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How to manage that pelvic fracture


Pelvic Fracture
CE Center

RN/Thomson AHC Home Study Program
CE CENTER

CE credit is no longer available for this article. (Expired August 2007)


Originally posted August 2005

By Bonnie L. Smith, RN, BSN, MFA

Bonnie Smith is a nurse administrator at Maine Medical Center in Portland. The author has no financial relationships to disclose.

Pelvic fractures, a frequent trauma seen in high-speed motor vehicle crashes, can have deadly consequences. It's essential that you look for associated injuries and take steps to prevent complications at every stage of a patient's hospital stay.

It's 4 a.m., and there's a lull in activity on your busy ED. An ambulance arrives and shatters the calm. The patient is a 26-year-old male whose motorcycle was involved in a high-speed collision with a truck. The truck's driver is unscathed, but the young motorcyclist is badly injured. He's unconscious and pallid, and you immediately notice that one of his legs is turning in at an unusual angle.

You suspect a fractured pelvis based on both your observations and the history you get from the EMTs. More than half of all pelvic fractures (60%) are the result of high-velocity motor vehicle crashes.1 And if this patient does have a fractured pelvis, the likelihood of additional injuries—to the head, thorax, abdomen, and genitourinary (GU) system—is very high.2,3

Your nursing skills are vital in assessing the nature and extent of this young man's injuries and initiating appropriate—possibly life-saving—interventions. Whether you encounter a patient with a pelvic fracture in the ED or on an inpatient unit at any time during his hospital stay, you'll need to be familiar with pelvic anatomy, the kinds of fractures and complications to watch for, and the care that's crucial for a patient who has sustained this type of traumatic injury.


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How serious is it? Here's what to look for

Overall mortality rates for patients with pelvic fractures can be as high as 55%, depending upon the severity of the fracture and the other injuries.4,5 Hemorrhage is a frequent complication, and mortality rates from pelvic fracture with hemorrhage can be as high as 40%.4 Associated injuries and multiple organ failure related to sepsis account for most non-hemorrhagic deaths.5

To understand what happens when the pelvic bones are fractured, consider the shape of the pelvis: It's a ring-like structure made up of three bones, the sacrum and two innominate (nameless) bones. The innominate pelvic bones have three parts—the ilium, ischium, and pubis—-and are joined in front by the pubic symphysis, a fibrocartilaginous disk. At the sacrum, the innominates are joined by strong, sacroiliac ligaments that complete the ring structure of the pelvis. The pubic symphysis acts as support for the pelvis, while the sacroiliac joints provide stability. (For more information on pelvic anatomy and the different types of pelvic fracture.)

The ring-like structure of the pelvic bones gives them great strength, so only a very strong force can break them. But because it's ring-like, if there's a fracture in one part of the structure, you should expect that there will be another fracture or severe ligamentous injury at another point in the pelvic ring.2 Not surprisingly, then, trauma forceful enough to break the pelvis usually produces other significant injuries. Often, these associated injuries are life-threatening and their treatment must take precedence over treatment of the pelvic fracture.

Open or closed head injuries, for example, are common in patients who incur high-velocity or impact trauma. If a patient survives the initial impact, repair of the pelvic fracture may be delayed for days or even weeks until intracranial hemorrhage and increased pressures are stabilized.6

As noted above, hemorrhage is also a common complication. Those who present with hypotension on admission to the ED have a mortality rate of 42%, compared to just 3.4% for those who are normotensive.3 While hemorrhage is most often the result of intra-abdominal injury, the possibility of extensive blood loss from the pelvic fracture itself should not be discounted. The bones of the pelvis have a rich blood supply, and approximately 90% of hemorrhaging associated with pelvic fracture involves venous bleeding from the disrupted bone surface.3

When such bleeding occurs, the blood most often pools in the retroperitoneum, which can hold up to four liters in an adult.2,3 With the capacity to hold this much blood, it's easy to see how exsanguination can occur without being detected.2 Patients with "open book" fractures, in which the pubic symphysis is disrupted and the pelvis opens like a hinge, face a particularly high risk of extensive bleeding into the pelvic cavity.1

Taking care of first things first

When a patient arrives in the ED, Advanced Trauma Life Support protocols and ABCs (Airway, Breathing, Circulation) are the top priorities.1,2 When he's been stabilized, turn your attention to the secondary survey of the patient. Suspect a pelvic fracture in all unconscious trauma patients and those who complain of pain in the pelvic area until the injury can be ruled out with radiographic studies.1

As part of the secondary survey, look for abrasions, contusions, asymmetry, isolated rotation of a lower extremity, or a discrepancy in the length of the patient's legs that may indicate a hip injury or an unstable pelvic fracture. If your patient is responsive, place your fist between his knees and ask him to squeeze your fist. If he has a pelvic fracture, this simple test will elicit pain without the risk of additional injury.

The physician will test for rotational stability by applying posterior pressure over the iliac crests and pubic symphysis. He'll avoid rocking the pelvis, however, as this could displace a fracture or disrupt a pelvic hematoma.3

For your part, you'll need to be vigilant about monitoring the patient's hemodynamic status. Look for deficits in oxygenation, tissue perfusion, or coagulopathy, and be prepared to initiate fluid resuscitation, transfusion, or both for hypovolemic and septic shock.6 Your assessment skills will be vital in determining the degree of injury and the direction of the treatment plan.

Up to one-fourth of patients with pelvic fractures also suffer genitourinary injuries, particularly those whose fractures are at or near the pubic symphysis. Inspect the urinary meatus for the presence of blood before inserting an indwelling catheter. If blood is present, it's likely that the urethra is injured, and the use of a catheter is contraindicated.2,3 Further radiographic studies will be needed to determine the nature and degree of the injury.

You'll also need to collect a urine sample and test for hematuria. If the sample tests positive for microscopic amounts of blood, the GU injury is usually not severe, but gross hematuria is always a sign of significant injury to the bladder or kidneys.3

Up to 40% of pelvic fracture patients have abdominal injuries, and both you and the physician should do an abdominal assessment. Anticipate the need to transport the patient to radiology for further evaluation, and ask the doctor to order pain medication before moving him to the CT or X-ray table.

A thorough neurological exam is necessary, too, because of the location of the paths of nerves in the pelvic region. The incidence of neurological injury is highest in patients with vertical sacral fractures at or above the level of L5 or a transverse sacral fracture.3

If the patient is hypotensive and has an unstable pelvic fracture—that is, one that interferes with the stability of the pelvic ring—external stabilization should be considered on admission. By stabilizing the fractured pelvic segments, you can avoid additional or new hemorrhages. To do that, a skilled orthopedic surgeon may apply an external fixator, a device that immobilizes the broken bones. Pins are drilled into the bony pelvis to anchor a frame that surrounds them.2 The goal is to reapproximate bony surfaces and thus reduce bleeding and restore the size of the pelvic cavity. The external fixator may remain in place until surgical repair can be safely done.

If, however, the patient with an unstable pelvic fracture is not hypotensive, he may go into surgery between 24 – 72 hours after injury to reduce the fracture using either internal or external fixation. Timing depends on the patient's overall status and response to resuscitation efforts.3

Complications to guard against

The treatment plan for a patient with a pelvic fracture, of course, depends upon the type of fracture and the associated injuries. Stable fractures, which comprise a little over half of all pelvic fractures, generally heal rapidly because of the rich blood supply of the cancellous bone of the pelvis.4,6 Treatment consists of bed rest, management of symptoms, and pain control.

But bed rest, as we all know, creates its own problems, putting the patient at risk of developing deep vein thrombosis (DVT), pulmonary embolism (PE), pneumonia, and constipation.3 You'll need to monitor fluid and fiber intake to avoid constipation, encourage coughing and deep breathing to prevent pneumonia, and use ankle and leg exercises and compression stockings to decrease the risk of DVT.

Management of the patient with an unstable pelvic fracture, of course, is more complex. When external fixators are used, they may remain in place for as long as six to 12 weeks. Meticulous observation is needed to spot signs of infection at the pin sites and note pins that are loosening and need to be replaced.3 Open pelvic fractures, in which the bone pierces the skin, often require repeated surgical debridement and irrigation for as long as four days after surgery. During the course of treatment, nursing interventions include pain management, wound care, and, often, extensive dressing changes.6

Patients with significant abdominal and pelvic injuries may require a temporary colostomy, which brings with it increased potential for infection. Careful inspection, assessment, and care of the new ostomy will prevent skin breakdown and contamination of any wounds or incisions in the surrounding area.3

In addition, patients will need medication for the pain. Morphine is the drug of choice unless the patient is allergic to it or is hemodynamically unstable, and patient-controlled analgesia (PCA) and continuous infusion methods typically provide more effective pain control than intermittent dosing.6 GI upset and constipation are two side effects that you'll need to watch for if your patient is on a narcotic.3

Your patient will also likely receive medication to stave off thromboembolic disease. DVT occurs in up to 80% of multi-trauma patients, and 10% develop PE. Prophylactic therapy, usually with low molecular weight heparin, such as enoxaparin (Lovenox) or dalteparin (Fragmin), should be part of the treatment plan, unless it is contraindicated by other injuries or complications. Frequently assess pulmonary function and oxygenation as well, to monitor for changes in respiratory status that would signal the development of pulmonary embolism.3

Sound nutrition promotes healing, so arrange for a consult with a nutritionist. Unless GI injuries preclude it, the patient should be able to eat within 24 hours of resuscitation. Those whose injuries prevent them from eating normally will require enteral or parenteral nutrition.3

Patients with pelvic fractures and multi-trauma are also at high risk for skin breakdown as a result of their immobility. Frequently reposition any patient who's immobile and consider the use of a therapeutic bed. Careful assessment of the skin should also be a high priority.6

Infection is yet another threat to pelvic fracture patients, and those with surgical incisions are especially at risk. Careful assessment, cleaning, and dressing changes are crucial, including close inspection of incisions and pin sites. If the patient has had intestinal trauma, make sure antibiotic therapy is administered, as ordered.6

Emotional support is vital, too. The treatment program for patients who have experienced pelvic fracture and multiple trauma can be long and arduous, and significant alterations in lifestyle may be necessary. Your awareness of both emotional and practical problems will help you build rapport that promotes healing.

Rehabilitation should be a joint undertaking with the department of physical therapy. Work with the physical therapist to develop a rehabilitation plan and smooth the transition from hospital to home. Include the patient and his family in the planning, and encourage them to focus on recovery.

Nurses play a critical role in every phase of care for the patient with a pelvic fracture. From the moment the ambulance wheels up to the ED door to the day the patient is discharged with a comprehensive rehabilitation plan in place, good nursing care makes all the difference.


REFERENCES

1. Coppola, P. T., & Coppola, M. (2000). Orthopedic emergencies. Emergency department evaluation and treatment of pelvic fractures. Emerg Med Clin North Am, 18(1), 1.

2. Watts, D. D., & Kokiko, J. (1999). Trauma notebook: External pelvic stabilization: Nursing implications. J Emerg Nurs, 25(1), 65.

3. Frakes M. A., & Evans, T. (2004). Major pelvic fractures. Crit Care Nurse, 24(2), 18.

4. Foster, L. M., & Barton, E. D. (2001). Managing pelvic fractures, Part 1: Understanding causes and types. J Crit Ill, 16(4), 207.

5. Raafat, A., & Wright, M. J. (2000). Current management of pelvic fractures. South Med J, 93(8), 760.

6. Foster, J. "Perspectives in nursing: Pelvic fractures: Emergency care to rehabilitation." 2003. www.perspectivesinnursing.org/v3n1/pelvicfractures.html (13 May 2005).


Classifying pelvic fractures

The pelvic bones join in a ring-like framework that surrounds and protects the viscera. Powerful ligaments connect the bones at their joints from front to back, giving the bony frame its strength and ability to evenly distribute the weight of the trunk to the legs. The ability to stand, bear weight, and twist and turn the trunk depends on a stable pelvic ring.


An open-book fracture, shown here, leaves the pelvis rotationally unstable but vertically stable.

When a pelvic fracture occurs, it can be classified by any number of methods, all intended to aid in identifying associated injuries and direct orthopedic repair. Typically, these injuries are classified as either stable or unstable fractures.

A stable pelvic fracture is one that doesn't deform the pelvic ring when normal pressure and weight are applied, and account for a little more than half of all injuries to the pelvis. The force that causes this type of fracture is considered low-energy, and is typically linked to a "common" fall such as when a person slips on ice or trips on a rug. Falls like this can cause sacral compression on the side of impact or an iliac wing fracture, for example.

Unstable fractures are those that interfere with the stability of the pelvic ring. They're caused by high-energy forces that result in either lateral compression (a side-impact motor vehicle crash or when a pedestrian is hit by a car), anterior-posterior compression (head-on collision), or vertical shear (like a fall from a tall building). Unstable fractures can be further divided into two groups by the dimension of the instability: rotationally unstable but vertically stable or rotationally and vertically unstable.

Rotationally unstable fractures involve disruption of one or more pelvic bones, plus the anterior pelvic ligaments, leaving the pelvis rotationally unstable but vertically stable. An example of this is an open-book fracture, shown above, where a break in the pubic bone and the disruption to the anterior pelvic ligaments cause the pelvis to open like a book.

A break in one or more of the pelvic bones plus disruption of the posterior ligaments leaves the pelvis both rotationally and vertically unstable. This latter category is often linked to injuries incurred in a head-on collision and is the most severe type of pelvic injury.

Sources:
1. Frakes, M. A., & Evans, T (2004). Major pelvic fractures. Crit Care Nurse, 24(2), 18. 2. Foster, J. "Perspectives in nursing: Pelvic fractures: Emergency care to rehabilitation." 2003. www.perspectivesinnursing.org/v3n1/pelvicfractures.html (13 May 2005).


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