Pelvic fracture

Dr. med. Mira Seidel is a freelance writer for the medical team.

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A pelvic fracture (pelvic fracture) is usually the result of severe forces, for example in the course of a traffic accident or fall. The patients often suffer from multiple trauma, i.e. simultaneous injuries to different parts of the body. A pelvic fracture can be life-threatening due to the large amount of blood lost. Sometimes conservative treatment is sufficient (slight pelvic fracture), in other cases an operation is necessary (unstable pelvic ring fracture). Read more about pelvic fractures.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. S32

Pelvic fracture: description

The pelvis is the connection between the spine and the legs and at the same time supports the intestines. It consists of several individual bones that are firmly connected to one another and form the pelvic ring. Basically, a pelvic fracture can occur in different sections of the pelvis.

Pelvic fracture: classification

In the case of a pelvic fracture, a distinction is made between injuries to the pelvic ring and the acetabulum. The Working Group for Osteosynthesis Questions (AO) classifies the various pelvic ring injuries according to the stability of the pelvic ring. A rough distinction is made between a stable and an unstable pelvic fracture.

Stable pelvic ring fracture

The stable pelvic ring fracture (pelvic fracture of type A) usually means an isolated fracture of the pelvic rim, an anterior pelvic ring fracture or a transverse fracture of the sacrum and coccyx. The pelvic ring is retained throughout, which is why one speaks of a stable pelvic fracture.

Unstable pelvic ring fracture

An unstable pelvic ring fracture is a complete fracture that involves the anterior and posterior pelvic rings. Doctors speak of type B when the pelvis is vertically stable but rotationally unstable. This concerns, for example, the symphysis rupture - "open book injury": The pubic symphysis is torn apart, the two halves of the symphysis are open like a book.

Furthermore, a type C pelvic fracture is when it is a completely unstable pelvic fracture. The pelvis is torn apart by vertical forces of gravity and is unstable both vertically and rotationally.

Acetabular fracture

The acetabular fracture is a joint fracture and therefore has a special position. It occurs in the event of severe direct force, when the head of the thigh is suddenly pressed against the acetabulum, or indirectly, when the force is transmitted via the thigh bone. This can happen, for example, if the knee hits the dashboard in a rear-end collision.

An acetabular cup fracture often occurs in combination with a hip dislocation ("dislocated hip"). In some cases (15 percent) the peripheral nerve of the leg, the sciatic nerve (sciatic nerve), is also injured.

Multiple trauma

A fractured pelvis is a serious injury. In 60 percent of the cases, the patients also have injuries to other parts of the body (i.e. they are poly-traumatized). The following injuries in particular can occur in combination with a pelvic fracture:

• Fractures of the peripheral skeleton (69 percent of pelvic fracture patients)
• Traumatic brain injury (40 percent)
• Chest injuries (in 36 percent)
• Injuries to the abdominal organs (in 25 percent)
• Spinal injury (in 15 percent)
• Urigenital injuries, i.e. injuries to the urinary and genital tracts (in 5 percent)

Pelvic fracture: symptoms

Symptoms of pelvic fracture include swelling, pain, and possibly an unstable pelvic bone. With a simple, stable pelvic fracture, the symptoms are usually less severe than with an unstable pelvic fracture.

In addition, contusion marks or bruises can appear on the dependent body parts such as testicles, labia and perineum. In some cases, the legs can be of different lengths due to the fracture of the pelvis.

Unstable pelvic fractures often occur as part of multiple injuries (multiple trauma). For example, bloody urine can indicate a bladder injury, which is more common in connection with pelvic fractures.

Often the pelvic bones can be easily shifted against each other in the patient. In extreme cases, the pool folds open like a book ("open book"). Walking is no longer possible for a person with such an injury.

Pelvic fracture: causes and risk factors

A pelvic fracture usually occurs as a result of a fall or an accident. The cause is significant direct or indirect violence to the pelvis, such as a fall from a great height or a motorcycle or car accident.

In the case of a fracture of the pelvis, it is important how great the force is and from which direction it comes. If the force hits the pelvis directly from the front, the pelvic blades usually move apart. A force applied from the side bends the pelvic ring, while an axially acting force pushes the pelvic halves vertically against each other.

The most common pelvic fracture is a hip or pubic bone fracture and is usually harmless. It can occur even with simple falls (such as slipping on black ice).

Unstable fractures are often the result of accidents and falls from great heights. Usually other bones and organs are also injured (multiple trauma). A bladder injury is particularly dangerous.

Pelvic fracture in the elderly

Older people aged 70 and over are particularly prone to pelvic fractures because they often suffer from osteoporosis: the bone is decalcified, the number of trabeculae is reduced, and the bony cortex becomes thinner. Even a small amount of force can result in a fracture. Patients often have other bone fractures, such as a fracture of the femoral neck. Women are particularly affected.

Pelvic fracture: examinations and diagnosis

The specialist responsible for a pelvic hernia is usually a doctor for trauma surgery and orthopedics. The precise recording of the course of the accident and the medical history (anamnesis) is groundbreaking for the diagnosis of a pelvic fracture. The doctor will ask you or, if necessary, relatives, these possible questions:

• How did the accident happen?
• Was there any direct or indirect trauma?
• Where is the possible fracture?
• How do you describe the pain?
• Have there been previous injuries or previous damage?
• Have you had any complaints before?

Physical examination

Next, the doctor will examine the patient closely for external injuries and palpate the pelvis for irregularities. With measured pressure on the pool scoop, he checks whether the pool is unstable. He feels the pubic symphysis and performs a rectal examination (examination of the anus) with the finger to rule out bleeding.

The doctor will also check the motor skills and sensitivity of the legs to see if any nerves have been damaged. He also controls the blood circulation in the legs and feet by feeling the pulse on the foot, for example.

Imaging procedures

A comprehensive x-ray of the pelvis is always part of the complete diagnosis of a pelvic fracture. This allows the fracture to be precisely localized and to determine whether it is a stable or unstable pelvic fracture.

If a posterior pelvic ring fracture is suspected, additional oblique images are taken during the X-ray examination. In this way, the pelvic entrance level as well as the sacrum and the sacroiliac joints (joints between the sacrum and iliac bone) can be better assessed. Dislocated or displaced fracture parts can be localized more precisely.

If a posterior pelvic fracture, an acetabular cup fracture, or a fracture of the sacrum is suspected, computed tomography (CT) can provide clarity. The precise imaging also allows the doctor to assess the severity of the injury more precisely - as well as neighboring soft tissues. For example, the doctor can use the CT to see how far a bruise has spread.

Magnetic resonance imaging (MRI, magnetic resonance imaging) is used to clarify a fracture in children and elderly patients. In contrast to CT, it does not contain any radiation exposure.

The doctor uses an ultrasound examination to check the abdomen for injuries to the internal organs. During the examination, he can also see whether there is free fluid such as blood in the abdomen.

If osteoporosis is suspected as the cause of the pelvic fracture, a bone density measurement is carried out.

Special examinations

In connection with a pelvic fracture, injuries to the urinary tract such as the ureter, bladder and urethra often occur. Excretory urography (a form of urography) therefore examines the kidneys and the urinary tract. To do this, the patient is injected with a contrast agent that is excreted through the kidneys and can be seen in the X-ray image.

Urethrography is an X-ray image of the urethra. This can be used to diagnose torn urethra. To do this, the doctor injects a contrast medium directly into the urethra and then x-rays it.

In the case of bleeding, angiography (x-ray of the blood vessels) can show the exact source of the bleeding. In most cases, however, bleeding in a pelvic fracture is caused by the fracture surfaces and veins. Angiography only makes sense if all other sources of bleeding have been excluded and the circulation is still unstable.

Pelvic fracture: treatment

A pelvic hernia carries a high risk of thrombosis. The treatment for a pelvic fracture differs according to how severe the injuries are (the condition of the posterior pelvic ring is important) and what condition the patient is in.

A stable type A pelvic injury with an intact pelvic ring can be treated with conservative methods. The patient must first maintain bed rest with a lap belt for a few days. Then he can begin to slowly do mobility exercises with a physiotherapist - with sufficient pain medication.

A type B or type C pelvic injury requires surgical treatment. Patients with an unstable pelvic fracture may need intensive care. A complex pelvic fracture often leads to major blood loss. Therefore, the sometimes life-threatening bleeding must first be reduced or stopped in order to stabilize the overall condition of the patient. The patient is also given a lot of fluid through the vein (shock therapy).

The pelvis is stabilized in an emergency - either with a front "external fixator" (holding system for immobilizing fractures, which is attached to the bone through the skin from the outside) or a pelvic clamp. If the spleen or liver is also injured, the abdominal cavity is opened as an emergency. The surgeon clears out the extensive bruise and stops the bleeding with abdominal towels. If there is a pubic bone fracture, the pubic bone is stabilized again with plates.

In the case of joint fractures (such as acetabular fractures), surgery is always necessary to prevent premature joint wear. An operation of the acetabulum should always be done in specialized centers, as it is a very demanding procedure. The fractions are fixed with screws and plates or an external stabilizer such as the "external fixator".

Pelvic fracture: complications

A number of complications can occur with a pelvic fracture:

• massive bleeding from torn veins
• Injuries to the bladder and urethra, vagina and anus
• Damage to nerves (such as the obturator nerve)
• in men with a herniated pubic bone: impotence
• Diaphragmatic tear as an accompanying injury
• venous thrombosis (occlusion of veins caused by blood clots)

The following complications are possible with acetabular fractures:

• post-traumatic osteoarthritis (depending on the extent of the destruction of cartilage and joint)
• Heterotopic ossification (remodeling of soft tissue into bone tissue): For prevention, the surgical area can be irradiated (two hours before an operation and up to 48 hours afterwards) and anti-inflammatory painkillers of the NSAID type can be given.
• Femoral head necrosis (death of the head of the thigh), when the trauma was very intense and the head of the femur was not supplied with blood for a long time

Pelvic fracture: disease course and prognosis

The prognosis for a pelvic fracture depends on the type and extent of the injury. A stable pelvic fracture heals without complications and usually does not leave any long-term damage.

An unstable pelvic fracture also usually heals well with appropriate therapy. Complications such as wound healing disorders, bleeding, secondary bleeding and infections are rare. In some cases, the pelvic fracture can damage nerves that supply the bladder and bowel. The patient may then no longer be able to hold the stool or urine (stool and urinary incontinence). Sexual function can also be impaired in men.

The result of therapy in the case of an unstable pelvic fracture depends largely on the additional injuries. In most cases, however, everyday movements and normal physical exertion are possible afterwards.

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