Pelvic Fractures

Management

For pelvic fractures that involve loss of integrity of the pelvic ring (the sacrum Sacrum Five fused vertebrae forming a triangle-shaped structure at the back of the pelvis. It articulates superiorly with the lumbar vertebrae, inferiorly with the coccyx, and anteriorly with the ilium of the pelvis. The sacrum strengthens and stabilizes the pelvis. Vertebral Column: Anatomy and the 2 innominate bones), definitive fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures management and bleeding control are carried out by the trauma and/or orthopedic surgeon. For pelvic fragility fractures in the elderly that do not require surgery, pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways control and early mobilization are important.

Treatment goals

• Return the patient to their pre-injury functional level to the greatest extent possible.
• Proper alignment of the bones (correcting the displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms) during healing is vital.
• If the joint does not heal correctly → cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology loss and osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis → loss of motion, decreased function, and pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.

Initial management

• Rapid hemorrhage control and fluid resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome
• Temporary external fixation to stabilize the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy: 
  • Centered over the greater trochanters to prevent further pelvic bleeding:
    • Sheet
    • Pelvic binder
    • Other noninvasive pelvic circumferential compression Compression Blunt Chest Trauma device
  • Temporary measure until the patient can be taken to the OR or transferred to a trauma center.
  • Should be avoided in LC-type fractures with an internal rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays component

Nonsurgical treatment

• Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways control
• Early mobilization with physical therapy Physical Therapy Becker Muscular Dystrophy
• Gait Gait Manner or style of walking. Neurological Examination assistance with walker or crutches
• Stable nondisplaced pelvic fractures without dislocation:
  • May require closed reduction Closed Reduction Radial Head Subluxation (Nursemaid’s Elbow) under anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts 
  • May need external fixation
• Surgery may not be indicated for:
  • Simple acetabular fractures of the anterior wall
  • Elderly patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with severe osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with multiple comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus or infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease

Surgery

• Surgical management of pelvic fractures depends on:
  • Joint stability
  • Fragment size and comminution
  • Patient’s age and comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus 
• Acetabular fractures are difficult to treat due to the proximity of:
  • Major blood vessels to the legs
  • Sciatic nerve Sciatic Nerve A nerve which originates in the lumbar and sacral spinal cord (l4 to s3) and supplies motor and sensory innervation to the lower extremity. The sciatic nerve, which is the main continuation of the sacral plexus, is the largest nerve in the body. It has two major branches, the tibial nerve and the peroneal nerve. Gluteal Region: Anatomy 
  • Intestines
  • Ureter and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess
• May need to wait for 5–10 days following an injury that causes an acetabular fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures due to the significant bleeding: 
  • Open reduction and internal fixation of acetabular fractures are based on the location of the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures(s):
    • Anterior or ilioinguinal approach for the anterior column Anterior column Spinal Cord: Anatomy, both columns, anterior column Anterior column Spinal Cord: Anatomy plus posterior hemitransverse, or T-shaped fractures
    • Posterior surgical approach for posterior wall, posterior column Posterior column Spinal Cord: Anatomy, transverse plus posterior wall, or posterior column Posterior column Spinal Cord: Anatomy plus posterior wall fractures
    • Transverse approach depends on whether the predominant direction of displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms is anterior or posterior.
  • Extensive comminution or displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms of both anterior and posterior fragments may require sequential Sequential Computed Tomography (CT) surgeries (anterior and posterior) or, less commonly, an extended iliofemoral approach.
  • Worst prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas is seen with the associated transverse and posterior wall fractures:
    • High incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of sciatic nerve Sciatic Nerve A nerve which originates in the lumbar and sacral spinal cord (l4 to s3) and supplies motor and sensory innervation to the lower extremity. The sciatic nerve, which is the main continuation of the sacral plexus, is the largest nerve in the body. It has two major branches, the tibial nerve and the peroneal nerve. Gluteal Region: Anatomy palsy Palsy paralysis of an area of the body, thus incapable of voluntary movement Cranial Nerve Palsies 
    • Potential osteonecrosis of the femoral head

Complications

• Hemorrhage (most important reversible factor)
• Hypovolemic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock 
• Bowel or urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence ( S2 S2 Heart Sounds–S5 sacral nerve root injury)
• Sexual dysfunction Sexual dysfunction Physiological disturbances in normal sexual performance in either the male or the female. Sexual Physiology ( S2 S2 Heart Sounds–S5 sacral nerve root injury):
  • Dyspareunia Dyspareunia Recurrent genital pain occurring during, before, or after sexual intercourse in either the male or the female. Primary Ovarian Insufficiency
  • Erectile dysfunction Erectile Dysfunction Erectile dysfunction (ED) is defined as the inability to achieve or maintain a penile erection, resulting in difficulty to perform penetrative sexual intercourse. Local penile factors and systemic diseases, including diabetes, cardiac disease, and neurological disorders, can cause ED. Erectile Dysfunction
• Urethral trauma

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

• Simple acetabular fractures: 80%–85% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship can expect a good to excellent recovery following surgery, provided that the hip can be properly aligned and fixed.
• Pelvic fractures and the often-associated concomitant injuries are potentially life-threatening and can lead to a significantly lower quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of life.
• Mortality Mortality All deaths reported in a given population. Measures of Health Status:
  • 10%–42% in closed pelvic fractures and hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
  • 50% in open pelvic fractures