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Pelvic Fractures Part 1. Evaluation, Classification, and PDF
Pelvic Fractures Part 1. Evaluation, Classification, and PDF
Abstract
Joshua R. Langford, MD Pelvic fractures range in severity from low-energy, generally benign
Andrew R. Burgess, MD lateral compression injuries to life-threatening, unstable fracture
patterns. Initial management of severe pelvic fractures should
Frank A. Liporace, MD
follow Advanced Trauma Life Support protocols. Initial reduction of
George J. Haidukewych, MD pelvic blood loss can be provided by binders, sheets, or some form
of external fixation, which serve to reduce pelvic volume, stabilize
clot formation, and reduce ongoing tissue damage. Persistently
unstable patients may benefit from angiography with selective
embolization, pelvic packing, or a combination of these
interventions. Open pelvic fractures involving the perineum or
bowel injury benefit from fecal diversion by colostomy. Trauma
team coordination facilitates efficient resuscitative efforts and may
affect definitive management by optimizing incision, ostomy, or
catheter placement. Established protocols for both open and closed
pelvic fractures help to standardize care.
Dr. Langford or an immediate family member serves as a paid consultant to Stryker and has stock or stock options held in the
Institute for Better Bone Health, LLC. Dr. Burgess or an immediate family member is a member of a speakers’ bureau or has made
paid presentations on behalf of, and has stock or stock options held in, Stryker. Dr. Liporace or an immediate family member has
received royalties from Biomet; is a member of a speakers’ bureau or has made paid presentations on behalf of Biomet, Synthes,
Stryker, and Medtronic; serves as a paid consultant to Biomet, Medtronic, Synthes, and Stryker; and serves as an unpaid consultant
to AO. Dr. Haidukewych or an immediate family member has received royalties from DePuy and Biomet; serves as a paid consultant
to Smith & Nephew, Synthes, and DePuy; has stock or stock options held in Orthopediatrics and the Institute for Better Bone Health;
has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related
funding (such as paid travel) from Synthes; and serves as a board member, owner, officer, or committee member of the American
Academy of Orthopaedic Surgeons.
Figure 2
The Young-Burgess classification of pelvic fracture. A, Anteroposterior compression (APC) type I. B, APC type II.
C, APC type III. D, Lateral compression (LC) type I. E, LC type II. F, LC type III. G, Vertical shear. The arrow in each
panel indicates the direction of force producing the fracture pattern. (Copyright Jesse B. Jupiter, MD, and Bruce D.
Browner, MD.)
by complete instability of the iliac from hemorrhage resulting from in- and adjustment of the compression
wing and cranial displacement of the jury to other structures, particularly applied (Figure 7, A and B). If a
ilium relative to the sacrum. Com- intra-abdominal causes such as a binder is not available, simple sheets
bined mechanism injuries are some- ruptured spleen. In such cases, the can be used to wrap the pelvis. It is
what difficult to classify but com- findings on CT examination and the important to understand that these
monly share features of many of the use of focused abdominal sonogra- are temporizing measures to be uti-
categories already mentioned. phy for trauma or diagnostic perito- lized until more definitive fixation
The Young-Burgess classification neal lavage may be useful. If such can be applied. The prolonged use of
has substantial intraobserver agree- studies suggest multiple sources of binders and sheets can lead to necro-
ment and moderate interobserver bleeding, then careful coordination sis of underlying soft tissues and is
agreement, which exceeds that of of care between specialists, based on not recommended.10 The amount of
previous classification systems.6,7 We predetermined protocols, is essential time that the skin can tolerate the
find the Young-Burgess classification to optimize patient care. Priorities pressure of a sheet or binder without
useful to assist in predicting resusci- for coordinated care should be estab- problematic breakdown has not been
tative requirements and reconstruc- lished by the trauma team in confer- determined; however, in general, the
tive decision making because of the ence before patients need it. The pro- sooner it is possible to perform some
understanding of the injured struc- tocol typically used at our institution form of external or internal fixation
tures and the amount of energy that for closed pelvic injury is summa- and remove external skin pressure,
the pelvis has absorbed. For exam- rized in Figure 5. the better.
ple, the APC injuries may be associ- If no other source of bleeding is The sheet or binder is applied at
ated with bladder or urethral disrup- identified, the pelvic fracture should the level of the greater trochanters,
tion, and the higher grades are be addressed expeditiously. Manage- never around the abdomen or waist,
associated with extensive blood loss ment is initially provided by wrap- and should be flat against the skin to
resulting from disruption of vascular ping the pelvis with a compressive maximize surface area. Sheets should
structures along with the pelvic floor sheet or by use of a pelvic binder. be secured with clamps to avoid un-
ligaments. The horizontal fracture of Modalities that “close” the pelvic due pressure from knots.11 Angio-
the ramus associated with LC inju- ring are sensible for injuries that graphic groin access, completion of a
ries creates a spike that may injure open or externally rotate the ring. generous laparotomy distally, and
medial structures (ie, bladder, va- The AP pelvic radiograph will iden- similar anterior access issues can be
gina, iliac arteries) when pushing tify injuries that may benefit from addressed by cutting access portals in
though the pelvis. LC type I injuries this approach; generally LC injuries the binder or sheet or by compress-
rarely require surgical intervention; will not, whereas APC and VS inju- ing the pelvis indirectly by means of
however, LC type II and III injuries ries will. Compression of an LC in- a secondary binder placed distally to
are typically surgical candidates. Al- jury is potentially damaging, al- the initial one on the thighs, com-
though all pelvic fractures can cause though different imaging modalities bined with taping the knees and an-
bleeding, instability, and visceral or demonstrate the difference in the pel- kles together. This “multiple binder”
neurovascular injury, awareness of vic position after applying a binder method is preferred at our institution
fracture pattern and degree of dis- for a lateral compression injury (Fig- and may alleviate some concerns
placement is helpful in risk assess- ure 6). Occasionally, an LC injury in about soft-tissue problems from pro-
ment. an elderly patient may have hemor- longed single-binder application
rhage associated with vascular or vis- (Figure 7, C). This method may also
ceral disruption; these patients will allow for a once-daily check of the
Initial Management and not benefit from wrapping or bind- skin overlying the greater trochan-
Resuscitation ing but may be candidates for an- ters by an experienced surgeon while
giography. maintaining general reduction. If
Provisional stabilization of the pelvic Closing the pelvic ring with a wrap notable vertical displacement exists
fracture can assist in control of hem- or binder has some effect on pelvic (>1 cm) or notable flexion deformity
orrhage and be an important part of volume but probably has a larger ef- is appreciated on screening radio-
patient resuscitation. In a patient fect on stabilization of clots from graphs, then skeletal traction can be
with pelvic fracture and shock, it bony surfaces and vascular struc- a useful adjunct for initial stabiliza-
may be difficult to separate the hem- tures.8,9 Several commercial binders tion. Traction can reduce displace-
orrhage resulting from the fracture are available that facilitate placement ment, add stability, improve hemo-
Figure 5
Algorithm for resuscitation of an unstable patient with a closed pelvic fracture. FFP = fresh frozen plasma, ICU = inten-
sive care unit, OR = operating room, ORIF = open reduction and internal fixation, PRBC = packed red blood cells
Figure 7
fixation in the emergency depart- and need for emergent stabilization teriography targets the 10% to 15%
ment has decreased in many institu- in forward areas. of patients who have bleeding from
tions. We do not recommend the use When other sources of bleeding have an arterial source.
of so-called C-clamps applied in the been ruled out, patients with persistent The selection of technique may de-
trauma bay with blind pin place- hemodynamic instability after control pend on the availability and ease of
ment, which can potentially injure of the pelvic volume with binder or ex- skilled arteriographers or on the pa-
intrapelvic neurovascular structures. ternal fixation should be treated with tient’s location. A patient who is al-
Most trauma centers typically em- angiography and selective emboliza- ready in the operating room because
ploy some form of pelvic binder and tion, or with pelvic packing, or both. of visceral bleeding may not be ap-
then later convert the patient to a These two methods address bleeding propriate for angiography until an
more definitive form of pelvic fixa- from different sources and should not intra-abdominal procedure is com-
tion. Some military, blast-induced always be thought of as competitive plete. Pelvic packing may be consid-
pelvic fractures have necessitated the but rather as complementary methods ered as a measure to improve hemo-
return of the technique of iliac crest of hemorrhage control.12 Pelvic pack- stasis. If the patient remains
pin placement because of blast in- ing helps control bleeding from ve- persistently unstable after the tho-
volvement with the anterior groin nous and bony sources, whereas ar- racic and abdominal procedures and
Figure 8 Figure 9
Figure 12
Algorithm for resuscitation of an unstable patient with an open pelvic fracture. ICU = intensive care unit,
I&D = irrigation and débridement, OR = operating room, ORIF = open reduction and internal fixation
tive embolization, pelvic packing, or 2. American College of Surgeons: Advanced of pelvic ring fractures with use of
Trauma Life Support Manual, ed 8. circumferential compression. J Bone
a combination of these two. Open Chicago, IL, American College of Joint Surg Am 2002;84(suppl 2):43-47.
pelvic fractures involving the Surgeons, 2008, p 366.
9. Krieg JC, Mohr M, Ellis TJ, Simpson TS,
perineum or bowel injury benefit 3. Tile M, Pennal GF: Pelvic disruption: Madey SM, Bottlang M: Emergent
from fecal diversion by colostomy. Principles of management. Clin Orthop stabilization of pelvic ring injuries by
Relat Res 1980;151:56-64. controlled circumferential compression:
A clinical trial. J Trauma 2005;59(3):
4. Sagi HC, Coniglione FM, Stanford JH: 659-664.
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