Pelvic injuries are common injuries from blunt trauma. They can be clinically insignificant injuries or life-threatening.
Death can occur from pelvic hemorrhaging in 0.5 percent of all blunt trauma patients. In fact, the overall mortality from fractures of the pelvic ring is about 6 percent. To complicate matters, no single specialty has all of the skills necessary for the treatment of complex pelvic injuries. The treatment of pelvic injuries
The pelvis is actually made of several bones which have fused together to form a ring that connects the spine to the lower extremities. In the back, there is the sacrum, which is actually part of the spinal vertebrae. In the front, the two bones come together to form a fibrous band called the pubic symphysis. Many muscles and ligaments are connected to the pelvis that give it its relative stability when it comes to trauma. There are veins and arteries in the area of the pelvis that can get disrupted. More veins than arteries are disrupted in pelvic injury. The pelvis houses many internal organs, such as the bladder, urethra, and rectum. They can be injured in cases of pelvic injuries.
Diagnosis of Pelvic Injuries
A good physical exam can raise the suspicion of a pelvic injury. This exam should be done gently; excessive rocking of the pelvis back and forth tends to increase bleeding and nerve injury in the area of an injured pelvis. The doctor should also inspect the perineum for bruising or swelling indicative of a pelvic injury.
A plain x-ray of the pelvis is part of a typical trauma series but some doctors believe that, if the examination is negative for pelvic injury, this x-ray does not have to be performed. Instead of doing a pelvic x-ray, which can miss many fractures of the pelvis, those who are suspected of having a pelvic injury should go ahead and have a CT scan of the pelvis instead. The CT scan cannot only help identify bony injuries but it can help identify non-bony trauma in the area of the pelvis as well. IV contrast is usually used to see the non-bony injuries. MRI examination can be done if x-ray exposure is an issue.
The focused abdominal sonography for trauma (FAST) evaluation has become a routine part of evaluations for abdominal and pelvic injuries. If there is no abdominal fluid found but the patient still has a low blood pressure, it can be suspected that a pelvic injury is the problem. A distorted contour of the bladder on a FAST exam can mean that it is receiving pressure from a large collection of blood from the pelvis.
Management of Pelvic Bleeding
As soon as a major pelvic injury is suspected, the patient should be resuscitated with fluids and blood products and preparations should be made for further diagnostic tests or treatment. Blood products and platelets can be given along with IV fluids to replace the blood lost in a pelvic injury.
Unstable pelvic fractures bleed because of ongoing injury to small vessels as the fractured pelvic fragments continue to move. The pelvis contains a lot of volume and bleeding can be severe and not blocked by anything to hold the bleeding at bay.
Pelvic binders can be used stabilize the pelvic bones and prevent the movement of the fractured elements. Binders can also control the amount of blood that can fill up the space around the pelvis. A crude pelvic binder can be made using a bedsheet that is tightened by rotating a stick until the appropriate pressure is applied to the pelvis. Pelvic binders should only be used for about 24 hours.
This can be done in the emergency room or in the operating room. There are crossbars and pins used to temporarily hold the pelvis together. External fixators allow for the fractured parts of the pelvis to be stabilized, decrease the volume inside the pelvis, and help a blood clot to form inside the pelvis. External fixators are useful in the patient who is lying down only and ae meant to be a stopgap between the injury and definitive treatment of the fracture. Pins and external fixation can remain in place for up to 12 weeks, with the most common complication being infection at the pin site.
This is a technique that can be used to stop bleeding in the pelvic area. A catheter is inserted into the circulation and an embolus is sent to the area of bleeding, plugging up the bleeding area. About a fourth of all angiographies performed on suspected bleeding areas show no bleeding areas, which wastes time and resources.
Most bleeding is done when the pubic symphysis is disrupted or in the back of the pelvis. Even fractures of the front of the pelvis can bleed, however, especially in situations where the person is older and is on blood thinning medications. Patients who show bleeding on CT scan can be good candidates to later have an angiogram done with the idea of using the angiogram to stop bleeding. Not every person with CT evidence of bleeding needs to have an angiogram, however. Gel foam is used through the catheter in bleeding patients to clog up the artery and stop the bleeding from inside the vessel. Small and large vessels can be treated this way.
This type of procedure can fail in 15 percent of cases, especially if the patient has blood clotting problems. The gel is put inside the artery but a clot does not form because the patient has a clotting problem. The artery will look as though it has clotted because the gel is in place but the clot doesn’t form and the gel washes away. If the patient continues to need blood transfusions after this procedure is performed, they need to go back to the angiography area for a second attempt at blocking the vessel.
Pelvic packing is problematic for pelvic fractures. Often the packs fail to stay in place and simply float up inside the abdomen. Often, several packs are necessary on both sides of the pelvis to control bleeding as a temporary measure before the pelvic fracture is repaired. Packing does not mean that the patient cannot have an angiogram with embolization procedure. Packing simply is a temporary measure until the team can be assembled to go ahead with the angiogram procedure.
Often, definitive repair of pelvic fractures are done in stages. First, they get the pelvic binder and then they receive external fixation. After that, the external fixator may be the only thing the person needs or they can go on to have open surgery to repair the fracture internally.
Screws and plates are used to repair pelvic fractures. A plate can be inserted across the pubic symphysis and plates and screws can be used for other fractured areas.
Many pelvic fractures are associated with injuries inside the pelvis and abdomen. There are often injuries outside of these areas with more than half of them having brain injuries and long bone fractures. These just complicate the picture as the trauma surgeon doesn’t know where to start first.
A common injury associated with pelvic fractures includes bladder and urethral injuries. These are because these organs are in close proximity to the pelvis. Urethral injuries are almost always seen in males. There are ways to determine if the urethra has been damaged and these should be done as part of an evaluation of pelvic fractures in the same area. Urethral injuries are usually repaired at a later stage with a suprapubic catheter placed until the inflammation settles down in the urethral area.
Open pelvic fractures are very challenging as they can be contaminated with bacteria from the outside. Sometimes a colostomy needs to be done in order to manage the stool while the open fracture (open in the perineal area) is healed. Patients with open wounds near the anus should have a colostomy to keep the anal area free of stool while the fracture heals.
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