Acute Management of

Pelvic Ring Injuries

Kyle F. Dickson, MD
Chief of Orthopaedics, Charity Hospital
Director of Orthopaedic Trauma
Tulane University
 Primary survey

A. Airway maintenance with

cervical spine protection
B. Breathing and ventilation
C. Circulation with hemorrhage control
D. Disability: Neurologic status
E. Exposure/environment control:
undress patient but prevent
hypothemia
 Transfer Criteria for Pelvic
Fractures
• Posterior instability/displacement
– Initial AP x-ray
• Bladder/urethra injury
• Open pelvic fractures
• Lateral directed force with fractures through
iliac wing, sacral ala or foramina
 Transfer (cont.)
• Open book with anterior displacement
> 2.5 cm
• Acetabular fractures
– > 1 mm articular step off on any view
– Lack of parallelism of femoral head and
roof
– Displacement of wall or column
 Factors Increasing Mortality
• Type of pelvic ring injury
– Posterior disruption
• High ISS
– Tile, 1980
– McMurty, 1980
• Hemorrhagic shock on admission
– Gilliland, 1982
 Factors Increasing Mortality
• Requirement for large quantities of blood
– 24 u vs. 7 u, McMurty, 1980
• Perineal lacerations, open fractures
– Hanson, 1991
• Associated injuries
– Head & abdominal, 50% mortality
• Age
– Looser, 1976
Extremely High Energy Injuries
with a Large Number and Variety
of Associated Injuries
 Associated Injuries

• Long bone injuries

• Knee injuries
• Foot injuries
 Morel – Lavalle’ Lesion
(Skin Degloving)
• Infected in 1/3 of cases
• Require thorough debridement prior to
definitive surgery
Example of Small Inadequate
Debridement with Subsequent
Infection
 Open Pelvic Injuries
• Colon, rectum, or perineum  Early
diverting colostomy
• Soft-tissue wounds  aggressively
debrided
• Early repair of vaginal lacerations minimize
subsequent pelvic abscess
 Team Approach

• Help with thorough debridement of entire

extent of the hematoma
 Team Approach (cont.)

• Direct the general surgeon for a transverse

colostomy vs. descending colostomy to
prevent possible wound contamination of an
anterior approach
Colostomy is Indicated for Any
Open Injury Where the Fecal
Stream Will Contact the Open
Area
 Urologic Injuries
• 15% incidence
• Blood at meatus or high riding prostate
• Eventual swelling of scrotum and labia
(occasional arterial bleeder requiring
surgery)
 Urologic (cont.)
• Retrograde urethrogram indicated in pelvic
injured patients but insure hemodynamic
stability or embolization may be difficult
due to dye extravasation
 Urologic (cont.)
• Intra & extra peritoneal bladder ruptures are
repaired
• Foley preferred supra-pubic catheter
tunneled to prevent ant. wound
contamination
 Urologic (cont.)
• Urethral injuries are repaired on a delayed
basis
 Neurologic Damage
• L5 & S1, most common
• L2 to S4 possible
• Dependent on location of fracture and
amount of displacement
 Denis, CORR 1988
• Sacral Fractures – Neurologic Injury
– Lateral to foramen – 6% injury
– Through foramen – 28% injury
– Medial to foramen – 57% injury
 Pohlemann, CORR 1994
• Amount of displacement move important
then location
 Neurologic Injury
• Careful exam may need decompression of
sacral foramen if progressive loss of neural
function
• May take up to 3 years for recovery
 Orthopaedic Surgeons
Initial Role
• Stabilization of pelvic hemorrhage
– Traction
– Anti-shock garments
– External fixation
– Open packing & ligation
• Referral to center for appropriate fixation
 Hemodynamically unstable Patient

Fluid resuscitation (causes of hypovolemia)

Intra-abdominal Bleeding
Other causes:
•external bleeding Assess: positive
(i.e. open fractures -- sterile •ultrasound AP Pelvis &
dressing) physical exam
•CT
•Hemothorax --- (chest tube)
•supraumbilical
•closed fractures
peritoneal lavage
(i.e. femur ---- traction
eventual early reduction and negative Mechanically Mechanically
fixation) stable pelvis unstable
•coagulopathies (hypothermia, low AP Pelvis & pelvis
calcium, acidosis) physical exam

Emergency External fixator Angiograph

laparotomy (should not delay y on
Mechanically Mechanically emergency
standby
stable pelvis unstable laparotomy)
pelvis
Assess retroperitoneal
External hemorrhage
fixator

Small Large and

Other causes of Patient Patien expanding
•look for
hypotension: unstabl t hematom
other
•cardiac e stable a
causes
•quadriplegia or
spinal
Surgical ligation &
injury
packing
•terminal brain injury
•hypothermia
Patient Patient
unstable stable
Angiographic
Patient
embolization Patien
unstabl
t
e
stable
 Hemodynamically unstable
Patient
Fluid resuscitation (causes of hypovolemia)

Intra-abdominal Bleeding
Other causes: Assess:
•external bleeding •ultrasound
(i.e. open fractures -- sterile dressing) •CT
•Hemothorax --- (chest tube) •supraumbilical
•closed fractures peritoneal lavage
(i.e. femur ---- traction
eventual early reduction and
fixation)
•coagulopathies (hypothermia, low
calcium, acidosis) Negative Positive
Negative AP Pelvis & Physical
Exam

Mechanically stable pelvis Mechanically unstable pelvis

Other causes of
External fixator
hypotension:
•cardiac
•quadriplegia or spinal
injury
Patient unstable Patient stable
•terminal brain injury
•hypothermia

Other causes
Positive
AP Pelvis & Physical Exam

Mechanically unstable
pelvis

Mechanically stable
pelvis

External fixator Angiography

Emergency laparotomy (should not delay on standby
emergency
laparotomy)
Positive

Assess retroperitoneal
hemorrhage

Small Large and expanding

hematoma
•look for other
causes
Surgical ligation & packing

Patient Patient
Patient Angiographic unstable stable
unstable embolization

Patient
stable
 Etiology of Hypovolemic Shock
• Intra-thoracic bleeding
• Intra-peritoneal bleeding
– Ultrasound
– Peritoneal tap
– CT
• Retroperitoneal bleeding
 Shock (cont.)

• Blood loss from open wounds

• Bleeding if closed extremity fracture
 Burgess, J Trauma 1990

• Mortality 8.6%
• 2/210 pelvic injury patients where pelvic
injury was primary cause of death
• Contributed 10/210
 Hemorrhage Control
• Average blood replacement (units)
– LC = 3.6
– AP = 14.8
– VS = 9.2
– CM = 8.5
• Mortality
– 3% hemodynamically stable patients
– 38% unstable patients
 Burgess (cont.)
• LC – head injury major cause of death
• APC – pelvic and visceral injury major
cause of death
Force Vector with Clinic Utilization
• LC1 and LC2  50% brain injury
• LC3 (windswept pelvis – rollover/crush)
– 60% retroperitoneal hematoma
– 40% lower extremity fracture
– 20% bowel injury
– 0% brain injury
 Force (cont.)
• AP3 (comprehensive posterior instability)
– 67% shock
– 59% sepsis
– 37% death
– 18.5% ARDS
 Force (cont.)
• Vertical shear
– 63% shock
– 56% brain injury
– 25% splenic injury
– 25% death
– 23% lung injury
 Coagulopathy

• Hypothermia
•  Ca2 (blood citrate)
• Acidotic
 Prolonged Hypovolemia
• Aggravate pulmonary contusion
• Head and visceral injuries
• Increased sepsis
• Adult respiratory distress syndrome
(ARDS)
• Multiple organ failure
Only patients with mechanical instability
can have hemodynamic instability related to
the pelvic injury
 Force Vectors

• Lateral compression
• Anterior posterior compression
• Vertical shear
Radiographic Signs of Instability

• Sacroiliac displacement of 5 mm in any

plane
• Posterior fracture gap (rather than
impaction)
• Avulsion of fifth lumbar transverse process,
lateral border of sacrum (sacrotuberous
ligament), or ischial spine (sacrospinous
ligament)
 Hemorrhage (cont.)
• Skeletal traction
• External fixation
• Mast suit
• Embolization
• Surgical stabilization with packing
• Towel clamp with sheet
 Hemorrhage (cont.)
• Contributes to 60% of deaths
• Retroperitoneal veins
• 20% arterial injury
 Slatis & Huittinen, 1972
• 147 cadavers, double vertical pelvic
fractures
– 84-88% bone bleeders
– 46% incidence at nerve lesion
– 57% multiple nerve roots
 Possible Arterial Bleeders in
Pelvic Injuries
• Iliolumbar artery
• Superior gluteal artery
• Lateral sacral artery
• Internal iliac artery
• Internal pudendal (active bleeding most
commonly found)
Anterior External Fixator vs.
Posterior External Fixator
 Anterior Frame
• Safer and easier to apply
• May not give the necessary posterior
support
• Indication acutely for a mechanically and
hemodynamically unstable pelvis injury
 Posterior Clamp
• Same indications
• Advantages, posterior stabilization
• Contraindications: Iliac wing fracture or
comminution of sacrum (over compression)
External fixation is a resuscitative
fixation and cannot be used as the
definitive fixation in completely
unstable pelvic injuries.
 Patient NJ
• VS initially attempted to be treated with
anterior plate and ex-fix with hardware
failure
• 3 stage pelvic reconstruction ( ant. 
post ant. 2 yr follow-up – Auburn football
player)
 External Fixation Placement
• Must understand the 3-D deformity
• Reduce the posterior complex (do not just
squeeze anterior symphysis together)
External Fixation Placement (cont.)

• Retroperitoneal space is massive (30L with

only  3 mmHg)
• Stabilization is from holding hemipelvis
stable not reducing pelvic volume
 Pin Placement Anterior Frame
• Glut. Medius tubercle
• Follow contour of iliac wing
• 2 - 2.5 cm post. To ASIS
 Anterior (cont.)
• K-wires helpful for inner and outer cortex
• Starting drill hole than let pin find direction
• Traction and close pelvis posteriorly
 Dickson, JOT 2001

• 16/151 unstable pelvic injuries referred with

external fixator as initial treatment
• Review AP, inlet, outlet, and CT before and
after external fixator
 Reduction
• 67% (8/12) worsening of posterior
complex
• 30% (3/10) loss of reduction
• Average maximum displacement 3 cm
(range 1.5 cm – 5.4 cm)
 Indications for Angiography
• Unexplained blood loss after stabilization
and aggressive resuscitation
• Pulselessness extremity
 Surgical
• Stabilization with internal fixation of pelvis
• Stabilization of hemodynamic instability
with surgical packing of retroperitoneal
space rare
The Pelvis is a Place to Work
Not a Place to Play
 Acknowledgement

Joel Matta, Jim Pohlemann,

Mark Vrahas

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