REVIEWS
Pelvic Fractures: An Anatomic Guide to Severity of Injury Review of 100 Cases Kevin G. Looser, MD,* Hartford, Connecticut H. David Crombie, Jr, MD, Hartford, Connecticut
Pelvic trauma is an increasingly common injury with today’s high speed society. Highway deaths and disability have increased each year until 1973. Little was presented in the literature about pelvic fractures prior to 1960, but since then discussions of this injury have appeared far more frequently and its associated morbidity is now well understood. Pelvic trauma and its attendant injuries carry a mortality of between 10.8 and 18.6 per cent and a morbidity of close to 50 per cent. Pelvic fractures sustained in violent trauma are often associated with urologic injury, retroperitoneal hemorrhage, visceral injury, other fractures, and nerve injuries. In our review, we have attempted to answer such questions as: what is the mechanism of injury; what is the mortality and its causes; is there a relationship between the type of pelvic fracture and associated injury; what organ injuries most commonly occur with pelvic fractures; what diagnostic studies are most valuable; and finally, what guidelines can be developed as to when to operate, when to explore the retroperitoneum, and what to do surgically. We have reviewed the case records of 100 consecutive patients sustaining pelvic fractures in violent trauma admitted to Hartford Hospital between June 1970 and September 1971. Hartford Hospital is a 945 bed community hospital that serves a population of approximately 750,000 people. Elderly patients who sustained pelvic fractures in nonviolent falls were excluded from this review, as these patients tended to sustain isolated bony injuries without severe associated soft tissue trauma. In the course of our review, it became apparent that pelvic fractures could be divided into two anatomic groups to guide clinical management. Group I comprises those patients who had pure anterior fractures, either single or multiple. Anterior fractures were localized to the ischium, pubis, acetabulum, and From the Department of Surgery. Hartford Hospital, Hartford, ConnectiCIA. ’ Resent
adbess and repint requests: Norman Winston House 6E. 430 East 67th Street, New York, New York 10021.
636
pubic symphysis. Group II comprises patients with posterior fractures involving sacrum, ilium, and sacroiliac joints. These patients almost invariably had anterior fractures as well. Figure 1 is a composite drawing of these fractures.
Results There were fifty-seven patients in group I and forty-three in group II. There was a total of fifty-five males and forty-five females. Average age in the 100 patients was 33.6 years (range, 2 to 84 years). Average length of stay for group I patients was 23.8 days (range, 1 to 145 days). Group II patients averaged 35.1 days (range, 1 to 148 days). Longer stays correlated well with associated injuries rather than with pelvic fractures per se; however, the frequency of associated injuries and complications was markedly increased in group II patients. Table I summarizes the two groups. Table II reveals the method of injury in these 100 patients, 73 per cent of patients received their injuries through automobile accidents either as drivers, passengers, or pedestrians. Patients who suffered falls did so from a significant height, such as a building or scaffolding. There was no real correlation between the method of injury and the locaSacro-iliac
reparation
Sscro-iliac
fracture
GROUP
Ii
\
I
lschium fracture
Symphysir reparation
Figure 1. ComposHe drawing of pelvic fractures to Mustrate anterior (group I) and poster/or (group f/J fractures.
The American Journal ol Surgery
Pelvic
TABLE
I Comparison
Group Group
No. of patients Sex (male/female) Age (yr) (average) Length of stay (days) (average) Associated injuries and complications Deaths (direct result of pelvic fracture) No. of patients undergoing laparotomy No. of patients transfused (average amount)
I and Group I
II Patients
43 24/l 9 12 to 80 (33.5) 1 to 148 (35.1)
89 in 41 patients
181 in 39 patients
6 (1)
5 (1)
6
18
cc)
36 (3.800
cc)
tion of fractures. Generally, posterior fractures required greater trauma. In group I with the less severe anterior fractures (57 patients), there were seventy associated major injuries and eighteen complications in forty-one patients. (Table II.) Sixteen patients had no significant associated injury or complication. In this group of fifty-seven patients there were five deaths (mortality, 8.8 per cent). One patient died of shock as a direct result of pelvic fracture and retroperitoneal bleeding. The mean age of those patients who died was significantly older than the mean age of the entire group. The deaths in group I are summarized in Table III. We observed a 29.8 per cent incidence of retroperitoneal hematoma in group I patients, the diagnosis of which was made by the following guidelines: (1) operative finding; (2) palpation of mass; (3) displacement or elevation of the bladder by cystogram; (4) angiography; and (5) presumptive evidence (transverse process fracture, other spinal fractures, or diagnosed pancreatic or other retroperitoneal organ injury). Six of fifty-seven patients (10.5 per cent) required abdominal exploration for hemoperitoneum. The findings were ruptured spleen in two patients, ruptured bladder in two, torn duodeum and sigmoid mesentery in one; one patient had a lacerated liver and, in addition, 1 patient required thoracotomy and underwent successful repair of lacerated coronary artery. (Table IV.) Two of the patients explored died, one from uncontrollable hemorrhage after opening the retroperitoneum and the second from irreversible brain damage. It is interesting to note that three of the five patients who died suffered significant urinary tract injury. One would conclude from this that the pelvic fracture patient who sustains significant urinary tract injury may have poVolume 132, November 7976
II
Method
of Injury
Injuries
and Complications
and Associated
Group II
57 31/26 2 to 84 (33.6) 1 to 145 (23.8)
16 (1,600
TABLE
Fractures
Method
Group I (anterior pelvis)
Group II (posterior pelvis)
of Injury
Automobile Pedestrian Motorcycle Fall Industrial crush
injuries
Associated Injuries Long bone fractures Retroperitoneal hematoma Fractured ribs, spine, shoulder, clavicle Urinary tract injury Intra-abdominal visceral injury Head injury Nerve injury lntrathoracic Total Associated
injury
24 20 4 8 1
20 14 2 5 2
14 17
21 36
21 5 5 7 0 1 70
22 12 14 12 5 3 125
7 5 0 3 2 0 0 1 0 18
11 11 10 7 0 3 3 1 1 47
Complications
Prolonged ileus Shock lung Fat emboli lcterus Gastrointestinal Thrombophlebitis Renal failure Pancreatitis Pelvic abscess Total
bleeding
tentially lethal associated injuries. Sixteen group I patients (28.1 per cent) required transfusion. Amounts varied from 300 to 4,000 cc (average, 1,600 cc). Of forty-three group II patients, only one had no anterior fracture demonstrated by x-ray film. Eighteen of forty-three patients (41.9 per cent) required exploratory laparotomy for intra-abdominal injury. Table IV lists the operative findings in group II patients compared with group I. Comparing this group to the pure anterior fractures, we can readily see that posterior injury carries a much higher morbidity. Thirty-six of the forty-three patients (83.7 per cent) had significant retroperitoneal hematoma. Thirtytwo (68 per cent) required blood transfusions in amounts varying from 500 to 16,500 cc (average, 3,800 cc). In the group of eighteen patients requiring laparotomy, there were four deaths, a 22 per cent operative mortality. Two additional patients died before reaching the operating room. Table V reviews the deaths in group II. In contrast to sixteen of fifty-seven group I patients, there were only four of forty-three patients in group II who had no significant associated injury or
639
Looser and Crombie
TABLE
Age(yrl and Sex 54,M
19,M
III
Summary of Deaths in Group (5 of 57, 8.8 percent) Type of Trauma
Pedestrian
Auto
driver
77,F
Pedestrian
84,M
Pedestrian
69,F
Passenger
Time and Place of Death Emergency
room
2 days postoperatively 12 hr post admission 1 hr post admission Operating room
I
IV
Operative -_
Findings
Finding
Cause of Death Hemorrhage (pelvis, spleen, kidney, sternum, ribs, and urethra) Neurologic Cardiac Respiratoryaspiration Hemorrhage uncontrolled retroperitoneal bleeding
complication in addition to their pelvic fracture. Associated injuries in group II tended to be greater in number and severity, a direct result of the increased trauma necessary to incur a posterior pelvic fracture. There was a total of 172 associated injuries and complications in group II, as shown in Table II. Comments
This survey demonstrates that pelvic fractures are not the benign injuries they were once thought to be. The 11 per cent mortality reported in this series agrees with other series on pelvic fractures. Reynolds, Balsano, and Reynolds [1] reported a mortality of 18.6 per cent in their unselected series of 273 patients. Trunkey et al [2] reported a mortality of 9.2 per cent in their series of 173 patients. Patterson and Morton (31 reviewed 683 pelvic fractures and recorded a 13.9 per cent mortality. This series is a selected one to the extent that we studied only patients who suffered violent trauma, excluding those who suffered minor falls, chiefly in the elderly age group. The proximity of the bony pelvis to intra-abdominal organs and major vessels as well as extraperitoneal vascular and urinary tract structures makes possible a myriad of associated injuries accompanying major pelvic fractures. This diverse organ involvement may call into play a multidisciplined team of specialists, including the general surgeon, orthopedist, urologist, neurologist, and vascular surgeon to plot the course of early management for these patients. We have divided our patients anatomically into two groups. Those who suffered anterior or ischiopubic arch fractures and those who suffered posterior or sacroiliac arch fractures. From the results 640
TABLE
Ruptured
in Patients Explored ------~ Group I Group II (6 of 57) ( 18 of 43) -~-
bladders
lntraperitoneal Extraperitoneal Both Liver laceration Ruptured spleen
1 2
3 2 4 5 4
Mesenteric tear Uncontrollable retroperitoneal
1
3
hemorrhage Urethral tears Iliac artery injury
1 2
0
2 3 1 1 3
1 1
0 1
11
29
Peritoneal tear No surgically correctable Torn duodenum Thoracic injury Total
1 1
lesion
there can be little doubt that posterior fractures carry a greater mortality (14 vs 8.8 per cent) and a markedly increased morbidity. After intra-abdominal injury has been ruled out, the three areas of concern related to pelvic fractures are hemorrhage, urinary tract injury, and nerve damage. The most frequently observed and severest complication of pelvic trauma is hemorrhage, and even in the absence of associated injury, this may result in death. The major site of hemorrhage is the retroperitoneum, and its control requires the maximum of correct judgment. In considering this, it is important to appreciate the almost astonishing capacity of the retroperitoneum to accomodate extravascular collections of blood. Disruption of large venous channels can account for accumulation of as much as 4,000 cc of blood before intravascular pressure is overcome and tamponade achieved [4]. This fact constitutes the precarious setting within which the trauma surgeon must gather his diagnostic information in managing patients with major pelvic fractures. The ideal strategy would be to resort to operative intervention only in those patients with surgically correctable injury and to transfuse the remainder until normal blood volume is restored. The argument over the proper management of pelvic hemorrhage continues in the literature. Those patients who have negative peritoneal lavage and do not stabilize after rapid and continuous blood transfusions may need exploration if only to rule out intraperitoneal hemorrhage. If it can be ruled out preoperatively, then the decision regarding operation is based on whether or not patients stabilize with multiple transfusions. Ravitch (51 occupies the most conservative locus,on the spectrum in recommending that up to 20 units of blood be given before resorting to surgical intervention. Most other authors The American Journal of Surgery
Pelvic
TABLE
V
Summary
of Deaths
in Group
II
(6 of 43, 14 per cent) Age (vr) and Sex
Type of Trauma
Time and Place of Death ___21 days postoperatively Emergency room (~4 hr)
12.M
Pedestrian
80,F
Pedestrian
68,F
Passenger
Emergency (
Pelvic Fractures: An Anatomic Guide to Severity of Injury Review of 100 Cases Kevin G. Looser, MD,* Hartford, Connecticut H. David Crombie, Jr, MD, Hartford, Connecticut
Pelvic trauma is an increasingly common injury with today’s high speed society. Highway deaths and disability have increased each year until 1973. Little was presented in the literature about pelvic fractures prior to 1960, but since then discussions of this injury have appeared far more frequently and its associated morbidity is now well understood. Pelvic trauma and its attendant injuries carry a mortality of between 10.8 and 18.6 per cent and a morbidity of close to 50 per cent. Pelvic fractures sustained in violent trauma are often associated with urologic injury, retroperitoneal hemorrhage, visceral injury, other fractures, and nerve injuries. In our review, we have attempted to answer such questions as: what is the mechanism of injury; what is the mortality and its causes; is there a relationship between the type of pelvic fracture and associated injury; what organ injuries most commonly occur with pelvic fractures; what diagnostic studies are most valuable; and finally, what guidelines can be developed as to when to operate, when to explore the retroperitoneum, and what to do surgically. We have reviewed the case records of 100 consecutive patients sustaining pelvic fractures in violent trauma admitted to Hartford Hospital between June 1970 and September 1971. Hartford Hospital is a 945 bed community hospital that serves a population of approximately 750,000 people. Elderly patients who sustained pelvic fractures in nonviolent falls were excluded from this review, as these patients tended to sustain isolated bony injuries without severe associated soft tissue trauma. In the course of our review, it became apparent that pelvic fractures could be divided into two anatomic groups to guide clinical management. Group I comprises those patients who had pure anterior fractures, either single or multiple. Anterior fractures were localized to the ischium, pubis, acetabulum, and From the Department of Surgery. Hartford Hospital, Hartford, ConnectiCIA. ’ Resent
adbess and repint requests: Norman Winston House 6E. 430 East 67th Street, New York, New York 10021.
636
pubic symphysis. Group II comprises patients with posterior fractures involving sacrum, ilium, and sacroiliac joints. These patients almost invariably had anterior fractures as well. Figure 1 is a composite drawing of these fractures.
Results There were fifty-seven patients in group I and forty-three in group II. There was a total of fifty-five males and forty-five females. Average age in the 100 patients was 33.6 years (range, 2 to 84 years). Average length of stay for group I patients was 23.8 days (range, 1 to 145 days). Group II patients averaged 35.1 days (range, 1 to 148 days). Longer stays correlated well with associated injuries rather than with pelvic fractures per se; however, the frequency of associated injuries and complications was markedly increased in group II patients. Table I summarizes the two groups. Table II reveals the method of injury in these 100 patients, 73 per cent of patients received their injuries through automobile accidents either as drivers, passengers, or pedestrians. Patients who suffered falls did so from a significant height, such as a building or scaffolding. There was no real correlation between the method of injury and the locaSacro-iliac
reparation
Sscro-iliac
fracture
GROUP
Ii
\
I
lschium fracture
Symphysir reparation
Figure 1. ComposHe drawing of pelvic fractures to Mustrate anterior (group I) and poster/or (group f/J fractures.
The American Journal ol Surgery
Pelvic
TABLE
I Comparison
Group Group
No. of patients Sex (male/female) Age (yr) (average) Length of stay (days) (average) Associated injuries and complications Deaths (direct result of pelvic fracture) No. of patients undergoing laparotomy No. of patients transfused (average amount)
I and Group I
II Patients
43 24/l 9 12 to 80 (33.5) 1 to 148 (35.1)
89 in 41 patients
181 in 39 patients
6 (1)
5 (1)
6
18
cc)
36 (3.800
cc)
tion of fractures. Generally, posterior fractures required greater trauma. In group I with the less severe anterior fractures (57 patients), there were seventy associated major injuries and eighteen complications in forty-one patients. (Table II.) Sixteen patients had no significant associated injury or complication. In this group of fifty-seven patients there were five deaths (mortality, 8.8 per cent). One patient died of shock as a direct result of pelvic fracture and retroperitoneal bleeding. The mean age of those patients who died was significantly older than the mean age of the entire group. The deaths in group I are summarized in Table III. We observed a 29.8 per cent incidence of retroperitoneal hematoma in group I patients, the diagnosis of which was made by the following guidelines: (1) operative finding; (2) palpation of mass; (3) displacement or elevation of the bladder by cystogram; (4) angiography; and (5) presumptive evidence (transverse process fracture, other spinal fractures, or diagnosed pancreatic or other retroperitoneal organ injury). Six of fifty-seven patients (10.5 per cent) required abdominal exploration for hemoperitoneum. The findings were ruptured spleen in two patients, ruptured bladder in two, torn duodeum and sigmoid mesentery in one; one patient had a lacerated liver and, in addition, 1 patient required thoracotomy and underwent successful repair of lacerated coronary artery. (Table IV.) Two of the patients explored died, one from uncontrollable hemorrhage after opening the retroperitoneum and the second from irreversible brain damage. It is interesting to note that three of the five patients who died suffered significant urinary tract injury. One would conclude from this that the pelvic fracture patient who sustains significant urinary tract injury may have poVolume 132, November 7976
II
Method
of Injury
Injuries
and Complications
and Associated
Group II
57 31/26 2 to 84 (33.6) 1 to 145 (23.8)
16 (1,600
TABLE
Fractures
Method
Group I (anterior pelvis)
Group II (posterior pelvis)
of Injury
Automobile Pedestrian Motorcycle Fall Industrial crush
injuries
Associated Injuries Long bone fractures Retroperitoneal hematoma Fractured ribs, spine, shoulder, clavicle Urinary tract injury Intra-abdominal visceral injury Head injury Nerve injury lntrathoracic Total Associated
injury
24 20 4 8 1
20 14 2 5 2
14 17
21 36
21 5 5 7 0 1 70
22 12 14 12 5 3 125
7 5 0 3 2 0 0 1 0 18
11 11 10 7 0 3 3 1 1 47
Complications
Prolonged ileus Shock lung Fat emboli lcterus Gastrointestinal Thrombophlebitis Renal failure Pancreatitis Pelvic abscess Total
bleeding
tentially lethal associated injuries. Sixteen group I patients (28.1 per cent) required transfusion. Amounts varied from 300 to 4,000 cc (average, 1,600 cc). Of forty-three group II patients, only one had no anterior fracture demonstrated by x-ray film. Eighteen of forty-three patients (41.9 per cent) required exploratory laparotomy for intra-abdominal injury. Table IV lists the operative findings in group II patients compared with group I. Comparing this group to the pure anterior fractures, we can readily see that posterior injury carries a much higher morbidity. Thirty-six of the forty-three patients (83.7 per cent) had significant retroperitoneal hematoma. Thirtytwo (68 per cent) required blood transfusions in amounts varying from 500 to 16,500 cc (average, 3,800 cc). In the group of eighteen patients requiring laparotomy, there were four deaths, a 22 per cent operative mortality. Two additional patients died before reaching the operating room. Table V reviews the deaths in group II. In contrast to sixteen of fifty-seven group I patients, there were only four of forty-three patients in group II who had no significant associated injury or
639
Looser and Crombie
TABLE
Age(yrl and Sex 54,M
19,M
III
Summary of Deaths in Group (5 of 57, 8.8 percent) Type of Trauma
Pedestrian
Auto
driver
77,F
Pedestrian
84,M
Pedestrian
69,F
Passenger
Time and Place of Death Emergency
room
2 days postoperatively 12 hr post admission 1 hr post admission Operating room
I
IV
Operative -_
Findings
Finding
Cause of Death Hemorrhage (pelvis, spleen, kidney, sternum, ribs, and urethra) Neurologic Cardiac Respiratoryaspiration Hemorrhage uncontrolled retroperitoneal bleeding
complication in addition to their pelvic fracture. Associated injuries in group II tended to be greater in number and severity, a direct result of the increased trauma necessary to incur a posterior pelvic fracture. There was a total of 172 associated injuries and complications in group II, as shown in Table II. Comments
This survey demonstrates that pelvic fractures are not the benign injuries they were once thought to be. The 11 per cent mortality reported in this series agrees with other series on pelvic fractures. Reynolds, Balsano, and Reynolds [1] reported a mortality of 18.6 per cent in their unselected series of 273 patients. Trunkey et al [2] reported a mortality of 9.2 per cent in their series of 173 patients. Patterson and Morton (31 reviewed 683 pelvic fractures and recorded a 13.9 per cent mortality. This series is a selected one to the extent that we studied only patients who suffered violent trauma, excluding those who suffered minor falls, chiefly in the elderly age group. The proximity of the bony pelvis to intra-abdominal organs and major vessels as well as extraperitoneal vascular and urinary tract structures makes possible a myriad of associated injuries accompanying major pelvic fractures. This diverse organ involvement may call into play a multidisciplined team of specialists, including the general surgeon, orthopedist, urologist, neurologist, and vascular surgeon to plot the course of early management for these patients. We have divided our patients anatomically into two groups. Those who suffered anterior or ischiopubic arch fractures and those who suffered posterior or sacroiliac arch fractures. From the results 640
TABLE
Ruptured
in Patients Explored ------~ Group I Group II (6 of 57) ( 18 of 43) -~-
bladders
lntraperitoneal Extraperitoneal Both Liver laceration Ruptured spleen
1 2
3 2 4 5 4
Mesenteric tear Uncontrollable retroperitoneal
1
3
hemorrhage Urethral tears Iliac artery injury
1 2
0
2 3 1 1 3
1 1
0 1
11
29
Peritoneal tear No surgically correctable Torn duodenum Thoracic injury Total
1 1
lesion
there can be little doubt that posterior fractures carry a greater mortality (14 vs 8.8 per cent) and a markedly increased morbidity. After intra-abdominal injury has been ruled out, the three areas of concern related to pelvic fractures are hemorrhage, urinary tract injury, and nerve damage. The most frequently observed and severest complication of pelvic trauma is hemorrhage, and even in the absence of associated injury, this may result in death. The major site of hemorrhage is the retroperitoneum, and its control requires the maximum of correct judgment. In considering this, it is important to appreciate the almost astonishing capacity of the retroperitoneum to accomodate extravascular collections of blood. Disruption of large venous channels can account for accumulation of as much as 4,000 cc of blood before intravascular pressure is overcome and tamponade achieved [4]. This fact constitutes the precarious setting within which the trauma surgeon must gather his diagnostic information in managing patients with major pelvic fractures. The ideal strategy would be to resort to operative intervention only in those patients with surgically correctable injury and to transfuse the remainder until normal blood volume is restored. The argument over the proper management of pelvic hemorrhage continues in the literature. Those patients who have negative peritoneal lavage and do not stabilize after rapid and continuous blood transfusions may need exploration if only to rule out intraperitoneal hemorrhage. If it can be ruled out preoperatively, then the decision regarding operation is based on whether or not patients stabilize with multiple transfusions. Ravitch (51 occupies the most conservative locus,on the spectrum in recommending that up to 20 units of blood be given before resorting to surgical intervention. Most other authors The American Journal of Surgery
Pelvic
TABLE
V
Summary
of Deaths
in Group
II
(6 of 43, 14 per cent) Age (vr) and Sex
Type of Trauma
Time and Place of Death ___21 days postoperatively Emergency room (~4 hr)
12.M
Pedestrian
80,F
Pedestrian
68,F
Passenger
Emergency (
