The pelvic ring forms from the sacrum and the two innominate bones, each containing an ilium, ischium, and pubis. There is no inherent stability to the bony anatomy of the ring. Therefore the strong ligamentous attachments are required for maintenance of the ring structure. The ring has to be disrupted in at least two sites for displacement to occur. Pelvic ring injuries cover a broad spectrum. Simple minimally displaced fractures of the sacrum or pubis may be treated conservatively, while high energy disruptions of the bony or ligamentous ring represent life-threatening injuries requiring intervention.
Ligamentous Anatomy of the Pelvic Ring
The bony ring, with its ligamentous tight structures, provides a stable compartment for the hollow viscera and the following neurovascular structures :
Pelvic ring injuries in young people are usually associated with high energy trauma, including falls from height and motor vehicle collisions. High force impact implies an increased incidence of associated injuries to other body regions. Geriatric pelvic ring injuries are unique and are usually the result of a low energy fall. Anterior-posterior compression injuries occur at high frequencies following equestrian saddle horn injuries and motorcycle accidents. Lateral compression injuries often happen as the pelvis is run over by a vehicle. Vertical injuries of the pelvis usually occur as a fall or injury involving an axial load. Whilst mortality is 1 to 15% in closed fractures, it can reach up to 50% in open fractures, with hemorrhage is the main cause of death. Closed head injuries have been reported to be the most common cause of mortality in lateral compression injuries.
The pelvic ring suffers disruption due to direct trauma to the pelvis or indirect trauma through compression or distraction of the spine and/or femurs. The pelvic ring fails in predictable patterns as described in the classification section. Depending on the degree of injury, stabilizing ligaments of the pelvis may be disrupted, requiring stabilization.
Due to the high energy nature of pelvic ring injuries, associated morbidities require thorough assessment. Incidence of associated trauma includes:
A pelvic ring injury can be a life-threatening injury or may be associated with a life-threatening injury, and a thorough exam is necessary.
Destot Sign – Palpable hematoma in the perineum above the inguinal ligament or proximal thigh may represent pelvic fracture with active bleeding.
Grey Turner Sign – Flank bruising indicative of retroperitoneal bleeding.
Morel-Lavallee Lesion – Internal degloving injury from skin shear at time of injury, may require intervention and may affect surgical planning, look for significant soft tissue abrasions, ecchymosis, or subdermal hematoma. May also be identified on CT scan with the assessment of soft tissues.
Type A – Stable
Type B – Rotationally unstable, vertically stable
Type C – Rotationally and vertically unstable
Young and Burgess Classification
Denis Classification of Sacral Fractures
Recognize that a pelvic ring injury may represent a life-threatening emergency and work as a team to resuscitate critically injured patients rapidly
Hemorrhage Associated with High Energy Trauma and Pelvic Ring Disruption
Pelvic ring injuries can have significant blood loss from sources, including:
Initial Management and Resuscitation
Ideally, a transfusion of PRBC:FFP: Platelets at a ratio 1:1:1 has been reported to improve mortality in cases where massive transfusion is necessary.
Pelvic Binder/Circumferential Sheet Placement
Anterior Subcutaneous Pelvic Fixator (INFIX)
Non-operative: indicated for stable fractures such as type I APC and LC injuries. Pubic rami fractures are managed conservatively as surgical dissection necessary for fixation outweigh the benefits.
Operative: indicated in unstable fractures such as APC and LC types II and III and VS Injuries. Operative intervention is relatively indicated in type I APC and LC injuries if there is significant displacement as indicated by lower limb rotational deformity resulting in complete loss of rotation or leg length discrepancy of 1.5 cm or more. Other relative indications include associated trauma necessitating laparotomy, tilt fracture protruding into the perineum, and refractory pain.
Open Reduction Internal Fixation
The timing for definitive fixation is controversial. Early definitive fixation is advantageous for pain relief, easier nursing care, better reduction quality, bleeding control, and early mobility. but that at the expense of increased bleeding risk and possible second hit in trauma patients who are not fully resuscitated.
The sequence of Events for Treating a Pelvic Ring Injury
Young-Burgess Classification Predicts Mortality
Reduction of the posterior ring within 1 cm improves long term outcomes.
Return to work rate is highly variable, with most patients reporting some form of persistent impairment.
Male gender and older age have higher mortality.
Chronic Pain and Disability
Depending on the specific injury and treatment method, the patient may require a period of weight-bearing restrictions to one or both extremities. Nursing and therapy will be necessary to assist with a patient's return to function. DVT prophylaxis postoperatively is paramount.
Clinicians need to address patient expectations early. Discussing reasonable outcomes and understanding some degree of chronic discomfort may be unavoidable. Also, discussing some intimate issues like erectile dysfunction or dyspareunia is important to patient well-being and making necessary referrals to OB-GYN or urology as necessary.
Patients with pelvic ring injuries are typically very sick and will require the assistance of multiple providers. Each provider must discuss their role with other providers and the patient. There may be multiple teams working on a single patient in complex scenarios, and interprofessional communication is essential. Because of the complexity of these injuries, the number of organs injured, and the high morbidity and mortality, it is imperative that an interprofessional team be involved in patient care. The brief roles of the interprofessional team are as follows:
The urologist may be required if there is a urethral injury; since these patients require suprapubic catheterization. Further, it is imperative that the catheter not be placed in the way of a diverting ileostomy for the general surgeon or a pelvic incision for the orthopedic surgeon. Diverting ileostomy/colostomy or suprapubic catheters should be placed as cephalad as possible to avoid interfering with the surgical incisions needed to operate on the pelvis.
A general surgeon may be required to divert the fecal flow by creating a diverting ileostomy or colostomy.
The radiologist is essential for localizing the injuries and their extent. Also, an interventional radiologist may be necessary for arterial embolization in cases of uncontrolled hemorrhage.
These patients are often managed in the trauma or surgery ICU and need close monitoring by the nurses. These patients also need DVT and pressure sore prophylaxis. Since most patients cannot eat an oral diet for a few days or weeks, a dietary consult for TPN may be required. If the patient has a stoma, a stoma nurse needs to educate the patient and the family about stoma care, the necessary changes in diet, maintaining hygiene around the appliance, and reporting back to the physicians of any issues encountered.
Pain control and antimicrobial therapy may be necessary, and the pharmacist should oversee medication reconciliation and dosing and let the team know of any potential interactions or dosing issues.
Because these patients are often bedridden for prolonged periods, physical and occupational therapy must be involved to exercise the muscles and maintain function. They can inform the team about the progress or lack thereof as the patient moves through the stages of rehabilitation.
A mental health nurse should see the patient before discharge as depression and anxiety are common after pelvic trauma. The road to recovery is long and unpredictable, causing extreme stress in many patients. These findings should go to the managing physician(s) as well as the nursing team.
Most patients require extensive rehabilitation after discharge and may need to follow up with many specialists, including the nurse practitioner.
In summary, as can be seen above, pelvic ring injuries/fractures require an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]
Pelvic trauma is a significant event, and despite optimal care, it correlates with very high morbidity. Many patients remain disabled after the injury and are not able to return to work. Most have difficulty performing daily living activities and often require assistance with ambulation. The long term prognosis for most of these patients is guarded.
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