| disease | Pelvic Fracture |
Pelvic fracture is a severe trauma, often caused by direct violence such as pelvic compression. It is commonly seen in traffic accidents and collapses, while in wartime, it results from firearm injuries. More than half of pelvic fractures are accompanied by complications or multiple injuries. The most severe cases involve traumatic hemorrhagic shock and injuries to pelvic organs, which can lead to high mortality if not treated properly.
bubble_chart Clinical Manifestations
(1) The patient has a history of severe trauma, especially a history of pelvic compression trauma.
(2) The pain is widespread and worsens with movement of the lower limbs or sitting. Local swelling is present, with visible subcutaneous bruising in the perineum and pubic symphysis, accompanied by obvious tenderness. Compressing the pelvic ring inward or separating it outward from both iliac crests causes pain at the fracture site due to stretching or compression (pelvic compression-separation test).
(3) The affected limb is shortened, with a reduced length from the umbilicus to the medial malleolus on the affected side. However, the length from the anterior superior iliac spine to the medial malleolus is usually not shortened, except in cases of femoral head central dislocation. In cases of sacroiliac joint dislocation, the posterior superior iliac spine on the affected side is significantly more prominent than on the healthy side, and the distance between it and the spinous process is also shorter than on the healthy side. This indicates that the posterior superior iliac spine is displaced backward, upward, and toward the midline.
The patient has a history of severe trauma, especially crush injuries to the pelvis. Diagnosis can be confirmed by X-ray examination.
bubble_chart Treatment MeasuresManagement should be based on the patient's overall condition, prioritizing the treatment of shock and any life-threatening complications.
(1) Prevention and treatment of shock. Patients often experience shock due to massive retroperitoneal bleeding. Close monitoring is required, along with blood transfusions and fluid resuscitation. For pelvic fractures, blood transfusions may exceed several thousand milliliters. If blood pressure continues to drop despite aggressive resuscitation and massive transfusions, and shock remains uncorrected, consider ligating one or both internal iliac arteries or performing internal iliac artery embolization via catheter.
(2) Bladder rupture should be repaired, accompanied by a suprapubic cystostomy. For urethral rupture, a catheter should be inserted first to prevent urinary extravasation and infection, and the catheter should remain in place until the urethra heals. If catheter insertion is difficult, perform a suprapubic cystostomy and urethral realignment.
(3) For rectal injuries, exploratory laparotomy should be performed, along with a colostomy to temporarily divert feces. The rectal laceration should be sutured, and a rectal tube should be placed for decompression.
(4) Management of pelvic fractures
1. For marginal pelvic fractures, bed rest alone is sufficient. For fractures of the anterior superior iliac spine, the hip should be placed in flexion; for fractures of the ischial tuberosity, the hip should be extended. Bed rest for 3–4 weeks is adequate.
2. For single-ring pelvic fractures with displacement, a pelvic sling can be used for suspension traction and fixation. The sling is made of thick canvas, with its upper edge reaching the iliac crest and the lower edge extending to the greater trochanter. The suspension weight should be sufficient to lift the buttocks off the bed. After 5–6 weeks, switch to a short hip spica cast for fixation.
3. For double-ring pelvic fractures with longitudinal displacement, manual reduction under anesthesia may be performed. The reduction method involves the patient lying supine while assistants hold and traction both lower limbs. A wide cloth strap padded with thick cotton is looped around the perineum for counter-traction toward the head. The surgeon gently pushes the affected ilium outward to disimpact the fracture. Then, while the assistant maintains traction and abducts the affected limb, the surgeon presses the iliac crest downward with both hands to correct upward displacement. A "click" sound may be heard as the fracture reduces. The patient is then turned to the unaffected side, and the surgeon compresses the iliac wing with the palm to interlock the fracture surfaces. Finally, thin cotton pads are placed under the sacrum and iliac crest, and a 15–20 cm wide adhesive tape is wrapped around the pelvis for fixation. Continuous skeletal traction is applied to the affected limb. Remove skeletal traction after 3 weeks and the adhesive tape after 6–8 weeks. During fixation, perform quadriceps contraction and joint mobility exercises. Weight-bearing walking can begin after three months.
4. For displaced fractures or dislocations of the sacrum or coccyx, manual reduction can be performed under local anesthesia by pushing the fracture backward through the rectum. For severe pain due to old coccygeal fractures, local prednisolone injection may be administered.
5. For central hip dislocation, in addition to skeletal traction of the affected limb, lateral traction should also be applied at the greater trochanter to achieve reduction.
6. For displaced fractures involving the acetabulum that cannot be reduced manually, open reduction and internal fixation should be performed to restore the anatomical articular surface of the acetabulum.
1. Retroperitoneal hematoma. The bones of the pelvis are primarily composed of cancellous bone, with abundant muscles in the pelvic wall and numerous arterial and venous plexuses nearby, resulting in rich blood supply. The space between the pelvic cavity and the retroperitoneum is composed of loose connective tissue, providing a large cavity that can accommodate hemorrhage. Therefore, fractures can lead to extensive bleeding. A massive retroperitoneal hematoma may extend to the renal region, subphrenic area, or mesentery. Patients often present with shock, along with symptoms of peritoneal irritation such as abdominal pain, abdominal distension and fullness, decreased bowel sounds, and abdominal muscle rigidity. To differentiate from intraperitoneal hemorrhage, a diagnostic peritoneal puncture may be performed, but the puncture should not be too deep to avoid entering the retroperitoneal hematoma and mistakenly diagnosing it as intraperitoneal bleeding. Thus, close and meticulous observation with repeated examinations is essential.
2. Urethral or bladder injury. The possibility of lower urinary tract injury should always be considered in patients with pelvic fractures. Urethral injuries are far more common than bladder injuries. Patients may exhibit difficulty urinating and blood oozing from the urethral orifice. The incidence of membranous urethral injury is higher in cases of bilateral pubic ramus fractures and pubic symphysis diastasis.
3. Rectal injury. Unless a pelvic fracture is accompanied by perineal open injury, rectal injury is not a common complication. If a rectal rupture occurs above the peritoneal reflection, it can lead to diffuse peritonitis; if it occurs below the reflection, perirectal infection may develop, often caused by anaerobic bacteria.
4. Nerve injury. This mostly occurs with sacral fractures, where the sacral 1 and sacral 2 nerve roots, which form the lumbosacral trunk, are most susceptible to injury. This can result in weakened muscle strength of the gluteal muscles, hamstrings, and calf gastrocnemius group, as well as sensory loss in the posterior calf and lateral foot. Severe sacral nerve injury may lead to the disappearance of the Achilles tendon reflex, but sphincter dysfunction is rare. The prognosis depends on the severity of the nerve injury. Grade I injuries have a good prognosis, with recovery generally expected within one year.
