Pelvic Fracture

Pelvic

26 ORNurse2014 Marchwww.ORNurseJournal.com

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

2.8 ANCC CONTACT HOURS

Tfract in adults By Colleen Walsh, DNP, RN, ONP-C, CS, ACNP-BC

2The wind whistled and the sound of the engine hummed through 26-year-old JBs helmet as he cruised on his motorcycle through the city streets. His peaceful sojourn ended abruptly when his front tire buckled in a pothole and sent him airborne. His impact with a telephone pole and the ground caused extensive physical damage. JB was wearing a helmet, and helpful civilians left it in place while they waited for emergency medical services (EMS). JB was alert and complaining about severe pain in his hips and abdomen. When EMS arrived, they found JB lying on his side; he was pale and diaphoretic. His vital signs were as follows: pulse: 124 and thready, respirations: 22 and slightly labored but no use of accessory muscles observed, BP: 90/56, oxygen saturation (SpO ): 89% on room air.Emergency medical technicians manually stabilized JBs cervical spine while assessing his airway and breathing, and applied a 100% nonrebreather face mask. Two peripheral I.V. lines were started in both anticubital spaces, and 0.9% sodium chloride solution was administered via rapid infusion. A hard cervical collar secured the cervical spine prior to transfer to a long backboard. During the transfer, the paramedics noted gross motion of the pelvis. The paramedics applied a sheet wrap around JBs pelvis and clamped the wrap in place under ten-sion. JB was transported via ambulance to a Level I trauma center. During transport, JBs BP remained low despite vigorous fluid resuscitation. His Glasgow Coma Scale (GCS) was 15, and he remained alert during the transport (see The GCS).

www.ORNurseJournal.comMarch ORNurse2014 27

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.2Best eye-opening responseScoreSpontaneously4Inappropriate words3Garbled sounds2Best motor responseScoreObeys commands6Abnormal extension (decerebrate)2No response19 to 12 suggests moderate impairment, and 13to 15 suggests mild impairment.Williams & Wilkins 2013:725.

Pelvic fractures in adults

He continued to complain of severe pain in his Alkaline phosphatase: 167 units/L abdomen and pelvis. Alanine aminotransaminase: < 40 units/LUpon arrival to the ED, JBs vital signs were as Aspartate aminotransferase: < 40 units/L follows: pulse: 148 and weak, respirations: 24 and Bilirubin total: 1.1 mg/dLshallow, BP: 80/40, SpO : 96% on 100% nonre- Protein total: 7.2 gm/dL breather mask Prothrombin time: 13.0 secondsJBs ED labs were: International normalized ratio: 1.2 Hgb: 6.2 g/dL Activated partial thromboplastin time: 32 seconds Hct: 18.5% The trauma workup in the ED included computed White blood cells: 24,200 cells/mm3tomography (CT) of the head and cervical spine, Platelets: 124,000/mm3which was negative for fractures and intracranial Na+: 132 mEq/Lbleeding. Thoracolumbar radiographs were negative K+: 5.7 mEq/Las well. The focused assessment with sonography for Cl: 99 mEq/Ltrauma (FAST) exam revealed intraperitoneal blood. Glucose: 143 mg/dLAnterior and posterior (AP) radiographs (X-rays) of Blood urea nitrogen: 39 mg/dLthe chest revealed nondisplaced left-sided 8th and Creatinine: 0.8 mg/dL9th rib fractures without pneumothorax. A urinarydrainage catheter was inserted without problem and returned 10 mL of dark amber urine. An AP pelvisThe GCSX-ray revealed a complete pubic diastasis with a dis-ruption of the left sacroiliac complex. Inlet and outlet radiographs of the pelvis demonstrated vertical dis-placement of the left pelvis. A CT scan of the pelvis To speech3confirmed the plain radiographs.To pain 2 The orthopedic trauma surgeon was consulted, No response 1 and he placed a pelvic external fixation device to stabilize the pelvis. JB was taken to the OR for anBest verbal responseScoreexploratory laparotomy; a grade III splenic fracture Oriented 5was identified and repaired by general surgery. The Confused conversation 4rest of the abdomen was negative.JBs BP continued to be unstable despite the infu-sion of 10 L of 0.9% sodium chloride, 8 units ofpacked red blood cells (PRBCs), and 2 units of fresh No response1frozen plasma (FFP). JB was taken to the radiologysuite for a bilateral iliac artery arteriogram and a ret-rograde urethrogram. The arteriogram demonstrated extravasation of the contrast from the left internalLocalizes stimuli5iliac artery, and a transcatheter arterial embolization Withdrawal from stimulus4was performed. The urethrogram was negative for Abnormal flexion (decorticate)3bladder or uretheral injury. No other injuries werediscovered during the primary and secondary trauma surveys. The orthopedist decided to wait until JBs hemodynamic status stabilized before definitive surgi-cal repair of the pelvis was attempted. After 4 more A total score of 3 to 8 suggests severe impairment,units of PRBCs, 2 units of platelets, and 2 units ofFFP, JBs BP began to stabilize, and he was transferred to the ICU in critical condition.Source: Morton PG, Fontaine DK. Critical Care Nursing: A HolisticHe arrived with a nasogastric tube (NGT) toApproach. 10th ed.; Philadelphia, PA: Wolters Kluwer/Lippincottlow intermittent suction and a triple lumen central venous catheter in the right subclavian vein. The

28 OR Nurse 2014 Marchwww.ORNurseJournal.com


patient was endotracheallyPurpose

intubated when he was operat-The purpose of this article is to ed on emergently. Twenty-fourdiscuss high-energy pelvic frac-hours after admission to thetures that have the potential to ICU, he was successfully extu-result in significant mortality and bated, as he was breathing onmorbidity. The role of periopera-his own with adequate oxy-tive nurse caring for these patients gen saturations on a 40%will be explained. Critical com-nonrebreather mask.munication among all healthcareOver the next 12 hoursproviders will also be discussed. postoperatively, JBs urinePelvic fractures haveoutput increased to 1,800 mL.Epidemiology

significant mortality,and it has been reportedthat as many as 9% to30% of patients die fromtheir injuries.His cardiac exam was normal,Pelvic fractures in the United and his lungs remained clearStates account for approximately despite his rib fractures. His3% of all skeletal fractures, and hemoglobin increased toabout 95% of these fractures are 9.2 g/dL with a hematocrit ofconsidered minor fractures.1 27.3%. He was alert and con-These fractures are usually the tinued to complain of severeresult of low-energy forces. Thispain in his pelvis despite the use of a morphine sulfatearticle will focus on the other 5% of pelvic fractures, patient control analgesia pump. The anesthesia painconsidered high-energy injuries, and these fractures service was contacted, and the basal rate of the infusionresult in significant mortality and morbidity.2was increased, which adequately controlled JBs pain.The incidence of pelvic fractures in the United JB required frequent turning and repositioning. States has been estimated to be 37 cases perThe nursing staff noted a large and extensive black100,000 person-years.3 The incidence of pelvic frac-and blue ecchymosis on his back starting at histures is the highest in people ages 15 to 28.3 In those scapula and ending at the top of his gluteal folds.younger than age 35, men sustain more pelvic frac-Both sclera were icteric, and his indirect bilirubintures than women; in persons over age 35, women increased to 7.1 mg/dL. He complained of intensesustain more pelvic fractures than men.3 Most pelvic pruritus, which was treated with oral hydroxyzinefractures that occur in younger patients result from via the NGT every 6 hours as needed. His coagula-high-energy mechanisms, whereas pelvic fractures tion studies were within normal limits despite thesustained in the older adult population occur from massive blood and fluid replacement he received.minimal trauma, such as a low-level fall.3His bilateral distal pulses remained strong, and hePelvic fractures have significant mortality, and it had normal neurologic function of his legs. The has been reported that as many as 9% to 30% of pin sites for the pelvic external fixation device patients die from their injuries.4 The majority of remained clean with serosanguinous drainage, and these mortalities are due to the other injuries that the pin sites were cleaned daily with chlorhexidine are sustained during the traumatic incident.1,3,4 The 4% solution. mortality from open pelvic fractures is much higherA three-dimensional reconstruction of JBs pelvisand approaches 50%.5 was obtained from the original pelvic CT scan, and5 days after his injury, JB was taken to the OR whereThe pelvic ring

he had an open reduction and internal fixationThe pelvis is the part of the skeletal system that con-(ORIF) of his left posterior sacroiliac joint and sym-nects the lower part of the lumbar spine and sacrum physis pubis using compression plates. He remainedto the femurs. Its a part of both the axial and appen-neurologically intact, his indirect bilirubin count wasdicular skeleton.6,7 Its main purpose is to support the coming down, and he was transferring from the bedbodys weight through the vertebral column as well to the chair with moderate assistance. On post injuryas to support and protect internal organs, such as the day 9, he was transferred to a rehabilitation hospitalurinary bladder, reproductive organs, and the devel-to continue his recuperation.oping fetus.7 The pelvis is comprised of two coxal

www.ORNurseJournal.comMarch ORNurse2014 29


Sacrum*Pubis**


(hip) bones. The coxal bones consist of three separateThe pelvis also has major vascular structures parts: the ilium, ischium, and the pubis. During skele- located within it. The common iliac artery divides tal maturity, the three bones fuse and connect to the into the internal and external branches. The internal sacrum posteriorly. Anteriorly, these bones are con- iliac artery lies more posterior and runs along the nected by the pubic symphysis or symphysis pubis. sacroiliac joint. The external iliac artery runs under This is the midline cartilaginous joint uniting the the pelvic brim and exits underneath the inguinal superior rami of the left and right pubic bones.7 (See ligament. The arteries have other branches that Bony structures of the pelvis and AP X-ray of the pelvis.) supply blood to the muscles surrounding theThe stability of the pelvis is dependent upon thepelvis.10 (See Arteries of the pelvis.) There are corre-ligamentous structures of the pelvic ring. The liga-sponding thin-walled veins that comprise the ments can be divided into those supporting thevenous plexus and are often the source of signifi-posterior region of the pelvic ring and the anteriorcant bleeding in certain types of pelvic fractures.10 ligaments.8 The posterior ligaments provide most of(See Veins of the pelvis.)the support of the pelvis and transmit weight-bearingThe five lumbar nerves and the first four sacral forces through the femoral necks across the sacroiliac nerves combine to form the lumbar (L1-4) and joint.9 These ligaments include the posterior sacroiliac the lumbosacral (L4-S4) plexuses. Each give rise to ligament, the sacrotuberous ligament, and the sacro- anterior and posterior branches. The anterior branch spinous ligament.8 The sacrotuberous and sacrospi- supplies the flexor muscles of the legs, while the nous ligaments are also responsible for inferior stabili- posterior branches supply the extensor and abductor ty by preventing external rotation and vertical shear muscles. The largest of these branches include the forces. Anteriorly, the anterior sacroiliac ligament femoral and obturator nerves. The cutaneousand the symphysis pubis provide support for the pel-branches include the ilioinguinal (L1), genitofemoral vis. The fifth lumbar vertebra also has a strong tie-innerve (L1 and L2), iliohypogastric nerve (L1), and with the ilium through the iliolumbar ligament.8the lateral cutaneous nerve of the thigh (L2 and L3), (See Ligaments of the pelvis.)which supplies the lateral and anterolateral thigh.10

Bony structures of the pelvis and AP X-ray of the pelvis

Iliac crestAla of sacrum Ala of ilium Sacro-iliac jointPelvic brim*Ilium Anterior superior iliac spine (ASIS)Anterior inferior iliac spineIschial spine Acetabular fossaSuperior ramus of pubisObturator foramenPubic tubercle IschiumIschial tuberosityInferior ramus Collectively form right hip boneof pubisOutlines of:Pubic symphysisPelvic inletPubic arch(B) Anteroposterior radiograph Pelvic outlet

(A) Anterior view

Source: Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy. 7th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2013:329.



Ligaments of the pelvis

Anterior longitudinal ligament

Iliolumbar ligament

Anterior sacroiliac ligament

Greater sciatic foramen

Sacrotuberous ligament

Sacrospinous ligament

Anterior sacrococcygeal ligament

Lesser sciatic foramen

Obturator membrane

Pubic symphysisANTERIORPOSTERIOR

Iliolumbar ligament

Posterior sacroiliac ligament

Greater sciatic foramen

Posterior sacrococcygeal ligament

Sacrotuberous ligament

Sacrospinous ligament

Lesser sciatic foramen

Obturator membrane

Pubic symphysis

Outline of right half of pelvic outlet (inferior pelvic aperture)


Classification of pelvic fractures

There are currently two classification systems used to assess pelvic fractures. These systems are useful tools to assist clinicians evaluating and planning the management of patients with significant pelvic fractures.11 The Tile classification is predicated on the stability of the pelvis, while the Young-Burgess classification is based on the mechanism of injury (MOI).12,13The Tile system classifies injuries according to the stability of the pelvic ring and integrity of the posteri-or sacroiliac complex. Categories A (stable), B (par-tially stable), and C (unstable) can be subdivided into different subtypes depending on the nature of the injury (see Tile classification of pelvic fractures). The Young-Burgess classification is based on whether the injury was sustained through AP compression, lateral compression (LC), vertical shear, or a combined MOI.13 (See Young-Burgess classification of pelvic ring fractures.) AP compression injuries usually occur as a result of motor vehicle or motorcycle injuries and are further divided into AP I, AP II, or AP III. LC injuries typically occur as a result of a pedestrian being struck by an automobile and are also subdivided into LC I, LC II, and LC III. Vertical shear injuries occur sec-ondary to a fall from a height, and complex fractures result from a combined mechanism of injury (MOI) and dont fit any classification.11 AP compression III injuries are also called open book fractures due to

www.ORNurseJournal.com the loss of sacroiliac stability and separation of the symphysis pubis.11

Prehospital care

For all patients with trauma, the primary goal of prehospital providers is management of the airway, breathing, and circulation.11,14-17 If a pelvic fracture is suspected, based on MOI and physical exam findings, applying a pelvic binder or wrapping a sheet around the pelvis is the recommended treat-ment in order to reduce bleeding and stabilize the pelvis.11,14-16 Patients should be transported as quickly as possible to a Level I trauma center where the necessary resources to manage the complex care are available.14-16

Resuscitation

Once the patient has arrived in the ED, advanced trauma life support protocols must be instituted immediately.18,19 An AP pelvis radiograph should be conducted on all hemodynamically unstable patients, and definitive CT scans should be delayed until the patient is stable.19 There is debate as to whether AP radiographs should be performed on every trauma patient, but in those patients with a GCS less than 13, an AP pelvis radiograph is warranted.20The FAST exam is performed to determine if there is intra-abdominal bleeding.15-19 Due to the high-energy nature of pelvic fractures, there are

March OR Nurse 2014 31


Superior and inferior


often associated injuries, such as visceral organ dam-PRBCs, FFP, and platelets in a 1:1:1 ratio to prevent age, genitourinary trauma, thoracic trauma, and headthe consumptive coagulopathies associated with trauma.14-16,19,20 If the FAST exam is positive, thelarge volume transfusions.21 These fractures are patient should be immediately taken to the OR foroften open fractures with significant injuries to the surgical evaluation. A pelvic stabilization device isbowel, perineum, urinary structures, and represent applied prior to the exploratory laparotomy. Thesignificantly increased mortalities.source of the bleeding must be identified and cor-rected. The patient usually requires massive transfu-Operative caresions of blood and blood products, often greater thanDespite the emergent nature of the injury or injuries 10 units of PRBCs. Recent studies support infusingrequiring surgery, the ED nurses and the perioperative

Arteries of the pelvis

Gonadal artery: (Ovarian artery)(Testicular artery)Abdominal aorta

Lumbar arteryInferior mesenteric artery

Circumflex iliac artery

Superior rectal artery

Common iliac artery

External iliac arteryMedian sacral artery

Anterior division of internal iliac artery

Inferior epigastric arterylateral sacral arteries Pubic branchSuperior gluteal artery

Obturator arteryInferior gluteal artery Pubic branchMiddle rectal artery Umbilical artery

Uterine arteryVaginal artery (female) Inferior vesical artery (male)Internal pudendal artery

Medial (or lateral) circumflex femoral artery




Veins of the pelvisnurses must have swift and accurate communication regarding the patients condition. This communi-Umbilical veincation allows the OR nurse toHepatic portal vein know what the patients currentSplenicphysiologic status is and allows forligamentmore accurate assessments whileRoundvein

the patient is in the OR. The ORof livernurse must quickly respond to themesentericRenal veinpatients and surgeons needs.Superior

Inferior venaInferiorDuring surgery, accurate communi-vein cation between the OR nurse andthe anesthesia provider is critical.cavamesentericveinThe anesthesia provider will alertMedian sacralvein the OR nurse for the need of bloodveinLeft and blood products as well as anyCommon iliactesticular other medication or equipment. Anvein

Superiorrectal veinexploratory laparotomy is usuallyIliolumbar performed to evaluate and repairveinsMiddlerectal veinsany identified visceral injuries.Right ovarian Oftentimes, several different surgicalveingluteal veinservices are involved in the patientsSuperior surgery, and equipment coordina-tion for these different services isExternal iliac the responsibility of both the sur-vein

geons and the OR nurse. It can beInternal iliac expected that the patient willveinrequire multiple units of blood andUterine blood products, and the OR nursevein

should coordinate with the Blood

will be on hand.Bank to assure an adequate supply(A) Anterior view

Hepatic portal veinand tributariesKeyUnfortunately, many of these pelvic fractures also result in seri-ous injuries to the rectum andbowel. The gross contaminationVena caval circulation of these wounds can lead to life-threatening infection, and the ORnurse can anticipate if there willSource: Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy. 7th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2013:356.be a need for irrigation and debridement of devitalized tissue.22Several regulatory agencies have recommendedNurses Perioperative Standards and Recommended and instituted patient safety goals and the SurgicalPractices.23

Care Improvement Project (SCIP). The SCIPs goalControlling preperitoneal bleeding is a major con-is to reduce the morbidity and mortality associated cern in managing traumatic pelvic injuries, and the with postoperative surgical site infections and to OR nurse should be prepared to have a large quanti-encourage the proper timing and administration of ty of laparotomy pads or surgical sponges available. appropriate antibiotics.22 Its recommended that the In some trauma centers, the concept of damage OR nursing staff adhere to the practices outlined control resuscitation is used to address the need to in the Association of periOperative Registered control initial hemorrhage and stabilize the bleeding

www.ORNurseJournal.comMarch OR Nurse 2014 33


plas commonly performed o stabilze the pel-31,32Type A: Stable A2: Stable, minimally displaced fractures of thering. B3: Lateral compression: contralateral (buckethandle).The first priority in themanagement of pelvicfractures is to controlbleeding.


quickly. This is accomplishedThis bleeding usually occurs by packing the preperitoneal due to traumatic injury to the cavity with pads to tamponade arterial or venous plexus in bleeding and applying some the pelvis and contributes to sort of external fixation device significant mortality unless cor-or clamp.14,15,24,25 In such cases, rected.26-28 The role of angiogra-its critically important for surgi- phy and embolization is wellcal counts to be correct. Anydocumented in the literature retained lap pads used for pre-and is the preferred method to vention of bleeding must becontrol arterial retroperitoneal documented in the operativebleedingusually from the iliac record.22,23arteries.14-16,24-28 The venousbleeding associated with pelvic Postoperative care andfractures is usually stopped when angiographythe pelvic ring is stabilized.26-28 Patients are discharged fromAny attempt at angiographythe OR when certain physio-should be performed by an logic criteria have been met,experienced interventional radi-although its difficult to generalize these criteria in ologist in a radiology suite that has CT available.26-28 the patient with a severe pelvic fracture. For scoringsystems, such as the Aldrete Score, the PostTreatment options for pelvic fractures Anesthesia Care Unit discharge criteria may notThere is general consensus that the first priority in be applicable to this patient population becausethe management of pelvic fractures is to control patients are intubated and sedated as part of thebleeding.24,25,29,30 Life-threatening bleeding must be post-operative critical care phase.22 In patients withcontrolled, and in emergency situations, the applica-unstable vital signs despite control of intraperitonealtion of an external fixation device is still recommend-bleeding, closure of the pelvic fracture by clamping,ed.9,14-16,25,29,30 After the patient is hemodynamically vigorous crystalloid, blood, blood product adminis-stable and other injuries managed, definitive treat-tration, and the issue of retroperitoneal bleedingment is based on the type of fracture sustained and must be considered.14,15,24-26whether or not there are other significant soft tissueinjuries.33Young-Burgess Type AP III fractures, the open-Tile classification ofbook fractures, usually require stabilization both pelvic fracturesanteriorly and posteriorly. ORIF of the symphysispubis and posterior iliosacral joint using compression A1: Fractures of the pelvis not involving the ring. vis.tes i (See Radiograph showingtanteriori plating of the sacroiliac joint.)Other less invasive techniques have been described Type B: Rotationally unstable, vertically stableas alternative treatments and include CT-guided B1: Open book.screw fixation, minimally invasive pinning of the dor- B2: Lateral compression: ipsilateral.sal pelvic ring, and percutaneous pinning concomitantwith external fixation.31-35 CT-guided screw fixation is usually performed in the radiology suite. Small inci-Type C: Rotationally and vertically unstablesions are made, and guide wires are placed into the C1: Unilateral.fracture site using fluoroscopy. (Fluoroscopy is used C2: Bilateral.rather than continuous tomography to decrease C3: Associated with an acetabular fracture.radiation exposure.) Once placement is confirmed,Source: Tile M. Pelvic ring fractures: should they be fixed? J Bonethe guide wire is removed, and cancellous boneJoint Surg Br. 1988;70(1):1-12. Used with Permission.screws are placed to stabilize the fracture.33 Minimally

34 ORNurse2014 Marchwww.ORNurseJournal.com


Young-Burgess classification for pelvic ring fractures

A) Lateral compression (LC) injuries with subsequent bilateral involvement as forces increase; B) anteroposterior (AP) injuries with progression of injury; C) vertical shear injury.

A

LC IL IILC III B

AP IAP IIAP III C

Vertical shear

Source: Young JWR , Burgess AR. Radiologic Management of Pelvic Ring Fractures. Baltimore: Urban and Schwarzenberg, 1987. Used with permission from Elsevier.

invasive fixation of posterior ring fractures is accom-plished through several small incisions, using the pos-terior superior iliac spine as the major landmark. Both sides of the fracture site are identified, and pedicle screws are inserted and bridged, providing solid reduction of the fractures.34 Percutaneous pinning, along with an external fixation frame, is often utilized in pelvic fractures with perineal injuries to provide more stability of fractures that have a significant rota-tional component.35 The surgical technique is similar to CT-guided pin fixation but is performed in the OR.

Complications of pelvic fractures

Due to the high-energy forces required to fracture a pelvis, other significant injuries often occur as well.

www.ORNurseJournal.com Head, chest, abdominal, and genitourinary injures are often present and must also be treated.4,5,10,16,19,32 The use of the Injury Severity Score (ISS) by clini-cians assists in predicting mortality. The greater the ISS, the greater the predicted patient mortality is.16,36,37 The ISS is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an abbrevi-ated injury scale (AIS) and is allocated to one ofsix body regions: the head, face, chest, abdomen, extremities (including pelvis), and external. Only the highest AIS score in each body region is used. The three most severely injured body regions have their score squared and added together to produce the ISS score.



minor pelvic fractures can be treated with bed restRadiograph showing anteriorplating of the sacroiliac joint


Genitourinary damage can be catastrophic andtaken prior to starting broad-spectrum antibiotics, includes deep perineal lacerations, urethral tears,should be initiated with any open fracture, and urinary bladder ruptures, and damage to thespecific antibiotics started once any positive blood, uterus.37 Sexual dysfunction and urinary inconti-urine, or wound culture is reported. Since time nence post injury result from damage to the sacralis of the essence with trauma victims, waiting for nerve roots three and four during the injury.38 Thea positive culture can be detrimental for patient damage to a woman of childbearing age is ofoutcomes. Targeted antibiotic therapies can be insti-greater concern. Due to the hormonally mediatedtuted if positive wound, blood, or urine cultures are relaxation of the symphysis pubis during labor andreported. Careful monitoring of vital signs such as delivery, many obstetricians are reluctant to allow atemperature, pulse, and BP is essential for early woman who has had a compression plate attemptdetection of infection.vaginal deliveries. Woman who have had pelvic frac-Deep vein thrombosis and pulmonary embolus tures are twice as likely to have cesarean sections as are serious and potentially fatal in patients with women who havent.39 Women should be advised pelvic fractures.42,43 The use of anticoagulants such to consult with high-risk obstetricians prior to any as warfarin and low-molecular-weight heparins are attempts to conceive, and an orthopedic consult contradicted in the initial treatment of pelvic frac-may be warranted to help guide labor and delivery tures due to the already heavy bleeding caused by decisions.39 the fracture.43 Some trauma centers feel the use ofPeripheral nerve root injuries, especially L5, canan inferior vena cava filter is warranted.43 Mechanical occur with posterior ring injuries. The L4 and L5compression stockings should be instituted as soon nerve roots are especially vulnerable to injury dueas possible, and pharmacologic therapies started once to the anatomy of the ring. Femoral and sciatic nervethe patient is stabilized.42-44injuries can also occur with fractures involving theThese patients are also prone to the hazards acetabulum.38,40 of immobility, such as atelectasis, pneumonia,Infection, especially in open pelvic fractures, isskin breakdown, and ongoing neurologic deficits. both an acute and chronic problem.35 PeripelvicManagement of these patients is complex and is abscesses can lead to systemic sepsis with resultantgeared toward preventing and managing actual or multiple organ dysfunction syndrome.41 The risk ofpotential complications.pin track infections increases and exists in patientswith external fixation devices. Cultures should beJeffs hospital courseJBs injury was atypical, as he didnt have the other body system injuries that are common in patients with pelvic fractures. He was lucky enough to have been close to a level I trauma center where his inju-ries were immediately and correctly treated. He was also wearing a helmet and was stabilized in the field prior to transport.His elevated liver function tests, posterior body bruising, and jaundice were due to the volume of blood that had settled in his retroperitoneal space. Hemolysis of the blood resulted in the severe jaundice. The liver has difficulty in processing the increased pigment load caused by the breakdown of the red blood cells due to the reabsorption of the extravasated blood by the phagocytic system.45The ORIF of his AP pelvic injuries allowed for early mobility, which certainly helped in preventingSource: Bucholz RW, Heckman, MD, Court-Brown CM, Tornetta MD.skin breakdown and other complications. Some Rockwood and Greens Fractures in Adults. 7th ed. Philadelphia, PA:Wolters Kluwer Health/Lippincott, Williams, & Wilkins; 2010:1450.and protected weight bearing, and those decisions



are made based on the individual patient presentation; however, the majority of significant pelvic fractures are surgically treated.16Functional outcomes after pelvic fractures are an area that hasnt, until recently, been extensively studied.46 Proper anatomical reduction of the posterior ring appears to lessen long-term com-plaints of pain and reduced range of motion.46 JB was sent to an acute rehabilitation center soon after his injury, and the expectation is that his recovery will result in an acceptable outcome that will allow him to resume his activities of daily living without problems.In addition, the National Association of Orthopaedic Nurses also advocates for home assessment following orthopedic surgery.22 Its most likely this assessment will be done prior to discharging patients from rehabilitation centers. Its an important aspect of total patient care so that further injuries arent incurred due to environ-mental issues.

Improving outcomes

The nursing care of the patient with pelvic frac-tures is complex and requires that all nurses involved in the care of these patients are aware of the actual or potential complications that can occur. The perioperative nurse is an important part of the entire team thats needed to manage these patients. Early and vigorous resuscitation, operative treatment of fractures, and postoperative rehabilitation all work together to improve patient outcomes. OR

REFERENCES

1. Mechem CC. Pelvic fractures in emergency medicine. Medscape Ref-erence. 2013. http://emedicine.medscape.com/article/825869-overview.

2. Weatherford B. Pelvic ring fractures. Orthobullets Reference. 2013. http://www.orthobullets.com/trauma/1030/pelvic-ring-fractures.

3. Russell GV. Pelvic fractures. Medscape Reference. 2012. http:// emedicine.medscape.com/article/1247913-overview#a0199.

4. Ooi CK, Goh HK, Tay SY, Phua DH. Patients with pelvic fracture: what factors are associated with mortality? Int J Emerg Med. 2010;3(4):299304.

5. Garlapati AK, Ashwood N. Overview of pelvic ring disruptions. Trauma. 2012;14(2):169178.

6. Crowther-Radulewicz CL. Structure and function of the musculoskel-etal system. In: McCance KL, Huether SE, Brashers VL, Rote NS, eds. Pathophysiology: The Biological Basis for Disease in Adults and Children. 6th ed. St. Louis, MO: Elsevier Mosby; 2010:1540-1567.

7. Altizer L. Anatomy and physiology. In: Schoenly L, ed. Core Curricu-lum for Orthopaedic Nursing. 7th ed. Chicago, IL: National Association of Orthopaedic Nurses; 2013:11-32.

www.ORNurseJournal.com 8. Niranjan NS. Pelvic girdle and lower limb: overview and surface anatomy. In: Standring S, ed. Grays Anatomy: The Anatomical Basis of Clinical Practice. 40th ed. London: Churchill Livingston Elsevier; 2008:1329-1348.

9. Bodden J. Treatment options in the hemodynamically unstable pa-tient with a pelvic fracture. Orthop Nurs. 2009;28(3):109-114.

10. Wheeless CR. Lumbar plexus. Wheeless Textbook of Orthopaedics; 2011. http://www.wheelessonline.com/ortho/lumbar_.

11. Walker J. Pelvic fractures: classification and nursing management. Nurs Stand. 2011;26(10):49-57.

12. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br. 1988;70(1):1-12.

13. Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990;30(7):848-856.

14. Clamp JA, Moran CG. Haemorrhage control in pelvic trauma. Trauma. 2011;13(4):300316.

15. Rommens PM, Hofmann A, Hessmann MH. Management of acute hemorrhage in pelvic trauma: an overview. Eur J Trauma Emerg Surg. 2010;36.

16. McCormack R, Strauss EJ, Alwattar BJ, Tejwani NC. Diagnosis and management of pelvic fractures. Bull NYU Hosp Jt Dis. 2010;68(4): 281-291.

17. Blackwell T. Pre-hospital care of the adult trauma patient. UpTo-Date Reference. 2013. http://www.uptodate.com.lib-proxy.usi.edu/con-tents/prehospital-care-of-the-adult-trauma-patient?source=see_link.

18. Advance Trauma Life Support. 8th ed. Chicago: American College of Surgeons; 2009.

19. Burlew CC, Moore EE. Severe pelvic fractures in the adult trauma patient. UpToDate Reference. 2013. http://www.uptodate.com.lib-proxy.usi.edu/contents/severe-pelvic-fracture-in-the-adult-trauma-patient? detectedLanguage=en&source=search_result&search=Pelvic+trauma%3 A+Initial+evaluation+and+management&selectedTitle=9~150&provider =noProvider.

20. McDevitt KA. Orthopaedic trauma. In: Schoenly L, ed. Core Curric-ulum for Orthopaedic Nursing. 7th ed. Chicago, IL: National Association of Orthopaedic Nurses; 2013:393-422.

21. Hess JR. Massive blood transfusion. UpToDate Reference. 2013. http://www.uptodate.com.lib-proxy.usi.edu/contents/massive-blood-transfusion?source=see_link.

22. Krieger PA. Perioperative patient care. In: Schoenly L, ed. Core Curriculum for Orthopaedic Nursing. 7th ed. Chicago, IL: National Association of Orthopaedic Nurses; 2013:113-140.

23. Association of periOperative Registered Nurses (AORN). Perioperative Standards and Recommended Practices. Denver, CO: Association of periOperative Registered Nurses; 2013.

24. Burlew CC, Moore EE, Smith WR, et al. Preperitoneal pelvic pack-ing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg 2011;212(4):628-635.

25. Lustenberger T, Meier C, Benninger E, Lenzlinger PM, Keel MJ. C-clamp and pelvic packing for control of hemorrhage in patients with pelvic ring disruption. J Emerg Trauma Shock. 2011;4(4):477-482.

26. Fu CY, Wang YC, Wu SC, et al. Angioembolization provides ben-efits in patients with concomitant unstable pelvic fracture and unsta-ble hemodynamics. Am J Emerg Med. 2012;30(1):207213.

27. Bozeman MC, Cannon RM, Trombold JM, et al. Use of computed tomography findings and contrast extravasation in predicting the need for embolization with pelvic fractures. Am Surg. 2012;78(8):825-830.

28. Jones RG. Interventional radiology in pelvic trauma. Trauma. 2011;13:155161.

29. Vcsei V, Negrin LL, Hajdu S. Todays role of external fixation in unstable and complex pelvic fractures. Eur J Trauma Emerg Surg. 2010;36:100106.



2011;71(6):1850-1868.34. Dienstknecht T, Berner A, Lenich A, Nerlich M, Fuechtmeier B. A35. Chen L, Zhang G, WU Y, Guo X, Yuan W. Percutaneous limitedinternal fixation combined with external fixation to treat open pelvicWheeless Textbook of Orthopaedics; 2012. http://www.wheelessonmanaging10.asp.fractures_and_extremity_fractures.Clin Biol. 2012;19(6):366367.financial or othe wise.


30. Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association40. Wheeless CR. Lumbrosacral plexus. Wheeless Textbook of Orthopae-for the Surgery of Trauma practice management guidelines for hemor-dics; 2012. http://www.wheelessonline.com/ortho/lumbrosacral_plexus. rhage in pelvic fractureupdate and systematic review. J Trauma.41. Kataoka Y, Minehara H, Shimada K, Nishimaki H, Soma K,Maekawa K. Sepsis caused by peripelvic soft tissue infections in criti-31. Grubor P, Milicevic S, Biscevic M, Tanjga R. Selection of treatmentcally injured patients with multiple injuries and unstable pelvic fracture. method for pelvic ring fractures. Med Arh. 2011;65(5):278-282.J Trauma. 2009;66(6):1548-1554; discussion 1554-1555.32. Leenen LPH. Pelvic fractures: soft tissue trauma. Eur J Trauma42. Lundy DW, Stannard JP. Treat pelvic, acetabular fractures carefully Emerg Surg. 2010;2:117-123.to reduce liability risk. American Association of Orthopaedic Surgeons. 33. Iguchi T, Ogawa K, Doi T, et al. Computed tomography fluoros-AAOS News. 2013;7(9). http://www.aaos.org/news/bulletin/marapr07/ copy-guided placement of iliosacral screws in patients with unstableposterior pelvic fractures. Skeletal Radiol. 2010;39(7):701705.43. Wheeless CR. DVT & PE arising from trauma, pelvic fractures, and extremity fractures. Wheeless Textbook of Orthopaedics; 2012. http://minimally invasive stabilizing system for dorsal pelvic ring injuries. Clinwww.wheelessonline.com/ortho/dvt_pe_arising_from_trauma_pelvic_ Orthop Relat Res. 2011;469(11):32093217.44. Wang H, Chen W, Su Y, et al. Thrombotic risk assessment ques-tionary helps increase the use of thromboprophylaxis for patients withfractures concomitant with perineal lacerations. Orthopedics. 2011;34(12):pelvic and acetabular fractures. Indian J Orthop. 2012;46(4):413-419. e827-e831.45. Lipka S, Singh J, Hurtado J, Avezbakiyev B, Atallah J, Mustacchia P. 36. Cestero RF, Plurad D, Green D, et al. Iliac artery injuries and pelvicExtravascular hemolysis mimicking severe obstructive jaundice. Transfus fractures: a national trauma database analysis of associated injuries andoutcomes. J Trauma. 2009;67(4):715-718.46. Sen RK, Veerappa LA. Outcome analysis of pelvic ring fractures. 37. Bjurlin MA, Fantus RJ, Mellett MM, Goble SM. Genitourinary inju-Indian J Orthop. 2010;44(1):79-83.ries in pelvic fracture morbidity and mortality using the NationalTrauma Data Bank. J Trauma. 2009;67(5):1033-1039. doi:10.1097/Colleen R. Walsh is an assistant professor, Graduate Nursing University of TA.0b013e3181bb8d6c.Southern Indiana, College of Nursing and Health Professions, Evansville,38. Wheeless CR. Neurologic injury in acetabular and pelvic fractures.Ind. and secretary of the National Association of Orthopaedic Nurses. com/ortho/neurologic_injury_in_acetabular_and_pelvic_fractures.line.The authors andrplanners have disclosed no potential conflicts of interest,39. Cannada LK, Barr J. Pelvic fractures in women of childbearing age.Clin Orthop Relat Res. 2010;468(7):17811789.DOI-10.1097/01.ORN.0000444117.03310.44

For more than 79 additional continuing education articles related to surgical topics, go to Nursingcenter.com/CE.

Earn CE credit online:Go to http://www.nursingcenter.com/CE/ORnurse and receive a certificate within minutes.

INSTRUCTIONSPelvic fractures in adultsTEST INSTRUCTIONSDISCOUNTS and CUSTOMER SERVICE To take the test online, go to our secure website Send two or more tests in any nursing journal published by Lippincott at http://www.nursingcenter.com/ORnurse. Williams & Wilkins together and deduct $0.95 from the price of each test. On the print form, record your answers in the We also offer CE accounts for hospitals and other health care facilities on test answer section of the CE enrollment form onnursingcenter.com. Call 1-800-787-8985 for details.page 39. Each question has only one correctanswer. You may make copies of these forms.PROVIDER ACCREDITATION Complete the registration information andLippincott Williams & Wilkins, publisher of ORNurse2014 journal, will award course evaluation. Mail the completed form and2.8 contact hours for this continuing nursing education activity. Lippincott registration fee of $24.95 to: Lippincott WilliamsWilliams & Wilkins is accredited as a provider of continuing nursing edu-& Wilkins, CE Group, 74 Brick Blvd., Bldg. 4cation by the American Nurses Credentialing Centers Commission on Suite 206, Brick, NJ 08723. We will mail yourAccreditation.certificate in 4 to 6 weeks. For faster service,Lippincott Williams & Wilkins is also an approved provider of continuing include a fax number and we will fax your nursing education by the District of Columbia and Florida #50-1223. This certificate within 2 business days of receiving activity is also provider approved by the California Board of Registered your enrollment form. Nursing, Provider Number CEP 11749 for 2.8 contact hours. You will receive your CE certificate of earnedYour certificate is valid in all states.contact hours and an answer key to reviewThe ANCCs accreditation status of Lippincott Williams & Wilkinsyour results.There is no minimum passingDepartment of Continuing Education refers only to its continuing nursing grade.educational activities and does not imply Commission on Accreditation Registration deadline is April 30, 2016.approval or endorsement of any commercial product.



Documents

Pelvic Fracture