Updated: 4/1/2018

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
  • Prognosis
    • improved outcomes in patients managed with early pelvic stabilization
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

References

 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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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? Review Topic | Tested Concept

QID: 109011
FIGURES:
1

CT scan of the abdomen and pelvis

10%

(4/42)

2

Placement of a pelvic binder

79%

(33/42)

3

Embolization of the pelvic vessels

10%

(4/42)

4

Large needle decompression of the 4th intercostal space

2%

(1/42)

5

Immediate blood transfusion

0%

(0/42)

L 3 D

Select Answer to see Preferred Response

(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? Review Topic | Tested Concept

QID: 109012
FIGURES:
1

Vessel embolization

37%

(11/30)

2

Repeat FAST exam

3%

(1/30)

3

Exploratory laparotomy

47%

(14/30)

4

Exploratory laparoscopy

3%

(1/30)

5

Norepinephrine

10%

(3/30)

L 3 D

Select Answer to see Preferred Response

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