ReviewContemporary management of pelvic fractures
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
References (68)
- et al.
Pelvic fractures and the general surgeon
Curr Surg
(2004) - et al.
Pelvic fracturesepidemiology and predictors of associated abdominal injuries and outcomes
J Am Coll Surg
(2002) - et al.
Pelvic ring fracturesimplications of vehicle design, crash type, and occupant characteristics
Surgery
(2004) - et al.
The increasing incidence of severe pelvic injury in motor vehicle collisions
Injury
(2004) - et al.
The utility of clinical examination in screening for pelvic fractures in blunt trauma
J Am Coll Surg
(2002) - et al.
Pelvic fracture patterns and their corresponding angiographic sources of hemorrhage
Orthop Clin North Am
(2004) The role of pelvic angiography in evaluation and management of pelvic trauma
Orthop Clin North Am
(2004)- et al.
Diagnosis and initial management of urological injuries associated with 200 consecutive pelvic fractures
J Urol
(1983) - et al.
Risk factors for urethral injuries in men with traumatic pelvic fractures
J Urol
(1988) - et al.
Compound fractures of the pelvis
Am J Surg
(1976)
The strength of iliosacral lag screws and transiliac bars in the fixation of vertically unstable pelvic injuries with sacral fractures
Injury
Biomechanics of pelvic fixation
Orthop Clin North Am
High-energy pelvic ring disruptions
Orthop Clin North Am
Outcome after pelvic ring fracturesevaluation using the medical outcomes short form SF-36
Injury
Causes of mortality in patients with pelvic fractures
Orthopedics
The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures
Injury
The effects of ligament sectioning and intern fixation on bending stiffness of the pelvic ring
Pelvic fracture in multiple traumaclassification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome
J Trauma
Pelvic trauma in rapidly fatal motor vehicle accidents
J Orthop Trauma
Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures
Ann Surg
Assessment of volume of hemorrhage and outcome from pelvic fracture
Arch Surg
Pelvic disruptionassessment and classification
Clin Orthop Relat Res
Acute pelvic fracturesI. Causation and classification
J Am Acad Orthop Surg
Pelvic ring disruptionseffective classification system and treatment protocols
J Trauma
OTA classification of fractures
J Orthop Trauma
Postmortem angiography and dissection of the hypogastric artery in pelvic fractures
Surgery
External fixation or arteriogram in bleeding pelvic fractureinitial therapy guided by markers of arterial hemorrhage
J Trauma
Prospective randomized evaluation of antishock MAST in post-traumatic hypotension
J Trauma
Definitive control of bleeding from severe pelvic fractures
Ann Surg
Management of severe bleeding in fractures of the pelvis
Surg Gynecol Obstet
Pelvic emergency clampsanatomic landmarks for a safe primary application
J Orthop Trauma
Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption
J Orthop Trauma
Hemorrhage in pelvic fracturewho needs angiography?
Curr Opin Crit Care
Bladder incarceration in a traumatic symphysis pubis diastasis treated with external fixationa case report and review of the literature
J Orthop Trauma
Cited by (130)
Evaluating the stability of external fixators following pelvic injury: A systematic review of biomechanical testing methods
2024, Journal of the Mechanical Behavior of Biomedical MaterialsSuperior gluteal artery injury in pelvic ring injury and acetabular fracture: Single center observational study
2023, Journal of Orthopaedic ScienceRadiography, anatomy and imaging in pelvic fractures
2022, Orthopaedics and Trauma