of the Pelvis and Acetabulum

Fig. 21.1

(a) X-ray showing disruption of R hemipelvis at symphysis and R SI joint. (b) Cystogram showing extravasation of dye through tear in the urethra

If a urethral tear is suspected, a retrograde urethrogram is easy to do with any available contrast medium. If not possible, a suprapubic cystostomy should be placed without an attempt to insert a retrograde catheter, which could complete a partial urethral tear.

A comprehensive neurovascular examination of the extremities is necessary with results recorded in the chart. When a patient is hemodynamically borderline or unstable, the pelvis should be wrapped in a 15–20-cm-wide sling centered over the greater trochanters, using a bed sheet or a large towel, which is then tightened and clamped [3] (Fig. 21.2). Pelvic binders control bleeding by compressing and stabilizing the fracture, rather than by reducing pelvic volume. They can be used in all patterns of fractures. This simple maneuver has proved to be as effective as other more expensive and sometimes more dangerous devices, such as the MAST suit.

../images/270913_2_En_21_Chapter/270913_2_En_21_Fig2_HTML.png — Fig. 21.2

(a) Compression wrapping of the pelvis using a towel or a sheet centered over the greater trochanters. (b, c) Tightening secured with a knot or clamps

Only in a rare case—in which a patient remains hemodynamically unstable in spite of proper resuscitation and the application of a pelvic sling or binder and where the surgeon is skilled with the use of external fixation, a set is available, and anesthesia resources are comfortable with this type of patient—should acute anterior external fixation be contemplated for hemorrhage control [4] (https://www.youtube.com/watch?v=ifouKV1e5mA).

This is best done through incisions large enough to allow the thumb and index finger to feel both the inner and outer tables to facilitate the insertion of two pins in each anterior crest. A two- or three-bar frame is then loaded in firm but not excessive compression, with the midline bar-to-bar connector or spanning middle bar low enough to permit access to the abdomen if needed for laparotomy and far enough anteriorly so the belly does not rest on it when sitting (Fig. 21.3). Alternatively, two pins can be inserted in the supra-acetabular area proximal to the greater trochanter and connected anteriorly with a basic delta frame.

../images/270913_2_En_21_Chapter/270913_2_En_21_Fig3_HTML.png — Fig. 21.3

(a) Simple external fixator configuration for pelvic ring compression. (b) Patient is able to lift himself from bed

Although a life-saving procedure, the ex-fix often becomes the definitive management of the pelvic ring injury, and reduction should be assessed with appropriate x-rays and, if needed, adjusted once the patient is hemodynamically stable (Fig. 21.4). A patient can usually tolerate 24–48 h of pelvic wrapping, but high blood transfusion demand (often a scarce resource) can mitigate toward external fixation. Arterial embolization is rarely an option, and iliac artery ligature should be considered a heroic maneuver for a patient already undergoing a laparotomy for something else [5].

../images/270913_2_En_21_Chapter/270913_2_En_21_Fig4_HTML.png — Fig. 21.4

(a) AP pelvis x-ray showing significant pubic diastasis, transverse or T-type fracture of the left acetabulum, and probable involvement of the left sacroiliac joint (asymmetric ala and fracture of left fifth transverse process). (b) Acceptable reduction of the pelvic ring after application of anterior external fixator in compression. The acetabular fracture is still slightly displaced, but the femoral head is concentrically reduced under the acetabular dome

With the increasing popularity of “damage control surgery,” temporary retroperitoneal packing with abdominal pads has shown good results [6]. The patient can be resuscitated and monitored more appropriately and returned to the operating room 24–48 h later for more definitive management of his injuries. Video of pelvic packing (https://www.youtube.com/watch?v=RYHbEPE-Tno).

Diagnostic Investigations

Radiographic investigation is often limited to an AP pelvis x-ray [7]. It is important to compare the damaged hemipelvis with the intact opposite side. Usually, enough of the lower lumbar spine is included to confirm if the AP view is true or the patient was rotated by noting the alignment of the spinous processes and the pedicles.

Start with evaluation of the pubic rami and measure any separation of the symphysis pubis. Widening less than 2.5 cm is managed nonoperatively, while a diastasis of more than 2.5 cm usually means associated sacroiliac involvement, increasing the possibility of instability. Perform a systematic assessment of the symmetry of the inferior sacroiliac joints, iliac wings, obturator foramina, pelvic inlet, and teardrop. Evaluation of the teardrop is especially helpful in excluding an acetabular fracture. Aspherical incongruency of the hip joint needs to be particularly assessed to rule out a fracture and/or dislocation. Radiographic landmarks for the acetabulum include the anterior and posterior wall, the ilio-innominate and ilio-ischial lines, the acetabular dome, and the teardrop (Fig. 21.5).

../images/270913_2_En_21_Chapter/270913_2_En_21_Fig5_HTML.png — Fig. 21.5

AP x-ray of the right hip showing ilio-pectineal line, ilio-ischial line, teardrop, acetabular roof, anterior wall of the acetabulum and posterior wall of the acetabulum

Indirect x-ray signs of pelvic instability and ligamentous tears include avulsion fractures of the ischial spine, medial border of the ischium, lateral border of the sacrum, and lower lumbar transverse processes [8]. Remember, the x-ray shows the position the pelvis has “sprung back” after injury, not the amount of initial displacement. Inlet (Fig. 21.6) and outlet views (Pennal) (Fig. 21.7) are easy to obtain since there is no need to move the patient, and they are helpful in determining the degree of instability. Iliac oblique and obturator oblique views (Judet) (Fig. 21.8) are only helpful if surgery is contemplated. Otherwise, they are of academic interest only and are painful for the patient, so should not be done routinely. CT scans are helpful if available.