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CHAPTER 55 Pelvic Trauma
Stephen B. Choi and A. Adam Cwinn
PERSPECTIVE
PRINCIPLES OF DISEASE
Background
Anatomy
Patients with traumatic pelvic ring injury may represent an
immense challenge for the emergency physician. First, patients
with pelvic ring fractures are at risk for exsanguinating pelvic
hemorrhage. Furthermore, the profound magnitude of force
required to disrupt the pelvic ring frequently causes severe injuries
to other organ systems. The resuscitation from hemorrhagic
shock, rapid identification of other major injuries and sites of
blood loss, and the coordination of definitive angiographic and
surgical treatments are paramount to achieving good clinical
outcomes.
Detailed descriptions of pelvic anatomy may be found in standard
anatomy texts. This section focuses on the relevant anatomy essential to understanding pelvic injuries.
Epidemiology
Based on data from trauma registries, the majority of high-energy
pelvic ring injuries are caused by motor vehicle collisions (MVCs),
motorcycle crashes, and pedestrians being struck by motor vehicles, together accounting for 80 to 84% of pelvic fractures; and
falls from height, which account for 5 to 12%1-5 of pelvic fractures. The mortality rates reported in the literature associated
with pelvic fracture range from 9 to 22%1-5; in studies of large
cohorts of trauma patients, the presence of pelvic fracture has
been consistently shown to be an independent risk factor for
death compared with trauma patients without pelvic fracture.6-8
Patients with pelvic fractures and with shock on arrival to the
hospital have mortality rates of 33 to 57%.3,4 Increased age, shock
on arrival at the hospital, high injury severity and revised trauma
scores (which generally reflect the presence of multisystem injuries), and the need for transfusion have all been shown to increase
the risk of death.3-5,9,10 The mortality rate among pedestrians
struck by motor vehicles who sustain pelvic injury has been
shown to be 23%.11
Despite advances in motor vehicle safety design, MVCs
continue to be a major cause of pelvic fracture. Rates of pelvic
fracture secondary to MVC range from 10 to 28%.9,12,13 Lateral
impact remains the most prevalent mechanism for pelvic trauma
in collisions, for which the widespread advent of front airbags
has little effect. Some have speculated that the increased popularity of sport-utility vehicles in past decades is contributing to
the severity of side-impact injuries, specifically as a result of
the higher bumper in these vehicles striking the side of
lower cars.9,12,14
656
Bony and Ligamentous Anatomy
The pelvic ring is made up of right and left innominate bones
and the sacrum. The innominate bones consist of the pubis,
ischium, and ilium (Fig. 55-1). The bony pelvis provides protection for its visceral contents, serves as attachment points for
muscles, and transmits weight from the trunk to the lower limbs.
The main weight-bearing forces are transmitted through the posterior wall of the pelvis, called the posterior arch, which is composed of thick bone and ligaments. The rich network of major
arteries, veins, and nerves that course in front of the posterior
arch may be injured concomitantly with forces causing bony
injuries of this arch.
Knowledge of the ligamentous attachments of the pelvic ring
is crucial to understanding how stability is maintained or disrupted in pelvic injury. The stability of the pelvis is maintained
by ligaments, as well as the muscles and fascia that make up the
pelvic floor. Anteriorly, the symphysis pubis provides the major
mechanical stability. Posteriorly, a complex of strong ligaments—
the sacrospinous, sacrotuberous, iliolumbar, and anterior and
posterior sacroiliac (SI) ligaments—maintains the integrity of
the posterior arch (Fig. 55-2). It is important to appreciate that
mechanically unstable pelvic fractures are unstable primarily
because of the disruption of these posterior ligaments.
Vascular Anatomy
Most of the blood supply to the pelvis comes from the left and
right internal iliac arteries. The internal iliac arteries course at the
level of the SI joints. The various arteries that derive from the
internal iliac arteries initially run in close proximity to the posterior pelvic arch and eventually anastomose extensively with one
another, forming a rich collateral network (Fig. 55-3). The superior gluteal artery is the largest branch and is commonly injured
in fractures of the posterior pelvic arch. The obturator and internal pudendal branches are often injured in fractures involving the
pubic rami.
Chapter 55 / Pelvic Trauma 657
16
2
15
Lateral
lumbosacral
ligament
1
13
14
19
Anterior
sacroiliac
ligament
3
4
17
11
20
18
Sacrospinous
ligament
6
10
5
Iliolumbar
ligament
8
7
Sacrotuberous
ligament
9
A
A
Iliolumbar
ligament
3
Posterior
sacroiliac
ligament
4
12a
Posterior
column of
acetabulum
11
10 6
B
Anterior
column
of acetabulum
12b
9
Sacrotuberous
ligament
7
8
Figure 55-1. Bony pelvic anatomy. A, Anterior view of pelvis.
B, Lateral view of right innominate bone. (1) Iliac fossa, (2) iliac crest,
(3) anterior superior iliac spine, (4) anterior inferior iliac spine,
(5) symphysis pubis, (6) superior ramus of pubis, (7) inferior ramus
of pubis, (8) ramus of ischium, (9) ischial tuberosity, (10) obturator
foramen, (11) ischial spine, (12) acetabulum ([12a] articular surface,
[12b] fossa), (13) sacrum, (14) anterior sacral foramina, (15) sacroiliac
joint, (16) anterior sacroiliac ligament, (17) coccyx, (18) arcuate
line, (19) posterior or femorosacral arch, through which main
weight-bearing forces are transmitted, (20) anterior arch.
The venous system also has many collateral branches and is
without valves, allowing bidirectional flow. The veins are arranged
in a plexus that adheres closely to the pelvic walls. Because these
veins are thin-walled, they do not have the ability to constrict in
response to damage. This anatomic arrangement of the arteries
and veins accounts for the hemorrhage often seen with pelvic
fractures.
Neurologic Anatomy
The cauda equina courses through the sacral spinal canal and exits
through the sacral neural foramina to form the lumbar and sacral
plexus. Injury to the posterior bony pelvis and sacrum may result
in neurologic deficits in the lower extremities and autonomic dysfunction involving the bowel, bladder, and genitalia.
Pathophysiology and Key Patterns
of Pelvic Fracture
Numerous classification schemes exist for pelvic fractures. Two
widely used schemes for pelvic injury are presented here. The classification by Tile stresses the biomechanical stability of the pelvic
Sacrospinous
ligament
B
Figure 55-2. A, Anteroposterior view of the pelvis indicates that the
sacrospinous ligament is a triangular strong ligament lying anterior to
the sacrotuberous ligament, which is a strong broad band extending
from the lateral portion of the dorsum of the sacrum to the ischial
tuberosity. B, The major posterior stabilizing structures of the pelvic
ring, that is, the posterior tension band of the pelvis, include the
iliolumbar ligament, posterior sacroiliac ligaments, sacrospinous
ligaments, and sacrotuberous ligaments.
Common iliac artery
External
iliac artery
Internal
iliac artery
External
iliac vein
Obturator
nerve
Superior
vesical artery
Obturator
artery
Internal
iliac vein
S1 nerve
S2 nerve
Superior gluteal
artery
Inferior gluteal artery
Internal pudendal artery
Figure 55-3. The internal iliac plexus of arteries and veins. (From Tile
M: Fractures of the Pelvis and Acetabulum, 3rd ed. Philadelphia,
Lippincott, Williams & Wilkins, 2003.)
ring15 (Box 55-1). The Young-Burgess classification emphasizes
the mechanisms of injury16 (Box 55-2). From a practical viewpoint, it is highly useful to consider both of these elements in the
assessment of a pelvic ring fracture. Within both classification
systems exist numerous subtypes of injuries, the interobserver
658 PART II ◆ Trauma / Section Three • Orthopedic Lesions
BOX 55-1 Tile’s Classification of Pelvic Fractures
Type A—Stable, posterior arch intact
Includes avulsion fractures, isolated iliac wing fracture, pubic
rami fractures, minimally displaced ring fracture, transverse
fractures of the sacrum or coccyx.
Type B—Partially stable, incomplete disruption of the posterior
arch
Includes anteroposterior injuries (open book) and lateral
compression injuries. May be unilateral or bilateral. These
injuries are rotationally unstable but vertically stable.
Type C—Unstable, complete disruption of the posterior arch
Includes iliac, sacroiliac, and vertical sacral injuries that result
from vertical shearing forces. May be unilateral or bilateral.
These injuries are both rotationally and vertically unstable.
From Tile M: Fractures of the Pelvis and Acetabulum, 3rd ed. Philadelphia,
Lippincott, Williams & Wilkins, 2003.
BOX 55-2 Young-Burgess Classification of Pelvic Fractures
Anteroposterior Compression
I. Symphysis diastasis <2.5 cm
II. Symphysis diastasis >2.5 cm, sacrospinous and anterior SI
ligament disruption, results in rotational instability
III. Symphysis diastasis >2.5 cm, with complete disruption of the
anterior and posterior SI ligament, results in complete
rotational and vertical instability
Lateral Compression
I. Sacral crush injury on ipsilateral side
II. Sacral crush injury with disruption of posterior SI ligaments;
iliac wing fracture may be present (crescent fracture);
rotationally unstable
III. Severe internal rotation of ipsilateral hemipelvis with external
rotation of contralateral side (“windswept” pelvis),
rotationally unstable
Vertical Shear
Vertical displacement of symphysis and sacroiliac joints resulting
in complete rotational and vertical instability
Combined Mechanisms
Any combination of the above mechanisms
From Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: Effective
classification system and treatment protocols. J Trauma 30:848, 1990.
SI, sacroiliac.
reliability of which has been questioned.17,18 For the emergency
physician, a good understanding of both the underlying principles
of pelvic stability and mechanisms of injury is far more important
than a detailed knowledge of the numerous subtypes of injury
that exist within the classification schemes. The broad distinction
of mechanically stable from unstable fractures of the pelvic ring
is clinically useful to bear in mind in assessing patients, as it
has been demonstrated consistently over time that those with
unstable injuries have higher mortality and greater transfusion
requirements.16,19,20
Stable Injuries (Tile Type A)
Fractures of individual bones without involvement of the pelvic
ring represent one third of all pelvic fractures. In general, most
stable pelvic fractures heal well with rest and analgesic drugs for
pain control (Fig. 55-4).15
Undisplaced or Minimally Displaced Fractures of the Pelvic Ring. The normal pelvis is not totally rigid because of the slight mobility
at the SI joints and symphysis pubis and the inherent elasticity of
bone. A single break in the ring is possible. Nevertheless, the pelvis
7
1
8
9
2
4
6
3
5
Figure 55-4. Fractures of individual pelvic bones. (1) Avulsion of
anterosuperior iliac spine, (2) avulsion of anteroinferior iliac spine,
(3) avulsion of ischial tuberosity, (4) fracture of superior pubic ramus,
(5) fracture of inferior pubic ramus, (6) fracture of ischial ramus,
(7) fracture of iliac wing, (8) transverse fracture of sacrum, (9) fracture
of coccyx. (From Tile M: Fractures of the Pelvis and Acetabulum, 3rd
ed. Philadelphia, Lippincott, Williams & Wilkins, 2003.)
is not totally forgiving, and identification of a single break in the
ring should prompt a search for a second disruption.
An isolated fracture of the superior or inferior pubic ramus is
the most common pelvic fracture. These fractures are stable. They
are common fractures in elderly people after a fall and should
be considered in the evaluation of an acutely painful hip. Fracture
of the body of the ischium is a rare injury that may result from a
fall in the sitting position. These fractures around the obturator
foramen are treated conservatively with bed rest, analgesia, and
early mobilization.
Fracture of the superior and inferior pubic rami on the
same side is a commonly encountered injury after a fall or MVC.
These are generally stable fractures and are treated conservatively.
However, the presence of significant displacement at the fracture
site indicates a second disruption elsewhere in the pelvic ring that
should be diagnosed. Alternatively, fractures of both rami on the
same side may be associated with an unrecognized impaction
fracture of the posterior pelvis.
If the patient with a ramus fracture reports posterior pelvic pain
and plain radiographs do not reveal posterior injury, further investigations may reveal occult posterior fractures. A study performed
more than 35 years ago found that patients who sustained apparently isolated pubic ramus fractures showed increased uptake of
radionuclides on bone scans in the acetabulum and SI joint, suggesting that occult bony or ligamentous injury accounted for the
pain.21 More recently, a study that prospectively evaluated elderly
patients who were diagnosed with isolated ramus fractures on
plain films found that 95% had sacral fracture detected by magnetic resonance imaging (MRI).22 This study does not imply a
need to perform MRI on all elderly patients with ramus fractures
in the ED; rather, it enhances our understanding of the pathophysiology of ramus fractures and underscores the importance of
adequate analgesia in these patients. The lateral compression type
I fracture described by Young and Burgess (Fig. 55-5)—characterized by pubic ramus fracture with ipsilateral sacral compression—
bears special consideration among the mechanically stable pelvic
fractures, as it has been shown to be associated with a mortality
rate of 8% with a high incidence of associated injuries.20,23,24
Also termed a straddle fracture, four-pillar injuries involve fractures of both pubic rami on both sides of the symphysis pubis,
Chapter 55 / Pelvic Trauma 659
A
I
B
I
II
II
III
III
C
Figure 55-5. Young-Burgess classification. A, Lateral compression. Type I: A posteriorly directed force causing a sacral crushing injury and
horizontal pubic ramus fractures ipsilaterally. Type II: A more anteriorly directed force causing horizontal pubic ramus fractures with an anterior
sacral crushing injury and either disruption of the posterior sacroiliac joints or fractures through the iliac wing. Type III: An anteriorly directed force
that is continued, causing external rotation of the contralateral side; the sacroiliac joint is opened posteriorly, and the sacrotuberous and spinous
ligaments are disrupted. B, Anteroposterior (AP) compression. Type I: Symphysis disrupted but with intact posterior ligamentous structures. Type II:
Continuation of a type I fracture with disruption of the sacrospinous and potentially the sacrotuberous ligaments and an anterior sacroiliac joint
opening. Type III: Continuation force disrupts the sacroiliac ligaments. C, Vertical shear. Vertical fractures in the rami and disruption of all posterior
ligaments. This injury is equivalent to an AP type III or a completely unstable and rotationally unstable fracture. Arrow indicates the direction of
force. (Redrawn from Young JWR, Burgess AR: Radiologic Management of Pelvic Ring Fractures. Baltimore, Munich, Urban & Schwarzenberg,
1987. Browner BD: Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed. Copyright © 2003 Saunders, an imprint of Elsevier.)
causing the so-called “butterfly segment” (Fig. 55-6). The injury
is produced by a direct blow with a straddle mechanism. Although
these fractures may occur without posterior arch disruption, fourpillar injuries are also commonly associated with lateral compression or vertical shear forces that may cause concomitant injuries
to the posterior pelvic arch. CT of the pelvis is required in cases
of four-pillar injuries to detect and classify precisely the posterior
arch injury and plan orthopedic treatment.15 The genitourinary
tract frequently is injured concomitantly with this type of pelvic
fracture and should be evaluated carefully (see Fig. 55-6).
Isolated fracture of the iliac wing was described by Duverney in
1751 and now bears his name. It is caused by direct trauma to the
iliac crest, usually by lateral compression forces. Although displacement is usually minimal because of the arrangement of the
muscle attachments of the abdominal wall, orthopedic consultation is recommended. The fracture may extend into the acetabulum, altering the treatment and prognosis. Severely displaced
fractures of the iliac wing require open reduction and internal
fixation.15 It is worth noting that a high incidence of major associated nonpelvic injuries among patients with isolated iliac wing
fracture has been reported.23
Transverse Fractures of the Sacrum. Transverse fractures of the
sacrum do not compromise the pelvic ring. Transverse fractures
at or below S4 are unlikely to be accompanied by neurologic
injury.25 An upper sacral transverse fracture is the result of a
flexion injury, such as being struck on the lower back by a heavy
load while bending over, or by direct forces to the sacrum, as in a
fall from a great height.25 The patient reports pain in the buttocks,
perirectal area, and posterior thighs. There may be local pain,
swelling, and bruising overlying the sacrum, and on gentle bimanual rectal examination, severe pain, abnormal motion, and palpable hematoma may be elicited. Radiographically, the fracture
may be difficult to visualize on anteroposterior (AP) and lateral
projections, in which case a pelvic outlet view may be helpful.
Simple transverse fractures at or below S4 are treated conservatively. Above S4, neurologic injuries are common, necessitating
careful clinical evaluation and surgery when neurologic compromise is present.
Avulsion Fractures. These usually occur during athletic activities
and are the result of a sudden, forceful muscular contraction or
excessive muscle stretch. They are seen more commonly in older
children and teenagers before closure of the corresponding physis
occurs; adults may have the same symptoms from ligamentous
injury at these sites without radiographic abnormality.
The ischial tuberosity may be avulsed during strenuous contraction of the hamstrings. There is pain on palpation of the
involved tuberosity, and this pain is increased by flexion of the hip
with the knee in extension (hamstrings stretched), but not with
the knee flexed (hamstrings relaxed). Ischial tuberosity avulsion
also may cause chronic discomfort with no history of acute injury.
A portion of the iliac crest epiphysis may be avulsed by contraction of the abdominal muscles. Similarly, the anterior superior
660 PART II ◆ Trauma / Section Three • Orthopedic Lesions
2
1
B
A
2
3
1
1
C
D
Figure 55-6. Four-pillar (straddle) fracture. A and B, Partial inlet view of pelvis shows straddle fracture. (1) and (2) Marked comminution of left
pubic bone and comminuted right superior and inferior rami. This partial inlet projection shows displacement of fragments into the pelvis, which is
not evident on the anteroposterior view of the same patient in C and D. A true inlet projection and computed tomography scan (not available)
would provide further information about the posterior arch, which is injured frequently in straddle fractures and should be imaged (see text). C and D, Postvoid cystogram of the same patient with anteroposterior pelvis. (1) Fractures of pubic rami are seen again but do not appear to be
as displaced compared with A and B because this projection is an anteroposterior view. Even minor degrees of angulation of the x-ray beam can
change the appearance of pelvic fracture displacement. (2) Extravascular contrast indicates bladder rupture; (3) left acetabular fracture is seen in
this projection but not in B because of the difference in projection. The acetabular fracture disrupts the ilioischial line (see also Fig. 55-13) and is a
posterior column fracture.
iliac spine may be avulsed by forcible contraction of the sartorius
muscle. Forceful contraction of the rectus femoris (as in kicking
a ball) can result in the less common injury of anterior inferior
iliac spine avulsion; however, this radiographic finding should be
distinguished from a normal variant, the os acetabuli, which is a
secondary center of ossification at the superolateral margin of the
acetabulum.26 Clinical examination is similar in these injuries and
reveals local pain, swelling, and limitation of motion.
Conservative treatment, including analgesia and bed rest in a
position that avoids tension on the affected muscles, is generally
all that is required for avulsion injuries; surgical treatment is
rarely necessary. Orthopedic consultation is advised for followup care.
Stress Fractures. Stress fractures occur with vigorous athletic or
military training and in the last trimester of pregnancy.27 The
diagnosis of stress fractures is based on the clinical evaluation
and can be confirmed, if required, by radionuclide bone scan,
although MRI has been shown to be a superior method for detecting these injuries.28
Pathologic and Insufficiency Fractures. Pathologic fracture related
to neoplasm, Paget’s disease, or dietary osteomalacia is included
in the differential diagnosis. Radiation therapy has also been
shown to increase the risk of pelvic fracture.
Partially Stable and Unstable Injuries
(Tile Types B and C)
Partially stable and unstable injuries are caused by high-energy
impacts. The forces applied to the pelvis determine the types
of injuries that occur. Broadly, forces may be applied to the
pelvic ring in AP, lateral, or vertical directions that result in
characteristic injury patterns; combinations of forces result in
Chapter 55 / Pelvic Trauma 661
more complex injuries. The terms unstable fracture (referring to
mechanical stability) and unstable patient (referring to hemodynamic status) should not be confused, although a cause-and-effect
relationship often exists.
Anteroposterior Compression. Severe AP compression forces
result in disruption at or near the symphysis pubis. Symphysis
widening of less than 2.5 cm is considered a stable injury (the
symphysis should normally be ≤0.5 cm in an adult but can increase
2-3 mm during or after pregnancy); however, with continued
force in the AP direction, the hemipelvis externally rotates, tearing
the sacrospinous, sacrotuberous, and anterior SI ligaments. The
SI joint opens and hinges on the intact posterior SI ligaments. The
resulting injury is aptly described as an “open-book” fracture.
The pelvis is rotationally unstable in the horizontal plane, but the
intact posterior SI ligaments maintain vertical stability.15,16
When diastasis of the pubic symphysis is greater than 2.5 cm
on the AP radiograph, the posterior injury is usually seen as widening of the SI joint and occasionally as a sacral or iliac fracture
(see Fig. 55-5).15 If the injurious forces continue, they may separate
the hemipelvis, and the SI joint is seen as widely separated on the
plain AP radiograph (Fig. 55-7) and the CT scan.15 The AP radiograph may be misleading in suggesting a pure open-book fracture
in cases with symphysis disruptions greater than 2.5 cm. These
2
3
4
1
5
A
2
3
6
4
6
B
1
5
Figure 55-7. Interpretive drawing (A) and radiograph (B). Severe
unilateral open-book fracture from anteroposterior compression forces
that is also open (compound). (1) Separated pubic symphysis with
asymmetry of hemipelvis, (2) normal sacroiliac joint, (3) separated
sacroiliac joint, (4) cystogram with displacement and abnormally
elongated shape of bladder caused by retroperitoneal hematoma
associated with separated left sacroiliac joint, which has pushed the
bladder to the right, (5) extravasated contrast into perineum from
urethral rupture, (6) soft tissue air indicating an open fracture.
cases commonly are associated with vertical shear fractures, and
careful clinical and computed tomography (CT) assessment for
vertical instability is essential to classify the fracture properly and
plan treatment.15
These same forces also may injure the neurologic and vascular
structures at the posterior arch; the overall volume of the pelvis is
increased in the open-book injury, facilitating the expansion of a
retroperitoneal hematoma. Several studies have demonstrated that
patients with severe grades of AP compression injuries have the
highest crystalloid and blood requirements.16,19
Lateral Compression. Lateral compression of the pelvic ring
results in varying degrees of internal rotation of the affected hemipelvis. Initially, this causes buckling of the sacrum and horizontal
pubic rami fractures. Rami fractures may occur on the ipsilateral
or contralateral side, the latter being referred to as the “buckethandle” fracture (Fig. 55-8).
As the magnitude of force increases, the symphysis may disrupt,
causing overlapping of the pubic bones. Note that on plain radiographs, evidence of injury to the sacrum may be subtle; overlapping pubic bones with any significant displacement should prompt
a search for a posterior injury.
Similar to the AP injury, with increasing disruption of the
posterior ligaments comes increasing rotational instability. In
the most severe lateral compression trauma, the ipsilateral pelvis
internally rotates to such a degree that the contralateral pelvis may
externally rotate. This is referred to as the “windswept” pelvis.
Lateral compressive injuries result in varying degrees of horizontal
rotational instability; however, the vertical stability of the pelvis is
maintained (see Fig. 55-8).
As internal rotation causes the pelvic volume to decrease, lateral
compressive injuries are generally associated with lesser degrees of
blood loss than are AP injuries.
Vertical Shear. Vertical shear injuries represent the most unstable injuries to the pelvic ring and are associated with violent axial
loading of the hemipelvis (e.g., fall from height, “submarining”
underneath a dashboard). Fractures occur in vertical planes.
Anteriorly, the symphysis and rami may be disrupted. Posteriorly,
gross displacement and instability in the rotational and vertical
planes may be present through the sacrum, the SI joint, or the
ilium such that the hemipelvis may displace posteriorly and cephalad15,16 (see Fig. 55-9).
Avulsion of the ischial spine, the lower lateral lip of the sacrum,
and the transverse process of the fifth lumbar vertebra (sites of
insertion of ligaments) (Fig. 55-9 and Box 55-3) are important
clues to the presence of vertical shear fractures.15 The vertical
shearing forces transmitted through the bony pelvis are also transmitted through the rich vascular network and nerve plexus that
are directly adjacent to the bone. This activity accounts for the
major hemorrhage and neurologic injuries associated with vertical
shear fractures.
Vertical Sacral Fractures. A crucial distinction in considering
sacral fractures is that transverse fractures do not involve the
pelvic ring, but vertical fractures do. Vertical sacral fractures are
caused by high-energy injuries and were classified by Denis
into three groups according to whether the fracture line extends
(1) laterally to the sacral foramina, (2) through the foramina, or
(3) medially to the foramina, involving the central spinal canal29
(Fig. 55-10). The radiographic diagnosis of this fracture hinges on
careful examination of the symmetrical cortical lines that are normally present at the superior margins of the sacral foramina on
the AP view. Disruption, distortion, or asymmetry of these lines
is an important marker of sacral fractures.26
There is a high risk of neurologic complications associated with
these injuries: 6% when lateral to the foramina, 28% when through
the foramina, and 58% when medial to the foramina.29 Neurologic
dysfunction correlates to the nerve roots involved but may include
any bowel, bladder, or sexual dysfunction. Surgery is commonly
662 PART II ◆ Trauma / Section Three • Orthopedic Lesions
2
1
5
2
5
1
5
5
3
3
4
A
B
4
2
2
1
C
1
2
1
2
1
D
Figure 55-8. Lateral compression fracture. A and B, Anteroposterior view of the pelvis. (1) Normal sacral foraminal lines on the left; (2) sacral
foraminal lines on the right are indistinct and do not mirror the normal side, indicating the subtle second break in the pelvic ring; (3) and
(4) fractures of the superior and inferior pubic rami are overriding and displaced, indicating the lateral compression forces (there must be a
second break in the pelvic ring); (4) is the “bucket-handle” fracture; (5) normal sacroiliac joints. C and D, Computed tomography scan of same
pelvis. (1) Normal sacroiliac joints, (2) compression fracture of the sacrum through the foramen corresponding to the loss of definition of the
foraminal lines in A and B.
performed for fractures associated with neurologic dysfunction,
with the goals of bony fixation of the sacrum and decompression
of affected nerve roots.
Open Pelvic Fractures
An open pelvic fracture is present when there is direct com­
munication between the fracture site and a skin, rectal, or vaginal
wound. These are potentially lethal injuries, especially if the
open nature is not recognized: hemorrhage accounts for early
mortality, but infection, sepsis, acute respiratory distress syndrome, and multisystem organ failure are all causes of delayed
death.24,30 The majority of case series before 1991 reported mortality rates greater than 50%; rates reported from 1991 to 1999
ranged from 5 to 30%,30 although a recent series reported a 45%
mortality rate.31
The skin over the posterior pelvis and gluteal area and perineum
is inspected carefully for wounds. Some fractures are open only by
virtue of a bone spicule penetrating the vagina or rectum and are
identified by careful digital rectal examination (DRE) and vaginal
examination. Hemorrhage from a large open laceration should be
treated by direct manual pressure or pressure dressing. Pelvic fractures communicating with the rectum have traditionally mandated a diverting colostomy; however, a systematic review of the
literature on this topic found no difference in infection rates
between patients treated with colostomy and those treated
without.32
Penetrating Pelvic Trauma
Because of the complex anatomy of the viscera, blood vessels, and
nerves within the pelvis, penetrating trauma to this area presents
a major challenge. Overall mortality in this group of patients has
been reported to be 6 to 12%, but the mortality rate of patients
in shock is 50%.33,34 Vascular injuries singly and in combination
may involve the aorta; common iliac artery; and external, internal,
and common iliac veins. Injuries to genitourinary structures and
hollow viscera may occur, with fecal contamination from colorectal injury being a major concern. When present, the finding of
blood on DRE is an important clue that rectal injury has occurred.
Emergent surgical consultation is required in all cases of penetrating pelvic trauma.
Chapter 55 / Pelvic Trauma 663
L3
4
4
L4
2
3
L5
1
5
1
5
B
A
1
C
2
1
2
D
Figure 55-9. A and B, Vertical shear fractures bilaterally. At first glance the pelvis appears normal because of the smooth, uninterrupted arcuate
line, but careful interpretation reveals the extremely critical nature of the injuries. (1) Fractures through the sacrum—note loss of definition and
symmetry of sacral foramina, indicating vertical fractures through both sides of the sacrum (see computed tomography scan in D). (2) Transverse
process fragment from right L5 (iliolumbar ligament attachment) is pathognomonic for a vertical shear fracture through the right sacrum. (3) Transverse process fragment from left L5, pathognomonic for a vertical shear fracture through the left sacrum. (4) Both hemipelves are
dislocated cephalad because of the double-ring fractures through each side of the sacrum. This dislocation explains why the L5 transverse
processes appear so close to the iliac crests (the body of L5 is obscured because of rotational dislocation of the central free sacral fragment
posteriorly and because of technique). (5) Normal sacroiliac joints. C and D, Computed tomography scan of same pelvis. (1) Bilateral comminuted
fractures of sacrum with lateral displacement of both hemipelves, (2) normal sacroiliac joints.
BOX 55-3
Radiographic Clues to Posterior Arch Fractures
Avulsion of L5 transverse process*
Avulsion of ischial spine*
Avulsion of lower lateral lip of the sacrum (sacrotuberous
ligament)*
Displacement at the site of a pubic ramus fracture
Asymmetry or lack of definition of bone cortex at superior
aspect of the sacral foramina
*Indicates mechanical instability.
CLINICAL FEATURES
History
Understanding the mechanism of injury is an important means
of determining a patient’s risk of having a pelvic fracture and,
if present, the pattern and severity of the fracture. Low-energy
injuries (e.g., fall on level ground) typically cause stable injuries
to the pelvis; patients who have sustained high-energy injuries
(e.g., MVCs, falls from heights) are at risk for unstable fracture
patterns of the pelvis as well as associated injuries to other organ
systems.
Determining the direction of forces applied to the pelvis can
also give important clues to the types of injury sustained. AP
forces (e.g., head-on MVCs) may cause open-book injuries to the
pelvis. Lateral forces to the pelvis (e.g., side-impact collisions) may
disrupt the posterior ligaments; however, the pelvic floor generally
remains intact. Vertical shear injuries (e.g., falls from height) may
disrupt the posterior ligaments and pelvic floor, causing gross
instability of the pelvis.
Age is an important consideration in patients with pelvic fracture. Osteopenic bone may be disrupted by lesser forces. Furthermore, studies consistently demonstrate higher morbidity and
mortality among elderly patients with pelvic fracture. Although
pelvic hemorrhage remains an important consideration among
elderly patients with pelvic fracture, higher mortality rates are
further influenced by a greater prevalence of preexisting medical
conditions in this population that increase the risk of death from
multisystem organ failure.35,36 Decreased physiologic reserves in
older patients may limit success in the acute resuscitation and
definitive treatment of injuries.
Injuries to other organ systems are extremely common in
patients with pelvic fracture.2,4,5 It is important to identify all
major injuries to other organ systems to prioritize definitive surgical treatment for the multiply traumatized patient. In women, it
is important to consider the possibility of pregnancy and to test
for pregnancy whenever appropriate.
664 PART II ◆ Trauma / Section Three • Orthopedic Lesions
I
I
II
III
II
Zone I
Zone II
Zone III
Figure 55-10. The Denis classification of vertical sacral fracture. Zone I is lateral to the sacral foramina (known as the sacral ala). Zone II is
transforaminal. Zone III is the central sacrum medial to the foramina.
Physical Examination
On inspection, rotation of the iliac crests indicates a serious pelvic
fracture. Leg-length discrepancy may suggest a hip injury or cephalad migration of an unstable hemipelvis. Careful inspection of the
skin and skin folds is necessary to identify open fractures. Perineal
or genital ecchymosis or hematoma may be observed, and in cases
in which many hours have elapsed since the injury, ecchymosis in
the periumbilical area (Cullen’s sign) or flanks (Grey Turner’s sign)
from retroperitoneal hemorrhage may be present. Careful palpation of the pelvic ring to seek the presence of point tenderness is
imperative; palpation starts at the symphysis anteriorly and proceeds to both pubic rami, the iliac spines and crests, and finally to
the sacrum and SI joints posteriorly. The presence of tenderness
in any of these locations is an important indicator of pelvic ring
injury in alert patients without distracting injury.37
Manipulation of the pelvis during physical examination should
be gentle and kept to a minimum. “Springboarding” of the pelvis
(i.e., vigorous downward pressure on the anterior superior iliac
spines) to assess the rotational stability of the pelvic ring should
be strictly avoided, as this maneuver has the potential to disrupt
any tenuous blood clotting that may have occurred around a fracture site and may therefore worsen hemorrhage.
The penis should be milked to examine for blood at the meatus.
Although the value of the DRE has been questioned in the literature with claims that it has extremely low sensitivity as a diagnostic
test, it remains useful as a screening tool.38 The DRE should evaluate sensation, sphincter tone, position and consistency of the pro­
state, presence of a presacral hematoma, bony contour of the
sacrum and coccyx, mucosal penetration of bony spicules, and
presence of frank or occult blood. In the setting of a pelvic fracture, female patients should undergo a vaginal examination to
diagnose an open fracture. Because it is possible to create an open
fracture iatrogenically through the vaginal or rectal wall, DRE and
vaginal examination should be performed carefully, especially in
an unconscious patient who cannot localize pain. The examiner
should be mindful when performing these examinations that bony
spicules can lacerate the examining finger. Extravasated urine may
be detected in the scrotum or the subcutaneous tissues of the
penis, vulva, or abdominal wall. The presence and quality of pulses
in the lower limb should be assessed, as should sensation, strength,
and deep tendon reflexes.
Associated Pelvic Injuries
Urologic Injury
The overall incidence of bladder or urethral disruption associated
with any pelvic fracture is approximately 4 to 6%, with increased
risk among those with severe pelvic injuries.2 Because the urethra
is far less exposed in women than in men, injury to the urethra in
women with pelvic fracture is rare.39,40
A review of 721 patients with pelvic fracture revealed an incidence of bladder rupture in 5% of patients. Those with fractures
of the anterior arch of the pelvis are at greatest risk for bladder
injury: diastasis of the symphysis more than 1 cm and fracture
around the obturator ring with displacement greater than 1 cm
were associated with a tenfold and threefold increased risk of
bladder rupture, respectively.41
The presence of gross hematuria indicates injury of the lower
urinary tract. Blood at the urethral meatus necessitates a retrograde urethrogram followed by a cystogram. Gross hematuria is
investigated with a combination of urethrography, intravenous
pyelography, cystography, and CT. The sequence and types of
examinations are individualized for each patient. Fracture to the
inferomedial pubic ramus and increasing symphyseal diastasis
have both been shown to be predictive of urethral injury.42 Of
note, it has been reported that retrograde urethrocystography
done before CT of the pelvis may impair the ability of CT to detect
extravasation of contrast that would indicate active pelvic bleeding.43 Therefore if CT is to be performed, it should be done before
retrograde urethrocystography.
Sexual dysfunction in both men and women is a recognized
complication of pelvic trauma. The incidence of impotence
associated with urethral rupture is significant. In the absence of
urethral injury, sexual dysfunction in men still may occur secondary to neurovascular disruption associated with the pelvic
fracture.38
Neurologic Injury
The risk of neurologic injury has been shown to correlate with
instability of the pelvic injury, with a reported incidence of neurologic dysfunction of 1.5, 3.8, and 14% in Tile type A, B, and C
fractures, respectively; acetabular fractures were associated with a
10% incidence of neurologic dysfunction.45 Neurologic injury
occurs commonly in patients with vertical sacral fractures or
transverse fractures above the S4 level. Among patients with vertical fractures that involve the foramina, 28% have associated neurologic deficits. In patients with fractures medial to the foramina
involving the spinal canal, 57% have neurologic deficits.29
Cauda equina syndrome and various plexopathies and radiculopathies may occur as follows. Injury to the L5 root may cause
weakness of muscles in the anterior tibial compartment and
sensory deficits in the dorsum of the foot and lateral calf. Injury
to S1 and S2 roots may cause weakness of hip extension, knee
flexion, and plantar flexion and sensory deficits on the posterior
Chapter 55 / Pelvic Trauma 665
aspect of the leg, sole and lateral foot, and genitalia. Injury to S2-5
roots and distal afferent, efferent, and autonomic fibers causes
sensory deficits in the perineum, sexual dysfunction, and bowel
and bladder dysfunction. Cauda equina syndrome may be fully or
partially present with sacral fractures. Hyperesthesia and later
anesthesia occur in a saddle-shaped distribution in the groin; in
addition, weakness of ankle plantar flexion, hamstrings, and
gluteus muscles and decreased or absent ankle jerk are present.
With involvement of the lower sacral roots, a neurogenic bladder
with overflow incontinence, motor and sensory deficits in the
lower extremities, anal sphincter dysfunction, and sexual dysfunction may occur. All patients with neurologic deficits from sacral
fractures require orthopedic or neurosurgical consultation.
Gynecologic Injury
Blood at the introitus may indicate a urethral injury, open pelvic
fracture, or local laceration without communication with the bony
pelvis. Delayed urologic and sexual dysfunction and complications
with pregnancy are common after pelvic injury.46 Gynecology consultation is indicated when there is injury to the female reproductive tract in association with a pelvic fracture and for all pregnant
women who sustain pelvic fracture of any kind.
Associated Nonpelvic Injuries
The magnitude of force required to disrupt the pelvis commonly
results in severe injuries to other organ systems. Among those
patients who die with pelvic fracture, it is rare that the pelvic
fracture is an isolated injury.1,2,19,47,48 Furthermore, associated injuries among trauma patients with pelvic fracture may contribute
more to mortality than the pelvic injury itself.10
Some authors have described patterns of associated nonpelvic
injuries with certain patterns of pelvic fracture; however, these
findings have not been consistently reproduced in the literature.19,49 Severe injuries to head, spine, thorax, and abdomen may
occur with both stable and unstable pelvic fractures; they may
all occur with all major mechanisms of pelvic injury. One associated injury that reflects the dispersion of enormous forces
throughout the body is the rupture of the thoracic aorta; albeit
uncommon in blunt trauma, it is five to eight times more likely
in older patients with pelvic fracture.2,50 Therefore the diagnosis
of a pelvic fracture should prompt a careful evaluation for other
system injuries.
DIAGNOSTIC STRATEGY
Radiology
Plain Radiography
Routine radiographs of the pelvis are not necessary in cases of
blunt trauma if the patient is asymptomatic, awake, and alert and
has normal findings on physical examination of the pelvis.51-54
However, routine AP plain radiography of the pelvis (PXR) is
advised by the Advanced Trauma Life Support (ATLS) guidelines
for patients with severe mechanisms of injury who are symptomatic or whose examination is compromised by either decreased
level of consciousness or distracting injuries.
On the AP radiograph, the symphysis pubis is normally
no more than 5  mm wide, and a small (1- or 2-mm) vertical
offset of the left and right pubic rami is normal.26 Overlapping
at the symphysis pubis is abnormal and is the result of a severe
crushing injury. Normally the SI joint is approximately 2 to
4  mm wide.26
On the AP view, the physician may judge the degree of pelvic
rotation caused by technique and positioning by the presence of
asymmetry in the size and shape of the left and right obturator
foramina and iliac wings. Diastasis of the SI joint also causes an
asymmetrical appearance of the obturator foramina and the iliac
wings: If there is displacement into external rotation, the affected
iliac wing appears broader, and the anterior iliac spine appears
more prominent.26 Avulsion fracture of the fifth lumbar transverse
process by the iliolumbar ligament often accompanies an SI joint
disruption or a vertical sacral fracture and is a valuable clue to
posterior arch injuries26 (see Fig. 55-9 and Box 55-3).
The reliability of the single AP PXR to detect pelvic fractures
has been questioned in the literature. Two case series have reported
sensitivities of only 64 and 68% with specificities of 90 and 98%,
respectively, thus prompting the question of whether PXR is necessary at all when patients are to undergo immediate abdominopelvic CT evaluation.55,56 In particular, sacral fractures and SI joint
disruptions are not well visualized on the AP view.57 However, the
addition of inlet and outlet views of the pelvis has been shown to
increase the sensitivity and specificity of plain radiographs in
detecting significant pelvic fracture (Fig. 55-11) and SI joint disruption and should be considered in all patients with presumed
stable anterior pelvic ring injuries with any complaints of posterior pelvic pain.58
When patients are too unstable to undergo CT investigation,
the AP PXR is useful in screening for pelvic injuries that are most
associated with major blood loss and potentially require urgent
intervention.59,60 That is, although PXR may miss many fractures,
a very abnormal PXR is predictive. Findings that predict the need
for transfusion include open-book fracture or displacement of
0.5 cm or more at any fracture site in the pelvic ring and displaced
symphysis pubis, displaced obturator ring fracture, or obvious
vertical displacement in the posterior pelvis.61,62 It is important to
note that all of these signs may be associated with posterior pelvic
injury. Therefore the PXR remains a vital test when CT cannot be
immediately performed and should be used to alert both surgeons
and angiographers of the potential need for definitive management of pelvic hemorrhage.63
Computed Tomography
CT is the imaging test of choice for evaluating the injured pelvis.
CT provides detailed information about the posterior arch and
rotational deformities that indicate the relative stability of the
pelvic ring; furthermore, the acetabulum, which may be difficult
to assess with plain radiographs, can be well visualized with CT.
CT has demonstrated a much higher sensitivity and specificity
than plain radiography in detecting pelvic fracture.55,56 Furthermore, abdominopelvic CT provides detailed information about
concomitant injury to abdominal organs that aids in the planning
of laparotomy, external fixation of the pelvis, angiography, and
definitive orthopedic management of the pelvic injury. Finally, it
has been demonstrated that selective CT scanning of the chest,
abdomen, and pelvis in patients who sustain high-energy trauma
results in a high miss rate of important diagnoses that alter treatments plans versus “pan” CT scanning (i.e., including all of the
head, neck, chest, abdomen, and pelvis).64,65 It should be noted that
the decision to “pan” CT scan should be based on a combination
of factors, such as abnormal vital signs, neurologic status, the
detection of injuries on clinical examination, and the patient’s
mechanism of injury. Clinical judgment should guide the decision,
to avoid wasting resources and unnecessarily exposing patients to
radiation.
Given the speed with which current CT scanners are able to
obtain images, unless patients require immediate lifesaving surgical treatment in the operating room, it is recommended that all
patients with high-energy mechanisms of injury with suspected
pelvic fracture or pelvic fracture confirmed by PXR undergo CT
investigation.
666 PART II ◆ Trauma / Section Three • Orthopedic Lesions
Inlet
Outlet
1
B
A
2
1
3
4
5
C
Figure 55-11. A, The inlet and outlet views. The inlet view is angled 60 degrees to the plate from head to feet; the outlet view is angled 30
degrees in the opposite direction. Both views can be obtained with a portable machine if necessary. Injuries to the sacrum and sacroiliac joint are
commonly difficult to visualize with the anteroposterior view only. The combination of all three views allows the identification of virtually all
significant injuries to the bony pelvis. B, Inlet of pelvis is well demonstrated in this radiograph of a unilateral vertical shear fracture with cephalad
and posterior displacement of the left hemipelvis. C, Schematic of unilateral vertical shear fracture. (1) Normal sacral ala on the right side, (2) left
sacral ala is indistinct because of a vertical fracture, and the cephalad and posterior displacement of this hemipelvis is shown by this inlet
projection, (3) ischial spine on the left is partially obscured by bowel gas, but it is located more cephalad compared with the right spine because of
cephalad displacement of the left hemipelvis, (4) fractured left superior pubic ramus with displacement cephalad, (5) the inlet view is taken looking
through the superior and inferior pubic rami, which are superimposed so that the obturator foramina are not seen.
Evaluation of Hemorrhage
Hemorrhage is the most devastating direct complication of pelvic
fracture. In the original series of high-energy pelvic injuries used
to formulate their classification system, Burgess and colleagues
analyzed blood transfusions and found that an average of 14.8
units were required in the AP compression group, 9.2 units in the
vertical shear group, and 3.6 units in the lateral compression
group.16 The correlation between transfusion requirements and
type of pelvic fracture has been confirmed in more recent studies
that demonstrate that unstable fracture patterns increase the need
for transfusion and risk of mortality,63 with one series reporting a
median of 10 units of blood required (range 1-70 units).3
Major pelvic hemorrhage results from lacerations of the rich
vascular network supplying the pelvis in the retroperitoneal space.
Pelvic hemorrhage is commonly venous in origin and may be
contained and tamponaded retroperitoneally by an intact peritoneum. However, it is possible for bleeding to extend beyond the
retroperitoneum and dissect into the anterior abdominal wall (to
the chagrin of the unwary clinician who introduces a scalpel or
peritoneal dialysis catheter) or through the peritoneum into the
Chapter 55 / Pelvic Trauma 667
abdominal cavity (see later). Bleeding also may occur from the
marrow at the fracture sites.66 Finally, coagulopathy is another
cause of persistent retroperitoneal bleeding and should be considered when the patient does not respond to fluid and blood
replacement.
The combination of both pelvic and intra-abdominal bleeding
is associated with devastating outcomes.63 In one large series,
major pelvic injury was associated with intra-abdominal injuries
in 31% of cases; the liver and spleen were injured in 10 and 6%
of these cases, respectively.2 In the patient with pelvic fracture
who is in shock, it is important to establish early whether there
is hemorrhage within the abdominal cavity necessitating laparotomy. Diagnostic strategies for evaluation of pelvic fracture–
associated hemorrhage include diagnostic peritoneal lavage
(DPL), ultrasound, and CT. Regardless of the modality of evaluation, it is crucial to avoid unnecessary laparotomy because
of the higher mortality rate for hemodynamically unstable
patients with pelvic fractures who undergo a negative abdominal
exploration.
Diagnostic Peritoneal Lavage
DPL is a widely accepted, rapid, and accurate means of establishing the presence of intra-abdominal hemorrhage. Although it has
been largely supplanted in many centers by ultrasound and CT,
DPL nevertheless remains an effective tool to assist with difficult
triage decisions in the trauma patient. A pelvic fracture presents a
special situation for DPL because of the possibility that a retroperitoneal hematoma may dissect into the anterior abdominal
wall. However, when a fully open technique is used (i.e., the peritoneum is entered under direct visual control), the false-positive
and false-negative rates are each 0.7%.67
DPL may be performed in the infraumbilical location in most
patients; however, the supraumbilical location should be used if
any of the following conditions are present: prior abdominal scars,
time delay since the injury of more than 1 hour, or a hematoma
encountered during the procedure.67
A negative peritoneal aspirate indicates that the peritoneal
cavity is not a major source of bleeding or a significant contributor
to hemorrhagic shock. If external and thoracic sources of blood
loss and spinal cord injury have been eliminated as causes of
hemodynamic instability, a negative peritoneal aspirate in a patient
with a major pelvic fracture indicates pelvic hemorrhage. A combination of angiography with rapid therapeutic embolization,
surgical packing of the pelvis, and mechanical fracture stabilization should be pursued.
Gross aspiration of blood indicates possible major intraabdominal hemorrhage, and laparotomy is recommended at the
earliest opportunity for hemodynamically unstable patients.47 The
lavage that is positive by cell count criteria alone is a special situation. If these patients are hemodynamically unstable, it is advisable to perform angiography with therapeutic embolization and
external pelvic fixation before laparotomy.66,67
Ultrasound
Focused assessment with sonography in trauma (FAST) is widely
used to identify free intraperitoneal fluid in the trauma patient.
An important caveat to note is that FAST is not helpful for evaluating the retroperitoneal space where pelvic hemorrhage occurs.
Although a positive FAST study that shows free fluid is widely used
as a triage point to decide on laparotomy in a hemodynamically
unstable patient, its reliability in patients with major pelvic injury
has been questioned. Sensitivities ranging from 24 to 81% and
specificities ranging from 87 to 96% for the detection of hemoperitoneum have been reported68,69 in patients with pelvic fracture;
the presence of pelvic fracture has been reported to be a predictor
of a false-negative FAST examination, with an odds ratio of 3.5
(95% confidence interval 1.3-9.2).70
Although these reports come from retrospective case series—
and therefore do not necessarily represent the highest levels of
evidence—the high incidence of false-negative FAST examinations reported in the literature in patients with pelvic injury is
nonetheless cause for concern. This is because pelvic and intraabdominal hemorrhages are highly associated and in combination
result in major blood loss.63
Computed Tomography
CT is unquestionably the diagnostic test of choice for detecting
pelvic and intra-abdominal injuries. It reveals bleeding in both
the peritoneal and retroperitoneal spaces. CT with intravenous
contrast often can distinguish a stable hematoma from ongoing
bleeding from pelvic arteries. The presence or absence of extra­
vasated intravenous contrast material on CT scan of the pelvis
is useful in predicting which patients will require therapeutic
angiography71; however, its absence does not rule out ongoing
pelvic bleeding: One series found the sensitivity for the detection
of arterial bleeding by CT to be only 66% in patients who
also underwent angiography.72 It is worth noting that with
improving CT technology, its use will continue to evolve for
patients with pelvic hemorrhage. Specifically, pelvic CT angiography (CTA) has been reported to not only localize active pelvic
bleeding but also distinguish bleeding from an arterial versus a
venous source.73,74 This is a distinction that could have great
impact on the decision to perform therapeutic angiography for
active arterial bleeding. Advancing CT technology will require
further study to define its role in patients with pelvic hemorrhage, but it is likely that it will also be concurrently incorporated
into clinical practice.
MANAGEMENT
Resuscitation
The mortality rate in patients with blunt trauma who have the
combination of pelvic ring fractures and hemorrhagic shock is
approximately 50%.1,2 ATLS guidelines advocate the initial use of
crystalloid solutions to stabilize vital signs in the trauma patient.
However, when severe hypotension is present in patients with
severe pelvic fracture, transfusion of blood products (including
packed red blood cells, plasma, platelets, and occasionally cryoprecipitate) is crucial early in the resuscitation. Some patients appear
to achieve hemodynamic stability after minimal volume infusion
only to decompensate precipitously. It is important to note that
case series commonly report patients with severe pelvic injury
who require transfusion of packed red blood cells on the order of
10 to 20 units within the first 24 to 48 hours.
The endpoint for fluid resuscitation should be evidence of
end-organ perfusion. A large body of evidence from animal
studies suggests that standard volumes of crystalloid fluids typically used in traumatic hemorrhagic shock to restore normal
heart rate and blood pressure lead to greater volumes of blood
loss compared with low-volume resuscitation strategies that
accept lower systemic blood pressures.75,76 Furthermore, in a
landmark human study of hypotensive patients with penetrating
chest injury, it was shown that delaying fluid resuscitation
(despite systolic blood pressure below 90 mm Hg) resulted in a
higher rate of discharge from the hospital than did immediate
fluid resuscitation.76a
For patients with pelvic fracture, attempts to achieve a normal
pulse and blood pressure with fluid resuscitation in the ED are
unrealistic and should not delay more definitive treatments to halt
the hemorrhagic process.
668 PART II ◆ Trauma / Section Three • Orthopedic Lesions
Lower limb intravenous sites should be avoided in patients with
severe pelvic fractures because the infused products may be delivered to the retroperitoneal space.
Box 55-4 details the methods for controlling hemorrhage in the
ED phase of the care of patients with pelvic fractures.
Control of Hemorrhage
In addition to blood transfusion, two important therapeutic
modalities for control of hemorrhage are mechanical stabilization
of the pelvis and angiographic embolization. There has been some
debate as to which of these modalities should take precedence, and
this has been predicated on institutional availability. As a general
rule, angiography with therapeutic embolization of bleeding
arteries is more effective than and takes precedence over invasive
external fixation.77,78
BOX 55-4
Pelvic Fracture–Related Hemorrhage: Goals
in the Emergency Department
1. Resuscitation: Recognize the patient who is in hemorrhagic
shock, and initiate blood transfusion early in the
resuscitation.
2. Recognition: Realize that patients with posterior arch injuries
are at higher risk for pelvic hemorrhage.
3. Evaluation: Identify associated nonpelvic injuries (especially
head, chest, and intra-abdominal) that contribute immensely
to increase in mortality in patients with pelvic fracture.
4. Stabilization: Wrapping the pelvis in a sheet and towel
clamps is the easiest way to immobilize the pelvis in the
emergency department. Stabilization by external fixation or
pelvic C-clamp should be performed by orthopedic surgeons.
5. Control of pelvic bleeding: Angiography is highly effective in
treating pelvic arterial hemorrhage. Pelvic packing during
laparotomy is another way of controlling bleeding.
Institutional practices determine if one or both techniques
are used.
Stabilizing the Pelvis
Noninvasive Techniques. The most readily available means to
quickly stabilize the pelvis in the ED may be realized with a simple
sheet and towel clamps. Wrapping the pelvis tightly with a sheet
and securing this with towel clamps has been shown to be effective
in reducing an open-book pelvic injury (Fig. 55-12),79,80 thereby
reducing the potential volume in the pelvis for blood loss. A technique of taping the lower extremities in internal rotation has also
been described as a means of achieving a closed pelvic reduction
in the presence of symphyseal diastasis.81
Other commercial circumferential compression devices have
been developed to facilitate noninvasive stabilization of the pelvis.
Generally speaking, in cadaveric studies, it appears these devices
are effective at reducing the open-book pelvis.82,83 One retrospective comparison of patients with exsanguinating pelvic hemorrhage found that patients treated with a noninvasive splinting
device had substantially lower transfusion requirements than
those who had formal external fixation of the pelvis performed
emergently (4.9 units vs. 17.1 units in the first 24 hours, P = .008).
However, there was no statistically significant change in mortality
between the two groups (26% vs. 37%, P = .11).84
Patients who have sustained AP open-book injuries are likely
to derive the most benefit from tight wrapping of the pelvis.
This maneuver may not be desirable when lateral compression
forces have already internally rotated the hemipelvis because
indiscriminately forceful wrapping may, in fact, worsen the degree
of displacement. Here, some judgment is required to discern
whether one is wrapping the pelvis to reduce the volume of an
externally rotated pelvis versus splinting a pelvis to minimize
pelvic movement that may occur, especially when the patient is
transferred.
Invasive Fixation. External fixation of the pelvis is performed by
orthopedic surgeons. The goal of fixation is to prevent movement
at pelvic fracture sites and attendant bleeding.15 Although the
acute application of an external fixator has not been proved to
A
B
C
D
Figure 55-12. A, Circumferential pelvic antishock sheeting is applied in this example patient. The patient’s clothing should be removed before
application. The sheet is positioned beneath the patient’s pelvis smoothly. The ends of the sheet are crossed in an overlapping manner anteriorly
(B) and are pulled taut (C). Clamps secure the smooth and snug sheet (D).
Chapter 55 / Pelvic Trauma 669
decrease morbidity or mortality in a prospective study, there is
evidence that this technique improves clinical outcome by limiting
hemorrhage and restoring mechanical integrity.66 Application of
the fixator is time-consuming; therefore it should not delay more
definitive treatment of pelvic bleeding by angiography or the
treatment of other sources of severe blood loss. The timing of the
application of the external fixator requires coordination among
the trauma surgeon, orthopedic surgeon, and interventional radiologist. Early surgical consultation is vital to efficient planning and
prioritization of surgical management.
Many stable AP and lateral compression fractures can be treated
definitively by the external fixator.15 When the pelvis is vertically
displaced, traction combined with external fixation is necessary to
reduce the pelvis pending definitive open surgical repair.15 Most
fixators can be constructed to allow convenient surgical access to
the abdomen and groin.
The pelvic C-clamp is one type of external fixation device that
can theoretically be applied rapidly by the orthopedic surgeon in
the ED to externally stabilize the posterior pelvic arch on an emergency basis.85 It is likely more effective in reducing AP than vertical
injuries.86 Institutional practices may influence the use of C-clamp
over standard external fixation. Although the C-clamp may aid in
stabilizing blood loss, its application does not obviate the need for
angiography.87 It is unclear whether the C-clamp offers any additional advantage over wrapping the pelvis with a sheet during
initial resuscitation efforts.
The specific mode of invasive fixation will be institution specific
and will rely heavily on the experience of the treating orthopedic
surgeons.
Angiography and Embolization
Arteriography and venography have been investigated for managing hemorrhage associated with pelvic fractures. Although pelvic
bleeding is commonly venous in origin, venography is not useful
in managing these cases; the extensive anastomoses and valveless
collateral flow make embolization ineffective. In contrast, arteriography is excellent at both diagnosing and managing arterial
bleeding.
Arteriography is performed with the contrast material injected
through the femoral artery on the less-injured side or via the
upper extremity. The examination starts above the level of the
aortic bifurcation and proceeds to selective branches of the internal iliac (hypogastric) artery. Transcatheter embolization with
thrombogenic coils, foam, or spherules is used to stop the hemorrhage from the branches of the internal iliac artery.
Embolization is highly effective for controlling arterial bleeding. One case series of 556 patients undergoing pelvic angiography reported that repeat angiography was necessary in only
7.5% of patients as a result of ongoing bleeding. These authors
found that hypotension, a need for more than 2 units of packed
red cells, symphysis widening, and more than two arteries embolized at the first angiogram predicted the need for repeat
angiography.88
Angiography is indicated when hypovolemia persists in a
patient with a major pelvic fracture despite control of hemorrhage
from other sources. Although it is impossible to determine whether
bleeding is venous or arterial in origin until angiography is performed, one study found that inadequate response to initial resuscitation (defined as failure to maintain a systolic blood pressure
above 90 mm Hg after the administration of 2 or more units of
packed red cells or less) and the presence of contrast extravasation
on admission CT were both indicative of active arterial bleeding.77
Although the presence of contrast extravasation on CT is an indication for angiography, the absence of contrast blush on CT is not
sufficient to rule out serious pelvic bleeding.77 SI joint disruption,
persistent systolic blood pressure below 100 mm Hg, and female
gender were shown to be predictors of need for embolization at
the time of angiography.89
The timing of angiography is individualized for each patient
depending on priorities for treatment of concomitant injuries.
Posterior arch disruptions are associated with the most severe
hemorrhage; angiography should be considered at an early stage
for these patients. Whether patients undergo angiography immediately from the ED or angiography immediately precedes laparotomy, it is important to be mindful of the logistical delay that
often occurs in mobilizing the angiography team, so this intervention should be anticipated as early as possible. The transfer of the
patient to the angiography suite also requires orchestrating
the necessary personnel and equipment to care for the critically
injured patient there. The feasibility of use of mobile angiography
equipment in the ED for acutely controlling pelvic hemorrhage
has been reported; this removes the usual logistic delays while
ensuring a greater degree of safety in monitoring patients during
the procedure.90
Hemodynamically Unstable Patients with Pelvic
and Intra-abdominal Hemorrhage
Patients who hemorrhage from both the pelvis and the abdomen
have mortality rates above 40% and deserve special consideration.
These patients may be too unstable to undergo CT imaging.
Prioritizing the need for laparotomy versus angiography in these
patients may be challenging when the need for laparotomy is
based on the detection of intra-abdominal fluid by FAST or DPL.
Unnecessary laparotomy performed in patients who are hemodynamically unstable with pelvic fracture has been shown to contribute to high mortality rates.91 Therefore in these cases, it is
crucial that the efforts of the general surgeon, orthopedic surgeon,
and interventional radiologist be coordinated to optimize the
timing of necessary procedures.
Gross aspirates of blood on DPL are strong indicators for
prompt laparotomy. Given the high rates of false-negative FAST
examinations in pelvic trauma, caution should be used in making
difficult triage decisions regarding laparotomy versus angiography on the basis of FAST findings in this setting. However,
when the FAST examination does reveal hemoperitoneum, it is
generally accepted that laparotomy be pursued first.92 When concurrent pelvic bleeding is highly suggested (e.g., severe openbook pelvis), it is advisable that angiography promptly follow
laparotomy.
At the time of laparotomy, it may be appropriate for the orthopedic surgeon to place either an external fixator or a pelvic
C-clamp. Packing of the pelvis at the time of laparotomy has been
reported as a means to obtain hemostasis in pelvic hemorrhage.93,94 Although there is limited evidence from clinical studies
to support packing, it has become a mainstay of treating pelvic
hemorrhage at some centers, especially in Europe. Part of the
rationale for use of packing rather than angiography is the fact
that pelvic bleeding is commonly venous in origin, for which
arteriography is useless. In contrast, packing may aid in tamponading bleeding from the posterior venous plexus. It is recommended that the pelvis be stabilized before packing to provide
solid structural support against which packing may be performed.94 Intraperitoneal, retroperitoneal, and extraperitoneal
techniques of packing have been described, with authors reporting retroperitoneal and extraperitoneal approaches being rapidly
done even in the ED setting.94,95 A systematic review of pelvic
packing concluded that for patients with hemodynamic instability
caused by pelvic hemorrhage, packing could be used as a temporizing measure for control of bleeding until more selective treatments could be performed.96
When FAST or DPL does not reveal hemoperitoneum in the
presence of severe pelvic fracture, emergent angiography should
670 PART II ◆ Trauma / Section Three • Orthopedic Lesions
A
B
C
Figure 55-13. Universal classification of acetabular fractures. A, Type A: Fractures of one column or one wall, for example, posterior column
(left) and anterior (right) column. B, Transverse or T-type fractures involving both columns but by definition leaving a fragment of articular cartilage
attached to the proximal ilium and, thus, to the axial skeleton. C, Type C: Two-column fracture of the acetabulum. By definition, no portion of the
articular surface remains attached to the axial skeleton because fracture of both columns of the ilium is proximal to the joint. (From Tile M:
Fractures of the Pelvis and Acetabulum, 3rd ed. Philadelphia, Lippincott, Williams & Wilkins, 2003.)
BOX 55-5 Classification of Acetabular Fractures
Type A
Fractures of one column of the acetabulum (anterior or
posterior column).
Type B
Transverse (T-type) fractures through both anterior and posterior
columns; portion of acetabulum remains attached to proximal
ilium.
Type C
Transverse (T-type) fractures through both anterior and posterior
columns; no portion of acetabulum remains attached to axial skeleton.
b
d
a
e
f
c
From Tile M: Fractures of the Pelvis and Acetabulum, 3rd ed. Philadelphia,
Lippincott, Williams & Wilkins, 2003.
be arranged. If pelvic bleeding continues despite angiography (i.e.,
secondary to venous bleeding), open stabilization and packing
should be considered as the next step.
For any trauma center, planning for challenging clinical situations by emergency physicians, trauma surgeons, and angiographers and the creation of protocols for care may be useful in
optimizing a timely and coordinated response.78,97,98
Acetabular Fractures
Many pelvic fractures in adults involve the acetabulum. Pain and
inability to bear weight are the hallmark complaints associated
with acetabular fractures. On clinical examination, tenderness
with percussion of the heel of the foot or medial pressure on the
greater trochanter is an important clue to the presence of an
acetabular fracture. It is important to note the presence of neurologic deficit, as the sciatic nerve is commonly injured. A common
mechanism of acetabular injury is the so-called “dashboard”
injury whereby the knee of a person seated in the front seat of a
car strikes the dashboard in sudden deceleration, driving the head
of the femur into the acetabulum; as a result, concurrent fracture
or dislocation of the patella (or both) are common.
Acetabular fractures are broadly classified into three types15
(Fig. 55-13 and Box 55-5).
Type A fractures may be subdivided into anterior and posterior
column injuries. Posterior wall fractures are the most common
acetabular injuries and are generally caused by a forceful impact
to a flexed knee (e.g., dashboard injury)—the force is transmitted
up through the femur through the posterior acetabulum. An
associated posterior dislocation of the hip is frequently associated
with posterior rim fracture of the acetabulum and may result
Figure 55-14. Schematic drawing of radiographic anatomy of
acetabulum in anteroposterior pelvis projection. (a) Arcuate (iliopubic)
line. (b) Ilioischial line. (c) Radiographic U, or teardrop, caused by
superimposition of parasagittal surface of ilium onto anteroinferior
portion of acetabulum. (d) Acetabular roof. (e) Anterior lip of
acetabulum. (f) Posterior lip of acetabulum. (Redrawn from Rogers LF,
Novy SB, Harris NF: Occult central fractures of the acetabulum. AJR Am
J Roentgenol 124:98, 1975.)
in an unstable hip joint and recurrent dislocation. Posterior hip
dislocation is commonly associated with secondary sciatic nerve
injury. The anterior column of the acetabulum is commonly
injured when a superior ramus fracture extends into the low anterior column.
Type B fractures involve both anterior and posterior columns,
but a portion of the acetabulum remains attached to the ilium.
When the columns are split, this is referred to as a T fracture. The
T fracture is associated with the worst prognosis, owing to the
difficulty in obtaining open anatomic reduction.
Type C fractures are readily apparent on plain radiographs as a
result of disruption of the ilium.
Assessment of the AP pelvic radiograph should focus on the
disruption of the ilioischial and iliopectineal lines as well as the
anterior and posterior lips of the acetabulum (Fig. 55-14). Ramus
fractures should be evaluated for possible extension into the acetabulum. Oblique views of the acetabulum (Judet views) can aid
in visualizing the anterior and posterior columns. CT is, without
question, the imaging test of choice for visualizing acetabular fractures and planning for possible surgical repair. It is important to
note that because fracture of the acetabulum often occurs with a
high-energy mechanism, even patients with isolated acetabular
fractures may have significant hemorrhage necessitating blood
Chapter 55 / Pelvic Trauma 671
99
transfusion. All patients with acetabular fracture require orthopedic referral in the emergency department.
Coccyx Fractures
Fractures of the coccyx occur frequently after a fall in the sitting
position or a kick. Fracture and injury also may occur during
parturition. Physical examination reveals local tenderness to palpation in the gluteal crease, with pain and sometimes abnormal
motion of the coccyx during palpation on DRE. Normally, the tip
of the coccyx moves 30 degrees anteriorly and 1 cm laterally.100
Displacement also is diagnosed on rectal examination, but
attempts at reduction are not recommended.
Radiographic confirmation of a coccygeal fracture is not always
necessary. Displaced fractures often are seen on the lateral view,
but the diagnosis is evident on rectal examination. Undisplaced
fractures may be difficult to show radiographically. The physician
must decide whether the knowledge gleaned from radiographic
studies would alter the therapy to a degree that warrants radiation
exposure to the pelvis, especially considering that most of these
fractures occur in women.
Treatment of coccygeal fracture consists of bed rest, stool softeners, analgesia, and sitz baths to relieve muscle spasm. As activity
is increased, maneuvers that may minimize discomfort include use
of an inflatable rubber donut cushion, alternate sitting on the side
of each buttock, slouching to displace body weight more proximally, and sitting on a hard chair rather than a soft one (sinking
into a soft chair may distribute weight onto the coccyx).100 Because
of muscle action on the fragment, healing is slow and patients
should be cautioned that discomfort may be prolonged. In the
case of persistent severe disability, an orthopedic consultation is
indicated for considerations of local steroid injection or possible
coccygectomy.101 Other causes of coccydynia (besides fracture)
include trauma during parturition; faulty posture; midline disk
herniations (caused by nonsegmental referral of pain from irritation of the dura); lumbar facet arthropathy; compression of the
first, fourth, and fifth sacral roots; neuralgia from sacral plexopathy or sacrococcygeal neuropathy; infections; and local tumors.100
KEY CONCEPTS
■ The most serious pelvic ring injuries caused by high-energy
impact include (1) AP compression fractures (open book), (2) vertical shear fractures, and (3) any fractures that involve
significant displacement. These are associated with major
blood loss and transfusion requirements.
■ Pelvic injury is a marker for serious injury of other organ
systems. The vast majority of patients who die with pelvic
fracture are those who have sustained multiple trauma.
■ Careful examination of the skin in the perineum and
buttocks and digital rectal and vaginal examinations are
necessary to diagnose open fractures because these are
associated with the highest mortality rates.
■ CT is the imaging test of choice to diagnose pelvic fracture
and concurrent intra-abdominal injuries for patients stable
enough to undergo CT. CT aids in establishing surgical
priorities and planning of definitive orthopedic care. The
presence of contrast extravasation with modern CT imaging
is a subject of ongoing research with respect to localizing
pelvic bleeding and distinguishing between arterial and
venous sources.
■ In the hemodynamically unstable patient who cannot
undergo CT imaging, the AP radiograph usually reveals
serious pelvic fractures that result in major pelvic bleeding.
Inlet and outlet radiographs improve the sensitivity and
specificity of pelvic plain radiography.
■ The combination of posterior arch fracture plus hypotension
is associated with a mortality rate of approximately 50%.
Early fluid resuscitation with blood products is recommended
for patients suspected to have active pelvic bleeding.
■ Trauma hospitals should have institutional guidelines and
mechanisms to facilitate early decisions regarding the
treatment for pelvic hemorrhage that may include
angiography and embolization, pelvic packing, invasive fixation, or any combination of these.
The references for this chapter can be found online by
accessing the accompanying Expert Consult website.
Chapter 55 / Pelvic Trauma 671.e1
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