Pelvic Fractures Clinical Presentation

Updated: Feb 26, 2018
  • Author: George V Russell Jr, MD; Chief Editor: William L Jaffe, MD  more...
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Presentation

Physical Examination

Because most unstable and displaced pelvic ring fractures occur as the result of high-energy mechanisms, many patients present with associated primary organ system injuries. A careful assessment of the patient must begin with an examination for immediately life-threatening injuries. Assessment should begin in an orderly fashion to avoid missing injuries.

The American College of Surgeons has popularized Advanced Trauma Life Support (ATLS), a program that provides a systematic and orderly treatment protocol for traumatized patients under the direction of a general surgeon or trauma surgeon. [24] This protocol has been used successfully at many trauma centers and is recommended by the authors.

Soft-tissue injuries

Soft-tissue injuries provide an indirect measurement of the energy sustained by the patient. Scrotal, labial, flank, and inguinal hematomas commonly accompany pelvic ring injuries and are indicative of intrapelvic hemorrhage. [25] Soft-tissue injury is observed along a continuum from superficial abrasions and lacerations, to closed internal degloving injuries, to open wounds. [26]

Lacerations of the perineum must be sought carefully during the initial physical examinations and secondary surveys. Rectal and vaginal lacerations may be overlooked because initial examinations concentrate on more obvious injuries. Rectal, vaginal, and perineal lacerations are indicative of severe injuries and indicate likely fracture contamination by urine, stool, and other environmental contaminants.

Manual palpation

Manual palpation of the pelvis should be included in assessing patients with pelvic ring injuries. Palpation must be undertaken carefully to avoid harming the patient. Manual palpation can reveal crepitus from fractures and can assist with determination of pelvic stability. Manual compression along the iliac crests provides a tactile assessment of pelvic ring stability. Contralateral push-pull examinations of the lower extremities are rarely necessary to identify instability.

Urethral injuries

Blood at the external urethral meatus is indicative of urethral disruption. Perineal and genital swelling also reflect urethral disruption. Digital rectal examination (DRE) may reveal a high-riding prostate gland in the male, which also suggests urethral disruption. Bladder disruptions occur frequently with pelvic fractures and may be intraperitoneal, extraperitoneal, or both. Gross hematuria is the most common clinical finding supporting a diagnosis of a bladder disruption. [27] Gross hematuria demands evaluation of the lower genitourinary (GU) system under the direction of a urologist.

Associated skeletal injuries

Axial and appendicular skeletal injuries are frequently associated with pelvic ring fractures. Careful examination of the spine and extremities is indicated as part of complete patient evaluation. Particular attention to the lower extremities may demonstrate limb length discrepancies associated with superior hemipelvic translations. Internal and/or external rotational deformities resulting from deformities of the pelvis may be noted by similar deformities in the lower extremities.

Associated neurovascular injuries

Injuries to the pelvic ring may cause injury to any of the neurovascular structures that traverse the pelvis. Vascular injuries are usually lacerations of venous structures. [1] Arterial injuries also occur, but much less frequently than venous injuries. [2] Despite the source of bleeding, venous or arterial, each may contribute to hemorrhage and demand emergency or urgent management.

Associated neurologic injuries

Neurologic injuries typically occur as injuries to the L5 or S1 nerve roots. [1, 28] L4 nerve root injuries also may occur with severe pelvic ring injuries. Sacral fractures frequently accompany pelvic ring fractures and may have S2-S5 sacral nerve root injuries. Lower sacral nerve root injuries may lead to bowel and bladder incontinence and sexual dysfunction. Detection of these nerve injuries is difficult acutely, but careful examination may demonstrate perineal numbness and decreased rectal tone in the acute period.

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Classification

Several classification systems have been developed to assist with injury-pattern recognition and management decisions; perhaps the best known are those described by Tile and by Burgess et al. [12, 29] Both of these classification schemes provide recommendations for management of pelvic fractures based on the function of the posterior ligamentous structures that support the pelvic ring. Others prefer to describe injuries based on the anatomic location of the pelvic ring injuries and the associated displacements and instabilities. [30]

Pennal and Tile developed a classification scheme for pelvic fractures that describes injuries to the pelvic ring on the basis of the vector of the deforming force; by this schema, these injuries may be divided into lateral compression (LC) injuries, anteroposterior compression (APC) injuries, and vertical shear injuries. [31]

Tile further modified this classification scheme to include radiographic signs of pelvic stability or instability. [12]  In the Tile classification scheme for pelvic fractures, type A injuries are rotationally and vertically stable and are subclassified as follows:

  • A1 - Avulsion fractures
  • A2 - Stable iliac wing fractures or minimally displaced pelvic ring fractures
  • A3 - Transverse sacral or coccyx fractures

Type B injuries are rotationally unstable and vertically stable and are subclassified as follows [12] :

  • B1 - Open-book injuries
  • B2 - LC injuries
  • B3 - Bilateral type B injuries

Type C injuries are rotationally unstable and vertically unstable and are subclassified as follows [12] :

  • C1 - Unilateral injury
  • C2 - Bilateral injuries in which one side is a type B injury and the contralateral side is a type C injury
  • C3 - Bilateral injury in which both sides are type C injuries

Young and Burgess further expanded Tile's classification by adding a combined mechanism category in recognition of the observation that many pelvic fractures result from a combination of vectors. Their classification divided LC and APC fractures into subgroups I, II, and III, which are based on the amount of disruption found on anteroposterior (AP), inlet, and outlet pelvic radiographs (see Workup). This classification facilitates stratification of the amount of energy imparted to the patient. [29, 11] It also has been demonstrated to be predictive of associated injury patterns on the basis of the type of pelvic ring deformity. [32]

Vertical shear fractures are characterized by vertical rami fractures or a diastasis of the symphysis pubis anteriorly and vertical displacement of the posterior pelvic ring through the sacroiliac (SI) joint, sacrum, or ilium. Combined mechanism fractures are characterized by a combination of the above-mentioned injury patterns.

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