Updated: 12/28/2021

Pelvic Fracture

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  • Snapshot
    • A 23-year-old man presents to the emergency department after a motor vehicle accident. He was riding in the front seat of the car while wearing a seatbelt. After the accident, he developed severe pain in the pelvic region. The emergency medical technician arrived at the scene and immediately immobilized the patient and intravenous fluids are started. The patient’s blood pressure is 98/62 mmHg and pulse is 104/min. In the emergency department, there is disfigurement of the hip with ecchymosis in the affected area. There is no blood in the urethral meatus. A radiograph of the pelvis demonstrates a pelvic fracture. A pelvic binder is placed and orthopedic surgery is consulted.
  • Introduction
    • Clinical definition
      • fracture of the pelvic bone
  • Epidemiology
    • Incidence
      • highest in patients 15-28 years of age
      • < 35 years of age
        • more common in men
      • > 35 years of age
        • more common in women
  • Etiology
    • Low-energy trauma
      • e.g., fall and athletic injury
    • High-energy trauma
      • e.g., motor vehicle accident
    • Pathogenesis
      • trauma to the pelvis may result in fracture
        • hemorrhage may occur with the pelvic fracture due to bleeding from
          • the exposed fracture
          • injury to soft tissues
          • venous bleeding
  • Presentation
    • Symptoms
      • pain
      • disability
    • Physical exam
      • physical exam findings depend on the severity of the trauma and involved structures
      • pelvic deformity
      • hematomas may be present
      • the patient may have associated injuries involving the
        • head
        • chest
        • abdomen
  • Imaging
    • Radiography
      • indication
        • initial imaging study in patients with suspected pelvic trauma
      • view
        • anteroposterior view of the pelvis
    • Computerized tomography (CT) scan
      • indication
        • gold standard imaging modality for pelvic fracture
  • Studies
    • Labs
      • in the emergency setting, the following labs are typically ordered
        • complete blood count
        • hemoglobin and hematocrit
          • to monitor for ongoing blood loss
        • blood type and screen
          • in case a blood transfusion is needed
        • creatinine and urine studies
        • coagulation profile
        • toxicology screen
    • Making the diagnosis
      • a clinical diagnosis supported by imaging studies
  • Treatment
    • Conservative
      • pelvic binder
        • indication
          • to create a tamponade effect, stabilize the fracture, and improve patient comfort
    • Operative
      • vessel embolization
        • indication
          • can be indicated in cases of refractory bleeding
  • Complications
    • Neurological injury
      • erectile dysfunction due to nerve damage
    • Infection
    • Hemorrhage
  • Prognosis
    • Improved outcomes in patients managed with early pelvic stabilization
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(M2.OR.17.4756) A 29-year-old male presents to the emergency department after a motor vehicle accident. The patient was an unrestrained passenger who was involved in a head-on collision. The patient has a Glasgow Coma Scale of 7 on arrival. On physical exam, you note a young man covered in bruises and scrapes. There is notable erythema and edema of his pelvis, and profound bruising of his dorsal upper back. His temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air. The patient is started on IV fluids and radiography is obtained as seen in Figure A and B. The patient’s blood pressure 15 minutes later is 98/69 mmHg. IV fluids are continued, and a FAST exam is performed which is negative for signs of intrathoracic or intraabdominal trauma. Which of the following is the best next step in management?

QID: 109011
FIGURES:

CT scan of the abdomen and pelvis

8%

(4/50)

Placement of a pelvic binder

76%

(38/50)

Embolization of the pelvic vessels

8%

(4/50)

Large needle decompression of the 4th intercostal space

4%

(2/50)

Immediate blood transfusion

2%

(1/50)

M 7 D

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(M2.OR.17.4757) A 69-year-old male presents to the emergency department after a car crash. The patient is unconscious and his shirt is covered in blood. The patient has severe JVD and seems to be struggling to breathe. His temperature is 99.5°F (37.5°C), pulse is 160/min, blood pressure is 90/50 mmHg, respirations are 18/min, and oxygen saturation is 93% on room air. Large needle decompression is performed, and IV fluids are started. A pelvic binder is placed and a full trauma assessment is started. The patient's physical exam is notable for multiple bruises and erythema over the ventral chest, arms, and pelvis. The patient has a type and screen sent off and a radiograph of the pelvis is ordered and is in Figure A. A radiograph of the chest is performed and is notable for multiple broken ribs. A FAST exam is ordered and returns negative for any signs of abdominal bleeding or cardiac tamponade. During this time, IV fluids are continued and a chest tube is placed. There is no drainage of blood from the chest tube. His temperature is 99.5°F (37.5°C), pulse is 170/min, blood pressure is 85/55 mmHg, respirations are 10/min, and oxygen saturation is 96% on room air. IV fluids are continued, however, the patient’s vitals do not improve. Which of the following is the best next step in management?

QID: 109012
FIGURES:

Vessel embolization

32%

(12/37)

Repeat FAST exam

3%

(1/37)

Exploratory laparotomy

46%

(17/37)

Exploratory laparoscopy

8%

(3/37)

Norepinephrine

8%

(3/37)

M 7 D

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