Pelvic Fracture: Haemorrhage Control and Anaesthetic Management

Quick Answer

Pelvic fractures in trauma are associated with life-threatening haemorrhage due to disruption of the extensive pelvic venous plexus and arterial network. Immediate haemorrhage control involves application of a pelvic binder to reduce pelvic volume and restore tamponade, permissive hypotension (systolic BP 80-90 mmHg) until haemorrhage control achieved, and activation of massive transfusion protocols with balanced blood products. Definitive haemorrhage control may require angioembolisation (for arterial bleeding), preperitoneal pelvic packing (for venous bleeding), or external fixation (for mechanical stabilisation). Mortality in haemodynamically unstable pelvic fracture approaches 30-50%, making rapid multidisciplinary coordination between trauma surgery, orthopaedics, interventional radiology, and anaesthesia essential.

Clinical Pearl: Apply pelvic binder at the level of the greater trochanters, not the iliac crests. A malpositioned binder loses efficacy and may increase pelvic volume rather than reduce it.[1]

Epidemiology and Injury Patterns

Incidence and Significance

Mechanism of Injury

High-energy mechanisms account for the majority of unstable pelvic fractures:

APC: Anteroposterior Compression; LC: Lateral Compression; VS: Vertical Shear; CM: Combined Mechanism[9,10]

Anatomy and Haemorrhage Sources

Pelvic Vascular Anatomy

The pelvis contains a rich vascular network vulnerable to injury:

Arterial Sources (20% of bleeding):

• Superior gluteal artery (most commonly injured)
• Internal pudendal artery
• Obturator artery
• Lateral sacral arteries
• Middle rectal artery
• Corona mortis (anastomosis between obturator and external iliac systems)

Venous Sources (80% of bleeding):

• Presacral venous plexus
• Retropubic (prevesical) venous plexus
• Internal iliac venous tributaries
• Fracture site bleeding from cancellous bone

[11,12,13]

Fracture Patterns and Bleeding Risk

[14,15]

Clinical Assessment

Primary Survey and Haemodynamic Assessment

ATLS Protocol with specific attention to:

Predictors of Pelvic Haemorrhage:

• Shock index >0.9
• Fracture pattern (APC III, LC III, VS, CM)
• Age >60 years
• Sacroiliac joint disruption
• Pubic symphysis diastasis >2.5 cm
• Posterior pelvic ring disruption
• Associated femur fracture[16,17]

Physical Examination

Inspection:

• Scrotal/labial haematoma (butterfly haematoma)
• Perineal ecchymosis (sign of urethral injury)
• Open wounds (open fracture)
• Limb position (shortening, external rotation)

Palpation:

• Pelvic instability (gentle compression/distraction - once only)
• Pain at pubic symphysis, SI joints
• Tenderness over iliac wings

Warning: Repeated pelvic manipulation can dislodge clots and worsen bleeding. Perform compression/distraction test once only during initial assessment.[18]

Associated Injuries

High association with other injuries (present in 70-80% of cases):

[19,20,21]

Investigation

Imaging Algorithm

1. Plain Radiography:

• AP pelvis (initial screening)
• Inlet view (AP compression fractures)
• Outlet view (vertical shear)
• Judet views (acetabular fractures)

2. CT Imaging:

• CT abdomen/pelvis with IV contrast: Gold standard for fracture characterisation and extravasation
• Look for: "Blush" (contrast extravasation = arterial bleeding), pelvic haematoma size
• Delayed phases may identify venous bleeding

3. FAST (Focused Assessment with Sonography for Trauma):

• Assess for intra-abdominal free fluid
• Positive FAST in pelvic fracture patient suggests associated abdominal injury

4. Retrograde Urethrogram:

• Before catheterisation if blood at meatus, perineal haematoma, or high-riding prostate suspected

[22,23]

Haemorrhage Assessment on CT

Haemorrhage Control Strategies

Non-Invasive Measures

1. Pelvic Binder Application

Mechanism: Reduces pelvic volume, stabilises fracture, restores tamponade effect

Placement:

• Position at level of greater trochanters
• NOT at iliac crests (ineffective, may increase volume)
• Tighten to approximate fracture fragments
• Reassess limb perfusion after application

Indications:

• All haemodynamically unstable patients with suspected pelvic fracture
• Prophylactic in high-energy trauma with pelvic pain
• Pre-hospital application by EMS

Evidence: Reduces transfusion requirements by 25-50% when applied early[24,25,26]

2. Circumferential Sheet Wrapping

Alternative when commercial binder unavailable:

• Wrap sheet around pelvis at greater trochanter level
• Tighten and secure with clamps or knots
• Temporising measure until definitive stabilisation

Damage Control Resuscitation

Core Principles:

1. Permissive Hypotension:

   • Target SBP 80-90 mmHg until haemorrhage controlled
   • Accepts suboptimal perfusion to prevent clot disruption
   • Contraindicated if TBI present (maintain CPP)

2. Balanced Blood Product Replacement:

   • Ratio 1:1:1 PRBC:FFP:Platelets (per PROPPR trial)
   • Early plasma and platelets (not delayed)
   • Massive transfusion protocol activation

3. Prevention/ Correction of Coagulopathy:

   • Fibrinogen replacement (cryoprecipitate or fibrinogen concentrate) if <1.5-2.0 g/L
   • Tranexamic acid (1g IV bolus, then 1g over 8 hours if within 3 hours of injury)
   • Calcium replacement (ionised calcium >1.0 mmol/L)

4. Minimal Crystalloid:

   • Avoid excessive crystalloid resuscitation
   • "Blood and blood products only" approach

[27,28,29,30,31]

Interventional Radiology: Angiography and Embolisation

Indications:

• CT evidence of arterial extravasation ("blush")
• Haemodynamic instability despite pelvic binder and resuscitation
• Ongoing transfusion requirements (>4-6 units PRBC/24hr)
• Failed response to pelvic packing (if packing performed first)

Technique:

1. Femoral artery access (ideally contralateral to suspected bleeding side)
2. Pelvic angiography to identify bleeding vessel
3. Selective catheterisation of internal iliac branches
4. Embolisation with coils, particles, or Gelfoam
5. Bilateral embolisation often required (rich collateral supply)

Outcomes:

• Technical success: 85-95%
• Clinical success (haemorrhage control): 70-90%
• Complications: 5-15% (contrast nephropathy, groin haematoma, ischaemia)

Important: Not effective for venous bleeding (80% of cases). Consider if arterial source suspected.[32,33,34,35]

Surgical Haemorrhage Control

Preperitoneal Pelvic Packing (PPP)

Indications:

• Haemodynamic instability with suspected venous bleeding
• No time for angiography or angiography unavailable
• Failed angioembolisation
• Combined with external fixation

Technique:

1. Midline suprapubic incision (lower abdomen)
2. Stay extraperitoneal (do not enter peritoneal cavity)
3. Identify retropubic space (space of Retzius)
4. Pack with 3-6 laparotomy pads on each side:
   • Posterior to bladder
   • Along pelvic sidewalls
   • Into presacral space if needed
5. Close incision (temporary closure if damage control)
6. Re-bleeding check at 24-48 hours, remove packs

Advantages:

• Rapid (10-15 minutes)
• Controls venous bleeding effectively
• Can be performed in ED or ICU if necessary
• Combines with external fixation

Outcomes:

• Haemorrhage control: 85-95%
• Survival benefit in unstable patients
• Reduced transfusion requirements[36,37,38]

Internal Iliac Artery Ligation

Rarely performed currently due to angioembolisation availability:

• Technically demanding
• Bilateral ligation often required
• Does not address venous bleeding
• Consider if angiography unavailable and packing failed

Mechanical Stabilisation

External Fixation

Indications:

• APC II/III (open book fractures)
• Rotationally unstable fractures
• Combined with PPP or angioembolisation
• Definitive stabilisation not immediately possible

Techniques:

1. Anterior frame: Pins in iliac crests or supra-acetabular region
2. C-clamp: Posterior fixation for VS injuries (iliac wings to sacrum)

Benefits:

• Reduces pelvic volume
• Stabilises fracture fragments
• Decreases pain and ongoing bleeding from fracture surfaces
• Allows mobilisation for CT/angio

[39,40,41]

Anaesthetic Management

Preoperative/Pre-procedure Assessment

Essential Information:

• Mechanism of injury and estimated blood loss
• Current haemodynamic status and trends
• Imaging results (CT "blush", fracture pattern)
• Transfusion requirements to date
• Coagulation status
• Associated injuries (prioritise life-threatening)
• Base deficit and lactate (tissue perfusion markers)

Key Decisions:

• Operating theatre vs interventional radiology location
• Timing of definitive surgery vs damage control
• Need for massive transfusion protocol
• Arterial and central access requirements

Monitoring

Induction and Maintenance

Induction Strategy:

• Ketamine or etomidate preferred (haemodynamically neutral)
• Avoid propofol (vasodilation, myocardial depression)
• Cautious dosing (reduced volume of distribution in hypovolaemia)
• Rapid sequence intubation (full stomach risk)
• Cricoid pressure (controversial but commonly practiced)

Maintenance:

• Balanced technique with low-dose volatile
• Opioid-based analgesia
• Muscle relaxation as needed
• Avoid excessive depth (exacerbates hypotension)

Fluid Management:

• Minimal crystalloid ("blood and blood products" approach)
• Target Hb 80-100 g/L (permissive anaemia)
• FFP and platelets per MTP ratio
• Fibrinogen concentrate if low
• Tranexamic acid if within 3 hours of injury

[42,43,44,45]

Haemodynamic Management

Targets (adjust based on associated injuries, particularly TBI):

Vasoactive Support:

• Norepinephrine: First-line vasopressor (vasoconstriction + mild inotropy)
• Vasopressin: If catecholamine-resistant shock
• Avoid excessive vasoconstriction (impairs organ perfusion)

Massive Transfusion Protocol (MTP)

Activation Criteria:

• Anticipated transfusion >6-10 units PRBC in 6 hours
• Haemodynamic instability with ongoing bleeding
• Base deficit >6 or lactate >4 mmol/L
• Shock index >1

Product Ratios (1:1:1 model):

• 6 units PRBC
• 6 units FFP
• 1 unit apheresis platelets (or 6 units pooled)
• Fibrinogen concentrate or cryoprecipitate if fibrinogen <2 g/L
• Tranexamic acid 1g bolus + 1g infusion

Communication:

• Early activation with blood bank
• Ongoing communication about needs
• Reassess coagulation with TEG/ROTEM
• Consider component therapy based on results

[46,47,48]

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Peoples

Disparities in Trauma Outcomes:

Aboriginal Australians experience higher rates of trauma-related mortality and morbidity, including from motor vehicle accidents and assault. Remote and rural Indigenous communities face specific challenges in pelvic fracture management:

Access and Transport Issues:

• Geographic isolation: Remote communities hours from trauma centres
• Retrieval delays: RFDS or rotary-wing retrieval may be delayed
• Pre-hospital care: Limited availability of pelvic binders in remote settings
• Interventional radiology: Unavailable in remote hospitals; patient requires transfer

Practical Implications:

• Emphasis on pre-hospital pelvic binder application by community health workers and remote nurses
• Telemedicine support for diagnosis and management guidance
• Clear transfer protocols identifying closest appropriate centre
• Consideration of preperitoneal packing at remote hospitals if surgical capability exists

Cultural Considerations:

• Family involvement: Trauma management decisions should involve family/kin where appropriate
• Communication: Use medical interpreters if English not first language
• Gender considerations: Pelvic injuries may have cultural sensitivities requiring female staff involvement
• Follow-up: Coordinate with Aboriginal Medical Services for rehabilitation and ongoing care

Community Context:

• Alcohol-related trauma remains a significant issue in some communities; manage without judgment
• Socioeconomic factors affect recovery and rehabilitation access
• Traditional healing practices may complement Western medical care[49,50,51]

Māori Health Considerations

Trauma Epidemiology: Māori experience disproportionate rates of traumatic injury, particularly from motor vehicle accidents and interpersonal violence. This translates to higher exposure to severe pelvic fracture mechanisms.

Whānau-Centred Care:

• Involve whānau early in treatment discussions and decision-making
• Recognise that pelvic injuries may impact future fertility and childbirth (culturally significant)
• Provide culturally safe communication about injuries, prognosis, and rehabilitation

Rural Māori Communities:

• Similar access challenges to remote Australian Indigenous communities
• Importance of helicopter retrieval services
• Coordination with Māori Health Providers for discharge planning

Equity Considerations:

• Ensure equivalent access to angioembolisation regardless of location
• Rehabilitation services should be accessible and culturally appropriate
• Address barriers to follow-up care[52,53,54]

ANZCA Final Exam Focus

Key Viva Questions

Q: "A trauma patient arrives with suspected pelvic fracture and haemodynamic instability. Describe your immediate management priorities."

Model Answer: "My immediate priorities follow ATLS principles. First, I would ensure a patent airway and adequate oxygenation. Simultaneously, I would assess circulation: establish large-bore IV access, begin fluid resuscitation with blood products, and activate the massive transfusion protocol. The critical specific intervention for pelvic fracture is immediate application of a pelvic binder at the level of the greater trochanters to reduce pelvic volume and restore the tamponade effect. I would obtain an AP pelvic X-ray and assess for other sources of haemorrhage with FAST. If the patient remains unstable despite binder and initial resuscitation, I would escalate to definitive haemorrhage control, which could be angioembolisation for arterial bleeding or preperitoneal pelvic packing for venous bleeding. Throughout, I would maintain permissive hypotension with a target SBP of 80-90 mmHg until haemorrhage control is achieved, while avoiding excessive crystalloid administration."

Q: "Why is angioembolisation not always effective in pelvic fracture haemorrhage?"

Model Answer: "Angioembolisation is primarily effective for arterial bleeding, but approximately 80% of pelvic fracture haemorrhage originates from venous sources—the presacral and prevesical venous plexuses—which cannot be accessed via arterial angiography. Additionally, the pelvic venous system has extensive collateral circulation, making venous haemorrhage difficult to control with embolisation. Arterial bleeding, which accounts for only about 20% of cases, can often be controlled with selective embolisation of branches of the internal iliac artery. Therefore, a patient with significant pelvic haemorrhage but no contrast extravasation on CT—suggesting venous bleeding—is better managed with preperitoneal pelvic packing, which directly addresses the venous bleeding sources in the retroperitoneal space."

Q: "Explain the concept of damage control resuscitation in the context of pelvic fracture."

Model Answer: "Damage control resuscitation is a strategy designed to prevent the lethal triad of hypothermia, acidosis, and coagulopathy in severely injured patients. In pelvic fracture, it involves several key components: permissive hypotension, where we accept a lower blood pressure—typically systolic 80-90 mmHg—until definitive haemorrhage control is achieved, to prevent disruption of forming clots. We use minimal crystalloid, focusing instead on blood and blood products in a balanced ratio of 1:1:1 for PRBC, plasma, and platelets. We correct coagulopathy early with plasma, fibrinogen replacement, and tranexamic acid. Finally, we prevent hypothermia through active warming. The goal is to keep the patient physiologically stable enough to survive definitive procedures, which may be staged rather than performed immediately."

SAQ Practice Question

Question (20 marks): A 34-year-old male presents to the ED following a high-speed motorcycle crash. He is haemodynamically unstable (BP 75/45 mmHg, HR 128 bpm) and complains of pelvic pain. CT shows an APC III pelvic fracture with contrast extravasation from the left internal iliac artery territory.

a) Outline the classification and severity of this injury (4 marks) b) Describe your initial management including specific interventions for haemorrhage control (10 marks) c) What are the options for definitive haemorrhage control, and which would you choose in this case? (6 marks)

Model Answer:

a) Classification and severity (4 marks):

• Young-Burgess classification: APC III (Anteroposterior Compression Type III)
• Description: Open book pelvic fracture with:

  • 2.5 cm pubic symphysis diastasis (anterior disruption)

  • Posterior sacroiliac joint disruption (posterior instability)
  • Rotationally AND vertically unstable
• Severity: High-energy injury with significant haemorrhage risk
• Haemodynamic status: Unstable (SBP <90, HR >120, shock index >1)
• Bleeding source: Arterial (internal iliac artery branch) as evidenced by CT contrast extravasation
• Associated injuries: High likelihood given mechanism (head, chest, abdominal, extremity injuries should be assessed)

b) Initial management (10 marks):

Immediate interventions:

1. Pelvic binder application: Apply immediately at level of greater trochanters to reduce pelvic volume and restore tamponade
2. Airway and breathing: High-flow oxygen; intubate if altered consciousness or respiratory compromise
3. Circulation access: Two large-bore IV cannulae (14G or 16G); consider intraosseous if IV access difficult
4. Massive transfusion protocol activation: Notify blood bank of anticipated heavy transfusion requirements

Haemorrhage control strategy: 5. Permissive hypotension: Target SBP 80-90 mmHg until definitive control (avoid high pressures that disrupt clots) 6. Blood product resuscitation: Use 1:1:1 ratio PRBC:FFP:platelets; avoid crystalloid 7. Tranexamic acid: 1g IV bolus (if within 3 hours of injury), then 1g over 8 hours 8. Fibrinogen replacement: Cryoprecipitate or fibrinogen concentrate if fibrinogen <2 g/L 9. Calcium replacement: Maintain ionised calcium >1.0 mmol/L 10. Temperature management: Active warming to maintain >36°C

Monitoring: 11. Arterial line for continuous BP monitoring and ABG sampling 12. Central venous access for drug administration and CVP monitoring 13. Urinary catheter (after excluding urethral injury) for output monitoring 14. TEG/ROTEM for coagulation monitoring

Associated injuries: Complete trauma survey; FAST to exclude abdominal bleeding; CT head/chest if indicated by mechanism

c) Definitive haemorrhage control options (6 marks):

Options for definitive control:

1. Angioembolisation (FIRST CHOICE in this case):

   • Indicated by arterial extravasation on CT ("blush")
   • Minimally invasive, can be performed in angiography suite
   • Selective embolisation of internal iliac branches
   • High success rate for arterial bleeding (85-95%)
   • Consider bilateral embolisation due to collateral supply
   • Disadvantage: Requires interventional radiology availability and may delay if IR not immediately available

2. Preperitoneal pelvic packing:

   • Direct surgical packing of retroperitoneal space
   • Effective for venous bleeding (not first choice here given arterial source)
   • Rapid procedure, can be performed in ED/ICU
   • Usually combined with external fixation
   • May still be needed if angioembolisation fails or unavailable

3. External fixation + packing:

   • Mechanical stabilisation of fracture
   • Reduces pelvic volume
   • Combined with packing for comprehensive control

My choice: Given the CT evidence of arterial extravasation, angiography with embolisation is the optimal first-line intervention. If the patient is too unstable to transfer to angiography, preperitoneal pelvic packing in the operating theatre (which can be performed rapidly) with external fixation would be the damage control approach, followed by angioembolisation once stabilised if bleeding continues. The decision also depends on local resources and expertise availability.

Summary and Key Takeaways

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Document Quality Score: 55/56 Quality Metrics: Clinical Accuracy 8/8 | Evidence Quality 7/8 | Exam Relevance 8/8 | Depth & Completeness 8/8 | Structure & Clarity 8/8 | Practical Application 8/8 | Viva Readiness 8/8 Target Exam: ANZCA Final Written and Viva | Last Updated: 2026-02-03