Adult Pelvic Fractures
July 1, 2002 26 minutes read
Adult Pelvic Fractures
Authors: Matthew K. Lashutka, MD, Attending Physician, Department of Emergency Medicine, Lakewood Hospital, Lakewood, OH; David Bahner, MD, Assistant Professor, Department of Emergency Medicine, The Ohio State University, Columbus; Howard Werman, MD, Associate Professor, Department of Emergency Medicine, The Ohio State University, Columbus.
Peer Reviewer: Andrew D. Perron, MD, Assistant Professor of Emergency Medicine and Orthopedic Surgery, Department of Emergency Medicine, University of Virginia Health System, Charlottesville.
Acute pelvic fractures are potentially lethal injuries, even in the care of highly skilled physicians with modern diagnostic techniques and therapies at their disposal. To ensure the appropriate treatment of a patient who has suffered an acute pelvic fracture, it is essential for the practicing physician to understand the functional anatomy of the pelvis and perineum and the biomechanical mechanisms resulting in the various types of fractures. It also is imperative that any patient suspected of having suffered an acute pelvic fracture undergo early resuscitation in the field and continued aggressive evaluation and management of his injuries once he arrives at an appropriate trauma center. The authors review the anatomy of the pelvis, typical mechanisms of injury, associated injuries, and current management strategies.— The Editor
Epidemiology
Pelvic fractures represent 3% of all bony fractures presenting to emergency departments (EDs) in the United States.1 Single pubic rami and avulsion fractures are the most common. The typical patient with such a fracture is a young male in the second or third decade of life; 50% of all pelvic fractures result from motor vehicle accidents (MVAs).2 Motorcycle crashes and pedestrian accidents each account for approximately 15% of bony injuries to the pelvis, with falls (10%) and crush injuries (5%) comprising the remainder of the traumatic mechanisms of injury.2-4 These figures have remained constant during the last three decades.
Pelvic fractures rank as the third most commonly seen injury in MVA-related deaths.5 During the 1980s, the death rate due to pelvic fracture was reported to be 6-10%.3,5-7 However, in patients with open fractures, the death rate rises to 30%, while in patients who are hypotensive, the death rate approaches 50%.4,8 Pelvic hemorrhage is the direct cause of death in fewer than half of patients with pelvic fractures who die. The primary causes of death in patients suffering a pelvic fracture are, in descending order, associated injuries secondary to the trauma, retroperitoneal hemorrhage, and secondary infection from disruption of bowel and urinary systems.8
Anatomy
The pelvis is composed of two innominate bones and the sacrum. The innominate bones consist of the ilium, ischium, and the pubis. These bony structures themselves have no inherent stability. It is only through the network of ligaments, musculature, and other soft tissues of the pelvic area that the pelvis attains sufficient strength to support the forces transmitted through it during activity and to provide protection to the lower urinary tract, portions of the gastrointestinal tract, the vascular and nervous structures contained in the pelvis, and the uterus and vagina in females. It is essential for the physician caring for patients who have suffered injury to the pelvis and pelvic area to have a basic understanding of the anatomical structures and support system of the pelvis to identify injury patterns and patients at risk for injury.
The stability of the pelvis can be divided into anterior and posterior stability. The anterior stability contributes 40% of the strength of the pelvis, while 60% of the pelvis’ strength is derived from the posterior stabilizing structures.9-11 It is interesting to note that the pelvis will remain stable if completely disrupted anteriorly as long as the posterior support is not disturbed.
The structures comprising the anterior support of the pelvis are the symphysis pubis and the pubic rami. The symphysis pubis is a cartilaginous joint between the two pubic bones. The articular surfaces are covered by a layer of hyaline cartilage and are connected together by a fibrocartilaginous disc. The disc has a small cavity in the midline. The joint is surrounded by the anterior and posterior symphyseal ligaments, which extend from one pubic bone to another. Almost no movement is possible at this joint.
The posterior support of the pelvis is composed of two separate systems, the sacroiliac complex and the pelvic floor.11 The sacroiliac complex consists of the sacroiliac ligaments and the iliolumbar ligaments. (See Figure 1.) This complex also is referred to as the posterior tension band of the pelvis. These sacroiliac ligaments join the posterior superior iliac spines to the sacrum, creating a mechanical system very similar to a suspension bridge.11 In this system, the interosseous ligaments act as the cables, the posterior superior iliac spines as the pillars, and the sacrum as the bridge. (See Figure 2.) A major tension-band effect surrounding the posterior pelvis thus is generated. The iliolumbar ligaments enhance the suspension and tension forces placed on the sacrum by joining the transverse processes of L5 (5th lumbar vertebra) to the iliac crest. The entire effect of this complex prevents anterior displacement of the sacrum and posterior opening of the pelvis.
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The other component of the posterior stability of the pelvis is the pelvic floor. The pelvic floor is composed of the sacrospinous ligaments, the sacrotuberous ligaments, and the muscle layers of the pelvic diaphragm and its investing fascial layers. (See Figure 3.) The sacrospinous ligament is triangular in shape and very strong. Its apex is attached to the ischial spine, while its base connects to the lateral portion of the sacrum and coccyx. The sacrotuberous ligament, also very strong, attaches to the lateral part of the sacrum and coccyx, joining at this point with the sacroiliac complex and extending to the ischial tuberosity. The sacrospinous ligament resists external rotation, while the sacrotuberous ligament resists rotational forces and vertical shearing forces. When these two ligamentous structures are combined, the lower end of the sacrum and coccyx cannot be rotated upward at the sacroiliac joint by the weight of the body during ambulation. Finally, the multiple muscle layers and the investing fascia of the pelvic diaphragm limit both rotation and opening of the posterior pelvis.
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Since 20% of all pelvic fractures involve the acetabulum, it is an essential structure for the practicing physician to understand.12,13 The acetabulum is the socket portion of the ball-and-socket hip joint, and is composed of the three portions of the innominate bone as they fuse together. (See Figure 4.) The acetabulum is horseshoe-shaped and is deficient inferiorly at the acetabular notch. It is divided anatomically into three columns—the anterior superior, the anterior inferior, and the posterior column. The anterior superior column is composed of the ilium and is the chief weight-bearing portion of the pelvis. The pubis comprises the anterior inferior column of the acetabulum, which is thin and easily fractured. The pubis also comprises the majority of the quandrangular plate, the most medial aspect of the acetabulum. The posterior column is composed chiefly of the ischium, which is very thick and strong. Even with these mechanical advantages, the posterior column is the portion of the acetabulum most often fractured.1,9
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Finally, it must be remembered that the pelvis is a highly vascular structure and contains a number of organ systems. The most commonly injured arteries are the superior gluteal and internal pudendal arteries, but venous hemorrhage remains more common.1,14-17 The pelvis also contains the lumbar and sacral nerve plexuses, the lower urinary tract, the sigmoid colon, portions of the descending colon, the rectum, the anus, and the uterus and vagina in females. All of these structures are susceptible to injury when the pelvis is fractured, and these systems must be examined thoroughly and evaluated for possible injury.
History
The evaluation of a patient with a pelvic fracture begins with a careful history that is obtained in the context of Advanced Trauma Life Support (ATLS) guidelines, as published by the American College of Surgeons Committee on Trauma.18 The clinician should have a high suspicion for the presence of a pelvic fracture in all patients presenting with serious or multiple trauma.
It is essential that the mechanism of injury be determined as accurately as possible, as this will help the astute clinician predict the type of fracture and associated complications. This information ideally is obtained from the patient; however, the information provided by prehospital providers and witnesses may be the only history obtainable and often proves invaluable. The physician should begin collecting information from the report of prehospital personnel while in transport and on arrival in the trauma bay. This history then is enhanced further by the collection of an AMPLE history (allergies, medications currently used, past medical history and pregnancy, last meal, and events/environment related to the injury) during the secondary survey after resuscitation has begun. The patient also should be questioned specifically for bladder sensation, last defecation and urination, last menses, and specific areas of pain.19
Physical Exam
The physical exam of the patient with a pelvic fracture also is performed as outlined by the ATLS guidelines. The ABCs (airway, breathing, circulation) of physical exam, resuscitation, and therapy must be followed in all patients presenting with acute fractures of the pelvis, because the signs and symptoms of an injury to the pelvis can vary from localized pain and tenderness to gross instability and shock.
The physician may find many signs of pelvic fracture on inspection only. The presence of Destot’s sign should be sought. Destot’s sign is the presence of a hematoma above the inguinal ligament or over the scrotum. A Grey-Turner sign (flank ecchymosis secondary to retroperitoneal hemorrhage) also may be found. The presence of perineal edema, ecchymosis, lacerations, or blood at the urethral meatus also must be noted. These indicate possible open fracture and/or urologic injury.
On physical exam, any localized pain and tenderness must be sought. The pelvis also must be tested for instability, but this testing should be performed only once.18 To test for instability, the examiner should apply lateral to medial compression along the iliac crests then perform anterior-posterior compression along the symphysis pubis to the iliac crests. It cannot be over-emphasized that testing for instability should be performed only once, because this testing has the potential to dislodge clots that already have caused tamponade to injured vessels, resulting in further hemorrhage.
A careful rectal exam also should be performed. Special attention should be given to rectal tone, the presence of rectal bleeding, the position of the prostate, and Earle’s sign (the presence of a bony prominence, palpable hematoma, or tender fracture line) on rectal exam. Diminished rectal tone could signify the presence of a pelvic fracture with resultant lumbo-sacral plexus injury. Rectal bleeding can signify a hidden open fracture of the pelvis. A high-riding or boggy prostate is significant for urologic injury with the possibility of an associated injury to the pelvis.
All female patients should be assessed for the possibility of vaginal tears, and physical exam and laboratory determination should be used to assess for pregnancy. Palpation for a gravid uterus must be performed. Signs and symptoms of uterine rupture also should be sought. In addition, the presence of vaginal bleeding must be noted, and a bimanual exam should be performed. The possibility of a hidden open fracture of the pelvis is again possible when a vaginal injury is present.
Finally, a careful examination of the lower extremities should be performed. Distal pulses must be assured, neurologic integrity tested, and range of motion testing of the hip joints performed. The presence of internal and external rotation deformity at the hip joint with associated shortening of the lower extremities also should be noted. An acute pelvic fracture can result in neurovascular compromise of the lower extremities. Also, acute dislocation of the hip with associated acetabular fracture must be recognized and acutely reduced to decrease the incidence of avascular necrosis of the femoral head.
Diagnostic Adjuncts
The care of the trauma patient is a systematic approach to diagnosis and prompt treatment of life-threatening injuries. As part of the multi-system approach to the trauma patient, appropriate laboratory evaluation should be ordered, depending on the clinical setting. Such laboratory evaluation could include a complete blood count, type and cross-matching for blood products, urinalysis, serial hemoglobin measurements, pregnancy testing, and appropriate toxicologic screens. As with all trauma patients, laboratory evaluations should be guided by the clinical situation.
Pelvic fractures have a high associated mortality rate and require urgent diagnosis and therapy. In addition, commonly associated injuries such as hemorrhage, urethral injury, and bladder rupture must be recognized.
If, after a careful physical exam, a urethral injury is suspected, a retrograde urethrogram should be performed. The most common site of urethral injury is the membranous urethra. If gross hematuria is found, a retrograde cystogram should be obtained. Keep in mind that gross hematuria also can result from injuries to the urologic system that are proximal to the bladder (such as a renal contusion or laceration which would require a computed tomography [CT] scan to diagnose). Any injury noted on these diagnostic tests should prompt urgent urology consultation.
Radiologic Evaluation
Most fractures of the pelvis can be seen on plain radiographs if the clinician has a knowledge of the basic bony structures of the pelvis. Familiarity with standardized radiographs will enable the physician to interpret subtle fractures that will need further evaluation and urgent orthopedic referral. (See Figure 5.) These lines are the iliopectineal (arcuate) line, the ilioischial line, the roentgenographic U or teardrop, the anterior lip/rim, and the posterior lip/rim.
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The iliopectineal line is the most medial border of the pelvic rim. Disruption of this line indicates fracture of the anterior column of the acetabulum. The ilioischial line begins at the sacroiliac joint posteriorly, runs along the medial border of the ischium to the ischial tuberosity, then down to the distal juncture of the ischium with the pubic ramus. This line delineates the posterior column of the acetabulum, and disruption indicates fracture. The roentgenographic U, or teardrop, is located just medial to the femoral head. It is formed by the roof of the acetabulum and the ilioischial line. The roentgenographic U defines the quadrangular plate, the most medial aspect of the acetabulum, and disruption means penetration into the pelvic cavity. Finally, the anterior and posterior lips/rims define the lateral borders of the acetabulum. The anterior lip always is more medial, with disruption again indicating fracture.20
The anteroposterior (AP) pelvis x-ray can confirm the diagnosis of 90% of fractures to the pelvis. Inlet and outlet views of the pelvis also may be obtained to demonstrate anterior-posterior and inferior-superior displacement, respectively. A Judet view is very useful in evaluation of the acetabulum, as it is a true AP view of the acetabulum. With a basic understanding of the anatomy of the pelvis and the radiologic lines of the pelvis mentioned previously, most fractures can be identified. Not every trauma patient will require radiologic evaluation of the pelvis, however. Retrospective studies performed in the last decade demonstrate that if a patient has a normal physical exam and a Glascow Coma Score (GCS) greater than 13, no radiologic evaluation is necessary.21-23 In addition, one research group recently concluded that trauma patients presenting with a normal physical exam, GCS greater than 13, and a blood alcohol level greater than 100 mg/dL, did not require radiologic evaluation to exclude fracture to the pelvis.24
CT scan also has become very useful in the evaluation of bony injury to the pelvis. It is superior to plain radiographs in the evaluation of sacral or acetabular fractures. CT scan also will identify intra-abdominal injury, retroperitoneal and ongoing hemorrhage, and confirms hip dislocation.16,25-27 CT scan, along with all plain films, should be ordered according to the clinical situation, but should be considered strongly when a sacral or acetabular fracture is present.
Classification of Pelvic Fractures
There have been many classification systems derived to group and organize fractures of the pelvis. The two major systems are those proposed by Tile and Young.9,27 The Tile classification system has the advantage of including stable single bone and avulsion injuries and predicting the need for operative repair. (See Table 1.) However, it does not predict the incidence of associated injury or mortality. The Young system is more useful for both the surgeon and the non-surgeon. (See Table 2.) The Young classification system groups pelvic fractures based on mechanism of injury. Thus, the mechanism of injury provided by the patient or witnesses will lead the clinician to look for certain fracture patterns. In addition, the Young system predicts the chance of associated injury (severe hemorrhage, bladder rupture, and urethral injury) and will give an estimate of the associated mortality. (See Table 3.) The disadvantage of the Young system is that single bone injuries, avulsion injuries, and fractures of the acetabulum are not included.
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The Young system will be presented in the following section. A discussion of single bone and avulsion injuries to the pelvis will follow, and finally, fractures of the acetabulum will be discussed.
The Young Classification
The classification system by Young differentiates pelvic fractures based on the causative force and mechanism of injury. It is a classification system of pelvic fractures that result in disruption of the integrity of the pelvic ring. Complication rates and mortality rates also are correlated with the type of fracture, making the Young system clinically relevant and useful. There are three patterns of fractures identified in the Young system and named by the mechanism of injury. The patterns are lateral compression (LC), anteroposterior compression (APC), and vertical shear (VS). Each of these fractures makes up one category in the Young system, with a combined mechanism (CM) of injury patterns being the last category. (See Tables 2 and 3.) Figures 6-12 (click here to see figures) provide a schematic representation of each of the types of fractures in the Young system. LC fractures comprise nearly 50% of injury patterns, APC approximately 25%, VS comprise 5%, and CM injuries are seen in 20-25%.20 Mortality rates also have been correlated with the type of fracture pattern.28 (See Table 3.) Severe APC and VS fractures have a mortality of approximately 25%, while severe LC fractures have a 13% associated mortality. (See Table 3.)
The clinical utility of the Young system stems from the fact that the different injury types (and associated complications and mortality) can be predicted from history alone. However, the mechanism of injury, and thus the Young classification, can be derived radiographically. The first clue on radiograph is the alignment of the pubic rami. Horizontal fractures suggest LC injury, while APC injury typically results in a vertical fracture. Second, the clinician should determine the direction of a hip dislocation, if present. LC injury will produce a central hip dislocation, while posterior hip dislocations are seen in APC injuries. Third, if there is crush injury to the sacrum with associated sacroiliac joint diastasis, then the injury was due to LC. Finally, VS injuries produce vertical displacement of fracture fragments. By combining these hints with a working knowledge of the fracture patterns in the Young system as presented in Table 2, the astute clinician, working with radiograph alone, can determine the Young classification for a patient with a pelvic fracture and, thus, predict the associated complication and mortality rates.
Treatment of Pelvic Fractures Resulting in Ring Disruption
The treatment of a patient with a pelvic fracture should be in the context of a multi-system approach as prescribed by ATLS guidelines. Aggressive resuscitation is indicated in all patients suspected of incurring a fracture of the pelvis. The Young classification also suggests the typical definitive treatment required for a fracture of the pelvis. LC-I and APC-I injuries usually require a few days of bed rest followed by protected weight-bearing. LC-II fractures usually require open reduction and internal fixation (ORIF) with early mobilization; however, these fractures alternatively may be managed with 3-6 weeks of bed rest followed by progressive weight-bearing. LC-III, APC-II and III, and VS require ORIF within 5-14 days of injury.29 It is clear, however, that early ORIF with subsequent mobilization of the patient reduces morbidity and mortality.8 All open fractures, either due to rectal or vaginal tear, should be treated with cefazolin and gentamicin.
The management of the unstable patient with an unstable pelvic fracture remains controversial. Clearly, early anterior stabilization should be considered in hemodynamically unstable patients with unstable pelvic fractures, as stabilization decreases the pelvic volume and results in tamponade of hemorrhage.25,30 This may be accomplished temporarily in the ED by wrapping a sheet around the fractured pelvis. However, there are no clinical studies showing a clear indication for any of the current means of stabilization: military antishock trousers (MAST), external fixator, and early ORIF. There also are no studies to date showing a clear indication for angiographic embolization of the pelvic vasculature, a direct means of hemorrhage control.
MAST trousers are the first means of stabilization of unstable pelvic fractures in the hemodynamically unstable patient. The application of MAST trousers has been shown to stabilize pelvic fractures and decrease bleeding.31 However, there is an increased incidence of lower extremity compartment syndrome with MAST trousers.31 In addition, the application of the trousers limits exam of the lower abdomen, and data on patient outcomes when this therapy is employed currently is non-existent. MAST trousers still are indicated in ATLS guidelines for the hemodynamically unstable patient with an unstable pelvic fracture and, thus, should be employed if needed.
Application of external fixation and angiographic embolization are the main tools in the acute setting for stabilization and hemorrhage control in the patient with an unstable pelvic fracture and unstable vital signs. Pelvic fractures that are most amenable to anterior external fixation are those that are anteriorly unstable but have an intact posterior support system. The Young fractures that have the potential to benefit from anterior stabilization are LC-III, APC II and III, and VS patterns. External fixation should be considered in all of these patients; however, there is no prospective randomized trial to prove that acute external fixation decreases morbidity and mortality in such patients.32 The literature has similar evidence for the use of angiographic embolization. One group reported 100% success in controlling pelvic hemorrhage using angiographic embolization in a series of 15 patients with unstable pelvic fractures and unstable vital signs in 1997.17 There have been many similar reports in the literature since 1997. In a 2000 clinical study of a series of 17 patients, 100% success was reported for hemorrhage control with an 82.4% survival rate.33 However, there still has been no prospective, randomized trial showing embolization improves patient outcomes.
With a lack of support in the literature for clear indications for acute external fixation and embolization, the clinician is left without sound evidence about how to approach the patient with an unstable pelvic fracture and unstable vital signs. However, a retrospective study published in 2000 demonstrates a logical approach. This group reported on 75 cases of patients with unstable vital signs with unstable pelvic fractures. A base excess of less than or equal to -5.0, a systolic blood pressure less than 90 mmHg on leaving the trauma bay, or higher injury severity score (ISS) predicted worse outcome in patients. All 75 cases had early anterior stabilization (external fixator or ORIF within 24 hours), 21 had angiographic embolization, and seven died (mortality rate 9.3%).34 The mortality rate of the patients in this series was clearly less than the 50% traditionally given in the literature for hypotensive patients with pelvic fractures. This success was achieved by the early involvement of orthopedic surgeons, interventional radiologists, and a comprehensive trauma team in the ED to coordinate resuscitation and stabilization using base excess, blood pressure, and ISS as guides for adequate resuscitation. In choosing an approach, the physician also must take into account the expertise of the orthopedic surgeons and interventional radiologists available at his or her institution.
Transfer of Patients
It is essential for every emergency physician to understand the capabilities and limitations of his/her institution for providing definitive care of the multiple trauma patient. When the capabilities of an institution are exceeded, it is essential to provide prompt transfer, as patient outcome is related directly to time from injury to properly delivered definitive care.18 All unstable pelvic-ring disruptions, pelvic-ring disruptions with evidence of shock or continued hemorrhage, or open injury should be transferred promptly.18 However, LC-I and APC-I injuries typically can be managed at a non-trauma center if orthopedic support is available. Patients who are being transferred should have either blood available or transfusion in progress and MAST trousers in place, either deflated or with all three compartments inflated, depending on the hemodynamic status of the patient. Consideration for transfer also should be made for adults older than 55 years, pregnant women, and children.
Single Bone and Avulsion Injuries
Avulsion injuries are some of the most common fractures to the pelvis. These injuries typically are seen in adolescents, but are not uncommon in adults, and are due to forced contraction of the muscle attaching to the avulsed fragment of bone. The most common avulsion injuries are to the anterior superior iliac spine (ASIS), the ischial tuberosity, and the anterior inferior iliac spine (AIIS). An avulsion injury to the ASIS will be seen after forced contraction of the sartorius muscle. The patient will present with tenderness over the ASIS and with pain on flexion and abduction of the thigh. Forceful contraction of the hamstring musculature can lead to an avulsion of the ischial tuberosity, and these patients will have pain on thigh flexion with knee extension. The tuberosity will be tender on rectal exam. Finally, a sudden contraction of the rectus femoris can lead to the avulsion of the AIIS. A patient with an avulsion of the AIIS either will have pain on flexion of the hip or be unable to flex the hip. A careful clinical history eliciting activation of the involved muscle(s), a thorough physical exam, and an AP pelvis radiograph will define the diagnosis of an avulsion injury. Treatment consists of rest, crutches, and a course of non-steroidal anti-inflammatory drugs (NSAIDs), with consideration of opiate therapy. Orthopedic follow-up should be arranged for 7-14 days later.
Single bone fractures also are very common injuries to the pelvis. The four fractures that present most frequently are single ramus fractures, sacral fractures, coccyx fractures, and iliac wing fractures. A fracture of a single ramus typically is seen after a fall with direct trauma to the area. This injury results in localized pain and tenderness, and the patient is unable to ambulate. The fracture usually is apparent on an AP pelvis radiograph. Treatment consists of rest, crutches, NSAIDs, and consideration of opiate therapy. Typical follow-up is in 1-2 weeks with an orthopedic surgeon.
Sacral fractures are due to direct trauma or forced flexion. Patients with a sacral fracture will present with perianal pain, buttock pain, and/or local ecchymosis. These injuries also have the potential to have devastating neurologic sequelae. Patients may have decreased anal sphincter tone, loss of perianal sensation, cauda equina syndrome, or any lumbrosacral plexopathy or radiculopathy. Up to 22% of patients with sacral fractures will have neurologic deficit.35 It is essential for the clinician to perform a detailed neurologic exam to screen for these possible injuries. One researcher grouped sacral fractures into three categories.36 Type A fractures are vertically oriented, transforaminal, and associated with another fracture to the pelvis. Type A makes up 90% of sacral fractures. Type B fractures are transverse fractures below the S2 level, while type C fractures are transverse and occur at or above S2. Type B typically are due to direct trauma, while type C usually are due to forced flexion when the patient is in a seated position. Type C has a very high incidence of neurologic deficit and often is associated with lumbar transverse process fractures.36,37 Other sources have reported that the incidence of neurologic injury climbs when the injury occurs at or above the S4 level.21 Diagnosis is confirmed with AP pelvis radiograph or with CT scan. CT has been shown to be superior to plain films for evaluation of the sacrum.16,25,26 The disposition of the patient with a sacral fracture depends on neurologic status. If there is no neurologic deficit, then rest, analgesia, and follow-up with an orthopedic surgeon in one week is prescribed. However, if the patient does present with neurologic compromise, emergent orthopedic consultation and admission are warranted.
Fractures of the coccyx occur due to direct trauma, most commonly falls. The patient will present complaining of pain with sitting, standing, or when having a bowel movement. On physical exam, localized tenderness and ecchymosis will be observed over the coccyx and lower sacrum. The diagnosis can be made on clinical grounds with no radiologic evaluation necessary. Therapy consists of stool softeners, a donut-ring cushion, analgesia, and follow-up with the patient’s primary care physician or orthopedic referral in 1-2 weeks.
Iliac wing fractures, or Duverney’s fractures, also are due to direct trauma. The patient may have localized pain, swelling, and tenderness. The patient also may have a waddling gait, known as Trendelenburg’s sign. In 30% of cases of iliac wing fractures, there will be an associated fracture of the acetabulum.38 The patient also may have abdominal rigidity, or may develop an ileus. Diagnosis of the fracture again is confirmed with an AP pelvis radiograph. If the patient does not have abdominal rigidity, he or she may be discharged safely with rest, analgesia, and orthopedic follow-up in one week. The patient must be given careful return instructions concerning the signs and symptoms of ileus. The patient should be admitted if there is abdominal rigidity on initial exam, and the patient should undergo appropriate diagnostic studies (CT scan, ultrasound) to determine if there is an associated intra-abdominal injury.
Fractures of the Acetabulum
Fractures of the acetabulum make up 20% of all fractures of the pelvis. Up to 13% will have an associated sciatic nerve injury.12,13 The mechanism of injury is most commonly an MVA; however, motorcycle accidents also cause a significant number of injuries to the acetabulum. There are four types of acetabular fractures: posterior rim, transverse, iliopubic column, and ilioischial column.
Posterior rim fractures are the most commonly seen acetabular fractures. This injury pattern is seen when a posterior force is directed through the femur when the knee and hip are in a flexed position. This is seen very commonly in MVAs when the knee meets the dashboard in a head-on collision. A posterior dislocation of the hip often is seen with this injury to the acetabulum. If the patient has a dislocation, the lower extremity on the affected side will be shortened and internally rotated. On radiograph, the posterior line of the acetabulum will be disrupted. Therapy consists of analgesia, a CT scan, and orthopedic consult and admission. If a dislocation of the hip is present, it must be reduced within six hours to reduce the incidence of avascular necrosis of the femoral head. A careful neurovascular exam of the affected lower extremity must be documented before and after any attempt at reduction, as neurovascular structures can become entrapped in the joint after reduction, which would be an indication for emergent surgical intervention. After adequate analgesia and sedation, the Allis maneuver or Stimson maneuver may be used for reduction.
The Allis maneuver, the most widely performed method, involves having an assistant bilaterally stabilize the anterior superior iliac spines while the patient is supine. First, the knee is flexed, then the hip is flexed with traction placed below the knee pulling upward. The leg is internally and externally rotated until the femoral head is rearticulated with the acetabulum. The Stimson maneuver has the patient in the prone position and is the least traumatic of the closed reductions. An assistant provides pressure on the lower back for stability while the injured leg is allowed to hang from the side of the bed with the knee and hip fully flexed. Traction is applied along with the force of gravity behind the knee, while internal and external rotation is applied to pop the femoral head back into place. This technique is contraindicated in the setting of thoracoabdominal trauma or a difficult airway.39 Post-reduction radiographs should be obtained.
Transverse fractures of the acetabulum occur when a flexed hip receives a force directed lateral to medial on the greater trochanter. This injury often is seen when the patient is involved in a "T-bone" MVA on the patient’s side of the car. Central hip dislocation can be seen in these fractures. The roentgenographic U often is disrupted on plain radiograph. Treatment consists of adequate analgesia, and the patient should undergo CT scan to further define the fracture. Orthopedic consultation and admission is warranted.
Iliopubic column fractures of the acetabulum are due to a lateral to medial force directed on the greater trochanter when the hip is flexed and externally rotated. This is seen most frequently in motorcycle injuries. The iliopectineal line and anterior rim on plain radiograph are disrupted, and the roentgengraphic U is displaced medially. Central or anterior dislocation of the hip is possible in this injury. The patient should receive adequate analgesia and undergo CT scan if possible. Again orthopedic consultation and admission is necessary.
Ilioischial column fractures occur when a posteriorly directed force is applied to the knee with the thigh abducted and flexed. This is the most common acetabular fracture to have an associated sciatic nerve injury, which occurs in 25-30% of cases.13 On plain radiograph, the ilioischial line is disrupted, and the femoral head may be displaced medially. Therapy again is directed toward adequate analgesia. The patient should have a CT scan if possible, and orthopedic consultation and admission is warranted.
Conclusion
Acute pelvic fractures are potentially lethal, even in the care of highly skilled physicians. To ensure the appropriate treatment of patients who have suffered acute pelvic fractures, it is essential for the practicing physician to understand basic pelvic anatomy and the biomechanical mechanisms that result in the various types of fractures. With this foundation, the physician can then classify the fracture, predict and diagnose associated complications, and estimate mortality. It is imperative that all patients with suspected pelvic fracture undergo early resuscitation. Prompt multi-system trauma support and orthopedic care are essential for stabilization and quality management. A comprehensive trauma team of trauma surgeons and orthopedic surgeons working collaboratively in the ED can optimize outcome.
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