Immediate management of pelvic fractures

Most patients who sustain pelvic fractures survive. It can be difficult to identify patients at risk for death. Once patients at risk are identified, it is difficult to decide on a best course of treatment to prevent mortality. The best markers for death after pelvic fracture are hemodynamic shock, age greater than 55 to 60 years, and the presence of a grossly unstable fracture. Emergency treatments to decrease hemorrhage are limited to: provisional stabilization of the pelvic fracture using a sheet, pelvic binder, pelvic clamp, or external fixator; angiographic embolization of bleeding vessels; and direct surgical approach with packing of the pelvis. Immediate application of a sheet or pelvic binder in high-risk patients seems reasonable, since these maneuvers carry little risk. But, there are no studies to show that these methods decrease mortality. For hypotensive patients with stable fracture patterns, exploratory laparotomy before angiography may decrease mortality, since the source of bleeding in these patients is commonly intraabdominal. For patients with unstable fracture patterns, angiography and embolization before laparotomy may decrease mortality, since the source of hemorrhage for these patients is often pelvic vascular injury. However, the best sequence of treatments is unknown because of the lack of controlled studies in this clinical area.