Fractures of the pelvis

FRACTURES OF THE PELVIS* A CLINICAL FRANCIS Associate

Attending

Surgeon,

Harlem

STUDY M.

OF 56 CASES

CONWAY,

M.D.

Hospital; Assistant Attending St. Vincent’s Hospital NEW

Surgeon

and Chief of Surgical

Clinic,

YORK CITY

T

HIS review of the peIvic ring injuries occurring on our SurgicaI Service for the nineteen month interva1 between ApriI, 193 I and November, 1933 was undertaken not onIy to cIassify the variety of unusuaI and interesting types of fractures and associated injuries presenting themseIves on the division but aIso to emphasize the striking infrequency, in our experience, of visceral complications attendant upon these injuries. The peIvic girdIe, surrounded as it is by muscIe beIIies and encased in fascia1 sheaths, must be regarded from both a dynamic and a static viewpoint. From the standpoint of dynamic injuries, one refers to muscIe tears, hematomata, and fascia1 ruptures which are concomitant with the fractures. The static injuries are those essentiaIIy osseous in nature but which wiI1 aIso incIude the vesica1, urethra1 and other peIvic viscera1 traumata. This concept of a static and a dynamic factor faciIitates an appreciation of the many post-traumatic diffIcuIties which are seen for varying periods of time after the origina injury. AIthough one attempts to divide these injuries under these two main headings, this is permissibIe only insofar as it serves to emphasize one rather eIementary truth: that whiIe “10s~ in continuity ” may be distressing from an anatomica aspect, this is not the chief concern in the probIem of the post-traumatic care and comfort of the individual. The residua1 myositic cicatrization, excessive caIIus formation and other more pronounced reactions to tissue injury are * From the Surgical Service of the HarIem Hospital,

quite sufficient to account for far more than the anticipated discomfort. ETIOLOGY

The cause of peIvic bone fractures must, of necessity, be an unusuaIIy severe type of vioIence and the data in TabIe I serve to bring out this fact. TABLE Cause of Fracture

I. Falls or jumps a height..

2. Automobilr

3. Crushing

Case

I No.

Tota,

I Percentage ,

1 of

Total

from

accidents

I

‘kt.o+

injuries.

4. Miscellaneous.

-__ .. .

5. Unknown

TabIe I is a summarization of the etioIogica1 factors invoIved in the production of these injuries. Of the entire group of 56 cases, there were 30 femaIe patients and 26 maIes. The youngest patient was a maIe child, seven years of age (Case XXXVI) and the oIdest a femaIe aged eighty-one (Case XLVI). New York, Dr. John F. Connors (deceased), 69

Director.

American Journal of Surgery

70

Conway-Fractures

of PeIvis

TABLE

Type of Pelvic Fracture

II Accompanying

C*“Se

_ I rracture

of right ibum, fissured and incompmte; no separation or displacement

I

Physical assault prtor to admissron to hospital

I. Fractured nasal,bone. 2. Laceratron of chm. 3. Hematoma of left upper eyelid. 4. Widening of left sacroiliac articulation

course: Uneventful exce t for an acute bronchitis whm .g subsided rapidly. Treatment: Symptomatic; rest in bed. Local treatment. Discharged: Improved

Fall from height of 40 feet

I. Laceration of chin. 2. Laceration of Iower tip 2 in. rn length. 3. Questronah erntracranial injury; patient hleeding from ears and nostrils on admission

Patient’s course satisfactory whiIe in hospital. Left against advice. Discharged: Improved

fracture of right ilium with line of fracture about z cm lateral to sacroibac articutation and parallel to it. Slight separation of fragments

Fall from a no foot height

I. Fracture of tuberosity of right ischium

Course uneventful. Left hospital against advice Discharged: Improved

shattering of Ieft Xium in its mid-portion with outward displacement of Iateral half. Radio shows lead-spattered graph tract and large broken slug which appears to be anterior to body of 4th lumbar vertebra

B,“l$z;i;Fnd e

I. Retroperitoneal rhage

Course jn hospital uneventful. AbdommaI tar negatwe for blood. No ex oratron and patient remove to Prison Ward ten days after admission. Discharged: Improved

1

Bullet wound of right side

I. Retroperitoneal hemor- Treatment: Laparotomy rhage. suture of seros* of colon. 2. Laceration of serosa of Course: Uneventful. heoatic flexure of colon. Discharged: _ Imnroved .

1‘racture

Ac;Fe;tobile

I. Laceration

1rissure fracture of left ilium

TEYb acci-

.-

I

out 5 cm. No separation displacement of fragments XI”

r-zo-32 r-25-32

before sion

admis-

or

Irracture of ri ht ilium, an incomplete f” assure fracture through midcorpus of bone

32 F

.XVI 8-20-3 I 8-3*3r

.7 JerticaI

_F

xv,,

12-19-31 r2--29-31

Result

?i;le;t_yent:

I o-8-3 I

Falling timber konddyzd ax;;;;

Course; Treatment; I

I. Hematoma ,of bank. 2. Lacerated rrght srde

ro-r-jr

” 4-21-31 5-2-31

Injury

I

of

hemor-

Symptomatic;

rest

Course: Satisfactory. Discharged: Improved

_-

xxx 2-12-31 a-29-3 I --

__

xXx,x rw2o-33 30-26-33

of anterior inferior spine of ilium with sIi ht downward dispbxement o B fragment

_-

I.1 12-7-3 I I z-7-3 I

ac-

I. Shock. a. Fractured skull. 3. Fractured right humer-

I

.I rissured

fracture of outer half of right ilium

AutomobiIe accident I month prior to admission to hospital service

of scalp

mrietal

reeion.

I. Fracture of right femur in mid-shaft with callus formation. a. Large infected hematoma 30 X r6 in. over centrat and Iateral aspects of right thigh

I. Extensive oblique fracture of right ibum extending from ores to inferior Portion of rrght sacroiliac jomt with about a cm. separation of fragments. 2. Fracture of descending and ascending rami of Ieft pubis transverse in t pe. 3. Separation o Psymphysis pubi -2 cm.

-

Patient in profound shock on admission. Short1 thereafter had several focal ry Its. Death in 12 hours despite all therapy.

._

Shortly after admission temperature rose to r02~-104~ and fluctuated between these two levels. In spite of incision and drainage and supportive transfusions patient declinedprogressiveIy and died of sepsis.

Treatment: Routine. Discharged: Improved

of right ilium; line of fracture extends through posterior portion of crest. There is an irregubar triang”Iar loose fragment about 5 cm. in width between anterior superior spine and anterior inferior spine. Alsa a transverse fracture of left pubis with line of fracture at junction of descending ramus and ischium

1

Treatment: Symptomatic. course: Uneventful. Result: Improved

4. %ct”red left femur 5. Fractured rieht tibia and fibula. I Autopsy: In addition to above mentioned injuries there was laceration of brain. SkulI showed depressed fracture of right frontal bone: linear fracture a in. long in right temporo-

I rracture

45 M

with

FaII from a one story height

I. Compound fracture of right femur-a double fracture: a. subtrochanteric h. comminuted fracture of mid-shaft

Treatment: Debridement of skin of ri ht thigh with closure; Russe ‘i 1 traction to right femur: pelvic sling. Result: Improved

NEW SERIES Var. XXX,

No.

I

Conway-Fractures

VARIETIES OF FRACTURES PeIvic girdIe fractures have been cIassified grossIy into two main groups: (a) Those fractures which break the pelvic ring. (b) Those not invoIving the peIvic ring. In the first group are pIaced: (I) pubic rami fractures with bursting of the symphysis pubis and a spreading apart of the two haIves of the peIvis; (2) diastasis, subIuxation or widening of the sacroiIiac joints; fractures of the iIium through the sacrosciatic notch and (3) varieties and combinations of (I) and (2). In the second group are: (I) fractures of the iIiac crest; (2) fractures of the ischia1 tuberosity, and (3) fractures of the acetabuIum rim, base or the steIIate type with the centra1 disIocation of the femoraI head into the peIvic bowI. Among the cases of peIvic bone fractures, the foIIowing types are encountered: FRACTURES OF THE ILIUM. There were 17 fractures of the iIiac bone in this series (Cases I, v, VIII, IX, XIV, XVI, XVII, XVIII, XXI, XXIX, xxx, XXXIX, XLV, LI, LII, LIII, LVI). Six of this number (Cases IX, XVIII, XXI, XXIX, XLI, LIII) occurred in association with fractures of the pubis and are deaIt with beIow under the head,ing of “doubIe vertical fractures of the peIvic ring”-the MaIgaigne type of peIvic girdIe fracture. Of the I I remaining cases which are essentiaIIy fractures of the iIium, per se, the foIIowing schema outIines their type, accompanying injuries and outcome at the time of their discharge from the service (TabIe II).

of PeIvis

Age

xxx1 ‘j-22-32 8-13-32

24 F

Type of PeIvic Fracture

IncompIete fracture of Ieft ischium at junction of ramus with body

‘I

In this group of I I cases, there were 8 fractures of the Iinear or fissure type confined to the mid-corpus of the ilium;

TABLE

Case

Amrrican Journul or Surgery

FIG. K. Case XXXIX. Radiograph taken October 20, 1933 discloses fracture of anterior inferior spine of ilium with slight downward displacement of fragment. In entire series this fracture was encountered on onIy one occasion.

of penetrating 2 cases were the resultants buIIet wounds shattering the body of the iIiac bone and the remaining case was a fracture involving the anterior inferior iIiac spine (Case XXXIX). (Fig. I .) With regard to the 2 mortaIities in this group: one patient (Case LI) succumbed tweIve hours after admission to the hospita1 of shock and the associated injuries which are detaiIed in the section of “MortaIities”; 111

Cause

FaII from fire escape, one floor above ground

Accompanying Injuries

1I. Fractured

skuI1. VerticaIfractureof Ieft fronta bone. 2. Laceration of scalp

Course in HospitaI and Treatment

1 Result

I. Pelvic binder.1 Im2. Rest in bed ~ proved

I/

American Journal of Surgery

72

Conway-Fractures

the second (Case LII) died of sepsis from an extensive infected hematoma present at the time of admission and after a proIonged stay on the service. FRACTURES OF THE ISCHIUM. Of the 13 fractures of the ischium which came under our observation, 12 cases were in association with other fractures of the peIvic ring and are presented in other categories as accompanying injuries. The one case (XXXI) in which onIy the ischium was fractured is presented in TabIe III. FRACTURES OF THE PUBIS: There were 42 cases in which fractures of the pubic bones were present. AI1 varieties of fracture of these bones were present as may be gathered from the foIIowing tabuIation YTabIe IV) : TABLE IV Case No. 11,

111, IX,

XXIII, XLII,

Site of Fracture XIX,

XXIV, LIV,

XL,

Right ascending rami

and descending

LV.

Right ascending and descending rami; body of pubis VI, XXIX. Right ascending ramus VII, XI. Right body of pubis VIII, XXII, XLVII. Left descending ramus XII, XXVIII, XXXIV, Right and left ascending and XLIX. descending rami XIII, XLVI. Rinht descendine ramus Lgft ascending- and descending xv, xx, xxv, XXXIII, XLIV, XLV. rami XVIII. Left pubic corpus; rightidescending ramus XXI. Left pubic corpus; right ascending ramus XXVII. Left ascending and descending rami; right side of symphysis XXXII, XLI, XLVI. Left ascending and descending rami; separation of symphysis xxxv. Riaht and left descending rami XXXVI . Le& descending ramus; comminuted fracture of symphysis XXXVIII. Left ascending ramus; right descending ramus; right corpus XLVIII. Left corpus 1. Symphysis IV.

In summarizing this tabuIation, there were : Fractures of the right ascending ramus-r 8 Fractures of the right descending ramus18 Fractures of the Ieft ascending ramus-g Fractures of the Ieft descending ramus-

OCTOBER, 1935

of PeIvis

Fractures of the 3 of left pubic bone body of the pubis 3 of right pubic bone. There were 6 cases of symphysea1 injuries which were: Case xxvrr. Fracture of right side ofsymphysis in good position ” xxx1 I. Separation of symphysis pubis XXXVI . Cornminuted fracture of symphysis pubis XLI. Separation of symphysis pubis of 3 cm. L. Fracture with separation of pubic symphysis LVI. Separation of symphysis pubis of 2 cm. It is in association with this group of cases that the viscera1 comphcations of peIvic bone fractures are most frequentIy seen. The viscera1 compIications encountered in 4 cases were: Case XXVIII. ExtraperitoneaI rupture of bIadder (see Figs. 2 and 3) XxxIII. Intraperitoneal rupture of bIadder XXXIV. Extra-peritonea1 rupture of bIadder xxxvr. CompIete transverse Iaceration of the membranous urethra. There were four deaths in this group (Cases XXXII, xxxv~, XLI, L) which wiII be discussed in detaiIed manner under the section devoted to MortaIities. FRACTURES OF THE SACRUM: There were 2 cases of fractures of the sacrum in this series (Cases x, XXVI). The death occurring in this group was due to shock and the accompanying injuries. FRACTURES

OF

THE

ACETABULUM.

There were 4 cases which presented fractures invoIving the acetabulum. Two cases (XLIII and L) invoIved the acetabular rim and 2 (XXXVII, XLVIII) were the steIIate type of acetabuIar fracture. In one of these (XXXVII) there was a centra1 dislocation of the femora1 head through the acetabuIum into the peIvic bowI. The one death in this group was due to the accompanying injuries and shock present at the time of admission.

NEW SERIES VOL.XXX, No.

I

Conway-Fractures

of PeIvis

American

Journal

of Surgery

‘3

TABLE v

Case

Age

31 F

8-231 8-13-31 --_____ XXVI

8-9-32 8-10-32

I /

Type of Pelvic Fracture

Course in HospitaI and Treatment

Accompanying Injuries

Cause

Incomplete fracture through Ieft Iateral mass of sacrum

Patient turned on heel and feI1 vioI IentIy on back

Fracture of right IateraI mass of sacrum

Jump from first Aoor window

Sacral

hematoma

Result

UneventfuI. Left1 Imhospita1 at own ! proved responsibility

I. Fractured skuI1. 2. Fractured right humerus. 3. Fracture transverse process of fifth Iumbar vertebra. 4. Shock

Patient in profound shock on admission from which she never raIIied. Her course was one of rapid decline and she died 24 hours after admission

TABLE VI

Type of PeIvic Fracture

Case

Accompanying

Case

Injuries

T

Cause and Result

rim Iinear

FaII from third story window

I. Compound fracture Iefit Death 8 hrs. admission tibia and fibuIa. 2. Fracture of pubic sym. physis. 3. Shock.

FaII from a Iadder 20 feet

None

3-28-33 3-3 I-33

Fracture of interna and posterior portions of Ieft acetabuium with sIight inward dispIacement of fragments

XL111 I-1 I-33

Linear fracture through upper rim of right acetabuIum

FaII from a Iadder6 feet

Fractured right acetabulum, steIIate in type with centra1 dislocation of femoral head through acetabuIar cavity

FalI from a height

Right acetabular fracture

&4:32 65-32

XLVllI

I-Home

XXXVII

ad-

vice

Improved

I-23-33 __10-4-33 1l-4-33

against

after

I. Fracture

of right iIium

I-

I. Reduction of dislocation under anesthesia. PIasterof-Paris spica. Discharged improved

DOUBLE

VERTICAL

PELVIC RING.

FRACTURES

OF THE

This type of fracture of the peIvic girdIe, first described by MaIgaigne, and referred to as the “double vertica1 fracture of the peIvic ring” occurred 6 times in this group of cases. These cases (IX, XVIII, XXI, XXIX, XLV, LIII) are tabuIated in TabIe VII. In addition to the specific peIvic fractures tabulated in the tabIes given, there were g cases in which sacroiIiac Iuxation or widening of the sacroiliac joint was present (Cases xxxvIr1, xLIv, LIII, L~I, XXVIII, XXIII, XVI, v, III). The most striking

smgIe observation made from this particuIar group is the extraordinary vioIence necessary to produce the type or combination of fractures known as the “doubIe vertica1 fracture.” The accompanying injuries which were present in Case XXIX, the onIy death in the group, are sufficient expIanation for the death of this individua1. COMPLICATIONS

AND

ASSOCIATED

INJURIES

It is of more note the increase

than passing interest to in the reported incidence

American Journal of Surgery

74

Conway-Fractures

of fractures of the peIvis and with them the assorted and varied injuries that accompany them. To MaIgaigne in 1849 TABLE Case

Age

Type of Pelvic Fracture

C*“Se

Vertical fracture of the midportion of /sff ilium with fracture of left pubis (ascending and descending rami).AIso wideningofright sacroiliac articulation with fracture of ascending and descending rami of right pubic bone

Jump from 3rd of a story burning house

OCTOBER, ,935

of PeIvis present in more cases. In an attempt

than

44 per cent

to evaluate

of the

these

condi-

VII Accompanying

Injuries

Course in Hospital and Treatment

Result

-. 18 F

LIl‘

s-20-33 7-r 3-33

--_

-.

Xl.” 5-20-33 6-16-33

25 F

-.

42 M

XXlX

12-‘8-32 I z-18-32

XXI 7-24-3 I 8-30-3 I

-.

31 F

XWlI

9-29-32 II-I-32

-.

26 M

6-65 I

7-1-31

-

Vertical fracture of inner por- Jumped from Laceration tion of left ilium. Trans2nd storv winverse fracture of ascending and descending rami of le/r pubis

of scaIp

Treated by Russell traction, 68 Ibs. of weight for 4 weeks. Pelvic sling to pelvis. Subsequently pelvis strapped with moleskin

Discharged improved

Same as Case LllI

Discharged improved

V-shaped fracture of right &urn. Fracture of ascending ramus of rigbt pubis

Jump from 5th story window

Death shortly after admission. I. Shock. a. Multiple fractures. Autopsy revealed: I. Fractured ribs, l-7 near spine. 2. Right hemothorax with subcutaneous emphysema of right axilta and right side of neck. 3. Right retropharyngeal hemorrhage. 4. Fracture of spine of seventh cervical vertebra. 5. Cornminuted fracture of upper third of left tibia and fibula

Extensive fracture of lefi ilium with stight upward displacement of outer fragment. Transverse fracture through descending rarnus of left pubis and ischium

Fall from 3rd story of a building

I. Fracture right pubis. 2. Fracture of left tibia and fib&. 3. Compound fracture of left mandible

Satisfactory

Improved

Extensive comminuted frac- Jump from 5th ture of left ilium, involving Roar of a lateral third. Downward dis- building placement of portion of *nterior superior spine. Transverse fracture of ascending ramus of lejt pubis &se to body

1. Shock. P. Fracture of descending ramus of rt. pubis at junctionoframuswithischium. 3. Multiple abrasions. 4. Extensive hematoma of right side of thorax but no intrathoracic injury

Abdominal tap negative. Course satisfactory

Discharged improved

Fall from 5th story

1. Fracture of ribs, rt. 5,6,7> 9. 10, II. +. Abdominal pain, tender. ness and rigidity in upper abdomen.

Abdominal tap negative. Course satisfactory

__

-. M6 .

None. Complicated during course in hospital by a right peritonsillar abscess

Extensive fracture of right ilium with good position of fragments. Irregular transverse fracture through descending ascending and rami of right pubis

__ Discharged improved

-

they were an unusua1 entity, for in his Treatise9 he caIIs attention to their infrequency by stating that over an eIeven year period at the H&e1 Dieu onIy IO cases of peIvic bone fracture were encountered and no record is made of any associated or compIicating injuries. In our review of the nineteen month interva1 of 1931-1933, the Iist of accompanying and compIicating injuries was a source of great information and interest. Associated fractures of other parts were

tions we have grouped these injuries into two main cIassifications as (a) extrapelvic injuries and (b) intrapelvic injuries. (a) Extrapelvic Injuries: Under this caption wiI1 come the extremity invoIvements, thoracic injuries, gas baciIIus infections; intracrania1 accidents and abdomina1 manifestations with and without intraabdomina1 viscera1 injury. In 26 cases of this series, there were associated extrapeIvic injuries, some of which were severe enough to account for

NEW SERIES

VOL.

XXX,

No.

Conway-Fractures

I

the death of the patient. The outline in TabIe VIII shows rather cIearIy the extent and variety of these injuries. Apart from these associated injuries in the form of the obvious gross concomi-

of PeIvis

Pelvic

Type

Associated

ramus.

Widening

of

I. 1.

_.

Fracture

of left

ilium

__ -. Right

ilium

Right

ilium

XIX

Right

pubis.

xx

Left

pubis,

ascending

XXI

Left

ilium;

left

IX

and

Fractured Fractured

Fracture hematoma

right

Right right

XXIIl

xxv

_.Left

and

pubis

and

XXIX

Right

xxx,

Left I. 2.

and

and

mass

of sacrum

Right pubis, ascending pubis, ascending and pubis,

rami

descending

descending

rami;

rami

ramus.

Right

left

ascending and descending of symphysis pubis. of left sacroiliac joint

Right ischium; Ing rami Left pubis symphysis

and

Left sacroiliac ramus; right Left

ischium;

Left

pubic

left pubis, ischium;

ascending

left pubis;

left

Right

pubis,

arch;

left

sacroiliac

descending

fracture

of

Fracture

ascending

mass

Gas

of sacrum

Left

Left Right

pubis,

descending

acetabulum;

subluxation

ramus

ramus symphysis

pubis

10;

ilium

! Improved lumbar

tibia

and

fibula,

left

femur.

Improved right humerus; of 5th lumbar frac-

right

ribs,

less

than

1Death in / 24 hours.

less than Autopsy

Death in 24 hours.

less than Autopsy

shaft,

lower

descending j

/

! Death

5 hours after admlsmon. Autopsy

Death 5 admission.

2-b

infection;

right processes

triceps

~Improved

muscle

zd-5th

hours after Autopsy

lumbar

Death 5 admission

hrs.

after

death admis-

Fractured

skull

Improved

Fractured compound fibula)

neck; fracture body right OS calcis; fracture right ankle (tibia and

Sepsis; sensility; 9 days after sion. Age 81

radius; left ribs., 5. 6; dislocaphalanx left nuddle finger

fracture

Fracture right ulna; body of first lumbar and pubis

Death in 24 hours

bilateral

transverse

left

Fracture right femur hematoma right side thigh

ramus

pubis, ascending of symphysis

Improved

fibula

tibia

fracture

and right

Improved

fibula

Death

humerus;

(mid-shaft); of abdomen

infected and riaht

corn ression verte g ra

fracture

Sepsrs. death after’admission! topsy

1

Improved I

Compound fracture right fracture (sub-trochanteric; shaft of femur)

femur-double comminurion

within

Death within Autopsy

I

Right ilium; left rami; separation

Improved

1Improved

Fracture right femur; fractured skull

descending

7, 8,

skull

bncillus

Compound

ilium

pubis,

and

skull; fracture transverse process

Fracture left tion terminal

_/ Right

tibia

Fracture transverse vertebr;w

.. .. ._Right

ribs-z,

Fracture right ribs, 1-6; right hemothorax and right axillary and cervical subcutaneous emphysema; fracture of 7th cervicsl vertebra. Fracture Ieft tibia and libula

Fyh;;;re

-1. . .

left

left

Frxture

and descend-

pubis, ramus

lateral

/ Improved

scapula

1

comminuted

dislocation; left pubis, descending

Improved of 4th

Comminuted fracture of left humerus; tured sternum; bilateral hemothorax

rami.

Improved

1Improved

of body

Fracture

, 2. 1Frsctured

Left pubis, Separation

chin;

II

transverse process of 5th subarachnoid hemorrhage

1I.

ilium

9. 10.

Result

Improved

bone

of

Fracture vertebra;

fracture vertebr:1

ischium

3. Separation

metatarsal

Fracture left tibia and tibula. Compound fracture left mandible

/ Fractured rami;

73

vertebra

right

Fracture left clavicle; left hemothornx I. 2.

and descending descending rami

ascending

/ Fracture

rami

descending

ascending

lateral

descending

ischium

pubis,, ascending sacrorhac relaxation pubis.

Right

XXYE

and

skull. left foot-5th

nasal bone; laceration of left upper eyelid

lumbar

ascending

I

Injury

1Fracture right ribs, 5, 6, 7, ~I, Intracranial hemorrhage. / 3. Fracture anterior portron

pubis

of Surgery

VIII

of Fracture

Right pubic bon:, ascending left sacroiliac jomt

III

Journal

tant Iesions, probabIy the most trying and baRIing of a11 was the interpretation of the significance of the abdomina1 signs present in this group of cases. Of 29 cases presenting abdomina1 signs, 5 patients were

TABLE

Case No.

American

of

Improved

8 hrs. I 2 hrs. 5z

days Au-

76

American Journal of Surgery

Conway-Fractures

subjected to Japarotomy. One of these (Case xxx) foIIowed a gunshot wound which shattered the iIium in its course;

of Pelvis

OCTOBER. 1935

tending IateraIIy was sufficient to confound the appearance and Iead the unwary to a diagnosis of an intra-abdomina1 catas-

FIG. 2. Case XXXIV. Radiograph taken September 25, 1932, discIoses comminuted fractures of ascending and descending rami of both pubic bones. Fragments of Ieft ascending ramus are displaced and project into true pelvic bowI. At aa occurred extraperitonea1 rupture of bIadder.

the remaining 4 patients were diagnosed preoperativeIy as cases with intraabdomina1 viscera1 injury. Of these 4 patients onIy one proved at operation to have a definite bIadder Iaceration. In this case, the vesica1 Iesion was demonstrated preoperativeIy by the instiIIation of neoskiodan directIy into the bIadder and an immediate radiograph being taken (Case XXXIV). (Figs. 2 and 3.) The majority of our cases were the resuItant of vioIent impact either as the resuIt of automobiIe accidents or faIIs from a height. In 4 of the cases (IX, XX, XLVII) there were muItipIe rib XXVIII, fractures with attendant abdomina1 waI1 spIinting and rigidity. In severa instances massive retroperitonea1 hemorrhage ex-

3. Case XXXIV. Radiograph taken September 25, 1932 reveals direct instiIIation of neo-skiodan per urethram into bladder and extraperitonea1 Ieakage of radiopaque substance into prevesical space at site of fracture, aa. BB indicates extravesica1 extravasation of neo-skiodan.

FIG.

trophe based upon cIinica1 findings as manifested by the abdomina1 waI1 pain, tenderness and rigidity. This cIinica1 picture is emphasized by Cotton” in his section on peIvic fractures and was present in 24 cases (LvI, LIII, xmx, XLvIII, xLvI, XL,

XLI,

XVII,

XxxVIII,

XVIII,

XXIII,

III, xxv,

IV,

VI,

XXVIII,

1x,

XI, XXXI,

XII,

xv,

xXx11,

xxxv). As a resuIt of this experience it has become a fairIy weII-established procedure to perform abdomina1 puncture in borderline cases in an attempt to estabIish the presence of free fluid within

XXXIII,

NEW SERIES VOL. XXX, No. 1

Conway-Fractures

the abdomina1 cavity-a positive tap pIus manifest cIinica1 findings justifying expIoration.

of PeIvis

American

Journal

ot Surgery

77

a puncture wound of the right arm, crepitation occurred in the region of the triceps muscIe. FoIIowing the isolation of the

FIG. 5.

FIG. 4.

FIG. 4. Case XXXVIII. Radiograph taken ApriI 19, 1933. Examination of pelvis shows Ieft sacroiliac disIocation with widening of joint space I cm. There is downward displacement of sacrum and upward riding of Ieft ilium. In addition, there is a comminuted fracture of Ieft ascending pubic ramus with a loose fragment about I inch in size at site of fracture. There is aIso a fracture of Ieft descending ramus, and fracture of transverse processes of left fourth and fifth lumbar vertebrae. FIG. 3. Case XXXVIII. Radiograph taken ApriI 26, 1933, thirty-six hours after RusseII traction appIication with g Ibs. weight, demonstrating reduction of fracture disIocation of Ieft sacroiliac articulation.

There are many who are opposed to this procedure on the basis of the apparent attendant dangers of bowe1 perforation at the time of this tap. This fear has, in the experience of the surgica1 service at our institution, been over-emphasized and exaggerated. Neuhof and Cohen* in their articIe on this diagnostic means set forth the Iimitations of the procedure and state the absoIute contraindications to its empIoyment with which we are in entire accord. The simuIation of an acute traumatic abdomina1 caIamity in the upper abdomen as the resuIt of biIatera1 rib fractures and a Iike simuIation in the Iower abdomina1 quadrants folIowing muItipIe peIvic bone fractures are we11 known. Indeed, one of the Iessons to be drawn from the review of this group of cases has been the frequency of occurrence of this clinical picture. There was one instance of a gas baciIIus infection (Case XXXVIII) where, foIIowing

organism from this region two heads of the triceps muscIe were extirpated with subsequent recovery. (b) Intrapelvic Complications. Under this grouping are included intrapeIvic viscera1 injuries and those bone and joint compIications which were not primariIy fractures. There were no rectaI, uterine or vaginal invoIvements. Of the viscera1 injuries there were 4 genitourinary compIications (Cases XXVIII, XXXIII,

XXXIV,

XXXVI).

CASE XXVIII. A thirty-seven year oId man was admitted October 6, 1932 in profound shock after having been struck by a bakery truck. In spite of al1 supportive measures to combat the shock, the patient succumbed shortly after admission. There was frank bIood in urine specimen and at necropsy in addition to the muItipIe fractures of the peIvis (ascending and descending rami of both pubes), there was marked perivesica1 hemorrhage with an extraperitoneal rupture of the bladder.

78

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Conway-Fractures

CASE XXXIII. A ten year oId boy was ad22, 1932 in profound mitted on November shock after having been struck by a heavy

FIG. 6. Case XXXVIII. Radiograph taken June 8, 1933, forty-nine days after injury, demonstrating apposition of fracture disIocation and calIus formation at site of pubic rami fractures.

truck. Exitus occurred shortIy after admission to hospita1. PeIvic fractures were recorded as “fracture of ascending and descending rami of Ieft pubis and fracture of the right ischium.” There was frank blood in urine specimen and necropsy demonstrated intraperitoneal rupture of the bIadder. CASE XXXIV. A twenty-eight year old woman was admitted to service on September been injured in an 2% 1932 after having automobiIe accident. PeIvic fracture was reported as “cornminuted fractures of both rami of both pubic bones.” Urine examination discIosed frank bIood in specimen. Laparotomy discIosed +$ inch Iaceration on anterior inferior surface of the bIadder extraperitoneaIIy. This was sutured with drainage of the extravesical space. ConvaIescence was compIeteIy satisfactory, and she was discharged on November 27, 1932 improved. (Figs. 2 and 3.)

CASE XXXVI. A seven year old boy was admitted to service on November 15, 1932 in profound shock after having been struck by a heavy truck. Radiograph of pelvis reveaIed “cornminuted fractures of the symphysis pubis, and in addition, Ieft pubis and ischium.” Exitus in Iess than twenty-four hours despite supportive treatment. Necropsy findings in

of Pelvis

addition to fractures reported in x-rays were: laceration of perineum and penis and complete transverse laceration of the membranous urethra. As wouId be expected, the vesical compIications were associated with extensive and severeIy cornminuted pubic fractures incIuding or adjoining the symphysis pubis. Lepoutre and Stobbaerts8 found that Iacerations of the membranous urethra were frequent comphcations of the peIvic girdle fractures that foIIow raihoad or mine accidents. In their study of ruptures of the urethra covering a thirteen year period, they found that 15 cases of a series of 59 urethra1 ruptures were associated with peIvic ring fractures. They believe that the mechanism causing the urethra1 tear is due to the compactness and SOIidarity of the membranous urethra and to the accompanying soft tissue Iacerations which invoIve this portion of the urethra. It is very rareIy that a bony fragment tears the urethra directIy. In children, the temporary diastasis of the urogenita1 diaphragm causes a concomitant Iaceration of the urethra. In the entire group of 56 cases, there were but 5 expIoratory ceIiotomies performed and it shouId not be amiss to emphasize again the importance of diagnostic acumen in the interpretation of abdominal signs in the presence of muItipIe injuries and the invaIuabIe information to be gIeaned from the diagnostic abdominaI puncture. It was rather striking in such a varied group of peIvic girdIe fractures to note the reIative infrequency of genito-urinary complications. At this point it might be we11 to mention the question of diagnostic procedure when intravesica1 damage is suspected. It has been a rather commona pIace procedure to instiI by catheter measured amount of Auid per urethram and then attempt to recover the same amount that was instiIIed. In our experience this manoeuver has not been uniformIy successfu1. Two suggestions which we beIieve are more heIpfu1 and accurate shouId be mentioned. The first method is

NEW SERIES VOL. XXX,

No.

Conway-Fractures

I

the direct instiIIation of some non-irritating radiopaque substance into the bIadder with subsequent immediate radiograph of the peIvic area. Leakage from the bladder into the genera1 peritonea1 cavity is immediately detectabIe and extraperitonea vesicaI tears wiII be easiIy demonstrated by the extension of the radiopaque material aIong the fines of the fascia1 attachments on the abdomina1 waI1 (see Figs. 2 and 3). Intravenous urography may be simiIarIy empIoyed to demonstrate intraperitonea1 or extraperitonea1 ruptures aIthough in the cases of severeIy shocked individuaIs it has been stated that with the attendant temporary cessation of renaI function, this diagnostic aid wouId be vaIueIess. Of the osseous compIications which are not primariIy fractures, the separations of the symphysis pubis and Iuxations of the sacroiIiac articuIation are the most important. AI1 degrees of symphysea1 separation were encountered from a simpIe division of the synchondrosis as evidenced in Case LvI, to a separation of 3 cm. as seen in Case XLI, or a compIete dissoIution of the symphysis with comminution as was present in Case XXXVI. There were 6 cases of marked widening of the symphysis pubis with 5 fatalities in this group (Cases XXXII, XXXVI, XLI, L, LV).

The sacroiIiac widening and Iuxations simiIarIy were present for varying distances and in varying degrees; the most compIete type being a compIete disIocation of the inominate bone in Case XXXVIII. This case is of sufbcient interest to be more compIeteIy detaiIed : CASE

XXXVIII.

F.

K.,

a

white

maIe

of

twenty-six years was admitted to the SurgicaI Service on ApriI 19, 1933, shortIy after having been thrown from a motorcycle which had coIIided with an automobiIe. On admission, he was in marked shock and in addition to the crushing injury to the peIvis, there were numerous abrasions about the body. There was a puncture wound of the middIe third of the right arm in the region of the triceps muscle. TweIve hours Iater the right arm was swoIIen

of PeIvis

American Journal of Surgery

‘9

and crepitation feIt beneath the skin. Direct smear from the wound showed Gram-positive baciIIi. The patient’s abdomen was rigid throughout and tender and he vomited once. Urine clear and examination negative. Operation performed for gas baciIIus infection of right triceps muscIe and two heads of the muscIe which were fiIIed with gas bubbIes were extirpated. The wound was Ieft wide open and a continuous wet dressing of potassium permanganate I :sooo employed. Radiographs were reported as foIIows: (a) Pelvis: “Examination of peIvis shows a Ieft sacroiliac reIaxation and disIocation with widening of the joint space. There is a downward dispIacement of the sacrum and an upward riding of the Ieft iIium. In addition, there is a fracture of the ascending ramus of the Ieft pubis; descending ramus of the right pubis and a fracture through the body of the right pubis.” (6) Spine: “There are fractures of the Ieft transverse processes of the fourth and fifth Iumbar vertebrae.” On ApriI 26, 1933 RusseII traction appIied to the Ieft Iower extremity with g pounds of weight and a radiograph taken thirty-six hours after reduction of the disIocation. Note Figure 4 and see Figure 5 which was taken thirty-six hours Iater. A peIvic sling was applied with 14 pounds of weight on each side of the sIing. Convalescence was uneventful. The wound of the right arm heaIed by secondary intention and the functional resuIt was satisfactory due to the remaining portion of the triceps muscIe which had been Ieft at operation. He was in bed for fifty-seven days after the accident and allowed up on crutches for four days prior to his discharge from the hospita1 on June 20, 1933. Probably the most striking feature of this case was the rapid reduction of the disIocated sacroiIiac articulation by means of the Russell traction apparatus and the smaI1 amount of weight used for the traction. Not onIy was the disIocation reduced but the position was maintained as shown by the foIIow up radiographs (Fig. 6).

This use of the RusseII traction for reducing gross disIocations of this type was nove1 in our experience but was

80

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Conway-Fractures

of Surgery

of PeIvis

exceedingIy effective especiaIIy in this type of a severeIy shocked patient with muItipIe injuries. It far outweighed any manua1 attempts that might have been made and was without any effect on the genera1 status of the patient. It was the first occasion we had had to employ this method of traction in this type of case but the resuIt obtained and the minimum

C3Se

Type

Age

xxw

Right

40

--

of Pelvic

lateral

.fractures

(both

rami

of

.-

_

--

DouhIe fracture of p&ic pubis and ilium)

42

--

ring

(right

.-

._ Fracture of left pubic symphysis

43

--

pubis;

separation

of

I. Left pubis, both Z, Right ischium

--

--

._

--

I.

__

right

right

& left

pubes

-.

__ I. Fracture 2. Fracture

1Fracture

55

_-

Shock

Autopsy: I. Fractured right ribs, 1-6, near spine 2. Right hemothorax 3. Fracture 7th cervical vertebra 4. Fracture left tibia & fibula

L.ess. than z4 hours

Shock

I.

Five

Shock

Fracture

tibia & fibula, abdominal tap

~

bladder

bilateral

hours

Less than 24 hours

Shock

Autopsy: I. Laceration of perineum and penis 2. Complete transverse laceration of membranous urethra 3, Fractured right ribs in anterior nxilIary line: 2-6

Less than 24 hours

Shock

1. Fracture of the transverse of z- 5 lumbar vertebrae

Less than 24 hours

Shock

9 days

Sepsis;

shock

13 days

Shock:

senility

femur. lower third bladder rupture

processes

I. Fracture right femur at neck 2. Compound fracture right ankle 3. Fracture right os c&is

I. Generalized 2. Laceration 1. Shock

arteriosclerosis of scalp

I. Compound frbuta 2. Shock

of right acetsbulum of symphysis pubis

fracture

right

tibia

Bi

8 hours

..

__

-_

~.ess than 24 hours

-.

pubis

-.

Fracture

50

of left

1I.

illium

2. 3. 2. F.

Fractured Fractured Fractured Fractured Shock

skull right humerus right femur rt. tibia & fib&

12 hours

Shock

._ Fracture of right ilium prior to admission)

52

--

(one

I. Fractured 2. Infected thigh

month

.Fracture of right to admission)

67

-

Fracture

._ 7o

hemothorax of Ieft humerus sternum; ruptured

vertebra

of Death

-_

I. Fracture of left ischium a. Fracture of left pubis 3. Separation of symphysis pubis of 3 cm. 4. Fracture of left lateral sacral mass

81

Autopsy: r. Bilateral 2. Fracture 3. Fractured

Shock

I. ._

._ 27

Cause

I.ess than 24 hours

2. BIoody

I. Cornminuted fracture of symphysis 2. Left pubis & left ischium

I

Injury

of skull of 5th lumbar right humerus

Autopsy: Fracture left 2. lntraperitoneal

rami

._ 7

IX

1. Fracture 2. Fracture 3. Fracture

._

._ to

Of the 56 cases incIuded in this review, there were 13 deaths. Nine patients expired within twenty-four hours after

Associated

mass of sacrum

Multiple pelvic both pubes)

MORTALITY

I

Fracture

.37

of discomfort in its apphcation justifies its being empIoyed more frequentIy in such cases.

TABLE

-

-

-

OCTOElER, 1933

-

pubis

(5 days

I.

right femnr hematomn of

Generalized 2. Hypertensive

prior

51

right

arteriosclerosis heart disease.

side

days

Sepsis

&

32 days

Autopsy:

Coronarysclerosis thrombosis

-

&

NEW

SERIES VOL. XXX. No.

I

Conway--Fractures

admission to the hospita1 and some of these patients Iived only a few hours. Two of the remaining patients, aged seventy and eighty-one respectiveIy, died within thirteen days after admission. Of the two remaining mortalities, one patient (Case LII) died of sepsis from an extensive infected hematoma which was present at the time of admission to the service after having been in the hospital fifty-two days. The remaining patient (Case LV), was brought to the aged sixty-seven, hospita1 five days after having received her injury and succumbed thirty-two days after admission of chronic cardio-vascular disease. Table IX wiI1 serve to demonstrate the fatal cases in this review. From this review of the fatal cases no indication from the standpoint of prognosis is warranted other than that the associated injuries themselves quite expIain the outcome in the afore-mentioned cases. TREATMENT 1 he treatment empIoyed in this group of cases was, as would be expected, individualized to fit the needs of each particuIar case. This statement is borne out by the review of the associated or accompanying injuries. With regard to the peIvic employed fractures per se, the method was a two-foId one and was directed toward stabilizing the pelvic girdle by means of extension traction on the Iower extremities and second, some form of peIvic sling to reduce spreading or the IateraI pelvic distortion. After widening or separation had been reduced or overcome, moIeskin strapping about the peIvic ring proved sufficient to maintain apposition. This was proved by foIIow-up radiographs after the primary distortion or disIocations had been reduced. As countertraction the foot of the bed was eIevated on bIocks. It has seemed worth whiIe to bring attention to an additiona use of the RusseII method of traction in the reduction of innominate bone disIocations. In one of our

of Pelvis

American Journal of Surgery

81

cases which is iIIustrated, this method of traction provided sufficient pull to reduce a complete disruption of the sacroihac articuIation and to hoId the fragments in their anatomica position after their reduction. The distribution of the puI1 through the femur and the Ieg is far more efbcient than the Buck’s extension apparatus and certainly more comfortable. The fma1 results in those cases which were reached by our follow-up system were disappointing; backache being the principa1 compIaint in those questioned. CONCLUSIONS I. In a review of 56 cases of peIvic fracture which were admitted over a nineteen month period, there were only 4 cases of accompanying genitourinary injury. 2. In 24 cases, abdomina1 signs of pain, tenderness and increased muscIe spasm were present due to retroperitoneal hemorrhage. 3. AbdominaI puncture as an adjuvant to the diagnosis of intra-abdominal injury has proved of inestimabIe vaIue-in positive cases. 4. The mortaIity rate in this series was definitely influenced by the degree of severity of the accompanying injuries, viz., of the 56 cases incIuded in this review there were 13 deaths. Nine patients expired within twenty-four hours foIIowing admission. Of the remaining 4, two eIderIy patients aged seventy and eighty-one years died, the first of sepsis from an infected hematoma, the second of coronary disease. 5. RusseII traction has a definite rBIe in the reduction of sacroihac disIocations and distortions. 6. In cases of suspected bIadder invoIvement, direct instiIIation of a radio-opaquz substance per urethram with subsequent radiograph is of more vaIue than tI_e attempt to siphon back a measured amount of instiIIed fluid. -. The mechanism of urethra1 injuries in chiIdren is beIieved to be due to a temporarydiastasis of the urogenitaI

82

American Journal of Surgery

Conway-Fractures

diaphragm with concomitant tearing of the urethra; onIy rareIy does a bony fragment Iacerate the urethra.

of PeIvis

OCTOBER, 1935

8. FinaIIy, the reIative infrequency of viscera1 compIications was an outstanding feature of the review of this group of cases.

REFERENCES I.

2.

3. 4.

5.

6. 7.

8. g. IO.

ASHHURST, A. P. C. Fractures of the peIvis. Ann. Surg., 49: 423, 1909. BURNHAM, A. C. Fractures of peIvis. Ann. Surg., pp. 703-15 (June) 1915. Crrrro~, F. J. DisIocations and Joint Fractures. PhiIa., Saunders, 1924, p. 654. DELORT, PIERRE. Quelques considerations sur Ie mecanisme, Ia symptomatoIogie et Ie traitment des fractures du bassin en generaI. Paris theses, VoI. 15, 1898-99. DESAULT, P. J. A Treatise on Fractures, Luxations and other Affections of the Bones. Ed. by Xav. Bichat. _~ Eng. transl. by CharIes CaIdweII. Phila., _ Fry & Kammerer, 1805, pp. 280-324. GILMOUR, W. R. Acute fractures of peIvis. Ann. Surg., 95: 161-66 (Feb.) 1932. LEADBET~ER, G. W. Fractures of the pelvis. Soutb. M. J., 25: 742, 1932. LEPOUTRE, C., and STOBBAERTS, F. Les ruptures de I’uretre. Paris, Vigot, 1934, 6: 1-178. MALGAIGNE, J. F. Treatise on Fractures. Am. ed. PhiIa., Lippincott, 1859, Chap. x, pp. 5 I 1-28. NEUHOF, H., and COHEN, I. Abdominal puncture

in the diagnosis of acute intra-peritonea1 disease. Ann. Surg., 83: 454-62 (April) 1926. I I. NOLAND, L., and CONWELL, H. E. Fractures of the pelvis. Surg. Gynec. Oh., 56: 522-25 (Feb. 15) '933. 12. PARKER, 0.

13.

14.

15.

16.

W. Fractures of the pelvis. Minnesota Med., 14: 742, 1932. PEABODY, C. E. Disruption of the peIvis with luxation of the inominate bone. Arch. Surg., 21: 971 (Dec.) 1930. TARDIEU, A. Fractures de bassin. Paris, Masson, 1869. VERDUC, L. La man&e de guerir Ies fractures et Ies Iuxations par Ie moyen des bandages. Paris, 1689. TransI. by BeIIoste. London, Sprunt, 1713, pp. 382-406. WAKELEY, C. P. G. Fractures of the pelvis; an analysis of 100 cases. &it. J. Surg., 17: 22-29,

‘929. 17. WHEELER, SIR W. Fractures

of the peIvis. Lancer,

11:313, 1925.

18. WHITE, E. W. Rupture of the bIadder. J. Ural., pp. 295-321 (March) 1933.