Signs and symptoms of pelvic injuries vary from local pain and tenderness to pelvic instability and severe shock. Examine the patient for pain, pelvic instability, deformities, lacerations, ecchymoses, and hematomas. Avoid excessive movement of unstable fractures as this could produce further injury and cause additional blood loss. Rectal examination may reveal displacement of prostate or rectal injury. Blood at the urethral meatus suggests urethral injury. A vaginal speculum examination may be indicated to detect lacerations that would suggest an open fracture. If a pelvic fracture is found, assume associated intraabdominal, retroperitoneal, gynecologic, or urologic injuries exist until proven otherwise.
Diagnosis and Differential
In patients with a suspected pelvic fracture, obtain a standard anteroposterior (AP) pelvis radiograph to evaluate for bony injury. Other radiographic views include lateral views, AP views of hemipelvis, internal and external oblique views of the hemipelvis, or inlet and outlet views of the pelvis. In an unstable blunt trauma patient, use an AP pelvic radiograph to identify a pelvic fracture quickly, allowing for emergent stabilization maneuvers. Routine pelvic radiographs are not needed in stable trauma patients who will undergo an emergent CT of the abdomen and pelvis. CT is superior to pelvic radiographs for identifying pelvic fractures and evaluating pelvic ring instability.
Pelvic fractures include those that involve a break in the pelvic ring, fractures of a single bone without a break in the pelvic ring, and acetabular fractures. Single bone fractures are described in Table 173-1.
Table 173-1 Avulsion and Single Bone Fractures ||Download (.pdf)
Table 173-1 Avulsion and Single Bone Fractures
Description/Mechanism of Injury
Disposition and Follow-Up
Iliac wing (Duverney) fracture
Direct trauma, usually lateral to medial
Analgesics, nonweightbearing until hip abductors pain-free, usually nonoperative
Discharge with orthopedic follow-up in 1 to 2 weeks; admit for open fracture or concerning abdominal examination
Single ramus of pubis or ischium
Fall or direct trauma in elderly; exercise-induced stress fracture in young or in pregnant women
Discharge with PCP or orthopedic follow-up in 1 to 2 weeks
External trauma or from fall in sitting position; least common pelvic fracture
Analgesics, bed rest, donut-ring cushion, crutches
Discharge with orthopedic follow-up in 1 to 2 weeks
Transverse fractures from direct anteroposterior trauma; upper transverse fractures from fall in flexed position
Analgesics, bed rest, surgery may be needed for displaced fractures or neurologic injury
Discharge with orthopedic follow-up 1 to 2 weeks; orthopedic consultation for displaced fractures or neurologic deficits
Fall in sitting position; more common in women
Analgesics, bed rest, stool softeners, sitz baths, donut-ring cushion
PCP or orthopedic follow-up in 2 to 3 weeks; surgical excision of fracture fragment if chronic pain
Anterior superior iliac spine
Forceful sartorius muscle contraction (eg, adolescent sprinters)
Analgesics, bed rest for 3 to 4 weeks with hip flexed and abducted, crutches...