eMedicine Specialties > Orthopedic Surgery > Hip

Unstable Pelvic Fractures: Workup

Author: Kenneth W Graf Jr, MD, Consulting Surgeon, Department of Orthopedic Trauma Services, Mission Hospitals
Coauthor(s): Madhav Karunakar, MD, Consulting Surgeon, Section of Orthopedic Surgery, Department of Surgery, University of Michigan Medical Center
Contributor Information and Disclosures

Updated: Jan 18, 2008

Workup

Laboratory Studies

  • Each patient observed in the ED with a pelvic fracture must receive a complete laboratory workup. This should include the following:
    • Complete blood cell count with platelets (CBCP), prothrombin time (PT), activated partial thromboplastin time (aPTT)
    • Liver function panel, electrolytes, BUN, creatinine (Cr)
    • Blood type and screen
    • Toxicology panel
    • Pregnancy test17
  • The results of these studies are particularly important before proceeding to the operating room. They give the treating physician baseline laboratory values to help direct further treatment.

Imaging Studies

  • Plain radiography: The most useful tool in the orthopedic evaluation of patients with pelvic fractures is an AP radiograph of the pelvis. This should be performed on every trauma patient observed in the ED and is part of the ED evaluation protocol. The standard AP pelvis radiograph demonstrates 90% of cases of posterior instability.
    • Stable fractures are characterized by one or more of the following: impacted vertical fractures of the sacrum; nondisplaced fractures of the posterior SI complex; and subtle fractures of the upper sacrum as evidenced by asymmetry of the sacral arcuate lines.
    • Unstable fractures are characterized by hemipelvic cephalad displacement that exceeds 0.5 cm and SI diastasis that exceeds 0.5 cm. Findings suggestive of pelvic instability include cephalad hemipelvic displacement less than 1 cm and/or a diastatic fracture of the sacrum or ilium less than 0.5 cm. These indeterminate cases may require further imaging to determine stability. Edeiken-Monroe et al18 found that standard radiographs accurately identified pelvic stability in 88% of cases.
    • A fracture of the fifth lumbar transverse process, previously described as a sign of an unstable pelvis, was found in both stable and unstable injuries and is not a reliable sign of pelvic instability.
    • If the patient is hemodynamically stable, additional radiographs can be obtained to improve the understanding of the fracture pattern. Treatment of an unstable fracture should never be delayed for additional radiographic studies.
      • The inlet pelvis radiograph is a 40-45° caudal tilt view that demonstrates AP displacement (see Image 6). It also exhibits internal rotation associated with lateral compression injuries.
      • An outlet pelvis radiograph is a 40-45° cephalad tilt view that demonstrates vertical displacement and fractures of the sacral foramina (see Image 7).
      • A lateral sacral view can help identify transverse sacral fractures.
    • All trauma patients in whom the spine cannot be clinically cleared must receive full cervicothoracolumbosacral (CTLS) spine series. All fractures or areas not visualized on the plain films must be further evaluated with a CT scan.
    • Initial evaluation also should include chest radiography to evaluate for pulmonary pathology. This includes pneumothorax, pulmonary contusion, and acute respiratory distress syndrome (ARDS). Chest radiography should also be used to identify free air in the abdomen.
  • CT scans: Each patient with polytrauma, if stable, often receives chest, abdomen, and pelvis CT scans.19
    • A dedicated 3-mm thin-slice CT scan of the pelvis can help define the anatomy of the sacrum. The scan assists in the evaluation of crescent fractures (see Image 8) and sacral fractures.
    • The chest, abdomen, and pelvis CT scans assist in the evaluation of concomitant injuries to the abdomen and chest, which are often life threatening. It identifies intra-abdominal bleeding, as well as the specific organ that is injured. If a head injury is suspected, a head CT scan is obtained. A head CT scan assists in determining severity of the injury and helps guide the surgical timing.
    • All spine fractures or areas not well visualized on plain radiographs should be visualized with a CT scan.
  • Magnetic resonance imaging (MRI) is seldom used in acute pelvic fractures.
  • Ultrasonography: Fluoroallergosorbent test (FAST) is often used as a first-line screen for intra-abdominal bleeding and fluid. It is inexpensive and can quickly provide valuable information. However, results are operator dependent.

Diagnostic Procedures

  • A supraumbilical diagnostic peritoneal lavage can be performed to evaluate for an intra-abdominal hemorrhage and a ruptured viscus. It is reported to have a positive predictive value of 98% and a negative predictive value of 97%. It should be performed through a supraumbilical incision to avoid a false-positive result secondary to pelvic hematoma. An emergency laparotomy is indicated if the initial aspirate reveals more than 5 mL of gross blood or obvious enteric contents.

More on Unstable Pelvic Fractures

Overview: Unstable Pelvic Fractures
Workup: Unstable Pelvic Fractures
Treatment: Unstable Pelvic Fractures
Follow-up: Unstable Pelvic Fractures
Multimedia: Unstable Pelvic Fractures
References
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References

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Further Reading

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Keywords

open-book fractures, Tile type B fractures, anterior-posterior compression injury, APC injury, lateral compression injury, LC injury, vertical shear injury, VS injury, combined mechanism injury, zone I sacral injury, zone II sacral injury, zone III sacral injury, pelvic fracture, fracture of the pelvis, acetabular fractures, lateral compression fractures, transverse fractures of the pubic rami, avulsion fracture, Young classification system, anterior-posterior compression fractures, anteroposterior compression fractures, pelvic ring injuries, broken pelvis, cracked pelvis, shattered pelvis, fractured hip, broken hip

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Contributor Information and Disclosures

Author

Kenneth W Graf Jr, MD, Consulting Surgeon, Department of Orthopedic Trauma Services, Mission Hospitals
Disclosure: Nothing to disclose.

Coauthor(s)

Madhav Karunakar, MD, Consulting Surgeon, Section of Orthopedic Surgery, Department of Surgery, University of Michigan Medical Center
Madhav Karunakar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and AO Foundation
Disclosure: Nothing to disclose.

Medical Editor

B Sonny Bal, MD, Associate Professor, Department of Orthopedic Surgery, University of Missouri School of Medicine
B Sonny Bal, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;
James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

William L Jaffe, MD, Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases
William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, Eastern Orthopaedic Association, and New York Academy of Medicine
Disclosure: Stryker Orthopaedics Consulting fee Speaking and teaching

 
 
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