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Pelvic Fractures—Preventing Complications Pelvic Fractures Are Serious Injuries That Can Be Associated with a High Mortality Rate

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Pelvic Fractures—Preventing Complications Pelvic Fractures Are Serious Injuries That Can Be Associated with a High Mortality Rate Pelvic Fractures—Preventing Complications Pelvic fractures are serious injuries that can be associated with a high mortality rate. Key to ED management is stabilizing the patient, diagnosing and prioritizing injuries that are an immediate threat to the patient’s life, and consulting with specialists from other departments to determine a treatment plan. Hina Zafar Ghory, MD, and Rahul Sharma, MD, MBA, FACEP epresenting about 3% of all skeletal frac- lisions (10% to 20%), pedestrian/motor vehicle ac- tures,1 pelvic fractures are typically mi- cidents (10% to 20%), falls (8% to 10%), and crush nor injuries (up to 95%).2 However, the injuries (3% to 6%).2,6 Falls in the elderly commonly spectrum ranges from simple pubic rami result in pubic rami fractures with an intact pelvic Rfractures after minor falls to complex disruptions in ring. With the rising percentage of elderly patients the pelvic ring following major trauma.2 Severe pelvic in the United States, the number of pelvic fractures fractures result from high-force mechanisms and have secondary to falls is likely to increase. a high incidence of concurrent injuries to other organ Pediatric pelvic fractures are commonly secondary systems. Mortality from pelvic fractures ranges from to pedestrian/motor vehicle accidents (60% to 80%), 10% to 50% in adults, depending on the severity of followed by motor vehicle crashes (20% to 30%).2 the fracture and associated injuries; it reaches 5% in pediatric patients.3,4,5 The overall mortality increases ANATOMY to 50% if the patient is hypotensive on arrival to the The pelvis is made up of the sacrum, the coccyx, ED.3 Open fractures, occurring in 4% to 5% of cases, and two innominate bones, which are formed by the are associated with a mortality rate of up to 70%.3,4 fusion of the embryonic ilium, ischium, and pubis. Mortality from pelvic fractures is usually second- The sacrum and innominate bones form the pelvic ary to massive retroperitoneal hemorrhage, ensuing ring, which hosts five joints facilitating support and infection, or associated injuries. Long-term morbid- movement: the lumbosacral, sacroiliac (SI), sacro- ity (including sexual dysfunction, dyspareunia, and coccygeal, the pubic symphysis, and the ball-and- incontinence) results from neurologic, gastrointes- socket joint of the acetabulum. Several ligaments, tinal, and urogenital injury. Through early recog- including the dorsal and ventral SI ligaments, the nition, diagnosis, and management, the emergency sacrotuberous ligaments, and the sacrospinous liga- physician has a critical role in minimizing and pos- ments, stabilize the pelvic ring. The integrity of sibly preventing these complications. the pelvic ring is intimately tied to the strength of these ligaments. The interosseous SI ligaments are MECHANISM OF INJURY the strongest in the body, while the pubic symphysis The major causes of pelvic fractures in adults include is the weakest joint of the pelvis and often the first motor vehicle crashes (50% to 60%), motorcycle col- to be disrupted in trauma.4,6 An intricate network of blood vessels surrounds Dr. Ghory is chief resident in the department of the pelvis. Included are the median sacral artery, the emergency medicine at NewYork-Presbyterian/Weill superior rectal artery, and the common iliac artery, Cornell Medical Center in New York City. Dr. Sharma is which divides into the external and internal iliac an attending physician and assistant director for operations in the department of emergency medicine at NewYork- arteries. The iliac arterial and venous trunks pass Presbyterian/Weill Cornell Medical Center. ventrally to the SI joints bilaterally. Disruption of 20 EMERGENCY MEDICINE | DECEMBER 2009 www.emedmag.com PELVIC FRACTURES these joints risks rupture of and hemorrhage from For instance, pelvic fractures can be associated with the associated vessels, especially the internal iliac closed head injury in up to 50% of cases and thoracic arteries. Injury to the external iliac arteries may be injury in 21% of cases.9 seen in acetabular fractures secondary to protrusion As the pelvis is more stable in pediatric patients of the femoral head into the pelvis. than in adults, a fracture in a child or adolescent The most common mechanism of bleeding in pel- implies an even stronger mechanism of injury. The vic fractures is bone edge laceration of small- and pediatric pelvis is also shallower, making the abdom- medium-sized veins. This hemorrhage is usually inal and pelvic viscera more susceptible to injury. controlled by self-tamponade as blood builds up in The rate of concomitant injuries in pediatric patients the pelvic retroperitoneal space. In 10% to 15% of with pelvic fractures ranges from 70% to 80%, with patients with an unstable pelvic fracture, the bleed- damage to the orthopedic (62%), neurologic (54%), ing is arterial, and death is secondary to arterial lac- vascular (39%), pulmonary (31%), and genitourinary erations that are not conducive to tamponade.1 The (15%) systems most common.5 superior gluteal and pudendal arteries are most com- monly involved. Patients older than 55 to 60 years CLASSIFICATION are more likely to have arterial bleeding in pelvic Although several classification schemes have been fractures than are younger patients.3,4 developed to describe the different types of pelvic Compared with older patients, pediatric patients fractures, they have limited applicability to the ED, usually experience less dramatic bleeding from pelvic where the key questions are often simple: Is there a fractures. When bleeding does occur, it usually re- fracture? If so, is it stable or unstable? Study find- sults from injury to distal solid organs. Nevertheless, ings differ concerning the most accurate predictor of 17% to 46% of pediatric patients with pelvic trauma mortality in pelvic fractures, but the major contribut- require blood transfusions.5 ing factors include the injury severity score, severity The pelvis receives its nerve supply through the of fracture, and the presence on CT of active arterial lumbar and sacral plexuses. Nerve root or peripheral bleeding requiring angiography or embolization. nerve injuries can be seen in pelvic fractures secondary to traction or pressure secondary to bony fragments Judet-Letournel Classification or hemorrhage. Sciatic nerve injury is commonly seen Elemental acetabular fractures are classified ac- with acetabular fractures. SI joint dislocation can lead cording to the Judet-Letournel scheme as posterior to lumbar root injuries and sacral fractures; in par- wall, posterior column, anterior wall, anterior column, ticular, fractures involving S1 and S2 vertebrae can and transverse acetabular fractures (Table 1).10 Com- lead to sacral root injuries. Neurologic injury can be binations of any of these seen in up to 25% of cases of sacral fractures.7 fractures are classified as >>FAST TRACK<< As the pelvis is closely associated with the geni- combined acetabular frac- Injuries to the bladder tourinary and gastrointestinal tracts, these systems tures. Ninety percent of and urethra are seen are vulnerable to injury from pelvic fractures. The acetabular fractures are in 15% to 20% of pelvic bladder and urethra are immediately posterior to the both-column, transverse, or fractures; however, signs pubic symphysis, while the rectum is located imme- posterior wall fractures.11 and symptoms may not be diately ventral to the sacrum. As a result, injuries to Acetabular fractures usually obvious immediately after the injury. the bladder and urethra are seen in 15% to 20% of occur when the acetabular pelvic fractures; however, signs and symptoms may socket is disrupted secondary to the femur being not be obvious immediately after the injury.4,8 Blad- driven backward into the hip (eg, as in a dashboard der injuries are more commonly seen in lateral com- injury in a motor vehicle collision or when the hip pression fractures, while urethral injuries can be seen is struck laterally in a pedestrian/motor vehicle ac- in both lateral and anterior compression injuries. cident). Associated hip dislocations are common. Rectal injuries are less common and are associated with urinary tract injuries and ischial fractures. Young-Burgess Classification Depending on the mechanism of the pelvic frac- Of the numerous schemes used to classify pelvic frac- ture, injuries to distant organ systems may be seen. tures that disrupt the pelvic ring, the Young-Burgess www.emedmag.com DECEMBER 2009 | EMERGENCY MEDICINE 21 PELVIC FRACTURES TABLE 1. Judet-Letournel Classification of Acetabular Fractures and Associated Injuries Fracture Mechanism Description Associated injuries Posterior wall Direct trauma to flexed Fractured acetabulum Sciatic nerve injury, hip and knee femoral fractures Posterior column Posteriorly directed force Fractured acetabulum Sciatic nerve injury, to abducted, flexed leg through obturator foramen inability to bear with ischial ring disruption weight Anterior wall Lateral force to the Fracture extends from Inability to bear greater trochanter with the anterior inferior iliac weight hip externally rotated spine to superior ramus with a disrupted ischial ring and iliopectineal line Anterior column Posterior force to knee Fracture from pubic ramus Inability to bear with hip abducted and through iliac crest with weight flexed disruption of the ischial ring and iliopectineal line Transverse Force lateral to medial Fracture extends anterior Sciatic nerve injury acetabular over greater trochanter to posterior through acetabulum with an intact
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