What is the treatment for a pelvic fracture?

Treatment of Pelvic Fractures

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

Initial Management

• Immediate pelvic ring closure and stabilization is the first-line treatment for patients with pelvic fractures, especially those with hemodynamic instability 1
• Pelvic closure can be achieved using:
  • External fixators 1
  • Pelvic binder 1
  • Bed sheet 1
  • Pelvic C-clamp 1
• Early detection of pelvic injuries is crucial for reducing mortality, which remains unacceptably high (8-15%) in patients with severe pelvic ring disruptions 1

Management of Ongoing Hemorrhage

For patients with persistent hemodynamic instability despite pelvic stabilization, a stepwise approach is recommended:

1. Preperitoneal packing 1

   • Can be performed simultaneously or soon after initial pelvic fracture stabilization
   • Decreases the need for pelvic embolization
   • Aids in early intrapelvic bleeding control
   • Can be combined with laparotomy if necessary

2. Angiography and embolization 1

   • Highly effective for controlling arterial bleeding that cannot be controlled by fracture stabilization
   • Particularly beneficial in patients with:
     • Sacroiliac joint disruption
     • Female gender
     • Prolonged hypotension

3. Surgical bleeding control when necessary 1

Markers of Pelvic Hemorrhage

• Anterior-posterior and vertical shear deformations on standard radiographs 1
• CT 'blush' (active arterial extravasation) 1
• Pelvic hematoma volumes >500 ml on CT 1
• Ongoing hemodynamic instability despite adequate fracture stabilization 1

Damage Control Approach

• Damage control surgery should be employed in severely injured patients with:
  • Deep hemorrhagic shock
  • Signs of ongoing bleeding
  • Coagulopathy 1
• Other factors that should trigger a damage control approach include:
  • Severe coagulopathy
  • Hypothermia
  • Acidosis
  • Inaccessible major anatomic injury
  • Need for time-consuming procedures
  • Concomitant major injury outside the abdomen 1

Special Considerations

• Non-therapeutic laparotomy should be avoided in patients with pelvic fractures as it may increase mortality 1
• Removal of pelvic packs should preferably be performed only after 48 hours to lower the risk of re-bleeding 1
• A multidisciplinary approach involving trauma surgeons, orthopedic surgeons, interventional radiologists, and critical care specialists is essential for optimal outcomes 1
• For urethral injuries associated with pelvic fractures, secure urinary drainage (typically via suprapubic catheter) while maintaining perineal compression if bleeding is present 2

Long-term Management

• Definitive surgical management is recommended for hemodynamically stable patients without factors requiring damage control approach 1
• Functional outcomes depend on the quality of rigid fixation and associated pelvic neural and visceral injuries 3
• Patients with unstable pelvic fractures have a significantly higher risk of complications than those with stable fractures 4

Pitfalls to Avoid

• Delaying pelvic ring closure in hemodynamically unstable patients 1
• Performing blind urethral catheterization when urethral injury is suspected 2
• Attempting primary definitive surgical management in patients with factors requiring damage control approach 1
• Removing pelvic packs too early (before 48 hours) 1
• Failing to recognize and address associated injuries, which are common with pelvic fractures due to the high-energy nature of these injuries 5, 3