76. Pelvis
From Primary Surgery
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76.1 Pelvic injuries
A patient's pelvis can be crushed, or it can be broken by a force transmitted to it through his femur. These are common injuries, and after a serious road accident, you may have to care for several patients with them. Pelvic injuries are of two kinds.
(1) Minor fractures in which a piece of a patient's pelvis breaks off, as in A, Fig. 76-1, while the ring itself remains intact. Apart from the associated soft tissue injuries, these minor fractures are of little importance and need no treatment.
(2) Major fractures which open a patient's pelvic ring as in C, D, E, and F, in Fig. 76-1. If the ring is to open, either he must have two fractures, or a single fracture must be combined with displacement of his sacro-iliac joint or his pubic symphysis. By themselves these fractures are much less important than the injuries to the organs inside his pelvis, and the massive bleeding that often follows. A patient with a fractured pelvis is particularly likely to injure his membranous urethra (68.3) or his bladder (68.2). A spicule of bone can also tear his femoral artery. Paralytic ileus sometimes follows the massive retroperitoneal haematoma that a pelvic fracture may cause, so watch for it (10.14).
ASSUME THAT ALL PATIENTS WITH A FRACTURED PELVIS HAVE COMPLICATIONS UNTIL YOU HAVE PROVED OTHERWISE
HAS THE PATIENT BROKEN HIS PELVIS?
Wherever a patient has had a history of a crush injury, suspect that he may have fractured his pelvis. Look for bruising and local tenderness in his groin, perineum, pubic area, and posteriorly over his sacro-iliac joints.
Grasp his pelvis firmly with your thumbs over its anterior superior iliac spines. Compress it from side to side. Then try to pull its two sides apart. Finally, press it firmly backwards, on to the couch. If you can feel movement or crepitus between its two parts, or, these procedures cause him great pain, he has fractured his pelvic ring.
Press over his pubic symphysis. If his pelvis is fractured, he may be tender locally, or he may feel pain over his sacro-iliac joints. Marked suprapubic tenderness suggests urinogenital damage. In a hinge fracture you may be able to feel a gap at his pubic symphysis.
Start at his anterior superior iliac spines and palpate each of his iliac crests for tenderness, irregularity, and crepitus. Palpate his pubic bones in his genitocrucral folds, and around his obturator foramina. Palpate his ischial tuberosities.
Look for signs of rupture of his bladder, and injury to his urethra, as described in Section 68.1. Look particularly for urethral bleeding, perineal bruising, and extravasation of urine.
Examine his rectum to feel if a bony fragment has injured its wall. Is there blood on your glove? Feel for fractures of his sacrum and coccyx. If the head of his femur has dislocated centrally through his acetabulum, you may be able to feel the wall of his pelvis deviated medially, or the head of his femur moving when you rotate his thigh.
Look for injuries to his sciatic nerves (55.8), and particularly for a dropped foot.
CAUTION! If he has broken his pelvis, he may bleed severely, become shocked, and need several units of blood.
X-RAYS Take an AP and a lateral film of his pelvis and hips. I f he has a fracture of his pelvic ring, look carefully for subluxation of his sacro-iliac joints. You can easily miss these.
FRACTURES OF THE PELVIS MAY CAUSE MASSIVE BLEEDING
76.2 Fractures which open the pelvic ring
Most pelvic fractures heal well. When the fragments of a patient's pelvis are seriously displaced, there are two ways in which you can reduce them: (1) When the two halves of his pelvis have hinged apart, yot. can try to bring them together. (2) If half of his pelvis has been pushed vertically upwards, you can apply skeletal traction to hi; leg and pull it down. You can leave most other fractures to heal themselves. Don't apply a Thomas splint because it is useless.
Compression fractures are those, such as C, and D, in Fig.76-1, in which there is no marked hinging or upward displacement of the fragments. Reduction is impossible and unnecessary,so splinting is unnecessary also.
Hinge fractures are the result of a strong force applied to one of the patient's anterior superior iliac spines pushing his ilium backwards and outwards. His symphysis separates, so that the two halves of his pelvis open like a book, hinging on one of his sacro-iliac joints, like Pelvis F, in Fig. 76-1.
Vertical fractures follow an accident in which a force applied through a patient's femur pushes one side of his pelvis several centimetres upwards, as in pelvis E, Fig. 76-1. The fracture lines run vertically through his pubic bone and his ischium. On the same side his ilium splits vertically, just lateral to one of his sacro-iliac joints. Reduce these fractures by applying strong traction to his leg on the injured side. You can apply this more easily through the upper end of his tibia than through the lower end of his femur, which is the alternative site.
PELVIC FRACTURES
COMPRESSION FRACTURES Leave the patient in bed and encourage him to move his hips and spine. After 3 weeks if displacement is mild,
HINGE SUBLUXATION FRACTURES Use the first method
where possible, and the others as necessary.
(1) Lie the patient on his most comfortable side on a soft bed, and the fracture will probably reduce itself naturally. Bind his pelvis with a tight girth. This is all that most patients need.
(2) Sling his pelvis from a beam for 2 weeks, as in Fig. 76-3. Use heavy weights which will lift it just clear of his bed. The disadvantage with this method !s that the sling has to be taken down for toilet purposes.
(3) Anaesthetize him, reduce the fracture by compressing the two sides of his pelvis, apply a hip spica, split it down the front, remove a strip a few centimetres wide, then bind it together with an Esmarch bandage.
(4) If the above methods are not practicable because of some other injuries, apply '90-90' traction to both legs (Fig. 77-11).
Leave the patient in bed for 3 weeks, and then get him up on crutches. Don't encourage him to bear weight for 6 weeks. Warn him that his sacra-iliac joints will be painful for some months.
DISPLACED VERTICAL FRACTURES Put a Steinmann or
Denham pin through the patient's tibia, as for extension traction
(Fig. 78-3), apply 10 to 15 kg of traction for 4 to 6 weeks,
and then allow him up on crutches. The injured side of his
pelvis can no longer support his weight, so he must not try
to bear weight on it for another 6 weeks.
Warn him that his injured leg may be a little short, and that his hip may be painful for 18 months or more. If he wears shoes, the shoe on his short side can be raised.
76.3 Acetabular fractures
The outlook for a patient with an acetabular fracture depends mostly on whether or not the head of his femur has destroyed the upper part of his acetabulum. This is the part which bears his weight, and if enough of it remains unbroken, his outlook is good. Otherwise severe degenerative arthritis is likely to follow.
Fracture of the posterior rim of the acetabulum is one of the results of a car accident in which the patient's knee hits the dashboard. The head of his femur is driven backwards, and breaks off a piece of the rim of his acetabulum. At the same time, his hip may dislocate posteriorly, and his sciatic nerve may be injured. Provided his hip has not been dislocated, the attitude of his leg is normal, and there is no shortening. These fractures are often missed and their late effects are underestimated.
Fracture of the floor of the acetabulum is the result of the patient's falling from a height onto his greater trochanter and forcing the head of his femur against the floor of his acetabulum. Or, he may be struck on the hip in a car accident. The head may remain in its socket as in A, Fig. 76-4, or it may dislocate centrally through the broken floor of his acetabulum into his pelvis, so that he has a central dislocation of his hip as in B, in this figure.
He cannot move his leg or lift his foot off the couch. His foot is in its normal position showing that his hip is in its normal attitude. Unless displacement is gross, his leg is not shortened. Although the X-ray is characteristic, fractures of the acetabular floor are often overlooked.
Traction combined with gentle movements gives suprisingly good results. Don't treat him in a Thomas splint.
ACETABULAR FRACTURES
FRACTURE OF THE POSTERIOR RIM
If the patient's hip is dislocated, reduce it (77.4). When you have reduced it, check it for stability. Flex his thigh to 90°, then push it posteriorly to see if it is stable or easily redislocates.
If it is stable, keep him in bed until he is comfortable, perhaps within a week. Then let him walk on crutches with partial weight bearing.
If the head of his femur wIll not stay in the acetabulum, refer him immediately to have the posterior lip of his acetabulum screwed back. The longer you delay the more difficult this will become. If you cannot refer him, put him in '90-90 traction' for 6 weeks as in Section 77.12.
If a fragment of bone is trapped inside the joint, it must be removed at open operation, so refer him.
FRACTURES OF THE FLOOR OF THE ACETABULUM
WITHOUT CENTRAL DISLOCATION Encourage the patient to move his hip actively and then get him up on crutches as soon as pain will allow.
WITH CENTRAL DISLOCATION This is a severe injury and
the patient is likely to need a blood transfusion. Anaesthetize
him; thiopentone (A 8.6) or ketamine (A 8.2) is suitable.
When he is lying on his back, his leg rotates laterally. Correct this by rotating his leg so that his patella faces anteriorly. Flex his hip a little and feel for his greater trochanter. Insert a Steinmann pin, or, better a Denham pin antero-posteriorly at point'X' in Fig. 76-4. It will go in more easily if you hammer it first, before using the handle.
CAUTION ! Don't put the pin too far medially or you may injure his sciatic nerve!
Insert another pin in his upper tibia, and apply 7 to 10 kg of longitudinal traction. Put a stirrup on the vertical pin and apply 15 kg for 15 minutes. If you can pull the head of his femur out, it will usually stay out. So remove the vertical pin and send him back to the ward with a tibial pin in for extension traction (Fig. 78-3).
Alternatively, t ry forcibly flexing and abducting his thigh. Or, try adducting it using your foot as a fulcrum. Or, put a block between his thighs and try to bring his knees together. X-ray him to check reduction.
If reduction is satisfactory, continue to apply 5 to 10 kg of extension traction to his tibia, and exert countertraction by raising the foot of his bed 25 cm. This will make him more comfortable, but it will not by itself reduce the dislocation. Put a sling under his thigh and pass the cord from this over a pulley to let him exercise his hip.
Keep him in traction for at least 6 weeks. Encourage him to exercise as much as he can. Then get him walking. Allow him up with crutches with gradually increasing weight beari ng (77.1). Remove his crutches as soon as he can stand normally on his injured leg.
If reduction is still unsatisfactory, refer him for open reduction.
