Eastern Association for the Surgery of Trauma …CLINICAL MANAGEMENT UPDATE Eastern Association for...
Transcript of Eastern Association for the Surgery of Trauma …CLINICAL MANAGEMENT UPDATE Eastern Association for...
CLINICAL MANAGEMENT UPDATE
Eastern Association for the Surgery of Trauma PracticeManagement Guidelines for Hemorrhage in Pelvic
Fracture—Update and Systematic Review
Daniel C. Cullinane, MD, Henry J. Schiller, MD, Martin D. Zielinski, MD, Jaroslaw W. Bilaniuk, MD,Bryan R. Collier, DO, John Como, MD, Michelle Holevar, MD, Enrique A. Sabater, MD, S. Andrew Sems, MD,
W. Matthew Vassy, MD, and Julie L. Wynne, MD
Background: Hemorrhage from pelvic fracture is common in victims ofblunt traumatic injury. In 2001, the Eastern Association for the Surgery ofTrauma (EAST) published practice management guidelines for the manage-ment of hemorrhage in pelvic trauma. Since that time there have been newpractice patterns and larger experiences with older techniques. The PracticeGuidelines Committee of EAST decided to replace the 2001 guidelines withan updated guideline and systematic review reflecting current practice.Methods: Building on the previous systematic literature review in the 2001EAST guidelines, a systematic literature review was performed to includereferences from 1999 to 2010. Prospective and retrospective studies wereincluded. Reviews and case reports were excluded. Of the 1,432 articlesidentified, 50 were selected as meeting criteria. Nine Trauma Surgeons, anInterventional Radiologist, and an Orthopedic Surgeon reviewed the articles.The EAST primer was used to grade the evidence.Results: Six questions regarding hemorrhage from pelvic fracture wereaddressed: (1) Which patients with hemodynamically unstable pelvic frac-tures warrant early external mechanical stabilization? (2) Which patientsrequire emergent angiography? (3) What is the best test to exclude extrapel-vic bleeding? (4) Are there radiologic findings which predict hemorrhage?(5) What is the role of noninvasive temporary external fixation devices? and(6) Which patients warrant preperitoneal packing?Conclusions: Hemorrhage due to pelvic fracture remains a major cause ofmorbidity and mortality in the trauma patient. Strong recommendations were maderegarding questions 1 to 4. Further study is needed to answer questions 5 and 6.Key Words: Pelvic fracture, Hemorrhage, Angiography, Embolization,External fixator, C-clamp, Temporary pelvic binder, Pelvic packing, Trauma,Intravenous contrast extravasation, Blush, PASG, Pelvic hematoma, FAST,CT scan, Fracture pattern.
(J Trauma. 2011;71: 1850–1868)
STATEMENT OF THE PROBLEMHemorrhage from pelvic fracture is common in victims of
blunt traumatic injury. In 2001, the Eastern Association for theSurgery of Trauma (EAST) published practice managementguidelines for the management of hemorrhage in pelvictrauma.1 Since that time there have been a number of newpractice patterns and larger experiences with older tech-niques. The Practice Guidelines Committee of EAST decidedto update the 2001 EAST guidelines and systematic reviewfor hemorrhage due to pelvic fracture. The design of theproject was to update the previous guideline as well as toevaluate new treatment methods and techniques. Six specificquestions are addressed regarding the management of pelvicfracture hemorrhage:
1. Which patients with hemodynamically unstable pelvicfractures warrant early external mechanical stabilization?
2. Which patients require emergent angiography?3. What is the best test to exclude extrapelvic bleeding?4. Are there radiologic findings which predict hemorrhage?5. What is the role of noninvasive temporary external fixa-
tion devices?6. Which patients warrant preperitoneal packing (PPP)?
PROCESSThe Practice Management Guidelines Committee of
the EAST (www.east.org) developed the process used bythis committee for review and development of practicemanagement guidelines. A computerized search of theNational Library of Medicine MEDLINE database wasundertaken using the OVID interface. English languagecitations were included for the period of 1999 through2010 using the primary search strategy: pelvis, fracturehemorrhage, trauma, and retroperitoneal hematoma. Thedates were selected to allow comprehensive review ofarticles published since the prior systematic review withminimal overlap.
Review articles and case reports were excluded.Moreover, studies not directly addressing hemorrhage withpelvic fracture were excluded. The PubMed Related Arti-cles algorithm was also used to identify additional articlessimilar to the items retrieved by the primary strategy. Ofthe 1,432 articles identified by these two techniques, those
Submitted for publication April 21, 2011.Accepted for publication October 18, 2011.Copyright © 2011 by Lippincott Williams & WilkinsFrom the Departments of Surgery (D.C.C., H.J.S., M.D.Z.) and Orthopedics (S.A.S.),
Mayo Clinic, Rochester, Minnesota; Department of Surgery, Morristown Memo-rial Hospital (J.W.B.), Morristown, New Jersey; Department of Surgery, Vander-bilt University Medical Center (B.R.C.), Nashville, Tennessee; Department ofSurgery, MetroHealth Medical Center (J.C.), Cleveland, Ohio; Department ofSurgery, Mount Sinai Hospital (M.H.), Chicago, Illinois; Department of Radiol-ogy, HIMA-San Pablo Hospital (E.A.S.), Bayamon, Puerto Rico; Department ofSurgery, Evansville Surgical Associates (W.M.V.), Newburgh, Indiana; andDepartment of Surgery, University of Arizona (J.L.W.), Tucson, Arizona.
Presented at the 22nd Annual Scientific Assembly of the Eastern Association forthe Surgery of Trauma, January 16, 2009, Lake Buena Vista, Florida.
Address for reprints: Daniel C. Cullinane, MD, Department of Surgery, Mayo Clinic,200 First St, SW, Rochester, MN 55905; email: [email protected].
DOI: 10.1097/TA.0b013e31823dca9a
1850 The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011
dealing with prospective or retrospective studies wereselected, comprising 50 studies specifically evaluatinghemorrhage associated with pelvic fracture in adult orpediatric patients.
The EAST, “Utilizing evidence based outcome mea-sures to develop practice management guidelines: a primer,”was used as a quality assessment instrument applied todevelop this guideline.2
The workgroup for the Practice Management Guide-lines for Hemorrhage in Pelvic Trauma consisted of nineTrauma Surgeons, an Orthopedic Surgeon specializing intrauma (S.A.S.), and an Interventional Radiologist (E.A.S.)(Table 1). Articles were compiled by the committee chair(D.C.C.) and were distributed among committee members forformal review. Each article was entered into a review datasheet with detailed summaries of the articles. Deficienciesand conclusions not validated by the data were also noted.The reviewers correlated the references with the method-ology established by the Agency for Health policy andResearch of the US Department of Health and HumanService. Each reference was classified as class I, class II,or class III data. There was no class I data found for thesearch period. Fifteen class II articles and 35 class IIIarticles were included in the review. All references werereviewed by at least two committee members for purposesof cross-validation. An evidentiary table was constructedusing the 50 references (Table 2).
Level IThis recommendation is convincingly justifiable based
on the available scientific information alone. It is generallybased on class I data or strong class II evidence may form thebasis for a Level I recommendation. Conversely, weak orcontradictory class I data may not be able to support a LevelI recommendation.
Level IIThis recommendation is reasonably justifiable by avail-
able scientific evidence and strongly supported by expertopinion. It is usually supported by class II data or a prepon-derance of class III evidence.
Level IIIThis recommendation is supported by available data,
but adequate scientific evidence is lacking. It is generallysupported by class III data. This type of recommendationis useful for educational purposes and in guiding futurestudies.
Although there were not any class I references avail-able, four Level I recommendations were made due to thestrong class II data (large retrospective and nonrandomizedprospective data) available for specific questions. Level IIrecommendations were supported by class II data and arejustified by available scientific evidence and strongly sup-ported by expert opinion. Nine Level II recommendationswere made from the available data. Level III recommenda-tions were based on class III data, where adequate scientificevidence is lacking. Twelve Level III recommendations areincluded in these recommendations.
RECOMMENDATIONS
Which Patients With HemodynamicallyUnstable Pelvic Fractures Warrant EarlyExternal Mechanical Stabilization?
1. The use of a pelvic orthotic device (POD) does not seemto limit blood loss in patients with pelvic hemorrhage.Level III recommendation
2. The use of a POD effectively reduces fracture displacement anddecreases pelvic volume. Level III recommendation
Scientific Foundation: Early External StabilizationIt is well known that the volume of the pelvis increases
after a mechanically unstable pelvic fracture (Tile B/C; Table3). This increased pelvic volume in complex pelvic fracturesis thought to reduce the tamponade effect of the retroperito-neal tissues and intrapelvic organs, leading to further bleed-ing into the pelvic space. Baque et al.3 demonstrated a 20%increase in the volume of the pelvis with a 5-cm pubicdiastasis in a cadaver pelvic-fracture model. The iliolumbarvein was noted to be disrupted in 60% of the pelvic fracturescreated, accounting for the venous hemorrhage seen withfractures of the sacroiliac portion of the pelvis. Using com-
TABLE 1. Members of the EAST Hemorrhage in Pelvic Fracture Workgroup
Name Organization/Place Email
Daniel C. Cullinane, MD—Chair Mayo Clinic, Rochester, MN [email protected]
Henry J. Schiller, MD Mayo Clinic, Rochester, MN [email protected]
Jaroslaw W. Bilaniuk, MD Morristown Memorial Hospital, Morristown, NJ [email protected]
Bryan R. Collier, DO Vanderbilt University Medical Center, Nashville, TN [email protected]
John Como, MD MetroHealth Medical Center, Cleveland, OH [email protected]
Michelle Holevar, MD Mount Sinai Hospital, Chicago, IL [email protected]
Enrique A. Sabater, MD HIMA-San Pablo Hospital, Bayamon, PR [email protected]
S. Andrew Sems, MD Mayo Clinic, Rochester, MN [email protected]
W. Matthew Vassy, MD Evansville Surgical Associates, Newburgh, IN [email protected]
Julie L. Wynn, MD University of Arizona, Tucson, AZ [email protected]
Martin D. Zielinski, MD Mayo Clinic, Rochester, MN [email protected]
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011 EAST Pelvic Fracture Guidelines
© 2011 Lippincott Williams & Wilkins 1851
TAB
LE2.
Evid
entia
ryTa
ble
1999
–201
0
Aut
hor(
s)Y
ear
Tit
leL
evel
ofE
vide
nce
Que
stio
nA
ddre
ssed
Syno
psis
Ref
eren
ce
Sm
ith
etal
.80
2005
Ret
rope
rito
neal
pack
ing
asa
resu
scit
atio
nte
chni
que
for
hem
odyn
amic
ally
unst
able
pati
ents
wit
hpe
lvic
frac
ture
:re
port
oftw
ore
pres
enta
tive
case
san
da
desc
ript
ion
ofte
chni
que
26
The
ISS
,R
TS
,nu
mbe
rof
tran
sfus
ions
,an
dag
e�
60w
ere
stat
isti
call
ysi
gnifi
cant
pred
icto
rsof
earl
ym
orta
lity
.F
xpa
tter
nan
dtr
eatm
ent
wit
han
gio/
embo
liza
tion
wer
eno
tpr
edic
tive
ofde
ath
JT
raum
a.20
05;5
9:15
10–
1514
Tot
term
anet
al.7
720
07E
xtra
peri
tone
alpe
lvic
pack
ing:
asa
lvag
epr
oced
ure
toco
ntro
lm
assi
vetr
aum
atic
pelv
iche
mor
rhag
e
32,
6P
atie
nts
unde
rwen
tre
trop
erit
onea
lpa
ckin
gas
asa
lvag
em
aneu
ver
afte
rpe
lvic
embo
liza
tion
.A
llha
dcl
ass
III
and
clas
sIV
hem
orrh
age.
30-d
surv
ival
was
72%
and
corr
elat
edin
vers
ely
toth
eag
eof
the
pati
ent.
The
auth
ors
conc
lude
dth
atpa
ckin
gm
aybe
life
savi
ngpr
oced
ure
JT
raum
a.20
07;6
2:84
3-85
2
Cot
hren
etal
.78
2007
Pre
peri
tone
alpe
lvic
pack
ing
for
hem
odyn
amic
ally
unst
able
pelv
icfr
actu
res:
apa
radi
gmsh
ift
31,
628
cons
ecut
ive
hem
odyn
amic
ally
unst
able
pati
ents
wit
hpe
lvic
Fxs
unde
rwen
tpe
lvic
Fx
fixa
tion
wit
han
ante
rior
exte
rnal
fixa
tor
orpo
ster
ior
pelv
icC
-cla
mp
foll
owed
bypr
eper
iton
eal
pelv
icpa
ckin
g.U
nsta
ble
pati
ents
then
unde
rwen
tan
gioe
mbo
liza
tion
(25%
).T
hebl
ood
tran
sfus
ion
requ
irem
ents
befo
repa
ckin
gw
ere
sign
ifica
ntly
grea
ter
than
afte
r(1
2�
2.0
vs.
6�
1.1;
p�
0.00
6).
Mor
tali
tyw
as25
%,
and
ther
ew
ere
node
aths
asa
resu
ltof
acut
ebl
ood
loss
.P
repe
rito
neal
pack
ing
isa
rapi
dm
etho
dfo
rco
ntro
llin
gpe
lvic
Fx-
rela
ted
hem
orrh
age
that
can
supp
lant
the
need
for
emer
gent
angi
ogra
phy.
The
yst
ated
that
this
appr
oach
seem
sto
redu
cem
orta
lity
inth
isse
lect
edgr
oup
ofpa
tien
ts
JT
raum
a.20
07;6
2:83
4–83
9
Bra
sel
etal
.61
2007
Sig
nifi
canc
eof
cont
rast
extr
avas
atio
nin
pati
ents
wit
hpe
lvic
frac
ture
33
CE
onC
Tsc
anw
asca
lcul
ated
toha
vea
sens
itiv
ity
of90
.5%
,sp
ecifi
city
of96
.1%
,P
PV
of45
.2%
,an
dN
PV
of99
.6%
.N
otal
lpa
tien
tsw
ith
CE
requ
ired
embo
liza
tion
;he
nce,
the
low
PP
V.
Som
epa
tien
tsre
quir
edan
giog
raph
yde
spit
eno
tha
ving
CE
JT
raum
a.20
07;6
2:11
49–
1152
Tot
term
anet
al.1
720
06A
prot
ocol
for
angi
ogra
phic
embo
liza
tion
inex
sang
uina
ting
pelv
ictr
aum
a
22
46pa
tien
tsun
derw
ent
angi
oba
sed
onpr
otoc
ol(u
nsta
ble
hem
odyn
amic
s�
6P
RB
Cor
stab
lehe
mod
ynam
ics
�4
PR
BC
).A
llpe
lvic
Fx
patt
erns
repr
esen
ted
inth
ose
unde
rgoi
ngan
gio.
31of
46pa
tien
tsun
derw
ent
embo
liza
tion
.S
urvi
val
84%
.N
opa
tien
tsdi
edof
hem
orrh
age
Act
aO
rtho
p.20
06;7
7:46
2–46
8
Vel
mah
oset
al.2
920
02A
pros
pect
ive
stud
yon
the
safe
tyan
def
fica
cyof
angi
ogra
phic
embo
liza
tion
for
pelv
ican
dvi
scer
alin
juri
es
22
Pro
spec
tive
stud
y.S
ixty
-five
ofth
e10
0pa
tien
tsha
dan
giog
raph
ybe
caus
eof
pelv
icF
xs;
the
rest
wer
edu
eto
visc
eral
inju
ries
.T
hesa
fety
rate
ofan
giog
raph
yw
as94
%,
and
effi
cacy
for
cont
roll
ing
blee
ding
was
93%
.A
naly
sis
iden
tifi
edth
ree
inde
pend
ent
pred
icto
rsof
posi
tive
angi
ogra
phy:
age
�55
,ab
senc
eof
long
bone
Fxs
,an
dem
erge
ntpr
oced
ure.
The
mod
elw
asm
ost
robu
stw
hen
all
thre
efa
ctor
sw
ere
pres
ent
JT
raum
a.20
02;5
2:30
3–30
8
Cullinane et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011
© 2011 Lippincott Williams & Wilkins1852
TAB
LE2.
Evid
entia
ryTa
ble
1999
–201
0(c
ontin
ued)
Aut
hor(
s)Y
ear
Tit
leL
evel
ofE
vide
nce
Que
stio
nA
ddre
ssed
Syno
psis
Ref
eren
ce
Vel
mah
oset
al.3
120
00A
ngio
grap
hic
embo
liza
tion
for
intr
aper
iton
eal
and
retr
oper
iton
eal
inju
ries
32
137
cons
ecut
ive
pati
ents
unde
rwen
tan
gio
wit
hth
ein
tent
ofem
boli
zati
on.
97of
137
for
pelv
icF
xs.
Of
the
137
pati
ents
,91
%su
cces
sto
cont
rol
blee
ding
;pe
lvic
blee
ding
not
isol
ated
asa
data
poin
t.9
pati
ents
fail
edem
boli
zati
on,
wit
h66
%m
orta
lity
.O
ne-t
hird
ofpe
lvic
embo
liza
tion
sw
ere
for
bila
tera
lin
tern
alil
iac
arte
ries
,bu
tno
post
proc
edur
em
orbi
dity
was
note
d
Wor
ldJ
Surg
.20
00;2
4:53
9–54
5
Sha
piro
etal
.30
2005
The
role
ofre
peat
angi
ogra
phy
inth
em
anag
emen
tof
pelv
icfr
actu
res
32
Ret
rosp
ecti
vere
view
of31
pelv
icF
xpa
tien
tsw
houn
derw
ent
pelv
ican
giog
raph
y.F
ifte
enpa
tien
tsha
dno
evid
ence
ofpe
lvic
arte
rial
hem
orrh
age,
and
5pa
tien
tsre
quir
edre
peat
angi
ogra
phy
for
recu
rren
thy
pote
nsio
n,w
ith
80%
havi
nga
trea
tabl
ele
sion
.M
oreo
ver,
3pa
tien
tsw
houn
derw
ent
coil
ing
init
iall
yal
sore
quir
edre
peat
angi
ogra
phy.
Inde
pend
ent
pred
icto
rsof
need
for
repe
atan
giog
raph
yw
ere
recu
rren
thy
pote
nsio
n,pe
rsis
tent
base
defi
cit
grea
ter
than
10,
and
abse
nce
ofin
tra-
abdo
min
alin
jury
JT
raum
a.20
05;5
8:22
7–23
1
Met
zet
al.2
820
04P
elvi
cfr
actu
repa
tter
nsan
dth
eir
corr
espo
ndin
gan
giog
raph
icso
urce
sof
hem
orrh
age
34
Ret
rosp
ecti
vere
view
ofim
agin
gan
dcl
inic
alco
urse
of49
cons
ecut
ive
hem
odyn
amic
ally
unst
able
pati
ents
wit
hpe
lvic
Fx.
Pat
ient
sw
ith
OT
Aty
peA
orC
Fx
patt
erns
orA
PC
Fx
patt
erns
had
high
erm
orta
lity
rate
s,IS
S,
and
tran
sfus
ion
requ
irem
ents
than
OT
Aty
peB
orL
Cpa
tter
ns.
Pat
ient
sw
ith
AP
Cin
juri
este
nded
tode
mon
stra
tepo
ster
ior
vasc
ular
inju
ries
,w
hile
LC
Fx
patt
ern
was
mor
eli
kely
tobe
asso
ciat
edw
ith
ante
rior
bran
chva
scul
arin
jury
Ort
hop
Cli
nN
orth
Am
.20
04;3
5:43
1–43
7
Kim
brel
let
al.2
720
04A
ngio
grap
hic
embo
liza
tion
for
pelv
icfr
actu
res
inol
der
pati
ents
22
Ana
lyse
sof
pros
pect
ive
coll
ecte
dda
tato
dete
rmin
ew
heth
erag
eca
npr
edic
tth
ene
edfo
rth
erap
euti
cem
boli
zati
on.
Dur
ing
this
tim
epe
riod
,in
dica
tion
sfo
rem
boli
zati
onw
ere
hypo
tens
ion
inth
eco
ntex
tof
pelv
icF
xan
dno
othe
rso
urce
ofbl
eedi
ng,
orsp
ecifi
cF
xpa
tter
ns,
orla
rge
pelv
iche
mat
oma.
92of
332
pati
ents
wit
hse
vere
pelv
icF
xun
derw
ent
angi
ogra
phy.
Age
�60
was
foun
dto
beas
soci
ated
wit
ha
94%
like
liho
odof
posi
tive
angi
ogra
phy.
The
auth
ors
reco
mm
end
libe
ral
arte
riog
raph
yfo
rse
vere
pelv
icF
xpa
tien
tsol
der
than
60yr
Arc
hSu
rg.
2004
;139
:728
–73
2
Mil
ler
etal
.18
2003
Ext
erna
lfi
xati
onor
arte
riog
ram
inbl
eedi
ngpe
lvic
frac
ture
:in
itia
lth
erap
ygu
ided
bym
arke
rsof
arte
rial
hem
orrh
age
32,
4R
etro
spec
tive
trau
ma
regi
stry
revi
ewof
all
patie
nts
with
hypo
tens
ion
rela
ted
tope
lvic
Fxs
who
unde
rwen
tan
giog
raph
y,as
wel
las
norm
oten
sive
pelv
icFx
patie
nts
who
unde
rwen
tan
giog
raph
y,to
dete
rmin
efa
ctor
spr
edic
ting
arte
rial
blee
ding
.35
patie
nts
had
initi
alhy
pote
nsio
n,an
d28
who
wer
eco
nsid
ered
tobe
nonr
espo
nder
sun
derw
ent
angi
ogra
phy,
with
73%
dem
onst
ratin
gar
teria
lble
edin
g.17
norm
oten
sive
patie
nts
unde
rwen
tang
iogr
aphy
base
don
Fxpa
ttern
,pre
senc
eof
pelv
iche
mat
oma,
orC
E,a
nd29
%w
ere
posi
tive
for
arte
rialb
leed
ing.
The
auth
ors
reco
mm
end
that
pelv
icFx
patie
nts
who
dono
tres
pond
toin
itial
resu
scita
tion
and
patie
nts
with
CE
onC
Tsc
an,u
nder
arte
riogr
aphy
JT
raum
a.20
03;5
4:43
7–44
3
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011 EAST Pelvic Fracture Guidelines
© 2011 Lippincott Williams & Wilkins 1853
TAB
LE2.
Evid
entia
ryTa
ble
1999
–201
0(c
ontin
ued)
Aut
hor(
s)Y
ear
Tit
leL
evel
ofE
vide
nce
Que
stio
nA
ddre
ssed
Syno
psis
Ref
eren
ce
Gou
rlay
etal
.22
2005
Pel
vic
angi
ogra
phy
for
recu
rren
ttr
aum
atic
pelv
icar
teri
alhe
mor
rhag
e2
2S
tudy
coho
rtof
39pa
tien
tsw
hoha
dre
peat
angi
ogra
phy
for
recu
rren
tpe
lvic
hem
orrh
age.
The
33pa
tien
tsw
ith
apo
siti
vese
cond
angi
ogra
mha
dbl
eedi
ngat
ane
wsi
tein
28(8
5%)
and
atth
epr
evio
usly
embo
lize
dsi
tein
11(3
3%).
All
embo
liza
tion
sat
the
repe
atan
giog
ram
wer
eth
ough
tto
bete
chni
call
ysu
cces
sful
.S
igni
fica
ntri
skfa
ctor
sfo
rre
curr
ent
pelv
icar
teri
alhe
mor
rhag
ear
e(1
)pr
eang
iogr
amhy
pote
nsio
n,(2
)pu
bic
sym
phys
isdi
srup
tion
,(3
)gr
eate
rnu
mbe
rof
inju
red
arte
ries
onin
itia
lar
teri
ogra
m,
(4)
coag
ulop
athy
,an
d(5
)re
quir
em
ore
bloo
dtr
ansf
usio
n.T
heau
thor
sco
nclu
ded
that
pati
ents
wit
hth
ese
char
acte
rist
ics
may
man
ifes
tre
curr
ent
arte
rial
blee
ding
,an
dit
may
bepr
uden
tto
reta
inth
ean
gio
shea
thfo
rup
to72
h
JT
raum
a.20
05;5
9:11
68–
1173
Tak
ahir
aet
al.3
220
01G
lute
alm
uscl
ene
cros
isfo
llow
ing
tran
scat
hete
ran
giog
raph
icem
boli
sati
onfo
rre
trop
erit
onea
lha
emor
rhag
eas
soci
ated
wit
hpe
lvic
frac
ture
32
Rev
iew
ofpa
tien
tsw
how
ent
bila
tera
lan
gioe
mbo
liza
tion
for
pelv
icF
x-re
late
dhe
mor
rhag
efo
und
that
5of
151
pati
ents
(3.3
%)
deve
lope
dgl
utea
lm
uscl
ene
cros
is.
All
had
embo
liza
tion
ofbi
late
ral
inte
rnal
ilia
car
teri
es.
Mor
tali
tyw
as60
%du
eto
seps
is/D
IC
Inju
ry.
2001
;32:
27–3
2
Yas
umur
aet
al.3
320
05H
igh
inci
denc
eof
isch
emic
necr
osis
ofth
egl
utea
lm
uscl
eaf
ter
tran
scat
hete
ran
giog
raph
icem
boli
zati
onfo
rse
vere
pelv
icfr
actu
re
32
8pa
tien
tsun
derw
ent
angi
ogra
phy
for
blee
ding
pelv
icF
xs.
6of
8un
derw
ent
embo
liza
tion
.4
of6
pati
ents
had
bila
tera
lin
tern
alil
iac
embo
liza
tion
s.2
of6
pati
ents
had
bila
tera
lsu
peri
or/i
nfer
ior
glut
eals
embo
lize
d.3
case
sof
tiss
uein
fect
ion,
4ca
ses
ofgl
utea
lne
cros
is,
and
2ca
ses
ofse
psis
.P
atie
nts
unde
rwen
tM
RI
at1
wk
and
4w
k.A
llw
ere
note
dto
have
glut
eal
mus
cle
necr
osis
,an
d2
pati
ents
deve
lope
dne
crot
izin
gso
ftti
ssue
infe
ctio
nne
cess
itat
ing
I&D
JT
raum
a.20
05;5
8:98
5–99
0
Fan
gio
etal
.20
2005
Ear
lyem
boli
zati
onan
dva
sopr
esso
rad
min
istr
atio
nfo
rm
anag
emen
tof
life
-thr
eate
ning
hem
orrh
age
from
pelv
icfr
actu
re
32
32he
mod
ynam
ical
lyun
stab
lepa
tien
tsun
derw
ent
pelv
ican
giog
raph
y,w
hich
was
foll
owed
byem
boli
zati
onin
25ca
ses.
Ang
iogr
aphy
was
succ
essf
ulin
24ca
ses
(96%
).T
here
was
hem
odyn
amic
impr
ovem
ent
in21
(84%
).L
iber
alus
eof
vaso
pres
sors
was
used
duri
ngth
eea
rly
stag
esof
hem
orrh
agic
shoc
kan
ddu
ring
angi
oem
boli
zati
on.
Mor
tali
ty36
%
JT
raum
a20
05;5
8:97
8–98
4
Bro
wn
etal
.62
2005
Doe
spe
lvic
hem
atom
aon
adm
issi
onco
mpu
ted
tom
ogra
phy
pred
ict
acti
vebl
eedi
ngat
angi
ogra
phy
for
pelv
icfr
actu
re?
32,
4R
etro
spec
tive
revi
ewof
37pe
lvic
Fx
pati
ents
who
unde
rwen
tC
Tan
dan
giog
raph
y.It
was
foun
dth
atth
esi
zeof
the
pelv
iche
mat
oma
onC
Tdi
dno
tco
rrel
ate
wit
hac
tive
pelv
icbl
eedi
ngon
angi
ogra
m.
Inad
diti
on,
the
abse
nce
ofa
cont
rast
blus
hdi
dno
tre
liab
lyex
clud
eac
tive
blee
ding
seen
onan
giog
raph
y
Am
Surg
.20
05;7
1:75
9–76
2
Coo
ket
al.1
920
02T
hero
leof
angi
ogra
phy
inth
em
anag
emen
tof
haem
orrh
age
from
maj
orfr
actu
res
ofth
epe
lvis
32,
423
pati
ents
wit
hon
goin
ghy
pote
nsio
nha
dan
giog
ram
wit
hun
stab
lepe
lvic
Fxs
.F
xpa
tter
ndi
dno
tpr
edic
tas
soci
ated
vasc
ular
inju
ry
JB
one
Join
tSu
rg.
2002
;84
:178
–182
Cullinane et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011
© 2011 Lippincott Williams & Wilkins1854
TAB
LE2.
Evid
entia
ryTa
ble
1999
–201
0(c
ontin
ued)
Aut
hor(
s)Y
ear
Tit
leL
evel
ofE
vide
nce
Que
stio
nA
ddre
ssed
Syno
psis
Ref
eren
ce
Net
toet
al.6
420
08R
etro
grad
eur
ethr
ocys
togr
aphy
impa
irs
com
pute
dto
mog
raph
ydi
agno
sis
ofpe
lvic
arte
rial
hem
orrh
age
inth
epr
esen
ceof
alo
wer
urol
ogic
trac
tin
jury
32,
449
pati
ents
wit
hpe
lvic
Fx
and
eith
era
uret
hral
orbl
adde
rru
ptur
e.23
had
RU
Gor
cyst
ogra
mpe
rfor
med
befo
reC
T,
and
26ha
dcy
stog
raph
yaf
ter
CT
scan
ning
.P
erfo
rmin
gcy
stog
raph
ybe
fore
CT
was
asso
ciat
edw
ith
cons
ider
atel
ym
ore
inde
term
inat
esc
ans
(N�
9)an
dfa
lse
nega
tive
s(N
�2)
for
pelv
icar
teri
alex
trav
asat
ion.
Con
side
rati
onsh
ould
begi
ven
tope
rfor
min
gre
trog
rade
uret
hrog
raph
yan
dcy
stog
raph
yaf
ter
CT
scan
ning
asth
eyin
terf
ere
wit
hth
ede
tect
ion
ofac
tive
extr
avas
atio
non
CT
JA
mC
oll
Surg
.20
08;
206:
322–
327
Won
get
al.2
520
00M
orta
lity
afte
rsu
cces
sful
tran
scat
hete
rar
teri
alem
boli
zati
onin
pati
ents
wit
hun
stab
lepe
lvic
frac
ture
s:ra
teof
bloo
dtr
ansf
usio
nas
apr
edic
tive
fact
or
32,
4R
etro
spec
tive
revi
ew.
17he
mod
ynam
ical
lyun
stab
lepe
lvic
Fx
pati
ents
unde
rwen
tth
erap
euti
cem
boli
zati
on,
and
3of
the
pati
ents
subs
eque
ntly
died
,fo
ra
mor
tali
tyra
teof
17.6
%.
Blo
odtr
ansf
usio
nra
tebe
fore
embo
liza
tion
asw
ell
asti
me
inte
rval
toem
boli
zati
onw
ere
sign
ifica
ntpr
edic
tors
ofm
orta
lity
,bu
tsi
zeof
CE
was
not.
The
auth
ors
conc
lude
dth
atea
rly
reco
gnit
ion
ofar
teri
alpe
lvic
blee
ding
wit
hea
rly
embo
liza
tion
ises
sent
ial
JT
raum
a.20
00;4
9:71
–75
Hag
iwar
aet
al.2
620
03P
redi
ctor
sof
deat
hin
pati
ents
wit
hli
fe-t
hrea
teni
ngpe
lvic
hem
orrh
age
afte
rsu
cces
sful
tran
scat
hete
rar
teri
alem
boli
zati
on
22,
461
pati
ents
eval
uate
dw
ith
pros
pect
ive
prot
ocol
.13
of61
died
desp
ite
100%
succ
essf
ulan
gioe
mbo
liza
tion
.P
oste
rior
pelv
icbl
eedi
ngan
dA
PA
CH
EII
scor
espr
edic
ted
mor
tali
ty.
Fx
patt
erns
did
not
pred
ict
mor
tali
ty.
Non
surv
ivor
sre
quir
edm
ore
flui
dto
achi
eve
hem
odyn
amic
stab
ilit
y
JT
raum
a.20
03;5
5:69
6–70
3
Cro
ceet
al.6
920
07E
mer
gent
pelv
icfi
xati
onin
pati
ents
wit
hex
sang
uina
ting
pelv
icfr
actu
re2
1,5
186
patie
nts
with
mul
tiple
seve
repe
lvic
Fxs
unde
rwen
tst
abili
zatio
nof
the
pelv
isw
itha
POD
(C-C
lam
p)(9
3)vs
.tem
pora
ryex
tern
alpe
lvic
bind
er(9
3).T
rans
fusi
onre
quir
emen
tsw
ere
redu
ced
with
the
use
ofth
ebi
nder
,as
was
hosp
ital
leng
thof
stay
.The
rew
asno
stat
istic
ally
sign
ifica
ntdi
ffer
ence
inth
em
orta
lity
rate
s.T
heau
thor
sco
nclu
deth
atth
eus
eof
the
bind
erre
duce
str
ansf
usio
nre
quir
emen
tsan
dle
ngth
ofho
spita
lst
ay
JA
mC
oll
Surg
.20
07;
204:
935–
939
Bot
tlan
get
al.7
020
02E
mer
gent
man
agem
ent
ofpe
lvic
ring
frac
ture
sw
ith
use
ofci
rcum
fere
ntia
lco
mpr
essi
on
31,
5O
pen-
book
pelv
icF
xsw
ere
indu
ced
in7
cada
vers
.S
tabi
liza
tion
was
init
iall
ypr
ovid
edw
ith
the
pelv
icsl
ing.
Sub
sequ
entl
y,st
abil
ized
wit
ha
post
erio
rpe
lvic
C-c
lam
p/an
teri
orex
tern
alfi
xato
r.S
tabi
lity
prov
ided
byth
epe
lvic
slin
gw
asdi
rect
lyco
mpa
rabl
eto
that
prov
ided
byth
epo
ster
ior
pelv
icC
-cla
mp,
but
the
slin
gpr
ovid
edon
ly1/
3rd
ofth
efl
exio
n-ex
tens
ion
stab
ilit
yan
d1/
10th
ofth
ein
tern
al-e
xter
nal
rota
tion
stab
ilit
yas
com
pare
dw
ith
the
exte
rnal
fixa
tor.
The
auth
ors
conc
lude
that
the
slin
gis
wel
lsu
ited
for
tem
pora
rily
stab
iliz
atio
nof
the
acut
ely
inju
red
pati
ent
JB
one
Join
tSu
rgA
m.
2002
;84:
43–4
7
Bot
tlan
get
al.7
120
02N
onin
vasi
vere
duct
ion
ofop
en-b
ook
pelv
icfr
actu
res
byci
rcum
fere
ntia
lco
mpr
essi
on
35
Par
tial
lyst
able
and
unst
able
exte
rnal
rota
tion
inju
ries
ofth
epe
lvic
ring
wer
ecr
eate
din
7ca
dave
rs.
Ape
lvic
stra
pw
asap
plie
dat
3di
ffer
ent
leve
lsar
ound
the
pelv
is.
The
stra
pac
hiev
edco
mpl
ete
redu
ctio
nof
sym
phys
isdi
asta
sis
JO
rtho
pT
raum
a.20
02;
16:3
67–3
73
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011 EAST Pelvic Fracture Guidelines
© 2011 Lippincott Williams & Wilkins 1855
TAB
LE2.
Evid
entia
ryTa
ble
1999
–201
0(c
ontin
ued)
Aut
hor(
s)Y
ear
Tit
leL
evel
ofE
vide
nce
Que
stio
nA
ddre
ssed
Syno
psis
Ref
eren
ce
Tie
man
net
al.1
320
05E
mer
genc
ytr
eatm
ent
ofm
ulti
ply
inju
red
pati
ents
wit
hun
stab
ledi
srup
tion
ofth
epo
ster
ior
pelv
icri
ngby
usin
gth
e“C
-cla
mp”
31
28pa
tient
sw
ithan
unst
able
post
erio
rpe
lvic
ring
Fxha
da
C-c
lam
pap
plie
dim
med
iate
lyaf
ter
diag
nosi
s.T
heav
erag
etim
efr
omtr
aum
ato
C-c
lam
pap
plic
atio
nw
as64
.7m
in(1
0–24
0m
in).
App
licat
ion
ofth
eC
-cla
mp
resu
lted
inst
abili
zatio
nof
BP
and
oxyg
enat
ion
insu
rviv
ors;
inth
eno
nsur
vivo
rgr
oup
(7of
28pa
tient
s)th
ere
was
nost
abili
zatio
nof
BP
orox
ygen
atio
n.T
heau
thor
sco
nclu
deth
atth
eC
-cla
mp
lead
sto
stab
iliza
tion
ofvi
tal
para
met
ers
with
ina
shor
tpe
riod
oftim
e
Eur
JT
raum
a.20
05;3
:24
4–25
1
Kre
iget
al.1
420
05E
mer
gent
stab
iliz
atio
nof
pelv
icri
ngin
juri
esby
cont
roll
edci
rcum
fere
ntia
lco
mpr
essi
on:
acl
inic
altr
ial
31,
516
pati
ents
wit
hpe
lvic
ring
Fxs
had
aP
CC
Dte
mpo
rari
lyap
plie
dun
til
defi
niti
vest
abil
izat
ion
was
prov
ided
.In
the
exte
rnal
rota
tion
grou
p,th
eP
CC
Dsi
gnifi
cant
lyre
duce
dth
epe
lvic
wid
thby
9.9%
�6%
,si
mil
arto
the
10.0
%�
4.1%
redu
ctio
nin
achi
eved
byde
fini
tive
stab
iliz
atio
n.In
the
inte
rnal
rota
tion
grou
p,th
eP
CC
Ddi
dno
tca
use
sign
ifica
ntov
erco
mpr
essi
on.
The
auth
ors
conc
lude
that
aP
CC
Dca
nef
fect
ivel
yre
duce
pelv
icri
ngin
juri
esw
hile
posi
ngm
inim
alri
skfo
rov
erco
mpr
essi
onan
dco
mpl
icat
ions
JT
raum
a.20
05;5
9:65
9–66
4
Gha
emm
agha
mi
etal
.68
2007
Eff
ects
ofea
rly
use
ofex
tern
alpe
lvic
com
pres
sion
ontr
ansf
usio
nre
quir
emen
tsan
dm
orta
lity
inpe
lvic
frac
ture
s
35
Pel
vic
bind
ers
wer
eap
plie
dto
118
pati
ents
wit
hun
stab
lepe
lvic
Fx,
pelv
icF
xin
apa
tien
tol
der
than
55yr
,or
ape
lvic
Fx
asso
ciat
edw
ith
hypo
tens
ion.
The
sepa
tien
tsw
ere
com
pare
dw
ith
hist
oric
alco
ntro
ls.
The
pelv
icbi
nder
had
noef
fect
onm
orta
lity
,ne
edfo
rpe
lvic
angi
oem
boli
zati
on,
or24
-htr
ansf
usio
ns.
The
auth
ors
conc
lude
dth
atea
rly
use
ofpe
lvic
bind
ers
does
not
redu
cehe
mor
rhag
eor
mor
tali
tyas
soci
ated
wit
hpe
lvic
Fxs
Am
JSu
rg.
2007
;194
:720
–72
3
Sto
ver
etal
.420
06T
hree
-dim
ensi
onal
anal
ysis
ofpe
lvic
volu
me
inan
unst
able
pelv
icfr
actu
re3
1A
mod
elw
asde
velo
ped
com
pari
ngin
tact
and
post
frac
ture
pelv
icvo
lum
esin
10ca
dave
rs;
the
pelv
icvo
lum
ew
asca
lcul
ated
usin
gC
T.
The
obse
rved
volu
me
chan
ges
wit
hin
crea
sing
pubi
cdi
asta
sis
wer
esm
alle
rth
anpr
evio
usly
repo
rted
JT
raum
a.20
06;6
1:90
5–90
8
Sad
riet
al.1
120
05C
ontr
olof
seve
rehe
mor
rhag
eus
ing
C-c
lam
pan
dar
teri
alem
boli
zati
onin
hem
odyn
amic
ally
unst
able
pati
ents
wit
hpe
lvic
ring
disr
upti
on
31,
214
hem
odyn
amic
ally
unst
able
pati
ents
wit
hty
pes
Ban
dC
pelv
icri
ngF
xsun
derw
ent
appl
icat
ion
ofpe
lvic
C-c
lam
p.5
pati
ents
rem
aine
din
shoc
kan
dun
derw
ent
angi
o/em
boli
zati
onw
ithi
n24
h.T
hem
orta
lity
rate
ofth
epa
tien
tsw
houn
derw
ent
angi
oem
boli
zati
onw
as14
%).
Alt
houg
hth
eC
-cla
mp
isef
fect
ive
inco
ntro
llin
ghe
mor
rhag
e,ar
teri
alem
boli
zati
onm
aybe
need
edto
rest
ore
hem
odyn
amic
stab
ilit
y
Arc
hO
rtho
ptr
aum
aSu
rg.
2005
;125
:443
–447
Bla
ckm
ore
etal
.85
2003
Ass
essm
ent
ofvo
lum
eof
hem
orrh
age
and
outc
ome
from
pelv
icfr
actu
re3
2,4
CT
scan
sof
592
pati
ents
wit
hpe
lvic
Fx
wer
ere
tros
pect
ivel
yre
view
edto
esti
mat
evo
lum
e.T
hese
esti
mat
esw
ere
then
corr
elat
edw
ith
pelv
icar
teri
albl
eedi
ngdi
agno
sed
byan
giog
raph
y.T
heri
skra
tio
for
pelv
icar
teri
alin
jury
was
4.8
insu
bjec
tsw
ith
�50
0m
Lof
pelv
icF
x-re
late
dhe
mat
oma
com
pare
dw
ith
subj
ects
wit
h�
500
mL
.V
olum
e�
500
mL
was
asso
ciat
edw
ith
high
tran
sfus
ion
requ
irem
ent
(ris
kra
tio
�4.
7)an
dw
ith
any
adve
rse
outc
ome
(ris
kra
tio
�7.
0).
The
auth
ors
conc
lude
that
pelv
iche
mor
rhag
evo
lum
esde
rive
dfr
ompe
lvic
CT
scan
can
pred
ict
the
need
for
pelv
icar
teri
ogra
phy
and
tran
sfus
ions
Arc
hSu
rg.
2003
;138
:504
–50
9
Cullinane et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011
© 2011 Lippincott Williams & Wilkins1856
TAB
LE2.
Evid
entia
ryTa
ble
1999
–201
0(c
ontin
ued)
Aut
hor(
s)Y
ear
Tit
leL
evel
ofE
vide
nce
Que
stio
nA
ddre
ssed
Syno
psis
Ref
eren
ce
Baq
ueet
al.3
2005
Ana
tom
ical
cons
eque
nces
of“o
pen
book
”pe
lvic
ring
disr
upti
on.
aca
dave
rex
peri
men
tal
stud
y
31
Bil
ater
alop
en-b
ook
pelv
icF
xsw
ere
crea
ted
in10
cada
vers
.P
elvi
cvo
lum
ew
asde
term
ined
afte
rto
tal
pelv
icex
ente
rati
on.
The
mea
nvo
lum
eof
pelv
icca
vity
was
872.
5m
L(5
80–7
56m
L).
The
aver
age
incr
ease
ofpe
lvic
volu
me
was
20.8
%af
ter
5cm
ofpu
bic
dias
tasi
s.In
60%
,a
lace
rati
onof
the
ilio
lum
bar
vein
occu
rred
afte
r5
cmof
pubi
cdi
asta
sis.
No
arte
rial
lace
rati
onoc
curr
ed.
The
auth
ors
conc
lude
dth
atop
en-b
ook
Fxs
crea
tean
incr
ease
ofpe
lvic
volu
me
that
faci
lita
tes
bloo
ddi
ffus
ion
from
the
pelv
icve
ssel
s.T
heil
iolu
mba
rpe
dicl
ese
ems
tobe
very
vuln
erab
lein
this
type
ofF
x
Surg
Rad
iol
Ana
t.20
05;
27:4
87–4
90
Jow
ett
and
Bow
yer7
220
07P
ress
ure
char
acte
rist
ics
ofpe
lvic
bind
ers
35
10vo
lunt
eers
wer
efi
tted
wit
ha
flex
ible
pres
sure
-se
nsit
ive
sens
orov
erth
esk
inco
veri
ngth
ean
teri
orsu
peri
oril
iac
spin
e,gr
eate
rtr
ocha
nter
and
sacr
um.
Ape
lvic
bind
erw
asth
enap
plie
dan
dti
ghte
ned
acco
rdin
gto
the
man
ufac
ture
rs’
inst
ruct
ions
.T
hepr
essu
res
obta
ined
corr
elat
edin
vers
ely
wit
hB
MI.
The
auth
ors
conc
lude
that
the
pres
sure
sde
velo
ped
betw
een
the
bind
eran
dth
esk
inov
erth
epr
omin
ence
sw
ere
all
grea
ter
than
the
pres
sure
reco
mm
ende
dat
inte
rfac
esto
avoi
dth
ede
velo
pmen
tof
pres
sure
sore
s,su
gges
ting
that
pati
ents
wit
hpe
lvic
Fxs
trea
ted
wit
hte
mpo
rary
pelv
icbi
nder
sar
eat
risk
ofde
velo
ping
pres
sure
sore
s
Inju
ry.
2007
;38:
118–
121
Kat
aoka
etal
.86
2005
Ilia
cve
inin
juri
esin
hem
odyn
amic
ally
unst
able
pati
ents
wit
hpe
lvic
frac
ture
sca
used
bybl
unt
trau
ma
32,
3,6
72pa
tien
tsw
ith
unst
able
pelv
icF
xsw
hopr
esen
ted
insh
ock
wer
ere
view
ed.
36of
61pa
tien
tsre
cove
red
from
shoc
kaf
ter
angi
oem
boli
zati
on.
18of
25w
hodi
dno
tre
cove
rfr
omsh
ock
died
.In
11of
25w
hodi
dno
tre
cove
rfr
omsh
ock
afte
ran
gio/
embo
liza
tion
,tr
ansf
emor
alve
nogr
aphy
was
perf
orm
ed,
reve
alin
gsi
gnifi
cant
veno
usex
trav
asat
ion
in9
(5co
mm
onil
iac
vein
,3
inte
rnal
ilia
cve
in,
and
1ex
tern
alil
iac
vein
).T
heau
thor
sco
nclu
deth
atil
iac
vein
inju
ryis
the
prin
cipa
lca
use
ofhe
mor
rhag
icsh
ock
inpa
tien
tsw
ith
unst
able
pelv
icF
xsan
dth
atve
nogr
aphy
isus
eful
for
iden
tify
ing
thes
ein
juri
es
JT
raum
a.20
05;5
8:70
4–71
0
Ste
phen
etal
.16
1999
Ear
lyde
tect
ion
ofar
teri
albl
eedi
ngin
acut
epe
lvic
trau
ma
32,
4R
etro
spec
tive
revi
ewof
111
pati
ents
wit
hpe
lvic
/ace
tabu
lar
Fxs
w/C
Tsc
an,
incl
udin
gst
able
and
unst
able
pati
ents
.11
pati
ents
had
extr
avas
atio
n.O
btur
ator
arte
ryw
as#1
caus
eof
hem
orrh
age
requ
irin
gem
boli
zati
onw
ith
supe
rior
glut
eal
#2.
CE
was
80%
sens
itiv
ean
d98
%sp
ecifi
cfo
rre
quir
ing
angi
ogra
phy.
The
yco
nclu
deth
atC
Ese
enon
CT
(whe
ther
hem
odyn
amic
ally
stab
leor
unst
able
)re
quir
esan
giog
raph
y,al
thou
ghso
me
hem
orrh
age
wil
lha
vest
oppe
dby
the
tim
ean
giog
raph
yis
unde
rtak
en
JT
raum
a.19
99;4
7:63
8–64
2
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011 EAST Pelvic Fracture Guidelines
© 2011 Lippincott Williams & Wilkins 1857
TAB
LE2.
Evid
entia
ryTa
ble
1999
–201
0(c
ontin
ued)
Aut
hor(
s)Y
ear
Tit
leL
evel
ofE
vide
nce
Que
stio
nA
ddre
ssed
Syno
psis
Ref
eren
ce
Per
eira
etal
.58
2000
Dyn
amic
heli
cal
com
pute
dto
mog
raph
ysc
anac
cura
tely
dete
cts
hem
orrh
age
inpa
tien
tsw
ith
pelv
icfr
actu
re
32,
4H
elic
alC
Tha
shi
ghN
PV
(99.
6%)
tode
term
ine
need
for
embo
liza
tion
PP
V69
.2%
;th
eref
ore,
appr
opri
ate
for
scre
enin
gpo
lytr
aum
apa
tien
tsw
ith
pelv
icF
xsto
elim
inat
ene
edfo
rem
erge
ntan
gio
embo
liza
tion
.29
0pe
lvic
Fxs
stud
ied
wit
hC
T,
only
13w
ith
CE
.T
hey
reco
mm
end
angi
oin
pati
ents
who
are
unst
able
and
have
CE
Surg
ery.
2000
;128
:678
–68
5
Rya
net
al.5
920
04A
ctiv
eex
trav
asat
ion
ofar
teri
alco
ntra
stag
ent
onpo
st-t
raum
atic
abdo
min
alco
mpu
ted
tom
ogra
phy
32,
4R
etro
spec
tive
revi
ewof
28in
itia
lly
hem
odyn
amic
ally
stab
lepa
tien
tsw
/ext
rava
sati
onon
CT
.S
ensi
tivi
tyw
as87
.5%
,S
peci
fici
tyw
as99
.5%
,P
PV
was
77.8
%,
and
NP
Vw
as99
.8%
.M
orta
lity
for
CE
grou
pw
as64
%an
d13
%fo
rth
ose
wit
hout
.A
utho
rsre
com
men
dan
gio
inpa
tien
tsw
ith
pelv
icF
xsan
dC
Ebe
com
eun
stab
le
Can
Ass
ocR
adio
lJ.
2004
;55
:160
–169
Ruc
hhol
tzet
al.4
520
04F
ree
abdo
min
alfl
uid
onul
tras
ound
inun
stab
lepe
lvic
ring
frac
ture
:is
lapa
roto
my
alw
ays
nece
ssar
y?
21,
2,3,
4,6
Ret
rosp
ecti
vere
view
of80
pati
ents
wit
hty
peB
orC
pelv
icri
ngF
xs.
Flu
idgr
oup
(fre
efl
uid
onin
itia
lF
AS
T)
had
31pa
tien
ts,
all
unde
rwen
tla
paro
tom
y.30
of31
had
anab
dom
inal
sour
ceof
blee
ding
.6
pati
ents
inth
eno
flui
dgr
oup
(n�
49)
wer
ehe
mod
ynam
ical
lyun
stab
le,
and
none
had
anab
dom
inal
sour
ces
ofbl
eedi
ng.
Hem
odyn
amic
ally
unst
able
pati
ents
w/o
free
flui
dre
quir
eea
rly
Ex
fix
stab
iliz
atio
nan
dhe
mod
ynam
ical
lyun
stab
lepa
tien
tsw
ith
apo
siti
veF
AS
Tre
quir
ela
paro
tom
yfi
rst,
retr
oper
iton
eal
pack
ing
asne
eded
,an
dex
fixa
tion
afte
rab
dom
inal
blee
ding
isco
ntro
lled
.F
urth
erim
agin
g(C
Tsc
an)
isne
eded
inhe
mod
ynam
ical
lyst
able
pati
ents
and
pati
ents
w/o
free
flui
dw
hoco
ntin
ueto
beun
stab
leaf
ter
exfi
xati
on
JT
raum
a.20
04;5
7:27
8–28
5
Niw
aet
al.2
420
00T
heva
lue
ofpl
ain
radi
ogra
phs
inth
epr
edic
tion
ofou
tcom
ein
pelv
icfr
actu
res
trea
ted
wit
hem
boli
sati
onth
erap
y
32,
4R
evie
wof
40pa
tien
tsre
quir
ing
angi
ogra
phic
embo
liza
tion
for
pelv
iche
mor
rhag
e.P
lain
pelv
icfi
lms
wer
ere
view
edre
tros
pect
ivel
yfo
rlo
cati
onof
bony
inju
ry(L
orR
isch
iopu
bic
orsa
croi
liac
)an
dF
oley
devi
atio
nto
see
ifhe
mor
rhag
icso
urce
coul
dbe
pred
icte
d.T
heau
thor
sco
nclu
ded
that
inth
ispa
tien
tgr
oup,
plai
nX
-ray
has
81%
sens
itiv
ity
and
91%
spec
ifici
tyin
iden
tify
ing
loca
tion
ofhe
mor
rhag
e.S
elec
tion
bias
ofre
view
ing
only
thos
ere
quir
ing
embo
liza
tion
and
does
not
tohe
lpid
enti
fyth
ose
who
may
requ
ire
embo
liza
tion
Br
JR
adio
l.20
00;7
3:94
5–95
0
Tay
alet
al.4
620
06A
ccur
acy
oftr
aum
aul
tras
ound
inm
ajor
pelv
icin
jury
32,
3,4
Sen
siti
vity
ofF
AS
Tin
pati
ents
wit
hpe
lvic
fx80
.8%
and
spec
ifici
ty86
.9%
.P
PV
72.4
%,
NP
V91
.4%
.O
f21
true
posi
tive
FA
ST
,fr
eefl
uid
was
urin
ein
4.P
ropo
sepe
rito
neal
tap
inhe
mod
ynam
ical
lyun
stab
lepa
tien
tsto
dete
rmin
ew
heth
erfl
uid
isbl
ood
orur
ine
from
blad
der
inju
ry
JT
raum
a.20
06;6
1:14
53–
1457
Cullinane et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011
© 2011 Lippincott Williams & Wilkins1858
TAB
LE2.
Evid
entia
ryTa
ble
1999
–201
0(c
ontin
ued)
Aut
hor(
s)Y
ear
Tit
leL
evel
ofE
vide
nce
Que
stio
nA
ddre
ssed
Syno
psis
Ref
eren
ce
Fri
ese
etal
.47
2007
Abd
omin
alul
tras
ound
isan
unre
liab
lem
odal
ity
for
the
dete
ctio
nof
hem
oper
iton
eum
inpa
tien
tsw
ith
pelv
icfr
actu
re
32,
3,4
96pa
tien
tsw
ith
pelv
icF
xan
din
crea
sed
risk
for
hem
orrh
age
(age
�55
,S
BP
�90
mm
Hg
inE
D,
orU
FP
)st
udie
dw
/FA
ST
whe
rere
sult
sco
nfirm
edw
ith
CT
orla
paro
tom
y.In
dete
ctin
gfr
eefl
uid
inpe
rito
neal
cavi
ty,
FA
ST
had
sens
itiv
ity
of26
%,
spec
ifici
ty96
%,
PP
V85
%,
NP
V63
%.
Wit
ha
nega
tive
FA
ST
,a
seco
ndte
stne
eds
tobe
done
:C
Tsc
anin
stab
lepa
tien
ts,
DP
Lin
unst
able
pati
ents
.A
utho
rsco
nclu
deF
AS
Tdo
esno
the
lpde
term
ine
lapa
roto
my
JT
raum
a.20
07;6
3:97
–10
2
Bal
lard
etal
.48
1999
An
algo
rith
mto
redu
ceth
ein
cide
nce
offa
lse-
nega
tive
FA
ST
exam
inat
ions
inpa
tien
tsat
high
risk
for
occu
ltin
jury
.F
ocus
edas
sess
men
tfo
rth
eso
nogr
aphi
cex
amin
atio
nof
the
trau
ma
pati
ent
23,
4P
rosp
ecti
ve,
nonr
ando
miz
edst
udy
ofbl
unt
trau
ma
pati
ents
w/p
elvi
cF
xs,
FA
ST
,an
dsu
bseq
uent
CT
orla
paro
tom
y.T
here
wer
e70
pelv
ictr
aum
apa
tien
tsw
/sen
siti
vity
of24
%an
dsp
ecifi
city
of10
0%an
d13
fals
ene
gati
ves.
The
auth
ors
conc
lude
that
any
pati
ent
wit
hpe
lvic
trau
ma
and
FA
ST
requ
ires
aC
Tsc
anto
eval
uate
for
furt
her
inju
rydu
eto
the
high
fals
e-ne
gati
vera
te
JA
mC
oll
Surg
.19
99;
189:
145–
150
Ham
ill
etal
.51
1999
Pel
vic
frac
ture
patt
ern
pred
icts
pelv
icar
teri
alha
emor
rhag
e3
3,4
Rev
iew
of76
pati
ents
wit
hpe
lvic
Fxs
who
requ
ired
�6
unit
sP
RB
Cin
1st
24h:
(ML
Das
defi
ned
byF
xcl
asse
sA
PC
IIor
III,
LC
III,
VS
,or
Com
bine
dM
echa
nism
)w
assh
own
toco
rrel
ate
wit
hin
crea
sed
need
for
embo
liza
tion
,bu
tse
nsit
ivit
y63
%an
dsp
ecifi
city
44%
.U
nabl
eto
use
pelv
icfx
clas
sto
iden
tify
pati
ents
who
requ
ire
embo
liza
tion
Aus
tN
ZJ
Surg
.20
00;7
0:33
8–34
3
Bla
ckm
ore
etal
.55
2006
Pre
dict
ing
maj
orhe
mor
rhag
ein
pati
ents
wit
hpe
lvic
frac
ture
22,
3,4
627
pati
ents
wit
hpe
lvic
fx.
Maj
orpe
lvic
hem
orrh
age
(defi
ned
asan
yof
3cr
iter
iaw
ere
pres
ent:
(1)
arte
rial
extr
avas
atio
non
angi
ogra
phy,
(2)
high
volu
me
pelv
iche
mat
oma
onC
T(�
600
mL
),or
(3)
high
tran
sfus
ion
requ
irem
ent
inth
eab
senc
eof
othe
rso
urce
ofhe
mor
rhag
e)w
asid
enti
fied
in12
8of
627
subj
ects
(20%
).F
our
fact
ors
rem
aine
das
pred
icto
rsof
maj
orpe
lvic
hem
orrh
age:
puls
e�
130,
hem
atoc
rit
of30
%or
less
,di
spla
ced
(1cm
)ob
tura
tor
ring
Fx,
ordi
asta
sis
ofth
epu
bic
sym
phys
isof
1cm
orm
ore.
The
fina
lpr
edic
tive
mod
elw
asab
leto
stra
tify
pelv
icF
xpa
tien
tsin
togr
oups
wit
hpr
obab
ilit
ies
ofm
ajor
hem
orrh
age
rang
ing
from
less
than
2%(4
of24
7)fo
r0
pred
icto
rsto
over
60%
(39
of59
)fo
r3
orm
ore
pred
icto
rs
JT
raum
a.20
06;6
1:34
6–35
2
Eas
trid
geet
al.5
020
02T
heim
port
ance
offr
actu
repa
tter
nin
guid
ing
ther
apeu
tic
deci
sion
-mak
ing
inpa
tien
tsw
ith
hem
orrh
agic
shoc
kan
dpe
lvic
ring
disr
upti
ons
32,
3,4
Ret
rosp
ecti
veof
193
pati
ents
w/h
ypot
ensi
onan
dpe
lvic
Fxs
.D
efine
dst
able
pelv
icF
xsas
LC
and
AP
C1.
Defi
ned
unst
able
pelv
icF
xsas
AP
C2/
3,L
C2/
3,an
dV
S85
%of
SF
Pw
/per
sist
ent
hypo
tens
ion
had
abdo
min
also
urce
ofhe
mor
rhag
ew
hile
28%
ofU
FP
had
anab
dom
inal
sour
ce.
Aut
hors
conc
lude
that
pers
iste
nthy
pote
nsio
nin
pelv
icF
xpa
tien
tsca
nbe
subd
ivid
edby
SF
Por
UF
Pan
dca
nbe
pred
icti
veof
outc
ome.
Rec
omm
end
lapa
roto
my
inhy
pote
nsiv
epa
tien
tsw
/SF
Pan
dst
rong
cons
ider
atio
nof
angi
obe
fore
lapa
roto
my
inhy
pote
nsiv
epa
tien
tsw
/UF
P
JT
raum
a20
02;5
3:44
6–45
0
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011 EAST Pelvic Fracture Guidelines
© 2011 Lippincott Williams & Wilkins 1859
TAB
LE2.
Evid
entia
ryTa
ble
1999
–201
0(c
ontin
ued)
Aut
hor(
s)Y
ear
Tit
leL
evel
ofE
vide
nce
Que
stio
nA
ddre
ssed
Syno
psis
Ref
eren
ce
Sar
inet
al.5
620
05P
elvi
cfr
actu
repa
tter
ndo
esno
tal
way
spr
edic
tth
ene
edfo
rur
gent
embo
liza
tion
32,
4R
etro
spec
tive
revi
ewof
283
pati
ents
w/h
ypot
ensi
onan
dM
LD
,i.e
.,A
PC
II/I
II,
LC
III,
and
VS
Mor
tali
ty,
ISS
,an
dP
RB
Cs
wer
egr
eate
rin
the
ML
Dgr
oup.
Did
not
find
corr
elat
ion
toM
LD
and
the
need
for
angi
ogra
phy.
Aut
hors
conc
lude
that
desp
ite
othe
rre
port
s,pe
lvic
Fx
patt
ern
cann
otbe
used
tode
term
ine
whe
ther
hypo
tens
ion
isfr
ompe
lvic
hem
orrh
age
oran
othe
rso
urce
JT
raum
a.20
05;5
8:97
3–97
7
Mag
nuss
enet
al.5
320
07P
redi
ctin
gbl
ood
loss
inis
olat
edpe
lvic
and
acet
abul
arhi
gh-e
nerg
ytr
aum
a3
1,2
289
Isol
ated
pelv
icF
xsre
view
edfo
rP
RB
Ctr
ansf
used
infi
rst
24h.
Pat
ient
sdi
vide
din
tope
lvic
fxon
ly(1
11),
acet
abul
arfx
only
(143
),an
dbo
th(3
5).
Pat
ient
sw
ith
both
requ
ired
mor
eP
RB
Cth
anth
ose
wit
hpe
lvic
orac
etab
ular
alon
e.P
RB
Cre
quir
emen
tseq
ual
betw
een
pelv
ican
dac
etab
ular
grou
p.W
ithi
npe
lvic
grou
p,44
%of
thos
ew
ith
ML
D(f
xpa
tter
nsL
CII
I,A
PC
II–I
II,
VS
,co
mbi
ned)
requ
ired
PR
BC
whi
leon
ly8.
5%of
thos
ew
/oM
LD
requ
ired
PR
BC
JO
rtho
pT
raum
a.20
07;
21:6
03–6
07
Lun
sjo
etal
.54
2007
Ass
ocia
ted
inju
ries
and
not
frac
ture
inst
abil
ity
pred
ict
mor
tali
tyin
pelv
icfr
actu
res:
apr
ospe
ctiv
est
udy
of10
0pa
tien
ts
21,
2,4
100
cons
ecut
ive
pati
ents
wit
hpe
lvic
Fx,
mor
tali
ty(9
%).
Pel
vic
Fx
clas
sifi
edas
O(n
oin
stab
ilit
y),
R(r
otat
iona
lin
stab
ilit
y),
orR
V(r
otat
iona
lan
dve
rtic
alin
stab
ilit
y).
Of
ISS
,R
TS
,pe
lvic
fxcl
assi
fica
tion
,P
RB
Ctr
ansf
used
,lo
gist
icre
gres
sion
show
edon
lyIS
Sto
bean
inde
pend
ent
pred
icto
rof
mor
tali
ty.
Pel
vic
Fx
patt
erns
dono
tpr
edic
tm
orta
lity
and
ther
efor
edo
esno
tpr
edic
tac
tive
hem
orrh
age
requ
irin
gan
giog
raph
y
JT
raum
a.20
07;6
2:68
7–69
1
Sm
ith
etal
.57
2007
Ear
lypr
edic
tors
ofm
orta
lity
inhe
mod
ynam
ical
lyun
stab
lepe
lvis
frac
ture
s
22,
4R
etro
spec
tive
revi
ewof
pros
pect
ive
trau
ma
data
base
.18
7H
Dun
stab
lepa
tien
tsw
/pel
vic
Fxs
.A
naly
zed
fact
ors
rela
ted
tom
orta
lity
.F
xpa
tter
n(Y
oung
and
Bur
gess
)an
dne
edfo
ran
giog
raph
yw
ere
not
pred
icti
veof
mor
tali
ty.
Age
,IS
S,
and
PR
BC
Tra
nsfu
sion
wer
epr
edic
tors
ofm
orta
lity
JO
rtho
pT
raum
a.20
07;
21:3
1–37
Sta
rret
al.2
120
02P
elvi
cri
ngdi
srup
tion
s:pr
edic
tion
ofas
soci
ated
inju
ries
,tr
ansf
usio
nsre
quir
emen
t,pe
lvic
arte
riog
raph
y,co
mpl
icat
ions
,an
dm
orta
lity
23,
4R
etro
spec
tive
revi
ewof
325
pati
ents
w/c
lose
dpe
lvic
Fxs
.S
hock
and
RT
Sw
ere
sign
ifica
ntly
asso
ciat
edw
/mor
tali
ty,
PR
BC
Tra
nsfu
sion
,IS
S,
and
AIS
S.
Old
erag
ean
dR
TS
wer
esi
gnifi
cant
lyas
soci
ated
w/
need
for
angi
ogra
phy.
LC
2/3
had
high
erra
teof
angi
ogra
phy,
but
noot
her
Fx
patt
ern
tone
edfo
ran
gio
was
foun
d.P
atie
nts
that
unde
rwen
tan
gio
had
high
erm
orta
lity
and
PR
BC
TX
need
.U
nabl
eto
dem
onst
rate
ast
atis
tica
lre
lati
onsh
ipbe
twee
nF
xpa
tter
nan
dne
edfo
rar
teri
ogra
phy
orm
orta
lity
JO
rtho
pT
raum
a20
02;
16:5
53–5
61
Bal
ogh
etal
.83
2005
Inst
itut
iona
lpr
acti
cegu
idel
ines
onm
anag
emen
tof
pelv
icfr
actu
re-
rela
ted
hem
odyn
amic
inst
abil
ity:
doth
eym
ake
adi
ffer
ence
?
21,
2,3,
4P
Ges
tabl
ishe
din
clud
ing
(1)
abdo
min
al“c
lear
ance
”(A
C)
usin
gF
AS
T�
DP
T;
(2)
Pel
vic
bind
ing
w/s
heet
,C
-cla
mp
(PB
);(3
)P
elvi
can
gio
wit
hin
90m
in,
and;
4)O
Fw
ithi
n24
h;pa
tien
tsm
eeti
nggu
idel
ines
pre/
post
PG
:A
C67
%/1
00%
;P
B0%
/86%
;P
A30
%/9
3%;
OF
52%
/86%
.M
orta
lity
6of
17pr
e-P
G(3
5%)
and
1of
14po
st-P
G(7
%).
Mul
tidi
scip
lina
rygu
idel
ines
seem
toim
prov
eou
tcom
e
JT
raum
a.20
05;5
8:77
8–78
2
Cullinane et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011
© 2011 Lippincott Williams & Wilkins1860
puted tomography (CT) scanning with mathematical model-ing, Stover et al.4 demonstrated an increase in pelvic volumeof 35% to 40% with a large 10-cm pubic diastasis, again in acadaver model.
Pelvic stabilization has been practiced for a number ofyears in an attempt to control pelvic bleeding by decreasingthe pelvis volume, leading to earlier tamponade. Methods thatclose the pelvic ring are thought to tamponade bleeding bydiminishing the pelvic volume, hastening clotting of thepelvic hematoma.5 Initially, the pneumatic antishock gar-ments (PASG) was used to stabilize the pelvis and decreasethe pelvic volume. In retrospective studies, Flint et al. andothers have demonstrated less blood loss when the PASG wasapplied.6–8 Other studies have questioned the ability ofPASG to limit hemorrhage from pelvic fracture.9,10 PASGhave largely fallen out of favor due to concerns about ab-dominal compartment syndrome and fluid and electrolytecomplications and because they are bulky, difficult to apply,and interfere with physical examination.
External pelvic fixation (EPF) and the pelvic C-clamphave been used more recently in an attempt to reduce pelvicvolume and control hemorrhage associated with pelvic frac-ture. In a study of 14 hemodynamically unstable patients withpelvic fractures, Sadri et al.11 found that blood loss was notstatistically different before/after placement of the pelvicC-clamp. Angiography was required in many of these pa-tients to control hemorrhage. Application of the pelvic C-Clamp is generally done quickly (5 minutes)12although othershave reported that it can take longer, averaging 64 minutes toapply (range, 10–240 minutes).13 When EPF is comparedwith a temporary pelvic binder (TPB) in patients with sacro-iliac fractures, EPF was found to have higher blood transfu-sion needs at 24 hours and 48 hours compared with the TPB.The reduced blood loss has been attributed to the ease andrapidity of TPB application compared with EPF.14
Placement of a C-Clamp or EPF decreases the pelvicvolume by 10% to 20% and reduces pelvic fractures.3,14,15
Whether this leads to less blood loss and better outcomes hasyet to be shown in the literature. The standard use of externalfixation in the initial treatment algorithms of patients withunstable pelvic injuries is common and remains a useful toolin the initial management of these patients.13,16 However,because of their ease of use and fast application, TPBs havelargely replaced the pelvic C-Clamp and EPF for earlymechanical stability in pelvic fracture.TA
BLE
2.Ev
iden
tiary
Tabl
e19
99–2
010
(con
tinue
d)
Aut
hor(
s)Y
ear
Tit
leL
evel
ofE
vide
nce
Que
stio
nA
ddre
ssed
Syno
psis
Ref
eren
ce
Bif
flet
al.8
220
01E
volu
tion
ofa
mul
tidi
scip
lina
rycl
inic
alpa
thw
ayfo
rth
em
anag
emen
tof
unst
able
pati
ents
wit
hpe
lvic
frac
ture
s
21,
2,3,
5R
etro
spec
tive
revi
ewof
143
pati
ents
in“e
arly
grou
p”vs
.73
“lat
egr
oup”
whi
chw
asde
fine
das
befo
rean
daf
ter
the
tim
ew
hen
2or
tho
trau
ma
staf
fw
ere
inth
etr
aum
aba
yfo
rde
cisi
onm
akin
gup
onpa
tien
tar
riva
l.L
ower
rate
ofhy
pote
nsio
n,in
crea
sed
use
ofP
B,
and
impr
oved
mor
tali
ty(3
1%vs
.15
%).
The
rew
ere
nodi
ffer
ence
sin
the
num
ber
ofpa
cked
red
cell
sor
fres
h-fr
ozen
plas
ma
unit
str
ansf
used
.T
here
wer
eno
sign
ifica
ntdi
ffer
ence
sbe
twee
nth
e2
grou
psin
term
sof
the
over
all
com
plic
atio
nra
teor
the
occu
rren
ceof
acut
ere
spir
ator
ydi
stre
sssy
ndro
me,
mul
tipl
eor
gan
fail
ure,
orpn
eum
onia
Ann
Surg
.20
01;2
33:8
43–
850
ISS
,in
jury
seve
rity
scor
e;R
TS
,re
vise
dtr
aum
asc
ore;
CE
,co
ntra
stex
trav
asat
ion;
PR
BC
,pa
cked
red
bloo
dce
lls;
OT
A,
Ort
hope
dic
Tra
uma
Ass
ocia
tion
;A
PC
,an
tero
post
erio
rco
mpr
essi
on;
LC
,la
tera
lco
mpr
essi
on;
DIC
,di
ssem
inat
edin
trav
ascu
lar
coag
ulop
athy
;MR
I,m
agne
tic
reso
nanc
eim
agin
g;I&
D,i
ncis
ion
and
drai
nage
;AP
AC
HE
,acu
teph
ysio
logy
and
chro
nic
heal
thev
alua
tion
;BP
,blo
odpr
essu
re;P
CC
D,p
elvi
cci
rcum
fere
ntia
lcom
pres
sion
devi
ce;
BM
I,bo
dym
ass
inde
x;F
x,fr
actu
re;
CT
,com
pute
dto
mog
raph
y;P
PV
,pos
itiv
epr
edic
tive
valu
e;N
PV
,neg
ativ
epr
edic
tive
valu
e;S
BP
,sys
toli
cbl
ood
pres
sure
;E
D,e
mer
genc
yde
part
men
t;V
S,v
erti
cal
shea
r;M
LD
,maj
orli
gam
ento
usdi
srup
tion
;S
FP
,st
able
frac
ture
patt
ern;
UF
P,
unst
able
frac
ture
patt
ern;
AIS
S,
abbr
evia
ted
inju
ryse
veri
tysc
ore;
PB
,pe
lvic
bind
ing;
PG
,pr
acti
cegu
idel
ine;
OF
,op
erat
ive
pelv
icfi
xati
on;
TX
,tr
ansf
usio
n.Q
uest
ions
:(1
)W
hich
pati
ents
war
rant
earl
yex
tern
alm
echa
nica
lst
abil
izat
ion?
(2)
Whi
chpa
tien
tsre
quir
eem
erge
ntan
giog
raph
y?(3
)W
hat
isth
ebe
stte
stto
excl
ude
extr
a-pe
lvic
blee
ding
?(4
)A
reth
ere
radi
ogra
phic
find
ings
whi
chpr
edic
the
mor
rhag
e?(5
)W
hat
isth
ero
leof
non-
inva
sive
tem
pora
ryex
tern
alfi
xati
onde
vice
s?an
d(6
)W
hich
pati
ents
war
rant
pre-
peri
tone
alpa
ckin
g?
TABLE 3. Tile Classification
Type A Stable pelvic ring injury
Type B Partially stable pelvic ring injury
B1: Open book injury (anteroposterior compression,external rotation)
B2: Lateral compression (internal rotation)
B3: Bilateral injuries
Type C Completely unstable (allows all degrees of translationaldisplacement)
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011 EAST Pelvic Fracture Guidelines
© 2011 Lippincott Williams & Wilkins 1861
Which Patients Require EmergentAngiography?
1. Patients with pelvic fractures and hemodynamic instability orsigns of ongoing bleeding after nonpelvic sources of bloodloss have been ruled out should be considered for pelvicangiography/embolization. Level I recommendation
2. Patients with evidence of arterial intravenous contrastextravasation (ICE) in the pelvis by CT may require pelvicangiography and embolization regardless of hemodynamicstatus. Level I recommendation
3. Patients with pelvic fractures who have undergone pelvicangiography with or without embolization, who havesigns of ongoing bleeding after nonpelvic sources ofblood loss have been ruled out, should be considered forrepeat pelvic angiography and possible embolization.Level II recommendation
4. Patients older than 60 years with major pelvic fracture(open book, butterfly segment, or vertical shear) should beconsidered for pelvic angiography without regard for he-modynamic status. Level II recommendation
5. Although fracture pattern or type does not predict arterialinjury or need for angiography, anterior fractures are morehighly associated with anterior vascular injuries, whereasposterior fractures are more highly associated with poste-rior vascular injuries. Level III recommendation
6. Pelvic angiography with bilateral embolization seems tobe safe with few major complications. Gluteal muscleischemia/necrosis has been reported in patients with he-modynamic instability and prolonged immobilization orprimary trauma to the gluteal region as the possible cause,rather than a direct complication of angioembolization.Level III recommendation
7. Sexual function in males does not seem to be impairedafter bilateral internal iliac arterial embolization. Level IIIrecommendation
Scientific Foundation: Emergent AngiographyPelvic angiography is useful control of arterial hemor-
rhage associated with pelvic fractures. In many pelvic frac-tures, much of the bleeding is venous in nature, generallyfrom bone fracture edges or the iliolumbar vein. Angiographywith embolization only controls arterial hemorrhage andtherefore is beneficial in only a minority of patients. Indeed,it seems that pelvic angiography is indicated in only 3% to10% of patients with pelvic fracture.17–23 Hemodynamic in-stability associated with pelvic fractures without anothersignificant source of bleeding is an indication for pelvicangiography.18–20,24,25 In a retrospective study of 325 patientsat a Level I trauma center, Starr et al. found that RevisedTrauma Score alone was predictive of the need for angiog-raphy. Age, shock on admission, and fracture pattern did notpredict need for angiography.21
There are several predictors to help determine whichpatients will need angiography. The presence of ICE seen onCT scan has a sensitivity of 60% to 84% and specificity of85% to 98% for the need for pelvic embolization.18 ICE is astrong predictor of need for angioembolization. Fracturepattern alone has not been predictive of who will or will not
require angiography.21,24,26 The combination of age �60 andmajor pelvic fracture is highly associated with need forangiography with embolization (odds ratio, 15) regardless ofthe patient’s hemodynamic status. Indeed, 62% of patientsolder than 60 years requiring angiographic embolization hadnormal vital signs on hospital admission.27 Although hemor-rhage from major pelvic fractures is common, several retro-spective studies contain patients with arterial bleeding fromisolated sacral or acetabular fractures.17 Although fracturetype does not predict need for angiography, in general,anterior fractures are associated with anterior vascular inju-ries, whereas posterior fractures are associated with posteriorvascular injuries.28
Pelvic angiography with embolization seems to be 85%to 97% effective in controlling bleeding. Some patients willcontinue to bleed and require repeat embolization to controlhemorrhage.22,23,29,30 4.6% to 24.3% of patients with either nobleeding seen on the initial angiogram or initially successfulpelvic embolization will require repeat pelvic angiographywith repeat embolization. Independent risk factors for recur-rent pelvic bleeding include transfusing greater than two unitspacked red blood cells per hour before angiography, findingmore than two injured vessels requiring embolization,22
repeated hypotension after initial angiography, absence ofintra-abdominal injury, and persistent base deficit.30 Thestandard embolization technique for an unstable patientbleeding from an internal iliac artery source is to nonselec-tively embolize both internal iliac arteries. In more stablepatients, some operators may attempt more selective embo-lization. However, a study by Fang et al.23 demonstrated thatrecurrent pelvic bleeding also seems to be more commonafter selective embolization than after nonselective treatment,suggesting this practice should be limited.
The safety of pelvic angiography/embolization seemsto be well established in several series.29,31 There are occa-sional reports of femoral artery injury requiring repair andtransient increases in serum creatinine in older patients.27
Cases of gluteal necrosis associated with embolizations seemto be related to primary trauma to the gluteal region alongwith protracted hypotension rather than a direct complicationof embolization.17,32 In one report, six of eight pelvic fracturepatients undergoing bilateral angioembolization for shockshowed magnetic resonance imaging changes consistent withsoft tissue infection or necrosis33 without primary glutealtrauma, suggesting that gluteal muscle ischemia may besubclinical. Ramirez et al.34 examined sexual dysfunction inmales undergoing bilateral internal iliac embolization andfound no difference compared with case-matched pelvic frac-ture patients not undergoing embolization.
What Is the Best Test to ExcludeIntra-Abdominal Bleeding?
1. Focused Assessment with Sonography for Trauma(FAST) is not sensitive enough to exclude intraperito-neal bleeding in the presence of pelvic fracture. Level Irecommendation
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2. FAST has adequate specificity in patients with unstablevital signs and pelvis fracture to recommend laparotomyto control hemorrhage. Level I recommendation
3. Diagnostic peritoneal tap (DP)/Diagnostic peritoneal la-vage (DPL) is the best test to exclude intra-abdominalbleeding in the hemodynamically unstable patient. LevelII recommendation
4. In the hemodynamically stable patient with a pelvic fracture,CT of the abdomen and pelvis with intravenous contrast isrecommended to evaluate for intra-abdominal bleeding re-gardless of FAST results. Level II recommendation
Scientific Foundation: Tests to ExcludeIntra-Abdominal Bleeding With Pelvic Fracture
Early detection of hemoperitoneum after blunt abdom-inal injury allows for rapid implementation of decision-making algorithms and decreasing the time to abdominalexploration in patients at high risk for intraperitoneal hemor-rhage. The indications for laparotomy in the patient with apelvic fracture are the same for all trauma patients. Withconcomitant pelvic fracture, differentiating between pelvic-bleeding and intra-abdominal hemorrhage is critical to theinitial decision-making and management of the patient.
Four methods are commonly used to help excludeintra-abdominal bleeding: DPL, ultrasound (FAST), DP, andCT.1 Each test has advantages and disadvantages specific totheir use in patients with pelvic fracture. DPL has been shownto have a high rate of false positives in patients with pelvicfractures.7,35,36 This is thought to be due to a high rate ofred cell diapedesis across the peritoneum. DP withoutlavage performed in the supraumbilical region seems tooffer similar sensitivity as DPL with a lower rate offalse-negative examinations.7,36,37
The FAST has been an effective tool for the evaluationof patients with intra-abdominal injuries and hypoten-sion.38–42 Patients with pelvic fractures are at high risk tohave other associated intra-abdominal injuries as a source ofbleeding.43,44 Although the specificity of the FAST in patientswho have pelvic fractures examination is reasonable as aninitial screening tool (87–100%), the sensitivity of the exam-ination in the presence of a mechanically unstable pelvicfracture (Tile B/C) is unacceptably low.45–48 Ruchholz et al.45
reported 75% sensitivity with concomitant pelvic fracture ina series of patients with type B/C pelvic fractures. Thisfinding was consistent with other reports in the literature.46,48
In a more recent report from a high volume trauma center,Freise et al.47 reported a very low sensitivity of 26% inpatients with pelvic fracture.
Because of the low sensitivity and low negative pre-dictive value of FAST when pelvic fracture is present, CT ofthe abdomen and pelvis with intravenous contrast is recom-mended in patients with pelvic fracture and a negative FASTexamination who are hemodynamically stable. A negativeFAST examination in a patient with pelvic fracture does notaid in determining whether a laparotomy or angiography iswarranted.46–48 Hemodynamically unstable patients with pel-vic fracture and a positive FAST should undergo emergentlaparotomy, whereas hemodynamically normal patients with
pelvic fracture and a positive FAST should receive an ab-dominal/pelvic CT scan.
Are There Radiologic Findings Which PredictHemorrhage?
1. Fracture pattern on pelvic X-ray does not single-handedlypredict mortality, hemorrhage, or the need for angiogra-phy. Level II recommendation
2. Presence/location of hematoma does not predict or ex-clude the need for angiography and possible embolization.Level II recommendation
3. CT of the pelvis is an excellent screening tool to excludepelvic hemorrhage. Level II recommendation
4. Absence of contrast extravasation on CT does not alwaysexclude active hemorrhage. Level II recommendation
5. Pelvic hematoma �500 cm3 in size has an increasedincidence of arterial injury and need for angiography.Level II recommendation
6. Isolated acetabular fractures are as likely to require angiographyas pelvic rim fractures. Level III recommendation
7. If a retrograde urethrocystogram is required, it should beperformed after CT with intravenous contrast. Level IIIrecommendation
Scientific Foundation: Radiographic Predictors ofHemorrhage
Two radiographic modalities have the potential to pro-vide clinically useful information during the evaluation oftraumatic pelvic fractures in the acute setting: pelvic X-rayand CT scan. Several recent studies attempt to correlateradiographic findings to clinical outcomes and specifically theneed for angiography.
The Young-Burgess classification system49 (Table 4)divides pelvic fractures by vector; anteroposterior, lateralcompression, vertical shear, and combined mechanical. Eachtype of fracture is also graded by severity (I, II, and III).Correlating the fracture pattern to the need for angiographyhas shown mixed results. Niwa et al.24 was able to show anassociation. This study was unable to define the cause ofdeath in 20% of their population. Posterior bleeding sourcesseem to correlate with anteroposterior type fractures, whereaslateral compression fractures are more likely to have ananterior (iliac) source of bleeding.28
In an effort to determine whether patients should un-dergo laparotomy or angiography in hemodynamically unsta-ble patients with pelvic fractures, Eastridge et al.50 found thatthose with higher grade or rotationally unstable pelvic frac-tures were more likely to have a pelvic source of bleeding.Patients with rotationally stable fractures were more likely tohave an abdominal source of hemorrhage and thereforeshould have a laparotomy performed as the primary proce-dure. Two studies were able to show a relationship betweenmajor ligamentous disruption and the need for pelvic embo-lization.51,52 The authors concede that, although positive, thecorrelation was too weak to assist in clinical decision-mak-ing. When looking at pelvic fractures outside the pelvic ring,isolated acetabular fractures were shown to have the sameblood transfusion requirements and presumably the need for
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angiography.53 Two other studies concluded that injury se-verity score was a better predictor of pelvic hemorrhage thanfracture pattern.50,54 Blackmore et al.55 developed a multiplelogistic regression model that was able to predict the proba-bility of pelvic arterial hemorrhage.55 The model included thefollowing factors: initial hematocrit 30 or less, heart rate 130or greater, and pelvic fracture patterns including obturatorring fracture greater than 1 cm or pubic symphysis diastasisof at least 1 cm. The presence of three or four of these riskfactors was only able to predict pelvic hemorrhage in 66% ofpatients. The remaining studies were unable to correlatepelvic fracture pattern with need for angioemboliza-tion.21,56,57 The available literature suggests that pelvic frac-ture pattern alone is insufficient to predict the need forangioembolization.
CT scanning has become a valuable asset in the acutemanagement of pelvic trauma. Two factors have been studiedto determine the need for angioembolization: ICE and thepelvic hematoma size. The absence of ICE on the admissionCT is an excellent screening test to exclude the presence ofactive arterial hemorrhage and therefore the need for angio-embolization, with the negative predictive values rangingfrom 98.0% to 99.8%.58–60 The presence of ICE, however,has shown varied results. Stephen et al.16 showed that thepositive predictive value of ICE needing angioembolizationwas 80%. The negative predictive value was 98%. Theyconcluded that the presence of ICE was an indication forangiography, regardless of hemodynamic status. Pereira etal.58 demonstrated a lower positive predictive value of 69.2%with ICE. Four of five patients who were hemodynamicallystable with a blush did not require embolization. They rec-ommend angiography only in hemodynamically unstable pa-tients with ICE. Ryan et al.59 reported their experience with18 patients with mechanically unstable pelvic fractures andICE. Nine of these patients underwent angiography for he-modynamic instability of which seven required embolization.The presence of ICE on CT was predicted the site of bleedingfound angiographically in all patients. They concluded thatICE on CT scan with a major pelvic fracture mandatesangiography regardless of hemodynamics. There were nocomplications from angiography reported in these studies.
Other studies have demonstrated a higher mortality ratefrom a delay in angiography.60 Brasel et al.61 retrospectivelyexamined CT scans with ICE and found 90% sensitivity forneeding angiography. They noted, however, that 33% ofpatients without ICE who were hemodynamically unstablealso required angiography. The data suggest that any hemo-dynamically unstable patient with pelvic fractures and ICErequires angiography in the absence of other bleedingsources. When patients are hemodynamically stable, the ev-idence is mixed. In a patient with stable hemodynamics, thedata suggest that angiography may be useful to preventfurther bleeding but may not be required in all patients.61
Need for angiography in hemodynamically stable patientswith ICE from pelvic trauma requires further study to deter-mine its usefulness.
Attempts at correlating the presence and size of a pelvichematoma seen on CT with the need for angiography havebeen undertaken. Brown et al.62 retrospectively studied 37patients who underwent CT and angiography. Contrast ex-travasation during angiography was noted in 83% of patientswithout hematoma (67% of patients with small hematomaand 73% of patients with significant hematoma). Blackmoreet al.55 found that hematomas �500 cm3 had a significantincreased risk ratio of 4.8 for arterial injury at angiography. Ingeneral, the presence of pelvic hematoma is insufficient toalter the indications for angiography and is not a predictor ofneed for transfusion or ongoing blood loss. Large hematomaswith volumes over 500 cm3 may have an increased risk ofarterial injury requiring angiography.
The presence of bladder and urethral injuries withconcomitant pelvic fractures is common. Retrograde urethro-gram (RUG) should be performed before placement of aurinary catheter; however, the sequencing of RUG and CThas been controversial.63 Netto et al.64 was able to show ahigher rate of indeterminate and false-negative CT if RUGwas performed first. This was due to contrast from the RUGinterfering with determining if ICE was present. The detec-tion of hemorrhage needs to take priority over detectingurologic injuries, and therefore CT scan with contrast shouldbe performed before the evaluation of the genitourinary tractin most settings.
TABLE 4. Young-Burgess Classification System
Fracture Type Common Characteristic Differentiating Characteristic
Lateral compression 1 Transverse pubic rami fracture Sacral Compression on side of impact
Lateral compression 2 Transverse pubic rami fracture Crescent (iliac wing) fracture
Lateral compression 3 Transverse pubic rami fracture Contralateral open-book (anteroposterior compression) injury
Anterior-posteriorcompression 1
Symphyseal diastasis (1–2 cm) Slight widening of symphysis and/or sacroiliac (SI) joint,stretched but intact anterior and posterior SI joint ligaments
Anterior-posteriorcompression 2
Symphyseal diastasis or vertical pubic rami fracture Widened SI joint, disrupted anterior SI ligaments withintact posterior SI ligaments
Anterior-posteriorcompression 3
Symphyseal diastasis or vertical pubic rami fracture Complete hemipelvis separation but no vertical displacement,anterior and posterior SI joint ligaments ruptured
Vertical shear Symphyseal diastasis or vertical pubic rami fracture Vertical hemipelvis displacement, usually through SI joint,occasionally through iliac wing or sacrum
Combined mechanism Vertical or transverse pubic rami fractures Combination of patterns; lateral compression with verticalshear or lateral compression with anterior-posterior compression
SI, sacroiliac.
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What Is the Role of Noninvasive TemporaryExternal Fixation Devices?
1. TPBs effectively reduce unstable pelvic fractures as wellas definitive stabilization and decrease pelvic volume.Level III recommendation
2. TPBs may limit pelvic hemorrhage but do not seem toaffect mortality. Level III recommendation
3. TPBs work as well or better than emergent EPF in con-trolling hemorrhage. Level III recommendation
Scientific Foundation: Temporary ExternalFixation Devices
Temporary binders have been used to control hemor-rhage from pelvic fractures for many years. Pneumatic anti-shock trousers were one of the early attempts to decrease thepelvic volume and limit hemorrhage. Sheets have been usedfor this task more recently.65–67 Commercial devices haverecently evolved to provide consistent compression in aconvenient prepackaged device. Results from studies of thesecommercial binders have been mixed. In a large study per-formed at Parkland Hospital, the use of a commercial binderhad no effect on transfusion requirements, need for angio-graphic embolization, or mortality when compared with his-torical controls.68 Croce et al. compared the use of EPFplaced in the operation room with TPB placed in the emer-gency department in a series of patients with hemodynami-cally instability and structurally unstable fractures. The use ofthe T-POD (Cybertech Medical, La Verne, CA) reducedblood transfusion needs at 24 hours and 48 hours comparedwith historical controls. Both the groups were in similardegree of shock. The authors attributed the reduced bloodloss to the rapidity of T-POD placement compared with EPF.No differences in mortality were found.69
Evidence suggests temporary binders decrease pelvicvolume with a pelvic fracture and may improve biomechani-cal stability. Bottlang et al.70,71 noted fracture reduction and55% to 61% improvement in biomechanical stability ofpelvic fractures in seven nonembalmed cadavers after appli-cation of an external compression device. In a study of 16patients with mechanically unstable pelvic fractures, Kreig etal.14 demonstrated a 9.9% decrease in pelvic width using aTPB with no complications related to the binder. The dataconfirming efficacy of pelvic binders in controlling hemor-rhage from pelvic fracture remain unclear because of con-flicting studies in the literature.14,68–72
The use of pelvic binders may predispose to skinbreakdown with prolonged use due to high pressure at bonyprominences.72 Shearing force applied when tightening thebinder might result in tissue trauma. Users of these devicesneed to be aware of the risk of pressure induced ischemicwounds. Because of the ease of application, relatively inex-pensive cost, low potential for complications, and benefit topelvic stability, temporary external stabilization devicesshould be considered for emergent application to all hemo-dynamically unstable patients with pelvic injuries.
Which Patients Warrant Retroperitoneal(Preperitoneal) Packing?
1. Retroperitoneal pelvic packing is effective in controllinghemorrhage when used as a salvage technique after an-giographic embolization. Level III recommendation
2. Retroperitoneal pelvic packing is effective in controllinghemorrhage when used as part of a multidisciplinaryclinical pathway including a POD/C-clamp. Level IIIrecommendation
Scientific Foundation: Retroperitoneal PackingEmergent PPP is a newer technique in the trauma
surgeon’s armamentarium. Its use is currently evolving. Orig-inally described in the European literature,73 several Euro-pean centers have described using PPP in combination withexternal mechanical fixation of the pelvis.74–77 Some traumacenters in the United States have adopted this technique andpublished on its use as a first-line therapy in-lieu of angiog-raphy.78 It is reportedly easy to learn.79
The technique involves creating a midline incision 8 cmin length just above the pubis extending toward the umbili-cus.80,81 Skin and subcutaneous tissue is opened in the mid-line, as is the fascia. The bladder is retracted away from thefracture and three laparotomy pads are placed in the retro-peritoneal space on each side toward the iliac vessels. Theprocedure is repeated on the opposite side and the fascia andskin are closed. The procedure can be performed in 20minutes by experienced surgeons.80,81
Cothren et al.78 reported using PPP as part of a clinicalpathway in treating hemorrhage from pelvic fracture. In thisgroup of severely injured patients (injury severity score �55), PPP was performed immediately after placement of aTPB in-lieu of angiography. There were no deaths attributedto hemorrhage after packing along with significantly fewerblood transfusions. This study reported an 83% success ratein controlling hemorrhage in hemodynamically unstable pa-tients who underwent PPP. The other 17% required angiog-raphy. In a follow-up study at their institution, pelvic packingwas found to occur faster than with angiography (45 minutesvs. 130 minutes). There was also a decrease need for trans-fusion. The results of the study are difficult to interpretbecause time to control hemorrhage was significantly differ-ent between the groups.81
PPP seems to have some advantage in controllinghemorrhage, particularly when angiography is unavailable orwould result in significant delay. Future comparative studieswill be needed to directly compare PPP with angiography forthe control of pelvic hemorrhage.
SUMMARYHemorrhage from pelvic fracture remains a difficult
problem facing the trauma surgeon. Today, there have beenmany changes in practice pattern that have been shown topredict and limit hemorrhage in the patient with a pelvicfracture. Biffl et al.82 found that a multidisciplinary team,including an Orthopedic Surgeon, improved outcomes com-pared with historical controls. Institutional guidelines alsohave been shown to improve outcomes and their use is
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encouraged to limit variability in care.82–84 Emergent externalfixation and the pelvic C-clamp used to control hemorrhage isnot supported by the available literature. Although they doreduce fractures effectively, they do not seem to limit hem-orrhage based on the available literature. Angiography forcontrol of hemorrhage has come of age and has an importantrole in the treatment of patients with pelvic fracture and issupported by the highest level of evidence. Pelvic angiogra-phy with embolization can be performed bilaterally if neededand even repeated to control bleeding without undo conse-quence. The data on using the FAST examination to excludeintra-abdominal hemorrhage are clear. FAST examination,although highly specific, does not have the sensitivity to ruleout an extrapelvic (abdominal) source of hemorrhage withmajor pelvic fracture. Although X-ray patterns of injury donot seem to predict hemorrhage, the use of CT scan with afinding of ICE is highly predictive of active bleeding andsupported by the literature. The use of pelvic externalfixation and C-Clamps has largely given way to TPBs. Thehope with these devices is that by stabilizing the fracture,bleeding will be limited. Although the data are limited,early studies seem promising. Further studies will beneeded to asses the ability of temporary abdominal bindersto minimize hemorrhage from pelvic fracture. Finally,retroperitoneal packing is an effective tool to limit hem-orrhage in the small studies that have investigated thetechnique. Its role in the management of pelvic hemor-rhage at this time remains unclear and will need directcomparison with angiography in future studies.
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