Pelvic Fracture in Emergency Medicine

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

Practice Essentials

Pelvic fracture is a disruption of the bony structures of the pelvis, including pelvic ring fractures, acetabular fractures, and avulsion fractures. Generally, pelvic fractures occur due to high-energy trauma; however, elderly patients may suffer pelvic injuries due to lower energy mechanisms.The bony pelvis consists of the ilium, ischium, and pubis, which form an anatomic ring with the sacrum. Disruption of this ring requires significant energy, often leading to multiple fractures. Because of the forces involved, pelvic fractures frequently cause injury to organs contained within the bony pelvis. In addition, trauma to extrapelvic organs is common. Pelvic fractures are often associated with severe hemorrhage due to the extensive blood supply to the region. [1, 2, 3, 4, 5, 6, 7]

Most commonly, pelvic fractures result from motor vehicle crashes, falls, and pedestrians struck by motor vehicles.  There tends to be a bimodal distribution of these injuries with younger males sustaining high-energy pelvic fractures with other associated traumatic injuries, and elderly female suffering low-energy pelvic fractures without associated injuries. [8, 9]

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. [11]  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. 

​​Anteroposterior pelvic radiography (see image below) is a basic screening test for pelvic fracture and has historically been indicated in all blunt trauma patients according to ATLS protocols. in patients who are hemodynamically stable, it may be reasonable to forego pelvic plain films and rely on CT, as it will likely not change their management or outcome. [12, 13, 14, 15]   

Anterior-posterior (AP) compression pelvic fractur Anterior-posterior (AP) compression pelvic fracture.

CT scanning (see the image below) has largely replaced plain radiographs except for screening, and it has virtually eliminated the use of auxiliary views.

Windswept pelvis (lateral compression injury) as s 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.

The pelvis should be rapidly stabilized with a sheet or commercial pelvic external stabilizer. This is very important prior to neuromuscular blockade because the muscles may be the only thing maintaining pelvic stability. When stabilizing the pelvis, be sure to place the binder around the greater trochanters to provide adequate compression.

The primary treatment of pelvic fracture is administration of  narcotic analgesics for pain.  Avoid nonsteroidal anti-inflammatory drugs until hemorrhage has been excluded. If open pelvic fracture is diagnosed or suspected, empiric antibiotics should be given within 6 hours to prevent osteomyelitis. Initial therapy should target gram-positive organisms with antibiotics such as cefazolin. [16]  If there is concern for associated perforation of the bowel or vagina, broad-spectrum antibiotic coverage against gram-negative and anaerobic pathogens should be considered. Patients with open pelvic fractures should also receive prophylaxis against tetanus. 

For related information, see Medscape's Fracture Resource Center. For excellent patient education resources, see eMedicineHealth's patient education article Total Hip Replacement.

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Pathophysiology

Pelvic fractures are most commonly described using one of two classification systems.  The Tile classification system is based on integrity of the posterior sacroiliac complex as well as stability in the rotational and vertical planes. The Young and Burgess Classification System is based on mechanism of injury: lateral compression, anterioposterior compression, vertical shear, or a combination of these forces.

Tile Classification System [17] (Open Table in a new window)

Type A Sacroiliac complex is intact.  Stable fractures of the pelvic ring that can be managed nonoperatively.
Type B Rotationally unstable, vertically stable.  Caused by external or internal rotation forces causing partial disruption of the posterior sacroiliac complex.  
Type C Rotationally and vertically unstable.  Complete disruption of the posterior sacroiliac complex.  

 

Young and Burgess Classification System [18] (Open Table in a new window)

Lateral Compression  
Grade I Sacral compression fracture on side of impact.
Grade II Sacral compression fracture with associated posterior iliac fracture on side of impact.
Grade III Type I or II plus associated contralateral sacroiliac joint injury.
Anterior-Posterior Compression  
Grade I Mild widening of the pubic symphysis with intact posterior pelvic ring ligaments and sacroiliac ligaments.
Grade II Diastasis of pubic symphysis with associated anterior sacroiliac joint widening with intact posterior sacroiliac joint ligaments.
Grade III Diastasis of pubic symphysis with complete disruption of sacroiliac joint and posterior pelvic ring ligaments.
Vertical Shear Displacement of the hemipelvis superiorly or posteriorly involving diastasis of the pubic symphysis, rami fractures, displacement of the sacroiliac joint, and/or fractures of the iliac wing or sacrum.
Combined Mechanism Because of the high-energy nature of these injuries, the mechanisms are often combined and difficult to determine and categorize.

See the images of anterior-posterior compression and vertical-sheer fractures below.

Anterior-posterior (AP) compression pelvic fractur Anterior-posterior (AP) compression pelvic fracture.

 

Vertical shear (VS) fracture pattern. Vertical shear (VS) fracture pattern.

 

A recent comparison of the Tile and Young and Burgess classification systems applied to a group of trauma patients with pelvic ring fractures showed no difference in predictive value for mortality, need for transfusion, or associated injuries. [19]   Intraobserver and interobserver variability among orthopedic surgeons asked to use these systems to classify pelvic fractures may limit their utility. [20]

Acetabular fractures most commonly involve disruption of the acetabular socket when the hip is driven backward in a motor vehicle accident. Occasionally, they occur in a pedestrian struck by a vehicle moving at a significant rate of speed.

Pelvic avulsion fractures (see the image below) occur due to indirect trauma from sudden muscular contraction causing injury to the muscular attachment on the pelvis. These most often occur in skeletally immature athletes because of the inherent weakness of the pelvic apophyses.  The three most common sites are the anterior superior iliac spine (ASIS), the anterior inferior iliac spine (AIIS), and the ischial tuberosity because of contraction of the sartorius, rectus femoris, and hamstring muscles, respectively. [21]

Pelvic apophyseal avulsion fracture of the ischial Pelvic apophyseal avulsion fracture of the ischial tuberosity due to contraction of the hamstring muscles. Courtesy of Wikipedia (https://de.wikipedia.org/wiki/Apophyse).
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Epidemiology

Pelvic fractures make up approximately 3% of all skeletal injuries. Open pelvic fractures are rare and represent only 2-4% of all pelvic fractures. [22]  Of all pelvic ring fractures, approximately 55% are stable, whereas 25% have rotational instability, and 20% have rotational and vertical instability.  Approximately 16% of patients have associated acetabular fractures. [23]

A study of a large patient database in the United States found that around 70% of patients sustaining pelvic ring fractures are female. [24] A trauma registry review from New South Wales, Australia, revealed that most patients sustaining high-energy pelvic ring fractures, such as from a motor vehicle crash, were male, whereas females predominated in low-energy injuries. [9]  Males also sustain associated genitourinary injuries more commonly than females. [25]

In the United States, a large patient database review found that the mean age of patients sustaining a pelvic ring fracture is about 65 years. The average age actually increased significantly over the 17-year study period, which may represent an increase in low-energy pelvic fractures.  [24]

 

 

 

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Prognosis

Mortality/Morbidity

An analysis of a database of more than 63,000 trauma patients showed that pelvic fracture was associated with higher mortality compared to trauma patients without pelvic fractures; however, these studies are difficult to interpret because of confounders.  Because pelvic fractures generally occur via high-energy mechanisms, these patients are more likely to suffer other associated injuries that may contribute to increased mortality. [26]

Cited mortality in patients with any type of pelvic fracture ranges from 4 to 15%. The in-hospital mortality in patients with unstable fractures in the United States is 8.3%. Mortality is 21.3% in the subset of patients with open unstable fractures. [27]

One study of pelvic fractures in children aged 16 years or younger cited a mortality of 5%, with death most commonly due to hemorrhage or multiple injuries. [28]  In hemodynamically unstable patients, pelvic hemorrhage is venous in origin in 80-90% of cases. [29]

Despite aggressive intervention, elderly patients with pelvic fractures have a worse outcome than younger patients with similar injuries. [30, 27]

Ultimately, the patient's Injury Severity Score, not the nature of the pelvic fracture, is the best predictor of mortality. Hemorrhage, either pelvic or extrapelvic, and associated severe head injury are the most common causes of early death, whereas multisystem organ failure and sepsis resulting from soft tissue infection near the fracture site are the main causes of delayed death. [31]

Patients with pelvic fractures combined with acetabular fractures have higher Injury Severity Scores and mortality rates and a greater need for transfusions than patients with either type of fracture alone. [32]

The complication rate associated with pelvic fractures is significant and is related to injury of underlying organs, bleeding, and multiorgan system failure. [33]  Because of the tremendous force necessary to cause most unstable pelvic fractures, concomitant severe injuries are common and are associated with high morbidity and mortality.

Pelvic fractures also increase the incidence of pulmonary emboli. [34]

Lower long-term quality of life based on validated questionnaires has been reported in patients with pelvic fractures following high-energy trauma. [35, 36]

 

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