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INTRODUCTION

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Pelvic injuries (PI) are frequent, particularly after blunt trauma (9% of all blunt trauma patients), and range from clinically insignificant minor pelvic fractures to life-threatening injuries that produce exsanguination (0.5% of all blunt trauma patients). The overall mortality rate of patients with pelvic ring fractures is approximately 6%. Uncontrolled pelvic hemorrhage accounts for 39% of related deaths, whereas associated head injury is responsible for 31% of the deaths. AP compression and vertical shear injuries are associated with a higher incidence of pelvic vascular injury and hemorrhage. There is little agreement about the preferred methods of management and, therefore, guidelines are vague or not followed. However, the recent evolution of rapid pelvic stabilization by external fixation or pelvic binding and of bleeding control by angiographic embolization or preperitoneal pelvic packing has significantly decreased the mortality rates of devastating PI. A multidisciplinary approach is crucial, as no single specialty has all the skills or controls all the resources that can be used to produce ultimately outcomes. Emergency medicine physicians, trauma and critical care surgeons, orthopedic surgeons, and interventional radiologists should play protagonist roles in a well-orchestrated trauma team that manages these complex patients.

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PELVIC ANATOMY

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The pelvic ring comprises the sacrum and the two innominate bones, all attached with strong ligaments. The innominate bones join the sacrum at the sacroiliac joints and each other anteriorly at the pubic symphysis. The anterior and posterior sacroiliac ligaments include shorter and longer elements that extend over the sacrum and to the iliac crests, and provide vertical stability across the sacroiliac joints. The pelvic floor is bridged by the sacrospinous and sacrotuberous ligaments that connect the sacrum to the ischial spine and the ischial tuberosity, respectively. The anterior elements, including the pubic rami and pubic symphysis, contribute to approximately 40% of the pelvic stability, but the posterior elements are more important, as shown by biomechanical studies.

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The internal iliac (hypogastric) arteries provide blood supply to the organs, bones, and soft tissues of the pelvis. The anterior division includes the inferior gluteal, obturator, inferior vesicular, middle rectal, and internal pudendal artery. The posterior division includes the iliolumbar, lateral sacral, and superior gluteal artery. The largest branch is the superior gluteal artery, which is the most commonly injured major arterial branch after pelvic fractures. Pelvic veins run parallel to the arteries and form an extensive plexus that drains into the internal iliac veins. The sacral venous plexus is adhered to the anterior surface of the sacrum and shredded after major pelvic fractures. Venous bleeding is more frequent than arterial bleeding after PI.

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The sciatic nerve is formed by the nerve roots of L4 to S3 and exits the pelvis under the piriformis muscle. The anterior roots of L4 and L5 cross the sacroiliac joints and can be injured in sacral ala fractures or sacroiliac joint dislocations.

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All pelvic organs are at risk of injury ...

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