40YO male presenting after being involved in a Road Traffic collision. A+E call you with the following X-Ray.
This is an AP plane film radiograph taken of an unknown skeletally mature individual’s pelvis. The most obvious abnormality is that there is diastasis of the pubic symphesis. This would be consistent with an AP compression type pelvic fracture.
Given the mechanism of injury I would approach this patient according to ATLS and BOAST principles. I would place a trauma call and complete a primary and secondary survey. As part of the primary survey I would stabilise the C-Spine, assess the patient’s airway, breathing, circulation and disability. I would also place a pelvic binder.
As part of the secondary survey I would assess the neurovascular status of the lower limbs and a PR/PV/urological examination to rule out open injury.
Pelvic fractures are classified according to the Young and Burgess Classification system
Young and Burgess classification
LC – 1
Rami fracture and ipsilateral sacral ala compression fracture
LC – 2
Rami fracture and iliac crescent fracture
LC – 3
Ipsilateral lateral compression and contralateral APC (bilateral pubis fracture)
APC – 1
Pubic diastasis <2.5cm
APC – 2
Pubic diastasis >2.5cm and anterior SI joint diastasis
APC – 3
Pubic diastasis >5cm and anterior SI joint diastasis
Vertical displacement of the hemipelvis, fractures of the pubis and SI joint.
Complex fracture with combined elements
At the level of the Greater trochanters bilaterally with internal rotation of the ankle.
A single, gentle attempt at catheterization can be performed.
16F soft silicone catheter should be used
The finding of blood stained urine mandates a retrograde cystogram via a catheter
If a urethral catheter does not pass or passes only blood then do not inflate the balloon instead perform a retrograde urethrogram.
The oncall urologist should be informed about bladder injuries
1.5 – 2L
% volume loss
- Major haemorrhage initiate major haemorrhage protocol (2222)
- Porters will go to a blood bank and bring ‘Pack A’ to ED
- Pack A: 4 units red blood cells, 4 units FFP
- If patient still haemodynamically unstable
- Pack B 4 units red blood cells, 4 units Fresh frozen plasma, 1 platelet
Reconstruction of the pelvic ring should occur within 72 hours of the stabilisation of the patient’s physiological state.