Case 5.4

                                  Case Presentation by Dr. Craig Sharkey

CC: Motorcycle crash

HPI:  A 34yo female presents as a trauma code 2 after a motorcycle crash.  She was traveling approximately 45 mph, not wearing a helmet, when a car turned in front of her.  She was unable to stop in time and ran into the car.  She has amnesia to events, but is alert and speaking appropriately on arrival to the emergency department.  She denies any alcohol or illicit drug use.  She complains of pain in her right shoulder, left forearm, abdomen, and right leg.  She denies any headache, SOB, nausea, or vomiting and does not know the date of her last tetanus vaccination.
ROS:

Constitutional:  No fever
Eye:  No diplopia

Nose: No discharge

Mouth: No sore throat
Respiratory: No difficulty breathing
Cardiovascular:  No palpitations
Gastrointestinal:  + Abdominal pain

MSK: + joint pains

Skin: + abrasions

Neurological: No Headache
PMHx:  HTN

PSHx:  C-section

Allergies: NKDA

Medications: HCTZ
Family Hx: HTN

Social: Denies tobacco/alcohol/street drug usage

Physical Exam:  Vitals:  BP 114/68, P 105 R 22 T 35.8 SpO2 99% on 15 LPM
General:  WD WN female in moderate distress due to pain, but conversant and cooperative
Head:  atraumatic, normocephalic

EENT:  Pupils are equal 3mm, round and reactive to light; Extraocular movements are intact.
Intact hearing to finger rubbing.  No rhinorrhea or epistaxis.  Mouth without injury or lesions.
Neck:  In a cervical collar, no step off deformity.

Respiratory:  Lungs CTA bilaterally, respirations are non-labored.
Cardiovascular:  Regular rhythm, normal S1S2, no murmurs/rubs/gallops
Gastrointestinal:  Soft, Non-distended, diffuse tenderness of abdomen.

Back: no TTP or stepoffs, no spine tenderness

Pelvis: TTP with instability

Rectal: Good tone, no blood, brown stool in vault, no saddle anesthesia
Musculoskeletal:  Upper: deformity of distal left forearm with left hand grip weakness compared to right.  Pain of right shoulder, no distal deformity; 2+ radial pulses, sensation intact in median/radial/ulnar distributions.  Lower:  Degloving of left knee; knee cap loose. 1+  right PT/DP pulse, 2+ left DP/PT.  EHL/FHL/TA/GSC intact.  Sensation intact to light touch in SP/DP/S/S distributions.
Integumentary:  Warm, Dry.
Neurologic:  AAO x 3, Cranial Nerves II-XII intact to H test, face is symmetric with intact sensation, tongue protrudes straight, shoulders shrug equally.

FAST scan: negative for intraperitoneal free fluid

.

.
Questions: 

1)  The proper anatomic landmarks for placement of the commercial belt-type pelvic binders are:

a)  not important, as the circumferential pressure is all that is necessary to reduce pelvic volume

b)  anterior superior iliac spines

c)  widest diameter of the soft tissues

d)  greater trochanters of the femurs

.

2)  Pelvic binders are contraindicated for:

a)  sacral fracture

b)  windswept pelvis

c)  vertical shear pelvis

d)  closed book pelvis

.

3)  Which of the following injury and clinical finding pairings is correct?

a)  L4, L5 root  :  Loss of ankle plantar flexion

b)  S1-S2 roots  :  Loss of knee extension

c)  S2-S4 roots  :  Loss of voluntary rectal tone

d)  pubic symphysis widening : urethral injury

Answers:

Question 1 – D

Question 2 – B

Question 3 – C

Stable Pelvic fractures:   Pelvic fractures that do not disturb the architecture of the pelvis, such as avulsion fractures, iliac wing fractures, isolated rami/sacral fractures generally heal with conservative treatment of rest and analgesia.  It is possible for an isolated fracture to be present, but one should always be wary of any other disruption that would indicate the pelvis is not stable.

Unstable fractures: 

Anteroposterior compression:  This patient had an AP compressive force, resulting in open book injury.  These injuries commonly involve the pubic symphysis/rami and, if severe enough, the sacroiliac joint.  Pubic symphysis width of 2.5 cm or greater is considered unstable.  These injuries are associated with the highest crystalloid and blood requirements.  Damage to the bladder or urethra is approximately 6% in all pelvic fractures, which increases drastically with symphysis widening/obturator fracture displacements over 1 cm.

Lateral compression:  Lateral impact is the most common type of motor vehicle crash, and forces transmitted to the pelvis can cause a multitude Windswept pelvis is a combination of internal rotation of a hemipelvis with external rotation of the contralateral hemipelvis after a lateral compression injury.  There are associated pubic rami fractures on either side of the pelvis as well as ligamentous injuries that all contribute to cause rotational instability of the pelvis.  These lateral compression injuries are associated with less blood loss compared to AP compression due to decreased pelvis volume.

Vertical shear:  Vertical shear injuries are caused by force applied vertically to one side of the pelvis, most commonly due to falls from height or motor vehicle crashes.  Fractures of the ischial spine, 5th lumbar vertebrae transverse processes and sacrum are seen.  They represent the most unstable of all pelvic fractures and have a good chance to cause neurologic impairment especially if they sacral fracture extends through the foramina.

Management: 

Early placement of pelvic binders decreases the transfusion requirements for most pelvic fractures even when compared to embolization or external fixation.  The greater trochanters are the proper landmark for the belt-type binders.   Improper placement across the iliac crests can cause a widening of the pubic symphysis and increase bleeding.  When using sheets instead of belt binders, they can be placed across the entire pelvis without identifying anatomic landmarks.  A windswept pelvis is the only relative contraindication to placing a pelvic binder, where indiscriminant wrapping of this injury can further displace the hemipelvis.  Binding can still be done in order to stabilize the pelvis for movement, but keep in mind that excessive pressure can worsen the injury.

References:

Rosen’s Emergency Medicine:  Pelvic Trauma.  Ch 52


2 Responses

  1. 1. Greater Trochanters of the femurs
    2. Windswept pelvis fractures (lateral Compression fx’s
    3. Loss of voluntary rectal tone, however pubic symphysis >1cm widening has been shown to result in Bladder injuries/Urethra injuries more so than other types of pelvic fractures

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