First aid for fracture of the pelvic bones

In modern society, the number of victims with a medical diagnosis of “fracture of the pelvic bones” has significantly increased. Such injuries are classified as severe injuries and are often associated with an increase in traffic intensity and, as a result, more accidents. According to medical statistics, 75% of traffic accidents end with a pelvic fracture in victims of road accidents.

Another reason for such injuries lies in the violation of safety and labor protection rules in the main areas of modern production. Such fractures often occur as a result of an unsuccessful fall from a height, in particular, on the side, buttocks or legs, as well as due to impact or compression of the pelvic bones during collapses. A special risk group is made up of elderly people, who may end up falling to the ground directly from a standing position with such injuries.

According to official statistics, pelvic fractures are recorded in seven percent of cases of damage to the entire musculoskeletal system. With them, there are also frequent cases of damage to the internal organs of the pelvis, such as the intestines, bladder, urethra, and even the kidneys.

Due to the deep location of the pelvic bones, their fractures are difficult to diagnose and require long-term treatment and rehabilitation.

A little anatomy

The pelvis is located in the lower part of our body. Its powerful bone ring, which connects the spine with the lower limbs, consists of the sacrum (a large triangular bone at the base of the spine), the coccyx and two nameless bones, also known as the hip bones. Each of them, in turn, consists of three more bones: the ilium, ischium and pubis. At the birth of a person, they are laid down as separate ones, but as his skeleton matures, they become one. The place of their confluence forms part of the hip joint and is called the acetabulum.

The bones of the pelvis with the sacrum are connected by ligaments (connecting bundles), and together they form a bowl-shaped cavity under the chest, containing the organs of the pelvis. In addition to large nerve trunks and blood vessels, it contains the bladder, part of the intestinal loops and reproductive organs. The pelvis simultaneously protects these important organs and is the attachment point for the muscles of the legs, abdomen, and thighs.

Causes of pelvic fractures

The main causes of pelvic fractures are high-energy injuries, which can be caused by the following circumstances:

1. Hits in traffic accidents.
2. Squeezing of the pelvis during the collapse of any structures.
3. Falling from height.
4. Decreased bone quality in the elderly due to osteoporosis. In such cases, fractures are observed during falls, even from the height of one’s own growth.
5. Injuries of the pelvis at the site of attachment of the muscle in young athletes, caused by the immaturity of the skeletal system.

Types of fractures

Since the pelvis looks like a ring, a fracture of one of its parts often ends in a fracture or damage to the ligaments of the other. Injuries to the pelvic bones are determined by the direction of the fracture line, taking into account the traumatic force that caused them.

According to the classification, in modern medicine the following groups of fractures of the pelvic bones are distinguished, depending on whether the structure of the integrity of the pelvic ring is preserved or broken:

1. Stable fractures – without violations of the pelvic ring.
2. Rotationally unstable or partially stable fractures are multiple fractures with disruption of the pelvic ring (for example, one half of the pelvis is displaced upward).
3. Unstable fractures – a complete rupture of the sacroiliac joint or a fracture of the bottom of the acetabulum and its edges, sometimes with hip dislocation.
4. Fracture dislocations – fractures with dislocation in the sacroiliac or pubic joint. With this type of injury, a fracture of the pelvic bones is combined with a dislocation in the pubic or sacroiliac joint.

Stable (low-energy) injuries include preserved anatomy of the pelvic ring, having one line of fracture. They usually grow quite well.

Rotationally unstable fractures are characterized by damage to the integrity of the pelvic ring at two or more points. They are characterized by a violation of the anatomy of the pelvis as a result of high-energy injuries. Depending on the injury received, fractures may be vertically unstable or rotationally unstable.

The former are characterized by a violation of the integrity of the pelvic ring in the anterior and posterior sections and displacement of debris in the vertical plane. Rotationally or rotationally unstable fractures include fractures with displacement of fragments in the horizontal plane. Such injuries are accompanied by quite serious complications, including massive bleeding, damage to internal organs or infections. For the stronger sex, this kind of injury is sometimes fraught with a fracture of the penis. With timely and effective treatment of complications, partially unstable fractures also heal well.

Acetabular fractures are accompanied by dysfunction of the hip joint and pain syndrome, which is aggravated by tapping on the thigh and axial load. Dislocation of the hip is characterized by a violation of the position of the greater trochanter and the forced position of the limb. An example of the most common mechanism for obtaining such injuries is a strong blow to the knees of the driver and the passenger sitting in front in an accident.

In case of dislocation fractures of the pelvic bones, in addition to pelvic fractures, a complete displacement of the articular ends of the bones relative to each other is observed.

The above fractures can be either open or closed. With the former, damage to the skin in the area of ​​​​the fracture is observed, and, unlike the latter, they require urgent medical intervention, since they open the way to infection.

It should be noted the difference in the methods of treatment of low- and high-energy injuries of the pelvic bones. In the case of low-energy injuries, a conservative way of treatment is sufficient, while high-energy injuries require surgical intervention.

Symptoms of a pelvic fracture

During the initial visual examination of the victim, the following is recorded: a changed color of the skin, increased sweating, palpitations, a drop in blood pressure, as well as unbearable pain in the pelvic region and the inability to stand up. Destruction of the pelvic bones due to impact or compression is often accompanied by separation of their parts, which causes swelling and inflammation caused by complications due to fracture.

Fragments of bones can damage soft tissues, creating additional injuries and causing bleeding. Hematomas are observed in the area of ​​injury, a crunch is heard when palpated in the presence of moving bone fragments, which, in turn, can cause a rupture of the bladder or urethra. Open fractures increase the risk of infection and the development of purulent inflammation (bloody urine may appear). Along with traumatic shock as a result of a blow or compression of the pelvis, paralysis may develop as a result of damage to the nerves and vessels of the pelvic region by fragments of bones.

With a more detailed examination, experts note the following signs in the victim, characteristic of a fracture of the pelvic bones:

1. “Volkovich position” (“frog pose”): on the back, with hips apart and legs half-bent at the knees and hip joint, the feet of which are turned (rotated) to the outside. (The name bears the name of Professor N. M. Volkovich, who first described it in 1928).
2. Symptom of “stuck heel”: the inability to raise and hold the straightened leg on their own and keep it in a raised state if the leg was helped to raise it. This symptom is considered the most important in the diagnosis of pelvic fractures.
3. “Verneuil’s symptom” – increased pain in case of even slight compression of the wings of the pelvis.
4. “Larrey’s symptom” – increased pain in case of dilution of the wings of the pelvis.
5. Acute pain does not allow the victim to independently take a sitting position, since the adoption of this position is associated with tension in the rectus abdominis muscles, which are attached to the site of the most frequent pelvic fractures – its anterior section.
6. Turning the feet outward, characteristic of a reflex decrease in efforts from the adductor muscles of the thighs.
7. The inability to take the leg back and to the side (to the places of muscle attachment) when able to get up and walk is evidence of avulsion fractures.
8. Extensive hemorrhages in the area of ​​the perineum and groin also confirm the fracture of the anterior pelvis.
9. A change in the shape of the pelvis (asymmetry or visible deformity) is a clear demonstration of a severe fracture.
10. Drops of blood in the external opening of the urethra, as well as the impossibility of independent urination or blood at the end of urination, is evidence that a fracture of the pelvic bones is complicated by rupture of the urethra and injuries of the bladder, and sometimes the kidneys.

The establishment of the final diagnosis and the appointment of treatment in case of detection of such disorders is preceded by a comprehensive study in a hospital setting.

First aid for a pelvic fracture

Properly rendered first aid at the slightest suspicion of a fracture of the pelvic bones will help to avoid unpleasant consequences, and the speed and professionalism of those nearby will prevent death if the victim has severe pelvic injuries.

In the event that doctors immediately appeared next to the victim, the first step is to remove the shock symptom and reduce the pain syndrome. For this, anesthesia is carried out, in particular, the introduction of special drugs directly into the fracture site (analgesic blockades). If the injury is accompanied by bleeding, it is necessary to treat open wounds, apply pressure bandages to bleeding vessels, and in case of significant blood loss, restore the volume of blood circulation. Only after this, the patient must be carefully transferred to a stretcher and transported to the nearest medical facility.

However, doctors are not always immediately nearby, which is why up to 30% of victims with an isolated injury are admitted to the hospital in a state of traumatic shock. Statistics show that death in such cases occurs in 6% of cases. This is one third lower than in those hospitalized with multiple pelvic fractures, where shock is observed in almost all victims, and death occurs in 20% of cases, mainly as a result of heavy internal bleeding.

Before the arrival of doctors, it is especially important to properly prepare the victim for transportation. The following is an approximate algorithm for the actions of rescuers located next to the injured:

1. After calling the doctors, evaluate breathing, pulse and examine the victim for injuries.
2. Provide rest to the victim and, if necessary, fix the cervical spine.
3. Remove pain shock with available medicines, if they are at hand. For those who are conscious and without obvious signs of severe injuries of the pelvic organs, two tablets of Analgin and one Dimedrol (or Aspirin with butadione), as well as strong sweet coffee, are recommended as an anesthetic.
4. Plentiful warm drink to relieve traumatic shock. It is recommended to give the victim warm water (up to 3-4 liters), adding 1 tbsp. a spoonful of table salt and 1 teaspoon of baking soda for each liter.
5. Give the patient a tincture of valerian (up to 20 drops) and 20 drops of cordiamine (Valocordin or Corvalol) to prevent heart failure and sedation in order to avoid complications during transportation.
6. Lay the injured back on a hard surface, for example, a shield covered with a mattress or a door removed from the hinges, in the “frog” position: with the legs half-bent at the knee joints, raised by about 30 cm with a pillow placed under them or an impromptu roller, knees apart.
7. Wrap a scarf, sheet or other improvised material around the pelvis to prevent further displacement of the broken pelvic bones.
8. Surround the limbs, if they are not injured, with heating pads (bottles) with hot water and wrap the victim warmly, regardless of the air temperature.
9. Constantly monitor the pulse until the arrival of doctors and, if it is difficult to determine it, raise the foot end of the makeshift stretcher by 30-45 cm.

In cases where it is impossible to call an ambulance, the victim will have to be transported on their own. In such cases, it is necessary to gently fix his knee joints and feet and tie the injured person to an impromptu stretcher.

Diagnosis and treatment

If a fracture of the pelvic bones is suspected, it is important to deliver the victim to a medical facility as soon as possible, where he will be prescribed qualified treatment based on the results of the diagnosis.

In support of the assumption of a fracture of the pelvic bones, compiled on the basis of existing symptoms during a visual examination of the patient, a narrow-profile specialist prescribes x-rays and ultrasound of the pelvic organs. In some cases, computed tomography is used to confirm the diagnosis, as well as an operative research technique – diagnostic laparoscopy, which allows you to see the state of the abdominal cavity without large incisions.

Based on the results of a comprehensive study, the patient is prescribed treatment.

General principles of treatment

The treatment procedure, as a rule, is carried out in several stages and involves both taking medications and a number of surgical and physiotherapeutic procedures:

1. Anesthesia (intraosseous or intrapelvic anesthesia with novocaine blockades) and antishock therapy (morphine).
2. Fractional blood transfusion within 2-3 days after injury with isolated fractures of the pelvic bones. Transfusion of large volumes of blood, in particular, the introduction of plasma, glucose, saline or blood substitutes in the first hours after injury with severe pelvic injuries.
3. Conducting immobilization, the type and duration of which depends on the location of the injury and the condition (violation or integrity) of the pelvic ring. So, in cases of marginal or isolated fractures, conservative treatment is sufficient, for example, fixing the patient on a special shield or in a hammock using rollers and splints, and violations of the integrity of the pelvic ring require skeletal traction technology.
4. Surgical intervention is indicated for fractures with severe displacements in cases of the presence of bone fragments, for their fixation, as well as for damage to internal organs. It should be borne in mind that the procedure for compiling bones for fractures (reposition) should be carried out in the first three weeks after injury. After this time, it is practically impossible.
5. Rehabilitation after a fracture of the pelvic bones is a long process and requires sufficient strength and attention. The patient is prescribed drugs that include collagen protein, which contributes to the normal restoration of bones and special ointments and gels.

Fracture of the ischium of the pelvis

Such injuries can be caused by a strong impact on the pelvic area, in particular, a fall on the buttocks during ice or during sports. Its symptoms are severe pain, loss of consciousness, bruising and swelling in the pelvic area, and the possibility of internal bleeding.

To confirm the diagnosis, an x-ray is performed, which reveals the type of fracture and the localization of internal injuries. Conservative treatment lasts about a month, during which the patient is required to strictly adhere to bed rest. Another 2-3 weeks are spent on rehabilitation, after which the victim returns to normal life.

Fracture of the pubic bone of the pelvis

Injury to the pubic bone can be caused by squeezing the pelvis or hitting it, as a rule, does not cause damage to the pelvic ring, but is extremely dangerous due to the possibility of damage to internal organs. Its symptoms include swelling, inability to move, sticky heel syndrome, subcutaneous hemorrhages, and disruption of the genitourinary system.

In more than a quarter of cases, such a fracture is accompanied by damage to internal organs and traumatic shock.

Treatment can be both conservative and surgical and consists of 6 weeks of immobilization and a long rehabilitation period, the timing of which is individual and dependent on a number of factors.

Fractures of the acetabulum

Acetabular injuries caused by road traffic accidents or falls from a height account for approximately 16% of all pelvic fractures. They are accompanied by a violation of the integrity of the pelvis in the area of ​​the glenoid fossa of the hip joint, pain, forced position of the victim and impaired function of the limbs. To confirm the diagnosis, radiography and computed tomography are performed.

Conservative treatment for such fractures is indicated in more than half of the cases. It consists in skeletal traction on a special bed with a load of 6-8 kg for one and a half to two months. During traction, therapeutic exercises are performed and the victim must be prescribed a course of fraxiparin to prevent the formation of blood clots (phlebothrombosis).

With the ineffectiveness of conservative treatment, as well as in the case of severe injuries in the acetabular region, the question arises of the use of surgical intervention. However, such operations differ in their scale, duration and seriousness.

Surgery for a pelvic fracture

Surgical intervention is inevitable in displaced pelvic fractures, when the surgeon needs to fasten individual fragments of the damaged bone. For such cases in pelvic surgery, devices such as wires, screws, metal plates, pins and other metal structures for fixing (connecting) bones are provided.

Surgical manipulations on the pelvic bones with the help of such implants are called osteosynthesis and are performed using general anesthesia. During the operation, the surgeon will have to carefully examine the internal organs that are located in the pelvic area, and eliminate the injuries resulting from injuries using internal fixation (submersible osteosynthesis). During this manipulation, implants can be installed directly on the bone, inside it, or in combination, while remaining forever inside the body.

Osteosynthesis is also divided into closed (extrafocal) and open, based on the method of its implementation (exposure of the manipulation zone). In modern pelvic surgery, minimally invasive osteosynthesis is increasingly used, in which the installation of implants is preceded by mini incisions or skin punctures.

The use of osteosynthesis for injuries of the acetabulum is not always justified and is determined by the nature of the fracture and its location (wall or bottom). In particular, the effect of such a surgical intervention in the case of a multi-comminuted fracture of the bottom is significantly lower than in cases of a large-comminuted fracture of the posterior wall.

In some cases, external fixation (percutaneous) is used, in which Ilizarov devices, rod devices and their other analogues are used. They are distinguished by a superficial location in relation to the bone.

How long does a pelvic fracture heal

A pelvic fracture is a serious injury, the outcome of the treatment of which depends on the fate of a person. If the wrong treatment was carried out or the patient did not follow the prescriptions of the doctors, the bones can grow together incorrectly and cause permanent problems in the future.

In general, it can take four to six months for the pelvic bones to fuse and rehabilitate after an injury, but for severe injuries, full recovery can take years. Despite the advances in modern traumatology, the number of people with disabilities after pelvic injuries remains quite significant (approximately 15%). In addition, pelvic injuries almost always cross out the career of professional athletes.

Although there is no specific time frame for complete healing of such injuries, there are a number of factors that are taken into account when making a prognosis.

These include the following:

1. Fracture type: open or closed.
2. The location of the injury and the number of injured bones and tissues.
3. Level of supply of damaged bones with blood.
4. Age of victim: It can take six months for adult bones to fuse, but only one for children.
5. General health: the level of bone mineralization, the state of the blood and muscle tissue.
6. The presence of aggravating factors: bad habits, concomitant and chronic diseases, etc.

Rehabilitation after a pelvic fracture

A pelvic fracture refers to severe injuries of the musculoskeletal system and requires a professional approach of specialists not only in the diagnosis and treatment, but also in the course of rehabilitation measures up to the complete recovery of the victim.

Full recovery from pelvic injuries, depending on the severity of the fracture, can take from one and a half to six months. Individual complexes will help in this, developed specifically for each case and including a number of the following activities:

1. Daily exercise therapy to maintain muscle tone, including special exercises to prevent the development of ankylosis, contractures and other joint complications.
2. Taking special medicines that help strengthen bones and nourish them with collagen for a complete restoration of the musculoskeletal system.
3. The use of ointments, creams and gels that restore the functioning of the joints and relieve pain and swelling of tissues.
4. Therapeutic massage, physiotherapy.
5. Walking in the fresh air with a gradual increase in their duration.
6. Proper diet. Consumption of foods high in calcium: sea and river fish, dairy products, greens, vegetables, nuts, persimmons, green beans, poppy seeds, sesame seeds, rose hips.

Consequences of a pelvic fracture

Large nerve and blood vessels are concentrated inside the pelvis, and the roots of the spinal cord end. In front of it there are nerve nodes and plexuses, also in the pelvic region there are five of the largest joints, two of which belong to the powerful joints of the body.

A fracture of the pelvic bones always leads to damage to the nerves, and often to the organs located there, which causes pain that does not go away for a long time. It, in turn, causes gait disturbance and even sexual dysfunction.

In addition, the damaged muscles that surround the pelvis only exacerbate the gait disorder. Their recovery can take almost a year, while lameness can be observed for several months. In particularly severe cases, a fracture of the pelvic bones may result in a shortening of the limb, in some cases, slow fusion of bone tissue is possible, leading to partial or complete loss of mobility.

Statistics show that deaths in victims as a result of a pelvic fracture are mostly associated with large blood loss. Abundant bleeding, in turn, is explained by the structure of the pelvis, which is surrounded by a significant number of muscles that do not allow blood vessels to sharply decrease in the lumen in order to stop the bleeding. In addition, hemostatic thrombi do not linger in damaged vessels due to the suction properties of fatty tissue inside the pelvis. In this regard, with a fracture of even one bone of the anterior pelvis, blood loss can reach almost a liter (700-800 ml).

Blood loss in more severe cases (fracture of the anterior and posterior pelvis, accompanied by rupture of the joints) ranges from 2,5 to 3 liters. The reason for such a long “fibrinolytic” bleeding is a violation associated with blood clotting.

In addition, traumatic compression can cause sensory impairment (paresthesia), the development of infectious inflammation (osteomyelitis), and joint deformity (osteoarthritis).

Among the complications are also damage to the internal organs (genitourinary system, intestines, sometimes kidneys), improper bone fusion, muscle atrophy or hypertrophy, and the formation of outgrowths on the bones.