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Pelvic fractures can be a big challenge in caring for the injured patient. Pelvic fractures are important as a cause for morbidity and mortality. The mortality can be 30% with unstable pelvic ring injuries, and 10-12% of this percentage alone is due to blood loss. Multiple complications can occur during a pelvic fracture. This article will help nurses assess and manage patients with pelvic injuries. Topics covered in the article include basic anatomy of the pelvis, diagnostic tests performed after a pelvic fracture, types of pelvic fractures, management of pelvic fractures, and complications.
The mechanisms of injury of pelvic fractures include motor vehicle crashes, 57%; pedestrians hit by motor vehicles, 18%; motorcycle crushes, 9%: falls, 9%; and crush injuries, 5% (Failinger & McGanity, 1992; Heetveld, Harris, Schlaphoff, & Sugrue, 2004). Mortality of the patient increases with the severity of the pelvic injury. The patient with a closed pelvic fracture who is hemodynamically unstable has a mortality of approximately 27%, which increases to approximately 55% for open pelvic fractures (Heetveld et al., 2004).
The unstable pelvic fracture can cause the most damage and is life threatening. The "open book" pelvic fracture is a type of fracture, and it will be discussed further in this article. The complications that can occur are massive, such as exsanguination (blood loss), genitourinary trauma, sepsis, chronic pain, bowel damage, neurological damage, and laceration of the vagina (Walsh, 2002).
This article explores traumatic pelvic fractures, classifications of injury, complications of pelvic fractures, and different forms of management and nursing implications.
The pelvis is a ring structure made up of three bones: the sacrum and two innominate bones. The fusion of three ossification centers, the ilium, the ischium, and the pubis, makes up the innominate bone. The pelvic ring is formed by the connection of the sacrum to the innominate bones at the sacroiliac (SI) joints and the symphysis pubis. The ligamentous structures help with the stability of the pelvis. The strongest and the most important ligamentous structures occur in the posterior aspect of the pelvis at the SI joints. The posterior ligaments have to hold up the weight-bearing forces that occur from the lower extremities to the spine and are transferred to the SI joints (Kellam & Mayo, 2003). The interosseous SI ligaments are considered the strongest in the body. They act to stabilize the SI complex. The symphysis acts more as a supporting "strut" because the SI joint is the stabilizing structure of the pelvic ring. If this "strut" is disturbed, this will not lead to instability of the pelvic ring and surgery (Young & Burgess, 1987).
The major blood vessels located on the inner wall of the pelvis are the median sacral artery and the superior rectal artery; the common iliac divides to give off the external iliac and the internal iliac, which also branches off to give the superior gluteal artery. During a pelvic fracture, these arteries and associated veins can be injured.
The organs and structures that can be affected during a trauma within the pelvis are the genitourinary system (bladder and urethra), the vagina, prostate, and gastrointestinal system. The lumbar and sacral plexuses that run posterior can also be affected during pelvic trauma (See Figures 1-3).
When a patient comes into the emergency room, the important aspects of his or her history are the mechanism of injury, location and where the pain radiates to, if gross hematuria is present in the urine post injury, last menstrual period, and possibility of pregnancy.
On physical examination, one would inspect to see if there was a rotation of the iliac crests. Rotation would indicate a serious pelvic fracture. Leg-length differences may suggest a hip injury or headward migration of an unstable hemipelvis. Gentle lateral compression and distraction of the iliac crests and gentle inward compression of the symphysis pubis are done to determine the stability of the pelvic ring. It is vitally important to be careful in maneuvering the pelvis so as not to cause potential fracture-related hemorrhage.
Inspection of the skin and skin folds is needed to identify open fractures. Perineal ecchymosis or hematoma may be observed. The digital examination should be done to evaluate sensation, sphincter tone, position and consistency of the prostate, and presence of frank or occult blood. Women should undergo a vaginal examination to diagnose a possible open fracture. Urine may be detected in the scrotum or subcutaneous tissues of the penis, vulva, or abdominal wall. Pulses should be palpated for presence and quality in the lower extremities and for sensation, strength, and deep tendon reflexes.
Radiographic images are obtained for patients who have experienced blunt trauma. It helps to determine the extent of the pelvic fracture. Radiographic images are considered the gold standard in determining a pelvic fracture. An anterior-posterior (AP) view of the pelvis will show most of the pelvic fractures and dislocations. However, this view does not allow one to determine the degree of bone displacement; small fractures can be missed. Inlet and outlet views are also obtained for the pelvis to obtain better images of the fracture (Cwinn, 2002).
The inlet view is taken from the head toward the feet at 60[degrees] with the patient lying supine. This view can show the posterior and cephalic displacement of the fractures of the posterior arch, widening of the SI joint, and inward displacement of the anterior arch.
The outlet view is taken from the foot of the bed directed at 45[degrees] toward the head. This type of X ray helps in determining the displacement or leg-length discrepancy, sacral fractures, and disruptions of the SI joints. The inlet and outlet X-ray views can be taken by simply angling the beam, thus not having to move the patient (Kellam & Mayo, 2003).
The CT scan plays an important part in determining the exact nature of the posterior injury. It can diagnose a crushing, shearing injury, SI joint displacement, acetabular injuries, and posterior osseous ligamentous structure of the pelvis. A CT scan can also help diagnose associated visceral injuries and hemorrhage.
The advances in technology have allowed us to develop three-dimensional reconstructions of CT scans that reveal more information in evaluation of the overall displacement of the pelvic fracture. The CT scan also helps prepare the surgeon by providing a clear visibility of the upper sacral vertebral bodies and lumbosacral junction in assessing the anatomic abnormalities of the area. The visualization of the anatomic abnormalities is important in preparation for stabilization and treatment of the L5-S1 facet joint injuries.
A classification is essentially a description of the bone injury; it does not define the injury. In defining the injury you need to look at all of the following: degree of displacement; stability of the pelvic ring; force direction; state of the soft tissues, including whether the fracture is open or closed; anatomic injury in the pelvis and the associated injuries (Tile, Helfet, & Kellam, 2003).
At this time there is no universally accepted classification system of determining pelvic fractures. There are different descriptions or classifications of the pelvic ring fractures. Letournel classified the fractures of the pelvic ring anatomically. Bucholz, Tile, and the Orthopaedic Trauma Society classified the fractures by the stability of the fracture. Based on the Pennal classification, Young and Burgess classified pelvic fractures by the mechanism of injury, in other words, how the injury was obtained (Guyton & Crockarell, 2003). This article will focus on the Tile classification and the Young and Burgess classification.
According to the Young and Burgess classification, injuries are grouped by mechanism of injury. They show it is important to think of three vectors of force and how this disrupts the pelvic ring. First, the most common vector of force is the lateral compression (LC). The vector force is applied from the lateral side of the pelvic ring from a T-bone (intersectional motor vehicle crash) or in a situation in which a pedestrian is struck from the side or a person lands from a great height on his or her side. Usually, in this type of injury the individual is injured mostly from associated injuries of the abdomen, thoracic contents, and the cervical spine. The force of the vector is not strong enough to open up the pelvis but can cause great damage to the internal organs from fracture fragments (Scalea & Burgess, 2004). An exception to this classification is when a LC-III injury occurs. If the lateral force that contacts one side of the pelvis creates an internal rotation, which continues to the opposite side of the pelvis creating an external rotation injury, an LC-III injury results. This is called a "windswept" pelvis. This type of injury is brought on by both initial impact and secondary crush injury (Burgess et al., 1990). It commonly occurs when a pedestrian is struck, then rolled over by a motor vehicle.
The next type of vector force, which can impact the pelvis, is either from the anterior or posterior (AP) direction. The injuries are mostly ligamentous with possible pubic rami fractures. The force is either at the iliac spine or through the femur. An example of this injury is often seen when a person's legs are spread apart in a motorcycle accident. The pelvis is widened from the force of impact. AP-III is usually called the "open book" pelvis, with complete disruption of all the SI ligaments, and it results in separate hemipelves. Usually this type of injury is associated with severe arterial damage, the internal iliac artery, and adjacent veins. Lumbosacral plexus injuries also usually occur.
The last example of vector force is the vertical shear (VS) that causes vertical shear injury. This usually occurs when a person jumps from a great height and lands on an extended lower extremity or other associated events. The injury will demonstrate an ipsilateral disruption of all the restraining ligaments of the hemipelvis, including the symphyseal, sacrospinous, sacrotuberous, and SI ligaments. This type of injury usually does not involve major arterial injuries of the posterior pelvic vascular complexes (Scalea & Burgess, 2004).
The complex mixed (CM) pattern of injuries does not fit into the other categories neatly. These injuries result from a combination of the aforementioned types of injuries (See Figure 4 and Table 1).
Tile's classification based the injuries according to the stability of the pelvic ring and the integrity of the posterior sacroiliac complex. The classifications start with minor complications (pelvic ring being stable) and increase to more complex injuries and complete instability of the posterior pelvic ring. The classification begins with minor complications, type A fractures that have no major instability of the posterior ring.
Type B fractures are fractures that are partially stable. They may have anterior displacement through the symphysis and/or pubic rami but no vertical or posterior displacement other than that allowed by rotation of the hemipelvis, usually less than 1 cm.
Type C fractures are unstable. These fractures are always caused by severe trauma such as from a crushing injury, motor vehicle crash, or fall from a great height. This injury involves the complete disruption of the posterior SI complex, involving vertical shear forces. This fracture can involve one or both sides of the pelvis (Tile et al., 2003) (See Table 2). Table 3 shows the comparison of the difference between the Tile classification and the Young and Burgess classification of pelvic fractures. The table demonstrates that the Young and Burgess classification is more condensed than the Tile classification.
The pelvic girdle may be used for an unstable pelvic fracture. The girdle acts as a temporary fix until surgical interventions can be initiated. A bedsheet may also be used temporarily to help stabilize the pelvic girdle. The bedsheet is placed underneath the patient and crossed over the anterior pelvis area to reduce the pelvic fracture. The bedsheet will stabilize the fracture and reduce the internal bleeding until fixation can be performed. Bottlang, Drieg, Mohr, Simpson, & Madey (2002) showed some means of circumferential pelvic compression for immediate temporary reduction and stabilization of open-book pelvic fractures, such as a pelvic sling or girdle is effective, noninvasive and safe.
In unstable patients, an emergent external fixation can be placed in the emergency room. An external fixation is usually applied to the "open book" or externally rotated pelvic fracture, an internally rotated pelvis, or other unstable fracture patterns. This intervention can reduce the amount of blood loss by causing a tamponade effect on the retroperitoneal hematoma. After the application of the external fixation, the fracture moves less. This assists in clot formation and allows the patient to become more mobile in transportation to the CT scan facility and other areas for evaluation. Early stabilization can help the nurse provide appropriate care to the patient, facilitate pulmonary toilet, decrease pain, and enable the patient to sit upright. Several types of external fixates can be used (See Figures 5 and 6). It is recommended to use a simple anterior frame with two 5-mm pins in each iliac wing. A C-clamp can also be used, which helps stabilize the posterior aspect of the pelvis.
Internal fixation has become the treatment of choice for treating the patients after they become more hemodynamically stable. The benefits include the following: it helps in obtaining and maintaining anatomic reduction of the fracture; it is biomechanically a more stable fixation; it is a safer technique for stabilization; it assists in early mobilization of the patient; it shortens hospitalization; it eases nursing care of the patient; and it improves outcomes in the patient care management (Tile et al., 2003). There are different techniques and surgical procedures that can be performed in reducing a pelvic fracture by internal fixation. It depends on the fracture type, type of fixation used, and surgeon's technique.
The following are the general guidelines in the fixation of pelvic fractures by Jones & Burgess (2001). In LC-I, and AP-I pelvic fractures, the injuries are minimally displaced, and ligamentous stability of the pelvic ring still exists with partial disruption of the bony structure. In this case, these patients are treated with protected weight bearing on the affected side and symptomatic treatment. Further surgical treatment might be needed if displacement of the fracture occurs after the patient starts to weight bear. Follow-up X rays can determine the displacement after 2-5 days of physical therapy.
In AP-II and LC-I pelvic fractures, the patient has a marked displacement of the anterior ring without complete posterior ring disruption. These types of fractures are usually treated with reduction and anterior ring stabilization.
In LC-II, LC-III, AP-III, and VS pelvic fractures, there is complete disruption of the posterior ring, and, in general, the patients require stabilization of both the anterior and posterior pelvic ring. According to Tile's classification, Table 4 shows the type of pelvic ring fixation one would use.
Pelvic fractures could be a life-ending event especially dealing with open-book fractures. The nurse's primary role is to assess the patient and be alert to the signs and symptoms of potential complications by performing a careful examination. The nurse should be suspicious and aware that other injuries could have occurred. It is important to keep the patient's pain under control. It is also important to keep the patient still after a pelvic girdle is applied to prevent disruption of the retroperitoneal tamponade, which could lead to hemorrhagic shock. The nurse is the first line of defense in recognizing complications.
The nurse needs to watch for the complications of a normal postoperative patient and other complications that can occur when a patient has sustained a traumatic pelvic injury. These complications include bleeding, infection at the incised site of any open wounds, pulmonary emboli, deep vein thrombosis (DVT), and pneumonia. Controlling the patient's pain is important to help with early ambulation and in preventing the above complications. Good pulmonary toilet by the nurse and patient can prevent respiratory complications.
Rehabilitation is an important aspect of the care of a patient with a pelvic fracture. Physical therapy needs to start early to mobilize the patient to prevent further complications. Rehabilitation can last long depending on the type of fracture and the condition that other injuries or complications had occurred.
Patients who sustain pelvic fractures usually have other complications associated with this injury. The most life-threatening injury is to blood vessels that can cause large amounts of blood loss. This large amount of blood loss can be associated with long bone fractures, and especially pelvic fractures. Aortic tears or lacerations usually occur in AP compression pelvic injuries. Closed-head injuries are also common in patients with pelvic fractures. Visceral injuries such as a bladder rupture (genitourinary injury), a diaphragmatic injury, or a small bowel injury can also occur. Urethral injuries are uncommon in women but they do exist. Urethral injuries are usually associated with bilateral pubic rami fractures, significant vertical displacement of the pelvis, and symphyseal disruption. Nerve injury occurs usually when there is a posterior pelvic injury, but it is difficult to determine because a pelvic fracture can also cause the same type of pain or mask the nerve pain in a particular area. It is important to complete a full physical examination of the patient at the time of admission to detect these other injuries (See Table 5).
DVT can occur in pelvic fractures. Most patients who have these types of fractures are immobile for large periods of time and become highly susceptible to thromboembolism. Compression devices and appropriate anticoagulation therapy can help prevent DVT. Inferior caval filter can also be used in preventing pulmonary embolism. A pulmonary embolis or fat embolis can occur in a patient with long-bone fractures or pelvic fracture. Atelectasis and pneumonia can also occur from immobilization. It is important for the patient to perform pulmonary toilet and get up out of bed as soon as possible. Infections due to open wounds that occur during the initial injury, pin site infections, and infections at incised sites can also occur. Other long-term complications with pelvic fractures consist of back pain, sexual dysfunction, impotence, and dyspareunia as documented in the literature. Malunion and nonunion of the surgical site is also documented in the literature.
Traumatic pelvic fractures can be complicated in the nursing care of the patient. Therefore, it is extremely important to assess, educate, and treat the patient with a pelvic fracture. Nursing is the first line of defense in preventing further complications and a longer hospitalization. It is important to understand the anatomic, physiologic components, treatment modalities, and classifications of pelvic fractures in taking better care of the patient and in the education of the patient and family.
I would like to thank Dr. Martin Tile for his insight, knowledge, and suggestions for my article.
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