Pelvic Trauma

You are the orthopaedic CT1 on call at a major trauma centre. You have been called to A&E to see a 35-year old female equestrian who fell off her horse. She is complaining of hip pain but not much else. The A&E doctor suspects she has a pelvic fracture. How would you proceed?

Example answer introduction
This is a potential surgical emergency and I would asses this patient immediately using the ATLS protocol, implement an initial management plan and discuss this patient with the Orthopaedic Registrar. 

Initial Assessment and Simultaneous Resuscitation

On arrival, manage the patient using an A to E approach according to the Advance Trauma Life Support Algorithm.

  • Airway with C-spine control

    • Check that airway is patient

  • Breathing

    • oxygen saturations, examine chest, examine work of breathing, breathing depth

    • if concerns give high flow oxygen through a non-rebreathe mask

  • Circulation

    • pulse, blood pressure, capillary refill time, skin turgor, fluid input/output

    • ensure IV access- 2 large bore etc- bloods as above, consider catheter

    • Give fluid challenge 500ml of crystalloid solution. If evidence of heavy bleeding apply pressure and activate Major Haemorrhage Protocol. Avoid deep probing open any neck wounds

    • If hypovolaemic think “blood on the floor + four more” - intrathoracic, intraperitoneal, retroperitoneal, pelvis/thigh – areas of internal haemorrhage

  • Disability - GCS, pupils, blood sugar, temperature

  • Exposure-  systemic signs of shock, other injuries

Provide constant reassessment during this acute phase.

Specific Pelvic Examination

Then if stable assess pelvis specifically for:

  • Bruising, asymmetry, open wounds

  • Palpate pubic symphysis, iliac crests gently. “I WOULD NOT ROCK THE PELVIS”.

  • Distraction of the iliac crests should be performed only once though performing it is a contentious issue 

  • Rectal, perineal and external genitalia examination – urethral and vaginal tears, rectal injury – high riding prostate.

  • Lower limbs for length discrepancy

It is important to say you will cover the patient at the end to prevent hypothermia. 

Focused history
  • Allergies

  • Medications - anticoagulants

  • Past medical history including previous surgery

  • Last meal

  • Events leading up to this point - mechanism of  injury is of utmost importance - there is a difference between falling off a hoarse and being kicked by one. 

Example questions to progress the station

Q1 - What are the differentials for post-traumatic hip pain?

Q2 - What investigations can be performed in this situation?

Q3 - How would you initially manage the patient with a suspected pelvic fracture?

Initial management and further investigations
Initital management
  • Adequate fluid resuscitation

  • Analgesia according to WHO ladder

  • Apply or arrange a pelvic binder

  • Patient will need further imaging

  • Escalate to Orthopaedic Registrar, Vascular Registrar if vascular injury,

  • Prep for theatre – Bloods, Anaesthetist, Emergency theatres

  • Keep patient and any relatives informed

  • Document, document, document!!!

 
Further investigations
A stable patient will go for a CT of the abdomen and pelvis with contrast.
 
Cystography may be performed if urethral/bladder injury is suspected.
 
In the unstable patient, and AP radiograph should be obtained in the Resus bay of the A&E department to rule out pelvic fracture. 
Remember to document your findings and management plan and inform the patient/parents.
 Escalation

Pelvic fractures occur due to high impact injury and suspicion of other injuries and major haemorrhage should be high.

 

Inform your registrar as soon as the patient is stabilised. In this scenario you will be liaising closely with the most senior A&E doctor present and it is likely your registrar would already have been called.  

Useful Resources

​NICE Guideline NG37: Fractures (complex): assessment and management

ATLS Algorithm

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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