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Pelvic Fracture in Emergency Medicine Clinical Presentation

  • Author: C Crawford Mechem, MD, MS, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Aug 20, 2015
 

History

Basic mechanism of significant blunt trauma should prompt consideration of a pelvic fracture.

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Physical

Tenderness, laxity, or instability on palpation of the bony pelvis suggests fracture. However, while physical examination is specific for pelvic instability, it has a low sensitivity.[16] Furthermore, in the later stages of pregnancy, the pelvic ligaments become stretched, mimicking bony instability. Finally, extensive manipulation of a fractured pelvis can increase the patient's discomfort and potentially increase bleeding.

Other signs that may suggest a pelvic fracture include hematuria; a hematoma over the ipsilateral flank, inguinal ligament, proximal thigh, or in the perineum; neurovascular deficits in the lower extremities; or rectal bleeding. Digital rectal examination has a very low sensitivity for diagnosing pelvic fractures. In fact, in a 2007 study assessing the utility of routine digital rectal examinations to diagnose injury in 1401 trauma patients, the rectal examination missed 100% of the 67 pelvic fractures.[17]

Vaginal bleeding or palpable fracture line on careful bimanual examination suggests pelvic fracture in females.

Instability on hip adduction and pain on hip motion suggests an acetabular fracture, with or without an associated hip fracture.

Urethral injuries vary widely by age, with injuries to the prostatic urethra and bladder neck limited to children. Direct lacerations to the urethra occur only in boys (small prostate) and women. Signs of urethral injury in males may include a scrotal hematoma and blood at the urethral meatus.  Assessment for a high-riding or boggy prostate on digital rectal examination has been shown to be unreliable.[18]

 

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Causes

Adults with significant pelvic fracture:

  • Motor vehicle crash (50-60%)
  • Motorcycle crash (10-20%)
  • Pedestrian versus car (10-20%)
  • Falls (8-10%)
  • Crush (3-6%)

Children:

  • Pedestrian versus car (60-80%)
  • Motor vehicle crash (20-30%)
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Contributor Information and Disclosures
Author

C Crawford Mechem, MD, MS, FACEP Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Emergency Medical Services Medical Director, Philadelphia Fire Department

C Crawford Mechem, MD, MS, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Anterior-posterior (AP) compression pelvic fracture.
Vertical shear (VS) fracture pattern.
Anteroposterior (AP) compression injury as seen on an AP radiograph of the pelvis. Characteristic features of an AP compression injury include symphyseal and sacroiliac joint diastasis. In this patient, the pubic symphysis and right sacroiliac joint are widened.
Windswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The patient sustained a left lateral compression injury with internal rotation of the left hemipelvis and a characteristic sacral buckle fracture. Note the concomitant left sacroiliac joint diastasis. The lateral force vector continued across the pelvis to produce external rotation of the right hemipelvis and diastasis of the right sacroiliac joint. The combination of injuries resulted in a windswept pelvis.
 
 
 
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