Management of Hemodynamically Unstable Pelvic Ring Fractures

Abstract

Hemodynamically unstable pelvic fractures are challenging high-energy traumas. In many cases, these severely injured patients have additional traumatic injuries that also require a trauma surgeon's attention. However, these patients are often in extremis and require a multidisciplinary approach that needs to be set up in minutes. This calls for an evidence-based treatment algorithm. We think that the treatment of hemodynamically unstable pelvic fractures should primarily involve thorough resuscitation, mechanical stabilization, and preperitoneal pelvic packing. Angioembolization should be considered in patients that remain hemodynamically unstable. However, it should be used as an adjunct, rather than a primary means to achieve hemodynamic stability as most of the exsanguinating bleeding sources in pelvic trauma are of venous origin. Time is of the essence in these patients and should therefore be used appropriately. Hence, the hemodynamic status and physiology should be the driving force behind each decision-making step within the algorithm.

Keywords: angioembolization; external fixation; hemodynamically unstable; pelvic fracture; pelvic packing.

Figure 1

Treatment algorithm for hemodynamically unstable pelvic fractures. Decision-making is based on the patient's physiological status. Hemodynamically unstable patients should not be taken to a CT scanner or to the angio suite but to the operating theater for mechanical stabilization, pelvic packing, and additional damage control surgery if needed.

Figure 2

Case of a patient with a hemodynamically unstable pelvic fracture. (A) closure of the pelvic space using a pelvic binder. (B) Supra-acetabular external fixator, and JJ stents after first surgical intervention. (C) Definitive repair including pelvic ring plating, and lumbosacral fixation.

Figure 3

Case of a patient in which a pelvic binder was used in the ED to temporarily stabilize the pelvis (A). After initial surgical stabilization with a supracetabular external fixator and pelvic packing a CT scan was made showing additional injury to the posterior side of the pelvic ring (B). Because of persisting posterior mechanical instability a C-clamp was also used to further reduce the pelvis (C,D) and allow for better control of the pelvic bleeding.

Figure 4

An overview of the time line of both angioembolization and mechanical stabilization, pelvic packing, CT scan and additional angioembolization. Procedural times and prepping times are extracted from real life cases and extracted from Burlew et al. (14). This overview shows that the time needed for prepping an operating theater and performing mechanical stabilization, preperitoneal packing and if needed additional damage control surgery, can be used to prepare the angio suite for additional angioembolization if required. It also becomes evident that preparing an angio suite causes an unnecessary delay in treatment in hemodynamically unstable patients.