Pelvic Fracture

Scenario

40YO male presenting after being involved in a Road Traffic collision. A+E call you with the following X-Ray.

Screenshot-2022-04-28-at-06.04.41

Image sourced from: https://en.wikipedia.org/wiki/Pelvic_fracture and used under CC BY-SA 3.0

This is an AP plane film radiograph taken of an unknown skeletally mature individual’s pelvis. The most obvious abnormality is that there is diastasis of the pubic symphesis. This would be consistent with an AP compression type pelvic fracture. 

Given the mechanism of injury I would approach this patient according to ATLS and BOAST principles. I would place a trauma call and complete a primary and secondary survey. As part of the primary survey I would stabilise the C-Spine, assess the patient’s airway, breathing, circulation and disability. I would also place a pelvic binder.

As part of the secondary survey I would assess the neurovascular status of the lower limbs and a PR/PV/urological examination to rule out open injury.

Pelvic fractures are classified according to the Young and Burgess Classification system

Young and Burgess classification

LC – 1

Rami fracture and ipsilateral sacral ala compression fracture

Stable

LC – 2

Rami fracture and iliac crescent fracture

Unstable

LC – 3

Ipsilateral lateral compression and contralateral APC (bilateral pubis fracture)

Unstable

APC – 1

Pubic diastasis <2.5cm

Stable

APC – 2

Pubic diastasis >2.5cm and anterior SI joint diastasis

Unstable

APC – 3

Pubic diastasis >5cm and anterior SI joint diastasis

Unstable

Vertical shear

Vertical displacement of the hemipelvis, fractures of the pubis and SI joint.

Unstable

Combined

Complex fracture with combined elements

Variable

At the level of the Greater trochanters bilaterally with internal rotation of the ankle.

A single, gentle attempt at catheterization can be performed.

16F soft silicone catheter should be used

The finding of blood stained urine mandates a retrograde cystogram via a catheter

If a urethral catheter does not pass or passes only blood then do not inflate the balloon instead perform a retrograde urethrogram.

The oncall urologist should be informed about bladder injuries

 

 

Class 1

Class 2

Class 3

Class 4

Blood loss

750ml

750ml-1.5L

1.5 – 2L

>2L

% volume loss

15%

15-30%

30-40%

>40%

Heart rate

<100

>100

>120

>140

SBP

No change

No change

Reduced

Very low

DBP

No change

Raised

Reduced

Unrecordable

Resp rate

<20

>20

>30

>40

Urine output

>30

20-30

10-20

>10

Extremities

Normal

Pale

Pale

Cold

Mental state

Alert

Anxious

Aggressive/ drowsy

Confused/ unconscious

  • Major haemorrhage initiate major haemorrhage protocol (2222)
  • Porters will go to a blood bank and bring ‘Pack A’ to ED
  • Pack A: 4 units red blood cells, 4 units FFP
  • If patient still haemodynamically unstable
  • Pack B 4 units red blood cells, 4 units Fresh frozen plasma, 1 platelet

Reconstruction of the pelvic ring should occur within 72 hours of the stabilisation of the patient’s physiological state.

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