We must not forget that every polytraumatized patient must undergo an assessment taking into account the A, B, C, D, E of resuscitation to direct management.
The anamnesis: is of vital importance and should be carried out in case of suspicion of a pelvic fracture to the patient, if the patient is conscious, to the companions or to witnesses.
The inspection: wounds, erosions, abrasions, contusions, deformities, trochanteric and/or iliac ecchymosis, hematomas, shortening of the lower extremities are looked for in detail. Likewise, the perineum will be examined to detect injuries and anorectal, vaginal and genitourinary bleeding.
The pubic symphysis and branches, iliac crests, sacroiliac joints, sacrum, ischial tuberosities, trochanteric regions are palpated, looking for pain, deformity, functional impotence, perform bitroncanteric compression, pelvic balance, confirm or rule out vertical instability by holding the fractured hemipelvis with one hand and with the other pulling the limb.
Palpate the peripheral pulses, comparatively, from the femoral artery to the dorsalis pedis artery.
Perform a rectal examination to detect lack of integrity, determine sphincter tone, wounds, blood, foreign bodies, bone fragments and characteristics of the prostate. In women, perform a vaginal examination in addition to a complete urological and/or gynecological examination.
Perform a neurological examination in search of damage at the level of L5 due to sacroiliac dislocation, which is manifested by alterations in the sensitivity of the dorsum of the foot and the external surface of the leg, motor alterations with paresis of the tibialis anterior, common extensor of the fingers. , extensor of the first artejo and lateral peroneal muscles.
Damage at the level of S1 occurs when there are fractures of the sacrum, which is associated in 90% when there is a pelvic fracture and is evidenced by impediment to extend the hip, flex the knee, plantar flexion of the foot, sensory alterations in the posterior surface of the leg, sole and external edge of the foot, perineum and genitals.
S2 injury causes sensory damage to the penis, labia majora, urethra, and anal canal. Lesions from S2 to S5 cause bladder and anal incontinence.
Other associated injuries are hemorrhages that can be caused by the exposed fracture surface, injury to small arteries and venous plexuses, or injuries to larger vessels that, although they occur in a low percentage, are associated with high mortality.
Gastrointestinal injuries can occur from the pelvic fracture itself or from the injury that caused the pelvic fracture.
Open fractures are associated with a high risk of infection and are associated with a large percentage of visceral injury, complicating treatment. Injuries occur due to mechanisms of anteroposterior forces with tearing of the perineum, severe injuries due to lateral compression, and direct loss of soft tissues due to the object that discharges the force in the pelvis.
Treatment
The initial objective is to prevent death either from hemorrhage or associated injuries by restoring circulatory volume and initiating treatment of intrathoracic, intra-abdominal, and intracranial injuries.
Subsequently, the consolidation of the fracture, preserving functionality and anatomy, avoiding prolonged bed rest to reduce complications such as pressure ulcers, kidney stones, urinary tract infection, depression, deep vein thrombosis, lung disorders and stress ulcers.
To achieve the above, correct immobilization and fixation of the fractures must be carried out. Almost all pelvic fractures heal quickly since these bones are largely spongy and therefore have a rich blood supply.
When both sides of the pelvis are fractured, a sling is used to immobilize the entire pelvic structure as a unit so that the patient can move the rest of his body with less pain.
The pelvic sling lifts the weight of the pelvis very slightly above the mattress.
Complex pelvic trauma requires surgical treatment of soft tissues, intrapelvic and extrapelvic bones with internal and external fixation.
Stable fractures have conservative treatment, three to four weeks with bed rest and ambulation with partial and progressive unloading accompanied by analgesia according to the patient’s need.
If we are faced with an injured person who has a suspected or certain pelvic fracture and must be transferred, he or she must be immobilized from the armpit to the ankle on a board. In the absence of this, the legs must be immobilized, but together, and the patient must be moved on a stretcher.
In patients who have pelvic fractures with vertical and rotational instability, an anterior external fixator should be placed, limiting intrapelvic bleeding and providing stability for possible transfers to surgery or while awaiting subsequent evaluations. This fixation should not interfere with possible future laparotomies. Keep in mind that this fixation is not sufficient, so open reduction and internal fixation must be used.
When a pelvic fracture occurs with significant vertical displacement, external fixation and skeletal traction through the tibia or femur can be used to reduce the superior displacement after which the rotational displacement is reduced, which must be confirmed by means of x-rays.
Surgical management of pelvic injuries is indicated to correct rotational or vertical instability, or both.
Nursing Management
Keep the patient hemodynamically stable through volume control and replacement, monitoring signs such as hypotension, tachycardia, active bleeding from open fractures, mucocutaneous pallor, etc.
Carry out daily cleaning of tutors and external fixations, aseptically heal surgical and traumatic wounds, avoid infections, according to the wound management guide of each institution.
Take care of the skin by lubricating it and making position changes to avoid pressure ulcers or wounds that complicate the patient’s situation.
Practice aseptic technique in the management of urinary catheters and cystostomies to avoid urinary infections.
Management of colostomies to avoid skin injuries and infections, following the corresponding management guide.
Antibiotic administration.
Provide the patient with protective measures such as splints or boots to prevent foot drop.
Look for signs of thrombophlebitis in the lower limbs such as edema, redness, heat and pain.
In case of skeletal or skin traction, the following must be taken into account:
• the patient must be in an aligned position with respect to the weight of the traction
• ensure that the patient has the appropriate weight and therefore, decreases pain
• the ropes must run freely through the pulleys, without knots impeding it
• the weights must hang freely
• encourage the patient to perform active lower limb exercises and perform passive exercises to maintain tone, strength and avoid muscle atrophy.
Control pain by administering the prescribed analgesics and keeping the patient in a comfortable and appropriate position.
Prevent the patient from adopting positions that do not favor the treatment and may contribute to the formation of contractures.
In patients with loss of consciousness or who cannot eliminate, a Foley catheter should be passed, as long as there is no presence of blood in the urinary meatus, which is a sign of rupture of the urethra, which is an absolute contraindication for the passage. of the probe.
Evaluate urine characteristics, looking for hematuria, bladder ballooning, inability to urinate, urethrorrhagia, involuntary urination, vaginal leakage of urine (due to urethrovaginal fistulas), pain during urination, among others.
Offer the patient a balanced nutritional contribution according to their metabolic needs.
Assess nutrition tolerance, prevent and treat constipation.
Provide emotional support by encouraging the patient to make their recovery more effective.
Bibliography
• Rodriguez A. et al. Trauma. Pan American Trauma Society 1997.
• Sholtis L., Smith D. Manual of Medical-Surgical Nursing. Editorial Interamericana SA 1984.
• Leit M. and Gruen G. Pelvic fractures. In: Manual of trauma, medical and surgical care. McGraw Hill. Interamericana 1998.
• Gomez R. Urological injuries associated with pelvic trauma. Workers’ Hospital of Santiago, Chile.