[Primary management of pelvic injuries]

Abstract

High energy fractures of the pelvis are often associated with genitourinary, neurological, vascular, intestinal, and other skeletal injuries. The pelvic fracture therefore reflects only some of the destructive energy sustained by the patient and is a marker for the associated soft tissue injuries. In these complex pelvic injuries assessment, stabilization, and definitive treatment are complicated. The mortality of complex pelvic injuries is high. Uncontrolled bleeding and septic complications are the main causes of death. The presence of the associated injuries necessitates thorough evaluation in every case. The goals of treatment are prevention of early death from hemorrhage, early detection and treatment of all concomitant injuries, and restoration of the patient to the preinjury level of function. At the scene of the accident, problems affecting the airway, breathing, and circulation should be dealt with first. For prehospital immobilization and transportation of the patient a beanbag should be used. With the aim of improving primary hospital treatment of patients with complex pelvic injuries, a trauma algorithm is presented. This provides for decisive therapeutic steps after brief clinical, radiologic and ultrasonographical assessments. The major questions in the flow chart take the pelvic ring and hemodynamic instability into account. Immediate laparotomy, surgical control of hemorrhage, and open reduction and internal fixation of an unstable pelvic ring are the most important requirements for successful treatment. From 1972 to 1990 the clinical course and outcome of 132 patients with complex pelvic injuries were reviewed. The overall mortality was 34.8%. As the changes in the treatment protocol were implemented mortality decreased from 66.7% (1972-1978) to 18.7% (1985-1990).