Case 20 from Dimity McCracken
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42yo man in high speed MBA (single vehicle accident: lost control on wet road, thrown from motorbike). He has superficial grazes to his right buttock, is complaining of hip & back pain. HR 136 sinus tachy. BP 97/58.
You suspect pelvic injury. Describe the findings on the pelvic xray.
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There is marked pubic symphysis diastasis & widening of the sacroiliac joints. An “open book” pelvic fracture.
This is the CT reconstruction (unfortunately a pelvic binder had not yet been applied).
CT findings are as follows:
*Pubic symphysis diastasis
*Vertical shear fracture of right sacrum
*Widened left sacroiliac joint
*Impacted right sacroiliac joint
*Comminuted left inferior & superior pubic rami fractures
*Left iliac crest avulsion fracture
*L5 left transverse process fracture
This is the xray taken after application of pelvic binder. Note how the pubic symphysis diastasis has reduced.
The patient went to Interventional Radiology for an embolisation. Apart from a groin haematoma, there were no complications, & the patient stabilised.
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Radiopaedia explains how to approach a pelvic xray – excellent, step-by-step instructions with clear pictures. http://radiopaedia.org/articles/pelvic-radiograph-an-approach
Management of severe pelvic trauma – as part of secondary survey:
-don’t “spring” the pelvis (ie. pushing outwards on iliac crests), it’s only going to make things worse if there is an open book fracture
-use a pelvic binder, but make sure it is in the correct position – around the greater trochanters. If it is too high & it can widen an open book fracture. Binding helps reduce a widened diastasis fracture, and may reduce venous ooze. It will not stop arterial bleeding – that requires definitive endovascular or surgical control.
Scott Weingart talking to the LITFL guys about haemodynamically unstable pelvic trauma. Great additional resources, including flowchart approach to major pelvic trauma. http://lifeinthefastlane.com/weingart-on-pelvic-trauma/
LITFL overview of pelvic fractures & summary of management strategies. http://lifeinthefastlane.com/ccc/pelvic-fracture-management/
LITFL’s Chris Nickson has excellent Q&A approach to pelvic injuries.
Part 1: http://lifeinthefastlane.com/trauma-tribulation-027/
Part 2: http://lifeinthefastlane.com/trauma-tribulation-028/
Karim Brohi (from Trauma.org) discusses the “ideal” pelvic binder. http://www.trauma.org/index.php/main/article/657/
NSW Health’s Institute of Trauma and Injury Management guideline for pelvic injuries. It is now a bit old (2007) but has clear algorithms for managing haemodynamically unstable pelvic trauma patients both with and without available angiography services. http://www.aci.health.nsw.gov.au/networks/itim/clinical/trauma-guidelines/Guidelines/pelvic_injury_cpg