This recommendation is convincingly justifiable based on the available scientific information alone. It is generally based on class I data or strong class II evidence may form the basis for a Level I recommendation. Conversely, weak or contradictory class I data may not be able to support a Level I recommendation.
This recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. It is usually supported by class II data or a preponderance of class III evidence.
This recommendation is supported by available data, but adequate scientific evidence is lacking. It is generally supported by class III data. This type of recommendation is useful for educational purposes and in guiding future studies.
Although there were not any class I references available, four Level I recommendations were made due to the strong class II data (large retrospective and nonrandomized prospective data) available for specific questions. Level II recommendations were supported by class II data and are justified by available scientific evidence and strongly supported by expert opinion. Nine Level II recommendations were made from the available data. Level III recommendations were based on class III data, where adequate scientific evidence is lacking. Twelve Level III recommendations are included in these recommendations.
Which Patients With Hemodynamically Unstable Pelvic Fractures Warrant Early External Mechanical Stabilization?
1. The use of a pelvic orthotic device (POD) does not seem to limit blood loss in patients with pelvic hemorrhage. Level III recommendation
2. The use of a POD effectively reduces fracture displacement and decreases pelvic volume. Level III recommendation
Scientific Foundation: Early External Stabilization
It is well known that the volume of the pelvis increases after a mechanically unstable pelvic fracture (Tile B/C; Table 3). This increased pelvic volume in complex pelvic fractures is thought to reduce the tamponade effect of the retroperitoneal tissues and intrapelvic organs, leading to further bleeding into the pelvic space. Baque et al.3 demonstrated a 20% increase in the volume of the pelvis with a 5-cm pubic diastasis in a cadaver pelvic-fracture model. The iliolumbar vein was noted to be disrupted in 60% of the pelvic fractures created, accounting for the venous hemorrhage seen with fractures of the sacroiliac portion of the pelvis. Using computed tomography (CT) scanning with mathematical modeling, Stover et al.4 demonstrated an increase in pelvic volume of 35% to 40% with a large 10-cm pubic diastasis, again in a cadaver model.
Pelvic stabilization has been practiced for a number of years in an attempt to control pelvic bleeding by decreasing the pelvis volume, leading to earlier tamponade. Methods that close the pelvic ring are thought to tamponade bleeding by diminishing the pelvic volume, hastening clotting of the pelvic hematoma.5 Initially, the pneumatic antishock garments (PASG) was used to stabilize the pelvis and decrease the pelvic volume. In retrospective studies, Flint et al. and others have demonstrated less blood loss when the PASG was applied.6–8 Other studies have questioned the ability of PASG to limit hemorrhage from pelvic fracture.9,10 PASG have largely fallen out of favor due to concerns about abdominal compartment syndrome and fluid and electrolyte complications and because they are bulky, difficult to apply, and interfere with physical examination.
External pelvic fixation (EPF) and the pelvic C-clamp have been used more recently in an attempt to reduce pelvic volume and control hemorrhage associated with pelvic fracture. In a study of 14 hemodynamically unstable patients with pelvic fractures, Sadri et al.11 found that blood loss was not statistically different before/after placement of the pelvic C-clamp. Angiography was required in many of these patients to control hemorrhage. Application of the pelvic C-Clamp is generally done quickly (5 minutes)12although others have reported that it can take longer, averaging 64 minutes to apply (range, 10–240 minutes).13 When EPF is compared with a temporary pelvic binder (TPB) in patients with sacroiliac fractures, EPF was found to have higher blood transfusion needs at 24 hours and 48 hours compared with the TPB. The reduced blood loss has been attributed to the ease and rapidity of TPB application compared with EPF.14
Placement of a C-Clamp or EPF decreases the pelvic volume by 10% to 20% and reduces pelvic fractures.3,14,15 Whether this leads to less blood loss and better outcomes has yet to be shown in the literature. The standard use of external fixation in the initial treatment algorithms of patients with unstable pelvic injuries is common and remains a useful tool in the initial management of these patients.13,16 However, because of their ease of use and fast application, TPBs have largely replaced the pelvic C-Clamp and EPF for early mechanical stability in pelvic fracture.
Which Patients Require Emergent Angiography?
1. Patients with pelvic fractures and hemodynamic instability or signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out should be considered for pelvic angiography/embolization. Level I recommendation
2. Patients with evidence of arterial intravenous contrast extravasation (ICE) in the pelvis by CT may require pelvic angiography and embolization regardless of hemodynamic status. Level I recommendation
3. Patients with pelvic fractures who have undergone pelvic angiography with or without embolization, who have signs of ongoing bleeding after nonpelvic sources of blood loss have been ruled out, should be considered for repeat pelvic angiography and possible embolization. Level II recommendation
4. Patients older than 60 years with major pelvic fracture (open book, butterfly segment, or vertical shear) should be considered for pelvic angiography without regard for hemodynamic status. Level II recommendation
5. Although fracture pattern or type does not predict arterial injury or need for angiography, anterior fractures are more highly associated with anterior vascular injuries, whereas posterior fractures are more highly associated with posterior vascular injuries. Level III recommendation
6. Pelvic angiography with bilateral embolization seems to be safe with few major complications. Gluteal muscle ischemia/necrosis has been reported in patients with hemodynamic instability and prolonged immobilization or primary trauma to the gluteal region as the possible cause, rather than a direct complication of angioembolization. Level III recommendation
7. Sexual function in males does not seem to be impaired after bilateral internal iliac arterial embolization. Level III recommendation
Scientific Foundation: Emergent Angiography
Pelvic angiography is useful control of arterial hemorrhage associated with pelvic fractures. In many pelvic fractures, much of the bleeding is venous in nature, generally from bone fracture edges or the iliolumbar vein. Angiography with embolization only controls arterial hemorrhage and therefore is beneficial in only a minority of patients. Indeed, it seems that pelvic angiography is indicated in only 3% to 10% of patients with pelvic fracture.17–23 Hemodynamic instability associated with pelvic fractures without another significant source of bleeding is an indication for pelvic angiography.18–20,24,25 In a retrospective study of 325 patients at a Level I trauma center, Starr et al. found that Revised Trauma Score alone was predictive of the need for angiography. Age, shock on admission, and fracture pattern did not predict need for angiography.21
There are several predictors to help determine which patients will need angiography. The presence of ICE seen on CT scan has a sensitivity of 60% to 84% and specificity of 85% to 98% for the need for pelvic embolization.18 ICE is a strong predictor of need for angioembolization. Fracture pattern alone has not been predictive of who will or will not require angiography.21,24,26 The combination of age >60 and major pelvic fracture is highly associated with need for angiography with embolization (odds ratio, 15) regardless of the patient's hemodynamic status. Indeed, 62% of patients older than 60 years requiring angiographic embolization had normal vital signs on hospital admission.27 Although hemorrhage from major pelvic fractures is common, several retrospective studies contain patients with arterial bleeding from isolated sacral or acetabular fractures.17 Although fracture type does not predict need for angiography, in general, anterior fractures are associated with anterior vascular injuries, whereas posterior fractures are associated with posterior vascular injuries.28
Pelvic angiography with embolization seems to be 85% to 97% effective in controlling bleeding. Some patients will continue to bleed and require repeat embolization to control hemorrhage.22,23,29,30 4.6% to 24.3% of patients with either no bleeding seen on the initial angiogram or initially successful pelvic embolization will require repeat pelvic angiography with repeat embolization. Independent risk factors for recurrent pelvic bleeding include transfusing greater than two units packed red blood cells per hour before angiography, finding more than two injured vessels requiring embolization,22 repeated hypotension after initial angiography, absence of intra-abdominal injury, and persistent base deficit.30 The standard embolization technique for an unstable patient bleeding from an internal iliac artery source is to nonselectively embolize both internal iliac arteries. In more stable patients, some operators may attempt more selective embolization. However, a study by Fang et al.23 demonstrated that recurrent pelvic bleeding also seems to be more common after selective embolization than after nonselective treatment, suggesting this practice should be limited.
The safety of pelvic angiography/embolization seems to be well established in several series.29,31 There are occasional reports of femoral artery injury requiring repair and transient increases in serum creatinine in older patients.27 Cases of gluteal necrosis associated with embolizations seem to be related to primary trauma to the gluteal region along with protracted hypotension rather than a direct complication of embolization.17,32 In one report, six of eight pelvic fracture patients undergoing bilateral angioembolization for shock showed magnetic resonance imaging changes consistent with soft tissue infection or necrosis33 without primary gluteal trauma, suggesting that gluteal muscle ischemia may be subclinical. Ramirez et al.34 examined sexual dysfunction in males undergoing bilateral internal iliac embolization and found no difference compared with case-matched pelvic fracture patients not undergoing embolization.
What Is the Best Test to Exclude Intra-Abdominal Bleeding?
1. Focused Assessment with Sonography for Trauma (FAST) is not sensitive enough to exclude intraperitoneal bleeding in the presence of pelvic fracture. Level I recommendation
2. FAST has adequate specificity in patients with unstable vital signs and pelvis fracture to recommend laparotomy to control hemorrhage. Level I recommendation
3. Diagnostic peritoneal tap (DP)/Diagnostic peritoneal lavage (DPL) is the best test to exclude intra-abdominal bleeding in the hemodynamically unstable patient. Level II recommendation
4. In the hemodynamically stable patient with a pelvic fracture, CT of the abdomen and pelvis with intravenous contrast is recommended to evaluate for intra-abdominal bleeding regardless of FAST results. Level II recommendation
Scientific Foundation: Tests to Exclude Intra-Abdominal Bleeding With Pelvic Fracture
Early detection of hemoperitoneum after blunt abdominal injury allows for rapid implementation of decision-making algorithms and decreasing the time to abdominal exploration in patients at high risk for intraperitoneal hemorrhage. The indications for laparotomy in the patient with a pelvic fracture are the same for all trauma patients. With concomitant pelvic fracture, differentiating between pelvic-bleeding and intra-abdominal hemorrhage is critical to the initial decision-making and management of the patient.
Four methods are commonly used to help exclude intra-abdominal bleeding: DPL, ultrasound (FAST), DP, and CT.1 Each test has advantages and disadvantages specific to their use in patients with pelvic fracture. DPL has been shown to have a high rate of false positives in patients with pelvic fractures.7,35,36 This is thought to be due to a high rate of red cell diapedesis across the peritoneum. DP without lavage performed in the supraumbilical region seems to offer similar sensitivity as DPL with a lower rate of false-negative examinations.7,36,37
The FAST has been an effective tool for the evaluation of patients with intra-abdominal injuries and hypotension.38–42 Patients with pelvic fractures are at high risk to have other associated intra-abdominal injuries as a source of bleeding.43,44 Although the specificity of the FAST in patients who have pelvic fractures examination is reasonable as an initial screening tool (87–100%), the sensitivity of the examination in the presence of a mechanically unstable pelvic fracture (Tile B/C) is unacceptably low.45–48 Ruchholz et al.45 reported 75% sensitivity with concomitant pelvic fracture in a series of patients with type B/C pelvic fractures. This finding was consistent with other reports in the literature.46,48 In a more recent report from a high volume trauma center, Freise et al.47 reported a very low sensitivity of 26% in patients with pelvic fracture.
Because of the low sensitivity and low negative predictive value of FAST when pelvic fracture is present, CT of the abdomen and pelvis with intravenous contrast is recommended in patients with pelvic fracture and a negative FAST examination who are hemodynamically stable. A negative FAST examination in a patient with pelvic fracture does not aid in determining whether a laparotomy or angiography is warranted.46–48 Hemodynamically unstable patients with pelvic fracture and a positive FAST should undergo emergent laparotomy, whereas hemodynamically normal patients with pelvic fracture and a positive FAST should receive an abdominal/pelvic CT scan.
Are There Radiologic Findings Which Predict Hemorrhage?
1. Fracture pattern on pelvic X-ray does not single-handedly predict mortality, hemorrhage, or the need for angiography. Level II recommendation
2. Presence/location of hematoma does not predict or exclude the need for angiography and possible embolization. Level II recommendation
3. CT of the pelvis is an excellent screening tool to exclude pelvic hemorrhage. Level II recommendation
4. Absence of contrast extravasation on CT does not always exclude active hemorrhage. Level II recommendation
5. Pelvic hematoma >500 cm3 in size has an increased incidence of arterial injury and need for angiography. Level II recommendation
6. Isolated acetabular fractures are as likely to require angiography as pelvic rim fractures. Level III recommendation
7. If a retrograde urethrocystogram is required, it should be performed after CT with intravenous contrast. Level III recommendation
Scientific Foundation: Radiographic Predictors of Hemorrhage
Two radiographic modalities have the potential to provide clinically useful information during the evaluation of traumatic pelvic fractures in the acute setting: pelvic X-ray and CT scan. Several recent studies attempt to correlate radiographic findings to clinical outcomes and specifically the need for angiography.
The Young-Burgess classification system49 (Table 4) divides pelvic fractures by vector; anteroposterior, lateral compression, vertical shear, and combined mechanical. Each type of fracture is also graded by severity (I, II, and III). Correlating the fracture pattern to the need for angiography has shown mixed results. Niwa et al.24 was able to show an association. This study was unable to define the cause of death in 20% of their population. Posterior bleeding sources seem to correlate with anteroposterior type fractures, whereas lateral compression fractures are more likely to have an anterior (iliac) source of bleeding.28
In an effort to determine whether patients should undergo laparotomy or angiography in hemodynamically unstable patients with pelvic fractures, Eastridge et al.50 found that those with higher grade or rotationally unstable pelvic fractures were more likely to have a pelvic source of bleeding. Patients with rotationally stable fractures were more likely to have an abdominal source of hemorrhage and therefore should have a laparotomy performed as the primary procedure. Two studies were able to show a relationship between major ligamentous disruption and the need for pelvic embolization.51,52 The authors concede that, although positive, the correlation was too weak to assist in clinical decision-making. When looking at pelvic fractures outside the pelvic ring, isolated acetabular fractures were shown to have the same blood transfusion requirements and presumably the need for angiography.53 Two other studies concluded that injury severity score was a better predictor of pelvic hemorrhage than fracture pattern.50,54 Blackmore et al.55 developed a multiple logistic regression model that was able to predict the probability of pelvic arterial hemorrhage.55 The model included the following factors: initial hematocrit 30 or less, heart rate 130 or greater, and pelvic fracture patterns including obturator ring fracture greater than 1 cm or pubic symphysis diastasis of at least 1 cm. The presence of three or four of these risk factors was only able to predict pelvic hemorrhage in 66% of patients. The remaining studies were unable to correlate pelvic fracture pattern with need for angioembolization.21,56,57 The available literature suggests that pelvic fracture pattern alone is insufficient to predict the need for angioembolization.
CT scanning has become a valuable asset in the acute management of pelvic trauma. Two factors have been studied to determine the need for angioembolization: ICE and the pelvic hematoma size. The absence of ICE on the admission CT is an excellent screening test to exclude the presence of active arterial hemorrhage and therefore the need for angioembolization, with the negative predictive values ranging from 98.0% to 99.8%.58–60 The presence of ICE, however, has shown varied results. Stephen et al.16 showed that the positive predictive value of ICE needing angioembolization was 80%. The negative predictive value was 98%. They concluded that the presence of ICE was an indication for angiography, regardless of hemodynamic status. Pereira et al.58 demonstrated a lower positive predictive value of 69.2% with ICE. Four of five patients who were hemodynamically stable with a blush did not require embolization. They recommend angiography only in hemodynamically unstable patients with ICE. Ryan et al.59 reported their experience with 18 patients with mechanically unstable pelvic fractures and ICE. Nine of these patients underwent angiography for hemodynamic instability of which seven required embolization. The presence of ICE on CT was predicted the site of bleeding found angiographically in all patients. They concluded that ICE on CT scan with a major pelvic fracture mandates angiography regardless of hemodynamics. There were no complications from angiography reported in these studies.
Other studies have demonstrated a higher mortality rate from a delay in angiography.60 Brasel et al.61 retrospectively examined CT scans with ICE and found 90% sensitivity for needing angiography. They noted, however, that 33% of patients without ICE who were hemodynamically unstable also required angiography. The data suggest that any hemodynamically unstable patient with pelvic fractures and ICE requires angiography in the absence of other bleeding sources. When patients are hemodynamically stable, the evidence is mixed. In a patient with stable hemodynamics, the data suggest that angiography may be useful to prevent further bleeding but may not be required in all patients.61 Need for angiography in hemodynamically stable patients with ICE from pelvic trauma requires further study to determine its usefulness.
Attempts at correlating the presence and size of a pelvic hematoma seen on CT with the need for angiography have been undertaken. Brown et al.62 retrospectively studied 37 patients who underwent CT and angiography. Contrast extravasation during angiography was noted in 83% of patients without hematoma (67% of patients with small hematoma and 73% of patients with significant hematoma). Blackmore et al.55 found that hematomas >500 cm3 had a significant increased risk ratio of 4.8 for arterial injury at angiography. In general, the presence of pelvic hematoma is insufficient to alter the indications for angiography and is not a predictor of need for transfusion or ongoing blood loss. Large hematomas with volumes over 500 cm3 may have an increased risk of arterial injury requiring angiography.
The presence of bladder and urethral injuries with concomitant pelvic fractures is common. Retrograde urethrogram (RUG) should be performed before placement of a urinary catheter; however, the sequencing of RUG and CT has been controversial.63 Netto et al.64 was able to show a higher rate of indeterminate and false-negative CT if RUG was performed first. This was due to contrast from the RUG interfering with determining if ICE was present. The detection of hemorrhage needs to take priority over detecting urologic injuries, and therefore CT scan with contrast should be performed before the evaluation of the genitourinary tract in most settings.
What Is the Role of Noninvasive Temporary External Fixation Devices?
1. TPBs effectively reduce unstable pelvic fractures as well as definitive stabilization and decrease pelvic volume. Level III recommendation
2. TPBs may limit pelvic hemorrhage but do not seem to affect mortality. Level III recommendation
3. TPBs work as well or better than emergent EPF in controlling hemorrhage. Level III recommendation
Scientific Foundation: Temporary External Fixation Devices
Temporary binders have been used to control hemorrhage from pelvic fractures for many years. Pneumatic antishock trousers were one of the early attempts to decrease the pelvic volume and limit hemorrhage. Sheets have been used for this task more recently.65–67 Commercial devices have recently evolved to provide consistent compression in a convenient prepackaged device. Results from studies of these commercial binders have been mixed. In a large study performed at Parkland Hospital, the use of a commercial binder had no effect on transfusion requirements, need for angiographic embolization, or mortality when compared with historical controls.68 Croce et al. compared the use of EPF placed in the operation room with TPB placed in the emergency department in a series of patients with hemodynamically instability and structurally unstable fractures. The use of the T-POD (Cybertech Medical, La Verne, CA) reduced blood transfusion needs at 24 hours and 48 hours compared with historical controls. Both the groups were in similar degree of shock. The authors attributed the reduced blood loss to the rapidity of T-POD placement compared with EPF. No differences in mortality were found.69
Evidence suggests temporary binders decrease pelvic volume with a pelvic fracture and may improve biomechanical stability. Bottlang et al.70,71 noted fracture reduction and 55% to 61% improvement in biomechanical stability of pelvic fractures in seven nonembalmed cadavers after application of an external compression device. In a study of 16 patients with mechanically unstable pelvic fractures, Kreig et al.14 demonstrated a 9.9% decrease in pelvic width using a TPB with no complications related to the binder. The data confirming efficacy of pelvic binders in controlling hemorrhage from pelvic fracture remain unclear because of conflicting studies in the literature.14,68–72
The use of pelvic binders may predispose to skin breakdown with prolonged use due to high pressure at bony prominences.72 Shearing force applied when tightening the binder might result in tissue trauma. Users of these devices need to be aware of the risk of pressure induced ischemic wounds. Because of the ease of application, relatively inexpensive cost, low potential for complications, and benefit to pelvic stability, temporary external stabilization devices should be considered for emergent application to all hemodynamically unstable patients with pelvic injuries.
Which Patients Warrant Retroperitoneal (Preperitoneal) Packing?
1. Retroperitoneal pelvic packing is effective in controlling hemorrhage when used as a salvage technique after angiographic embolization. Level III recommendation
2. Retroperitoneal pelvic packing is effective in controlling hemorrhage when used as part of a multidisciplinary clinical pathway including a POD/C-clamp. Level III recommendation
Scientific Foundation: Retroperitoneal Packing
Emergent PPP is a newer technique in the trauma surgeon's armamentarium. Its use is currently evolving. Originally described in the European literature,73 several European centers have described using PPP in combination with external mechanical fixation of the pelvis.74–77 Some trauma centers in the United States have adopted this technique and published on its use as a first-line therapy in-lieu of angiography.78 It is reportedly easy to learn.79
The technique involves creating a midline incision 8 cm in length just above the pubis extending toward the umbilicus.80,81 Skin and subcutaneous tissue is opened in the midline, as is the fascia. The bladder is retracted away from the fracture and three laparotomy pads are placed in the retroperitoneal space on each side toward the iliac vessels. The procedure is repeated on the opposite side and the fascia and skin are closed. The procedure can be performed in 20 minutes by experienced surgeons.80,81
Cothren et al.78 reported using PPP as part of a clinical pathway in treating hemorrhage from pelvic fracture. In this group of severely injured patients (injury severity score = 55), PPP was performed immediately after placement of a TPB in-lieu of angiography. There were no deaths attributed to hemorrhage after packing along with significantly fewer blood transfusions. This study reported an 83% success rate in controlling hemorrhage in hemodynamically unstable patients who underwent PPP. The other 17% required angiography. In a follow-up study at their institution, pelvic packing was found to occur faster than with angiography (45 minutes vs. 130 minutes). There was also a decrease need for transfusion. The results of the study are difficult to interpret because time to control hemorrhage was significantly different between the groups.81
PPP seems to have some advantage in controlling hemorrhage, particularly when angiography is unavailable or would result in significant delay. Future comparative studies will be needed to directly compare PPP with angiography for the control of pelvic hemorrhage.
Hemorrhage from pelvic fracture remains a difficult problem facing the trauma surgeon. Today, there have been many changes in practice pattern that have been shown to predict and limit hemorrhage in the patient with a pelvic fracture. Biffl et al.82 found that a multidisciplinary team, including an Orthopedic Surgeon, improved outcomes compared with historical controls. Institutional guidelines also have been shown to improve outcomes and their use is encouraged to limit variability in care.82–84 Emergent external fixation and the pelvic C-clamp used to control hemorrhage is not supported by the available literature. Although they do reduce fractures effectively, they do not seem to limit hemorrhage based on the available literature. Angiography for control of hemorrhage has come of age and has an important role in the treatment of patients with pelvic fracture and is supported by the highest level of evidence. Pelvic angiography with embolization can be performed bilaterally if needed and even repeated to control bleeding without undo consequence. The data on using the FAST examination to exclude intra-abdominal hemorrhage are clear. FAST examination, although highly specific, does not have the sensitivity to rule out an extrapelvic (abdominal) source of hemorrhage with major pelvic fracture. Although X-ray patterns of injury do not seem to predict hemorrhage, the use of CT scan with a finding of ICE is highly predictive of active bleeding and supported by the literature. The use of pelvic external fixation and C-Clamps has largely given way to TPBs. The hope with these devices is that by stabilizing the fracture, bleeding will be limited. Although the data are limited, early studies seem promising. Further studies will be needed to asses the ability of temporary abdominal binders to minimize hemorrhage from pelvic fracture. Finally, retroperitoneal packing is an effective tool to limit hemorrhage in the small studies that have investigated the technique. Its role in the management of pelvic hemorrhage at this time remains unclear and will need direct comparison with angiography in future studies.
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Keywords:Copyright © 2011 Wolters Kluwer Health, Inc. All rights reserved.
Pelvic fracture; Hemorrhage; Angiography; Embolization; External fixator; C-clamp; Temporary pelvic binder; Pelvic packing; Trauma; Intravenous contrast extravasation; Blush; PASG; Pelvic hematoma; FAST; CT scan; Fracture pattern