Chapter 22: Pelvic Fracture-Related Hemorrhage

INTRODUCTION

Pelvic fractures have an overall incidence of 9.3% and are a common pattern observed with a blunt mechanism of injury.¹ Pelvic ring disruption constitute 8.9% of all pelvic fractures and are more frequently noted in motorcycle collisions (15.5%) and struck pedestrians (13.8%).¹ Exsanguination associated with severe pelvic fractures can be catastrophic. Although most patients who present with pelvic fractures arrive at the Emergency Department (ED) hemodynamically stable, 5% to 10% will arrive hemodynamically unstable due to hemorrhagic shock.² The mortality rate for this group of patients was reported to be 32% by the American Association for the Surgery of Trauma (AAST) Pelvic Fracture Study Group³ and 21% in another 11-year series of preferential pre-peritoneal pelvic packing and external fixation.² Overall, the mortality from pelvic fracture ranges widely based on the type of fracture and is highest in patients presenting with refractory hemorrhagic shock.^1,3,4 Over a third of patients with pelvic fractures will require a blood transfusion, and the average transfusion is ~900 mL.¹ More than half receive blood when the Abbreviated Injury Score (AIS) is ≥4 and when these fractures coexist with other associated abdominal injuries, 75% will receive a blood transfusion.¹ Pelvic angiography may be necessary in 13% to 24% of those who have refractory shock and more than half of them will have therapeutic embolization with a variety of materials.^1–4

Pelvic fractures are indicative of high energy forces that cause injury to the intra-abdominal organs, bladder, and urethra.¹ The association between injury severity, hemodynamic stability, multi-trauma, and mortality highlights the significance of quickly identifying the source(s) of hemorrhage.^3,4 A team approach to controlling pelvic hemorrhage typically consists of active blood product resuscitation, external pelvic fixation, and hemorrhage control techniques that include pelvic packing, angioembolization, or vessel ligation while concomitant injuries are evaluated and treated.⁴

The management of pelvic fractures has evolved with recent attention on strategies that emphasize the importance of emergency release of blood products and the endorsement of warm whole blood resuscitation. Resuscitative endovascular aortic balloon occlusion (REBOA) and pelvic binders attempt to restore physiology while modern diagnostic imaging such as portable digital radiographs and high-speed multi-slice computed tomographic angiography expedite the detection of life-threatening injuries. Spacious hybrid operating rooms offer endovascular capability by dual trained trauma vascular surgeons using overhead fluoroscopic units to perform both selective and nonselective angioembolization. Controversy regarding triggers for angioembolization or proceeding directory to the operating room for pelvic packing continue to spark spirited debate. Ultimately, institutional practices driven by success, local expertise, and resources determine the best approach.³ The optimal diagnostic modalities, limitations, and treatment strategies for the patient with a pelvic ring disruption and refractory hemorrhagic shock are the focus of this chapter.

ANATOMY

Bones and Ligaments

The pelvis is a bony ring held together by strong anterior ...