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Pelvic Fracture

  • A break of the bony structure of the pelvis
    • Includes sacrum, hip bones (ischium, pubis, ilium) or coccyx

Epidemiology

  • Younger male patients – high energy trauma
  • Older female patients – minor trauma
  • Haemorrhage is the leading cause of death
  • Associated injuries – chest injury, long bone fractures, spine fractures, urogenital and abdominal injury

Etiology

  • Motor vehicle accident
  • Fall from height
  • Sports injury
  • Pelvic insufficiency fractures – in older patients
    • Risk factors – osteoporosis, extended corticosteroid use, rheumatoid arthritis, mechanical changes after hip arthroplasty

Anatomy

  • Ring structure is made up of sacrum, ischium, ilium and coccyx
  • Displacement only occurs when there is disruption of the ring in two places
Ligaments
  • Anterior – pubic symphysis ligaments
  • Pelvic floor – sacrospinous, sacrotuberous
  • Posterior sacroiliac complex – most important for pelvic ring instability
    • Anterior sacroiliac ligament
    • Interosseous sacroiliac ligament
    • Posterior sacroiliac ligament
    • Iliolumbar ligament

Vascular

  • Aorta bifurcates into common iliac arteries at L4
    • External iliac a. emerges as the common femoral artery distal to the inguinal ligament
    • Internal iliac artery – give off anterior and posterior division, branch into
      • Iliolumbar, lateral sacral, gluteal (superior + inferior), pudendal, inferior vesicle (males), middle rectal, vaginal (females), obturator, umbilical, uterine (females)

Pathophysiology

  • Pelvic fractures can lead to uncontrolled haemorrhage
  • Most commonly affected arteries – internal iliac, superior gluteal, obturator, internal pudendal
  • Most commonly affected veins – presacral and prevesical venous plexus
    • More likely haemorrhage than arteries

Classification

Tile Classification – based on the stability of the pelvic ring

  • A – stable
  • B – rotationally unstable, vertically stable (including ‘Open book fracture’ )
  • C – rotationally and vertically unstable

Young-Burgess Classification – based on vector of the displacing force

  • Anterior posterior compression (APC)
  • Lateral compression (LC)
  • Vertical shear (VS)

Clinical features

  • Pain and inability to bear weight
  • Skin
    • Scrotal, labial or perineal haematoma, swelling or ecchymosis
    • Flank hematoma
    • Perineal lacerations
  • Loss of sphincter tone and rectal sensation
  • Gross hematuria

Diagnosis

  • X-ray
  • CT – investigation of choice for complex pelvic fractures to evaluate for signs of vascular injury such as
    • Abrupt narrowing of an artery
    • Intraluminal linear filling defects (dissection)
    • Focal outpouching (pseudoaneurysm)
    • Arterial cut-off (thrombosis)

Treatment

Type A fractures

  • Analgesia and bed rest until mobility is restored – 3-6 weeks

Type B and C fractures

  • Resuscitate
  • Correct hypovolemia, anticipate coagulopathy, cross-match blood in case transfusion is required
  • Pelvic binder
  • External fixation
  • Angiography/embolisation

Complications

  • Rupture of urethra – more common in males
  • Rupture of bladder
  • Injury to rectum or vagina
  • Injury to major vessels – e.g. common iliac artery or its branches
  • Injury to nerves – of the lumbosacral plexus
  • Rupture of the diaphragm – in severely displaced pelvic fractures
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