Pelvic fractures are severe injuries often resulting from significant force. An open book pelvic fracture is a specific type, important to understand due to its high risk of internal bleeding and instability.
Understanding the Injury
An open book pelvic fracture involves a specific disruption of the pelvic ring, which is a bony structure formed by the sacrum and two hip bones. This fracture pattern typically occurs when a strong force pushes the front of the pelvis outward, causing the pubic symphysis to separate. The pubic symphysis is the cartilaginous joint connecting the left and right pubic bones at the front of the pelvis.
This outward rotation resembles an open book, with the hinges being the sacroiliac joints at the back of the pelvis. While the pubic symphysis separates, the sacroiliac joints, located where the sacrum meets the iliac bones, may also be stretched, partially torn, or completely disrupted. The mechanism often involves a direct anterior-posterior compression force.
Such a widespread disruption of the pelvic ring can lead to significant instability and a substantial increase in the volume within the pelvic cavity. This increased volume allows for a greater accumulation of blood, making hemorrhage a major concern. Tearing of ligaments and damage to blood vessels within the pelvis contribute to the severity of this injury.
Causes and Risk Factors
Open book pelvic fractures arise from high-energy trauma. High-speed motor vehicle accidents are a common cause, particularly head-on collisions where the impact force is directed towards the front of the pelvis. Pedestrian-vehicle impacts can also generate the necessary anterior-posterior compression.
Falls from significant heights can likewise produce the extreme forces needed to cause this type of fracture. Crush injuries also frequently lead to open book pelvic fractures. These scenarios all involve a direct and forceful anterior-posterior impact on the pelvis, causing it to “open”.
The specific force involved is a direct anterior-posterior compression, which essentially pushes the two halves of the pelvis away from each other at the front. This mechanism differentiates it from other pelvic fracture types that might result from lateral compression or vertical shear forces. The magnitude of energy involved underscores the severity of the resulting injury.
Diagnosis and Initial Management
Upon arrival at a medical facility, individuals with suspected open book pelvic fractures often present with severe pain in the pelvic region and an inability to bear weight. Other clinical signs can include visible deformity of the pelvis, leg length discrepancy, or signs of hypovolemic shock due to significant internal bleeding. Medical professionals will observe for bruising or swelling in the groin or lower abdomen.
Diagnosis begins with a physical examination, where medical staff carefully assess for pelvic instability and tenderness. Imaging techniques confirm the diagnosis and assess the injury’s extent. X-rays are often the first step, revealing the widened pubic symphysis and potential sacroiliac joint disruption.
A computed tomography (CT) scan provides a more detailed view of the bony structures and can identify associated injuries to internal organs or blood vessels. Initial management focuses on life-saving measures, including stabilizing the pelvis to reduce ongoing bleeding. This often involves applying a pelvic binder or sheet around the hips to compress the pelvis and close the “open book”. Concurrently, measures to manage hemorrhage are initiated.
Treatment and Rehabilitation
Treatment for an open book pelvic fracture primarily aims to stabilize the pelvic ring, control bleeding, and restore the pelvis’s anatomical alignment and function. Given the instability and potential for significant blood loss, surgical intervention is frequently necessary for these severe fractures. External fixation is often used in the initial stages, where metal pins are inserted into the pelvic bones and connected to a frame outside the body, providing immediate stabilization.
Once the patient is stable, internal fixation may be performed, involving plates and screws to permanently secure the separated bones and joints. In cases of severe bleeding that does not respond to mechanical stabilization, angiography with embolization may be performed. This procedure involves identifying and blocking the bleeding blood vessels using specialized materials.
Rehabilitation begins after surgical stabilization and focuses on restoring strength, mobility, and function. Physical therapy plays a central role, starting with gentle range-of-motion exercises and progressing to weight-bearing activities as healing allows. Pain management is also a significant component throughout the recovery process. The timeline for recovery varies depending on the injury’s severity, but it can range from several months to over a year for return to pre-injury activities.