Pelvic Fracture Hemorrhage-Update and Systematic Review

Published 2011
Citation: J Trauma. 2011 Dec;71(6):1850-68.

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Authors

Cullinane, Daniel C. MD; Schiller, Henry J. MD; Zielinski, Martin D. MD; Bilaniuk, Jaroslaw W. MD; Collier, Bryan R. DO; Como, John MD; Holevar, Michelle MD; Sabater, Enrique A. MD; Sems, S. Andrew MD; Vassy, W. Matthew MD; Wynne, Julie L. MD

Author Information

From the Departments of Surgery (D.C.C., H.J.S., M.D.Z.) and Orthopedics (S.A.S.), Mayo Clinic, Rochester, Minnesota; Department of Surgery, Morristown Memorial Hospital (J.W.B.), Morristown, New Jersey; Department of Surgery, Vanderbilt University Medical Center (B.R.C.), Nashville, Tennessee; Department of Surgery, MetroHealth Medical Center (J.C.), Cleveland, Ohio; Department of Surgery, Mount Sinai Hospital (M.H.), Chicago, Illinois; Department of Radiology, HIMA-San Pablo Hospital (E.A.S.), Bayamon, Puerto Rico; Department of Surgery, Evansville Surgical Associates (W.M.V.), Newburgh, Indiana; and Department of Surgery, University of Arizona (J.L.W.), Tucson, Arizona.

Submitted for publication April 21, 2011.

Accepted for publication October 18, 2011.

Presented at the 22nd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 16, 2009, Lake Buena Vista, Florida.

Address for reprints: Daniel C. Cullinane, MD, Department of Surgery, Mayo Clinic, 200 First St, SW, Rochester, MN 55905; email: cullinane.daniel@mayo.edu.

Statement of the Problem

Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma.[1] Since that time there have been a number of new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to update the 2001 EAST guidelines and systematic review for hemorrhage due to pelvic fracture. The design of the project was to update the previous guideline as well as to evaluate new treatment methods and techniques. Six specific questions are addressed regarding the management of pelvic fracture hemorrhage:

1. Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization?

2. Which patients require emergent angiography?

3. What is the best test to exclude extrapelvic bleeding?

4. Are there radiologic findings which predict hemorrhage?

5. What is the role of noninvasive temporary external fixation devices?

6. Which patients warrant preperitoneal packing (PPP)?

Process

The Practice Management Guidelines Committee of the EAST (www.east.org) developed the process used by this committee for review and development of practice management guidelines. A computerized search of the National Library of Medicine MEDLINE database was undertaken using the OVID interface. English language citations were included for the period of 1999 through 2010 using the primary search strategy: pelvis, fracture hemorrhage, trauma, and retroperitoneal hematoma. The dates were selected to allow comprehensive review of articles published since the prior systematic review with minimal overlap.

Review articles and case reports were excluded. Moreover, studies not directly addressing hemorrhage with pelvic fracture were excluded. The Related Articles algorithm was also used to identify additional articles similar to the items retrieved by the primary strategy. Of the 1,432 articles identified by these two techniques, those dealing with prospective or retrospective studies were selected, comprising 50 studies specifically evaluating hemorrhage associated with pelvic fracture in adult or pediatric patients.

The EAST, “Utilizing evidence based outcome measures to develop practice management guidelines: a primer,” was used as a quality assessment instrument applied to develop this guideline.[2]

The workgroup for the Practice Management Guidelines for Hemorrhage in Pelvic Trauma consisted of nine Trauma Surgeons, an Orthopedic Surgeon specializing in trauma (S.A.S.), and an Interventional Radiologist (E.A.S.) (Table 1). Articles were compiled by the committee chair (D.C.C.) and were distributed among committee members for formal review. Each article was entered into a review data sheet with detailed summaries of the articles. Deficiencies and conclusions not validated by the data were also noted. The reviewers correlated the references with the methodology established by the Agency for Health policy and Research of the US Department of Health and Human Service. Each reference was classified as class I, class II, or class III data. There was no class I data found for the search period. Fifteen class II articles and 35 class III articles were included in the review. All references were reviewed by at least two committee members for purposes of cross-validation. An evidentiary table was constructed using the 50 references (Table 2).

Level I

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.

Level II

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.

Level III

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.

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)[12]although 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 necrosis[33] 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 cm[3] 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 system[49] (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 cm[3] 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 cm[3] 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.

Summary

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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  25. Wong YC, Wang LJ, Ng CJ, Tseng IC, See LC. Mortality after successful transcatheter arterial embolization in patients with unstable pelvic fractures: rate of blood transfusion as a predictive factor. J Trauma. 2000;49:71–75.
  26. Hagiwara A, Minakawa K, Matsuda T, Murata A, Masuda H, Shimazaki S. Predictors of death in patients with life-threatening pelvic hemorrhage after successful transcatheter arterial embolization. J Trauma. 2003;55:696–703.
  27. Kimbrel BJ, Velmahos GC, Chan LS, Demetriades D. Angiographic embolization for pelvic fractures in older patients. Arch Surg. 2004;139:728–732.
  28. Metz CM, Hak DJ, Goulet JA, Williams D. Pelvic fracture patterns and their corresponding angiographic sources of hemorrhage. Orthop Clin North Am. 2004;35:431–437.
  29. Velmahos GC, Toutouzas KG, Vassiliu A, et al. A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma. 2002;53:303–308.
  30. Shapiro M, McDonald AA, Knight D, Johannigman JA, Cuschieri J. The role of repeat angiography in the management of pelvic fractures. J Trauma. 2005;58:227–231.
  31. Velmahos GC, Chahwan S, Falabella A, Hanks SE, Demetriades D. Angiographic embolization for intraperitoneal and retroperitoneal injuries. World J Surg. 2000;24:539–545.
  32. Takahira N, Shindo M, Tanaka K, Nishimaki H, Ohwada T, Itoman M. Gluteal muscle necrosis following transcatheter angiographic embolisation for retroperitoneal haemorrhage associated with pelvic fracture. Injury. 2001;32:27–32.
  33. Yasumura K, Ikegami K, Kamohara T, Nohara Y. High incidence of ischemic necrosis of the gluteal muscle after transcatheter angiographic embolization for severe pelvic fracture. J Trauma. 2005;58:985–990.
  34. Ramirez JI, Velmahos GC, Best CR, Chan LS, Demetriades D. Male sexual function after bilateral internal Iliac artery embolization for pelvic fracture. J Trauma. 2004;56:734–739.
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  39. Healey MA, Simons RK, Winchell RJ, et al. A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful? J Trauma. 1996;40:875–883.
  40. Glaser K, Tschmelitsch J, Klingler P, Wetscher G, Bodner E. Ultrasonography in the management of blunt abdominal and thoracic trauma. Arch Surg. 1994;129:743–747.
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  44. Allen CF, Goslar PW, Barry M, Christiansen T. Management guidelines for hypotensive pelvic fracture patients. Am Surg. 2000;66:735–738.
  45. Ruchholtz S, Waydhas C, Lewan U, et al. Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary? J Trauma. 2004;57:278–285.
  46. Tayal V, Nielsen A, Jones AE, Thomason MH, Kellam J, Norton HJ. Accuracy of trauma ultrasound in major pelvic injury. J Trauma. 2006;61:1453–1457.
  47. Friese RS, Malekzadeh S, Shafi S, Gentilello LM, Starr A. Abdominal ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture. J Trauma. 2007;63:97–102.
  48. Ballard RB, Rozycki GS, Newman PG, et al. An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. Focused assessment for the sonographic examination of the trauma patient. J Am Coll Surg. 1999;189:145–150; discussion 150–151.
  49. Young JWR, Burgess AR. Radiologic Management Of Pelvic Ring Fractures in Systematic Radiographic Diagnosis. Baltimore: Urban and Scwarzenberg; 1987.
  50. Eastridge BJ, Starr A, Minei JP, O'Keefe GE, Scalea TM. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma. 2002;53:446–450.
  51. Hamill J, Holden A, Civil I. Pelvic fracture pattern predicts pelvic arterial haemorrhage. Aust N Z J Surg. 2000;70:338–343.
  52. Fu CY, Wu SC, Chen RJ, et al. Evaluation of pelvic fracture stability and the need for angioembolization: pelvic instabilities on a plain film have an increased probability of requiring angioembolization. Am J Emerg Med. 2009;27:792–796.
  53. Magnussen RA, Tressler MA, Obremskey WT, Kregor PJ. Predicting blood loss in isolated pelvic and acetabular high-energy trauma. J Orthop Trauma. 2007;21:603–607.
  54. Lunsjo K, Tadros A, Hauggaard A, Blomgren R, Kopke J, Abu-Zidan FM. Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients. J Trauma. 2007;62:687–691.
  55. Blackmore CC, Cummings P, Jurkovich GJ, Linnau KF, Hoffer EK, Rivara FP. Predicting major hemorrhage in patients with pelvic fracture. J Trauma. 2006;61:346–352.
  56. Sarin EL, Moore JB, Moore EE, et al. Pelvic fracture pattern does not always predict the need for urgent embolization. J Trauma. 2005;58:973–977.
  57. Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;21:31–37.
  58. Pereira SJ, O'Brien DP, Luchette FA, et al. Dynamic helical computed tomography scan accurately detects hemorrhage in patients with pelvic fracture.Surgery. 2000;128:678–685.
  59. Ryan MF, Hamilton PA, Chu P, Hanaghan J. Active extravasation of arterial contrast agent on post-traumatic abdominal computed tomography. Can Assoc Radiol J. 2004;55:160–169.
  60. Evers BM, Cryer HM, Miller FB. Pelvic fracture hemorrhage: priorities in management. Arch Surg. 1989;124:422–424.
  61. Brasel KJ, K. Pham, Yang H, Christensen R, Weigelt JA. Significance of contrast extravasation in patients with pelvic fracture. J Trauma. 2007;62:1149–1152.
  62. Brown CVR, Kasotakis G, Wilcox A, Rhee P, Salim A, Demetriades D. Does pelvic hematoma on admission computed tomography predict active bleeding at angiography for pelvic fracture? Am Surg. 2005;71:759–762.
  63. Brandes S, Borrelli J. Pelvic fracture and associated urologic injuries. World J Surg. 2001;25:1578–1587.
  64. Netto FA, Hamilton P, Kodama R, et al. Retrograde urethrocystography impairs computed tomography diagnosis of pelvic arterial hemorrhage in the presence of a lower urologic tract injury. J Am Coll Surg. 2008;206:322–327.
  65. Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA. Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma. 2006;20:S3–S6.
  66. Simpson T, Krieg JC, Heuer F, Bottlang M. Stabilization of pelvic ring disruptions with a circumferential sheet. J Trauma. 2002;52:158–161.
  67. Warme WJ, Todd MS. The circumferential antishock sheet. Mil Med. 2002;167:438–441.
  68. Ghaemmaghami V, Sperry J, Gunst M, et al. Effects of early use of external pelvic compression on transfusion requirements and mortality in pelvic fractures. Am J Surg. 2007;194:720–723; discussion 723.
  69. Croce MA, Magnotti LJ, Savage SA, Wood GW II, Fabian TC. Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg. 2007;204:935–939; discussion 940–942.
  70. Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg Am. 2002;84:43–47.
  71. Bottlang M, Simpson T, Sigg J, Krieg JC, Madey SM, Long WB. Noninvasive reduction of open-book pelvic fractures by circumferential compression.J Orthop Trauma. 2002;16:367–373.
  72. Jowett AJL, Bowyer GW. Pressure characteristics of pelvic binders. Injury. 2007;38:118–121.
  73. Pohlemann T, Gansslen A, Hufner T, Tscherne H. Extraperitoneal packing at laparotomy. Presented at: OTA-AAST Annual Meeting, October 12–14, 2000, San Antonio, Texas.
  74. Ertel W, Karim E, Keel M, Trentz O. Therapeutical strategies and outcome of polytraumatized patients with pelvic injuries. Eur J Trauma. 2000;26:278–286.
  75. Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma. 2001;15:468–474.
  76. Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury. 2004;35:671–677.
  77. Totterman A, Madsen JE, Skaga NO, Roise O. Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. J Trauma. 2007;62:843–852.
  78. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitoneal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007;62:834–839; discussion 839–842.
  79. Bach A, Bendix J, Hougaard K, Christensen EF. Retroperitoneal packing as part of damage control surgery in a Danish trauma centre—fast, effective, and cost-effective. Scand J Trauma Resusc Emerg Med. 2008;16:4.
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  81. Osborn PM, Smith WR, Moore EE, et al. Direct retroperitoneal packing versus pelvic angiography: a comparison of two management protocols for heamodynamically unstable pelvic fractures. Injury. 2009;40:54–60.
  82. Biffl WL, Smith WR, Moore EE, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures.Ann Surg. 2001;233:843–850.
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  84. Jeske HC, Larndorfer R, Krappinger D, et al. Management of hemorrhage in severe pelvic injuries. J Trauma. 2010;68:415–420.
  85. Blackmore CC, Jurkovich GJ, Linnau KF, Cummings P, Hoffer EK, Rivara FP. Assessment of volume of hemorrhage and outcome from pelvic fracture. Arch Surg. 2003;138:504–509.
  86. Kataoka Y, Maekawa K, Nishimaki H, Yamamoto S, Soma K. Iliac vein injuries in hemodynamically unstable patients with pelvic fractures caused by blunt trauma. J Trauma. 2005;58:704–710.

Tables

TABLE 1. Members of the EAST Hemorrhage in Pelvic Fracture Workgroup
NameOrganization/PlaceEmail

Daniel C. Cullinane, MD—Chair

Mayo Clinic, Rochester, MN

cullinane.daniel@mayo.edu

Henry J. Schiller, MD

Mayo Clinic, Rochester, MN

schiller.henry@mayo.edu

Jaroslaw W. Bilaniuk, MD

Morristown Memorial Hospital, Morristown, NJ

jwbil@hotmail.com

Bryan R. Collier, DO

Vanderbilt University Medical Center, Nashville, TN

bryan.collier@vanderbilt.edu

John Como, MD

MetroHealth Medical Center, Cleveland, OH

jcomo@metrohealth.org

Michelle Holevar, MD

Mount Sinai Hospital, Chicago, IL

michellehmail-career@yahoo.com

Enrique A. Sabater, MD

HIMA-San Pablo Hospital, Bayamon, PR

easabater@gmail.com

S. Andrew Sems, MD

Mayo Clinic, Rochester, MN

sems.andrew@mayo.edu

W. Matthew Vassy, MD

Evansville Surgical Associates, Newburgh, IN

thevassys@yahoo.com

Julie L. Wynn, MD

University of Arizona, Tucson, AZ

jwynne@surgery.arizona.edu

Martin D. Zielinski, MD

Mayo Clinic, Rochester, MN

zielinski.martin@mayo.edu

TABLE 2. Evidentiary Table 1999–2010
First AuthorYearTitleLevel of EvidenceQuestion AddressedSynopsisReference

Smith et al.[80]

2005

Retroperitoneal Packing as a Resuscitation technique for Hemodynamically Unstable Patients with pelvic Fracture: Report of two Representative Cases and a Description of Technique.

2

6

The ISS, RTS, number of transfusions, age > 60 were statistically significant predictors of early mortality.  Fracture pattern and treatment with angio/embolization were not predictive of death.

J Trauma 2005;59:1510-1514

Totterman et al.[77]

2007

Extraperitoneal Pelvic Packing: a Salvage Procedure to Control Massive Traumatic Pelvic Hemorrhage.

3

2, 6

Patients underwent retroperitoneal packing as a salvage maneuver after pelvic embolization. All had Class III - Class IV hemorrhage.  30 day survival was 72% and correlated inversely to the age of the patient.  The authors concluded that packing may be life-saving procedure.

J Trauma 2007;62:843-852

Cothren et al.[78]

2007

Preperitoneal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures: A Paradigm Shift

3

1, 6

28 consecutive hemodynamically unstable patients with pelvic fractures underwent pelvic fracture fixation with an anterior external fixator or posterior pelvic C-clamp followed by preperitoneal pelvic packing.  Unstable patients then underwent angioembolization (25%). The blood transfusion requirements prior to packing were significantly greater than after (12 +/- 2.0 vs 6 +/- 1.1; p = 0.006). Mortality was 25%, there were no deaths as a result of acute blood loss.  Preperitoneal packing is a rapid method for controlling pelvic fracture-related hemorrhage that can supplant the need for emergent angiography.  They state that this approach appears to reduce mortality in this select group of patients. 

J Trauma 2007;62:834-842

Brasel et al.[61]

2007

Significance of contrast Extravasation in patients with Pelvic fracture

3

3

Contrast Extravasation (CE) on CT scan was calculated to have a sensitivity of 90.5%, a specificity of 96.1%, positive predictive value of 45.2%, and negative predictive value of 99.6%. Not all patients with CE required embolization, hence the low PPV. Some patients required angiography despite not having CE

J Trauma 2007, 62:1149-1152

Totterman et al.[17]

2006

A Protocol for Angiographic embolization in Exsanguinating Pelvic Trauma

2

2

46 patients underwent angio based on protocol (unstable hemodynamics + 6pRBC or stable hemodynamics + 4pRBC). All pelvic fracture patterns represented in those undergoing angio.  31/46 underwent embolization. Survival 84%. No patients died of hemorrhage.

Acta Orthopaedica 2006; 77(3):462-468

Velmahos et al.[29]

2002

A Prospective Study on the Safety and efficacy of Angiographic Embolization for Pelvic and Visceral Injuries

2

2

Prospective study. Sixty-five of the 100 patients had angiography because of pelvic fractures; the rest were due to visceral injuries. The safety rate of angiography was 94%, and efficacy for controlling bleeding was 93%.  Analysis identified three independent predictors of positive angiography:  age >55, absence of long bone fracture, and emergent procedure.  The model was most robust when all three factors were present.

J Trauma 2002;52:303-308

Velmahos et al.[31]

2000

Angiographic embolization for intraperitoneal and Retroperitoneal Injuries

3

2

137 consecutive patients underwent angio with the intent of embolization. 97/137 for pelvic fractures. Of the 137patients, 91% success to control bleeding; pelvic bleeding not isolated as a data point. 9 patients failed embolization, with 66% mortality. One third of pelvic embolizations were for bilateral internal iliac arteries, but no post procedure morbidity was noted.

World J Surg 2000; 25(5) 539-545

Shapiro et al.[30]

2005

The Role of Repeat Angiography in the Management of Pelvic Fractures

3

2

Retrospective review of 31 pelvic fracture patients who underwent pelvic angiography. Fifteen patients had no evidence of pelvic arterial hemorrhage, five patients required repeat angiography for recurrent hypotension, with 80% having a treatable lesion.  As well, three patients who underwent coiling initially also required repeat angiography.  Independent predictors of need for repeat angiography were recurrent hypotension, persistent base deficit greater than 10, and absence of intra-abdominal injury.

J Trauma 2005; 58:227-231

Metz et al.[28]

2004

Pelvic Fracture Patterns and their Corresponding Angiographic Sources of Hemorrhage

3

4

Retrospective review of imaging and clinical course of 49 consecutive hemodynamically unstable patients with pelvic fracture.  Patients with OTA type A or C fracture patterns or APC fracture patterns had higher mortality rates, ISS, and transfusion requirements than OTA type B or LC patterns.  Patients with APC injuries tended to demonstrate posterior vascular injuries, while LC fracture pattern was more likely to be associated with anterior branch vascular injury.

Orthop Clin N Am 2004; 35: 431-437

Kimbrell et al.[27]

2004

Angiographic Embolization for Pelvic Fractures in Older Patients

2

2

Analysis of prospective collected data to determine if age can predict the need for therapeutic embolization.  During this time period indications for embolization were:  hypotension in the context of pelvic fracture and no other source of bleeding, or specific fracture patterns, or large pelvic hematoma.  92 of 332 patients with severe pelvic fracture underwent angiography.  Age >60 was found to be associated with a 94% likelihood of positive angiography.  The authors recommend liberal arteriography for severe pelvic fracture patients >60 years.

Arch Surg 2004; 139: 728-733

Miller et al.[18]

2003

External Fixation or Arteriogram in Bleeding Pelvic Fracture: Initial Therapy Guided by Markers of Arterial Hemorrhage

3

2, 4

Retrospective trauma registry review of all patients with hypotension related to pelvic fractures who underwent angiography, as well as normotensive pelvic fracture patients who underwent angiography, to determine factors predicting arterial bleeding.  35 patients had initial hypotension, and 28 who were considered to be non-responders underwent angiography, with 73% demonstrating arterial bleeding.  17 normotensive patients underwent angiography based on fracture pattern, presence of pelvic hematoma, or contrast extravasation, and 29% were positive for arterial bleeding.  The authors recommend that pelvic fracture patients who do not respond to initial resuscitation and patients with contrast extravasation on CT scan, under arteriography.

J Trauma 2003;54:437-443

Gourlay et al.[22]

2005

Pelvic Angiography for Recurrent Traumatic Pelvic Arterial Hemorrhage

2

2

Study cohort of 39 patients who had repeat angiography for recurrent pelvic hemorrhage.  The 33 patients with a positive second angiogram had bleeding at a new site in 28 (85%) and at the previously embolized site in 11 (33%).  All embolizations at the repeat angiogram were thought to be technically successful.  Significant risk factors for recurrent pelvic arterial hemorrhage (1)pre-angiogram hypotension (2)pubic symphysis disruption (3)greater number of injured arteries on initial arteriogram (4)coagulopathy (5)require more blood transfusion.  The authors concluded that patients with these characteristics may manifest recurrent arterial bleeding, and it may be prudent to retain the angio sheath for up to 72 hours.

J Trauma 2005; 59: 1168-1174

Takahira et al.[32]

2001

Gluteal Muscle necrosis following transcatheter angiographic embolization for retroperitoneal hemorrhage associated with pelvic fracture

3

2

Review of patients who went bilateral angioembolization for pelvic fracture-related hemorrhage found that 5 of 151 patients (3.3%) developed gluteal muscle necrosis.  All had embolization of bilateral internal iliac arteries.  Mortality was 60% due to sepsis/DIC.

Injury, Int J Care Injured 2001;32:27-32

Yasumura et al.[33]

2005

High Incidence of Ischemic Necrosis of the Gluteal Muscle after Transcatheter Angiographic Embolization for Severe Pelvic Fracture

3

2

8 patients underwent angiography for bleeding pelvic fractures. 6/8 underwent embolization. 4/6 patients had bilateral internal iliac embolizations. 2/6 patients had bilateral superior/inferior gluteals embolized.  3 cases of tissue infection, 4 cases of gluteal necrosis, 2 cases of sepsis. Patients underwent MRI at 1 and 4 weeks.  All were noted to have gluteal muscle necrosis, and two patients developed necrotizing soft tissue infection necessitating I&D.

J Trauma 2005; 58:985-990

Fangio et al.[20]

2005

Early Embolization and Vasopressor Administration for Management of Life-Threatening Hemorrhage from Pelvic Fracture

3

2

32 hemodynamically unstable patients underwent pelvic angiography, which was followed by embolization in 25 cases.  Angiography was successful in 24 cases (96%).  There was hemodynamic improvement in 21 (84%) Liberal use of vasopressors was used during the early stages of hemorrhagic shock and during angioembolization .Mortality 36%.

J Trauma 2005; 58:978-984

Brown et al.[62]

2005

Does Pelvic Hematoma on Admission Computed Tomography Predict Active Bleeding at Angiography for Pelvic Fracture

3

2, 4

Retrospective review of 37 pelvic fracture patients who underwent CT and angiography.  It was found that the size of the pelvic hematoma on CT did not correlate with active pelvic bleeding on angiogram.  Also, the absence of a contrast blush did not reliably exclude active bleeding seen on angiography.

Am Surgeon 2005; 71(9): 759-762

Cook et al.[19]

2002

The Role of Angiography in the Management of Haemorrhage from Major Fractures of the Pelvis

3

2, 4

23 patients with ongoing hypotension had angiogram with unstable pelvic fractures. Fracture pattern did not predict associated vascular injury.

J Bone and Joint Surg 2002; 84(2): 178-182

Netto et al.[64]

2008

Retrograde Urethrocystography Impairs Computed Tomography Diagnosis of Pelvic Arterial Hemorrhage in the Presence of a Lower Urologic tract Injury

3

2, 4

49 patients with pelvic fracture and either a urethral or bladder rupture.  23 had RUG or cystogram performed before CT, and 26 had cystography after CT scanning.  Performing cystography before CT was associated with considerately more indeterminate scans (N=9) and false negatives (N=2) for pelvic arterial extravasation. Consideration should be given to performing retrograde urethrography and cystography after CT scanning since they interfere with the detection of active extravasation on CT

JACS 2008; 206(2): 322-327

Wong et al.[25]

2000

Mortality after Successful Transcatheter Arterial Embolization in Patients with Unstable Pelvic Fractures: Rate of Blood Transfusion as a Predictive Factor

3

2, 4

Retrospective review.  Seventeen hemodynamically unstable pelvic fracture patients underwent therapeutic embolization, and three of the patients subsequently died, for a mortality rate of 17.6%.  Blood transfusion rate prior to embolization as well as time interval to embolization were significant predictors of mortality, but size of contrast extravasation was not.  The authors concluded that early recognition of arterial pelvic bleeding with early embolization is essential.

J Trauma 2000; 49:71-74

Hagiwara et al.[26]

2003

Predictors of Death in Patients with Life-Threatening Pelvic Hemorrhage after Successful transcatheter Arterial Embolization

2

2, 4

61 patients evaluated with prospective protocol. 13/61 died despite 100% successful angioembolization. Posterior pelvic bleeding and APACHE II scores predicted mortality. Fracture patterns did not predict mortality. Non-survivors required more fluid to achieve hemodynamic stability.

J Trauma 2003; 55: 696-703

Croce et al.[69]

2007

Emergent Pelvic Fixation in Patients with Exsanguinating pelvic Fracture

2

1, 5

186 patients with multiple severe pelvic fractures underwent stabilization of the pelvis with a pelvic orthotic device (C-Clamp)(93) vs. temporary external pelvic binder (93).  Transfusion requirements were reduced with the use of the binder, as was hospital length of stay.  There was no statistically significant difference in the mortality rates.  The authors conclude that the use of the binder reduces transfusion requirements and length of hospital stay.

J Am Coll Surg 2007;204(5): 935-939

Bottlang et al.[70]

2002

Emergent Management of Pelvic Ring fractures with Use of Circumferential Compression

3

1, 5

Open-book pelvic fractures were induced in 7 cadavers.  Stabilization was initially provided with the pelvic sling.  Subsequently, stabilized with a posterior pelvic C-clamp/anterior external fixator.  Stability provided by the pelvic sling was directly comparable to that provided by the posterior pelvic C-clamp, but the sling provided only 1/3 of the flexion-extension stability and 1/10th of the internal-external rotation stability as compared with the external fixator.  The authors conclude that the sling is well suited for temporarily stabilization of the acutely injured patient.

J Bone Joint Surg Am

Bottlang et al.[71]

2002

Noninvasive Reduction of Open-Book Pelvic Fractures by Circumferential Compression

3

 5

Partially stable and unstable external rotation injuries of the pelvic ring were created in 7 cadavers.  A pelvic strap was applied at three different levels around the pelvis.  The strap achieved complete reduction of symphysis diastasis.

J Ortho Trauma 2002;16(6): 367-373

Tiemann et al.[13]

2005

Emergency Treatment of Multiply Injured Patients with Unstable Disruption of the Posterior Pelvic Ring by Using the "C-Clamp"

3

1

28 patients with an unstable posterior pelvic ring fracture had a C-clamp applied immediately after diagnosis.  The average time from trauma to C-clamp application was 64.7 min (10 - 240 min).  Application of the C-clamp resulted in stabilization of BP and oxygenation in survivors; in the non-survivor group (7/28 patients) there was no stabilization of BP or oxygenation.  The authors conclude that the C-clamp leads to stabilization of vital parameters within a short period of time.

European Journal of Trauma 2005; 3:244-251

Kreig et al.[14]

2005

Emergent Stabilization of Pelvic Ring Injuries by Controlled Circumferential Compression: A Clinical Trial

3

1, 5

16 patients with pelvic ring fractures had a pelvic circumferential compression device (PCCD) temporarily applied until definitive stabilization was provided.  In the external rotation group, the PCCD significantly reduced the pelvic width by 9.9 +/- 6%.  , similar to the 10.0 +/- 4.1% reduction in achieved by definitive stabilization.  In the internal rotation group, the PCCD did not cause significant over compression.  The authors conclude that a PCCD can effectively reduce pelvic ring injuries while posing minimal risk for over compression and complications.

J Trauma 2005; 59:659-664

Ghaemmaghami et al.[68]

2007

Effects of Early Use of External Pelvic Compression on Transfusion Requirements and Mortality in Pelvic Fractures

3

5

Pelvic binders were applied to 118 patients with either: unstable pelvic fracture, pelvic fracture in a patient > 55 y/o, or a pelvic fracture associated with hypotension.  These patients were compared to historical controls.  The pelvic binder had no effect on mortality, need for pelvic angioembolization, or 24-hour transfusions.  The authors concluded that early use of pelvic binders does not reduce hemorrhage or mortality associated with pelvic fractures.

Am J Surg 2007;194:720-723

Stover et al.[4]

2006

Three-Dimensional Analysis of Pelvic Volume in an Unstable Pelvic Fracture

3

1

A model was developed comparing intact and postfracture pelvic volumes in 10 cadavers; the pelvic volume was calculated using CT.  The observed volume changes with increasing pubic diastasis were smaller than previously reported.

J Trauma 2006;61:905-908

Sadri et al.[11]

2005

Control of Severe Hemorrhage using C-Clamp and Arterial Embolization in Hemodynamically Unstable patients with Pelvic Ring Disruption

3

1, 2

14 hemodynamically unstable patients with types B & C pelvic ring fractures underwent application of pelvic C-clamp.  5 patients remained in shock and underwent angio/embolization within 24 hours.  The mortality rate of the patients who underwent angio-embolization was 14%).  Although the C-clamp is effective in controlling hemorrhage, arterial embolization may be needed to restore hemodynamic stability.

Arch Orthop Trauma Surg 2005; 125:443-447

Blackmore et al.[85]

2003

Assessment of Volume of Hemorrhage and Outcome From Pelvic Fracture

3

2, 4

CT scans of 592 patients with pelvic fracture were retrospectively reviewed to estimate volume. These estimates were then correlated with pelvic arterial bleeding diagnosed by angiography.  The risk ratio for pelvic arterial injury was 4.8 in subjects with > 500 ml of pelvic-fracture-related hematoma compared with subjects with < 500 ml.  Volume > 500 ml was associated with high transfusion requirement (risk ratio=4.7) and with any adverse outcome (risk ratio=7.0).  The authors conclude that pelvic hemorrhage volumes derived from pelvic CT scan can predict the need for pelvic arteriography and transfusions.

Arch Surg 2003; 138:504-509

Baque et al.[3]

2005

Anatomical Consequences of "open book" pelvic ring Disruption. A Cadaver Experimental Study

3

1

Bilateral open-book pelvic fractures were created in 10 cadavers. Pelvic volume was determined after total pelvic exenteration.  The mean volume of pelvic cavity was 872.5 mL (580 - 756 mL).  The average increase of pelvic volume was 20.8% after 5 cm of pubic diastasis.  In 60%, a laceration of the ilio-lumbar vein occurred after 5 cm of pubic diastasis.  No arterial laceration occurred.  The authors concluded that open-book fractures create an increase of pelvic volume that facilitates blood diffusion from the pelvic vessels.  The ilio-lumbar pedicle seems to be very vulnerable in this type of fracture.

Surg Radiol Anat 2005; 27:487-490Jowett A

Jowett and Bowyer[72]

2007

Pressure Characteristics of Pelvic Binders

3

5

10 volunteers were fitted with a flexible pressure-sensitive sensor over the skin covering the anterior superior iliac spine, greater trochanter and sacrum.  A pelvic binder was then applied and tightened according to the manufacturers' instructions. The pressures obtained correlated inversely with BMI.  The authors conclude that the pressures developed between the binder and the skin over the prominences were all greater than the pressure recommended at interfaces to avoid the development of pressure sores, suggesting that patients with pelvic fractures treated with temporary pelvic binders are at risk of developing pressure sores.

Injury, Int J Care Injured 2007; 38, 118-121

Kataoka et al.[86]

2005

Iliac Vein injuries in Hemodynamically unstable Patients with Pelvic Fractures caused by Blunt Trauma

3

2, 3, 6

72 patients with unstable pelvic fractures who presented in shock were reviewed.  36/61 patients recovered from shock after angioembolization.  18/25 who did not recover from shock died.  In 11/25 who did not recover from shock after angio/embolization, transfemoral venography was performed, revealing significant venous extravasation in 9 (5 common iliac vein, 3 internal iliac vein, 1 external iliac vein).  The authors conclude that iliac vein injury is the principal cause of hemorrhagic shock in patients with unstable pelvic fractures and that venography is useful for identifying these injuries.

J Trauma 2005;58:704-710

Stephen et al.[16]

1999

Early Detection of Arterial Bleeding in Acute Pelvic Trauma

3

2, 4

Retrospective review of 111 pts with pelvic/acetabular Fx's w/ CT scan, including stable and unstable pts. 11 patients had extravasation. Obturator artery was #1 cause of hemorrhage requiring embolization with superior gluteal #2.  Contrast extravasation was 80% sensitive and 98% specific for requiring angiography. They conclude that contrast extravasation seen on CT (whether hemodynamically stable or unstable) requires angiography, although some hemorrhage will have stopped by the time angiography is undertaken.

J Trauma 1999;47(4):638

Pereira et al.[58]

2000

Dynamic Helical Computed Tomography Scan Accurately Detects Hemorrhage in Patients with Pelvic Fracture

3

2, 4

Helical CT has high negative predictive value (99.6%) to determine need for embolization--positive pred value 69.2%; therefore appropriate for screening polytrauma patients with pelvic fractures to eliminate need for emergent angio embolization. 290 pelvic fractures studied with CT, only 13 with contrast extravasation They recommend angio in pts that are unstable and have contrast extravasation.

Surgery 2000;128:678-85

Ryan et al.[59]

2004

Active Extravasation of Arterial Contrast Agent on Post-traumatic Abdominal Computed Tomography

3

2, 4

Retrospective review of 28 initially hemodynamically stable pts w/ extravasation on CT. Sensitivity was 87.5%, Specificity was 99.5%, positive predictive value was 77.8%, and negative predictive value was 99.8%. Mortality for contrast extravasation group was 64% and 13% for those without. Authors recommend angio in patients with pelvic fractures and contrast extravasation become unstable.

Can Assoc Radiol J 2004;55(3):160-9

Ruchholtz et al.[45]

2004

Free Abdominal Fluid on Ultrasound in Unstable Pelvic Ring Fracture: Is Laparotomy Always Necessary?

2

1, 2, 3, 4, 6

Retrospective review of 80 pts with type B or C pelvic ring Fractures. Fluid group (free fluid on initial FAST) had 31 pts, all underwent laparotomy. 30 of 31 had an abdominal source of bleeding. 6 pts in the No fluid group (n=49) were hemodynamically unstable, none had an abdominal sources of bleeding. Hemodynamically unstable pts w/o free fluid require early Ex fix stabilization and hemodynamically unstable pts with a positive FAST require laparotomy first, retroperitoneal packing as needed and ex fixation after abdominal bleeding is controlled. Further imaging (CT scan) is needed in hemodynamically stable pts and pts w/o free fluid who continue to be unstable after ex fixation.

J Trauma 2004; 57:278-286

Niwa et al.[24]

2000 The value of plain radiographs in the prediction of outcome in pelvic fractures treated with embolisation therapy  3 2, 4

Review of 40 patients requiring angiographic embolization for pelvic hemorrhage. Plain pelvic films were reviewed retrospectively for location of bony injury (L or R ischiopubic or sacroiliac) and Foley deviation to see if hemorrhagic source could be predicted. The authors concluded that in this patient group, plain X-ray has 81% sensitivity and 91% specificity in identifying location of hemorrhage. Selection bias of reviewing only those requiring embolization and does not to help identify those who may require embolization

Br J Radiol. 2000;73:945– 950

Tayal et al.[46]

2006

Accuracy of Trauma Ultrasound in Major Pelvic Injury

3

2, 3, 4

Sensitivity of FAST in pts with pelvic fx 80.8% and specificity 86.9%.  PPV 72.4%, NPV 91.4%.  Of 21 true positive FAST, free fluid was urine in 4. Propose peritoneal tap in hemodynamically unstable pts to determine if fluid is blood or urine from bladder injury.

J Trauma 2006; 51:1453-1457

Friese RS[47]

2007

Abdominal Ultrasound is an Unreliable Modality for the Detection of Hemoperitoneum in Patients with Pelvic Fracture

3

2, 3, 4

96 pts with pelvic fx and increased risk for hemorrhage (age>55, SBP<90 in ED, or unstable fracture pattern) studied w/ FAST where results confirmed with CT or laparotomy.   In detecting free fluid in peritoneal cavity, FAST had sensitivity=26%, specificity= 96%, PPV 85%, NPV 63%.  With a negative FAST a second test needs to be done:  CT Scan in stable patients, DPL in unstable patients. Authors conclude FAST does not help determine laparotomy.

J Trauma 2007; 63:97-102

Ballard RB[48]

1999

An Algorithm to Reduce the Incidence of False-Negative FAST* Examinations in Patients at High Risk for Occult Injury

2

3, 4

Prospective, non-randomized study of blunt trauma pts w/ pelvic Fractures, - FAST, and subsequent CT or laparotomy. There were 70 pelvic trauma pts w/ sensitivity of 24% and specificity of 100% and 13 false negatives. Conclude that any pt with pelvic trauma and - FAST requires a CT scan to evaluate for further injury due to the high false negative rate.

J Am Coll Surg 1999;189:145-151

Hamill et al.[51]

1999

Pelvic Fracture Pattern Predicts Pelvic Arterial Haemorrhage

3

3, 4

Review of 76 pts with pelvic fractures who required >6 u PRBC in 1st 24 hrs:  Major Ligamentous Disruption (MLD as defined by fracture classes APC II or III, LC III, Vertical Shear, or Combined Mechanism) was shown to correlate with increased need for embolization, but sensitivity 63% and spec 44%.  Unable to use pelvic fx class to identify patients who require embolization.

Aust N.Z. J Surgery 2000;70:338-343

Blackmore et al.[55]

2006

Predicting Major Hemorrhage in Patients with Pelvic Fracture

2

2, 3, 4

627 patients with pelvic fx. Major pelvic hemorrhage (defined as any of 3 criteria were present: (1) arterial extravasation on angiography, (2) high volume pelvic hematoma on CT (>600 ml), or (3) high transfusion requirement in the absence of other source of hemorrhage) was identified in 128 of 627 subjects (20%). Four factors remained as predictors of major pelvic hemorrhage: pulse > 130, hematocrit of 30% or less, displaced ( 1 cm) obturator ring fracture, or diastasis of the pubic symphysis of 1 cm or more.  The final predictive model was able to stratify pelvic fracture patients into groups with probabilities of major hemorrhage ranging from less than 2% (4/247) for 0 predictors to over 60% (39/59) for 3 or more predictors.

J Trauma 2006;61:346-352

Eastridge et al.[50]

2002

The Importance of Fracture Pattern in Guiding Therapeutic Decision-Making in Patients with Hemorrhagic Shock and Pelvic Ring Disruptions

3

2, 3, 4

Retrospective of 193 pts w/ hypotension and pelvic Fractures. Defined stable pelvic Fractures (SFP) as LC and APC 1. Defined unstable pelvic Fractures (UFP) as APC 2/3, LC 2/3, and vertical shear. 85% of SFP w/ persistent hypotension had abdominal source of hemorrhage while 28% of UFP had an abdominal source. Authors conclude that persistent hypotension in pelvic Fx pts can be subdivided by SFP or UFP and can be predictive of outcome. Recommend laparotomy in hypotensive pts w/ SFP and strong consideration of angio prior to laparotomy in hypotensive pts w/ UFP.

J Trauma 2002;53:446-451

Sarin et al.[56]

2005

Pelvic Fracture Pattern Does Not Always Predict the Need for Urgent Embolization

3

2, 4

Retrospective review of 283 pts w/ hypotension & major ligamentous disruption (MLD), ie APC II/III, LC III and VS. Mortality, ISS and PRBCs were greater in the MLD group.  Did not find correlation to MLD and the need for angiography. Authors conclude that despite other reports, pelvic Fx pattern cannot be used to determine whether hypotension is from pelvic hemorrhage or another source.

J Trauma 2005;58:973-977

Magnussen et al.[53]

2007

Predicting Blood Loss in Isolated Pelvic and Acetabular High-Energy Trauma

3

1, 2

289 ISOLATED pelvic fractures reviewed for PRBC transfused in first 24 hrs.  Pts divided into pelvic fx only (111), acetabular fx only (143) and both (35).  Pts with both required more PRBC than those with pelvic or acetabular alone.  PRBC requirements equal between pelvic and acetabular group.  Within pelvic group, 44% of those with MLD (fx patterns LCIII, APC II-III, VS, combined) required PRBC while only 8.5% of those w/o MLD required PRBC.

J Orthop Trauma 2007;21:603-607

Lunsjo et al.[54]

2007

Associated Injuries and Not Fracture Instability Predict Mortality in Pelvic Fractures: A Prospective Study of 100 Patients

2

1, 2, 4

100 consecutive patinets with pelvic fx, mortality (9%).  Pelvic fx classified as O (no instability), R (rotational instability), or RV (rotational and vertical instability).  Of ISS, RTS, pelvic fx classification, PRBC transfused, logistic regression showed only ISS to be an independent predictor of mortality. Pelvic Fx patterns do not predict mortality and therefore does not predict active hemorrhage requiring angiography.

J Trauma 2007;62:687-691

Smith et al.[57]

2007

Early Predictors of Mortality in Hemodynamically Unstable Pelvis Fractures

2

2, 4

Retrospective review of prospective trauma database. 187 HD unstable patients w/ pelvic Fractures. Analyzed factors related to mortality. Fracture pattern (Young & Burgess) and need for angiography were not predictive of mortality. Age, ISS and PRBC Transfusion were predictors of mortality.

J Orthop Trauma 2007;21:31-37

Starr et al.[21]

2002

Pelvic Ring Disruptions: Prediction of Associated Injuries, Transfusions Requirement, Pelvic Arteriography, Complications, and Mortality

2

3, 4

Retrospective review of 325 pts w/ closed pelvic fractures. Shock and Revised Trauma Score (RTS) were significantly associated w/ mortality, PRBC Transfusion, ISS & AISS. Older age and RTS were significantly associated w/ need for angiography. LC 2/3 had higher rate of angiography, but no other Fx pattern to need for angio was found. Pts that underwent angio had higher mortality & PRBC TX need. Unable to demonstrate a statistical relationship between fracture pattern and need for arteriography or mortality.

J Orthop Trauma 2002;16:553-561

Balogh et al.[83]

2005

Institutional Practice Guidelines on Management of Pelvic Fracture-Related Hemodynamic Instability: Do They Make a Difference?

2

1, 2, 3, 4

Practice Guideline (PG) established including

1) abdominal "clearance" (AC) using FAST +/- DPT

2) Pelvic binding w/ sheet, C-clamp (PB)

3) Pelvic angio (PA) within 90 min, and

4) Operative pelvic fixation (OF) within 24 hrs. 

 

Patients meeting guidelines pre/post PG:  AC 67%/100%; PB 0%/86%; PA 30%/93%;  OF 52%/86%.  Mortality 6/17 pre-PG (35%) and 1/14 post-PG (7%). Multidisciplinary guidelines appear to improve outcome.

J Trauma 2005;58:778-782

Biffl et al.[82]

2001

Evolution of a Multidisciplinary Clinical Pathway for the Management of Unstable Patients With Pelvic Fractures

2

1, 2, 3, 5

Retrospective review of 143 pts in "early group" vs 73 "late group" which was defined as before and after the time when 2 ortho trauma staff were in the trauma bay for decision making upon patient arrival. Lower rate of hypotension, increased use of pelvic binding & improved mortality (31% v 15%). There were no differences in the number of packed red cells or fresh-frozen plasma units transfused. There were no significant differences between the two groups in terms of the overall complication rate or the occurrence of acute respiratory distress syndrome, multiple organ failure, or pneumonia.

Annals of Surgery 2001;233:843-850

TABLE 3. Tile Classification
Type A Stable pelvic ring injury
Type B

Partially stable pelvic ring injury

B1: Open book injury (AP compression, external rotation)

B2: Lateral compression (internal rotation)

B3: Bilateral injuries
Type C  Completely unstable (allows all degrees of translational displacement)
TABLE 4. Young-Burgess Classification System
Fracture TypeCommon CharacteristicDifferentiating Characteristic

Lateral Compression 1

Transverse pubic rami fracture

Sacral Compression on side of impact

Lateral Compression 2

Transverse pubic rami fracture

Crescent (iliac wing) fracture

Lateral Compression 3

Transverse pubic rami fracture

Contralateral open-book (anteroposterior compression) injury

Anterior-posterior compression 1

Symphyseal diastasis (1-2 cm)

Slight widening of symphysis and/or sacroiliac (SI) joint, stretched but intact anterior and posterior SI joint ligaments

Anterior-posterior compression 2

Symphyseal diastasis or vertical pubic rami fracture

Widened SI joint, disrupted anterior SI ligaments with intact posterior SI ligaments

Anterior-posterior compression 3

Symphyseal diastasis or vertical pubic rami fracture

Complete hemipelvis separation but no vertical displacement, anterior and posterior SI joint ligaments ruptured

Vertical shear

Symphyseal diastasis or vertical pubic rami fracture

Vertical hemipelvis displacement, usually through SI joint, occasionally through iliac wing or sacrum

Combined mechanism

Vertical or transverse pubic rami fractures

Combination of patterns; lateral compression with vertical shear or lateral compression with anterior-posterior compression

SI, sacroiliac.


Previous version of this guideline

Pelvic Hemorrhage in Pelvic Fracture, Management of (2001)

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