Complex Pelvic Injuries

Adapted from Dr. Sarani's Grand Rounds presentation October 5th, 2016

Types of Pelvic Trauma

Isolated Pelvis Fractures: relatively good recovery potential
Lethal Associated Injuries: Increased risk of blood loss and poor outcomes. Identification of injuries and correct treatment from EMS to the OR is important to treating severe pelvic trauma. Thoracic aorta, intracranial, intra-abdominal 

Pelvis Fracture Classifications

Lateral compression: Most common pelvic fracture. Lateral forces causing fractures of the iliac crest/pubic symphysis Associated with abdominal injuries and low-speed injuries as well as pedestrian struck injuries.
AP Compression Fracture: Anterior/posterior pressure with 67% shock and 30% mortality
Vertical Shear: vertical traction force due to acceleration/deceleration forces. Causes pubic symphysis disruption and widening. 
Combined Fracture: Mixture of multiple fracture types. 

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Treatment

1. Stop Hemorrhage

• Stabilize the fracture: Utilize pelvic binder BELOW the iliac crests near the trochanter utilizing the gluteal cleft as the center of your pelvic binder. 
• Resuscitation with blood products and procoagulation: Prevent acidosis, hypothermia and hypovolemia. Aim for permissive hypotension with systolic blood pressure 80-100mmHg. FFP is just as important, if not more important, than RBCs, so aim for a 1:1 RBC:FFP ratio, although 1:2 is more common due to the easier availability of RBCs. Consider TXA. 

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2. Disposition

• Embolization or ex-lap depending on type of injury. If a positive FAST is present or the patient is unstable, Ex-Lap is indicated for further treatment. If IR is immediately available or the patient is hemodynamically stable, the patient should continue to the IR suite. 
• Control Contamination: Identify any rectal, perineal, bladder, or vaginal injuries that can become urgent life threatening infections.  Identify bladder injuries by foley catheter placement for evaluation of hematuria with retrograde cystogram. If not fully transected, pass the foley catheter to treat the urethral rupture. If you meet resistance, call for urology cystoscopy. 

3. Resuscitate in the ICU
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​4. Morbidity

• Chronic Pain 90%
• Disability 75%
• Neurologic Injury 30%