Gen Surg Cases · trauma
Open-book pelvis with perineal communication and shock — haemorrhage now, sepsis next, fixation last
Fellowship clinical-management station on open unstable pelvic fracture with shock: binder-first resuscitation, venous packing doctrine, embolisation timing, urethral-injury sequencing, open-fracture haemorrhage-then-sepsis staging, WSES prognosis and GU-injury counsel.
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Study tools
Target exams
FRACSFRCS(Gen Surg)ABSFRCSC
Prompt
A 29-year-old man 60 minutes after a motorcycle-versus-car collision: systolic 76, heart rate 130, open-book pelvic diastasis on film, a perineal wound communicating with the fracture, blood at the urethral meatus, FAST negative, chest clear. The candidate must run the binder-transfusion resuscitation, choose packing versus embolisation with clocks, sequence the urethral workup, stage the open-wound operations, and counsel the family with the published numbers.
Management
- Resuscitate: binder immediately (standard, yet missing in over half of eligible cases), blood with the binder, FAST and films in parallel — negative FAST changes nothing about the retroperitoneum.[14]
- Control haemorrhage: extraperitoneal packing for instability despite red cells — proven to control haemorrhage even in open fractures, with 7% mortality in that series.[10]
- Sequence urology: blood at the meatus with an unstable ring — urethrogram before catheter, since lower urinary tract injury runs 7.7% and concentrates entirely in unstable patterns.[21]
- Stage the open wound: haemorrhage first, contamination control and specialist wound/diversion/fixation decisions second — counsel 24% dead with 17.2-unit transfusions and 60-day stays, against WSES class prognosis of 3.5%, 11.2% and 23.8%.[26][33]
- Counsel honestly: pooled open-plus-GU data — 31.2% dead, 18.7% infected, one in five with genitourinary injury and one in three females with vaginal laceration — so examine the perineum, vagina and rectum in every open case.[36]
References6ShowHide
- [10]Moskowitz EE, Burlew CC, Moore EE, et al. Preperitoneal pelvic packing is effective for hemorrhage control in open pelvic fractures. Am J Surg, 2018.PMID 29179908
- [14]Vaidya R, Roth M, Zarling B, et al. Application of Circumferential Compression Device (Binder) in Pelvic Injuries: Room for Improvement. West J Emerg Med, 2016.PMID 27833687
- [21]Zhao X, Lu S, Wang B, et al. Fracture Types Influence the Likelihood of Lower Urinary Tract Injuries in Patients with Pelvic Fractures. J Clin Med, 2023.PMID 37109301
- [26]Dong JL, Zhou DS Management and outcome of open pelvic fractures: a retrospective study of 41 cases. Injury, 2011.PMID 21349516
- [33]Li PH, Hsu TA, Kuo YC, et al. The application of the WSES classification system for open pelvic fractures-validation and supplement from a nationwide data bank. World J Emerg Surg, 2022.PMID 35624457
- [36]Tischler EH, Wolfert AJ, Lyon T, et al. A review of open pelvic fractures with concurrent genitourinary injuries. Eur J Orthop Surg Traumatol, 2023.PMID 36209481