injuries such as car accidents or falls. Patients present with pelvic pain, reduced range of motion, and hematomas. Concomitant injuries such as urethral injury are common. The pelvic stability of every patient with multiple trauma must be checked, as shifted pelvic injuries tend to lead to extensive intraperitoneal and retroperitoneal bleeding, which can lead to hemorrhagic shock or death. The treatment for stable fractures is often conservative, with short-term bed rest and subsequent pain‑adapted mobilization. Unstable pelvic ring fractures with open fractures or significant bleeding require surgery for hemorrhage control, external fixation. This is followed by definitive fixation with plates or screws after the patient becomes hemodynamically stable. Alongside other possible complications, there is a significantly increased risk of thrombosis, and prophylaxis should be administered accordingly.

• Peak incidence: 15–28 years
• 20% of multiple trauma patients have a pelvic injury.
• 60% of patients with pelvic injury have multiple trauma.

References:^[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

• High speed car and motorcycle accidents
• Falls, especially in the elderly

References:^[4]

Tile classification of pelvic fractures

• Classification is based on fracture location and remaining stability of pelvic ring
• Type A: stable or minimally displaced
  • Type A1: fracture of the pelvic edge (avulsion or pelvic wing)
  • Type A2: fracture of the anterior pelvic ring
  • Type A3: Transverse sacral fracture of the sacrum/coccyx
• Type B: pelvic ring fractures that are rotationally unstable and vertically stable (anterior and posterior pelvic ring affected)
  • Type B1: symphysic diastasis (“open-book” injury; external rotation)
  • Type B2: lateral compression injury (internal rotation)
  • Type B3: bilateral fractures
• Type C: injury of the pelvic ring with rotational and vertical instability (The posterior pelvic ring is completely unstable)
  • Type C1: unilateral fracture of the iliac bone (C1-1), sacroiliac dislocation (C1-2), or sacral fracture (C1-3)
  • Type C2: bilateral fracture with one side type B fracture and one side type C fracture
  • Type C3: bilateral fracture with bilateral type C fractures

• Pelvic pain caused by movement, weightbearing, and compression of the iliac crests
• Tilted pelvis and unequal leg length with reduced range of motion in the hip joint
• Pelvic instability
• Labial, scrotal, flank, and inguinal hematomas
• Concomitant injuries may occur
  • Urethral injury: blood at urethral meatus, high-riding or nonpalpable prostate, perineal swelling
  • Bladder injury: frank hematuria
  • Rectal, vaginal, perineal lacerations suggest an open fracture
  • Acute abdomen in abdominal trauma (bowel perforation, spleen, liver rupture)
  • Neurovascular injury : decreased rectal tone, perianal paresthesia, compromise of lower limbs
  • Axial and long bone injuries

An isolated unilateral anterior fracture of the pelvic ring may exhibit fairly mild symptoms!

References:^{[1][3][4][5][6][7]}

• Pelvic X-ray: : (anterior-posterior, as well as special inlet and outlet views; views of the obturator and ala): confirm pelvic fracture
• CT (in stabilized patients): detailed imaging (fractures, deformities) and the exclusion of further injuries (tissue, ligaments, intra-abdominal organs)
• Angiography: diagnostic and therapeutic of vascular injury and active hemorrhage (e.g., superior gluteal artery)
• Suspected injury of the urinary tract
  • Retrograde pyelourethrogram
  • Only consider suprapubic catheterization, not transurethral, if confirmed!

Pelvic injuries can lead to heavy and potentially fatal blood loss!

References:^[1][8]

• General
  • Adequate resuscitation and stabilization
  • Prompt pelvic stabilization with an external binder
• Conservative treatment
  • Indication: stable pelvic fracture
  • Methods: bed rest, analgesia, thrombosis prevention, early physical therapy, periodic blood pressure and hematocrit check
• Surgical treatment
  • Indication: open or unstable fractures, complications (e.g., urological injury), hemorrhage
  • Procedures
    • Emergency surgery in the case of massive bleeding: angiography with embolization of affected blood vessels, external fixation , or pelvic C-clamp if needed
    • Definitive surgical treatment of the pelvic fracture and post-intensive care stabilization: stabilization and refixation of dislocated fragments, employing plates or screw external or internal fixation (for hemodynamically stable patients)
    • Rapid treatment of concomitant injuries (urinary tract, sphincter, intestinal injuries)

References:^[1][8][9]

• Intraperitoneal and retroperitoneal bleeding can cause hemorrhagic shock
• Abdominal compartment syndrome
• Deep vein thrombosis
• Post-operative wound infection
• Neurological injury: bowel and bladder incontinence, sexual dysfunction

A pelvic injury always requires thrombosis prevention because of the high risk of thrombosis associated with it!

References:^[6][9]

We list the most important complications. The selection is not exhaustive.