PELVIS

The sacrum, ilium, pubis, and ischium bones form the pelvic bone, a fused, stable, bony ring in adults (Fig. 69-9). Falls, motor vehicle crashes, and crush injuries can cause pelvic fractures. Pelvic fractures are serious because at least two thirds of affected patients have significant and multiple injuries. Management of severe, life-threatening pelvic fractures is coordinated with the trauma team. Hemorrhage and thoracic, intra-abdominal, and cranial injuries have priority over treatment of fractures. There is a high mortality rate associated with pelvic fractures, related to hemorrhage, pulmonary complications, fat emboli, intravascular coagulation, thromboembolic complications, and infection. Pelvic fracture symptoms include ecchymosis; tenderness over the symphysis pubis, anterior iliac spines, iliac crest, sacrum, or coccyx; local swelling; numbness or tingling of pubis, genitals, and proximal thighs; and inability to bear weight without discomfort. Computed tomography of the pelvis helps to determine the extent of injury by demonstrating sacroiliac joint disruption, soft tissue trauma, pelvic hematoma, and fractures. Neurovascular assessment of the lower extremities is completed to detect injury to pelvic blood vessels and nerves. Hemorrhage and shock are two of the most serious consequences that may occur. Bleeding arises from the cancellous surfaces of

the fracture fragments, from laceration of veins and arteries by bone fragments, and possibly from a torn iliac artery. The peripheral pulses of both lower extremities are palpated; absence of pulses may indicate a torn iliac artery or one of its branches. Peritoneal lavage may be performed to detect intra-abdominal hemorrhage. The patient is handled gently to minimize further bleeding and shock. The nurse assesses for injuries to the bladder, rectum, intestines, other abdominal organs, and pelvic vessels and nerves. To assess for urinary tract injury, the patients urine is examined for blood. A voiding cystourethrogram and an intravenous urogram may be performed. Laceration of the urethra is suspected in males with anterior fracture of the pelvis and blood at the urethral meatus. (Females rarely experience a lacerated urethra.) A catheter should not be inserted until the status of the urethra is known. Abdominal pain and signs of peritonitis suggest injury to the intestines or abdominal bleeding. Paralytic ileus may accompany pelvic fractures. Numerous classification systems have been used to describe pelvic fractures in relation to anatomy, stability, and mechanism of injury. Some fractures of the pelvis do not disrupt the pelvic ring; others disrupt the ring, which may be rotationally or vertically unstable. The severity of pelvic fractures varies. Long-term complications of pelvic fractures include malunion, nonunion, residual gait disturbances, and back pain from ligament injury.

Stable Pelvic Fractures

Stable fractures of the pelvis (Fig. 69-10) include fracture of a single pubic or ischial ramus, fracture of ipsilateral pubic and ischial rami, fracture of the pelvic wing of ilium (ie, Duverneys fracture), and fracture of the sacrum or coccyx. Also, if injury results in only a slight widening of the pubic symphysis or the anterior sacroiliac joint and the pelvic ligaments are intact, the disrupted pubic symphysis is likely to heal spontaneously with conservative management. Most fractures of the pelvis heal rapidly because the pelvic bones are mostly cancellous bone, which has a rich blood supply. Stable pelvic fractures are treated with a few days of bed rest and symptom management until the pain and discomfort are controlled. The patient on bed rest is at risk for complications from immobility, including constipation, venous stasis, and pulmonary

complications. Fluids, dietary fiber, ankle and leg exercises, elastic compression stockings to aid venous return, log rolling, coughing and deep breathing, and skin care reduce the risk for complications and increase the patients comfort. The patient with a fractured sacrum is at risk for paralytic ileus, and bowel sounds should be monitored. The patient with fracture of the coccyx experiences pain on sitting and with defecation. Sitz baths may be prescribed to relieve pain, and stool softeners may be given to prevent the need to strain on defecation. As pain resolves, activity is gradually resumed with the use of ambulatory aids (eg, crutches, walker) for protected weight bearing. Early mobilization reduces problems related to immobility.

Unstable Pelvic Fractures

Unstable fractures of the pelvis (Fig. 69-11) may result in rotational instability (eg, the open book type, in which a separation occurs at the symphysis pubis with some sacral ligament disruption), vertical instability (eg, the vertical shear type, with superiorinferior displacement), or a combination of both. Lateral or anteriorposterior compression of the pelvis produces rotationally unstable pelvic fractures. Vertically unstable pelvic fractures occur when force is exerted on the pelvis vertically, as when the person falls from a height onto extended legs or is struck from above by a falling object. Vertical shear pelvic fractures involve the anterior and posterior pelvic ring with vertical displacement, usually through the sacroiliac joint. There is generally complete disruption of the posterior sacroiliac, sacrospinous, and sacrotuberous ligaments. Vertical displacement of the hemipelvis is usually evident. Treatment of unstable pelvic fractures generally involves external fixation or open reduction and internal fixation. This promotes

hemostasis, hemodynamic stability, comfort, and early mobilization.

Acetabulum
Fractures of the acetabulum are seen after motor vehicle crashes in which the femur is jammed into the dashboard. Treatment depends on the pattern of fracture. Stable, nondisplaced fractures and fractures that involve minimal articular weight bearing may be managed with traction and protective (toe touch) weight bearing. Displaced and unstable acetabular fractures are treated with open reduction, joint dbridement, and internal fixation or arthroplasty. Internal fixation permits early nonweight-bearing ambulation and ROM exercise. Complications seen with acetabular fractures include nerve palsy, heterotopic ossification, and posttraumatic arthritis.

Medical Management
Temporary skin traction, Bucks extension, may be applied to reduce muscle spasm, to immobilize the extremity, and to relieve pain. The findings of a recent study ( Jerre et al., 2000) suggested

that there is no benefit to the routine use of preoperative skin traction for patients with hip fractures and that the use of skin traction should be based on evaluation of the individual patient.

The goal of surgical treatment of hip fractures is to obtain a satisfactory fixation so that the patient can be mobilized quickly and avoid secondary medical complications. Surgical treatment consists of (1) open or closed reduction of the fracture and internal fixation, (2) replacement of the femoral head with a prosthesis (hemiarthroplasty), or (3) closed reduction with percutaneous stabilization for an intracapsular fracture. Surgical intervention is carried out as soon as possible after injury. The preoperative objective is to ensure that the patient is in as favorable a condition as possible for the surgery. Displaced femoral neck fractures may be treated as emergencies, with reduction and internal fixation performed within 12 to 24 hours after fracture. This minimizes the effects of diminished blood supply and reduces the risk for avascular necrosis. After general or spinal anesthesia, the hip fracture is reduced under x-ray visualization using an image intensifier. A stable fracture is usually fixed with nails, a nail-and-plate combination, multiple pins, or compression screw devices (Fig. 69-13). The orthopedic surgeon determines the specific fixation device based on the fracture site or sites. Adequate reduction is important for fracture healing (the better the reduction, the better the healing). Hemiarthroplasty (replacement of the head of the femur with a prosthesis) is usually reserved for fractures that cannot be satisfactorily reduced or securely nailed or to avoid complications of nonunion and avascular necrosis of the head of the femur. Total hip replacement (see Chap. 67) may be used in selected patients with acetabular defects.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS Elderly people with hip fractures are particularly prone to complications that may require more vigorous treatment than the fracture. In some instances, shock proves fatal. Achievement of homeostasis after injury and after surgery is accomplished through careful monitoring and collaborative management, including adjustment of therapeutic interventions as indicated. Neurovascular complications may occur from direct injury to nerves and blood vessels or from increased tissue pressure. With hip fracture, bleeding into the tissues is expected. Excessive swelling may be observed. Therefore, the nurse must monitor the neurovascular status of the affected leg. Deep vein thrombosis is the most common complication. To prevent DVT, the nurse encourages intake of fluids and ankle and foot exercises. Elastic compression stockings, sequential compression devices, and prophylactic anticoagulant therapy may be prescribed. The nurse assesses the patients legs at least every 4 hours for signs of DVT. Pulmonary complications are a threat to elderly patients undergoing hip surgery. Deep-breathing exercises, a change of position at least every 2 hours, and the use of an incentive spirometer help to prevent respiratory complications. The nurse assesses breath sounds at least every 4 to 8 hours to detect adventitious or diminished sounds. Skin breakdown is often seen in elderly patients with hip fracture. Blisters caused by tape are related to the tension of soft tissue edema under the nonelastic tape. An elastic hip spica wrap dressing (Fig. 69-14) or elastic tape applied in a vertical fashion may reduce the incidence of tape blisters. In addition, patients with hip fractures tend to remain in one position and may develop pressure ulcers. Proper skin care, especially on the heels, back, sacrum, and shoulders, helps to relieve pressure. High-density foam, static air, or another type of special mattress may provide protection by distributing pressure more evenly. Loss of bladder control (incontinence) may occur. In general, the routine use of an indwelling catheter is avoided because of the high risk for urinary tract infection. If a catheter is inserted at the time of surgery, it usually is removed on the morning of the first postoperative day. Because urinary retention is common after surgery, the nurse must assess the patients voiding patterns. To ensure proper urinary tract function, the nurse encourages liberal fluid intake within the cardiovascular tolerance of the patient. Delayed complications of hip fractures include infection, nonunion, avascular necrosis of the femoral head (particularly with femoral neck fractures), and fixation device problems (eg, protrusion of the fixation device through the acetabulum, loosening of hardware). Infection is suspected if the patient complains of persistent, moderate discomfort in the hip and has a mildly elevated sedimentation rate. The nursing management of the elderly patient with a hip fracture is summarized in the Plan of Nursing Care. HEALTH PROMOTION Osteoporosis screening of patients who have experienced hip fracture is important for prevention of future fractures. With dualenergy x-ray absorptiometry (DEXA) scan screening, the actual risk for additional fracture can be determined. Specific patient education regarding dietary requirements, lifestyle changes, and exercise to promote bone health is needed. Specific therapeutic interventions need to be initiated to retard additional bone loss and to build bone mineral density. Studies have shown that health care providers caring for patients with hip fractures fail to diagnose or treat these patients for osteoporosis despite the high probability that hip fractures are secondary to osteoporosis (Kamel, et al., 2000). Fall prevention is also important and may be achieved through exercises to improve muscle tone and balance and through the elimination of environmental hazards. In addition, the use of hip protectors that absorb or shunt impact forces may help to prevent an additional hip fracture if the patient were to fall.

Postoperative Nursing Management

The immediate postoperative care for a patient with a hip fracture is similar to that for other patients undergoing major surgery (see Care of the Patient Undergoing Orthopedic Surgery in Chap. 20 and Chap. 67). Attention is given to pain management, prevention of secondary medical problems, and early mobilization of the patient so that independent functioning can be restored. During the first 24 to 48 hours, relief of pain and prevention of complications are priorities. The nurse encourages deep breathing, coughing, and foot flexion exercises every 1 to 2 hours. Thighhigh elastic compression stockings and pneumatic compression devices are used to prevent venous stasis. The nurse administers prescribed intravenous prophylactic antibiotics and monitors the patients hydration, nutritional status, and urine output. A pillow is placed between the legs to maintain abduction and alignment and to provide needed support when turning the patient.

REPOSITIONING THE PATIENT The nurse may turn the patient onto the affected or unaffected extremity as prescribed by the physician. The standard method involves placing a pillow between the patients legs to keep the affected leg in an abducted position. The patient is then turned onto the side while proper alignment and supported abduction are maintained. PROMOTING STRENGTHENING EXERCISE The patient is encouraged to exercise as much as possible by means of the overbed trapeze. This device helps strengthen the arms and shoulders in preparation for protected ambulation (eg, toe touch, partial weight bearing). On the first postoperative day, the patient transfers to a chair with assistance and begins assisted ambulation. The amount of weight bearing that can be permitted depends on the stability of the fracture reduction. The physician prescribes the degree of weight bearing and the rate at which the patient can progress to full weight bearing. Physical therapists work with the patient on transfers, ambulation, and the safe use of a walker and crutches. The patient who has experienced a fractured hip can anticipate discharge to home or to an extended care facility with the use of an ambulatory aid. Some modifications in the home may be needed to permit safe use of walkers and crutches and for the patients continuing care.