What is the treatment approach for pelvic fractures caused by shearing forces?

Treatment Approach for Pelvic Fractures Caused by Shearing Forces

Patients with pelvic ring disruption from shearing forces should undergo immediate pelvic ring closure and stabilization, followed by early preperitoneal packing, angiographic embolization, and/or surgical bleeding control if hemodynamic instability persists despite stabilization. 1

Initial Management

Immediate Stabilization

• Apply non-invasive external pelvic compression (pelvic binder) as an early strategy to stabilize the pelvic ring and decrease hemorrhage 1
  • Commercial pelvic binders are superior to sheet wrapping for hemorrhage control 1
  • Position around the great trochanter and symphysis pubis to reduce fracture and decrease pelvic internal volume
  • Remove as soon as physiologically justifiable and replace with external fixation or definitive stabilization 1

Hemodynamic Assessment

• Perform E-FAST and pelvic X-ray in hemodynamically unstable patients to identify life-threatening pelvic ring injuries 1, 2
• CT scan with intravenous contrast is the gold standard for stable patients (sensitivity and specificity for bone fractures of 100%) 1
  • Look for contrast extravasation and pelvic hematoma size (≥500 cm³ suggests arterial injury even without visible blush) 1

Treatment Algorithm for Shearing Fractures

For Hemodynamically Unstable Patients:

1. Apply pelvic binder immediately
2. Perform pelvic ring closure and stabilization 1
3. If instability persists despite stabilization:
   • Implement early preperitoneal packing to control venous bleeding 1
   • Consider angiographic embolization for arterial bleeding 1
   • Employ surgical bleeding control techniques as needed 1

For Hemodynamically Stable Patients:

1. Complete CT evaluation with 3D reconstruction
2. Plan definitive fixation based on fracture pattern:
   • For vertical shear injuries, lumbopelvic fixation shows better outcomes than iliosacral screws alone 3
   • Consider damage control orthopedics for polytrauma patients 4

Surgical Considerations for Shearing Fractures

Fixation Options

• External fixation using a Ganz clamp or anterior pelvic external fixator for initial stabilization 2
• Definitive fixation options:
  • Lumbopelvic fixation shows lower rates of neurological complications, infection, and malunion compared to iliosacral screws alone in vertical shear fractures 3
  • Percutaneous techniques reduce soft tissue trauma but may increase malunion risk 4
  • Open reduction and internal fixation provides superior anatomical restoration but higher infection risk 4

Timing of Surgery

• For unstable patients: damage control approach with temporary external fixation
• For stable patients: early total care with definitive fixation within 24-48 hours shows 30-40% reduction in pulmonary complications and shorter ICU stays 4

Pitfalls and Caveats

• Non-therapeutic laparotomy should be avoided in pelvic trauma patients as it may increase mortality 1
• E-FAST is not sensitive enough to exclude pelvic bleeding but can help determine if laparotomy is needed 1
• Vertical shear injuries (classified as VS in Young-Burgess or Type C in Tile) are among the most unstable and hemorrhage-prone patterns 5, 6
• Posterior pelvic ring instability represents a definite surgical indication for anatomic fracture reduction and stable internal fixation 2
• Consider urethral and rectal injuries, which are common with pelvic fractures:
  • Perform retrograde urethrogram prior to urethral catheterization if urethral injury is suspected 1
  • Conduct rectal examination to detect blood, rectal wall weakness, and non-palpable prostate 1

By following this structured approach to pelvic fractures caused by shearing forces, you can optimize patient outcomes by addressing both immediate hemorrhage control and definitive fracture stabilization.