Pelvic trauma

The pelvic fracture is one of the most dangerous injuries in the trauma, because the pelvis is a ring of bone surrounded by a rich venous plexus and the branches of the internal iliac artery, and the retroperitoneal space can hold 3 to 4 litres of blood before the tamponade. The unstable pelvic ring fracture — the open-book or the vertical shear — is the source of the massive haemorrhage that kills in the first hours, and its management is one of the few situations in which the emergency physician's intervention (the pelvic binder) directly saves the life. The pelvic fracture carries an overall mortality of 10 to 15 per cent, rising to 30 to 50 per cent in the open pelvic fracture and in the haemodynamically unstable patient, so the recognition of the unstable pattern and the immediate mechanical and the haematological resuscitation are the central competencies of the trauma team.[1][1]

The mechanism and the classification

The pelvic ring fracture is produced by the lateral compression (the side-impact collision, the crush), the anteroposterior compression (the open-book, the frontal collision), or the vertical shear (the fall from a height, the dashboard impact). The Young and Burgess classification classifies the patterns by the force vector and predicts the bleeding and the mortality. The lateral compression (LC) is the most common pattern (around 60 per cent of the pelvic fractures) and is generally the most stable; it is caused by the side-impact and produces the internal rotation and the crescent fracture of the sacrum, but the higher grades (the LC2 and the LC3) with the iliac wing or the sacral crushing can still bleed. The anteroposterior compression (APC) — the open-book — widens the pelvic volume, opens the sacroiliac joints and the symphysis pubis, and carries the highest transfusion requirement and a mortality of 20 to 30 per cent. The vertical shear (VS) — the Malgaigne — shears the hemipelvis vertically through the sacroiliac joint and the rami and is unstable in all the planes, with a mortality around 25 per cent. The combined mechanism (CM) is the fourth pattern and is the most lethal because it mixes the vectors and disrupts the ring in every direction.[1]

The Tile classification (the equivalent of the AO/OTA) classifies the biomechanical stability for the surgeon: the Type A is the stable, the avulsion and the isolated ramus; the Type B is the rotationally unstable but the vertically stable (the open-book and the lateral compression); the Type C is the unstable in all the planes (the vertical shear and the combined) and requires the surgical fixation. The Tile type guides the orthopaedic fixation, and the Young-Burgess type guides the emergency resuscitation because it predicts the bleeding. The two classifications are complementary and both are asked in the Fellowship examination.[1]

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1. [1]Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review J Trauma, 2011.PMID 22182895
2. [2]Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition Crit Care, 2023.PMID 36859355
3. [3]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
4. [4]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial JAMA, 2015.PMID 25647203
5. [5]Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg, 2012.PMID 22006852