- Approach to Pelvic Injury
Fracture of the pelvis can be life-threatening due to extensive hemorrhage hemorrhage that may prove very difficult to stop. Pelvic fracture immediately raises suspicion of injury to organs that reside in the pelvis.
Pelvic fracture may be associated with urethral or ureteral tear, bladder rupture, rectal rupture, uterine rupture, or placental abruption. Back to Top
Ureteral injury is usually due to penetrating trauma, although severe fractures of the pelvis may tear the urethra.
Clinical Findings: Usually, the presence of blood on urinalysis results in urologic x-rays, which leads to the diagnosis. In the acute setting, there are no specific physical exam findings.
Diagnosis: On IVP, leakage of dye from the ureter is identified.
Treatment: Surgical repair. This injury will be low priority behind head, neck, chest, and abdominal injury. Back to Top
Urethral injuries are usually due to fracture of the pelvis. Exclude urethral injury by physical exam before placement of a foley catheter in every trauma patient.
Clinical Findings: Signs of an anterior pelvic fracture will usually be present. The pubic symphysis may be tender and boggy. A perineal or scrotal hematoma may be noted. If blood or bloody ooze is seen in the urethral opening, urethral injury is assumed. A tender, mobile, or high prostate on rectal exam also means urethral tear until proven otherwise.
Diagnosis: If a tear is suspected on clinical grounds, order a retrograde urethrogram. This study can be performed in seconds at the bedside, if other emergent problems do not take priority.
Treatment: A suprapubic cystostomy provides bladder drainage and allows monitoring of fluid output. Further management is left to the urologist, as a lower-priority injury. Back to Top
The bladder may rupture upward into the peritoneal cavity, or may rupture into the tissues between the pelvic wall and peritoneum. Rupture is usually caused by pelvic fracture.
Clinical Findings: The ruptured bladder may present with blood in the urethral meatus. Lower abdominal or pubic area pain will usually be present.
Diagnosis: For patients with blood at the urethral opening, make the diagnosis by retrograde urethrogram. The contrast media enters the bladder then exits through the rupture. Patients who present without external signs will have minimal bloody urine exit via the foley catheter. If bladder injury is suspected, perform cystogram via the foley. If the source of hematuria is unclear, the diagnosis will be established during IVP.
Treatment: Place a foley catheter to provide drainage. Urologic consultation is required. This injury may be managed surgically, or conservatively, depending on the location and severity of the injury. Back to Top
Pelvic fracture is a common result of blunt trauma, and is often a source of major hemorrhage. The bleeding occurs from multiple vessels, and cannot usually be surgically fixed.
Clinical Findings: Pelvic fracture may be obvious due to tenderness, crepitance, or hematomas, or it may be relatively silent. A high level of suspicion of pelvic fracture is required, or the injury will be missed.
Diagnosis: Pelvic x-ray should be obtained on every severely injured patient, regardless of whether external signs of injury are present.
Treatment: Orthopedic referral is wise for all but the most minor of pelvic fractures. Initial attention, however, is treatment of hemorrhage and diagnosis of associated injuries. Major hemorrhage may decrease with the application of anti-shock trousers. Careful screening for associated urologic injury is required. Back to Top
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All material referenced through this menu is excerpted from copyrighted works by Bruce Argyle, MD. You are welcome to use selected portions, as long as appropriate credit is given. The credit for the text referenced through this menu is:
Argyle, B., Trauma One! Computer Program Manual.
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