Pelvic fracture

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Pelvic fracture
Diastasis symphysis pubis 1300500.JPG
A pelvic X-ray showing an open book fracture
Symptoms Pelvic pain, particularly with movement [1]
Complications Internal bleeding, bladder injury, vaginal trauma [2] [3]
TypesStable, unstable [1]
CausesFalls, motor vehicle collisions, vehicle hitting a pedestrian, crush injury [2]
Risk factors Osteoporosis [1]
Diagnostic method Based on symptoms, confirmed by X-rays or CT scan [1]
Differential diagnosis Femur fracture, vertebral fracture, low back pain [4]
TreatmentBleeding control (pelvic binder, angiographic embolization, preperitoneal packing), fluid replacement [2]
Medication Pain medication [1]
Prognosis Stable: Good [1]
Unstable: Risk of death ~15% [2]
Frequency3% of adult fractures [1]

A pelvic fracture is a break of the bony structure of the pelvis. [1] This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. [1] Symptoms include pain, particularly with movement. [1] Complications may include internal bleeding, injury to the bladder, or vaginal trauma. [2] [3]

Contents

Common causes include falls, motor vehicle collisions, a vehicle hitting a pedestrian, or a direct crush injury. [2] In younger people significant trauma is typically required while in older people less significant trauma can result in a fracture. [1] They are divided into two types: stable and unstable. [1] Unstable fractures are further divided into anterior posterior compression, lateral compression, vertical shear, and combined mechanism fractures. [2] [1] Diagnosis is suspected based on symptoms and examination with confirmation by X-rays or CT scan. [1] If a person is fully awake and has no pain of the pelvis medical imaging is not needed. [2]

Emergency treatment generally follows advanced trauma life support. [2] This begins with efforts to stop bleeding and replace fluids. [2] Bleeding control may be achieved by using a pelvic binder or bed-sheet to support the pelvis. [2] Other efforts may include angiographic embolization or preperitoneal packing. [2] After stabilization, the pelvis may require surgical reconstruction. [2]

Pelvic fractures make up around 3% of adult fractures. [1] Stable fractures generally have a good outcome. [1] The risk of death with an unstable fracture is about 15%, while those who also have low blood pressure have a risk of death approaching 50%. [2] [4] Unstable fractures are often associated with injuries to other parts of the body. [3]

Signs and symptoms

Symptoms include pain, particularly with movement. [1]

Complications

Complications are likely to result in cases of excess blood loss or puncture to certain organs, possibly leading to shock. [5] [6] Swelling and bruising may result, more so in high-impact injuries. [6] Pain in the affected areas may differ where severity of impact increases its likelihood and may radiate if symptoms are aggravated when one moves around.[ citation needed ]

Causes

Common causes include falls, motor vehicle collisions, a vehicle hitting a pedestrian, or a direct crush injury. [2] In younger people significant trauma is typically required while in older people less significant trauma can result in a fracture. [1]

Pathophysiology

The bony pelvis consists of the ilium (i.e., iliac wings), ischium, and pubis, which form an anatomic ring with the sacrum. Disruption of this ring requires significant energy. When it comes to the stability and the structure of the pelvis, or pelvic girdle, understanding its function as support for the trunk and legs helps to recognize the effect a pelvic fracture has on someone. [7] The pubic bone, the ischium and the ilium make up the pelvic girdle, fused together as one unit. They attach to both sides of the spine and circle around to create a ring and sockets to place hip joints. Attachment to the spine is important to direct force into the trunk from the legs as movement occurs, extending to one's back. This requires the pelvis to be strong enough to withstand pressure and energy. Various muscles play important roles in pelvic stability. Because of the forces involved, pelvic fractures frequently involve injury to organs contained within the bony pelvis. In addition, trauma to extra-pelvic organs is common. Pelvic fractures are often associated with severe hemorrhage due to the extensive blood supply to the region. The veins of the presacral pelvic plexus are particularly vulnerable. Greater than 85 percent of bleeding due to pelvic fractures is venous or from the open surfaces of the bone.[ citation needed ]

Diagnosis

If a person is fully awake and has no pain in the pelvis, medical imaging of the pelvis is not needed. [2]

Classification

Fractures of the superior (in two places) and inferior pubic rami on the person's right, in a person who has had prior hip replacements FractureRtSandIRami(Sin2).png
Fractures of the superior (in two places) and inferior pubic rami on the person's right, in a person who has had prior hip replacements

Pelvic fractures are most commonly described using one of two classification systems. The different forces on the pelvis result in different fractures. Sometimes they are determined based on stability or instability. [8]

Tile classification

The Tile classification system is based on the integrity of the posterior sacroiliac complex.[ citation needed ]

In type A injuries, the sacroiliac complex is intact. The pelvic ring has a stable fracture that can be managed nonoperatively. Type B injuries are caused by either external or internal rotational forces resulting in partial disruption of the posterior sacroiliac complex. These are often unstable. Type C injuries are characterized by complete disruption of the posterior sacroiliac complex and are both rotationally and vertically unstable. These injuries are the result of great force, usually from a motor vehicle crash, fall from a height or severe compression.[ citation needed ]

Young-Burgess classification

Superior view, Pelvic Fracture Types (2006). Force and break are shown by matching color: Anteroposterior compression type I (orange), Anteroposterior compression type II (green), Anteroposterior compression type III (blue); Lateral compression type I (red), Lateral compression type II (purple), F. Lateral compression type III (black). Increased force and breaks are shown by increasing size. Pelvic Fracture Young-Burgess Classification.png
Superior view, Pelvic Fracture Types (2006). Force and break are shown by matching color: Anteroposterior compression type I (orange), Anteroposterior compression type II (green), Anteroposterior compression type III (blue); Lateral compression type I (red), Lateral compression type II (purple), F. Lateral compression type III (black). Increased force and breaks are shown by increasing size.
This fracture is best viewed anteriorly, while the other fractures are viewed superiorly. The arrow indicates where the force is coming from, and the colored lines indicate where the break occurs. Anterior view, Vertical Shear Fracture.png
This fracture is best viewed anteriorly, while the other fractures are viewed superiorly. The arrow indicates where the force is coming from, and the colored lines indicate where the break occurs.

The Young-Burgess classification system is based on mechanism of injury: anteroposterior compression type I, II and III, lateral compression types I, II and III, and vertical shear, [5] or a combination of forces.

Lateral compression (LC) fractures involve transverse fractures of the pubic rami, either ipsilateral or contralateral to a posterior injury.

  • Grade I – Associated sacral compression on side of impact
  • Grade II – Associated posterior iliac ("crescent") fracture on side of impact
  • Grade III – Associated contralateral sacroiliac joint injury

The most common force type, lateral compression (LC) forces, from side-impact automobile accidents and pedestrian injuries, can result in an internal rotation. [9] The superior and inferior pubic rami may fracture anteriorly, for example. Injuries from shear forces, like falls from above, can result in disruption of ligaments or bones. When multiple forces occur, it is called combined mechanical injury (CMI). The best imaging modality to use for this classification is probably a pelvic CT scan. [10]

Open book fracture

One specific kind of pelvic fracture is known as an 'open book' fracture. This is often the result of a heavy impact to the groin (pubis), a common motorcycling accident injury. In this kind of injury, the left and right halves of the pelvis are separated at front and rear, the front opening more than the rear, i.e. like an open book that falls to the ground and splits in the middle. Depending on the severity, this may require surgical reconstruction before rehabilitation. [11] Forces from an anterior or posterior direction, like head-on car accidents, usually cause external rotation of the hemipelvis, an “open-book” injury. Open fractures have an increased risk of infection and hemorrhaging from vessel injury, leading to higher mortality. [12]

Prevention

As the human body ages, the bones become weaker and brittle and are therefore more susceptible to fractures. Certain precautions are crucial in order to lower the risk of getting pelvic fractures. The most damaging is one from a car accident, cycling accident, or falling from a high building which can result in a high energy injury. [13] This can be very dangerous because the pelvis supports many internal organs and can damage these organs. Falling is one of the most common causes of pelvic fracture. Therefore, proper precautions should be taken to prevent this from happening.[ citation needed ]

Treatment

An example of pelvic binding using a sheet and cable ties

A pelvic fracture is often complicated and treatment can be a long and painful process. Depending on the severity, pelvic fractures can be treated with or without surgery. [14]

Initial

A high index of suspicion should be held for pelvic injuries in anyone with major trauma. The pelvis should be stabilized with a pelvic binder. [15] This can be a purpose-made device, but improvised pelvic binders have also been used around the world to good effect. [16] Stabilisation of the pelvic ring reduces blood loss from the pelvic vessels and reduced the risk of death.

Surgery

Surgery is often required for pelvic fractures. Many methods of pelvic stabilization are used including external fixation or internal fixation and traction. [17] [18] There are often other injuries associated with a pelvic fracture so the type of surgery involved must be thoroughly planned. [19]

Rehabilitation

Pelvic fractures that are treatable without surgery are treated with bed rest. Once the fracture has healed enough, rehabilitation can be started with first standing upright with the help of a physical therapist, followed by starting to walk using a walker and eventually progressing to a cane.[ citation needed ]

Prognosis

Mortality rates in people with pelvic fractures are between 10 and 16 percent. [20] However, death is typically due to associated trauma affecting other organs, such as the brain. Death rates due to complications directly related to pelvic fractures, such as bleeding, are relatively low. [20]

Epidemiology

In the United States of America, about 10 percent of people that seek treatment at a level 1 trauma center after a blunt force injury have a pelvic fracture. [20] Motorcycle injuries are the most common cause of pelvic fractures, followed by injuries to pedestrians caused by motor vehicles, large falls (over 15 feet), and motor vehicle crashes. [20]

See also

Related Research Articles

<span class="mw-page-title-main">Acetabulum</span> Cavity where the thigh bone (femur) articulates with the pelvis

The acetabulum, also called the cotyloid cavity, is a concave surface of the pelvis. The head of the femur meets with the pelvis at the acetabulum, forming the hip joint.

<span class="mw-page-title-main">Pelvic floor</span> Anatomical structure

The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus muscle, and associated connective tissue which span the area underneath the pelvis. The pelvic diaphragm is a muscular partition formed by the levatores ani and coccygei, with which may be included the parietal pelvic fascia on their upper and lower aspects. The pelvic floor separates the pelvic cavity above from the perineal region below. Both males and females have a pelvic floor. To accommodate the birth canal, a female's pelvic cavity is larger than a male's.

<span class="mw-page-title-main">Sacroiliac joint</span> Joint of the pelvis and spine

The sacroiliac joint or SI joint (SIJ) is the joint between the sacrum and the ilium bones of the pelvis, which are connected by strong ligaments. In humans, the sacrum supports the spine and is supported in turn by an ilium on each side. The joint is strong, supporting the entire weight of the upper body. It is a synovial plane joint with irregular elevations and depressions that produce interlocking of the two bones. The human body has two sacroiliac joints, one on the left and one on the right, that often match each other but are highly variable from person to person.

<span class="mw-page-title-main">Obturator internus muscle</span> One of six small hip muscles in the lateral rotator group

The internal obturator muscle or obturator internus muscle originates on the medial surface of the obturator membrane, the ischium near the membrane, and the rim of the pubis.

<span class="mw-page-title-main">Hip dislocation</span> Orthopedic injury

A hip dislocation is when the thighbone (femur) separates from the hip bone (pelvis). Specifically it is when the ball–shaped head of the femur separates from its cup–shaped socket in the hip bone, known as the acetabulum. The joint of the femur and pelvis is very stable, secured by both bony and soft-tissue constraints. With that, dislocation would require significant force which typically results from significant trauma such as from a motor vehicle collision or from a fall from elevation. Hip dislocations can also occur following a hip replacement or from a developmental abnormality known as hip dysplasia.

<span class="mw-page-title-main">Blunt trauma</span> Physical trauma caused to a body part, either by impact, injury or physical attack

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is physical trauma or impactful force to a body part, often occurring with road traffic collisions, direct blows, assaults, injuries during sports, and particularly in the elderly who fall. It is contrasted with penetrating trauma which occurs when an object pierces the skin and enters a tissue of the body, creating an open wound and bruise.

<span class="mw-page-title-main">Ischium</span> Lower and back region of the hip bone

The ischium forms the lower and back region of the hip bone.

<span class="mw-page-title-main">Pubis (bone)</span> Most forward-facing of the three main regions making up the os coxa

In vertebrates, the pubic region is the most forward-facing of the three main regions making up the coxal bone. The left and right pubic regions are each made up of three sections, a superior ramus, inferior ramus, and a body.

<span class="mw-page-title-main">Pelvic cavity</span> Body cavity bounded by the bones of the pelvis

The pelvic cavity is a body cavity that is bounded by the bones of the pelvis. Its oblique roof is the pelvic inlet. Its lower boundary is the pelvic floor.

The interosseous sacroiliac ligament, also known as the axial interosseous ligament, is a ligament of the sacroiliac joint that lies deep to the posterior ligament. It connects the tuberosities of the sacrum and the ilium of the pelvis.

<span class="mw-page-title-main">Pelvic outlet</span>

The lower circumference of the lesser pelvis is very irregular; the space enclosed by it is named the inferior aperture or pelvic outlet. It is an important component of pelvimetry.

<span class="mw-page-title-main">Pubic symphysis diastasis</span> Medical condition

Pubic symphysis diastasis is the separation of normally joined pubic bones, as in the dislocation of the bones, without a fracture that measures radiologically more than 10 mm. Separation of the symphysis pubis is a rare pathology associated with childbirth and has an incidence of 1 in 300 to 1 in 30,000 births. It is usually noticed after delivery but can be observed up to six months postpartum. Risk factors associated with this injury include cephalopelvic disproportion, rapid second stage of labor, epidural anesthesia, severe abduction of the thighs during delivery, or previous trauma to the pelvis. Common signs and symptoms include symphyseal pain aggravated by weight-bearing and walking, a waddling gait, pubic tenderness, and a palpable interpubic gap. Treatment for pubic symphysis diastasis is largely conservative, with treatment modalities including pelvic bracing, bed rest, analgesia, physical therapy, and in some severe cases, surgery.

Protrusio acetabuli is an uncommon defect of the acetabulum, the socket that receives the femoral head to make the hip joint. The hip bone of the pelvic bone/girdle is composed of three bones, the ilium, the ischium and the pubis. In protrusio deformity, there is medial displacement of the femoral head in that the medial aspect of the femoral cortex is medial to the ilioischial line. The socket is too deep and may protrude into the pelvis.

Pelvic girdle pain can be described as a pregnancy discomfort for some women and a severe disability for others. PGP can cause pain, instability and limitation of mobility and functioning in any of the three pelvic joints. PGP has a long history of recognition, mentioned by Hippocrates and later described in medical literature by Snelling.

The affection appears to consist of relaxation of the pelvic articulations, becoming apparent suddenly after parturition or gradually during pregnancy and permitting a degree of mobility of the pelvic bones which effectively hinders locomotion and gives rise to the most peculiar and alarming sensations.

<span class="mw-page-title-main">Hip bone</span>

The hip bone is a large flat bone, constricted in the center and expanded above and below. In some vertebrates it is composed of three parts: the ilium, ischium, and the pubis.

<span class="mw-page-title-main">Sacroiliac joint dysfunction</span> Medical condition

The term sacroiliac joint dysfunction refers to abnormal motion in the sacroiliac joint, either too much motion or too little motion, that causes pain in this region.

<span class="mw-page-title-main">Acetabular fracture</span> Broken bone in acetabular portion of hip bone

Fractures of the acetabulum occur when the head of the femur is driven into the pelvis. This injury is caused by a blow to either the side or front of the knee and often occurs as a dashboard injury accompanied by a fracture of the femur.

<span class="mw-page-title-main">Pelvis</span> Lower part of the trunk of the human body between the abdomen and the thighs

The pelvis is the lower part of the trunk, between the abdomen and the thighs, together with its embedded skeleton.

<span class="mw-page-title-main">Vaginal support structures</span> Structures that maintain the position of the vagina within the pelvic cavity

The vaginal support structures are those muscles, bones, ligaments, tendons, membranes and fascia, of the pelvic floor that maintain the position of the vagina within the pelvic cavity and allow the normal functioning of the vagina and other reproductive structures in the female. Defects or injuries to these support structures in the pelvic floor leads to pelvic organ prolapse. Anatomical and congenital variations of vaginal support structures can predispose a woman to further dysfunction and prolapse later in life. The urethra is part of the anterior wall of the vagina and damage to the support structures there can lead to incontinence and urinary retention.

<span class="mw-page-title-main">Pelvic binder</span> Device used to compress the pelvis

A pelvic binder is a device used to compress the pelvis in people with a pelvic fracture in an effort to stop bleeding.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 "Pelvic Fractures". OrthoInfo - AAOS. February 2016. Retrieved 17 May 2018.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 ATLS - Advanced Trauma Life Support - Student Course Manual (10 ed.). American College of Surgeons. 2018. pp. 89, 96–97. ISBN   9780996826235.
  3. 1 2 3 Peitzman, Andrew B.; Rhodes, Michael; Schwab, C. William (2008). The Trauma Manual: Trauma and Acute Care Surgery. Lippincott Williams & Wilkins. p. 322. ISBN   9780781762755.
  4. 1 2 Walls, Ron; Hockberger, Robert; Gausche-Hill, Marianne (2017). Rosen's Emergency Medicine - Concepts and Clinical Practice E-Book. Elsevier Health Sciences. pp. 577, 588. ISBN   9780323390163.
  5. 1 2 Walker, J (Nov 9–15, 2011). "Pelvic fractures: classification and nursing management". Nursing Standard. 26 (10): 49–57, quiz 58. doi:10.7748/ns2011.11.26.10.49.c8816. PMID   22206172.
  6. 1 2 "Fracture of the Pelvis". OrthoInfo. American Academy of Orthopaedic Surgeons.
  7. ↑ Dimon, Theodore Jr. (2010). The body in motion : its evolution and design. Berkeley, Calif.: North Atlantic Books. pp. 49–56. ISBN   978-1556439704.
  8. ↑ Young, JW; Resnik, CS (December 1990). "Fracture of the Pelvis: Current Concepts of Classification". AJR. American Journal of Roentgenology. 155 (6): 1169–75. doi:10.2214/ajr.155.6.2122661. PMID   2122661.
  9. ↑ Lee, C; Porter, K (February 2007). "The prehospital management of pelvic fractures". Emergency Medicine Journal. 24 (2): 130–3. doi:10.1136/emj.2006.041384. PMC   2658194 . PMID   17251627.
  10. ↑ "Pelvic Fractures". The Lecturio Medical Concept Library. Retrieved 3 October 2021.
  11. ↑ "Anteroposterior Compression Fracture of Pelvis (Open Book Fracture)". Elsevier: Netter's Images.
  12. ↑ Rothenberger, D; Velasco, R; Strate, R; Fischer, RP; Perry JF, Jr. (March 1978). "Open pelvic fracture: a lethal injury". The Journal of Trauma. 18 (3): 184–7. doi:10.1097/00005373-197803000-00006. PMID   642044.
  13. ↑ "High Energy Fractures". International Society for Fracture Repair. Archived from the original on 2013-01-27.
  14. ↑ Davis DD, Foris LA, Kane SM, et al. (January 2021). "Pelvic Fracture". National Center for Biotechnology Information, U.S. National Library of Medicine. PMID   28613485 . Retrieved 2 October 2021.
  15. ↑ "The Ideal Pelvic Binder". www.trauma.org. Retrieved 5 June 2018.
  16. ↑ Mallinson, T (2013). "Alternative improvised pelvic binder". African Journal of Emergency Medicine. 3 (4): 195–6. doi: 10.1016/j.afjem.2013.04.006 .
  17. ↑ Mirghasemi A, Mohamadi A, Ara AM, Gabaran NR, Sadat MM (2009). "Completely displaced S-1/S-2 growth plate fracture in an adolescent: case report and review of literature". J Orthop Trauma. 23 (10): 734–8. doi:10.1097/BOT.0b013e3181a23d8b. PMID   19858983. S2CID   6651435.
  18. ↑ Taguchi, T; Kawai, S; Kaneko, K; Yugue, D (1999). "Operative management of displaced fractures of the sacrum". Journal of Orthopaedic Science. 4 (5): 347–52. doi:10.1007/s007760050115. PMID   10542038. S2CID   46282760.
  19. ↑ Hancharenka, V.; Tuzikov, A.; Arkhipau, V.; Kryvanos, A. (March 2009). "Preoperative planning of pelvic and lower limbs surgery by CT image processing". Pattern Recognition and Image Analysis. 19 (1): 109–113. doi:10.1134/S1054661809010209. S2CID   34590414.
  20. 1 2 3 4 Vincent, Jean-Louis (2011). Textbook of Critical Care (6th ed.). Philadelphia, PA: Elsevier/Saunders. p. 1523. ISBN   9781437713671.
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