Chapter 173. Pelvis, Hip, and Femur Injuries

Clinical Features

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.

Acetabular fractures are commonly associated with hip dislocations and can be diagnosed with pelvis radiographs and Judet views. CT is more sensitive than radiography in detecting acetabular injury and is helpful in preoperative planning.

Emergency Department Care and Disposition

1. Due to associated hemorrhage and other injuries, patients with pelvic fractures may need resuscitation with crystalloid, blood, and blood products.

2. Stabilize the pelvis with a bed sheet or other pelvic binding device to stabilize fracture ends.

3. In hemodynamically unstable patients, evaluate for other locations of bleeding such as the thorax and the peritoneal cavity using a chest radiograph and the focused assessment with sonography for trauma (FAST) examination.

4. After excluding other sources of hemorrhage, treatment for ongoing hemodynamic instability in patients with pelvic fractures includes angiography with embolization and external fixation.

5. With the exception of lateral compression type I and AP compression type I injuries, all other pelvic ring fractures require open reduction and internal fixation (ORIF).

6. Acetabular fractures require orthopedic consultation and hospital admission. Nondisplaced fractures may be treated with analgesia and bed rest. Displaced fractures are treated with early ORIF.

7. The treatment and disposition of single bone fractures are listed in Table 173-1.

Clinical Features

The vast majority of hip fractures occur in older patients with osteoporosis or other bony pathology who present after a fall (Table 173-2). The affected leg is classically shortened and externally rotated. Patients with hip fractures may complain of pain at the site of injury or in the groin and knee. After performing a primary survey and stabilizing the patient, examine the patient for pain, shortening, rotation, deformities, pelvic instability, and neurovascular status. If no significant abnormalities are found, carefully evaluate range of motion. A history of fall or significant trauma should prompt the examiner to evaluate for other injuries.

Diagnosis and Differential

Radiographic evaluation of the hip includes AP and lateral views. Other radiographic views that may be helpful include an AP pelvis, which allows a comparison of both sides, and Judet views. Radiographs of the femur and knee may also be indicated. Significant pain with weightbearing or inability to bear weight in patients with normal radiographs should raise suspicion for occult fracture. MRI is very sensitive (nearly 100%) for identifying occult hip fractures and may identify other sources of pain. CT may be useful in identifying fractures not seen on radiographs, but it is not as sensitive as MRI for occult fracture. The differential diagnosis includes pelvic fracture, hip dislocation, femur fracture, sprains, and strains.

Emergency Department Care and Disposition

1. The treatment of hip fractures is listed in Table 173-3.

2. If clinical suspicion of an occult fracture is high, obtain either a CT or MRI scan. Alternatively, arrange urgent follow-up for imaging and have the patient remain nonweightbearing.

3. Traction devices may be used for immobilization of subtrochanteric fractures; however, they are contraindicated in femoral neck fractures.

Hip dislocations may be anterior or posterior, and commonly result from a high-speed motor vehicle crash. Ninety percent of hip dislocations are posterior, and they may be associated with acetabular fractures. On examination, the extremity is shortened, internally rotated, and adducted. With anterior dislocations the extremity is held in abduction and external rotation. Assess the patient's neurovascular status. Radiographs of the hip and pelvis will evaluate for hip dislocation. Further assessment of the acetabulum and femur may be done with Judet views or CT.

Hip dislocations are true orthopedic emergencies and should be reduced within 6 hours because delays in reduction correspond with a higher incidence of avascular necrosis. One of the most common methods for hip reduction is described in Fig. 173-1. Order postreduction radiographs or CT to confirm reduction and evaluate for injuries not apparent on initial radiographs.

Fractures of the femoral shaft occur most commonly in younger patients secondary to high-energy trauma. Pathologic fractures can occur due to malignancies. Clinical features include shortening, pain, swelling, and deformity. Assess the patient for neurovascular status, signs of an open fracture, and other injuries. ED treatment includes splinting the extremity with a traction splint unless the patient has a sciatic nerve injury or a grossly contaminated open fracture. Open femur fractures require broad spectrum antibiotics and copious irrigation. Obtain emergent orthopedic consultation for further debridement and definitive management.