Should the pelvic floor be stabilized?

Pelvic Floor Stabilization in Pelvic Trauma

In patients with suspected severe pelvic trauma, external pelvic compression should be applied as soon as possible to stabilize the pelvic ring and limit life-threatening bleeding. 1, 2

Indications for Pelvic Stabilization

Pelvic stabilization is critical in the following scenarios:

• Suspected pelvic fracture - Even before radiological confirmation
• Hemodynamic instability with suspected pelvic trauma
• Pelvic ring disruption - Particularly in Tile B and C fractures
• Open pelvic injuries
• Major bleeding associated with pelvic trauma

Methods of Pelvic Stabilization

Immediate External Stabilization

• Pelvic binders are the preferred initial method 1, 2
  • Should be positioned around the greater trochanters and symphysis pubis
  • Commercial binders are more effective than improvised "home-made" ones 1
  • Should be applied before mechanical fixation when pelvic ring fracture is suspected

Surgical Stabilization Options

For patients requiring definitive stabilization:

• External fixation 1, 2

  • Ganz clamp - Recommended primarily for Tile C fractures after heavy traction (15% of patient's weight) 1
  • Anterior pelvic external fixator - For Tile C fractures and to reduce ring disruption in Tile B1 and B3 fractures 1
  • Should be placed anteriorly and inferiorly to allow for possible laparotomy 1

• Pre-peritoneal pelvic packing - For temporary hemostasis when angioembolization cannot be performed within 60 minutes 1

Timing of Stabilization

• Apply external compression immediately upon suspicion of pelvic fracture 1, 2
• Remove pelvic binders as soon as physiologically justifiable and replace with external fixation or definitive stabilization 1
• Early external fixation is recommended for patients with severe pelvic trauma and hemodynamic instability 1

Special Considerations

• Position pelvic binders cautiously in pregnant women and elderly patients 1
• Transfer patients from spine board early when possible to reduce skin pressure lesions 1
• Severe open pelvic trauma should be managed in referral centers due to complexity and need for multidisciplinary approach 1
• Bleeding control and management of perineal contamination should be primary objectives in open pelvic trauma 1

Diagnostic Approach

• E-FAST (Extended Focused Assessment with Sonography for Trauma) should be performed in all patients with suspected severe pelvic trauma 1, 2
• CT scan with intravenous contrast for hemodynamically stable patients to exclude pelvic hemorrhage 1, 2
• 3D reconstructions can reduce tissue damage during invasive procedures and risk of neurological disorders after surgical fixation 1

Common Pitfalls to Avoid

• Relying solely on clinical examination - Has low sensitivity (26-44%) for detecting pelvic instability 3, 4
• Delaying stabilization in unstable pelvic fractures 2
• Inadequate assessment for associated injuries 2
• Failure to recognize arterial bleeding requiring angioembolization 2

Pelvic floor stabilization is a critical component in the management of pelvic trauma, particularly in hemodynamically unstable patients. Early application of external compression devices followed by appropriate definitive stabilization significantly improves patient outcomes by controlling hemorrhage and providing mechanical stability.