Pelvic Fracture in Emergency Medicine Treatment & Management

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

Prehospital Care

Address acute life-threatening conditions. Be very aware that the amount of force necessary to cause a significant pelvic fracture is likely to have caused other significant injuries.

Application of an external compression device to a grossly unstable pelvis will provide mechanical stabilization while controlling hemorrhage from the fracture site. A sheet or one of a variety of inexpensive, commercial products may be used. [45]  

Avoid excessive movement of the pelvis.

Obtain large-bore intravenous (IV) access, and administer analgesia and fluids in accordance with local protocols.

Closely monitor vital signs.

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Emergency Department Care

Treatment involves an algorithmic, multidisciplinary approach.

Investigate associated intra-abdominal and intrapelvic injuries. A FAST examination should be performed as soon as possible, as well as a chest radiograph to look for other injuries or bleeding sources, especially in the unstable patient.

Avoid excessive movement of the pelvis.

If not done by prehospital providers, 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.

In some patients, such as those with truncal obesity, internal rotation of the lower extremities and taping together the knees may be more effective than a compression binder. [46]  

In the case of unstable pelvic fractures, early application of an external fixation device by the appropriate surgical consultant should be considered.

Administer fluid replacement and analgesics as needed.

Do not place a urinary catheter until urethral injury has been ruled out or determined to be unlikely by physical examination or retrograde urethrography.

Pelvic apophyseal avulsion fractures are generally managed conservatively with rest and ice, followed by incremental protected weight-bearing with crutches until symptoms improve.  Afterwards, progression to light stretching and full weight-bearing can proceed as tolerated with eventual return to full sports participation once full strength is regained.  Surgical intervention is rarely warranted, but may be necessary for large bony fragments with more than 2 cm of displacement. [21]

Elderly patients with isolated pubic rami fractures due to pelvic insufficiency can be safely discharged if they can be cared for at home or in another facility. They will require adequate pain management to allow them to ambulate, or they should have sufficient help. If they are nonambulatory, DVT prophylaxis should be considered. [47]

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Consultations

Consult an orthopedic surgeon when a pelvic fracture is diagnosed. Hemodynamically unstable patients with unstable pelvic fractures require emergent orthopedic consultation for possible external fixation. Pelvic or retroperitoneal packing may be required for hemorrhage control. [48] .  Intra-aortic or intrailiac balloon occlusion may also have a role to control massive bleeding. [49, 50]  

Transcatheter embolization for hemorrhage control is being used with increasing frequency in patients with pelvic fractures.  If this is a consideration, an interventional radiologist should be consulted early in the patient's evaluation. [51, 52]

Consult a urologist for any suspected urethral injury.

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Medical Care

Monitor patients with pelvic fracture for signs of ongoing blood loss and signs of infection. In addition, patients should be closely observed for development of neurovascular problems in the lower extremities. For example, injury to the sacral nerves, lower lumbar nerves, and sympathetic chain may occur.

Consider deep venous thrombosis (DVT) prophylaxis in all patients, especially those with traumatic injuries.

Pain management is very important to facilitate early mobilization, thereby reducing the risk of thromboembolic disease.

Management of urethral injuries should be directed by a urologic consultation. If a urinary catheter is required prior to the urologist's arrival, a suprapubic catheter should be placed.

Transfer all patients except those with minor pelvic fractures to a trauma center.  Trauma center care is associated with decreased mortality in patients with unstable pelvic fractures or complicated acetabular fractures. [53]

Application of a pelvic circumferential compression device prior to transfer has been shown to decrease the amount of tranfusions required and length of ICU stay at the receiving hospital and is therefore recommended. [54, 55]

If possible, hemorrhage should be controlled and the pelvis stabilized prior to transfer.

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