Concerns, Controversies, and Considerations in the Management of Pelvic Trauma

While relatively straightforward, the management of pelvic trauma is not without its controversies and conversations. In the prehospital environment, new adjuncts and approaches are shaping the outcomes of these injuries.

Numbers and Data

How often do prehospital clinicians encounter these pelvic trauma? Pelvic injuries are actually more frequent than cervical spine injuries in the setting of blunt trauma. Roughly 8-9% of blunt trauma involves a pelvic injury.¹ In one British study, there was a 10% incidence of pelvic injury in all trauma admissions for the study period.¹

Mortality in pelvic trauma populations ranges between 5-16% and is <1% in isolated pelvic trauma.¹ One paper places it as high as 30%.⁶ Mortality is much higher when the patient is in shock and requires massive transfusion of blood products, and is often associated with massive hemorrhage from solid organ injury as is, most commonly seen with the spleen, liver, kidneys, and bladder.⁴ Hemorrhage specific to pelvic injuries is more likely to be from the fractured bone and transected veins (85%), and life-threatening hemorrhage from arterial disruption is present 15% of the time.¹

Anatomy Review

The pelvic region, specifically the area between the iliac crests, is saturated with blood vessels. The left and right common iliac arteries come right directly off the aorta as they continue through the pelvic floor into the left and right femoral arteries. There are an additional 30 or so arteries that feed oxygenated blood to the bones, organs, and tissues located in the pelvic region and an equal amount number of veins carrying the de-oxygenated blood back out of the pelvic region. Female patients add a very vascular uterus to the region that can be injured and bleed into the pelvic space as well. Simply stated, the pelvic region is highly vascular and has innumerable potential sources of non-compressible hemorrhage that is difficult, if not impossible, to manage in the prehospital environment.

The most prominent bony features of the pelvic region, better known as the pelvic girdle, include the sacrum, iliac wing, acetabulum, pubic symphysis, and inferior pubic rami. Each of these is connected to the other via a series of ligaments that serve to hold the whole pelvic girdle together.⁵

Pelvic injuries are classified by type or described by one of two systems; the Tile classification system and/or the Young-Burgess classification system. They classify the injuries as either rotationally and/or vertically unstable. Most prehospital providers lack radiographic imaging capabilities and are generally unable to assign a type to pelvic trauma in the field. There are a number of great resources available online that describe each of these classification systems in detail. The key is to remember the old adage we have all heard since our first EMT or EMR class:

“The pelvis is like a pretzel. It is impossible to break it in just one place.”

There are three forces that can be exerted upon the pelvis to induce an injury: (adapted from: https://litfl.com/classification-of-pelvic-fractures/)

• Anterior/Posterior compression (APC)
• Lateral compression (LC)
• Vertical sheer (VS)

Each of these forces can disrupt the pelvic girdle in a number of ways. APC forces generally separate the pelvis at the pubic symphysis and at the SI joint (sacroiliac joint) and are generally isolated to one side of the pelvic ring. This is also the type of compression that results in an open-book pelvic fracture due to the loss of connection at the pubic symphysis and rami. LC forces (think a T-bone style MVC), disrupt the pelvic girdle at the pubic symphysis, inferior rami, and somewhere along the iliac crest. The higher the kinetic energy or the more violent the mechanism causing the LC force, the higher the likelihood of the pelvis being “crushed” and there being complete disruption of the ring in several places on both sides of the pelvis. VS stress has generally the same disruption pattern as APC forces, however, the injured section is displaced upward toward the abdominal cavity and is generally considered one of the higher energy injuries exerted upon the pelvis. Take note, the classification does not necessarily give you any indication as to the extent of the hemorrhage taking place within the pelvic girdle.⁵

Hemorrhage associated with pelvic injuries is of great concern, for a couple of reasons. First, with the pelvic ring intact, the pelvic cavity can hold ~1.5L – 2L of volume (depending on the source you read), and it can do so often with little or no external signs to draw your attention to it. Second, if the pelvic ring is disrupted and the pelvis “opens up”, the volume of blood that the pelvic cavity can accommodate increases exponentially.^4,5 In some cases it can hold a patient’s entire circulating blood volume. This can be complicated by the involvement of highly vascular abdominal organs like the liver and spleen.^4,5 There can also be damage to the genitals, anus, and the spinal cord.⁵

Prehospital providers should take note that hemodynamic instability associated with isolated pelvic injury is relatively rare, and there should be a high index of suspicion (based on your physical exam and mechanism of injury) that there is some other associated injury contributing to the hemodynamic instability.

Assessment

A conscious patient, without a distracting injury, and with no pain on evaluation can almost completely rule out the presence of a pelvic injury.

Look at the patient and evaluate for limb length discrepancies, rotation in of the foot, tissue disruption (yes there is such thing as an open compound pelvic fracture), hematomas, and obvious deformities of the pelvic region. At some point in the evaluation, the genitals and anus should be inspected for the presence of blood, which would be an indicator of hemorrhage in the pelvic cavity. Patients may also have a loss of sensation on the affected side distal to the injury.

Physical examination of the pelvis includes gentle… gentle palpation and pressure on the iliac crest and pubic symphysis. If there is any pain on palpation, proceed no further, the exam is positive for a fracture until ruled out by radiographic study. Furthermore, if there is a complaint of pain in the pelvic region, there is reason enough to not palpate it in an attempt to confirm the presence of a fracture. Care should be taken to not “rock” the pelvis (assessing the pelvis by leaning back and forth on each side of the pelvis). While this is classically taught in many trauma assessment modules, rocking the pelvis has been widely refuted as an appropriate assessment method due to the risk of displacing fractured areas and disrupting/destabilizing any clots that may have formed.⁵ Not to mention, it causes further, unnecessary pain to the patient. In the unconscious patient, rocking the pelvis is still not advised. Instead, prehospital providers should apply gentle pressure to the iliac crest and assess for any mobility/movement.⁵

Management

The overall management of pelvic trauma is straightforward in the prehospital environment. Identify that it is there and then splint it. There are a number of commercially available pelvic binders that have been studied and compared (there are a couple of great comparisons in the Journal of Special Operations Medicine jsomonline.org). No one device performed better than the others in reducing and stabilizing a pelvic fracture. Sheets are still used in some places with great effect in pelvic injuries, and while there are those who argue that this is a substandard or ill-advised approach to stabilizing pelvic injuries, it is still a widely accepted method to use. There is some risk to the patient when a binder is misplaced either too high or too low; and when it is placed too tightly and the pelvis is “over-reduced.”6 In this situation, new stress is placed on a fractured and strained pelvic girdle that could result in further injury.6 Proper placement is key, with some data suggesting that nearly 50% of the time they are misplaced (often too high) and as a result, offer little benefit.⁶

In researching this topic, one may find themselves scratching their heads and asking, “Why don’t we put pelvic binders on all blunt trauma patients for the same reason that we place c-collars on many blunt trauma patients? After all, c-collars remain a mainstay in the management of blunt trauma patients despite the low rate of real injury and the known risk of injury, so why not empirically place pelvic binders on all blunt trauma patients?” If 8-10% of blunt traumas have a confirmed pelvic fracture, and conversely a 2.4%-3.7% incidence of blunt trauma involves a cervical injury; does it not make sense then to empirically bind the pelvis? After all, there is a 90% chance that there is no pelvic trauma, so there may be no harm in not doing so. In this author’s opinion, the harm is nil if the pelvic binder is placed properly and the patient had no pelvic fracture, much like a c-collar, and much like a c-collar if it is misplaced or misused it can result in harm to the patient.^1,2,3,6

The benefits of placing a pelvic binder are three-fold. First, it stabilizes the fracture (like a splint) and reduces the risk of further vascular injury (by ensuring the bone ends do not tear other vessels). Second, it provides stability for clots to form and protects the clots that are already forming by reducing the amount of movement in the injured areas. Finally, it “closes the book” and can reduce the amount of space for volume loss.^4,5

This mental model is not without some controversy. Applying a pelvic binder and reducing the injury can and does reduce the space for volume loss. The controversy comes when we are hoping to achieve a “tamponade effect” in doing so. The tamponade effect described here is the result of blood filling up the pelvic cavity to the degree that it tamponades or slows the rate of hemorrhage from the injured vessels. A pelvic binder reduces that space and can attain this result faster. This is likely true for venous bleeds, however, large arterial bleeds are not likely to experience this tamponade effect due to the pressure in the arterial system.

This leads to the next phase in pelvic trauma management, hemostatic resuscitation. At the 10,000-foot view, pelvic trauma is uncontrolled, non-compressible trauma. This means that this is the type of hemorrhage for which the only cure is to get the patient to the surgical suite for surgical intervention, which is likely some form of embolization. Prehospital providers should select a damage-control resuscitation strategy for the ongoing management of these injuries until the patient is delivered to a trauma center.

Damage control resuscitation has been described in several journals and has been presented in many different forums. Its origins are in military medicine and far-forward deployed environments. Most recent iterations of the strategy can range from buddy transfusions (if you are an Army Ranger) or be limited to permissive hypotension. Regardless of the chosen strategy, the goals remain the same: do the best for the patient without making things worse, while ensuring that the patient is delivered to the trauma center a viable candidate for continued resuscitation. This is achieved by controlling all sources of external hemorrhage; maintaining a MAP of ~65 or SBP ~90 via permissive hypotension; preventing hypothermia; volume replacement with blood products (supplemented with calcium and TXA) to the greatest extent possible; and limiting or eliminating the use of crystalloid as a resuscitation fluid to the greatest extent possible.7 The obvious intent here is to prevent the untoward effects of the lethal trauma diamond: acidosis, hypothermia, coagulopathy, and hypocalcemia. All of this should be happening during the rapid transport to the closest trauma center via the most appropriate conveyance.

Conclusion

Pelvic trauma can either be an isolated, straightforward event for prehospital providers; or it can be a complicated, damage-control resuscitation in the field. Keep the basics of trauma management uppermost in your mind and keep it simple. As always, good trauma management begins with a good assessment, and the selection of the most appropriate management strategy should be based on your assessment findings. Poor mental models and assessment skills can be pitfalls in the management of pelvic trauma, so it is of great benefit to slow down and use your head in order to do the best for the patient without making things worse.

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References

1. Abdelrahman, H., El-Menyar, A., Keil, H. et al. Patterns, management, and outcomes of traumatic pelvic fracture: insights from a multicenter study. J Orthop Surg Res 15, 249 (2020). https://doi.org/10.1186/s13018-020-01772-w)
   
2. Milby AH, Halpern CH, Guo W, Stein SC. Prevalence of cervical spinal injury in trauma. Neurosurg Focus. 2008;25(5):E10. doi: 10.3171/FOC.2008.25.11.E10. PMID: 18980470.
   
3.  Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman JR, Mower WR; NEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001 Jul;38(1):17-21. doi: 10.1067/mem.2001.116150. PMID: 11423806.
   
4. Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J, Holevar M, Sabater EA, Sems SA, Vassy WM, Wynne JL. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture–update and systematic review. J Trauma. 2011 Dec;71(6):1850-68. Review. PubMed PMID:22182895.
   
5. Tullington JE, Blecker N. Pelvic Trauma. [Updated 2023 Mar 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556070/
   
6. DuBose JJ, Burlew CC, Joseph B, Keville M, Harfouche M, Morrison J, Fox CJ, Mooney J, O’Toole R, Slobogean G, Marchand LS, Demetriades D, Werner NL, Benjamin E, Costantini T. Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control. J Trauma Acute Care Surg. 2021 Oct 1;91(4):e93-e103. doi: 10.1097/TA.0000000000003331. PMID: 34238857.
   
7. Coccolini F, Stahel PF, Montori G, Biffl W, Horer TM, Catena F, Kluger Y, Moore EE, Peitzman AB, Ivatury R, Coimbra R, Fraga GP, Pereira B, Rizoli S, Kirkpatrick A, Leppaniemi A, Manfredi R, Magnone S, Chiara O, Solaini L, Ceresoli M, Allievi N, Arvieux C, Velmahos G, Balogh Z, Naidoo N, Weber D, Abu-Zidan F, Sartelli M, Ansaloni L. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017 Jan 18;12:5. doi: 10.1186/s13017-017-0117-6. PMID: 28115984; PMCID: PMC5241998.