Unstable Pelvic Fractures Clinical Presentation

Updated: Nov 19, 2018
  • Author: Kenneth W Graf, Jr, MD; Chief Editor: William L Jaffe, MD  more...
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Presentation

History

Upon admission to the emergency department (ED), treatment of a multiply injured patient with a pelvic ring injury requires a multidisciplinary approach, including the attention of specialists from general surgery and orthopedics and emergency care personnel. The initial evaluation should include the ABCs (airway, breathing, circulation) of trauma care, as described in the Advanced Trauma Life Support (ATLS) protocols.

Although the initial history is often lacking in such patients, it is vital to gather as much information as possible. Especially important to the orthopedic evaluation is the mechanism of injury. This information assists in determining the energy with which the injury has occurred, as well as in predicting the injury pattern.

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Physical Examination

Several clinical signs may help with diagnosis before radiography is performed. The Destot sign, a superficial hematoma above the inguinal ligament, in the scrotum, or in the thigh, can indicate a pelvic fracture. The examiner should look for a rotational deformity of the pelvis or lower extremities. Leg-length discrepancies may also be present with pelvic fractures. The practice of compressing and distracting the iliac wings and applying manual traction to determine stability lacks specificity and should be avoided.

Neurologic injuries are commonly overlooked. The lower extremities must undergo a thorough neurovascular examination. The prevalence of neurologic injury in pelvic fractures has been reported to be in the range of 3.5-13%.

Sacral fractures and sacroiliac (SI) disruptions have a particularly high incidence of neurologic injury. According to the Denis classification of pelvic fractures, [15]  zone I sacral fractures are associated with a 5.9% incidence of neurologic injury. Zone II injuries have a 28% neurologic injury rate, usually involving L5, S1, and S2 nerve roots. Zone III injuries have a 56% incidence of neurologic injury. Such injuries frequently involve the bowel and bladder and may also cause sexual dysfunction. [27]

All patients with sacral fractures must undergo vaginal and rectal examinations in the ED. Open pelvic fractures can communicate directly with the rectum, vagina, or skin laceration and may carry a mortality as high as 50%. Many lacerations are missed if such examinations are not performed. A urethral disruption can also be revealed as a high-riding prostate on the rectal examination. The perineal area should be examined for blood at the meatus, which is a sign of a possible urethral tear. [28]

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