- Discussion:
- pelvic fracture menu / arterial anatomy of lower limbs
- massive retroperitoneal hemorrhage may result from bony fragments and lacerated blood vessels, leading to coagulopathy and
exsanguination;
- associated injuries:
- up to 40% of pts who have a pelvic fracture will have an intra-abdominal source of bleeding that contributes to mortality and
morbidity after blunt trauma;
- evaluation of hematuria
- reference:
- Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients.
- arterial bleeding:
- massive blood loss usually occurs from injury to superior gluteal artery or anterior branches of the internal iliac artery;
- superior gluteal injury occurs because of its relation to SI joint;
- internal pudendal artery injury occurs from sharp fascia of piriformis;
- less often occurs injury to lateral sacral artery in disruptions of posterior portion of pelvic ring;
- obturator artery:
- ref: Aberrant obturator artery is a common arterial variant that may be a source of unidentified hemorrhage in pelvic fracture patients.
- arterial injuries are uncommon & usually seen w/ open pelvic frx;
- arterial injuries occur most often in APC - Type II & Type III
- arterial bleeding is amenable to a variety of embolization techniques;
- magnitude of bleeding:
- damage control orthopaedics
- magnitude of blood loss often goes unrecognized;
- retroperitoneal space may accumulate upto 4 liters of blood before venous tamponade occurs;
- w/ 3-cm pubic symphysis diastasis will cause doubling of normal volume of pelvis, which would allow several units of
addition blood to accumulate before a tamponade effect occurs;
- w/ posterior instability, avg blood loss is > 15 units pRBC compared to avg of 5 pRBC required for pelvic frx w/o
posterior instability;
- always consider need for FFP inaddition to pRBC in cases of massive blood loss;
- CT Scan:
- CT scanning has become an alternative to peritoneal lavage for the diagnosis of intra-abdominal hemorrhage;
- references:
- Contrast-enhanced CT accurately detects hemorrhage in torso trauma: direct comparison with angiography.
- Detection of bleeding in patients with major pelvic fractures: value of contrast-enhanced CT
- Management Options:
- fluid management in the trauma patient
- blood product menu and medical management of bleeding
- angiography & embolization
- in pelvic fractures, selective angiography may aid in the dx of of superior gluteal artery lacteration;
- during the angiography, the artery may be embolized thru the diagnostic cannula, avoiding a pelvic exploration;
- if one is using the anterior or posterior approaches to the acetabulum using trochanteric osteotomy, superior gluteal vessels
must be intact in order to avoid necrosis of medius & minimus;
- this is becuase origin and insertion of muscles is detached in these approaches;
- if acetabular fracture involves a displaced frx of sciatic notch preoperative angiography is advised to ensure that
neurovascular pedicle is intact;
- laparotomy to control hemorrhage
- Preperitoneal pelvic packing is not associated with an increased risk for surgical site infections after internal anterior pelvic
ring fixation.
- external fixators to control bleeding
- reduction of pelvic volume
Delaying urinary catheter insertion in the reception and resuscitation of blunt multitrauma and using a full bladder to tamponade pelvic bleeding.
Pelvic ring disruptions: effective classification system and treatment protocols.
Traction vertical shear pelvic ring fracture: a marker for severe arterial injury? A case report.
Hemorrhage After Low-Energy Pelvic Trauma
Predicting major hemorrhage in patients with pelvic fracture.
Physiologic parameters may help predict pelvic fracture-related arterial bleeding