DETROIT TRAUMA SYMPOSIUM

• PELVIC FRACTURE
AND HEMORRHAGE
Ortho, IR and ME

Lawrence N Diebel MD
Professor of Surgery
Wayne State University
• Journal of Trauma 69: 483-488; 2010

• “ No other injury has treatment undergone

such an evolution, yet successful
treatment of pelvic fracture remains one of
the most difficult clinical problems in the
management of the injured.”
BONY PELVIS
• INNOMINATE BONES
AND SACRUM
• HELD TOGETHER BY
STRONG LIGAMENTS
• PUBIC SYMPHYISIS IS
THE WEAK LINK
• INJURY USALLY IN
MORE THAN ONE AREA
AND INVOVLES BOTH
BONE AND
LIGAMENTOUS INJURY
 PELVIC FRACTURE
• MORTALITY WITH ISOLATED
FRACTURE IS 1-2% INDEPENDENT OF
FX SEVERITY
• MORTALITY RATES IN MULTIPLE
BLUNT TRAUMA PATEIENTS
INCREASES TO 10-15%
• FACTORS THAT PREDICT MORTALITY
INCLUDE AGE, ISS, AND MASSIVE
BLEEDING NOT FX PATTERN
 PELVIC FX : MARKER OF
SIGNIFICANT TRAUMA
• SIGNIFICANT FORCE REQUIRED TO
DISRUPT THE PELVIS
• ASSOCATIATED INJURIES COMMON
• EXTRA-PELVIS SOURCES OF
BLEEDING INCLUDE CHEST IN 15% OF
CASES, ABDOMINAL IN 32% AND LONG
BONES IN 40%
 MORTALITY IN PTS WITH
PELVIC FX
• 42% OF CASES IT IS DUE TO BLEEDING AND
THE SOURCE IS THE PELVIS IN 62%, AND
38% OF THE TIME IT IS FROM THE
EXTREMITIES, OR THORACIC AND
ABDOMINAL SOURCES
• LATE DEATHS : MOF AND SEVERE CHI
• HEMODYNAMIC AND MECHANICALLY
UNSTABLE PTS MAKE UP <10% OF ALL
PELVIC FX PTS BUT MOST OF THE THOSE
PTS THAT ULTIMATELY DIE.
 IMPORTANCE OF
HEMORRAHAGE IN MORTALTY
WITH PELVIC FX
• VERBEEK (WJS 2008 MULTICENTER)

• 217 PTS WITH SEVERE INJURY

(ISS>16, PELVIC AIS> INITIAL BP<90
RBC TX >6 U FIRST 24 HR

OVERALL MORTALITY 32%, HRM 19% 1/3

FROM BLOOD LOSS FROM PELVIS
 INTIAL ASSESSMENT OF PTS
WITH SUSPECTED PELVIC FX

• HEMODYNAMIC STATUS IS THE

PRIMARY FOCUS (PATIENT STABILTY)

• PELVIC FRACTURE PATTERN IS

SECONDARY (STABILITY OF PELVIC
RING).
Young-Burgess Classification :
Mortality, Transfusion and other
injuries
PELVIC FX CLASSIFICATION
• FORCE VECTORS AND FRACTURE
PATTERNS INCONSISTENTLY
PREDICT THOSE WITH ARTERIAL
HEMORRHAGE AND NEED FOR AG/E
• EXSANGIUNATION DOES OCCUR IN
ALL FX PATTERNS.

ACTUAL FORCE VECTORS MAY DIFFER

FROM PERCEIVED INJURY PATTERN.
INITIATIAL DECISION TREE IN
PATIENTS WITH ? PELVIC FX
PELVIC FRACTURE CLINICAL
PATHWAY
 PELVIC FRACTURE AND
HEMODYNAMIC INSTABILITY
 IMPROVING OUTCOME IN PTS
WITH PELVIC FX
• THE MOST IMPORTANT FACTOR IN
SURVIVAL OF PTS WITH PELVIC FX IS
“URGENT HEMOSTASIS”.
• EARLY INSTITUTION OF MTP AND A
DAMAGE-CONTROLLED APPROACH
TO RESUSCITATION AND TX OF
INJURIES.
• NEED TO HAVE A “CLOCK IN YOUR
HEAD” MENTALITY.`
 KEY ELEMENTS IN
MANAGEMENT OF HD
UNSTABLE PT WITH PELVIC FX
IMMEDIATE IDENTIFICATION OF “AT
RISK” PATIENT
EARLY USE OF PELVIC COMPRESSION
DEVICE
USE OF DAMAGE CONTROL
RESUSCIATION AND MASSIVE
TRANFUSION PROTOCOL
EARLY IDENFICATION OF OTHER
SOURCES OF HEMORRHAGE
ORTHOPEDIC PELVIC FX
STABILIZATION
NONSELECTIVE INJECTION
WAYNE COUNTY MEDICAL
EXAMINER: NOT THIS “ME”.
 Physical Exam and Pelvic Fracture: How
good is it?
( JT 2009 UCLA Medical Center)
115 patients, 34 with Tile B or C

Sensitivity Specificity
Pelvic Pain any Fx 74% 97%
(GCS > 13) unstable 100% 93%

Pelvic Deformity any fx 30% 98%

unstable 55% 97%

Ring stability any fx 8% 26%

unstable 20% 99%
SOURCES OF BLLEDING IN PTS
WITH PELVIC FX
• EXTERNAL
• OTHER FX SITES
• CHEST
• ABDOMEN
• PELVIS
 SOURCES OF BLOOD LOSS
FROM THE PELVIS
• VENOUS : PRIMARY SOURCE,
PARTICULARLY FROM POSTERIOR
PELVIC VENOUS PLEXUS
• BONE (CANCELLOUS BONY
FRAGMENTS)
• ARTERIAL -10-15% OF CASES
USUALLY FROM BRANCHES OF
INTERNAL ILIAC ARTERY, RARELY
MAIN ILIACS.
 CONTROL OF PELVIC FX
ASSOCIATED BLEEDING
• PELVIC STABILIZATION FOR VENOUS
AND BONE BLEEDING

EXTERNAL BINDERS –the method of

choice for immediate stabilization.

PELVIC EXTERNAL FIXATORS (ANT)

PELVIC C- CLAMP (POSTERIOR)

ORTHOPEDIC PELVIC FX
STABILIZATION
Exterior fixation does not “fix”
posterior fractures.
 USE OF BEDSHEET AS
TEMPORARY PELVIC BINDER
 SAM Sling T-POD

Pelvic Binder The old stand-by sheet

FUNCTIONS OF PELVIC BINDER
• SPLINT THE BONY PELVIS TO REDUCE
HEMORRHAGE FROM BONE AND VENOUS
SOURCES
• TO REDUCE PAIN AND FX MOVEMENT
DURING PATIENT TRANSFERS
• TO PROVIDE PELVIC INTEGRITY WHEN
PELVIC PACKING IS DONE
• TO PROVIDE PELVIC STABILIZATION UNTIL
DEFINITIVE STABILIZATION DONE
External Compression for Pelvic Fx
• Bottlang et al: mechanical stability
 External Pelvic Compression and
TX and Death
• Note: SBP < 90 in only 19% and 10% in
no EMC and EMC groups respectively
 Effect of external pelvic
compression on transfusion and
death
• Ghaemmaghami et al ; AJS 2007
Benefit of “emergent” pelvic fixation
in pelvic fx hemorrhage
• Croce el JACS 2007. 186 patients
 ? THE ROLE OF PELVIC
BINDERS AND EXTERNAL
FIXATORS
• HAVE BEEN PROVEN TO DECREASE
PELVIC VOLUME WITH A MODEST
INCREASE IN PRESSURE IN CERTAIN
FX PATTERNS

• IT IS QUESTIONABLE IN THEY TRUALU

HAVE A TAMPONADING EFFECT
 INDICATIONS FOR PELVIC
BINDER
• HEMODYNAMICALLY UNSTABLE
PATIENT WITH UNSTABLE PELVIS
• HEMODYNAMICALLY UNSTABLE
PATIENT WITH SUSPECTED PELVIC
FRACTURE
• HEMODYNAMICALLY STABLE PATIENT
WITH UNSTABLE PELVIC FRACTURE
 CT IN MULTIPLE TRAUMA PT
WITH PELVIC FX
HELPS IN LOCATING PRIMARY SOURCE
OF BLEEDING
ALLOWS EARLY IDENTIFICATION OF
INJURIES AMENABLE TO AG/E
CAN GUIDE IR TO LIKELY AG/E (WHICH
SIDE IN PT WITH PELVIC FX)
CT ANGIOGRAMS WITH 64 SLICE
SCANNERS SIGNIFICANT ADVANCE
LIMITATIONS OF FAST EXAM IN
PATIENTS WITH PELVIC FX
BALLARD (JACS 1999)
13/70 PATIENTS HAD FALSE NEG.
WITH 4/13 HAVING TX. LAP.
Sensitivity 24%
FRIESE (JT 2007)
“HIGH RISK PTS (AGE, BP,FX TYPE)
31/96 FALSE NEG; 6/31 TX LAP
Sensitivity 26% 2/96 false pos FAST
 IMPACT OF FIRST
INTERVENTION ON MORTALTIY
FROM HEMORRHAGE
• LAPAROTOMY 29%
• ANGIOGRAPHY 18%
• LAPAROTOMY/PELVIC FIXATION 16%
• PELVIC FIXATION ONLY 10%

• PROBABLY REFLECTS SEVERITY OF

BLEEDING. HOWEVER OF 109 PTS
WITH LAP FIRST NEG LAP RATE 49%
 ANGIOGRAMS AND
ANGIOEMBOLIZATION (AG/E)
• ARTERIAL SOURCES OF BLEEDING IN
10-15 OF PATIENTS
• “HIGH PROBABLITY” OF NEED FOR
AG/E INCLUDE PERSISTENT HD
INSTABITLY AFTER INTIAL
RESUSCITATION, PELVIC
COMRESSION, AND EXCLUDE OTHE
SOURCES OF BLEEDING
 ISSUES WITH TIME AND AG/E
IN PELVIC FX
ALTHOUGH ARTERIAL BLEEDING MAY
BE MORE LIKELY IN UNSTABLE
PELVIC FS PATTERNS, THERE IS NO
CORREALATION BETWEEN NEED FOR
AG/E AND TYPE OF FX
EARLY (< 3 HR ) AFTER PT ARRIVAL MAY
IMPROVE SURVIVAL
IT TAKES TIMETO DO! ( AT LEAST 90
MIN).
SELECTIVE INTERNAL ILIAC
INJECTION
 Embolic Materials
 Temporary
 Gelfoam
 Occlusion balloon catheter
 Thrombin
 Autologous clot

 Permanent
 PVA/ particles/ microspheres
 Coils (macrocoils and microcoils)
 Distal vs. proximal deployment
 Glue/ Onyx
 Detachable balloon
 Alcohol/ Ethanolamine oleate/ sodium morrhuate
s/ p coil embolization
PELVIC FX: NEED FOR REPEAT
AG AFTER INITIAL AG/E
• POTENTIAL FOR REBLEEDING IN UP TO 10%
OF CASES

• SITES OF REBLEED: 68% NEW SITES, 18%

INTITIAL SITE AND 14% COMBO.

• PREDICT REBLEED: UNSTABLEHD AND TX

REQUIREMENTS PRIOR TO AG/E, AND . 2
SITES IDENTFIED BY AG/E
Follow-up Non-selective Pelvic
Arteriogram

No additional bleeding
GLUTEAL NECROSIS AFTER A/E
New Concept in Management of
Pelvic Venous Bleeding

• CT blush – A-Gram negative

• Abdomen explored for other reasons
• Ongoing blood requirements – A-
Gram negative
• Consider pelvic packing
 TECHNIQUE FOR
EXTRAPERITONEAL PACK
PLACEMENT
TIMING PF PELVIC PACKING
• AT TIME OF EXP LAP

• EXTRAPERITONEAL PACK
PLACEMENT WHEN AG/E NOT
IMMEDIATELY AVAILABLE.
•
• USED IN CONJUNCTION WITH PELVIC
FIXATION AND COMPLEMENTARY TO
AG/E
TREATMENT ALGORITHMS FOR
MANAGEMENT OF UNSTABLE
PTS WITH PELVIC FX
• THERE ARE A NUMBER OF STUDIES
SHOWING IMPROVED OUTCOMES
DUE TO DECREASED EARLIER
DEATHSFROM EXSANGINATION AND
LATE MOF DEATHS.
• TREATMENT ALGORITHMS SHOULD
BE MULITIDISCIPLINARY AND
INSTITUTIONALLY BASED TO WORK
AB: CAR CRASH DIFFICULT
EXTRACTION
AB: CT OF CHEST
AB: CT OF ABDOMEN
AB: CT OF PELVIS
AB: CT OF PELVIS
VB: MOTORCYCLE CRASH
VB: CT OF PELVIS
VB: CYSTOGRAM (CT READ AS
BLADDER RUPTURE)
VB: NONSELECTIVE ANGIO
VB: INTERNAL ILIAC INJECTION
VB: POST-INTERNAL
STABILIZATION
 MANAGEMENT TIMELINE
• OBTAIN CXR AND PELVIC AP FILM <10
MINUTES
• ABDOMINAL EVALUATION BY
FAST/DPA IN < 30 MINUTES
• OUT OF ED RESUSCITATION AREA <
45 MINUTES TO EITHER ICU, OR, or
I/R
• RECOGNIZE NEED FOR AG/E < 90
MINUTES AND IN ANGIO <3 HOURS.
 PELVIC BLOOD SUPPLY:
EXTENSIVE COLLATERALS