|SYMPOSIUM ON PELVIC TRAUMA
|Year : 2014 | Volume
| Issue : 1 | Page : 1-7
Introduction to pelvic injury and its acute management
Purnendu Saxena1, Harshal Sakale2, Alok C. Agrawal3
1 Consultant Orthopaedic Surgeon, Visharad Hospital, Raipur, Chhattisgarh, India
2 Assistant Professor Pt. Jawahar Lal Nehru Memorial Medical College, Raipur, Chhattisgarh, India
3 Professor and Head of the Department, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
|Date of Web Publication||6-Jun-2014|
Consultant Orthopaedic Surgeon, Visharad Hospital, Motibag, Raipur-492 001, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Human pelvis is a very stable structure. It achieves its stability from the surrounding musculature and ligaments. Hence, pelvic disruption requires high energy trauma specifically in young people. It is usually associated with multisystem injuries due to its close proximity to the vital structures. Mortality in pelvic injuries is mostly due to the uncontrolled hemorrhage and the late mortality due to associated multisystem injuries, multiorgan failure, and sepsis. Acute management focus on the complex pelvic trauma it includes the systemic control of hemorrhage, pelvic stabilization with external pelvic binder or external fixator, use of pelvic angiography, and embolization and preperitoneal packing. Every institute should develop its own protocol depending on facilities available.
Keywords: Acute management, external fixator, hemodynamic instability, pelvic binders, pelvic injuries
|How to cite this article:|
Saxena P, Sakale H, Agrawal AC. Introduction to pelvic injury and its acute management. J Orthop Traumatol Rehabil 2014;7:1-7
|How to cite this URL:|
Saxena P, Sakale H, Agrawal AC. Introduction to pelvic injury and its acute management. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 May 27];7:1-7. Available from: http://www.jotr.in/text.asp?2014/7/1/1/133995
| Introduction|| |
Human pelvis is an extremely stable structure and requires a great amount of force to cause disruption. It is made up of two innominate bones and sacrum. Pelvic ring is completed anteriorly by pubic symphysis and posteriorly by left and right sacroiliac joints. The surrounding supporting ligaments and pelvic floor with its musculature act as stabilizer of the pelvic ring. 
False pelvis above the pelvic brim is a part of the abdominal cavity, whereas true pelvis below the pelvic brim accommodates the pelvic viscera (major vessels, neural plexuses, urinary bladder, ureter, rectum, vagina, and uterus in female). Due to close relationship of these structures to bony cage, pelvic fractures are frequently associated with neurological, genitourinary, and gastrointestinal organs injury. Besides, delayed sepsis due to associated visceral injuries and consequences of prolonged hemodynamic instability may be seen. It is also associated with an extensive vascular network; therefore, these fractures can cause life-threatening blood loss. The sources of bleeding include iliac vessels and their branches, low pressure venous plexus, and fractured cancellous bone surfaces. Thus, pelvic fractures are not only a cause of death but also serve as a marker for other life-threatening injuries .
Advances in prehospital care, widespread use of, Advanced Trauma Life Support (ATLS) protocol, better intensive care facilities, together with a multidisciplinary approach to trauma with pelvic fractures, have resulted in decreased morbidity and mortality seen in recent years.
| Epidemiology|| |
Pelvic fractures represent approximately 3%-8% of skeletal injuries.  With mortality ranges from 5% to 16%, while open pelvic fractures, which comprise 2%-4% of all pelvic fractures, are associated with a mortality rate of up to 45%. ,, Most fatalities stem from associated internal injuries; deaths attributed solely to pelvic fractures range from 0.4% to 0.8% of trauma fatalities. , Patients aged greater than 65 with pelvic fractures have a mortality rate of approximately 20%.  Overall, pelvic fractures are associated with an increased risk of death among trauma patients. , The mortality associated with acetabular fracture is 3%. 
Mechanism of injury and classification-Pelvic fractures most commonly result from high-impact injuries such as motor vehicle accidents or falls from height, male preponderance is seen with a bimodal distribution, with a peak in the 20-40 years age group and a second peak in the elderly population. In older patients, however, even low-impact injuries can lead to pelvic fractures due to weakened osteoporotic bone.  High-impact injuries resulting in pelvic ring disruption are more likely associated with severe injuries to the central nervous system, abdomen, and chest. The mechanism of injury determines the severity of pelvic ring disruption like with side-impact compression, lateral impaction injuries occur in the pelvic ring. In head-on type collisions, an anteriorposterior (AP)-directed force results in external rotation of the hemipelvis and opening of the pelvic ring. Combinations of these patterns may also occur. With vertical shear force:Forces are directed perpendicularly through the sacrum or ilium, resulting in severe disruptions of the sacroiliac joint, ilium, and sacrum, leading to significant pelvic instability. The stability of the injured pelvic ring is evaluated based on, physical findings, radiological appearances, and the knowledge of the mechanism of injury. 
Various classification systems have been devised based on the mechanism of injury and of the resulting force vector.
Pennal et al., developed mechanistic classification in which pelvic fractures are described as AP compression, lateral compression (LC), or vertical shear injuries. Marvin Tile modified the penal system to make it into three subgroups depending on stability. Young and Burgess proposed different modification of original Pennal classification adding a new category of combined mechanical injuries. AO/OTA classified pelvic injuries into three different grades depending on stability and instability. Sacral fractures are classified separately by Denis et al.
It has been shown that these different kinds of injuries have different presentation and outcomes. Dallal et al., have done a study on 343 pelvic injuries and their data indicate that the mechanical force type and severity of the pelvic fracture are the keys to the expected organ injury pattern, resuscitation needs, and mortality. There were major differences in the causes of death in LC versus AP compression (APC) injuries, with brain injury compounded by shock being significant contributors in LC. In contrast, in APC there were significant influences of shock, sepsis, and acute respiratory distress syndrome related to the massive torso forces delivered in APC, with large volume losses from visceral organs and pelvis of greater influence in APC, but brain injury was not a significant cause of death. 
| Prehospital care|| |
The treatment at the scene of the accident with suspected pelvic injury follows the general ATLS guidelines. Clinical survey (ABCDE: Airway, Breathing, Circulation, Disability, Exposure) and includes a full trauma evaluation. Initial resuscitation measures should be instituted to address life-threatening injuries.
A high degree of suspicion of pelvic injuries should be maintained in polytraumatized patients, who have sustained high-impact trauma as obvious clinical signs for pelvic injuries seldom occur.
If the patient can communicate, detailed history regarding the mechanism of injury should be elicited, patient should be asked about the presence of pain in the pelvic, back, or groin regions and the pelvis should be routinely immobilized using an external compression splint (commercial or modified e.g., sheet) if pain is present and there is suspicion of pelvic fracture. Do not fully log roll the patient. a scoop stretcher should be used to facilitate the patient's movement on to a spinal board or vacuum mattress for transport. Fluid resuscitation should be done to maintain a radial pulse only. A pelvic splint should not be removed in the presence of a suspected unstable pelvic injury until it is radiologically confirmation of absence of fracture or the patient is in operation theatre. 
| Evaluation and management|| |
Management of patients with simple pelvic fractures with little soft tissue injury and pure osteoligamentous instability is aimed at reconstruction of the osteoligamentous structures on a semielective basis.
However, patients who have sustained displaced pelvic ring fractures, require emergency hemorrhage control, and a multidisciplinary team approach for the associated injuries. The management of this specific group of patients is challenging and has evolved over the years to what is known today ''Damage control orthopedics.'' 
On admission in the emergency department, the management of a polytraumatized patient with a pelvic ring injury requires a multidisciplinary approach. General surgeons, orthopedic surgeons, emergency physicians, urologists, and interventional radiologists, all are called upon to render their services in the care of pelvic fractures patients.
A comprehensive examination should be done to identify injuries to the head, neck, chest, abdomen, extremities, spine. Concomitant chest injury is present in approximately 20% of patients with a pelvic fracture. Thus, a diligent search must be made to identify pneumothorax, hemothorax, or rib fractures. All patients with pelvic fractures require evaluation for intraabdominal injury with clinical examination, Focused Assessment with Sonography for Trauma (FAST), or diagnostic peritoneal lavage if required. Approximately, 25% of patients with pelvic fractures will harbor intraabdominal injuries despite having a true negative FAST. Computed tomography (CT) scanning is, therefore, required. CT scan also offers the advantage of imaging retroperitoneum and abdomen simultaneously. 
| Pelvic fracture examination|| |
Primary inspection of the completely undressed patient is done to identify the wounds, hematomas, contusions in the pelvic region. Massive flank or buttock contusions and swelling with hemorrhage indicate significant bleeding. The Destot's sign, a superficial hematoma above the inguinal ligament, in the scrotum, or in the thigh, can indicate a pelvic fracture. Pelvic asymmetry, leg length discrepancy, and degree of shortening provides a clue to the type of fracture present careful manual palpation of pelvis with performance of various maneuvers like AP and LC test for pelvic instability should be done. However, repeated examination for pelvic instability should be avoided in unstable situations to prevent further induction of blood loss. Palpation of the posterior aspect of the pelvis for large hematoma or a defect, or a dislocation of the sacroiliac joint. Palpation of symphysis pubis should be performed to detect any defect and diastasis. 
Perineum should be carefully inspected for evidence of bleeding from urethra, rectum, or vagina and per rectal [for high riding prostate] and per vaginal examination should be performed. Bleeding from urogenital system suggests an occult open fracture of the pelvis. An extended decollement of the anterolateral fascia of the thigh and pelvis is rarely combined with pelvic injuries popularly known as Morel-Lavalle΄ lesions. 
A complete neurological examination is mandatory as injuries to lumbosacral plexus, presacral plexus, and sciatic nerve are very common in pelvic fractures, rectal tone and bulbocavernosus reflex should be checked, distal motor and sensory function at the foot and ankle should be checked. Vascular status is analyzed by palpation of lower extremity pulses and inspection of capillary refill. 
| Radiological investigations|| |
The standard radiographs required for evaluation of pelvis are AP view of pelvis and special views of the pelvis includes inlet view (taken by tilting the tube 40° cephalad from vertical line 2.5 cm above the pubic symphysis) it shows rotational deformity or AP displacement of the hemipelvis, outlet view (taken by tilting the tube 40 degrees caudal to vertical line 2.5 cm above the pubic symphysis); it shows vertical displacement of the hemipelvis, sacral fractures, and widening or fracture of the anterior pelvis.  Radiographic signs like, widening of the symphysis of more than 2.5 cm indicates APC type with rotationally unstable pelvis. Avulsion fractures of the lateral sacrum and ischial spine also are signs of rotational instability. Widening of the anterior pelvis is rupture of the anterior sacroiliac ligament, making the sacroiliac joint appear widened on the AP view. Sacral fracture with a gap indicates vertical instability. , Along with that standard trauma series radiographs that are lateral view of cervical spine, AP view of chest and radiographs of other involved extremities should be obtained. The acetabulum can be evaluated radiographically with an AP pelvic view as well as with the 45° oblique views of the pelvis commonly called Judet views [Iliac and obturator views].  CT plays an important role in evaluation of pelvic injury, as it allows evaluation of the posterior portion of the pelvic ring that may be poorly seen on standard radiographs .
| Pelvic fractures with haemodynamic intability|| |
Bleeding from pelvic fractures can occur from various sources. Blood loss leading to hemodynamic stability can be external and internal (bleeding in the thorax, abdomen or retroperitoneal space, and multiple bone fractures). Pelvic fractures can cause retroperitoneal hemorrhage secondary to disruption of the venous plexus in the posterior pelvis, bleeding from cancellous bone edges and arterial injury to external or internal iliac vessels, superior gluteal and pudendal vessel. Most commonly, a combination of arterial and venous injury within the internal iliac distribution is seen in patients with substantial blood loss. ,
Venous hemorrhage and bleeding from bone edges can be controlled secondary to tamponade from increasing tissue pressure in the pelvic retroperitoneal space. Arterial bleeding can however overcome the tamponade effect of the retroperitoneal tissues, thus, leading to shock and significant mortality.
Occasionally, patients may occasionally bleed from common iliac, proximal internal or external iliac artery, and/or vein. Bleeding from these major vessels is often dramatic and these patients usually present with hemodynamic instability. 
| Acute management|| |
In pelvic injuries managing hemodynamic instability is the most challenging part. It is not always easy to tell the exact source of blood loss. Pelvic injuries can be associated with bleeding injuries in abdomen and even in chest that may not be obvious. Initially, administration intravenous crystalloids and a fluid challenge must be given. This approach aims to maintain perfusion of brain, myocardium, and kidney but does not allow excessive hemodilution. This also prevents disruption of primary clot and occurrence of secondary hemorrhage. The initial aim in such cases is to maintain a palpable radial pulse, which is palpable at around 80 mm of systolic. Two important adjuvant key factors of this strategy are early control of bleeding and judicious use of blood products to get normal blood pressure. 
Severe pelvic injuries need multiple blood transfusions. For such scenario, a massive transfusion protocol must be an established in institutes where such injuries are entertained. In this system, once a blood sample for group and cross match is sent with a request for massive transfusion protocol it will automatically initiate a procedure in the blood bank whereby platelets and fresh frozen plasma will also be provided with every second or third unit of packed cells or whole blood. These proportions and protocols can be decided locally. Similarly, calcium gluconate must be given in such protocols and warming the blood is also emphasized. Tranexamic acid has also been used in cases with severe bleedings and its use in first 3 h has shown benefits. , It does not lead to any coagulation problems and is safe. Avoidance of coagulation disturbances, the systemic inflammatory response, adult respiratory distress syndrome, and multiple organ dysfunction syndrome is of paramount importance for reduced mortality rates .
For the emergency, hemostasis of patients with pelvic fractures following treatment option can be considered temporary pelvic binders, external fixation devices, direct surgical hemostasis, pelvic packing, pelvic angiography, and embolization.
Pelvic stabilization should be performed early, in the resuscitative phase of management. The volume of the pelvis increases after a mechanically unstable pelvic fracture which is thought to reduce the tamponade effect of the retroperitoneal tissues and intrapelvic organs, causing further bleeding into the pelvic space. Pelvic stabilization is performed in order to control pelvic bleeding by decreasing the pelvis volume and hastening clotting of the pelvic hematoma leading to earlier tamponade. 
| Temporary pelvic binders|| |
The pneumatic antishock garments (PASGs) have been used to stabilize the pelvis and decrease the pelvic volume. In retrospective studies, Flint et al.,  and others have demonstrated less blood loss when the PASG was applied. Other studies have questioned the ability of PASG to limit hemorrhage from pelvic fracture.  Complications of PASG include abdominal compartment syndrome and fluid and electrolyte complications, they are bulky, difficult to apply, and limit access to the traumatized site and hinder physical examination.  Other options available are, military antishock trousers: Typically applied in the field, severe complications reported (compartment syndrome, extremity loss),  pelvic binder (pelvic wrap): This is wrapped circumferentially around the pelvis. A sheet can be used if a binder is not available. Important thing is to ensure that it is wrapped over the trochanters and not on iliac crests. This allows for inspection of abdomen and at the same time reduces the fracture well In an incomplete unstable type of fracture (e.g., an open book injury), internal rotation of the legs, if intact, will reduce the volume of the pelvic cavity and significantly improve the clinical condition.
| External pelvic fixator|| |
In the acute phase, many advocate external fixation as a temporary device to achieve stabilization of the fracture with a positive effect on hemorrhage. It allows access to the abdomen and perineum, can be used as definitive fixation in some patients, or as an adjunct to internal fixation in others. Fractures of the iliac wing, acetabulum, or both usually are contraindications to pelvic external fixation, two 5-mm pins are placed in between the iliac cortical tables, placing the pins in the supraacetabular bone improves stability and is safe if insertion is carried out under fluoroscopic guidance. 
An anteriorly applied external fixator does not control motion in the posterior sacroiliac complex, hence to control the posterior pelvis in the resuscitation phase: The Ganz C-clamp  and the pelvic stabilizer developed by Browner et al.  The pelvic C-clamp acts like a simple carpenter's clamp and can exert transverse compression directly across the sacroiliac joint. The C-clamp is generally applied in the emergency department, if possible with the aid of an image intensifier. The typical site for pin placement is at the point of intersection of a line from the posterior to the anterior superior iliac spine, with the extension of the longitudinal axis of the dorsal border of femur. C-clamp application can not only be difficult but dangerous in cases of comminuted sacral fractures, neurovascular injury can occur due to crushing of the sacrum. As a temporary stabilizing device that should be removed within 5 days if possible. Open reduction and internal fixation can be undertaken if the patient is undergoing emergency laparotomy for other indications. It is frequently contraindicated by itself because loss of the tamponade effect may encourage further hemorrhage. 
In a study of 14 hemodynamically unstable patients with pelvic fractures, Sadri et al.,  found that blood loss was not statistically different before/after placement of the pelvic C-clamp. Angiography was required in many of these patients to control hemorrhage. When external pelvic fixation (EPF) is compared with a temporary pelvic binder (TPB) in patients with sacroiliac fractures, EPF was found to have higher blood transfusion needs at 24 h and 48 h compared with the TPB. The reduced blood loss may be due to the ease and rapidity of TPB application compared with EPF. 
Placement of a C-Clamp or external pelvic fixator decreases the pelvic volume by 10%-20% and reduces pelvic fractures, which leads to less blood loss and better. The standard use of external fixation in the initial treatment algorithms of patients with unstable pelvic injuries is common and remains a useful tool in the initial management of these patients. However, TPB, because of their ease of use and fast application, has largely replaced the pelvic C-Clamp and external pelvic fixator for early mechanical stability in pelvic fracture. 
Pelvic angiography is useful control of arterial hemorrhage associated with pelvic fractures. In many pelvic fractures, much of the bleeding is venous in nature, generally from bone fracture edges or the iliolumbar vein.  Angiography with embolization only controls arterial hemorrhage and therefore is beneficial in only a minority of patients. Indeed, it seems that pelvic angiography is indicated in only 3%-10% of patients with pelvic fracture. Hemodynamic instability associated with pelvic fractures without another significant source of bleeding is an indication for pelvic angiography. However, it is recommended that each institution develop its own protocol, depending on resources and facilities. 
| Retroperitoneal (Preperitoneal) Packing|| |
It is the way to control bleeding from venous plexus and fracture sites. It also controls arterial bleedings. Even when it fails to control arterial bleeding for long, it still provides enough time to arrange for arterial embolization. The technique consists of creating a midline incision 8 cm in length just above the pubis extending toward the umbilicus, skin and subcutaneous tissue, and fascia is opened in the midline. The bladder is retracted away from the fracture and three laparotomy pads are placed in the retroperitoneal space on each side toward the iliac vessels. The procedure is repeated on the opposite side and the fascia and skin are closed. The procedure is easy to perform can be done in 20 min by experience surgeons. These packs need to be removed after 24-48 h or when hemodynamic situation is stabilized but a definitive fixation of pelvic fractures can be done at the same time. ,
Cothren et al.,  reported using packing as part of a clinical pathway in treating hemorrhage from pelvic fracture. In this group of severely injured patients (injury severity score = 55), packing was performed immediately after placement of a TPB or EPF. There were no deaths attributed to hemorrhage after packing along with significantly fewer blood transfusions. This study reported an 83% success rate in controlling hemorrhage in hemodynamically unstable patients who underwent packing. The other 17% required angiography. In a follow-up study at their institution, pelvic packing was found to occur faster than with angiography (45 vs. 130 min). There was also a decrease need for transfusion. The results of the study are difficult to interpret because time to control hemorrhage was significantly different between the groups.
Retroperitoneal packing has a role in controlling hemorrhage, particularly when angiography is unavailable or it would result in significant delay, favorable results have been reported with retroperitoneal packing and external fixation [Table 1] and Graph 1]. 
| Summary|| |
Emergency management of the pelvic injuries includes care of ABCDE, blood and blood component transfusions, fixator, or binders to stabilize pelvic fractures, establishing source of bleeding if possible, surgical control of bleeding, and damage control surgeries for visceral injuries. Each institute should set the protocol depending upon the facilities available, multidisciplinary approach is necessary. Immediate external fixation or temporary pelvic binding of the unstable pelvis with pelvic packing to control pelvic hemorrhage seems to be a useful approach in patients with complex injuries.
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