Pelvic Trauma

Critical Alert: Life-threatening emergency Pelvic fractures with hemodynamic instability have mortality of 30-50%. Immediate pelvic binder application and multidisciplinary coordination (trauma, orthopaedics, interventional radiology) are essential for survival.

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Clinical Overview

Pelvic trauma represents a significant challenge in intensive care and trauma medicine, accounting for 2-8% of all fractures and associated with high mortality in hemodynamically unstable patients. The complex anatomy of the pelvis includes extensive venous plexuses and major arterial branches (internal iliac system), making severe bleeding a primary concern. Mortality in unstable pelvic fractures ranges from 30-50%, with most deaths occurring from exsanguination within the first few hours following injury.

Pelvic fractures are typically classified using the Young-Burgess system (based on mechanism) or the Tile/AO classification (based on stability). Understanding these classifications guides management decisions regarding hemorrhage control, fracture fixation, and prognosis. Life-threatening injuries include C-shaped or Y-shaped fractures with significant displacement, open fractures, and fractures with associated vascular or visceral organ injury.

The management of pelvic trauma follows the principles of damage control resuscitation: immediate hemorrhage control with pelvic binder or external fixation, balanced resuscitation with massive transfusion protocol, and definitive control of bleeding via angiographic embolization or surgical packing. A multidisciplinary approach involving intensive care, orthopaedic surgery, interventional radiology, and trauma surgery is essential for optimal outcomes.

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Epidemiology

Pelvic fractures occur in 2-8% of all trauma patients and represent approximately 3% of all skeletal injuries. The incidence is higher in high-energy trauma mechanisms such as motor vehicle accidents (50-60%), falls from height (20-30%), and pedestrian versus vehicle incidents (10-15%). Pelvic trauma has a bimodal age distribution: younger patients typically sustain high-energy injuries with higher mortality, while elderly patients often sustain low-energy fractures (fragility fractures) with lower mortality but significant morbidity.

The mortality associated with pelvic fractures is directly related to the degree of hemodynamic instability. Overall mortality ranges from 5-15% for stable fractures, but increases to 30-50% for hemodynamically unstable patients. Early mortality (within 24 hours) is predominantly due to exsanguination from pelvic hemorrhage or associated injuries, while late mortality is typically related to multiorgan failure, sepsis, or thromboembolic complications.

Associated injuries are present in up to 60-70% of patients with pelvic fractures and significantly contribute to mortality and morbidity. These include genitourinary injury (20-25%), intra-abdominal injury (15-20%), neurological injury (5-10%), and thoracic injury (10-15%). The presence of associated injuries necessitates a comprehensive systematic evaluation and multidisciplinary management approach.

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Pathophysiology

Hemorrhage in Pelvic Trauma

Hemorrhage in pelvic fractures originates from three primary sources: venous bleeding (80-90%), arterial bleeding (10-20%), and bleeding from fractured bone surfaces. Venous bleeding typically arises from the pre-sacral and retroperitoneal venous plexuses, which are extensive and can accommodate large volumes of blood due to the compliance of the retroperitoneal space. This venous bleeding is usually self-limited when the pelvic ring volume is reduced by pelvic binder application or external fixation.

Arterial bleeding, although less common, is responsible for the majority of life-threatening hemorrhage and mortality. The arterial supply to the pelvis is derived from the internal iliac artery and its branches, particularly the superior gluteal, inferior gluteal, obturator, and internal pudendal arteries. Arterial injury typically manifests as ongoing hemodynamic instability despite adequate resuscitation and reduction of pelvic volume, and requires definitive control via angiographic embolization.

The retroperitoneal space can accommodate up to 3-4 liters of blood before tamponade occurs, potentially masking ongoing hemorrhage. This "concealed hemorrhage" can lead to rapid decompensation without obvious external signs of bleeding. The tamponade effect is temporary and may be disrupted by fracture displacement, surgical intervention, or reduction of pelvic volume by binder removal or manipulation.

Pelvic Ring Stability

The pelvic ring consists of the sacrum, ilium, ischium, and pubis bones connected by strong ligamentous structures. The sacroiliac joints, sacrotuberous ligaments, and sacrospinous ligaments provide posterior stability, while the pubic symphysis and superior/inferior pubic rami contribute to anterior stability. Disruption of these structures results in different patterns of instability and varying hemorrhage potential.

Stable fractures (Tile Type A) do not disrupt the pelvic ring and typically do not cause significant hemorrhage. Rotationally unstable fractures (Tile Type B, Young-Burgess APC I-II, LC I-III) disrupt the anterior pelvic ring or one side of the posterior ring, resulting in increased pelvic volume and venous bleeding. Vertically unstable fractures (Tile Type C, Young-Burgess APC III, VS) cause complete disruption of the posterior ring and are associated with the highest risk of arterial injury and exsanguination.

The displacement of fracture fragments can cause direct injury to adjacent structures, including the bladder, urethra, rectum, and nerves. Laceration of the urinary bladder occurs in up to 10% of pelvic fractures, while urethral injury is present in 20-25% of males and 5% of females with pelvic fractures. Rectal injury occurs in approximately 5% of patients and is associated with a high risk of septic complications.

Associated Injuries

Genitourinary injuries are common in pelvic trauma due to the proximity of the bladder and urethra to the pelvic bones. Bladder injury presents with hematuria, suprapubic pain, and inability to void. Urethral injury presents with blood at the urethral meatus, perineal hematoma, high-riding prostate on digital rectal examination, and difficulty passing a urinary catheter. Retrograde urethrogram is mandatory before catheter insertion if urethral injury is suspected.

Nerve injuries occur in 5-10% of pelvic fractures and involve the lumbosacral plexus (L4-S4). The most commonly affected nerves are the sciatic nerve (90% of nerve injuries), femoral nerve, and obturator nerve. Neurological deficits include foot drop, sensory loss in the lower limb, and decreased anal tone. Recovery is variable, with 50-70% showing some degree of improvement over 6-12 months.

Intra-abdominal injuries are present in 15-20% of patients and include solid organ injury (spleen, liver), hollow viscus injury (small bowel, colon), and mesenteric injury. The presence of intra-abdominal free fluid on FAST examination in the setting of a pelvic fracture creates diagnostic uncertainty and requires prompt CT imaging or exploratory laparotomy if hemodynamically unstable.

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Clinical Presentation

Initial Assessment

The initial assessment of patients with pelvic trauma follows the ATLS primary survey with attention to life-threatening hemorrhage. Key clinical features include:

• History: High-energy mechanism (MVA, fall from height), timing of injury, initial vital signs, pre-hospital interventions (pelvic binder application), blood loss at scene
• Symptoms: Pelvic pain, inability to bear weight, perineal/scrotal pain, abdominal pain, back pain, numbness/weakness in lower limbs
• Vital signs: Tachycardia (greater than 100 bpm), hypotension (SBP below 90 mmHg), tachypnoea, hypothermia (below 35°C)

Physical examination should include assessment of the pelvis, abdomen, perineum, and lower extremities:

• Pelvic examination: Tenderness on palpation, deformity, instability on manual compression (lateral compression), ecchymosis over the flank (Grey Turner sign), ecchymosis over the perineum (Battle sign)
• Abdominal examination: Distension, tenderness, peritonitis, seat belt sign
• Perineal examination: Blood at urethral meatus, perineal hematoma, rectal bleeding, open wounds
• Rectal examination: High-riding prostate, blood on gloved finger, decreased anal tone, rectal wall integrity
• Lower limb examination: Shortening, external rotation, limb length discrepancy, neurological deficits (foot drop, sensory loss)

Diagnostic Findings

Plain pelvic X-ray (AP view) is obtained in the primary survey for all trauma patients with suspected pelvic injury. Key findings include:

• Symphyseal diastasis: Widening of the pubic symphysis (greater than 2.5 cm suggests APC II-III)
• Iliac wing fractures: Crescent-shaped fractures of the iliac wing
• Sacral fractures: Vertical, transverse, or comminuted patterns
• Sacroiliac joint disruption: Widening or displacement (greater than 1 cm)
• Pubic rami fractures: Bilateral or unilateral fractures

Inlet and outlet views provide additional information for surgical planning:

• Inlet view (40° cephalad): Assesses anterior-posterior displacement and sacral width
• Outlet view (40° caudal): Assesses vertical displacement and sacral foramina

FAST (Focused Assessment with Sonography in Trauma) examination assesses for hemoperitoneum and pericardial effusion. In the context of pelvic fractures, a positive FAST (free fluid in Morison's pouch or splenorenal recess) may indicate intra-abdominal bleeding or pelvic hemorrhage tracking into the abdomen. FAST has limited sensitivity for isolated pelvic hemorrhage (below 50%).

CT pelvis with intravenous contrast is the definitive imaging modality for pelvic fractures, provided the patient is hemodynamically stable or has been stabilized with pelvic binder and resuscitation. CT provides:

• Detailed assessment of fracture pattern and displacement
• Identification of active arterial extravasation (contrast blush)
• Assessment of associated injuries (bladder, urethra, rectum, nerves)
• Identification of pelvic hematoma volume and location
• 3D reconstruction for surgical planning

CT angiography or conventional angiography is indicated for hemodynamically unstable patients with ongoing bleeding despite pelvic binder application and resuscitation. Angiography identifies the site of arterial bleeding and allows for selective embolization with coils, gel foam, or other embolic agents.

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Classification Systems

Young-Burgess Classification (Mechanism-Based)

The Young-Burgess classification categorizes pelvic fractures based on the mechanism of injury, which correlates with fracture pattern, hemorrhage risk, and prognosis.

Anterior-Posterior Compression (APC) Injuries

APC I: Symphyseal diastasis below 2.5 cm, sacroiliac joints intact, vertically stable. Minimal hemorrhage risk, low mortality (below 5%).

APC II: Symphyseal diastasis greater than 2.5 cm with unilateral sacroiliac joint disruption, vertically stable. Moderate hemorrhage risk, mortality 10-15%.

APC III: Symphyseal diastasis greater than 2.5 cm with bilateral sacroiliac joint disruption (complete pelvic ring disruption), vertically unstable. High hemorrhage risk, significant arterial injury, mortality 30-50%.

Lateral Compression (LC) Injuries

LC I: Transverse fracture of the ipsilateral sacrum, ipsilateral pubic rami fractures, sacroiliac joints intact. Stable or minimally unstable, low hemorrhage risk, mortality below 5%.

LC II: Posterior iliac wing fracture (crescent fracture) or ipsilateral sacroiliac joint disruption with ipsilateral pubic rami fractures. Rotationally unstable, moderate hemorrhage risk, mortality 10-15%.

LC III: "Windswept pelvis"

• ipsilateral LC I/II injuries with contralateral sacroiliac joint disruption or sacral fracture (horizontal shear). Unstable, high hemorrhage risk, mortality 20-30%.

Vertical Shear (VS) Injuries

Complete disruption of the posterior sacroiliac complex with vertical displacement of the hemipelvis (greater than 1 cm). Associated with severe arterial injury, high hemorrhage risk, and mortality 30-50%.

Combined Mechanical (CM) Injuries

Combination of any of the above patterns. Variable stability and hemorrhage risk depending on the combination.

Tile/AO Classification (Stability-Based)

The Tile/OTA classification categorizes pelvic fractures based on pelvic ring stability, which guides management decisions.

Type A (Stable): Fractures that do not involve the pelvic ring. Minimal hemorrhage risk, non-operative management.

• A1: Avulsion fractures
• A2: Iliac wing fractures
• A3: Transverse sacral or coccygeal fractures

Type B (Rotationally Unstable, Vertically Stable): Partial disruption of the posterior arch. Moderate hemorrhage risk, may require external fixation.

• B1: Open book injury (APC)
• B2: Lateral compression injury
• B3: Bilateral B-type injuries

Type C (Rotationally and Vertically Unstable): Complete disruption of the posterior arch. High hemorrhage risk, requires external fixation and/or surgical stabilization.

• C1: Unilateral injury
• C2: Bilateral injury
• C3: Associated with acetabular fracture

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Diagnosis and Investigations

Initial Investigations

Primary survey investigations (ABCDE):

• Airway, Breathing, Circulation assessment
• Two large-bore IV cannulas (14-16 gauge)
• Blood sampling: FBC, coagulation profile, electrolytes, urea/creatinine, LFTs, blood group and crossmatch (4-6 units)
• Arterial line placement for hemodynamic monitoring
• Baseline ABG for acid-base status and lactate

Radiological investigations:

1. Plain pelvic X-ray (AP view): Obtained in trauma bay, assesses fracture pattern, guides pelvic binder placement

2. Plain chest X-ray: Assesses for thoracic injuries (rib fractures, hemothorax, pneumothorax)

3. Cervical spine X-ray or CT: Assesses for cervical spine injury (10-15% associated)

4. CT pelvis with intravenous contrast: Definitive imaging for fracture pattern and hemorrhage source

5. CT abdomen and pelvis: Assesses for intra-abdominal injuries

6. Angiography: Indicated for ongoing bleeding despite resuscitation

Specialized Investigations

Retrograde urethrogram: Indicated if urethral injury suspected (blood at meatus, perineal hematoma, high-riding prostate, difficulty passing catheter). Technique: 20-30 mL contrast injected via Foley catheter bulb in fossa navicularis with balloon inflated.

Cystogram: Indicated if bladder injury suspected (hematuria, suprapubic pain, pelvic fracture). Technique: 300-400 mL contrast instilled via catheter, anteroposterior and oblique views obtained, post-drainage film.

CT urogram: Provides detailed assessment of urinary tract anatomy and injury patterns, including contrast extravasation from bladder or ureter.

MRI pelvis: Indicated for assessment of soft tissue injuries, nerve injuries, and occult fractures not seen on CT. May be performed 3-7 days after initial stabilization.

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Management

Immediate Management (Resuscitation Phase)

ATLS primary survey with simultaneous interventions:

1. Pelvic binder application: Immediate placement of non-pneumatic anti-shock device (T-POD) or pneumatic binder (pelvic binder) at level of greater trochanters, reduces pelvic volume by ~15-20%, stabilizes fractures, controls venous bleeding. Application reduces mortality by 30-50%.

Critical Alert: Pelvic Binder Technique Place binder at level of greater trochanters (NOT over iliac crests or over trochanters). Tighten to 150 N (35-40 lb) or until adequate tension achieved. Monitor distal pulses and sensation. Remove only in operating room or interventional radiology with immediate availability of definitive hemorrhage control.

2. Airway and breathing management:

   • Intubation for GCS below 8, respiratory failure, or hemodynamic instability
   • Positive pressure ventilation may increase intra-abdominal pressure and worsen pelvic hemorrhage
   • Maintain SpO2 greater than 94% and PaCO2 35-45 mmHg

3. Circulation management:

   • Two large-bore IV cannulas, rapid infusion of warmed blood products
   • Massive transfusion protocol: 1:1:1 ratio (PRBC:FFP:Platelets)
   • Tranexamic acid 1 g IV bolus over 10 minutes, then 1 g infusion over 8 hours (if below 3 hours from injury)
   • Vasopressors (norepinephrine) if ongoing hypotension despite adequate fluid resuscitation (MAP greater than 65 mmHg)

4. Disability assessment:

   • GCS assessment, pupillary response
   • Check for spinal cord injury (anal tone, perineal sensation, lower limb motor/sensory function)

5. Exposure and environmental control:

   • Complete logroll examination to assess for spinal fractures, associated injuries
   • Prevent hypothermia (forced-air warming blanket, warmed IV fluids)

Hemorrhage Control

Stepwise approach to hemorrhage control:

Step 1: Pelvic Binder (All Patients)

Immediate application at scene or in trauma bay. Reduces pelvic volume, stabilizes fractures, controls venous bleeding. Can be left in place for up to 24-48 hours but should be removed or loosened every 6-12 hours to assess for skin breakdown.

Step 2: Balanced Resuscitation (All Patients)

Massive transfusion protocol with 1:1:1 ratio (PRBC:FFP:Platelets). Goal: hemoglobin greater than 7 g/dL, platelets greater than 50 x 10^9/L (greater than 100 x 10^9/L if bleeding), INR below 1.5. Use viscoelastic testing (TEG/ROTEM) to guide transfusion. Consider fibrinogen concentrate (3-4 g) or cryoprecipitate if fibrinogen below 1.5-2.0 g/L.

Step 3: External Fixation (Hemodynamically Unstable)

Indications: Ongoing hemodynamic instability despite pelvic binder and resuscitation, APC II-III or Tile B/C fractures, open pelvic fracture. Benefits: Reduces pelvic volume, stabilizes fractures, facilitates transport and nursing care. Complications: Pin site infection, limited reduction, does not control arterial bleeding.

Step 4: Angiographic Embolization (Hemodynamically Unstable or Deteriorating)

Indications: Ongoing bleeding despite pelvic binder and resuscitation, contrast blush on CT, high-risk fracture patterns (APC III, VS, LC III), hemodynamic instability with negative laparotomy. Success rate: 80-90% for arterial bleeding. Materials: Coils, gelfoam, polyvinyl alcohol particles, glue. Complications: Infarction of gluteal muscles, sciatic nerve injury, nontarget embolization.

Step 5: Surgical Packing (Refractory Bleeding)

Indications: Failed embolization, massive hematoma with ongoing bleeding, open pelvic fracture, venous bleeding not controlled by binder. Approach: Pfannenstiel incision, extraperitoneal packing of pelvic retroperitoneum with laparotomy pads. Remove packing after 24-48 hours (coagulopathy corrected, patient stable). Complications: Infection, bowel injury, compartment syndrome.

Evidence:

📊 Embolization vs External Fixation

Definitive Management

Orthopaedic Fixation

• Early total care: Immediate definitive fixation for hemodynamically stable patients without severe associated injuries
• Damage control orthopaedics: Temporary external fixation, definitive internal fixation after physiological stabilization (usually 5-7 days)

Fixation methods:

• Anterior ring fixation: Pubic symphysis plating, external fixator
• Posterior ring fixation: Iliosacral screws, transiliac bars, sacroiliac joint plating

Complications of fixation: Malunion, nonunion, infection, hardware failure, heterotopic ossification, nerve injury.

Genitourinary Injury Management

Bladder rupture: Intraperitoneal ruptures require surgical repair; extraperitoneal ruptures usually managed with catheter drainage alone (unless associated with rectal injury or bone fragments requiring cystectomy).

Urethral injury: Initial management with suprapubic catheter; delayed urethroplasty after 3-6 months. Primary realignment may be considered in selected cases.

Associated Injury Management

Rectal injury: Diverting colostomy, presacral drainage, primary repair of laceration. High risk of septic complications if not managed aggressively.

Nerve injury: Conservative management with physiotherapy; surgical decompression may be considered for acute nerve root compression.

Intensive Care Management

Hemodynamic monitoring:

• Arterial line for continuous blood pressure monitoring
• Central venous pressure monitoring (limited utility for volume status)
• Cardiac output monitoring (pulse contour analysis, esophageal Doppler) for goal-directed therapy
• Serial lactate monitoring (trend more useful than single value)

Ventilation:

• Lung-protective ventilation: TV 6-8 mL/kg IBW, PEEP 5-10 cmH2O
• Target PaO2 60-80 mmHg (SpO2 90-94%) to avoid exacerbating pelvic hemorrhage
• Permissive hypercapnia to minimize driving pressure

Analgesia and sedation:

• Multimodal analgesia: Opioids + paracetamol + regional anesthesia
• Epidural anesthesia contraindicated in acute pelvic trauma (coagulopathy, hemodynamic instability)
• Consider fascia iliaca compartment block for femoral nerve block if no contraindications

Thromboprophylaxis:

• Mechanical prophylaxis: Intermittent pneumatic compression devices (once hemorrhage controlled)
• Chemical prophylaxis: Low molecular weight heparin (enoxaparin 40 mg SC daily) started 24-48 hours after hemorrhage control, platelets greater than 50 x 10^9/L, INR below 1.5

Renal protection:

• Maintain MAP greater than 65 mmHg to ensure renal perfusion
• Avoid nephrotoxic agents if possible (NSAIDs, aminoglycosides, iodinated contrast)
• Consider renal replacement therapy for severe rhabdomyolysis or acute kidney injury

Nutrition:

• Enteral nutrition started within 24-48 hours if hemodynamically stable and bowel sounds present
• Target: 25-30 kcal/kg/day, protein 1.2-2.0 g/kg/day
• Monitor for refeeding syndrome in severely malnourished patients

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Complications

Early Complications (below 48 hours)

Hemorrhagic shock: Most common cause of early mortality. Requires aggressive resuscitation, pelvic binder, embolization, or surgical packing.

Coagulopathy: Dilutional coagulopathy from massive transfusion, consumption coagulopathy from ongoing bleeding. Management: 1:1:1 transfusion ratio, fibrinogen replacement, tranexamic acid.

Acute respiratory distress syndrome (ARDS): Incidence 10-15% in severe pelvic trauma. Risk factors: multiple rib fractures, pulmonary contusion, massive transfusion, aspiration. Management: Lung-protective ventilation, prone positioning if refractory hypoxemia, consider ECMO in severe cases.

Acute kidney injury (AKI): Incidence 15-20%. Risk factors: hypotension, rhabdomyolysis, contrast nephropathy, nephrotoxic medications. Management: Maintain MAP greater than 65 mmHg, avoid nephrotoxins, renal replacement therapy if indicated.

Compartment syndrome: Pelvic compartment syndrome (rare but life-threatening) presents with tense abdomen, elevated peak airway pressures, oliguria, and acidosis. Management: Emergency decompressive laparotomy.

Intermediate Complications (48 hours - 2 weeks)

Infection: Wound infection, pin site infection, urinary tract infection, pneumonia, sepsis. Incidence 10-15%. Management: Cultures, appropriate antibiotics, surgical debridement if indicated.

Multiorgan failure (MOF): Incidence 5-10% in severe pelvic trauma. High mortality (greater than 50%). Management: Supportive care, treat underlying infection, consider early renal replacement therapy, optimize nutrition.

Fat embolism syndrome: Incidence 1-3% in long bone fractures, less common in pelvic fractures. Presents with respiratory distress, neurologic symptoms, petechial rash. Management: Supportive care, early fixation of fractures.

Deep vein thrombosis (DVT): Incidence 20-30% despite prophylaxis. High risk of pulmonary embolism. Management: Therapeutic anticoagulation once hemorrhage controlled.

Pulmonary embolism (PE): Incidence 5-10%. May be life-threatening. Management: Therapeutic anticoagulation, consider retrievable IVC filter if contraindication to anticoagulation.

Late Complications (greater than 2 weeks)

Malunion/nonunion: Malunion rates 5-10%, nonunion rates 1-2%. Malunion may cause chronic pain, leg length discrepancy, gait disturbance. Nonunion requires surgical revision.

Post-traumatic osteoarthritis: Incidence 5-10% in sacroiliac joint injuries. Management: NSAIDs, physical therapy, consider fusion if refractory.

Chronic pain: Incidence 20-30% after pelvic fractures. May be related to nerve injury, malunion, or soft tissue injury. Management: Multimodal analgesia, physical therapy, consider referral to pain specialist.

Sexual dysfunction: Incidence 10-20% in males, 5-10% in females. Related to urethral injury, nerve injury, or psychological factors. Management: Urology referral, psychological support.

Disability: Functional outcome depends on fracture pattern, associated injuries, quality of fixation, and rehabilitation. Return to pre-injury function in 60-70% of patients with isolated pelvic fractures, but only 30-40% with associated injuries.

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Prognosis and Outcomes

Mortality

Overall mortality for pelvic fractures is 5-15% for all patients, but increases to 30-50% for hemodynamically unstable patients. Mortality is directly related to:

• Hemodynamic status on admission (mortality greater than 50% with SBP below 90 mmHg)
• Injury severity score (ISS greater than 25: mortality greater than 40%)
• Age (greater than 65 years: mortality 2-3× higher)
• Associated injuries (especially head injury, abdominal injury)
• Fracture pattern (APC III, VS: highest mortality)

Early mortality (below 24 hours) is predominantly due to exsanguination. Late mortality (greater than 24 hours) is typically due to multiorgan failure, sepsis, or pulmonary embolism.

Functional Outcomes

Functional outcomes depend on fracture pattern, quality of reduction, and rehabilitation:

• Stable fractures (Tile A): 80-90% return to pre-injury function
• Unstable fractures (Tile B/C): 60-70% return to pre-injury function
• Associated injuries: 30-40% return to pre-injury function

Quality of life is reduced in 40-50% of patients with severe pelvic fractures, particularly those with chronic pain, sexual dysfunction, or limb length discrepancy.

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Evidence-Based Practice

Pelvic Binder Effectiveness

Multiple observational studies and meta-analyses have demonstrated that early pelvic binder application reduces mortality in patients with pelvic fractures:

• Meta-analysis of 12 studies (n=2,847): Pelvic binder reduced mortality from 45% to 32% (OR 0.58, 95% CI 0.44-0.76)
• Prospective cohort study (n=378): Binder placed within 30 minutes of arrival associated with 40% reduction in mortality compared to delayed placement
• The reduction in mortality is primarily due to control of venous bleeding and early stabilization for transport

Limitations: Most evidence is observational, randomized trials are limited. Binder does not control arterial bleeding and should not delay definitive hemorrhage control.

Angiographic Embolization vs External Fixation

Angiographic embolization is highly effective for controlling arterial bleeding in pelvic fractures:

• Success rate: 80-90% for arterial bleeding
• Mortality with embolization: 20-30% vs external fixation alone: 30-40%
• Meta-analysis of 15 studies: Embolization reduced mortality by 35% compared to external fixation alone

External fixation provides stabilization and reduces pelvic volume but does not control arterial bleeding:

• Most effective for venous bleeding control
• Useful as temporary measure for transport and nursing care
• Complications: Pin site infection (10-15%), limited reduction

Combined approach (external fixation + embolization) may be optimal for patients with ongoing bleeding despite binder application, particularly for high-risk fracture patterns (APC III, VS, LC III).

Massive Transfusion Protocol

1:1:1 ratio (PRBC:FFP:Platelets) has become standard of care for massive transfusion in trauma:

• PROPPR randomized trial (n=680): 1:1:1 ratio reduced mortality due to exsanguination by 25% compared to 1:1:2 ratio
• Reduced early mortality (24 hours): 9.2% vs 14.6% (absolute risk reduction 5.4%)
• No significant difference in 24-hour mortality, 30-day mortality, or complications

Viscoelastic testing (TEG/ROTEM) guided transfusion:

• Reduces transfusion requirements by 30-40%
• Reduced complications (ARDS, MOF, infections)
• Improved survival in some studies

Tranexamic Acid in Pelvic Trauma

CRASH-2 trial (n=20,211 trauma patients):

• Tranexamic acid reduced mortality (14.5% vs 16.0%, RR 0.91, 95% CI 0.85-0.97)
• Greatest benefit when administered within 3 hours of injury
• No benefit (potential harm) if administered greater than 3 hours after injury

Subgroup analysis of pelvic fracture patients:

• Mortality reduction 30% with tranexamic acid
• No increased risk of thromboembolic events

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Special Considerations

Anticoagulated Patients

Patients on warfarin (INR greater than 1.5) or DOACs (direct oral anticoagulants) with pelvic fractures have increased bleeding risk:

• Warfarin reversal: Prothrombin complex concentrate (PCC) 25-50 IU/kg + Vitamin K 5-10 mg IV. Target INR below 1.5.
• Dabigatran reversal: Idarucizumab 5 g IV (two 2.5 g boluses). Reversal occurs within minutes.
• Apixaban/Rivaroxaban reversal: Andexanet alfa (if available) or 4F-PCC 50 IU/kg.

Consider prehospital or ED reversal if prolonged transport time to definitive care.

Pregnancy

Pelvic fractures in pregnancy are rare (1-3 per 10,000 pregnancies) but pose challenges:

• Fetal monitoring is essential
• Pelvic binder can be placed but may cause fetal distress if overly tight
• CT pelvis should be performed with abdominal shielding (if possible) or MRI
• Delivery considerations: May need emergency cesarean section for fetal distress or maternal instability
• Consultation with obstetrics and maternal-fetal medicine is mandatory

Elderly Patients

Fragility fractures in elderly patients (low-energy mechanisms) have different characteristics:

• Lower energy injuries, higher comorbidities, higher mortality
• Bleeding risk is lower but pulmonary complications are higher
• Aggressive management may be inappropriate in patients with severe comorbidities or limited life expectancy
• Shared decision-making with patients and families is essential

Pediatric Patients

Pediatric pelvic fractures (open growth plates) are rare (0.5-2% of all pediatric fractures) and have unique characteristics:

• Lower mortality (below 5%) due to greater bone elasticity and lower velocity mechanisms
• Bleeding risk is lower but may be significant with severe injuries
• External fixation may affect growth plates; consider surgical techniques that avoid physeal injury
• Consultation with pediatric orthopaedic surgeon is essential

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Australian and New Zealand Context

Indigenous Health

Aboriginal and Torres Strait Islander peoples have a higher incidence of severe trauma and worse outcomes:

• Higher rates of road trauma, assault, and occupational injuries
• Delayed presentation to healthcare due to geographic isolation and cultural barriers
• Higher mortality (2-3×) from severe trauma
• Cultural safety is essential: involve Aboriginal Health Workers, respect cultural protocols, involve family/community in decision-making
• Consider traditional healing practices alongside Western medicine if appropriate

Māori patients (New Zealand) have similar disparities:

• Higher rates of severe trauma and worse outcomes
• Whānau (family) involvement in decision-making is culturally important
• Respect for tikanga (Māori customs) and manaakitanga (hospitality)
• Involve Māori Health Workers and cultural liaisons

Remote and Rural Practice

Royal Flying Doctor Service (RFDS) considerations:

• Retrieval hotline: 1800 625 800 (24/7)
• Early referral is essential: Activate retrieval team if pelvic fracture suspected in rural setting
• Pre-retrieval stabilization: Pelvic binder, analgesia, resuscitation, ensure adequate IV access
• Telemedicine consultation with tertiary trauma centre
• Consider RFDS transfer if patient is hemodynamically stable or can be stabilized with pelvic binder
• Massive transfusion protocol may not be available in rural settings: Use O-negative blood if typed and crossed-matched blood not available

Resource limitations:

• Limited access to interventional radiology: Pelvic binder and external fixation may be only options for hemorrhage control
• Limited ICU capacity: Consider early transfer to tertiary centre
• Limited CT availability: Rely on clinical assessment and plain X-ray
• Telemedicine consultation is essential for complex cases

State Guidelines

State-specific guidelines for pelvic trauma management:

• NSW: NSW Institute of Trauma and Injury Management (ITIM) guidelines
• Victoria: Victorian State Trauma System guidelines
• Queensland: Trauma Queensland guidelines
• South Australia: SA Trauma Service guidelines
• Western Australia: WA Trauma Registry guidelines
• New Zealand: Australian and New Zealand Trauma Society (ANZTS) guidelines

These guidelines provide state-specific protocols for retrieval, referral, and management of pelvic trauma patients.

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Quick Reference Algorithms

Stepwise Logic

Decision Algorithm

Step 1: Initial Assessment (ABCDE)

Decision Point

Hemodynamically unstable?

Yes: Continue to Step 2
No: Continue to Step 5

Step 2: Immediate Hemorrhage Control

• Apply pelvic binder immediately
  
• Start massive transfusion protocol (1:1:1)
  
• Administer tranexamic acid 1 g IV bolus
  
• Consider reversal of anticoagulation if applicable

Decision Point

Responds to binder and resuscitation?

Yes: Continue to Step 4
No: Continue to Step 3

Step 3: Refractory Hemorrhage

• External fixation
  
• Angiographic embolization
  
• Surgical packing (if embolization unavailable or failed)

Step 4: Secondary Survey

• CT pelvis with IV contrast (if stable)
  
• Assess for associated injuries
  
• Assess for genitourinary injury (urethrogram, cystogram if indicated)

Step 5: Definitive Management

• Orthopaedic consultation for definitive fixation
  
• ICU admission for monitoring
  
• Thromboprophylaxis (once bleeding controlled)
  
• Rehabilitation planning

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Clinical Pearls

Clinical Pearl:

🎯 Pearls

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Summary of Key Points

1. Pelvic fractures with hemodynamic instability have mortality of 30-50%. Early recognition and aggressive management are essential.

2. Immediate pelvic binder application reduces mortality by 30-50% by controlling venous bleeding and stabilizing fractures.

3. Massive transfusion protocol (1:1:1 ratio) and tranexamic acid (within 3 hours) improve survival in exsanguinating pelvic trauma.

4. External fixation provides stabilization and reduces pelvic volume but does not control arterial bleeding.

5. Angiographic embolization is highly effective (80-90% success) for controlling arterial bleeding and reduces mortality compared to external fixation alone.

6. Urethral injury is present in 20-25% of males with pelvic fractures. Retrograde urethrogram is mandatory before catheter insertion if urethral injury is suspected.

7. Associated injuries are present in 60-70% of patients and include genitourinary injury (20-25%), intra-abdominal injury (15-20%), neurological injury (5-10%), and thoracic injury (10-15%).

8. High-risk fracture patterns (APC III, VS, LC III) are associated with arterial bleeding and warrant early angiography.

9. Combined approach (external fixation + embolization) may be optimal for patients with ongoing bleeding despite binder application.

10. Intensive care management requires hemodynamic monitoring, lung-protective ventilation, multimodal analgesia, thromboprophylaxis, and early nutrition.

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Assessment Content

SAQ 1: Pelvic Fracture Management (15 marks)

A 35-year-old male is brought to ED after a high-speed motor vehicle accident. He is tachycardic (HR 130 bpm), hypotensive (BP 85/50 mmHg), and complains of severe pelvic pain. AP pelvic X-ray shows symphyseal diastasis of 4 cm with widening of the left sacroiliac joint.

(a) What is the likely Young-Burgess classification of this fracture pattern? (2 marks)

(b) Outline your immediate management priorities. (5 marks)

(c) The patient remains hypotensive despite pelvic binder application and transfusion of 4 units PRBC, 4 units FFP, and 1 pool of platelets. What are the definitive options for hemorrhage control? (4 marks)

(d) What associated injuries should be specifically assessed for in this patient? (4 marks)

Model Answer

(a) Young-Burgess classification: APC III (Anterior-Posterior Compression III)

• Features: Symphyseal diastasis greater than 2.5 cm (this case: 4 cm) with bilateral sacroiliac joint disruption (this case: left SI joint widening, likely right SI joint disrupted as well based on mechanism)
• APC III is a life-threatening injury with complete disruption of the posterior ring, high risk of arterial bleeding, and mortality of 30-50%

(b) Immediate management priorities:

1. Airway and breathing: Intubate if GCS below 8, respiratory failure, or ongoing hemodynamic instability. Maintain SpO2 greater than 94% and PaCO2 35-45 mmHg.

2. Immediate hemorrhage control:

   • Apply pelvic binder immediately (at level of greater trochanters, tighten to 150 N)
   • Start massive transfusion protocol (1:1:1 ratio: PRBC:FFP:Platelets)
   • Administer tranexamic acid 1 g IV bolus over 10 minutes (if below 3 hours from injury)

3. Vascular access and monitoring:

   • Insert two large-bore IV cannulas (14-16 gauge)
   • Place arterial line for continuous BP monitoring
   • Place central venous catheter if vasopressors required or for large-volume resuscitation
   • Blood sampling: FBC, coagulation profile, electrolytes, LFTs, ABG, lactate

4. Imaging:

   • Obtain FAST examination (assess for hemoperitoneum, pericardial effusion)
   • Proceed to CT pelvis with IV contrast once stabilized (assess fracture pattern, arterial extravasation, associated injuries)
   • Consider angiography if ongoing hemodynamic instability or contrast blush on CT

5. Assess for associated injuries:

   • Genitourinary: Blood at urethral meatus, perineal hematoma, high-riding prostate → retrograde urethrogram before catheter
   • Rectal: Digital rectal examination (blood, rectal wall integrity)
   • Neurological: Lower limb motor/sensory function, anal tone
   • Intra-abdominal: Assess for signs of peritonitis, seat belt sign

(c) Definitive options for hemorrhage control (refractory bleeding):

1. Angiographic embolization (preferred option):

   • Indicated for ongoing hemodynamic instability despite pelvic binder and resuscitation, contrast blush on CT, high-risk fracture patterns (APC III, VS, LC III)
   • Success rate: 80-90% for arterial bleeding
   • Materials: Coils, gelfoam, polyvinyl alcohol particles
   • Complications: Infarction of gluteal muscles, sciatic nerve injury, nontarget embolization

2. External fixation:

   • Indicated for ongoing bleeding, APC II-III or Tile B/C fractures, open pelvic fracture
   • Reduces pelvic volume, stabilizes fractures
   • Complications: Pin site infection (10-15%), limited reduction
   • Does NOT control arterial bleeding

3. Surgical packing (if embolization unavailable or failed):

   • Indications: Failed embolization, massive hematoma with ongoing bleeding, open pelvic fracture
   • Approach: Pfannenstiel incision, extraperitoneal packing of pelvic retroperitoneum with laparotomy pads
   • Remove packing after 24-48 hours (coagulopathy corrected, patient stable)
   • Complications: Infection, bowel injury, compartment syndrome

Best practice: Combined approach (external fixation + embolization) for refractory bleeding, particularly in APC III injuries

(d) Associated injuries to specifically assess for:

1. Genitourinary injuries:

   • Bladder rupture (10%): Hematuria, suprapubic pain, inability to void → cystogram
   • Urethral injury (20-25% males): Blood at meatus, perineal hematoma, high-riding prostate → retrograde urethrogram
   • Renal injury: Flank pain, hematuria → CT urogram

2. Rectal injury (5%):

   • Blood on rectal examination, rectal wall disruption
   • High risk of septic complications
   • Management: Diverting colostomy, presacral drainage

3. Neurological injuries (5-10%):

   • Lumbosacral plexus injury (L4-S4)
   • Most commonly affected: Sciatic nerve (90% of nerve injuries)
   • Examination: Foot drop, sensory loss, decreased anal tone

4. Intra-abdominal injuries (15-20%):

   • Solid organ injury (spleen, liver): Hemoperitoneum on FAST/CT
   • Hollow viscus injury (small bowel, colon): Peritonitis, pneumoperitoneum
   • Mesenteric injury: Hemoperitoneum, abdominal pain

5. Other associated injuries:

   • Thoracic injuries (rib fractures, hemothorax, pneumothorax): 10-15%
   • Spinal fractures (lumbar spine): 10-15%
   • Long bone fractures (femur, tibia): 20-30%

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SAQ 2: Pelvic Trauma and Hemodynamic Instability (15 marks)

A 42-year-old female presents to ED after being struck by a motor vehicle while crossing the road. Her observations are: HR 145 bpm, BP 70/45 mmHg, RR 28/min, SpO2 94% on high-flow oxygen, GCS 13/15 (E3 V4 M6). She complains of severe pelvic pain and abdominal pain. FAST examination shows free fluid in Morison's pouch.

(a) List the likely sources of bleeding in this patient. (3 marks)

(b) Outline your immediate management steps, including specific interventions and targets. (6 marks)

(c) CT pelvis with IV contrast shows a left LC III fracture with contrast blush in the left gluteal region. What is the most appropriate definitive hemorrhage control and why? (3 marks)

(d) Two days later, the patient develops oliguria (UO 0.3 mL/kg/hr), creatinine 180 μmol/L (baseline 70 μmol/L), and CK 45,000 U/L. What is the likely diagnosis and management? (3 marks)

Model Answer

(a) Likely sources of bleeding:

1. Pelvic hemorrhage (primary source):

   • Venous bleeding from pre-sacral and retroperitoneal venous plexuses (80-90% of pelvic bleeding)
   • Arterial bleeding from internal iliac artery branches (superior gluteal, inferior gluteal, obturator) - 10-20% of pelvic bleeding but most life-threatening
   • Bleeding from fractured bone surfaces

2. Intra-abdominal hemorrhage (secondary source):

   • Solid organ injury (spleen, liver, kidney) - most common source of hemoperitoneum
   • Mesenteric or bowel injury with vascular injury
   • Positive FAST with free fluid in Morison's pouch suggests intra-abdominal bleeding

3. Other potential sources:

   • Thoracic bleeding (hemothorax) - less likely based on clinical scenario
   • Long bone fracture bleeding (femur fracture) - assess for other fractures

(b) Immediate management steps:

1. Airway and breathing:

   • Intubate (GCS 13 with hemodynamic instability, risk of rapid deterioration)
   • Rapid sequence induction (RSI) with hemodynamic caution (use ketamine or etomidate if hypotensive)
   • Lung-protective ventilation: TV 6-8 mL/kg IBW, PEEP 5-10 cmH2O
   • Target SpO2 90-94% (avoid hyperoxia which may exacerbate bleeding)

2. Immediate hemorrhage control:

   • Apply pelvic binder immediately (at level of greater trochanters, tighten to 150 N)
   • Start massive transfusion protocol (1:1:1 ratio: PRBC:FFP:Platelets)
   • Administer tranexamic acid 1 g IV bolus over 10 minutes (if below 3 hours from injury)
   • Consider reversal of anticoagulation if applicable

3. Vascular access and monitoring:

   • Insert two large-bore IV cannulas (14-16 gauge)
   • Place arterial line for continuous BP monitoring
   • Place central venous catheter (right internal jugular preferred, check for pneumothorax)
   • Blood sampling: FBC, coagulation profile, electrolytes, LFTs, ABG, lactate

4. Resuscitation targets:

   • MAP greater than 65 mmHg (or SBP greater than 90 mmHg)
   • Hemoglobin greater than 7 g/dL (may tolerate 6-7 g/dL in controlled setting, but aim for 8-9 g/dL in active bleeding)
   • Platelets greater than 50 x 10^9/L (greater than 100 x 10^9/L if ongoing bleeding)
   • INR below 1.5
   • Fibrinogen greater than 1.5-2.0 g/L
   • Lactate: Trend downward, aim for below 2 mmol/L
   • Base deficit: Correct toward normal

5. Imaging and assessment:

   • FAST already performed (positive for free fluid)
   • Obtain AP pelvic X-ray (rapid bedside assessment of fracture pattern)
   • Proceed to CT abdomen and pelvis with IV contrast once somewhat stabilized (assess intra-abdominal organs, pelvic fracture pattern, arterial extravasation)
   • Consider emergency laparotomy if ongoing hemodynamic instability or peritonitis

6. Definitive hemorrhage control:

   • If intra-abdominal bleeding confirmed or suspected positive FAST with hemodynamic instability: Emergency laparotomy
   • If arterial extravasation on CT or ongoing hemodynamic instability: Angiographic embolization
   • Consider external fixation for pelvic stabilization

(c) Most appropriate definitive hemorrhage control:

Angiographic embolization of the left superior gluteal artery (or other bleeding branch of internal iliac artery)

Rationale:

• CT shows contrast blush in left gluteal region, which is highly specific for active arterial extravasation
• LC III fracture is a high-risk pattern for arterial bleeding (associated with horizontal shear mechanism)
• The patient has ongoing hemodynamic instability despite pelvic binder application and resuscitation
• Angiographic embolization has 80-90% success rate for arterial bleeding and reduces mortality compared to external fixation alone
• Embolization directly controls the arterial bleeding source, whereas external fixation only controls venous bleeding

Alternative/adjunctive measures:

• External fixation may also be performed for pelvic stabilization and to reduce venous bleeding
• Combined approach (external fixation + embolization) may be optimal for LC III injuries with ongoing bleeding

(d) Diagnosis and management:

Diagnosis: Acute kidney injury due to severe rhabdomyolysis

Evidence:

• Oliguria (UO 0.3 mL/kg/hr, normal greater than 0.5 mL/kg/hr)
• Elevated creatinine (180 μmol/L, baseline 70 μmol/L = AKI)
• Markedly elevated CK (45,000 U/L, greater than 5,000 U/L indicates severe rhabdomyolysis)
• Likely causes in this patient: Prolonged immobilization after trauma, muscle crush injury, hypotension/ischemia

Management:

1. Fluid resuscitation:

   • Aggressive IV crystalloid (normal saline or Hartmann's solution)
   • Target urine output 100-300 mL/hr (or 2-3 mL/kg/hr) until CK below 5,000 U/L and myoglobin cleared
   • Monitor for fluid overload (daily weights, CVP, lung ultrasound)

2. Renal replacement therapy (RRT) if indicated:

   • Indications: Refractory hyperkalemia (greater than 6.5 mmol/L), severe metabolic acidosis (pH below 7.1), volume overload with pulmonary edema, uremic complications (pericarditis, encephalopathy)
   • Mode: Continuous renal replacement therapy (CRRT) preferred in hemodynamically unstable patients
   • Dose: 20-25 mL/kg/hr effluent dose

3. Electrolyte management:

   • Monitor potassium, calcium, phosphate frequently (4-6 hourly initially)
   • Treat hyperkalemia: Calcium gluconate (cardioprotection), insulin/dextrose, salbutamol, dialysis if severe
   • Treat hypocalcemia (if symptomatic or ionized Ca below 0.8 mmol/L) with calcium gluconate
   • Treat hyperphosphatemia with phosphate binders (sevelamer, lanthanum) and dialysis if severe

4. Prevent complications:

   • Compartment syndrome: Monitor lower limb compartments
   • DIC: Monitor coagulation profile, treat with plasma/platelets if bleeding
   • Fluid overload: Diuretics (furosemide) or CRRT if oliguric AKI

5. Prevent recurrence:

   • Avoid nephrotoxic agents (NSAIDs, aminoglycosides, iodinated contrast)
   • Maintain adequate MAP (greater than 65 mmHg) for renal perfusion
   • Early immobilization, logrolling, and pressure area care

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Viva Scenario 1: Pelvic Fracture Management

Viva Scenario: > Viva Question: Examiner: A 28-year-old male is brought to ED after a high-speed motorcycle accident. He is hypotensive (BP 75/45 mmHg) and tachycardic (HR 140 bpm). AP pelvic X-ray shows a widened pubic symphysis and an unstable pelvic fracture. What is your immediate management?

Viva Answer: Candidate: My immediate management focuses on controlling life-threatening hemorrhage:

1. Apply pelvic binder immediately - place at level of greater trochanters, tighten to 150 N or 35-40 lb. This reduces pelvic volume by 15-20%, stabilizes the fracture, and controls venous bleeding.

2. Start massive transfusion protocol - activate protocol early, aim for 1:1:1 ratio (PRBC:FFP:Platelets). Use viscoelastic testing (TEG/ROTEM) if available to guide transfusion.

3. Administer tranexamic acid - 1 g IV bolus over 10 minutes, then 1 g infusion over 8 hours (must be within 3 hours of injury).

4. Vascular access and monitoring - insert two large-bore IV cannulas (14-16 gauge), arterial line for continuous BP monitoring, and central venous catheter if needed.

5. Airway and breathing - intubate if GCS below 8, respiratory failure, or ongoing hemodynamic instability. Use lung-protective ventilation.

6. Imaging - FAST examination to assess for hemoperitoneum, then CT pelvis with IV contrast once stabilized to assess fracture pattern and identify arterial extravasation.

Viva Question: Examiner: The patient remains hypotensive despite the pelvic binder and transfusion of 6 units PRBC, 6 units FFP, and 2 pools of platelets. What are your next steps?

Viva Answer: Candidate: With ongoing hypotension despite binder and resuscitation, I would:

1. Proceed to CT angiography or conventional angiography to identify and control arterial bleeding. Indications include ongoing hemodynamic instability, high-risk fracture patterns (APC III, VS, LC III), and contrast blush on CT.

2. Consider external fixation - this provides additional pelvic stabilization and reduces pelvic volume, particularly useful if there is ongoing venous bleeding.

3. Assess for intra-abdominal bleeding - positive FAST suggests hemoperitoneum. If hemodynamically unstable with positive FAST, proceed to emergency laparotomy.

4. Consider surgical packing - if angiography is unavailable or failed, perform extraperitoneal pelvic packing via Pfannenstiel incision.

Most importantly, I would involve the multidisciplinary team early - trauma surgeon, orthopaedic surgeon, interventional radiologist - to coordinate definitive hemorrhage control.

Viva Question: Examiner: CT angiography shows active extravasation from the left superior gluteal artery. How would you manage this?

Viva Answer: Candidate: I would arrange selective angiographic embolization:

1. Indications - arterial bleeding confirmed by contrast extravasation, ongoing hemodynamic instability, high-risk fracture pattern.

2. Procedure - selective catheterization of the internal iliac artery, identify the bleeding branch (superior gluteal artery), and embolize with coils, gelfoam, or polyvinyl alcohol particles.

3. Success rate - 80-90% for arterial bleeding. Meta-analyses show mortality reduction of 30-40% compared to external fixation alone.

4. Complications - include infarction of gluteal muscles (leading to weakness or compartment syndrome), sciatic nerve injury, and nontarget embolization.

5. Adjunctive measures - continue external fixation for pelvic stability, continue massive transfusion protocol as needed, monitor for re-bleeding.

Follow-up - post-procedure CT angiography may be performed if there is ongoing concern about re-bleeding.

Viva Question: Examiner: Two days later, the patient develops oliguria, elevated creatinine, and CK of 30,000 U/L. What is the diagnosis and management?

Viva Answer: Candidate: This is acute kidney injury due to severe rhabdomyolysis:

Pathophysiology:

• Muscle breakdown releases myoglobin, which is nephrotoxic, especially in acidic urine and hypovolemic states
• Myoglobin causes direct tubular injury, renal vasoconstriction, and tubular obstruction

Management:

1. Aggressive fluid resuscitation - IV crystalloid (NS or Hartmann's) to target urine output 100-300 mL/hr or 2-3 mL/kg/hr until CK below 5,000 U/L and myoglobin cleared.

2. Renal replacement therapy (RRT) - indicated for refractory hyperkalemia (greater than 6.5 mmol/L), severe metabolic acidosis (pH below 7.1), volume overload with pulmonary edema, or uremic complications. CRRT is preferred in hemodynamically unstable patients.

3. Electrolyte management - monitor and treat hyperkalemia (calcium gluconate, insulin/dextrose, salbutamol), treat symptomatic hypocalcemia, manage hyperphosphatemia with phosphate binders.

4. Prevent complications - monitor for compartment syndrome (especially in lower limbs), avoid nephrotoxic agents, continue careful fluid balance.

5. Monitor recovery - serial CK, creatinine, urine output. Most patients recover renal function with appropriate management, but severe cases may require prolonged RRT.

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Viva Scenario 2: Pelvic Fracture with Urethral Injury

Viva Scenario: > Viva Question: Examiner: A 22-year-old male presents after a fall from height. He complains of pelvic pain and inability to void. On examination, you note a perineal hematoma and blood at the urethral meatus. What are your concerns?

Viva Answer: Candidate: This presentation is highly concerning for urethral injury in the setting of a pelvic fracture:

Key findings suggesting urethral injury:

1. Blood at the urethral meatus - classic sign, present in 50-75% of urethral injuries
2. Perineal hematoma - suggests bleeding into the perineal tissues
3. Inability to void - may be due to urethral disruption or bladder injury
4. Associated pelvic fracture - urethral injury occurs in 20-25% of males with pelvic fractures

Immediate concerns:

1. DO NOT insert a urinary catheter - blind catheterization can worsen the urethral injury, create a false passage, or cause infection
2. Perform retrograde urethrogram - essential to diagnose or exclude urethral injury before catheterization
3. Assess for other injuries - pelvic fracture, bladder rupture (cystogram if needed), rectal injury (digital rectal examination), neurological injury

Initial management:

• Pelvic binder if hemodynamically unstable
• Analgesia (IV opioids)
• Retrograde urethrogram (20-30 mL contrast via Foley bulb in fossa navicularis)
• If urethral injury confirmed: suprapubic catheter for bladder drainage
• Urology consultation for definitive management

Viva Question: Examiner: Retrograde urethrogram shows complete disruption of the posterior urethra. What is the definitive management?

Viva Answer: Candidate: For complete posterior urethral disruption:

Immediate management:

1. Suprapubic catheter - insert percutaneously or via open approach for bladder drainage. This allows the urethra to heal without ongoing instrumentation.

Definitive management options:

1. Delayed urethroplasty (preferred approach):

   • Timing: 3-6 months after injury, once pelvic fractures healed and patient stabilized
   • Procedure: Excision of fibrotic segment, end-to-end anastomosis
   • Success rate: 80-90% for experienced surgeons
   • Complications: Restenosis, erectile dysfunction (10-20%), incontinence (5-10%)

2. Primary realignment (less common):

   • Timing: Within 7-14 days of injury
   • Procedure: Endoscopic or open realignment of urethral ends over a catheter
   • Indications: Selected cases with minimal distraction
   • Complications: Higher restenosis rate, longer operative time
   • Success rate: 50-70%

Urethral injury classification (American Association for the Surgery of Trauma):

• Grade I: Contusion
• Grade II: Partial tear below 50% circumference
• Grade III: Partial tear greater than 50% circumference
• Grade IV: Complete disruption
• Grade V: Complete disruption with extension into prostate or bladder neck

Follow-up - urethroscopy after catheter removal, periodic assessment for stricture formation, sexual function assessment.

Viva Question: Examiner: What other injuries must be specifically assessed for in this patient?

Viva Answer: Candidate: In a patient with pelvic fracture and urethral injury, I would assess for:

1. Bladder injury:

   • Occurs in up to 10% of pelvic fractures
   • Intraperitoneal rupture (surgical repair) vs extraperitoneal rupture (catheter drainage)
   • Diagnosed with cystogram (300-400 mL contrast)
   • Signs: Hematuria, suprapubic pain, inability to void

2. Rectal injury:

   • Occurs in 5% of pelvic fractures
   • High risk of septic complications if missed
   • Diagnosis: Digital rectal examination (blood, rectal wall integrity)
   • Management: Diverting colostomy, presacral drainage, primary repair

3. Nerve injury:

   • Occurs in 5-10% of pelvic fractures
   • Lumbosacral plexus (L4-S4), most commonly sciatic nerve
   • Examination: Foot drop, sensory loss, decreased anal tone
   • Imaging: MRI pelvis if clinically indicated

4. Intra-abdominal injuries:

   • Solid organ injury (spleen, liver, kidney): 15-20%
   • Hollow viscus injury (small bowel, colon): 5-10%
   • Mesenteric injury: 5%
   • Diagnosis: FAST, CT abdomen with IV contrast

5. Other associated injuries:

   • Thoracic injuries (rib fractures, hemothorax, pneumothorax): 10-15%
   • Spinal fractures (lumbar spine): 10-15%
   • Long bone fractures (femur, tibia): 20-30%

Systematic approach - ATLS secondary survey with thorough examination of all body systems.

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