What is pelvis?
The pelvis is made up of the sacrum and two inominate bones (each inominate bone is made of three separate bones namely ilium, ischium and pubis) which are held together like a ring by strong ligaments in the front and the back important for weight bearing. The pelvis encloses hollow organs like bladder, reproductive structures and a large complex of important blood vessels. An injury to the pelvic ring can cause substantial bleeding from the sacral venous plexus (located at the back) and the arterial network of the pelvis.
What is the mechanism of injury in a fractured pelvis?
There are three broad categories of sustaining this injury.
1. Compression from front to back of the pelvis (anterior posterior compression injuries- Type A injuries)
2. Compression from either side (lateral compression injuries- Type B injuries): They are the commonest injuries.
3. Vertical shear injuries (Type C injuries) which are usually due to a fall from height and are unstable.
What are Pelvic Fractures?
Pelvic fractures are life-threatening injuries. It is usually sustained as a high velocity injury like falling off a great height, crush injury or a road traffic accident. It causes significant internal bleeding within the pelvis called as retroperitoneal haemorrhage. This happens as the major blood vessels within the pelvis usually get torn off or rupture. Patients can lose as much as 2-3 L of blood in a very short span of time, causing hemorrhagic shock. This greatly reduces the amount of blood in the body for vital structures like brain, heart and kidneys causing death. There are some fractures of the outer pelvis rim not involving the cavity like pubic rami fractures which do not cause any threat to life and are treated by analgesia and physiotherapy.
What are the Symptoms of Pelvis Fractures?
There is history of a large velocity trauma. Patients feel severe pain in the groin and may have multiple injuries. There may be an obviously noticeable deformity. Any movement of the pelvis will be too painful. Tenderness is present on pressing the bony bits of the pelvis. There may be bruising and or blood at the urinary meatus. Patients may feel dizzy or lose consciousness due to the excessive blood loss.
What are the Investigations for Pelvic Fracture?
In a pelvic fracture it is vital to investigate for abdominal, rectal, vaginal and neurological injuries.
The investigations are:
1. Plain radiographs (X-Rays)
2. CT Scans of pelvis
3. CT Urethrograms or Cystograms to look for urethral or bladder injuries.
4. Plain X-Rays of neck, chest and abdomen to rule out accompanying injuries.
5. Blood tests to assess degree of blood loss and medical complications like renal failure.
6. Ultrasound to assess intra abdominal injuries.
7. Angiogram for identifying source of arterial bleeding.
What is the Management of Pelvic Fractures?
Pelvic fractures are managed in emergency departments worldwide by rapid intravenous infusion of intravenous fluids and blood. Blood and blood products are rapidly transfused while the instability of the bony structures is reduced by externally fixing them. Attempts are made to reduce the volume of the pelvic cavity by a sheet or binder wrapped around the pelvis or by using clamps or external fixators. The pelvic cavity is reduced back to its normal anatomical position surgically by fixing pins in the pelvic rim. The patient is urgently taken to operating theatre and resuscitated aggressively by trauma and orthopaedic surgeons.
What is the surgical management of pelvic fractures?
Surgical management of pelvic fractures can be divided into two, acute and late.
Acute management: It involves fixing pins surgically on the pelvic rim on the iliac crest or near the iliac spine to close the increased volume of the pelvic cavity. This usually stops the bleeding. If the patient still remains haemodynamically unstable then embolization of the bleeding site using an angiogram is the next management plan. Urgent surgery is needed to manage any arterial injury. In extreme cases an exploratory laprotomy is performed to find the source of bleeding.
Late management: late onset management of patients who luckily survive the acute episode consists of extensive surgeries. This is in the form of open reduction and internal fixation by using plates and screws to reduce the fracture dislocation. Usually there are many other bony injuries in the rest of the body which need to be treated at this stage. These patients need months and years of rehabilitation.
What are the complications of pelvic fractures?
Complications can be due to the fracture itself or the surgery to treat it.
Pelvic fractures can cause injuries to all of the structures which occupy the pelvic cavity. Commonly these can be seen in the bladder, urethra and the rectum. Injuries to the weight bearing area of the pelvis can lead to early arthritis.
1. Nerve Injury: These are common and the more severe they are at injury the worse their prognosis. The L5 nerve is most likely to get injured.
2. Infection: Any surgery can lead to infection.
3. Malunion and non union: Malunion is commonly seen after non surgical management of pelvic fractures. It affects sexual function, sleep, gait and sitting.
4. DVT & P.E.: Blood clots in the leg’s or lungs (called as DVT or P.E). These happen due to prolonged immobilization, stress of surgery and dehydration. These conditions tend to produce reduced blood flow causing it to clot where it gets pooled within the vein.
5. Genitourinary Complications: Severe trauma can injure the bladder and the lower urinary system. Erectile failure after such injuries is not uncommon.
6. Abdominal injuries: These are common along with pelvic fractures and can cause rupture of the diaphragm, intestinal injury along with damage to the spleen and liver.
7. Death: Pelvic fractures have extremely high death rates of 10% – 20% due to irreversible shock, multiple organ failure, infection in case of open injuries or from contamination of the abdominal cavity by urine or faeces.
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