Pelvic Fractures

DRG Category:	535
Mean LOS:	5.4 days
Description:	MEDICAL: Fractures of Hip and Pelvis With Major CC

A pelvic fracture is a break in the integrity of either the innominate bones or the sacrum. The innominate bones are connected posteriorly at the level of the sacrum and anteriorly to the symphysis pubis. These structures form a ring of bones with ligaments that are designed to accommodate weight distributed from the trunk to the pelvis across both the sacrum and the joints at the S1 vertebra. The S1 joints are maintained by the anterior and posterior ligaments and pelvic floor ligaments. The iliac vascular structures, lumbosacral plexus, lower genitourinary tract, reproductive organs, portions of the small bowel, distal colon and rectum, iliofemoral vessels, and lumbosacral plexus bilaterally all may be affected by a pelvic fracture.

Pelvic fractures account for approximately 3% of all fractures, with an associated mortality rate that ranges from 10% to 50%. The most immediate, serious complications associated with pelvic fractures are hemorrhage and exsanguination, which together cause up to 60% of the deaths from pelvic injuries because they can lead to the loss of 2 or 3 L of blood. Pelvic fractures associated with sacral and sacroiliac disruption may cause sciatic and sacral nerve injuries.

Causes

Two out of three occurrences of pelvic fractures are associated with motor vehicle crashes (MVCs) and automobile–pedestrian trauma. Fractures associated with MVCs generally have the greatest morbidity and mortality as compared to other causes because of the significant forces involved. Industrial accidents, falls, crush injuries, and sports injuries also cause pelvic fractures. Pelvic fractures may also occur from a low-impact fall or direct blows to bony prominences. In older persons, the most common cause is a fall from a standing position. A variety of classification systems have been developed to describe pelvic fractures. See Table 1 for one such classification.

Functional Classification of Pelvic Fractures (other classification systems also exist)

Table 1. Functional Classification of Pelvic Fractures (other classification systems also exist)
CLASSIFICATION	DESCRIPTION/STABILITY
Lateral compression	Rotationally unstable but vertically stable
	Posterior elements are stable
	May cause soft tissue and genitourinary tract injury
Anterior-posterior compression	“Open book injury” with symphysis pubis disruption
	Posterior element stability is variable
	May be associated with genitourinary tract injury
Vertical shear	Virtually always instability in the posterior elements
	Commonly associated with soft tissue, skin, vascular, genitourinary, gastrointestinal, and neurological injury
Acetabular disruption	Includes simple fractures, dislocations, and implosion of the head of the femur into the pelvis
	Generally unstable
	May be associated with genitourinary and neurovascular injuries

Genetic considerations

Genetic disorders, such as osteogenesis imperfecta (OI), that decrease bone strength can increase the likelihood of pelvic fractures. Mutations in collagen genes COL1A1 and COL1A2 are associated with some cases of OI.

Gender, ethnic/racial, and life span considerations

Pelvic fractures may occur at any age, from the pediatric to the elderly populations. Traffic crashes are the most common cause of pelvic fractures in children. Complex pelvic fractures are more common in men and women younger than age 35 and are less frequent in patients older than 65. The overall incidence of pelvic fractures is similar for men and women, with an increase in incidence in women older than 85, perhaps because of their increased incidence of osteoporosis. During young adulthood, more males than females have pelvic fractures. There are no known racial/ethnic considerations in pelvic fractures.

Global health considerations

Specifically with respect to abdominal and pelvic trauma, MVCs are the leading cause of injury, and they occur most commonly in males ages 14 to 30. According to the World Health Organization, falls from heights of less than 5 meters are the leading cause of injury globally, but estimates are that only 6% of those are related to abdominal or pelvic trauma.

Assessment

History

Establish a history of the mechanism of injury, along with a detailed report from prehospital professionals. In cases of MVCs, include the type of vehicle and speed at the time of the crash. Determine whether the patient was a driver or passenger and whether he or she was using a safety restraint. If the patient experienced a fall, determine the point of impact, distance of the fall, and type of landing surface. Ask if the patient experienced suprapubic tenderness, the inability to void, or pain over the iliac spikes. Determine if the patient has any underlying medical disorders, such as polycystic kidney disease or frequent urinary tract infections. Take a medication history and determine if the patient has a current tetanus immunization.

Physical examination

The initial evaluation or primary survey of the trauma patient is centered on assessing the airway, breathing, circulation, disability (neurological status), and exposure (completely undressing the patient). Inspection may reveal abrasions, pain and tenderness, ecchymosis, or contusions over bony prominences, the groin, genitalia, and suprapubic area. Ecchymosis or hematoma formation over the pubis or blood at the urinary meatus is significant for associated lower genitourinary tract trauma. Palpation of the iliac crests and anterior pubis may suggest underlying injury; however, “rocking of the pelvis” is discouraged because it may cause an increase in vascular injury and bleeding. Internal rotation of the lower extremity or “frog leg positioning” is suggestive of pelvic ring abnormalities. Instability on hip adduction and pain on hip motion may indicate an acetabular fracture with or without an associated hip fracture.

Perform complete rectal and pelvic examinations to assess for bleeding; rectal tone; and, in women, the presence of vaginal wall disruptions. Check the position of the prostate gland in men and palpate for a “high-riding” prostate, which may indicate genitourinary tract injury. Assess the lower extremities for paresis, hypoesthesia, alterations in distal pulses, and abnormalities in the plantar flexion and ankle jerk reflexes. Inspect the perineum, groin, and buttocks for lacerations that may have been caused by open pelvic fractures. Note that from one-third to one-half of all trauma patients have an elevated blood alcohol level, which complicates assessments and may mask abdominal pain.

Monitor hourly fluid volume status, including hemodynamic, urinary, and central nervous system parameters. Notify the physician if delayed capillary refill, tachycardia, urinary output less than 0.5 mL/kg per hour, or alterations in mental status (restlessness, agitation, and confusion) occur. Body weights are helpful in indicating fluid volume status over time.

Psychosocial

The patient who has a pelvic fracture faces stressors that range from the unexpected nature of the traumatic event and acute pain to potential life-threatening complications. The traditional means of verbal communication are often limited or absent, thus leading to the patient’s fear, loss of control, and isolation. Significant lifestyle and functional changes may occur in patients with pelvic fractures and their associated injuries. Assess patients’ coping strategies, level of anxiety, and overall understanding of their injuries. Assess patients’ ability to adapt to their current circumstances.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Pelvic x-rays	Intact bony structure	Evidence of fractures and dislocations	Demonstrates radiographic evidence of pelvic injury; uncovers 90% of pelvic fractures with initial screening
Ultrasound; focused assessment with sonography for trauma	Intact bony structure of pelvis with no hemorrhage	Intrapelvic bleeding and fluid accumulation; intraperitoneal bleeding is also possible	Shows location of bleeding to explain shock
Retrograde urethrography	Intact urethra	Injured or transected urethra	Shows location and extent of genitourinary injury
Computed tomography scan	Intact bony structure	Evidence of fractures, dislocations, and sacral injuries	Assesses pelvis and sacroiliac joint and sacral injuries; best study to evaluate pelvic anatomy and amount of bleeding within and around the pelvic cavity; confirms hip dislocation associated with acetabular fracture

Other Tests: Pregnancy test, hematocrit, hemoglobin, platelet count, prothrombin time

Primary nursing diagnosis

Diagnosis

Fluid volume deficit related to active hemorrhage secondary to pelvic fracture and adjacent vascular structures

Outcomes

Fluid balance; Circulation status; Cardiac pump effectiveness; Hydration

Interventions

Bleeding reduction; Fluid resuscitation; Blood product administration; Intravenous therapy; Circulatory care; Shock management

Planning and implementation

Collaborative

Maintenance of airway, breathing, and circulation are the highest priority. Many patients are in hypovolemic shock (see Hypovolemic/Hemorrhagic Shock, p. 606) and require fluid resuscitation. Avoid excessive movement of the pelvis whether the fracture is stable or unstable. Patients with stable pelvic fractures can be managed with bedrest alone, and early ambulation is guided by their level of pain or associated injuries. Patients with unstable pelvic fractures can also be managed with bedrest, spica casts, or sling traction, but there is an increasing risk of complications associated with prolonged bedrest. Movement, weight-bearing restrictions, and head of bed elevation are prescribed by the orthopedic surgeon. The physician often prescribes sequential compression devices to prevent venous stasis.

External immobilization helps decrease pain, reduce the amount of blood transfusions, and facilitate early ambulation. Immobilization can be achieved through the use of several devices that can be applied externally or percutaneously to the pelvis through the skin into the bony structure. This type of fixation can be performed at the scene of the injury in an attempt to decrease bleeding and to immediately immobilize bony deformities. A pneumatic antishock garment (PASG) immobilizes unstable bony injuries and provides a tamponade effect, but it is a controversial intervention because its use has been associated with an increase in prehospital time and hemodynamic abnormalities. External stabilization can also be accomplished through the use of an external skeletal fixation device.

Surgical open reduction and internal fixation of pelvic ring disruptions are accomplished with the use of a variety of plates and screws that are secured internally. The goal of internal fixation is to restore the pelvis to its original anatomic configuration. When to perform the open reduction and internal fixation is controversial. Monitor for erythema, drainage, and edema at all wound sites, incision sites, and external fixator appliance insertion sites every 4 hours. Perform pin care as prescribed every 4 to 6 hours.

Pharmacologic highlights

General Comments: Surgeons may choose to follow cultures of wounds, urine, blood, and sputum rather than use prophylactic antibiotics. A tetanus booster may be administered to patients, depending on their history.

Medication or Drug Class	Dosage	Description	Rationale
Narcotic analgesics	Varies with drug but generally given IV in the early phases	Morphine sulfate, fentanyl, meperidine	Provide relief of pain

Other Drugs: Antibiotics such as gentamicin, ampicillin, vancomycin, metronidazole; other analgesics such as hydrocodone bitartrate and acetaminophen, oxycodone and acetaminophen

Independent

Maintain the patient in a supine position if it is not contraindicated because of other injuries. Ensure adequate airway and breathing in this position. Because Trendelenburg’s position may have negative hemodynamic consequences, may increase the risk of aspiration, and may interfere with pulmonary excursion, it is not recommended. If the PASG has been applied to stabilize the bony fractures and tamponade bleeding, protect the extremities with towels.

Wound care varies, depending on the severity of wounds, the presence of an open fracture, and the type of fixation device applied. Initial débridement may be done in the operating room at the time of the exploratory laparotomy. Wounds and any exposed soft tissue and bone are covered with wet sterile saline dressings. Avoid povidone-iodine (Betadine)–soaked dressings to limit iodine absorption and skin irritation. Use universal precautions to avoid exposing patients to infection.

Extensive periods of bedrest increase the risk of complications. Remove devices every shift to assess the underlying skin and provide skin care. Sequential compression devices may be applied to the upper extremities if the lower extremities are fractured or in skeletal traction. Provide active or passive range-of-motion exercises to uninjured extremities every shift, as appropriate. Maintain traction by keeping it free-hanging; do not remove weights when moving or repositioning the patient. Some patients may benefit from the use of specialty beds, such as a rotating bed that may improve pulmonary status while maintaining bony stability. Do not use external fixation devices to move or turn patients. Maintain skin integrity by using specialty mattresses with pressure-releasing components. Protect the patient from injury by covering all wire ends with plastic tips, corks, or gauze. When positioning the patient with an external fixation device, protect the skin with padding. Keep the patient’s skin clean and dry. Gently massage the patient’s bony prominences every 4 hours.

Evidence-Based Practice and Health Policy

Bramos, A., Velmahos, G.C., Butt, U.M., Fikry, K., Smith, R.M., & Chang, Y. (2011). Predictors of bleeding from stable pelvic fractures. Archives of Surgery, 146(4), 407–411.

In a study among 391 patients with stable pelvic fractures that did not require external or internal fixation, 5% of the patients had significant bleeding caused by the fracture that required intervention within the first 24 hours of admission.
When compared with patients without significant bleeding, patients with bleeding were more likely to have been injured from a fall (76% of patients with bleeding versus 56% of patients without bleeding) than from a motor vehicle crash (24% of patients with bleeding versus 40% of patients without bleeding) (p = 0.04).
Predictors of bleeding included a hematocrit of 30% or lower (p < 0.001), the presence of a pelvic hematoma (p < 0.001), and systolic blood pressure ≤ 90 mm Hg (p = 0.01). The presence or absence of all three predictors was 100% accurate in predicting or eliminating patients with a significant bleed.

Documentation guidelines

Physical findings: Vital signs, urine output, body weight, capillary refill, mental status, quality of peripheral pulses, urethral bleeding, bowel sounds, wound healing, bruising
Response to bedrest and immobility, position of external fixation device, degree of range of motion, progress toward rehabilitation
Presence of complications: Infection; pressure sores; inadvertent injury from external fixation devices, hemorrhages
Pain: Location, duration, precipitating factors, responses to interventions

Discharge and home healthcare guidelines

To prevent complications of prolonged immobility, encourage the patient to participate in physical and occupational therapy as prescribed. If compression stockings are prescribed, teach the patient or family the correct application. Verify that the patient has demonstrated safe use of assistive devices such as wheelchairs, crutches, walkers, and transfers. Teach the patient the purpose, dosage, schedule, precautions, potential side effects, interactions, and adverse reactions of all prescribed medications. Review with the patient all follow-up appointments that are arranged. If home care is necessary, verify that appropriate arrangements have been completed.