Some argue that pelvic binders can lead to an under-appreciation of pelvic ring injuries with studies showing that approximately 13% of anterior-posterior compression fractures were not appreciated on imaging with a pelvic binder in place.15 The most frequently missed injuries being unstable ligamentous injuries that require surgical stabilization.11 To prevent this, patients with pelvic binders/sheets in place require a pelvic x-ray as an adjunct to the primary survey, with the binder released ONLY if hemodynamically stable. Patients with any kind of rotational instability/displacement noted on pelvis XR should have the pelvis reduced and binder/sheet replaced immediately after the x-ray.

Pelvic binders/sheets should be transitioned to external fixation or definitive stabilization as soon as the patient is physiologically stable, and the resources are available for the procedure. There have been reports of pressure ulcerations and skin necrosis from pelvic binders when left in place for greater than 3-4 hours;16 however it is not always feasible to remove the binder within this time frame due to patient instability or need to transfer to a higher level of care. Binders left in place for prolonged periods of time should have regular skin checks at a minimum of every 12 hours, and every effort should be made to convert to either external fixation or definitive fixation (when appropriate) within 24 hours.

After pelvic stabilization and resuscitation, hemorrhage control of pelvic injuries can be accomplished through PPP, angioembolization (AE), or a combination of the two. Preperitoneal packing involves placing laparotomy pads in the preperitoneal space along the pelvic ring to tamponade both venous and bony sources of bleeding. This is a damage control procedure that requires fewer resources than AE. PPP should be first line treatment for patients who continue to be hypotensive (SBP < 90) despite appropriate binder placement and initiation of blood resuscitation, have a positive FAST requiring emergent laparotomy with a pelvic hematoma present, and have persistent hypotension despite adequate blood resuscitation and intra-abdominal hemorrhage control, or a persistently hypotensive patient with an unstable pelvic fracture in an austere environment when AE is not available. In patients with a pelvic fracture requiring exploratory laparotomy, remember to maintain the pre-peritoneal space so adequate PPP is possible.

To perform PPP an infraumbilical vertical midline incision is made and carried through the fascia, leaving the peritoneum is left intact. Bluntly enter the preperitoneal space anterior to the bladder and remove any encountered blood clot. Then place 3-4 laparotomy pads on each side of the bladder and posterior and deep into the pelvis to compress the iliac veins and pelvic venous plexus 17,18 Preperitoneal packing should ideally be completed at the same time as external fixation. Pelvis external fixation can be performed using two different techniques: 1) the iliac crest technique, and 2) the supra-acetabular technique. The supra-acetabular technique is not described in this CPG and should only be performed when fluoroscopy is available, and the surgical team is appropriately trained and comfortable with this technique.

Postoperatively, patients should get further resuscitation in an ICU setting. When not immediately available, the patient should be transferred to a higher level of care with ICU and potentially IR capability as soon as stable for transport. Laparotomy pads will need to be removed in the OR in 24-48 hours after being placed.17,18 If there is continued pelvic bleeding despite PPP or if the patient remains hypotensive (SBP <90) with PPP and ICU level resuscitation, AE can be attempted for further hemorrhage control when available. If AE is not available or the patient remains in extremis, unilateral or bilateral temporary internal iliac (hypogastric) ligation can be performed. However, this places the patient at risk for gluteal muscle necrosis, and this maneuver should only be performed as a “last ditch” effort.