Pelvic fractures: Clinical sciences

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Introduction0:00–1:21

Pelvic fractures occur in the bones that form the pelvic ring. They can be caused by low-energy trauma, like a fall, or a high-energy trauma, like a car crash.
Pelvic fractures can be associated with damage to nearby structures, like venous plexus shear or arterial injuries, resulting in extensive blood loss, which can be life-threatening and is a surgical emergency; as well as rectal, vaginal, and bladder lacerations.
Pelvic fractures can also be associated with neurological injuries that may cause bowel or bladder incontinence and dysfunctional sexual activity.
Now, pelvic fractures can be stable or unstable. Stable fractures occur in one spot, so the pelvis remains stable.
On the other hand, unstable fractures involve multiple fractures at different spots that can cause the bones of the pelvic ring to become displaced, and the entire pelvic ring to become unstable.
A type of unstable pelvic fracture are "open-book" fractures, which involve disruption of the sacroiliac joints; and are associated with retroperitoneal hemorrhage.As with any trauma patient, the first step in assessing a patient with a chief concern suggesting pelvic trauma is to perform the primary survey including the ABCDE assessment.

ABCDE Assessment/Acute Management1:21–2:44

Acute management should be started immediately to stabilize the patient's airway, breathing, and circulation. First, secure the airway and ensure adequate ventilation.
Then, place multiple large-bore peripheral IVs or IOs, immediately start fluid resuscitation, and monitor vital signs continuously.
Next, you’ll calculate the Glasgow Coma Scale, position the patient supine in a flat position, and assess for spinal cord injury.
Finally, it’s essential to ensure that the patient's entire skin is exposed, meaning back and front, to be certain there are no other obvious injuries.
Bear in mind that severe bleeding is commonly associated with pelvic fractures, so be on the lookout for it, and in addition to giving volume resuscitation, you need to stop any life-threatening bleeding.
That’s why it’s important to assess the pelvic ring first. Start by pushing down on the iliac crests.
If they open like a book, we are talking about open-book pelvic fractures. For these types of fractures, you need to place a pelvic binder, which will hold the pelvis in place, and maintain internal pressure, which helps control the bleeding.Okay, if your patient is unstable, move on to the secondary survey.

Unstable patient2:44–4:48

This step includes a focused history, physical examination, and adjunctive tests like typical trauma labs, such as CBC, serum lactate, and urinalysis.
Let’s start with history. These patients typically present after a fall from height or a motor vehicle crash.
They might report pelvic pain. When it comes to the physical exam, it can reveal signs of hemodynamic instability like tachycardia and hypotension.
You’ll also notice signs of a pelvic fracture, such as tenderness and crepitus on palpation of the pelvic ring, ecchymosis over the iliac wings, pubis, labia, or scrotum, unequal leg lengths, pelvic deformities, and an unstable pelvis.
Next, be sure to look for any signs of associated injuries like spinal and neurovascular injuries, blood at the urethral meatus, or rectal bleeding.
Finally, on a digital rectal exam, you might find loss of sphincter tone and a non-palpable or high-riding prostate.Let’s move on to labs.
They might reveal low hemoglobin and hematocrit due to blood loss, and elevated serum lactate due to poor organ perfusion.
An important thing to mention is that initial labs may not actually reflect the degree of blood loss, as a hemorrhage can rapidly evolve, but it takes time for lab values to reflect it.
So even if initial labs are normal, you can’t rule out hemorrhage. On urinalysis you might notice microscopic hematuria.
Furthermore, if you notice gross hematuria, place an indwelling urinary catheter, also known as Foley. However, if you notice a high-riding prostate on physical exam, it might indicate that the urethra has been injured, so do not place a catheter!Alright, if you see these findings, you can suspect a pelvic fracture.

Unstable patient - Imaging4:48–5:15

The next logical step is to order adjunctive imaging. Get a pelvic X-ray to detect bone fractures.
Let’s go over some findings. First of all, if the pelvic X-ray shows no pelvic fracture, it may be necessary to consider an alternative diagnosis.
However, if pelvic X-rays reveal a pelvic fracture, you’ve got your diagnosis! Okay, once these initial steps are complete, you need to assess if the patient is still bleeding.

Unstable patient - Management5:15–6:30

If bleeding is successfully controlled, the patient can be managed through non-operative treatment by admitting them to the ICU, monitoring vital signs, ensuring bed rest, and managing pain.
However, if bleeding persists or is extensive, it's important to check on assessing the stability of the pelvic ring. If the pelvic ring is stable, meaning that the patient has a stable pelvic fracture, continue with the same nonoperative management including ICU admission, while looking for signs of other bleeding or cause for instability, monitoring vital signs, ensuring bed rest, and managing pain.
However, if the fracture is unstable, or if there are other severe injuries, surgical intervention is probably necessary.
Open reduction and internal fixation, or ORIF in short, may be performed in these cases, along with possible laparotomy, packing, angiographic embolization, aggressive debridement, and management of associated injuries such as bladder or urethral damage.Now that unstable patients are taken care of, let’s go all the way back to management of stable patients.

​​Stable Patient6:30–8:17

As before, the next step is to conduct a secondary survey, which includes a focused history, physical examination, and adjunctive laboratory tests like CBC, serum lactate levels, and urinalysis.
Now, history is pretty similar to our unstable patient. So, you might find a history of a fall from standing height as well as pelvic pain and inability to bear weight.On a physical exam, similarly to unstable patients, you can find those signs of pelvic fracture like tenderness and crepitus on palpation of the pelvic ring; ecchymosis over the iliac wings, pubis, labia, or scrotum; unequal leg lengths; pelvic deformities; or an unstable pelvis.
Other signs may include spine and neurovascular injuries, or blood at the urethral meatus. Finally, during a digital rectal exam, you may find rectal bleeding and loss of sphincter tone, and a non-palpable or high-riding prostate.
And although these patients are still stable, they may quickly deteriorate and become unstable, so you need to keep a close eye.When it comes to labs, hemoglobin and hematocrit can become low due to blood loss, while serum lactate levels are typically normal.
Urinalysis can also reveal gross or microscopic hematuria associated with bladder and urinary tract injuries.Here's a clinical pearl!
It is a good idea to follow up with serial hematocrit levels, as they will help you monitor resuscitation efforts during the acute phase.Alright, if you see these findings, you can suspect a pelvic fracture.

Stable patient - Imaging8:17–9:33

Once again, imaging is the next step. First, order a pelvic x-ray anteroposterior view, inlet, and outlet view.
Next, get a CT abdomen and pelvis with IV contrast to confirm bone fractures and detect any vascular or bowel injury. Lastly, you’ll need a retrograde urethrogram, or RUG for short, if you suspect urethral injury.Now that we have all this imaging, let’s talk about results.
If the pelvic X-ray shows no pelvic fracture, you should consider an alternative diagnosis. On the other hand, If X-rays or CT scans show pelvic fractures you can make a diagnosis of a pelvic fracture.
Additionally, you might notice contrast extravasation on the CT scan, also known as contrast blush. This means that the contrast is pooling around an injured leaking vessel, which is an indication for angiography and embolization.
Finally, RUG may detect any associated bladder or urethral injuries.Alright, since we finally have a diagnosis, let’s talk about management.

Stable patient - Management9:33–10:10

Start by assessing the pelvic ring stability. If the pelvic fracture is stable, you can manage the patient nonoperatively, which includes possibly admitting them, monitoring vital signs, and managing pain.
However, if the fracture is unstable or associated with another injury, you should consult the orthopedic surgeon. It involves open reduction and internal fixation or ORIF in short, a laparotomy, aggressive debridement of open fractures, and managing associated injuries like bladder or urethral injury.Alright, as a quick recap… Pelvic fractures occur in the bones forming the pelvic ring.

Review 10:10–11:14

Initial management involves stabilizing the pelvis with a binder. Unstable patients with pelvic fractures should be evaluated with an X-ray.
If the patient is no longer bleeding, continue with nonoperative treatment, which involves monitoring vitals and pain management.
Unstable pelvic fractures with active bleeding require embolization by angiography or surgical intervention, such as open reduction and internal fixation, a laparotomy, packing, aggressive debridement of open fractures, and managing associated injuries.
When it comes to stable patients, they are evaluated with a pelvic X-ray, CT with IV contrast, and possibly retrograde urethrogram.
Stable pelvic fractures are managed nonoperatively, while unstable pelvic fractures require surgical interventions like open reduction and internal fixation, a laparotomy, and aggressive debridement of open