What are the primary concerns and acute complications in a patient with an open book open fracture of the pelvis?

Acute Complications of Open Book Open Pelvic Fractures

Primary Life-Threatening Concerns

Open book pelvic fractures with open wounds carry mortality rates exceeding 50%, with exsanguinating hemorrhage and perineal contamination representing the two immediate threats to survival. 1, 2

Hemorrhagic Complications

• Massive hemorrhage is the leading cause of death, with patients requiring an average of 15-29 units of blood transfusion in the acute phase 3, 4, 5
• Bleeding originates from multiple sources including:
  • Disrupted pelvic venous plexus from the expanded pelvic ring 1
  • Arterial injuries requiring angioembolization in approximately 15-23% of cases 3, 4
  • Bone bleeding from fracture surfaces 1
• Hemodynamic instability occurs frequently and requires immediate mechanical stabilization to limit hematoma expansion 1, 6

Infectious Complications

• Pelvic sepsis is the second leading cause of mortality after hemorrhage control is achieved 1, 4
• Perineal contamination from open wounds creates high risk for deep pelvic infections, particularly when fecal contamination occurs 1, 2
• Patients with perineal wounds who do not receive diverting colostomy develop pelvic infectious complications in nearly all cases, including pelvic abscess, osteomyelitis, and perineal wound infections 5
• Infection risk increases significantly without early antibiotic administration within 3 hours and definitive wound coverage within 7 days 2

Associated Injuries Requiring Immediate Recognition

Genitourinary Trauma

• Bladder injuries occur in 4-15% of unstable pelvic fractures, particularly intraperitoneal ruptures that require early surgical closure 1
• Posterior urethral injuries are present in 4-19% of pelvic fractures, especially with bilateral pubic rami fractures and sacroiliac dislocation 1
• These injuries require early drainage but are not immediate surgical emergencies unless intraperitoneal bladder rupture is present 1

Visceral Injuries

• Rectal and sigmoid injuries must be ruled out via sigmoidoscopy, as they dramatically increase infection risk 1
• Intra-abdominal injuries are common given the high-energy mechanism and require exploratory laparotomy when indicated 1, 7

Neurological Complications

• Peripheral nerve injuries are common and account for significant long-term morbidity 4
• Lumbosacral plexus injuries occur with sacral fractures and sacroiliac disruption 1

Immediate Management Priorities (First 60 Minutes)

The following algorithm must be executed rapidly, as bleeding control procedures should not exceed 60 minutes from hospital admission: 1

1. Mechanical stabilization with pelvic binder application immediately upon recognition 6
2. Hemorrhage control via external fixation (Ganz clamp for Tile C fractures or anterior external fixator for Tile B1/B3) 1, 6
3. Angioembolization if bleeding persists after mechanical stabilization, ideally within 60 minutes 1, 6
4. Antibiotic administration within 3 hours: cefazolin plus gram-negative coverage (aminoglycoside or piperacillin-tazobactam) for open fractures 2

Wound Management Complications

• Soft tissue injury requires aggressive debridement and frequent dressing changes under anesthesia to prevent infection 4
• Definitive wound coverage must occur within 7 days to reduce fracture-related infection risk 2
• Failure to achieve early wound coverage results in significantly higher rates of osteomyelitis and chronic infection 2, 5

Critical Pitfalls to Avoid

• Never delay colostomy in patients with buttock or perineal wounds—this is associated with near-universal pelvic sepsis 5
• Do not exceed 60 minutes from admission to bleeding control intervention, as this increases mortality 1, 6
• Avoid antibiotic delay beyond 3 hours, as infection risk increases exponentially 2
• Do not extend antibiotics beyond 72 hours without documented infection 2
• Never miss associated rectal injuries—perform sigmoidoscopy in all open pelvic fractures 1

Long-Term Morbidity Considerations

• Chronic disability is common, with severe impairment in physical functioning and role performance even years after injury 5
• Many patients remain unemployed long-term due to chronic pain and physical limitations 5
• Functional consequences are typically severe despite survival 1