tr7

8/11/2019 tr7

1/17

Pelvic fractures 381

Classification and causes 382

Minor pelvic fractures 382

Major pelvic fractures 384

Complications 392

Chapter 7

Pelvic fractures

8/11/2019 tr7

2/17

382

Classification and causes

Classification

Minor fractures of the pelvic ring

Major fractures of the pelvic ring

Anterior-posterior forcefractures

Vertical forcefractures

Diastasisof the pelvis

Combined displacement.

Acetabular fractures

Common causesThe forces responsible may be divided into 3 main types:

Antero-posterior force This may occur when a pedestrian

is struck head-on by a car or in any crush injury in which an

antero-posterior compressionforce is applied to thepelvis.

This may result inpubic rami fracturesand damage to the

bladderandurethra.

Vertical force Often results from a fall froma height.

The pubic rami may be fractured and the hemipelvis may be

displaced superiorly. These areunstable fractureswhich may

potentially damagepelvic viscera,and produce

neurovascular complicationsincluding stretching of the

sciatic nerve. Book fractures Thepelvis is opened outand may be

associated with a diastasis of the sacro-iliac joint and a

retropelvic massive haemorrhage.

Combined displacement This may be caused by a variety

of forces including lateral compression.

Minor pelvic fracturesTypes of fracture

These are fractures in which thepelvic ringis stillstable.

They may vary from an isolated chipoff the rim of the pelvis

to asingle crackthrough thepelvic ringand fractures of the

pubic ramuswithminimal displacement.

Investigations

Springing the pelvis There isminimalor no painon

springing the pelvis.

8/11/2019 tr7

3/17


Pelvic fractures

Common causes

Antero-posterior force

Bladder damage

Vertical force

Sciatic nerve damage

Diastasis of the pelvis Massive haemorrhage

Examination

Assess the stability of

the pelvic ring by gently

springing the pelvis

Single fracture of

pelvic ringPubic rami fracture

Minor Fractures

Huckstep 1999

Huckstep 1999

Huckstep 1999

Huckstep 1999

Huckstep 1999

Huckstep 1999

8/11/2019 tr7

4/17

384

Complications As thepelvic ringis intact there should

be no damage to themajor intrapelvic structures such as the

bladder, urethra, sciatic nerves and major blood vessels.

X-ray This will show a fracture which has not disturbed

thestabilityof thepelvicring.

Treatment

A pelvic fracture may be muchmore extensivethan can be

seen onX-ray, as the sacro-iliacjoint may have been damaged.

Admission The patient should be admitted to hospital

and nursed on a soft mattress, which is in turn placed on

fracture boards.

Mobilisation The patient can often be mobilised and

discharged (with or without crutches) from 1 to 3 weeks after

admission and often earlier,provided the sacro-iliacjoints

are notdamaged.

Exercises Leg exercisesand early walkingshould be

encouraged.

Deep vein thrombosis Prophylactic anticoagulants

(subcutaneous low molecular weightheparin) are indicatedif the patient isconfined to bed.

Major pelvic fractures

Types of fracture

These are fractures in which there is disruptionof thepelvic

ringinmore than one place, resulting indisplacementof part

of thepelvis. They can be classified into 3 main groups

according to their cause, as listed above anterior-posterior,

verticalforceanddiastasis force.

Combined fractures In severe injuries all 3 types of

fractures can be combined. This may lead to diastasis of the

pelvis and disruption of the sacro-iliacjoints,with severe

bleeding and upward displacementof the pelvis, withdamage to the sciatic nerve. Thebladder and urethra may be

injuredby backward displacement of thepubic rami.

Fractures of the acetabulum These are discussed

separately under Dislocation of the hip (see page 402).

Complications

Complications are often more important than the displacement

itself and must be looked for.

Hypovolaemicshock This results from considerable

retropelvic bleeding.(see page 397).

Bladderand urethral injuries.

Sciatic nerve damage.

8/11/2019 tr7

5/17



Classification and complications

Anterior-posterior force:

pubic rami are displaced

posteriorly

Bladder and urethral

damage

Vertical force: hemipelvis

is shifted superiorly

Sciatic nerve damage

Diastasis or book

fracture: pelvis is

opened out, at

the pubic symphysis

Retropelvic haemorrhageHuckstep 1999

Huckstep 1999

Huckstep 1999

8/11/2019 tr7

6/17

386

Anterior-posterior force fractures

These occur incrush types of injury. All 4 pubic rami may

be fractured and displaced posteriorly. Thepelvic ringis

usuallystable.

Investigation

The important complication of this fracture is damage to the

bladder and urethra (see below).

Rectal examination This must be never omitted. This is

particularly important if there is any possibility of damage to

the urinary tract. In the case of rupture of the membranousurethra, apart from urethral bleedingand inability to

micturate, a rectal examinationwill show a gap anteriorly

due to theprostate being displaced upwardswith thebladder

in males.

Treatment

Nursing The patient should lie on a soft mattress

supported byfracture boards. The actual fracture hardly everrequires reduction, even if displaced.

Mobilisation This can commence within 3-6 weeksand

often earlier with the support of crutchesor a walking frame.

In elderly patientswithout complications, the patient can

often be mobilised within a few days.

Complications The management of urethral andbladder

injuriesis discussed below.

Vertical force fracture

Cause

These may be due to a fall from a heightonto the feet,

resulting inone half of the pelvisbeingdisplaced superiorly.

Minor displacement Treatment Thepatient is nursedlying flat on a soft

mattresssupported by fracture boards.Skin tractionof

approximately5 kgis applied to the relevant leg, as illustrated.

Severe displacement

Traction A Steinmanns pinshould be inserted into the

tibial tuberosityor lower femur. Tractionof approximately

10-12 kgis applied, graduallyreducingto7 kgover 2-3 weeks.This is maintained for a total of 3-6 weeks.

Mobilisation The patient can bemobilised on crutches,

but no weight-bearingshould be allowed on the affected side

for 3 monthsfrom the time of the original injury.

8/11/2019 tr7

7/17



Anterior-posterior force

Moderate

displacement of

pubic rami

Fractured pubis

with disruption

Minimal or no

displacement of

pubic rami

Pubic fracture alone

1-3 weeks of bed rest on a well

supported mattress

Early mobilisation

Treatment

External fixateur is ideal

treatment

for severe disruption

H uckstep 199 9 Hu ckste p 1999

Huckstep 1999

Huckstep 1999

Huckstep 1999

8/11/2019 tr7

8/17

388

External fixateur Insevere displacementof thepelvis

this may be required for 2-3 months.

Internal fixation This may be necessary withplatesand

screwsin some casesafterinitial stabilisationwithexternal

fixateurs.

Complications

Sciatic nervedamage:

Neurapraxia This is common.

Axonotmesis This is common.

Neurotmesis This is rare.

Other complications Shockdue toblood loss, leg

shortening and low back pain.

Book fractures.The whole pelvis opens out like a book. The diastasis is

usually, but not always, at the symphysis pubis.

Treatment

Nursing A soft mattresssupported by fracture boardswith the patientlying on the side. The effect of this is usually

toshut the book(i.e. reduce the fracture).

Conservative treatment Elevatingthe whole pelvisin a

very wide large padded canvas slingor in aplaster spica.

Severe displacement Closed manipulationof the fracture

followed by an external fixateurand aplateif necessary.

External fixateur Pinsin each ilium.

Internal fixation Aplateacross thesymphysis pubis

afterinitial externalfixateur.

Complications

Bleeding This is due to disruption of theposterior iliac

vessels.Early reductionof the fracture is important with an

external fixateurif possible.Urgent resuscitationmay be

necessary, includingmassiveblood transfusion. Other complications Bladder and urethral damage,

sciatic nerve injury,intestinal damageand other fractures.

Chronic low backache This is due to opening out of the

sacro-iliacjoint and is common.

Multiple pelvic fracturesThe various fractures of the pelvis are often combined. This

is particularly so in cases where there is ahigh velocity impact

injury. All the various complications described above can be

present.

8/11/2019 tr7

9/17

8/11/2019 tr7

10/17

390


Vertical displacement

associated with central

dislocation of the hip

Conservative management

Severe upward

displacement with diastasis

Disruption of the pelvis

External fixateur followed by

plating if necessary

Treatment of complications

External fixateur is

ideal treatment

for severe disruption

Vertical force

Moderate or severe

vertical displacement

Huckstep 1999

Huckstep 1999

Huckstep 1999

Huckstep 1999

Huckstep 1999

8/11/2019 tr7

11/17


Symphysis pubis

is opened out

Symphysis pubis is

separated with appreciable

sacro-iliac disruption

Severe book fracture

associated with displacement

and disruption of the pelvis


Book fractures

Huckstep 1999

Huckstep 1999

Huckstep 1999

8/11/2019 tr7

12/17

392

Complications of pelvic

fractures

Urological complications common

See hospital emergency section page 114

Intraperitoneal ruptureof thebladder

Extraperitoneal ruptureof thebladder

Ruptureof themembranous urethra

Ruptureof thepenile urethra.

Neurological complications

Sciatic nerve lesion

Lumbosacral plexus damage.

Vascular complications

Major vessel damage

Massive haemorrhagefrom retropelvic vessels.

Intestinal complications

Paralytic ileus common

Small intestinal damage uncommon

Large intestineand rectal damage uncommon.

Other complications

Damage to liver, spleen and pancreas

Damageto the heart, lungs and great vessels

Damage to thespinal cord, brain and limbs.

8/11/2019 tr7

13/17


Pelvic fractures

Complications 1

Rupture of the bladder or

urethra

(See page 114)

Pelvic haematoma, involving colon and rectum.

Massive retropelvic haemorrhage

Foot drop due to sciaticnerve lesion

Huckstep 1999

Huckstep 1999

8/11/2019 tr7

14/17

394

Urological complicationsThebladderand urethralcomplications of a pelvic fracture

are oftenmore importantthan the fractureitself. They must

be looked for carefully, because if left untreated they are

potentially fatal.

Clinical assessment

Bleedingfrom theurethrashould be looked for and the patient

asked whether he or she haspassed urine since the accident.

A careful abdominal examination, including rectal

examination, must never be omitted. Displacement of the

prostate andbladder superiorlyoccurs in rupturesof themembranous urethra.

Investigations

A cystogramand an intravenous pyelogramshould be

performed if there isany doubtabout urinary tract damage.

Aurethogrammay also be indicated. This is discussed further

under emergency hospital care see page 114.

Bladder or urethral damage

If apartialorcomplete ruptureof thebladderis suspected, a

soft cathetershould be passed with full sterile precautions.

Aurethrogramor cystogram is often of assistance, as is an

intravenous pyelogram.

Intraperitoneal rupture of the bladder

This often occurs when a full bladderis traumatised. Thebladder shouldbe repairedin 2 layers and an indwelling

urethral catheterinserted.Prophylactic antibioticsshould be

prescribed.

In severe bleedingor damage, leave in a suprapubic

catheterorfine plastic tubeas well for2-3 daysto help with

bladder irrigation. The urethral catheteris removed after 2

weeks.

Extraperitoneal rupture of the bladder

This is relatively common. Repair is often notpossible. A

suprapubic drainshould always be insertedplus a

suprapubic catheterorsuction drain. Aurethral catheterwill

be required for 2-3 weeks. Prophylactic antibiotics are also

essential.

8/11/2019 tr7

15/17


Pelvic fractures

Complications 2

Sciatic nerve foot drop and sensory disturbance

Massive blood loss retropelvic vessel damage

Damage to colon and

rectum is uncommon

Back pain: common

Huckstep 1999

Huckstep 1999

8/11/2019 tr7

16/17

396

Rupture of the membranous urethra

The importance of aroutinerectal examinationinall fractures

of thepelvisis stressed. Passage of aurethral cathetershould

be done under fullsterile precautionspreferably intheatre.

Treatment

1.Open the bladder and pass ametal soundinto the prostatic

urethra, to insert aFoley catheter.

2.Inflate the 30 ml balloonin the tip of the catheter with

sterile water.

3.Theprostate is drawn down to thepelvic floorand the

Foley catheter leftin place.

4.Prophylactic antibioticsshould be prescribed.

5.TheFoley catheteris left for2-3 weeks.

Complications

The main late complication of urethral damageis a urethral

stricture. This may require regular dilatationsand sometimes

surgerytoreconstructtheurethra.If a rupture of themembranous urethra has beenmissed

for several days, severe scar tissue may necessitate ureteric

transplantinto theintestine.

Emergency laparotomy

This is important, with repair and drainageof thebladder

and urethra(see page 116).

Neurological complications

Sciatic nerve lesions

Vertical force fractureMuscles below the knee are weak

or completelyparalysedwith a foot dropand sensory loss.

Exploration of the nerveis only necessaryifpressure on the

nerve is being caused by aposterior acetabular fracture.

Lumbo-sacral plexus

These may involve the lumbo-sacral plexusor individual

nerves.

Prognosis for recovery This depends on the type of

neurological damage.

Neurapraxia and axonotmesis These are relatively

commonand usuallypartially or completely recover. Neurotmesis This is uncommon and does not recover. It

occurs where there is significant superior displacementof the

hemipelvis.

8/11/2019 tr7

17/17

Pelvicfractures 397

Sacral fractures These may damage nerves within the

sacral foramina.

Displacementof thesacro-iliac joint The nerves may be

stretched and damaged.

Vascular damage

Major vessel

Common iliac artery This is occasionally damaged by

bone fragmentsor completely divided.

Treatment This involvesrepairingthe vessel or

replacement with a syntheticorvein graft.

Massive haemorrhage

Retropelvic arteries These may produce amassive pelvic

haematoma, especially inpelvic diastasis.Urgent

resuscitationandblood transfusionplus reduction of the

fracture withexternal fixateursis urgently required.Vascular

embolisationunder radiological control may also be

useful.(see page 119)

Treatment

MAST suit This should be the initial emergency

treatment prior to reductionof the fracture dislocation.

Reduction of the fracture An external fixateur, plus

massive blood transfusion is essential with resuscitationof

the patient oftenbefore laparotomy and repair of intestinal

injuryorvascular exploration.Two intravenous cannulaeof least14-16 gaugeshould beinserted.

Intestinal complications Paralytic ileus This is common.

Small intestine, colon and rectum These are uncommon

asdisplacedfractures of the sacrumare relatively rare.

Rectal examination This should be routinely carried out,to assess anal sphincter tone,bleeding into the rectumand

prostatic upward displacementin rupture of the

membranous urethra.

Osteoarthritis Acetabular fractures These may result in secondary

osteoarthritisof the hip jointusually due to damage to the

articular surface. Disruption of theblood supplyto the

femoral headassociated with fracture of thehead or neck of

femur is less common.

Chronic back pain This is common, especially when one

or bothsacro-iliacjoints have been disrupted.

tr7

Documents

Transcript of tr7