Pelvic damage control

Abstract

Pelvic fractures account approximately for 3 % of all skeletal injuries. About 10 % of pelvic fractures may be classified as “complex," characterized by mechanical and/or hemodynamic instability. The mortality of patients with hemodynamically unstable pelvic fractures has been reported between 40 and 60 %. According to the mechanism of trauma, pelvic fracture patterns are classified into four types: anterior-posterior compression (APC), lateral compression (LC), vertical shear (VS), and combined types. All patients with suspected unstable pelvic fracture should be managed by a multidisciplinary team. The main goals of initial management are to identify pelvic fracture pattern, to achieve bleeding control, to identify associated life-threatening extrapelvic injuries. The hemodynamic response of the patient after initial resuscitative measures indicates the following decision-making. On physical exam, direct and indirect signs of pelvic fracture need to be addressed. The pelvis radiogram highlights the fracture pattern, its degree of biomechanic instability, and the associated risk of hemodynamic derangement, the right maneuvers to be performed in order to obtain the best fracture reduction and bleeding control. E-FAST may detect the presence of abdominal free fluid. Pelvic binders are the best way to quickly achieve bleeding control. External fixators are positioned after POD to take care more effectively of the initial hemodynamic instability. Preperitoneal pelvic packing (PPP), in association with EF, is a damage control technique that may “bridge” the patient to other diagnostic and therapeutic procedures. Angiography must be considered as a part of the ongoing resuscitative efforts during damage control strategy. In case of complex pelvic fractures, the presence of associated intra-abdominal organ injuries has to be addressed.