ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Severe pelvic fracture in the adult trauma patient

Severe pelvic fracture in the adult trauma patient
Literature review current through: Jan 2024.
This topic last updated: May 11, 2022.

INTRODUCTION — One-third of patients arriving in shock with an unstable pelvic fracture to level I trauma centers in the United States succumb to their injuries [1,2]. Pelvic injuries often occur in conjunction with other life-threatening injuries, and there is not universal agreement on all aspects of management. Following initial resuscitation, current management algorithms in the United States incorporate variable timeframes for bony stabilization and hemorrhage control options including resuscitative endovascular balloon occlusion of the aorta (REBOA), preperitoneal pelvic packing with external skeletal fixation, and angioembolization. We suggest early skeletal fixation and pelvic packing for patients who remain hemodynamically unstable despite red cell transfusion, reserving angioembolization for noncoagulopathic patients who continue to bleed from a pelvic source despite pelvic packing and external skeletal fixation. The management of severe pelvic fractures is optimized using a multidisciplinary approach involving the trauma surgeon, orthopedic surgeon, vascular interventionalist, anesthesiologist, and the blood bank services.

Methods to treat severe pelvic fractures, including controlling ongoing hemorrhage, are reviewed here. The diagnosis and initial trauma management of patients with pelvic fractures are discussed elsewhere. (See "Pelvic trauma: Initial evaluation and management".)

ANATOMIC CONSIDERATIONS — Blunt injury to the pelvis can produce complex fractures that often result in moderate-to-severe hemorrhage. The Young and Burgess classification uses the force vector to categorize pelvic fractures (ie, lateral compression [LC], anterior/posterior compression [APC], or vertical shear [VS]) (figure 1 and table 1) [3,4]. Within each category, the amount of ligamentous injury, bony fracture, and overall displacement of the hemipelvis further categorizes the patient's pelvic injury from type I (less severe) to type III (most severe). However, a patient's fracture pattern may not adhere to a single category; a combination of LC, APC, and VS may be present. Higher grades, particularly APC III and VS, are more commonly associated with hemodynamic instability and the need for early transfusion and intervention. (See "Pelvic trauma: Initial evaluation and management", section on 'Fracture types'.)

Pelvic fractures can also be described as biomechanically stable or unstable within the Academy of Orthopedics/Orthopedic Trauma Association classification system [5]. Unstable pelvic fractures require two or more breaks in the pelvic ring. It is important to note that biomechanical instability of the pelvic fracture does not necessarily equate to hemodynamic instability. The fracture components and ligamentous instability may result in a rotationally unstable (partially stable pelvis, type B) or a rotationally and vertically unstable (completely unstable, type C) pelvis (figure 2). Generally, APC II and LC II and III injuries are considered rotationally unstable while APC III, VS, and combined injuries are both rotationally and vertically unstable.

Fractures that create soft tissue defects are termed "open" fractures; the break can penetrate the bladder, rectum, vagina, or skin, and these associated injuries complicate management. (See 'Management of associated soft tissue injury' below.)

Movement of the bony surfaces of the pelvic bones can lead to shearing and avulsion of the pelvic vasculature (figure 3). The veins of the presacral pelvic plexus are particularly vulnerable. Greater than 85 percent of bleeding due to pelvic fractures is venous or from the open surfaces of the bone [1,2,6]. Pelvic fracture may also be associated with injury to the iliac arteries [7].

TRAUMA EVALUATION — We perform initial resuscitation, diagnostic evaluation, and management of the trauma patient with blunt or penetrating trauma following guidelines recommended by the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma [8]. The initial resuscitation and evaluation of the patient with blunt or penetrating abdominal or thoracic trauma is discussed in detail elsewhere.

(See "Initial management of trauma in adults".)

(See "Initial evaluation and management of blunt thoracic trauma in adults".)

(See "Initial evaluation and management of blunt abdominal trauma in adults".)

Severe pelvic fractures can be life-threatening injuries due to uncontrolled bleeding. [1]The patient's blood pressure and pulse in the ED should be monitored closely. A systolic blood pressure <90 mmHg in adults is assumed to be due to hemorrhage until proven otherwise, and a diagnosis of pelvic fracture as a cause of hemodynamic instability should trigger resuscitation using a massive transfusion protocol. Trauma-induced coagulopathy will exacerbate bleeding, and a diagnosis should be sought actively. We prefer thrombelastography (TEG) for goal-directed management in blood product transfusion. Prior to TEG results, empiric transfusion of low-titer O negative whole blood is used. (See "Massive blood transfusion" and "Etiology and diagnosis of coagulopathy in trauma patients", section on 'Trauma-induced coagulopathy'.)

Pelvic fracture as the primary source of hemodynamic instability should be quickly differentiated from other life-threatening injuries such as hemopneumothorax, cardiac tamponade, or hemoperitoneum. Trauma bay chest radiograph, pelvic radiograph, and extended Focused Abdominal Sonography for Trauma (eFAST) are critical in delineating the source of shock in the trauma bay. If the patient stabilizes, computed tomography (CT) scans should be obtained as soon as possible to identify other life-threatening injuries (eg, severe traumatic brain, blunt thoracic aortic injury). Associated life-threatening injuries influence initial management (algorithm 1) [9-11]. (See 'Fracture-related injuries' below.)

If the patient's primary source of bleeding is considered likely to be in the pelvis due to mechanism of injury (eg, motor vehicle-pedestrian crash, bicyclist struck by auto, motorcycle crash, fall from height >30 ft), temporary external pelvic stabilization with a sheet or binder should be placed immediately prior to radiographic fracture confirmation (picture 1) [12]. However, it is important to recognize that excessive pelvic compression may worsen bleeding with a lateral compression III pattern. (See "Pelvic trauma: Initial evaluation and management", section on 'Initial stabilization and approach' and 'Fracture stabilization' below.)

History and physical — Injured patients complaining of pelvic pain or tenderness to pelvic palpation are assumed to have a pelvic fracture until proven otherwise. Approximately 80 percent of pelvic fractures can be detected on careful clinical examination [13]. Overlying abrasions or contusions are commonly seen. Patients who cannot relate pain, such as patients who are intubated or those with altered mental status, should undergo plain radiography in the trauma bay. Hemodynamically stable patients should be transported for CT of the pelvis.

Although formerly used as a technique on clinical exam to identify pelvic instability, "rocking" the pelvis by pressing down on the iliac crest from front to back and side to side should not be used, because it risks disrupting any pelvic hematoma that has formed, potentially "re-opening" an unstable pelvis, and increases the risk for further vascular injury. Instead, presumptive pelvic binding should be applied in hemodynamically unstable patients at high risk for major pelvic fractures (eg, auto-versus-pedestrian accidents, bicycle or motorcycle crashes, falls from >30 ft).

Extended FAST scan — The extended Focused Abdominal Sonography for Trauma (eFAST) scan is important in the initial evaluation of abdominal trauma and includes rapid assessment for associated hemopneumothorax (eFAST). Although the eFAST exam is available in most trauma centers, diagnostic peritoneal aspiration (DPA) may be needed if the source of shock cannot be identified [14-19]. (See "Initial management of trauma in adults", section on 'Ultrasound (FAST exam)' and "Initial management of trauma in adults", section on 'Diagnostic peritoneal tap or lavage'.)

Hemodynamically unstable patients with a positive abdominal FAST scan should be taken emergently for exploratory laparotomy to identify and control intra-abdominal bleeding. eFAST results can be helpful in determining appropriate zone placement (I versus III) if REBOA placement is considered (figure 4) [20]. (See 'General approach' below.)

Pelvic imaging — Pelvic imaging, optimally with CT, is used to identify bony disruptions and classify the pelvic fracture [21-25]. The initial diagnostic approach to pelvic fracture is discussed in detail elsewhere. (See "Pelvic trauma: Initial evaluation and management", section on 'Diagnostic tests'.)

In hemodynamically unstable patients, CT evaluation of the pelvic fracture should be deferred unless REBOA is used to improve central perfusion to enable rapid CT scanning to identify additional life-threatening injuries. (See 'General approach' below.)

Transport of the persistently hypotensive patient (systolic blood pressure <90 mmHg) is unsafe because ongoing bleeding may result in rapid cardiac decompensation. Hemodynamically stable patients undergoing further CT imaging should be accompanied by a senior member of the trauma team who should be prepared to abort the study and transport the patient directly to the operating room if the patient becomes hemodynamically unstable.

CT scanning, particularly with three-dimensional reconstruction, is useful for planning definitive fracture repair by defining the geometry of the pelvic fracture, identifying occult fractures not seen on plain film, quantifying pelvic displacement, and evaluating the integrity of the ligaments. Pelvic bleeding may also be seen as contrast extravasation, but this finding should not be used in isolation as an indication for arteriography [26-29]. (See 'Management' below.)

Fracture-related injuries — Pelvic injury is indicative of a high-energy trauma, and patients with pelvic fractures frequently have severe associated injuries [30-32]. In one retrospective review of 3576 patients with pelvic fracture, 21 percent had chest trauma, 17 percent had head injuries, 8 percent had injuries of the liver or spleen, and 8 percent had ≥2 long bone fractures [9]. The mean injury severity score (ISS) for patients with severe pelvic fracture was 18, with no significant differences in ISS between rotationally unstable, vertically unstable, or combined injuries [10,33]. (See 'Anatomic considerations' above.)

The clinical evaluation may identify injuries that are directly related to the bony fracture. These include:

Lower genitourinary tract injury – Hematuria is a sign of lower genitourinary tract injury. Bladder rupture is commonly associated with severe pelvic fractures. Urethral injury is suggested by the presence of blood at the meatus or scrotal/perineal bruising; the rectal exam in males may also reveal a high-riding prostate. The management of associated lower genitourinary injuries is discussed separately. (See "Overview of traumatic lower genitourinary tract injury".)

Iliac vessel injury – Although uncommon, a stretch injury of the external iliac artery as it passes over the pelvic brim may result in an intimal tear, which may cause arterial thrombosis and lower extremity ischemia [32,34]. Common iliac artery injuries can also occur with extensive pelvic fractures [35,36]. Thus, in addition to routine palpation of the extremity pulses, ankle-brachial indices (ABIs) should be obtained bilaterally. Significant differences (>0.10) in the index values between the extremities may indicate injury on the side with the lower ABI. (See "Noninvasive diagnosis of upper and lower extremity arterial disease", section on 'Ankle-brachial index' and "Clinical features and diagnosis of acute lower extremity ischemia" and 'Management of associated vascular injury' below.)

Rectal injury – All patients with a pelvic fracture should undergo digital rectal examination to evaluate for the presence of blood or bony spicules indicative of rectal perforation [37,38]. Patients with a suspected rectal injury should undergo an exam under anesthesia in the operating room with rigid proctoscopy (preferred) or flexible sigmoidoscopy to definitively exclude a rectal injury. (See "Traumatic gastrointestinal injury in the adult patient", section on 'Colorectal injuries'.)

Vaginal injury – Vaginal examination with a speculum should be performed in women with pelvic fractures to exclude an open fracture. (See "Evaluation and management of female lower genital tract trauma".)

Perineal injury – The perineum should be inspected for external lacerations that communicate with the pelvic fracture (ie, an open pelvic fracture). (See 'Management of associated soft tissue injury' below.)

Nerve injury – A systematic sensory and motor examination of the lower extremities should be performed to identify any deficits that may be due to an associated spine injury or nerve root avulsion. (See "Lumbosacral plexus syndromes", section on 'Trauma' and "Acute traumatic spinal cord injury".)

MANAGEMENT — The management of severe pelvic fracture in hemodynamically unstable patients involves control of bleeding using a combination of techniques: external fracture stabilization with preperitoneal pelvic packing and angioembolization [39,40]. Following an interval of ongoing resuscitation and management of other urgent injuries, internal fracture fixation should be performed as soon as possible.

General approach — Hemodynamically unstable patients with indications for surgery (eg, positive extended Focused Assessment with Sonography in Trauma [eFAST] scan, massive hemothorax on chest radiograph or by chest tube output) should be taken directly to the operating room to identify and manage hemorrhage. A massive transfusion protocol should be active for hemodynamically unstable patients.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an option used in some centers where appropriate equipment and expertise is available to achieve hemodynamic stability, which permits transfer to the operating room or may occasionally facilitate expedited CT scanning prior to pelvic hemorrhage control [41-45]. This should be placed in zone III for presumed pelvic fracture bleeding (figure 4 and picture 2) and zone I if associated intra-abdominal bleeding [46,47]. The availability of partial REBOA is the latest advance of this technology [48]. (See "Endovascular methods for aortic control in trauma".)

In the operating room, bleeding in the thorax or abdomen is under control and the patient is hemodynamically stable, the pelvic fracture can be stabilized using an external fixation device. If there is ongoing hemodynamic instability thought to be due to retroperitoneal bleeding from the pelvic fracture, then, in addition to external fixation, we use preperitoneal pelvic packing. Pelvic-fracture-related bleeding is often evident on laparotomy as a large pelvic space hematoma. Alternatively, in an appropriately equipped operating room, intraoperative angiography and embolization may be an option. (See 'Fracture stabilization' below.)

Based upon observational studies evaluating each therapy, combined with our clinical experience, we suggest operative control with preperitoneal pelvic packing as first-line therapy to tamponade bleeding in hemodynamically unstable patients, reserving angioembolization for the few patients who demonstrate persistent bleeding in spite of these maneuvers [29,39,49-57]. A minority of patients (approximately 15 percent) who undergo arteriography have a lesion that is amenable to embolization, and arteriography does not address the potentially severe venous bleeding that is the source in more than 85 percent of patients who have lethal pelvic injuries [6,50,51,58,59]. Predicting who might benefit from emergent angioembolization remains a challenge [60,61]. Management in the operating room also allows examination of the rectum and vagina under anesthesia, and washout of any open wounds.

For patients who are responsive to fluid resuscitation and without other urgent indications for surgery, further evaluation is appropriate [52,53,62-67]. The use of arteriography and angioembolization to control retroperitoneal bleeding depends upon ready availability of a trauma-vascular surgeon, support staff, and appropriate equipment and supplies associated with the procedure [68]. The increasing availability of hybrid operating rooms is changing the approach to pelvic arterial bleeding, and trauma surgeons are being trained to provide endovascular control of visceral and vascular hemorrhage. (See 'Arteriography and angioembolization' below.)

Fracture stabilization — Fracture stabilization is critical to decrease pelvic volume, promote tamponade of venous bleeding, and prevent shifting of the bony elements that can lead to secondary hemorrhage [69,70]. Prompt external fracture stabilization is an important step in the initial management of the hemodynamically unstable patient with pelvic fractures. Definitive fracture stabilization can be accomplished with external or internal fixation.

External stabilization – For patients who are hemodynamically unstable, immediate stabilization is essential, which can be performed by wrapping a sheet around the pelvis (picture 1), using a commercially available binder, or placing an external frame [71]. Although the sheet or binder helps to realign the pelvis and is ideal for "open book" pelvic fracture, temporary stabilization may not improve pelvic alignment if the posterior elements are completely disrupted. Other disadvantages of binders are necrosis of the skin overlying bony prominences and the potential to contribute to abdominal compartment syndrome [72]. Thus, if a sheet or binder has been placed, it is important that it is replaced with an external frame as soon as possible [8,22,52,73-76]. (See "Pelvic trauma: Initial evaluation and management", section on 'Initial stabilization and approach'.)

External fixation – External frames (anterior external fixator or posterior pelvic C-clamp) can be placed in the emergency department or operating room and are usually placed by an orthopedic surgeon, but, occasionally, placement by the trauma surgeon may be needed [69]. The external frame should be placed with the connecting bars positioned lower, almost over the groin crease, to allow operative access to the abdomen and pelvis. Once the frame is in place, it may serve as definitive fixation (ie, six to eight weeks) or be removed once the fracture is internally stabilized.

Internal fracture fixation – The decision for and timing of internal fixation is highly individualized, depending upon the nature of the pelvic fracture, the presence and severity of associated injuries, and the patient's medical comorbidities, which may limit the timing or ability to return to the operating room. Definitive open reduction and internal fixation (ORIF) is often performed within 10 days of injury, but for some patients, particularly those with other major associated thoracic or abdominal injuries, definitive treatment of the pelvic fracture may be accomplished by external fixation alone. Clearly, internal fixation should not be performed in the hemodynamically unstable patient.

Preperitoneal pelvic packing — Preperitoneal pelvic packing refers to a surgical procedure in which laparotomy sponges are placed into the preperitoneal space to tamponade bleeding and reduce the available volume of the retroperitoneal space [29,49,77-79]. In the hemodynamically unstable patient, we suggest preperitoneal pelvic packing for controlling hemorrhage from severe pelvic fractures, rather than angioembolization, because it can be quickly accomplished and addresses venous and bony sources of hemorrhage [41,55,80]. External fixation of the pelvis can be performed concurrently with, and often minutes just prior to, preperitoneal pelvic packing. This allows one to pack into a stable pelvic frame. (See 'Fracture stabilization' above.)

Preperitoneal pelvic packing is performed through a small suprapubic incision (picture 3) [81]. This incision should remain separate from any necessary laparotomy incision. A minimum of six laparotomy pads (four in children) are placed directly into the space around the bladder (figure 5). These are placed in an inverted "U"with the first pack down onto the sacrum. A more detailed description of the specific technique can be found elsewhere [81]. The original technique described for control of retroperitoneal bleeding consisted of transabdominal (transperitoneal) packing of the retroperitoneum for hemorrhage control; however, sufficient tamponade was difficult to achieve [53,79], and thus, this technique was modified to directly pack the pelvic space through a preperitoneal approach [77,82].

Preperitoneal pelvic packing can lead to infectious complications, which may affect the timing and choice of definitive stabilization. In a review that evaluated 75 patients who underwent preperitoneal pelvic packing for pelvic fracture, pelvic space infection occurred in 15 percent [49]. The majority occurred in patients with open fracture-associated bowel/bladder injuries or those with repacking of the pelvic space. A significantly lower rate of pelvic space infection was found in those patients who were packed only once (6 versus 47 percent) compared with those who underwent more than one packing procedure. Although pelvic packing is typically removed within 24 to 36 hours, removal of pelvic packs should be delayed if bleeding and an associated coagulopathy persist to avoid repeated packing of the pelvis.

In the author's institution, a 22 percent incidence of deep venous thrombosis (DVT) has been associated with pelvic packing [83]. This suggests the importance of early pack removal as soon as patient transitions from a hypocoagulable to hypercoagulable state, which is generally in 12 to 24 hours. In addition, this would support early DVT screening in these patients.

Following pelvic packing, approximately 15 percent of patients with severe pelvic fractures will have ongoing transfusion requirements despite correction of coagulopathy [53]. Persistent bleeding may indicate the need for arteriography to identify the source. Transfusion greater than 4 units after normalization of the patient's coagulation status is considered an indication for angiography if transfusion is needed acutely following packing (ie, within 12 hours) and is not attributed to another source (ie, draining hemothorax).

Arteriography and angioembolization — Angioembolization is a technique in which bleeding sites are controlled by using intra-arterial catheters to selectively place thrombotic agents into branches of the internal iliac arteries that are feeding the area of bleeding. Advocates of emergent angioembolization (hemodynamically unstable patients) argue that the technique can be safe in selected patients and effective in controlling pelvic arterial hemorrhage [52,84,85]. However, in one study, patients admitted at night or on weekends had a significant increase in time to angioembolization compared with those arriving during the daytime and during the week, and after-hours admission was associated with significantly increased mortality [68,86]. The technique is less successful if bleeding is of venous origin or from the raw surfaces of the disrupted bone.

The reported indications for arteriography have included low blood pressure in spite of blood product transfusion, large retroperitoneal hematoma, and active contrast extravasation indicative of arterial bleeding on computed tomography of the pelvis [52,62-67]. About 20 to 25 percent of patients with extravasation seen on CT scan demonstrate bleeding at diagnostic angiography requiring angioembolization. A number of authors have sought to predict the need for arteriography based upon fracture classification and physiologic criteria [52,62,85,87-89]. In general, anterior/posterior compression, lateral compression type II and III, and vertical shear pelvic fractures are at a greater risk for arterial hemorrhage. However, predicting who will benefit from angioembolization remains difficult [60].

At the time of diagnostic arteriography, the entire pelvic vasculature and iliofemoral systems must be evaluated because multiple sites of hemorrhage are common in complex pelvic fractures [90]. Selective embolization at a targeted site of bleeding is performed using absorbable gelatin. Historically, if the patient's bleeding was severe and not localized, nonselective embolization of the internal iliac arteries was performed. Current management cautions against empiric bilateral internal iliac artery embolization because of an increased risk for complications such as gluteal claudication, pelvic ischemia, and tissue necrosis [91-93].

Management of associated vascular injury — Iliac artery and vein injury can occur in conjunction with severe pelvic fractures. The management of vascular injuries are discussed in detail separately [35,36]. (See "Abdominal vascular injury", section on 'Iliac arteries'.)

Management of associated soft tissue injury — In addition to the challenges faced with complex pelvic fractures, patients with open pelvic fractures often require management of extensive soft tissue destruction.

On examination, external lacerations should be inspected to determine if there is a communication with the pelvic fracture (ie, an open pelvic fracture). Larger defects such as perineal degloving injuries are obvious (picture 4).

During the initial evaluation in the emergency department, large degloving injuries of the perineum should be packed through the skin opening and taken to the operating room. Local exploration of the wound in the emergency department should not be done, as bleeding can be provoked.

Associated injuries to the vagina and rectum should be ruled out with a speculum exam and sigmoidoscopy, respectively. In patients with external wounds due to the pelvic fracture, bleeding should be controlled first, and then the formal examination performed.

Soft tissue wounds should be surgically debrided and irrigated to remove bony fragments and other foreign materials. The wound can be left to heal by secondary intention. Negative pressure wound therapy is a useful adjunct to control drainage and reduce the size of the defect. (See "Basic principles of wound management" and "Negative pressure wound therapy".)

To reduce potential contamination of the open pelvic or perineal wounds, which can lead to pelvic sepsis and osteomyelitis, a temporary diverting sigmoid colostomy or loop ileostomy is typically performed once the patient is hemodynamically stable [94,95]. (See "Overview of surgical ostomy for fecal diversion".)

RESUSCITATION AND CARE — The period of acute resuscitation typically encompasses the first 12 hours following injury and combines several key principles, including optimization of tissue perfusion, establishing normothermia, and restoring normal coagulation. Early optimization determines when the patient can return to the operating room to remove pelvic packing or definitively manage other injuries that were previously handled using damage control techniques. Specific goals of resuscitation include a base deficit <6, normal coagulation status, and a core temperature >36ºC.

Fluid management algorithms are aimed at restoring tissue perfusion and reducing the base deficit or lactate. The resuscitation of injured patients with pelvic fractures may require infusion of substantial volumes of crystalloid during the initial resuscitative phase to attain an adequate preload. Although early colloid administration is appealing, evidence to date does not support this concept in patients who do not manifest ongoing trauma-induced coagulopathy. Managing crystalloid volume remains a challenging aspect of early care, balancing optimal cardiac performance against excessive tissue edema, which can contribute to pulmonary edema, abdominal compartment syndrome, and poor wound healing. A goal-directed resuscitation approach consisting of initial volume loading to attain adequate preload, followed by the judicious use of inotropic agents or vasopressors, can be used to limit the amount of crystalloid administered to the patient [96].

Although the optimal hemoglobin (Hg) level remains debated, we prefer to maintain the Hg >10 g/dL to optimize oxygen delivery and hemostasis during the initial resuscitation phase, based on thrombelastography assessment. Thereafter, transfusion for Hg <7 g/dL (euvolemic patient) limits the adverse inflammatory effects of stored red blood cells. (See "Etiology and diagnosis of coagulopathy in trauma patients", section on 'Etiologies' and "Indications and hemoglobin thresholds for RBC transfusion in adults" and "Massive blood transfusion" and "Ongoing assessment, monitoring, and resuscitation of the severely injured patient".)

Abdominal compartment syndrome — Retroperitoneal hemorrhage increases the risk for abdominal compartment syndrome (ACS) due to a volume effect from retroperitoneal bleeding. In addition, secondary tissue edema from crystalloid fluid resuscitation may be superimposed. Patients with severe pelvic fractures should be monitored for ACS and treated, as indicated. (See "Abdominal compartment syndrome in adults".)

When operative decompression is needed, a variety of techniques can be used to provide temporary abdominal closure. The diagnosis and management of abdominal compartment syndrome is discussed elsewhere. (See "Management of the open abdomen in adults" and "Negative pressure wound therapy".)

Deep vein thrombosis — Patients with severe pelvic fractures requiring surgical fixation have multiple risk factors for deep venous thromboembolism, including the presence of multiple fractures of the pelvis and lower extremities and decreased venous blood flow in the lower extremities (immobility, paralysis) [97]. Following injury, pulmonary embolus can occur very early in the patient's hospital course [98]. Patients should receive prophylaxis (mechanical and pharmacologic) for deep vein thrombosis, unless contraindicated. For patients with complex pelvic fractures and other injuries (eg, central nervous system trauma) that contraindicate pharmacologic prophylaxis, a removable inferior vena cava filter is an alternative. (See "Overview of inpatient management of the adult trauma patient", section on 'Thromboprophylaxis' and "Venous thromboembolism risk and prevention in the severely injured trauma patient" and "Venous thromboembolism risk and prevention in the severely injured trauma patient", section on 'Thromboprophylaxis'.)

MORTALITY — The mortality associated with severe pelvic fractures ranges from 8 to 40 percent and depends upon the presence of associated injuries, the severity of the pelvic fracture, and degree of shock at presentation. In spite of appropriate multidisciplinary management, mortality for patients with severe pelvic fractures who present in shock remains >30 percent in many modern series [1,2,86,87,94,99-105]. In a review of data from the National Inpatient Sample (NIS), those with open pelvic fractures had three times the mortality of those with closed pelvic fracture [106]. Isolated series of patients undergoing pelvic packing report a mortality rate of 21 percent [29,49]. These higher mortality rates reflect, in part, the other injuries associated with the pelvic fracture. Injury severity score, not the type of pelvic instability, is the most important predictor of mortality in patients with pelvic fracture [10,87,100,107].

Early mortality (<6 hours) is predominantly from inability to control hemorrhage [108]. In reports from the last two decades, approximately one-third of patients died as a result of hemorrhage [10,30,108-111]. Late mortality is related to associated injuries (eg, traumatic brain injury) or multiple organ failure.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pelvic trauma" and "Society guideline links: Lower extremity (excluding hip) fractures in adults" and "Society guideline links: Severe blunt or penetrating extremity trauma".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Pelvic fracture (The Basics)")

SUMMARY AND RECOMMENDATIONS

Severe pelvic fracture – Injury to the bony pelvis is indicative of a high-energy trauma, and patients with pelvic fractures frequently have additional life-threatening injuries including traumatic brain injury and torn thoracic aorta. Directly associated injuries include bladder, urethral, rectal, vaginal, spinal, and vascular injury. Mortality in patients with severe pelvic fractures is up to 40 percent and is correlated more to the injury severity score, and degree of shock at presentation, which reflects associated injuries rather than the specific type of pelvic fracture. (See 'Fracture-related injuries' above and 'Mortality' above.)

Pelvic fracture classification – Pelvic fractures can be described as mechanically stable or unstable. Two or more breaks in the pelvic ring are needed to create an unstable pelvic fracture. Pelvic fractures are classified as rotationally unstable, vertically unstable, or both. The hemodynamic status of the patient is not necessarily related to the type of mechanical stability of the pelvis. Fractures that create soft tissue defects are termed "open" fractures, and associated injuries complicate management. (See 'Anatomic considerations' above.)

Management – Hemodynamically unstable patients with pelvic fracture and indications for surgery (eg, positive extended Focused Abdominal Sonography for Trauma [eFAST] scan indicating substantial hemoperitoneum) are taken directly to the operating room to promptly identify and manage the source of hemorrhage, which may be intrathoracic, intra-abdominal, or due to the pelvic fracture. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is emerging as an important adjunct to limit pelvic bleeding and allow the ability to obtain preoperative CT scanning. (See 'General approach' above.)

Fracture stabilization and preperitoneal pelvic packing – For patients in whom hemodynamic instability unresponsive to red cell transfusion is thought to be due to retroperitoneal bleeding from the pelvic fracture, we suggest operative control of hemorrhage using external fracture fixation plus preperitoneal pelvic packing to tamponade bleeding (Grade 2C). (See 'Fracture stabilization' above and 'Preperitoneal pelvic packing' above.)

Fracture fixation decreases pelvic volume, promotes tamponade of venous bleeding, and prevents shifting of the bony elements limiting secondary hemorrhage.

Preperitoneal pelvic packing involves the placement of laparotomy sponges into the preperitoneal space via a suprapubic incision, which reduces the available volume of the retroperitoneal space and tamponades pelvic bleeding. (See 'Fracture stabilization' above and 'Preperitoneal pelvic packing' above.)

Angioembolization – Angioembolization may be an option to control pelvic arterial hemorrhage from pelvic fracture under certain circumstances. However, most severe bleeding due to pelvic fractures is venous in origin, and only a relatively small percentage of patients (15 percent) will have a bleeding site that is amenable to angioembolization. (See 'Arteriography and angioembolization' above.)

Indications – Indications for angioembolization include:

-Patients with evidence for postoperative bleeding following external fracture fixation and preperitoneal pelvic packing, typically >4 units of red blood cells/six hours in the noncoagulopathic patient.

-Patients who are hemodynamically stable but demonstrate evidence for ongoing bleeding that cannot be attributed to another source.

Selective versus nonselective embolization – If arteriography identifies arterial bleeding, selective arterial embolization should be performed to minimize the potential for tissue ischemia or necrosis, rather than performing nonselective embolization, whenever possible.

Definitive fracture fixation – Following an interval of ongoing resuscitation and management of other urgent injuries, the decision for and timing of internal fixation is highly individualized, depending upon the nature of the pelvic fracture, the presence and severity of associated injuries, and the patient's medical comorbidities. For some patients, definitive treatment of the pelvic fracture may be accomplished by external fixation alone. (See 'Fracture stabilization' above.)

Thromboprophylaxis – Patients with severe pelvic fractures have multiple risk factors for deep vein thrombosis and should receive early thromboprophylaxis. Intermittent pneumatic compression should be used until bleeding is controlled and pharmacologic prophylaxis can be instituted. For those patients who have contraindications to pharmacologic prophylaxis, a removable inferior vena cava filter is an alternative. (See 'Deep vein thrombosis' above and "Venous thromboembolism risk and prevention in the severely injured trauma patient", section on 'Thromboprophylaxis'.)

  1. Costantini TW, Coimbra R, Holcomb JB, et al. Pelvic fracture pattern predicts the need for hemorrhage control intervention-Results of an AAST multi-institutional study. J Trauma Acute Care Surg 2017; 82:1030.
  2. Duchesne J, Costantini TW, Khan M, et al. The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study. J Trauma Acute Care Surg 2019; 87:117.
  3. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986; 160:445.
  4. Young, JWR, Burgess, AR. Fractures of the pelvis. In: Imaging in Trauma and Critical Care, Mirvis SE, Young JWR (Eds), Williams & Wilkins, Baltimore 1992. p.382.
  5. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma 1996; 10 Suppl 1:v.
  6. Huittinen VM, Slätis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973; 73:454.
  7. Tanizaki S, Maeda S, Ishida H, et al. Clinical characteristics of external iliac artery branch injury in pelvic trauma. Am J Emerg Med 2017; 35:1636.
  8. ATLS Subcommittee, American College of Surgeons’ Committee on Trauma, International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg 2013; 74:1363.
  9. Giannoudis PV, Grotz MR, Tzioupis C, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma 2007; 63:875.
  10. Lunsjo K, Tadros A, Hauggaard A, et al. Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients. J Trauma 2007; 62:687.
  11. Charbit J, Millet I, Martinez O, et al. Does the size of the hemoperitoneum help to discriminate the bleeding source and guide therapeutic decisions in blunt trauma patients with pelvic ring fracture? J Trauma Acute Care Surg 2012; 73:117.
  12. Pizanis A, Pohlemann T, Burkhardt M, et al. Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques. Injury 2013; 44:1760.
  13. Pehle B, Nast-Kolb D, Oberbeck R, et al. [Significance of physical examination and radiography of the pelvis during treatment in the shock emergency room]. Unfallchirurg 2003; 106:642.
  14. Ruchholtz S, Waydhas C, Lewan U, et al. Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary? J Trauma 2004; 57:278.
  15. Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma 1995; 39:375.
  16. Dolich MO, McKenney MG, Varela JE, et al. 2,576 ultrasounds for blunt abdominal trauma. J Trauma 2001; 50:108.
  17. Tayal VS, Nielsen A, Jones AE, et al. Accuracy of trauma ultrasound in major pelvic injury. J Trauma 2006; 61:1453.
  18. Schwed AC, Wagenaar A, Reppert AE, et al. Trust the FAST: Confirmation that the FAST examination is highly specific for intra-abdominal hemorrhage in over 1,200 patients with pelvic fractures. J Trauma Acute Care Surg 2021; 90:137.
  19. Friese RS, Malekzadeh S, Shafi S, et al. Abdominal ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture. J Trauma 2007; 63:97.
  20. Christian NT, Burlew CC, Moore EE, et al. The focused abdominal sonography for trauma examination can reliably identify patients with significant intra-abdominal hemorrhage in life-threatening pelvic fractures. J Trauma Acute Care Surg 2018; 84:924.
  21. Guillamondegui OD, Pryor JP, Gracias VH, et al. Pelvic radiography in blunt trauma resuscitation: a diminishing role. J Trauma 2002; 53:1043.
  22. Berg EE, Chebuhar C, Bell RM. Pelvic trauma imaging: a blinded comparison of computed tomography and roentgenograms. J Trauma 1996; 41:994.
  23. McCormick JP, Morgan SJ, Smith WR. Clinical effectiveness of the physical examination in diagnosis of posterior pelvic ring injuries. J Orthop Trauma 2003; 17:257.
  24. Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg 2002; 194:121.
  25. Duane TM, Tan BB, Golay D, et al. Blunt trauma and the role of routine pelvic radiographs: a prospective analysis. J Trauma 2002; 53:463.
  26. Brasel KJ, Pham K, Yang H, et al. Significance of contrast extravasation in patients with pelvic fracture. J Trauma 2007; 62:1149.
  27. Diamond IR, Hamilton PA, Garber AB, et al. Extravasation of intravenous computed tomography scan contrast in blunt abdominal and pelvic trauma. J Trauma 2009; 66:1102.
  28. Verbeek DO, Zijlstra IA, van der Leij C, et al. Management of pelvic ring fracture patients with a pelvic "blush" on early computed tomography. J Trauma Acute Care Surg 2014; 76:374.
  29. Burlew CC, Moore EE, Stahel PF, et al. Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg 2017; 82:233.
  30. Scalea, TM, Stein, et al. Pelvic Fractures. In: Trauma, 6, Feliciano, DV, Mattox, KL, Moore, EE (Eds), McGraw-Hill, New York 2008. p.759.
  31. Figler BD, Hoffler CE, Reisman W, et al. Multi-disciplinary update on pelvic fracture associated bladder and urethral injuries. Injury 2012; 43:1242.
  32. Trauma, 8th ed, Moore EE, Feliciano DV, Mattox KL (Eds), McGraw-Hill Education, New York 2017.
  33. Coleman JR, Moore EE, Vintimilla DR, et al. Association between Young-Burgess pelvic ring injury classification and concomitant injuries requiring urgent intervention. J Clin Orthop Trauma 2020; 11:1099.
  34. Frykberg, ER, Schinco, MA. Peripheral vascular injuries. In: Trauma, 6, Feliciano, DV, Mattox, KL, Moore, EE (Eds), McGraw-Hill, New York 2008. p.941.
  35. Mogannam AC, Cubas RF, Gutierrez IM, et al. Blunt Traumatic Occlusion of the Common Iliac Artery Repaired With Segmental Excision and Internal Iliac Artery Patch Angioplasty. Ann Vasc Surg 2017; 39:284.e1.
  36. Tuech JJ, Villapadierna F, Singland JD, et al. Blunt injury to the common iliac artery. Eur J Vasc Endovasc Surg 2000; 20:47.
  37. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma 2005; 59:1314.
  38. Steele SR, Maykel JA, Johnson EK. Traumatic injury of the colon and rectum: the evidence vs dogma. Dis Colon Rectum 2011; 54:1184.
  39. Tang J, Shi Z, Hu J, et al. Optimal sequence of surgical procedures for hemodynamically unstable patients with pelvic fracture: A network meta-analysis. Am J Emerg Med 2019; 37:571.
  40. Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review. J Trauma 2011; 71:1850.
  41. Bugaev N, Rattan R, Goodman M, et al. Preperitoneal packing for pelvic fracture-associated hemorrhage: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. Am J Surg 2020; 220:873.
  42. Adnan SM, Wasicek PJ, Crawford A, et al. Endovascular control of pelvic hemorrhage: Concomitant use of resuscitative endovascular balloon occlusion of the aorta and endovascular intervention. J Trauma Acute Care Surg 2019; 86:155.
  43. Costantini TW, Coimbra R, Holcomb JB, et al. Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg 2016; 80:717.
  44. Scott DJ, Eliason JL, Villamaria C, et al. A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock. J Trauma Acute Care Surg 2013; 75:122.
  45. Harfouche M, Inaba K, Cannon J, et al. Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database. J Trauma Acute Care Surg 2021; 90:659.
  46. Biffl WL, Fox CJ, Moore EE. The role of REBOA in the control of exsanguinating torso hemorrhage. J Trauma Acute Care Surg 2015; 78:1054.
  47. Brenner ML, Moore LJ, DuBose JJ, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg 2013; 75:506.
  48. Russo RM, White JM, Baer DG. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta: A Systematic Review of the Preclinical and Clinical Literature. J Surg Res 2021; 262:101.
  49. Burlew CC, Moore EE, Smith WR, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg 2011; 212:628.
  50. Spahn DR, Cerny V, Coats TJ, et al. Management of bleeding following major trauma: a European guideline. Crit Care 2007; 11:R17.
  51. Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury 2009; 40:343.
  52. Biffl WL, Smith WR, Moore EE, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg 2001; 233:843.
  53. Cothren CC, Osborn PM, Moore EE, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 2007; 62:834.
  54. Marzi I, Lustenberger T. Management of Bleeding Pelvic Fractures. Scand J Surg 2014; 103:104.
  55. Tai DK, Li WH, Lee KY, et al. Retroperitoneal pelvic packing in the management of hemodynamically unstable pelvic fractures: a level I trauma center experience. J Trauma 2011; 71:E79.
  56. Magnone S, Coccolini F, Manfredi R, et al. Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery). World J Emerg Surg 2014; 9:18.
  57. Moskowitz EE, Burlew CC, Moore EE, et al. Preperitoneal pelvic packing is effective for hemorrhage control in open pelvic fractures. Am J Surg 2018; 215:675.
  58. Hamill J, Holden A, Paice R, Civil I. Pelvic fracture pattern predicts pelvic arterial haemorrhage. Aust N Z J Surg 2000; 70:338.
  59. Costantini TW, Bosarge PL, Fortlage D, et al. Arterial embolization for pelvic fractures after blunt trauma: are we all talk? Am J Surg 2010; 200:752.
  60. Gourlay D, Hoffer E, Routt M, Bulger E. Pelvic angiography for recurrent traumatic pelvic arterial hemorrhage. J Trauma 2005; 59:1168.
  61. Toth L, King KL, McGrath B, Balogh ZJ. Factors associated with pelvic fracture-related arterial bleeding during trauma resuscitation: a prospective clinical study. J Orthop Trauma 2014; 28:489.
  62. Eastridge BJ, Starr A, Minei JP, et al. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002; 53:446.
  63. Pereira SJ, O'Brien DP, Luchette FA, et al. Dynamic helical computed tomography scan accurately detects hemorrhage in patients with pelvic fracture. Surgery 2000; 128:678.
  64. Miller PR, Moore PS, Mansell E, et al. External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 2003; 54:437.
  65. Brown CV, Kasotakis G, Wilcox A, et al. Does pelvic hematoma on admission computed tomography predict active bleeding at angiography for pelvic fracture? Am Surg 2005; 71:759.
  66. Blackmore CC, Jurkovich GJ, Linnau KF, et al. Assessment of volume of hemorrhage and outcome from pelvic fracture. Arch Surg 2003; 138:504.
  67. Salim A, Teixeira PG, DuBose J, et al. Predictors of positive angiography in pelvic fractures: a prospective study. J Am Coll Surg 2008; 207:656.
  68. Schwartz DA, Medina M, Cotton BA, et al. Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention. J Trauma Acute Care Surg 2014; 76:134.
  69. Stahel PF, Mauffrey C, Smith WR, et al. External fixation for acute pelvic ring injuries: decision making and technical options. J Trauma Acute Care Surg 2013; 75:882.
  70. Köhler D, Sellei RM, Sop A, et al. Effects of pelvic volume changes on retroperitoneal and intra-abdominal pressure in the injured pelvic ring: a cadaveric model. J Trauma 2011; 71:585.
  71. Croce MA, Magnotti LJ, Savage SA, et al. Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg 2007; 204:935.
  72. Jowett AJ, Bowyer GW. Pressure characteristics of pelvic binders. Injury 2007; 38:118.
  73. Ertel W, Karim E, Keel M, Trentz O. Therapeutic strategies and outcome of polytraumatized patients with pelvic injuries. Eur J Trauma 2000; 26:278.
  74. Ochsner MG, Knudson MM, Pachter HL, et al. Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis. J Trauma 2000; 49:505.
  75. Mason WT, Khan SN, James CL, et al. Complications of temporary and definitive external fixation of pelvic ring injuries. Injury 2005; 36:599.
  76. Taeger G, Ruchholtz S, Waydhas C, et al. Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma 2005; 59:409.
  77. Ertel W, Keel M, Eid K, et al. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001; 15:468.
  78. Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury 2004; 35:671.
  79. Smith WR, Moore EE, Osborn P, 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.
  80. Li Q, Dong J, Yang Y, et al. Retroperitoneal packing or angioembolization for haemorrhage control of pelvic fractures--Quasi-randomized clinical trial of 56 haemodynamically unstable patients with Injury Severity Score ≥33. Injury 2016; 47:395.
  81. Burlew CC. Preperitoneal pelvic packing: A 2018 EAST Master Class Video Presentation. J Trauma Acute Care Surg 2018; 85:224.
  82. Pohlmann, T, Gansslen, A, Hufner, T, Tscherne, H. Extraperitoneal packing at laparotomy. OTA-AAST Annual Meeting 2000.
  83. Heelan Gladden AA, Freedberg M, Moore EE, et al. Worth looking! Venous thromboembolism in patients who undergo preperitoneal pelvic packing warrants screening duplex. Submitted presentation, Southwestern Surgical Congress Annual Meeting, Ojai, CA September 2020.
  84. Panetta T, Sclafani SJ, Goldstein AS, et al. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 1985; 25:1021.
  85. Rossaint R, Duranteau J, Stahel PF, Spahn DR. Nonsurgical treatment of major bleeding. Anesthesiol Clin 2007; 25:35.
  86. Tesoriero RB, Bruns BR, Narayan M, et al. Angiographic embolization for hemorrhage following pelvic fracture: Is it "time" for a paradigm shift? J Trauma Acute Care Surg 2017; 82:18.
  87. Starr AJ, Griffin DR, Reinert CM, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma 2002; 16:553.
  88. Niwa T, Takebayashi S, Igari H, et al. The value of plain radiographs in the prediction of outcome in pelvic fractures treated with embolisation therapy. Br J Radiol 2000; 73:945.
  89. Jeske HC, Larndorfer R, Krappinger D, et al. Management of hemorrhage in severe pelvic injuries. J Trauma 2010; 68:415.
  90. O'Neill PA, Riina J, Sclafani S, Tornetta P 3rd. Angiographic findings in pelvic fractures. Clin Orthop Relat Res 1996; :60.
  91. Suzuki T, Kataoka Y, Minehara H, et al. Transcatheter arterial embolization for pelvic fractures may potentially cause a triad of sequela: gluteal necrosis, rectal necrosis, and lower limb paresis. J Trauma 2008; 65:1547.
  92. Yasumura K, Ikegami K, Kamohara T, Nohara Y. High incidence of ischemic necrosis of the gluteal muscle after transcatheter angiographic embolization for severe pelvic fracture. J Trauma 2005; 58:985.
  93. DuBose J, Inaba K, Barmparas G, et al. Bilateral internal iliac artery ligation as a damage control approach in massive retroperitoneal bleeding after pelvic fracture. J Trauma 2010; 69:1507.
  94. Naam NH, Brown WH, Hurd R, et al. Major pelvic fractures. Arch Surg 1983; 118:610.
  95. Sinnott R, Rhodes M, Brader A. Open pelvic fracture: an injury for trauma centers. Am J Surg 1992; 163:283.
  96. Moore FA, McKinley BA, Moore EE, et al. Inflammation and the Host Response to Injury, a large-scale collaborative project: patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006; 61:82.
  97. El-Daly I, Reidy J, Culpan P, Bates P. Thromboprophylaxis in patients with pelvic and acetabular fractures: A short review and recommendations. Injury 2013; 44:1710.
  98. Menaker J, Stein DM, Scalea TM. Incidence of early pulmonary embolism after injury. J Trauma 2007; 63:620.
  99. Poole GV, Ward EF. Causes of mortality in patients with pelvic fractures. Orthopedics 1994; 17:691.
  100. Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma 2007; 21:31.
  101. Mucha P Jr, Welch TJ. Hemorrhage in major pelvic fractures. Surg Clin North Am 1988; 68:757.
  102. Heetveld MJ, Harris I, Schlaphoff G, et al. Hemodynamically unstable pelvic fractures: recent care and new guidelines. World J Surg 2004; 28:904.
  103. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 2002; 195:1.
  104. Gustavo Parreira J, Coimbra R, Rasslan S, et al. The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures. Injury 2000; 31:677.
  105. Gaski IA, Barckman J, Naess PA, et al. Reduced need for extraperitoneal pelvic packing for severe pelvic fractures is associated with improved resuscitation strategies. J Trauma Acute Care Surg 2016; 81:644.
  106. Yoshihara H, Yoneoka D. Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: trends and in-hospital mortality. J Trauma Acute Care Surg 2014; 76:380.
  107. Fu CY, Chan SY, Wang SY, et al. The effect of angioembolization for life-threatening retroperitoneal hemorrhage in patients with pelvic fracture. Am J Emerg Med 2019; 37:603.
  108. Vaidya R, Scott AN, Tonnos F, et al. Patients with pelvic fractures from blunt trauma. What is the cause of mortality and when? Am J Surg 2016; 211:495.
  109. Verbeek DO, Sugrue M, Balogh Z, et al. Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice. World J Surg 2008; 32:1874.
  110. Hauschild O, Strohm PC, Culemann U, et al. Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma 2008; 64:449.
  111. Papakostidis C, Kanakaris N, Dimitriou R, Giannoudis PV. The role of arterial embolization in controlling pelvic fracture haemorrhage: a systematic review of the literature. Eur J Radiol 2012; 81:897.
Topic 15151 Version 22.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟