Pelvic Fracture in Emergency Medicine Clinical Presentation

Updated: Oct 10, 2017
  • Author: Nicholas Moore, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
  • Print
Presentation

History

Basic mechanism of significant blunt trauma should prompt consideration of a pelvic fracture.  Helpful historical features include inability to ambulate at the scene, bowel or bladder incontinence, and objective numbness or weakness of lower extremities. 

Pelvic apophyseal avulsion fractures generally occur in young athletes, and are commonly associated with sports involving rapid acceleration and deceleration, such as soccer, football, gymnastics, basketball, and baseball. [21]

Next:

Physical

In patients who are awake and alert, the presence of pelvic pain or tenderness to palpation has high sensitivity and specificity for the diagnosis of pelvic fracture: 74% and 97%, respectively. However, in patients who are not awake and alert to express pain and tenderness, physical exam is less useful.  Palpation of a pelvic deformity has a sensitivity of 30% for pelvic fractures and 55% for unstable pelvic fractures.  Palpating an unstable pelvic ring has a sensitivity of only 8%, but specificity of 99%. Thus, physical exam should not be used to rule out a pelvic fracture in unconscious patients, but it can nearly definitively rule it in. [10]  The clinical exam is useful in patients who are awake and alert, even with elevated ethanol levels, as long as their GCS is 14 or higher. [11]  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 one 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. [37]

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.

The overall incidence of genitourinary injury associated with pelvic fracture is around 4.6% and is overall more common in men. Men with pelvic fractures are 10 times more likely to sustain urethral injuries. [25] 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. [38]

Pelvic apophyseal avulsion fractures generally present with acute onset of localized pain that is exacerbated by passive or active stretching of the involved muscle.  Patients will attempt to assume a position that incurs the least tension on the affected muscle. [21]

 

Previous
Next:

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%)
Previous
Next:

Complications

Complications of pelvic fracture include the following:

  • The incidence of deep venous thrombosis is increased.

  • Continued bleeding from fracture or injury to pelvic vasculature may occur.

  • GU problems from bladder, urethral, prostate, or vaginal injuries: The incidence of urethral injuries varies by the type of pelvic fracture. Sexual dysfunction may develop.

  • Infections from disruption of bowel or urinary system may develop.

  • Chronic pelvic pain, more so if the sacroiliac joints are involved, may occur. [39]  

Previous