Hip Check

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Be aware of the potential for hemorrhages associated with pelvic ring disruptions.

The Case

A 61-year-old male, with a history of morbid obesity and dyslipidemia, complained of pain in his right pelvic and right gluteal region after a fall. Patient stated he was standing on the first step of a ladder. When he stepped down to the floor with his right leg he slipped in water and slid into the splits.


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He stated he was unable to ambulate after the fall. He complained of excruciating pain when he tried to lift his right leg off the ground. He denied any numbness or tingling. No abdominal pain, neck or back pain. He did not hit his head. He denied the use of blood thinners.

On arrival his temperature was 97.1 F, pulse 80, respiration rate 17, blood pressure 140/76, and oxygen saturation 97% on room air. The patient’s weight was 163kg with a BMI of 45. The physical exam revealed a morbidly obese male sitting in a wheelchair in mild to moderate distress.

Heart and lung exams were unremarkable. Abdomen was obese with bilateral lower quadrant tenderness without rebound or guarding. Musculoskeletal exam demonstrated severe pain with movement of bilateral hips, but no point tenderness. Examination of the pelvis was limited due to obesity and pain; however no obvious deformities were noted. Neurological exam was unremarkable.


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hip check - pelvic pain

X-rays of the right hip were obtained, which demonstrated a marked diastasis of the pubic symphysis of 6.6cm and bilateral sacroiliac widening consistent with an open book pelvic ring disruption. Trauma and orthopedic consultations were urgently obtained, and the patient had a pelvic binder applied.

CT of the abdomen/pelvis was obtained, which confirmed the widening of the symphysis pubis and sacroiliac joint disruptions. A small extraperitoneal hemorrhage was also noted. Significant improvement of the diastasis was noted after pelvic binder application.

The patient’s vital signs and hemoglobin were monitored and remained stable. The patient was admitted to the trauma service with orthopedic consultation. The patient was taken to the OR the next day and underwent ORIF of the pubic symphysis and percutaneous screw fixation of the bilateral sacroiliac joints.


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Post operatively, the patient was limited to no weight bearing with pivoting for bedside commode for six weeks. He was evaluated by PM&R and inpatient rehab was recommended. Patient was transferred to inpatient rehab and remained in therapy for approximately two weeks before being discharged home with nursing care.

Discussion

Pelvic ring fractures may result from both high and low-energy mechanisms. High-energy mechanisms are more common and typically result from blunt trauma from MVCs or falls from significant heights. Low-energy pelvic ring fractures are increasing because of increased rates of fragility fractures in patient populations greater than 60.[4]

Incidences of pelvic ring fractures occur in 37 out of 100,000 in the US, more commonly in those from 15-28 years of age.[3]

Due to a majority occurring from high impact mechanisms, pelvic ring fractures are associated with additional injuries and fractures. Worldwide morbidity and mortality rates from pelvic ring fractures range from 6% to 35%.[2]

Diagnosis is made from pelvic radiographs demonstrating evidence of a fracture or disruption of the pelvic ring. CT scans are used to further characterize the injury allowing for evaluation of the ligamentous structures. High-energy mechanisms are also associated with vascular and organ involvement that can be evaluated on CT.

Pelvic ring fractures are classified based on the direction and magnitude of force applied and stability of the ligamentous structures of the pelvis. The Young and Burgess classification system is commonly used in pelvic ring fractures and criteria can be referenced in Table 1. Pelvic ring fractures, APC-III in particular, can be associated with vascular injuries and thus need to be evaluated for in the initial management, especially in those with high-energy mechanisms.

Pelvic Ring Fracture Case Report - Wallace.docx - Microsoft Word non-commercial use 212022 41145 PM

Most vascular injuries are venous, originating from the posterior venous plexus.[3]Those with anterior posterior compression (APC) fractures, as in this patient, benefit from placement of a pelvic binder to reduce the deformity and decrease pelvic volume in the case of vascular injury.[1]

Initial treatment in the emergency department of pelvic ring fractures involves evaluating the patient’s hemodynamic stability as part of the primary survey. Those with unstable vitals require immediate resuscitation efforts with placement of 2 large bore IVs and administration of 1-2 L fluid bolus.

Patients unresponsive to fluids call for activation of a transfusion protocol. In cases of unstable vitals, laparotomy or vessel embolization may be required. Placement of a pelvic binder over the greater trochanters in APC-type injuries helps decrease pelvic volume and can tamponade the pelvic vessels until definitive treatment can be arranged.

The patient presented here was diagnosed with an APC-III injury: disruption of anterior and posterior SI ligaments and disruption of the sacrospinous and sacrotuberous ligaments. The presentation can be like that of this patient with immediate pain and inability to bear weight. Definitive management in this patient was ORIF of the pubic symphysis with an anterior multi-hole plate and bilateral posterior stabilization of the SI joints with percutaneous placement of partially threaded cannulated screws.

Conclusion

重要的是醫生to be aware of the potential for hemorrhage associated with pelvic ring disruptions. Treatment in the emergency department involves evaluating the patient’s hemodynamic stability as part of the primary survey. Those with unstable vitals require immediate resuscitation efforts. Patient’s unresponsive to fluids call for activation of a transfusion protocol.

在不穩定的重要器官的情況下,剖腹手術或血管embolization may be required. Placement of a pelvic binder over the greater trochanters in APC-type injuries can help decrease pelvic volume and tamponade the pelvic vessels until definitive treatment can be arranged. In this patient the application of the pelvic binder demonstrated marked improvement in the pelvic deformity.

Although the patient did have a small extraperitoneal hemorrhage the application of the binder may have prevented a more significant hemorrhage and resultant hemodynamic instability.

The patient was ultimately taken to the operating room the next day for ORIF of the pubic symphysis and percutaneous screw fixation of bilateral SI joints. This patient tolerated this procedure well and proceeded with inpatient rehabilitation before being discharged home.

Pelvic Ring Fracture Case Report - Wallace.docx - Microsoft Word non-commercial use 212022 41145 PM

References:

  1. Alton, T. , Gee, A. & (2014).Clinical Orthopaedics and Related Research, 472(8), 2338-2342. doi: 10.1007/s11999-014-3693-8.
  2. Brown JV, Yuan S. Traumatic Injuries of the Pelvis. Emerg Med Clin North Am. 2020 Feb;38(1):125-142. doi: 10.1016/j.emc.2019.09.011. PMID: 31757246.
  3. Davis DD, Foris LA, Kane SM, Waseem M. Pelvic Fracture. 2021 Feb 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 28613485.
  4. Grieser, T. Radiological diagnosis of pelvic ring fractures.Radiologist60,226-246 (2020). https://doi-org.proxy1.cl.msu.edu/10.1007/s00117-020-00656-8

ABOUT THE AUTHORS

Dr. Laurie Wallace is the Clerkship Director and Core Faculty for the Beaumont Farmington Hills Emergency Medicine Residency and an Assistant Clinical Professor for Michigan State University College of Osteopathic Medicine.

Dr. Aaron Hess is a first year Orthopedic Resident at Garden City Hospital.

Brandon Wallace is a fourth year Medical Student at Michigan State University College of Osteopathic Medicine with an interest in Orthopedic Surgery.

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