Executive Editor: Peter Trafton

Pelvic ring - Acute pelvic treatment

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Glossary

General considerations

Before proceeding with definitive repairs, the patient must be fully resuscitated, fully evaluated, and fit for anesthesia and surgery by a prepared team.

The most immediate threat of life directly related to a pelvic ring injury is that of exsanguination. This is due to intrapelvic vascular (primarily venous) injury related to displacement and instability of the pelvic ring. Acute treatment to reduce the bleeding is directed towards reducing pelvic deformity and adding stability. This is done initially with a pelvic wrap or binder which is applied during the primary survey.

Emergency care for pelvic ring injuries should be available and preplanned at every trauma hospital. Patients with complex pelvic ring injuries may need to be referred to a specialized center.

Extraperitoneal pelvic packing
Main indication Skill Equipment
Unstable pelvis, hemodynamic instability, unresponsive to resuscitation Highly experienced and skilled surgeon Basic equipment only

Indications

  • Unstable pelvis, hemodynamic instability, unresponsive to resuscitation
  • Should be part of institutional protocol

Advantages

  • Faster than angioembolization
  • Potentially more effective than angioembolization vs. venous bleeding
  • Angioembolization can follow

Disadvantages

  • Prior training and familiarity are advisable
  • Second surgery required for packing removal
Angio embolization
Main indication Skill Equipment
Hemodynamically unstable patient, especially with arterial bleeding Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Hemodynamically unstable patient
  • Pelvis related bleeding
  • Persistent bleeding after pelvic packing
  • Should be part of institutional protocol

Advantages

  • Possible to perform selective embolization of the bleeding vessels
  • More effective against arterial bleeding
  • Minimally invasive
  • Can be combined with pelvic packing

Disadvantages

  • Requires interventional radiology specialist
  • In principle, less effective vs venous bleeding
  • Lengthy preparation and procedure
  • High cost

NOTE – External fixation is not required before embolization. However, a pelvic binder should be applied and maintained, in a way that permits angiographic access.

External fixation: Emergency stabilization with a C-clamp
Main indication Skill Equipment
Mechanically unstable pelvic ring without obvious innominate bone comminution or fracture line at pin site Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Mechanically unstable pelvic ring without obvious innominate bone comminution or fracture line at pin site
  • C-clamp, applied posteriorly, is more effective for correcting posterior displacement
  • To stabilize pelvis during laparotomy and/or pelvic packing

Contraindications

  • Iliac wing fracture at C-clamp pin site
  • Comminuted fracture of either innominate bone

Relative contraindications

  • Comminuted sacral alar fractures, if compressed excessively, may injure sacral nerve roots

Advantages

  • Allows access to anterior abdomen for laparotomy and/or pelvic packing
  • Trained and experienced staff can apply rapidly

Disadvantages

  • Technically demanding procedure
  • Difficult to gain sufficient practice
  • High cost
  • Poor placement may lead to perforation of the iliac wing
  • Can compromise the insertion point of SI screw
External fixation
Main indication Skill Equipment
Unstable pelvis with hemodynamic instability Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Unstable pelvis with hemodynamic instability
  • Need for laparotomy and/or pelvic packing
  • May be more appropriate than crest pins for some iliac fractures

Contra indications

  • Iliac wing fractures that involve the supraacetabular region
  • Lack of fluoroscope

Advantages

  • More stable than iliac crest configuration
  • With appropriate pin and frame placement, patients usually tolerate
  • Will permit access for laparotomy and pelvic packing

Disadvantages

  • C-arm imaging recommended
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2015-12-10