Pelvic Ring Injury

synonyms: Pelvic ring injury, pelvic fracture, pelvic ring disruption

Pelvic Ring Injury ICD-9

• 808.43 (multiple with disruption of pelvic circle, closed)
• 808.53 (multiple with disruption of pelvic circle, open)
• 808.41 (ilium closed)
• 808.51 (ilium open)
• 808.42 (ischium closed)
• 808.52 (ischium open)
• 808.2 (pubis closed)
• 808.3 (pubis open)

Pelvic Ring Injury Etiology / Epidemiology / Natural History

• Lateral compression injuries are sustained by direct lateral force to the iliac wing leading to internal rotation deformity of the affected hemipelvis.
• Pelvic fractures are associated with mortality in trauma patients, but less so than hemodynamic shock, severe head injury, and age >60 years. (Sathy, AK, JBJS 2009;91A:2803)

Pelvic Ring Injury Anatomy

• See Hip / Pelvis anatomy.

Pelvic Ring Injury Clinical Evaluation

• ATLS resuscitation. These can be high enegery injuries, assessment should begin with the A,B,C's.
• Gently inspect iliac crests for instability, inspect perineum, during log role evaluate for open injuries.
• Rectal exam: evaluate for blood, high riding prostate.

Pelvic Ring Injury Xray / Diagnositc Tests

• A/P pelvis, inlet and outlet views.
• CT scan generally indicated.

Pelvic Ring Injury Classification / Treatment

• Young, Burgess Classification J Trauma 30:848;1990
• non-op treatment (Henderson RC, J Orthop Trauma 3:41;1989)
• Anteroposterior Compression (diastasis of the symphysis and scroiliac joints): immediate stabilization with pelvic binder/PCCD, MAST trousers, C-clamp, or wrapping a sheet around the pelvis, (Krieg JC, J Trauma 2005;59:659). Consider interventional radiology for hypovolemic shock which fails to respond to IVF & 2 units pRBCs (Miller PR, J Trauma 2003;54:437). Other options = laparotomy with pelvic packing of venous bleeding.
• Lateral Compression, <1cm posterior displacement, no neurologic deficit:
  Treatment: NWB until fracture union
• Lateral Compression, >1cm posterior displacement, or neurologic deficit:
  Treatment: Consider skeletal traction if pelvis is cranially displaced. ORIF / Sacral screws Pelvic Ring.
• Pregnancy and Pelvic ring injury: (Pape JC, JOT 2000;14:238).
• Document discussion of DVT risk and prophylaxis options in the medical record. Generally prophylaxis is provided with sequential compression devices prior to surgery and warfarin or low molecular weight heparin post-operatively.
• ORIF Pelvic Ring
• Pelvic External Fixation

Pelvic Ring Injury Associated Injuries / Differential Diagnosis

• Retroperitoneal venous bleeding
• Pelvic arterial bleeding
• Watnik NF, Coburn M, Goldberger M: Urologic injuries in pelvic ring disruptions.  Clin Orthop 1996;329:37-45.
• Thoracic trauma
• Intra-abdominal injury
• Extremity fractures
• Urologic injury (15%; consider retrograde urethrogram before passing foley catherter in anterior pelvic ring injuries).
• Sexual dysfunction

Pelvic Ring Injury Complications

• Infection
• Poor wound healing
• Chronic Osteomyelitis
• Pain
• Painful hardware
• Loss of reduction
• Nonuion
• Limb length discrepancy
• Sitting imbalance
• Gait disturbance
• DVT / PE (Borer DS, JOT 2005;19:92).

Pelvic Ring Injury Follow-up Care

• Early mobilization to an upright position is key to reducing morbidity and mortality.
• Post-op: 24hrs antibiotic, SCDs, Ted hose, Partial weight bearing. Review reduction on post op A/P pelvis, inlet and outlet views.
• 7-10 Days: Wound check. Continue partial/non weight bearing
• 6 Weeks: Advance weight bearing gradually. Review A/P pelvis, inlet and outlet views.
• 3 Months: Review A/P pelvis, inlet and outlet views.
• 6 Months: Return to labor. Review reduction on post op A/P pelvis, inlet and outlet views. Obtain follow-up CT scan.
• 1Yr:Assess outcome. Review A/P pelvis, inlet and outlet views.

Pelvic Ring Injury Review References

• Starr AJ, Chapter 41, Rockwood and Greens.
• Cole JD, Blum DA, Ansel LJ: Outcome after fixation of unstable posterior pelvic ring injuries. Clin Orthop 1996;329:160-179.
  Miranda MA, Riemer BL, Butterfield SL, Burke CJ III: Pelvic ring injuries: A long-term functional outcome study. Clin Orthop 1996;329:152-159.
  Tornetta P III, Matta JM: Outcome of operatively treated unstable posterior pelvic ring disruptions.  Clin Orthop 1996;329:186-193.
• Dujardin FH, Hossenbaccus M, Duparc F, et al:  Long-term functional prognosis of posterior injuries in high-energy pelvic disruption.  J Orthop Trauma 1998;12:145-151.
• Tornetta P III, Matta JM: Outcome of operatively treated unstable posterior pelvic ring disruptions.  Clin Orthop 1996;329:186-193.
• Holdsworth F W: Dislocation and fracture dislocation of the pelvis.  J Bone Joint Surg Br 1948;30:461-465.
• Henderson RC: The long-term results of nonoperatively treated major pelvic disruptions.  J Orthop Trauma 1989;3:41-47.
• Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: Effective classification system and treatment protocols.  J Trauma 1990;30:848-856.
• Evers BM, Cryer HM, Miller FB: Pelvic fracture hemorrhage: Priorities in management.  Arch Surg 1989;124:422-424.
• Flint L, Babikian G, Anders M, Rodriguez J, Steinberg S: Definitive control of mortality from severe pelvic fracture.  Ann Surg 1990;211:703-707.
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