What are the treatment options for a patient with a pelvic fracture?

Treatment of Pelvic Fracture

Immediate pelvic binder application around the greater trochanters is the critical first intervention for any suspected pelvic fracture with hemodynamic instability, followed by a structured algorithmic approach based on hemodynamic status to control hemorrhage and prevent the 30-50% mortality associated with severe pelvic ring disruptions. 1, 2

Immediate Stabilization (First 2 Minutes)

Apply pelvic binder immediately around the greater trochanters within 2 minutes of identification - this takes absolute priority over all imaging and directly reduces transfusion requirements, ICU length-of-stay, and mortality by 15-30%. 3, 2 Any commercial pelvic binder is acceptable except sheet wrapping, which yields no benefit. 3 Alternative methods include external fixators, C-clamp, or bed sheet if commercial binders unavailable. 1

Algorithmic Approach Based on Hemodynamic Status

For Hemodynamically UNSTABLE Patients (SBP <90 mmHg):

1. Maintain pelvic binder and initiate permissive hypotension resuscitation targeting SBP 80-90 mmHg using packed red blood cells while minimizing crystalloids to avoid dilutional coagulopathy. 2

2. Perform E-FAST within 30 minutes to identify intra-abdominal bleeding source and obtain pelvic X-ray upon arrival to confirm fracture pattern. 3, 2

3. Proceed immediately to definitive hemorrhage control - time to hemorrhage control must be <163 minutes, as mortality increases approximately 1% every 3 minutes of delay. 2

Definitive Hemorrhage Control Options (Choose Based on Availability):

Primary option: Angiography with embolization - this is the primary definitive intervention for ongoing instability despite adequate pelvic ring stabilization, with success rates of 73-97%. 1, 2 Patients with CT "blush" (active arterial extravasation), pelvic hematoma >500 ml, anterior-posterior/vertical shear deformations, or ongoing hemodynamic instability despite fracture stabilization require angioembolization. 1, 2

Alternative when angiography unavailable within 60 minutes: Preperitoneal pelvic packing (PPP) - can be performed in <20 minutes, decreases need for subsequent embolization to only 13-20%, and can be combined with laparotomy when necessary. 1, 2 Critical pitfall: Pelvic packs must remain in place for at least 48 hours before removal to lower re-bleeding risk. 3, 2

External fixation for mechanical stabilization: Use Ganz C-clamp for Tile C fractures after heavy traction (15% of patient's weight), which can be placed in emergency room by trained operators. 1, 3 Use anterior external fixator for Tile C fractures and to reduce ring disruption in Tile B1 and B3 fractures, positioned anteriorly and inferiorly to allow potential laparotomy. 1, 3

For Hemodynamically STABLE Patients:

Skip pelvic X-ray and proceed directly to CT scan with IV contrast of entire pelvis to comprehensively assess fracture pattern, identify arterial bleeding, and evaluate for associated injuries. 3 Delayed sequences should analyze iodine contrast excretion to diagnose urinary lesions. 1

Damage Control Surgery Indications

Employ damage control surgery when the patient presents with: 1

• Deep hemorrhagic shock with signs of ongoing bleeding
• Coagulopathy (the "lethal triad" of acidosis, hypothermia, coagulopathy)
• Hypothermia or severe acidosis
• Inaccessible major anatomic injury requiring time-consuming procedures
• Concomitant major injury outside the abdomen

The damage control approach consists of abbreviated resuscitative laparotomy for bleeding control, restoration of blood flow, and contamination control, followed by temporary closure and deferred definitive repair. 1

Special Considerations for Open Pelvic Fractures

Open pelvic fractures carry mortality rates exceeding 50% and must be managed in referral centers with multidisciplinary teams. 1, 4 The four management priorities are: 1

1. Bleeding control (as above)
2. Perineal contamination control with early colostomy - delaying colostomy in patients with buttock or perineal wounds is associated with near-universal pelvic sepsis. 4
3. Cleaning and debridement of wounds with definitive coverage within 7 days to reduce infection risk. 4
4. Treatment of pelvic fracture (external fixation as above)

Antibiotic administration within 3 hours is essential - infection risk increases exponentially with delays beyond 3 hours, but antibiotics should not extend beyond 72 hours without documented infection. 4

Associated Injury Evaluation

Urethral injuries: Perform retrograde urethrogram (RUG) prior to urethral catheterization when local signs or disruption on X-ray are present (occurs in 4-19% of pelvic fractures, especially with bilateral pubic rami fractures). 4

Bladder injuries: Occur in 4-15% of unstable pelvic fractures, particularly intraperitoneal ruptures requiring early surgical closure. 4

Rectal injuries: Perform sigmoidoscopy in all open pelvic fractures - missing these injuries has severe consequences. 1, 4

Critical Pitfalls to Avoid

• Never delay pelvic ring closure in hemodynamically unstable patients - this is the single most important mortality-reducing intervention. 3, 2
• Never remove pelvic packs before 48 hours - early removal dramatically increases re-bleeding risk. 3, 2
• Never perform non-therapeutic laparotomy in patients with pelvic fractures as it may increase mortality by disrupting the tamponade effect of the retroperitoneal hematoma. 3
• Never exceed 60 minutes from admission to bleeding control intervention when angiography or PPP is indicated. 1, 4

Transport Requirements

All patients with severe pelvic trauma must be transported to a Level I trauma center with 24/7 availability of trauma surgery, interventional radiology, and orthopedic surgery - this approach decreases mortality by 15-30% compared to non-specialized facilities. 3, 2