pelvic fracture
Introduction
Introduction to pelvic fracture A pelvic fracture is a serious trauma that is caused by direct violent pelvic compression. More common in traffic accidents and landslides. In wartime, there were firearm injuries, pelvic fractures were traumatic, and more than half were accompanied by comorbidities or multiple injuries. The most serious is traumatic hemorrhagic shock, combined with pelvic organ injury, and a high mortality rate due to improper treatment. basic knowledge The proportion of illness: 0.3% Susceptible people: no specific population Mode of infection: non-infectious Complications: hemorrhagic shock retroperitoneal hematoma
Cause
Causes of pelvic fracture
Trauma factor (90%)
Violence directly affects the pelvis, causing damage to the integrity of the bone, causing pelvic fractures, and pelvic fractures caused by direct violence become the main cause of pelvic fractures. In addition, pelvic fractures caused by squeezing violence are more common in traffic accidents and landslides. Local swelling, pain, subcutaneous ecchymosis after pelvic fracture; often urethral injury, urethral bleeding, dysuria, perineal hematoma, bladder rupture, hematuria, abdominal pain, nausea, vomiting and other complications.
Pathogenesis
Most of the pelvic fractures are caused by direct violent impact, crushing the pelvis or falling from a high place. Sudden exertion is too strong during exercise. The muscles from the pelvis suddenly contracted violently, which may cause the pelvic avulsion fracture at the starting point, low energy. Most of the fractures caused by injury do not destroy the stability of the pelvic ring. It is relatively easy to treat. However, medium and high energy injuries, especially motor vehicle traffic injuries, are not limited to the pelvis. When the pelvic ring is damaged, it often combines extensive soft tissue injuries. Intrapelvic organ injury or other bone and visceral injuries, therefore, pelvic fractures are often one of the multiple injuries, 20% of those with multiple pelvic fractures, and 25% to 84.5% of those with pelvic fractures. Pelvic fracture is one of the three major causes of motor vehicle accident death, second only to head injury and chest injury. Early death after injury is mainly caused by massive bleeding, shock, multiple organ failure and infection, etc. In the treatment of pelvic trauma, prevention of life-threatening bleeding and timely diagnosis and treatment of combined injuries is the key to reducing the mortality rate.
Prevention
Pelvic fracture prevention
There are no special preventive measures for this disease, mainly to pay attention to production and life safety and avoid trauma.
The postoperative functional exercise is more important to the patient. The patient and his family should be introduced to the meaning and method of functional exercise. The functional exercise mode varies according to the degree of fracture.
(1) Does not affect the intact fracture of the pelvic ring:
1 simple fracture, no combined injury, no need to reset, bed rest, supine and lateral alternate (healthy side), early in the bed to do upper limb stretching, lower limb muscle contraction and ankle activity.
2 After 1 week, the patient was practiced in a semi-recumbent position and a hip joint, and the flexion and extension of the knee joint.
3 2-3 weeks after the injury, if the general condition is still good, you can get out of bed and walk slowly, and gradually increase the amount of activity.
4 After 3-4 weeks of injury, do not limit activities, practice normal walking and squatting.
(2) A fracture that affects the integrity of the pelvic ring:
1 After the injury, there is no comorbidity, rest in a hard bed, and perform upper limb activities.
2 In the second week after the injury, the semi-sitting position was started, and the lower limb muscle contraction exercise was performed, such as quadriceps contraction, ankle joint extension and plantar flexion, and toe flexion and extension.
3 In the third week after the injury, the hip and knee joint activities were carried out on the bed, first passive, then active.
4After the injury, the 6th to 8th week (that is, the clinical healing of the fracture), the traction is fixed, and the abduction is walking.
5 Gradually exercise in the 12th week after the injury, and abandon the weight-bearing walk.
Complication
Pelvic fracture complications Complications, hemorrhagic shock, retroperitoneal hematoma
(A), hemorrhagic shock: bleeding at the fracture end and posterior structural damage caused by rupture of the anterior tibiofibular plexus as the main cause of shock, large blood vessels rupture less, only 10-15%, other reasons for open wounds, blood pneumothorax , intra-abdominal hemorrhage, long bone fractures, etc.
(B), retroperitoneal hematoma: the bones of the pelvis are mainly cancellous bone, there are many pelvic wall muscles, there are many arterial plexus and venous plexus in the vicinity, the blood supply is abundant, and the gap between the pelvic cavity and the posterior membrane is composed of loose connective tissue. There is a large gap to accommodate bleeding, so extensive bleeding can occur after a fracture. A large retroperitoneal hematoma can spread to the kidney, underarm or mesentery. Patients often have shock and may have symptoms of abdominal pain, abdominal distension, weakened bowel and abdominal muscle tension. In order to distinguish from intra-abdominal hemorrhage, abdominal biopsy can be performed, but the puncture should not be too deep to avoid entering the retroperitoneal hematoma, which is mistaken for intra-abdominal hemorrhage. Therefore, it is necessary to observe carefully and repeatedly.
(C), urethral or bladder injury: patients with pelvic fractures should always consider the possibility of lower urinary tract injury, urethral injury is much more common than bladder injury. Patients may have dysuria and urethral hemorrhage. When bilateral pubic symphysis fractures and pubic symphysis are separated, the incidence of urethral membrane damage is higher.
(D), rectal injury: unless pelvic fracture with open genital injury, rectal injury is not a common complication, rectal rupture, such as occurs in the peritoneal reflex, can cause diffuse peritonitis; if it occurs below the reflex, An infection around the rectum can occur, often as an anaerobic infection.
(5), nerve damage: more occurs in the fracture of the tibia, S1 and S2 that constitute the lumbosacral nerve trunk are most vulnerable to injury, muscle strength of the gluteal muscle, hamstring and calf muscles can be weakened, the back of the calf and the lateral side of the foot Part of the feeling is lost. When the sacral nerve injury is severe, Achilles tendon reflex can disappear, but sphincter dysfunction rarely occurs. It is related to the degree of nerve damage. Mild injury is good afterwards, and it is expected to recover within one year.
Symptom
Symptoms of pelvic fracture Common symptoms Acute pain Abdominal pain Pelvic damage Funnel Pelvic bladder dysfunction Bloating Skin Pale pubic symphysis Separation sphincter dysfunction Urinary pain
(1) The patient has a history of severe trauma, especially the history of traumatic injury of the pelvis.
(B), a wide range of pain, increased activity when the lower limbs or sitting position. Local tenderness, congestion, lower extremity rotation, shortening deformity, urethral bleeding, perineal swelling.
(C), umbilical spine distance can be seen to increase (separate fracture) or reduced (compression fracture); posterior iliac spine can be increased (compression fracture), reduction (isolated fracture), upshift (vertical fracture) ).
(D), pelvic separation and compression test, 4 characters, torsion test is positive, but it is forbidden to check patients with severe fractures.
Examine
Pelvic fracture examination
For most pelvic fractures, the fracture mechanism can be judged by a positive radiograph, the initial first aid plan is determined, and other imaging studies can help with fracture classification and guide the final treatment.
(1) X-ray inspection
1. The pelvis positive position. Routine, necessary basic examination, 90% of pelvic fractures can be found by orthotopic examination.
2. The pelvic entrance slice. When the tube is tilted 40° to the head, it can better observe the fracture of the radial humerus, dislocation of the ankle joint, anterior and posterior pelvic rotation, pubic symphysis fracture, and pubic symphysis separation.
3, pelvic outlet tablets. When shooting, the tube is tilted 40° to the tail end to observe whether the tibia and the pupil are fractured and whether the pelvis has a vertical displacement.
(two), CT
CT is the most accurate method of examination for pelvic fractures. Once the patient's condition is stable, a CT scan should be performed as soon as possible. For the posterior pelvic injury, especially the tibiofibular fracture and ankle joint injury, the CT examination is more accurate. CT examination should also be performed when the acetabular fracture is involved. CT three-dimensional reconstruction can more accurately show the anatomy of the pelvis and the fracture between the fractures. The positional relationship, forming a clear and realistic three-dimensional image, is of high value for judging the type of pelvic fracture and determining the treatment plan. CT can also display both retroperitoneal and intra-abdominal bleeding.
(three), angiography
For the diagnosis and treatment of large blood vessel hemorrhage, ruptured large blood vessels can be found by angiography and bleeding can be controlled by embolization of blood vessels.
Diagnosis
Diagnosis and diagnosis of pelvic fracture
diagnosis:
1. The patient has a history of severe trauma, especially the history of traumatic pelvic compression.
2, extensive pain, increased activity in the lower limbs or sitting position, local swelling, subcutaneous ecchymosis in the perineal, pubic symphysis, tenderness, from the bilateral sacral site inward or outward separation of the pelvic ring, fractures are Pain caused by being pulled or squeezed (pelvic crush separation test).
3. The limbs of the affected side are shortened, shortening from the umbilical to the length of the medial malleolus, but the anterior superior iliac spine to the medial malleolus length often does not shorten the dislocation of the femoral head. When the ankle joint is dislocated, the affected side is paralyzed. The spine is more prominent on the healthy side, and the distance from the spinous process is also shorter than the healthy side, indicating that the posterior superior iliac spine is posterior, upward, and displaced toward the midline.
Differential diagnosis
1. Pelvic ring fracture:
The fracture line runs through the pelvic ring structure, which interrupts the pelvic ring. Single fractures often have unilateral pubic fractures, pubic symphysis, unilateral tibiofibular fractures, acetabular fractures and unilateral ankle subluxation with small fractures. Multiple fractures often have bilateral pubic symphysis fractures, pubic symphysis fracture with pubic symphysis separation, pubic symphysis fracture and pubic fracture with ankle dislocation.
2. Pelvic edge fractures:
Common fractures of the humerus, partial pubic bone fracture, acetabular edge fracture and appendix fracture, etc., the fracture line shape can be horizontal or oblique, the displacement can be less obvious.
3. Pelvic avulsion fracture:
The fracture site is often located in places where strong muscles are attached, such as the anterior superior iliac spine, the anterior iliac spine and the ischial tuberosity. The fracture fragments are often less and often displaced.
