Pelvic Trauma
The pelvis should be assessed clinically as part of the Secondary Survey.
1. Look abrasion or bruising over bony prominences.
- Scrotal or perineal haematoma.
- Blood at the urethral meatus.
- Leg length discrepancy
2. Feel/move posterior compression of iliac wings
- medial compression of iliac wings
- compression of pubic symphysis
- hip flexion and rotation
- rectal examination
All "impaired" patients and any patient with signs or symptoms of pelvic injury should have a plain AP x-ray of the pelvis. When fractures are identified, orthopaedic consultation is necessary.
If a patient with a pelvic fracture is haemodynamically unstable a DPL (supra
umbilical) or FAST scan is required:
If grossly positive (DPL >10ml frank blood), the patient must go to the
OR for a laparotomy.
If grossly negative pelvic angiography and embolisation of arterial
bleeders is next step.
In major pelvic injury, stressing the pelvis should be avoided as it may
dislodge vital clot.
Orthopaedic stabilisation of mechanically unstable pelvic fractures follows
laparotomy or angiography to reduce venous loss (see algorithm).
Intensivist, orthopaedic and trauma specialists should be involved early.
Genitourinary injuries
Anterior pelvic fractures are associated with a high rate of bladder and
urethral injuries.
Cystogram can be used to investigate these injuries. Gross haematuria with
anterior pelvic fractures will likely have bladder rupture as a cause.
An alternative to cystography in the screening room is a CT cystogram. (The
bladder is filled with 300 ml of contrast prior to obtaining a CT 'run' through
the pelvis. Post-drainage views of the bladder are then taken). Views of the
bladder during a standard trauma CT are not sufficiently sensitive or specific
for bladder injury.
Retrograde urethrogram is required for the patient with: blood at the
urethral meatus, scrotal bruising, high-riding prostate on PR or the stable
patient with multiple grossly displaced superior and inferior pubic rami
fractures.