Pelvic Fractures and the Unstable Patient

Pelvic Fractures and the 

Unstable Patient 

Adam M. Shiroff, M.D. 

Assistant Professor of Surgery 

Section of Trauma and Surgical Critical Care 

UMDNJ-RWJUH

Outline 

• History 

•Anatomy 

• Biomechanics 

• Classification 

• Diagnosis of fracture/bleeding 

• Polytrauma 

• Unstable patients 

• Algorithm

Scope of the Problem 

• Pelvic fractures continue to be a source of 

major morbidity and mortality 

• Mortality from pelvic fractures: 

Any: 5-10% 

Hemodynamically unstable: 40-60% 

Open fractures: up to 70%

History 

• 1901 Booth, P.L. Lancet 

NORTH LONSDALE HOSPITAL, BARROW-IN- 

FURNESS. A CASE OF FRACTURE OF THE 

PELVIS WITH INJURY TO THE BLADDER AND 

PELVIC VESSELS 

• 1964 Seavers, R. Surgery 

Hypogastric artery ligation for uncontrollable 

hemorrhage in acute pelvic trauma.

History 

• 1970 Hawkins, L. Journal of Trauma 

Laparotomy at the time of pelvic fracture. 

• 1972 Margolies, M.N. NEJM 

Arteriography in the management of 

hemorrhage from pelvic fractures.

History 

• 1973 Ring, E.J. Radiology 

Arteriographic management of hemorrhage 

following pelvic fracture 

• 9 pts, autologous clotted blood 

• “hemostasis was produced”

Anatomy 

• 2 innominate bones (arise from embryonic 

pubis, ilium and ischium) and sacrum 

• No inherent stability

Ligamentous Anatomy 

• Posteriorly: anterior and posterior SI 

ligaments 

• Anteriorly: pubic symphysis (weakest link) 

• Inferiorly: sacrospinus and sacrotuberous

Vascular Anatomy 

• Large blood vessels 

• Veins more posterior, closer to bone 

• Iliac arteries directly over SI joint

Neuroanatomy

Pelvic Volume

Biomechanics of Fracture 

• Vectors of force: 

Lateral compression: ped struck at 90° 

Anterior-posterior: MCC/Crush injury 

Vertical sheer: fall from height

Lateral Compression 

• Acute shortening in 

diameter across pelvis 

• Ligaments often intact, 

not “open” 

• Vascular injury less 

likely 

• Ex-fix no good/ T- 

POD not helpful

• Force via iliac spine, 

femurs or straddle 

injuries 

• Diameter widens, 

opens pelvis 

• High risk of vascular 

injury 

• Highest energy = 

posterior SI ligament 

disruption 

Anterior-Posterior

• Usually a fall from 

height landing on 

extended extremity 

• Disruption of all 

ligaments of 

hemipelvis 

• Mechanically unstable 

• Not as bad from 

vascular injury 

standpoint 

Vertical Sheer

Classification

Diagnosis of Fracture 

• Strong suspicion based on mechanism 

• Any high energy blunt trauma should be 

suspected to have pelvic injury 

• Physical exam for stability to be done once 

• Perineum, rectal, vaginal exam important 

• AP pelvis film?

Team Pryor (a few)


• Salvino 1992 Journal of Trauma 

779 awake and alert blunt trauma pts, all got 

AP pelvis 

743 negative physical exams, and no 

complaints of pelvic/hip pain 

0.4% rate of missed pelvic fractures 

3 simple anterior rami fractures requiring no 

intervention 

• AP pelvic film not necessary in the reliable, 

examinable patient


• CT scanning is routine 

• Excellent for occult fracture identification 

• Adds information about injury magnitude 

• Posterior elements better visualized 

• Define instability 

• Help operative planning, especially with 3D 

reconstruction

Diagnosing Bleeding 

• Vascular injury and fracture sites 

• Can be a life-threatening problem 

• Postmortem angio study Huittinen 1973: 

Mostly venous bleeding (veins/bone) 

One or more sites of arterial bleeding in 

those who died of pelvic hemorrhage 

Putting bone back together good

Diagnosing Bleeding 

• With known fractures, bleeding is diagnosis of 

exclusion 

• Most hemorrhage stops (venous/tamponade) 

• Arterial bleeding 

• Signs of ongoing bleeding: 

Non-responders 

Transient responders 

Return of hypotension = >70% arterial bleeding 

on angio (Miller, 2003)

Markers for pelvic hemorrhage 

• Plain films 

• Fracture pattern and displacement at that 

single point in time 

• No idea of displacement at time of injury 

• Clues to major ligamentous disruption = 

arterial bleeding 

• Sarin 2005: neither fracture pattern or class 

was predictive of need for angio 

embolization


• Plain films PLUS: 

• Blackmore 2006: Anatomy/ 

physiology: 

Pubic symphysis diastasis > 1cm, 

Obturator ring fxr displaced > 1cm 

HCT130 

• All four: 66% major arterial injury 

• Two of four: 46%


• CT Scan with contrast 

• Excellent for fracture, hematoma, blush 

• Brown (LAC) 2005: Hematoma predicts of 

positive angiogram? 

37 patients with CT and Angiogram 

Significant hematoma (> 2 x 3cm): 73% 

Smaller hematoma: 67% 

Blush: 83% 

No blush: 71% 

• Need physiologic information

Initial Management 

• ABC’s 

• Adjuncts to survey: 

CXR 

AP Pelvis 

FAST 

compressive device? 

• Anticipate blood requirements: 

Huge potential space 

Signs of shock on admission: > 5 units over 

24 hrs 

20% of those will need > 15 units 

(Klein, 1992)

Polytrauma 

• Pelvic fractures 

commonly associated 

with other significant 

injuries: 89% (Parreira, 

2000) 

CHI- 37% 

Abdomen- 42% 

Chest- 25% 

Other Fractures- 48%

Polytrauma 

• Rapidly assess severity of other injuries: 

Serial exams/Hgb not indicated 

CXR 

FAST- requires approx. 200ml of fluid, 

operator dependent 

DPL/DPA- supraumbilical, up to 30% false 

positive rate 

CT scan

The Unstable Patient 

• Difficult dilemma 

• Multiple potential sources 

• Rapid assessment of 

hemorrahge is key 

Hx/Inspection/Exam 

CXR 

FAST/DPL(A)


• Not on the street 

• Abdomen and Chest “cleared” 

• Pelvis as compelling source 

• 3 ways to bleed 

Bone 

Artery 

Vein


• Pelvic stabilization 

Helps with the bone 

/venous bleeding 

Creates tamponade 

• Angiography with 

embolization 

Solves the artery 

problem


• Expect competing priorities 

Neurosurgery 

Orthopedic surgery 

Cardiothoracic surgery 

Vascular surgery

What can be done? 

•MAST 

• Compression devices 

• External fixation 

• C-clamp 

• Angiography/Embolization 

•OR?

MAST 

• Military antishock trousers 

• Advocated in 1970-80’s 

• Induce pelvic tamponade and increase 

venous return 

• Also, lower extremity ischemia/reperfusion, 

compartment syndrome, and skin necrosis 

• Largely discontinued

Compressive Devices 

• Adjunct to primary/secondary survey 

• Bed sheet or T-POD 

• Consider placing during roll 

• Provides external compression and “closes” the 

open pelvis- use when pelvic volume is expanded 

• Decreases pelvic volume 

• DeAngelis (2007): Cadaveric study, T-POD 

significantly improved diastasis reduction vs bed 

sheet.


• Placement: 

Centered over greater trochanters, not the iliac 

wings 

Binder can be cut for access to groin vessels/ 

won’t hinder laparotomy 

• Place before moving patient to another 

stretcher/OR table/IR suite 

• Reduce disruption of clot or secondary damage 

from the movement of bony fragments


• Lee C. (2007) EMJ: 

Prehospital Care 

Do not log roll 

Do not examine by 

palpation or springing 

“If there is any 

suspicion of fracture, 

immobilize the pelvis 

using an external 

compression splint.”

Emergent External Fixation 

• Was mainstay of treatment for 30 years 

• Can be done in the ED 

• Reduces pelvic geometry (small), reduces fracture 

fragment bleeding and may “stabilize the clot” 

• Currently more common in Europe 

• Largely replaced by binders in the U.S. 

Noninvasive 

Minimal resources 

No posterior stabilization

External Fixation

C-clamp 

• Form of external fixation 

• Can be placed without floro 

• Can provide posterior support depending on 

placement 

• Doesn’t limit access to abdomen or 

perineum 

• Not applicable in iliac fractures 

• Requires experienced orthopedic surgeon

Angiography and Embolization 

• Started in early 70’s 

• Clotted blood metal coils and gelatin 

sponges 

• Fractures who need embolization:


• Agolini 1997: significantly greater survival 

with angio in less that 3 hrs 

• Balogh 2002: improved mortality with 

angio within 90 min 

• 24 hour angiography on emergency basis is 

desirable


• Selective embolization appropriate for 

hemodynamically stable patients 

• HD instability consider non-selective tx 

Intermittent bleeding- hypotension 

Vasospasm 

Changing coagulation profile 

Collaterals 

Time 

B/L internal iliac embo in the dying pt


• Problems: 

• Issues with arterial access (body habitus, 

hypotension, injury to groin etc…) 

• Stick site complications 

• Radiation / Contrast exposure 

• High pressure injection 

• Recurrent bleeding


• Problems continued… 

• CT needed/preferred prior to embolization, 

not the place for unstable pts 

• Time to embolization: 50 min to 5.5 hrs 

• Many success rates based on angio not 

vitals 

• Tissue ischemia and necrosis 

7% gluteal necrosis with B/L embo

A difficult situation… 

• Unresponsive at the scene intubated 

• Hypotension getting volume 

Responds to IVF, blood started 

• CXR OK 

• Open book pelvic fracture 

T-POD 

• FAST negative 

• Run to CT scan to triage cranium

Don’t be scared

Suddenly the patient is in the OR 

• Head being shaved 

• Recurrent hypotension, pelvic bleeding 

• Laparotomy? 

Don’t believe the negative CT/ negative 

FAST combo 

Negative laparotomies bad 

• Pelvic packing 

How?

Pelvic Packing 

• Historically: Open exploration and ligation 

Difficult access, wide collateralization 

Bloody fatal mess 

70’s-80’s: Pelvic should never be opened for 

bleeding fractures 

• Shouldn’t delay hemostasis waiting for IR 

Damage control 

Laparotomy and PACKING 

• Ertel, 2001: 20 pts 

Laparotomy and packing after c-clamp 

5 had intraabdominal injuries 

4 deaths from hemorrhagic shock, 1 from sepsis

Pre-peritoneal Packing 

• Direct packing of retroperitoneum 

• Keeps you of out the abdomen 

• Faster (20min), easier, less invasive than 

open packing 

• How is it done?

Technique 

• Low midline incision (6-8cm long) or Pfannenstiel 

• Open linea alba, stay out of the peritoneum 

• Hematoma has generally done the dissection for 

you 

• Bluntly sweep peritoneum from inner symphysis 

pubis and laterally 

• Place 3 (maybe more) laps on each side 

• CLOSE THE FASCIA, clip the skin 

• Planned removal/repacking 24-48 hours later


• Totterman (2007): 18 pts 

• 72% survival at 30 days 

• Significant rise in BP after packing 

• All went to angio 

80% positive angio post op


• Cothren (2007): 28 pts, HD unstable (bp

Pre-peritoneal packing 

• Problems: 

• Invasive (whatever) 

• Increase ACS 

• Ineffective for large arterial bleeding 

• Need re-operation 

• Risk of infection

Putting it all together… 

• Hemodynamically unstable patients with 

pelvic fractures are “hard” 

• Need immediate and precise identification 

of cause of HD instability 

• Currently not possible with trauma bay 

imaging 

• Must remain flexible

Negative 

FAST Exam 

Positive 

Angio 

NO 

Responder 

YES 

OR: laparotomy 

and pack pelvis 

Pan CT 

SICU 

OR: PPP, 

address other 

injuries 

Pan CT scan 

Blush 

Pelvic injury 

only 

No 

Blush 

Angio 

SICU 

±Pan CT 

Pelvic injury + 

Other life/limb 

Threatening injuries 

Angio 

SICU

“You can only do what you can do, and you 

can’t do what you can’t do.” 

J.P.

Questions…

Pelvic Fractures and the Unstable Patient

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