Summary

Pelvic fractures represent the most lethal orthopedic injury, with a mortality rate of 10-50% depending on hemodynamic stability. The pelvis is a ring structure; for it to displace, it must break in two places (or one break + ligament disruption). Hemorrhage is the primary killer, usually from the low-pressure Presacral Venous Plexus (85%), though arterial injury (Internal Iliac branches) is rapidly fatal. Management prioritizes containment (Binder), resuscitation (1:1:1), and haemorrhage control (Angioembolization or Packing). [1,2,3]

Key Facts

• The Killer: Hemorrhagic Shock. The retroperitoneum can accommodate >4 Litres of blood before tamponade.
• The Source: Venous (85%) vs Arterial (15%). Venous bleeding is controlled by reducing pelvic volume (Binder). Arterial bleeding requires Angioembolization.
• The Binder: Must be applied at the level of the Greater Trochanters, NOT the Iliac Wings. Incorrect placement (too high) can worsen the fracture by flexing the posterior elements.
• Open Fractures: Any communication with the rectum or vagina constitutes an open fracture. Mandatory DRE and Speculum exam. Mortality approaches 50% due to sepsis.

Clinical Pearls

"Do Not Rock the Pelvis": The traditional "Springing the Pelvis" text to check for stability is CONTRAINDICATED in trauma. It dislodges the tentative clot formed at the presacral plexus and restarts torrential bleeding. One gentle feel is allowed. If unstable, apply binder and don't touch it again.

"Destot's Sign": Hematoma over the scrotum (men) or labia majora (women) or inguinal ligament. Indicates pelvic floor disruption and likely retroperitoneal bleeding tracking down.

"The Corona Mortis": The "Crown of Death". An aberrant anastomosis between the External Iliac (Obturator branch) and Internal Iliac systems behind the superior pubic ramus. Lethal if cut during surgery or fracture displacement.

              UNSTABLE TRAUMA PATIENT
              (Pelvic Pain / Mechanism)
                         ↓
              APPLY PELVIC BINDER (ED)
              (Level of Trochanters)
                         ↓
                FAST SCAN / CXR / PXR
                         ↓
           HEMODYNAMICALLY UNSTABLE? (SBP <90)
           ┌─────────────┴─────────────┐
          YES                         NO
           ↓                          ↓
    RESPONDER TO FLUIDS?           CT SCAN
    ┌──────┴──────┐             (Define Fracture)
   NO            YES                  ↓
(Transient)       ↓                STABLE?
    ↓          CT SCAN           ┌────┴────┐
   FAST +ve?      ↓             YES        NO
   ┌──┴──┐     BLUSH?         (Ward)    (Surgery)
 YES     NO    ┌──┴──┐
  ↓      ↓    YES    NO
LAPAR  ANGIO  ANGIO  ICU
OTOMY  EMBO   EMBO
(Pack)

1. Resuscitation (Damage Control)

• Pelvic Binder: Closes the "Open Book". Reduces pelvic volume. Tamponades venous bleeding.
  • Rule: Do NOT apply for Lateral Compression (LC) fractures (can implode the pelvis further). If unsure, apply it loosely or rely on clinical suspicion of "Open vs Closed".
• MTP (Massive Transfusion Protocol): 1:1:1 ratio (PRBC:FFP:Platelets).
• TXA (Tranexamic Acid): 1g IV Stat (if <3 hours).
• Calcium: Prevent hypocalcaemia from citrate in blood products.

2. Arterial Control (Angioembolization)

• Indication: Contrast blush on CT. Persistent instability despite binder.
• Technique: IR radiologist coils the Bleeder (e.g. Superior Gluteal) or Gelfoam for temporary occlusion.
• Success: 85-95%.

3. Surgical Stabilization (Orthopaedics)

• External Fixation:
  • Indication*: "Resuscitation frame". Temporary stability in ICU.
  • Pins: Iliac crest or Supra-acetabular (AiS).
• Internal Fixation (ORIF):
  • Timing: Days 3-5 (when stable and "Second Hit" inflammatory risk lowers).
  • Symphysis: Plating.
  • SI Joint: Iliosacral Screws (percutaneous) or Tension Band Plating.

4. Pre-Peritoneal Packing (PPP)

• Indication: Patient dying on table. Angio unavailable or too slow.
• Technique: Midline incision. Pack pads directly behind the pubis into the retroperitoneal space (Space of Retzius). Tamponades the venous plexus.

Urological (10-15%)

• Bladder Rupture: Intraperitoneal (needs repair) vs Extraperitoneal (catheter only).
• Urethral Disruption: Membranous urethra tears at the urogenital diaphragm.
  • Sign: Blood at meatus.
  • Action: Do not catheterise. Call Urology. Suprapubic catheter.

Rectal / Vaginal

• Open Fracture: A bony spike penetrating the rectum is an OPEN fracture. The rectum is full of bacteria.
• Management: Diverting Colostomy (Stoma) usually required to prevent pelvic sepsis. Washout.

Neurological (Lumbosacral Plexus)

• L5 Nerve Root: Extensor Hallucis Longus (Big toe up) weakness. Sensation 1st webspace.
• S1 Nerve Root: Ankle jerk lost. Plantarflexion weakness.
• Cauda Equina: Bowel/Bladder dysfunction.

The BOAST 10 Guidelines (UK)

• Management of Hemodynamically Unstable Pelvic Fracture.
• Key: Transfer to Major Trauma Centre (MTC).
• Key: Binder at Trochanter level.
• Key: Urology involvement early.

REACT Study

• Comparison of REBOA (balloon occlusion of aorta) vs Standard Resuscitation.
• REBOA is effective at raising BP but carries ischaemic risks to legs/gut. Reserved for peri-arrest patients in specialist centres.

The Injury

The pelvis is a ring of bone, like a pretzel. It is very strong. To break it, you need huge force (like a car crash). You have broken the ring in two places.

The Danger

The pelvis protects major blood vessels. The break can tear these vessels, causing internal bleeding. Our first job is to stop that bleeding with a special belt (binder) and blood transfusions.

The Treatment

• Binder: Tight corset to hold bones together.
• Surgery: Once you are stable (usually a few days), we use metal plates and screws to rebuild the ring so you can walk again.
• Fixator: Sometimes we put a metal frame on the outside (external fixator) as a temporary bridge.

Recovery

• Non-Weight Bearing: You cannot walk on this leg for 6-12 weeks.
• Wheelchair: You will need to use a chair/bed transfers.
• Long term: Most people walk well again, but ache in the back/hips is common.

Q1: Where exactly do you apply a pelvic binder and why? A: Centered over the Greater Trochanters of the femur. This exerts force directly across the acetabulum to the pelvic ring, efficiently closing the diastasis. Applying it high (over the Iliac Crests) acts as a fulcrum, closing the top but opening the bottom of the SI joint, potentially worsening the instability.

Q2: What is "Destot's Sign"? A: A superficial hematoma appearing above the inguinal ligament or in the scrotum/labia. It signifies disruption of the pelvic floor fascia and implies a large retroperitoneal bleed tracking downwards. It is a marker of high-energy severe injury.

Q3: Explain the vascular "Corona Mortis". A: Latin for "Crown of Death". It is an aberrant anastomotic vessel connecting the External Iliac and Internal Iliac (Obturator) systems. It runs on top of the Superior Pubic Ramus (approx 4-6cm from symphysis). It is at high risk of laceration during the approach for acetabular surgery or from superior ramus fractures. Laceration causes rapid, difficult-to-control hemorrhage as the vessel retracts into the pelvis.

(End of Topic)