DRG Category: 535
Mean LOS: 4.7 days
Description: Medical: Fractures of Hip and Pelvis With Major Complication or Comorbidity
The pelvis, or pelvic ring, consists of two innominate bones connected anteriorly at the symphysis pubis and posteriorly at the sacrum. 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 bony structures protect vascular structures, nerves, and organs. A pelvic fracture is a break in the integrity of either the innominate bones or the sacrum. Pelvic fractures account for approximately 3% of all fractures, with an associated mortality rate that ranges from 3% for low-risk fractures to 25% for high-risk fractures.
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. The pelvic area is highly vascular, and bleeding can occur from exposed fractures, soft tissue injury, and local venous and arterial bleeding. 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. Other complications include gait disturbances, erectile dysfunction, genitourinary tract trauma, hip dislocation, and thromboembolic phenomena including fat emboli. A variety of classification systems have been developed to describe pelvic fractures. See Table 1 for one such classification.
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 (Combined Mechanism) | 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 |
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Two out of three occurrences of pelvic fractures are associated with traffic crashes, which are high-energy events. Fractures associated with traffic crashes generally have the greatest morbidity and mortality as compared to other causes because of the significant forces involved. Combat blast injuries are also high injury events that can lead to pelvic fracture. They may also occur from low-energy events such as falls, sports injuries, or direct blows to bony prominences. Industrial accidents, crush injuries, and assaults also cause pelvic fractures. In older persons, the most common cause is a fall from a standing position. Risk factors for a pelvic fracture include old age, osteoporosis, visual dysfunction, corticosteroid use, vitamin deficiency, physical inactivity, alcohol abuse, and tobacco use.
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 cause OI.
Pelvic fractures may occur at any age, from infants to older adults. Traffic crashes are the most common cause of pelvic fractures in young children as well as in young adults 15 to 28 years of age. During young adulthood, more males than females have pelvic fractures. Complex pelvic fractures (pelvic fractures with soft tissue injury) are more common in men and women younger than age 35 years and are less frequent in patients older than age 65 years. The overall incidence of pelvic fractures is similar for men and women, with an increase in incidence in women older than age 85 years, perhaps because of their increased incidence of osteoporosis.
In recent years, Black persons have been killed in traffic crashes at a rate almost 25% higher than White persons (National Highway Traffic Safety Administration [NHTSA], 2021). Native American persons have the highest rate of traffic crash injury in the United States, more than twice the rate of Black persons (NHTSA, 2021). Experts have noted that Black and Native American communities tend to be crisscrossed by more dangerous roads than other locations, placing people from those communities at risk for injury. Recent work has shown evidence that rural populations have injury mortality rates that are more than twice as high as urban rates. Many factors contribute to these health disparities, including the risk of traffic injury in narrow rural roads, the lack of graded curves and lighted traffic signals on rural highways, and the distance from major trauma centers. Many of the most dangerous occupations, such as mining and agriculture, are found in rural areas and can result in injury, disability, and death. Sexual and gender minority persons have high risk for dating and interpersonal violence, violence related to bullying, and intentional and unintentional injury (Healthy People 2020).
Specifically with respect to abdominal and pelvic trauma, traffic crashes are the leading cause of injury, and they occur most commonly in males ages 14 to 30 years. 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.
PLANNING AND IMPLEMENTATION
Collaborative
Maintenance of airway, breathing, and circulation are the highest priority. Many patients are in hypovolemic shock (see Hypovolemic/Hemorrhagic Shock) and require fluid resuscitation. FAST facilitates a timely diagnosis for patients with blunt abdominal trauma and pelvic fractures and often occurs simultaneously with emergency care. FAST decreases the time to diagnosis, demonstrates the location and severity of hemoperitoneum (intra-abdominal hemorrhage), and can be repeated to assess further bleeding. During care, 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. Prevention of venous thrombosis is a critical part of care.
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.
There is a growing trend to use early surgical treatment to decrease blood transfusion requirements, decrease systemic complications, prevent deformities, and improve survival. 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.
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; anticoagulants or antiplatelet drugs as appropriate
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 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
Chaijareenont, C., Krutsri, C., Sumpritpradit, P., Singhatas, P., Thampongsa, T., Lertsithichai, P., Choikrua, P., & Poprom, N. (2020). FAST accuracy in major pelvic fractures for decision-making of abdominal exploration: Systematic review and meta-analysis. Annals of Medicine and Surgery, 60, 175–181.
- The authors wanted to determine the accuracy of FAST in diagnosing significant intra-abdominal hemorrhage following pelvic fracture to determine if therapeutic abdominal exploration was necessary. They reviewed electronic databases and found 677 cases, and they added 28 cases from their own institution.
- Leading mechanisms of injury were motor vehicle collision, fall from height, and motorcycle collision. Overall mortality rate was 11.65%. The pooled sensitivity, specificity, and accuracy of FAST to identify significant intra-abdominal hemorrhage was 79%, 90%, and 93%, respectively. The authors concluded that FAST in major pelvic fracture accurately detected significant intra-abdominal hemorrhage. It also allowed practitioners to determine whether to perform abdominal exploration with the expectation of finding significant intra-abdominal hemorrhage that required surgical control.