Treatment of Pelvic Fractures

Initial Management

• Immediate pelvic ring closure and stabilization is the first-line treatment for patients with pelvic fractures, especially those with hemodynamic instability 1, 2
• Pelvic closure can be achieved using external fixators, pelvic binder, bed sheet, or pelvic C-clamp 3, 2
• Early detection of pelvic injuries is crucial for reducing mortality, which remains unacceptably high (8-15%) in patients with severe pelvic ring disruptions 4, 5

Management of Ongoing Hemorrhage

• Preperitoneal packing can be performed simultaneously or soon after initial pelvic fracture stabilization, and decreases the need for pelvic embolization, aids in early intrapelvic bleeding control, and can be combined with laparotomy if necessary 1, 6
• Angiography and embolization are highly effective for controlling arterial bleeding that cannot be controlled by fracture stabilization, particularly beneficial in patients with sacroiliac joint disruption 1, 6, 2
• Surgical bleeding control should be employed when necessary 1, 6

Markers of Pelvic Hemorrhage

• Anterior-posterior and vertical shear deformations on standard radiographs, CT 'blush' (active arterial extravasation), pelvic hematoma volumes >500 ml on CT, and ongoing hemodynamic instability despite adequate fracture stabilization are markers of pelvic hemorrhage 1, 3

Damage Control Approach

• Damage control surgery should be employed in severely injured patients with deep hemorrhagic shock, signs of ongoing bleeding, coagulopathy, severe coagulopathy, acidosis, inaccessible major anatomic injury, need for time-consuming procedures, or concomitant major injury outside the abdomen 6, 3, 2, 5

Special Considerations

• Non-therapeutic laparotomy should be avoided in patients with pelvic fractures as it may increase mortality 1, 3
• Removal of pelvic packs should preferably be performed only after 48 hours to lower the risk of re-bleeding 1, 5
• A multidisciplinary approach involving trauma surgeons, orthopedic surgeons, interventional radiologists, and critical care specialists is essential for optimal outcomes 1, 2

Pitfalls to Avoid

• Delaying pelvic ring closure in hemodynamically unstable patients 1, 6
• Removing pelvic packs too early (before 48 hours) 1, 5
• Attempting primary definitive surgical management in patients with factors requiring damage control approach 2

Pelvic Fracture Management

Immediate Stabilization and Hemorrhage Control

• The American Society of Anesthesiologists recommends the use of a Ganz clamp for Tile C fractures after heavy traction of the ascended lower limb, which can be placed in the emergency room by trained operators 7
• External fixator placement is recommended for Tile C fractures and to reduce ring disruption in Tile B1 and B3 fractures, positioned anteriorly and inferiorly to allow for potential laparotomy 7, 8

Special Considerations for Open Pelvic Fractures

• Open pelvic fractures must be managed in referral centers due to their rarity and complexity, with management priorities including bleeding control, perineal contamination control, cleaning and debridement of the wound, identification and treatment of associated lesions, and treatment of the pelvic fracture 7, 8
• Surgical management of open pelvic fractures often requires temporary stoma, external pelvic fixator, and occasionally hemipelvectomy, with embolization as an adjunct for hemostasis 7, 8

Initial Management of Pelvic Fracture with Vascular Injuries

Immediate Pelvic Stabilization

• External pelvic compression with a pelvic binder should be applied as soon as possible in all patients with suspected severe pelvic trauma (Grade 1+ recommendation) 9, 10, 11, 12
• The pelvic binder must be placed around the greater trochanters to be effective compared to surgical C-clamp compression 13, 9
• Any commercial pelvic binder is acceptable except sheet wrapping, which yields no potential benefit 14
• This intervention directly reduces transfusion requirements, ICU length-of-stay, and hospital length-of-stay 14

Simultaneous Vital Signs Assessment

• Assess and reassess vital signs frequently, focusing on hemodynamic stability (systolic blood pressure <90 mmHg indicates instability requiring urgent intervention) 13, 11
• Signs of hemorrhagic shock (altered consciousness, ongoing bleeding) should be identified 14
• The presence of pelvic instability on examination confirms high-risk injury 14

Algorithmic Approach Based on Hemodynamic Status

• For hemodynamically unstable patients, perform E-FAST within 30 minutes of arrival to identify intra-abdominal bleeding source (Grade 2+ recommendation) 13, 9
• For hemodynamically unstable patients, obtain pelvic X-ray upon arrival to confirm fracture pattern (Grade 2+ recommendation) 13, 11
• For hemodynamically stable patients, skip pelvic X-ray and proceed directly to CT scan with IV contrast of the entire pelvis (Grade 2- recommendation against X-ray in stable patients) 13, 11

Transport Considerations

• All patients with severe pelvic trauma should be transported to a Level I trauma center with 24/7 availability of trauma surgery, interventional radiology, and orthopedic surgery (Grade 1+ recommendation) 13, 10
• This approach decreases mortality by 15-30% compared to non-specialized facilities 11, 12

Management of Pelvic Trauma with Hemodynamic Status-Driven Algorithm

Prehospital Management

• The American College of Surgeons recommends applying external pelvic compression with a commercial pelvic binder as soon as pelvic trauma is suspected, positioning it around the greater trochanters to achieve compression equivalent to surgical C-clamp (Grade 1+ recommendation) 15
• Prehospital physician-delivered care decreases severe trauma mortality by 30% 15
• Transport all suspected severe pelvic trauma patients directly to a designated Level I trauma center with 24/7 availability of trauma surgery, interventional radiology, and orthopedic surgery (Grade 1+ recommendation) 15

Hospital Management Algorithm

For Hemodynamically Unstable Patients

• Obtain pelvic X-ray immediately upon arrival to confirm fracture pattern (Grade 2+ recommendation) 15
• Perform E-FAST to identify intra-abdominal bleeding source (Grade 2+ recommendation), which has 97% positive predictive value for intra-abdominal hemorrhage 15
• For hemodynamically stable patients, do not obtain pelvic X-ray (Grade 2- recommendation) 15
• Proceed directly to CT scan of entire body including pelvis with IV contrast 15