Pelvic Fractures

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Epidemiology: 

  • Pelvic Fractures occur in 5-11% of all major blunt Trauma 
  • Early Suspicion, Identification, Management and Triage are critical for good outcomes
  • Mortality is between 7-19%. (mortality increases to ~50% in open pelvic fracture)
  • The Most Common Mechanism of Injury resulting in pelvic fracture is MVA (Motor Vehicle Accident)

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Recognition:

  • Springing the pelvis is BAD! don’t do it! (springing to asses for fracture has a specificity of 71% and a sensitivity of 59%, suggesting that routine use of this examination should be abandoned.)
  • Instead, pain, MOI and S/Sx should be sufficient indication for management and radiology.
  • In this study, 90% of pelvic fractures involved the Pubis along the Rami.
  • In the Gonzalez et al‘s study ( Gonzalez R P, Fried P Q, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg 2002. 195740.) of patients with GCS 14 or 15, the most common positive finding in patients with pelvic fractures was of the patient complaining of pelvic pain (67% of 97 patients) whereas only 32% had pain on iliac compression and 37% had pain on palpation of the pubic symphysis.

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Management:

  • This study found an increased benefit with the use of POD’s – Pelvic Orthotic Devices
  • Early Surgical Intervention to externally fixate is recommended and improves morbidity and mortality. Article.
  • Quality training should be conducted regularly in the application of surgical external fixation. In this study, 47% of external fixators were applied incorrectly, possibly increasing morbidity/mortality!
  • Fluid Resuscitation with transfusions is neccasary. (In one study (Rothenberger et al., 1978) of 26 patients who died primarily of pelvic fracture 18 died of exsanguination in the first 9 h)
  • This study recommends Boluses of 250 ml normal saline should be titrated until restoration of the radial pulse.These principles are supported by the National Institute for Health and Clinical Excellence in the guideline Pre‐hospital initiation of fluid replacement therapy in trauma.
  • New research supporting permissive hypotension, transfusions protocols and management of major trauma is, as expected, the way to go.

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References:

‘The prehospital management of pelvic fractures’  

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