What Is Pelvic Fracture 

Introduction

There are three major bones that make up the pelvis they are the Sacrum and 2 innominate bones, which are linked at the sacroiliac joint and the symphysis. The anterior symphysis is held together by a thickened fibrous capsule that helps prevent collapse of the pelvis. An injury to the pelvis is more likely to affect many anatomical structures within its proximity, such as organs and tissues. These may include the urethra, skin, bladder, rectum, vagina, neurological and visceral injuries.¹

The pelvis has remarkable strength and has a high network of blood vessels. This anatomical setup makes haemorrhage one of the most unwanted complications of pelvic fractures because it could lead to fatal complications. Pelvic fracture and its associated injuries (such as injury to surrounding soft tissues, exposed cancellous bones, or blood vessels that surround the bones) have been associated with a high mortality rate for decades. This is why it has received a significant amount of attention over the years.² 

Historical records on pelvic fracture

Historical records of the ancient Egyptians show that as much as 5000 years ago, early men were familiar with the concept of fracture stabilization healing, haemostasis, and even reduction of deformity. It was discovered that wooden sticks and roller bandages were used in fractured patients. In the 19^th century, there was an emergence of newer pelvic fracture management. This began with the work of the famous French surgeon Joseph-François Malgaigne (1806-1865). His scholarly body of work showed that back in the 19th century, with the unavailability of radiographic technologies, physical examination was the main means of diagnosis. He suggested that vertically displaced fractures of the pelvic region were usually followed by loss or impairment of the functionalities of the lower extremities. He, therefore, prioritized the repair and maintenance of the length of the lower extremities. He promoted long-term immobilization in traction, without which patients tend to heal with major limb shortening. He noted that many patients may not survive the injury and stand a risk of visceral injuries and bleeding especially depending on the pattern of fracture. These treatment protocols were maintained up until the early 20^th century. A German physicist, Wilhelm Conrad Röntgen (1845-1923) introduced the X-ray technology in 1895. These significantly improved the diagnosis, injury classification and healing monitoring of these injuries. However, non-surgical methods and prolonged bed rest were still the treatment modalities. Furthermore, Sir Frank Wild Holdsworth helped further refine the diagnosis and strategies for therapeutic management of pelvic fractures. Thereafter, slings and skeletal traction were adopted in the treatment of such injuries.^3,4

In 1961, Pennal and Sutherland classified pelvic fractures based on the means of injury and this was used to predict the expected outcomes. They categorized them into Avulsion, Stable, and Unstable fractures. These served as the basis of decision-making in treatment/ management protocols even today. As high-speed motor vehicles kept increasing over the decades, it became clearer that pelvic fractures were involved in many life-threatening injuries, which are mostly linked to hemorrhagic events. The role of orthopaedic surgeons in patients who had suffered disruptions of the pelvic ring became more popular towards the latter end of the 20^th century. These led to the advent of external fixation methods in early management. The theory is that this would reduce blood loss and intrapelvic volume.^3,5

Complications and health outcomes 

Pelvic fractures are usually accompanied by other life-threatening injuries. In fact, death that occurs within the first 24 hours of sustaining the injury is usually associated with blood loss and related injuries. Individuals with hemodynamic complications who suffer from pelvic fractures present even more challenges in treatment due to the high likelihood of sharp bone fragments lacerating the surrounding soft tissues and causing excessive bleeding. The hollow visceral contents in the stomach, the pelvic region, the lumbar plexus and the L5 nerve root may also be at risk.^6,7 

The 5th leading cause of mortality in adults over 65 years in the United States is trauma. The complications of having other medical co-morbidities and the risk factor of advancement in age make clinical management a complex situation for clinicians. The elderly usually are predisposed to a higher risk of morbidity or mortality in comparison with younger individuals. Pelvic injuries have been associated with many organ system injuries, and they demand quick and efficient management to prevent morbidity and mortality events. Despite quick interventions, mortality rates have been found to be between 5 and 16 %, and most of the associated deaths have been found to be due to haemorrhagic events, injury to the head or organ failures.⁸

Evaluation and treatment

In the management of pelvic fractures, it is quite important to determine if the patient is hemodynamically stable and to identify the mechanical stability of the pelvic fracture. Where the patient is hemodynamically stable, it is essential to locate sites of haemorrhage to reduce the possibility of other fatal injuries. The chest, abdomen, pelvis, and other possible sites of haemorrhage must be examined and evaluated. Haemorrhage from pelvic fractures is usually traced to the arterial, venous(accounts for over 70 % haemorrhage incidence) or cancellous bone. Preventing venous haemorrhage can be controlled using manoeuvres, which stabilize the pelvis and reduce the pelvic volume. About 30 % of haemorrhages are associated with arterial sources, and this usually needs procedures like surgical packing (also called embolization). Where bleeding continues, bilateral internal iliac artery ligation may be adopted. Here there is a temporary clamping of the aorta, this is expected to stop the bleeding before further ligation of the iliac arteries. It is also essential to ensure the stabilization of the individual immediately after the trauma. This may be with the use of pelvic external fixation, pelvic binders, bean bags, etc. It is also critical that the trauma team is made up of a multidisciplinary team with expertise in early trauma and orthopaedic surgery. The initial aim should be to identify the injury, early mechanical stability, and determination of hemodynamic stability, as well as a quick intervention where necessary and surgical treatments as needed. This is critical for the survival of the patient.^7,9

Diagnosis and therapeutic management used in pelvic fractures solely depend on the patient. Their characteristics, the injury mechanism, and the hemodynamic state at the time of the injury. It is essential to have sufficient knowledge and information on the biomechanics and the anatomy of the pelvis to ensure initial stability and aid in the determination of strategies to be adopted in the management of the fracture so as to ensure that the health outcomes are favourable to the patient and their quality of life is improved. The focus during diagnosis should be on the stability of the pelvic ring. This can be determined clinically by physical examination or with the use of radiographic technology. Management of patients must begin at the pre-hospital stage, and the mechanism of the trauma/ injury should be made available to the clinician. Where pelvic instability is confirmed, the pelvic volume must be reduced to stabilize the pelvis using the pelvic binder. Hemothorax and hemoperitoneum must be ruled out using a plain chest film and FAST, especially to help identify and mitigate other sources of bleeding outside the fracture site, the cancellous bone, or the arterial or venous system around the pelvis. In cases where the patient remains unstable after using a pelvic binder, more examinations must be carried out, such as full imaging, arterial angiography, and embolization. Thereafter, an operative fixation may be needed.¹⁰

Recommendations

Experts suggest that blood transfusions, sufficient resuscitation, management of associated injuries and use of damage control orthopaedics where necessary, such as external fixation and +/- C clamp, are necessary at the early stages to ensure healthy outcomes. They also strongly recommend a multi-disciplinary input in the management of open pelvic fractures. This would ensure prompt and efficient diagnosis and choice of therapeutic management as well as appropriate continuous monitoring of overall health of the patient so as to ensure timely intervention if required.¹¹

Conclusion

The pelvis is a strong, weight-bearing bone that is made up of the sacrum and 2 innominate bones linked to the sacroiliac joint and the symphysis. Being associated with many anatomical structures and highly vascularised, a fracture to this bone is likely to affect many other organs and tissues in close proximity to it. Such injuries predispose the patient to the risk of suffering a haemorrhage, which is one of the leading causes of death among individuals who fracture their pelvis. 

As far as 5000 years ago, up until today, there has been much scientific research and modification of management modalities on the management of pelvic fractures, and this is because of its significant mortality and morbidity rates. This includes neurological complications, haemorrhage, and organ and systemic injuries, to name a few. 

In the management of patients with pelvic fractures, it is essential to determine the haemodynamic and mechanical stability of the individual to determine the best approach to treatment and prevent avoidable complications that may lead to the overall reduction in the quality of life of the individual. 

Experts recommend that the management of pelvic fracture must include a multi-disciplinary approach to ensure early and efficient diagnosis, appropriate treatment and careful follow-up to ensure that minimal to zero complications are ensured and patient health outcomes are optimal.

Pelvic fractures account for a significant amount of high mortality and morbidity globally, especially among the elderly. This is due to its accompanying associated complications, such as fatal haemorrhagic events. A multi-disciplinary approach must be adopted in the management of the trauma to ensure optimal health outcomes.