Jeffrey G. Norvell
PELVIS FRACTURES
EPIDEMIOLOGY
Pelvic fractures are associated with high morbidity and mortality rates because of the immense forces needed to fracture the bony pelvis; concomitant abdominal, chest, and head injuries; and the potential of severe hemorrhage.
Most pelvic fractures are the result of motor vehicle crashes or falls from height.
CLINICAL FEATURES
Pelvic fractures should be considered in all patients with serious blunt trauma.
In patients who are awake and alert, the physical examination is very sensitive for the diagnosis of pelvic fractures.
Signs and symptoms of pelvic injuries vary from local pain and tenderness to pelvic instability and severe shock.
Examine the patient for pain, pelvic instability, deformities, lacerations, ecchymoses, and hematomas.
Rectal examination may reveal rectal injury or a displaced prostate.
Blood at the urethral meatus may suggest urethral injury.
A pelvic examination may be necessary to detect lacerations that would suggest an open fracture.
Avoid excessive movement of unstable pelvic fractures as this could cause further injury.
Hypotension may be secondary to abdominal or thoracic injuries, or blood loss from disrupted pelvic bones or vessels.
DIAGNOSIS AND DIFFERENTIAL
An anteroposterior (AP) pelvic radiograph is often used to evaluate for bony injury.
Other radiographic views include lateral views, AP views of either hemipelvis, internal and external oblique views of the hemipelvis, or inlet and outlet views of the pelvis.
In an unstable trauma patient, a pelvic radiograph can be used to quickly identify a pelvic fracture and allow for emergent stabilization maneuvers.
Routine pelvic radiographs are probably not needed in stable trauma patients who will undergo emergent CT scan of the abdomen and pelvis.
CT is superior to pelvic radiographs for identifying pelvic fractures and evaluating pelvic ring instability. Contrast extravasation on CT scan is 80% to 90% sensitive for the identification of arterial bleeding.
Consider CT in patients with a high suspicion for pelvic fractures and negative radiographs, or in patients with fractures on radiographs to evaluate for additional injuries.
Pelvic fractures include those that involve a break in the pelvic ring, fractures of a single bone without a break in the pelvic ring, and acetabular fractures.
The Young-Burgess classification system for pelvic ring fractures is shown in Table 175-1. This system differentiates fracture patterns based on mechanism of injury and direction of force. The incidence of complications is correlated with fracture pattern.
Single bone fractures are described in Table 175-2.
TABLE 175-1 Young-Burgess Classification System and Incidence of Complications
TABLE 175-2 Avulsion and Single Bone Fractures
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Due to pelvic bleeding and associated injuries, patients with pelvic fractures may need resuscitation with crystalloid, blood, and blood products.
Most bleeding in pelvic fractures is due to low-pressure venous bleeding and bleeding from the bone edges. Arterial bleeding occurs in 10% to 15% of patients with pelvic fractures.
The pelvis can be stabilized with a bedsheet or other pelvic-binding device to reduce pelvic volume and to stabilize fracture ends. The simplest technique is the application of a folded bedsheet tightly wrapped around the pelvis and upper legs and secured by towel clips.
In hemodynamically unstable patients, evaluate for other locations of bleeding such as the thorax and peritoneal cavity using a chest radiograph and the focused assessment with sonography for trauma (FAST), respectively.
After excluding other sources for bleeding, treatment for ongoing hemodynamic instability in patients with pelvic fractures includes angiography with emboliza-tion and external fixation.
Angiographic embolization is effective at controlling arterial bleeding, and external fixation is thought to be effective at controlling venous bleeding.
Hemorrhage refractory to resuscitation is more likely arterial than venous in origin; angiography with possible embolization should be pursued.
Pelvic ring fractures require orthopedic consultation and hospital admission.
With the exception of lateral compression type I and anteroposterior compression type I injuries, all pelvic ring fractures require open reduction and internal fixation.
The management and complications of pelvic ring fractures are described in Table 175-1.
The treatment and disposition of avulsion and single bone fractures are described in Table 175-2.
ACETABULAR FRACTURES
Acetabular fractures are usually secondary to a motor vehicle crash.
If an acetabular fracture is suspected, it can be evaluated with an AP view, a 45-degree iliac oblique view, and a 45-degree obturator oblique view, together known as Judet views.
CT is more sensitive than radiography in detecting acetabular injury. Also, CT gives additional information about the severity of fracture that is useful in preoperative planning.
The most common complication is a sciatic nerve injury.
Early orthopedic consultation and hospital admission are indicated for patients with acetabular fractures.
Early reduction and internal fixation is indicated for displaced fractures.
HIP FRACTURES
EPIDEMIOLOGY
The vast majority of hip fractures occur in older patients with osteoporosis or other bony pathology secondary to systemic disease.
CLINICAL FEATURES
The affected leg is classically shortened and externally rotated.
Patients with a hip fracture will typically have pain at the site of injury, but may also report knee pain or groin pain.
After performing a primary survey and stabilizing the patient, examine the patient for pain, shortening, rotation, deformities, pelvic instability, and neurovascular status.
If no significant abnormalities are detected, carefully evaluate range of motion.
The demographics and clinical features of hip fractures are shown in Table 175-3.
TABLE 175-3 Proximal Femur Fractures: Demographics and Clinical Features
DIAGNOSIS AND DIFFERENTIAL
The threshold for imaging in elderly patients should be low.
Radiographic evaluation of the hip includes AP and lateral views. Other radiograph views that may be helpful are an AP view of the pelvis and Judet views. Radiographs of the femur and knee may be indicated.
Significant pain with weightbearing or inability to bear weight should raise suspicion of occult fracture.
MRI is very sensitive (near 100%) for identifying occult hip fractures.
CT may be helpful in identifying fractures not seen on radiographs, but it is not as sensitive as MRI for occult fractures.
Bone scanning may also be used for the detection of occult fractures.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
The treatment of hip fractures is listed in Table 175-4.
If clinical suspicion of an occult fracture is high, obtain CT or MRI imaging in the ED. Alternatively, arrange urgent follow-up for imaging and the patient should remain non-weightbearing.
Traction devices may be used for immobilization of subtrochanteric fractures. However, if there is concern for neurovascular injury, traction should not be applied.
Traction is contraindicated in femoral neck fractures.
TABLE 175-4 Proximal Femur Fractures: Treatment Issues
HIP DISLOCATIONS
Hip dislocations are true orthopedic emergencies and commonly result from a high-speed motor vehicle crash.
Ninety percent of dislocations are posterior. Ten percent of dislocations are anterior.
Hip dislocations may have associated acetabular or femoral head fractures.
Assess neurovascular status.
Radiographs of the hip and pelvis will evaluate for hip dislocation. Further assessment of the femur and acetabulum may be done with Judet views or CT.
Reduce hip dislocations within 6 hours in order to decrease the incidence of avascular necrosis.
One of the most common techniques for hip reduction is described in Fig. 175-1.
Order post-reduction radiographs or CT to confirm reduction and evaluate for injuries not apparent on initial radiographs.
FIG. 175-1. A and B. Allis maneuver for reduction of posterior hip dislocation.
FEMORAL SHAFT FRACTURES
Fractures of the femoral shaft occur most commonly in younger patients secondary to high-energy trauma.
Pathologic fractures may occur due to malignancies.
Clinical features include pain, swelling, deformity, and shortening.
Assess the patient for neurovascular status, signs of an open fracture, and other injuries.
Obtain radiographs to evaluate for fractures.
ED treatment includes splinting the extremity with a traction splint unless the patient has a sciatic nerve injury or open fracture with grossly contaminated, exposed bone.
Obtain urgent orthopedic consultation.
Open fractures require broad-spectrum antibiotics.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 269, “Pelvis Injuries,” by Mark T. Steele and Jeffrey G. Norvell, and Chapter 270, “Hip and Femur Injuries,” by Mark T. Steele and Amy M. Stubbs.