What is the management of an open book pelvic fracture?

Management of Open Book Pelvic Fracture

Pubic symphysis plating is the modality of choice for anterior fixation of "open book" injuries with a pubic symphysis diastasis > 2.5 cm (APC-II, APC-III). 1

Initial Assessment and Stabilization

• Perform immediate hemodynamic assessment, as mortality can exceed 50% in open pelvic fractures due to massive bleeding and pelvic sepsis 2
• For hemodynamically unstable patients, apply a pelvic binder to limit expansion of pelvic hematoma 1
• Obtain pelvic X-ray to identify life-threatening pelvic ring injuries, though sensitivity is only 50-68% 1
• Perform E-FAST (Extended Focused Assessment with Sonography for Trauma) to exclude other sources of hemorrhage, though it's not sensitive enough to exclude pelvic bleeding 1
• CT scan with contrast is the gold standard for stable patients, with 98% accuracy for identifying contrast extravasation 1

Hemorrhage Control

• For hemodynamically unstable patients with severe pelvic trauma, perform early external fixation of the pelvis using either a Ganz clamp or an anterior pelvic external fixator 1
• Consider pre-peritoneal pelvic packing when:
  • Patient cannot be transferred to CT scan
  • Angioembolization cannot be performed within 60 minutes of diagnosis 1
• Angiography/angioembolization should be considered after controlling extrapelvic and non-arterial sources of bleeding 1
• Elderly patients may require angioembolization more frequently regardless of hemodynamic status 1

Definitive Management Based on Fracture Classification

• Open book pelvic fractures are typically classified as APC-II or APC-III (anterior-posterior compression) injuries with pubic symphysis diastasis > 2.5 cm 1
• For rotationally unstable APC-II/APC-III injuries:
  • Pubic symphysis plating is the modality of choice for anterior fixation 1
  • Consider additional posterior fixation, especially for APC-III injuries with posterior instability 1, 3
• Timing of definitive fixation:
  • Hemodynamically stable patients can undergo definitive fixation within 24 hours post-injury 1
  • Hemodynamically unstable patients should be successfully resuscitated before definitive fixation 1
  • For physiologically deranged polytrauma patients, postpone definitive fixation until after day 4 post-injury 1

Special Considerations for Open Pelvic Fractures

• Open pelvic fractures should be managed in referral centers due to their complexity and need for multidisciplinary approach 1
• Management priorities for open pelvic fractures:
  1. Bleeding control
  2. Cleaning and debridement of the wound
  3. Identification and treatment of associated lesions
  4. Treatment of the pelvic fracture 1
• Consider diverting colostomy for patients with buttock or perineal wounds to prevent invasive infection 4
• Assess for associated injuries, particularly genitourinary and peripheral nerve trauma, which account for significant long-term morbidity 4

Outcomes and Prognosis

• Despite advances in trauma management, mortality following open pelvic fracture remains high at approximately 23.7% 2
• Patients require an average of 13.5 units of packed red blood cells in the first 24 hours 2
• Mean length of ICU stay is 12.5 days, with total hospital stay averaging 53 days 2
• Aggressive hemorrhage and sepsis control can improve survival rates significantly 5

Evolving Trends in Management

• There is growing debate about whether anterior fixation alone is sufficient for open book injuries 3
• Newer surgeons tend to favor combined anterior plus posterior fixation (44% of surveyed trauma surgeons), while more experienced surgeons often prefer anterior plate fixation alone (56%) 3
• CT with 3-Dimensional bone reconstruction can help reduce tissue damage during invasive procedures and improve patient recovery times 1