BACKGROUND

Traumatic pelvic fractures in the hemodynamically unstable patient are one of the more complex injury patterns to manage in trauma care. While only an estimated 9% of blunt trauma patients sustain an injury to the pelvis, the overall mortality rates in the setting of major pelvic injuries are reported to be 13-56%, with greater than 40% mortality rate in hemodynamically unstable patients, and 50% mortality rate for open pelvic fractures.1-7 More than 70% of the bleeding that occurs in the setting of pelvic fractures is from the pelvic venous plexus, 15-25% of the bleeding is arterial requiring procedural intervention, and the remainder is from cancellous bone surfaces.1, 3-5 Features predictive of needed procedural hemorrhage control are:

1.Injury severity score

2. Advancing age

3. Blood product transfusion

4. Open pelvic fractures

5. Pelvic fracture pattern, specifically:

a. Vertical shear

b. Type III anterior-posterior compression 8-9

Historically, these injuries were relatively uncommon in the combat environment. However, during the Global War on Terror (GWOT), improvised explosive device (IED) attacks were common and resulted in an increased incidence of traumatic pelvic injuries from either dismounted operations or attacks against tactical vehicles.1 Combat-related pelvic fractures tend to be more complex, more difficult to classify, and more commonly open than those seen in civilian trauma.7 The mean Injury Severity Score (ISS) for patients with combat-related pelvic fractures is 31 versus a mean ISS of 15 seen in civilian trauma centers7 due to the fact that combat related pelvic ring injuries tend to be high-energy, unstable injuries, and frequently require procedural intervention and operative fixation.

Studies have found that 71% of combat-related pelvic fractures were open fractures, complicating open fracture management, as they have higher associated mortality and morbidity rates compared to the closed pelvic fractures more commonly seen in civilian trauma.10 Twenty-six percent of Service Members who died during Operations Iraqi and Enduring Freedom had a pelvic fracture.11 Other differences between combat-related and civilian pelvic injuries include a higher association with lower extremity amputations, which was seen in 63% of pelvic fractures and 39% had bilateral, traumatic above the knee amputations. The most common Young-Burgess classification (Figure 1) of pelvic fractures seen in combat environments were anterior-posterior compression (APC) fractures, compared to civilian settings where the most common type is lateral compression (LC). The APC fracture pattern increases the likelihood of requiring procedural hemorrhage control: 72% of APC injuries require procedural hemorrhage control compared to only 25% of LC injuries.