Pelvic trauma

Approach:

• Most pelvic fractures are benign and not life-threatening
  • 60% don't need intervention
  • 40% need pelvic ORIF
  • 5% need angiography
• Key is to discern the vulnerable patients with high-energy patterns early

Mechanism

• Most common injury is fall from standing height (generally elderly patients with osteoporotic bone). Direct impact through GT or iliac crest, placing a lateral compression force across the pelvis, which typically generates a compression fracture through sacral alar area and a corresponding, more displace, anterior pelvic ring fracture through superior/inferior pubic ramus. These are rarely life-threatening, but may still be debilitating long-term injuries.
• High-energy fractures - MVA, MBA, fall from height, others.
  • Larger degrees of displacement
  • Younger patients
  • May involve lateral compression, anteroposterior compression, or vertical loading of pelvic ring.
  • Associated with other injuries and bleeding.
• Open book and vertical shear injuries are most likely to bleed

Pathophysiology of pelvic bleeding

• Lacerated vessels - arteries and veins - veins are harder to control and can certainly cause enough bleeding to create a problem
• 85% is venous bleeding, but arterial leads to shock more often
• Large surface area of fracture
• All iliac vessels cross the SIJ, with a venous plexus in front of it
• Pelvic peritoneum can accommodate >3L blood

External signs

• Gross lower limb deformity
• Open wounds of perineum and lumbosacral posterior torso - bone fragments can puncture skin
• Bruising around GTs and thigh
• Subcutaneous pelvic swelling
• Morel-Lavallée
  • Compressive dressings
• Lower limb neurologic disruption

Important history factors

• Prior surgery
• Radiation
• Prior abdo/pelvic trauma

Primary interventions

• X-ray pelvis in trauma bay if any suspicion bleeding
• Indications for pelvic binder: (examine perineum etc first)
  • Gross displacement of pelvis
  • Gross asymmetry of pelvic bones
  • Vertical shifting of the ilium on one side
  • Open book deformity of pelvis
  • Probably not useful in LC1 or LC2 injuries
• Binder application
  • Don't apply if going straight to OT
  • If bleeding/open pelvic wounds, rapidly irrigate and pack them prior to binder
  • Bring heels together and internally rotate legs
  • Centre over GTs so compressive force is applied inward through femoral heads
  • Avoid wrinkles in sheets or binders
  • Adequate compression - often need 2 to 3 people
  • Leave for up to 24 hours, and only longer if necessary for life
• External pelvic fixation
  • Good for venous bleeding, may not work as well for arterial
• Antibiotics if open wounds - cefazolin for simple wounds, ceftriaxone/metronidazole if large degloving wounds or bowel injuries

Need to check on admission in pelvic fracture

• Associated injuries:
  • Bladder/urethral
  • Vaginal tears
  • Rectum
• Perineum for open fractures/fragment penetration
• Theoretically should do DRE
• Blood at urethral meatus?
• Limb shortening
• Flexion/extension of all joints
• Check all lumbar and sacral roots
• Rectal tone and perianal sensation

Pelvic bleeding

Approach

• Coordinated and multidisciplinary including MTP
• Resus as per ATLS
• Quickly treat/exclude extra-pelvic sites of blood loss
• Fracture reduction (binder)
• Definitive treatment options can be employed as complementary techniques. The decision point is the overall stability of the patient and injury pattern. Unstable patients or those with other injuries requiring OT are generally managed with pelvic packing.
  • Angioembolisation
  • Operative pelvic packing
  • Operative external fixation to reduce pelvic volume and stabilise fractures
  • REBOA
• CT with arterial and delayed PV phase
• Decide ICU non-op vs embolisation vs OT

Angioembolisation

• Indications
  • Non-responders or transient responders who have confirmed arterial bleeding, but don't have other indications for OT, and are stable enough for IR
  • After pelvic packing
• Ideally targeted, in worst case scenario can do non-targeted embolisation to both internal iliacs but this carries significant morbidity

Surgery (pelvic packing)

• Indications
  • Retroperitoneal haemorrhage as source of hypotension and patient not responsive to other measures
  • Especially suspected venous small vessel bleeding
• Steps
  • Ideally takes place after external fixation of pelvic fractures
  • Low vertical midline laparotomy and check and pack abdomen
  • Artery clips on cut edge of peritoneum and retract cephalad
  • Develop plane between rectus and peritoneum, just lateral to bladder, down obliquely towards the true pelvis (can develop plane bluntly with hands if haematoma has already dissected for you), posteriorly as far as SIJ
  • Evacuate pelvic haematoma, then pack the extraperitoneal space (it's not a big space, usually only 1-2 packs each side, as posterior and deep as possible)
    • One pack posteriorly at SIJ
    • One just anterior at the middle of the pelvic brim
    • Last just posterior and lateral to the pubis
    • Intra-peritoneal packing may also be helpful
  • Finish by suturing the peritoneal reflection to the ipsilateral posterior sheath to prevent the packs migrating
  • Leave abdomen open (high risk ACS)
  • Packs out 48 hours later, which usually deals with the bleeding

Fracture management

• APC1: no surgery
• APC2
• APC3: immediate surgery
• LC1: in elderly patients generally stable, but young patients often unstable requiring surgery
• LC3: commonly have appreciable haemorrhage
• Greatest risk of haemorrhage in AP3, LC3 and VS