The wind whistled and the sound of the engine hummed through 26-year-old JB's helmet as he cruised on his motorcycle through the city streets. His peaceful sojourn ended abruptly when his front tire buckled in a pothole and sent him airborne. His impact with a telephone pole and the ground caused extensive physical damage. JB was wearing a helmet, and helpful civilians left it in place while they waited for emergency medical services (EMS). JB was alert and complaining about severe pain in his hips and abdomen. When EMS arrived, they found JB lying on his side; he was pale and diaphoretic. His vital signs were as follows: pulse: 124 and thready, respirations: 22 and slightly labored but no use of accessory muscles observed, BP: 90/56, oxygen saturation (SpO2): 89% on room air.
Emergency medical technicians manually stabilized JB's cervical spine while assessing his airway and breathing, and applied a 100% nonrebreather face mask. Two peripheral I.V. lines were started in both anticubital spaces, and 0.9% sodium chloride solution was administered via rapid infusion. A hard cervical collar secured the cervical spine prior to transfer to a long backboard. During the transfer, the paramedics noted gross motion of the pelvis. The paramedics applied a sheet wrap around JB's pelvis and clamped the wrap in place under tension. JB was transported via ambulance to a Level I trauma center. During transport, JB's BP remained low despite vigorous fluid resuscitation. His Glasgow Coma Scale (GCS) was 15, and he remained alert during the transport (see The GCS). He continued to complain of severe pain in his abdomen and pelvis.
Upon arrival to the ED, JB's vital signs were as follows: pulse: 148 and weak, respirations: 24 and shallow, BP: 80/40, SpO2: 96% on 100% nonrebreather mask
JB's ED labs were:
- Hgb: 6.2 g/dL
- Hct: 18.5%
- White blood cells: 24,200 cells/mm3
- Platelets: 124,000/mm3
- Na+: 132 mEq/L
- K+: 5.7 mEq/L
- Cl: 99 mEq/L
- Glucose: 143 mg/dL
- Blood urea nitrogen: 39 mg/dL
- Creatinine: 0.8 mg/dL
- Alkaline phosphatase: 167 units/L
- Alanine aminotransaminase: < 40 units/L
- Aspartate aminotransferase: < 40 units/L
- Bilirubin total: 1.1 mg/dL
- Protein total: 7.2 gm/dL
- Prothrombin time: 13.0 seconds
- International normalized ratio: 1.2
- Activated partial thromboplastin time: 32 seconds
The trauma workup in the ED included computed tomography (CT) of the head and cervical spine, which was negative for fractures and intracranial bleeding. Thoracolumbar radiographs were negative as well. The focused assessment with sonography for trauma (FAST) exam revealed intraperitoneal blood. Anterior and posterior (AP) radiographs (X-rays) of the chest revealed nondisplaced left-sided 8th and 9th rib fractures without pneumothorax. A urinary drainage catheter was inserted without problem and returned 10 mL of dark amber urine. An AP pelvis X-ray revealed a complete pubic diastasis with a disruption of the left sacroiliac complex. Inlet and outlet radiographs of the pelvis demonstrated vertical displacement of the left pelvis. A CT scan of the pelvis confirmed the plain radiographs.
The orthopedic trauma surgeon was consulted, and he placed a pelvic external fixation device to stabilize the pelvis. JB was taken to the OR for an exploratory laparotomy; a grade III splenic fracture was identified and repaired by general surgery. The rest of the abdomen was negative.
JB's BP continued to be unstable despite the infusion of 10 L of 0.9% sodium chloride, 8 units of packed red blood cells (PRBCs), and 2 units of fresh frozen plasma (FFP). JB was taken to the radiology suite for a bilateral iliac artery arteriogram and a retrograde urethrogram. The arteriogram demonstrated extravasation of the contrast from the left internal iliac artery, and a transcatheter arterial embolization was performed. The urethrogram was negative for bladder or uretheral injury. No other injuries were discovered during the primary and secondary trauma surveys. The orthopedist decided to wait until JB's hemodynamic status stabilized before definitive surgical repair of the pelvis was attempted. After 4 more units of PRBCs, 2 units of platelets, and 2 units of FFP, JB's BP began to stabilize, and he was transferred to the ICU in critical condition.
He arrived with a nasogastric tube (NGT) to low intermittent suction and a triple lumen central venous catheter in the right subclavian vein. The patient was endotracheally intubated when he was operated on emergently. Twenty-four hours after admission to the ICU, he was successfully extubated, as he was breathing on his own with adequate oxygen saturations on a 40% nonrebreather mask.
Over the next 12 hours postoperatively, JB's urine output increased to 1,800 mL. His cardiac exam was normal, and his lungs remained clear despite his rib fractures. His hemoglobin increased to 9.2 g/dL with a hematocrit of 27.3%. He was alert and continued to complain of severe pain in his pelvis despite the use of a morphine sulfate patient control analgesia pump. The anesthesia pain service was contacted, and the basal rate of the infusion was increased, which adequately controlled JB's pain.
JB required frequent turning and repositioning. The nursing staff noted a large and extensive black and blue ecchymosis on his back starting at his scapula and ending at the top of his gluteal folds. Both sclera were icteric, and his indirect bilirubin increased to 7.1 mg/dL. He complained of intense pruritus, which was treated with oral hydroxyzine via the NGT every 6 hours as needed. His coagulation studies were within normal limits despite the massive blood and fluid replacement he received. His bilateral distal pulses remained strong, and he had normal neurologic function of his legs. The pin sites for the pelvic external fixation device remained clean with serosanguinous drainage, and the pin sites were cleaned daily with chlorhexidine 4% solution.
A three-dimensional reconstruction of JB's pelvis was obtained from the original pelvic CT scan, and 5 days after his injury, JB was taken to the OR where he had an open reduction and internal fixation (ORIF) of his left posterior sacroiliac joint and symphysis pubis using compression plates. He remained neurologically intact, his indirect bilirubin count was coming down, and he was transferring from the bed to the chair with moderate assistance. On post injury day 9, he was transferred to a rehabilitation hospital to continue his recuperation.
The purpose of this article is to discuss high-energy pelvic fractures that have the potential to result in significant mortality and morbidity. The role of perioperative nurse caring for these patients will be explained. Critical communication among all healthcare providers will also be discussed.
Pelvic fractures in the United States account for approximately 3% of all skeletal fractures, and about 95% of these fractures are considered minor fractures.1 These fractures are usually the result of low-energy forces. This article will focus on the other 5% of pelvic fractures, considered high-energy injuries, and these fractures result in significant mortality and morbidity.2
The incidence of pelvic fractures in the United States has been estimated to be 37 cases per 100,000 person-years.3 The incidence of pelvic fractures is the highest in people ages 15 to 28.3 In those younger than age 35, men sustain more pelvic fractures than women; in persons over age 35, women sustain more pelvic fractures than men.3 Most pelvic fractures that occur in younger patients result from high-energy mechanisms, whereas pelvic fractures sustained in the older adult population occur from minimal trauma, such as a low-level fall.3
Pelvic fractures have significant mortality, and it has been reported that as many as 9% to 30% of patients die from their injuries.4 The majority of these mortalities are due to the other injuries that are sustained during the traumatic incident.1,3,4 The mortality from open pelvic fractures is much higher and approaches 50%.5
The pelvic ring
The pelvis is the part of the skeletal system that connects the lower part of the lumbar spine and sacrum to the femurs. It's a part of both the axial and appendicular skeleton.6,7 Its main purpose is to support the body's weight through the vertebral column as well as to support and protect internal organs, such as the urinary bladder, reproductive organs, and the developing fetus.7 The pelvis is comprised of two coxal (hip) bones. The coxal bones consist of three separate parts: the ilium, ischium, and the pubis. During skeletal maturity, the three bones fuse and connect to the sacrum posteriorly. Anteriorly, these bones are connected by the pubic symphysis or symphysis pubis. This is the midline cartilaginous joint uniting the superior rami of the left and right pubic bones.7 (See Bony structures of the pelvis and AP X-ray of the pelvis.)
The stability of the pelvis is dependent upon the ligamentous structures of the pelvic ring. The ligaments can be divided into those supporting the posterior region of the pelvic ring and the anterior ligaments.8 The posterior ligaments provide most of the support of the pelvis and transmit weight-bearing forces through the femoral necks across the sacroiliac joint.9 These ligaments include the posterior sacroiliac ligament, the sacrotuberous ligament, and the sacrospinous ligament.8 The sacrotuberous and sacrospinous ligaments are also responsible for inferior stability by preventing external rotation and vertical shear forces. Anteriorly, the anterior sacroiliac ligament and the symphysis pubis provide support for the pelvis. The fifth lumbar vertebra also has a strong tie-in with the ilium through the iliolumbar ligament.8 (See Ligaments of the pelvis.)
The pelvis also has major vascular structures located within it. The common iliac artery divides into the internal and external branches. The internal iliac artery lies more posterior and runs along the sacroiliac joint. The external iliac artery runs under the pelvic brim and exits underneath the inguinal ligament. The arteries have other branches that supply blood to the muscles surrounding the pelvis.10 (See Arteries of the pelvis.) There are corresponding thin-walled veins that comprise the venous plexus and are often the source of significant bleeding in certain types of pelvic fractures.10 (See Veins of the pelvis.)
The five lumbar nerves and the first four sacral nerves combine to form the lumbar (L1–4) and the lumbosacral (L4-S4) plexuses. Each give rise to anterior and posterior branches. The anterior branch supplies the flexor muscles of the legs, while the posterior branches supply the extensor and abductor muscles. The largest of these branches include the femoral and obturator nerves. The cutaneous branches include the ilioinguinal (L1), genitofemoral nerve (L1 and L2), iliohypogastric nerve (L1), and the lateral cutaneous nerve of the thigh (L2 and L3), which supplies the lateral and anterolateral thigh.10
Classification of pelvic fractures
There are currently two classification systems used to assess pelvic fractures. These systems are useful tools to assist clinicians evaluating and planning the management of patients with significant pelvic fractures.11 The Tile classification is predicated on the stability of the pelvis, while the Young-Burgess classification is based on the mechanism of injury (MOI).12,13
The Tile system classifies injuries according to the stability of the pelvic ring and integrity of the posterior sacroiliac complex. Categories A (stable), B (partially stable), and C (unstable) can be subdivided into different subtypes depending on the nature of the injury (see Tile classification of pelvic fractures). The Young-Burgess classification is based on whether the injury was sustained through AP compression, lateral compression (LC), vertical shear, or a combined MOI.13 (See Young-Burgess classification of pelvic ring fractures.) AP compression injuries usually occur as a result of motor vehicle or motorcycle injuries and are further divided into AP I, AP II, or AP III. LC injuries typically occur as a result of a pedestrian being struck by an automobile and are also subdivided into LC I, LC II, and LC III. Vertical shear injuries occur secondary to a fall from a height, and complex fractures result from a combined mechanism of injury (MOI) and don't fit any classification.11 AP compression III injuries are also called “open book” fractures due to the loss of sacroiliac stability and separation of the symphysis pubis.11
For all patients with trauma, the primary goal of prehospital providers is management of the airway, breathing, and circulation.11,14–17 If a pelvic fracture is suspected, based on MOI and physical exam findings, applying a pelvic binder or wrapping a sheet around the pelvis is the recommended treatment in order to reduce bleeding and stabilize the pelvis.11,14–16 Patients should be transported as quickly as possible to a Level I trauma center where the necessary resources to manage the complex care are available.14–16
Once the patient has arrived in the ED, advanced trauma life support protocols must be instituted immediately.18,19 An AP pelvis radiograph should be conducted on all hemodynamically unstable patients, and definitive CT scans should be delayed until the patient is stable.19 There is debate as to whether AP radiographs should be performed on every trauma patient, but in those patients with a GCS less than 13, an AP pelvis radiograph is warranted.20
The FAST exam is performed to determine if there is intra-abdominal bleeding.15–19 Due to the high-energy nature of pelvic fractures, there are often associated injuries, such as visceral organ damage, genitourinary trauma, thoracic trauma, and head trauma.14–16,19,20 If the FAST exam is positive, the patient should be immediately taken to the OR for surgical evaluation. A pelvic stabilization device is applied prior to the exploratory laparotomy. The source of the bleeding must be identified and corrected. The patient usually requires massive transfusions of blood and blood products, often greater than 10 units of PRBCs. Recent studies support infusing PRBCs, FFP, and platelets in a 1:1:1 ratio to prevent the consumptive coagulopathies associated with large volume transfusions.21 These fractures are often open fractures with significant injuries to the bowel, perineum, urinary structures, and represent significantly increased mortalities.
Despite the emergent nature of the injury or injuries requiring surgery, the ED nurses and the perioperative nurses must have swift and accurate communication regarding the patient's condition. This communication allows the OR nurse to know what the patient's current physiologic status is and allows for more accurate assessments while the patient is in the OR. The OR nurse must quickly respond to the patient's and surgeons' needs. During surgery, accurate communication between the OR nurse and the anesthesia provider is critical. The anesthesia provider will alert the OR nurse for the need of blood and blood products as well as any other medication or equipment. An exploratory laparotomy is usually performed to evaluate and repair any identified visceral injuries. Oftentimes, several different surgical services are involved in the patient's surgery, and equipment coordination for these different services is the responsibility of both the surgeons and the OR nurse. It can be expected that the patient will require multiple units of blood and blood products, and the OR nurse should coordinate with the Blood Bank to assure an adequate supply will be on hand.
Unfortunately, many of these pelvic fractures also result in serious injuries to the rectum and bowel. The gross contamination of these wounds can lead to life-threatening infection, and the OR nurse can anticipate if there will be a need for irrigation and debridement of devitalized tissue.22 Several regulatory agencies have recommended and instituted patient safety goals and the Surgical Care Improvement Project (SCIP). The SCIP's goal is to reduce the morbidity and mortality associated with postoperative surgical site infections and to encourage the proper timing and administration of appropriate antibiotics.22 It's recommended that the OR nursing staff adhere to the practices outlined in the Association of periOperative Registered Nurses' Perioperative Standards and Recommended Practices.23
Controlling preperitoneal bleeding is a major concern in managing traumatic pelvic injuries, and the OR nurse should be prepared to have a large quantity of laparotomy pads or surgical sponges available. In some trauma centers, the concept of “damage control” resuscitation is used to address the need to control initial hemorrhage and stabilize the bleeding quickly. This is accomplished by packing the preperitoneal cavity with pads to tamponade bleeding and applying some sort of external fixation device or clamp.14,15,24,25 In such cases, it's critically important for surgical counts to be correct. Any retained lap pads used for prevention of bleeding must be documented in the operative record.22,23
Postoperative care and angiography
Patients are discharged from the OR when certain physiologic criteria have been met, although it's difficult to generalize these criteria in the patient with a severe pelvic fracture. For scoring systems, such as the Aldrete Score, the Post Anesthesia Care Unit discharge criteria may not be applicable to this patient population because patients are intubated and sedated as part of the post-operative critical care phase.22 In patients with unstable vital signs despite control of intraperitoneal bleeding, closure of the pelvic fracture by clamping, vigorous crystalloid, blood, blood product administration, and the issue of retroperitoneal bleeding must be considered.14,15,24–26
This bleeding usually occurs due to traumatic injury to the arterial or venous plexus in the pelvis and contributes to significant mortality unless corrected.26–28 The role of angiography and embolization is well documented in the literature and is the preferred method to control arterial retroperitoneal bleeding—usually from the iliac arteries.14–16,24–28 The venous bleeding associated with pelvic fractures is usually stopped when the pelvic ring is stabilized.26–28 Any attempt at angiography should be performed by an experienced interventional radiologist in a radiology suite that has CT available.26–28
Treatment options for pelvic fractures
There is general consensus that the first priority in the management of pelvic fractures is to control bleeding.24,25,29,30 Life-threatening bleeding must be controlled, and in emergency situations, the application of an external fixation device is still recommended.9,14–16,25,29,30 After the patient is hemodynamically stable and other injuries managed, definitive treatment is based on the type of fracture sustained and whether or not there are other significant soft tissue injuries.33
Young-Burgess Type AP III fractures, the open-book fractures, usually require stabilization both anteriorly and posteriorly. ORIF of the symphysis pubis and posterior iliosacral joint using compression plates is commonly performed to stabilize the pelvis.31,32 (See Radiograph showing anterior plating of the sacroiliac joint.)
Other less invasive techniques have been described as “alternative treatments” and include CT-guided screw fixation, minimally invasive pinning of the dorsal pelvic ring, and percutaneous pinning concomitant with external fixation.31–35 CT-guided screw fixation is usually performed in the radiology suite. Small incisions are made, and guide wires are placed into the fracture site using fluoroscopy. (Fluoroscopy is used rather than continuous tomography to decrease radiation exposure.) Once placement is confirmed, the guide wire is removed, and cancellous bone screws are placed to stabilize the fracture.33 Minimally invasive fixation of posterior ring fractures is accomplished through several small incisions, using the posterior superior iliac spine as the major landmark. Both sides of the fracture site are identified, and pedicle screws are inserted and bridged, providing solid reduction of the fractures.34 Percutaneous pinning, along with an external fixation frame, is often utilized in pelvic fractures with perineal injuries to provide more stability of fractures that have a significant rotational component.35 The surgical technique is similar to CT-guided pin fixation but is performed in the OR.
Complications of pelvic fractures
Due to the high-energy forces required to fracture a pelvis, other significant injuries often occur as well. Head, chest, abdominal, and genitourinary injures are often present and must also be treated.4,5,10,16,19,32 The use of the Injury Severity Score (ISS) by clinicians assists in predicting mortality. The greater the ISS, the greater the predicted patient mortality is.16,36,37 The ISS is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an abbreviated injury scale (AIS) and is allocated to one of six body regions: the head, face, chest, abdomen, extremities (including pelvis), and external. Only the highest AIS score in each body region is used. The three most severely injured body regions have their score squared and added together to produce the ISS score.
Genitourinary damage can be catastrophic and includes deep perineal lacerations, urethral tears, urinary bladder ruptures, and damage to the uterus.37 Sexual dysfunction and urinary incontinence post injury result from damage to the sacral nerve roots three and four during the injury.38 The damage to a woman of childbearing age is of greater concern. Due to the hormonally mediated relaxation of the symphysis pubis during labor and delivery, many obstetricians are reluctant to allow a woman who has had a compression plate attempt vaginal deliveries. Woman who have had pelvic fractures are twice as likely to have cesarean sections as women who haven't.39 Women should be advised to consult with high-risk obstetricians prior to any attempts to conceive, and an orthopedic consult may be warranted to help guide labor and delivery decisions.39
Peripheral nerve root injuries, especially L5, can occur with posterior ring injuries. The L4 and L5 nerve roots are especially vulnerable to injury due to the anatomy of the ring. Femoral and sciatic nerve injuries can also occur with fractures involving the acetabulum.38,40
Infection, especially in open pelvic fractures, is both an acute and chronic problem.35 Peripelvic abscesses can lead to systemic sepsis with resultant multiple organ dysfunction syndrome.41 The risk of pin track infections increases and exists in patients with external fixation devices. Cultures should be taken prior to starting broad-spectrum antibiotics, should be initiated with any open fracture, and specific antibiotics started once any positive blood, urine, or wound culture is reported. Since time is of the essence with trauma victims, waiting for a positive culture can be detrimental for patient outcomes. Targeted antibiotic therapies can be instituted if positive wound, blood, or urine cultures are reported. Careful monitoring of vital signs such as temperature, pulse, and BP is essential for early detection of infection.
Deep vein thrombosis and pulmonary embolus are serious and potentially fatal in patients with pelvic fractures.42,43 The use of anticoagulants such as warfarin and low-molecular-weight heparins are contradicted in the initial treatment of pelvic fractures due to the already heavy bleeding caused by the fracture.43 Some trauma centers feel the use of an inferior vena cava filter is warranted.43 Mechanical compression stockings should be instituted as soon as possible, and pharmacologic therapies started once the patient is stabilized.42–44
These patients are also prone to the hazards of immobility, such as atelectasis, pneumonia, skin breakdown, and ongoing neurologic deficits. Management of these patients is complex and is geared toward preventing and managing actual or potential complications.
Jeff's hospital course
JB's injury was atypical, as he didn't have the other body system injuries that are common in patients with pelvic fractures. He was lucky enough to have been close to a level I trauma center where his injuries were immediately and correctly treated. He was also wearing a helmet and was stabilized in the field prior to transport.
His elevated liver function tests, posterior body bruising, and jaundice were due to the volume of blood that had settled in his retroperitoneal space. Hemolysis of the blood resulted in the severe jaundice. The liver has difficulty in processing the increased pigment load caused by the breakdown of the red blood cells due to the reabsorption of the extravasated blood by the phagocytic system.45
The ORIF of his AP pelvic injuries allowed for early mobility, which certainly helped in preventing skin breakdown and other complications. Some minor pelvic fractures can be treated with bed rest and protected weight bearing, and those decisions are made based on the individual patient presentation; however, the majority of significant pelvic fractures are surgically treated.16
Functional outcomes after pelvic fractures are an area that hasn't, until recently, been extensively studied.46 Proper anatomical reduction of the posterior ring appears to lessen long-term complaints of pain and reduced range of motion.46 JB was sent to an acute rehabilitation center soon after his injury, and the expectation is that his recovery will result in an acceptable outcome that will allow him to resume his activities of daily living without problems.
In addition, the National Association of Orthopaedic Nurses also advocates for home assessment following orthopedic surgery.22 It's most likely this assessment will be done prior to discharging patients from rehabilitation centers. It's an important aspect of total patient care so that further injuries aren't incurred due to environmental issues.
The nursing care of the patient with pelvic fractures is complex and requires that all nurses involved in the care of these patients are aware of the actual or potential complications that can occur. The perioperative nurse is an important part of the entire team that's needed to manage these patients. Early and vigorous resuscitation, operative treatment of fractures, and postoperative rehabilitation all work together to improve patient outcomes.
Tile classification of pelvic fractures
Type A: Stable
- A1: Fractures of the pelvis not involving the ring.
- A2: Stable, minimally displaced fractures of the ring.
Type B: Rotationally unstable, vertically stable
- B1: Open book.
- B2: Lateral compression: ipsilateral.
- B3: Lateral compression: contralateral (bucket handle).
Type C: Rotationally and vertically unstable
- C1: Unilateral.
- C2: Bilateral.
- C3: Associated with an acetabular fracture.
Source: Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br. 1988;70(1):1–12. Used with Permission.
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