Pelvic Fractures

Atraumatic posterior pelvic ring fractures that simulate the form of presentation of metastatic diseases can be produced by glucocorticoid administration (SEDA-19, 377 200). 

Heiner JP, Joyce MJ, Carter JR, Makley JT. Atraumatic posterior pelvic ring fractures simulating metastatic disease in patients with metabolic bone disease. Orthopedics 1994 17(3) 285-9. 

Musculoskeletal All extremities, the pelvic ring, peripheral pulses, and thoracic and lumbar spine should be assessed. If necessary. X-rays should be obtained when the patient is stabilized. Hemorrhage from pelvic fractures is not uncommon. Hand, foot, and wrist fractures and soft tissue injuries may be missed. Frequent reevaluation should take place to identify these. 

A 6-year-old boy sustained pelvic injuries and a femoral fracture. The first anesthetic he received consisted of thiopental, suxamethonium, isoflurane, and nitrous oxide. He also received two units of blood. He subsequently underwent four halothane anesthetics over 6 weeks for dilatation of a urethral stricture. Two days after the last anesthetic he was noted to be jaundiced. He had a negative viral screen but was positive for antitrifluoroacetyl IgG antibodies. He developed fulminant hepatic failure with grade 2 hepatic encephalopathy and underwent an auxiliary Uver transplantation 24 days after his last exposure to halothane. He died of septicemia 18 days later. Both at autopsy and on a previous hepatobiliary scan he was noted to have had extensive native Uver regeneration. 

Patients with a high risk for clotting require thromboprophylaxis. Some risk factors for venous thromboembolism include age greater than 40 years, prolonged immobility, history of prior venous thromboembolism (DVT, pulmonary embolism [PE]), cancer, major surgery (abdominal, pelvic, or lower extremity), fracture (pelvis, hip, or leg), CHF, Ml, stroke, obesity, and high-dose estrogen use. 

Although the basic pathophysiology is similar for the various causes of hypovolemic shock, there are unique considerations relative to each. For example, whereas isolated head injuries associated with trauma typically do not result in substantial blood loss or shock, pelvic fractures may sequester several liters of blood as hematoma formation. Patients with traumatic or thermal injuries, as well as postoperative patients, may have substantial fluid accumulation in sites where it cannot be readily transferred back into blood vessels (i.e., third-spaced fluid) for maintaining pressure. With these types of injuries, prompt control of compressible bleeding sources with rapid patient transfer to the hospital for definitive treatment may preclude the cascade of events leading to shock. Indeed, with trauma patients, a scoop and run approach is used in most urban hospitals that places a priority on rapid transport to a hospital. ... 

Agolini, S.F., Shah, K., Jaffe, J., Newcomb, J., Rhodes, M., Reed, J.F. 1997. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 43, 395-399. 

Concomitant venous/bone marrow hemorrhage (major venous injury, unstable pelvic fracture with marrow bleeding)... 

Ramirez Jl, Velmahos GC, Best CR, Chan LS, Demetriades D (2004) Male sexual function after bilateral internal iliac artery embolization for pelvic fracture. J Trauma 56 734-739... 

Ben-Menachem Y, Coldwell DM, Young JWR, et al. (1991) Hemorrhage associated with pelvic fractures causes, diagnosis, and emergent management. AJR Am J Roentgenol 157 1005-1014... 

Verheyden, A., et al., Percutaneous stabilization of dorsal pelvic ring fractures—transiliosacral screw placement in the open MRI, in First Annual Meeting ofCAOS International, 2001, Davos, Switzerland. 

Margolies MN, Ring EJ, Waltman AC, Kerr WS Jr, Baum S (1972) Arteriography in the management of hemorrhage from pelvic fractures. N Engl J Med 287 317-321... 

Indications for Pelvimetry 318 Breech Presentation and Maternal Preference for Spontaneous Delivery After Cesarean Section Due to Arrest of Labor 318 Clinically Conspicuous Abnormalities of Pelvic Shape and Status Post Pelvic Fracture 318... 

Clinically Conspicuous Abnormalities of Pelvic Shape and Status Post Pelvic Fracture... 

With knowledge of common accidental fractures, the finding of a fracture at an unusual site will suggest an unusual mechanism of injury. In the absence of a history of an unusual mechanism, abuse should be considered. Unusual sites of fractures in infants and toddlers include phalanges (Fig. 11.9), meta-carpals, metatarsals, pelvis and scapula (Fig. 11.10). Pelvic fractures have been described in association with sexual abuse (Johnson et al. 2004). 

Pelvic trauma in children can result in a wide variety of different fractures and soft tissue injuries these range from isolated, relatively henign avulsion injuries to very complex multiple pelvic fractures and joint dissociations. The type of injury will depend on the causative mechanism as well as the age and development of the child. Compared with adults, pelvic fractures are relatively uncommon in children (ScHLiCKWEi and Keck 2005) and indicate a significant high energy impact. 

Paediatric pelvic ring fractures are rare. The incidence has been estimated to between 2%-7% of all childhood fractures (Ismail et al. 1996 Junkins et al. 2001). When one compares the admissions rates of large trauma centres, pelvic fractures in adults occur in about 10% of cases as opposed to less than 5% in children. With motor vehicle and pedestrian injuries, adults are twice as likely to suffer pelvic fractures as children (Demetriades etal. 2003). Pelvic fractures in children are more likely to be associated with a pedestrian injury rather than passenger injury. 

The ilio-lumbar ligaments extend from the transverse process of the lower lumbar vertebrae to the superflcial aspects of the anterior sacral iliac ligaments. Traction forces on these ligaments may avulse part of the transverse process and are associated with pelvic fractures (Fig. 12.2a,b). 

The AP radiograph is useful in demonstrating pelvic fractures, but it may miss some injuries (Berg et al. 1996). While additional views such as the inlet and outlet, may detect further fractures, their use is no longer indicated if there is reasonable access to CT imaging. 

The AP radiograph should be closely reviewed for signs of pelvic ring discontinuity by identifying various anatomical lines, the absence of which implies ring disruption or a fracture. These lines are the ischio-ilial line, ilio-pectineal line, and the anterior and posterior acetabular walls. The ilio-ischial line is formed by the posterior structures of the pelvis and the ilio-pectineal by the anterior acetabular structures (Ersoy et al. 1995) (Fig. 12.3). 

Avulsion fractures of the posterior inferior iliac spine and the transverse process of the 5 lumbar vertebra are rare but indicative of severe trauma. The former occurs as a result of external rotation of the hemi-pelvis which avulses the sacrospinous ligament at its insertion. The latter injury results when the ilio-lumber ligament is avulsed from the tip of the transverse process of L5 by shearing forces in the vertical plane. These injuries should arouse suspicion of pelvic instability. 

Approximately 30% of pelvic fractures seen on CT can be missed on plain films (Resnik et al. 1992 Berg et al. 1996). In particular, AP radiographs may miss sacroiliac diastasis, acetabular, intra-articular and vertical shear fractures (Montana et al. 1986 ... 

The classification of pelvic fractures has been widely discussed for adult patients. In general, the classification of any paediatric injury follows adult practice, but there is less data available on paediatric injuries. The aim of any classification system is to try and determine the mechanism of injury, assess the degree of instability, aid appropriate management and if possible predict outcome. The multitude of classification systems makes comparison of incidence, mechanism of injury, morbidity and mortality between different studies difficult. 

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