From the Guidelines
The condition where the pelvic symphysis opens up causing massive bleeding into the pelvis is called a pelvic fracture with symphyseal diastasis, specifically an "open book" pelvic fracture. This injury occurs when external rotational forces cause the pelvis to open like a book at the pubic symphysis joint, disrupting the strong ligaments that normally hold the pelvic ring together. The separation of the symphysis pubis allows for significant internal bleeding as major blood vessels in the pelvis can be torn or damaged. This is a life-threatening emergency requiring immediate intervention.
Key Considerations
- Treatment typically involves stabilization of the pelvis using external fixation devices or pelvic binders to reduce the pelvic volume and tamponade bleeding, followed by fluid resuscitation and blood transfusions as needed 1.
- In severe cases, angiographic embolization may be necessary to stop arterial bleeding, while pelvic packing can help control venous hemorrhage 1.
- The mortality rate for open book pelvic fractures with hemodynamic instability remains high due to the difficulty in controlling retroperitoneal bleeding and the associated risk of hypovolemic shock 1.
Management Principles
- Aggressive hemostatic resuscitation, bony stabilization of the pelvis, and identification and management of extra-pelvic bleeding are fundamental management principles 1.
- Pelvic Angiography/Angioembolization (AG/AE) is expected to benefit only a small minority of patients, and therefore should be employed once extrapelvic and non-arterial sources of bleeding are controlled 1.
- Arterial contrast extravasation seen on CT scan is a good indicator of the need for pelvic AG/AE 1.
Patient Outcomes
- The implementation of standardized multidisciplinary clinical guidelines that include early surgical management with pelvic external fixation and direct preperitoneal pelvic packing for hypotensive patients with hemodynamical and mechanical unstable pelvic ring injuries led to a significant decrease of transfused blood products and to a significantly decreased post-injury mortality 1.
- Elderly patients with pelvic fractures should be considered for pelvic angiography/angioembolization regardless of hemodynamic status 1.
From the Research
Condition Description
The condition where the pelvic symphysis opens up, causing massive bleeding into the pelvis, is known as traumatic pubic symphysis diastasis or symphysis pubis diastasis. This condition can be life-threatening and often requires operative fixation 2.
Causes and Symptoms
Traumatic pubic symphysis diastasis can occur due to various types of injuries, including anteroposterior compression injuries and vertical shear injuries 3. The symptoms of this condition can be severe and may include significant bleeding, pain, and instability in the pelvic region.
Diagnosis and Treatment
Diagnosis of traumatic pubic symphysis diastasis can be made using various imaging techniques, including X-rays, CT scans, and ultrasound 4. Treatment of this condition often involves operative fixation, which can be performed using various techniques, including:
- Multiple-hole plate fixation 2
- Two-hole plating 3, 2
- Percutaneous fixation using a TightRope and external fixator 5
- Percutaneous cannulated screw fixation 5
Key Points
- Traumatic pubic symphysis diastasis is a life-threatening condition that requires prompt treatment 2.
- Operative fixation is often necessary to stabilize the pelvic region and control bleeding 3, 2.
- Various fixation techniques are available, and the choice of technique depends on the severity of the injury and the patient's overall condition 2, 5.
- Bedside ultrasound examination can be used to identify pubic symphysis widening in trauma patients, which can help guide treatment decisions 4.