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Pelvic injuries
Pelvic injuries are caused by serious trauma that may involve other body systems or other
skeletal injuries, especially abdominal visceral injuries or most commonly urogenital injuries that
occurs in 10% of the cases of pelvic injury.
Clinical assessment:
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Always look for associated other system injury.
Look for possible shock because of associated pelvic bleeding.
Look for urethral injury that may show as bleeding per urethra or urinary retention.
Abdominal injury may give acute abdomen or tenderness,
PR/exam is essential to assess associated prostate, urethral or sacrococcygial injury.
X-ray:
Five main views are available, AP, inlet view, outlet view and two oblique views.
CT scan is the best for assessment of the pelvic injuries.
Contrast studies are used for possible abdominal or urogenital injuries.
Types of pelvic fracture:
There are 3 main types;
1. Isolated fracture with intact pelvic ring.
2. Fractures with broken ring which can be stable or unstable.
3. Fractures of the acetabulum.
Isolated fractures:
Those are avulsion injury, direct injury or stress fractures.
 Avulsion by the sartorios tendon causes fracture of the anterior superior iliac spine
(ASIS).
 Avulsion by the rectus femoris tendon causes fracture of the anterior inferior iliac spine
(AIIS).
 Direct injury cases direct fracture anywhere in the pelvis.
 All above are simple stable injuries that needs only bed rest for several days.
 Stress fracture of the pubic rami may occur with osteomalasia or osteoporosis.
Fractures of the pelvic ring:
 The pelvis is like a complete ring formed by the 2 hip bones and the sacrum they are
joined by the symphysis pubis anteriorly and the 2 sacroiliac joints with their strong
sacroiliac and iliolumber ligaments posteriorly.
 Anterior pelvic segment disruption may occur with disruption of symphysis pubis,
fracture of the body of the pubis, or both pubic rami fracture (single ramus fracture is an
isolated fracture without ring disruption).
 Posterior segment disruption can occur with fracture of the sacrum, iliac crest fracture or
complete sacroiliac joint disruption. Sometimes the joint is only partially disrupted with
ligament injury.
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 Disruption of the ring at one point usually associated with other point disruption which is
sometimes a partial one.
 Fracture of pelvic ring is said to be stable if there is single complete ring disruption only.
 Fracture of pelvic ring is said to be unstable if there is two or more complete ring
disruptions that can be anterior and/or posterior ones on the same side or on both sides.
Mechanism of pelvic injury:
This can be one of the followings;
1. Anteroposterior compression: as the frontal force that may be caused by a car hitting a
pedestrian leading to complete disruption of the symphysis pubis (open book fracture) or
one side double pubic rami fracture, this is usually associated with only partial posterior
disruption and the fracture here is usually stable.
2. Lateral compression: side-to-side ring compression causing highly unstable fracture with
complete anterior and posterior disruptions.
3. Vertical shear injury: the hip bone of one side vertically displaced upwards causing
unstable fracture with both anterior and posterior disruptions on the same side.
4. Complex injury: it’s a combination of any of the above injuries which is highly serious
and associated with other system injury.
a;anteroposterior compression injury with open book fracture; b;lateral compression force
with double rami fracture that may occur on both sides, c; vertical shear injury with complete
disruption of both anterior and posterior segments of one side.
Clinical features
 With isolated fractures and stable injuries the patient is not severely shocked but has pain
on attempting to walk.
 There is localized tenderness but seldom any damage to pelvic viscera.
 With unstable injuries the patient is severely shocked, in great pain and unable to stand;
he may also be unable to pass urine. There may be blood at the external meatus.
 One leg may be partly anaesthetic because of sciatic nerve injury. These are extremely
serious injuries, carrying a high risk of associated visceral damage.
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Emergency treatment:
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As with all major injuries, the first priority is to ensure that the airway is clear and
ventilation is unimpaired.
Shock and blood loss should be treated immediately and throughout the period of
assessment. If the blood pressure cannot be restored, a diagnostic peritoneal
aspiration should be carried out to exclude intra-abdominal bleeding.
Occasionally an emergency laparotomy is necessary to deal with visceral injuries.
If the patient cannot pass urine he must not be catheterized; gentle retrograde
urethrography is harmless and may show a urethral tear.
Urogenital damage is particularly likely in bilateral pubic rami fractures. If the
urethra is ruptured, urinary drainage should be provided by suprapuhic
cystostomy.
Treatment of the fractures:
1. Undisplaced ring fractures:
These injuries can usually be treated by 4 weeks rest in bed. Throughout this period exercises
are encouraged.
2. Displaced fractures without sacroiliac disruption:
 Disruption of the symphysis pubis (the ‘open book’ injury) if displacement is not marked,
simply nursing the patient on his side for 6—8 weeks can reduce it. For more severe
degrees of displacement, or if urogenital surgery is being done, external fixation is better.
The fixator is retained for 6—8 weeks but the patient can get up and walk around.
 Pubic rami fractures, these are usually due to lateral compression. If displacement is not
severe, bed rest and leg traction for 3—6 weeks will be enough. For severe displacement,
external fixation provides more stability.
3. Displaced fractures with sacroiliac disruption:
 All vertical shear injuries, and some of the more severe compression injuries, disrupt the
sacroiliac joint or produce unstable fractures around the joint. The fracture or dislocation
must be stabilized, either by internal fixation with plates and screws or by combined
external fixation and prolonged traction in bed (8—12 weeks).
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Figure shows external fixation of pelvis
Complications:
1. Urogenital damage; Compression fractures are the usual cause of urogenital tract
damage; also with all pelvic ring disruptions, damage must be excluded. All that needs is
adequate urinary drainage, which is accomplished by suprapubic cystostomy. Definitive
repair can be delayed while the patient’s general condition improves.
2. Nerve injury; Displacement of the sacroiliac joint or fracture of the sacrum may injure the
lumbosacral plexus. The damage is usually permanent and some weakness will have to be
accepted.
3. Persistent sacroiliac pain; this is fairly common after unstable pelvic fractures and may
occasionally indicates arthrodesis of the sacroiliac joint.
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Fractures of the acetabulum:
Fractures of the acetabulum occur when the head of the femur is driven into the pelvis. This is
caused either by a blow on the side (as in a fall from a height) or by a blow on the front of the
knee, usually in a dashboard injury when the femur also may be fractured.
The types of fracture:
There are four main types of acetabular fracture: anterior, posterior, transverse and
combinations of these.
1. Anterior column fracture; the fracture runs through the anterior part of the acetabulum
separating a segment. It is uncommon, does not involve the weight— bearing area and
has a good prognosis.
2. Posterior column fracture; This fracture runs upwards separating the posterior ischiopubic
column of bone and breaking the weight-bearing part of the acetabulum. It is usually
associated with a posterior dislocation of the hip and may injure the sciatic nerve. Treatment is more urgent and usually involves internal fixation to obtain a stable joint.
3. Transverse fracture; this is a fracture running transversely through the acetabulum and
separating the iliac portion above from the pubic and ischial portions below. It is usually
fairly easy to reduce and to hold reduced.
4. Complex fractures; some acetabular fractures are complex injuries which damage either
the anterior or the posterior segments (or both) as well as the roof of the acetabulurn. The
joint surface is disrupted; the fractures are difficult to reduce and the end result is likely
to he less than perfect.
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Clinical features:
There has usually been a severe injury —either a traffic accident or a fall from a height.
Associated fractures are not uncommon.
The patient may be severely shocked, and the complications associated with pelvic fractures
should be sought. There may be bruising around the hip and the limb may lie in internal rotation
(if the hip is dislocated). an attempt should be made to examine movements at the hip.
X-RAY:
Several views of the hip, and sometimes a CT scan as well, may be needed before the fracture
can be accurately visualized.
Treatment:
 Emergency treatment should consist only of counteracting shock and reducing a dislocation.
 Traction is then applied to the limb (10 kg will suffice) and during the next 3 or 4 days
the patient’s general condition is brought under control.
 Definitive treatment of the fracture is delayed until he is fit and operating facilities are
optimal.
 With simple anterior or posterior fractures closed reduction under general anesthesia is
attempted. If this is successful, traction is maintained for a further 6 weeks.
 If closed reduction fails and adequate surgical expertise is available, operative reduction
and internal fixation with plates and screws is advisable.
 Complex fractures are difficult to reduce, and operative reduction and fixation is justified.
It should not be attempted in the absence of ideal operating facilities and adequate
surgical expertise.
 If comminution is so severe that the architecture cannot he restored, again operation
should not be attempted. Traction is continued and exercises started as soon as possible.
If necessary, arthroplasty of the hip can be carried out years later when union is complete.
Complications:
1. Nerve injury: with posterior fractures the sciatic nerve may be injured. The nerve
is usually not severed, so the chances of recovery are good.
2. Avascular necrosis: As in all severe injuries of the hip, femoral head necrosis may
occur. The changes take months or even years to develop. If this progresses to
fragmentation and collapse of the head, arthroplasty may be indicated.
3. Osteoarthritis: Secondary osteoarthritis of the hip is a common (late)
complication, especially if the fracture involves the weight-bearing surface.
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Injuries to the sacrum and coccyx:
A blow from behind or a fall onto the ‘tail’ may fracture the sacrum or coccyx, or sprain the
joint between them.
If the fracture is displaced, reduction is worth attempting. The lower fragment may be pushed
backwards per rectum. The reduction is stable, which is fortunate. The patient is allowed to
resume normal activity, but is advised to use a U-shaped cushion when sitting.
Persistent pain, especially on sitting, is common after coccygeal injuries. If the pain is not
relieved by the use of a cushion or by the injection of local anaesthetic into the tender area,
excision of the coccyx may be considered.
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Traumatic hip dislocation
Posterior dislocation of the hip:
Four out of five traumatic hip dislocations are posterior (80%). Usually this occurs in a road
accident when someone seated in a truck or car is thrown forward, striking the knee against the
dashboard. The femur is thrust upwards and the femoral head is forced out of its socket; often a
piece of bone at the back of the acetabulum is sheared off as well (fracture-dislocation).
Special features:
In a straightforward case the diagnosis is easy: the leg is short and lies adduçted, internally
rotated and slightly flexed. However, if one of the long bones is fractured — usually the femur
— the hip injury can easily be missed. The lower limb should be examined for signs of sciatic
nerve injury.
X-RAY:
In the anteroposterior film the femoral head is seen out of its socket and above the acetabulum.
Multiple views (and sometimes even a CTscan) may be needed to exclude a fracture of the
acetabular rim or the femoral head.
Treatment:
 The dislocation must be reduced under general anesthesia. An assistant hold the pelvis;
the surgeon flexes the patient’s hip and knee to 90 degrees and pulls the thigh vertically
upwards.
 X-rays are essential to confirm reduction and to exclude a fracture.
 If it is suspected that bone fragments have been trapped in the joint CT is needed.
 Reduction is usually stable, but the hip has been severely injured and needs to be rested.
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The simplest way is to apply traction and maintain it for 3 weeks.
 Movement and exercises are begun as soon as pain allows. At the end of 3 weeks the
patient is allowed to walk with crutches.
Complications
1) Fracture acetabulum: A fragment of the acetabulum may have been sheared off; if
it is large it should be fixed in place by screws. lf fragments of bone is small it
should be removed by operation.
2) Femoral head fracture: The segment of the femoral head if it does not fall back
into place when the dislocation is reduced, it must either be replaced and fixed in
position or removed.
3) Nerve injury: The sciatic nerve is sometimes damaged but it usually recovers
spontaneously.
4) Avascular necrosis: The blood supply of the femoral head is seriously impaired in
at least 10 per cent of traumatic hip dislocations. Avascular necrosis shows on xray as increased density it may take weeks to show in x-ray, this may indicate
osteotomy in young patients and hip replacement in older patients.
5) Osteoarthiritis: Secondary osteoarthritis may occur due to any of the following:
(1) cartilage damage, (2) retained fragments in the joint, (3) deformity of the
acetabulum or femoral head, (4) femoral head necrosis. Those may indicate hip
replacement.
Anterior dislocation of the hip:
 This is rare compared with posterior dislocation. The leg lies externally
rotated, abducted and slightly flexed. Seen from the side, the anterior
bulge of the dislocated head is unmistakable.
 X-RAY In the anteroposterior view the dislocation is usually obvious, but
occasionally the head is almost directly in front of its normal position; a
lateral film resolves any doubt.
 Treatment: The way of reduction under anesthesia employed is almost
identical with that used to reduce a posterior dislocation, except that while
the flexed thigh is being pulled upwards, it should he adducted. The
subsequent treatment is similar to that for posterior dislocation. Avascular
necrosis is the only complication.
Central dislocation of the hip:
 This is not a true dislocation because the femoral head does not really come out of its
socket; it is driven through the medial wall of the fractured acetabulum into the pelvis.
 X-RAY Usually the floor of the acetabulum is shattered and comminuted.
 Treatment: An attempt should always be made to reduce the dislocation. Even if
secondary osteoarthritis is inevitable, a more or less normal anatomy will make reconstructive surgery easier. Strong traction is applied and, if successful, maintained for 4—6
weeks. The hip is then mobilized and the patient is allowed up on crutches.
 If secondary osteoarthritis develops, this may need operative treatment; usually an
arthroplasty.
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