Pelvic fractures and hemorrhage

Anatomy & Classification - The Pelvic Puzzle

• Pelvic Ring: Composed of two innominate bones and the sacrum. Stability depends on the posterior ligamentous complex.
• Key Ligaments: Sacrospinous, sacrotuberous, and the critical posterior sacroiliac (SI) ligaments.

• Young-Burgess Classification (by mechanism):
  • Anteroposterior Compression (APC): "Open book" injury.
  • Lateral Compression (LC): Most common type.
  • Vertical Shear (VS): High-energy, unstable; disrupts pelvic floor.

⭐ The posterior SI ligament complex is the primary stabilizer of the pelvis; its disruption signifies major instability.

Initial Assessment & Resuscitation - Code Red Protocol

• Primary Survey (ATLS): Focus on C (Circulation). Suspect pelvic fracture in any high-energy trauma, especially with hypotension.
• Hemodynamic Instability: SBP < 90 mmHg or HR > 120 bpm despite initial fluid bolus.
• Immediate Actions:
  • Apply pelvic binder at the level of greater trochanters.
  • Activate Massive Transfusion Protocol (MTP) / Code Red.

⭐ Early administration of Tranexamic Acid (TXA) within 3 hours of injury significantly reduces mortality from bleeding in trauma patients. Administer a 1g load over 10 min, then 1g infusion over 8 hours.

Hemorrhage Control - Plugging the Dam

• Source of Bleeding: Primarily from the posterior venous plexus (85%) and raw bone surfaces, not major arteries.
• Immediate Management:
  • Apply a pelvic binder or sheet at the level of the greater trochanters.
  • This reduces pelvic volume, stabilizes fracture, and promotes tamponade.
  • Initiate massive transfusion protocol for persistent hypotension.

⭐ Most bleeding is venous. However, persistent hemodynamic instability despite binder application and fluid resuscitation strongly suggests an arterial injury requiring intervention.

Definitive Management & Complications - The Aftermath

• Surgical Fixation (ORIF):
  • Indicated for unstable fractures after the patient is hemodynamically stable.
  • Goal: Restore pelvic ring integrity, enabling early mobilization.

• Major Complications:
  • Neurologic Injury: Damage to the lumbosacral plexus (L5/S1 nerve roots common), potentially causing foot drop.
  • Urogenital Injury: Urethral tears and bladder rupture are frequent. Suspect with blood at the meatus.
  • Thromboembolism: High risk for DVT/PE; requires chemical and/or mechanical prophylaxis.
  • Long-term: Chronic pain, gait disturbance, sexual dysfunction.

⭐ Injury to the lumbosacral plexus is a classic complication, especially with posterior pelvic ring disruptions. Always perform a thorough neurovascular exam of the lower extremities.

High‑Yield Points - ⚡ Biggest Takeaways

• Pelvic fractures from high-energy trauma can cause life-threatening hemorrhage, a key ATLS priority.
• Initial management: apply a pelvic binder to stabilize the pelvis and control common venous bleeding.
• For unstable patients with ongoing bleeding, angiography with embolization is critical for arterial hemorrhage.
• CT imaging is the gold standard for stable patients to define fracture anatomy.
• Always suspect associated urogenital injuries, like posterior urethral disruption in males.