What is the treatment approach for a patient with a fractured pelvis?

Treatment of Pelvic Fractures

Immediate Stabilization Based on Hemodynamic Status

For hemodynamically unstable patients with pelvic fractures, immediate pelvic ring closure using a pelvic binder is the critical first intervention, followed by transfusion and preparation for angiographic embolization or preperitoneal packing—never exploratory laparotomy as the primary intervention. 1, 2

Hemodynamically Unstable Patients (Systolic BP <90 mmHg)

Apply pelvic binder immediately around the greater trochanters within 2 minutes of identification—this is life-saving and takes priority over all imaging 1, 2. Any commercial pelvic binder is acceptable except sheet wrapping 1.

Resuscitation strategy:

• Target systolic BP 80-90 mmHg using permissive hypotension until hemorrhage is controlled 2
• Transfuse packed red blood cells while minimizing crystalloids to avoid dilutional coagulopathy 2
• Consider tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion 2

Determine bleeding source algorithmically:

• Perform E-FAST within 30 minutes to identify intra-abdominal bleeding 1
• Obtain pelvic X-ray upon arrival to confirm fracture pattern 1
• If ongoing hypotension persists despite binder placement, this indicates arterial bleeding requiring additional intervention 2

Definitive hemorrhage control (choose based on availability and CT findings):

• Angiography with embolization is the primary definitive intervention for ongoing instability despite adequate pelvic ring stabilization, with success rates of 73-97% 2
• CT "blush" (active arterial extravasation) or pelvic hematoma >500 ml strongly indicates need for angioembolization 3, 1, 2
• Preperitoneal packing can be performed in <20 minutes if angiography is not immediately available, decreases need for subsequent embolization to only 13-20%, and should be removed only after 48 hours 1, 2
• External fixation should be placed for Tile C fractures and to reduce ring disruption in Tile B1 and B3 fractures, positioned anteriorly and inferiorly to allow potential laparotomy 1

Critical pitfall: Non-therapeutic laparotomy dramatically increases mortality in patients with pelvic fracture hemorrhage and should be avoided unless there is clear evidence of intra-abdominal injury requiring surgical intervention 1, 2. The extensive collateral circulation in the retroperitoneum makes surgical control of pelvic bleeding extremely difficult 2.

Hemodynamically Stable Patients

Skip pelvic X-ray and proceed directly to CT scan with IV contrast of the entire pelvis—this is the gold standard with 100% sensitivity and specificity for bone fractures 3, 1. CT with 3D bone reconstruction is helpful for surgical planning and reduces operative times and complications 3.

Management based on mechanical stability:

Mechanically unstable fractures (APC-II/III, LC-II/III, Tile B/C):

• Early definitive pelvic fracture fixation within 24 hours for patients without physiologic derangement 4
• Postpone definitive fixation until after day 4 post-injury in physiologically deranged polytrauma patients 4
• Pubic symphysis plating for "open book" injuries with diastasis >2.5 cm 4

Stable fracture patterns (APC-I, LC-I, Tile A):

• Conservative management with pain control, activity modification, and early mobilization as tolerated 4
• No surgical intervention required 4

Associated Injury Management

Urethral injuries (present in 7-25% of pelvic ring fractures):

• Clinical signs: perineal/scrotal hematoma, blood from urethral meatus, high-riding prostate, unstable pelvic fracture 3
• Perform retrograde urethrogram (RUG) prior to urethral catheterization when local signs or disruption on X-ray are present 3
• If RUG positive or high suspicion, place suprapubic catheter with delayed cystogram 3
• Critical pitfall: Inserting transurethral catheter without prior investigation can cause complete urethral transection, stricture formation, impotence, and incontinence 3

Ano-rectal injuries (18-64% incidence):

• Perform perineal and rectal digital examination to detect blood, rectal wall weakness, and non-palpable prostate 3
• If positive rectal examination, strongly consider rigid proctoscopy 3

Transport and Institutional Requirements

All patients with severe pelvic trauma should be transported to a Level I trauma center with 24/7 availability of trauma surgery, interventional radiology, and orthopedic surgery—this decreases mortality by 15-30% compared to non-specialized facilities 1.

Timing Considerations

Time to hemorrhage control should be <163 minutes, as mortality increases approximately 1% every 3 minutes of delay 2. The probability of arterial bleeding on angiography is 73% in non-responders to initial resuscitation 2.