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Diagnosis and Management of Pelvic Fractures

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Diagnosis and Management of Pelvic Fractures Bulletin of the NYU Hospital for Joint Diseases 2010;68(4):281-91 281 Diagnosis and Management of Pelvic Fractures Richard McCormack, M.D., Eric J. Strauss, M.D., Basil J. Alwattar, M.D., and Nirmal C. Tejwani, M.D. Abstract types of pelvic fractures “by direction of force”: lateral The diagnostic and therapeutic modalities utilized in the compression (LC), anteroposterior compression (APC), and management of pelvic ring fractures depend on patient vertical shear (VS). That these categories are still used in characteristics, mechanism of injury, and hemodynamic pelvic fracture classification systems is testimony to Pennal’s status at the time of presentation. Knowledge of the complex work. During this time-period and up until the mid-1970s, anatomy and biomechanics of pelvic stability may guide pelvic injuries generally were managed nonoperatively, us- appropriate initial management strategies. Even with the ing compression devices, plaster casts, and bed rest. Over development of specific treatment algorithms and advances time, outcome studies demonstrated that posttraumatic in both diagnostic and operative techniques, fractures of the anatomic deformities and pelvic instability correlated with pelvis continue to cause significant morbidity and mortality. persistent pain and functional limitation. The current paper reviews the diagnosis and management The poor outcomes associated with conservative man- of pelvic ring fractures, focusing on current concepts with agement of pelvic fractures spurred the development of respect to initial assessment and treatment protocols, includ- various operative treatment strategies for these injuries. ing the identification of associated injuries and emergency Expanding indications for pelvic fracture surgery coupled methods of provisional pelvic stabilization. with improved techniques and instrumentation helped reduce the morbidity and mortality associated with pelvic trauma ince the initial description of a “double vertical” in the 1970s and 1980s. During the last two decades, ad- fracture as a combination of pubic rami fractures and vances in radiographic imaging, critical care management Sa fracture of the iliac wing by French surgeon Joseph of the polytrauma patient, and minimally invasive surgical Malgaigne in his 1859 atlas of traumatology, pelvic fractures approaches, as well as the development of specific treatment have received a considerable amount of attention in the algorithms, have continued to improve the outcomes seen orthopaedic literature, having to do with their complexity in pelvic fracture patients. and associated morbidity and mortality.1 Classic anatomic and biomechanical studies in pelvic dis- Epidemiology ruption, performed during the mid-20th century by George Incidence F. Pennal,2 a Canadian surgeon, helped define the three main Fractures of the pelvic ring have been reported to comprise 2% to 8% of all skeletal injuries3-6 and are often associated Richard McCormack, M.D., is a Resident; Eric J. Strauss, M.D., is with high-energy trauma, most commonly, motor vehicle Assistant Professor, Division of Sports Medicine; Basil J. Alwattar, accidents and falls from a height. The incidence of pelvic M.D., at time of submission, was a Chief Resident; and Nirmal C. fracture appears to be increasing, secondary to increases in Tejwani, M.D., is Associate Professor, Division of Orthopaedic the number of high-speed motor vehicle accidents and the Trauma in the Department of Orthopaedic Surgery at the NYU Hospital for Joint Diseases, NYU Langone Medical Center, New number of patients surviving these accidents, due to airbags York, New York. and safer car designs. Among multiply injured patients with Correspondence: Nirmal C. Tejwani, M.D., Department of Ortho- blunt trauma, almost 20% have pelvic injuries. paedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th A classic epidemiologic assessment of pelvic fractures Street, New York, New York 10003; [email protected]. presenting to the Mayo Clinic was reported by Melton and McCormack R, Strauss EJ, Alwattar BJ, Tejwani NC. Diagnosis and management of pelvic fractures. Bull NYU Hosp Jt Dis. 2010;68(4):281-91. 282 Bulletin of the NYU Hospital for Joint Diseases 2010;68(4):281-91 colleagues.7 The overall reported incidence in this patient Mortality cohort was 37 per 100,000 person-years. Among patients 15 Mortality rates associated with pelvic fractures range from as to 25 years of age, the incidence was significantly greater low as 5% to 10% to as high as 50% to 60% in the orthopae- in males compared to females, with the majority associated dic surgery and trauma literature.9,11,14,16,19,20 This variability with severe trauma. After age 55, there was an exponential in reported mortality rates is likely related to significant increase in the incidence of pelvic fracture in both genders, differences in patient cohorts and fracture types reported in with elderly females having a reported incidence of 446 these studies. Hemodynamic instability and multiple organ fractures per 100,000 person-years. A similar incidence failure (MOF) as direct consequences of pelvic hemorrhage of 24 fractures per 100,000 person-years was reported by have been identified as the primary causes of death fol- Ragnarsson and Jacobsson8 in their review of cases present- lowing pelvic fracture. Smith and colleagues19 reported an ing to a Swedish center over a 10-year period. Once again, overall mortality rate of 21% in their review of 187 hemo- high-energy, unstable pelvic fractures were more common dynamically unstable patients with pelvic fractures. Among among younger male patients, while lower energy, stable patients who did not survive their injuries, autopsy findings fracture types were seen with increased incidence among demonstrated that the principal cause of death in 74% was elderly females. Gansslen and coworkers9 in a multicenter exsanguination, while MOF was the primary cause in 18%. study out of Germany, reported on 3260 pelvic fractures The investigators found that, while fracture pattern and treated over a 3-year period. These investigators also treatment with angiography-embolization did not correlate identified a bimodal distribution of injuries, with peaks with mortality, Injury Severity Score (ISS), Revised Trauma in frequency occurring in patients aged 15 to 30 years Score (RTS), age (greater than 60 years), and transfusion and those 50 to 70 years old. Higher-energy, unstable Tile requirement (more than 6 units in the first 24 hours) were type C fractures were more commonly seen in the younger directly correlated. Demetriades and coworkers16 reported patient population. a 16.5% mortality rate among their 1545 pelvic fracture Open pelvic fractures in which direct communication ex- patients. In their study, an ISS greater than 25 was identified ists between a skin, vaginal, or rectal wound and the fracture as the only risk factor associated with increased mortality. site have been reported to comprise 2% to 4% of all pelvic O’Sullivan and associates21 examined 174 consecutive pa- injuries.4,10,11 They are most commonly seen in young males tients with unstable pelvic fractures in an effort to identify involved in traffic accidents and range from small puncture specific risk factors for mortality. The investigators reported wounds to complete traumatic hemi-pelvectomy. Secondary an overall mortality rate of 20% and found that an ISS of to the transmission of the high-energy impact associated with more than 25, an RTS score less than 8, an age greater than open pelvic fracture, there is often disruption of the pelvic 65, systolic blood pressure under 100 mmHg, a Glasgow floor musculature, leading to the loss of the tamponade effect Coma Scale under 8, transfusion requirements of more than and persistent bleeding.5 Even with standardized treatment 10 units in the first 24 hours, and a colloid infusion of more protocols, aggressive fracture care, and advances in critical than 6 liters in the first 24 hours were all associated with care, the mortality rates associated with open pelvic fractures an increased risk of death from injury. The RTS was most remain as high as 25% to 50% in some reported series.12-15 predictive in this study, with a score less than 8 correlating with a 65% mortality rate. Associated Injury Kido and colleagues22 performed a retrospective review Secondary to the high-energy mechanisms of injury required of 102 consecutive patients with bleeding pelvic fractures to cause a pelvic fracture, these injuries are commonly as- and severe associated injury (ISS greater than or equal to 3) sociated with injuries to other body systems. Epidemiologic at their level I trauma center, to identify patient character- studies have reported that 12% to 62% of patients with pelvic istics associated with increased early mortality (within 24 fractures had additional injuries to the thorax, brain, long hours). At their institution, all patients with a pelvic fracture bones, and abdominal organs, to include the genitourinary and signs of intraperitoneal bleeding (hypotension) receive system, spine, and the peripheral nervous system.9,16,17 In a computed tomography (CT) scan with IV contrast after Gänsslen’s multicenter review, of the 312 pelvic fracture initial fluid resuscitation to evaluate for bleeding. In the patients with associated injuries, 63% had injury to the blad- study, patients diagnosed with pelvic arterial bleeding (by der or urethra, 35% had associated head injuries, 24% had extravasation of contrast) underwent
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