47 years old lady was hit by a tractor trolley resulting in fall. The lady was brought to casualty with complaints of pain in back and around the hip. She was not able to bear weight on right lower limb. Xrays of back and pelvis were done fter initial assessment.

The xray of spine was normal. Xray pelvis revealed following picture.

The xray showed fracture of pubis bone [Arrows show the extent].

The patient is being managed with analgesics, supportive therapy and rest and is showing imporvement.

Related posts:

1. Fracture of Ilium In 50 Years Old Lady – Anteroposterior View Pelvis
2. Anteroposterior View of Intertrochanteric Fracture of Femur
3. Fracture Of Radial Head – Anteroposterior View of Elbow

Related posts:

1. Fracture of Pubic Bone – Anteroposterior View Of Pelvis
2. Undisplaced Oblique Fracture of Lower Tibia – Anteroposterior View Xray
3. Uppper Femoral Fracture In 3 Years Old Child -Anteroposterior Xray

It also permits the patient to return to normal function earlier than nonoperative treatment.

Nonoperative treatment used in a minority of displaced acetabulum fractures. Indications for nonoperative treatment are based on

• Patient condition
• Fracture configuration
• Congruence of the hip joint.

Nonoperative treatment is reserved for patients with nondisplaced fracture, those with tolerable incongruity or displacement, and those in whom surgery is contraindicated.

Displaced fractures that should be considered for nonoperative treatment are

• A large portion of the acetabulum remains intact and the femoral head remains congruous with this portion of the acetabulum.
• Secondary congruence is present following only moderate displacement.

Many low anterior column fractures involving only the pubic portion of the acetabulum can be treated nonoperatively.

Indications for surgical stabilization include

• Instability or subluxation of the hip
• Associated marginal impaction of the articular surface
• Retained osteochondral fragments with joint incongruence.

There are three degrees of instability of the hip.

• I-The hip is stable
• II-The hip is unstable
• III-Instability is inconsistent

if there is a small posterior wall fractures associated with a stable hip joint -manage conservatively. Careful follow up is needed to monitor for signs and symptoms of late instability in the initial months following injury.

Loss of the normal congruent relationship of the femoral head with the acetabulum is frequently associated with osteochondral fragments incarcerated within the acetabulum.

Loss of congruency between the femoral head and acetabular articular surface is often associated with the development of degenerative arthritis of the hip.

In case of both column fracture loss of parallelism on any of the three views to be an indication for surgery.

Surgery is usually undertaken 2 to 3 days following the injury, when the initial bleeding from the fracture and intrapelvic vessels has subsided. Generally, use skeletal traction preoperatively for posterior fracture patterns with hip instability out of traction.

Advanced age is not an absolute contraindication to surgery. Factors such as general medical status, pre-existing arthrosis, and bone quality may affect making.

Related posts:

1. Pelvic Fractures-Clinical and Radiograhic Assessment
2. Displaced Fractures of the Pelvic Ring-An Overview
3. Pelvic Fractures-Associated Blood Loss and Therapeutic Intervention

Complications related To Treatment

Most complications of extenral fixation are the result of pin loosening or infection, and inadequacies of the reduction and fixation. Improper insertion and location of fixation pins in the ilium usually results in early loss of fixation. This leads to pain, loss of reduction, and pin-track infection.

Infection and fixation in malposition are frequent complications of internal fixation.

The risk of postoperative infection of pelvic surgery is quite significant.

Neurologic Complications

Neurologic injury is a major cause of long-term morbidity after a pelvic ring disruption, particularly a posterior ring disruption. The incidence of neurologic injury varies between 2 percent and 50 percent

The lumbosacral trunk is injured as a result of traction from significant external rotation and posterosuperior displacement of the hemipelvis.

The superior gluteal nerve usually is injured directly by fracture fragments near the SI joint.

Recovery from neurologic injury is unpredictable. Most nerve injuries are traction induced and require early conservative treatment.

The results of surgical repair of the sciatic nerve are poor.

Thromboembolism

Deep venous thrombosis (DVT) with the potential for a subsequent fatal PE is a common complication of a pelvic fracture. It can be minimized  by the use of appropriate prophylactic measures.

These rates may become much higher if the patient has sustained polytrauma with the involvement of multiple organ systems.

A high injury severity score, increased age, a concomitant lower extremity or spinal cord injyry, and a part history of venous stasis disease increase the risk.

Persistent Pelvic Pain

About 60% of pelvic fracture victims have prolonged posterior pelvic pain.

Electromyographic studies and nerve conduction velocities and an MRI or myelography may be useful for evaluating neurologic pain.

Nonunion and Malunion

Late deformities and a nonunion can involve one or more sites around pelvic ring.

Urologic and Gynecologic Problems

These may include incontinence, urinary dysfunction, dyspareunia, dysmenorrhea, and difficulty with vaginal delivery and overall sexual function.

Overall, serious problems appear to be relatively uncommon.

Related posts:

1. Displaced Fractures of the Pelvic Ring-An Overview
2. Open Pelvic Fractures
3. Pelvic Fractures In Elderly Persons

Radiologic evaluation is carried out by plain xrays (anteroposterior, inlet, outlet, Judet views), computed tomography, fluoroscopy and stress views. In case of need specialized imaging like 3D CT, angiogram, magnetic resonance imaging can be done.

Pelvic region should be examined for evidence of asymmetry or instability, or the presence of an open wound. A laceration in the groin, scrotum, or perineal region of the vagina and rectum is highly suspicious of an open pelvic fracture. An apparent deformity of the lower extremity in the absence of a fracture in the lower limb may indicate a pelvic fracture.

If there is marked hemodynamic instability, limit the initial radiographic assessment of the pelvis to an AP view. Once hemodynamic and other urgent considerations permit, obtain additional radiographic views so that the injury can be precisely characterized.

At least three views are required: Anteroposterior, inlet, and outlet.

To obtain an inlet view of the supine patient, direct the x-ray beam from the head to the midpelvis at about 45 degree with respect to the radiographic table or 45 degree from the vertical reference axis.

This illustrates the true pelvic inlet as well as anteroposterior displacement of a pelvic disruption.

To obtain an outlet projection of a supine patient, direct the beam from the foot to the pubic symphysis at 45 degree with respect to the radiographic plate.

The outlet projection discloses superior displacement of the posterior half of the pelvis.

If the anteroposterior view indicates a possible acetabular disruption, supplementary Judet or oblique obturator and iliac views for acetabulum should be obtained.

Judet views can be obtained by rolling the injured patient carefully from one side to the other to provide 45 degree views.

Occult pelvic instability may be detected by anteroposterior radiographs.

Computed tomography is indispensable for documentating sites of pelvic disruption, displacement, and comminution.

Ct has a definitive role is to clarify posterior disruption of a pelvic ring fracture. A sacral fracture that can be missed on radiographs is readily seen on CT. The degree of separation and instability of a SI joint or sacral fracture is evident.

Computer programs now can produce 3D surface reformations, or so-called 3D CT images which can be helpful for surgical decisions.

Related posts:

1. Pelvic Fractures-Associated Blood Loss and Therapeutic Intervention
2. Open Pelvic Fractures
3. Displaced Fractures of the Pelvic Ring-An Overview

A Foley’s Catheter is routinely used to document urinary output as a crucial determinant of adequate volume resuscitation in trauma.

In the presence of a major pelvic fracture, urinary catheterization requires special requires special consideration.

The incidence of concomitant injury to the bladder or urethra is about 20 percent.

if there is any suspicion of a urethral injury in male patients, it is advisable to obtain a urethrogram because Attempts to pass a catheter blindly through a partially disrupted male urethra can aggravate a partial tear and result in a stricture, incontinence, or impotence.

If the urethrogram indicates the passage of contrast medium into the bladder without extravasation, advance the catheter into the bladder.

Then perform a cystogram to exclude a rupture of the bladder.

Urologic management for a pelvic fracture victim

A Foley catheter can be placed directly into the bladder of a female patient because the risk is lesser owing to smaller size of urethra

If there is overt urethral injury then alternatives like use of suprapubic cystoscopy and drainage, urethral stent, or magnetic catheters should be considered.

In the typical pelvic fracture, a large pelvic hematoma usually distorts the image of the bladder.

The hematoma requires no specific treatment, although it may indicate a large blood loss and need for supplementary fluid or blood replacement. If a urethral injury is identified, a suprapubic cystoscopy may be indicated.

This procedure can be technically difficult in the presence of a large hematoma.

Recently, as a therapeutic alternative, radiographically visible stents have been inserted primarily into the site of the urethral disruption.

Magnetic catheters have been devised, which permit simultaneous urethral and suprapubic insertions.

Related posts:

1. Urethral and OtherVisceral Injuries With Pelvic Trauma
2. Mechanisms of Injury to the Pelvic Ring
3. Pelvic Fracture-Asessment, Emergency Management and Definitive Treatment

Injury patterns correlate with the vector of the provocative blow. The force vectors and pelvic injury patterns also correlate with the anticipated patterns of additional injuries to the abdomen, intrapelvic contents, chest, and head, as well as with the potential for significant hemorrhage.

A anteroposterior (AP) pelvic radiograph, therefore, provides insight into the force vector and the likelihood for co-injuries for which appropriate diagnostic tests can be initiated promptly.

Principal pelvic fracture patterns based on the vector of the provocative force

Anteroposterior: Anteroposterior compression/external rotation injury
Lateral: Lateral compression/internal rotation injury
Vertical: Vertical shear fracture

Related posts:

1. Fracture Pelvis-Mechanisms of Injury
2. Displaced Fractures of the Pelvic Ring-An Overview
3. Pelvic Fractures-An Outline of Management of Urologic Injury

In history of substantial trauma of any form, whether it is motor vehicular accident or fall from height should always alert the physician or health worker to rule out all life threatening conditions. As per protocol patient is assessed for airway, breathing and circulation at the sit of accident.

A head to toe examination is carried out to look for any gross injury in any other part of body.

Pelvis is tested by direct palpation,Pelvic Compression and Distraction Tests.

In case of injury the pelvis would reveal tenderness. If compressssion or distraction tests are positive for pelvis, it indicates instability of the pelvis.

If there is an overt bleeding , a pressure bandage should be applied. Pelvis should be quickly and temporarily stabilized by wrapping sheet a tightly around it and securing it with a clamp.

On arrival in the emergency department, the patient may be in a pneumatic antishock garment.

Deflate it carefully to avoid precipitous hypotension. If hypotension does occur, reinflate the garment and transfer the patient to the operating room so that, upon removal of the suit, immediate alternative surgical measures to restore hemodynamic stability can be undertaken.

Sidenote: Pneumatic Antishock Garments may not be available in many centers. In India, many tertiary care centers do not have it.

The diagnosis of intraabdonminal hemorrhage can be made by ultrasound, peritoneal lavage, or minilaparotomy. Abdominal and pelvic CT scans are useful as well.

Emergency Pelvic Stabilization

External pelvic fixation is a highly effective method to control intrapelvic bleeding associated with a major pelvic fracture.

The external fixation is for temporary haemodynamic stability. It should be followed by suitable internal fixation.

Reduction of the pelvic fracture produces an increase in interstitial tissue pressure and provides a tamponade of the retroperitoneal bleeding. It also markedly reduces the volume of the true pelvis in which extravasated blood may accumulate.

Reduction and compression of the cancellous fracture surfaces reduces the rate of bleeding.

Relative contraindications to external pelvic fixation for control of acute hemorrhage

• Fracture of iliac crest and anterior inferior spine that eliminates any realize site for insertion of a pin
• Bilateral sacroiliac dislocations or comparable bilateral posterior injuries
• Bilateral both-column or high anterior column acetabular fractures
• Stable pelvic ring with source of intrapelvic hemorrhage
• Bleeding of a major pelvic vessel (i.e., aorta, iliac, or femoral vessels)
• Late presentation
• Marked osteoporosis
• Small child

In the presence of iliac comminution and florid osteoporosis, the pins do not achieve sufficient pelvic anchorage. In a small child, the disproportionately small pelvis is not a realistic target for effective anchorage of the pins.

Control of Bleeding

Bleeding in pelvic fracture can be controlled directly by use angiographic embolization of autologous blood clots or Gelfoam clots.

For the management of bleeding from vessels that are greater than 5 mm in diameter, such as the femoral and common iliac arteries, operative intervention is usually necessary.

Related posts:

1. Pelvic Fractures-An Outline of Management of Urologic Injury
2. Pelvic Fractures-Associated Blood Loss and Therapeutic Intervention
3. Open Pelvic Fractures

Increasing number of aged people is having a profound impact on pelvic fracture management. As the number of elderly people increases, so would be old patients with increasing number of injuries.

Pelvic trauma in young individuals occur due to severe trauma in young individuals. However, the elderly people can get fractures with minor trauma due to weakened skeletal framework as a result of osteoporosis.The elderly experience higher mortality and late morbidity than younger patients with comparable injuries.

In the elderly person, the potential for intensive care management and the duration of hospitalization and rehabilitation are likely to be much greater.

Certain problems in the elderly people impact heavily on the management of the pelvic fracture.

Preexisting cardiac disease compromises the cardiac reserve during the stressful early posttraumatic period and renders the patient vulnerable to serious arrhythmia and myocardial infarction.

Posttraumatic atelectasis, possibly in association with multiple rib fracture or a pneumothorax, is immeasurably aggravated by pretraumatic pulmonary disease.

Hepatic dysfunction in alcoholics may impair co-angulation and compromise the prognosis for retroperitoneal hemorrhage.

Following are the common comorbidities that occur with pelvic fractures

• Ischemic heart disease
• Obstructive airway disease
• Hepatic dysfunction with resultant coagulopathy
• Peripheral vascular disease
• Central neurologic impairment

The trauma may dislodge a preexisting plaque in the common or external iliac artery, resulting in a cold, pulseless limb that requires medical or surgical intervention. With central neurologic impairment, such as pretraumatic senility, intention tremor, or generalized weakness, the rehabilitation after a pelvic fracture may be greatly impeded.

After an extensive open reduction, the elderly and infirm have a higher incidence, and necrosis of flaps. External fixation pins tend to loosen quickly.

It is wise to limit the use of definitive fixation. Extensile approaches and large wounds should be minimized. If possible percutaneous internal fixation should be carried. Surgery should be performed at the earliest because chances of occuring a complication increases with time.

Related posts:

1. Pelvic Fractures-Associated Blood Loss and Therapeutic Intervention
2. Open Pelvic Fractures
3. Displaced Fractures of the Pelvic Ring-An Overview

Visceral injuries are a potential source of life-threatening complications in a pelvic fracture. Injury to the lower urinary tract is a common consequence of a disruption of the anterior pelvic ring, and it can involve the ureter or, more commonly, the bladder and urethra.

Urogenital system injury (injury to urethra, bladder, kidney) occurs in as many as 25% of all cases involving disruption of the pelvic ring.

It is more common with bilateral pubic arch injury. Potential sites of visceral injury with a pelvic fracture. other potential sites of injury are

• Large and small Intenstines
• Bladder and urethra
• Vagina
• Rectum
• Other intraabdominal structures

Commonest injury to occur in viscera is injury to urethra. Male urethra being longer than females is at higher risk than female urethra.

Classic area for urethral disruption is just distal to the apex of the prostate gland. and at the juncture of the membranous urethra and the bulbous urethra.

A presence of blood at the meatus ( tip of the urethra) is suggestive of urethral tear. Other features that are suggestive of a urethral tear include , local swelling, the inability to void, gross hematuria, or a high-riding prostate gland.

If any of these signs are present, a dynamic retrograde urethrogram prior to the insertion of a urinary catheter to rule out a significant urethral injury must be done.

In female patients, a meticulous gynecologic examination is essential, particularly in the presence of vaginal bleeding.

A cystogram can be done after the injury to evaluate bladder.

Most urologists favor a delayed urethral reconstruction, which in their view lowers the risk of impotence, incontinence, and urethral stricture.

When the urologic injury is a rupture of the bladder, an acute surgical repair may be indicated.

In the presence of a stable pelvic fracture and an extrepeitoneal bladder injury, nonoperative management of both problems may be done.

Related posts:

1. Pelvic Fractures-An Outline of Management of Urologic Injury
2. Open Pelvic Fractures
3. Pelvic Fractures-Associated Blood Loss and Therapeutic Intervention