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- Pelvic fractures in adult are either stable fractures resulting from low-energy trauma, such as falls in elderly patients, or fractures caused by high-energy trauma that result in significant morbidity and mortality.
- Mortality rate is 15% for closed fractures, and 50% for open pelvic fractures.
- Early mortality most commonly results from hemorrhage or closed-head injury.
- Late mortality occurs from sepsis or multiple system organ failure.
Risk factors for increased mortality
- Risk factors for increased mortality in pelvic fractures include:
- Patient’s age
- injury severity score
- Associated head or visceral injury
- Blood loss
- Unstable or open pelvic fractures.
Potential complications of high-energy pelvic fractures:
- Injuries to the major vessels and nerves of the pelvis.
- Injuries to the major viscera, such as the intestines, the bladder, and the urethra.
- Avulsion injuries to the surrounding soft tissues.
Anatomy of the pelvis
- The pelvis is composed anteriorly of the ring of the pubic and ischial rami connected with the symphysis pubis. A fibrocartilaginous disc separates the two pubic bodies.
- Posteriorly, the sacrum and the ilium bones are joined at the sacroiliac joint on each side.
- Symphyseal ligaments.
- Pelvic floor: consists of the sacrospinous ligaments and sacro-tuberous ligaments.
- Posterior sacroiliac complex.
See Also: Pelvic Anatomy
Tile Classification of Pelvic fractures:
|Type A||Stable (posterior arch intact).||– A1: Avulsion injury.|
– A2: Iliac-wing or anterior-arch fracture due to a direct blow.
– A3: Transverse sacrococcygeal fracture.
|Type B||Partially stable (incomplete disruption of posterior arch).||– B1: Open-book injury (external rotation).|
– B2: Lateral-compression injury (internal rotation):
– B2-1: Ipsilateral anterior and posterior injuries.
– B2-2: Contralateral (bucket handle) injuries.
– B3: Bilateral.
|Type C||Unstable (complete disruption of posterior arch).||– C1: Unilateral:|
– C1-1: Iliac fracture.
– C1-2: Sacroiliac fracture dislocation.
– C1-3: Sacral fracture.
– C2: Bilateral, with one side type B, one side type C.
– C3: Bilateral.
- Anterior Posterior Compression (APC):
- Symphysis widening < 2.5 cm.
- Symphysis widening > 2.5 cm.
- Anterior SI joint diastasis.
- Posterior SI ligaments intact.
- Disruption of sacrospinous and sacro-tuberous ligaments.
- Disruption of anterior and posterior SI ligaments (SI dislocation).
- Disruption of sacrospinous and sacro-tuberous ligaments.
- APCIII associated with vascular injury.
- Lateral Compression (LC):
- Oblique or transverse ramus fracture and ipsilateral anterior sacral ala compression fracture.
- Rami fracture and ipsilateral posterior ilium fracture dislocation (crescent fracture).
- Ipsilateral lateral compression and contralateral APC (windswept pelvis).
- Common mechanism is rollover vehicle accident or pedestrian vs auto.
- Vertical Shear:
- Posterior and superior directed force.
- Associated with the highest risk of hypovolemic shock (63%).
- Mortality rate up to 25%.
- Hemodynamic status:
- Hemorrhage is a leading cause of death.
- There are three main sources for hemorrhage resulting from pelvic fractures: vascular, osseous, and visceral.
- Neurologic examination:
- The lumbosacral trunk and sciatic nerve are at risk with fractures and dislocations of the sacrum and sacroiliac joint.
- The femoral nerve is less commonly injured.
- Pelvic fractures can also injure the pudendal nerve.
- Gastrointestinal injury:
- Required abdominal and rectal examination.
- Genitourinary injury:
- If blood is present at the urethral meatus, a retrograde urethrogram should be performed.
- Bladder injuries are common with pelvic fractures and should be looked for on CT scan or cytogram.
- Anteroposterior pelvis.
- Inlet view: evaluate anteroposterior displacement of sacroiliac joint and internal/external rotational deformity.
- Outlet view: evaluate vertical displacement of sacroiliac joint and flexion of hemipelvis.
- CT: particularly useful to evaluate posterior pelvic injury patterns.
- Control hemorrhage and provisionally stabilize pelvic ring.
- 85% of bleeding due to venous injury, only 15% arterial source.
- Volume resuscitation and early blood transfusion.
- Pelvic binder, wrapped sheet or external fixation.
- Angiographic embolization.
- Indicated for stable pelvic fractures:
- Weight bearing as tolerated for isolated anterior injuries.
- Protected weight bearing for ipsilateral anterior and posterior ring injuries.
- Symphysis diastasis greater than 2.5 cm.
- Anterior and posterior sacroiliac ligament disruption.
- Vertical instability of posterior hemipelvis.
- Sacral fracture with displacement greater than 1 cm.
- Open fractures.
- Anterior injuries:
- ORIF with plate fixation.
- External fixation.
- Posterior injuries:
- Percutaneous iliosacral screw fixation.
- Anterior plate fixation across the sacroiliac joint.
- Posterior transiliac sacral bars or sacral plating.
- Spinal-pelvic fixation considered for bilateral sacral fractures.
- Vertically unstable patterns with anterior and posterior dislocations:
- Anterior ring internal fixation and percutaneous sacroiliac screw has been shown to be most stable fixation construct.
- Spinal-pelvic fixation may also be considered.
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