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'.)
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