Makindo Medical Notes

Related Subjects: |Fractured Neck of Femur |Fractured Shaft Femur |Supracondylar Femur Fractures |Femoral fractures and Injuries

Pelvic fractures are commonly associated with other big injuries and blood loss. If there is any suggestion of either of these being present, please discuss with the major trauma centre.

About

• Mortality 10% for closed fractures and 50% if open
• low-energy osteoporotic fractures or high energy fractures

Aetiology

• Pelvis is formed by a ring of bones held together with ligaments
• Sacrum, Sacroiliac joints, Innominate bone, Pubic symphysis
• Fractures tend to occur in two places
• Mechanism is high force trauma - RTA, Falls from height, direct trauma, crush
• Can affect blood vessels, bladder, urethra, vagina, uterus

Clinical

• Shocked due to haemorrhage which may be hidden
• Local Pain, bruising, bleeding PU at the urethral meatus
• PV: Bleeding may be found
• PR: Bleeding or high-riding or boggy prostate
• Look for other trauma

Predictors of major haemorrhage in Pelvic fractures

• Hct < 30%
• Pulse rate of > 130 beats/min
• Displaced fracture of the obturator ring
• Wide pubic symphyseal diastasis.

Tile Classification

Simple classification

• Stable, in which the pelvis has one breakpoint in the pelvic ring, limited bleeding and the bones are staying in place.
• Unstable, in which there are two or more breaks in the pelvic ring with moderate to severe bleeding.

Complications

• Venous thromboembolism
• Intrapelvic compartment syndrome
• Associated bladder, urethral prostate or vaginal damage
• Sexual dysfunction may be a long-term problem.
• Impotence, sex usual dysfunction
• bladder rupture, urethral injury

Investigations

• FBC, U&E, LFTs, Coagulation screen if indicated, Group and cross match
• Urinalysis
• X-ray: AP pelvis
• CT: pelvis inlet and outlet and can show pelvic contents
• Retrograde Urethrogram / IVU
• Angiography: If ongoing bleeding > 0.5 units/hr consider for angiography/embolisation. Not without its consequences such as soft-tissue necrosis, infection and sepsis, multiple organ failure and death. Specialist trauma centres should certainly be able to provide angiographic embolisation on a 24-hour basis.

Management

• ATLS, balanced resuscitation, analgesia. Pelvic fractures are commonly associated with other big injuries and blood loss. If there is any suggestion of either of these being present, please discuss with the major trauma centre.
• In Type B/C fractures avoid rolling the patient and instead perform a straight lift with a number of helpers.
• Avoid catheter as a potential urethral injury - consider suprapubic if needed
• Transfuse if needed and consider angiography is bleeding continues see above.
• Type A: Surgery not usually needed. Analgesia, initial bed rest and then mobilisation. Will take time to fully weight-bear. Crutches or a walker will be used to aid mobilisation. If acetabulum involved needs good reduction and fixation
• Type B/C: Look for signs of bleeding. Massive fluid resuscitation is generally still recommended but there is some evidence that a restrained fluid volume therapy may improve outcomes. Reduce blood loss by reducing pelvic volume, stabilising clot formation and reducing ongoing tissue damage. Can be done using external fixation which involves long screws inserted into the pelvic bones from the sides and a large external frame.
• Pelvis Binders: these are haemostatic devices that splint the pelvis and allow clot formation. The decision to use is based on assessment for blood loss. If there has been any sniff of haemodynamic instability, then the binder stays on until the team leader feels that the risk of going back into shock/dislodging a clot has gone and this often means the binder is removed in theatre. Don't forget to give the patient analgesia and check pre and post pain scores!
• Open pelvic fractures involving the perineum or bowel may need a colostomy. Do not catheterise if the 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.
• Further management is case-specific. Some need traction; others may require internal fixation with plates or screws. For some external fixation will be sufficient to relieve pain and bleeding and is important for mobilisation and pain control and for the prevention of deformity and chronic instability.

References