Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. . This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation. Cite this article: Bone Joint J 2014; 96-B:1143–54

Introduction: Patients with complex pelvic fractures with uncontrollable haemorrhage have a very mortality from pelvic haemorrhage and associated injuries. Management remains controversial and includes an number of techniques including pelvic stabilisation, angiography and direct surgical control of haemorrhage. Packing the pelvic cavity is a technique used rarely in this situation but is popular to control haemorrhage from other sources in similar situations. We have reviewed our experience of pelvic packing for uncontrollable haemorrhage to assess the effectiveness of this technique. Materials & Methods: From a prospectively gathered database of 132 patients with significant pelvic fractures admitted between April 2002 and December 2005, 8 patients (5 males and 3 females) with an average age of 52.9 yrs were identified who underwent pelvic stabilisation and packing as an emergent life saving procedure for uncontrolled haemorrhage associated with pelvic fracture. Basic data including their presenting vital signs, pelvic fracture pattern and associated injuries were recorded. All were subject to pelvic stabilisation packing and their subsequent clinical course including their transfusion requirements and additional management was also assessed. Results: 6 out of these 8 patients died, 5 within the first 24 hrs after injury and one after 14 days from sepsis & MOF/MODS. The exact source of bleed could not be identified in any of these patients and was assumed to be venous and from large fractured bony surfaces. 4 patients had angiography and embolisation in addition and 2 of these survived. Conclusion: The mortality of haemodynamically unstable pelvic fractures remains high and all modalities of treatment should be used to control bleeding. Pelvic packing may form an important part in the armamentarium of haemostatic measures; its role, however, needs to be better defined by larger multi-centre studies. Although difficult to conclude, the pelvic packing may have been responsible for reducing the mortality in this subgroup from a 100% to 75%

Purpose of the study: These fractures, and the patients, are generally unstable. Mortality associated with these fractures remains high. It is mainly due to the haemorrhagic risk of the presacral venous plexus and the iliac system. Different techniques have been described to control the haemorrhage: pelvic girdle, embolisation, ligature of the iliac arteries, pelvic packing, pelvis clamp or external fixator. Our objective was to analyse our series of fractures of this type in order to optimise patient outcome. Material and methods: A prospective study was undertaken from January 2003 to December 2006. Among 450 multiple injury patients, 68 presented an unstable fracture of the pelvis, type B or C. The 38 patients included in this series were haemodynamically unstable. The mean ISS for these patients was 53, mean age 38.6 years (range 24–51). Fractures were diagnosed on plain x-rays of the pelvis, ap view, completed by a total body scan. Results: All patients were victims of high-energy traffic accidents and were managed using the ATLS protocol. Five patients died early despite intensive care. The patients were divided into three groups: group X: 19 patients treated with a first-intention external fixator, with or without arteriography, 18 patients survived, 94%; group Y: 8 patients treated with a first-intention external fixator with arteriography and followed by laparotomy, 7 patients survived, 87%; group Z: 6 patients had laparotomy without an external fixator, 6 patients died, 100% mortality. Conclusion: In our experience, the best way to control bleeding associated with unstable fractures of the pelvis is as follows: pelvic girdle at the scene of the accident to the emergency room, emergency external fixation followed by laparotomy if the ultrasound is positive. False positives occur due to suffusion of the retroperitoneal haematoma. Emergency laparotomy without prior external fixation of the pelvis lead to 100% mortality in our series. Similarly pelvic packing or the retroperitoneal approach cannot be proposed without exploration

Background: Unstable pelvic ring fractures are frequently associated with severe hemodynamic instability and mortality. Hemorrhage control of these disrupted pelvic fractures requires an urgent reduction of the intrapelvic volume and immediate mechanical stabilization. The aim of this study was to investigate the control of the intrapelvic volume and pelvic stability by different modes of external stabilization in a cadaver model. Methods: Various degrees of pelvic ring instability were induced in unembalmed human torsos. Haemorrhage induced volume displacement into the presacral and retroperitoneal space (RPP) was assessed by positioning two infusion lines right in front of the sacroiliac joint. The abdominal pressure measurement (IAP) was obtained by a percutaneous catheter in the abdominal cavity. Baseline pressure measurements of the intra pelvic volume were documented before and after dissection for uni-as bilateral instability. Reduction of pelvic instability was performed by non invasive T-POD. ®. Pelvic Stabilizer, a supraacetabular, iliac crest fixator, application of the pelvic C-Clamp without and with pelvic packing. Results: Baseline measurements (RPP) of the intact pelvis showed an average increase of 8,03 cmH2O per 1000 cc of infused fluid. In case of uni- and bilateral instability the pressure decreased to a rate of 2,88 and 1,48 cmH2O per 1000 cc. Following the application of each device an increase of RPP of 3,5 cmH2O (pelvic binder), 3,2 cmH2O (anterior frames), 5,4 cmH2O (C-Clamp) and 8,4 cmH2O (C-Clamp + packing) per 1000 cc was obtained in case of unilateral instability. In bilateral disruptions a significantly lower increase of pressure up to 4,0 cmH2O was seen. Conclusions: We investigated the efficacy of various external stabilization Methods: on potential hemorrhage on experimentally induced uni- and bilateral pelvic ring fractures. In case of intact pelvis the retroperitoneal space responds to fluid application with rapidly rising pressures. The application of external devices enable the reduction of the pelvic volume and thereby the retroper-itoneal pressure increase. The C-clamp combined with pelvic packing resulted to be superior

High energy fractures of the pelvis are a challenging problem both in the immediate post-injury phase and later when definitive fixation is undertaken. No single management algorithm can be applied because of associated injuries and the wide variety of trauma systems that have evolved around the world. Initial management is aimed at saving life and this is most likely to be achieved with an approach that seeks to identify and treat life-threatening injuries in order of priority. Early mortality after a pelvic fracture is most commonly due to major haemorrhage or catastrophic brain injury. In this article we review the role of pelvic binders, angiographic embolisation, pelvic packing, early internal fixation and blood transfusion with regard to controlling haemorrhage. Definitive fixation seeks to prevent deformity and reduce complications. We believe this should be undertaken by specialist surgeons in a hospital resourced, equipped and staffed to manage the whole spectrum of major trauma. We describe the most common modes of internal fixation by injury type and review the factors that influence delayed mortality, adverse functional outcome, sexual dysfunction and venous thromboembolism

Aim: To investigate the training of civilian Orthopaedic Trainee’s in complex trauma management. Methods: A web-based survey of orthopaedic trainees utilising three scenarios for investigating complex trauma management. 225 responses obtained, achieving a < 0.05 error rate with 90% confidence. Results:. Pelvic packing in exanguinating pelvic trauma:. 2.2% fully confidentto manage such a case. A positive correlation exists between increasing training and confidence. 58.9% have never seen such a case. No correlation exists between time in training and exposure. 62.8% report training in this case inadequate. A positive correlation exists between time in training and perceived inadequacy of ability to manage such a case. Junctional traum with non-compressible groin haemorrhage:. 0.4% fully confident. A positive correlation exists between time in training and confidence. 73.0% have never seen such a case. 67.9% report training in this case inadequate. No correlation was found between time spent in training and perceived training adequacy. Blood product resuscitation in trauma:. 11.6% were fully confident. 18.8% have never seen such a case. No correlation exists between time in training and confidence or exposure. 45.0% report training as inadequate in this case. No correlation seen between time in training and perceived training adequacy. Conclusion: Current training provides limited opportunities for exposure to significant trauma. The quality of care afforded to service personnel and civilians in recent conflict is unsurpassed and it is essential that the lessons learnt by deployed surgeons form a continuum to their successors. For military orthopaedic trainees this reinforces the need for closely supervised secondments on deployment; attendance at established military surgical training courses and appropriate fellowships to maximise exposure prior to first consultant deployment

We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths.

Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients.

Cite this article: Bone Joint J 2014;96-B:1090–7.

The open blast fracture of the pelvis is considered to be the most severe injury within the spectrum of battlefield trauma. We report our experience of 29 consecutive patients who had sustained this injury in Afghanistan between 2008 and 2010. Their median new injury severity score (NISS) was 41 (8 to 75), and mean blood requirement in the first 24 hours was 60.3 units (0 to 224). In addition to their orthopaedic injury, six had an associated vascular injury, seven had a bowel injury, 11 had a genital injury and seven had a bladder injury. In all, eight fractures were managed definitively with external fixation and seven required internal fixation. Of those patients who underwent internal fixation, four required removal of metalwork for infection. Faecal diversion was performed in nine cases. The median length of hospital stay following emergency repatriation to the United Kingdom was 70.5 days (5 to 357) and the mean total operating time was 29.6 hours (5 to 187). At a mean follow-up of 20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk and 26 (89.7%) had clinical and radiological evidence of stability of the pelvic ring.

As a result of the increase in terrorism, injuries that were previously confined exclusively to warfare can now occur anywhere, with civilian surgeons who are involved in trauma care potentially required to manage similar injuries. Our study demonstrates that the management of this injury pattern demands huge resources and significant multidisciplinary input. Given the nature of the soft-tissue injury, we would advocate external fixation as the preferred management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is necessary in all cases.