A 25-year-old man is brought in by ambulance having been found on the side of a motorway after a presumed pedestrian vs car accident. He describes extreme pelvic and suprapubic pain and an open left tib/fib fracture. A pelvic binder was placed pre-hospital
He is haemodynamically unstable with HR 140, BP 85/50 and appears very pale. He received massive transfusion protocol in emergency with 7x PRBC, 2x FFP and 2x cryoprecipitate.
EFAST is positive, with free fluid in his pelvis.
A large perineum wound from scrotum to the anus required packing while in the ED to achieve haemostasis.
A Pelvic X-Ray is performed in the trauma bay
Describe and interpret the X-Ray
Pelvic X-Ray interpretation
There is pubic symphysis diastasis and left sacroiliac joint widening.
There is also prominent surgical emphysema, this is most obvious within the pelvis, however it can also be seen to extend above and below the pelvis.
Following transfusion he was stable enough to be taken to CT.
Describe and interpret the CT scan
The case demonstrates pelvic ring fracture with features in keeping with a Type 3 Anteroposterior Compression fracture (also known as an “open book” fracture).
There is pubic diathesis and bilateral sacroiliac (SI) joint widening.
There are various systems for classifying pelvic fractures. The Young-Burgess classification system is one of the most widely used. It is particularly useful in the ED as it is based on the mechanism, and it also helps in determining stability of the fracture.
Based on the Young-Burgess classification, fractures are divides into;
- Anteroposterior compression (APC)
- Lateral compression (LC)
- Vertical shear (VS)
- Combined mechanism fractures
APC fractures are further categorised into types 1, 2 and 3 depending upon the degree of pubic diathesis and widening of the SI joints;
|<2.5cm pubic diastasis
|>2.5cm pubic diathesis Anterior SI joint widening Posterior SI ligaments are intact
|Vertically stable Rotational instability
|Hemipelvis separation with complete disruption of pubic symphysis Anterior and posterior SI joint widening
An ‘open book’ fracture is associated with high risk of associated injuries to the genitourinary and perineal structures. They are also often associated with vascular injury with arterial dissection, pseudoaneurysm, transection or arteriovenous fistula formation.
Active bleeding in the pubic symphysis and pubic rami region indicate injury to the internal pudendal artery, obturator artery and inferior epigastric artery, whereas bleeding at the iliac wing and sacroiliac joint region could indicate injury of the gluteal artery, iliolumbar artery and sacral arteries.
This extensive surgical emphysema seen in this case should raise concern for a hollow viscus perforation. Indeed, the intra-operative findings reveals a large rectal injury extending into the scrotum, perineum, anus and anteromedial thigh. There was also near complete bladder avulsion.
Intra-operative management involved open repair of the bladder (to achieve urinary tract integrity necessary for urinary drainage).
The pelvic fracture was managed with closed reduction and external-fixation of the anterior pelvis and bilateral distal femur skeletal traction due to the unstable bilateral SI joints.
- Nickson C. Classification of Pelvic Fractures. LITFL
- Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990 Jul;30(7):848-56.
- Khurana B, Sheehan SE, Sodickson AD, Weaver MJ. Pelvic ring fractures: what the orthopedic surgeon wants to know. Radiographics. 2014 Sep-Oct;34(5):1317-33.
- Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 1. Evaluation, classification, and resuscitation. J Am Acad Orthop Surg. 2013 Aug;21(8):448-57 [PDF]
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Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).