Clinical Scenario
Pelvic Fracture

Please interpret the radiograph and tell me what you are concerned about in this patient?

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An AP radiograph of the pelvis is presented in a 21-year-old male. There is evidence of a lateral compression type injury (LC3) with an open book pelvic fracture with pubic symphysis diastasis. There is an ipsilateral superior pubic ramus fracture. This is a life-threatening injury, and the patient should be managed in accordance with ATLS principles, and a trauma call placed.

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Key Concerns

1. High energy injury - ATLS Principles

2. Pelvic fracture

• Manage as per BOAST: The Management of Patients with Pelvic Fracture [1]

• Ensure haemodynamically stable

• Exclude open injury / urethral injury

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How would you manage this patient?

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ATLS

“I would ensure that patient had had a thorough trauma call, primary and secondary survey.My immediate concerns would be haemodynamic stability as I am aware he could lose a large amount of blood into the pelvis. I would therefore ensure he was optimised and stable from haemodynamic perspective and pelvic binder was applied correctly before moving on to assess for associated pelvic injuries.”

 

Haemodynamically stable on primary survey = Apply Pelvic Binder + Trauma CT

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Haemodynamically unstable on primary survey =

• Resuscitation fluids

• Blood product support + activation of major haemorrhage protocol

• TXA 1g IV (within 1 hour)

• Pelvic Binder

• FAST Scan

• ?Non-responder to above intervention? 

  • Consider CT embolization Vs laparotomy for peritoneal packing

  • Contact orthopaedic consultant

 

History

• A               Allergies

• M              Medication

• P               Past Medical History

• L               Last Ate

• E               Events

 

Examination

• Evaluate for common associated injuries

• Urethral injury

  • Blood at meatus

  • Unable to pass catheter

  • Retrograde urethrogram

  • Contact Urology - Manage as per BOAST: The Management of Urological Trauma Associated with Pelvic Fractures [2]

• PV (female) + PR

  • ?Bowel injury - contact general surgeons

  • Should be treated as open fracture - Manage as per BOAST: Open Fractures [3]

 

Investigations

• Portable AP Pelvis

• Trauma CT

  • ONLY if haemodynamically stable

  • All pelvic ring fractures should have trauma CT on admission (As per BOAST)

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Management 

• Depends on haemodynamic stability as outlined above

• Other contributing factors including presence of urological or open injury

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 How do pelvic binders work? When should they be removed? 

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Pelvic binders work by a tamponade effect allowing a haematoma to form and preventing further bleeding

They need to be applied correctly - at the level of the greater trochanters

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Pelvic binders should be removed within 24 hours - due to risk of pressure sores

Should perform XR on removal as a well applied pelvic binder can mask a significant pelvic injury

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Where does the haemorrhage occur from in pelvic ring fractures?

 

Haemorrhage is a major cause of death from displaced pelvic ring fractures

Occurs from the pelvic venous plexus (90% of bleeding)

 Bleeding from internal arterial injury is responsible in <15% of cases - thus embolisation may not always be successful.

 

Note: Pelvic Binders will prevent the majority of bleeding due to venous plexus (tamponade effect) it is often arterial bleeding that are non responders to initial blood management resuscitation. It is this patients that may then require CT embolisation to stop ongoing haemorrhage 

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Give some methods of major haemorrhage control in pelvic fractures?

 

Blood Loss Management Strategies:

• Pelvic binders

• IV TXA

• Major haemorrhage blood products (4:4:1)

• Internal / External Fixation

• Laparotomy packing

• CT embolisation

 

When should definitive fixation be performed?

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Definitive pelvic fixation should occur within 72 hours of patients being physiologically stable

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If there is an open pelvic ring fracture (communicating with the rectum) how should this be managed?

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Pelvic fractures can be open if communicating with skin / vaginal / rectal wall. All patients with pelvic trauma should have a PR and PV examination during their initial assessment.  These patientsTreated in line with BOAST: Open Fractures [3]. 

 

There should be early discussion with general surgeons and patients may need a de-functioning stoma. This would need to be sited away from the surgical site area for pelvic fixation

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On examination the patient has blood at the urethral meatus – how would you proceed?

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Signs of urethral injury include:

1. Blood at urethral meatus

2. Perineal bruising

3. High-riding prostate

 

If urethral suspect patients should be managed according to BOAST: The Management of Urological Trauma Associated with Pelvic Fractures [1]. A single attempt of catheterisation should be performed with two potential outcomes:

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Unable to pass catheter

• Perform a retrograde urethrogram (do NOT inflate balloon) via the catheter

• If evidence of urethral / bladder injury - contact on-call urologist

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Blood-stained urine (but able to pass catheter)

• Perform a retrograde cystogram via catheter

• If evidence of urethral / bladder injury - contact on-call urologist

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When is CT embolization appropriate?

 

CT Embolisation

 

Indicated for arterial bleeding from branches of:

• Internal iliac artery

• Obturator artery

• Superior gluteal artery

 

For patients who haven’t responded to resuscitation but with ongoing pelvic bleeding

 

 

Which patients cannot be managed by CT Embolisation?

 

• Venous or cancellous bone bleeding is not controlled by embolization

• Can only target arterial bleeding

• Requires retroperitoneal packing instead

 

How is bleeding managed in haemodynamically unstable pelvic fracture patients?

 

Retro-Peritoneal Packing

 

• Immediate surgical control needed:

  • Perform a midline laparotomy / Pfannesteil Incision

• Perform retroperitoneal pelvic packing:

  • 3 large swabs each side

  • Packed around sacrum and posterior pelvis

  • Remove packs within 48 hours

  • No drains should be inserted

• General surgeon should attend the procedure with orthopaedics

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Should Pelvic External-Fixation be used routinely? 

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Pelvic External Fixation

 

Modern pelvic binders have been shown to close the pelvic ring as well as the application of an external fixator they should be reserved for:

• Uncontrollable bleeding

• Damage Control Orthopaedics

• When definitive fixation cannot occur

• Patient too physiologically unstable for definitive fixation

  • E.g. pelvic binder required >24 hours to control pelvic ring 

 

How is an external fixator applied in pelvic fractures?

 

Pelvic External Fixation

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• Use 2 Schanz screws per side

• Two options for pin placement:

  • Iliac crest

    • Along anterior border of iliac crest

    • K-wires can be used on inner and outer table of iliac crest to guide placement

  • Supra-acetabular

    • ​(preferred – avoids interfering with future surgical approaches)

    • 5cm distal and 3cm medial to ASIS

    • Just above AIIS

• Construct the frame well above the abdomen to avoid obstructing access

• Should be placed before laparotomy

• Discuss with pelvic fracture unit early

 

Pelvic In-fix

 

• Is anterior subcutaneous placement of bar connecting rods

• Can be done when pelvic external fixation is indicated for longer duration

• Reduces pin-site complications

 

Note: Avoid superior /anterior pin placement à risk of injuring lateral femoral cutaneous nerve

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What classification system do you know for pelvic fractures?

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Young and Burgess Classification [4]

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• Most commonly used classification system for pelvic injuries

• Has three key types depending on the direction of force:

  • Anteroposterior Compression (Subtypes 1-3)

  • Lateral Compression (Subtypes 1-3)

  • Vertical Shear

• Each category has further subtypes (except vertical shear type) with increasing severity and more instability with increasing numbers within that subtype

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Note: this injury is a lateral compression type injury

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What are Judet views? 

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Judet views help plan surgery and classify fractures (Judet and LeTournel classification of acetabular fractures)

They consist of two sets of views:

• Obturator oblique view - shows the anterior column + posterior wall

• Iliac oblique view - shows posterior column + anterior wall

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These are often asked for on initial assessment / follow up of pelvic and acetabular fractures. They require a component radiographers to perform correctly. 

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Label the diagram in the images section (labelled A-G). Which line represents the anterior column? Which line indicates the posterior column

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A = Ilioischial (posterior acetabular column)

B = Iliopectineal (anterior acetabular column)

C = Acetabular fossa

D = Anterior wall of acetabulum

E = tear drop

F = Posterior wall of acetabulum

G = Shenton’s lines

 

Disruption to the ilioischial and iliopectineal lines can indicate an anterior or posterior column fracture (respectively) - this often indicates patients require a CT scan to assess posterior structures (polo ring theory) and establish morphology of pelvic ring injury

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Note: Arcuate line is also posteriorly at level of sacroiliac joints

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What is The National Major Trauma Registry (NMTR)?

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• The National Major Trauma Registry (NMTR) started is a national clinical audit that collects trauma data from all major trauma networks within the UK

• Started as TARN (Trauma Audit and Research Network) in 1990 and was developed by the University of Manchester. It was re-established as the NMTR by NHS England in 2023.

• It allows hospitals to monitor its performance against national standards

• Identifies high functioning units to lead by example

• Can help identify areas / hospitals where improvement in trauma services is needed

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References

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[1] BOA. BOAST – Management of Patients with Pelvic Fractures. Available at: https://www.boa.ac.uk/resources/boast-3-pdf.html 

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[2] BOA. BOAST – The Management of Urological Trauma Associated with Pelvic Fractures. Available at: https://www.boa.ac.uk/resources/boast-14-pdf.html 

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[3] BOA. BOAST – Open Fractures. Available at: https://www.boa.ac.uk/resources/boast-4-pdf.html 

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[4] Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology. 1986;160:445-451