Maxime Coles MD, FRCS, FICS, FAANOS.
Orthopedic Surgeon and Traumatologist
Sebasticook Valley Health
Pittsfield ME 04967
Pelvic Trauma may lead to a disruption of the pelvis, sacrum, acetabulum and hip bones, presenting a benign to a life threatening situation. In the Elderly a simple fall can be catastrophic while often in the younger population a high energy force will be necessary for a disruption. The pediatric population may benefit from a better coverage of the bone with a stronger Periosteum but they can be also involved in this type of injury. Motor vehicle (MVA) and Motorcycle (MCA) accidents (43-58%) or Pedestrian such by car (22%) or fall from Height (5-30 %) are by far the most common mechanisms. We will review a little the anatomy and the mechanism of injury and will discuss initial evaluation and management.
Pelvic Fractures represent 3% of all skeletal injury with a mortality rate ranging from 5-16 %. An open injury can increase the mortality rate to 45 %. Most fatalities are associated with internal organ injuries (Liver, Spleen, Bladder, Urethra etc) but rarely the traumatized patient will die from an acute blood loss. In most Trauma facilities, the death rate ranges .4-.6%. An Australian study on Pelvic Ring Fractures showed recently an incidence 23 per 100.000 persons per year while a British study on Acetabular fractures coined a 3 per 100.000 persons per year. In USA, Two large Trauma registries found an incidence of 9% per year.
The bony pelvis is bounded by the Ilium, Ischium and Pubis forming an anatomic ring connected to the Sacrum. It will take significant force to disrupt this pelvic girdle and one has to remember his role of support for the trunk and legs to understand its impact on the patient. Various muscles will play an important role in its stability.
The initial assessment with stabilization of the airway, breathing and circulation take precedence. There are many suggestive signs of suspicion of a pelvic fracture: Abnormal position of the extremities, Flank or Perineal or Scrotal Ecchymosis, Pain over bony pelvis, Lower extremity weakness and loss of sensation, Hematuria or Bleeding from the rectum and/or vagina. Diagnostic tests like Bedside Ultrasound (FAST) is performed in the great majority of blunt trauma to evaluate the hemoperitoneum, Diagnostic peritoneal aspiration, Plain Radiograph, CT Scan, Retrograde Cystourethrogram will be useful in assessing the trauma patient presenting a complex pelvic bony injury.
Two main classifications are used by Trauma surgeons: The Tile Classification and the Young-Burgess Classification. The Tile based on the integrity of the Posterior Sacro-illiac ligament and the Young-Burgess based on the mechanism of injury will be demonstrated in the presentation.
Surgical treatment of a pelvic fracture is often required and many methods of stabilization or fixation will be presented. Pelvic stabilization in the Emergency room with trouser, sheet, harness, pelvic binder or traction to External fixation and Internal fixation are part of the Armamentarium of any orthopedic traumatologist. Pelvic fractures treatable with only bed rest in low energy injury can benefit from a rehabilitation program using walker, crutches and canes once they can be mobilized.
Complications are numerous notably with acute blood loss and shock, hemorrhage from internal organ injury. Disability from multiple fractures in the pelvis, chronic pain, and leg length discrepancy, deformity, neurological deficits and genitourinary problems are often difficult to deal with such patients. Remember always that there is a 15 % mortality rate associated to Pelvic fractures.