Pelvic fractures

Question 1

What is the benefit of classifying pelvis fractures?

Answer 1

helps to describe and direct treatment, as well as being able to predict the likelihood of other injuries

Question 2

What are 3 aspects of the initial management of a pelvic fractures?

Answer 2

1. Treat hypovolaemia
2. Seek associated injuries
3. Stabilise the pelvis with a commercial splint

Question 3

What are the 4 key types of pelvic fractures according to the Young and Burgess pelvic fracture classification?

Answer 3

1. Lateral compression (LC)
2. Anterior posterior compression (APC)
3. Vertical shear (VS)
4. Combination

Question 4

What is another name for anterior-posterior compression fracture of the pelvis?

Answer 4

open book fracture

Question 5

What is the most common type of pelvic fracture?

Answer 5

lateral compression fractures

Question 6

What do lateral compression fractures of the pelvis result in?

Answer 6

internal rotation of the affected hemi-pelvis

Question 7

What type of mechanism of injury typically leads to lateral compression fractures?

Answer 7

side-on impacts in RTCs

Question 8

What knock-on effect is there on the pelvic contents from lateral compression fractures?

Answer 8

pelvic volume is reduced, so bleeding is less of a problem than the associated head and intra-abdominal injuries

Question 9

What types of lateral compression fractures are encompassed within this class of fractures?

Answer 9

range from simple to complex, multiple-traumatized (types I-III)

Question 10

What is the common features of anterior-posterior compression fractures?

Answer 10

disruption to the pubic symphysis, caused by the ‘opening’ nature of the anterior-posterior comrpession forces (known as open book fractures)

Question 11

What can be said about the stability of anterior-posterior compression fractures when involving the posterior sacro-iliac joints?

Answer 11

rotationally unstable and vertically stable

Question 12

Under what circumstances may anterior-posterior compression fractures (open book fractures) be stable?

Answer 12

if no posterior component

Question 13

What is the rate of pelvic bleeding like in anterior-posterior compression fractures and why?

Answer 13

• rate of pelvic bleeding high (unlike lateral compression) due to increased pelvic volume

Question 14

What may occur as a result of the high rate of pelvic bleeding in anterior-posterior compression fractures?

Answer 14

untamponaded haematomas expand rapidly into retroperitoneum

exsanguination may occur

Question 15

What types of injury do anterior-posterior compression fractures have a strong association with?

Answer 15

brain and intra-abdominal injury

Question 16

What is the initial life-saving therapy in anterior-posterior compression fractures?

Answer 16

application of a sheet or SAM splint (with sheet - tie it around pelvis in similar fashion as SAM in image)

Question 17

What is typically the type of mechanism that causes vertical shear fractures of the pelvis?

Answer 17

typically result from a fall from height

Question 18

What type of joints are typically affected in vertical shear fractures?

Answer 18

ipsilateral pubic rami and sacro-iliac joint disruption due to shearing forces

Question 19

What can be said about the stability of vertical shear fractures?

Answer 19

rotationally unstable and vertically unstable

Question 20

What are 4 types of pelvic fracture for which external fixation may be suitable?

Answer 20

1. APC II/III
2. LC II/III
3. VS
4. Combination

Question 21

What are the 2 key things to remember about pelvic fractures and the effect on pelvic volume?

Answer 21

• lateral compression fractures: reduce pelvic volume
• open book fractures (AP): increase pelvic volume

Question 22

What is the name of the classification system for the key types of pelvic fracture?

Answer 22

Young and Burgess pelvic fracture classification

Question 23

In addition to the types of fractures outlined by the Young and Burgess classification, what are 5 additional types of pelvic fractures to be aware of?

Answer 23

1. Pubic rami fractures
2. Avulsion fractures
3. Minimally displaced ring fractures
4. Coccyx fractures
5. Sacral fractures

Question 24

What can typically be said about the stability of pelvic fractures outside of the Young and Burgess classification?

Answer 24

typically rotationally and vertically stable

either not involving pelvic ring or if they do are minimally displaced and hence stable

Question 25

What is generally the treatment of pelvic fractures outside the Young and Burgess classification system?

Answer 25

bed rest for analgesia and then mobilisation as pain allows

Question 26

In which patient group are pubic rami fractures common?

Answer 26

in elderly following falls

Question 27

What is the management of pubic rami fractures?

Answer 27

* non-operative * analgesia and mobilisation as pain allows * may need referral to medical team/rehabilitation if unable to mobilise

Question 28

What determines whether follow up is neeed in fracture clinic for pubic rami fractures?

Answer 28

* not required for simple fractures in elderly * can occur in younger patients due to trauma - follow up needed

Question 29

What is meant by pelvic avulsion fractures?

Answer 29

* avulsion = injury to bone where tendon/ligament attaches, and it pulls off a piece of the bone * result of muscle contraction avulsing bony fragments

Question 30

Which age groups are affected by pelvic avulsion fractures?

Answer 30

all age groups e.g. young athletes and the elderly

Question 31

What is the management of pelvic avulsion fractures?

Answer 31

* patients who can mobilise are sent home * management is conservative * open reduction + internal fixation can be considered later for painful non-unions

Question 32

What are 3 examples of typical muscles and associated fractures involved in avulsion fractures?

Answer 32

1. Anterior superior iliac spine and sartorius 2. Anterior inferior iliac spine and rectus femoris 3. Iliac crest and abodminal muscles

Question 33

Which bones are typically affected by minimally displaced ring fractures of the pelvis?

Answer 33

superior pubic rami fractures and iliac wing injuries

Question 34

What is the management of minimally displaced ring fractures?

Answer 34

* minimal displacement requires only symptomatic treatment * effective analgesia provided by sitting on rubber ring and avoiding constipation

Question 35

What typically causes coccyx fractures?

Answer 35

after falling in a seated position onto a hard surface

Question 36

Is routine x-ray indicated for coccyx fractures and what will it show?

Answer 36

* no because doesn't change management * if needed, lateral x-rays show variable fracture patterns

Question 37

What are 4 aspects of the management of coccyx fractures?

Answer 37

symptomatic treatment: 1. effective analgesia provided by sitting on rubber ring and avoiding constipation 2. all cases safely sent home with fracture clinic follow-up 3. orthopaedic review/admission only needed if open fracture 4. if painful non-union takes hold, excision can be performed

Question 38

What causes unstable sacral fractures?

Answer 38

associated with high energy transfer, are part of an unstable pelvic fracture pattern

Question 39

What is typically the cause of sacral fractures that are simple transverse fractures?

Answer 39

low energy falls typically in elderly -

Question 40

What can be said about the features of simple transverse fractures of the sacrum?

Answer 40

invariably non-displaced or minimally displaced

Question 41

What is the management of simple transverse sacral fractures?

Answer 41

symptomatic treatment

Question 42

What structures may be damaged in sacral fractures and what clinical effects can this result in?

Answer 42

sacral nerve roots may be involved, giving rise to lower limb neurological symptoms

Question 43

What investigation should be performed in patients with sacral fractures with suspected sacral nerve root involvement?

Answer 43

CT and MRI scans - to assess stability and nerve root involvement

Question 44

What is the management of sacral fractures with sacral nerve root involvement?

Answer 44

most should be admitted for investigation short period of bed rest, followed by safe mobilisation