NOTE: Refer to Appendix A.
Key issues in management of pelvic fractures are to identify if the patient is hemodynamically stable and if the pelvic fracture is mechanically stable. If the patient is not hemodynamically stable, it is imperative to identify all site(s) of hemorrhage as pelvic fractures often occur in conjunction with other life threatening injuries. Appropriate evaluation of the abdomen, chest, and other potential sites of injury and hemorrhage cannot be overstressed. Additionally, a thorough examination of the pelvis and perineum is required to rule out associated injuries to the rectum and genitourinary/gynecologic systems. Pelvic fracture is a common component of Dismounted Complex Blast Injury.10
When pelvic fractures cause hemorrhage, the bleeding occurs from three major sources: arterial, venous, and cancellous bone. Over 70% of hemorrhage associated with blunt pelvic trauma causing pelvic fracture is venous in nature and may be controlled with maneuvers that reduce the pelvic volume and stabilize the pelvis.11 The other nearly 30% is associated with an arterial source and often requires procedural interventions such as surgical packing and/or embolization.12 Pelvic packing can be a valuable technique, particularly when the patient is in extremis, or when laparotomy is required for associated injuries.13
In the austere environment, if open pelvic fractures continue to bleed despite retroperitoneal packing, bilateral internal iliac artery ligation should be considered.14 In these dire circumstances, temporary cross-clamping of the aorta may help control life-threatening hemorrhage prior to dissection and ligation of the internal iliac arteries.
For pelvic fractures, initial stabilization with whatever means are available (sheet, pelvic binders, bean or sand bags, or pelvic external fixation) must be promptly implemented. In the combat environment, when fracture stability is unclear and specialist expertise is not available to determine pelvic fracture stability, stabilization with a sheet or binder is recommended. When possible, taping the knees and ankles together can minimize additional external rotational movement, and help improve the pelvic reduction achieved with a sheet or binder. Pelvic binders are correctly placed by centering over the greater trochanter of the femur, applying an internal rotational force to each hemi-pelvis through the hip joints.
The establishment of standardized clinical treatment algorithms for patients with pelvic fractures has been shown to greatly increase the probability of rapid stabilization of trauma patients.15-18 Appendix A shows an algorithm in unstable patients.
A multidisciplinary approach with early trauma surgery and orthopedic surgery coordination is critical. The focus of the evaluation and treatment is early identification of injury with early mechanical stabilization as necessary and determination of hemodynamic instability with aggressive resuscitation for hemorrhage. When available, angiographic exploration with early embolization by skilled interventionalist for the hemodynamically unstable patient with intrapelvic hemorrhage may be beneficial-preferably in the operating room.19
Given that this capability is rarely available outside of a Role 3 facility, the next most beneficial maneuver is retroperitoneal packing via a suprapubic incision.20,21 The temptation to open a retroperitoneal pelvic hematoma (as a result of a pelvic fracture) from inside the abdomen should be resisted and attempted only as a last resort although this may be necessary due to other intra-abdominal or pelvic injuries. In the casualty who remains hemodynamically compromised in spite of these efforts bilateral iliac artery ligation should be considered.14 However, these interventions should not delay the necessary acute surgical treatment for concomitant hemorrhagic injuries.