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1836 SECTION 22: Orthopedics lupus, and other prior joint infections. 67,68 Postoperative infections can be acute (0 to 3 months), subacute (3 months to 1 year), or late (after 1 year). One study of 2512 patients reported that of the 26 infected replacements, the mean time to infection development was 3.5 years. The typical presentation of infection is nonspecific shoulder pain. The workup for infection includes blood work including WBC count, erythrocyte sedimentation rate, and C-reactive protein. Unfortunately, one cannot completely rely on the laboratory markers to be elevated. In one study, the average WBC count of infected shoulders was 11.98/mm 3, with an erythrocyte sedimentation rate of 75 mm/h. 68 Other studies have shown an average WBC of 7.4/mm 3, erythrocyte sedimentation rate of 47 mm/h, and C-reactive protein elevation in only 25% of infected cases. 69,70 Fractures, dislocations, neurovascular compromise, joint instability, and suspected infection require orthopedic consultation in the ED. REFERENCES The complete reference list is available online at www.TintinalliEM.com. FIGURE 272-1. Bones and joints of the pelvis. Iliolumbar ligament Posterior sacroiliac ligament Sacrotuberous ligament Sacrospinous ligamentFIGURE 272-2. Pelvic ligaments. Pelvis Injuries Ciara J. Barclay-Buchanan Melissa A. Barton EPIDEMIOLOGY Pelvic fractures are most commonly the result of a motor vehicle or motorcycle collision, automobile versus pedestrian collision, fall from a significant height, or a crush injury. Isolated pubic rami fractures can occur in the elderly following a low-energy mechanism of injury, such as falling off of a chair, due to underlying fragility and osteopenia. 1 The in-hospital mortality rate from all pelvic fractures is approximately 8% and approaches 20% with complex pelvic fractures. 2 Higher mortality rates are found in older patients, men, African Americans, and those living in the northeastern United States. 2 The mortality rate is 30% in patients who present in shock.3 Pelvic ring fractures have been found to be an independent risk factor for death.4 ANATOMY AND BIOMECHANICS The major functions of the bony pelvis are protection of the visceral organs, mechanical support, and hematopoiesis. The bony pelvis con sists of the sacrum, coccyx, and bilateral innominate bones: the ischium, ilium, and pubis. Collectively, they provide pelvic stability that is further supported by the strong posterior sacroiliac, sacrotuberous, and sacro spinous ligaments (Figures 272-1 and 272-2). A small amount of pelvic stability is also provided by the pubic symphysis. Five joints that allow some movement of the bony ring are incorpo rated into the pelvic structure. The lumbosacral, sacroiliac, and sacro coccygeal joints, as well as the symphysis pubis, allow limited movement. The acetabulum, a ball-and-socket joint, is divided into three portions: (1) the iliac portion, or superior dome, is the chief weight-bearing sur face; (2) the inner wall, which consists of the pubis, is thin and easily fractured; and (3) the posterior acetabulum, which is derived from the thick ischium. Generally, a single break in the ring results in a stable injury without significant risk of displacement, and two breaks in the ring result in an unstable injury. The pelvis is extremely vascular. The iliac artery and venous trunks pass near the sacroiliac joints bilaterally. The nerve supply through the pelvis is derived from the lumbar and sacral plexuses.

ults in a stable injury without significant risk of displacement, and two breaks in the ring result in an unstable injury. The pelvis is extremely vascular. The iliac artery and venous trunks pass near the sacroiliac joints bilaterally. The nerve supply through the pelvis is derived from the lumbar and sacral plexuses. Injury to the pelvis may produce deficits at any level from the nerve root to small peripheral branches (Figure 272-3). The lower urinary tract is contained in the pelvis (Figure 272-4). In the adult, the bladder lies behind the symphysis and pubic bones, and the peritoneum covers the dome and base poste riorly. The location of the bladder and the degree of peritoneal reflec tion are determined by urine volume. Portions of the lower GI tract are housed in the pelvis including a portion of the descending colon, as well as the sigmoid colon, rectum, and anus. In women, the uterus and vagina are also located within the bony pelvis. The location of these organs places them at risk following a traumatic pelvic injury. CLINICAL FEATURES  HISTORY Determining the mechanism of injury is important when assessing a trauma patient. Consider the possibility of a pelvic fracture in every patient with serious blunt trauma (e.g., fall from a height, pedestrian struck by a motor vehicle, crush injury, ejection from a vehicle, motor cycle or all-terrain vehicle collision). Ask the patient about location of pain, last urination or defecation, present bladder sensation, and last solid and fluid intake. In addition, determine the time of the last menses or the presence of pregnancy. Obtain a brief past medical history, current medications, and allergies.  PHYSICAL EXAMINATION In patients who are awake and alert, a careful physical examination is sensitive (93% in one study) for the diagnosis of a pelvic fracture. 5 Signs and symptoms of bony pelvic injury vary from localized pain and tenderness and inability to bear weight to pelvic instability and severe shock. Unexplained hypotension may be the only sign of a major pelvic disruption. CHAPTER Tintinalli_Sec22_p1767-1880.indd 1836 8/2/19 6:17 PM

diagnosis of a pelvic fracture. 5 Signs and symptoms of bony pelvic injury vary from localized pain and tenderness and inability to bear weight to pelvic instability and severe shock. Unexplained hypotension may be the only sign of a major pelvic disruption. CHAPTER Tintinalli_Sec22_p1767-1880.indd 1836 8/2/19 6:17 PM CHAPTER 272: Pelvis Injuries 1837 FIGURE 272-4. Sagittal section of the male pelvis showing the relationships of the full bladder. Serious Injury For a patient with a serious or high-energy mechanism of injury, examine for abdominal tenderness, perineal and pelvic ecchymoses, lacerations, and deformities. Scrotal hematoma (Destot’s sign) indicates a pelvic fracture. Leg length discrepancy or rotational deformity of the lower extremity without an obvious femur fracture or dislocation suggests a pelvic fracture. Evidence of blood at the urethral meatus suggests a urethral injury. Perform a FAST examination as an adjunct to the physical examination during the primary trauma survey in any unstable patient or when the mechanism of injury could suggest a pelvic fracture. Fluid in the peritoneum can suggest solid organ injury, but fluid in the pelvis can also lead the clinician to suspect a pelvic fracture prior to radiographic confirmation. Assess for pelvic instability on every trauma patient, which could include visual inspection in patients with obvious pelvic fractures, pelvic rim compression, or radiologic survey. Gentle downward and medial manual compression of the pelvis over the iliac wings should be per formed only once during the trauma survey. Repeated manipulation of the pelvic ring on a patient with a suspected pelvic fracture can increase the severity of injury, resulting in greater blood loss. Do not perform compressive pelvic maneuvers in a patient with shock or an obvious FIGURE 272-3. Arterial and nerve supply of the pelvis. a. = artery; aa. = arteries; Ext. = exterior; Inf. = inferior; Int. = interior; Lat. = lateral; Sup. = superior. [Reproduced with permission from Pansky B: Review of Gross Anatomy, 6th ed. Copyright © 1995, McGraw-Hill, New York.] pelvic fracture. Movement of an unstable fracture can worsen the injury and lead to further blood loss. Rectal examination may detect superior or posterior displacement of the prostate, rectal injury, an abnormal bony prominence, large hema toma, or tenderness along the suspected fracture line. Proctoscopic or bimanual pelvic examinations may be required to assess for mucosal tears indicating an open fracture. Such injuries increase the risk of infection at the fracture site and resultant sepsis. 6 Decreased anal sphincter tone may suggest neurologic injury. Carefully evaluate lower extremity pulses and sensation. Assume an associated intra-abdominal, retroperitoneal, gynecologic, and urologic injury until proven otherwise. Stable Patient and Low Mechanism of Injury In stable patients or those with a low-energy mechanism of injury (e.g., an elderly patient who falls from a seated position), examine the entire spine and the abdomen. Palpate for tenderness along the pelvic bony structures, including the iliac crests, pubic rami, sacrum, and coccyx. Compress the pelvis, lateral to medial, through the iliac crests, as well as through the greater trochanters. In addition, compress the pelvic ring from anterior to posterior through the symphysis pubis and iliac crests. Evaluate lower extremity pulses, motor function, and sensation. IMAGING The initial stabilization of the patient takes priority over imaging. If not already done, perform a FAST exam to identify intraperitoneal bleeding. If there is no tenderness to palpation in an otherwise stable, alert patient, a standard anteroposterior pelvis radiograph is not indicated.

nction, and sensation. IMAGING The initial stabilization of the patient takes priority over imaging. If not already done, perform a FAST exam to identify intraperitoneal bleeding. If there is no tenderness to palpation in an otherwise stable, alert patient, a standard anteroposterior pelvis radiograph is not indicated. In patients with a suspected hip fracture, a standard anteroposterior pelvic radiograph is often used to evaluate for bony injury. However, routine pelvic radiographs are not needed in stable patients who will otherwise undergo an emergent CT scan of the abdomen and pelvis unless there is suspicion for a hip fracture or dislocation. 7-12 Indications for an anteroposterior pelvis radiograph include hemo dynamic instability, pelvic tenderness, or other physical examination findings that are concerning for pelvic fracture, hip fracture, or hip dislocation. With an unstable blunt trauma patient, a pelvic radiograph should be obtained for early identification, stabilization, and rapid mobilization of resources for emergent angiography. CT is the gold standard for evaluating bony and ligamentous pelvic injury. CT is more sensitive than plain radiographs for the detection of pelvic fracture. Compared with CT, pelvic radiographs have a sensitivity of ≤85% for identifying pelvic fractures in blunt trauma patients. 1 CT is also superior to radiography in evaluating pelvic ring instability.9-11,13 Therefore, a CT scan should be ordered when a pelvic fracture is suspected despite negative pelvic radiographs. Additionally, if a pelvic fracture is identified on plain films, a CT should be ordered to evaluate for additional fractures or instability. Contrast-enhanced CT can assess for associated ligamentous injury, contrast extravasation, pelvic hematoma, and retroperitoneal bleeding. Contrast extravasation on CT scan is 80% to 90% sensitive for the identification of arterial bleeding. The approach to pelvic imaging varies at the extremes of age. Up to half of elderly patients with a low-energy mechanism and pubic ramus fracture may have an associated posterior pelvic ring disruption demonstrated on CT scan. 15 Sacral fractures are often missed on plain radiographs due to degenerative bony changes (i.e., osteoporosis) and overlying bowel gas.16 This often overlooked finding may contribute to the fact that one third of elderly patients with isolated rami fractures do not return to their previous independent living or fail conservative treatment for pain management. Pain on sacral palpation is suggestive of a posterior ring disruption and indicates the need for a CT scan. Most children with a low-energy mechanism and normal examination do not usually require imaging because pelvic fractures are rare in the pediatric population. Avulsion-type iliac wing fractures from sports injuries are reportedly the most common pelvic injuries in children. 17 Clinical scenarios associated with pelvic fracture in children include a high-risk mechanism (e.g., motor vehicle collision with ejection or rollover; automobile versus pedestrian or bicycle) combined with either a Glasgow Coma Scale score <14 or pelvic tenderness, and also medically complex children, such as those with preexisting bone disease or developmental delay. 17,18 Tintinalli_Sec22_p1767-1880.indd 1837 8/2/19 6:17 PM

icle collision with ejection or rollover; automobile versus pedestrian or bicycle) combined with either a Glasgow Coma Scale score <14 or pelvic tenderness, and also medically complex children, such as those with preexisting bone disease or developmental delay. 17,18 Tintinalli_Sec22_p1767-1880.indd 1837 8/2/19 6:17 PM 1838 SECTION 22: Orthopedics PELVIC FRACTURE PATTERNS Pelvic fractures include breaks in the pelvic ring, fractures of a single bone without a break in the pelvic ring, and acetabular fractures. The most clinically useful classification, the Y oung-Burgess Pelvis Fracture Classification System, is presented in a simplified version in Table 272-1. This system differentiates fracture patterns based on mechanism of injury and direction of causative force. The incidence of complications (e.g., urogenital and vascular) is correlated with the frac ture pattern, making identification of the type more clinically significant and useful. There are three main types of pelvic fracture patterns: lateral com pression, anterior-posterior compression (open-book), and vertical shear. The different injury types may be suggested by history, but may often be differentiated radiographically. The pattern of a pubic rami fracture is a clue to the mechanism and direction of force. In general, horizontal fractures suggest lateral compression injury, whereas vertical fractures suggest a vertical shear force. Open-book fractures point to an anteroposterior injury. Based on the recognition of the fracture pattern, one can then predict the likelihood of severe hemorrhage or urogenital injury (see Table 272-1).  LATERAL COMPRESSION FRACTURE Lateral compression fractures are the most common, accounting for 60% to 70% of pelvic fractures with an overall mortality rate of 8%. 19 Motor vehicle collisions, in which a car is broadsided or a pedestrian is struck from the side, are possible mechanisms that could result in a lateral compression fracture. At a minimum, a pubic ramus will be fractured. If the pelvis is further compressed, the sacroiliac joint is crushed, leading to disruption of the posterior ligaments, fracture of the sacrum, and rotation of the contralateral hemipelvis (Figure 272-5).  ANTERIOR-POSTERIOR COMPRESSION OR OPEN-BOOK FRACTURE Anterior-posterior compression injuries, or open-book fractures, account for about 25% of severe injuries. A head-on motor vehicle crash is the classic example. The force is delivered in an anteroposterior direction (arrow in Figure 272-6), “opening” the pelvis, splaying the pubic symphysis, and rupturing the sacral ligaments. Finally, total disruption of the sacroiliac joint will occur because of the wide “opening” of the pelvis. All supporting ligament groups, including the posterior sacroiliac ligaments, can be disrupted.  VERTICAL SHEAR FRACTURE The least common are vertical shear fractures, which typically result from a fall or jump from a height, and account for approximately 5% of pelvic fractures. With this injury, the force vector is delivered in a vertical plane (Figure 272-7). Fractures of the pubic rami are usually seen anteriorly, whereas fractures of the sacrum, sacroiliac joint, or iliac wing are usually seen posteriorly. Any of the pelvic ligaments may be disrupted. Combinations of injury patterns make up the other 20% to 25% of injuries. AVULSION AND SINGLE-BONE PELVIC FRACTURES Isolated, closed avulsion fractures and single-bone, closed pelvic frac tures are more common than pelvic ring disruption. It is important to know which of these fractures require further diagnostic testing, orthopedic consultation, or admission.

e other 20% to 25% of injuries. AVULSION AND SINGLE-BONE PELVIC FRACTURES Isolated, closed avulsion fractures and single-bone, closed pelvic frac tures are more common than pelvic ring disruption. It is important to know which of these fractures require further diagnostic testing, orthopedic consultation, or admission. Isolated fractures of the anterior superior iliac spine, anterior inferior iliac spine, ischial tuberosity, pubic ramus, body of the ischium, iliac wing, sacrum, or coccyx typically do not disrupt the pelvic ring and, as a result, typically do not require surgical repair ( Figure 272-8 and Table 272-2). Most of these fractures require only analgesia, crutches, bed rest or non–weight-bearing status, and orthopedic follow-up on an outpatient basis. TABLE 272-1 Abbreviated Young-Burgess Pelvis Fracture Classification System and Potential Incidence of Complications Category Characteristics Severe Hemorrhage (%) Bladder Rupture (%) Urethral Injury (%) Lateral compression (LC) Transverse pubic rami fracture ipsilateral or contralateral to posterior injury 60 20 20 Anterior-posterior (AP) (“open-book”) Symphyseal diastasis or longitudinal rami fractures Injury to secondary structures varies based on severity of AP pelvic fracture Minimal widening of sacroiliac (SI) joint with intact posterior ligaments Complete SI joint widening with disruption of posterior ligaments Vertical shear (VS) Separation of symphysis or SI joint with vertical displacement anteriorly or posteriorly, occasionally through iliac wing or sacrum 75 15 25 Mixed patterns Combination of other injury patterns LC and VS patterns are most common 58 16 21 FIGURE 272-5. Lateral compression fracture (arrows 1 and 2) with rupture of posterior sacroiliac ligaments (R), sacrospinous/sacrotuberous complex (T), and rupture of pubic ramus (B). FIGURE 272-6. Open-book fracture, with opening of the anterior pelvis ( arrow) and rupture of the sacral ligaments. Tintinalli_Sec22_p1767-1880.indd 1838 8/2/19 6:17 PM

n fracture (arrows 1 and 2) with rupture of posterior sacroiliac ligaments (R), sacrospinous/sacrotuberous complex (T), and rupture of pubic ramus (B). FIGURE 272-6. Open-book fracture, with opening of the anterior pelvis ( arrow) and rupture of the sacral ligaments. Tintinalli_Sec22_p1767-1880.indd 1838 8/2/19 6:17 PM CHAPTER 272: Pelvis Injuries 1839 FIGURE 272-7. Vertical shear fracture. Injury vector is delivered in a vertical plane (arrow). There is injury to the posterior (R) and anterior (A) sacroiliac ligaments and sacrospinous/sacrotuberous (T) ligaments. TABLE 272-2 Avulsion and Single Bone Fractures Fracture Description/Mechanism of Injury Clinical Findings/ Associated Injuries Treatment Disposition and Follow-Up Iliac wing (Duverney) fracture Direct trauma, usually lateral to medial Swelling, tenderness over iliac wing; abdominal pain; ileus; acetabular fractures Serious injury infrequent Analgesics, non–weight bearing until hip abductors pain-free, usually nonoperative Discharge with orthopedic follow-up in 1–2 wk Admit for open fracture or concerning abdominal examination Single pubic rami or ischium fracture Fall or direct trauma in elderly; exercise-induced stress fracture in young adult; or in pregnant women Local pain and tenderness; may have inability to ambulate Analgesics, crutches, weight bearing as tolerated Discharge with PCP or orthopedic follow-up in 1–2 wk Admit for intractable pain or mobility concerns (elderly) Ischium body fracture External trauma or fall in sitting position Least common pelvic fracture Local pain and tenderness; pain with hamstring movement Analgesics, bed rest, donut-ring cushion, crutches Discharge with orthopedic follow-up in 1–2 wk Sacral fracture Transverse: direct anteroposterior trauma Upper transverse: fall in flexed position Pain on rectal examination; vertical fractures may transect the pelvic ring; sacral root injury with upper transverse fractures Analgesics, bed rest, surgery may be needed for displaced fractures or neurologic injury Discharge with orthopedic follow-up in 1–2 wk Orthopedic consultation for displaced fracture or neurologic deficit Coccyx fracture Fall in sitting position More common in women Pain, tenderness over coccyx region; pain on compression during rectal examination Analgesics, bed rest, stool softeners, sitz baths, donut-ring cushion; surgical excision of fracture fragment if chronic pain Discharge with PCP or orthopedic follow-up in 2–3 wk Anterior-superior iliac spine fracture Forceful sartorius muscle contraction (e.g., adolescent sprinter) Pain with hip flexion and abduction Analgesics, bed rest for 3–4 wk with hip flexed and abducted, crutches Discharge with orthopedic follow-up in 1–2 wk Anterior-inferior iliac spine fracture Forceful rectus femoris muscle contraction (e.g., adolescent soccer player) Pain in groin; pain with hip flexion Analgesics, bed rest for 3–4 wk with hip flexed, crutches Discharge with orthopedic follow-up in 1–2 wk Ischial tuberosity fracture Forceful contraction of hamstrings Pain with sitting or flexing the thigh Analgesics, bed rest for 3–4 wk in extension, external rotation, crutches Discharge with orthopedic follow-up in 1–2 wk Abbreviation: PCP = primary care physician. ACETABULAR FRACTURES Acetabular fractures are usually secondary to motor vehicle collisions. The fracture force is either transmitted laterally through the hip or posteriorly through the femur as with a knee-versus-dashboard mech anism. Acetabular fractures are commonly associated with other inju ries, including pelvic, femur, hip, and knee injuries ( Figure 272-11A) . However, these fractures may be subtle and, as a result, necessitate careful inspection via radiography (Figure 272-11B).

y through the femur as with a knee-versus-dashboard mech anism. Acetabular fractures are commonly associated with other inju ries, including pelvic, femur, hip, and knee injuries ( Figure 272-11A) . However, these fractures may be subtle and, as a result, necessitate careful inspection via radiography (Figure 272-11B). If an acetabular fracture is suspected, it can be evaluated with an anteroposterior film, Simple fractures in the elderly may not be as benign as at first glance. If indicated by physical exam or mechanism of injury, obtain a CT scan of the pelvis with bone windows to detect occult posterior pelvic ring disruption that will alter management (Figures 272-9 and 272-10). Although isolated pelvic ramus fractures are frequently due to lowimpact trauma (e.g., fall from standing) in the elderly, isolated pelvic fractures still result in increased rates of hospital admission, morbidity, need for living assistance after hospital discharge, and overall mortality at 1 year. Pay special attention to isolated fractures of either the sacrum or iliac wing due to the tremendous amount of force required to produce this type of fracture. If there is concern for associated injuries, a more extensive evaluation is mandated with admission for observation. 8 3 FIGURE 272-8. Avulsion fractures of the pelvis. (1) Iliac wing fracture (Duverney fracture). (2) Superior pubic ramus fracture. (3) Inferior pubic ramus fracture. (4) Transverse sacral fracture. (5) Coccyx fracture. (6) Anterior superior iliac spine avulsion. (7) Anterior inferior iliac spine avulsion. (8) Ischial tuberosity avulsion. Tintinalli_Sec22_p1767-1880.indd 1839 8/2/19 6:18 PM

re (Duverney fracture). (2) Superior pubic ramus fracture. (3) Inferior pubic ramus fracture. (4) Transverse sacral fracture. (5) Coccyx fracture. (6) Anterior superior iliac spine avulsion. (7) Anterior inferior iliac spine avulsion. (8) Ischial tuberosity avulsion. Tintinalli_Sec22_p1767-1880.indd 1839 8/2/19 6:18 PM 1840 SECTION 22: Orthopedics a 45-degree iliac oblique view, and a 45-degree obturator oblique view—together known as Judet views. CT is more sensitive than radi ography in detecting acetabular injury. 21 CT provides more detailed information about the displacement of fracture fragments, degree of comminution, and other information that is useful in preoperative planning. Patients with acetabular fractures require hospital admission and orthopedic consultation, as well as evaluation for associated visceral, neurovascular, and other orthopedic injuries. Sciatic nerve injury is a common complication. TREATMENT It is important to prevent movement of fracture segments, particularly in the hemodynamically unstable patient. The pelvis can be temporar ily yet quickly stabilized with a bed sheet or other pelvic binding device to reduce pelvic volume and stabilize fracture ends. 22-24 The simplest technique is the application of either a folded bed sheet secured with towel clips or a commercially manufactured binder that is tightly wrapped around the pelvis at the level of the greater trochanters. A pelvic binder can decrease the volume of the pelvis and, in turn, help diminish blood loss for both open-book and vertical shear fractures. Lateral compression pelvic fractures do not benefit from the applica tion of a pelvic binder because they are already rotated internally; in fact, these patients may be harmed from further lateral compression. Provide appropriate resuscitation with crystalloid, blood, and blood products. Retroperitoneal bleeding may complicate pelvic fractures. Up to 4 L of blood can be lost in the pelvis before vascular pressure is FIGURE 272-9. Fracture of superior ramus ( top arrow) as the result of fall from standing. Healed fracture of the inferior ramus is noted as well ( bottom arrow). [Photo used with permission of Patrick Studer, MD.] FIGURE 272-10. Same patient with fracture of left lateral sacral body discovered on CT scan. [Photo used with permission of Patrick Studer, MD.] FIGURE 272-11. A. Left posterior hip dislocation with avulsed fracture fragments of the posterior acetabular rim. B. Multiple curvilinear lucencies demonstrating nondisplaced fractures (arrows) of the right acetabulum and right ischium. Pubic symphysis is also slightly widened. Tintinalli_Sec22_p1767-1880.indd 1840 8/2/19 6:18 PM

11. A. Left posterior hip dislocation with avulsed fracture fragments of the posterior acetabular rim. B. Multiple curvilinear lucencies demonstrating nondisplaced fractures (arrows) of the right acetabulum and right ischium. Pubic symphysis is also slightly widened. Tintinalli_Sec22_p1767-1880.indd 1840 8/2/19 6:18 PM CHAPTER 272: Pelvis Injuries 1841 overcome and tamponade occurs. Most bleeding is due to the low-pressure venous injury, rather than from arterial vessels, or results from broken, mobile bone edges. Predictors for the need of either a transfusion or a therapeutic intervention (tranexamic acid) due to hemorrhage include: (1) initial hematocrit <30%, (2) presence of pelvic hematoma on CT scan, or (3) systolic blood pressure <90 mm Hg on arrival. 26 Presence of any of these factors mandates intensive care admission. 26 Moreover, a recent prospective study showed that a base deficit <6 mmol/L or a worsening base deficit >2 mmol/L while in the ED significantly correlated with the need for either angiography or laparotomy.  FAST, CT, AND PELVIC FRACTURE In hemodynamically unstable trauma patients with pelvic fractures, carefully evaluate for other sources of blood loss. Patients who have sustained a pelvic fracture from a significant mechanism of injury should undergo a thoraco-abdomino-pelvic CT scan even if the FAST exam is negative. In the presence of pelvic fracture and serious blunt trauma mechanism, patients with a negative FAST exam are still very likely to have concomitant visceral injury. If the FAST exam reveals free intraperitoneal fluid (Figure 272-12), then CT scan is also needed to determine the next treatment step. The FAST false-positive rate for intraperitoneal hemorrhage in patients with pelvic ring disruption can be up to 30%. 29,30 Distortion of the anatomy from fractures, retroperitoneal bleeding, urine from a rup tured bladder, or pelvic hematoma may mimic free intraperitoneal fluid. The sensitivity and specificity of FAST exam for free peritoneal blood in major pelvic injury appear to be related to the severity of the pelvic fracture. 29,30 One study reported the overall sensitivity and specificity of the FAST exam to detect free peritoneal fluid in major pelvic injury to be 81% and 87%, respectively. 30 The fluid was blood in 76% and urine in 19%. 30 Moderate to large free fluid as evidenced by fluid noted in two or more regions of the FAST exam is reported to be associated with the need for hemorrhage control, either by laparotomy or angiography.  HEMORRHAGE CONTROL: ANGIOGRAPHY, EMBOLIZATION, EXTERNAL FIXATION, PREPERITONEAL PACKING, AND RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA The need for hemorrhage control can be predicted based on the fracture pattern and whether blood products were given during resuscitation.3 If a patient with a pelvic fracture is hemodynamically unstable and other sources of bleeding (e.g., splenic or liver laceration) have been excluded through CT scan or laparotomy, treatment options include angiography with embolization, with or without external fixation of the pelvic frac ture. Angiographic embolization is effective at controlling arterial bleeding. External fixation is thought to be effective at controlling venous bleeding. 32,33 Both may be needed to control hemorrhage. Shock and death are generally due to arterial rather than venous bleeding.14,34,35 Arterial bleeding can occur in all types of pelvic fractures yet does so in only 10% to 15% of cases. 32 The arteries involved are typically branches of the internal iliac system, with the superior gluteal artery and the obturator artery being the most common (see Figure 272-3). Hemorrhage from pelvic fractures refractory to resuscitation is more likely arterial than venous in origin.

es so in only 10% to 15% of cases. 32 The arteries involved are typically branches of the internal iliac system, with the superior gluteal artery and the obturator artery being the most common (see Figure 272-3). Hemorrhage from pelvic fractures refractory to resuscitation is more likely arterial than venous in origin. Angiography and embolization can control arterial hemorrhage in most patients. 32-34 Consider angiography early in a hemodynamically unstable patient with a pelvic fracture, after other sources of bleeding have been excluded. Contrast extravasation on CT is considered by many to be an indi cation for angiography to evaluate for an arterial source of bleeding that may be amenable to embolization. 14,33,36 Some protocols advocate angiography based on hemodynamic status, the need for ongoing blood transfusion, or in patients who meet certain blood transfusion criteria. 14,32 No intervention is needed for nearly half of all patients who demonstrate a pelvic blush on CT scan without clinical signs of ongoing bleeding. 37 The need for arterial embolization has a positive predictive value of 39% for death in open pelvis fractures, as noted in one recent study. Preperitoneal packing, in which surgically placed packs tamponade the potential space available for ongoing blood loss, can be performed quickly to control bleeding in a hemodynamically unstable patient. Consider this treatment option for an unstable patient when angiog raphy is not readily available, when a laparotomy is needed prior to angiography, or if the patient is in extremis and needs quick stabilization prior to angiography. 26,38 Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a newer technique that can be used to temporarily limit aortic inflow to the pelvis, limit arterial bleeding, and preserve cerebral and myocardial perfusion. The definitive treatment of pelvic fractures occurs once the patient has been stabilized and after other associated injuries have been addressed. All pelvic fractures require orthopedic consultation, even in the most stable of patients, and admission when warranted. Elderly patients with simple pubic ramus fractures typically require admission for pain control, observation for complications, and physical therapy for ambulation. The exact treatment is guided by fracture location and pelvic stability. Fractures that disrupt the pelvic ring often need open reduction and internal fixation. Early operative fixation has been associated with better long-term function outcomes. 40 The admitting service will vary between hospitals and depends on multiple factors including the presence of a trauma surgery service, volume of orthope dic cases, comorbidities of the patient, and absence of other significant injuries. COMPLICATIONS OF PELVIC FRACTURES Acute complications and associated injuries of pelvic fractures include urogynecologic injury, rectal injury, ruptured diaphragm, and nerve root injury. Pelvic fractures can also have long-term effects, including chronic pain, sexual dysfunction, and persistent functional disability.  UROGYNECOLOGIC INJURY If a urethral injury is suspected clinically, perform retrograde ure thrography before Foley catheter placement. Urinary tract injuries are discussed in greater detail in Chapter 265, “Genitourinary Trauma. ” Gynecologic injuries are uncommon with pelvic trauma. Vaginal laceration can occur with anterior pelvic fractures. Perform a bimanual pelvic examination on women with pelvic fractures. If blood is detected, a speculum examination is needed to identify vaginal hematoma, laceration, or urethral bleeding.

rinary Trauma. ” Gynecologic injuries are uncommon with pelvic trauma. Vaginal laceration can occur with anterior pelvic fractures. Perform a bimanual pelvic examination on women with pelvic fractures. If blood is detected, a speculum examination is needed to identify vaginal hematoma, laceration, or urethral bleeding. Unstable patient to whom a pelvic binding device has been applied Results of FAST exam performed during primary survey Patient is hemodynamically stable or responded to initial resuscitation CT scan NegativeP ositive *If unavailable or significant delay, then consider extraperitoneal packing in OR while waiting. LaparotomyAngiography* Pelvis Fracture FIGURE 272-12. Suggested algorithm for pelvic fracture treatment. OR = operating room. Tintinalli_Sec22_p1767-1880.indd 1841 8/2/19 6:18 PM