The management of patients with hemodynamic
instability from pelvic fracture is
challenging and controversial. Mortality
rates have ranged from 18% to 40% in
reported series1-4
and death within the first 24 hours of
injury was most often a result of acute
blood loss.2
Significant decreases in mortality rates
have been shown with adoption of algorithms
for management of these injuries.5-7
The key issues in management are identifying
the site(s) of hemorrhage and then
controlling the bleeding. Bleeding from
pelvic fractures occurs from three major
sources; arterial, venous, and cancellous
bone. A seminal study from 1973 identified
extravasation of contrast from the
hypogastric arteries in 23 of 27 autopsy
cases. Bleeding sources were bilateral in
63%, and 61% had more than one bleeding site
identified. Careful dissection revealed
lesions to main arteries in only three
specimens, and the authors noted that
bleeding from cancellous bone and from
vessels in adjacent soft tissue hampered
identification of arterial injuries. They
also stressed the significance of hemorrhage
from the fracture sites.8
A more recent study reported that over 70%
of unstable patients with pelvic fractures
will have arterial bleeding.9
Furthermore, blunt force injury severe
enough to fracture the pelvic ring can cause
concomitant intra-abdominal injuries. The
frequency of abdominal injury, in
association with pelvic fracture can range
from 16% to 55%.10-12
Appropriate evaluation of the abdomen for
associated intra-abdominal injuries cannot
be overstressed.
Management of hemodynamically unstable
patients with pelvic fracture requires a
multidisciplinary team. In addition to the
general trauma surgeon, an experienced
orthopedic surgeon and a skilled
interventional radiologist are needed for
optimal care.
