High-energy trauma: MVCs, pedestrian vs. auto, falls from height (>15 ft) in young pts.
Low-energy trauma: Fragility falls from standing height in elderly pts with osteoporosis.
High mortality rate (up to 20–50% if hemodynamically unstable), primarily due to massive retroperitoneal hemorrhage.
Clinical Features
History: Severe pelvic/groin/hip pain after blunt trauma; inability to bear weight.
Physical Exam:
Pelvic instability: Abnormal motion or crepitus on gentle manual compression of the iliac crests (compress only once; avoid repeated rocking to prevent clot disruption).
Deformity: Asymmetric limb shortening or rotational leg deformity.
Ecchymosis: Flank/periumbilical (retroperitoneal bleed), perineal, or scrotal/labial hematoma.
Urogenital signs: Blood at the urethral meatus, high-riding or non-palpable prostate on DRE, perineal “butterfly” hematoma.
Neurologic deficits: Lumbosacral plexus injury (e.g., lower extremity motor weakness, altered sensation, loss of rectal tone).
Diagnosis
Initial / Screening:
AP Pelvis X-ray: Rapid portable screen in the trauma bay (identifies open-book fractures, sacroiliac disruption, vertical shear).
eFAST: Assesses for concomitant intraperitoneal hemorrhage vs. pure retroperitoneal bleed.
Confirmatory / Gold Standard:
CT Abdomen/Pelvis with IV contrast: Definitive imaging in hemodynamically stable pts to assess fracture architecture, retroperitoneal hematoma, and active arterial contrast extravasation (“contrast blush”).
Key Labs:
Type & Screen / Crossmatch (immediate priority).
Serial CBC (Hgb/Hct), Coagulation profile (PT/INR, PTT, Fibrinogen).
Blood gas (Lactate, Base deficit) to quantify hypoperfusion/shock.
Urinalysis (gross or microscopic hematuria).
Adjunctive Diagnostic Tests:
Retrograde Urethrogram (RUG): Mandatory prior to blind urethral catheterization if blood at meatus, scrotal hematoma, or high-riding prostate is present.
Retrograde Cystography (or CT Cystography): Indicated for gross hematuria or pelvic ring disruption to rule out extraperitoneal vs. intraperitoneal bladder rupture.
Differential Diagnostics
Femoral Neck / Intertrochanteric Hip Fracture:
Diff by shortened and externally rotated lower extremity, isolated hip tenderness; stable pelvic ring on AP pelvis X-ray.
Intra-abdominal Organ Injury (Liver/Spleen Laceration):
Diff by (+) free fluid on FAST in RUQ/LUQ, focal abdominal guarding, lack of pelvic ring disruption on plain radiographs.
Acetabular Fracture:
Diff by pain localized strictly to the hip joint on axial loading, often associated with posterior hip dislocation (shortened, internally rotated leg), confirmed on Judet views or CT.
Proximal Femur / Diaphyseal Fracture:
Diff by obvious mid-thigh deformity, swelling, and localized bone instability on exam and femur X-ray.
Airway/Breathing/Circulation: Establish 2 large-bore IVs (16G or larger) or IO access.
Massive Transfusion Protocol (MTP): Transfuse pRBCs, FFP, and Platelets in a 1:1:1 ratio; target permissive hypotension (MAP ~65 mmHg) until bleeding is controlled.
Mechanical Pelvic Stabilization: Apply a pelvic binder (or bedsheet wrapped tightly) centered directly over the greater trochanters (closes the pelvic volume, reducing venous bleed from the presacral plexus). c
Second-Line / Hemodynamic Stratification:
Hemodynamically Unstable:
FAST (+) (free fluid in abdomen): →Emergent Exploratory Laparotomy (for intra-abdominal source) + concurrent pre-peritoneal pelvic packing.
FAST (-) (no free fluid, retroperitoneal source suspected): →Angiography with Embolization of bleeding internal iliac artery branches (or emergent surgical pre-peritoneal pelvic packing if angio unavailable). c
Hemodynamically Stable:
Perform CT Abdomen/Pelvis with IV contrast.
If active arterial contrast extravasation (blush) seen →Interventional Radiology (IR) Pelvic Angioembolization.
Definitive / Surgical Management:
External Fixation (Ex-Fix): Temporary mechanical stabilization if pelvic binder insufficient.
Open Reduction & Internal Fixation (ORIF): Definitive reconstruction once the patient is hemodynamically stable and resuscitated.
Complications
Hemorrhagic Shock & Exsanguination:
Most common source is the presacral venous plexus (80–90%); arterial injury involves branches of the internal iliac artery (e.g., superior gluteal, internal pudendal, lateral sacral) in 10–20%.
Urogenital Trauma:
Posterior Urethral Disruption (at the bulbomembranous junction).
High incidence due to pelvic venous stasis and endothelial injury (place IVC filter if pharmacologic prophylaxis is contraindicated due to active bleeding).
Abdominal Compartment Syndrome (ACS):
Secondary to massive fluid/blood resuscitation and expanding retroperitoneal hematoma (monitor bladder pressures).