Pelvic Fractures… a real page turner

by Jonathan Lee, MD

 

Pelvic structures are held together by the strong ligamentous connections surrounding it; this is disrupted in pelvic fractures. Keep in mind that the internal iliac vessels and the lumbosacral plexus are intimately associated with posterior pelvic ligaments.

MORTALITY RATE 15-25% for closed fractures, as much as 50% for open fractures… most commonly caused by hemorrhage. The pelvis can hold up to 3-4 liters of blood (nearly HALF your body’s blood volume!)

 

ASSESSING THE PELVIS

Inspection for ECCHYMOSIS; it can point you towards a bleeding pelvic fracture:

  • Periumbilical (Cullens Sign)
  • Flanks (Grey Turner Sign)
  • Iguinum / Perineum / Scrotum / Upper Thigh (Destot Sign)

Check for GROSS HEMATURIA – 21% of males and 8% of females.

Check the vagina and rectum to rule out OCCULT OPEN FRACTURES … if so: abx are imperative.

Apply gentle rotational force on each iliac crest

PERFORM THIS ONLY ONCE! DO NOT ‘ROCK’ THE PELVIS!

low sensitivity for detecting instability Get a bedside pelvic x-ray

 

MANAGEMENT

RESUSCITATION – CABDE (worry about those catastrophic bleeds).

Consider massive transfusion!

PRBC:FFP:Platelets ideally should be transfused 1:1:1

 

PELVIC BINDER

The purpose of a pelvic binder is to CONTROL BLEEDING. It should be centered over the GREATER TROCHANTERS. Do not place over iliac crest/abdomen. Augment with internal rotation of lower extremities and taping at ankles/knees.

 

CLASSIFICATION

The most commonly used system is the young-burgess system that organizes fractures by direction of the impact force:

  • Anterior-Posterior compression
  • Lateral compression
  • Vertical Sheering

 

So when you check your pelvis x-ray, quickly MEASURE to see if there is >2.5cm displacement of the symphysis pubis and >1cm displacement between he sacroiliac joints! This may not only point you towards disposition (surgery vs. conservative management) but also indicates to what degree of bleeding to expect. More displacement = More sheering of vessels.

Keep in mind that 80-90% of pelvic fracture bleeds are venous. Yes, they may be brisk bleeds that present to your trauma room hypotensive, but they can also be slow bleeds. So if your patient stays in your ER longer than intended, make sure you get serial H/H’s.

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