Pelvis trauma

Patients that are haemodynamically unstable should have their pelvis assessed as a potential source of haemorrhage as part of the primary survey.

 

If a significant pelvis injury is suspected, a pelvic binder should be applied as soon as practical

 

Clinical assessment

Look

  • Abrasions/contusions over bony prominences
  • Skin integrity, open wounds
  • Scrotal/perineal haematoma
  • Blood at urethral meatus
  • Leg length discrepancy

Feel/move

Pelvis stressing or “springing” should be avoided as it can displace a vital clot and is painful
  • If a significant pelvic injury is suspected, defer any pelvis or hip examination until a PXR is performed
  • Gentle palpation of the ileal wings, pubic symphysis, posterior sacroiliac joints, ischial tuberosities and spine (including sacrum and coccyx)
  • Very gentle posterior or medial compression of iliac wings
  • Hip flexion and rotation
  • If radiologically significant pelvic injury
    • PR to detect rectal injury, high riding prostate (note: controversy regarding clinical utility)
    • PV in women with new PV bleeding since the time of injury

 

Imaging

Haemodynamically unstable patients should have a CXR and PXR and eFAST performed as part of the primary survey

  • If these patients do not respond to resuscitation, they should NOT progress to CT scan but rather have angiography or operative exploration dependent on whether there is free fluid in the peritoneum

Patients with a significant pelvis fracture that remain haemodynamically stable can be further assessed by performing a CT scan with contrast

  • If extravasation is seen – consider proceeding to angiography (if bleeding from a vessel amenable to embolization)

 

Management

Patients who are haemodynamically unstable with a pelvis fracture should be managed in a step-wise manner.

  1. Seek and treat other sources of haemorrhage and instability

 

  1. Perform a FAST examination looking for free intraperitoneal fluid

This is the branch decision point for management

  • If the FAST is positive: then the patient should proceed to laparotomy
  • If the FAST is negative: then angiography the key intervention.

 

However, as angiography may not be available after hours (or not at all in some hospitals), this will influence management.

 

Management of the haemodynamically unstable patient with a fractured pelvis

Angiography available

pelvis angio available latest

Angiography NOT available

pelvis no angio

 

Disposition – interhospital transfer guidelines

 

Discuss all pelvis fractures with local orthopaedic team first

 

open

 

open unstable

 

acetabulum final

 

About this guideline

Published: February 2018

Author: Emma Batistich

Approved by: Northern Region Trauma Network, ADHB, WDHB, CMDHB, NDHB

Review due: 2 years