Pelvic Trauma & Retroperitoneal Hemorrhage
Comprehensive resuscitation protocol for unstable pelvic ring fractures and life-threatening retroperitoneal hemorrhage. Covers Young-Burgess injury mechanisms, anatomically correct pelvic binder placement over the greater trochanters, massive transfusion protocol (MTP), retrograde urethrogram (RUG), and pre-peritoneal pelvic packing vs. angioembolization.
Resuscitation Quick Ribbon (First 2 Minutes)
Bottom-Line Clinical Pearl
Apply pelvic circumferential compression (pelvic binder or sheet) centered strictly over the GREATER TROCHANTERS, not the iliac crests. Correct trochanteric placement reduces pelvic volume by closing open-book fractures and tamponades low-pressure venous retroperitoneal bleeding.
| Classification & Mechanism | Anatomic Injury Pattern | Vascular / Hemorrhage Risk | ED Stability |
|---|---|---|---|
| Lateral Compression (LC-I) | T-bone MVC or pedestrian side-impact; sacral crush on impacted side, ipsilateral rami fractures | Low vascular injury risk; internal rotation of hemipelvis reduces pelvic volume | Mechanically stable; typically does not require emergency binding. |
| Lateral Compression (LC-II / LC-III) | LC-II: Crescent fracture of iliac wing. LC-III: 'Windswept pelvis' (LC on one side, open-book on other) | Moderate-to-high vascular injury risk; internal iliac branches endangered | Rotationally unstable; may require operative stabilization. |
| Anterior-Posterior Compression (APC-I) | Head-on collision or crush; pubic symphysis diastasis < 2.5 cm | Low risk of life-threatening hemorrhage | Mechanically stable. |
| Anterior-Posterior Compression (APC-II / APC-III) 'Open-Book' | APC-II: Symphysis diastasis > 2.5 cm + sacrospinous/sacrotuberous ligament tear. APC-III: Complete sacroiliac joint disruption | EXTREME EXSANGUINATION RISK: Laceration of pelvic venous plexus and internal iliac branches (superior gluteal, internal pudendal) | Rotationally and vertically unstable; MANDATORY immediate pelvic binder application. |
| Vertical Shear (VS) | Fall from height landing on one leg; complete anterior and posterior disruption with vertical displacement of hemipelvis | Extreme vascular and retroperitoneal hemorrhage risk; high mortality | Completely unstable (rotationally and vertically); traction splint + pelvic binder. |
- Identify Landmark: Palpate the prominence of the GREATER TROCHANTERS bilaterally (NOT the iliac crests). Placing a binder too high over the iliac wings exerts a lever effect that can actually open the pelvic ring further.
- Position the Sheet or Binder: Slide sheet or commercial binder (SAM Pelvic Sling, T-POD) beneath the patient's pelvis, centered precisely over the greater trochanters and pubic symphysis.
- Internal Rotation of Lower Extremities: Internally rotate both lower limbs at the hips and tape the knees and feet together (or tie sheets around thighs/feet). This anatomically reduces the pelvic volume.
- Tighten & Fasten: Pull commercial binder tension cord until the ratchet clicks (typically 150 N force), or clamp/cross the sheet with towel clamps over the anterior midline.
- Re-evaluate: Verify reduction via STAT portable AP pelvis radiograph.
Understanding the source of bleeding dictates whether the patient requires pelvic binding, pre-peritoneal packing, or angioembolization:
| Source Category | Percentage of Bleeding | Anatomic Structures Involved | Definitive Treatment |
|---|---|---|---|
| Presacral / Retroperitoneal Venous Plexus & Cancellous Bone | 85 - 90% | Presacral venous plexus, prevesical veins, exposed cancellous fracture surfaces | Pelvic binder circumferential compression + Pre-Peritoneal Pelvic Packing (PPP) |
| Arterial Branches of Internal Iliac Artery | 10 - 15% | Superior gluteal artery (most common), internal pudendal artery, obturator artery, lateral sacral artery | Transcatheter Arterial Embolization (TAE) in Interventional Radiology |
Unstable Pelvic Fracture Algorithm: In an unstable patient with pelvic fracture: (1) Apply pelvic binder; (2) Perform eFAST. If eFAST is POSITIVE for intraperitoneal fluid -> Patient has intra-abdominal injury -> Rush to OR for Exploratory Laparotomy + Pre-Peritoneal Pelvic Packing. If eFAST is NEGATIVE -> Bleeding is purely retroperitoneal -> Transfer immediately to Interventional Radiology for Angioembolization OR OR for Pre-Peritoneal Packing if IR is delayed.
- Urethral Injury Signs: Blood at the external urethral meatus, scrotal/perineal butterfly hematoma, or high-riding / 'floating' prostate on rectal exam.
- Retrograde Urethrogram (RUG): If any urethral injury sign is present, DO NOT blindly pass a Foley catheter (risks converting a partial tear into a complete transection). Perform RUG by injecting 20-30 mL of water-soluble contrast into the meatus and obtain oblique fluoroscopy/radiograph.
- Bladder Rupture: Associated with anterior rami fractures. Extra-peritoneal rupture (85%) -> Managed conservatively with catheter drainage. Intra-peritoneal rupture (dome of bladder, 15%) -> Requires emergent operative primary repair.
- Open Pelvic Fracture: Inspect perineum, groin, and rectum for lacerations or visible bone. An open pelvic fracture carries mortality exceeding 30-50% and requires immediate broad-spectrum IV antibiotics (Cefazolin + Gentamicin + Metronidazole) and emergent surgical debridement.
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