Background

Fractures of the pelvis account for less than 5 per cent of all skeletal
injuries, but they are particularly important because of the high incidence of
associated softtissue injuries and the risks of severe blood loss, shock, sepsis and
acute respiratory distress syndrome (ARDS). Like other serious injuries, they
demand a combined approach by experts in various fields. About two-thirds of all
pelvic fractures occur in road accidents involving pedestrians; over 10 per cent of
these patients will have associated visceral injuries (Solomon et al., 2010).
Pelvic trauma (PT) is one of the most complex management in trauma
care. Patients with pelvic fractures are usually young and they have a high overall
injury severity score (ISS) (25 to 48 ISS). Mortality rates remain high, probably in
excess of 10 per cent, particularly in patients with hemodynamic instability. For
these reasons, a multidisciplinary approach is crucial to manage the resuscitation,
to control the bleeding and to manage bones injuries particularly in the first hours
from trauma. PT patients should have an integrated management between trauma
surgeons, orthopedic surgeons, interventional radiologists, anesthesiologists, ICU
doctors and urologists (Coccolini et al., 2017).
At present no comprehensive guidelines have been published about these
issues. No correlation has been demonstrated to exist between type of pelvic ring
anatomical lesions and patient physiologic status. Moreover the management of
pelvic trauma has markedly changed throughout the last decades with a significant
improvement in outcomes, due to improvements in diagnostic and therapeutic
tools. In determining the optimal treatment strategy, the anatomical lesions
classification should be supplemented by hemodynamic status and associated
injuries. The anatomical description of pelvic ring lesions is fundamental in the
management algorithm but not definitive. In fact, in clinical practice the first
decisions are based mainly on the clinical conditions and the associated injuries,
and less on the pelvic ring lesions. Ultimately, the management of trauma requires
an assessment of the anatomical injury and its physiologic effects (Coccolini et
al., 2017).
Anatomy of the Pelvis
The pelvic ring is made up of the two innominate bones and the sacrum,
articulating in front at the symphysis pubis (the anterior or pubic bridge) and
posteriorly at the sacroiliac joints (the posterior or sacroiliac bridge). This basin-
like structure transmits weight from the trunk to the lower limbs and provides
protection for the pelvic viscera, vessels and nerves. The stability of the pelvic
ring depends upon the rigidity of the bony parts and the integrity of the strong
ligaments that bind the three segments together across the symphysis pubis and
the sacroiliac joints. The strongest and most important of the tethering ligaments
are the sacroiliac and iliolumbar ligaments; these are supplemented by the
sacrotuberous and sacrospinous ligaments and the ligaments of the symphysis
pubis. As long as the bony ring and the ligaments are intact, load-bearing is
unimpaired.

Figure 1. Ligaments supporting the pelvis (Solomon et al., 2010)

The major branches of the common iliac arteries arise within the pelvis
between the level of the sacroiliac joint and the greater sciatic notch. With their
accompanying veins they are particularly vulnerable in fractures through the
posterior part of the pelvic ring. The nerves of the lumbar and sacral plexuses,
likewise, are at risk with posterior pelvic injuries. The bladder lies behind the
symphysis pubis. The trigone is held in position by the lateral ligaments of the
bladder and, in the male, by the prostate. The prostate lies between the bladder
and the pelvic floor. It is held laterally by the medial fibres of the levator ani,
whilst anteriorly it is firmly attached to the pubic bones by the puboprostatic
ligament. In the female the trigone is attached also to the cervix and the anterior
vaginal fornix. The urethra is held by both the pelvic floor muscles and the
pubourethral ligament. Consequently in females the urethra is much more mobile
and less prone to injury.
In severe pelvic injuries the membranous urethra is damaged when the
prostate is forced backwards whilst the urethra remains static. When the
puboprostatic ligament is torn, the prostate and base of the bladder can become
grossly dislocated from the membranous urethra. The pelvic colon, with its
mesentery, is a mobile structure and therefore not readily injured. However, the
rectum and anal canal are more firmly tethered to the urogenital structures and the
muscular floor of the pelvis and are therefore vulnerable in pelvic fractures.
Pelvic ring is a close compartment of bones containing urogenital organs,
rectum, vessels and nerves. Bleeding from pelvic fractures can occur from veins
(80%) and from arteries (20%). Principal veins injured are presacral plexus and
prevescical veins, and the principals arteries are anterior branches of the internal
iliac artery, the pudendal and the obturator artery anteriorly, and superior gluteal
artery and lateral sacral artery posteriorly. Others sources of bleeding include
bones fractures. Among the different fracture patterns affecting the pelvic ring
each has a different bleeding probability. In cases of high-grade injuries, thoraco-
abdominal associated injuries can occur in 80%, and others local lesions such as
bladder, urethra (1.6-25% of cases), vagina, nerves, sphincters and rectum (18–
64%), soft tissues injuries (up to 72%). These injuries should be strongly
suspected particularly in patients with perineal hematoma or large soft tissue
disruption. These patients need an integrate management with other specialists.
Some procedures like supra-pubic catheterization of bladder, colostomy with local
debridement and drainage, and antibiotic prevention are important to avoid
aggravating urethral injuries or to avoid fecal contamination in case of a digestive
tract involvement. Although these conditions must be respected and kept in mind
the first aim remains the hemodynamic and pelvic ring stabilization.
 Figure 2. Anatomy of the Pelvis (Netter, 2014)

Physiopathology
The lesions at the level of the pelvic ring can create instability of the ring
itself and a consequent increase in the internal volume. This increase in volume,
particular in open book lesions, associated to the soft tissue and vascular
disruption, facilitate the increasing hemorrhage in the retroperitoneal space by
reducing the tamponing effect (pelvic ring can contain up to a few liters of blood)
and can cause an alteration in hemodynamic status (Gosling et al., 2013).
In the management of severely injured and bleeding patients a cornerstone
is represented by the early evaluation and correction of the trauma induced
coagulopathy. Resuscitation associated to physiologic impairment and to suddenly
activation and deactivation of several procoagulant and anticoagulant factors
contributes to the insurgence of this frequently deadly condition. The massive
transfusion protocol application is fundamental in managing bleeding patients. As
clearly demonstrated by the literature blood products, coagulation factors and
drugs administration has to be guided by a tailored approach through advanced
evaluation of the patient’s coaugulative asset. Some authors consider a normal
hemodynamic status when the patient does not require fluids or blood to maintain
blood pressure, without signs of hypoperfusion; hemodynamic stability as a
counterpart is the condition in which the patient achieve a constant or an
amelioration of blood pressure after fluids with a blood pressure >90 mmHg and
heart rate <100 bpm; hemodynamic instability is the condition in which the
patient has an admission systolic blood pressure <90 mmHg, or > 90 mmHg but
requiring bolus infusions/transfusions and/or vasopressor drugs and/or admission
base deficit (BD) >6 mmol/l and/or shock index > 1 and/or transfusion
requirement of at least 4–6 Units of packed red blood cells within the first
24 hours (Paydar et al., 2013).
The Advanced Trauma Life Support (ATLS) definition considers as
“unstable” the patient with: blood pressure < 90 mmHg and heart rate > 120 bpm,
with evidence of skin vasoconstriction (cool, clammy, decreased capillary refill),
altered level of consciousness and/or shortness of breath. The present
classification and guideline utilize the ATLS definition. Some authors suggested
that the sacroiliac joint disruption, female gender, duration of hypotension, an
hematocrit of 30% or less, pulse rate of 130 or greater, displaced obturator ring
fracture, a pubic symphysis diastasis can be considered good predictors of major
pelvic bleeding. However unfortunately the extent of bleeding is not always
related with the type of lesions and there is a poor correlation between the grade
of the radiological lesions and the need for emergent hemostasis (Mutschler et al.,
2013).

Management
Unstable Pelvic Fracture
Hemodinamic Control
1. Preperitoneal pelvic packing (PPP)
In the last 10 years PPP has gained popularity as a tool to control
venous bleeding in pelvic trauma. Since the first report from Pohlemann in
1994 and Ertel in 2001 many papers demonstrated this is a feasible, quick and
easy procedure. PPP has been already adopted in some centers as a key
maneuver for unstable patients. It can be accomplished both in the emergency
department (ED) and the operating room (OR). Our CC agreed that PPP can
be quickly done both in the shock room in the ED or in the OR, according to
local organization. In a mechanically unstable pelvic fracture PPP has to be
done together with fixation of the pelvis with EF, when feasible and possibile,
as indicated by Pohlemann, Ertel and Cothren as well as others authors. In
conclusion PPP is a pivotal procedure, as well as external stabilization, in the
emergency setting, both in the OR and the ED. When patient is in extremis
PPP, together with external stabilization can be life saving.
a. PPP is effective in controlling hemorrhage when used as part of a
multidisciplinary clinical pathway including AG and EF.
b. PPP is effective in controlling hemorrhage when used as a salvage
technique (Magnone et al., 2014).
PPP was performed by trauma surgeons who completed the Definitive
Surgical Trauma Care (DSTC) course provided by the International
Association for Trauma Surgery and Intensive Care (IATSIC). During the
procedure, the patient was placed supine and a 7–8-cm vertical skin incision
was made starting at the symphysis pubis (Fig. 1a). After vertically resecting
the anterior sheath of the rectus abdominis muscle and splitting the muscle,
the peritoneum was palpated using a fingertip. Blunt dissection was
performed through the preperitoneal space in the posterolateral direction to
palpate the lateral border of the sacroiliac (SI) joint. Medial migration of the
peritoneum with a Deaver retractor was used to improve the operative view
where necessary (Fig. 1b). Three surgical laparotomy pads were then packed
firmly from the near side of the SI joint using ringed forceps (Fig. 1c). The
same procedure was repeated on the contralateral side and skin was
approximated with a continuous suture. Then, external fixation was
performed according to the orthopedic surgeon’s decision. After PPP, patients
were sent to the trauma intensive care unit (TICU) and resuscitation and
transfusion were maintained until patients stabilized. After the patient’s
coagulopathy was sufficiently corrected, decisions regarding the need for a
second operation were made, and if possible, it was performed within 48 h.
During the second operation, the packed surgical laparotomy pads were
removed and the bleeder was controlled. Then, a closed suction drain was
 inserted into the preperitoneal space and fascia repair was performed (Fig.
1d). When the amount of drainage decreased below 50 cc, the drain catheter
was removed (Jang et al., 2014).

2. External fixation
The volume of the pelvis increases after a mechanically unstable
pelvic fracture. EF has always been the mainstay of emergency treatment in
order to reduce the volume of the pelvis and control hemorrhage. Two main
techniques are available to externally fix the unstable pelvic ring: external
fixator and C-Clamp. While the external fixator is indicated in type B
fractures, the pelvic C-clamp is used in unstable C type injuries, according to
AO/OTA classification. Placement of a C-Clamp or EPF decreases the pelvic
volume by 10% to 20% and reduces pelvic fractures. Whether this leads to
less blood loss and better outcomes has yet to be shown in the literature. The
standard use of external fixation in the initial treatment algorithms of patients
with unstable pelvic injuries is common and remains a useful tool in the
initial management of these patients. However, because of their ease of use
and fast application, TPBs have largely replaced the pelvic C-Clamp and EPF
for early mechanical stability in pelvic fracture (Daniel C et al., 2012).
Temporary binders are used to control the hemorrhage from the pelvic
fractures. These devices are very simple and quick to apply, and they can
 reduce the pelvic volume. However pelvic binders (PB) are not external
fixator because they do not provide mechanical stabilization of the pelvis and
they must be removed within 24 hours to avoid pressure sores on the patient.
The data confirming efficacy of pelvic binders in controlling hemorrhage
from pelvic fracture remain unclear because of conflicting studies in the
literature. The Consensus Conference considered EF a pivotal procedure in
presence of a mechanically unstable pelvic fracture and agreed that EF can be
performed both in the shock room in the ED or in the OR, according to the
local facilities. PB is a valid tool, mainly if applied in the prehospital setting,
as a bridge to fixation. It can provide an external stabilization that could be
life saving in patients in extremis. When EF is not possible (ie orthopedic
surgeon is on call during night hours) PB is a valid alternative, provided EF is
accomplished as soon as possible or the patient transferred to another facility.
a. PB should be applied as soon as pelvic mechanic instability is assessed,
better in the prehospital setting.
b. Anterior or posterior EF must be accomplished in unstable fractures as
soon as possible in substitution of PB.
c. EF can be accomplished in the ED or in the OR and appear to be a quick
tool to reduce venous and bony bleeding.
d. EF, whenever possible, can be the first maneuver to be done in patients
with hemodynamic instability and a mechanically unstable pelvic fracture
(Magnone et al., 2014).
3. Angiography
AG emerged in the ‘80s as a valid tool to control arterial bleeding and
for many years has been regarded in the vast majority of trauma centers as the
first-line treatment in unstable patients. On the other hand it has long
activation time, as teams are often on call and they are not present in the
hospital on a 24 hours basis. In the last years improvement of technology
allowed for portable instruments that can lower the threshold for indication
towards this method. Pelvic angiography with embolization seems to be 85%
to 97% effective in controlling bleeding. Some patients will continue to bleed
and require repeat embolization to control hemorrhage. 4.6% to 24.3% of
patients with either no bleeding seen on the initial angiogram or initially
successful pelvic embolization will require repeat pelvic angiography with
repeat embolization (Magnone et al., 2014).
Which Patients Require Emergent Angiography?
1. Patients with pelvic fractures and hemodynamic instability or signs of
ongoing bleeding after nonpelvic sources of blood loss have been ruled out
should be considered for pelvic angiography/embolization.
2. Patients with evidence of arterial intravenous contrast extravasation (ICE)
in the pelvis by CT may require pelvic angiography and embolization
regardless of hemodynamic status.
3. Patients with pelvic fractures who have undergone pelvic angiography
with or without embolization, who have signs of ongoing bleeding after
nonpelvic sources of blood loss have been ruled out, should be considered
for repeat pelvic angiography and possible embolization.
4. Patients older than 60 years with major pelvic fracture (open book,
butterfly segment, or vertical shear) should be considered for pelvic
angiography without regard for hemodynamic status.
5. Although fracture pattern or type does not predict arterial injury or need
for angiography, anterior fractures are more highly associated with anterior
vascular injuries, whereas posterior fractures are more highly associated
with posterior vascular injuries.
6. Pelvic angiography with bilateral embolization seems to be safe with few
major complications. Gluteal muscle ischemia/necrosis has been reported
in patients with hemodynamic instability and prolonged immobilization or
primary trauma to the gluteal region as the possible cause, rather than a
direct complication of angioembolization.
7. Sexual function in males does not seem to be impaired after bilateral
internal iliac arterial embolization (Daniel C et al., 2012).

The decisional algorithm

 During the Conference, after debating the statements, a draft for an
algorithm was proposed to the SC, the JP and the audience (Figure 2). A
formal consensus was reached on the use of PPP, as a first maneuver only, in
mechanically stable fractures of the pelvis. In mechanically unstable fractures
EF should be applied as a substitution of the PB as soon as possible even in
the ED or in the OR according to local protocols. PPP without any kind of
mechanical stabilization is not adequate, because it needs a stable frame for
packing to be effective. In the last few months the algorithm was written in
detail and conducted to a double pathway according to the local
expertise/availability of trauma surgeons/orthopedics.
In the unstable patient EF can be done in the ED or the OR. The
unanimous consent in the Conference regards the fact that AG is no more
considered the first maneuver in the unstable patient, but is considered only
for patients who remains unstable after EF and PPP.

Figure 2. Hemodinamically Unstable Pelvic Trauma Algorythm

(Magnone et al., 2014)
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