Western Trauma Association Critical Decisions in Trauma: Management of pelvic fracture with hemodynamic instability-2016 updates.

The management of patients with hemodynamic instability from pelvic fracture is challenging and controversial. Mortality rates have ranged from 18% to 40% in reported series and death within the first 24 hours of injury was most often a result of acute blood loss. Significant decreases in mortality rates have been shown with adoption of algorithms for management of these injuries. The key issues in management are identifying the site(s) of hemorrhage and then controlling the bleeding. Bleeding from pelvic fractures occurs from three major sources; arterial, venous, and cancellous bone. A seminal study from 1973 identified extravasation of contrast from the hypogastric arteries in 23 of 27 autopsy cases. Bleeding sources were bilateral in 63%, and 61% had more than one bleeding site identified. Careful dissection revealed lesions to main arteries in only three specimens, and the authors noted that bleeding from cancellous bone and from vessels in adjacent soft tissue hampered identification of arterial injuries. They also stressed the significance of hemorrhage from the fracture sites. A more recent study reported that over 70% of unstable patients with pelvic fractures will have arterial bleeding. Furthermore, blunt force injury severe enough to fracture the pelvic ring can cause concomitant intra-abdominal injuries. The frequency of abdominal injury, in association with pelvic fracture can range from 16% to 55%. Appropriate evaluation of the abdomen for associated intra-abdominal injuries cannot be overstressed. Management of hemodynamically unstable patients with pelvic fracture requires a multidisciplinary team. In addition to the general trauma surgeon, an experienced orthopedic surgeon and a skilled interventional radiologist are needed for optimal care.