Fig. 1
The pelvis consists of the pubis, the ischium, and the ilium (Adapted from Bruce Blausen, Blausen Medical Communications, under Creative Commons Attribution 3.0 Unported license as published on http://en.wikipedia.org/wiki/File:Blausen_0723_Pelvis.png. Downloaded 28 Dec 2013)
(b)
Ligaments:
(i)
Pubic symphysis.
(ii)
Sacroiliac (SI).
1.
Posterior SI ligaments are strongest: Important factor for vertical stability of pelvis.
(iii)
Illiolumbar: Avulsion fracture can be sign of unstable ring injury.
(c)
Triradiate cartilage :
(i)
Closes around age 14 in boys, 12 in girls.
(ii)
Adolescent patients with closed triradiate cartilage at greater risk for pelvic ring injuries.
3.
History and physical exam:
(a)
ATLS evaluation for life threatening injuries.
(b)
Complete neurovascular examination and secondary survey.
(c)
Compression/palpation of pelvis: assess stability.
(d)
Through urogenital examination.
(i)
Rectal examination required.
(ii)
Retrograde urethrogram required prior to bladder catheter placement if urethral injury is suspected.
(iii)
Assess for Morel-Lavellee lesion: shearing of subcutaneous fat and skin over the fascia.
(iv)
Assess for open pelvic fracture: rare, but may require diverting colostomy.
(e)
Look for associated orthopaedic injuries: fractures of long bones, proximal femur and hip dislocations can occur with pelvic and acetabular trauma.
4.
Diagnostic imaging:
(a)
X-rays:
(i)
AP pelvis part of initial trauma evaluation.
(ii)
Judet views (45° oblique view of the affected hip): obtained for acetabular fractures.
(iii)
Pelvic inlet and outlet radiographs: obtained for pelvic fractures.
(b)
Computed tomography (CT):
(i)
Improved osseous detail.
(ii)
Better delineation fracture pattern: can also use CT three-dimensional reconstructions, when available.
(iii)
“Stable” fractures with posterior SI joint tenderness require CT.
(c)
MRI/Bone Scan:
(i)
Limited value in acute setting.
(ii)
Can be useful to diagnose occult fractures or avulsion injuries.
5.
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Classification of pelvic fractures:
(a)
Many classifications systems exist.
(b)
Limited clinical utility – variability exists in the ability for classification systems to determine treatment and prognosis.
(c)
Pediatric pelvic fracture classification.
(i)
Torode and Zieg:
1.
I: Avulsion.
2.
II: Iliac wing.
3.
III: Simple ring.
4.
IV: Ring disruption.
(d)
Adolescent pelvic fractures often resemble adult patterns.
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