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KEY POINTS

KEY POINTS

  • The anterior elements of the pelvis, including the pubic rami and pubic symphysis, only contribute to approximately 40% of pelvic stability.

  • In the Tile classification of pelvic fractures, type A are stable, type B are vertically stable but rotationally unstable, and type C are vertically and rotationally unstable.

  • In the Young-Burgess classification of pelvic fractures, the three types are anteroposterior compression (APC), lateral compression, and vertical shear.

  • Pelvic binders are indicated for APC (“open book”) fractures when first diagnosed, but not for lateral compression fractures.

  • Early external fixation stabilizes the fractured elements, decreases the pelvic volume, and allows clot to form.

  • For the patient who is exsanguinating from a closed pelvic fracture, embolization of the bilateral internal iliac arteries is considered to be the “damage control” procedure of choice.

  • In the technique of preperitoneal pelvic packing for hemorrhage, three laparotomy pads are placed on either side of the bladder in the retroperitoneum.

  • APC III, most lateral compression II, and vertical shear pelvic fractures typically require posterior stabilization by internal fixation.

  • The mean Injury Severity Score (ISS) for patients with pelvic fractures is 18, reflecting the significant number of patients with associated injuries to the brain, thorax, abdomen, and long bones.

  • Control of bleeding in open pelvic fractures includes packing through the laceration, application of a pelvic binder, angiographic embolization, and definitive bony fixation.

INTRODUCTION

Pelvic ring fractures (PRFs) 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 can lead to exsanguination (0.5% of all blunt trauma patients). The overall mortality rate of patients with PRFs is approximately 8%.1 Anterior-posterior compression and vertical shear injury mechanisms are associated with a higher incidence of pelvic vascular injury and hemorrhage. Pelvic fractures are one of the insidious, unrecognized sources of shock and death in polytrauma patients with other distracting injuries. This is largely due to the fact that an actively bleeding pelvis is not usually appreciated on clinical exam or focused abdominal sonography for trauma (FAST) and occasionally does not present with active extravasation of contrast on computed tomography (CT) of the pelvis. These complicating factors make the management of an exsanguinating pelvic fracture challenging, with lack of consensus on a single best management approach. The recent evolution of rapid pelvic stabilization by pelvic binding or external fixation during the trauma primary survey, combined with a selective approach to preperitoneal pelvic packing and angiographic embolization, has significantly decreased the mortality rates of devastating PRF. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been introduced as a promising hemorrhage control modality in the immediate management of exsanguinating PRF, which will be discussed later in this chapter. A multidisciplinary coordinated approach is crucial in managing patients with PRF, as there is no single treatment modality that has been shown to be the gold standard.

PELVIC ANATOMY

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