Unstable Pelvic Fractures Guidelines

Updated: Oct 01, 2020
  • Author: Kenneth W Graf, Jr, MD; Chief Editor: William L Jaffe, MD  more...
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Guidelines

WSES Guidelines on Pelvic Trauma

In 2017, the World Society of Emergency Surgery (WSES) published the following guidelines for management of pelvic trauma. [35]

Role of pelvic binder in hemodynamically unstable pelvic fractures

The application of noninvasive external pelvic compression is recommended as an early strategy for stabilizing the pelvic ring and decreasing the amount of pelvic hemorrhage in the early resuscitation phase.

Pelvic binders are more effective than sheet wrapping for pelvic hemorrhage control.

Noninvasive external pelvic compression devices should be removed as soon as is physiologically justifiable and replaced with external pelvic fixation or definitive pelvic stabilization, if indicated.

Pelvic binders should be positioned cautiously in pregnant women and elderly patients.

In a patient with a pelvic binder, early transfer from the spine board, whenever possible, significantly reduces skin pressure lesions.

Role of REBOA in hemodynamically unstable pelvic ring injuries

Resuscitative thoracotomy with aortic cross-clamping represents an acute measure of temporary bleeding control for unresponsive patients in extremis with exsanguinating traumatic hemorrhage.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) may provide a valid innovative alternative to aortic cross-clamping.

In hemodynamically unstable patients with suspected pelvic bleeding (systolic blood pressure < 90 mm Hg or lack of response to direct blood product transfusion), REBOA in zone III should be considered as a bridge to definitive treatment.

In major trauma patients with suspected pelvic trauma, arterial vascular access via a femoral artery (eg, 5 French) introducer might be considered as the first step for eventual REBOA.

Partial REBOA, intermittent REBOA, or both should be considered for decreasing occlusion time and ischemic insult.

Role of preperitoneal pelvic packing in hemodynamically unstable pelvic fractures

Patients with pelvic fracture–related hemodynamic instability should always be considered for preperitoneal pelvic packing, especially in hospitals with no angiography service.

Direct preperitoneal pelvic packing represents an effective surgical measure of early hemorrhage control in hypotensive patients with bleeding pelvic-ring disruptions.

Pelvic packing should be performed in conjunction with pelvic stabilization to maximize the effectiveness of bleeding control.

Patients with pelvic fracture–related hemodynamic instability with persistent bleeding after angiography should always be considered for preperitoneal pelvic packing.

Preperitoneal pelvic packing is an effective technique for controlling hemorrhage in patients with pelvic fracture–related hemodynamic instability who have undergone prior anterior/C-clamp fixation.

Role of external pelvic fixation in hemodynamically unstable pelvic-ring injuries

External pelvic fixation provides rigid temporary pelvic ring stability and serves as an adjunct to early hemorrhage control in hemodynamically unstable pelvic-ring disruptions.

External pelvic fixation is a required adjunct to preperitoneal pelvic packing to provide a stable counterpressure for effective packing.

Anterior “resuscitation frames” through the iliac crest or supra-acetabular route provide adequate temporary pelvic stability in anteroposterior compression (APC)-II/III and lateral compression (LC)-II/III injury patterns. A posterior pelvic C-clamp can be indicated for hemorrhage control in vertical shear (VS) injuries with sacroiliac (SI) joint disruptions.

Pelvic C-clamp application is contraindicated in comminuted and transforaminal sacral fractures, iliac wing fractures, and LC-type pelvic ring disruptions.

Role of angioembolization in hemodynamically unstable pelvic fractures

Angioembolization is an effective measure of hemorrhage control in patients with arterial sources of retroperitoneal pelvic bleeding.

A computed tomography (CT) scan demonstrating arterial contrast extravasation in the pelvis and the presence of a pelvic hematoma are the most important signs predictive of the need for angioembolization.

After pelvic stabilization, initiation of aggressive hemostatic resuscitation, and exclusion of extrapelvic sources of blood loss, patients with pelvic fractures and hemodynamic instability or evidence of ongoing bleeding should be considered for pelvic angiography/angioembolization.

Patients with a CT scan demonstrating arterial contrast extravasation in the pelvis may benefit from pelvic angiography/angioembolization regardless of hemodynamic status.

After extrapelvic sources of blood loss have been ruled out, patients with pelvic fractures who have undergone pelvic angiography with or without angioembolization and who have persisting signs of ongoing bleeding should be considered for repeat pelvic angiography/angioembolization.

Elderly patients with pelvic fractures should be considered for pelvic angiography/angioembolization regardless of hemodynamic status.

Indications for definitive surgical fixation of pelvic ring injuries

Posterior pelvic ring instability represents a surgical indication for anatomic fracture reduction and stable internal fixation. Typical injury patterns requiring surgical fixation include rotationally unstable (APC-II, LC-II) and/or vertically unstable pelvic-ring disruptions (APC-III, LC-III, VS, combined mechanisms [CM]).

Selected LC patterns with rotational instability (LC-II, LC-III) benefit from adjunctive temporary external fixation, in conjunction with posterior pelvic ring fixation.

Pubic symphysis plating represents the modality of choice for anterior fixation of open-book injuries with a pubic symphysis diastasis greater than 2.5 cm (APC-II, APC-III).

The technical modality of posterior pelvic ring fixation remains a topic of debate, and individual decision-making is largely guided by surgeons’ preference. Spinopelvic fixation has the benefit of immediate weightbearing in patients with vertically unstable sacral fractures.

Patients who are hemodynamically stable and mechanically unstable, with no other lesions requiring treatment and with a negative CT scan, can proceed directly to definitive mechanical stabilization.

Ideal time window for proceeding with definitive internal pelvic fixation

Hemodynamically unstable patients and coagulopathic patients in extremis should be successfully resuscitated before definitive pelvic fracture fixation.

Hemodynamically stable patients and borderline patients can be safely managed by means of early definitive pelvic fracture fixation within 24 hours after injury.

Definitive pelvic fracture fixation should be postponed until after day 4 post injury in physiologically deranged polytrauma patients.

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First Italian Consensus Conference on Pelvic Trauma Guidelines

In 2014, the First Italian Consensus Conference on Pelvic Trauma, which included members from Italian and international societies focusing on surgery, critical care, radiology, emergency medicine, and orthopedics, published the following cooperative guidelines for hemodynamically unstable pelvic trauma [40] :

  • Preperitoneal pelvic packing (PPP) is effective in controlling hemorrhage when used as part of a multidisciplinary clinical pathway that includes angiography and external fixation
  • PPP is effective in controlling hemorrhage when used as a salvage technique
  • Pelvic binders should be applied as soon as pelvic mechanic instability is assessed, better in the prehospital setting
  • Anterior or posterior external fixation must be accomplished in unstable fractures as soon as possible in substitution of pelvic binders
  • External fixation can be accomplished in the emergency department (ED) or in the operating room (OR) and appears to be a quick tool to reduce venous and bony bleeding
  • External fixation, whenever possible, can be the first maneuver to be done in patients with hemodynamic instability and a mechanically unstable pelvic fracture
  • After nonpelvic sources of blood loss have been ruled out, patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding should be considered for pelvic angiography/embolization
  • Patients in whom computed tomography (CT) demonstrates arterial intravenous contrast extravasation in the pelvis may require pelvic angiography and embolization regardless of hemodynamic status
  • After nonpelvic sources of blood loss have been ruled out, patients with pelvic fractures who have undergone pelvic angiography with or without embolization and who have persistent signs of ongoing bleeding should be considered for repeat pelvic angiography/embolization
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EAST Guidelines for Management of Hemorrhage in Pelvic Fracture

In 2011, the Eastern Association for the Surgery of Trauma published the following guidelines for management of hemorrhage in pelvic fracture [39] :

  • The use of a pelvic orthotic device (POD) does not seem to limit blood loss in patients with pelvic hemorrhage (level III recommendation)
  • The use of a POD effectively reduces fracture displacement and decreases pelvic volume (level III recommendation)
  • Patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out should be considered for pelvic angiography/embolization (level I recommendation)
  • Patients with evidence of arterial intravenous contrast extravasation in the pelvis by CT may require pelvic angiography and embolization regardless of hemodynamic status (level I recommendation)
  • Patients with pelvic fractures who have undergone pelvic angiography with or without embolization, who have signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out, should be considered for repeat pelvic angiography and possible embolization (level II recommendation)
  • Patients older than 60 years with major pelvic fracture (open book, butterfly segment, or vertical shear) should be considered for pelvic angiography without regard for hemodynamic status (level II recommendation)
  • Although fracture pattern or type does not predict arterial injury or need for angiography, anterior fractures are more highly associated with anterior vascular injuries, whereas posterior fractures are more highly associated with posterior vascular injuries (level III recommendation)
  • Pelvic angiography with bilateral embolization seems to be safe with few major complications; gluteal muscle ischemia/necrosis has been reported in patients with hemodynamic instability and prolonged immobilization or primary trauma to the gluteal region as the possible cause, rather than a direct complication of angioembolization (level III recommendation)
  • Sexual function in males does not seem to be impaired after bilateral internal iliac arterial embolization (level III recommendation)
  • Focused assessment with sonography for trauma (FAST) is not sensitive enough to exclude intraperitoneal bleeding in the presence of pelvic fracture (level I recommendation)
  • FAST has adequate specificity in patients with unstable vital signs and pelvis fracture to recommend laparotomy to control hemorrhage (level I recommendation)
  • Diagnostic peritoneal tap/diagnostic peritoneal lavage (DPL) is the best test to exclude intra-abdominal bleeding in the hemodynamically unstable patient (level II recommendation)
  • In the hemodynamically stable patient with a pelvic fracture, CT of the abdomen and pelvis with intravenous contrast is recommended to evaluate for intra-abdominal bleeding regardless of FAST results (level II recommendation)
  • Fracture pattern on pelvic x-ray does not single-handedly predict mortality, hemorrhage, or the need for angiography (level II recommendation)
  • Presence or location of hematoma does not predict or exclude the need for angiography and possible embolization (level II recommendation)
  • CT of the pelvis is an excellent screening tool to exclude pelvic hemorrhage (level II recommendation)
  • Absence of contrast extravasation on CT does not always exclude active hemorrhage (level II recommendation)
  • Pelvic hematoma larger than 500 cm 3 has an increased incidence of arterial injury and need for angiography (level II recommendation)
  • Isolated acetabular fractures are as likely to require angiography as pelvic rim fractures (level III recommendation)
  • If a retrograde urethrocystogram is required, it should be performed after CT with intravenous contrast (level III recommendation)
  • Temporary pelvic binders (TPBs) effectively reduce unstable pelvic fractures as well as definitive stabilization and decrease pelvic volume. (level III recommendation)
  • TPBs may limit pelvic hemorrhage but do not seem to affect mortality (level  III recommendation)
  • TPBs work as well or better than emergency external pelvic fixation in controlling hemorrhage (level III recommendation)
  • Retroperitoneal pelvic packing is effective in controlling hemorrhage when used as a salvage technique after angiographic embolization (level III recommendation)
  • Retroperitoneal pelvic packing is effective in controlling hemorrhage when used as part of a multidisciplinary clinical pathway including a POD/C-clamp (level III recommendation)
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