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Triaging Orthopaedic Pelvic Injuries
Introduction
Pelvic injuries are among the most severe orthopaedic traumas encountered in emergency medicine. The pelvis is a critical structure that protects vital organs, provides skeletal stability, and supports ambulation. Pelvic fractures often result from high-energy trauma such as motor vehicle accidents, falls from significant heights, or crush injuries. Given the potential for life-threatening hemorrhage, prompt and effective triage is essential to optimize outcomes. This article outlines the triaging process, assessment techniques, classification of pelvic injuries, and management principles.
1. Understanding Pelvic Anatomy and Injury Mechanisms
Pelvic Anatomy
The pelvis consists of the sacrum, coccyx, and paired innominate bones (ilium, ischium, and pubis). These structures form a stable ring that houses major vascular structures, nerves, and organs such as the bladder, intestines, and reproductive organs. The pelvic ring is held together by strong ligaments, particularly the sacroiliac, sacrospinous, and sacrotuberous ligaments.
Mechanisms of Injury
Pelvic injuries commonly result from:
- High-energy trauma: Motor vehicle collisions, falls from height, and industrial accidents.
- Low-energy trauma: More common in elderly populations due to osteoporosis, often resulting from falls.
- Direct compression forces: Lateral impact injuries leading to crush fractures.
- Vertical shear injuries: Force applied superiorly along the femur, causing pelvic displacement.
Understanding the mechanism of injury assists in predicting fracture patterns and associated complications.
2. Initial Triage and Assessment
Primary Survey: Identifying Life-Threatening Conditions
Pelvic injuries are often accompanied by hemorrhage, neurovascular compromise, and internal organ damage. The Advanced Trauma Life Support (ATLS) protocol guides the initial assessment using the ABCDE approach:
- Airway and Cervical Spine Stabilization: Secure the airway while assuming spinal injury until ruled out.
- Breathing and Oxygenation: Assess for rib fractures, pneumothorax, or other thoracic injuries.
- Circulation and Hemorrhage Control: Severe pelvic injuries can lead to massive blood loss. Hypotension and tachycardia indicate hemorrhagic shock.
- Disability and Neurological Evaluation: Check for neurological deficits indicating spinal or lumbosacral nerve involvement.
- Exposure and Environmental Control: Remove clothing to identify other injuries while preventing hypothermia.
If a pelvic fracture is suspected, immediate stabilization and hemodynamic control take precedence.
Secondary Survey: Detailed Examination
Once the patient is stabilized, perform a thorough examination:
- Inspect for deformities, bruising, or swelling. Open wounds indicate open fractures, which have a high risk of infection.
- Palpate the pelvis gently for instability—excessive manipulation can exacerbate hemorrhage.
- Assess limb length discrepancies and rotation deformities. These suggest displacement.
- Examine for signs of urethral injury, such as blood at the urethral meatus, perineal hematoma, or inability to void.
- Perform a neurovascular assessment, checking pulses and sensation in the lower extremities.
3. Classification of Pelvic Injuries
Pelvic fractures are classified based on the stability of the pelvic ring and the mechanism of injury. The Young-Burgess classification and Tile classification are commonly used.
Young-Burgess Classification (Based on Injury Mechanism)
- Lateral Compression (LC) Injuries: Common in side-impact collisions, resulting in rotational instability but generally stable hemodynamics.
- Anterior-Posterior Compression (APC) Injuries: “Open-book” fractures caused by frontal impact, leading to pelvic widening and high hemorrhage risk.
- Vertical Shear (VS) Injuries: High-energy trauma causing one hemipelvis to be displaced superiorly, leading to instability and significant bleeding.
- Combined Mechanism Injuries: Result from multiple forces acting on the pelvis, often seen in polytrauma patients.
Tile Classification (Based on Stability)
- Type A: Stable fractures (e.g., avulsion fractures, isolated pubic ramus fractures).
- Type B: Rotationally unstable but vertically stable fractures (e.g., APC injuries).
- Type C: Completely unstable fractures with both rotational and vertical instability (e.g., VS injuries).
Understanding these classifications helps guide management and surgical decisions.
4. Imaging and Diagnostic Modalities
1. X-ray (First-Line Imaging)
- Anteroposterior (AP) Pelvis X-ray: Rapid identification of fractures, dislocations, and widening of the symphysis pubis.
- Inlet and Outlet Views: Assess anteroposterior displacement and vertical shear injuries.
2. CT Scan (Gold Standard)
- Provides detailed bony and soft tissue assessment to evaluate fracture displacement, organ damage, and hemorrhage.
- Angiography-CT (CTA) is crucial for detecting arterial bleeding.
3. FAST (Focused Assessment with Sonography for Trauma)
- Identifies intraperitoneal bleeding but cannot rule out retroperitoneal hemorrhage.
- Often used in hemodynamically unstable patients.
5. Management Strategies
1. Hemodynamic Stabilization
- Early hemorrhage control is critical, as pelvic injuries can lead to life-threatening blood loss.
- Pelvic binders or sheets should be applied in suspected APC or VS injuries to reduce bleeding.
- IV fluid resuscitation with balanced crystalloids, followed by blood products if necessary.
- Massive transfusion protocols (MTP) may be required in ongoing hemorrhage.
2. Definitive Hemorrhage Control
- Angiographic embolization: Effective in arterial bleeding when non-responsive to initial stabilization.
- External fixation: Temporary stabilization for unstable fractures, reducing pelvic volume and hemorrhage.
- Surgical intervention: Open reduction and internal fixation (ORIF) is needed for unstable fractures.
3. Orthopaedic Management
- Non-operative management: Stable fractures can be treated with analgesia, bed rest, and physiotherapy.
- Surgical stabilization: Required for unstable fractures to restore function and mobility.
4. Addressing Associated Injuries
- Urethral and bladder injuries: Require urological evaluation; suprapubic catheterization may be needed.
- Nerve injuries: Lumbosacral plexus involvement should be assessed for long-term rehabilitation planning.
6. Rehabilitation and Long-Term Considerations
Recovery from pelvic fractures can be prolonged, requiring a multidisciplinary approach:
- Early mobilization prevents complications like deep vein thrombosis (DVT) and pneumonia.
- Physiotherapy and rehabilitation focus on restoring strength, gait, and function.
- Pain management and psychological support are essential for patient recovery.
Conclusion
Triaging orthopaedic pelvic injuries requires a systematic approach that prioritizes hemodynamic stabilization, accurate classification, and timely intervention.
Given the high morbidity and mortality associated with these injuries, early recognition, appropriate imaging, and definitive management are crucial in improving patient outcomes.
Coordinated care between emergency physicians, orthopaedic surgeons, trauma specialists, and rehabilitation teams ensures optimal recovery and functional restoration.