Pelvic Injury

27th July 2018

Pelvic injuries can be life threatening, especially in a remote environment where we are far from help.  To safely manage a casualty with a pelvic injury requires particular understanding of the cause, recognition and treatment.

 

The Pelvis

The pelvis is a large, stable and strong ring-like structure.  Each illium is joined to either side of the sacrum - the base of the spine.  The 'ring' is completed at the front by a cartilage bridge called the symphysis pubis.  This flexible joint is necessary for the pelvis to flex and expand during childbirth.  Because all eggs carry the female X chromosome all foetuses start off as females which is why men also have a symphysis pubis.   And nipples, but that's irrelevant.

Pelvis

 

To complicate the situation, a fractured pelvis can become unstable and will require support to stabilise it, especially if the casualty is to be moved.  This is essential as the femoral arteries run across the front of the pelvis. Movement of broken bone ends can cause catastrophic internal bleeding. 

Pelvic Blood Vessels Logo.png

Contrary to popular belief, The pelvis does not ‘fill’ with blood rather haemorrhage spreads through disrupted tissue planes, extending through the retroperitoneum out of the pelvis into the abdominal retroperitoneum up into the thorax, and anteriorly around the bladder and the anterior abdominal wall. (1)  The increase in volume of the pelvis, following fracture, is much less than expected: a large pubic separation of 10 cm corresponds to only a 35% increase in pelvic volume, or 480 cm. (2)

'Closing the pelvis' does not prevent this and as such a pelvic sling is not used to reduce the volume of the pelvis or achieve perfect anatomical alignment.  The reduction and stabilisation of the pelvic ring is to reduce the degree of fracture (3), decrease bleeding from the fracture (4-7) while protecting any initial blood clot from disruption. In theory, a small decrease in the pelvic volume (8) may create a tamponade thus reducing venous bleeding. (9-11)

 

Epidemiology

Casualties who are haemodynamically unstable on arrival to the Emergency Department have a much higher mortality rate than the stable patient(12).  Bleeding pelvic fractures associated with hemodynamic instability may have up to 40% mortality (13) whilst Anterior compression injuries ("open book" fractures) are associated with the highest mortality (48%) (14).

 

Mechanism of Injury

The prevalence of pelvic fracture in patients with blunt trauma is between 5% and 16% (15-18) as the forces needed to break a pelvis are significant.  If we think about the type of incidents which can create such forces we think of:

  • Falls from Height
  • Anything involving a vehicle  - driver, occupant, pedestrian, cyclist etc.
  • High speed sports impact - skiing, snowboarding or mountain biking etc.

The mechanisms are exactly the same as those for a suspected spinal injury.

 

Anything under tension of compression will break at the weakest points; in the pelvis these likely weak points are:

  • The joint between the illium and the sacrum - the sacroilliac joint
  • Where the pelvis is thinnest, such as the rami of the pubis and ischium - the thin bridges at the front of the pelvis.
  • The symphysis pubis
  • The acetabulum - the socket the hip sits in

Any damage to these parts can cause instability, threfore we do not move the pelvis.  Moving the pelvis can cause further damage, trap nerves or blood vessels or even collapse the pelvic ring.  (18).  Movement should be limited to the point that no casualty with a pelvic injury should even be log-rolled except for the purposes of airway management (20).  A scoop stretcher should be used for all casualty movement.

 

Assessment

So how do we assess a casualty for a pelvic injury if we cannot move it?

‘Springing the pelvis’ had a poor sensitivity (59%) and specificity (71%) (21). There is also concern that compressing the pelvis can cause further haemorrhage and as a result this technique is no longer recommended. (19, 21)

We are not going to physically assess for a pelvic injury in the field, The Royal College of Surgeons of Edinburgh’s Faculty of Pre Hospital Care Consensus Initial Statement on The Pre-hospital Management of Pelvic Fractures provides an algorithm for pre-hospital decision making (20):

  After Scott I, Porter K, Laird C, Bloch M and Greaves I (2013) (20)

After Scott I, Porter K, Laird C, Bloch M and Greaves I (2013) (20)

A simplified decision tool would be; Are you treating the casualty for a spinal injury?  As the incidents which could reasonably cause a pelvic injury are the same as those that could have caused a spinal injury, if you are treating a casualty for a spinal injury, treat them for pelvic injury as well.

 

Treatment

Current pre-hospital guidance for all suspected pelvic injuries is the early application of a pelvic splint (20).

“If the patient is haemodynamically compromised with a significant mechanism suggestive of a pelvic injury, a pelvic binder should be applied…the pelvic binder is a treatment intervention rather than a packaging device and if the device is thought of as a haemorrhage control device this should promote early application.”

 

Although definitive evidence demonstrating improved survival with pelvic binder use is lacking, the  recommendation for pelvic binder use as initial management of pelvic fracture haemorrhage is overwhelming in both and military practice guidelines. (20, 22-37).

 

Pelvic Stabilisation

  • Consideration to pulling the legs out to length (with appropriate analgesia as needed) (20)
  • Apply a pelvic binder positioned at the Greater trochanter (36-43) – NOT around the waist.
  • Binding the legs together at the knees and figure of 8 around the ankles and feet should be made. (20)
  • If applying any traction causes increased pain or further haemodynamic instability then the legs should be strapped together in the position found. (20)
  • For casualties with lower limb injuries as well as pelvic injuries, there is no evidence that pelvic binders are harmful when applied to patients with proximal femur or acetabular fracture. (26)
  • The manufacturers of traction splints do not recommend their use with pelvic fractures however, consideration for a device such as the Kendrick Traction Device (KTD) which allows you to work around the problem of hip and groin trauma and may also be applied more rapidly than older devices whilst still allowing reasonable ease of extrication and packaging. (20)
 Care must be taken to align the pelvic sling central to the gretaer trochanters

Care must be taken to align the pelvic sling central to the gretaer trochanters

 

Long term care considerations

The pressure excreted by the pelvic ling on the boney processes of the greater trochanters, pubis and sacrum can, over time, lead to tissue damage (44-50) as pressure, sufficient to cause pressure sores and skin necrosis, is believed to occur when contact pressures above 9.3 kPa are sustained continuously for more than 2 or 3h (51).

In a comparison of a selection of pelvic binders in 80 healthy volunteers, the pressures exceeded 9.3 kPa at the greater trochanters in all devices whilst used on a spinal board.  On a hospital bed this pressure was reduced below the theoretical tissue-damaging threshold. (52)

The polytrauma patient is more likely to be at increased risk of soft-tissue damage due to systemic factors promoting tissue breakdown and trauma associated local soft-tissue injuries. (53-55)

In all cases one should follow the manufacture’s instructions, but consider releasing the binder briefly every 24hrs if being maintained for longer. (26)

 

Summary

  • Where a high suspicion of Pelvic Injury exists, a pelvic sling should be applied quickly.
  • If the lower limbs can be placed into normal alignments the ankles should be stabilised.
  • The pelvic sling should be centred over the greater trochanters.
  • Casualty movement should be limited; a scoop stretcher should be used.
  • Airway management will still take priority
  • For prolonged care (>24hrs), consider briefly releasing the pelvic sling to prevent tissue damage. 

 

Related Article - An Improvised Pelvic Sling

 

References

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