Makindo Medical Notes

Related Subjects: |Fractured Neck of Femur |Fractured Shaft Femur |Supracondylar Femur Fractures |Supracondylar Humerus Fractures |Femoral fractures |Fractured Tibia and Fibula |Pelvic fractures

Pelvic Fractures 🦴🚨 are high-risk injuries often associated with major trauma, haemorrhage, and multi-organ injury. 👉 Mortality ≈10% in closed fractures, up to 50% in open fractures. Always consider associated injuries and hidden blood loss → involve the major trauma centre early.

📖 About

• Pelvis = bony ring formed by sacrum, SI joints, innominate bones, and pubic symphysis.
• Fractures usually occur in ≥2 places due to ring structure.
• Mechanism: high-energy trauma (RTA, fall from height, crush). Low-energy fragility fractures in elderly/osteoporotic patients.

⚙️ Aetiology

• High force → RTA, falls, crush injuries.
• Low force → osteoporotic or pathological fractures.
• Structures at risk: bladder, urethra, vessels, rectum, uterus/vagina.

🩺 Clinical Features

• Shock from haemorrhage (may be hidden retroperitoneal).
• Severe pelvic/hip pain, bruising, swelling.
• Urethral injury signs: blood at meatus, high-riding prostate (on PR).
• PV/PR bleeding may indicate vaginal/rectal injury.
• Always assess for other trauma (head, chest, abdomen, spine).

🔎 Predictors of Major Haemorrhage

• Hct < 30% 📉
• HR > 130 bpm ❤️‍🔥
• Displaced obturator ring fracture
• Wide pubic symphyseal diastasis

📊 Tile Classification

🧾 Simple Classification

• Stable: single break, minimal bleeding, bones remain aligned.
• Unstable: ≥2 breaks, moderate–severe bleeding, deformity.

⚠️ Complications

• Massive haemorrhage, intrapelvic compartment syndrome.
• Bladder, urethral, vaginal, rectal injuries.
• Venous thromboembolism.
• Sexual dysfunction, impotence.
• Chronic instability, deformity, pain.
• Infection/osteomyelitis (esp. open fractures).

🧪 Investigations

• Bloods: FBC, U&E, coagulation, group & crossmatch.
• Urinalysis (haematuria → bladder/urethral injury).
• X-ray: AP pelvis (trauma screen).
• CT: pelvic inlet/outlet, evaluate associated injuries.
• Retrograde urethrogram if urethral injury suspected.
• Angiography: for ongoing bleeding (>0.5 units/hr) → embolisation.

💊 Management

• Initial: ATLS protocol, balanced resuscitation, analgesia.
• Pelvic binder: apply if haemodynamic instability suspected → reduces pelvic volume, promotes clot formation. Keep on until definitive management.
• Do not roll in unstable B/C fractures → use straight lift with ≥4 helpers.
• Avoid urethral catheter if blood at meatus/high-riding prostate → consider suprapubic catheter.
• Open wounds: IV antibiotics, tetanus, urgent debridement. May need colostomy if bowel involved.
• Definitive:
  • Type A: usually conservative → analgesia, rest, mobilisation with aids. Fixation if acetabulum involved.
  • Type B/C: external fixation (pins + frame) or internal fixation (plates/screws). Consider angiography/embolisation if persistent bleeding.

📌 OSCE / Exam Pearls

• Pelvic fracture = assume massive blood loss until proven otherwise.
• Blood at urethral meatus 🚨 → do NOT catheterise → retrograde urethrogram first.
• Apply pelvic binder early in shocked trauma patient with pelvic injury suspicion.
• Stable vs unstable classification is high-yield in exams.

📚 References

• ATLS®: Advanced Trauma Life Support, 10th edition.
• BOAST Guidelines: Management of Pelvic Fractures.
• Rockwood & Green’s Fractures in Adults, 9th edition.