Assessment

HISTORY. Establish a history of the mechanism of injury, along with a detailed report from prehospital professionals. In cases of MVCs, include the type of vehicle and speed at the time of the crash. Determine whether the patient was a driver or passenger and whether he or she was using a safety restraint. If the patient experienced a fall, determine the point of impact, distance of the fall, and type of landing surface. Ask if the patient experienced suprapubic tenderness, the inability to void, or pain over the iliac spikes. Determine if the patient has any underlying medical disorders, such as polycystic kidney disease or frequent urinary tract infections. Take a medication history, and determine if the patient has a current tetanus immunization.

Pelvic Fractures 703

PHYSICAL EXAMINATION. The initial evaluation or primary survey of the trauma patient is centered on assessing the airway, breathing, circulation, disability (neurological status), and exposure (completely undressing the patient). Inspection may reveal abrasions, ecchymosis, or contusions over bony prominences, the groin, genitalia, and suprapubic area. Ecchymosis or hematoma formation over the pubis or blood at the urinary meatus is significant for associated lower genitourinary tract trauma. Palpation of the iliac crests and anterior pubis may suggest underlying injury; however, "rocking of the pelvis" is discouraged because it may cause an increase in vascular injury and bleeding. Internal rotation of the lower extremity or "frog leg positioning" is suggestive of pelvic ring abnormalities.

Perform complete rectal and pelvic examinations to assess for bleeding, rectal tone, and in women, the presence of vaginal wall disruptions. Check the position of the prostate gland in men and palpate for a "high-riding" prostate, which may indicate genitourinary tract injury. Assess the lower extremities for paresis, hypoesthesia, alterations in distal pulses, and abnormalities in the plantar flexion and ankle jerk reflexes. Inspect the perineum, groin, and buttocks for lacerations that may have been caused by open pelvic fractures. Note that from one-third to one-half of all trauma patients have an elevated blood alcohol level, which complicates assessments and may mask abdominal pain.

Monitor hourly fluid volume status, including hemodynamic, urinary, and central nervous system parameters. Notify the physician if delayed capillary refill, tachycardia, urinary output less than 0.5 mL/kg per hour, or alterations in mental status (restlessness, agitation, and confusion) occur. Body weights are helpful in indicating fluid volume status over time.

PSYCHOSOCIAL. The patient who has a pelvic fracture faces stressors that range from the unexpected nature of the traumatic event and acute pain to potential life-threatening complications. The traditional means of verbal communication are often limited or absent, thus leading to the patient's fear, loss of control, and isolation. Significant lifestyle and functional changes may occur in patients with pelvic fractures and their associated injuries. Assess patients' coping strategies, level of anxiety, and overall understanding of their injuries. Assess patients' ability to adapt to their current circumstances.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Pelvic x-rays

Intact bony structure

Evidence of fractures

Demonstrates radiographic

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