Ortho-Preferred

Work Up for Pelvic Fracture

- Trauma Management:
    - damage control resusitation
            - ref:  Damage-Control Orthopedics Versus Early Total Care in the Treatment of Borderline High-Energy Pelvic Fractures

    - fluid management
            - hypotension is associated with an increased risk of mortality, ARDS, and multiple organ failure;
            - IV access is secured with at least 2 large-bore catheters; 
            - transfusion requirements w/ active bleeding:
                   - LC injuries: average 3.6 units of packed red blood cells
                   - APC average 14.8 units packed cells;
    - references:
            - Predicting blood loss in isolated pelvic and acetabular high-energy trauma.
            - Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome.
            - Pelvic ring disruptions: effective classification system and treatment protocols.
            - The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fractures. 

- Physical Exam:
    - vascular injuries (reduction of pelvic volume)
    - inspection of soft tissues:
    - palplation:
             - symphysis, pubic rami, iliac crests, sacroiliac;
             - bimanual compression & distraction of the iliac wings, & abduction & adduction of the hip should be done to detect instability;
             - manual traction can aid in the determination of vertical instability
    - gyn / urinary / rectal injuries:
             - RUG vs. suprapubic catheter placement;
             - gross hematuria is an extremely reliable indicator for significant lower GU tract injury, whereas microscopic hematuria is not
                         associated with such injury;
    - neurologic injury 
    - references:
             - Clinical effectiveness of the physical examination in diagnosis of posterior pelvic ring injuries.

- Radiology of the Pelvis
    - r/o concomitant Hip or Femur Fractures;
    - CT Scan: Protocol;
          - 3.0 mm axial cuts from SI joint to the acetabulum;
          - 1.5 mm axial cuts thru the acetabulum;
    - Anteroposterior:
          - LC-II: look for pattern of all 4 rami fractured anteriorly;
    - 40-degree cephalad (Outlet)
          - demonstrates sacral foramina & displacements of ischial tub.
    - 40-degree caudad (Inlet)
          - visualizes pelvic Inlet & magnitude of sacroiliac joint
    - associated fractures:
          - Spine 
          - Femur 
          - references:
                  - Femoral Shaft Fractures Associated With Unstable Pelvic Fractures
                  - The Role of Standard Roentgenograms in the Evaluation of Instability of Pelvic Ring Disruption. 

- Classification:
    - posterior pelvic injury
    - anterior pelvic injuries
    - classification should always be whether the frx is stable or unstable, which is best assessed under flouroscopy if available;
           - the most severe degree of instability will allow motion in all three planes (medial-lateral, AP, and cephalad-caudad);
           - lesser degree of instability will allow motion in only one plane; 
           - LC injury, which is unstable to internal rotation but is stable to external rotation (and actually reduces in external rotation); 
           - references:
                  - Review Article: Fracture of the Pelvis: Current Concepts of Classification.
                  - Pelvic frx in trauma: classification by mechanism is key to organ injury, resuscitative requirements, and outcome.
                  - Pelvic ring disruptions: effective classification system and treatment protocols.

- Initial Treatment by System: 
     - head injury
            - Head injuries coexistent with pelvic or lower extremity fractures--early or delayed osteosynthesis. 
     - cranio-maxillo-facial 
     - neuro: document any preoperative neurological deficits; 
            - Neurologic deficits in major pelvic injuries
     - c-spine
     - spine
     - pelvis: (bleeding w/ pelvic frx / reduction of pelvic volume)
     - frx - menu 
     - cardiac
     - pulmonary
     - gyn / urinary / rectal injuries: suprapubic vs. foley catheter (consider RUG)
          - patients with displaced rami fractures and sacroiliac joint disruptions may be at especially high risk of urethral injuries, and
                  consideration is given to initial retrograde urethrograms before urethral instrumentation; 
          - references:
                - Bladder rupture associated with pelvic fracture due to blunt trauma.
                - The single indication for cystography in blunt trauma.
                - Incidence of urethral disruption in females with traumatic pelvic fractures
                - Delaying catheter insertion in resuscitation of blunt multitrauma and using a full bladder to tamponade pelvic bleeding.

     - bleeding w/ pelvic frx
     - compartments
     - hepatic / GI tract: need for diversion w/ open fractures; 

- Late Complications:
     - dvt & pe from pelvic fractures
              - Deep-vein thrombosis after fracture of the pelvis: assessment with serial duplex-ultrasound screening.
              - The diagnosis of deep vein thrombosis in the multiply injured patient with pelvic ring or acetabular fractures
     - hematoma:
              - Year Book: Mortality in Retroperitoneal Hematoma.
              - Year Book: Retroperitoneal Hematomas of Traumatic Origin. 
     - infection:
              - Retroperitoneal abscess. A potentially fatal complication of closed fracture of the pelvis
     - mortality:
              - Factors affecting mortality in pelvic fractures
              - Definitive control of mortality from severe pelvic fracture

     - references:
              - Complications of pelvic fractures from blunt trauma
              - Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries. 
              - Complications and late therapeutic results of conservatively managed, unstable pelvic ring disruptions



Comminuted fractures of the iliac wing.

Use of the initial trauma CT scan to aid in diagnosis of open pelvic fractures

Does colostomy prevent infection in open blunt pelvic fractures? A systematic review.

Timing and duration of the initial pelvic stabilization after multiple trauma in patients from the German trauma registry: is there an influence on outcome?



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, March 8, 2016 6:40 am