Pelvic # Management

1. ID mechanism, suggesting possibility of a pelvic #.

2. Inspect pelvic area for ecchymosis, perineal or scrotal haematoma or blood at the urethral meatus.

3. Inspect legs for differences in length or asymmetry in rotation of the hips.

4. Perform rectal, noting position and mobility of the prostate, palpable fracture or gross blood in stool.

5. Perform vaginal, noting palpable #s, size/consistency of uterus, or presence of blood.  Remember to think of pregnancy.

6. Obtain an AP # if 1-5 suggests injury.

7. Palpate bony pelvis if steps 2-6 are normal.

8. Determine pelvic stability by gently applying AP compression and lateral to medial compression, over ASI crests. Test for axial mobility by gently pushing and pulling on the legs.

9. Insert a urinary catheter cautiously if not contraindicated (or perform retrograde urethrograam if urethral injury suspected).

10. Interpret pelvic XR, giving special consideration to those #s associated with greater blod loss (increase pelvic volume, esp vertical shear / open book #s):

Systematically evaluate film for:
- width of symphysis pubis: >1cm separation signifies significant posterior pelvic injury.
- integrity of superior/inferior pubic rami bilaterally
- integrity of acetabula as well as femoral heads / necks.
- symmetry of the ilium / width of sacroiliacs.
- symmetry of sacral foramina by evaluating arcuate lines.
- # of transverse process of L5
- if one # is found, look for another; displacement of ring implies 2 # sites.

11. Reduce Blood Loss:
- avoid repeat manipulation
- internally rotate lower legs to close an open-book #, pad bony prominences and tie rotated legs together
- apply / inflate PASG
- early ortho consult for pelvic external fixation.
- early ortho consult for skeletal limb tractoin
- consider pelvic vessel embolisation
- sandbags under each buttock if no indication of spinal injury & other techniques not available
- pelvic binder
- transfer to definitive care setting.