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

Inspection 

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

When a significant pelvis injury is suspected, obtain an AP pelvis x-ray to guide examination and treatment

Feel/move

• Pelvic stressing or ‘springing’ should not be performed as it is painful and adds little
• Palpation also adds little in significant pelvic injuries
• If radiologically significant pelvic injury
  • PR to detect rectal injury
  • PV in women with new PV bleeding since the time of injury (obtain menstruation history if able in appropriate patients)

Imaging

Haemodynamically unstable patients should have a CXR, AP pelvis x-ray 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 with external fixation (if appropriate) on whether there is free fluid in the peritoneum

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

• If extravasation is seen from a vessel amenable to embolisation consider proceeding to angiography if available. If not available consider transfer
• Inlet, outlet and Judet views are redundant in the presence of a CT scan. They have no place in the early treatment of pelvic and acetabular fractures.

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
   • exsanguinating external haemorrhage
   • tension pneumothorax or massive haemothorax
   • cardiac tamponade

2. 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.

NB: angiography may not be available after hours (or at all) in some hospitals (see algorithms below)

3. The AP pelvic x-ray will aid in the selection of interventions

• • External fixation requires the ilium to be intact. It is of no use in widely displace acetabular fractures
  • Sheets and binders require intact femoral necks and acetabulae.
  • Vertically displaced hemipelves respond best to longitudinal traction (potentially followed by sheeting/binder)
  • Persisting symphyseal diastasis in a patient already in a binder indicates the need for it’s reapplication

4. After any mechanical intervention (sheet, binder or traction) a repeat AP pelvis should be obtained at an appropriate time to confirm it has achieved the desired effect.

Management of the haemodynamically unstable patient with a fractured pelvis

Angiography available

Angiography NOT available

Disposition – interhospital transfer guidelines

Discuss all pelvis fractures with local orthopaedic team first