CHAPTER I

INTRODUCTION

Severe pelvic fractures are life-threatening injuries. Extensive bleeding due to

pelvic fractures is relatively common, but is especially common with high-strength
fractures. About 15-30% of patients with severe pelvic injuries are haemodynamically
unstable, which may be directly related to blood loss from pelvic injuries. Bleeding is
a major cause of death in patients with pelvic fractures, with an overall mortality rate
of 6-35% in high-strength large-scale pelvic fractures.11
Pelvic fractures represent about 3% of all bone injuries each year in the
United States and account for 9% of trauma patients who are hospitalized. These
injuries range from mild to life-threatening, with an overall mortality of 10-16%.
However, open pelvic fractures which represent about 2-4% of pelvic injuries, have
the highest mortality rate at almost 45%. Pelvic fractures most often occur in patients
aged 15-28% years who are still active, the mechanism of side effects from injuries
such as falls from height, or motorized collisions (MVC) but serious pelvic injuries
can also occur from small mechanisms such as falling to the ground especially applies
to patients with old age
Bleeding due to pelvic fracture requires efficient evaluation and prompt
intervention. Evaluation and treatment of patients with pelvic fractures requires a
multidisciplinary approach. Although general surgical trauma experts ultimately
direct the treatment of someone with multiple injuries, it is important for patients with
pelvic fractures that orthopedic surgeons are involved in every phase of treatment,
including primary resuscitation. Early assessment by an orthopedic surgeon who is
familiar with pelvic fracture patterns makes it easy for the treatment team to establish
diagnoses and priorities

1
 In addition to treating the fracture, complications need to be addressed that
can include major bleeding, bladder rupture, or urethral injury. A careful
understanding of the source of potential bleeding and awareness of treatment options
is important for all doctors involved1

2
 CHAPTER II

LITERATURE REVIEW

A. Definition
Pelvic fractures are disorders of the pelvic bone structure. In the elderly, the
most common cause is falling from a standing position. However, fractures that
are associated with the greatest morbidity and mortality involve significant things
such as motor vehicle accidents or falling from a height 2

B. Etiology
With increasing traffic accidents resulting in dislocation of the hip joint is
often found. Pelvic dislocation is a severe trauma. Pelvic fractures should be
suspected if there is a history of trauma that compresses the lower body or if
there are degloving, bruising, or hematoma in the waist, sacrum, pubis or
perineum area.22

C. Epidemiology
Two thirds of hip fractures occur as a result of traffic accidents. Ten percent
of them are accompanied by trauma to tools in the pelvic cavity such as the
urethra, bladder, rectum and blood vessels with a mortality rate of around 10%. 2
Pelvic fractures represent about 3% of all bone injuries each year in the
United States and account for 9% of trauma patients who are hospitalized. These
injuries range from mild to life-threatening, with an overall mortality of 10-16%.
However, open pelvic fractures which represent about 2-4% of pelvic injuries,
have the highest mortality rate at almost 45%. Pelvic fractures most often occur
in patients aged 15-28% years who are still active, the mechanism of side effects
from injuries such as falls from height, or motorized collisions (MVC) but

3
 serious pelvic injuries can also occur from minor mechanisms such as falling to
the ground especially applies to patients with old age.

D. Pelvic Anatomy
The pelvis is a ring-like structure formed from three bones, the sacrum and
two innominata bones, each of which consists of ilium, ischium and pubis.
Innominata bones are fused with the sacrum in the posterior part of the two joints
of the sacroiliaca; anteriorly, these bones unite at the symphysis pubis. The
symphysis acts as a support along the weight of the body to maintain the
structure of the pelvic ring.1
The three bones and three joints make the pelvic ring stable by ligamentous
structures, the strongest and most important are the posterior sacroiliac
ligaments. These ligaments are made of short oblique fibers that cross from the
posterior sacrum bulge to the posterior superior iliac spine (SIPS) and the
posterior inferior iliac spine (SIPI) as well as longitudinal fibers that extend
longer from the lateral sacrum to the posterior superior iliac spine (SIPS) and
inferior posterior iliac spine (SIPI) as well as longitudinal fibers that extend
longer from the lateral sacrum to the posterior superior iliac spine (SIPS) and
inferior posterior iliac spine (SIPI) as well as longitudinal fibers that extend
across the lateral sacrum to the posterior superior iliac spine (SIPS) and inferior
posterior iliac spine (SIPI). SIPS) and join the sacrotuberale ligament. The
anterior sacroiliaca ligament is much less powerful than the posterior sacroiliaca
ligament. The sacrotuberale ligament is a strong web that crosses from the
posterolateral sacrum and the dorsal aspect of the posterior iliac spine to the
ischiadic tuber. This ligament, together with the posterior sacroiliaca ligament,
provides vertical stability to the pelvis. The sacrospinosum ligament crosses the
lateral border of the sacrum and coccygeus to the sacrotuberale ligament and
enters the spina ischiadica. The iliolumbale ligament crosses from the fourth and
fifth lumbar transverse processes to the posterior iliac crista; the lumbosacrale
4
ligament transversely from the fifth lumbar transverse process to the sacral ossis
style (figure 1).3

Figure 1. Posterior (A) and anterior (B) views of the pelvic ligament.

The iliaca communis artery divides into the iliaca externa artery, which
is located in the anterior pelvis above the pelvic margin. The internal iliaca
artery is located above the periphery of the pelvis. The arteries flow anteriorly
and deeply close to the sacroliliaca joint. The posterior branches of the
internal iliac artery include the iliolumbar artery, the superior glutea artery and
the lateral sacral artery. The superior glutea arteries travel around to form a
larger pelvis, which is located directly above the bone. The anterior branches

5
of the internal iliaca artery include the obturatoria artery, the umbilical artery,
the vesical artery, the pudendal artery, the inferior glutea artery, the rectal
artery and the hemorrhoidal artery. The pudendal arteries and obturatoria are
anatomically related to pubic flax and can be injured by fractures or injuries to
these structures. These arteries as well as the accompanying veins can all be
injured during pelvic disruption (figure 2). An understanding of pelvic
anatomy will help orthopedic surgeons to recognize which fracture patterns
are more likely to cause direct damage to major blood vessels and cause
significant retroperitoneal bleeding. 1

Figure 2. Internal aspects of the pelvis that show major blood vessels located
on the wall in the pelvis

6
E. Trauma Mechanism
The mechanism of trauma to the pelvic ring consists of: 3 3
1. Antero-Posterior Compression (APC) 
This usually occurs due to a collision between a pedestrian and a
vehicle. The ramus pubis has a fracture, the inominate bone is split and
undergoes external rotation accompanied by symphysis tears. This
situation is referred to as an open book injury. The posterior portion of the
iliac sacro ligament has a partial tear or may be accompanied by a fracture
behind the ilium
2. Lateral Compression (LC)
Compression from the side will cause the ring to crack. This
happens if there is a side trauma due to a traffic accident or falling from a
height. In this situation the front of the pubic ramus on both sides is
fractured and the back is a strain of the iliac sacro or ilium fracture or the
ramus pubis may be fractured on the same side.
3. Vertical Trauma (SV)
The inominata bone on one side experiences vertical movement
with ramus pubis fracture and disruption of the iliac sacro joint on the
same side. This happens when someone falls from a height on one leg
4. Combination Trauma (CM)
In more severe trauma a combination of the above disorders can
occur.

7
F. Injury / Fractional Classification Type
Pelvic injuries are divided into several groups: 3
1. An isolated fracture with an intact pelvic ring
 Fraktur avulsi
A piece of bone is attracted by intense muscle contractions. This
fracture is usually found in sportsmen and athletes. The Sartorius
musculus can attract the anterior superior iliac spine, the femoral
rectus attracts the inferior anterior iliac spine, the adductor longus pulls
a piece of the pubis, and the striated veins attract parts of the ischium.
Pain usually disappears within a few months. Avulsion of the ischium
apophysis by the knee muscles rarely results in persistent symptoms, in
this case open reduction and internal fixation are indicated
 Direct fracture
A direct blow to the pelvis, usually after falling from a high
place, can cause an ischial or ossis iliic fracture. In this case it requires
total bed rest until the pain subsides.
 Pressure fracture
Fractures on pubic flax are quite common and often feel painless.
In patients with osteoporosis and severe osteomalasia. What is more
difficult to diagnose is a pressure fracture around the sacroiliaca joint.
This is an unusual cause of sacroiliaca pain in parents suffering from
osteoporosis
2. Fracture of the pelvic ring
It has long been argued that because of the pelvic stiffness, a
fracture in one ring must be followed in another, except for fractures due
to direct blows or fractures in symphysis children and sacroiliac joints are
still elastic. However, a second fracture is often not found, either because
the fracture is reduced immediately or because the sacroiliaca joint is only

8
partially damaged. In this case the visible fracture does not experience a
shift and the ring is stable. Fractures or obvious joint damage are
displaced, and all obvious double ring fractures are unstable. This
difference is more practical than classification into single and double ring
fractures.
Anteroposterior pressure, this injury is usually caused by a frontal
collision during an accident. Pubic flax has a fracture or a fractured
inominata bone which splits and rotates out with symphysis damage. This
fracture is usually called "open book". The posterior portion of the
sacroiliaca ligament is partially torn, or there may be a fracture in the
posterior part of the ilium
Lateral pressure, pressure from side to side of the pelvis causes the
ring to bend and break. In the anterior part of the pubic flax, one or both
sides have a fracture and in the posterior there is a severe sacroiliaca
strain or a fracture on the ilium, either on the same side as the pubic flax
fracture or on the opposite side of the pelvis. If there is a large shift in the
sacroiliaca joint, the pelvis is unstable.
Vertical twisting, the inominate bone on one side shifts vertically,
causing vertical fractures, causing pubic flax fractures and damaging the
sacroiliaca area on the same side. This typically occurs on one foot when
falling from a height. These injuries are usually severe and unstable with
soft tissue tears and retroperitoneal bleeding.
Tile (1988) divides pelvic fractures into stable injuries, injuries that
are rotatively unstable and injuries that are rotational and vertically
unstable.

9
  Type A / stable; these include avulsions and fractures in the pelvic
ring with little or no shift
- A1: hip fracture does not affect the pelvic ring
- A2: stable, there is minimal shift of the ring from the fracture

 Type B; rotation is not stable but vertically stable. External

rotational forces that hit on one side of the pelvis can damage and
open the symphysis commonly called open book fractures or internal
rotational forces that are lateral pressures that can cause fractures in
ischiopubic flax on one or both sides are also accompanied by
posterior injuries but there is no symphysis opening.
- B1 : open book
- B2 : lateral compression  ipsilateral
- B3 : lateral compression  contralateral (bucket-handle)
 Type C is rotational and vertically unstable, there is damage to the
hard posterior ligament with injuries on one or both sides and vertical
shifts on one side of the pelvis, there may also be an acetabulum
fracture.
- C1 : unilateral
- C2 : bilateral
- C3 : accompanied by an acetabulum fracture

G. Clinical manifestations
Pelvic fractures are often part of one of the multiple trauma that can
affect other organs in the pelvis. Pelvic fractures should also be suspected if
there is a history of trauma that compresses the lower body or if there are
degloving, bruising, or hematoma in the waist, sacrum, pubis, and perineum.
The patient comes in anemic state and is shocked because of heavy bleeding.
There is impaired function of the lower limbs. The diagnosis is made when
10
subjective and objective pain is found, and abnormal movements in the pelvic
ring
Dislocation and dislocation of the hip joint are divided into 3 types : 3
1. Posterior dislocation
 Without fracture
 Accompanied by a single large posterior rim fracture
 Accompanied by a posterior acetabulum fracture communitive with or
without damage to the base of the acetabulum.
 Femoral head fractures are accompanied
The mechanism of posterior dislocation trauma accompanied by
fractures is that the femoral head is forced out behind the acetabulum
through a trauma delivered to the femur diaphysis where the hip joint is in a
flexed or semi-flexed position. Trauma usually occurs due to a traffic
accident where the passenger knee is flexed and crashing violently on the
front of the knee. This disorder can also occur while riding a motorcycle.
50% dislocation is accompanied by a fracture at the edge of the acetabulum
with small or large fragments. Patients usually come after a severe trauma
accompanied by pain and deformity in the hip joint. The palpable joints
protrude backward in the position of adduction, flexion and internal rotation.
There is a shortening of the lower limbs. By X-ray examination will find out
the type of dislocation and whether the dislocation is accompanied by a
fracture or not.33
2. anterior dislocation
 Obturator 
 Iliaca
 Pubic 
 Femoral head fractures are accompanied

11
3. The central dislocation of the acetabulum
 Only affects the inside of the acetabulum wall
 A partial fracture from the dome of the acetabulum
 Overall displacement of the pelvis accompanied by communicative
acetabulum fractures.
Mechanism of trauma A central dislocation fracture occurs when the
femoral head is pushed into the medial wall of the acetabulum in the pelvic
cavity. Here the capsule remains intact. The acetabulum fracture occurs
because of a strong lateral push or fall from a height on one side or a
pressure through the femur where the abduction is. Obtained bleeding and
swelling in the area of the limbs proximal but the position remains normal.
Tenderness in the trochanter area. Movement of the hip joint is very limited.
With radiological examination found a shift from the femoral head through
the pelvis.3
In type A injuries the patient does not experience severe shock but
feels pain when trying to walk. There is local tenderness but there is rarely
damage to the pelvic viscera. Plain photos of the pelvis can show a fracture.
In type B and C injuries the patient experiences severe shock, is very
painful and cannot stand up, cannot urinate. There may be blood in the
external meatus. Dopath tenderness is local but often widespread, and the
effort to move one or both ossis ilii will be very painful. One of the legs may
have anesthetics partly because of a sciatic nerve injury. This injury is so
great that it carries a high risk of visceral damage, bleeding in the stomach
and retroperitoneal, shock, sepsis and ARDS. The mortality rate is also quite
high.1
history:
a. The state and time of trauma
b. Last urination

12
 c. Time and amount of the last meal and drink
d. If a woman sufferer is pregnant or menstruating
e. Other trauma such as trauma to the head

Clinical Examination :
a. General condition
- Heart rate,blood pressure and respiration
- Conduct other possible trauma surveys
b. Local
- Examination of pain :
 Pressure from the side of the pelvic ring
 Pull on the pelvic ring
c. Perineal inspection to find out the bleeding, swelling and deformity
d. Determine the degree of instability of the pelvic ring by palpation of
the ramus and symphysis pubis
e. Digital rectal examination

H. Diagnosis
The diagnosis is made when subjective and objective pain is found, and
abnormal movements in the pelvic ring. For this reason, the pelvis is pressed
backward and medially gently on the two anterior superior iliac spines, medial
to both major trochanters, backward on the pubic symphysis, and medially on
both the iliac crest. If this examination causes pain, hip fractures should be
suspected.4
Then look for urinary disorders such as urinary retention or bleeding
through the urethra, and a digital rectal examination to assess the sacrum, or
pubic bone from within.
X-rays can show fractures in the pubic flax, ipsilateral or contra lateral
fractures of the posterior elements, symphysis separation, damage to the

13
 sacroiliaca joint or combination. CT scan is the best way to show the nature of
the injury.4

I. Classification System and Prognostic Value

Several classification systems have been formulated to describe pelvic

injuries based on the nature and stability of pelvic disruption or based on the
magnitude and direction of pressure applied to the pelvis. Each classification
has been developed to provide guidance to general and orthopedic surgeons
about the types and possible problems of management difficulties that may be
faced with each type of fracture. This pelvic fracture classification system, the
one described by Young and Burgess, is most closely related to the
resuscitation needs and patterns associated with injury. This system is based
on a standard series of pelvic images and internal and external images, as
described by Pennal et al.1

The Young-Burgess classification divides pelvic disruption into anterior-

posterior compression (APC), lateral compression (LC), vertical shear (VS),
and combination (CM) mechanisms (figure 3). The APC and LC categories
are further sub-classified from types I - III based on the increasing
deterioration of injury resulting from a large increase in pressure. APC
injuries are caused by anterior collisions against the pelvis, often leading to
pubic symphysis diastases. There are "open book" injuries that interfere with
the anterior sacroiliaca ligament as well as the ipsilateral sacrospinale
ligament and sacrotuberale ligament. APC injury is considered to be a good
radiographic marker for branches of the internal iliac arteries, which are in
close alignment with the anterior sacroiliaca joints.11

14
Figure 3. Classification of Young-Burgess pelvic fractures. A, anteroposterior type I
compression, B, anteroposterior type II compression, C, anteroposterior type III
compression. D, lateral compression type I. E, lateral compression type II. F, lateral
compression type III. G, vertical shear. The arrows on each panel indicate the direction of
pressure which results in a fracture pattern.

LC injury as a result of a lateral impact on the pelvis that rotates the

pelvis on the side of the impact towards the midline. The sacrotuberale
ligament and sacrospinale ligament, as well as the internal iliaca veins, are
shortened and are not subject to tensile forces. Large named blood vessel
disruption (for example, internal iliac arteries, superior gluteal arteries) is
relatively unusual with LC injuries; when this happens, it is thought to be a
result of laceration of the fracture fragment ..
VS injuries are distinguished from vertical removal of the hemipelvis.
Hemipelvis displacement may be accompanied by severe local vascular
injury. The CM injury pattern includes high-strength pelvic fractures caused
by a combination of two separate pressure vectors.
Young-Burgess pelvic fracture classification and suspected pressure
vectors have also been shown to correlate well with patterns of organ injury,
resuscitation requirements, and mortality. In particular, increases in mortality
have been proven as increases in APC rates. The pattern of injury seen in APC

15
 type III fractures has correlated with the largest 24-hour fluid requirement. In
a series of 210 consecutive patients with pelvic fractures, Burgess et al found
that transfusion requirements for patients with LC injuries averaged 3.6 units
of PRC, compared with an average of 14.8 units for patients with APC
injuries. In the same series, patients with VS injuries averaged 9.2 units, and
patients with CM injuries had an average transfusion requirement of 8.5 units.
The overall mortality rate in this series is 8.6%. Higher mortality rates were
seen in the APC pattern (20%) and the CM pattern (18%) compared to the LC
pattern (7%) and the VS pattern (0%). Burgess et al noted blood loss from
pelvic injuries resulting from lateral compression was rare, and the authors
attributed death to patients with LC injuries to other causes. The most
commonly identified cause of death in patients in this series with LC fractures
is closed head injury. In contrast, the cause of death identified in patients with
APC injuries is a combination of pelvic and visceral injuries. These findings
indicate that the ability to recognize pelvic fracture patterns and the
appropriate direction of injury pressure can help the resuscitation team
anticipate the need for fluid and blood transfusion as well as assist for initial
initial assessment and treatment. Patients with complete posterior instability
can be anticipated so as not to cause heavy bleeding.1

J. Management of Pelvic Fracture

1. Identification and Management of Pelvic Fractures 5
a. Identification of the mechanism of trauma that causes the possibility
of pelvic fractures such as being thrown from a motorcycle, crush
injury, pedestrians hit by a vehicle, motorcycle collision.
b. Examine the pelvic region for ecchymosis, perianal or scrotal
hematoma, blood in the urethral meatus.
c. Check the legs for differences in length or asymmetry of pelvic
rotation.

16
d. Perform rectal examination, position and mobility of the prostate
gland, palpable fracture, or the presence of blood in the stool.
e. Perform vaginal examination, touch fracture, size and consistency of
the uterus, presence of blood. Keep in mind that sufferers may be
pregnant
f. If abnormalities are found on b to e, if the mechanism of trauma
supports the occurrence of pelvic fractures, do an AP pelvic X-ray
examination (trauma mechanism can explain the type of fracture).
g. If b to e is normal, palpate the pelvic bone to find the site of pain.
h. Determine pelvic stability by carefully applying anterior-posterior
and lateral-medial pressure to SIAS. Check axial mobility by
carefully pushing and pulling legs, determining cranial-caudal
stability.
i. Pay attention to using a urine catheter, if there are no
contraindications, or do a ureterrogrammed retrograde examination if
there is a suspicion of urethral trauma.
j. assessment of pelvic x-ray images, attention to cases of fractures that
are often accompanied by heavy blood loss, for example fractures
that increase the volume of the pelvis.
k. Match the patient's identity in the photo
l. Check photos systematically;
o Width of the pubis-separation symposium more than 1 cm
indicates posterior pelvic trauma
o of the superior ramus and inferior bilateral pubis
o Integrity of acetabulum, capsule and femoral column
o Symmetry of the ileum and the width of the sacroiliac joints
o Symmetry of the sacrum foramen with arcuate line evaluation
o Transversus L5 prosessus fracture

17
m. Remember, because the pelvic bones are circular rarely damage only
in one place.
n. Remember, fractures that increase pelvic volume, such as vertical
shears and open-book fractures, are often accompanied by heavy
bleeding.
o. Techniques to reduce bleeding
o Prevent excessive or repetitive manipulation
o The lower leg is rotated inward to close the open-book fracture.
Place the pads on the bone protrusions and tie the two rotated
limbs. This action will reduce sympathetic shifts, reduce pelvic
volume, useful for action while waiting for definitive treatment.
o Tide and develop PASG. This tool is useful for carrying /
transporting patients.
o Tide the pelvic external fixator (immediate orthopedic
consultation)
o Tide skeletal traction (immediate orthopedic consultation)
o Pelvic artery embolization through angiography
o Conduct surgical / orthopedic consultations immediately to
determine priorities
o Put a sand pillow under the left-right buttocks if there is no
trauma to the spine or other ways to close the pelvis is not
available.
o Tide the pelvic binder
o Arrange transfer items to definitive therapeutic facilities if
unable to do so.

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2. Management Method6

 Military Antishock Trousers

     Military antishock trousers (MAST) or military anti-shock pants

can provide temporary compression and immobilization of the pelvic
ring and lower extremities through air-filled pressure. In the 1970s and
1980s, the use of MAST was recommended to cause pelvic tamponade
and increase venous return to aid resuscitation. However, the use of
MAST restricts abdominal examination and may cause lower
extremity compartment syndrome or increase by one. Although still
useful for stabilizing patients with pelvic fractures, MAST has been
widely replaced by the use of commercially available pelvic binders.

Figure 4. Illustration demonstrating Military Antishock Trousers

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 Pelvis Binder and Sheet

Circular compression may be readily achieved in the prehospital

setting and initially provides the advantage of stabilization during
transport and resuscitation. The folded sheet wrapped in a circle
around the pelvis is cost effective, non-invasive, and easy to apply.
Various commercial pelvic binders have been found. A pressure of 180
N seems to provide maximum effectiveness. A study reported pelvic
binder reduces the need for transfusion, length of hospital stay, and
mortality in patients with APC injuries (figure 5).

Figure 5. Illustration demonstrating application of a proper pelvic circular

compression device (pelvic straps), with additional buckles (arrows) to control
pressure

External rotation of the inferior limb is commonly seen in people

with a pelvic fracture disposition, and the force acting through the hip
joint may contribute to pelvic deformity. Correction of external
rotation of the lower limb can be achieved by bandaging the knee or

20
 leg together, and this can improve the pelvic reduction that can be
achieved by circular compression.

 External fixation
o Standard External Anterior fixation
Several studies have reported the benefits of external pelvic
emergency fixation in resuscitation of hemodynamically unstable
patients with unstable pelvic fractures. The beneficial effects of
external fixation on pelvic fractures can arise from several factors.
Immobilization can limit pelvic displacement during movement
and movement of the patient, reducing the likelihood of blood clot
disruption. In some patterns (for example, APC II), pelvic volume
reduction may be achieved with the application of an external
fixator. Experimental studies have shown that reducing "open
book" pelvic injury leads to increased retroperitoneal pressure,
which can help tamponade venous bleeding. Addition of
disposition fractures can ease the path of hemostasis to control
bleeding from the rough bone surface.
o C-Clamp
Standard external pelvic fixation does not provide adequate
posterior pelvic stabilization. This limits the effectiveness of
fracture patterns that involve significant posterior disruption or in
cases where the ossis ileum fractures. A C-clamp applied
posteriorly has been developed to cover this deficiency. The clamp
provides application of the posterior compressive force right
through the sacroiliaca joints. Great care must be exercised to
prevent iatrogenic injury during application; the procedure must
generally be carried out under the guidance of fluoroscopy. The
application of C-clamp to the trochanter femur region offers an
21
 alternative to standard anterior external fixation for temporary
fixation of APC injuries.1

Gambar 6. . Illustration demonstrating C-Clamp showing

 Angiography
Angiographic exploration should be considered in patients with
unexplained sustained blood loss after stabilization of pelvic fracture
and aggressive fluid infusion. The overall prevalence of patients with
pelvic fractures requiring embolization is reported to be <10%. In one
recent series, angiography was performed in 10% of patients supported
by a pelvic fracture. Older patients and those who have a higher
Revised Trauma Score most often experience angiography. In another
study, 8% of 162 patients reviewed by the authors needed
angiography. Embolization is needed in 20% of APC injury patterns,
VS injuries, and complex pelvic fractures, but only 1.7% in LC
injuries. Eastridge et al reported that 27 of 46 patients with persistent
hypotension and pelvic fractures were completely unstable, including
APC II, APC III, LC II, LC III and VS injuries, had active arterial
bleeding (58.7%). Miller et al. Found that 19 of 28 patients with
persistent haemodynamic instability due to pelvic fracture showed
arterial bleeding (67.9%). In another study, when angiography was
22
 performed, it successfully stopped pelvic arterial bleeding in 86-100%
of cases. Ben-Menachem et al advocated "embolization in advance,"
emphasizing that if an artery found on angiography is transected, then
the artery must be embolized to prevent the risk of delayed bleeding
that can occur along with blood clot lysis. Other authors describe non-
selective embolization of bilateral internal iliac arteries to control the
location of multiple bleeding and conceal arterial injuries caused by
vasospasm.1
Early angiography and subsequent embolization have been
shown to improve patient outcomes. Agolini et al showed that
embolization within 3 hours of arrival produced a significantly greater
survival rate. Another study found that pelvic angiography performed
within 90 minutes of admission improved survival rates. However,
aggressive use of angiography can cause ischemic complications.
Angiography and embolization are not effective in controlling bleeding
from venous injury and location in bone, and venous bleeding presents
a greater source of bleeding in high-strength pelvic fractures. The time
spent on angiographic sequences in hypotensive patients without
arterial injury may not support survival.

 Pelvic bandage
dressing was developed as a method to achieve direct hemostasis
and to control venous bleeding caused by pelvic fractures. For more
than a decade, trauma surgeons in Europe have been advocating
exploratory laparotomy followed by pelvic dressing. This technique is
believed to be especially useful in severe patients. Ertel et al showed
that multiple injured patients with pelvic fractures can be safely treated

23
using a C-clamp and pelvic dressing without arterial embolization.
Local dressing is also effective in controlling arterial bleeding. 1
Lately, a method for modifying pelvic wraps - retroperitoneal
wraps - has been introduced in North America. This technique
facilitates control of retroperitoneal bleeding through a small incision
(figure 7). The intraperitoneal cavity is not entered, leaving the
peritoneum intact to help develop the effect of tamponade. The
procedure is quick and easy to do, with minimal blood loss.
Retroperitoneal dressing is appropriate for patients with varying
severity of hemodynamic instability, and this can reduce less important
angiography. Cothren et al reported no deaths as a result of acute blood
loss in patients who were hemodynamically unstable when bandages
were used directly. Only 4 of the 24 non-respondents in this study
needed further embolization (16.7%), and the authors concluded that
dressing quickly controlled bleeding and reduced the need for
emergency angiography.

Figure 7. Illustration demonstrating retroperitoneal dressing technique. A, an

8-cm midline vertical incision is made. The bladder is pulled to one side, and

24
 the three folded parts of the sponge are wrapped into the pelvis (under the
edge of the pelvis) with a forceps. The first is placed posteriorly, bordering
the sacroiliaca joints. The second is placed anteriorly from the first sponge at
the point corresponding to the mid-pelvic edge. The third sponge is placed in
the retropubic space into and lateral to the bladder. The bladder is then pulled
to the other side, and the process is repeated. B, Illustration demonstrating the
general location of the six parts of the sponge following the pelvic dressing.

3. fluid resuscitation

Fluid resuscitation is considered quite important as an attempt is made

to assess and control the location of bleeding. Two large (≥16-gauge) drill
cannulas intravenously must be built centrally or in the upper limb during
initial assessment. Crystalloid solutions ≥ 2 L must be given in 20 minutes,
or faster in patients who are in a state of shock. If an adequate blood
pressure response can be obtained, a crystalloid infusion can be continued
until special-type or overall suitable blood can be available. Special-type
blood, which is crossmatched for ABO and Rh types, can usually be
provided in 10 minutes; however, such blood can contain incompatibilities
with other minor antibodies. Blood that has the type and crossmatch as a
whole carries less risk for transfusion reactions, but it also takes the most
time to be obtained (60 minutes on average). When the crystalloid infusion
response is transient or blood pressure fails to respond, an additional 2
liters of crystalloid fluid can be given, and a special type of blood or non-
crossmatch universal donor blood (ie, negative O group) is given
immediately. The lack of response indicates that there is a possibility of
ongoing blood loss, and angiography and / or surgical control of bleeding
may be needed. 6 6

25
4. Evaluate of Resuscitation status

The endpoint of resuscitation is determined based on a combination

of laboratory data and physiological signs. Hemoglobin level readings are
known to be inaccurate during the acute phase of resuscitation.
Resuscitation end points that are generally considered include normal
blood pressure, decreased heart rate, adequate urine output (≥ 30 mL / hr),
and normal central venous pressure (CVP). However, even after
normalizing these parameters, inadequate tissue oxygenation can persist.
Additional laboratory measurements that can be used to evaluate tissue
oxygenation include deficits of bases, bicarbonate and lactate. All of these
assess anaerobic glycolysis. The terms base deficit and base excess are
used interchangeably, the only difference being base deficit is shown as a
positive number and base excess is shown as a negative number. Normal
base deficit is 0-3 mmol / L; this figure is routinely measured through
arterial blood gas (AGDA) analysis. A permanent base deficit indicates
inadequate resuscitation 1

5. Treatment Algorithms and Survival Rates 1 

A retrospective analysis of the final results before the formation of a

treatment algorithm dramatically illustrates the artificial difficulty that
these protocols are seeking to avoid. In one series, the deaths of 43 patients,
representing 60% of deaths in this series, were related in whole or as part
of a pelvic fracture. Of the 26 patients whose pelvic fractures were
considered the main cause of death, 24 patients experienced shock or had
clinical evidence of hypovolemia at admission, and 18 patients lost blood
due to their pelvic fracture immediately after admission.

26
 The establishment of standard clinical treatment algorithms for
patients with pelvic fractures greatly increases the possibility of
stabilization and rapid survival. Bosch et al reported that the
implementation of standard protocols at trauma centers led to decreased
mortality due to high-strength pelvic fractures from 66.7% to 18.7%. Biffl
et al reported that their clinical pathways, including the immediate
emergence of orthopedic surgeons in the emergency department, pelvic
dressing, and subsequent use of aggressive C-clamps, led to a significant
reduction in mortality, from 31% to 15% (P <0, 05). Balogh et al.
Established evidence-based institutional guidelines consisting of pelvic
binding and abdominal examination in 15 minutes, pelvic angiography in
90 minutes, and minimally invasive orthopedic fixation within 24 hours.
The use of these guidelines reduced the 24-hour PRC transfusion volume
from 16 ± 2 U to 11 ± 1 U (P <0.05) and reduced mortality from 35% to
7% (P <0.05).
Some algorithms are too complex which seems impossible to follow.
One reason for this complexity is that there is so much variation in the
cause of shock and the many sources of bleeding in patients with pelvic
fractures. Also, treatment tends to be high case-dependent. Another reason
is that most treatment algorithms are set based on institutional capabilities
to be developed. Although the basic principles of the protocols are useful, it
may also be important to modify the algorithms to suit the resources and
expert staff at each institution.
Patients with severe pelvic fractures brought to our institution with
hemodynamic instability were initially given 2 L crystalloid solution
(figure 6). Portable chest radiography, along with radiographic images of
the pelvis and lateral cervical spine, are examined to rule out the source of
blood loss from the thorax. A central venous pressure line is installed, and

27
the base deficit is measured. A focused abdominal sonography examination
for trauma (focused abdominal sonography for trauma / FAST) is done. If
the results are positive, the patient is taken directly to the operating room
for exploratory laparotomy. A pelvic external fixator is mounted, and a
pelvic dressing is performed. Patients who hemodynamically remain
unstable undergo pelvic angiography before being transferred to the ICU. If
hemodynamic stability is restored, the patient is transferred directly to the
ICU. At the ICU, patients receive continued fluid resuscitation and are
warmed up; various attempts were made to normalize the status of
coagulation. If the patient requires ongoing transfusion in the ICU, an
angiographic assessment, if not previously done, must be done. rFVIIa
must be considered if the patient's condition is against all other
interventions.88

If the FAST result is negative, the PRC transfusion begins in the

emergency department. If the patient remains hemodynamically unstable
while following the second PRC unit, the patient is taken to the operating
room for pelvic external fixation and pelvic dressing. Patients who
hemodynamically remain unstable receive pelvic angiography before being
transferred to the ICU. If hemodynamic stability is restored, the patient is
transferred directly to the ICU. Abdominal CT scan can be done at this
time. If the patient needs a continuous transfusion while in the ICU, an
angiographic assessment, if not previously done, must be done. 1

28
 Gambar 8. Figure 8. Algorithm for the treatment of patients with pelvic fractures that
appear with hemodynamic instability. Patients who have not had a laparotomy usually
have an abdominal CT scan that begins in the ICU. At the ICU, the patient receives
further fluid resuscitation and is warmed up; various attempts were made to normalize
the status of coagulation. rFVIIa must be considered if the patient's condition is against
all other interventions. FAST = focused abdominal sonography for trauma, PRBCs =
packed red blood cells.7

K. complication2

29
1. Sacroiliaca pain
Often found after an unstable pelvic fracture and sometimes requires
artrodesis in the sacroiliaca joint. Sciatic nerve injuries usually heal but
sometimes require exploration. Severe urethral injuries can cause urethral
stricture, incontinence and impotence
2. Posterior urethral rupture
Most often caused by pelvic bone fractures. Fractures that affect the
ramus or symphysis pubis and cause damage to the pelvic ring can cause
prostate-membranacea urethral tears. Pelvic fractures and tearing of blood
vessels in the pelvic cavity cause extensive hematomas in the retzius cavity
so that if the pubo-prostatic ligament is torn, the prostate and bladder will be
lifted to the cranial. 7
3. Anterior urethral rupture
Injury from the outside which often causes damage to the anterior
urethra is a straddle injury (groin injury) that is the urethra is sandwiched
between the pelvic bone and blunt objects. The type of urethral damage that
occurs in the form of urethral wall contusion, partial rupture, or total rupture
of the urethral wall. In urethral contusions, patients complain of urethral
bleeding or hematuria. If there is a tear in the corpus spongiosum, visible
hematoma on the penis or butterfly hematoma. In this situation, patients often
do not get proxy. 7
4. Acetabulum fracture
Occurs when the femoral head is pushed into the pelvis. This fracture
combines the complexity of the pelvic fracture with joint damage. There are
4 types of acetabulum fractures, namely anterior column fracture, posterior
column fracture, transverse fracture, and complex fracture. The clinical
picture is somewhat obscured because there may be other injuries that are

30
 clearer / divert attention from more pressing pelvic injuries. X-ray
examination needs to be done7
5. Injuries to the sacrum and coccyx
Blows from behind or falling on the coccyx can break the sacrum and
coccyx. Extensive bruising occurs and tenderness occurs when the scrum or
coccyx is palpated from behind or through the rectum. Sensation can be lost in
the distribution of sacral nerves. X-rays can show; 1) transverse fractures in
the sacrum can be accompanied by lower fragments pushed forward, 2)
coccyx fractures are sometimes accompanied by lower fragments angled
forward, 3) a normal appearance if the injury is only a strain in the
sacrocoxigeal joint.
If the fracture is shifted, you should try to do a reduction. The lower
fragment can be pushed back through the rectum. Reduction is stable, a
favorable condition. Patients are allowed to resume normal activities, but it is
recommended to use a rubber ring or Sorbo cushion when seated. Sometimes
accompanied by complaints of difficulty urinating. Pain that persists,
especially when sitting is often found after a coccigis injury. If pain does not
decrease with the use of Sorbo pads or by injection of local anesthetics into
the painful area, excision of coccyxis can be considered.8

31
 CHAPTER III

CONCLUSION

Severe pelvic fractures with hemodynamic instability are among the most
severe traumatic injuries. Efficient treatment and coordinated assessment is important
to ensure the best chance of survival. Hemodynamic evaluation and recognition of
fracture patterns are the first steps in management. In most trauma centers, the
treatment paradigm consists of angiographic embolization along with early
mechanical pelvic stabilization. An emergency pelvic dressing can also be an
effective treatment
APC injuries are caused by anterior collisions against the pelvis, often leading
to pubic symphysis diastases. There are "open book" injuries that interfere with the
anterior sacroiliaca ligament as well as the ipsilateral sacrospinale ligament and
sacrotuberale ligament. APC injury is considered to be a good radiographic marker
for branches of the internal iliac arteries, which are in alignment close to the anterior
sacroiliaca joints.
         Successful management of pelvic fracture bleeding is best accomplished by a
team approach that involves professionals from a variety of specialties. Experienced
orthopedic surgeons can provide proper recognition of fracture patterns, achieve
pelvic stabilization immediately, and assist with making appropriate decisions to
maximize patient survival.
The establishment of standard clinical treatment algorithms for patients with
pelvic fractures greatly increases the possibility of stabilization and rapid survival.
Bosch et al reported that the implementation of standard protocols at trauma centers
led to decreased mortality due to high-strength pelvic fractures from 66.7% to 18.7%.
Biffl et al reported that their clinical pathways, including the immediate emergence of

32
orthopedic surgeons in the emergency department, pelvic dressing, and subsequent
use of aggressive C-clamps, led to a significant reduction in mortality.4

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