Prevent movement of fracture segments, particularly in the hemodynamically unstable patient. The pelvis can be temporarily yet quickly stabilized with a bed sheet or other pelvic binding device to reduce pelvic volume and stabilize fracture ends.21,22,23 The simplest technique is the application of either a folded bed sheet secured with towel clips or a commercially manufactured binder that is tightly wrapped around the pelvis at the level of the greater trochanters. A pelvic binder can decrease the volume of the pelvis and, in turn, help diminish blood loss for both open-book and vertical shear fractures. Lateral compression pelvic fractures would not benefit from the application of a pelvic binder because they are already rotated internally; in fact, these patients may be harmed from further lateral compression.24
Provide resuscitation as needed with crystalloid, blood, and blood products. Retroperitoneal bleeding may complicate pelvic fractures. Up to 4 L of blood can be accommodated in the pelvis, until vascular pressure is overcome and tamponade occurs. Most bleeding is due to low-pressure venous bleeding and bleeding from mobile bone edges. Predictors for the need for either a transfusion or a therapeutic intervention due to hemorrhage include: (1) initial hematocrit less than 30%, (2) presence of pelvic hematoma on CT scan, or (3) a systolic blood pressure of less than 90 mm Hg upon arrival.25 Presence of any of these factors mandates close observation of the patient in an intensive care setting.25 Moreover, a recent prospective study showed that base deficit <6 mmol/L or worsening base deficit >2 mmol/L while in the ED also significantly correlated with the need for either angiography or laparotomy.26
FAST, CT, AND PELVIC FRACTURE
In hemodynamically unstable trauma patients with pelvic fractures, carefully evaluate for other sources of blood loss. Patients who have sustained a pelvic fracture from a significant mechanism of injury should undergo a thoraco-abdomino-pelvic CT scan even if the FAST is negative. In the presence of pelvic fracture and serious mechanism blunt trauma, FAST-negative patients are still very likely to have concomitant visceral injury.27
If the FAST examination reveals free intraperitoneal fluid (Figure 272-12), then CT scan is also needed to determine the next treatment step. The FAST false-positive rate for intraperitoneal hemorrhage in patients with pelvic ring disruption can be up to 30%.28,29 Distortion of the anatomy from fractures, retroperitoneal bleeding, urine from ruptured bladder, or pelvic hematomas may result in fluid collections that mimic free intraperitoneal fluid. The sensitivity and specificity of FAST for free peritoneal blood in major pelvic injury appear to be related to the severity of the pelvic fracture.28,29
Suggested algorithm for pelvic fracture treatment. FAST = focused abdominal sonogram for trauma; OR = operating room.
One study reported the overall sensitivity and specificity of FAST to detect free peritoneal fluid in major pelvic injury to be 81% and 87%, respectively.29 The fluid was blood in 76% and urine in 19%.29 Moderate to large free fluid as evidenced by fluid noted in two or more regions of the FAST exam is reported to be associated with the need for hemorrhage control, either by laparotomy or angiography.30
ANGIOGRAPHY, EMBOLIZATION, AND EXTERNAL FIXATION
If a patient with a pelvic fracture is hemodynamically unstable and other sources of bleeding (e.g., splenic or liver laceration) have been excluded through CT scan or laparotomy, treatment options include angiography with embolization, with or without external fixation of the pelvic fracture. Angiographic embolization is effective at controlling arterial bleeding, and external fixation is thought to be effective at controlling venous bleeding.31,32 Both may be needed to control hemorrhage.
Shock and death are generally due to arterial rather than venous bleeding.12,13,33,34 Arterial bleeding can occur in all types of pelvic fractures yet does so in only 10% to 15% of cases.31 The arteries involved are typically branches of the internal iliac system, with the superior gluteal artery and the obturator artery being the most common (Figure 272-2). Hemorrhage from pelvic fractures refractory to resuscitation is more likely arterial than venous in origin; angiography and embolization can control arterial hemorrhage in most patients.31,32,33 Consider angiography early in a hemodynamically unstable patient with a pelvic fracture, after other sources of bleeding have been excluded.
Contrast extravasation on CT is considered by many to be an indication for angiography to evaluate for an arterial source of bleeding that may be amenable to embolization.12,13,32,35 Some protocols advocate angiography based on hemodynamic status, the need for ongoing blood transfusion, or in patients who meet certain blood transfusion amounts.13,31 No intervention is needed for nearly half of all patients who demonstrate a pelvic blush on CT scan without clinical signs of ongoing bleeding.36 The need for arterial embolization has a positive predictive value of 39% for death in open pelvis fractures, as noted in one recent study.4
Another hemorrhage control method used in the treatment of pelvic fractures is extraperitoneal packing. This technique involves surgically placing packing in the pelvis to reduce the potential space needed to tamponade bleeding. Consider this treatment option for an unstable patient who is bleeding secondary to a significant pelvis fracture in a hospital where angiography is not readily available, when a laparotomy is needed prior to angiography, or the patient is in extremis and needs quick stabilization prior to angiography.25
The definitive treatment of pelvic fractures occurs once the patient has been stabilized and after other associated injuries have been addressed. All pelvic fractures require orthopedic consultation and admission, even in the most stable of patients. Elderly patients with simple pubic ramus fractures typically require admission for pain control, observation for complications, and physical therapy for ambulation. The exact treatment of pelvic fractures is guided by fracture location and pelvic stability. Fractures that disrupt the pelvic ring need open reduction and internal fixation within 5 to 14 days of injury.37 The decision as to which service to which to admit the patient will vary between hospitals and depend on multiple factors including the presence of a trauma surgery service, volume of orthopedic cases, comorbidities of the patient, and absence of other significant injuries.38