What is the treatment for a pelvic fracture?

Treatment of Pelvic Fractures

The treatment of pelvic fractures depends critically on hemodynamic stability: unstable patients require immediate pelvic ring closure with external fixation or pelvic binder followed by hemorrhage control through preperitoneal packing and/or angioembolization, while stable patients with mechanically unstable fractures need early definitive fixation within 24 hours, and stable fracture patterns can be managed nonoperatively. 1

Immediate Stabilization for Hemodynamically Unstable Patients

Pelvic ring closure is the first-line treatment and must be performed immediately in any patient with hemodynamic instability from pelvic fracture. 1 This can be achieved through:

• Pelvic binder, bed sheet wrapping, or external fixator to reduce pelvic volume, stabilize clot formation, and decrease ongoing tissue damage 1, 2
• Ganz clamp for Tile C fractures after heavy traction of the ascended lower limb (15% of patient's weight), which can be placed in the emergency room by trained operators 3
• External fixator placement for Tile C fractures and to reduce ring disruption in Tile B1 and B3 fractures, positioned anteriorly and inferiorly to allow for potential laparotomy 3

Hemorrhage Control Algorithm

After initial pelvic stabilization, ongoing bleeding requires a systematic approach:

Primary Hemorrhage Control:

• Preperitoneal packing should be performed simultaneously or soon after initial stabilization when bleeding continues and angioembolization cannot be achieved quickly 1, 4
• This decreases the need for pelvic embolization, aids in early intrapelvic bleeding control, and can be combined with laparotomy if necessary 1
• Pelvic packs must remain in place for at least 48 hours to lower re-bleeding risk 1, 4

Angiography and Embolization:

• Highly effective for arterial bleeding uncontrolled by fracture stabilization, particularly in sacroiliac joint disruption 1, 4
• Indicated when markers of ongoing hemorrhage are present: CT 'blush' (active arterial extravasation), pelvic hematoma >500 ml, anterior-posterior or vertical shear deformations, or persistent hemodynamic instability despite adequate stabilization 1, 4

Damage Control Surgery:

Employ damage control approach in patients with deep hemorrhagic shock, ongoing bleeding, coagulopathy, acidosis, inaccessible major anatomic injury, or concomitant major injury outside the abdomen 1, 4

Definitive Management for Stable Patients

Mechanically Unstable Fractures:

• Early definitive pelvic fracture fixation within 24 hours is recommended for hemodynamically stable patients with mechanically unstable fractures and no physiologic derangement 4, 5
• Early total care (ETC) within 24-48 hours demonstrates 30-40% reduction in pulmonary complications and shorter ICU stays in stable polytrauma patients 5
• Postpone definitive fixation until after day 4 post-injury in physiologically deranged polytrauma patients 4

Stable Fracture Patterns:

• Nonoperative management for stable patterns such as APC-I and LC-I injuries 4
• Conservative management includes appropriate pain control, activity modification, and early mobilization as tolerated 4

Rotationally and Vertically Unstable Fractures:

• Definitive internal fixation required for APC-II, LC-II, APC-III, LC-III, vertical shear, and combined mechanism injuries 4
• Pubic symphysis plating is the treatment of choice for "open book" injuries with diastasis >2.5 cm 4

Special Considerations for Open Pelvic Fractures

Open pelvic fractures must be managed in referral centers due to their rarity (1.7% of all pelvic fractures), complexity, and mortality exceeding 50%. 3 Management priorities are:

1. Bleeding control (primary objective) 3
2. Perineal contamination control (primary objective) 3
3. Cleaning and debridement of the wound 3
4. Identification and treatment of associated lesions 3
5. Treatment of the pelvic fracture 3

Surgical management often requires temporary stoma, external pelvic fixator, and occasionally hemipelvectomy, with embolization as an adjunct for hemostasis. 3

Critical Pitfalls to Avoid

• Never delay pelvic ring closure in hemodynamically unstable patients 1, 4
• Avoid non-therapeutic laparotomy in patients with pelvic fractures as it may increase mortality 1
• Do not remove pelvic packs before 48 hours to prevent re-bleeding 1, 4
• Do not attempt primary definitive surgical management in patients requiring damage control approach 1
• Unstable pelvic fractures have significantly higher complication rates than stable fractures, requiring heightened vigilance 6

Multidisciplinary Coordination

A multidisciplinary approach involving trauma surgeons, orthopedic surgeons, interventional radiologists, and critical care specialists is essential for optimal outcomes and has been shown to improve patient survival. 1, 7