Management Update on Pelvic Fracture

A. 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 (Guthrie Hc et al., 2012;
Coccolini et al., 2017).

B. 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 (Solomon et al.,
2010).

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
(Guthrie Hc et al,. 2012; Netter, 2014).

Figure 2. Anatomy of the Pelvis (Netter., 2014)

 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 (Cocolini et al., 2017).

C. Pelvic instability
If the pelvis can withstand weightbearing loads without displacement,
it is stable; this situation exists only if the bony and key ligamentous
structures are intact. An anterior force applied to both halves of the pelvis
forces apart the symphysis pubis. If a diastasis occurs because of capsular
rupture, the extent of separation is checked by the anterior sacroiliac and
sacrospinous ligaments. Should these restraints fail through the application of
a still greater force, the pelvis opens like a book until the posterior iliac spines
abut; because the more vertically oriented long posterior sacroiliac and
sacrotuberous ligaments remain intact, the pelvis will still resist vertical shear
 but it is rotationally unstable. If, however, the posterior sacroiliac and
sacrotuberous ligaments are damaged, then the pelvis is not only rotationally
and vertically unstable, but there will also be posterior translation of the
injured half of the pelvis. Vertical instability is therefore ominous as it
suggests complete loss of the major ligamentous support posteriorly. It should
be remembered that some fracture patterns can cause instability which
mimics that of ligamentous disruption; e.g. fractures of both pubic rami may
behave like symphyseal disruptions, and fractures of the iliac wing combined
with ipsilateral pubic rami fractures are unstable to vertical shear (Solomon et
al., 2010).

D. 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).

E. Mechanisms of injuries
Principal mechanisms of injuries that cause a pelvic fracture are due to
a high energy impact as fall from height, sports, road traffic collision
(pedestrian, motorcyclist, motor vehicle, cyclist), person stuck by vehicles.
Ten to fifteen percent of patients with pelvic fractures arrive to the ED in
shock and one third of them will die reaching a mortality rate in the more
recent reports of 32%. The causes of dying are represented in the major part
by uncontrolled bleeding and by patient’s physiologic exhaustion (Cocolini et
al., 2017).
 The Young and Burgess classification is recomended for pelvic
fracture which is derived from the initial anteroposterior (AP) radiograph and
is based predominantly on the mechanism of injury and severity of pelvic
fracture.1 Fractures are divided into one of four categories based on the
mechanism of injury, two of which are further subdivided according to the
severity of injury.
1. Anterior posterior compression – secondary to a direct or indirect
force in an AP direction leading to diastasis of the symphysis pubis,
with or without obvious diastasis of the sacroiliac joint or fracture
of the iliac bone.
a. APC I: stable
pubic diastasis <2.5 cm
b. APC II: rotationally unstable, vertically stable
 pubic diastasis >2.5 cm
 disruption and diastasis of anterior part of sacroiliac joint,
with intact posterior sacroiliac joint ligaments
c. APC III: equates to a complete hemipelvis separation (but
without vertical displacement); unstable
 pubic diastasis >2.5 cm
 disruption-diastasis of both anterior and posterior
sacroiliac joint ligaments with dislocation
2. Lateral compression – lateral compression force, which cause
rotation of the pelvis inwards, leading to fractures in the sacroiliac
region and pubic rami.
a. LC I: stable
 oblique fracture of pubic rami
 ipsilateral anterior compression fracture of sacral ala
b. LC II: rotationally unstable, vertically stable
 fracture of pubic rami
  posterior fracture with dislocation of ipsilateral iliac wing
(crescent fracture)
c. LC III: unstable
 ipsilateral lateral compression (LC)
 contralateral anteroposterior compression (APC)
3. Vertical shear – an axial shear force with disruption of the iliac or
sacroiliac junction, combined with cephalic displacement of the
fracture component from the main pelvis.
4. Combined mechanism – a combination of two of the above
vectors, which leads to a pattern of pelvic fracture that is a
combination of one or more of the above fracture types (Guthrie
Hc; Owens R; Bircher, 2012).

Figure 3. Young and Burgees classification for skeletal pelvic lesions

(Guthrie Hc; Owens R; Bircher, 2012)

WSES Classification
The anatomical description of pelvic ring lesions is not definitive in
the management of pelvic injuries. The classification of pelvic trauma into
minor, moderate and severe considers the pelvic ring injuries anatomic
classification (Antero-Posterior Compression APC; Lateral Compression LC;
 Vertical Shear VS; CM: Combined Mechanisms) and more importantly, the
hemodynamic status. As already stated the 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
(Cocolini et al., 2017).
The WSES Classification divides Pelvic ring Injuries into three
classes:
1. Minor (WSES grade I) comprising hemodynamically and
mechanically stable lesions
2. Moderate (WSES grade II, III) comprising hemodynamically stable
and mechanically unstable lesions
3. Severe (WSES grade IV) comprising hemodynamically unstable
lesions independently from mechanical status.

F. Management
1. Early Management
Treatment should not await full and detailed diagnosis. It is vital to
keep a sense of priorities and to act on any information that is already
available while moving along to the next diagnostic hurdle. ‘Management’
in this context is a combination of assessment and treatment, following the
ATLS protocols. Six questions must be asked and the answers acted upon
as they emerge:
• Is there a clear airway?
• Are the lungs adequately ventilated?
• Is the patient losing blood?
• Is there an intra-abdominal injury?
• Is there a bladder or urethral injury?
• Is the pelvic fracture stable or unstable?
With any severely injured patient, the first step is to make sure that
the airway is clear and ventilation is unimpaired. Resuscitation must be
 started immediately and active bleeding controlled. The patient is rapidly
examined for multiple injuries and, if necessary, painful fractures are
splinted. A single anteroposterior x-ray of the pelvis is obtained. A more
careful examination is then carried out, paying attention to the pelvis, the
abdomen, the perineum and the rectum. The urethral meatus is inspected
for signs of bleeding. The lower limbs are examined for signs of nerve
injury. If the patient’s general condition is stable, further x-rays can then
be obtained. If a urethral tear is suspected, an urethrogram is gently
performed. The findings up to that stage may dictate the need for an
intravenous urogram. By now the examining doctor will have a good idea
of the patients general condition, the extent of the pelvic injury, the
presence or absence of visceral injury and the likelihood of continued
intra-abdominal or retroperitoneal bleeding. Ideally, a team of experts will
be on hand to deal with the individual problems or undertake further
investigations (Skinner HB, 2003; Solomon et al., 2010).

2. Management Of The Urethra And Bladder

Urological injury occurs in about 10 per cent of patients with pelvic
ring fractures. As these patients are often seriously ill from other injuries, a
urinary catheter may be required to monitor urinary output. There is no
place for passing a diagnostic catheter as this will most probably convert
any partial tear to a complete tear. For an incomplete tear, the insertion of a
suprapubic catheter as a formal procedure is all that is required. Around
half of all incomplete tears will heal and require little long-term
management. The treatment of a complete urethral tear is controversial.
Primary realignment of the urethra may be achieved by performing
suprapubic cystostomy, evacuating the pelvic haematoma and then
threading a catheter across the injury to drain the bladder. If the bladder is
floating high it is repositioned and held down by a sling suture passed
through the lower anterior part of the prostatic capsule, through the
perineum on either side of the bulbar urethra and anchored to the thighs by
 elastic bands. An alternative –and much simpler – approach is to perform
the cystostomy as soon as possible, making no attempt to drain the pelvis
or dissect the urethra, and to deal with the resulting stricture 4–6 months
later. The latter method is contraindicated if there is severe prostatic
dislocation or severe tears of the rectum or bladder neck. With both
methods there is a significant incidence of late stricture formation,
incontinence and impotence (Solomon et al., 2010; Atom A et al., 2013)
Primary reconstruction of the posterior urethral rupture is a simple
procedure that provides a low morbidity rate. It might be a treatment
option for the patients with no other intra–abdominal injuries or damages
of the other pelvic organs. But mostly, the surgical intervention for the
ruptured urethra in men should occur within several weeks after the injury.
Partial rupture of the anterior urethra in men is treated with suprapubic
catheter or urethral catheterization. Suprapubic cystostomy has an
advantage since in that case there is no need for urethral catheterization,
which may further exacerbate the condition of the urethra. Damage of the
urethra in women often occurs with rupture of the bladder and, therefore, it
is treated at the same time. Rarely, in cases of the proximal urethral
injuries, the transvesical approach might be used. In majority of cases
transvaginal reconstruction is successful (Atom A et al., 2013).

3. Hemodinamic Control on Unstable Pelvic Fracture

a. 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.
i. PPP is effective in controlling hemorrhage when used as part
of a multidisciplinary clinical pathway including AG and EF.
ii. 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).

Figure 4. Preperitoneal pelvic packing (Jang et al., 2014)

b. 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.
i. PB should be applied as soon as pelvic mechanic instability is
assessed, better in the prehospital setting.
ii. Anterior or posterior EF must be accomplished in unstable
fractures as soon as possible in substitution of PB.
iii. EF can be accomplished in the ED or in the OR and appear to
be a quick tool to reduce venous and bony bleeding.
 iv. 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).

Figure 5. Internal and External Fixation of the Pelvic Fracture

(Solomon et al., 2010)

c. Angiography
Angioraphy 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?
i. 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.
ii. Patients with evidence of arterial intravenous contrast
extravasation (ICE) in the pelvis by CT may require pelvic
angiography and embolization regardless of hemodynamic
status.
iii. 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.
iv. 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.
v. 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.
vi. 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.
 vii. 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 4). 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
(Magnone et al., 2014).
.
Figure 6. Hemodinamically Unstable Pelvic Trauma Algorythm
(Magnone et al., 2014)
Figure 7. The classification considers the Young-Burgees classification, the
hemodynamic status and the associated lesions (Cocolini et al., 2017).

4. Fracture Treatment
a. Isolated fractures and minimally displaced fractures
These injuries need only bed rest, possibly combined with
lower limb traction. Within 4–6 weeks the patient is usually
comfortable and may then be allowed up using crutches.
b. Open-book injuries
Provided the anterior gap is less than 2 cm and it is certain that
there are no displaced posterior disruptions, these injuries can usually
be treated satisfactorily by bed rest; a posterior sling or a pelvic binder
helps to close the book. The most efficient way of maintaining
 reduction is by external fixation with pins in both iliac blades
connected by an anterior bar; closing the book may also reduce the
amount of bleeding. Placing the pins is made easier if two temporary
pins are first inserted hugging the medial and lateral surfaces of each
iliac blade and then directing the fixing pins between them. Internal
fixation by attaching a plate across the symphysis should be
performed: (a) during the first few days after injury only if the patient
needs a laparotomy; and (b) later on if the gap cannot be closed by
less radical methods.
Fractures of the iliac blade can often be treated with bed rest.
However, if displacement is marked, or if there is an associated
anterior ring fracture or symphysis separation, then open reduction
and internal fixation with plates and screws will need to be considered
(e.g. in displaced LC-II injuries causing a leg length discrepancy
greater than 1.5 cm). It is also possible to reduce and hold some of
these fractures by external fixation.
c. APC-III and VS injuries
These are the most dangerous injuries and the most difficult to
treat. It may be possible to reduce some or all of the vertical
displacement by skeletal traction combined with an external fixator;
even so, the patient needs to remain in bed for at least 10 weeks. This
prolonged recumbency is not without risk. As these injuries represent
loss of both anterior and posterior support, both areas will need to be
stabilized. Two techniques are used: (a) anterior external fixation and
posterior stabilization using screws across the sacroiliac joint, or (b)
plating anteriorly and iliosacral screw fixation posteriorly. Posterior
operations are hazardous (the dangers include massive haemorrhage,
neurological damage and infection) and should be attempted only by
surgeons with considerable experience in this field. Persisting with
skeletal traction and external fixation is probably safer, though the
malposition is likely to leave a legacy of posterior pain. It should be
 emphasized that more than 60 per cent of pelvic fractures need no
fixation.
d. Open pelvic fractures
Open fractures are best managed by external fixation. A
diversion colostomy may be necessary (Solomon et al., 2010).

Indications for definitive surgical fixation of pelvic ring injuries

1. Posterior pelvic ring instability represents a surgical indication for
anatomic fracture reduction and stable internal fixation. Typical
injury patterns requiring surgical fixation include rotationally
unstable (APC-II, LC-II) and/or vertically unstable pelvic ring
disruptions (APC-III, LC-III, VS, CM).
2. Selected lateral compression patterns with rotational instability (LC-
II, L-III) benefit from adjunctive, temporary external fixation, in
conjunction to posterior pelvic ring fixation.
3. Pubic symphysis plating represents the modality of choice for
anterior fixation of “open book” injuries with a pubic symphysis
diastasis > 2.5 cm (APC-II, APC-III).
4. The technical modality of posterior pelvic ring fixation remains a
topic of debate, and individual decision-making is largely guided by
surgeons’ preference. Spinopelvic fixation has the benefit of
immediate weight bearing in patients with vertically unstable sacral
fractures.
5. Patients hemodynamically stable and mechanically unstable with no
other lesions requiring treatment and with a negative CT-scan can
proceed directly to definitive mechanical stabilization (Cocolini et
al., 2017).

Pelvic ring injuries with rotational or vertical instability require

surgical fixation with the goal of achieving anatomic reduction and
stable fixation as a prerequisite for early functional rehabilitation. There
is general consensus that pelvic ring disruptions with instability of
posterior elements require internal fixation. Trauma mechanism-guided
fracture classifications, including the widely used Young & Burgess
system, provide guidance for surgical indications for pelvic fracture
fixation For example, stable fracture patterns, such as antero-posterior
compression type 1 (APC-I) and lateral compression type 1 (LC-I)
injuries are managed non-operatively, allowing functional rehabilitation
and early weight bearing. In contrast, rotationally unstable APC-
II/APC-III (open book) injuries and LC-II fracture patterns (crescent
fracture), as well as rotationally and vertically unstable LC-III
(windswept pelvis), vertical shear (VS), and combined mechanism
(CM) fracture patterns require definitive internal fixation (Halawi MJ,
2015).
Multiple technical modalities of surgical fixation have been
described, including open reduction and anterior plating of pubic
symphysis disruptions, minimal-invasive percutaneous iliosacral screw
fixation for unstable sacral fractures and iliosacral joint disruptions,
plating of iliac wing fractures, and spino-pelvic fixation (named
“triangular osteosynthesis” in conjunction with iliosacral screw
fixation) or tension band plating for posterior pelvic ring injuries,
including vertically unstable sacral fractures. In addition, selected
lateral compression (LC) type injuries are occasionally managed with
temporary adjunctive external fixators for 6 weeks post injury, to
protect from rotational instability of the anterior pelvic ring. Minimal
invasive anterior “internal fixators” have been recently described as an
alternative technical option. The ultimate goal of internal fixation of
unstable pelvic ring injuries is to allow early functional rehabilitation
and to decrease long-term morbidity, chronic pain and complications
that have been historically associated with prolonged immobilization
(Jones CB, 2012).
 Ideal time-window to proceed with definitive internal pelvic fixation
1. Hemodynamically unstable patients and coagulopathic patients “in
extremis” should be successfully resuscitated prior to proceeding
with definitive pelvic fracture fixation.
2. Hemodynamically stable patients and “borderline” patients can be
safely managed by early definitive pelvic fracture fixation within
24 h post injury.
3. Definitive pelvic fracture fixation should be postponed until after
day 4 post injury in physiologically deranged politrauma patients
(Cocolini et al., 2017).

G. Complications
1. Thromboembolism
A careful watch should be kept for signs of deep vein thrombosis or
pulmonary embolism. Prophylactic anticoagulants are advocated in some
hospitals.
2. Sciatic nerve injury
It is essential to test for sciatic nerve function both before and after
treating the pelvic fracture. If the nerve is injured it is usually a
neuropraxia and one can afford to wait several weeks for signs of recovery.
Occasionally, though, nerve exploration is necessary.
3. Urogenital problems
Urethral injuries sometimes result in stricture, incontinence or
impotence and may require further treatment.
4. Persistent sacroiliac pain
Unstable pelvic fractures are often associated with partial or complete
sacroiliac joint disruption, and this can lead to persistent pain at the back
of the pelvis. Occasionally arthrodesis of the sacroiliac joint is needed
(Skinner HB, 2003; Jang et al., 2014).
 Daftar Pustaka

Atom A. Ter–Grigorian, George Kasyan, Dmitry Y. Pushkar (2013). Urogenital

disorders after pelvic ring injuries. Central Euro Journal Urology 2013; 66:
352-356

Coccolini F, Stahel P, Montori G, Biffl W, Moer T, Catena F, Kluger Y, et al,

(2017). Pelvic trauma: WSES classification and guidelines. World Journal of
Emergency Surgery 12:5.

Daniel C. Cullinane, Henry J. Schiller, Martin D, Zielinski, Jaroslaw W, Bilaniuk,

Bryan R. Collier. (2012). Eastern Association for the Surgery of Trauma
Practice Management Guidelines for Hemorrhage in Pelvic Fracture—Update
and Systematic Review. The Journal of TRAUMA® Injury, Infection, and
Critical Care:71( 6).

Goslings JC, Ponsen KJ, van Delden OM. Injuries to the pelvis and extremities.
In: ACS Surgery: Principles and Practice: Decker Intellectual Properties.
2013.

Guthrie Hc, Owens R, Bircher (2012). Focus On Pelvic Fractures. British

Editorial Society of Bone and Joint Surgery 2012.

Halawi MJ (2015). Pelvic ring injuries: Emergency assessment and management.

J Clin Orthop Trauma. 2015;6:252–8.

Jang Y, Shim Hongjin, Pil Young Jung, Seongyup Kim and Keum Seok Bae.
(2016). Preperitoneal pelvic packing in patients with hemodynamic instability
due to severe pelvic fracture: early experience in a Korean trauma center.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine ; 24
(3)

Jones CB (2012). Posterior pelvic ring injuries: when to perform open reduction
and internal fixation. Instr Course Lect. 2012;61:27–38.

Magnone et al. (2014). Management of hemodynamically unstable pelvic trauma:

results of the first Italian consensus conference (cooperative guidelines of the
Italian Society of Surgery, the Italian Association of Hospital Surgeons, the
Multi-specialist Italian Society of Young Surgeons, the Italian Society of
Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia,
Resuscitation and Intensive Care, the Italian Society of Orthopaedics and
Traumatology, the Italian Society of Emergency Medicine, the Italian Society
of Medical Radiology -Section of Vascular and Interventional Radiology- and
 the World Society of Emergency Surgery). World Journal of Emergency
Surgery, 9:18.

Mutschler M, Nienaber U, Brockamp T, et al. Renaissance of base deficit for the

initial assessment of trauma patients: a base deficit-based classification for
hypovolemic shock developed on data from 16,305 patients derived from the
TraumaRegister DGU(R). Crit Care. 2013;17:R42.

Netter FH (2014). Atlas of Human Anatomy 5th edition. USA: Elsevier

Paydar S, Ghaffarpasand F, Foroughi M, et al. Role of routine pelvic radiography

in initial evaluation of stable, high-energy, blunt trauma patients. Emerg Med
J. 2013;30:724–7.

Skinner HB (2003). Current diagnosis & treatment in orthopedics- 3rd ed. New
York: McGraw-Hill Medical Publishers

Solomon L, Warwick D, Nayagam S (2010). Apley’s: System of Orthopaedics and

Fractures Ninth Edition. UK: University of Bristol, pp: 337, 341-2, 351-2.