Pelvic Fracture – Causes, Symptoms, Diagnosis, Treatment

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Pelvic Fracture/A pelvic fracture involves damage to the hip bones, sacrum, or coccyx – the bony structures forming the pelvic ring. Due to the inherent structural and mechanical integrity of this ring, the pelvis is a highly stable structure. Therefore, fractures of the pelvis occur most commonly in the setting of a high-impact trauma and are often associated with additional fractures or injuries elsewhere in the body. 

pelvic fracture is a break of the bony structure of the pelvis.[1] This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. Symptoms include pain, particularly with movement. Complications may include internal bleeding, injury to the bladder, or vaginal trauma.[rx][rx]

Pelvic Fracture

 

Types of Pelvic Fracture

There are two main classification systems used to describe pelvic fractures – Tile (based on the integrity of the posterior sacroiliac complex) and Young (based on the mechanism of injury).

The Tile classification system: developed by Pennal and Tile, divides injuries into lateral compression (LC), anteroposterior compression (APC) or vertical shear (VS) injuries.  This classification system also takes into consideration radiographic signs of pelvic stability or instability.

  • Type A – The sacroiliac complex remains intact, and the pelvic ring contains a stable fracture (often managed operatively).A1 – avulsion fracturesA2 – stable iliac wing fracture or minimally displaced pelvic ring fractureA3 – transverse sacral or coccyx fracture
  • Type B – Partial disruption of the posterior sacroiliac complex – caused by external or internal rotational forces (rotationally unstable and vertically stable).B1 – open-book injuryB2 – LC injuryB3 – bilateral type-B injury
  • Type C – Complete disruption of the posterior sacroiliac complex (both rotationally and vertically unstable) often as a result of intense force (e.g. motor vehicle accident, fall from a height or severe compression injury). C1 – unilateral injuryC2 – bilateral injury (one side is a type B, and the other is a type C)C3 – bilateral injury (both sides type C)

The Young classification system

  • Developed by Young and Burgess, expanded on Tile’s classification by including combined fractures (as many pelvic fractures occur as a combination of forces in multiple directions).
  • The most common combination fracture is LC/VS.   LC fractures involve transverse fractures of the pubic rami (either ipsilaterally or contralaterally to the posterior injury).  VS fractures involve symphyseal diastasis or vertical displacement (either anteriorly or posteriorly – usually through the SI joint, or less commonly through the iliac wing or sacrum).

Grade I

  • A slight widening of the pubic symphysis or anterior sacroiliac (SI) joint and sacral compression on the side of the impact
  • Sacrotuberous, sacrospinous and posterior SI ligaments remain intact

Grade II

  • Widening of the anterior SI joint (e.g. due to disruption of the anterior SI, sacrotuberous and sacrospinous ligaments) and posterior iliac (“crescent”) fractures on the side of the impact
  • Posterior SI ligaments remain intact.

Grade III (open book) 

  • Complete SI joint disruption and lateral displacement (e.g. disruption of the anterior SI, sacrotuberous, sacrospinous, and posterior SI ligaments
  • Contralateral sacroiliac joint injury.

Pelvic Fracture

Causes of Pelvic Fracture

  • Sudden forceful  fall down
  • Road traffic accident
  • Falls – Falling onto an outstretched hand is one of the most common causes of the broken pelvic.
  • Sports injuries – Many pelvic fractures occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause necks of femur fracture to break, sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis –  a disease that weakens your bones
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing.
  • Previous pelvic fractures record.
  • Wave an inadequate intake of calcium or vitamin D.
  • Football or soccer, especially on artificial turf
  • Athletic injury with a sports injury.
  • Horseback riding
  • Hockey
  • Skiing
  • Snowboarding
  • In-line skating
  • Jumping on a trampoline

Symptoms Of Pelvic Fracture

Common symptoms of fractures include:

  • Severe pain that might worsen when gripping or squeezing or moving your hip.
  • Inability to move immediately after a fall
  • Severe pain in your pelvic or groin.
  • Inability to put weight on your leg on the side of your injured pelvic.
  • Stiffness, bruising and swelling in and around your hip area
  • Shorter leg on the side of your injured hip and pelvic
  • Turning outward of your leg on the side of your injured
  • Swelling
  • Tenderness
  • Bruising
  • Obvious deformity, such as a bent pelvic.
  • Pain
  • Pain, especially when flexing the hip
  • Deformity of the pelvic, causing it to look crooked and bent.
  • Your hip is in great pain.

Diagnosis of Pelvic Fracture

Due to the high energy nature of pelvic ring injuries, associated morbidities require thorough assessment. Incidence of associated trauma includes:

  • Chest trauma 63%
  • Long bone fractures 50%
  • Head injuries 40%
  • Visceral organ damage 40%
  • Spinal fractures 25%
  • Intestinal injuries 14%
  • Genitourinary injuries 6 to 15%
  • Open fractures 5%

    • Mortality of open pelvis fractures is around 50%, urgent antibiotic administration is necessary
    • Perform a rectal and vaginal exam and look for breaks in the skin around the perineum

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.

  • Advanced trauma life support (ATLS)
  • Motor and sensory exam
  • Physical exam of the pelvis including push/pull test and lateral compression test
  • Look for leg length inequality not explained by a limb fracture
  • A high riding prostate or blood at urethral meatus may indicate genitourinary injury
  • Rectal and/or vaginal exam
  • Perineum exam may reveal swollen and/or mobile genitalia

Destot sign – Palpable hematoma in perineum above 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.

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Imaging

      X – rays – CXR, AP pelvis

  • Inlet view – allows evaluation of anterior or posterior translation
  • Outlet view – allows evaluation of coronal plane deformity
  • Flamingo views – for assessment of chronic pelvic ring instability

CT scan – should be obtained for all pelvic ring injuries

  • Helps to assess the extent of the sacral injury

MRI – rarely indicated in acute pelvic ring trauma

Classification

Tile Classification

Type A – Stable

  • A1 – Fractures not involving the pelvic ring
  • A2 – Stable minimally displaced fractures of the pelvic ring

Type B – Rotationally unstable, vertically stable

  • B1 – Open book
  • B2 – Lateral compression ipsilateral
  • B3 – Lateral compression contralateral

Type C – Rotationally and vertically unstable

  • C1 – Unilateral
  • C2 – Bilateral
  • C3 – Associated with an acetabular fracture

Young and Burgess Classification

Lateral Compression (LC)

  • LC1 – Anterior sacral compression fracture +/- pubic rami fractures (often a stable pattern)
  • LC2 – Crescent fracture +/- pubic rami fracture (Unstable)
  • LC3 – LC 1 or 2 with a contralateral APC injury

Anterior-Posterior Compression (APC)

  • APC1 – Minor symphysis widening or distracted ramus fracture
  • APC 2 – Opening of symphysis greater than 2.5 cm, disruption of sacrospinous and anterior SI ligaments, assumes posterior SI ligaments remain intact
  • APC3 – Complete disruption of symphysis and SI joint

Vertical Shear (VS)

  • VS – Vertical displacement of hemipelvis, represents complete instability

Combined Mechanism (CM)

  • CM – Any combination

Denis Classification of Sacral Fractures

  • Zone 1 – Lateral to the sacral foramen
  • Zone 2 – Entering sacral foramen
  • Zone 3 – Medial to sacral foramen – Highest incidence of neurologic injury including nerve root or cauda equina

Lumbopelvic Dissociation

  • Fracture pattern which renders the base of the spine discontinuous with the pelvis requiring fixation
  • Beyond the scope of this activity
  • Bilateral sacral fractures have a high incidence of lumbopelvic dissociation, and CT scan should be reviewed carefully for coronal plane sacral disruptions.

Imaging

  • Computed tomography (CT) – scans of the abdomen/pelvis will provide the best visualization of pelvic anatomy and allow for evaluation of any pelvic, retroperitoneal or intraperitoneal bleeding. A CT scan will also allow for confirmation of hip dislocation and help determine whether or not there is an associated acetabular fracture.
  • The best screening test for a pelvic fracture however, is an anteroposterior (AP) pelvic radiograph – this will reveal 90% of pelvic injuries.  Although most trauma patients undergo routine CT scans to the abdomen and pelvis, AP pelvic radiograph should be considered (as a rapid diagnostic tool) for hemodynamically unstable patients, to allow for earlier intervention.
  • The pelvis should also be examined as part of the Focus Assessment with Sonography for Trauma (FAST) examination – this may help identify intraperitoneal bleeding (potentially pinpointing a source of shock) if it is present.
  • Retrograde urethrography – should also be performed in patients suspected of having a urethral tear (e.g., males presenting with blood at the urethral meatus or females whom, after careful attempts, are unable to have a Foley catheter inserted, or have a vaginal tear or palpable fragments adjacent to the urethra).
  • Cystography – Individuals presenting with hematuria in the setting of an intact urethra (e.g., suspected of having a urinary bladder injury) should undergo a cystography.
  • Pelvic Angiography – may be performed if a patient is experiencing persistent hemorrhage despite adequate intravenous fluid resuscitation and pelvic stabilization – this may detect occult or obvious injuries and allow for embolization of any damaged arteries in addition to helping visualize before manipulative reduction.

Treatment of Pelvic Fracture

Pelvic Fracture

Prehospital management

Prehospital management of a suspected pelvic fracture should adhere to the following principles:

  • Read the mechanism of injury.
  • Ask the alert patient about the presence of pain in the pelvic, back or groin regions and routinely immobilize the pelvis if there is any positive reply.
  • The examination is unreliable (especially if reduced GCS, or distracting injuries) and the pelvis should not be palpated, to avoid further internal hemorrhage.
  • If there is any suspicion of fracture, immobilize the pelvis using an external compression splint (commercial or modified eg, sheet).
  • Do not fully log roll the patient.
  • Use a scoop stretcher to facilitate the patient’s movement on to a spinal board or vacuum mattress for transport. In the emergency department, this process should be reversed.
  • Fluid resuscitation to maintain a radial pulse only.
  • Do not remove a pelvic splint in the presence of a suspected unstable pelvic injury until it is radiologically confirmed that there is no fracture or the patient is in a theatre.

Non-Surgical Treatment

Treatment available can be broadly

  • Skeletal traction – Available evidence suggests that treatment depends on the part of the pelvic fracture that is fractured. Traction may be useful for pelvic fracture because it counteracts the force of the muscle pulling the two separated parts together, and thus may decrease bleeding and pain.[rx] Traction should not be used in the femoral neck and pelvic fracture or when there is any other trauma to the leg or pelvis.[rx][rx] It is typically only a temporary measure used before surgery. It only considered the definitive treatment for patients with significant comorbidities that contraindicate surgical management.[rx]
  • Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your hip area, then get medical care immediately. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up. Other symptoms include immediate swelling and/or bruising near the fracture, grinding sounds with arm movements and potential numbness, and tingling in the leg.
  • Apply ice – After you get home from the hospital pelvic fracture (regardless if you had surgery or not), you should apply a bag of crushed ice (or something cold) to your injured in order to reduce the swelling and numb the pain. Ice therapy is effective for acute (recent) injuries that involve swelling because it reduces blood flow by constricting local blood vessels. Apply the crushed ice to your radial head fractures  for 15 minutes three to five times daily until the soreness and inflammation eventually fades away
  • Lightly exercise after the pain fades – After a couple of weeks when the swelling has subsided and the pain has faded away, remove your arm sling for short periods and carefully move your hip joints in all different directions. Don’t aggravate the pelvic fracture so that it hurts, but gently reintroduce movements to the involved joints and muscles. Start cautiously, maybe starting with light, and then progress to holding light weights (five-pound weights to start).
  • Practice stretching and strengthening exercises – of the fingers, leg if your doctor recommends them.
  • A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
  • A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
  • Get a supportive arm sling – Due to their anatomical position, necks of pelvic fracture can’t be cast like a broken limb can. Instead, a supportive arm sling or “figure-eight” splint is typically used for support and comfort, either immediately after the injury if it’s just a hairline fracture or following surgery, if it’s a complicated fracture. A figure-eight splint wraps around both hip and the base of your back in order to support the injured hip and keep it positioned up and back. Sometimes a larger swath of material is wrapped around the sling to keep it closer to your body.
  • Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your hip and lower chest look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and necks of femur fracture movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
  • Rigid fixation – osteosynthesis with locking plate, hook plate fixation, fixation with a locking plate, coracoclavicular screws, Knowles pin fixation.
  • Flexible fixation – simple k wire fixation, tension band wiring, suture anchors, vinyl tape, dacron arterial graft for ligament reconstruction.
  • A splint – which you might use for a few days to a week while the swelling goes down; if a splint is used initially, a cast is usually put on about a week later.
  • A cast – which you might need for six to eight weeks or longer, depending on how bad the break is (you might need a second cast if the first one gets too loose after the swelling goes away.)
  • Rest Your Leg – Once you’re discharged from the hospital in an arm sling, your top priority is to rest your necks of femur fracture and not further inflame the injury. Of course, the arm sling not only provides support, but it also restricts movement, which is why you should keep it on even during sleep. Avoiding the temptation to move your shoulder and arm will help the bone mend quicker and the pain fades away sooner.
    • Depending on what you do for a living and if the injury is to your dominant side, you may need to take a couple of weeks off work to recuperate.
    • Healing takes between four to six weeks in younger people and up to 12 weeks in the elderly, but it depends on the severity of the radial head fractures.
    • Athletes in good health are typically able to resume their sporting activities within two months of breaking they’re ulnar styloid depending on the severity of the break and the specific sport.
    • Sleeping on your back (with the sling on) is necessary to keep the pressure off your shoulder and prevent stressing the hip injury.
  • Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins are proven to help heal broken bones of all types, including necks of femur fracture. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your necks of pelvic fracture. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
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    • Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
    • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
    • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
    • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items and foods made with lots of refined sugars and preservatives.

Physical Therapy

  • Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury.  After a neck of femur fracture, it is common to lose some leg strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle hip, knee exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.

Follow-Up Care

  • You will need to see your doctor regularly until your fracture heals. During these visits, he or they will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.

Breathing Exercise

  • To elevate breathing problems or remove lung congestion if needed.

Medication

Rx

Recognize that a pelvic ring injury may represent a life-threatening emergency and work as a team to rapidly resuscitate critically injured patients

  • ATLS first
  • If a patient has a pelvic ring injury, do not assume they do not have another source of hemorrhage
  • A pelvic ring injury should remind all practitioners of high energy trauma and to perform a thorough assessment of all body systems
  • Exclude thoracic and abdominal bleeding before assuming a patients hemorrhage is from a pelvic ring injury

Hemorrhage associated with high energy trauma and pelvic ring disruption

Pelvic ring injuries can have significant blood loss from sources, including:

  • Internal iliac system
  • Pelvic venous plexus
  • Osseous blood supply including nutrient arteries

Pelvic Binder/Circumferential Sheet Placement

  • Temporary intervention to partially reduce the displacement of a pelvic ring injury. Adding stability will help with clot formation within the pelvis and limit hemorrhage. It is controversial whether this actually changes the pelvic volume.

    • Indications

      • Hemodynamically unstable pelvic ring injuries including APC and VS injuries
      • LC injuries treated with binder may be over compressed and may cause harm to other structures in the pelvis
    • Contraindications

      • Acetabular fractures
  • May mask an injury from being identified

    • If the patient is hemodynamically stable on arrival without radiographic evidence of a pelvic ring injury, remove the binder and obtain repeat imaging

 Angiography/Embolization

  • Pelvic ring injuries that remain hemodynamically unstable despite transfusion and binder placement should undergo further intervention. At most centers, the next step is angiography and embolization. External fixation and open pelvic packing are the next steps at some centers; however, this is controversial.

 External Fixation

  • Temporary or definitive fixation of pelvic ring injuries
  • Pin positions: Gluteal pillar, supraacetabular, or subcristal

Anterior Subcutaneous Pelvic Fixator (INFIX)

  • New technique to avoid complications associated with pelvic external fixation including pin site infection

Diverting Colostomy

  • May be necessary for open pelvic ring injury with perineal trauma

Open Reduction Internal Fixation

  • Plates and screws across the symphysis can support the anterior ring.
  • Parasymphyseal pubic ramus fracture is treatable with open plating or percutaneous screw fixation.
  • SI dislocation or sacral fracture can be treated with sacroiliac, transiliac transacral or transiliac screws percutaneously. A thorough understanding of pelvic ring osseous fixation pathways is necessary to perform these techniques safely. Sacral dysmorphism is common and can complicate safe percutaneous fixation of the posterior pelvic ring.
  • Open plating of SI joints or sacral fractures may be necessary if a closed reduction is unobtainable or the fracture pattern is not amenable to percutaneous fixation.

 Triangular Osteosynthesis

  • Lumbosacral pedicle screw fixation combined with a sacroiliac fixation for management of lumbopelvic discontinuity.
  • Absolute indications are still unclear.

Long Turm Treatment Planning of

The sequence of Events for Treating a Pelvic Ring Injury

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On arrival:

  • ATLS

    • Two large-bore IVs
    • Foley catheter

      • Contraindicated if blood at the urethral meatus
      • Indications for a retrograde cystourethrogram

        • Male patients with symphysis disruptions, hematuria, blood at meatus, inability to void, ecchymosis or hematoma of the perineum, high-riding or boggy prostate
    • Rectal and vaginal exam
    • Hemodynamic instability treated with fluids vs. immediate blood products
  • CXR

    • High energy trauma may also have widened mediastinum or pneumothorax
  • AP Pelvis

    • Try to decipher between APC and LC/VS/CM injury patterns

      • If the symphysis has significantly widened its likely an APC pattern

        • If the symphysis is wide and the patient is hemodynamically unstable, apply a pelvic binder or circumferential sheet
      • If the pelvis is broken/disrupted, but it is not clearly an APC pattern, consider other interventions before a pelvic binder

        • Traction for a VS injury
  • CT head, neck, chest, abdomen and pelvis

    • Fine cuts (2 mm) of the pelvis
    • Look for other injuries including head/neck/chest/abdominal/pelvic hemorrhage
  • If the patient remains hemodynamically unstable

    • Identifiable source of bleeding outside of pelvis:

      • Control by other means per general surgery recommendations
    • No other source of bleeding identified other than pelvic ring injury:

      • Interventional radiology embolization

        • Best next step in most centers
      • Emergent pelvic external fixation and pelvic packing

        • Controversial
  • Once the patient is hemodynamically stable

    • Inlet and outlet X-rays of the pelvis

      • For surgical planning
    • If the patient has polytrauma, it indicates a reason for the delay of definitive surgical intervention

      • Temporary external fixation per damage control orthopedic principles
    • If the patient is stable (lactate corrected)

      • Definitive fixation

Prognosis

Young-Burgess Classification predicts mortality

  • Combine the classification into stable (LC1, APC1) vs. unstable (LC2,3 APC 2,3)

    • Stable – mortality of 7.9%
    • Unstable – mortality 11.5%

Reduction of the posterior ring within 1 cm improves long term outcomes.

Return to work rate is highly variable with the majority of patients reporting some form of persistent impairment.

  • 24% lose a job
  • 34% returned to work but changed duties
  • 46% unable to perform pre-injury duties

Male gender and older age have higher mortality.

Females with symphysis fixation can still have safe vaginal deliveries.

  • As long as the front and back of the pelvis are not both restrained by fixation

Complications

Malunion

  • Controversial how to define or measure displacement and malunion
  • Patient with anatomic reductions have better outcomes, but displacement less than 1 cm are often tolerable
  • Sometimes difficult to discern stable patterns from unstable patterns
  • May consider manipulation under anesthesia to determine stability in select cases or to guide treatment during surgery
  • Complete sacral fractures with ipsilateral rami fractures treated nonoperatively will displace over time 39% of the time
  • Complete sacral fractures with bilateral rami fractures treated nonoperatively will displace over time 68% of the time

Hardware Failure

  • Micromotion is present even in a well aligned and healed pelvic ring. Therefore, there is a high rate of hardware failure over time. If the pelvic ring has healed, there should be no displacement if and when the hardware fails; this is not an indication for hardware removal
  • Plating across the symphysis has a hardware failure rate of 43% at one year
  • 97% of hardware failures were asymptomatic

 Neurologic Dysfunction

  • Denis 3 fractures of the sacrum have approximately 50% rate of neurologic dysfunction of lumbosacral nerve roots.

 Sexual Dysfunction

  • Erectile dysfunction occurs in 46% of males after pelvic ring injury
  • Dyspareunia occurs in 56% of females after pelvic ring injury, 91% with APC injuries, and 79% of patients treated with symphysial plating

 Chronic Pain and Disability

  • See prognosis section

Infection

  • As high as 16% with a posterior approach to the sacrum
  • Obesity increases the risk of complications and reoperation

DVT/PE

  • Pelvic ring injury may require IVC filter

References

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