BACKGROUND

Historically, injuries to the bony pelvis were relatively uncommon in the combat environment. The prevalence of Improvised Explosive Device (IED) attacks seen in the Iraq and Afghanistan operations against technologically improved tactical vehicles, as well as during dismounted operations, has led to an increased incidence of blunt trauma pelvic injuries.1 The patterns of pelvic fracture in the combat environment tend to be more complex, more difficult to classify, and more commonly open than those seen in civilian trauma.

 

Hemodynamically compromised patients with pelvic fractures present a complex challenge to the trauma team as sharp spikes of bone resulting from pelvic ring injuries can lacerate surrounding soft tissues and induce brisk bleeding. The most common sources of bleeding are from fracture surfaces and the retroperitoneal venous plexus, with gluteal artery injuries occurring less commonly.2, 3 Also at risk are the hollow visceral contents of the abdomen and pelvis, L5 nerve root, and lumbar plexus.

Pelvic fractures often occur in conjunction with other life threatening injuries. Civilian mortality rates have ranged from 6-35% with higher mortality rates associated with open fractures.4-8  Death within the first 24 hours of injury in these patients is most often a result of acute blood loss and associated injuries.8

Recent analysis of mortality with combat related pelvic fractures identified large vessel injury, head injury, and injury to solid abdominal organs as risk factors for mortality in the setting of combat related pelvic ring injuries.9 Open pelvic fractures in the combat environment have become more common most  likely secondary to the increased prevalence of blast mechanisms of injury, combined with better patient survivability - attributed to rapid transport to surgical stabilization, use of tourniquets, the use of enhanced body armor and more aggressive massive transfusion protocols. These open fractures are often associated with other severe injuries, including lower extremity amputations. Combat related pelvic ring injuries are commonly high-energy and unstable injuries, frequently requiring operative fixation.