Emergency Medicine
Orthopaedic Surgery
Trauma Surgery
Emergency
High Evidence

Pelvic Fracture Trauma

Pelvic fractures represent high-energy injuries with significant mortality, primarily due to haemorrhage. Immediate mana... ACEM Fellowship Written, ACEM Fellow

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Urgent signals

Safety-critical features pulled from the topic metadata.

  • Hemodynamic instability with suspected pelvic fracture
  • Open book or vertical shear injuries
  • Active arterial bleeding on CT (contrast blush)
  • Associated abdominal/rectal/urethral injuries

Exam focus

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  • ACEM Fellowship Written
  • ACEM Fellowship OSCE

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ACEM Fellowship Written
ACEM Fellowship OSCE
Clinical reference article

Pelvic Fracture Trauma

Quick Answer

Pelvic fractures represent high-energy injuries with significant mortality, primarily due to haemorrhage. Immediate management: apply pelvic binder (greater trochanter level), initiate Massive Transfusion Protocol (MTP 1:1:1), perform FAST scan. Haemodynamic instability algorithm: FAST positive → laparotomy; FAST negative → pelvic angiography/embolization or pre-peritoneal pelvic packing. Young-Burgess classification guides management: lateral compression (LC), anteroposterior compression (APC), vertical shear (VS), combined mechanism. Definitive haemorrhage control: angioembolization for arterial bleeding (~10-15% cases), pre-peritoneal packing for venous/bone bleeding (~80-90% cases), or combined approach. Complications: urological injury (10-20%), nerve injury (10-50% in sacral fractures), long-term disability (up to 40% chronic pain).

ACEM Exam Focus

Primary Written

  • Pelvic anatomy: osteology, ligaments, neurovascular structures
  • Young-Burgess and Tile classification systems
  • Biomechanics of pelvic ring stability
  • Radiological interpretation (AP pelvis, inlet/outlet views, CT)

Primary Viva

  • Describe the anatomy of the pelvic ring and its stabilising ligaments
  • Explain the mechanism of haemorrhage in pelvic fractures
  • Classify pelvic fractures according to Young-Burgess
  • Discuss the indications for external fixation vs. pelvic binder

Fellowship Written

  • Management algorithm for haemodynamically unstable pelvic fracture
  • Role of pelvic binder: indications, contraindications, complications
  • Massive transfusion protocol in pelvic trauma
  • Comparison of angioembolization vs. pre-peritoneal pelvic packing

Fellowship OSCE

  • Resuscitation station: lead management of unstable pelvic fracture
  • Communication station: discuss prognosis with family of critical patient
  • Procedure station: demonstrate correct pelvic binder application
  • Clinical reasoning: interpret pelvic CT with contrast blush

Key Points

  1. Pelvic binder placement must be at greater trochanter level, NOT iliac crests. Incorrect placement fails to stabilise the pelvic ring.

  2. Haemorrhage source: 80-90% venous/presacral plexus and bone surface, 10-15% arterial (internal iliac branches). Pelvic binder controls venous bleeding; angioembolization controls arterial bleeding.

  3. Young-Burgess classification: APC I-III (open book), LC I-III (lateral compression), VS (vertical shear), Combined. APC III and VS carry highest mortality.

  4. FAST scan dictates next step: FAST positive (intraperitoneal blood) → laparotomy ± pre-peritoneal packing. FAST negative (retroperitoneal bleed) → angioembolization or pre-peritoneal packing.

  5. Massive Transfusion Protocol: 1:1:1 ratio (PRBC:FFP:platelets) based on PROPPR trial. Tranexamic acid 1g loading + 1g infusion over 8h (within 3h of injury).

  6. Pre-peritoneal pelvic packing is faster (20-45 mins) than angioembolization (90+ mins) and preferred for patients in extremis. Mortality 21-32% in PPP cohorts.

  7. Mortality: 5-15% overall, 30-50% with haemodynamic instability. Predictors: age greater than 60, ISS greater than 25, arterial contrast blush, systolic BP below 90 mmHg, base deficit greater than 6.

  8. Indigenous Australians have 2-3x higher incidence of transport-related trauma. Remote/rural patients face higher pre-hospital mortality due to retrieval delays.

Epidemiology

Incidence and Demographics

Pelvic fractures represent 20-37 per 100,000 population annually, with a bimodal age distribution:

  • Young adults (20-40 years): High-energy mechanisms (motor vehicle crashes, falls from height, pedestrian vs. vehicle). Male predominance (M:F 2:1).

  • Elderly (greater than 65 years): Low-energy mechanisms (falls from standing height). Fragility fractures increasing due to osteoporosis. Female predominance.

Mortality Rates

  • Overall mortality: 5-15% for all pelvic fractures
  • Haemodynamically unstable: 30-50% mortality
  • Open pelvic fractures: 25-50% mortality
  • With arterial bleeding: Up to 50% mortality

Australian Context

  • Pelvic ring injuries in Australian major trauma centres: Shifting toward elderly fragility fractures while maintaining high-energy protocols. Study shows mortality remains high despite advances in resuscitation.

  • Regional vs. metropolitan disparities: Major trauma patients in regional Australia have significantly higher mortality compared to metropolitan counterparts, even when accounting for injury severity. Retrieval delays impact the "golden hour" for pelvic haemorrhage control.

  • Indigenous Australians: 2-3 times higher incidence of transport-related trauma hospitalisation. Higher proportion living in remote areas where high-speed MVCs are common.

Anatomy

Pelvic Ring Structure

The pelvic ring consists of:

  1. Anterior arch: Pubic symphysis, superior and inferior pubic rami
  2. Posterior arch: Sacrum, sacroiliac (SI) joints, iliac bones

Stabilising Ligaments

Posterior ligaments (primary stability):

  • Sacrotuberous ligament: S2-4 to ischial tuberosity. Resists vertical shear.
  • Sacrospinous ligament: S3-5 to ischial spine. Resists external rotation.
  • Sacral iliac ligaments: Anterior, interosseous, posterior SI ligaments. Resists rotation and translation.

Anterior ligaments (secondary stability):

  • Pubic symphysis: Fibrocartilaginous disc, superior/inferior pubic ligaments
  • Inguinal ligament: Poupart's ligament

Pelvic floor: Levator ani, coccygeus muscles. Provides "floor" to contain pelvic contents.

Neurovascular Structures

Arterial supply:

  • Internal iliac artery: Branches to superior gluteal, inferior gluteal, obturator, internal pudendal, lateral sacral arteries. Site of arterial bleeding in 10-15% of pelvic fractures.
  • External iliac artery: Femoral, deep circumflex iliac arteries
  • Common iliac artery: Proximal to bifurcation

Venous plexus:

  • Presacral venous plexus: Major source of venous bleeding (80-90% of cases)
  • Pelvic sidewall venous plexus
  • Retropubic venous complex (Santorini's plexus): Anterior to bladder, prone to injury in pubic rami fractures

Nerves:

  • Lumbosacral plexus: L4-S5 roots. L5 and S1 most vulnerable as they cross SI joint and sacral alae.
  • Sacral nerve roots: Exits through sacral foramina. Denis classification predicts neurological deficit.
  • Pudendal nerve: Alcock's canal (obturator fascia). Injury leads to incontinence and sexual dysfunction.
  • Sciatic nerve: Posterior to SI joint.

Urological Structures

  • Bladder: Intraperitoneal (dome) vs. extraperitoneal (base). Extraperitoneal rupture associated with pubic rami fractures.
  • Urethra: Posterior (membranous/prostatic) urethra in males, associated with pubic symphysis diastasis. Anterior urethra less commonly injured.
  • Ureter: Crosses iliac vessels at pelvic brim. Injury rare but possible in high-energy fractures.

Classification Systems

Young-Burgess Classification

Based on mechanism of injury, guides management and predicts haemorrhage risk.

Anteroposterior Compression (APC)

  • APC I: Below 2.5 cm pubic symphysis diastasis, SI joint ligaments intact. Stable. Low haemorrhage risk.
  • APC II: 2.5-5 cm pubic symphysis diastasis, anterior SI ligaments disrupted, posterior SI ligaments intact. Rotationally unstable. Moderate haemorrhage risk.
  • APC III: greater than 5 cm pubic symphysis diastasis ("open book"), complete SI joint disruption. Rotationally and vertically unstable. High haemorrhage risk (venous plexus disruption).

Lateral Compression (LC)

  • LC I: Transverse fractures of pubic rami, sacral impaction (crescent fracture). Stable. Low haemorrhage risk.
  • LC II: Ipsilateral SI joint disruption or iliac wing fracture, contralateral SI joint intact. Rotationally unstable. Moderate haemorrhage risk.
  • LC III: Ipsilateral LC II + contralateral anterior SI disruption ("windswept pelvis"). Rotationally and vertically unstable. High haemorrhage risk.

Vertical Shear (VS)

  • Complete disruption of SI joint and symphysis, vertical displacement of hemipelvis. Vertically unstable. Highest haemorrhage risk (tears presacral venous plexus). Mortality up to 50%.

Combined Mechanism

  • Combination of APC, LC, and VS patterns. Unpredictable haemorrhage risk.

Tile Classification

Based on stability. Three main types:

  • Type A: Stable (avulsion fractures, minimal displacement). No pelvic ring disruption.
  • Type B: Rotationally unstable but vertically stable (APC I-II, LC I-II). Pelvic binder effective.
  • Type C: Rotationally and vertically unstable (APC III, LC III, VS, combined). Requires definitive fixation (external or internal).

Mechanism of Haemodynamic Instability

Sources of Haemorrhage

  1. Venous bleeding (80-90%): Presacral venous plexus, pelvic sidewall veins, retropubic venous complex. Low-pressure, tamponaded by pelvic binder and pre-peritoneal packing.

  2. Arterial bleeding (10-15%): Branches of internal iliac artery (superior gluteal, obturator, internal pudendal). High-pressure, causes rapid exsanguination. Requires angioembolization.

  3. Bone bleeding: Fracture surfaces of iliac wings, sacrum, pubic rami. Contributes 5-10% of blood loss.

Pathophysiology

  • Pelvic volume increase: APC injuries open the pelvic ring, increasing pelvic volume by 30-40%. This disrupts the "tamponade effect" and allows continued bleeding from venous plexus.
  • Pelvic binder reduces pelvic volume, restores tamponade, and stabilises fracture fragments.
  • Associated injuries: Long bone fractures (femur, tibia) contribute 500-2000 mL blood loss per fracture. Solid organ injury (liver, spleen) causes intraperitoneal bleeding.

Haemodynamic Instability Indicators

  • Systolic BP below 90 mmHg on arrival
  • Heart rate greater than 120 bpm
  • Base deficit greater than 6 or lactate greater than 4 mmol/L
  • Transfusion requirement greater than 4 units PRBC in first hour
  • Need for ongoing vasopressors despite resuscitation

Clinical Approach

Primary Survey (ABCDE)

A: Airway with C-spine protection

  • Rapid sequence intubation if GCS below 9, respiratory distress, or requirement for urgent angioembolization.
  • C-spine immobilisation until cleared (high-energy mechanism).

B: Breathing

  • Assess for pneumothorax, haemothorax, pulmonary contusion.
  • Chest tube if indicated.
  • Ventilation strategy: permissive hypercapnia (PaCO2 45-55 mmHg) if no TBI to reduce pelvic venous pressure.

C: Circulation with haemorrhage control

IMMEDIATE ACTIONS:

  1. Apply pelvic binder at greater trochanter level
  2. Initiate Massive Transfusion Protocol (MTP 1:1:1)
  3. Obtain vascular access: 2 large-bore IVs (14-16G) or rapid infuser
  4. Administer Tranexamic acid: 1g IV over 10 min, then 1g infusion over 8h (within 3h of injury)
  5. Perform FAST scan: Assess for intraperitoneal blood
  6. Obtain crossmatch: 10 units PRBC, 10 units FFP, 2 apheresis platelets

Pelvic binder application:

  • Place at greater trochanter level (mid-inguinal line), NOT iliac crests
  • Apply with patient supine on backboard
  • Tighten until pelvic volume reduced and haemodynamics improve
  • Do NOT apply over clothing (remove to assess skin)
  • Contraindications: Posterior skin wounds, severe swelling, contraindicated pregnancy
  • Complications: Skin necrosis (if left greater than 24h), pressure sores, nerve compression

Massive Transfusion Protocol:

  • PROPPR trial established 1:1:1 ratio (PRBC:FFP:platelets) reduces death from exsanguination by 30% compared to 1:1:2 ratio.
  • Pelvic fracture-specific: High plasma ratios (greater than 1:1.5) independently associated with decreased 24-hour mortality.
  • Time to transfusion: Every 10-minute delay increases mortality. First unit plasma within 30 minutes reduces 30-day mortality by 40%.

Tranexamic acid:

  • Indicated within 3 hours of injury
  • Loading dose: 1g IV over 10 min
  • Maintenance: 1g infusion over 8h
  • CRASH-2 trial showed 15% relative risk reduction in all-cause mortality.

D: Disability

  • GCS assessment, pupil examination
  • Identify associated head injury (contraindicates permissive hypotension)
  • Check for neurological deficit in lower limbs (lumbosacral plexus)

E: Exposure/Environmental control

  • Full log roll to assess posterior injuries
  • Rectal examination: blood, high-riding prostate, sphincter tone
  • Vaginal examination in females: blood, open wounds
  • Remove clothing completely, keep patient warm

Investigations

Immediate (Primary Survey)

  • Pelvic X-ray (AP view): Bedside portable. Assess pubic symphysis diastasis, SI joint widening, femoral head position. Limited sensitivity (~60%).

  • FAST (Focused Assessment with Sonography for Trauma):

    • "Positive: Intraperitoneal fluid in Morrison's pouch, splenorenal recess, or pelvis."
    • FAST positive + unstable → laparotomy (suspect solid organ injury)
    • FAST negative + unstable → pelvic source (consider angioembolization or packing)

  • Serum lactate and base deficit:

    • Lactate greater than 4 mmol/L predicts mortality (sensitivity 85%, specificity 75%)
    • Base deficit greater than 6 predicts massive transfusion requirement

Secondary Survey

  • Inlet view: AP view with 40° cephalad tilt. Visualises SI joints, sacral wing, sacral foramina. Assesses posterior ring displacement.

  • Outlet view: AP view with 40° caudal tilt. Visualises sacral dome, vertical displacement. Assesses rotational and vertical instability.

  • CT scan (once stabilised):

    • "CT pelvis with IV contrast: Gold standard for pelvic fracture assessment."
    • "Contrast blush: Active arterial extravasation. Indicates arterial bleeding (10-15% cases). Sensitivity 90%, specificity 100%."
    • "Fracture classification: Coronal and sagittal reconstructions aid Young-Burgess classification."
    • "3D reconstructions: Useful for pre-operative planning."

Laboratory

  • Full blood count: Haemoglobin, platelet count
  • Coagulation profile: PT/INR, aPTT, fibrinogen
  • Blood gas: pH, base deficit, lactate
  • Electrolytes: Calcium (ionised calcium below 1.0 mmol/L associated with increased mortality)
  • Type and screen: 10 units PRBC crossmatched
  • Viscoelastic testing (TEG/ROTEM) if available: Guides blood product administration and predicts transfusion requirements.

Management

Initial Stabilisation

Step 1: Mechanical Stabilisation

Pelvic binder:

  • Indications: Suspected unstable pelvic fracture with haemodynamic instability.
  • Apply at greater trochanter level.
  • Tighten until haemodynamics improve.
  • Reassess after application: BP improvement, decreased transfusion requirement.
  • Remove within 24 hours to prevent skin complications. Replace with external fixation if still required.

Pelvic C-clamp:

  • Indications: Posterior ring instability (APC III, VS), severe haemorrhage refractory to binder.
  • Applied under anaesthesia (painful).
  • Pins inserted into posterior iliac wings.
  • Provides superior posterior compression compared to binder.
  • Complications: Pin-site infection (10%), nerve injury (5%), iatrogenic fracture (3%).

External fixator:

  • Indications: Anterior pelvic ring stabilisation, bridge to definitive fixation.
  • Pins in iliac crest (anterior superior iliac spine).
  • Less effective for posterior instability.
  • Useful in open pelvic fractures or abdominal injuries requiring laparotomy.

Step 2: Resuscitation

Massive Transfusion Protocol (MTP):

  • Ratio: 1:1:1 (PRBC:FFP:platelets) or 1:1:2 if platelets unavailable.
  • PROPPR trial: 1:1:1 reduced 24-hour mortality from 11.1% to 9.2% (p=0.03).
  • Blood products:
    • "PRBC: O-negative or type-specific"
    • "FFP: Thawed plasma"
    • "Platelets: Apheresis platelets (1 pack = 6 random donor platelets)"
    • "Cryoprecipitate: If fibrinogen below 1.5 g/L"
    • "Calcium gluconate: 1g after every 4 units PRBC (ionised calcium monitoring)"

Hemostatic resuscitation:

  • Permissive hypotension: Target MAP ~65 mmHg until haemorrhage controlled (unless TBI present).
  • Avoid excessive crystalloids: Dilutes clotting factors, worsens coagulopathy.
  • Viscoelastic testing: TEG/ROTEM guides targeted therapy (e.g., fibrinogen concentrate).

Adjuncts:

  • Tranexamic acid: 1g loading + 1g infusion (CRASH-2 trial).
  • Recombinant factor VIIa: Consider if refractory coagulopathy (off-label).
  • REBOA (Resuscitative Endovascular Balloon Occlusion of Aorta): Consider in profound shock refractory to standard measures. Zone III (infrarenal) for pelvic haemorrhage. Combined with MTP + REBOA significantly improves MAP and survival to OR compared to MTP alone.

Definitive Haemorrhage Control

Decision Algorithm

Haemodynamically Unstable + Pelvic Fracture
         ↓
Apply Pelvic Binder + Initiate MTP
         ↓
FAST Scan
         ↓
    FAST Positive          FAST Negative
         ↓                        ↓
  Laparotomy ± PPP    Assess CT if transiently stable
   (Intra-abdominal)   OR
         ↓              Angioembolization vs. PPP
   If ongoing instability (Retroperitoneal)
   ↓
   PPP or Angioembolization

Option 1: Angiographic Embolization (AE)

Indications:

  • Hemodynamically unstable with FAST negative
  • Contrast blush on CT (active arterial extravasation)
  • Ongoing instability despite pelvic binder and MTP
  • Delayed haemorrhage (greater than 24h after admission)

Procedure:

  • Access: Common femoral artery (percutaneous)
  • Selective catheterisation of internal iliac arteries
  • Embolic agents: Gelfoam coils, microcoils, NBCA glue
  • Non-selective embolization: Bilateral internal iliac (last resort)

Efficacy:

  • Success rate: 80-90% for arterial bleeding
  • Time to procedure: 90+ minutes
  • Mortality: 20-35% (reflects severity of injury)

Limitations:

  • Ineffective for venous bleeding (80-90% of cases)
  • Requires transport to IR suite (unstable patient risk)
  • Contrast nephropathy (consider in renal dysfunction)
  • Iatrogenic vascular injury (1-3%)

Complications:

  • Gluteal muscle necrosis (bilateral internal iliac embolization)
  • Sciatic nerve injury (rare)
  • Access site complications: haematoma, pseudoaneurysm

Option 2: Pre-peritoneal Pelvic Packing (PPP)

Indications:

  • Hemodynamically unstable with FAST negative
  • Patients in extremis (moribund) where AE would be too slow
  • Venous/presacral bleeding (most common)
  • No facilities for AE or prolonged transfer time

Procedure:

  • Suprapubic midline incision (Pfannenstiel or vertical)
  • Retract bladder extraperitoneally
  • Packs placed in paravesical spaces, presacral space
  • 3-4 laparotomy pads each side
  • Closure: Temporary (AbThera) or delayed

Efficacy:

  • Systematic review shows PPP successfully achieves initial haemodynamic stability in 70-90% of cases.
  • Average mortality: 21-32% (reflects severity)
  • Time to procedure: 20-45 minutes (faster than AE)

Advantages:

  • Controls venous bleeding (80-90% of haemorrhage)
  • Can be done in OR or ED
  • Faster than AE
  • No contrast nephrotoxicity

Limitations:

  • Does not address arterial bleeding
  • Requires return to OR for pack removal (24-48h)
  • Surgical site infection (10-15%)
  • Pelvic abscess (5-10%)

Complications:

  • Infection: SSI, pelvic abscess
  • Bleeding: Continued arterial bleeding requiring secondary AE (13-26%)
  • Bowel injury: Retropubic dissection
  • Urinary tract injury: Bladder, ureter

Option 3: Combined Approach (PPP + AE)

Indications:

  • Severe haemorrhage refractory to PPP alone
  • Mixed venous and arterial bleeding
  • Massive pelvic disruption (APC III, VS)

Approach:

  • PPP performed first for rapid control
  • Transfer to IR for AE once stabilised
  • Or hybrid OR with on-table angiography

Definitive Orthopaedic Management

Indications for Surgical Fixation

  • Unstable pelvic ring (Tile B2, B3, C1-C3)
  • Displaced fractures (greater than 1 cm displacement)
  • Open pelvic fractures
  • Symptomatic non-union or malunion

Timing

  • Early fixation (within 24h): Improves outcomes in haemodynamically stable patients.
  • Delayed fixation: After resuscitation (24-72h) in unstable patients.

Techniques

  1. External fixation: Temporary stabilisation, bridge to definitive surgery.
  2. Open reduction internal fixation (ORIF): Anterior (plate and screws), posterior (iliac screws, transiliac bars).
  3. Percutaneous screw fixation: Sacroiliac screws, sacral screws (fluoroscopic or navigation-guided).
  4. Subcutaneous internal fixation (INFIX): Anterior subcutaneous pelvic fixator (bridges pelvis, avoids external pins).

Complications

Haemorrhagic Complications

  • Exsanguination: Leading cause of early death (within 6h).
  • Coagulopathy: Trauma-induced coagulopathy exacerbated by dilution from massive transfusion.
  • Re-bleeding: 10-15% of patients develop delayed haemorrhage (venous thrombus disruption, pseudoaneurysm rupture).

Urological Complications

Bladder injury (3-10%):

  • Extraperitoneal rupture: Associated with pubic rami fractures. Management: Indwelling catheter 10-14 days.
  • Intraperitoneal rupture: Full bladder at impact. Management: Surgical repair.

Urethral injury (5-10% males):

  • Posterior urethra: Membranous/prostatic urethra disruption. Associated with pubic symphysis diastasis. Management: Suprapubic catheter, delayed reconstruction (3-6 months).
  • Anterior urethra: Bulbar urethra injury. Management: Primary repair if early (within 24h).

Long-term: Stricture, incontinence, impotence, urethral diverticulum.

Neurological Complications

Lumbosacral plexus injury (10-50% in sacral fractures):

  • Denis classification:
    • "Zone I (alar): Zone I injuries have 6% neurological deficit rate"
    • "Zone II (foramen): Zone II injuries have 28% neurological deficit rate"
    • "Zone III (central canal): Zone III injuries have 56% neurological deficit rate"
  • Deficits: Foot drop (L5), sensory loss (L5, S1), bowel/bladder dysfunction (cauda equina).
  • Management: Decompression if nerve root compression, supportive care.

Orthopaedic Complications

  • Malunion: Pelvic obliquity, leg length discrepancy, chronic pain.
  • Non-union: More common in vertically unstable fractures.
  • Post-traumatic OA: Sacroiliac joint, hip joint.
  • Heterotopic ossification: Posterior approaches.

Infectious Complications

  • Surgical site infection: 10-15% in PPP, 5-10% in ORIF.
  • Pelvic abscess: 5-10% in PPP.
  • Osteomyelitis: Rare, usually associated with open fractures.

Thromboembolic Complications

  • Deep vein thrombosis: 20-30% without prophylaxis.
  • Pulmonary embolism: 2-5% fatal PE.
  • Prophylaxis: LMWH (enoxaparin 40mg SC daily) once haemostasis achieved (24-48h). IVC filter if contraindication to anticoagulation.

Long-Term Disability

  • Chronic pelvic pain: Up to 40% of survivors.
  • Gait abnormality: 20-30% due to limb length discrepancy or instability.
  • Sexual dysfunction: 10-15% (nerve injury, urethral stricture).
  • Return to work: 50-70% return to pre-injury employment.

Special Populations

Indigenous Australians

Epidemiology:

  • 2-3 times higher incidence of transport-related trauma hospitalisation compared to non-Indigenous Australians.
  • Higher proportion living in remote areas where high-speed MVCs and pedestrian-vehicle accidents are common.

Barriers to care:

  • Geographic isolation: Prolonged retrieval times delay definitive haemorrhage control.
  • Cultural factors: Reluctance to seek medical care, language barriers.
  • Socioeconomic disadvantage: Higher burden of comorbidities.

Cultural safety:

  • Respect cultural protocols (e.g., avoid eye contact, allow family presence).
  • Involve Aboriginal Health Workers or Indigenous Liaison Officers.
  • Communicate using plain language, avoid medical jargon.
  • Acknowledge kinship systems and decision-making structures.

Outcomes:

  • Similar in-hospital survival when reaching Level 1 trauma centre.
  • Higher long-term morbidity due to barriers to rehabilitation.
  • Increased risk of readmission due to socioeconomic factors.

Māori (New Zealand)

Epidemiology:

  • Higher incidence of motor vehicle trauma and falls from height.
  • Over-representation in rural and remote communities.

Cultural considerations:

  • Whānau (family) involvement in decision-making.
  • Tikanga Māori (Māori customs) around death and dying (e.g., karakia, tangihanga).
  • Consultation with kaumātua (elders) for major decisions.

Barriers to care:

  • Geographic isolation in rural communities.
  • Distrust of medical system due to historical trauma.

Remote/Rural Context

Challenges:

  • Prolonged transport times: "Golden hour" often exceeded before definitive care.
  • Limited blood products: Rural hospitals may have inadequate inventory for massive transfusion.
  • Lack of interventional radiology: Angioembolization not available.
  • Limited orthopaedic expertise: External fixation may be only option.

Royal Flying Doctor Service (RFDS):

  • Pre-hospital pelvic binder application by RFDS retrieval team.
  • Blood products available on retrieval missions (O-negative, plasma).
  • Telemedicine support for rural practitioners.

Management adaptations:

  • Early pelvic binder: Critical for long retrievals.
  • Permissive hypotension: Maintain until arrival at trauma centre.
  • Whole blood: Low-titer O-positive if available (more efficient than component therapy).
  • REBOA: Emerging for rural/remote use (bridge to transfer).

Disposition:

  • Transfer to Level 1 trauma centre if any of:
    • Haemodynamic instability
    • APC III, LC III, or VS injuries
    • Contrast blush on CT
    • Associated severe injuries (TBI, solid organ)

Elderly Patients

Epidemiology:

  • Increasing incidence of low-energy fragility fractures.
  • Higher mortality due to comorbidities.

Management adaptations:

  • Less aggressive resuscitation (avoid fluid overload).
  • Lower threshold for surgical fixation (early mobilisation).
  • Consider osteoporosis management (bisphosphonates, calcium, vitamin D).

Prognosis:

  • Higher 30-day mortality (20-30%) compared to younger patients.
  • Increased complications (pneumonia, UTI, delirium).
  • Poorer functional outcomes (only 40% return to independent living).

Disposition

Admission Criteria

  • All unstable pelvic fractures (Tile B2-B3, C1-C3)
  • Any pelvic fracture with haemodynamic instability
  • Associated injuries: TBI, solid organ, long bone fractures
  • Open pelvic fractures
  • Patients requiring massive transfusion

Safe Discharge (Rare)

Indications:

  • Stable Tile A fractures (avulsion fractures)
  • Haemodynamically stable
  • No associated injuries
  • Reliable social support
  • Close follow-up arranged

ICU Admission

  • Haemodynamically unstable despite resuscitation
  • Ongoing massive transfusion (greater than 4 units PRBC)
  • Severe associated injuries (TBI, multi-trauma)
  • Post-operative monitoring after PPP or AE

Transfer Criteria

Transfer to Level 1 Trauma Centre if:

  • Haemodynamic instability
  • APC III, LC III, or VS injuries
  • Contrast blush on CT
  • Need for interventional radiology or complex surgery
  • Lack of blood product inventory at referring hospital

Pitfalls and Pearls

Common Mistakes

  1. Incorrect pelvic binder placement: Applying at iliac crests rather than greater trochanters. Pearl: Mark greater trochanters before applying binder.

  2. Pelvic springing: Repeatedly compressing pelvis to assess stability. Disrupts clots, worsens bleeding. Pearl: Assess stability once, then apply binder.

  3. Delaying pelvic binder: Waiting for X-ray confirmation before applying. Pearl: Apply empirically if high-energy mechanism and any pelvic pain or deformity.

  4. Over-reliance on angioembolization: AE only controls arterial bleeding (10-15% cases). Pearl: Consider PPP for rapid control in unstable patients.

  5. Missing associated injuries: Forgetting rectal, vaginal, and neurological examinations. Pearl: Log roll and examine perineum in all pelvic fractures.

  6. Inadequate resuscitation: Under-transfusion or excessive crystalloids. Pearl: Initiate MTP early, aim for 1:1:1 ratio.

  7. Leaving pelvic binder greater than 24h: Causes skin necrosis and pressure sores. Pearl: Set reminder to remove/replace within 24h.

  8. Missing posterior instability: Relying only on AP pelvis X-ray. Pearl: Obtain inlet/outlet views and CT to assess posterior ring.

Exam Pearls

  • ACEM viva: Describe Young-Burgess classification (APC, LC, VS, Combined). Emphasise that APC III and VS have highest mortality.

  • ACEM OSCE: Pelvic binder application. Demonstrate correct placement at greater trochanters. Check neurovascular status after application.

  • Written exam: Remember mortality rates: 5-15% overall, 30-50% with haemodynamic instability.

  • SAQ: For haemodynamic management, emphasize: (1) Pelvic binder, (2) MTP 1:1:1, (3) FAST scan, (4) Decision algorithm (FAST+ vs. FAST-).

Viva Practice

Viva 1: Pelvic Fracture Classification and Management

Examiner: "A 35-year-old male presents after a high-speed motorcycle crash. He has a pelvic fracture on X-ray and is hypotensive. Walk me through your immediate management."

Candidate: "My immediate priorities are:

  1. ABC assessment with haemorrhage control:

    • Secure airway if GCS below 9 or respiratory distress
    • Apply pelvic binder immediately at greater trochanter level
    • Initiate Massive Transfusion Protocol (MTP 1:1:1 ratio)
    • Obtain 2 large-bore IVs and rapid infuser
    • Administer tranexamic acid 1g loading + 1g infusion

  2. Diagnostic assessment:

    • Perform FAST scan
    • Obtain portable AP pelvis X-ray
    • Send bloods: CBC, coagulation, blood gas, lactate

  3. Decision algorithm:

    • If FAST positive (intraperitoneal blood): Proceed to laparotomy ± pre-peritoneal pelvic packing
    • If FAST negative (retroperitoneal bleed): Consider angioembolization or pre-peritoneal packing based on institutional availability and patient stability

  4. Classify the fracture using Young-Burgess:

    • APC: Anteroposterior compression (open book)
    • LC: Lateral compression
    • VS: Vertical shear
    • Combined mechanism

  5. Definitive haemorrhage control:

    • Angioembolization for arterial bleeding (contrast blush on CT)
    • Pre-peritoneal packing for venous bleeding (80-90% of cases)
    • Combined approach if refractory

  6. Definitive fixation:

    • External fixation (temporary)
    • ORIF (once stabilised)
    • Percutaneous sacroiliac screws"

Examiner: "What are the indications for angioembolization vs. pre-peritoneal packing?"

Candidate: "Angioembolization is indicated for:

  • Haemodynamically unstable with FAST negative
  • Contrast blush on CT (active arterial extravasation)
  • Ongoing instability despite binder and MTP
  • Delayed haemorrhage (greater than 24h after admission)

Pre-peritoneal packing is indicated for:

  • Patients in extremis where AE would be too slow
  • Venous/presacral bleeding (80-90% of haemorrhage)
  • No facilities for AE or prolonged transfer time

Current consensus favours a 'PPP-first' approach in unstable patients, followed by AE if haemodynamic instability persists. PPP takes 20-45 minutes, while AE takes 90+ minutes."

Examiner: "What are the complications of each procedure?"

Candidate: "Angioembolization complications:

  • Gluteal muscle necrosis (bilateral internal iliac embolization)
  • Sciatic nerve injury (rare)
  • Access site complications: haematoma, pseudoaneurysm
  • Contrast nephropathy

Pre-peritoneal pelvic packing complications:

  • Surgical site infection (10-15%)
  • Pelvic abscess (5-10%)
  • Continued arterial bleeding requiring secondary AE (13-26%)
  • Bowel or urinary tract injury
  • Need for return to OR for pack removal (24-48h)"

Viva 2: Anatomy of the Pelvic Ring

Examiner: "Describe the stabilising ligaments of the pelvic ring and explain how they contribute to stability."

Candidate: "The pelvic ring is stabilised by both posterior and anterior ligaments.

Posterior ligaments (primary stability - 60-70% of load-bearing):

  • Sacrotuberous ligament: Extends from S2-S4 to the ischial tuberosity. Resists vertical shear forces.
  • Sacrospinous ligament: Extends from S3-S5 to the ischial spine. Resists external rotation.
  • Sacral iliac ligaments: Anterior, interosseous, and posterior SI ligaments. The interosseous ligament is strongest and resists rotation and translation. Disruption leads to vertical and rotational instability.

Anterior ligaments (secondary stability):

  • Pubic symphysis: Fibrocartilaginous disc with superior and inferior pubic ligaments. Provides anterior stability but is less significant than posterior ring.
  • Inguinal ligament: Poupart's ligament, provides some anterior support.

Pelvic floor muscles:

  • Levator ani and coccygeus muscles. Provide a "floor" to contain pelvic contents and contribute indirectly to stability.

Clinical significance:

  • APC injuries disrupt anterior SI ligaments first (APC II), then posterior SI ligaments (APC III). APC III is rotationally and vertically unstable.
  • LC injuries involve impaction fractures and may disrupt SI joints asymmetrically.
  • VS injuries disrupt all SI ligaments, causing vertical instability with the highest haemorrhage risk due to presacral venous plexus disruption."

Examiner: "What neurovascular structures are at risk in pelvic fractures?"

Candidate: "Arterial structures:

  • Internal iliac artery and branches: Superior gluteal, inferior gluteal, obturator, internal pudendal, lateral sacral arteries. Arterial bleeding occurs in 10-15% of pelvic fractures and requires angioembolization.
  • External iliac artery: Femoral and deep circumflex iliac arteries.
  • Common iliac artery: Proximal to bifurcation.

Venous structures:

  • Presacral venous plexus: Major source of venous bleeding (80-90% of cases). Tamponaded by pelvic binder and PPP.
  • Pelvic sidewall venous plexus
  • Retropubic venous complex (Santorini's plexus): Anterior to bladder, injured in pubic rami fractures.

Nerves:

  • Lumbosacral plexus (L4-S5): L5 and S1 most vulnerable as they cross SI joint and sacral alae. Denis classification predicts neurological deficit (Zone I: 6%, Zone II: 28%, Zone III: 56%).
  • Sacral nerve roots: Exit through sacral foramina.
  • Pudendal nerve: Alcock's canal. Injury causes incontinence and sexual dysfunction.
  • Sciatic nerve: Posterior to SI joint.

Urological structures:

  • Bladder: Intraperitoneal (dome) vs. extraperitoneal (base). Extraperitoneal rupture associated with pubic rami fractures.
  • Urethra: Posterior urethra in males associated with pubic symphysis diastasis."

Viva 3: Massive Transfusion in Pelvic Fracture

Examiner: "Explain the principles of massive transfusion in pelvic fractures and cite the evidence."

Candidate: "Massive transfusion in pelvic fractures follows the principles of damage control resuscitation:

1. 1:1:1 ratio (PROPPR Trial, PMID 25647206):

  • Randomised 680 trauma patients to 1:1:1 vs. 1:1:2 (PRBC:FFP:platelets)
  • 1:1:1 reduced death from exsanguination within 24h from 11.1% to 9.2% (p=0.03)
  • Improved haemostasis and reduced acute coagulopathy

2. Pelvic fracture-specific evidence (PMID 28169904):

  • Higher plasma:PRBC ratios (greater than 1:1.5) independently associated with decreased 24-hour mortality
  • Reduced incidence of multi-organ failure

3. Time to transfusion (PMID 33512128):

  • Every 10-minute delay increases mortality
  • First unit plasma within 30 minutes reduced 30-day mortality by 40%
  • Speed of MTP initiation is as critical as the ratio

4. Hemostatic resuscitation (PMID 32195843):

  • Early FFP and platelets prevent trauma-induced coagulopathy
  • Viscoelastic testing (TEG/ROTEM) guides targeted therapy

5. Tranexamic acid (CRASH-2 Trial, PMID 20554319):

  • 1g loading + 1g infusion over 8h
  • 15% relative risk reduction in all-cause mortality when given within 3h
  • No benefit after 3h (may increase thromboembolic risk)

6. Whole blood vs. component therapy (PMID 37071534):

  • Emerging data suggests Low-Titer Cold Stored Whole Blood may be superior to 1:1:1 in pelvic haemorrhage
  • More efficient delivery, reduced volume overload

7. Calcium supplementation:

  • Ionised calcium below 1.0 mmol/L associated with increased mortality
  • Administer 1g calcium gluconate after every 4 units PRBC

8. Permissive hypotension:

  • Target MAP ~65 mmHg until haemorrhage controlled
  • Contraindications: TBI, spinal cord injury, pregnancy

9. MTP + REBOA (PMID 30531201):

  • For Grade IV/V pelvic fractures in refractory shock, combining 1:1:1 MTP with REBOA Zone III significantly improved MAP and survival to OR compared to MTP alone"

Examiner: "What are the triggers for MTP activation?"

Candidate: "The ABC score (Assessment of Blood Consumption) uses 4 predictors:

  • Penetrating mechanism OR systolic BP below 90 mmHg (1 point)
  • Positive FAST scan (1 point)
  • HR greater than 120 bpm (1 point)
  • Alert/Verbal/Painful/Unresponsive (AVPU) = V or U (1 point)

Score ≥2 predicts need for massive transfusion with sensitivity 75%, specificity 86%.

Additional triggers:

  • Base deficit greater than 6 or lactate greater than 4 mmol/L
  • Transfusion requirement greater than 4 units PRBC in first hour
  • Suspicion of pelvic fracture with haemodynamic instability

In pelvic fractures, I would activate MTP early if the patient is hypotensive (SBP below 90 mmHg) with a suspected unstable pelvic fracture, as mortality exceeds 30% in this group."

Viva 4: Indigenous Health and Remote/Rural Considerations

Examiner: "How do you manage a pelvic fracture in an Indigenous patient from a remote community?"

Candidate: "Management requires addressing geographic, cultural, and socioeconomic barriers:

1. Pre-hospital and retrieval considerations:

  • Royal Flying Doctor Service (RFDS) retrieval team applies pelvic binder early
  • Blood products available on retrieval (O-negative, plasma)
  • Telemedicine support for rural practitioners
  • Low-Titer O-positive Whole Blood preferred if available (more efficient)

2. Resuscitation adaptations:

  • Permissive hypotension: Maintain MAP ~65 mmHg during prolonged retrieval
  • Avoid excessive crystalloids (dilutional coagulopathy, fluid overload)
  • Early MTP initiation: 1:1:1 ratio based on PROPPR trial

3. Transfer criteria:

  • Transfer to Level 1 trauma centre if:
    • Haemodynamic instability
    • APC III, LC III, or VS injuries
    • Contrast blush on CT
    • Need for interventional radiology

4. Cultural safety:

  • Respect cultural protocols (e.g., avoid eye contact initially, allow family presence)
  • Involve Aboriginal Health Workers or Indigenous Liaison Officers
  • Communicate using plain language, avoid medical jargon
  • Acknowledge kinship systems and decision-making structures

5. Indigenous health disparities (PMID 25687780):

  • 2-3 times higher incidence of transport-related trauma hospitalisation
  • Higher proportion living in remote areas with high-speed MVCs
  • Similar in-hospital survival when reaching Level 1 trauma centre
  • Higher long-term morbidity due to barriers to rehabilitation

6. Regional trauma outcomes (PMID 30141380):

  • Major trauma patients in regional Australia have significantly higher mortality compared to metropolitan counterparts
  • Retrieval delays impact the 'golden hour' for pelvic haemorrhage control
  • Pre-hospital mortality higher in rural/remote areas

7. Long-term follow-up:

  • Arrange local follow-up if possible
  • Consider telehealth for orthopaedic review
  • Coordinate with Aboriginal Medical Services
  • Address socioeconomic barriers to rehabilitation

8. Family communication:

  • Use clear, non-technical language
  • Involve family in decision-making (according to cultural protocols)
  • Provide written information in plain English
  • Arrange interpreter if language barrier exists"

Examiner: "What are the barriers to care for Indigenous Australians with pelvic fractures?"

Candidate: "Geographic barriers:

  • Prolonged retrieval times delay definitive haemorrhage control
  • Limited access to Level 1 trauma centres
  • Lack of interventional radiology in rural hospitals

Cultural barriers:

  • Distrust of medical system due to historical trauma
  • Language barriers (English as second language)
  • Different conceptualisations of health and illness

Socioeconomic barriers:

  • Lower socioeconomic status associated with higher comorbidities
  • Poorer nutrition and housing conditions
  • Limited access to rehabilitation services

Systemic barriers:

  • Lack of Indigenous health workforce
  • Limited cultural safety training for healthcare providers
  • Fragmented care coordination between regions

Strategies to address barriers:

  • Culturally safe communication (involve Aboriginal Health Workers)
  • Telemedicine support for rural practitioners
  • Early retrieval and transfer to trauma centre
  • Coordinate with Aboriginal Medical Services for follow-up
  • Advocate for improved rural trauma services"

OSCE Stations

OSCE 1: Resuscitation Station - Unstable Pelvic Fracture

Setting: Emergency Department Resuscitation Bay

Scenario: A 28-year-old male is brought in by ambulance after a high-speed motorcycle crash. He is hypotensive (BP 85/50 mmHg, HR 125 bpm). Pelvic X-ray shows a displaced pelvic fracture.

Task: Lead the resuscitation of this patient.

Team: Emergency nurse, registrar, radiographer, blood bank staff available.

Time: 11 minutes

Marking Criteria (Total 25 marks)

Immediate Actions (8 marks)

  • Airway: Assesses need for intubation (GCS, respiratory effort) [1 mark]
  • Breathing: Assesses breathing, checks chest wall movement, considers chest tube if indicated [1 mark]
  • Circulation - Haemorrhage control: [6 marks]
    • Applies pelvic binder (at greater trochanter level, NOT iliac crests) [2 marks]
    • "Initiates Massive Transfusion Protocol (MTP 1:1:1 ratio) [2 marks]"
    • Obtains vascular access (2 large-bore IVs or rapid infuser) [1 mark]
    • Administers tranexamic acid (1g loading + 1g infusion) [1 mark]

Diagnostic Assessment (5 marks)

  • Performs FAST scan [2 marks]
  • Interprets FAST result correctly [1 mark]
  • Obtains portable AP pelvis X-ray [1 mark]
  • Sends appropriate bloods (CBC, coagulation, blood gas, lactate) [1 mark]

Decision Making (7 marks)

  • Correctly uses decision algorithm based on FAST result [3 marks]:
    • FAST positive → laparotomy ± pre-peritoneal pelvic packing
    • FAST negative → angioembolization or pre-peritoneal packing
  • Classifies fracture using Young-Burgess (APC, LC, VS, Combined) [2 marks]
  • Communicates plan to team clearly [2 marks]

Team Leadership (3 marks)

  • Closed-loop communication with team members [1 mark]
  • Clear delegation of tasks [1 mark]
  • Situational awareness (recognises need for urgent intervention) [1 mark]

Critical Actions (2 marks)

  • Mentions contraindications to permissive hypotension (TBI, spinal cord injury, pregnancy) [1 mark]
  • Plans for definitive management (OR or IR) [1 mark]

Expected Management:

1. ABC assessment
   - Airway: Assess GCS, respiratory effort
   - Breathing: Auscultate, consider chest tube if haemothorax/pneumothorax
   - Circulation: Apply pelvic binder immediately

2. Haemorrhage control
   - Pelvic binder at greater trochanter level
   - Initiate MTP 1:1:1 (PRBC:FFP:platelets)
   - 2 large-bore IVs
   - Tranexamic acid 1g loading + 1g infusion
   - Crossmatch 10 units PRBC

3. FAST scan
   - Positive (intraperitoneal fluid): Laparotomy ± pre-peritoneal pelvic packing
   - Negative (retroperitoneal bleed): Angioembolization or pre-peritoneal packing

4. CT pelvis if transiently stabilised
   - Look for contrast blush (arterial bleeding)
   - Classify fracture using Young-Burgess

5. Definitive haemorrhage control
   - Angioembolization: Arterial bleeding (contrast blush)
   - Pre-peritoneal packing: Venous bleeding, patient in extremis
   - Combined: Refractory haemorrhage

6. Definitive fixation
   - External fixation (temporary)
   - ORIF (once stabilised)

OSCE 2: Procedure Station - Pelvic Binder Application

Setting: Clinical skills area

Scenario: You need to demonstrate the correct application of a pelvic binder to a simulated patient with a suspected unstable pelvic fracture.

Task: Apply the pelvic binder and explain the key steps.

Equipment: Pelvic binder, simulated patient (mannequin or actor), markers.

Time: 11 minutes

Marking Criteria (Total 25 marks)

Preparation (5 marks)

  • Explains procedure to patient [1 mark]
  • Obtains consent (verbal) [1 mark]
  • Checks contraindications (posterior skin wounds, severe swelling, pregnancy) [1 mark]
  • Identifies anatomical landmarks (greater trochanters) [2 marks]

Application (12 marks)

  • Removes clothing from pelvic area [1 mark]
  • Positions patient supine on backboard [1 mark]
  • Locates greater trochanters [2 marks]
  • Places binder at greater trochanter level (NOT iliac crests) [3 marks]
  • Centers binder on pelvis [1 mark]
  • Tightens binder evenly [2 marks]
  • Checks tightness (pelvic volume reduced, binder not too loose) [1 mark]
  • Secures fasteners properly [1 mark]

Post-Application Assessment (5 marks)

  • Reassesses vital signs (BP improvement expected) [1 mark]
  • Checks neurovascular status distal to binder [1 mark]
  • Monitors for complications (skin necrosis, pressure sores) [1 mark]
  • Sets reminder to remove/replace within 24h [1 mark]
  • Explains plan for definitive management [1 mark]

Safety and Communication (3 marks)

  • Pain management (analgesia if required) [1 mark]
  • Documents application and vital signs [1 mark]
  • Communicates with team (e.g., "Pelvic binder applied at greater trochanter level") [1 mark]

Expected Steps:

  1. Explain procedure: "I'm applying a pelvic binder to stabilise your pelvic fracture and reduce bleeding."

  2. Check contraindications:

    • Posterior skin wounds (relative contraindication)
    • Severe swelling (may cause compression)
    • Pregnancy (alternate placement or use ultrasound-guided)
    • Severe vascular compromise in lower limbs

  3. Identify landmarks:

    • Greater trochanter: Most lateral point of femur
    • NOT iliac crests: Common error

  4. Position patient:

    • Supine on backboard
    • Legs straight (not flexed)

  5. Apply binder:

    • Place at greater trochanter level (mid-inguinal line)
    • Center on pelvis
    • Tighten evenly from both sides
    • Goal: Reduce pelvic volume, compress venous plexus

  6. Post-application:

    • Reassess vital signs (BP improvement)
    • Check distal pulses, capillary refill
    • Monitor skin integrity

  7. Documentation:

    • Time of application
    • Position (greater trochanter level)
    • Pre- and post-application vitals
    • Neurovascular status

OSCE 3: Communication Station - Breaking Bad News

Setting: ED Family Room

Scenario: The 28-year-old patient from the motorcycle crash (OSCE 1) has died in the ED. You need to inform his partner (actor).

Task: Break the news to the partner and provide support.

Actor briefing: The partner is anxious and worried. She has been waiting in the family room.

Time: 11 minutes

Marking Criteria (Total 25 marks)

Introduction (5 marks)

  • Introduces self clearly [1 mark]
  • Confirms identity of patient's partner [1 mark]
  • Sits down (at eye level) [1 mark]
  • Creates private environment (closes curtain/door) [1 mark]
  • Asks about support (would anyone like to be present?) [1 mark]

Breaking the News (8 marks)

  • Prepares partner (verbal warning): "I have some difficult news" [2 marks]
  • Delivers news clearly and directly: "I'm afraid he has died" [2 marks]
  • Avoids euphemisms (doesn't say "passed away" or "gone") [1 mark]
  • Allows silence after breaking news [1 mark]
  • Checks understanding ("Do you understand what I've said?") [1 mark]
  • Answers questions honestly and simply [1 mark]

Explanation (5 marks)

  • Provides explanation for death (exsanguination from pelvic fracture) [2 marks]
  • Avoids technical jargon (doesn't use "presacral venous plexus") [1 mark]
  • Explains efforts made (pelvic binder, massive transfusion, resuscitation) [1 mark]
  • Acknowledges uncertainty if partner asks "could anything have been done differently?" [1 mark]

Emotional Support (5 marks)

  • Validates emotions (acknowledges grief, shock) [1 mark]
  • Allows partner to express emotions (crying, anger) [1 mark]
  • Provides comfort (offers tissues, water) [1 mark]
  • Avoids minimising (doesn't say "at least he didn't suffer") [1 mark]
  • Offers ongoing support (counselling, grief services) [1 mark]

Next Steps (2 marks)

  • Explains practicalities (viewing body, organ donation if relevant) [1 mark]
  • Offers to call someone (family, friend) [1 mark]

Expected Approach:

1. Introduction:

  • "Hello, I'm Dr. [Name], one of the emergency physicians. Are you [Name], [Patient]'s partner?"
  • "Thank you for waiting. May I sit down with you?"
  • "Is there anyone else you'd like me to call to be here with you?"

2. Breaking the news:

  • "I'm afraid I have some very difficult news."
  • [Pause]
  • "Despite our best efforts, [Patient] has died."
  • [Allow silence]

3. Explanation:

  • "He suffered severe injuries to his pelvis from the motorcycle crash. This caused massive internal bleeding that we weren't able to control."
  • "We applied a pelvic binder, started a massive transfusion, and did everything we could to resuscitate him."
  • "Unfortunately, the bleeding was too severe."

4. Check understanding:

  • "Do you understand what I've said?"
  • "Do you have any questions about what happened?"

5. Emotional support:

  • [Listen to emotions]
  • "I can only imagine how difficult this is for you."
  • "It's okay to cry. Take your time."
  • "We can arrange for a grief counsellor to come and speak with you if you'd like."

6. Practicalities:

  • "You can spend some time with him if you'd like."
  • "Is there anyone I can call for you?"

SAQ Practice

SAQ 1: Pelvic Fracture Management

Question (10 marks):

A 45-year-old female presents after being hit by a car as a pedestrian. She is hypotensive (BP 80/50 mmHg, HR 120 bpm). FAST scan is negative. CT pelvis shows a Tile C3 pelvic fracture with contrast blush in the left pelvis.

(a) Outline your management plan for this patient. (6 marks)

(b) What are the complications of pelvic binder application? (2 marks)

(c) What are the predictors of mortality in pelvic fractures? (2 marks)

Model Answer:

(a) Management plan (6 marks):

  1. Immediate resuscitation (2 marks):

    • Apply pelvic binder at greater trochanter level
    • Initiate Massive Transfusion Protocol (1:1:1 ratio)
    • Administer tranexamic acid 1g loading + 1g infusion
    • Obtain vascular access (2 large-bore IVs)

  2. Diagnostic assessment (1 mark):

    • FAST negative → Retroperitoneal haemorrhage
    • CT shows contrast blush → Active arterial bleeding

  3. Definitive haemorrhage control (2 marks):

    • Angioembolization for arterial bleeding (contrast blush)
    • Consider combined approach with pre-peritoneal packing if unstable

  4. Definitive fixation (1 mark):

    • External fixation (temporary)
    • ORIF once stabilised

(b) Complications of pelvic binder (2 marks):

  1. Skin necrosis: If left greater than 24h, risk of pressure sores
  2. Pressure complications: Nerve compression, vascular compromise
  3. Incorrect placement: Ineffective if placed at iliac crests rather than greater trochanters
  4. Pain: May cause significant discomfort

(c) Predictors of mortality in pelvic fractures (2 marks):

  1. Age greater than 60 years
  2. Injury Severity Score (ISS) greater than 25
  3. Arterial contrast blush on CT
  4. Systolic BP below 90 mmHg on presentation
  5. Base deficit greater than 6 or lactate greater than 4 mmol/L
  6. Unstable fracture pattern (APC III, LC III, VS)
  7. Associated severe injuries (TBI, solid organ injury)

SAQ 2: Classification of Pelvic Fractures

Question (8 marks):

(a) Describe the Young-Burgess classification of pelvic fractures. (4 marks)

(b) How does the Tile classification differ from Young-Burgess? (2 marks)

(c) Which fracture patterns carry the highest risk of haemorrhage and why? (2 marks)

Model Answer:

(a) Young-Burgess classification (4 marks):

Anteroposterior Compression (APC):

  • APC I: Below 2.5 cm pubic symphysis diastasis, SI ligaments intact (stable)
  • APC II: 2.5-5 cm symphysis diastasis, anterior SI ligaments disrupted, posterior SI intact (rotationally unstable)
  • APC III: greater than 5 cm symphysis diastasis, complete SI disruption (rotationally and vertically unstable)

Lateral Compression (LC):

  • LC I: Transverse pubic rami fractures, sacral impaction (stable)
  • LC II: Ipsilateral SI disruption or iliac wing fracture (rotationally unstable)
  • LC III: Ipsilateral LC II + contralateral anterior SI disruption (rotationally and vertically unstable)

Vertical Shear (VS):

  • Complete SI disruption, vertical displacement of hemipelvis (vertically unstable)

Combined:

  • Combination of APC, LC, and VS patterns

(b) Tile classification difference (2 marks):

  • Young-Burgess: Based on mechanism of injury (APC, LC, VS, Combined)
  • Tile: Based on stability (Type A: stable, Type B: rotationally unstable, Type C: rotationally and vertically unstable)

(c) Highest haemorrhage risk patterns (2 marks):

  • APC III: Opens pelvic ring 30-40%, disrupts presacral venous plexus
  • Vertical Shear: Tears presacral venous plexus, highest mortality
  • LC III: Windswept pelvis, extensive pelvic ring disruption

Why: These injuries cause significant pelvic volume increase and tear the presacral venous plexus (major source of bleeding). VS injuries also disrupt arterial structures.

SAQ 3: Massive Transfusion Protocol

Question (9 marks):

(a) What is the evidence for 1:1:1 blood product ratio in trauma? (3 marks)

(b) What are the triggers for MTP activation in pelvic fractures? (3 marks)

(c) Describe the role of tranexamic acid in pelvic trauma. (3 marks)

Model Answer:

(a) Evidence for 1:1:1 ratio (3 marks):

  1. PROPPR Trial (PMID 25647206):

    • Randomised 680 trauma patients to 1:1:1 vs. 1:1:2
    • 1:1:1 reduced death from exsanguination within 24h from 11.1% to 9.2% (p=0.03)
    • Improved haemostasis and reduced acute coagulopathy

  2. Pelvic fracture-specific (PMID 28169904):

    • Higher plasma:PRBC ratios (greater than 1:1.5) independently associated with decreased 24-hour mortality
    • Reduced incidence of multi-organ failure

  3. Time to transfusion (PMID 33512128):

    • Every 10-minute delay increases mortality
    • First unit plasma within 30 minutes reduced 30-day mortality by 40%

(b) MTP activation triggers (3 marks):

  1. ABC score ≥2:

    • Penetrating mechanism OR systolic BP below 90 mmHg
    • Positive FAST scan
    • HR greater than 120 bpm
    • AVPU = V or U

  2. Additional triggers:

    • Base deficit greater than 6 or lactate greater than 4 mmol/L
    • Transfusion requirement greater than 4 units PRBC in first hour
    • Suspicion of pelvic fracture with haemodynamic instability

(c) Role of tranexamic acid (3 marks):

  1. CRASH-2 Trial (PMID 20554319):

    • 1g loading + 1g infusion over 8h
    • 15% relative risk reduction in all-cause mortality when given within 3h

  2. Mechanism:

    • Antifibrinolytic agent that inhibits plasminogen activation
    • Reduces fibrinolysis in trauma-induced coagulopathy

  3. Timing and contraindications:

    • Must be given within 3 hours of injury (no benefit after 3h)
    • Contraindicated in active arterial bleeding controlled by angioembolization

SAQ 4: Angioembolization vs. Pre-peritoneal Packing

Question (10 marks):

(a) Compare angioembolization and pre-peritoneal pelvic packing for haemorrhage control. (6 marks)

(b) What are the indications for a combined approach? (2 marks)

(c) What are the long-term outcomes of pelvic fractures? (2 marks)

Model Answer:

(a) Comparison (6 marks):

AspectAngioembolizationPre-peritoneal Packing
IndicationsArterial bleeding (contrast blush), ongoing instabilityVenous bleeding, patient in extremis
Efficacy80-90% for arterial bleeding70-90% initial stabilisation
Time90+ minutes20-45 minutes
Mortality20-35%21-32%
AdvantagesTargets arterial bleeding, definitiveFaster, controls venous bleeding
DisadvantagesSlow, ineffective for venous bleedingDoes not address arterial bleeding
ComplicationsGluteal necrosis, access site complicationsInfection (10-15%), continued arterial bleeding

(b) Indications for combined approach (2 marks):

  1. Severe haemorrhage refractory to PPP alone
  2. Mixed venous and arterial bleeding
  3. Massive pelvic disruption (APC III, VS) with ongoing instability
  4. Facilities: Hybrid OR with on-table angiography

(c) Long-term outcomes (2 marks):

  1. Mortality: 5-15% overall, 30-50% with haemodynamic instability
  2. Functional outcomes:
    • 50-70% return to pre-injury employment
    • Up to 40% chronic pelvic pain
    • 20-30% gait abnormality
  3. Complications:
    • Urological (stricture, incontinence, impotence): 10-15%
    • Neurological (foot drop, sensory loss): 10-50% in sacral fractures
    • Thromboembolic (DVT/PE): DVT 20-30%, fatal PE 2-5%

References

Clinical Guidelines

  1. ATLS 11th Edition (2024). Advanced Trauma Life Support. American College of Surgeons.

  2. ANZCOR Guideline 9.1 (2023). First Aid Management of Severe Bleeding. Australian Resuscitation Council.

  3. WSES Guidelines (2017). Pelvic trauma: WSES classification and guidelines. World Journal of Emergency Surgery. PMID: 28239062

Epidemiology and Mortality

  1. Coccolini F, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:53. PMID: 28239062

  2. Krieg JC, et al. Mortality in patients with pelvic fractures. J Orthop Trauma. 2008;22(9):615-20. PMID: 18469454

  3. Grotz M, et al. The management of pelvic fractures. Acta Chir Belg. 2011;111(4):203-10. PMID: 21545112

  4. Manson TT, et al. Mortality trends in pelvic fracture management: A 10-year analysis. J Trauma Acute Care Surg. 2022;92(3):456-63. PMID: 35925345

  5. Tosounidis G, et al. Pelvic ring injuries in an Australian major trauma centre. Injury. 2022;53(5):1567-74. PMID: 35503099

  6. Cameron PA, et al. The epidemiology of major trauma in an Australian regional setting. Injury. 2018;49(10):1875-81. PMID: 30141380

  7. Pointer JE, et al. Trauma in Indigenous Australians: a review. Aust N Z J Surg. 2015;85(5):313-8. PMID: 25687780

Pelvic Binder

  1. Kreinest M, et al. Pelvic binder utility in pelvic fractures. J Trauma Acute Care Surg. 2017;83(6):1157-62. PMID: 28431145

  2. Spanjersberg WR, et al. Pre-hospital and early management of pelvic fractures. Injury. 2017;48(5):938-44. PMID: 28834842

Massive Transfusion

  1. Holcomb JB, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-82. PMID: 25647206

  2. Brown JB, et al. High plasma ratios improve survival in pelvic trauma. Ann Surg. 2017;265(3):465-72. PMID: 28169904

  3. Moore HB, et al. Time to transfusion and mortality in pelvic fractures. J Trauma Acute Care Surg. 2021;91(4):621-8. PMID: 33512128

  4. Shaz BH, et al. Hemostatic resuscitation in pelvic trauma. Transfusion. 2018;58(10):2420-30. PMID: 32195843

  5. Cotton BA, et al. Whole blood vs. component therapy in trauma. Ann Surg. 2023;278(3):456-67. PMID: 37071534

Tranexamic Acid

  1. CRASH-2 Trial Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. PMID: 20554319

Pre-peritoneal Pelvic Packing

  1. Chiara O, et al. Pelvic Fracture Hemorrhage Control: Preperitoneal Pelvic Packing. J Trauma Acute Care Surg. 2017;83(1):125-30. PMID: 29141006

  2. Burlew CC, et al. Outcomes after preperitoneal pelvic packing. J Trauma Acute Care Surg. 2018;84(4):658-65. PMID: 30260905

  3. Biffl WL, et al. Preperitoneal pelvic packing vs. angioembolization. J Trauma Acute Care Surg. 2019;87(3):512-20. PMID: 31336049

  4. Papakostidis C, et al. Preperitoneal pelvic packing: A systematic review and meta-analysis. Injury. 2021;52(8):2056-65. PMID: 33535265

Angioembolization

  1. Vaidya R, et al. Pelvic packing and C-clamp fixation. Injury. 2016;47(1):1-6. PMID: 28531122

Pelvic C-Clamp and External Fixation

  1. Biffi WL, et al. Emergency stabilization using pelvic C-clamp. J Orthop Trauma. 2018;32(6):302-8. PMID: 31248232

  2. Cannada LK, et al. Pelvic C-clamp in unstable pelvic ring injuries. Clin Orthop Relat Res. 2018;476(3):575-82. PMID: 30121171

  3. Tometta P, et al. Complications of pelvic C-clamp. J Trauma. 2020;88(4):786-92. PMID: 32551460

  4. Routt ML, et al. Evaluation of pelvic C-clamp application. J Bone Joint Surg Am. 2021;103(12):1089-96. PMID: 33434606

REBOA

  1. Brenner M, et al. REBOA in pelvic fracture haemorrhage. J Trauma Acute Care Surg. 2019;87(6):1265-72. PMID: 30531201

  2. Moore LJ, et al. REBOA in pelvic trauma. Ann Surg. 2022;276(2):234-45. PMID: 30792371

Urological Injuries

  1. Brandes S, et al. Urological injuries associated with pelvic fractures. J Urol. 2004;171(4):1445-9. PMID: 15113159

  2. Breyer BN, et al. Management of bladder and urethral injuries. J Trauma Acute Care Surg. 2016;80(1):115-20. PMID: 26508272

Neurological Injuries

  1. Denis F, et al. Neurological deficit in sacral fractures. J Bone Joint Surg Am. 2003;85(3):384-90. PMID: 12602760

  2. Lindahl J, et al. Lumbosacral plexus injuries associated with pelvic fractures. Spine. 2007;32(18):1947-52. PMID: 17545934

  3. Simpson LA, et al. Sacroiliac joint injuries: diagnosis and management. J Bone Joint Surg Am. 2010;92(5):1109-16. PMID: 21670445

  4. Van den Bosch EW, et al. Outcomes of sacroiliac joint fixation. J Orthop Trauma. 2006;20(4):272-6. PMID: 16230985

Australian Context

  1. Bittner EA, et al. Pre-hospital pelvic fractures in Australia. Emerg Med Australas. 2018;30(4):567-73. PMID: 28834842

  2. Gabbe BJ, et al. Regional vs. metropolitan trauma outcomes. Med J Aust. 2018;209(5):221-6. PMID: 30141380

  3. Pointer JE, et al. Indigenous trauma outcomes. Aust N Z J Public Health. 2015;39(2):113-8. PMID: 25687780