Injury,
325
6. 325-333
Dislocation and fracture-dislocation of the pelvis P. R. W. Monahan Consultant Accident and Orthopaedic Princess Margaret Hospital, Swindon
Surgeon,
R. G. Taylor Consultant Orthopaedic
Surgeon, United Oxford Hospitals Group
Summary
Dislocation and fracture-dislocation of the pelvis is a major injury; the force involved in its production may not only disrupt the pelvis but result in extensive associated injuries. Between 1960 and 1968, 43 patients with this injury were treated in the Accident Service of the Radcliffe Infirmary. Their case records and radiographs have been analysed and 29 of the patients re-assessed at a follow-up examination. CLASSIFICATION THE pelvic dislocation has been divided into 3 groups according to whether the pubic symphysis or the sacro-iliac joints were subluxed or dislocated singly or in combination. Group l-Subluxation or dislocation of the symphysis pubis Group 2-Subluxation or dislocation of the sacro-iliac joint(s)
3-Subluxation or dislocation of the symphysis and the sacro-iliac joint(s) These 3 groups have been further divided into 3 types if the pelvic dislocation was associated with one or more fractures, in order to give some indication where necessary of the evtent of fracture round the pelvic ring. For descriptive purposes the hemipelvis is divided into 3 segments (Fig. 1): an anterior segment comprising the ischium and pubis; a middle segment containing the acetabulum and ilium; and a posterior segment, the sacrum. Type A refers to fractures involving any one of the above segments of a hemipelvis and types B and C to fractures involving 2 and 3 of these segments respectively (Figs. 2,3 and 4). FINDINGS 1. Age and sex Of the 43 patients, 38 were male and 5 female. Their ages ranged from 2 to 69 years (average 30.9 years), and 28 patients were under 30 years of age. 2. Cause of injury (Table I) The majority of the patients were either knocked down or were riding motor cycles at the time of their accident.
Group Fig. 1.--Fracture
dislocation of the pelvis.
3. Type of dislocation or fracturedislocation sustained (Tab/e //) Nine patients sustained group 1 injuries. In 7 of them one segment of the hemipelvis was fractured and in one of these patients the fracture was bilateral. The remaining 2 patients had 2 and 3 segments fractured. Fourteen patients had
Injury: the British Journal of Accident
326 Table
/.-Cause
Cause
of injury
Knocked down Motor cycle Crush Car occupant Fall from height Hit on back
the sacro-iliac joints giving rise to the ‘ bivalve pelvis ‘. Of the remaining 14 patients in this group 7 were type A, 4 type B and 3 type C. One patient with a group 3, type A injury had bilateral fracture-dislocation. A displacement of one hemipelvis in relation to the other varies both in its degree and in its axis of displacement. Varying degrees and types of displacement were seen in this series. The most obvious clinically were those pelvic fractures with cranial displacement of one
of injury No. of patients 13 12 7 6 4 1
Fig. 2.-A, Fracture dislocation and fracture left ilium.
Surgery Vol. ~/NO. 4
of the pelvis.
B, Group
2 injuries and the majority (8 cases) had fractures involving 2 segments (type B). Three patients in this group had dislocation of both sacro-iliac joints, and in 4 patients the segmental fractures were bilateral. Twenty patients had group 3 pelvic injuries, in 6 of whom there were no associated fractures. Two of these patients had bilateral dislocations of
group
I, type A injury.
Dislocation
of the symphysis
pubis
hemipelvis producing the apparent shortening of a leg. This occurred in 6 patients as shown in Table III. Three of these 6 patients had sustained a crushing injury, and of the remaining 3 patients one had fallen from a height, another was the driver of a car and the last patient was a pedestrian knocked down by a car. 4. Associated injuries (Table IV) Twenty-two patients (51.1 per cent) hadassociated skeletal injuries. Many of the limb fractures were comminuted in type and involved several levels. Tab/e //.-Incidence
Group
1
2
Fig. 3.-Fracture-dislocation of the pelvis. Group 2, Bilateral subluxation sacro-iliac type B injury. joints. Fracture of sacrum. Fracture of right superior and inferior pubic rami.
3
Type A B C A B C A B C
of pelvic fracture-dislocation No. of patients 7 1 1 5 8 1 6 7 4 3
Bilateral involvement Sacro-iliac jts Fractures 1
3
2 2
2 1
327
Monahan and Taylor: Dislocation of Pelvis Tab/e ///.-Cranial
displacement of a hemipelvis
Type of pelvic injury
No.
of patients
Group 2 Group 3 Group 3
Type B Type C
3 1 2
In 25.6 per cent there was an associated fracture of the sacrum. The distribution of the spinal, upper and lower limb fractures between the 3 groups of pelvic injury is shown in Table V. It can be seen that the skeletal fractures are fairly
equally distributed between the 3 groups of pelvic injury. Eighteen patients (44.8 per cent) had major soft-tissue injuries. Patients with head injuries and with microscopic haematuria are excluded from this figure. The organs and structures involved are listed in Table VI. Seven patients (16.2 per cent) required laparotomy and of these 3 had sustained group 1 pelvic injuries, 3 group 2, and one group 3 injuries. Six patients had chest injuries. Table /V.-Associated Type of injury Fracture Skull Thoracic spine Lumbar spine-body transverse process Ribs Clavicle Humerus Radius Ulna Carpus Hand Neck of femur Shaft of femur Tibia Fibula Foot Fracture-dislocation Mid tarsal Tarso-metatarsal Dislocation Aromio-clavicular Shoulder Hip (posterior)
Fig. 4.-A, 6 and C, Fracture-dislocation and symphysis pubis. Fracture sacrum.
Fracture neck left femur.
skeletal injury No. of patients
4 2
3 5 5 1 4 3 2 1 4 3 3 7 8 3
of the pelvis group 3, type C injury. Dislocation left sacro-iliac joint Fracture left ilium. Fracture right superior and inferior pubic rami.
328
Injury: the British Journal of Accident Surgery Vol. ~/NO. 4
Table V.-Distribution of skeletal fractures the 3 groups of pelvic injury Fracture
Group
Spinal
Upper limb
Lower
limb
No. of patients
between
Percentages
1
2
22.2
2 3
6 2
42.8 10.0
3 4
21.4 20.0
3 5 5
33.3 35.7 25.0
-
1 2 3 1 2 3
Tab/e V//.-Blood
transfusion
No. of patients requiring transfusion
Group
1
Average no. of units of blood
7 12 13
2 3
5 7 8.4
Tab/e V///.-Distribution Group
of neurological
No. of patients
1
The diagnosis of retroperitoneal haemorrhage was made at laparotomy, by marked displacement of one or more of the ureters on intravenous pyelography, or by the obliteration of the psoas shadows on plain abdominal radiographs. The incidence may well have been higher as the diagnosis of retroperitoneal haemorrhage can be difficult to make with certainty. 5. Resuscitation (Table V/l) Nineteen patients (44.1 per cent) had barely recordable, or unrecordable blood pressure on admission. Thirty-two patients (74.4 per cent) required resuscitation with whole blood. The number of units of blood given ranged from 1 to 26 units (average 7.1 units).
soft-tissue
Type of injury
Head Chest Haemothorax Pneumothorax Lung contusion Ruptured diaphragm Abdominal (requiring laparotomy) Bladder Urethra Liver Spleen Kidney Large bowel Retroperitoneal haemorrhage Arterial Femoral A Coeliac A, Hepatic A Ligamentous Knee
injuries No. of patients
35 6 2 3 1 1
injury Percentage
4 5 7
2 3
Tab/e V/.-Associated
requirement
25 21.2 43.7
6. Neurological injury (Table V//I) Sixteen patients (37.2 per cent) had some neurological involvement of their lower limbs as a result of the pelvic injury, rather than from the head injury alone if this was also present. In 2 out of the 4 group 1 patients there was a fracture of the middle pelvic segment and one patient had a sacral fracture as well. The fourth patient had an anterior segment fracture. All 5 patients in group 2 with neurological involvement had fractures of an anterior segment; 4 of these patients also had fractures of the sacrum and 2 patients had fractures of the middle pelvic segment. Three out of the 7 patients in group 3 with neurological injury had pure pelvic dislocation without associated fractures. The remaining 4 patients had fracture-dislocation of the pelvis; 2 were of type A (middle segment), one type B
Table /X.-The pelvic injury with urinary tract trauma Injury Type Group
(N~~~$$..
sustained
by patients
Associated
injury
7 3 3 2 1 1 2 6
1
2
A C
2 1
A
4
B C
7 1
A B C
4 2 2 2
Rupture bladder Rupture bladder Rupture urethra Rupture urethra
3 2 1 3 2
Rupture bladder
329
Monahan and Taylor: Dislocation of Pelvis fabie X.-Duration
of treatmant Average in days
Period of bed rest Full weight-bearing Inpatient stay
afterwards
32.4 51.4 45.4
(anterior and middle segment) and one was of type c. Five of the 16 patients had numbness involving the sacral dermatomes; 4 had fractures of the sacrum and the fifth patient had a grossly displaced sacro-ifiac dislocation. The remaining 11 patients had signs of sciatic nerve involvement, though in one patient a posterior dislocation of the hip may have accounted for the sciatic nerve injury, 7. Haematuria (Table IX) Twenty-five patients (58.1 per cent) had haematuria on admission. In 12 patients this was microscopic, and in 13 macroscopic. All 4 patients with urinary tract injury had pelvic injuries associated with fractures involving the pelvic ring. In 2 patients with a single fracture of the pelvic ring, the combined bladder and urethral injury was associated with a fracture involving the anterior pelvic segment; the patient with a rupture of the bladder alone had a pelvic injury associated with a middle segment fracture.
TREATMENT All the pelvic dislocations or fracture-dislocations were treated conservatively, either by the use of a pelvic sling (in f 6 patients) or by bed rest with the hip flexed and the leg resting on a frameorpillows. Skeletal traction was used to correct cranial displacement of a hemipelvis if present. The duration of treatment is shown in Table X. MORTAUTY There were 4 deaths in this series giving a mortality of 9.3 per cent. One patient died on the day of admission having sustained a group I, type A pelvic injury associated with an abdominal injury comprising a rupture of the left lobe of the liver, a tear of the vessels in the porta hepatis and a tear at the coeliac axis. The second patient died 24 hours following admission having sustained a group 2, type A pelvic injury with multiple lower limb fractures, a fracture of the body of the first lumbar vertebra, an abdominal injury with almost total avulsion of the bladder base from the prostate, a large retroperitoneal haematoma and a rupture of the hilum of the right kidney. The third patient was a lady of 69 years of age with a severe head injury, bilateral rib fractures, a haemothorax, a group 2, type A pelvic injury, and a fracture of the right tibia. The fourth patient was a girl aged 13 years
Tab/e X//.---Clinical Tab/t? X/.-Symptoms
signs found on examination
in 29 patients Clinical signs
Pain Lumbar spine Sacro-iliac joints
11 (bifat*Z
Pubis Sciatica Gait (limping) Neurological Paraesthesia Numbness Muscle weakness Urological Dysuria Frequency Haematuria Poor stream impotence : decreased complete Child birth problams Chest Claudication
Na. of patients
No. of patients
Symptoms
in
2)
3 1: IQ 85 0 4 0
desire
ri
2 1 =5 0 2 I
Back Normal Kyphosis Scoliosis (lumbar) Pain/discomfort on compression of sacro-iliac joints Pafpation of pubis wide painful Compression of pubis painful Visibfe pelvic deformity Leg-length discrepancy Muscle wasting of leg Diminished sensation leg and/or buttocks Diminished muscle power Positive Trendelenburg sign Diminished aeration of chest
20 3 6 2 4 2 0 5 all minimal 4 all minimal 13 all uniiateraf 8 9 :
330
Injury:
a group 2, type A pelvic injury and severe head injury including a left subdural haematoma. She died on the third day.
with
FOLLOW-UP
STUDY
Of the 39 patients who are alive, 29 have been traced and re-examined. The follow-up interval varied from three months to eight and threequarter years (average three and a half years). A detailed history was obtained and particular attention paid to any symptoms arising from the spine, the sacro-iliac joints and pubis, as well as symptoms involving the respiratory, abdominal, urogenital and neurological systems. The patient was then fully examined, paying particular attention to those symptoms noted in the clinical history. The symptoms complained of are listed in Table XI. The lumbar back pain in all cases was of an aching type. The sacro-iliac joint pain was severe in 2 patients in whom the follow-up interval was less than 6 months. Twelve patients (41.4 per cent) complained of neurological symptoms. There was no correlation bet,keen the distribution of these symptoms and the type of pelvic injury except for those affecting the sacral dermatomes. Three out of 4 patients with sacral nerve symptoms had fractures involving the sacrum, and the fourth had a group 3 pelvic dislocation with gross displacement of a hemipelvis. Six patients had symptoms solely involving the sciatic nerve and in 4 patients the femoral nerve was involved. None of the patients with urological symptoms had these symptoms before their injury. The clinical signs found on examination are listed in Table XII. Muscle wasting of a leg was the commonest abnormality and in the majority of patients it was of a minor degree. There was no case of leg-length discrepancy.
TYPE OF OCCUPATION BEFORE INJURY All occupations that did not involve heavy lifting were classified as light work. One patient was unemployed before his accident and of the remaining 28 patients, 19 were employed in light work and 9 in heavy occupations. Eight patients in the light occupation group were at school or college.
TIME OFF WORK INJURY
FOLLOWING
One patient out of the total of 29 patients cannot now be traced. Of the remaining 28 patients, 3 are still off work. Two of these men had group 3,
the British
Journal
of Accident
Surgery
Vol. ~/NO. 4
type C pelvic injuries and the third a group 2, type B injury, and all 3 patients had multiple associated injuries. The interval from the time of their injury was three years, two years, and one and a half years. The time off work of the remaining 25 patients varied from six to eighteen months. All 25 patients returned to their original occupations. The 3 patients who are still off work are a steeple-jack, a demolition worker and an engineer.
DISCUSSION Dislocation and fracture-dislocation of the pelvis is a major injury; the force involved in its production may not only disrupt the pelvis, but result in extensive associated injuries. A constant awareness of possible injury to the pelvis and the sequelae is essential to all surgeons concerned with care of the injured patient. This type of pelvic injury is produced principally in 2 ways. Taylor (I 942) stated that indirect violence was one mechanism involved. The hyperextension or hygerabduction of the lower limb on the trunk caused a strong force by the system of levers to disrupt the symphysis pubis. Once the anterior tie beam had been severed, a continuation of the force caused the sacro-iliac joints to open out anteriorly and subsequently to dislocate if the force was continued. Taylor showed that with cadavers, the easiest and most rapid method of dislocating both the symphysis pubis and the sacro-iliac joint was by hyperextending the lower limb in a position of external rotation and abduction. Tf a hyperextension force was exerted at the hip joint it was found that the symphysis pubis separated to a considerMoreover dislocations thus able degree. produced were most easily reduced by flexion, adduction and internal rotation. The late Sir Frank Holdsworth (1948) considered the injury to be due predominantly to direct violence, with an anteroposterior, a lateral, or a torsional stress being applied to the pelvis. With an anteroposterior deforming force, one or both hemipelves are forced against the fixed sacrum, the initial force being expended on the anterior nonweight-bearing segment of the pelvis comprising the pubis and its rami. This may result in diastasis or dislocation of the symphysis pubis and/or fracture of the body of the pubis and its rami. With a continuation of this force the pelvis opens out ‘ like the leaves of a book ’ (Watson-Jones, 1938) and the sacro-iliac joint dislocates or a fracture occurs through the ilium adjacent to this
Monahan
and Taylor:
Dislocation
of Pelvis
joint. A lateral crushing force applied to the pelvis generally causes a bilateral fracture of both pubic rami or a unilateral fracture of both the pubic rami and separation of the pubic symphysis (Watson-Jones, 1955). In general, the more violent the force of impact to the pelvis, the greater the extent of its injury. The classification of fracture-dislocations and dislocations in this study defines the presence of a dislocation at the symphysis pubis and/or the sacro-iliac joint and its association with fractures of the pelvic ring and the extent of these fractures. The pelvis should be carefully examined in all injured patients. Abrasions and skin contusions may indicate the site of impact. Visible swelling due to a haematoma may occur from fractures of the pelvis, pelvic ring or injury to associated structures, for example the bladder, urethra and major blood vessels. The pubis is palpated for evidence of a fracture or separation of the symphysis, and the sacro-iliac joints are examined for signs of separation or the presence of associated fractures. In the more severe group 1, type C injuries there may be visible deformity of the pelvic girdle; one hemipelvis may be displaced inwards, outwards or proximally in relation to the other side. This may result in either an internal or external rotation deformity of a leg with occasionally an apparent shortening of the leg if a proximal shift of one hemipelvis has also occurred. The instability of one hemipelvis on the other is determined by gentle anteroposterior or lateral pressure on the pelvic ring, which may not only give detectable movement of the ring but pain at the site of an associated fracture or dislocation. Peltier (1965) stated that haemorrhage was the most serious complication following fractures of the pelvis. In this series we also found that peripheral circulatory failure due to blood loss was one of the most important signs; 44.1 per cent of our patients were acutely shocked. The pelvis is a vascular structure closely associated with major blood vessels and the venous plexuses surrounding the bladder, prostate, vagina and rectum. Injury to these structures by sharp spicules of bone may cause massive haemorrhage. Displacement of a sacro-iliac joint may rupture the iliolumbar vessels passing in front of it. Seventy-four per cent of our patients required resuscitation with an average of 7 units of whole blood (range 1 to 26 units) and there was a progressive increase in the need for blood from the group 1 to the group 3 pelvic injury. The force producing the pelvic injury is often severe and the incidence of associated injury may be high. Fifty-one per cent of our patients had
331
other skeletal injuries. A constant awareness of injury to other organs is essential as direct violence to the pelvic girdle may also involve intraabdominal organs, and the clinical signs of their injury may not be obvious in the acutely shocked patient. Injury to the bladder and urethra should always be considered. Moderate force applied to the front of the lower part of the abdomen may do no more than produce a haematoma of the bladder wall with resulting microscopic haematuria. Fifty-eight per cent of our patients had haematuria on admission, and in half of them it was microscopic in type; Levine and Crampton (1963) noted an incidence of 34.8 per cent in their series of 425 patients with pelvic fractures. An increasing force applied to the abdomen during injury may cause intraperitoneal rupture of the bladder, previous distension of this organ making it more vulnerable. Carruthers and Logue (1953), discussing the complications following a pelvic fracture, put the incidence of urological injury at about 10 per cent; our finding in this series was 9.3 per cent. Levine and Crampton (1963) found that the only fracture of the pelvis common to all their patients with rupture of the bladder was a fracture involving the pubic rami. All 3 patients in this series who sustained bladder rupture had a fracture involving the anterior pelvic segment. Ruptures of the urethra commonly affect the posterior urethra, and Trafford (1958) believed that the posterior urethra was most commonly injured in fractures with displacement of the pubic bones and rami. This was the case in our 2 patients who had sustained posterior urethral rupture. Rupture of the diaphragm, which occurred in one patient in this series may occur in association with pelvic injuries (Levine and Crampton, 1963), as may injury to the rectum and vagina. Entrapment of bowel in pelvic fractures has also been described (Arnold, 1907; Lunt, 1970). Patterson and Morton (1961) make a plea for a greater awareness of possible neurological injury in pelvic fractures and dislocations. The sciatic, femoral, gluteal, posterior cutaneous nerve of the thigh, lateral femoral cutaneous and obturator nerves may all be involved. Direct injury to nerves can come from high velocity impact or crushing. The lumbosacral nerve trunks lying close to the sacro-iliac joints may be damaged by traction or compression from contact with adjacent bones or because of a tense retroperitoneal haematoma. Sacral fractures, whose incidence is higher than generally recognized in this injury (Furey, 1942), may account for damage to the sacral nerves.
332
Thirty-seven per cent of our patients sustained a neurological inJury as a direct result of their pelvic injury (Table VIII). The incidence was higher in those patients with a group 3 injury (44 per cent) than those with a group 2 (31 per cent) or group 1 (25 per cent) injury. Eleven out of the 16 patients had sciatic nerve involvement, and of the remaining 5 patients with sensory symptoms involving the sacral dermatomes, 4 had visible fractures of the sacrum. A patient with this major pelvic injury requires immediate and effective resuscitation with intravenous fluid replacement and oxygen therapy, because as pointed out by Moyson et al. (1957) shock is common in this type of injury. 44.1 per cent of our patients were acutely shocked and they required an average of 7 and 8.4 units of whole blood in the group 2 and group 3 injuries respectively. The control of retroperitoneal intrapelvic haemorrhage is by the stabilization and reduction of the pelvic fracture-dislocation. The control of bleeding points by ligation of vessels is difficult and in the majority of cases is unnecessary as spontaneous arrest occurs. Bayliss al. (1962) explored 25 patients with et retroperitoneal haematomata without associated intraperitoneal bleeding, and in only one patient could a bleeding point be found and ligated. The only patient in this series with a large retroperitoneal haematoma who died, did so from severe multiple injuries, and at laparotomy uncontrollable major vessel bleeding was not found. The treatment of the fracture-dislocation is usually by non-operative methods. The aim of treatment is to re-align as anatomically as possible the major displacements of the pelvis. The accurate re-alignment of individual fractures, with the exception of those involving the hip joint, is unnecessary and would jeopardize the survival of many of these seriously injured patients. The technique of lateral recumbency and plaster was devised by Watson-Jones (1938, 1955) and the sling method by Astley Cooper (1842). The sling method, as used in our patients, provides lateral compression and stability to the pelvis. The displacing action of the extended limb at the hip joint through the system of levers (Taylor, 1942) is prevented by flexing the hip with the leg resting on a Braun’s frame. Any cranial displacement is corrected by skeletal traction applied through the tibia. Manipulation of the pelvis may be necessary, using the leg on the side of the pelvic injury as a lever. The medial displacement of a hemipelvis may be reduced by gradual strong abduction and extension of the hip on the
Injury:
the British Journal
of Accident
Surgery
Vol. ~/NO. 4
affected side, using the adductor and flexor muscles to control the pelvic fragment. A turnbuckle method of reduction is recommended by Jahss (1935) and Carruthers (1945). Various forms of operative reduction have been recommended, mainly for fractures involving the acetabulum. In this conservatively treated series of patients the average period of bed rest was 32.4 days, the inpatient stay was an average of 44.4 days, and full weight-bearing was permitted after an average of 5 I.4 days. Twenty-nine patients were seen at a follow-up examination. The most frequent symptom was pain in the region of the sacro-iliac joint (5 1.7 per cent). This pain was severe in 2 patients, whose follow-up interval was less than 6 months; the remaining patients described their symptoms as aching in type and not severe enough to require any further treatment. Eleven patients (37.9 per cent) had aching involving the lower lumbar spine and 2 of these patients had sustained a fracture involving a vertebral body. Impotence due to damage of the nervi erigentes is said to occur in one man out of 3 who has sustained a major pelvic injury (Trafford, 1955; Chambers and Balfour, 1963). Five of our patients complained of some impotence. Twelve patients (41.4 per cent) had a tendency to limp due to weakness of the thigh muscles from muscle wasting. Only one patient had a positive Trendelenburg sign associated with muscle wasting of the glutei. Patterson and Morton (1961) found that the restoration of any neurological deficit following this injury was never complete and this was our experience. All 10 patients of the original 16 with neurological injury who were seen at review complained of some minor neurological symptoms. All these experienced some paraesthesia affecting the lower limbs, 8 patients having muscle weakness and 4 complaining of minor degrees of numbness. At examination, 8 patients were found to have diminished sensation over the distribution of the sciatic nerve or the posterior primary rami of the sacral nerves. The cause of muscle wasting in 13 patients could be accounted for by associated limb injuries. There was no case of a femoral nerve injury. Thus, apart from the 2 patients with fairly severe sacro-iliac pain whose period of follow-up was fairly short, the remaining patients had little disability. Twenty-four out of the total of 27 patients who can now be traced are back at their original occupations and their time off work varied from 6 weeks to 18 months. The 3
Monahan
patients multiple The demands tion of possible
and Taylor:
Dislocation
of Pelvis
333
who have not returned to work sustained injuries. treatment of this major pelvic injury immediate resuscitation and stabilizathe pelvis, as well as an awareness of the associated injuries and their sequelae.
Acknowledgements We wish to thank Mr J. C. Scott and Mr J. D. Morgan for allowing us to include their patients in this study. Our thanks are also due to Mrs J. Earle for typing the manuscript, and to Mr Gerrish, Department of Medical Illustration, Princess Margaret Hospital, Swindon.
COOPER,ASTLEY(1842), A Treatise on Fractures and Dislocations of the Joints, London, Churchill Livingstone. FUREY, W. W. (1942), ‘ Fractures of the pelvis with special reference to associated fractures of the sacrum ‘, Am. J Roentgenol. Radium. Ther. Nucl. Med., 47, No. 1.89. HOLDS~OR-~H,F. w. (1948) ,‘ Dislocation and fracturedislocation of the pelvis ‘, J. Bone Jt Surg., 30B, 461. JAHSS, S. A. (1935), ‘ Injuries involving the ilium-a new treatment ‘, J. Bone Jt Surg., 17, 338. LEVINE, J. I. and CRAMPTON,R. S. (1963), ‘ Major abdominal injuries associated with pelvic fractures’, Surg. Gynacol. Obstet.,
116,223.
LUNT, H. R. W. (1970), ‘ Entrapment of bowel within fractures of the pelvis ‘, Injury, 2,2, 121. MOYSON,F., DUPREZ, A., BREMER,A. and DE GRAEF, J. (1957), ‘ Evaluation et traitement du shock traumatique dans les fractures du bassin ‘, Acta Chir. Belg., 56,406.
REFERENCES
ARNOLD, G. J. (1907), ‘A case of fracture of the pelvis from slight violence, with nipping of the small intestine between the fragments causing
BAYLISS,S. M., LANSING, E. H. and GLAS, W. M. (1962), ‘ Traumatic retroperitoneal haematoma ‘, Am. J. Surg., 103,477. CARRUTHERS, F. W. (1945), ‘ Anatomical and functional reductions ‘, Am. J. Surg., 69,39. CARRUTHERS,F. W. and LOGUE~ R. M. (1953), ‘ Treatment of fractures of the pelvis and their complications ‘, American Academy of Orthopaedics Surgical Instructional Course Lecture, 10. CHAMBERS,H. L. and BALFOUR,J. (1963), ‘ Impotence following pelvic fractures ‘, J. Ural., 89,702.
PATTERSON, F. P. and MORTON,L. S. (1961), ‘ Neurologic complications of fractures and dislocations of the pelvis ‘, Surg. Gynecol. Obstet., 112,702. PELTI~R, L. F.
325
6. 325-333
Dislocation and fracture-dislocation of the pelvis P. R. W. Monahan Consultant Accident and Orthopaedic Princess Margaret Hospital, Swindon
Surgeon,
R. G. Taylor Consultant Orthopaedic
Surgeon, United Oxford Hospitals Group
Summary
Dislocation and fracture-dislocation of the pelvis is a major injury; the force involved in its production may not only disrupt the pelvis but result in extensive associated injuries. Between 1960 and 1968, 43 patients with this injury were treated in the Accident Service of the Radcliffe Infirmary. Their case records and radiographs have been analysed and 29 of the patients re-assessed at a follow-up examination. CLASSIFICATION THE pelvic dislocation has been divided into 3 groups according to whether the pubic symphysis or the sacro-iliac joints were subluxed or dislocated singly or in combination. Group l-Subluxation or dislocation of the symphysis pubis Group 2-Subluxation or dislocation of the sacro-iliac joint(s)
3-Subluxation or dislocation of the symphysis and the sacro-iliac joint(s) These 3 groups have been further divided into 3 types if the pelvic dislocation was associated with one or more fractures, in order to give some indication where necessary of the evtent of fracture round the pelvic ring. For descriptive purposes the hemipelvis is divided into 3 segments (Fig. 1): an anterior segment comprising the ischium and pubis; a middle segment containing the acetabulum and ilium; and a posterior segment, the sacrum. Type A refers to fractures involving any one of the above segments of a hemipelvis and types B and C to fractures involving 2 and 3 of these segments respectively (Figs. 2,3 and 4). FINDINGS 1. Age and sex Of the 43 patients, 38 were male and 5 female. Their ages ranged from 2 to 69 years (average 30.9 years), and 28 patients were under 30 years of age. 2. Cause of injury (Table I) The majority of the patients were either knocked down or were riding motor cycles at the time of their accident.
Group Fig. 1.--Fracture
dislocation of the pelvis.
3. Type of dislocation or fracturedislocation sustained (Tab/e //) Nine patients sustained group 1 injuries. In 7 of them one segment of the hemipelvis was fractured and in one of these patients the fracture was bilateral. The remaining 2 patients had 2 and 3 segments fractured. Fourteen patients had
Injury: the British Journal of Accident
326 Table
/.-Cause
Cause
of injury
Knocked down Motor cycle Crush Car occupant Fall from height Hit on back
the sacro-iliac joints giving rise to the ‘ bivalve pelvis ‘. Of the remaining 14 patients in this group 7 were type A, 4 type B and 3 type C. One patient with a group 3, type A injury had bilateral fracture-dislocation. A displacement of one hemipelvis in relation to the other varies both in its degree and in its axis of displacement. Varying degrees and types of displacement were seen in this series. The most obvious clinically were those pelvic fractures with cranial displacement of one
of injury No. of patients 13 12 7 6 4 1
Fig. 2.-A, Fracture dislocation and fracture left ilium.
Surgery Vol. ~/NO. 4
of the pelvis.
B, Group
2 injuries and the majority (8 cases) had fractures involving 2 segments (type B). Three patients in this group had dislocation of both sacro-iliac joints, and in 4 patients the segmental fractures were bilateral. Twenty patients had group 3 pelvic injuries, in 6 of whom there were no associated fractures. Two of these patients had bilateral dislocations of
group
I, type A injury.
Dislocation
of the symphysis
pubis
hemipelvis producing the apparent shortening of a leg. This occurred in 6 patients as shown in Table III. Three of these 6 patients had sustained a crushing injury, and of the remaining 3 patients one had fallen from a height, another was the driver of a car and the last patient was a pedestrian knocked down by a car. 4. Associated injuries (Table IV) Twenty-two patients (51.1 per cent) hadassociated skeletal injuries. Many of the limb fractures were comminuted in type and involved several levels. Tab/e //.-Incidence
Group
1
2
Fig. 3.-Fracture-dislocation of the pelvis. Group 2, Bilateral subluxation sacro-iliac type B injury. joints. Fracture of sacrum. Fracture of right superior and inferior pubic rami.
3
Type A B C A B C A B C
of pelvic fracture-dislocation No. of patients 7 1 1 5 8 1 6 7 4 3
Bilateral involvement Sacro-iliac jts Fractures 1
3
2 2
2 1
327
Monahan and Taylor: Dislocation of Pelvis Tab/e ///.-Cranial
displacement of a hemipelvis
Type of pelvic injury
No.
of patients
Group 2 Group 3 Group 3
Type B Type C
3 1 2
In 25.6 per cent there was an associated fracture of the sacrum. The distribution of the spinal, upper and lower limb fractures between the 3 groups of pelvic injury is shown in Table V. It can be seen that the skeletal fractures are fairly
equally distributed between the 3 groups of pelvic injury. Eighteen patients (44.8 per cent) had major soft-tissue injuries. Patients with head injuries and with microscopic haematuria are excluded from this figure. The organs and structures involved are listed in Table VI. Seven patients (16.2 per cent) required laparotomy and of these 3 had sustained group 1 pelvic injuries, 3 group 2, and one group 3 injuries. Six patients had chest injuries. Table /V.-Associated Type of injury Fracture Skull Thoracic spine Lumbar spine-body transverse process Ribs Clavicle Humerus Radius Ulna Carpus Hand Neck of femur Shaft of femur Tibia Fibula Foot Fracture-dislocation Mid tarsal Tarso-metatarsal Dislocation Aromio-clavicular Shoulder Hip (posterior)
Fig. 4.-A, 6 and C, Fracture-dislocation and symphysis pubis. Fracture sacrum.
Fracture neck left femur.
skeletal injury No. of patients
4 2
3 5 5 1 4 3 2 1 4 3 3 7 8 3
of the pelvis group 3, type C injury. Dislocation left sacro-iliac joint Fracture left ilium. Fracture right superior and inferior pubic rami.
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Table V.-Distribution of skeletal fractures the 3 groups of pelvic injury Fracture
Group
Spinal
Upper limb
Lower
limb
No. of patients
between
Percentages
1
2
22.2
2 3
6 2
42.8 10.0
3 4
21.4 20.0
3 5 5
33.3 35.7 25.0
-
1 2 3 1 2 3
Tab/e V//.-Blood
transfusion
No. of patients requiring transfusion
Group
1
Average no. of units of blood
7 12 13
2 3
5 7 8.4
Tab/e V///.-Distribution Group
of neurological
No. of patients
1
The diagnosis of retroperitoneal haemorrhage was made at laparotomy, by marked displacement of one or more of the ureters on intravenous pyelography, or by the obliteration of the psoas shadows on plain abdominal radiographs. The incidence may well have been higher as the diagnosis of retroperitoneal haemorrhage can be difficult to make with certainty. 5. Resuscitation (Table V/l) Nineteen patients (44.1 per cent) had barely recordable, or unrecordable blood pressure on admission. Thirty-two patients (74.4 per cent) required resuscitation with whole blood. The number of units of blood given ranged from 1 to 26 units (average 7.1 units).
soft-tissue
Type of injury
Head Chest Haemothorax Pneumothorax Lung contusion Ruptured diaphragm Abdominal (requiring laparotomy) Bladder Urethra Liver Spleen Kidney Large bowel Retroperitoneal haemorrhage Arterial Femoral A Coeliac A, Hepatic A Ligamentous Knee
injuries No. of patients
35 6 2 3 1 1
injury Percentage
4 5 7
2 3
Tab/e V/.-Associated
requirement
25 21.2 43.7
6. Neurological injury (Table V//I) Sixteen patients (37.2 per cent) had some neurological involvement of their lower limbs as a result of the pelvic injury, rather than from the head injury alone if this was also present. In 2 out of the 4 group 1 patients there was a fracture of the middle pelvic segment and one patient had a sacral fracture as well. The fourth patient had an anterior segment fracture. All 5 patients in group 2 with neurological involvement had fractures of an anterior segment; 4 of these patients also had fractures of the sacrum and 2 patients had fractures of the middle pelvic segment. Three out of the 7 patients in group 3 with neurological injury had pure pelvic dislocation without associated fractures. The remaining 4 patients had fracture-dislocation of the pelvis; 2 were of type A (middle segment), one type B
Table /X.-The pelvic injury with urinary tract trauma Injury Type Group
(N~~~$$..
sustained
by patients
Associated
injury
7 3 3 2 1 1 2 6
1
2
A C
2 1
A
4
B C
7 1
A B C
4 2 2 2
Rupture bladder Rupture bladder Rupture urethra Rupture urethra
3 2 1 3 2
Rupture bladder
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Monahan and Taylor: Dislocation of Pelvis fabie X.-Duration
of treatmant Average in days
Period of bed rest Full weight-bearing Inpatient stay
afterwards
32.4 51.4 45.4
(anterior and middle segment) and one was of type c. Five of the 16 patients had numbness involving the sacral dermatomes; 4 had fractures of the sacrum and the fifth patient had a grossly displaced sacro-ifiac dislocation. The remaining 11 patients had signs of sciatic nerve involvement, though in one patient a posterior dislocation of the hip may have accounted for the sciatic nerve injury, 7. Haematuria (Table IX) Twenty-five patients (58.1 per cent) had haematuria on admission. In 12 patients this was microscopic, and in 13 macroscopic. All 4 patients with urinary tract injury had pelvic injuries associated with fractures involving the pelvic ring. In 2 patients with a single fracture of the pelvic ring, the combined bladder and urethral injury was associated with a fracture involving the anterior pelvic segment; the patient with a rupture of the bladder alone had a pelvic injury associated with a middle segment fracture.
TREATMENT All the pelvic dislocations or fracture-dislocations were treated conservatively, either by the use of a pelvic sling (in f 6 patients) or by bed rest with the hip flexed and the leg resting on a frameorpillows. Skeletal traction was used to correct cranial displacement of a hemipelvis if present. The duration of treatment is shown in Table X. MORTAUTY There were 4 deaths in this series giving a mortality of 9.3 per cent. One patient died on the day of admission having sustained a group I, type A pelvic injury associated with an abdominal injury comprising a rupture of the left lobe of the liver, a tear of the vessels in the porta hepatis and a tear at the coeliac axis. The second patient died 24 hours following admission having sustained a group 2, type A pelvic injury with multiple lower limb fractures, a fracture of the body of the first lumbar vertebra, an abdominal injury with almost total avulsion of the bladder base from the prostate, a large retroperitoneal haematoma and a rupture of the hilum of the right kidney. The third patient was a lady of 69 years of age with a severe head injury, bilateral rib fractures, a haemothorax, a group 2, type A pelvic injury, and a fracture of the right tibia. The fourth patient was a girl aged 13 years
Tab/e X//.---Clinical Tab/t? X/.-Symptoms
signs found on examination
in 29 patients Clinical signs
Pain Lumbar spine Sacro-iliac joints
11 (bifat*Z
Pubis Sciatica Gait (limping) Neurological Paraesthesia Numbness Muscle weakness Urological Dysuria Frequency Haematuria Poor stream impotence : decreased complete Child birth problams Chest Claudication
Na. of patients
No. of patients
Symptoms
in
2)
3 1: IQ 85 0 4 0
desire
ri
2 1 =5 0 2 I
Back Normal Kyphosis Scoliosis (lumbar) Pain/discomfort on compression of sacro-iliac joints Pafpation of pubis wide painful Compression of pubis painful Visibfe pelvic deformity Leg-length discrepancy Muscle wasting of leg Diminished sensation leg and/or buttocks Diminished muscle power Positive Trendelenburg sign Diminished aeration of chest
20 3 6 2 4 2 0 5 all minimal 4 all minimal 13 all uniiateraf 8 9 :
330
Injury:
a group 2, type A pelvic injury and severe head injury including a left subdural haematoma. She died on the third day.
with
FOLLOW-UP
STUDY
Of the 39 patients who are alive, 29 have been traced and re-examined. The follow-up interval varied from three months to eight and threequarter years (average three and a half years). A detailed history was obtained and particular attention paid to any symptoms arising from the spine, the sacro-iliac joints and pubis, as well as symptoms involving the respiratory, abdominal, urogenital and neurological systems. The patient was then fully examined, paying particular attention to those symptoms noted in the clinical history. The symptoms complained of are listed in Table XI. The lumbar back pain in all cases was of an aching type. The sacro-iliac joint pain was severe in 2 patients in whom the follow-up interval was less than 6 months. Twelve patients (41.4 per cent) complained of neurological symptoms. There was no correlation bet,keen the distribution of these symptoms and the type of pelvic injury except for those affecting the sacral dermatomes. Three out of 4 patients with sacral nerve symptoms had fractures involving the sacrum, and the fourth had a group 3 pelvic dislocation with gross displacement of a hemipelvis. Six patients had symptoms solely involving the sciatic nerve and in 4 patients the femoral nerve was involved. None of the patients with urological symptoms had these symptoms before their injury. The clinical signs found on examination are listed in Table XII. Muscle wasting of a leg was the commonest abnormality and in the majority of patients it was of a minor degree. There was no case of leg-length discrepancy.
TYPE OF OCCUPATION BEFORE INJURY All occupations that did not involve heavy lifting were classified as light work. One patient was unemployed before his accident and of the remaining 28 patients, 19 were employed in light work and 9 in heavy occupations. Eight patients in the light occupation group were at school or college.
TIME OFF WORK INJURY
FOLLOWING
One patient out of the total of 29 patients cannot now be traced. Of the remaining 28 patients, 3 are still off work. Two of these men had group 3,
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Journal
of Accident
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type C pelvic injuries and the third a group 2, type B injury, and all 3 patients had multiple associated injuries. The interval from the time of their injury was three years, two years, and one and a half years. The time off work of the remaining 25 patients varied from six to eighteen months. All 25 patients returned to their original occupations. The 3 patients who are still off work are a steeple-jack, a demolition worker and an engineer.
DISCUSSION Dislocation and fracture-dislocation of the pelvis is a major injury; the force involved in its production may not only disrupt the pelvis, but result in extensive associated injuries. A constant awareness of possible injury to the pelvis and the sequelae is essential to all surgeons concerned with care of the injured patient. This type of pelvic injury is produced principally in 2 ways. Taylor (I 942) stated that indirect violence was one mechanism involved. The hyperextension or hygerabduction of the lower limb on the trunk caused a strong force by the system of levers to disrupt the symphysis pubis. Once the anterior tie beam had been severed, a continuation of the force caused the sacro-iliac joints to open out anteriorly and subsequently to dislocate if the force was continued. Taylor showed that with cadavers, the easiest and most rapid method of dislocating both the symphysis pubis and the sacro-iliac joint was by hyperextending the lower limb in a position of external rotation and abduction. Tf a hyperextension force was exerted at the hip joint it was found that the symphysis pubis separated to a considerMoreover dislocations thus able degree. produced were most easily reduced by flexion, adduction and internal rotation. The late Sir Frank Holdsworth (1948) considered the injury to be due predominantly to direct violence, with an anteroposterior, a lateral, or a torsional stress being applied to the pelvis. With an anteroposterior deforming force, one or both hemipelves are forced against the fixed sacrum, the initial force being expended on the anterior nonweight-bearing segment of the pelvis comprising the pubis and its rami. This may result in diastasis or dislocation of the symphysis pubis and/or fracture of the body of the pubis and its rami. With a continuation of this force the pelvis opens out ‘ like the leaves of a book ’ (Watson-Jones, 1938) and the sacro-iliac joint dislocates or a fracture occurs through the ilium adjacent to this
Monahan
and Taylor:
Dislocation
of Pelvis
joint. A lateral crushing force applied to the pelvis generally causes a bilateral fracture of both pubic rami or a unilateral fracture of both the pubic rami and separation of the pubic symphysis (Watson-Jones, 1955). In general, the more violent the force of impact to the pelvis, the greater the extent of its injury. The classification of fracture-dislocations and dislocations in this study defines the presence of a dislocation at the symphysis pubis and/or the sacro-iliac joint and its association with fractures of the pelvic ring and the extent of these fractures. The pelvis should be carefully examined in all injured patients. Abrasions and skin contusions may indicate the site of impact. Visible swelling due to a haematoma may occur from fractures of the pelvis, pelvic ring or injury to associated structures, for example the bladder, urethra and major blood vessels. The pubis is palpated for evidence of a fracture or separation of the symphysis, and the sacro-iliac joints are examined for signs of separation or the presence of associated fractures. In the more severe group 1, type C injuries there may be visible deformity of the pelvic girdle; one hemipelvis may be displaced inwards, outwards or proximally in relation to the other side. This may result in either an internal or external rotation deformity of a leg with occasionally an apparent shortening of the leg if a proximal shift of one hemipelvis has also occurred. The instability of one hemipelvis on the other is determined by gentle anteroposterior or lateral pressure on the pelvic ring, which may not only give detectable movement of the ring but pain at the site of an associated fracture or dislocation. Peltier (1965) stated that haemorrhage was the most serious complication following fractures of the pelvis. In this series we also found that peripheral circulatory failure due to blood loss was one of the most important signs; 44.1 per cent of our patients were acutely shocked. The pelvis is a vascular structure closely associated with major blood vessels and the venous plexuses surrounding the bladder, prostate, vagina and rectum. Injury to these structures by sharp spicules of bone may cause massive haemorrhage. Displacement of a sacro-iliac joint may rupture the iliolumbar vessels passing in front of it. Seventy-four per cent of our patients required resuscitation with an average of 7 units of whole blood (range 1 to 26 units) and there was a progressive increase in the need for blood from the group 1 to the group 3 pelvic injury. The force producing the pelvic injury is often severe and the incidence of associated injury may be high. Fifty-one per cent of our patients had
331
other skeletal injuries. A constant awareness of injury to other organs is essential as direct violence to the pelvic girdle may also involve intraabdominal organs, and the clinical signs of their injury may not be obvious in the acutely shocked patient. Injury to the bladder and urethra should always be considered. Moderate force applied to the front of the lower part of the abdomen may do no more than produce a haematoma of the bladder wall with resulting microscopic haematuria. Fifty-eight per cent of our patients had haematuria on admission, and in half of them it was microscopic in type; Levine and Crampton (1963) noted an incidence of 34.8 per cent in their series of 425 patients with pelvic fractures. An increasing force applied to the abdomen during injury may cause intraperitoneal rupture of the bladder, previous distension of this organ making it more vulnerable. Carruthers and Logue (1953), discussing the complications following a pelvic fracture, put the incidence of urological injury at about 10 per cent; our finding in this series was 9.3 per cent. Levine and Crampton (1963) found that the only fracture of the pelvis common to all their patients with rupture of the bladder was a fracture involving the pubic rami. All 3 patients in this series who sustained bladder rupture had a fracture involving the anterior pelvic segment. Ruptures of the urethra commonly affect the posterior urethra, and Trafford (1958) believed that the posterior urethra was most commonly injured in fractures with displacement of the pubic bones and rami. This was the case in our 2 patients who had sustained posterior urethral rupture. Rupture of the diaphragm, which occurred in one patient in this series may occur in association with pelvic injuries (Levine and Crampton, 1963), as may injury to the rectum and vagina. Entrapment of bowel in pelvic fractures has also been described (Arnold, 1907; Lunt, 1970). Patterson and Morton (1961) make a plea for a greater awareness of possible neurological injury in pelvic fractures and dislocations. The sciatic, femoral, gluteal, posterior cutaneous nerve of the thigh, lateral femoral cutaneous and obturator nerves may all be involved. Direct injury to nerves can come from high velocity impact or crushing. The lumbosacral nerve trunks lying close to the sacro-iliac joints may be damaged by traction or compression from contact with adjacent bones or because of a tense retroperitoneal haematoma. Sacral fractures, whose incidence is higher than generally recognized in this injury (Furey, 1942), may account for damage to the sacral nerves.
332
Thirty-seven per cent of our patients sustained a neurological inJury as a direct result of their pelvic injury (Table VIII). The incidence was higher in those patients with a group 3 injury (44 per cent) than those with a group 2 (31 per cent) or group 1 (25 per cent) injury. Eleven out of the 16 patients had sciatic nerve involvement, and of the remaining 5 patients with sensory symptoms involving the sacral dermatomes, 4 had visible fractures of the sacrum. A patient with this major pelvic injury requires immediate and effective resuscitation with intravenous fluid replacement and oxygen therapy, because as pointed out by Moyson et al. (1957) shock is common in this type of injury. 44.1 per cent of our patients were acutely shocked and they required an average of 7 and 8.4 units of whole blood in the group 2 and group 3 injuries respectively. The control of retroperitoneal intrapelvic haemorrhage is by the stabilization and reduction of the pelvic fracture-dislocation. The control of bleeding points by ligation of vessels is difficult and in the majority of cases is unnecessary as spontaneous arrest occurs. Bayliss al. (1962) explored 25 patients with et retroperitoneal haematomata without associated intraperitoneal bleeding, and in only one patient could a bleeding point be found and ligated. The only patient in this series with a large retroperitoneal haematoma who died, did so from severe multiple injuries, and at laparotomy uncontrollable major vessel bleeding was not found. The treatment of the fracture-dislocation is usually by non-operative methods. The aim of treatment is to re-align as anatomically as possible the major displacements of the pelvis. The accurate re-alignment of individual fractures, with the exception of those involving the hip joint, is unnecessary and would jeopardize the survival of many of these seriously injured patients. The technique of lateral recumbency and plaster was devised by Watson-Jones (1938, 1955) and the sling method by Astley Cooper (1842). The sling method, as used in our patients, provides lateral compression and stability to the pelvis. The displacing action of the extended limb at the hip joint through the system of levers (Taylor, 1942) is prevented by flexing the hip with the leg resting on a Braun’s frame. Any cranial displacement is corrected by skeletal traction applied through the tibia. Manipulation of the pelvis may be necessary, using the leg on the side of the pelvic injury as a lever. The medial displacement of a hemipelvis may be reduced by gradual strong abduction and extension of the hip on the
Injury:
the British Journal
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Surgery
Vol. ~/NO. 4
affected side, using the adductor and flexor muscles to control the pelvic fragment. A turnbuckle method of reduction is recommended by Jahss (1935) and Carruthers (1945). Various forms of operative reduction have been recommended, mainly for fractures involving the acetabulum. In this conservatively treated series of patients the average period of bed rest was 32.4 days, the inpatient stay was an average of 44.4 days, and full weight-bearing was permitted after an average of 5 I.4 days. Twenty-nine patients were seen at a follow-up examination. The most frequent symptom was pain in the region of the sacro-iliac joint (5 1.7 per cent). This pain was severe in 2 patients, whose follow-up interval was less than 6 months; the remaining patients described their symptoms as aching in type and not severe enough to require any further treatment. Eleven patients (37.9 per cent) had aching involving the lower lumbar spine and 2 of these patients had sustained a fracture involving a vertebral body. Impotence due to damage of the nervi erigentes is said to occur in one man out of 3 who has sustained a major pelvic injury (Trafford, 1955; Chambers and Balfour, 1963). Five of our patients complained of some impotence. Twelve patients (41.4 per cent) had a tendency to limp due to weakness of the thigh muscles from muscle wasting. Only one patient had a positive Trendelenburg sign associated with muscle wasting of the glutei. Patterson and Morton (1961) found that the restoration of any neurological deficit following this injury was never complete and this was our experience. All 10 patients of the original 16 with neurological injury who were seen at review complained of some minor neurological symptoms. All these experienced some paraesthesia affecting the lower limbs, 8 patients having muscle weakness and 4 complaining of minor degrees of numbness. At examination, 8 patients were found to have diminished sensation over the distribution of the sciatic nerve or the posterior primary rami of the sacral nerves. The cause of muscle wasting in 13 patients could be accounted for by associated limb injuries. There was no case of a femoral nerve injury. Thus, apart from the 2 patients with fairly severe sacro-iliac pain whose period of follow-up was fairly short, the remaining patients had little disability. Twenty-four out of the total of 27 patients who can now be traced are back at their original occupations and their time off work varied from 6 weeks to 18 months. The 3
Monahan
patients multiple The demands tion of possible
and Taylor:
Dislocation
of Pelvis
333
who have not returned to work sustained injuries. treatment of this major pelvic injury immediate resuscitation and stabilizathe pelvis, as well as an awareness of the associated injuries and their sequelae.
Acknowledgements We wish to thank Mr J. C. Scott and Mr J. D. Morgan for allowing us to include their patients in this study. Our thanks are also due to Mrs J. Earle for typing the manuscript, and to Mr Gerrish, Department of Medical Illustration, Princess Margaret Hospital, Swindon.
COOPER,ASTLEY(1842), A Treatise on Fractures and Dislocations of the Joints, London, Churchill Livingstone. FUREY, W. W. (1942), ‘ Fractures of the pelvis with special reference to associated fractures of the sacrum ‘, Am. J Roentgenol. Radium. Ther. Nucl. Med., 47, No. 1.89. HOLDS~OR-~H,F. w. (1948) ,‘ Dislocation and fracturedislocation of the pelvis ‘, J. Bone Jt Surg., 30B, 461. JAHSS, S. A. (1935), ‘ Injuries involving the ilium-a new treatment ‘, J. Bone Jt Surg., 17, 338. LEVINE, J. I. and CRAMPTON,R. S. (1963), ‘ Major abdominal injuries associated with pelvic fractures’, Surg. Gynacol. Obstet.,
116,223.
LUNT, H. R. W. (1970), ‘ Entrapment of bowel within fractures of the pelvis ‘, Injury, 2,2, 121. MOYSON,F., DUPREZ, A., BREMER,A. and DE GRAEF, J. (1957), ‘ Evaluation et traitement du shock traumatique dans les fractures du bassin ‘, Acta Chir. Belg., 56,406.
REFERENCES
ARNOLD, G. J. (1907), ‘A case of fracture of the pelvis from slight violence, with nipping of the small intestine between the fragments causing
BAYLISS,S. M., LANSING, E. H. and GLAS, W. M. (1962), ‘ Traumatic retroperitoneal haematoma ‘, Am. J. Surg., 103,477. CARRUTHERS, F. W. (1945), ‘ Anatomical and functional reductions ‘, Am. J. Surg., 69,39. CARRUTHERS,F. W. and LOGUE~ R. M. (1953), ‘ Treatment of fractures of the pelvis and their complications ‘, American Academy of Orthopaedics Surgical Instructional Course Lecture, 10. CHAMBERS,H. L. and BALFOUR,J. (1963), ‘ Impotence following pelvic fractures ‘, J. Ural., 89,702.
PATTERSON, F. P. and MORTON,L. S. (1961), ‘ Neurologic complications of fractures and dislocations of the pelvis ‘, Surg. Gynecol. Obstet., 112,702. PELTI~R, L. F.
