Clinical Evaluation

HISTORY Assume that all victims of serious or multiple trauma have fractures of the pelvis. A patient with a suspected pelvic fracture should be questioned about details of the accident to determine the mechanism of injury and about prehospital evaluation and treatment. The patient should be specifically questioned to determine areas of pain, last urination or defecation, present bladder sensation, and the last solid and fluid intake. In addition, the time of the last menses or the presence of pregnancy, current medications, and allergies should be ascertained.

PHYSICAL EXAMINATION Symptoms and signs of pelvic injuries vary from local pain and tenderness, especially with walking, to pelvic instability and severe shock. The physician must maintain alertness, perception, and concern in evaluating these patients. On inspection look for perineal and pelvic edema, ecchymoses, lacerations, and deformities. Look for hematomas above the inguinal ligament or over the scrotum (Destot's sign). Roll the patient over if appropriate and examine the areas over-lying the sacrum and coccyx. On palpation feel for irregularities, crepitance, or movement at the iliac crests, pubic rami, and ischial rami. Palpation of a bony prominence or large hematoma or tenderness along the fracture line is possible by rectal examination (Earle's sign). Compress the pelvis lateral to medial through the iliac crests, anterior to posterior through the symphysis pubis, and anterior to posterior through the iliac crests. Compress the greater trochanters and determine the range of motion of the hips. On rectal examination, superior or posterior displacement of the prostate, or rectal injuries are indicative of intraperitoneal and urologic injury. Proctoscopic examination may be required to fully assess for the presence of rectal tears. 4 Decrease in anal sphincter tone may suggest neurologic injury and blood at the urethral meatus, urologic injury. Pelvic examination should be carefully performed in women to detect the presence of blood or lacerations suggesting the possibility of open fracture. Carefully evaluate neurovascular function. If a pelvic fracture is found, assume intra-abdominal, retroperitoneal, gynecologic, and urologic injuries until proved otherwise.

RADIOLOGIC EVALUATION Stabilization of the patient takes priority over obtaining x-ray films. Unnecessary movement may produce further injury or cause more blood loss. After stabilization, roentgenographic evaluation of the pelvis is a must in all unconscious patients who have sustained multiple injuries. Lower extremity long bone fractures as well as pelvic symptoms or signs are also indications for roentgenograms. A standard anteroposterior (AP) view of the pelvis is indicated in the presence of multisystem blunt trauma or if pelvic fracture is suspected. If additional studies are needed, lateral views, AP views of either hemipelvis, internal and external oblique views of the hemipelvis, or inlet and outlet views of the pelvis may be done. An inlet view shows anterior-posterior displacement of ring fractures ( Fig.

265-3 and Fig 265-4). An outlet view shows superior-inferior displacement. Oblique views of the hemipelvis are true AP and lateral views of the acetabulum.

Tomography, computed tomography (CT) scans, and special studies may be needed to fully evaluate and manage patients, particularly for acetabular and sacral fractures. CT is superior to plain radiography in assessing the posterior pelvic arch and acetabulum 5 and has the added advantage of being able to identify the presence or absence of ongoing pelvic hemorrhage.6 Angiography or venography may be necessary to determine a source of bleeding. The patient's condition must dictate what is done and when.

FIG. 265-3. A. Anatomic appearance in the inlet projection. B. Radiologic appearance in the inlet projection. (From Tile M. Assessment. In: Fractures of the Pelvis and Acetabulum. Baltimore: Williams & Wilkins, 1984, p 63. Used with permission.)

FIG. 265-4. A. Anatomic appearance in the outlet projection. B. Radiologic appearance in the outlet projection. (From Tile M. Assessment. In: Fractures of the Pelvis and Acetabulum. Baltimore: Williams & Wilkins, 1984, p 64. Used with permission.)

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