Pelvic fractures: Clinical sciences

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. 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. 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. 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. 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.