The pelvic ring forms from the sacrum and the two innominate bones each containing an ilium, ischium, and pubis. There is no inherent stability to the bony anatomy of the ring. Therefore the strong ligamentous attachments are required for maintenance of the ring structure. Pelvic ring injuries cover a broad spectrum. Simple minimally displaced fractures of the sacrum or pubis may be treated conservatively while high energy disruptions of the bony or ligamentous ring represent life-threatening injuries requiring intervention.
Pelvic ring injuries are usually associated with high energy trauma, including falls from height and motor vehicle collisions. Geriatric pelvic ring injuries are unique and are usually the result of a low energy fall. Anterior-posterior compression injuries occur at high frequencies following equestrian saddle horn injuries and motorcycle accidents. Lateral compression injuries often happen as the pelvis is run over by a vehicle. Vertical injuries of the pelvis usually occur as a fall or injury involving an axial load.
Due to direct trauma to the pelvis or indirect trauma through compression or distraction of the spine and/or femurs, the pelvic ring suffers disruption. The pelvic ring fails in predictable patterns as described in the classification section. Depending on the degree of injury, stabilizing ligaments of the pelvis may be disrupted requiring stabilization.
Due to the high energy nature of pelvic ring injuries, associated morbidities require thorough assessment. Incidence of associated trauma includes:
A pelvic ring injury can be a life-threatening injury or may be associated with a life-threatening injury, and a thorough exam is necessary.
Destot sign – Palpable hematoma in perineum above inguinal ligament or proximal thigh, may represent pelvic fracture with active bleeding.
Grey Turner sign – Flank bruising indicative of retroperitoneal bleeding.
Morel-Lavallee lesion – Internal degloving injury from skin shear at time of injury, may require intervention and may affect surgical planning, look for significant soft tissue abrasions, ecchymosis or subdermal hematoma. May also be identified on CT scan with the assessment of soft tissues.
Type A – Stable
Type B – Rotationally unstable, vertically stable
Type C – Rotationally and vertically unstable
Young and Burgess Classification
Denis Classification of Sacral Fractures
Recognize that a pelvic ring injury may represent a life-threatening emergency and work as a team to rapidly resuscitate critically injured patients
Hemorrhage associated with high energy trauma and pelvic ring disruption
Pelvic ring injuries can have significant blood loss from sources, including:
Pelvic Binder/Circumferential Sheet Placement
Anterior Subcutaneous Pelvic Fixator (INFIX)
Open Reduction Internal Fixation
The sequence of Events for Treating a Pelvic Ring Injury
Young-Burgess Classification predicts mortality
Reduction of the posterior ring within 1 cm improves long term outcomes.
Return to work rate is highly variable with the majority of patients reporting some form of persistent impairment.
Male gender and older age have higher mortality.
Chronic Pain and Disability
Depending on injury and method of treatment, the patient may require a period of weight bearing restrictions to one or both extremities. Nursing and therapy will be necessary to assist with a patients return to function. DVT prophylaxis postoperatively is paramount.
CLinicians need to address patient expectations early. Discussing reasonable outcomes and understanding some degree of chronic discomfort may be unavoidable. Also, discussion of some intimate issues like erectile dysfunction or dyspareunia is important to patient well-being and making necessary referrals to OBGYN or urology as necessary.
Patients with pelvic ring injuries are typically very sick and will require the assistance of multiple providers. It is imperative that each provider discuss their role with other providers and the patient. In complex scenarios, there may be multiple teams working on a single patient, and interprofessional communication is essential. Because of the complexity of these injuries, the number of organs injured, and the high morbidity and mortality, it is imperative that an interprofessional team be involved in the care of the patient. The brief roles of the interprofessional team are as follows:
The urologist may be required if there is a urethral injury; since these patients require suprapubic catheterization. Further, it is imperative that the catheter not be placed in the way of a diverting ileostomy for the general surgeon or a pelvic incision for the orthopedic surgeon. Diverting ileostomy/colostomy or suprapubic catheters should be placed as cephalad as possible to avoid interfering with the surgical incisions needed to operate on the pelvis.
A general surgeon may be required to divert the fecal flow by creating a diverting ileostomy or colostomy.
The radiologist is essential for localizing the injuries and their extent. Also, an interventional radiologist may be necessary for arterial embolization in cases of uncontrolled hemorrhage.
These patients are often managed in the trauma or surgery ICU and need close monitoring by the nurses. These patients also need DVT and pressure sore prophylaxis. Since most patients cannot eat an oral diet for a few days or weeks, a dietary consult for TPN may be required. If the patient has a stoma, a stoma nurse needs to educate the patient and the family about stoma care, the necessary changes in diet and maintaining hygiene around the appliance, and report back to the physicians of any issues encountered.
Pain control and antimicrobial therapy may be necessary, and the pharmacist should oversee medication reconciliation and dosing, and let the team know of any potential interactions or dosing issues.
Because these patients are often bedridden for prolonged periods, physical and occupation therapy must be involved to exercise the muscles and maintain function. They can inform the team as to the progress or lack thereof as the patient moves through the stages of rehabilitation.
A mental health nurse should see the patient prior to discharge as depression and anxiety are common after pelvic trauma. The road to recovery is long and unpredictable, causing extreme stress in many patients. These findings should go to the managing physician(s) as well as the nursing team.
Most patients require extensive rehabilitation after discharge and may need to follow up with many specialists, including the nurse practitioner.
In summary, as can be seen above, pelvic ring injuries/fractures require an interprofessional team approach, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]
Pelvic trauma is a significant event, and despite optimal care, it correlates with very high morbidity. Many patients remain disabled after the injury and are not able to return to work. Most have difficulty performing daily living activities and often require assistance with ambulation. The long term prognosis for most of these patients is guarded.
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