Management of Pelvic Trauma

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Introduction   

Traumatic pelvic injuries result from high-energy trauma and can be life-threatening, leading to lifelong disabilities. Trauma is the leading cause of death in patients between the ages of 15 and 24 [1]. Severe pelvic fractures from high-energy trauma, such as motor vehicle collisions or significant falls, cause extensive damage to the pelvic bones and surrounding soft tissues, including major blood vessels, nerves, and vital organs, leading to life-threatening hemorrhage and neurological deficits [1]. These injuries often involve multi-system trauma, complicating management and increasing the risk of mortality and long-term complications due to associated damage to organs like the liver, spleen, kidneys, and lungs [1]. 

Trauma remains the leading cause of death among individuals aged 15 to 24 and accounts for 30% of all intensive care unit (ICU) admissions per year [1]. Traumatic injuries range from minor wounds to severe, complex conditions that can induce shock and multi-system organ dysfunction. Such injuries are associated with additional traumas, increased transfusion requirements, and prolonged rehabilitation periods.  

Understanding the evaluation and management of traumatic pelvic injuries is essential for all healthcare professionals. An interprofessional team approach is crucial in managing patients with pelvic fractures due to the complexity and potential complications involved. 

Anatomical Concerns  

The pelvis is a ring-like bony structure composed of the sacrum, coccyx, and innominate bones—the pubis, ischium, and ilium—which converge to form the acetabulum [2]. The innominate bones join at the pubic symphysis anteriorly, forming the pelvis, which houses vital structures such as blood vessels, nerves, urogenital organs, and the rectum [3]. 

The pelvis is associated with several major vascular structures. At the level of the fourth lumbar vertebra (L4), the aorta divides into the common iliac arteries, which further split into the internal and external iliac arteries at the sacroiliac joint [4]. Pelvic trauma injures the gluteal artery, which branches from the iliac artery and exits the pelvis at the notch [1]. Other arteries susceptible to injury include the inferior gluteal, rectal, obturator, and vesical arteries. Accompanying veins are also prone to damage due to their proximity to the arteries, leading to a high incidence of combined vascular injuries [1][5]. The risk of hematoma formation and shock increases fracture severity, making hemorrhage a cause of morbidity and mortality in these cases [6]. 

While nerve injuries are less common than vascular injuries in pelvic trauma, they do occur [1]. Pelvic injuries to the sacroiliac joint and acetabulum often affect the lumbosacral plexus due to its proximity to these sites [7]. Severe pelvic trauma can result in root avulsion. Injuries to the lumbar plexus are less common and result from traction or compression caused by retroperitoneal bleeding [8]. 

Case Study: Complex Open Pelvic Fracture in an 8-Year-Old  

Presentation and Initial Assessment: An 8-year-old girl in rural North Carolina sustained a complex when an off-road utility vehicle (UTV) overturned. Upon arrival to the trauma center, the trauma team initiated a massive transfusion protocol due to signs of severe hemorrhage and unstable vitals. The primary survey identified a Glasgow Coma Score (GCS) of 14, and the team applied a binder due to fractures. They intubated the patient to secure the airway and proceeded with imaging. 

Imaging and Diagnosis: A series of diagnostic tests, including X-rays and CT scans, revealed multiple traumatic injuries. The team identified the following injuries: 

• Bilateral superior and inferior pubic rami fractures 

• Right iliac bone fracture 

• Bilateral sacral fractures 

• Large pelvic hematoma with active hemorrhage 

• Skull fracture with a hemotympanum 

• Nondisplaced left clavicle fracture 

• Degloving injuries of the urogenital, left thigh, groin, and right buttock areas 

Given the severity of the pelvic injuries and ongoing hemorrhage, the team decided to proceed with pelvic embolization. 

Surgical Intervention: The patient underwent embolization of pelvic arteries to control hemorrhage. Despite embolization, bleeding from injuries persisted, and surgeons performed laparotomy. 

Physicians classified the patient’s fractures as bilateral unstable lateral compression Type 1 fractures. The orthopedic trauma team employed an internal-external fixator (INFIX), a subcutaneous temporary internal fixation device, which requires careful management to prevent infection and facilitate rehabilitation [9]. 

Challenges and Complications: Open pelvic fractures carry high morbidity and mortality rates due to the combination of skeletal immaturity and associated injuries [10]. The patient’s complex injuries, including the degloving and urogenital trauma, required innovative surgical approaches. In this instance, the INFIX provided both biomechanical stability and reduced infection risk, enhancing the patient’s recovery [11]. 

Etiology  

The pelvic ring is a strong structure that requires substantial force to disrupt, making pelvic fractures uncommon. When pelvic fractures occur, they result from events such as motor vehicle collisions, falls from heights, or incidents where vehicles strike pedestrians or cyclists.  

Pelvic fractures make up 5% of all traumatic fractures, with 30% being isolated cases. They occur in 10–20% of severe trauma patients and correlate with higher trauma severity scores. Although rare, pelvic fractures involve injuries in 12–62% of patients. Pelvic trauma causes high mortality rates of 8–15% due to active bleeding and associated injuries to the head, abdomen, or chest [1][12]. 

Epidemiology  

Pelvic fractures comprise 10% of fractures resulting from blunt trauma [13]. Among these patients, more than 16% have at least one associated injury, with intra-abdominal organs—the liver, spleen, and kidneys—being the most affected [1][13]. Urogenital injuries account for over 40% of associated injuries [1][14] Up to 24% of patients with pelvic trauma sustain a urethral injury [14] [15]. In males, these injuries most occur at the bulbomembranous junction [16]. Bladder Lacerations occur in about 20% of cases involving pelvic trauma [17]. 1% to 2% of pelvic fracture cases involve injuries to the rectum, while lacerations of the vagina occur in 2% to 4% of incidents [1] [18]. 

AAST Vaginal Injury Classification 

The American Association for the Surgery of Trauma (AAST) categorizes vaginal injuries into three degrees [1] [18]: 

• First-degree: Contusions, hematomas, and superficial lacerations involving the mucosa. 

• Second-degree: Lacerations involving deep fat or muscle tissue. 

• Third-degree: Lacerations that involve the cervix, peritoneum, or extend into adjacent organs. 

In adults, open pelvic fractures represent about 2% to 5% of all pelvic ring injuries and carry an overall mortality rate of up to 50% [19]. Studies reported mortality rates for children reaching 25% [20]. However, advancements in surgical techniques and improvements in standards of care have led to a decrease in mortality rates in recent studies. 

Pathophysiology  

Disruption of the pelvic ring increases the internal volume of the pelvis, which decreases the tamponade effect of the retroperitoneal space and allows for increased blood loss [1][21]. There are two primary classification systems for pelvic fractures: the Tile classification and the Young-Burgess classification [1][22]. 

Tile Classification 

• Type A: Fractures that neither rotate nor move on an axis. Fractures that include avulsions and injuries. 

• Type B: Fractures with rotational instability but vertical stability. 

• Type C: Fractures where bones can rotate and move up or down. 

Young-Burgess Classification 

This system classifies pelvic fractures based on the mechanism of injury: 

• Anteroposterior Compression (APC): 

• Often unstable and referred to as “open book” fractures. 

• Associated with pelvic and retroperitoneal hemorrhage. 

• Result from head-on motor vehicle collisions. 

• Lateral Compression (LC): 

• Most common type of pelvic fracture. 

• Often stable but can be associated with bladder rupture. 

• Result from side-impact collisions, such as T-bone accidents or pedestrians struck from the side. 

• Vertical Shear (VS): 

• Often unstable. 

• Require substantial force on one or both hemipelves  

• Cause complete ligamentous injury. 

• Combined Mechanism (CM): 

• Involves a combination of the above mechanisms. 

Limitations of Traditional Classifications 

Both the Tile and Young-Burgess classifications focus on the anatomical aspects of pelvic fractures but do not consider the patient’s hemodynamic stability [1][22]. To address this limitation, the World Society of Emergency Surgery (WSES) developed a classification system that incorporates both anatomical injury and hemodynamic status to guide treatment decisions [23]. 

WSES Classification and Management 

The WSES classification divides pelvic injuries into three categories: minor, moderate, and severe [24]. 

Minor Injuries (WSES Grade I) 

Minor injuries under WSES Grade I involve fractures in patients with hemodynamic stability [24]. This category includes Grade I fractures such as Anteroposterior Compression Type I (APC I) and Lateral Compression Type I (LC I) fractures. Management involves nonoperative treatment, as these injuries are stable and do not usually require surgical intervention [24]. 

Moderate Injuries (WSES Grades II and III) 

Moderate injuries encompass WSES Grades II and III and involve unstable fractures in hemodynamically stable patients [24]. Grade II includes fractures like APC II, APC III, LC II, and LC III, while Grade III comprises Vertical Shear (VS) and Combined Mechanism (CM) fractures [24]. Management for moderate injuries involves applying a pelvic binder at the scene to stabilize the pelvis [1][24]. If CT imaging shows a blush—indicating bleeding—consider angioembolization to control hemorrhage [1]. 

Severe Injuries (WSES Grade IV) 

Classify injuries as WSES Grade IV for patients with instability of blood circulation, regardless of fracture stability [24]. This category includes any fracture pattern in a hemodynamically unstable patient. Immediate management involves the application of a pelvic binder in the field to provide initial stabilization [24]. Upon arrival at the hospital, initiate interventions such as packing, REBOA, and angioembolization to control bleeding and stabilize the patient. 

By incorporating both the anatomical classification and the patient’s hemodynamic status, the WSES system provides a comprehensive framework for managing pelvic fractures. The trauma team manages minor injuries without surgery. Moderate injuries may require interventions like angioembolization if clinicians detect bleeding, and severe injuries necessitate strategies to control hemorrhage and stabilize the patient. 

Initial Approach to Trauma Patients 

Trauma patient management follows Advanced Trauma Life Support (ATLS) guidelines, focusing on rapid recognition and stabilization of life-threatening injuries [25]. An extensive initial history is unnecessary; EMS personnel provide a brief overview upon the patient’s arrival at the emergency department [25]. After stabilizing the patient, obtain a history that focuses on the mechanism of injury, whether the patient walked at the scene, and any signs of bowel or bladder incontinence, numbness, or weakness. In alert patients, a thorough history and physical examination are sensitive for detecting pelvic trauma [1]. 

The initial evaluation, known as the primary survey, uses the mnemonic ABCDE to address immediate threats [25]: 

• A: Airway and Cervical Spine Protection: Assess airway patency by asking the patient to speak; protect the cervical spine when suspecting a neck injury. 

• B: Breathing: Observe chest movement and listen for breath sounds to ensure adequate ventilation. 

• C: Circulation: Evaluate pulse, skin color, and capillary refill to assess circulatory status and identify signs of shock or hemorrhage. 

• D: Disability: Assess neurological status using the Glasgow Coma Scale (GCS); check pupil size and reactivity. 

• E: Exposure and Environmental Control: Expose the patient to identify all injuries while preventing hypothermia. 

Following the primary survey, the secondary survey involves a comprehensive head-to-toe examination. 

Treatment / Management 

Pelvic fractures, regardless of their severity, can become life-threatening and require prompt and effective management. Treatment begins with addressing the ABCs—airway, breathing, and circulation—during the primary survey [25]. Adequate resuscitation is crucial; all trauma patients should receive two large-bore intravenous lines upon arrival [25]. The trauma team manages hypotension with aggressive fluid resuscitation, followed by blood product administration if it persists [26][27]. 

Apply binders when signs of ring disruption occur in patients, regardless of stability [1]. The binder serves two main purposes: it compresses bleeding from bone fractures and reduces the pelvic volume to promote tamponade of bleeding vessels [1][28]. Place the binder over the greater trochanters and pubic symphysis to adduct the legs and decrease pelvic volume [28]. Do not use pelvic binders in fractures resulting from lateral compression fractures as they may increase bleeding [1][28]. 

Patients who are stable but show evidence of bleeding on a CT scan should undergo angioembolization [29]. Interventional radiology performs this procedure with access via the femoral artery. Angioembolization succeeds in 85% to 100% of cases [1] [30]. If the femoral artery is not accessible, interventional radiologists may opt for the brachial or axillary artery [29][30]. The procedure involves visualizing and embolizing vessels, often branches of the iliac artery like the gluteal, obturator, and pudendal arteries. An angiogram confirms that bleeding has stopped. Early angioembolization within 90 minutes of arrival improves survival [29[30]. For unstable patients, immediate interventions are critical. While some advocate for immediate laparotomy, others suggest that angioembolization should precede surgery due to the likelihood of arterial bleeding and the correlation between early embolization and improved survival [29[30]. 

Preperitoneal Packing (PPP) is another option in centers without IR capabilities [31]. PPP involves placing surgical pads against the peritoneum to create tamponade and is quicker than angioembolization. Surgeons make a midline or Pfannenstiel incision, insert pads into the space before the peritoneum, and control bleeding [31]. 

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an alternative to aortic cross-clamping [32]. REBOA involves inserting a balloon catheter to occlude the aorta, minimizing life-threatening hemorrhage [32]. It is useful in pelvic trauma, with zone III (infrarenal) occlusion being effective and causing minimal visceral injury [32]. Access the femoral artery; if it is unavailable, use the brachial or carotid artery. Inflate the balloon to occlude the aorta, keeping inflation time under 30 minutes and not exceeding 60 minutes. After deflation, changes in blood flow may occur, so consider intermittent reinflation if necessary. Transport the patient quickly to IR or the operating room for treatment. 

Unstable pelvic fractures require surgical fixation [1] [33]. Early fixation improves pain control, fracture reduction, mobilization, and bleeding control. The trauma team resuscitates the patient, then performs repair [33]. 

Timing of Surgery: Patients who are stable or “borderline” can undergo definitive repair within 24 hours of injury [33]. In polytrauma patients with derangements, delay surgery until they stabilize, waiting at least four days to reduce complications [33]. 

Surgical Techniques: Posterior ring injury reconstructions are crucial for functional outcomes [1] [34]. Management varies by fracture type: 

• APC I and LC I: Managed without surgery. 

• APC II: Managed with anterior symphyseal plating. 

• APC III: Treated with anterior symphyseal plating or external fixation plus posterior stabilization with sacroiliac screws. 

• LC II: Treated with open reduction and internal fixation (ORIF) of the ilium. 

• LC III and VS: Require posterior stabilization with sacroiliac screws. 

Management of Associated Injuries 

• Bladder Injuries: Treatment depends on the injury’s location.  

• Extraperitoneal bladder injuries Physicians treat bladder injuries outside the peritoneum with catheter drainage, avoiding surgery; injuries inside the peritoneum require repair through surgery [17]. A Foley catheter remains in place for about 14 days, followed by a repeat cystogram before removal. 

• Urethral Injuries: Management of complete transections includes a suprapubic catheter and delayed repair [17]. Manage partial transactions with a Foley catheterization. Close monitoring is necessary to detect potential fistula formation. 

• Rectal Injuries: When possible, debride sigmoid and intraperitoneal injuries [37]. For those involving less than half the circumference, consider repair to reduce complications. For larger injuries, perform resection with anastomosis, with or without diversion. Treat injuries with repair and colostomy; drainage or washout is not necessary. 

• Vaginal Lacerations: Treatment depends on the severity. First-degree injuries may only require gauze packing, while second and third-degree injuries necessitate surgical repair performed by a gynecologist [35]. 

Conclusion

Pelvic injuries, often resulting from high-energy trauma such as motor vehicle collisions or falls from significant heights, can be life-threatening and lead to long-term disabilities [1]. These injuries require an interprofessional team approach due to their complexity and the potential for severe complications, including hemorrhage and multi-organ dysfunction.  

Trauma remains the leading cause of death among individuals aged 15 to 24 and accounts for a substantial percentage of intensive care unit admissions per year [36]. Understanding the evaluation and management of pelvic fractures is essential for healthcare professionals to improve patient outcomes. 

Management of pelvic injuries begins with following Advanced Trauma Life Support (ATLS) guidelines, focusing on rapid assessment and stabilization using the ABCDE approach—Airway, Breathing, Circulation, Disability, and Exposure [25]. Classification systems like the Tile and Young-Burgess methods categorize fractures based on anatomical and mechanical factors but do not account for hemodynamic stability [1][22].  

The World Society of Emergency Surgery (WSES) classification addresses this by incorporating both injury type and patient stability, guiding treatment decisions ranging from nonoperative management to surgical interventions like angioembolization, preperitoneal packing, or resuscitative endovascular balloon occlusion of the aorta (REBOA) [23] [32]. Early surgical fixation when necessary and addressing associated injuries to organs such as the bladder, urethra, rectum, and vagina to reduce morbidity and mortality [1][33]. 

Effective evaluation and multidisciplinary management of pelvic fractures, guided by comprehensive classification systems and prompt interventions, are crucial for reducing mortality and improving patient outcomes in trauma care. 

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