Review Question - QID 4503

The patient has an Anterior-Posterior Compression type 3 pelvic ring injury (APC3), and this injury places the patient at risk of life- threatening hemorrhage. The most appropriate next step in the trauma bay is to place the patient in a pelvic binder in order to minimize pelvic volume and impart stability to the injured hemipelvis to allow for clot formation.

Pelvic fractures are high energy injuries with a high association of concomitant musculoskeletal trauma and damage to multiple organ systems. It is important that any patient with a high-energy pelvic ring injury undergo a complete work-up including a CT of the chest abdomen and pelvis to look for alternative sources of bleeding. Application of a pelvic binder should occur once a pelvic ring injury is identified as part of the ongoing resuscitation of the patient.

Karadimas et al. retrospectively reviewed 34 patients at a single center who underwent pelvic arterial embolization as part of their resuscitation. APC injuries had the highest mean transfusion rate during the initial 24 hours, and the overall mortality for pelvic fractures requiring embolization was 23.5% in this series.

Manson et al. conducted a retrospective case-controlled study, evaluating mortality factors on LC-1 fractures. They found that in LC-1 fractures, the sacral fracture pattern does not predict mortality; however, mortality rate was increased in patients with a brain injury, chest injury, or abdominal injury.

Figure A demonstrates an APC3 pelvic ring injury with widening of both the symphysis and the right SI joint. Illustration A demonstrates the same injury as seen in Figure A after application of a pelvic binder with improved alignment of the pelvic ring. Illustration B shows appropriate application of a pelvic binder in a multiply injured patient.

Incorrect Answers:
Answer 1: While this patient may need to go emergently to the OR for multiple reasons, the work-up needs to be completed. However, the patient’s pelvis should be stabilized with a pelvic binder in the interim.
Answer 2: These images should be obtained, but the pelvis should be closed with a pelvic binder first.
Answer 3: While the pelvis may not be the only location of bleeding, the patient has a known source for bleeding, and it can be quickly stabilized with a pelvic binder. After the pelvic binder is placed, continued resuscitation and investigation of other possible locations of bleeding should occur.
Answer 4: While this patient may benefit from embolization, the first step is to close down the pelvis. Closing down the pelvis may prevent the need for embolization.