What is the initial management for a suspected pelvis fracture?

From the Guidelines

The initial management for a suspected pelvic fracture should focus on stabilization and preventing further injury, with the use of a pelvic binder being recommended to limit life-threatening bleeding in the pre-hospital setting, as stated in the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1. The initial assessment should include evaluating the patient's hemodynamic status and addressing life-threatening bleeding through external pelvic stabilization using a pelvic binder or sheet wrapped around the greater trochanters. Some key points to consider in the management of suspected pelvic fractures include:

• Avoiding excessive movement of the patient and maintaining spinal precautions if indicated
• Establishing large-bore IV access for fluid resuscitation with crystalloids and preparing for potential blood transfusion
• Administering analgesia such as morphine or fentanyl titrated to pain control
• Obtaining portable AP pelvic radiographs to confirm the diagnosis, followed by CT imaging when the patient is stable
• Monitoring vital signs closely, including blood pressure, heart rate, and urine output It is also important to note that pelvic fractures can cause significant internal bleeding into the retroperitoneal space due to the rich vascular supply in this region, which is why early stabilization is crucial to reduce mortality, as highlighted in the study by Coccolini et al. 1. In terms of specific management strategies, the use of pelvic binders has been shown to be effective in controlling bleeding and reducing mortality, with the European guideline recommending the adjunct use of a pelvic binder in the pre-hospital setting to limit life-threatening bleeding in the presence of a suspected pelvic fracture 1. Additionally, pre-peritoneal pelvic packing (PPP) has been proposed as an alternative to angiography for controlling bleeding in hemodynamically unstable pelvic fractures, with some studies suggesting that PPP can be a quick and easy-to-perform technique that can be accomplished both in the emergency department and the operating room 1. However, the decision to use PPP or angiography should be made on a case-by-case basis, taking into account the patient's individual needs and the availability of resources, as recommended by the guidelines on pelvic trauma: WSES classification and guidelines 1. Overall, the management of suspected pelvic fractures requires a multidisciplinary approach, with prompt consultation of orthopedic surgery and trauma services, as definitive management may require surgical intervention depending on fracture type and hemodynamic stability, as stated in the study by Croce et al. 1.

From the Research

Initial Management of Suspected Pelvis Fracture

The initial management of a suspected pelvis fracture involves a multidisciplinary approach, focusing on swift and adequate resuscitation, reversal of shock and acidosis, and rapid control of hemorrhage to facilitate patient survival 2.

Key Elements in Management

• Swift and adequate resuscitation
• Reversal of shock and acidosis
• Rapid control of hemorrhage
• Multimodality therapies, including external pelvic stabilization, angioembolization, and preperitoneal pelvic packing 2
• A minimum time of 6-8 weeks in frame may be required for definitive management of all fractures 3

Stabilization Techniques

• External fixation techniques, such as supra-acetabular pins, can be used to stabilize unstable pelvic fractures 3
• Percutaneous fixation has become increasingly more common for both the anterior and posterior ring 4

Classification and Radiographic Evaluation

• Radiographic evaluation and classification of the pelvic injury guide initial management, provisional stabilization, and preoperative surgical planning 5, 4
• CT angiography and interventional radiographic angiography can be useful tools for determining the location of bleeding and the amount of blood loss 5

Manipulation of Suspected Pelvis Fracture

• Manipulation of a suspected pelvis fracture should be approached with caution, and the decision to manipulate should be made on a case-by-case basis, taking into account the patient's overall condition and the severity of the fracture 5, 4
• In general, manipulation is not recommended as an initial step, and instead, focus should be on stabilization and control of hemorrhage 2, 5