Hip and Pelvis Injuries

Plain films are not sufficiently sensitive to rule out fractures of the hip or pelvis.

If plain films are negative, but a fracture is is still suspected then further imaging is required. Grounds for suspicion may include:

• patient unable to weight bear
• high risk mechanism
• severe osteoporosis
• a feeling in your gut

MRI is the investigation of choice. If unavailable, CT scan may be an option but sensitivity is considerably less than MRI for occult hip fractures.

Traditional ATLS teaching is that the retrograde cystourethrogram should be performed to detect urethral rupture prior to attempted IDC insertion if any of the following are present:

• scrotal or vulval hematoma
• high-riding or boggy prostate
• blood at the urethral meatus

However, a recent case series lends weight to the view that a gentle attempt at IDC insertion is acceptable even in the presence of these clinical signs. It should be remember that if performed, an RUG may interfere with subsequent angiographic investigation of pelvic bleeding.

Widening of the pubic symphysis is typical of anteroposterior compression injuries of the pelvic ring.

In the non-pregnant patient the pubic symphysis is normally no greater than 5 mm. When the anterior pelvic ring is widened >2.5cm the posterior portion of the pelvis is routinely injured resulting in a significant increase in the pelvic volume and risk of hemorrhage.

A pelvic binder can be applied to any type of pelvic fracture that causes ring disruption.

Any fracture resulting in pelvic ring disruption can result in life-threatening hemorrhage and imaging may not reveal the true extent of the injury as ‘pelvic recoil’ may have occurred after the injury but prior to imaging.

There is no evidence that commercial pelvic binders are better than low tech methods.

The purpose of pelvic binding is to reduce the volume of the pelvis thus tamponading any hemorrhage, as well as provide biomechanical stabilisation. This can be achieved by wrapping a folded sheet around the pelvis. The sheet should center on the greater trochanters and extend to the iliac crests. Taping the thighs or the feet together also helps maintain the anatomical position of the pelvis.

Hell no!

Check stability clinically by gently compressing the pelvis once, making sure that you don’t displace fracture fragments.

We’re meant to treat injury not cause it!

Over-reduction should be avoided as this may aggravate pelvic injuries.

Pelvic binders should be appropriately tensioned to achieve approximately anatomical alignment. Correct reduction should result in symmetrical positioning of the lower limbs, especially the greater trochanters and the patella.

This radiograph shows a ‘wind swept’ pelvis consistent with a lateral compression type 3 injury.

The black arrows show iliac and pubic rami fractures resulting in an internal rotation deformity. The white arrow shows slight contra-lateral hemi-pelvis external rotation. The lateral compression force on the right hemipelvis has transmitted across to the left hemipelvis. Thus the ‘book is closed’ on the right and ‘open’ on the left.

The Young-Burgess classification is based on mechanism. There are 4 broad groupings:

• lateral compression
• anteroposterior compression
• vertical shear
• combined mechanisms

The miss rate for pelvic fractures using plain films varies from about 4 to 23% in different studies, and other studies comparing radiographs to CT scans indicates that the sensitivity of pelvic radiographs is only 64-78%.

A CT scan is the imaging modality of choice for assessing pelvic ring injury.

Even when an injury is detected by plain radiography, CT is generally necessary to further delineate the nature of injury and rule out other injuries.

Those who are:

• Conscious (e.g. GCS >13)
• no pelvis, back, hip or abdominal complaints
• no tenderness over the lower back, bony pelvis, hip, groin or lower abdomen.

Assess stability while the patient is still under procedural sedation.

Perform gentle hip flexion, extension, adduction, abduction, internal and external rotation. Apply downward pressure to the flexed hip to check posterior stability. If the hip re-dislocates, perform relocation and notify the orthopedics team that the hip is unstable. Unstable hips generally require operative intervention.

After this, perform post-reduction radiographs.

First, up the Allis reduction technique. Personally, I’m not a big fan of standing on the bed…

Here’s a modified Allis technique, what Billy Mallon calls the ‘Captain Morgan Spiced Rum’ method (I’m also a bit concerned about the patient’s knee in this video):