Hip and Pelvis Injuries

aka Trauma Tribulation 028b

It’s time for a look at the latest review from EBMedicine. This post focuses on the following article:

Fiechtl JF, Gibbs MA (2010). An Evidence-Based Approach to Managing Hip and Pelvis Injuries in the Emergency Department.  Emergency Medicine Practice, 12(12).

This review cover a lot of territory and is well worth reading for its comprehensive yet lucid overview of traumatic injuries to the pelvis and hip. The review’s selection of clinical and educational images alone makes it worth the effort. The following Q-and-A pearls are only the merest glimpse of what this paper contains in its 24 pages. One of the authors (Jim Fiechl) you may remember from the video on the FARES method of shoulder reduction produced by the guys at Keeping Up in Emergency Medicine.


Questions

Q1. How should you proceed if you suspect a hip fracture but initial radiographs are negative?

Answer and interpretation

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.


Q2. When should you perform retrograde cystourethrogram on a patient with a pelvic fracture?

Answer and interpretation

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.


Q3. Define a widened pubic symphysis and what is the significance?

Answer and interpretation

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.


Q4. To what type of fractures can a pelvic binder be applied? How?

Answer and interpretation

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.


Q5. Should you rock the pelvis to check for stability?

Answer and interpretation

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!


Q6. How can over-reduction of pelvic fractures be avoided?

Answer and interpretation

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.


One of the many excellent images in this review.

Q7. Using the Young-Burgess classification, what type of pelvic fracture is shown above?

Answer and interpretation

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.

lateral compression type 3

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

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

Q8. How useful is the plain radiograph in the investigation of pelvic ring trauma?

Answer and interpretation

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.


Q9. Which trauma patients do not require pelvic imaging?

Answer and interpretation

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.

Q10. What should be performed immediately following relocation of a dislocated hip?

Answer and interpretation

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.

Video References

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):



Trauma Tribulation back

CLINICAL CASES

Trauma Tribulation

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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