Review
Contemporary management of pelvic fractures

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Abstract

Background

Pelvic fractures occur when there is high kinetic energy transfer to the patient such as would be expected in motor vehicle crashes, auto-pedestrian collisions, motorcycle crashes, falls, and crush injuries. High-force impact implies an increased risk for associated injuries to accompany the pelvic fracture, as well as significant mortality and morbidity risks. Choosing the optimum course of diagnosis and treatment for these patients can be challenging. The purpose of this review is to supply a contemporary view of the diagnosis and therapy of patients with this important group of injuries.

Methods

A comprehensive review of the medical literature, focusing on publications produced in the last 10 years, was undertaken. The principal sources were found in surgical, orthopedic, and radiographic journals.

Conclusions

The central challenge for the clinician evaluating and managing a patient with a pelvic fracture is to determine the most immediate threat to life and control this threat. Treatment approaches will vary depending on whether the main threat arises from pelvic fracture hemorrhage, associated injuries, or both simultaneously. Functional outcomes in the long-term depend on the quality of the rigid fixation of the fracture, as well as associated pelvic neural and visceral injuries.

Section snippets

Pertinent Anatomy

Three bones combine to form the pelvic ring. The 2 innominate bones arise from the fusion of the embryonic pubis, ilium, and ischium to the midline sacrum, which is the caudal end of the axial skeleton. The acetabulum, or hip socket, is located at the center of the fusion site where the embryonic bones join.

The pelvic bones unite anteriorly in the midline via the articulation between the pubic bones and the symphyseal ligaments. Posteriorly, the sacrum is situated between the right and left

Epidemiology of Pelvic Fracture

In decreasing order of frequency, pelvic fractures are caused by motorcycle crashes, auto-pedestrian collisions, falls, and motor vehicle crashes [6]. Crush injuries may also cause pelvic fracture (Table 1). As the incidence of high-velocity motor vehicle crashes increases, so does the incidence of pelvic fracture. Side impact with lateral force transfer and vehicle incompatibility (small vehicles impacted by large vehicles) are the main risk factors for pelvic fracture morbidity and mortality

Pre-hospital Management

Information gleaned from witnesses at the crash scene in addition to data from pre-hospital care professionals regarding patient presentation and examination findings may raise the suspicion for pelvic injury. Uniform pre-hospital transport protocols are helpful and improve efficiency of early injury care and the delivery of the patient to the appropriate hospital. Appropriate immobilization, airway protection, and initial circulatory support with expedient transport are the main goals.

Initial Assessment

The multiple-injury patient is at risk for thoracic, intra-abdominal, soft tissue, pelvic, and extremity hemorrhage. Once the primary survey is completed, the airway is secured and a search for sources of controllable bleeding begins. Radiographs of the chest and pelvis may assist in localizing a bleeding site. The focused abdominal ultrasound for trauma (FAST) can detect intraperitoneal fluid. A positive FAST in an unstable patient is an indication for exploration of the abdomen [10].

Early Detection and Management of Associated Injuries

As a result of the energy required to cause pelvic fracture, injuries to other areas are commonly encountered. The thorax, long bones, brain, abdominal organs, and spine are most frequently involved. An early decision to explore the pleural space or peritoneum when bleeding or intestinal injury is suspected will reduce the risk of death or serious complications. Most of the time, this decision can be made during the primary survey. More extensive diagnostic procedures can be postponed until

Classification of Pelvic Fractures

Classification of pelvic fractures and dislocations requires adequate plain radiography (AP, inlet, and outlet x-rays) and thin-cut (3-mm) CT scanning. If possible, the AP pelvis film is obtained prior to bladder catheterization and cystography to avoid obscuring landmarks. The purposes of classifying pelvic fracture are to provide a common language to facilitate communication among medical professionals caring for the patient and to provide a means for relating clinical findings to prognosis.

Diagnosis of Pelvic Fracture Bleeding

Bleeding secondary to vascular lacerations and bone edge bleeding is the most important life-threatening problem due to pelvic fractures. Huittinen and Slatis [17], in a classic contribution to the field of pelvic fracture care, showed with postmortem angiography that pelvic fracture hemorrhage results most frequently from the venous structures and bleeding bone edges. This hemorrhage stops in most patients secondary to tamponade from increasing tissue pressure in the pelvic retroperitoneal

Treatment of Pelvic Fracture Hemorrhage—Persistent Controversies

Fortunately, most bleeding from pelvic fracture arises from torn small- and medium-sized veins and edges of fractured bone. These sites will usually stop by natural hemostatic mechanisms if patient cardiovascular function, blood volume, and coagulation status are kept within acceptable limits. We transfuse all patients who do not immediately stabilize after 2000 mL of balanced salt solution. If a patient requires transfusion of more than 4 U of blood, support of coagulation with fresh-frozen

Diagnosis and Management of Genitourinary Injuries in Patients With Pelvic Fracture

Injuries to the bladder and urethra are common with pelvic fractures, with an incidence as high as 15% to 20% [36], [37], [38]. Because of the significant force required to rupture a hollow viscus within the pelvis, mortality can be as high 22% to 34% when pelvic fractures are accompanied by a bladder rupture [39]. Bladder injuries tend to cluster in those patients with a lateral compression mechanism, while urethral injury is seen with both anterior compression and lateral compression

Open Pelvic Fractures

Open pelvic fractures occur when there is communication between a fracture fragment and the skin or a pelvic visceral cavity. These injuries are observed in 4% to 5% of patients with pelvic fracture [43]. The incidences of pelvic infection including soft tissue infection and osteomyelitis, as well as high mortality and long-term disability, are raised in patients with open pelvic fracture as documented in the reports by Brenneman et al [44] and Raffa et al [45]. Skin lacerations communicating

Principles of Definitive Fixation of Pelvic Fractures

The basic tenets of pelvic fracture fixation are:

  • 1

    With complete instability of the posterior ring (i.e., the posterior SI ligaments are disrupted), anterior fixation alone is inadequate.

  • 2

    With complete instability of the posterior ring and vertical instability, any posterior fixation should be supplemented with some form of anterior stabilization.

  • 3

    With partial instability of the pelvic ring (i.e., the posterior SI ligaments are intact), anterior fixation alone is adequate and full weight-bearing

Disruptions of the Pubic Symphysis

The options for stabilizing symphyseal disruptions include anterior external fixators or internal fixation with plate and screws. Available data from biomechanical studies have shown that there is no significant difference between external or internal fixation of the pelvis for controlling the symphysis [47], [48]. In addition, there is significant improvement in pelvic stability when posterior fixation is augmented with some form of anterior fixation in VS injury patterns [49]. Fig. 6 shows

Fixation of Posterior Pelvic Fractures

Iliac wing fractures can be fixed with the patient prone via a posterior approach with an incision along the crest and elevation of the gluteal musculature from the outer table of the ilium, or supine via an anterior approach with the lateral window of the ilioinguinal or Smith-Peterson exposures of the inner table. Depending on the fracture pattern and the patient’s condition and/or associated injuries, one approach may offer advantages over the other. As a general rule, the anterior approach

Clinical Outcomes of Pelvic Fracture Fixation

Stabilization of unstable pelvic injuries has only recently evolved to include early internal fixation and restoration of anatomic relations. Prior to the 1980s, very little was understood regarding the biomechanics and contributions to stability of the various pelvic bony and ligamentous structures. As recently as the 1970s, many pelvic ring disruptions were treated with nonoperative techniques; generally skeletal traction and pelvic slings to prevent excessive cephalad migration of the

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