Pelvic ring injuries: Emergency assessment and management

Abstract

Pelvic ring injuries are associated with significant morbidity and mortality. Understanding the anatomy of the pelvic ring is essential for accurate diagnosis and treatment. A systematic approach taking into account the mechanism of injury, physical examination, and radiographic assessment is important to quickly identify unstable pelvic disruptions and associated injuries. Because the pelvis is a ring structure, isolated pubic rami fractures on plain radiographs are unusual and should warrant careful evaluation for posterior pelvic disruption with computed tomography. Hemorrhagic shock can occur in about 10% of pelvic ring injuries. Immediate recognition and treatment of this life-threatening condition is critical in emergency management. In addition to fluid resuscitation and blood transfusion, circumferential wrapping, angiographic embolization, laparotomy with pelvic packing, and external fixation can be important life-saving adjuncts in the setting of hemodynamic instability.

Pelvic trauma: WSES classification and guidelines

“…The biomechanics of pelvic ring injuries and the underlying trauma mechanism dictate the need for external fixation [58, 95]. Pelvic ring disruptions in hemodynamically unstable patients should be temporarily stabilized to prevent further hemorrhage and to support measures of hemorrhage control, including angiography and pelvic packing [28, 46, 58, 96, 97].…”

“…There is general consensus that pelvic ring disruptions with instability of posterior elements require internal fixation [95, 121]. Trauma mechanism-guided fracture classifications, including the widely used Young & Burgess system, provide guidance for surgical indications for pelvic fracture fixation [58, 122].…”

The importance of pelvic ring stabilization as a life-saving measure in pre-hospital – A case report commented by autopsy

“…9 Particularly open book fractures were associated with more severe injuries of the abdomen, spine, and extremities in both classification systems. 10 It is crucial to note the importance of the anatomic relationships between the pelvis bones and articulations, vessels and organs. The higher the energy associated with such fractures, the greater is the risk of adjacent lesions.…”

“…It is the fastest way to provide immediate stabilization for hemodynamic instability secondary to pelvic ring disruption. 10 A sheet was placed under the body, centered over the greater trochanters and crossed anteriorly 18 (application of the binder above the level of the greater trochanter is a common mistake and results in poor reduction of the pelvic diastasis and inadequate hemodynamic control 19 ); both sides were then rolled together over the inguinal region in order to compress de pelvic ring. The amount of pressure to apply is hard to determine, as an equilibrium should be obtained in order to maintain enough pressure to close the open-book lesion, but assuring that it doesn't compromises skin vascularization.…”

“…Aggressive resuscitation measures seem to have the highest impact on patients outcomes, although the optimal transfusion protocol is still subject of ongoing research. 10 …”