Visual Element: An algorithm flowchart titled "Pelvic Trauma Pathway," starting from "Unstable Patient" down to "Binder" -> "Response" -> "Angio vs Packing," clearly showing the decision nodes.

The Killer in the Trauma Bay

Of all orthopaedic injuries, the hemodynamically unstable pelvic fracture is the one most likely to kill a patient within the first hour. It is a high-stakes, high-pressure scenario that demands immediate, rehearsed action.

The pelvis is a bony ring. When broken, it can expand, creating a massive retroperitoneal space that can accommodate the patient's entire blood volume. Your job is to close the space, stop the bleeding, and buy time.

Classification: Speaking the Language

Understanding the fracture pattern predicts the bleeding risk.

Young & Burgess Classification

Based on the Mechanism of Injury (force vector).

1. APC (Anterior-Posterior Compression):

   • Mechanism: Head-on collision or motorcycle crash.
   • Pattern: Symphysis pubis widens ("Open Book"). SI joints open anteriorly.
   • Bleeding Risk: HIGH. The "Open Book" tears the retroperitoneal venous plexus and potentially internal iliac branches.
   • Management: Needs closing (Binder/Ex-Fix).

2. LC (Lateral Compression):

   • Mechanism: T-bone crash (side impact).
   • Pattern: Ramus fractures + Sacral compression fracture (buckle).
   • Bleeding Risk: Lower. The pelvis is "closed down," creating tamponade.
   • Risk: High risk of associated organ injury (bladder rupture, brain injury).

3. VS (Vertical Shear):

   • Mechanism: Fall from height landing on extended leg.
   • Pattern: Complete disruption of symphysis and posterior SI complex. Hemipelvis shifts up.
   • Risk: Highest Mortality. Massive energy. Severe soft tissue and vascular disruption.

The Anatomy of Bleeding

Where is the blood coming from?

• Venous (85-90%): Presacral plexus and bony surfaces. Low pressure. Responds well to tamponade (Binder/Packing).
• Arterial (10-15%): Branches of the Internal Iliac (Superior Gluteal, Obturator, Internal Pudendal). High pressure. Does NOT respond to tamponade. Needs Angioembolization.

The Algorithm: Step-by-Step

Step 1: Recognition & The Binder

• Signs: Hypotension, tachycardia, bruising (scrotal/labial), unequal leg lengths.
• Action: Apply a Pelvic Binder.
• Position: Greater Trochanters.
  • Why? The force vector closes the symphysis.
  • Trap: Placing it at the Iliac Crests (waist) acts as a fulcrum and can open an LC fracture further.

Step 2: Haemostatic Resuscitation

• Activate Massive Transfusion Protocol (1:1:1).
• Give Tranexamic Acid (1g IV).
• Rule out other bleeding (FAST scan, CXR).

Step 3: Assess Response

• Responder: Pulse normalizes. BP stabilizes. -> CT Scan.
• Transient Responder: Improves then drifts. -> CT Scan (with contrast) -> Angio/Theatre.
• Non-Responder: Dying. Do not go to CT. Go to Theatre/Angio suite immediately.

The "Angio vs. Packing" Debate

If the patient remains unstable despite a binder, what next?

Pre-Peritoneal Packing (PPP)

• Technique: Midline incision (Pfannenstiel). Stay outside the peritoneum. Pack laparotomy sponges deep into the true pelvis (paravesical space) and along the SI joints.
• Pros: Fast (<15 mins). Can be done in ED or OT. Controls venous bleeding effectively.
• Cons: Does not stop arterial spray.

Angio-Embolization

• Technique: Interventional Radiologist accesses femoral artery, finds bleeder, coils it.
• Pros: The only way to stop arterial bleeding without major surgery.
• Cons: Takes time (mobilize team, travel). Not available in all centres.

Current Consensus: For the crashing patient (Non-Responder), PPP is often the first line (surgical control) combined with external fixation. If they stabilize but show contrast blush on CT, or continue to leak, they go to Angio. Many trauma centres now have "Hybrid Suites" to do both.

Associated Injuries: The "Dirty" Pelvis

• Urological: Urethral injury (blood at meatus). Don't force a catheter. Do a retrograde urethrogram.
• Rectal/Vaginal: Open pelvic fractures communicating with rectum/vagina have 50% mortality if missed. Mandatory DRE and Speculum exam in all pelvic trauma. Diverting colostomy required for faecal contamination.

Conclusion

The unstable pelvis is a team sport.

1. Binder (Trochanters).
2. Blood (1:1:1 + TXA).
3. Decision: Responder (CT) vs Non-Responder (Packing/Angio).

Memorize this algorithm. You won't have time to look it up when the patient arrives.

References

1. Cullinane DC, et al. "Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture." J Trauma. 2011.
2. Burgess AR, et al. "Pelvic ring disruptions: effective classification system and treatment protocols." J Trauma. 1990.
3. Magnussen RA, et al. "Mechanical stability of the pelvic circumference compressor (binder)." J Orthop Trauma. 2005.