Pelvic structure and types of fractures
The pelvis is formed by two innominate bones and the sacrum, connected in front by the pubic articulation, and in the back by the sacroiliac joints and powerful ligaments. If these ligaments are intact, the ring remains stable even if one bone is broken. If the posterior structures are torn, half of the pelvis becomes mobile, which greatly increases the risk of bleeding and displacement. A separate group is fractures of the acetabulum, that is, the articular part of the pelvis: they directly affect the future function of the hip joint. There are also marginal avulsion fractures, typical of young athletes.
- Stable fractures without breaking the integrity of the ring
- Unstable fractures with rupture of the anterior and posterior sections
- Acetabular fractures involving the joint
- Fractures of the sacrum and coccyx
- Avulsion fractures of tuberosities and spines in athletes
- Fractures of the pubic bones in the elderly due to a fall on the side
Why is a pelvic fracture dangerous?
The main threat is bleeding. Around the pelvis there is a venous plexus and large arteries, and the retroperitoneal space can accommodate a large volume of blood without noticeably enlarging the abdomen. A person may turn pale, sweat and lose consciousness, although there are no outward wounds. The second threat is damage to the bladder and urethra: fragments of the pubic bones are located close to them. The third is injury to the nerve trunks and rectum. That is why, in case of a pelvic fracture, not only the bones, but also the internal organs are examined.
- Massive blood loss into the retroperitoneal space
- Rupture of the bladder or urethra
- Damage to the rectum and vagina due to open fractures
- Injury to the sciatic and obturator nerves
- Deep vein thrombosis due to prolonged immobility
- Combined injuries of the abdomen and spine
Symptoms
The victim complains of severe pain in the pelvic region, groin, sacrum, which sharply intensifies when trying to move a leg, turn or sit down. Standing and walking are usually impossible; the leg may be turned outward or shortened. Swelling and bruising appear in the groin, perineum and buttocks, sometimes with a delay of a day or two. Compression of the pelvis from the sides or front causes sharp pain - but you should not check this yourself so as not to increase the bleeding. In elderly patients with a fracture of the pubic bone, complaints may be limited to pain in the groin when walking.
- Severe pain in the pelvis, groin and sacrum
- Inability to stand or step on one's foot
- Forced position with legs bent and spread
- Swelling and bruising in the groin and perineum
- Shortening or external rotation of the leg
- Urinary retention or blood in the urine
Diagnostics
In the emergency department, the first step is to assess the state of blood circulation and breathing, stop the bleeding, and, in case of an unstable pelvis, apply a pelvic girdle. An X-ray of the pelvis in a direct projection gives a quick idea of the damage, but the gold standard is a computed tomography: it shows all fracture lines, the condition of the posterior parts of the ring, the acetabulum and the presence of a retroperitoneal hematoma. Abdominal ultrasound reveals free fluid. A urine test and, if a urethral rupture is suspected, a contrast study of the urinary tract are required.
- Assessment of vital signs and blood loss
- X-ray of the pelvis in direct and lateral projections
- CT scan of the pelvis and hip joints
- Abdominal ultrasound for free fluid
- Complete blood count and urine test
- Contrast examination of the urinary tract in case of suspected rupture
Treatment and recovery
Stable fractures without displacement are treated conservatively: pain relief, bed rest for several weeks with early activation in bed, then walking with crutches and dosed exercise. Prevention of thrombosis and pneumonia, breathing exercises and leg exercises are mandatory. Unstable fractures and displaced fractures of the acetabulum require surgery: plates, screws, and external fixation devices are used. The recovery is long - from three months to a year, with a gradual increase in support under the control of photographs. Rehabilitation includes physical therapy, gait work, and strengthening of the pelvic muscles.
- Pain relief and stabilization in hospital
- Pelvic girdle for unstable pelvis at the prehospital stage
- Bed rest with early activation and breathing exercises
- Prevention of deep vein thrombosis
- Osteosynthesis with plates and screws for unstable fractures
- Gradual return of support and long-term rehabilitation