Overview
The pelvis is a funnel-shaped ring structure made up of the sacrum, coccyx, hip, pubic bone and sit bones. There is a pubic symphysis in the front and sacroiliac joints on both sides in the back, all connected by strong ligaments. It has a very stable mechanical structure and is suitable for the body’s movement physiology. A pelvic fracture is a serious injury, usually combined with an intrapelvic hematoma and damage to the internal pelvic organs.
A pelvic fracture is a serious trauma, mostly caused by direct violent pelvic compression. It is most often seen in traffic accidents and landslides. In wartime, it is a firearm injury. More than half of the pelvic fractures are associated with comorbidities or multiple injuries. The most serious ones are traumatic hemorrhagic shock and combined pelvic organ injuries, which have a high mortality rate when not treated properly.
Etiology
The pelvis is a complete closed bone ring. It consists of the sacrococcygeal bone and the hip bones (pubic bone, sciatic bone and iliac bone) on both sides. The pelvis has an important protective role for the pelvic organs, nerves and blood vessels. When fracture, also easy to damage these organs, pelvic organs, although different from men and women, but the order of their arrangement is basically the same, from the front to the back of the three organs of the urinary, reproductive and digestive systems. The bladder and urethra in the front and the rectum in the back are highly susceptible to injury. Because the pelvis is richly vascularized and the pelvis itself is a cancellous bone with abundant blood circulation, bleeding is often severe when the pelvis is fractured.
Symptoms
(I) The patient has a history of severe trauma, especially a history of trauma with pelvic compression.
(ii) Pain is widespread and worsens when moving the lower extremity or sitting. Local swelling, subcutaneous petechiae were seen at the perineum and pubic symphysis, and pressure pain was obvious. If the pelvic ring is squeezed inward or separated outward from the iliac crest area on both sides, the fracture site is painful due to traction or compression (pelvic compression separation test).
(C) The affected limb is shortened from the umbilicus to the length of the inner ankle on the affected side. The exception is that the length from the anterior superior iliac spine to the inner ankle is often not shortened on the affected side in the case of central dislocation of the femoral head. When there is a dislocation of the sacroiliac joint, the posterior superior iliac spine on the affected side is significantly more convex than the healthy side, and the distance between it and the spinous process is also shorter than that on the healthy side. This indicates posterior, upward, and midline displacement of the posterior superior iliac spine.
Examination
The patient has a history of severe trauma, especially a history of trauma with pelvic compression.
X-rays can clarify the type of fracture and displacement.
Ultrasound can help determine if there is a combined pelvic organ injury.
Treatment
(a) Prevention and treatment of shock: Shock and various life-threatening comorbidities should be treated first according to the systemic condition.
(B) Bladder rupture can be repaired with suprapubic cystostomy. For urethral rupture, it is advisable to place a catheter first to prevent urinary extravasation and infection, and leave the catheter in place until the urethra heals. If the catheter insertion is difficult, suprapubic cystostomy and urethral rendezvous can be performed.
(C) rectal injury, a dissection should be performed, a colostomy should be done to temporarily reroute the stool, suture the rectal fissure, and an anal tube should be placed in the rectum for exhaustion.
1. For marginal pelvic fractures: only bed rest is required. Bed rest for 3 to 4 weeks is sufficient.
2.For single-ring pelvic fracture with separation, use pelvic pocket belt suspension traction fixation. 5-6 weeks later, change to plaster shorts fixation.
3.For pelvic double ring fracture with longitudinal misalignment, the patient can be repositioned manually under anesthesia. The patient’s sacrum and iliac crest are padded with a thin cotton pad and fixed with a strip of adhesive tape around the pelvis after repositioning. At the same time, continuous bone traction is applied to the affected limb, which is removed after 3 weeks and the tape is removed after 6 to 8 weeks. During the immobilization period, exercises for contraction of the quadriceps muscle and joint movement were performed. After three months, the patient can walk with weight.
4. For dislocated sacral or caudal fracture dislocation, the fracture can be reset by pushing the fracture backward with fingers under local anesthesia. For severe pain of old tailbone fracture, local prednisolone closure can be made.
5, the hip joint central dislocation, in addition to the affected limb for bone traction, at the large ridge should be made again side traction. It should be reset.
6.For the dislocation fracture involving the acetabulum, if the fracture cannot be repaired by manipulation, the fracture should be repaired by open internal fixation to restore the mesoscopic articular surface of the acetabulum.
Pelvic fracture is a serious trauma, mostly caused by direct violence pelvic extrusion. It is mostly seen in traffic accidents and landslides. In wartime, it is a firearm injury. More than half of the pelvic fractures are associated with comorbidities or multiple injuries. The most serious is traumatic hemorrhagic shock, and combined pelvic organ injuries, improper treatment has a high mortality rate.
(I) The patient has a history of severe trauma, especially a history of trauma with pelvic compression.
(ii) The pain is widespread and worsens when moving the lower extremities or sitting. Local swelling, subcutaneous petechiae were seen at the perineum and pubic symphysis, and pressure pain was obvious. If the pelvic ring is squeezed inward or separated outward from the iliac crest area on both sides, the fracture site is painful due to traction or compression (pelvic compression separation test).
(C) The affected limb is shortened from the umbilicus to the length of the inner ankle on the affected side. The exception is that the length from the anterior superior iliac spine to the inner ankle is often not shortened on the affected side in the case of central dislocation of the femoral head. When there is a dislocation of the sacroiliac joint, the posterior superior iliac spine on the affected side is significantly more convex than the healthy side, and the distance between it and the spinous process is also shorter than that on the healthy side. It indicates that the posterior superior iliac spine is displaced posteriorly, upward, and toward the midline.
Diagnosis
The patient has a history of severe trauma, especially trauma with pelvic compression. x-ray examination confirms the diagnosis.
Complications
1. retroperiosteal hematoma. The pelvic bones are mainly cancellous bones, and there are many muscles in the pelvic wall and many arterial and venous plexuses in the vicinity, which are rich in blood supply, and the gap between the pelvic cavity and the posterior superficial membrane is composed of loose connective tissue, which has a huge space to accommodate bleeding, thus causing extensive bleeding after fracture. A large retrodural hematoma may spread to the renal area, subdiaphragm, or mesentery. Patients are often in shock and may have symptoms of peritoneal irritation such as abdominal pain, abdominal distention, diminished bowel sounds and abdominal muscle tension.
To differentiate from intraperitoneal hemorrhage, a diagnostic puncture of the abdominal cavity may be performed, but the puncture should not be too deep to avoid entering the retroperitoneal hematoma and mistaking it for intraperitoneal hemorrhage. Therefore, close and careful observation and repeated examination are necessary.
2. Urethral or bladder injury. The possibility of lower urinary tract injury should always be considered in patients with pelvic fractures, and urethral injury is far more common than bladder injury. Patients may have difficulty urinating and blood spillage from the urethra. The incidence of urethral membrane injury is higher in the case of bilateral pubic branch fractures and pubic symphysis separation.
3. Rectal injury. Unless the pelvic fracture is accompanied by an open pubic injury, rectal injury is not a common comorbidity. Rectal rupture can cause diffuse peritonitis if it occurs above the peritoneal reflex; if it occurs below the reflex, perirectal infection can occur, often with anaerobic bacteria.
4.Nerve injury. Sacral 1 and sacral 2, which constitute the lumbosacral nerve trunk, are the most vulnerable to injury, and the muscle strength of the gluteus, N cord and calf gastrocnemius muscle group may be weakened, and the sensation of the posterior part of the calf and lateral part of the foot may be lost. If the sacral nerve is severely injured, the Achilles tendon reflex may disappear, but sphincter dysfunction rarely occurs, which is related to the degree of nerve injury.
According to the systemic situation, shock and various life-threatening comorbidities should be treated first.
(A) The prevention and treatment of shock. Patients with massive retroperitoneal bleeding are often combined with shock. Blood transfusion, fluid transfusion, and transfusion for pelvic fracture should be performed under close observation. If blood pressure continues to drop after active resuscitation with massive blood transfusion and fails to correct shock, ligation of one or both internal iliac arteries or embolization of internal iliac artery via catheter may be considered.
(B) Bladder rupture can be repaired and suprapubic cystostomy can be performed at the same time. For urethral rupture, it is advisable to place a catheter first to prevent urinary extravasation and infection, and leave the catheter in place until the urethra heals. If the catheter insertion is difficult, suprapubic cystostomy and urethral rendezvous can be performed.
(C) rectal injury, a dissection should be performed, a colostomy should be done to temporarily reroute feces, suture the rectal fissure, and an anal tube should be placed in the rectum for exhaustion.
(D) Treatment of pelvic fractures
1. For marginal pelvic fractures. Only bed rest is required. Patients with anterior superior iliac spine fractures are placed in the flexed hip position; sciatic tuberosity fractures are placed in the extended hip position. Bed rest for 3 to 4 weeks is sufficient.
2. For single ring pelvic fractures with separation, the pelvic pockets can be used for suspension and traction fixation. The pelvic belt is made of thick canvas, the width of which is up to the iliac wing and down to the greater trochanter of the femur, and the weight of suspension is appropriate to lift the hip off the bed. 5-6 weeks later, it is replaced with plaster shorts for fixation.
3. For pelvic bicircular fractures with longitudinal dislocation, a manual repositioning under anesthesia can be performed. The method of resetting is that when the patient is supine, the two lower limbs are held by the assistant for traction, and a wide cloth belt lined with thick cotton pad is used to go around the perineum for antagonistic traction to the head side, and the operator first gently pushes the affected iliac bone outward to loosen the interposition, then the assistant abducts the affected lower limb under traction, and the operator uses both hands to push the iliac crest to the distal side to correct the upward displacement, at which time the fracture can be heard to reset the ” Click” sound can be heard at this time, the patient changes the position of the healthy side, and the operator squeezes the iliac wing with the palm of the hand to make the fracture surfaces insert each other.
Finally, the patient’s sacrum and iliac crest are padded with a thin cotton pad and fixed with a 15-20 cm wide strip of adhesive tape around the pelvis. At the same time, the affected limb was subjected to continuous bone traction, which was removed after 3 weeks, and the fixed adhesive tape was removed after 6-8 weeks. During the immobilization period, exercises for contraction of the quadriceps muscle and joint movement were performed. After three months, the patient can walk with weight.
4. For dislocated sacral or caudal fracture dislocation, the fracture can be reset by pushing the fracture backward with fingers under local anesthesia. For severe pain of old tailbone fracture, local prednisolone closure can be made.
5, the hip joint central dislocation, in addition to the affected limb for bone traction, at the large ridge should be made again side traction. It should be reset.
6.For the dislocation fracture involving the acetabulum, if the fracture cannot be repaired by manipulation, it should be repaired by open internal fixation to restore the mesoscopic articular surface of the acetabulum.
The treatment of patients whose pelvic fractures seriously affect the systemic hemodynamics is very complicated and tricky. Multidisciplinary trauma teams must control bleeding, restore hemodynamics, and rapidly diagnose and treat associated life-threatening trauma. The investigators’ clinical approach includes five points: immediate arrival of the attending trauma physician in the emergency room, early and simultaneous transfusion of blood and coagulation factors, timely diagnosis and management of life-threatening trauma, pelvic band immobilization, and timely pelvic angiography and embolization.
Two other orthopaedic specialists also emphasized the importance of prompt arrival of the attending orthopaedic surgeon in the emergency room and working with the trauma surgeon to make treatment decisions, close the pelvic wound in the emergency room, and apply nontraditional external fixation methods.