Fractures well cured make us more strongRalph Waldo Emerson
You already know where we are and where we are heading…
As always, you’re on call (it looks like you’re living in the hospital!) and you receive a call from the pre-hospital service:
- A – 33 y.o. male;
- T – 30 minutes ago;
- M – bricklayer crushed between a wall and a piece of machinery;
- I – abdominal and pelvic crush;
- S – BP 80/50mmHg, HR 125 bpm, GCS 15, Sat 99% in room air;
- T – spinal board and cervical collar.
The accident location is 2 km away from your ED and there is only a basic life support team on the scene; advanced teams are occupied on other services, they decide to scoop the patient and run.
- A – airway maintained spontaneously, the trachea is in line, the cervical collar on site;
- B – Sat 100% in room air, breath sounds bilateral, normal thoracic expansion;
- C – BP 70/40mmHg, HR 135 bpm, abdomen not tender, unstable pelvis ring on palpation, both legs are extra-rotated, no long bone fractures, no external bleeding. The nurse suggests you put on a pelvic ring…
- D – GCS 15, PEARL, sensibility maintained, unable to move the legs due to pain;
- E – massive perineal hematoma with blood in the urethra, Temp 36.5°C;
- e-FAST – no pericardial effusion, no lung effusions, good lung sliding, free fluid around the kidneys bilaterally and in the pelvis;
- ABG– pH 7.2; pO2 99; pCO2 33; HCO3 20; BE -7; Lac 6; Hb 15 g/dL; Ht 52%
Good news folks, he’s in deep shock!
And now? Let’s review some literature!
Pelvic fracture is one of the most complex injuries in trauma care. The incidence is relatively low and accounts for approximately 3% of all skeletal fractures from trauma.
Nonetheless, these patients are usually young and have a high overall injury severity score (ISS).
Most of these injuries result from high-energy trauma such as car/motorbike accidents (70%), falls from height (20%), and crushes (10%).
Despite the low incidence, the mortality rate is high (5-10%), but in the case of hemodynamic instability reaches 60%. Also, if it is an open fracture or it is associated with other severe injuries, mortality reaches 70%.
Due to the complexity of these patients, the long-living debate in the literature, with plenty of classifications and protocols, has not still established the best treatment strategy for these patients.
The patient with pelvic trauma remains impossible to photograph in an instant, but it is a continuous evolution of events and this continuous mutation makes it even more difficult to frame it.
In this scenario, a multidisciplinary evaluation of patients is indispensable. The main players are general surgeons, orthopedic surgeons, anesthesiologists, and radiologists. Fundamental must be the activation of the blood bank.
The entire management algorithm is based on the hemodynamic and physiologic stability of the patient (like any trauma!), but this, in pelvic trauma, depends on two fundamental factors: the trauma of the pelvis itself and the associated injuries.
The bleed that leads to hemorrhagic shock is the most frequent cause of mortality during the first 24 hours. Contributing to blood loss is an intrinsic dysregulation of the blood coagulation system named trauma-induced coagulopathy (TIC), which must be treated. [Read The Art of Alchemy – Part 1 for more information]
So, the management of these patients focuses on controlling hemorrhage and identifying the source of bleeding. This is subsequently followed by definitive management and repair.
And bleeding control maneuver is based on two key principles: reduce the pelvic volume and restore mechanical stability.
The lesion at the level of the pelvic ring can create instability of the ring itself and a consequent increase in the internal volume. This increase in volume associated with soft tissue and vascular disruption, facilitate the increasing hemorrhage in the retroperitoneal space by reducing the tamponing effect.
Pelvic Fracture Classification
To describe the severity of the pelvic fracture, the Young- Burgess (YB) and Tile classification systems are the two most commonly recognized systems in the literature.
The Tile classification is based on the integrity of the sacroiliac ligament of the pelvis and its mechanical instability, and it classifies pelvic fracture in 3 groups of severity: Type A (stable pelvic ring), type B (partially stable), and type C (unstable).
On the other hand, the YB system is focused on the mechanism responsible, describing three mechanisms and for each of these an increasing degree of severity:
- Lateral Compression (LC) – lateral compressive force vector at the sacroiliac joints and pubic branches. The affected hemipelvis is usually rotated superiorly and medially;
- Antero-Posterior Compression (APC) – AP direct force vector. Initially, there is a rupture of the interpubic ligament and a tear of the symphysis, then laceration of the anterior sacroiliac and sacrospinous ligaments or bony avulsion at their insertion point;
- Vertical Shear (VS) – fracture with posterosuperior dislocation of the hemipelvis.
Although the anatomical fracture pattern is no doubt an important component determining the likelihood of significant vascular injury, the utility of the YB and the Tile classification systems in predicting the need for blood transfusion and angiography in the initial resuscitation phase has shown mixed results. So, which one to use between them?
Many papers have shown that there are no significant differences between the two classifications in their ability to predict mortality, but the highest mortalities were observed in patients with high degrees of pelvic fractures (i.e. Tile C, LC 2/3, APC 2/3, VS).
In general, when we talk about unstable fracture we refer to type C of the Tile classification, and LC II-III, APC II-III, and VS of the YB classification.
A somewhat dated but still valid work has shown that deaths related to fractures with LC mechanism are more related to associated injuries, while those by AP mechanism depend more on injuries of the pelvis itself.
And talking about the pelvis… What should be looked at in a pelvic x-ray?
- Step 1 (RED) –Check for disruption of the main pelvic ring and the two obturator rings (three rings rule), including the pubic symphysis;
- Step 2 (GREEN) –Check for enlargement or misalignment of the sacroiliac joints. Check the transverse processes of L5 because they can fracture secondary to the sacroiliac diastasis;
- Step 3 (YELLOW) –Check the sacrum for signs of fracture;
- Step 4 (BLUE) –Check the acetabulum bilaterally to exclude breaks and femoral dislocation. Check the femoral head and neck bilaterally to exclude fractures.
Which Are Our Weapons?
First of all, bleeding from pelvic fractures can occur from veins (80%) and/or from arteries (20%). The most common injured veins are those of the presacral plexus and the prevescical veins; on the other hand, the principal injured arteries are the anterior branches of the internal iliac artery, the pudendal artery and the obturator artery anteriorly, and the superior gluteal artery and the lateral sacral artery posteriorly. Other sources of bleeding include bones along the fracture lines. Arterial bleeding may be predominant in patients with persistent hemodynamic instability after mechanical stabilization. Therefore, our weapons must aim to control venous bleeding first and reduce the volume of the pelvis.
A. Pelvic Binders
Pelvic binders (PB) are temporary devices to reduce and stabilize the fractured pelvic rings, preventing movement and bleeding from the fracture sites. They can aid in hemorrhage control. Their application should be done immediately in the pre-hospital setting, even if a pelvic fracture is just suspected.
Pelvic binders could be “home-made” (as a bed- sheet) or commercial. However, commercial devices are better than sheets in terms of requirements for blood transfusion.
The cornerstone of PB is to apply it correctly. The position should be around the great trochanters and the symphysis pubis in order to create a circumferential pressure able to reduce the pelvic fracture and to adduct the lower limbs.
Pelvic binders can be used as a bridge to definitive mechanical stabilization or other stabilization modalities.
Some complications, such as skin necrosis and pressure ulcers, could occur if the binder is not removed rapidly (max 24-48 hours).
Controversy surrounds the use of PB on LC fracture of the YB classification as they may become more hemodynamically unstable with the application of a binder because of the pelvis collapsing inwards.
Furthermore, pelvic binders should be positioned cautiously in pregnant women and elderly patients.
B. Preperitoneal Pelvic Packing (PPP)
In recent years, preperitoneal pelvic packing (PPP) has become a commonly used technique to control bleeding in hemodynamically unstable pelvic fractures.
The idea to pack the pelvis was initially described in the 1980s and early 1990s in Germany and Switzerland, and it was obtained by inserting packs through a trauma laparotomy.
Later, the technique was improved by the Denver Trauma Team to a concept of ‘direct’ PPP by applying a distinct surgical technique through a suprapubic midline incision that allows packing directly into the space of Retzius, without the necessity of opening the retroperitoneal compartment through a laparotomy.
To date, the PPP is a quick and easy-to-perform technique in hemodynamically unstable patients, and it could be accomplished both in the emergency department (ED) and the operating room (OR).
It starts with a short (8-10 cm) midline incision above the symphysis pubis. The midline fascial layer between both rectus abdominis muscles is transected. The peritoneum is not opened. The blood and blood clots encountered must be evacuated from the pelvis. After the drainage, several abdominal swabs are placed in the space where the hematoma was, typically in the retropubic space or along the medial walls of the posterior columns and acetabulum.
Clearly, the PPP is a damage control procedure. A second-look operation within 24-48 hours is mandatory to remove the abdominal swabs, to further debride the ischemic tissues, and to control the remaining bleeding sources.
Remember that, even if the PPP is a surgical procedure, when it is required you need to hurry, so don’t care about asepsis, prepping, etc… Infections are not normally an issue: early second look and re-do PPP (if bleeding is still going on) are fine, and it’s better to do them sooner than later. Don’t forget to send a swab to the lab for culture!
The current literature supports that PPP represents an effective technique for acute hemorrhage control that is associated with significantly reduced mortality.
C. External Fixation (Ex-Fix) – C-Clamp and External Fixator
Pelvic external fixation (Ex-Fix) represents a crucial resuscitative tool for acute hemorrhage control, as retroperitoneal bleeding is decreased after closure and reduction of the pelvic ring, and Ex-Fix gives more stability. Furthermore, PPP is more effective in conjunction with Ex-Fix, because the Ex-Fix provides a counter-pressure from the pelvic ring to the applied lap sponges in the retroperitoneal space.
There are two main fixers available: C-Clamp and external fixator.
C-Clamp is very effective for posterior instability and vertically unstable pelvic ring disruptions, such as “vertical shear” injuries. The antishock pelvic clamp was introduced in 1991.
Two thick pins are placed percutaneously through the gluteal regions at the side of the injured and uninjured hemipelvis. The tip of each pin is inserted into the bone of the dorsal ilium at the level of the sacroiliac joint. The pins are connected via an external fixator.
The two major advantages of the C-Clamp are that it allows exposure to the operating field if needed, and it quickly positionable in the ED.
Contraindications for the application of a pelvic C-Clamp include comminuted and transforaminal sacral fractures, fractures of the iliac wing, and lateral compression-type injuries.
APC-like or LC-like injury patterns are preferably stabilized by anterior Ex-Fix: in this case, pins could be applied quickly in the OR (15-20 min) at the iliac crest or supra-acetabular level through a fluoroscopy-guide.
For both fixators, the major risk is an infection of the insertion sites. Moreover, during the C-Clamp positioning, there is a high risk of neurovascular injury.
D. Angiography and Embolization
Angioembolization is an effective measure of hemorrhage control in patients with arterial sources of retroperitoneal pelvic bleeding.
In patients amenable to emergency multislice CT with contrast-enhanced angiographic phase (i.e. hemodynamically stable patients), the diagnosis of active pelvic bleeding can be made early. Contrast extravasation not only confirms but also identifies the sources of bleeding.
In hemodynamically unstable patients, the timing for angiography becomes more complex to assess. It is a complex and time-consuming procedure and, consequently, cannot be recommended to patients in extremis.
After pelvic stabilization, aggressive “hemostatic resuscitation” and exclusion of extra-pelvic sources of bleeding, patients with pelvic fractures and hemodynamic instability or evidence of ongoing pelvic bleeding should be considered for angiography and angioembolization.
Ultimately, angioembolization and packing should not be competitive, but complementary in the management of hemodynamically unstable pelvic trauma patients.
E. REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta)
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged in recent years as an alternative to emergent resuscitative thoracotomy with cross-clamping of the aorta in hemodynamically unstable trauma patients.
REBOA is presented as a “bridge-to-surgery” system in patients with pelvic trauma, and it can be followed by surgery, angioembolization, or both to obtain definitive bleeding control.
The REBOA technique consists of a percutaneous femoral arterial cannulation either by direct arterial palpation or under ultrasound guidance. The approximate distance of catheter insertion is measured externally with the bottom of the balloon located at the umbilicus. This estimated distance should be documented before catheter insertion. The balloon catheter is then advanced to Zone III of the aorta, which is just proximal to the aortic bifurcation and distal to renal arteries. Zone III is preferred in pelvic trauma in order to avoid visceral ischemic insults. At this time, quality scientific data from ongoing prospective trials on REBOA for hemorrhage control in pelvic trauma are in progress, and future validation studies are needed to determine the value of REBOA in the multidisciplinary management of hemorrhagic shock from bleeding pelvic fractures
A Pelvic Trauma Algorithm
We are talking about trauma, so the primary assessment must be the usual ABCDE & Co. protocol [Refresh the protocol with The Five Letters On Which Trauma Stands – Part 1].
The one reported above is the algorithm proposed by the World Society of Emergency Surgery in 2017. It is just one out of many. The important thing about pelvic trauma algorithms is to take into account the patient’s hemodynamic status first. Therefore, it is important to distinguish between unstable patients (i.e. hemodynamic status) and unstable fractures (pelvic status), remembering that unstable pelvic fractures are at higher risk for bleeding.
Never underestimate the associated injuries, especially the intra-abdominal ones (e.g. spleen, kidney, liver, bladder, intestine, and mesentery), which are present in about one-third of patients, but also the extra-abdominal (e.g. thoracic injuries and head trauma).
So, always expect collateral damage and act accordingly….
Last but not least, trauma-induced coagulopathy (TIC) must be considered and corrected within the first few hours. Trauma-induced coagulopathy has been a matter of concern and a topic for extensive research since it was first described in 2003. The physiological environment in which TIC arises is a complex mixture of inflammation, anticoagulation, and cellular dysfunction of mixed etiology. [Go back to The Art of Alchemy – Part 1]
This diagram taken from the latest European guideline shows the main factors involved in the onset of TIC. Clinically, TIC is manifested by an increase in international normalized ratio (INR).
For the initial management of patients with expected massive hemorrhage, European Guidelines recommends activating one of these two massive transfusion strategies: transfusing equal amounts of red blood cells, fresh frozen plasma, and platelets (i.e. 1:1:1 of volume ratio, not numbers of packs!) or administering concentrate fibrinogen and red blood cells.
There is still a lack of good data to compare these two strategies…
Now that we know a bit more about this issue, let’s return to our patient…
We have almost completed our primary survey… We have gone through ABCDE and eFAST. Before moving to the XRs, you can do something: set up a pelvic binder and call for a massive transfusion protocol (your first pack of blood products may be of 3 blood bags + 3 plasma bags + 1 g of tranexamic acid and a ROTEM/TEG exam).
After that, you may ask for the chest and pelvic XR:
- The chest is clean;
- The pelvis shows (still) a widen pubic symphysis with disruption of the main pelvic ring and opening of the left sacroiliac articulation. According to the YB classification, this is an anterior-posterior compression grade II-III.
Just to recap, we are treating an unstable patient with an unstable pelvis!
Now, you should tighten the pelvic binder (to better close the symphysis), transfuse the patient, and prepare for a preperitoneal pelvic packing (in case the patient won’t stabilize).
After transfusing 3 packs of blood with a LevelOne (i.e. a rapid infuser), this is the new assessment:
- A – still self-maintained;
- B – no changes, Sat 98% in room air with a good thoracic excursion;
- C – BP 80/40 mmHg, HR 120 bpm, pelvic binder on, knees and ankles closed together, abdomen soft;
- D – GCS 14 (E3V5M6), pupils still equals (unchanged);
- E – nothing changed;
- e-FAST – no pericardial effusion, no lung effusions, good lung sliding, stable bilateral effusions around the kidneys and in the pelvis;
- ABG – pH 7.15; pO2 98; pCO2 35; HCO3 15; BE -11; Lac 8; Hb 14 g/dL; Ht 55%
We improved a bit blood pressure and HR, but we are still in a very unstable situation (look at the ABG)! You must go for the preperitoneal pelvic packing along with the second pack of the massive transfusion protocol (i.e. 4 blood + 4 plasma + 1pack of platelets + what the ROTEM/TEG suggests). The anesthesiologist helps you performing rapid sequence intubation.
After completing the transfusions, tubing, and packing, now things look a bit better:
- A – secured with ETT 7.5 at 23 cm;
- B – ventilated in SIMV 490 ml, RR 16 bpm, ETCO2 34 mmHg, good lungs movements, Sat 100% with FiO2 35%;
- C – BP 90/50 mmHg, HR 100 bpm, abdomen soft, pelvic binder and packing on-site, legs still bonded;
- D – GCS 3 due to sedation and intubation;
- E – Temp 36.1°C;
- e-FAST – unchanged.
- ABG: pH 7.30; pO2 104; pCO2 35; HCO3 22; BE -7; Lac 5; Hb 9 g/dL; Ht 45%
The situation seems to have taken a good turn. You may have managed the venous bleeding from the pelvis, but you are sure there is still some arterial bleeders on the loose (patients unstable non-responding to initial resuscitation have a high probability of arterial bleed!). A damage control resuscitation should be kept on and the patient should be sent to angio.
The interventional radiologist finds active bleeding from the left internal iliac artery and manages to stop it by positioning a covered-stent. After the third pack of the MTP, the patient has good vitals and the blood gas is slowly getting better.
Your job for today is done, and the patient has been sent to the intensive care unit for the night. Tomorrow the orthopedics will stabilize the pelvis in the OR.
In conclusion, we still do not have gold standard management of severe pelvic fractures!
Stick always to the ABCDE approach and consider multidisciplinary management… First, close the pelvis and stop the bleeding. Contextually, be concerned with correcting coagulopathy. Finally, always expect collateral damage and act accordingly.
See you next time…
- Frassini S, et al. Emergency Management of Pelvic Bleeding. J Clin Med 2021;10:129.
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- Tile M. Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg 1996;4:143-51.
- Dalal SA, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. The Journal of Trauma: Injury, Infection, and Critical Care 1989;29:981-1002.
- Smith WR, et al. Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. J Trauma 2005;59:1510-4.
- Ganz R, et al. The antishock pelvic clamp. Clin Orthop Relat Res 1991;267:71-8.
- Reitano E, et al. Infectious complications of extra-peritoneal pelvic packing in emergency room. Updates Surg 2020. DOI: 10.1007/s13304-020-00856-w.
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- Coccolini F, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg 2017;12:5.
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How to Cite This Post
Galvanin J, Marrano E, Bellio G, Sammartano F. Pelvic Trauma 101. Surgical Pizza. Published on March 20, 2021. Accessed on July 31, 2021. Available at [https://surgicalpizza.org/trauma/pelvic-trauma-101].