What is Pelvic Fracture?

The pelvis is designed to be extremely sturdy. But, high-impact injuries, such as car accidents, can cause pelvic ring fractures. It’s quite common for these to occur along with injuries to other body parts. Certain types of pelvic fractures, like ones to the iliac wing, don’t disrupt the pelvic ring and usually don’t require surgery. Acetabulum fractures, which can often happen from high-energy injuries, hip dislocations or falls in older adults, are also common.

For diagnosing these injuries, doctors often use the Young-Burgess classification. This tool helps trauma surgeons and emergency doctors assess the extent of injury, begin the right treatment and share important details about the injury with the orthopedic surgeon handling the case.

To use this system properly, doctors need a deep understanding of the pelvis structure. The pelvis is made up of the ilium, ischium, and pubis, which comes together to form a ring with the sacrum. Different ligaments stabilize the ring: the symphyseal ligaments on the front side, the pelvic floor ligaments, and the posterior sacroiliac complex in the back. The most posterior ligament, or the one at the farthest back, in the pelvic ring is the most crucial for its stability. If these ligaments are injured, it means the accident was incredibly high-energy.

Injuries to the pelvic ring often come with significant tissue damage. This makes it common for those with this injury to also have vascular, neurologic, and visceral injuries. The most common cause of bleeding with these injuries is the venous plexus, a network of blood vessels, in the back of the pelvis. A structure called the corona mortis, which connects two major arteries, if damaged during surgery can quickly lead to excessive blood loss, making the situation critical. This is why doctors have to carefully inspect for any other injuries when dealing with a pelvic ring fracture.

What Causes Pelvic Fracture?

Most fractures of the pelvic ring are caused by severe injuries like car accidents or falls from great heights. However, these injuries can also come from less severe incidents, such as sports activities or simple falls while walking.

Risk Factors and Frequency for Pelvic Fracture

In the United States, pelvic fractures happen to about 37 out of 100,000 people every year. These types of injuries are most common in people between the ages of 15 and 28. It is also noted that these fractures are mostly seen in men under 35 and women over 35.

Signs and Symptoms of Pelvic Fracture

Pelvic injuries often indicate severe trauma, requiring a comprehensive trauma evaluation. This usually involves following the guidelines provided by the American College of Surgeons, which cover measures for detecting any life-threatening conditions. In cases of pelvic injuries, patients may also have multiple other injuries, so it’s crucial to check for key signs like difficulty breathing, unconsciousness, and lack of pulse as these require immediate medical attention. Once the patient is stabilized, a more detailed examination can be done.

Pelvic ring fractures are often found together with damage to the spine or limbs. Therefore, checking the spine and limbs for any abnormalities, including differences in limb length or odd twists and bends, is a key part of the examination. It’s also possible for the nerves and blood vessels around the pelvis to be affected, which is why a thorough neurological examination is crucial for proper treatment and monitoring.

One common issue with pelvic fractures is significant blood loss. This can happen even if the fracture isn’t open or readily visible. As much as 40% of the time, there may be internal bleeding in the abdomen. There could also be bleeding within the chest, behind the peritoneum (the membrane lining the abdominal cavity), or within a confined area of the body. Bleeding within the pelvis is usually caused by the pelvic veins being torn, which can result in large blood clots. Additionally, a fracture at the back of the pelvis could potentially harm a large artery situated in the buttock area, a situation that would necessitate immediate surgical intervention.

The degree of the patient’s injuries can also be indicated by damages to the surrounding soft tissues. Specifically, tears in the perineum (the area between the anus and the genitals) can signal a high-impact injury. In such cases, the fracture could be contaminated by substances like urine, feces, or dirt.

Pelvic fractures can sometimes result in neurological injuries, particularly affecting the L5 or S1 nerve roots. If a fracture occurs in the sacrum (the triangular bone at the base of the spine), it could affect the S2 to S5 sacral nerves, possibly resulting in problems with bowel, bladder, and sexual function.

Testing for Pelvic Fracture

Computed tomography (CT) scans work really well for looking at the inside of the pelvis. These scans allow doctors to check for any internal bleeding and confirm things like a dislocated hip or a fractured pelvis.

An anteroposterior (AP) pelvic radiograph is often the first step for checking a potential pelvic fracture. This quick and convenient test can usually identify most pelvic fractures. It’s especially helpful for patients who are in severe condition and need immediate treatment. On the other hand, CT scans of the abdomen and pelvis are usually part of the routine check-up for trauma patients.

Also, ‘Focus Assessment with Sonography for Trauma’, known as a FAST examination, includes checking the pelvis. This specific test helps identify possible sources of severe blood loss, like internal bleeding.

Retrograde urethrography is another imaging procedure. It is used for patients who might have a tear in the urethra. This kind of injury might be suspected in men if there’s blood at the opening of the urethra, and in women if they can’t have a Foley catheter inserted, have vaginal tears, or have fragments near the urethra that can be felt during examination. Now if a person has blood in their urine but the urethra seems to be intact, a cystography is done to check for a urinary bladder injury.

In cases where a patient continues to bleed despite receiving enough intravenous (IV) fluids and stabilizing the pelvis, doctors might perform a pelvic angiography. This test can detect injuries that might not be immediately apparent, allows for blocking off any injured arteries, and show the area better before attempting to correct the position of a dislocated bone or joint.

For detecting pelvic fragility fractures, magnetic resonance imaging (MRI) has been reported to be more accurate than CT scans. Dual Energy Computed Tomography (DECT) is an exciting new technology that shows promise in picking up pelvic fractures in older patients even more effectively than traditional CT scans.

Treatment Options for Pelvic Fracture

Patients with pelvic fractures are quite often victims of serious injuries and require immediate life-saving treatment, following a guideline known as the Advanced Trauma Life Support protocol. If a patient is experiencing difficulties with their heart or breathing, action needs to be taken right away.

The main goal when treating pelvic injuries is to make the damaged area in the body stable quickly. This can help reduce the amount of blood transfusions a patient needs, the chances of complications, and how long the hospital stay is, which in turn can enhance the patient’s chances of survival. Unnecessary movement of the pelvic area should be avoided. Immediate steps should be taken to allow medical fluids, drugs that stimulate the heart, and pain relievers to be administered intravenously. Close monitoring of the patient’s heart function, oxygen levels, and crucial body signs should take place.

One way to help stabilize a patient’s pelvic ring and control bleeding is to use an external compression device, like a pelvic binder or sheet. However, this method should be avoided in some types of injuries which involve internal rotation. In such cases, skeletal traction can be used instead for stabilization. External pelvic fixation can also be considered as a treatment option, particularly for patients who are not stable. This procedure can be executed together with an emergent operation of the abdomen.

The use of pelvic implants, contemporary anesthetic techniques, and intraoperative imaging, combined with a greater understanding of injury patterns, has led to a shift towards increased surgical intervention of pelvic fractures that were previously treated non-surgically. This change has led to early repair of major pelvic defects, early mobilization, and improved outcomes for patients.

Some pelvic fractures can be managed without surgery. Certain types of fractures can be treated by having the patient start moving as soon as possible while allowing them to handle as much weight as they can tolerate. Slightly displaced pelvic fractures may be treated without surgery but need to be evaluated on a case-by-case basis.

The overall goal in patients with multiple injuries is to maintain the patient’s vital functions, control bleeding, and prevent harmful immune responses. In some cases, rapid and minimally invasive intervention to control bleeding and stabilize fractures can help to prevent exacerbating the patient’s immune response.

For complex cases involving pelvic, spinal, and limb fractures, urgent treatment of unstable spinal injuries with neurological deficits is required including decompressing and internal fixation. These procedures can be performed along with treating pelvic injuries. If extremity injuries are present, such as open fractures, dislocations, vascular injuries or compartment syndrome, these need immediate attention as well. External fixation is usually the preferred method over primary definitive osteosynthesis in these cases.

Open pelvic fractures have around a 50% mortality rate; therefore, they need vigorous treatment, including controlling bleeding, preventing infections by early surgical treatment, diagnosing other injuries, and definite fixation of bones. Multiple measures can be considered to improve patient outcomes such as avoiding the closure of the primary wound, considering fecal diversion, and ensuring there’s good coordination between surgical teams. New advances in dealing with complex pelvic fractures, such as fracture mapping and 3D printing, show promise for future medical applications.

Pelvic fractures can include different types of breaks, such as in the acetabulum (the part of your pelvis that joins your hip) and the wings of your ilium (the big, wing-shaped bones at the top of your pelvis). Breaks in the iliac wings can sometimes be managed without surgery. But fractures in the acetabulum might require more careful examination because they could be a bit more complicated.

There are generally 10 different ways an acetabulum can fracture, according to the Letournel Classification. Treatment for a fracture in the acetabulum can vary. High-risk patients or those with only slight displacement in their fractures might not need surgery and can avoid bearing weight on the affected area. But, if the fracture has moved out of place significantly or has caused instability in the hip, surgery may be necessary to set the bones back in place and stabilize them.

What to expect with Pelvic Fracture

Even two years after treatment for a pelvic fracture, patients often report a significant decline in both mental and physical quality of life. This remains the case even when the healing process appears to be going well based on x-rays. Pelvic fractures are often accompanied by other injuries, which in combination can result in disability and negatively impact quality of life.

People who have suffered other injuries to the bones at the same time report worse disability and significantly poorer mental, social, and work-related outcomes. There has been concern that pelvic fractures may influence sexual function, potentially impacting live births and fertility in women. However, recent research has found that pelvic fractures do not lead to a decrease in live births or cause infertility.

Possible Complications When Diagnosed with Pelvic Fracture

People who have had injuries to the pelvic ring often report various issues long after the injury occurred. Painful intercourse, also known as dyspareunia, is reported by 56% of women, especially when the injury causes a shift of 5mm or more in the pubic symphysis, the joint at the front of the pelvis. Moreover, women who’ve had these types of injuries are more prone to needing a cesarean section when giving birth.

It’s not only women who experience problems after these injuries. Men also report sexual issues, with about 61% noting some form of sexual dysfunction after a pelvic ring injury. Of these issues, erectile dysfunction is reported in 19% of cases. However, for those with Anteroposterior Compression (APC) injuries, this rate soars to 90%.

It’s important to note that currently, there’s no strong evidence to suggest that stabilizing these types of fractures can reduce sexual dysfunction or neurological damage arising from the injury.

Preventing Pelvic Fracture

The main goal of preventing pelvic injuries is to reduce the risk of injury and promote strong, healthy bones to prevent fractures. Some ways to do this include:

Preventing falls and evaluating the risk of falls in older individuals.
Regular exercise and physical therapy to strengthen bones and muscles.
Making sure to get enough calcium and vitamin D in your diet.
Following safety rules at work or during sports.
Using correct techniques when moving and doing physical activities.
Making changes around the house to lower the risk of injury.
Avoiding behaviors that can increase the risk of hip injuries.

For those who have experienced pelvic ring injuries, it’s important to understand the possible long-term effects, especially if there are injuries in other areas as well. Many people who have these injuries may face lifelong disabilities, which can impact their life financially, mentally, and physically. The help of a team made up of different health professionals is essential for these patients to heal and manage their disabilities effectively.

Frequently asked questions

A pelvic fracture is a break in the bones of the pelvis, which can occur due to high-impact injuries such as car accidents. Pelvic fractures can often be accompanied by injuries to other body parts and may require surgery depending on the type and severity of the fracture.

Pelvic fractures happen to about 37 out of 100,000 people every year.

Signs and symptoms of a pelvic fracture can vary depending on the severity of the injury, but some common signs and symptoms include: - Difficulty breathing: This can be a sign of a life-threatening condition and requires immediate medical attention. - Unconsciousness: Loss of consciousness can indicate severe trauma and should be taken seriously. - Lack of pulse: If a patient does not have a pulse, it is a critical sign that immediate medical attention is needed. - Abnormalities in the spine and limbs: Pelvic fractures are often found together with damage to the spine or limbs, so it is important to check for any differences in limb length or odd twists and bends. - Neurological symptoms: Pelvic fractures can affect the nerves and blood vessels around the pelvis, so a thorough neurological examination is crucial. This can help identify any nerve damage and guide proper treatment and monitoring. - Significant blood loss: Pelvic fractures can result in internal bleeding, even if the fracture is not open or visible. Up to 40% of the time, there may be internal bleeding in the abdomen, chest, peritoneum, or within a confined area of the body. Bleeding within the pelvis is often caused by torn pelvic veins and can lead to large blood clots. - Soft tissue damage: Tears in the perineum, the area between the anus and genitals, can indicate a high-impact injury. In these cases, the fracture may be contaminated by substances like urine, feces, or dirt. - Neurological injuries: Pelvic fractures can sometimes result in nerve damage, particularly affecting the L5 or S1 nerve roots. Fractures in the sacrum, the triangular bone at the base of the spine, can affect the S2 to S5 sacral nerves, potentially leading to problems with bowel, bladder, and sexual function.

When diagnosing a pelvic fracture, a doctor needs to rule out the following conditions: 1. Injuries to other body parts: Pelvic fractures often occur along with injuries to other body parts, so doctors need to check for any additional injuries. 2. Vascular injuries: Pelvic fractures can cause significant tissue damage and may result in vascular injuries, particularly bleeding from the venous plexus in the back of the pelvis. 3. Neurologic injuries: Pelvic fractures can also cause neurologic injuries, so doctors need to assess for any nerve damage or dysfunction. 4. Visceral injuries: Pelvic fractures may be associated with visceral injuries, such as damage to organs within the pelvis. Doctors need to carefully inspect for any signs of visceral injury. 5. Urethral tear: In men, a tear in the urethra may be suspected if there is blood at the opening of the urethra. In women, a tear may be suspected if they can't have a Foley catheter inserted, have vaginal tears, or have fragments near the urethra that can be felt during examination. 6. Urinary bladder injury: If a patient has blood in their urine but the urethra seems intact, a cystography is done to check for a urinary bladder injury. 7. Excessive blood loss: Doctors need to assess for sources of severe blood loss, such as internal bleeding, which can occur with pelvic fractures. This is particularly important to identify and manage promptly. 8. Instability in the hip: If the pelvic fracture has caused instability in the hip joint, surgery may be necessary to set the bones back in place and stabilize them. 9. Dislocated bone or joint: Doctors need to check for any dislocated bones or joints that may be associated with the pelvic fracture. 10. Other associated injuries: Doctors need to rule out any other injuries or complications that may be present in conjunction with the pelvic fracture.

The types of tests that are needed for pelvic fractures include: 1. Anteroposterior (AP) pelvic radiograph: This is often the first step in checking for a potential pelvic fracture and can usually identify most fractures. 2. Computed tomography (CT) scans of the abdomen and pelvis: These scans are part of the routine check-up for trauma patients and allow doctors to check for internal bleeding and confirm fractures or dislocations. 3. Focus Assessment with Sonography for Trauma (FAST examination): This specific test helps identify possible sources of severe blood loss, like internal bleeding. 4. Retrograde urethrography: This imaging procedure is used to check for a tear in the urethra. 5. Cystography: This test is done to check for a urinary bladder injury if a person has blood in their urine but the urethra seems to be intact. 6. Pelvic angiography: This test is performed if a patient continues to bleed despite receiving enough intravenous fluids and stabilizing the pelvis. It can detect injuries that might not be immediately apparent and allows for blocking off any injured arteries. 7. Magnetic resonance imaging (MRI): This test is more accurate than CT scans for detecting pelvic fragility fractures. 8. Dual Energy Computed Tomography (DECT): This new technology shows promise in picking up pelvic fractures in older patients more effectively than traditional CT scans. It is important to note that the specific tests ordered may vary depending on the individual patient and their specific condition.

Pelvic fractures are treated by making the damaged area stable quickly, which helps reduce the need for blood transfusions, the chances of complications, and the length of hospital stay. Unnecessary movement of the pelvic area should be avoided, and medical fluids, heart stimulants, and pain relievers should be administered intravenously. Close monitoring of the patient's heart function, oxygen levels, and body signs is important. External compression devices like pelvic binders or sheets can be used to stabilize the pelvic ring and control bleeding, but should be avoided in certain types of injuries. Surgical intervention may be necessary for some pelvic fractures, leading to early repair of major defects and improved outcomes. Some fractures can be managed without surgery, and treatment should be evaluated on a case-by-case basis. In complex cases involving pelvic, spinal, and limb fractures, urgent treatment of unstable spinal injuries and extremity injuries is required. Open pelvic fractures require vigorous treatment to control bleeding, prevent infections, and fix the bones.

When treating pelvic fractures, there can be several side effects or complications that may arise. These include: - Increased need for blood transfusions - Higher chances of complications - Prolonged hospital stay - Potential impact on the patient's chances of survival - Painful intercourse (dyspareunia) in women, especially if there is a shift of 5mm or more in the pubic symphysis - Increased likelihood of needing a cesarean section during childbirth for women with pelvic injuries - Sexual dysfunction in men, with a higher prevalence in cases of Anteroposterior Compression (APC) injuries - Erectile dysfunction in a significant number of cases of sexual dysfunction in men - Currently, there is no strong evidence to suggest that stabilizing these fractures can reduce sexual dysfunction or neurological damage resulting from the injury.

Orthopedic surgeon