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Major pelvic fractures result from very high-energy trauma and require urgent hospital treatment. However, more minor, stable fractures may only require a period of rest and analgesia followed by gradual mobilisation.
Fractures of pubic rami with insignificant or minimal trauma, particularly in elderly patients, can be a presentation of osteoporosis. Consider other causes of pathological fracture in such cases.
- In elderly persons, the most common cause is a fall from a standing position. Isolated pubic ramus fractures are common and often missed in the elderly.
- However, the most significant fractures involve significant forces such as a car crash or fall from a significant height.
- Any history of significant blunt trauma should raise the consideration of a pelvic fracture.
- Tenderness, bruising, swelling and crepitus of pubis, iliac bones, hips and sacrum.
- Attempts to 'spring the pelvis' to assess stability should be avoided as this is unreliable and may cause additional haemorrhage or injury.
- A thorough assessment for associated wounds and other injuries is essential.
- Rectal examination: for anal tone, palpable fractures and to detect bleeding, rectal tears and urethral damage. Signs of urethral injury in males include a high-riding or boggy prostate on rectal examination, scrotal haematoma, or blood at the urethral meatus.
- Instability on hip adduction and pain on hip motion suggests an additional fracture of the acetabulum.
- A pelvic fracture in females is suggested by vaginal bleeding or a palpable fracture line on bimanual examination.
- Other signs of pelvic fracture include:
Tile classification of pelvic injuries
- Type A:
- Stable injuries: include avulsion fractures, isolated pubic ramus fractures, iliac wing fractures or single stable fractures elsewhere in the pelvic ring.
- Avulsion fractures occur at the point of attachment of muscles:
- Anterior inferior iliac spine: rectus femoris; often resulting from a mis-kick into the ground.
- Anterior superior iliac spine: sartorius.
- Ischial tuberosity: hamstrings.
- Type B:
- Rotationally unstable but vertically stable.
- B1: 'open book' anteroposterior compression fractures, causing separation of the pubic symphysis and widening of one or both sacroiliac joints.
- B2: ipsilateral compression causing the pubic bones to fracture and override.
- B3: contralateral compression injury resulting in pubic rami fractures on one side and compression sacroiliac injury on the other side.
- Type C:
- Rotationally and vertically unstable.
- The pelvic ring is completely disrupted or displaced at two or more points.
- Associated with massive blood loss and a very high mortality.
- Subdivided into:
- C1: unilateral.
- C2: bilateral.
- C3: involving acetabular fracture.
- Urinalysis: may show gross or microscopic haematuria.
- Pregnancy test is indicated a female of childbearing age if there is any uncertainty about whether she is pregnant.
- Serial haemoglobin and haematocrit measurements to monitor ongoing blood loss; group and cross-match.
- Anteroposterior pelvic X-ray diagnoses the vast majority of pelvic injuries.
- Destruction of normal pelvis contours (Shenton's lines), asymmetry and widening of the pubic symphysis or sacroiliac joints.
- CT scan:
- To determine whether any other injury is present.
- For evaluation of pelvic anatomy and degree of pelvic, retroperitoneal, and intraperitoneal bleeding.
- Also confirms possible acetabular fracture and hip dislocation.
- To detect intrapelvic bleeding or fluid.
- Retrograde urethrography is necessary for males with a displaced or boggy prostate or blood at the urethral meatus and for females in whom a urethral catheter cannot easily pass.
- For females with a vaginal tear or palpable fracture fragments adjacent to the urethra.
- If the patient is haemodynamically unstable and ultrasound, CT scan or peritoneal tap excludes significant intraperitoneal bleeding.
- Allows for determination of the bleeding site and potentially embolisation as a means of control.
- If there is haematuria and an intact urethra.
Stable type A injuries
- Refer to orthopaedics for analgesia, initial bedrest and then mobilisation (usually after 3 to 6 weeks).
- Avulsion fractures: usually only require rest and pain relief.
- Larger avulsions, especially of the ischial tuberosity, may require internal fixation to avoid complications such as non-union.
Unstable type B and type C fractures
- An orthopaedic emergency: resuscitate as for any major injury.
- Assess for and treat hypovolaemia, anticipate coagulopathy and ensure blood is rapidly available, as a massive transfusion may be required.
- Avoid rolling the patient and instead perform a straight lift with a number of helpers.
- Minimise movement and support an obviously unstable pelvic fracture associated with severe haemorrhage using, for example, medical anti-shock trousers (MAST suit).
- Reduction and immobilisation using an external fixator may be required to stop the bleeding; angiography and selective embolisation may also be required.
- Do not catheterise if urethral injury is suspected.
- Diagnostic peritoneal lavage may be required and should be performed by a supra-umbilical approach, as a pelvic haematoma may track up the abdominal wall.
- Increased incidence of thrombophlebitis.
- Intrapelvic compartment syndrome.
- Continued bleeding from fracture or injury to pelvic blood vessels.
- Associated bladder, urethral prostate or vaginal damage is common.
- Associated thoracic and abdominal injuries occur in 10-20%; massive internal haemorrhage may occur.
- Sexual dysfunction may be a long-term problem.
- Prognosis varies depending on severity of fracture and associated injuries.
- Severe compound fractures of the pelvis lead to a mortality rate of over 50%.
- Car safety - seat belts, airbags.
- Any safety procedure to reduce risk of falls from high levels.
- The use of bisphosphonates where appropriate.
Further reading & references
- Pelvic Fractures, Wheeless' Textbook of Orthopaedics
- Mechem CC, Pelvic Fracture in Emergency Medicine, Medscape, May 2010
- Shenfeld OZ, Kiselgorf D, Gofrit ON, et al; The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption. J Urol. 2003 Jun;169(6):2173-6.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Colin Tidy
Dr Richard Draper