What is the management approach for a patient with pelvic trauma?

Management of Pelvic Trauma

Apply a pelvic binder immediately around the greater trochanters at the scene, transport directly to a Level I trauma center, and then follow a hemodynamic status-driven algorithm that prioritizes hemorrhage control through sequential interventions including pelvic stabilization, preperitoneal packing, and angioembolization. 1, 2

Prehospital Management

Immediate Stabilization

• Apply external pelvic compression with a commercial pelvic binder as soon as pelvic trauma is suspected (Grade 1+ recommendation), positioning it around the greater trochanters—not the iliac crests—to achieve compression equivalent to surgical C-clamp 3, 1, 2
• Avoid sheet wrapping, which provides no benefit compared to commercial devices 1, 2
• This single intervention directly reduces transfusion requirements and ICU length-of-stay 1
• Prehospital physician-delivered care decreases severe trauma mortality by 30% 3, 2

Transport Destination

• Transport all suspected severe pelvic trauma patients directly to a designated Level I trauma center with 24/7 availability of trauma surgery, interventional radiology, and orthopedic surgery (Grade 1+ recommendation) 3, 1, 2
• This approach decreases mortality by 15-30% compared to initial transport to non-specialized facilities 1, 2

Hospital Management Algorithm

For Hemodynamically Unstable Patients (SBP <90 mmHg)

Immediate Actions (within 30 minutes of arrival):

• Obtain pelvic X-ray immediately upon arrival to confirm fracture pattern (Grade 2+ recommendation) 3, 1, 2
• Perform E-FAST to identify intra-abdominal bleeding source (Grade 2+ recommendation), which has 97% positive predictive value for intra-abdominal hemorrhage 3, 1
• Reassess pelvic binder placement and ensure it remains properly positioned around greater trochanters 1

Sequential Hemorrhage Control Strategy:

1. If E-FAST positive for intra-abdominal bleeding: Proceed to immediate laparotomy with concomitant pelvic stabilization to control intra-abdominal and venous pelvic hemorrhage 4
2. Preperitoneal packing should be performed simultaneously or immediately after initial stabilization, which decreases need for angioembolization and aids early intrapelvic bleeding control 1
3. Angiography and embolization (within 45 minutes of arrival if no intra-abdominal bleeding) for arterial bleeding that persists despite fracture stabilization, using steel coils or Gelfoam 1, 4

Markers Indicating Need for Angioembolization:

• CT "blush" showing active arterial extravasation 1
• Pelvic hematoma volumes >500 mL on CT 1
• Ongoing hemodynamic instability despite adequate fracture stabilization 1
• Sacroiliac joint disruption patterns 1

For Hemodynamically Stable Patients

• Do NOT obtain pelvic X-ray (Grade 2- recommendation) 3, 1, 2
• Proceed directly to CT scan of entire body including pelvis with IV contrast 3, 1, 2
• CT angiography identifies active bleeding with 82-89% sensitivity 2

Definitive Fracture Stabilization

External Fixation

• Position external fixators anteriorly and inferiorly to allow potential laparotomy access 1
• Recommended for Tile C fractures and to reduce ring disruption in Tile B1 and B3 fractures 1

Damage Control Approach

Employ damage control surgery when patients present with: 1

• Deep hemorrhagic shock with signs of ongoing bleeding
• Coagulopathy or severe acidosis
• Inaccessible major anatomic injury
• Need for time-consuming procedures
• Concomitant major injury outside the abdomen

Critical Pitfalls to Avoid

• Never delay binder application for radiographic confirmation—apply based on mechanism and clinical suspicion 1, 2
• Never place binders over iliac crests—they must be positioned around greater trochanters for effectiveness 3, 1, 2
• Avoid non-therapeutic laparotomy in pelvic fracture patients as it may increase mortality 1
• Do not remove pelvic packs before 48 hours to lower re-bleeding risk 1
• Monitor for skin injury from prolonged binder use, particularly in elderly, thin patients, or males 2
• Recognize that some B2-B3 fractures may be displaced by external stabilization 2

Special Considerations

Open Pelvic Fractures

• Must be managed in referral centers due to rarity and complexity 1
• Management priorities include bleeding control, perineal contamination control, wound debridement, and identification of associated lesions 1
• Often requires temporary stoma, external pelvic fixator, and occasionally hemipelvectomy 1

Associated Injuries

• More than 80% of patients with unstable pelvic fractures have additional musculoskeletal injuries 5
• Bladder, urethra, and nerve roots are predisposed to injury given their intimate pelvic location 5
• Intestinal injury remains one of the most commonly missed injuries on initial CT (20% detection failure rate) 6

Multidisciplinary Coordination

• Essential involvement of trauma surgeons, orthopedic surgeons, interventional radiologists, and critical care specialists for optimal outcomes 1