Pelvic

• The pelvic ring is formed by the two innominate bones (ilium, ischium and pubis) and the sacrum, and their supporting ligaments.
• The true pelvis contains the rectum, bladder and uterus in females, as well as the iliac vessels and the lumbosacral nerve roots. As such, pelvic fractures can be associated with life-threatening haemorrhage, neurological deficit, urogenital trauma, and bowel injury.
• Clinical features:

  • Most often caused by high energy blunt trauma
  • May have an obvious deformity to their pelvis with significant pain and swelling - may also be lower limb rotational deformity
  • Typically hypotensive and have severe pelvic tenderness and instability on exam
  • Assess pelvic ring by pushing down on iliac crests - pain suggests fracture
  • If you feel laxity of the iliac crest - suggests open book pelvic fracture
• Investigation:

  • Immediate pelvic X-ray with 3 views - if suspected and haemodynamically unstable
  • FAST scan can identify free fluid
  • CT scan
• Tile classification:

  • A-type: rotationally and vertically stable
  • B-type: horizontally unstable but vertically stable
  • C-type: both horizontally and vertically unstable
• It is important to examine the genitals as signs of a pelvic fracture such as vaginal, scrotal, urethral or rectal bleeding
• Any hypotensive patient with a history of pelvic trauma should be assumed to have a pelvic fracture until proven otherwise and a pelvic binder should be applied:

  • Tamponade effect on bleeding
  • Placed around greater trochanter and pubic symphysis
  • Remains in situ during surgery
• Management of unstable fracture:

  • ABCDE approach
  • Pelvic binder
  • IV tranexamic acid
  • Imaging - XR +/- CT scan
  • Resuscitation - if no response, surgical packing of the pelvis or interventional radiology with embolization is needed
  • Surgical reconstruction of the pelvic ring
• Complications following pelvic fractures include urological injury (more common in men), venous thromboembolism (DVT in ~60% and PE in ~25%, therefore prophylaxis is essential), and long-standing pelvic pain.
• Stable pelvic fractures:

  • There is often only one break in the pelvic ring and there is minimal displacement:
  • Iliac wing fracture
  • Sacrum fracture
  • Superior pubic ramus fracture
  • Inferior pubic ramus fracture
• Unstable fractures:

  • usually two or more breaks in the pelvic ring and there is displacement
  • Anterior-posterior compression fracture (pelvis pushed inwards) - open book fracture
  • Lateral compression fracture (pelvis pushed inwards)
  • Vertical shear fracture
• Open book fractures are associated with urethral injury