Chapter 3 – Pelvic emergencies



Chapter 3 Pelvic emergencies




Michael C. Bond



Pelvic fractures



Key facts





  • Pelvic fractures represent 3% of all fractures, and are associated with significant morbidity and mortality



  • The mortality rate for high-energy pelvic fractures is between 10% and 20%



  • Pelvic fractures can result in significant hemorrhage, and a large volume of blood loss (up to 4 liters)




    • About 50% of the patients admitted with pelvic fractures will require a blood transfusion



    • Non-displaced fractures are not associated with large volume blood loss, so if the patient is hypotensive with this type of injury a search for another more serious injury needs to ensue




  • Twenty percent of pelvic fractures are associated with neurologic injuries




    • Acetabular and sacroiliac fractures are most highly associated with neurologic injuries



    • Fractures medial to the sacral foramina have an incidence of 57% of a neurologic injury




  • The pelvis is an anatomic ring that typically will have two disruptions in the ring. This can consist of two fractures, or a fracture and dislocation




Anatomy





  • The pelvis consists of the ilium, pubis, and ilium on each side forming the innominate bones that are then joined at the pubis symphysis anteriorly and the sacrum posteriorly



  • Some of the strongest ligaments in the body secure the innominate bone to the sacrum. Disruption of these ligaments will affect normal weight bearing



  • Strong interpubic ligaments hold the pubic symphysis in place. Disruption of these ligaments can result in an “open book” pelvis




Signs of pelvic fracture





  • Destot’s sign: a superficial hematoma above the inguinal ligament or on/in the scrotum



  • Earle’s sign: a large hematoma, or abnormal bony prominence, or tender fracture line that is felt on a rectal examination



  • Roux’s sign: radiologic sign. Sign is present when the distance measured from the greater trochanter to the pubic spine is diminished on one side




Physical examination





  • The patient should be disrobed in order to look for signs of ecchymosis, lacerations, deformity or swelling



  • Special attention should be accorded to the rectum and penis/vagina to ensure there is no bleeding that could denote a more serious injury



  • Pelvic instability can often be felt on physical examination though retesting should not be performed if instability is noted as this increases the risk of pelvic bleeding from disruption of bone fragments or a hematoma



  • Test for instability by applying internal and external compression forces on the iliac wings to check for instability



  • Vertical instability can be checked by applying traction and axial loading to the leg while one hand is palpating the iliac wing on the ipsilateral side



  • Sensation should be checked over the perineum and in both legs, as sacral fractures can cause neuropathies, and acetabular fractures are associated with injuries to the sciatic nerve



  • Radiographs should be obtained




    • Plain radiographs are a good initial screening test to look for displaced pelvic fractures



    • CT may be needed for non-displaced fractures and for operative planning of complex fractures





Classification system





  • Several classification systems have been developed to describe pelvic fractures



  • The initial classification system was developed by Pennal and Sutherland and was based on the mechanism of injury



  • The Pennal and Sutherland system was modified by Burgess and Young in an attempt to correlate the injury with the degree of hemodynamic instability



  • The Burgess and Young system is the most commonly used one now




    • Based on mechanism of injury



    • Subdivided by degree of predicted hemodynamic instability



    • Does not address fractures not involving the pelvic ring




      • Avulsion fractures



      • Coccyx fractures






Specific pelvic fractures



Avulsion fractures





  • Mechanism: Generally caused by a forceful muscular contraction that causes an apophyseal center to be pulled off the pelvic ring




    • Can occur at:




      • Anterior–superior iliac spine at the insertion of the sartorius muscle



      • Anterior–inferior iliac spine at the insertion of the rectus femoralis muscle



      • Ischial tuberosity at the insertion of the hamstring muscles






Symptoms





  • Typically have pain and tenderness over the site



  • Often have increased pain with ambulation, and with ischial tuberosity fractures can have increased pain when sitting down



Diagnosis (Figure 3.1)





  • Often based on symptoms and plain radiographs



  • If there is significant ambulatory dysfunction may need to obtain a CT in order to exclude more serious fractures





Figure 3.1 Avulsion fracture of the anterior inferior iliac spine (AIIS) is noted on the right. The AIIS is the insertion site of the rectus femoralis muscle.


(Image courtesy of Michael C. Bond, MD.)


Treatment





  • Treatment is non-operative and is aimed at controlling symptoms



  • Anterior–superior iliac spine fractures:




    • 3 to 4 weeks bed rest with the hip in flexion and abduction



    • Complete recovery can take more than 8 weeks




  • Anterior–inferior iliac spine fractures:




    • 3 to 4 weeks bed rest with the hip in flexion but not abducted




  • Ischial tuberosity fracture:




    • Bed rest with the thigh in extension with external rotation and slight abduction



    • A donut pillow can help when sitting




  • All patients would benefit from analgesics




    • Ibuprofen 800 mg orally every 6–8 hours as needed



    • Naproxen 500 mg orally every 6–8 hours as needed



    • Oxycodone/acetaminophen 5/325 mg; one or two tablets every 4–6 hours as needed for severe pain



    • Hydrocodone/acetaminophen 5/325 mg; one or two tablets every 4–6 hours as needed for severe pain




Non-displaced pelvic fractures



Pubic ramis fractures



Mechanism





  • Fractures involving a single pubic ramis are usually caused by a fall in the elderly, though in the young it is often the result of persistent tension/stress on the adductors or hamstrings resulting in a fracture at their site of origination



  • Fractures through both pubic rami are typically caused by direct trauma (i.e., horizontal or compressive forces)



Symptoms





  • Patients will often complain of persistent groin pain after a fall (i.e, elderly) or with a more insidious onset in the young



  • The pain is often worse with deep palpation or walking/running



  • A lateral compression force will often exacerbate fractures involving both rami




Diagnosis





  • Pain on palpation over the pubic ramis



  • Plain radiographs (AP view of the pelvis) are normally enough to make the diagnosis



  • CT of the pelvis with 3-D reconstruction views may be needed to exclude a more serious injury, especially if there is tenderness over the sacroiliac joint




Treatment





  • Single pubic rami fractures (Figure 3.2)




    • Symptomatic treatment




      • Pain control with NSAIDs or narcotics as needed



      • Weight-bearing as tolerated for 8–12 weeks. Patients benefit from crutches to limit the amount of weight (i.e., crutch walking)





  • Dual pubic rami fractures are generally stable though these fractures should be referred to orthopedics early as they may require operative repair if there is any posterior pelvic injury




    • Symptomatic treatment




      • Pain control with NSAIDs or narcotics as needed



      • Weight-bearing as tolerated for 8–12 weeks. Patients benefit from crutches to limit the amount of weight (i.e., crutch walking)





  • Straddle fracture is a fracture through both pubic rami bilaterally as can happen when falling from a height and landing on the perineum. Figure 3.3 demonstrates this fracture pattern






Figure 3.2 Fracture of the superior pubic rami on the right.


(Image courtesy of Michael C. Bond, MD.)




Figure 3.3 A straddle fracture. Notice the bilateral dual pubic ramis fractures.


(Image courtesy of Michael C. Bond, MD.)


Ischial body fractures



Mechanism





  • Typically caused by a fall on to the buttocks. Can be associated with fractures of the lumbar and thoracic spine



Symptoms





  • Patients will often complain of buttock pain that is worse with deep palpation or contraction of the hamstrings




Diagnosis





  • Pain on palpation over the ischial body



  • Plain radiographs (AP view of the pelvis) are normally enough to make the diagnosis



  • CT of the pelvis with 3-D reconstruction views may be needed to exclude a more serious injury




Treatment





  • Symptomatic treatment




    • Pain control with NSAIDs or narcotics as needed



    • Bed rest for 4 to 6 weeks with physical therapy to prevent loss of range of motion



    • Inflatable seat cushion (i.e., donut pillow) for comfort when seated





Ilium fractures



Mechanism





  • Iliac wing fractures: Result from a medially directed force against the iliac wing. Because of the high energy needed for these fractures the emergency provider should ensure that other injuries are not also present, such as




    • Acetabular fractures



    • Solid and hollow organ injuries



    • Thoracic injuries




  • Ilium body fractures are usually the result of a direct force on the ilium that pushes the ilium postomedially




Symptoms





  • Iliac wing fractures: Patients will complain of pain over the iliac wing that is worsened by palpation, walking or stressing of the hip abductors



  • Ilium fractures: Patients will have tenderness over the posterior pelvis near the sacrum that is often exacerbated by straight-leg raises, and anterior and lateral compressive forces




Diagnosis





  • Pain on palpation over the iliac wing or ilium. Worse with compression or distraction



  • Plain radiographs (AP view of the pelvis) are normally enough to make the diagnosis. Oblique views may help demonstrate the fracture better



  • CT of the pelvis with 3-D reconstruction views may be needed to exclude a more serious injury




Treatment





  • Iliac wing fractures




    • Symptomatic treatment




      • Pain control with NSAIDs or narcotics as needed



      • Bed rest for 4 to 6 weeks or until there is no pain with stressing of the hip abductors





  • Ilium fractures




    • Early referral to orthopedics



    • Symptomatic treatment




      • Pain control with NSAIDs or narcotics as needed



      • Pelvic sling or belt may help provide comfort and stability



      • Bed rest that will be advanced to crutch walking by orthopedics



      • Typically takes 3 to 4 months to return to baseline






Sacral fractures



Mechanism





  • Horizontal fractures result from a direct blow to the sacrum or from a fall with the patient landing in the seated position



  • Vertical fractures are the result of anterior forces on the pelvis that drive the pelvic ring posteriorly




Symptoms





  • Patients will complain of pain over the sacrum, and ecchymosis may be noted. Patients will also have increased pain on rectal examination if pressure is applied to the sacrum. Pain is often increased with lateral and anterior compression applied to the pelvis. Patients may have loss of sensation or neurologic dysfunction if the sacral nerves are compressed as they exit the sacral foramina




Diagnosis





  • Pain on palpation over the sacrum. A digital rectal examination needs to be performed to ensure that the fracture is not open as evidenced by a laceration of the rectum



  • Plain radiographs (AP view of the pelvis) are normally enough to make the diagnosis. An AP outlet view is often better at noting displayed fractures



  • CT of the pelvis with 3-D reconstruction views may be needed to exclude a more serious injury




Treatment





  • Vertical fractures should be referred to orthopedics early because of the higher risk of neurologic involvement




    • Vertical fractures can also be treated with a pelvic binder/belt




  • Fractures that are associated with any neurologic dysfunction need immediate referral to orthopedics for possible operative repair



  • Symptomatic treatment




    • Pain control with NSAIDs or narcotics as needed



    • Bed rest to advance to crutch walking as tolerated



    • An inflatable seat cushion can be used for comfort




  • Open fractures require immediate antibiotic coverage and orthopedic consultation




Coccyx fractures



Mechanism





  • Usually caused by a fall and landing in a sitting position




Symptoms





  • Patients will complain of pain over their buttocks near their rectum. Spasms of the anococcygeal muscle may also be noted during bowel movements or when trying to sit




Diagnosis





  • Pain on palpation over the coccyx, and pain on digital rectal examination with palpation of the coccyx. Rectal examination must be done to ensure there is no rectal laceration



  • Plain radiographs (AP view of the pelvis and lateral coccyx view) are normally enough to make the diagnosis



  • CT of the pelvis with 3-D reconstruction views may be needed to exclude a more serious injury


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Jan 19, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Chapter 3 – Pelvic emergencies
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