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P
23
Pelvic Trauma
Pierre E. Bize • Yann Lachenal • Alban Denys
elvic hemorrhage is usually related to unstable pelvic fractures, which
are observed in up to 25% of all polytrauma patients.1 Because pelvic
fractures are usually caused by high-energy trauma and often
associated with injuries in other parts of the body, their management requires
a multidisciplinary approach and triage decision between all bleeding sites.
Despite the advances made in all disciplines of resuscitative medicine and
surgery, the mortality rate following pelvic ring injuries ranges from 20% to
40%.
2–5
Pelvic trauma represents a particular physiologic condition in the trauma
spectrum. Usually, the pelvic compartment represents a closed space in
which tamponade occurs rapidly, limiting the extension of bleeding. But in
case of pelvic ring disruption, this tamponade effect does not occur, and it has
been demonstrated that a gap of only 3 cm in the pelvic symphysis increases
the volume of the pelvic compartment of as much as 1.5 L.
6
Then, in case of pelvic fracture, patients can bleed up to 4 L of blood in
a closed, difficult-to-reach compartment. According to the Advanced Trauma
Life Support (ATLS) recommendation, the external stabilization of the pelvis
should be performed in any case where there is suspicion or clinical evidence
of pelvic fracture.7 This can be achieved at the patient’s arrival in the hospital
or before using dedicated pelvic belts. A chest and pelvic x-ray should be
obtained in the emergency room in all trauma patients to rule out hemothorax
or pneumothorax and assess the presence or absence of evident pelvic
fractures. Hemodynamically stable patient should then undergo computed
tomography (CT) scan for a throughout workup. Hemodynamically unstable
patients should benefit from a focused assessment by sonography for trauma
(FAST) to look for free peritoneal fluid. Unstable patients with free
abdominal fluid should be rushed to the operating room for exploratory
laparotomy. However, note that if the peritoneum is not breached, the
bleeding can be completely occult at FAST. In case of hemodynamically
unstable patients without any other seriously bleeding injury and with no, or
not enough, free intraperitoneal fluid to explain instability, retroperitoneal
bleeding from the pelvis should be suspected.
5
Bleeding in the pelvis can occur from arteries, veins, or directly from the
broken bones. The immobilization of the pelvic ring with a strap or an
external fixator helps restore the tamponade effect and has been shown to
restore hemodynamic stability in polytrauma patients suffering from pelvic
fractures.8 However, tamponade is efficient only in case of bleeding from
broken bones or lacerated veins. In patients with persistent hemodynamic
instability despite pelvic ring immobilization, an arterial bleeding should be
suspected. In this case, four treatment options are usually described:
immediate external surgical fixation, direct surgical vessel ligation,
retroperitoneal packing, and transcatheter arterial embolization (TAE).
9
There is no consensus on which of these treatment options is the most
efficient in restoring hemodynamic stability, but there is a growing evidence
in the literature suggesting that external fixation should be performed first
and does not preclude any other subsequent adjuvant treatment.9 However,
this can be ponderated when arterial lesions are evidenced on the CT scanner
and when surgical procedure is complex and would delay arterial bleeding
control by TAE.
Figure 23.1 describes the decision-making algorithm proposed by
Geeraerts et al.
5
There are many classifications of pelvic fractures based on the
underlying traumatic mechanism or on the presence or absence of posterior
ring elements instability.10 The classification of Pennal et al.11 describes three
types of underlying mechanism: type 1 (anteroposterior compression),
resulting in transverse opening of the pelvic ring (open book fracture) and
risk of lesion of the internal iliac artery (IIA); type 2 (lateral compression),
with risk of lesion of the iliac vessels and retropubic venous plexus; and type
3 (vertical shearing), with structural instability of the posterior ring elements.
The classification of Burgess et al.12 adds a fourth category for mixed