Management of Open Book Pelvic Fracture

Initial Assessment and Stabilization

For hemodynamically unstable patients, apply a pelvic binder to limit expansion of pelvic hematoma, as recommended by the American Society of Anesthesiologists 2
Obtain pelvic X-ray to identify life-threatening pelvic ring injuries, with a sensitivity of 50-68%, according to the World Journal of Emergency Surgery guidelines 3
Perform E-FAST (Extended Focused Assessment with Sonography for Trauma) to exclude other sources of hemorrhage, though it's not sensitive enough to exclude pelvic bleeding, as stated by the World Journal of Emergency Surgery 3
CT scan with contrast is the gold standard for stable patients, with 98% accuracy for identifying contrast extravasation, as reported by the World Journal of Emergency Surgery 3

For hemodynamically unstable patients with severe pelvic trauma, perform early external fixation of the pelvis using either a Ganz clamp or an anterior pelvic external fixator, as recommended by the Anaesthesia guidelines 4
Consider pre-peritoneal pelvic packing when patient cannot be transferred to CT scan or angioembolization cannot be performed within 60 minutes of diagnosis, according to the Anaesthesia guidelines 2
Angiography/angioembolization should be considered after controlling extrapelvic and non-arterial sources of bleeding, as stated by the World Journal of Emergency Surgery 5
Elderly patients may require angioembolization more frequently regardless of hemodynamic status, as reported by the World Journal of Emergency Surgery 5

Open book pelvic fractures are typically classified as APC-II or APC-III (anterior-posterior compression) injuries with pubic symphysis diastasis > 2.5 cm, according to the World Journal of Emergency Surgery guidelines 1
For rotationally unstable APC-II/APC-III injuries, pubic symphysis plating is the modality of choice for anterior fixation, as recommended by the World Journal of Emergency Surgery 1
Consider additional posterior fixation, especially for APC-III injuries with posterior instability, as stated by the World Journal of Emergency Surgery 1
Timing of definitive fixation: hemodynamically stable patients can undergo definitive fixation within 24 hours post-injury, as reported by the World Journal of Emergency Surgery 1
Hemodynamically unstable patients should be successfully resuscitated before definitive fixation, according to the World Journal of Emergency Surgery 1
For physiologically deranged polytrauma patients, postpone definitive fixation until after day 4 post-injury, as recommended by the World Journal of Emergency Surgery 1

Open pelvic fractures should be managed in referral centers due to their complexity and need for multidisciplinary approach, as stated by the Anaesthesia guidelines 6
Management priorities for open pelvic fractures:

CT with 3-Dimensional bone reconstruction can help reduce tissue damage during invasive procedures and improve patient recovery times, as reported by the World Journal of Emergency Surgery 3