Pelvic fractures – nursing considerations by Laura Daniels - British Veterinary Nursing AssociationBritish Veterinary Nursing Association

ABSTRACT: If we think of the pelvis as a box with four sturdy sides, then breaking one side of the square weakens the whole structure. The aim of this article is firstly to review the architecture of the pelvis and, secondly, to give consideration to the nursing issues that apply to the feline patient in this situation.

Anatomy

The pelvis consists of two bones which are fused together at the site known as the pubic symphysis. Each bone consists of another three bones that are fused together. The first is the pubis, which forms the cranial section of the pelvic floor. The second is the ischium, which sits adjacent to the pubis and is, therefore, considered the caudal section of the pelvic floor (Figure 1).

Figure 1: Radiograph of canine pelvis

Finally, the biggest of the three is the ilium and it consists of a shaft attaching to the acetabulum; and the ‘wing’ extends from the attachment to the sacrum cranially as a prominent extension. All three bones meet and fuse to form the acetabulum.

Physiology

The nerve supply to the bladder, urethra, terminal colon and rectum are the pudendal, pelvic and hypogastric nerves which collectively arise from the sacral nerves. This is important when we consider that the sacrum has a strong cartilaginous joint, within the pelvis at the ilium, called the sacro-iliac junction. The anatomy is such that these nerves may be compromised during an injury to the pelvis and can result in the inability to control urination and defecation.

The pelvic canal contains the urethra, which arises from the bladder, sitting in the caudal abdomen. The caudal abdomen also contains the uterus and other soft tissue structures and it is vital when nursing the fractured pelvis patient to ensure that that no trauma has occurred to these organs.

Narrowing of the pelvic canal, through trauma, may cause a stricture or nerve damage to the bladder, or to the colon resulting in constipation and ultimately leading to obstipation in the case of the colon. The bladder will begin to fill and the possible nerve damage from trauma may cause it to lose the tonicity and ability to control itself. Alternatively, the urethra may have been torn, causing signs such as bruising, soft tissue swelling – particularly around the proximal part of the hind limb, resulting in tissue necrosis.

Arrival of the patient

When the patient is first presented, the attending veterinary surgeon will carry out an examination and obtain a full history from the owner. Monitoring the patient’s airway, breathing and cardiac function is paramount in any first aid situation and must be checked initially. The patient is placed on intravenous fluid therapy to treat for shock, and given oxygen via an oxygen chamber or intra-nasal tube. A fracture will result in haemorrhage and even small volumes can be significant.

Warmth is provided by placing the patient on to a heat pad to counteract the reduction in body temperature that occurs during shock. It is essential to take measures to prevent thermal contact injuries, which can occur when movement is limited and circulation may be impaired.

Cats are more ‘protective’ of injuries than dogs and may require analgesia before any attempt is made to conduct an orthopaedic examination. Therefore, when fractures are suspected, the patient should be handled as little and as gently as possible to minimise the risk of fragment movement.

Once the patient’s condition is stable, radiography is carried out in two orthogonal planes. Lateral and ventrodorsal views are initially obtained and, occasionally, the veterinary surgeon will require an oblique view of the pelvis to identify any fragments that may not be apparent on the two primary views.

Obtaining as much information as possible from radiographs can give the surgeon the scope to plan the pelvic repair and to minimise untoward ‘surprises’. Having a ‘plan B’ – or even ‘C’ – ensures the surgeon is prepared for most eventualities and complications!

Nursing management

There are two common methods of managing pelvic fractures.

1. Conservative/non-surgical management

Conservative management of the fractured pelvis is considered when there is minimal displacement of fracture fragments or when financial limitations do not allow surgery to be considered. The large volume of muscle around the pelvis provides considerable support and resulting stability.

Although closed fractures are not contaminated by the environment, damaged tissue and haematomas at the fracture site create a suitable environment into which bacteria from other sites in the body can settle and multiply. Some surgeons will, therefore, choose to institute antibiotic therapy on presentation of the patient.

2. Surgical management

Surgical management is necessary when there is considerable displacement of the bones and when the pelvis requires the input of stability. In some patients this type of management is preferred as the anatomy of restored fragments and healing can begin sooner. There are, however, disadvantages associated with implants and the reuniting of bone surgically.

The implant may move or loosen and the animal may develop a reaction, leading to hygroma formation – a fluid-filled ‘blister’ over the implant.

Both of these types of fracture management require strict cage rest; and, depending upon the severity of the injuries, the patient will require regular monitoring of urination. If the bladder is left distended for long periods, it can become over-stretched and this will result in it becoming flaccid. Equally, constant emptying can cause the bladder to become resistant to the stimulus it requires to empty itself.

Nursing considerations are extremely important at this time because the patient should be monitored for haematuria and tenesmus. The nurse should liaise with the owner regarding the type of litter the patient prefers as this may contribute to the unwillingness to urinate, especially if the process is painful. If necessary, the veterinary surgeon will place an indwelling urinary catheter.

The passage of faeces should also be monitored as this can be painful initially and the patient should be monitored for constipation.

The prevention of decubital ulcers in the recumbent patient is also important. Soft bedding will prevent bony prominences from becoming sore and the placing of incontinence pads under the patient to absorb any bodily fluid will help reduce urine scalding. Turning the patient from left to right lateral recumbency – and vice versa – every two hours will help prevent hypostatic pneumonia and ensure the full function of the lungs. However, this should be performed with care if the cat is in significant pain.

Throughout a patient’s hospitalisation, pain levels must be monitored and the administration of analgesia reviewed and altered accordingly. The cat is well adapted to hiding signs of pain, so asking the owner to describe typical behaviour at home may enlighten the nurse as to deterioration of the patient’s status and the efficiency of the analgesia.

Devising a pain management chart, similar to the Glasgow Coma Scale, works well and is clear and precise. This is important w
hen other staff may be involved in daily management. An ‘alert’ column on the chart – which can be used to indicate when the patient reaches a certain status – is advisable, so that the veterinary surgeon can then be informed and make adjustments to the treatment protocol.

Recovery

As recovery progresses, the patient may require assisted ambulation and physiotherapy. Ensuring that the patient is given plenty of ‘TLC’ and attention can minimise stress and anxiety, which will aid the recovery process.

Assisting the cat to stand by supporting the abdomen is a key step and can indicate how the architecture is withstanding the strain of load bearing. Once the patient begins to move around more, the pelvis and the adjoining structures will begin to strengthen. To aid in this process activities that involve the patient standing, either being assisted or not assisted by the nurse, can help.

When healing is progressing well, encourage the patient to use its hind limbs without support by tempting it with a suspended piece of open weave bandage. This often works well (Figure 2). Activities like these enable the cat to use their hind limbs and re-establish their balance and co-ordination. Cat treats and toys can make the activities pleasurable too, resulting in the cat being more amenable to the sessions.

Figure 2: Encourage the patient to use its hind limbs without support by tempting it with a suspended piece of open weave bandage

Beams of light from torches can be moved along the floor and across walls to gain the cat’s interest and encourage movement, whilst also improving the patient’s demeanour.

Discharge

When the patient leaves the hospital, the owners should be advised that strict cage rest is to be continued and only limited physiotherapy exercises, devised by a chartered veterinary physiotherapist, should be used. This must be impressed on the clients, as they often have a very different idea of what strict rest means compared with what is actually required.

As the fractures heal, the cat will become more mobile, resulting in a decrease in any muscle atrophy that may have arisen from long-term recumbency. Increased exercise is likely to occur when the cat is solitary and more active at night. This can also be a less stressful environment than during the day, when there is more activity at home.

Owners should bring the cat back to the surgery for the staples/sutures to be removed and follow-up radiographs are often obtained to monitor progress.

Mobility in dogs with fractured pelvis

As dogs are generally much heavier in body mass when compared to the feline patient, they require increased levels of assistance during the initial post-trauma period when the patient is ataxic. Canine patients will generally tolerate assisted walking very well, using a sling or towel under the abdomen to support the hind limbs and pelvis. As healing progresses, the sling can be lowered gradually so the patient takes more of its own weight and becomes more self-ambulatory.

Additionally, the sit-to-stand exercise takes the pelvis through a range of movements that simulate everyday life and strengthens the quadriceps muscle. Referral to a chartered veterinary physiotherapist for rehabilitation may also be an option, if required.

In conclusion…

Nursing the fractured pelvis patient is a demanding, time-consuming role which can be incredibly rewarding. It is vital that all body systems are monitored constantly. Communication with the owner is paramount as the hospitalisation period can be extensive and recovery at home will require close liaison between the nurse and the client in order to gain accurate information to provide the best advice and care as the patient recovers.

Author

Laura Daniels RVN MBVNA

Laura has been in practice for four years, working in a busy Tier 3 hospital based in Cheshire. Since qualifying in January 2009, she has a developed a keen interest in orthopaedic nursing care and is working to build her knowledge in this field.

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Pelvic fractures – nursing considerations by Laura Daniels