World Journal of Surgery

, Volume 28, Issue 9, pp 904–909 | Cite as

Hemodynamically Unstable Pelvic Fractures: Recent Care and New Guidelines

  • Martin J. Heetveld
  • Ian Harris
  • Glen Schlaphoff
  • Zsolt Balogh
  • Scott K. D’Amours
  • Michael Sugrue
Original Scientific Reports


Consistent care of hemodynamically unstable pelvic fracture patients is a major management issue. It was uncertain whether the introduction of newly developed clinical practice guidelines would require much change in current delivery of care at our institution. Assessment of recent care was undertaken and compared with the newly developed evidence-based best practice guidelines. A multidisciplinary project team developed clinical practice guidelines for determination of early optimum management of hemodynamically unstable patients with pelvic fractures. The guidelines recommend a definitive management plan to arrest hemorrhage within 30 minutes. Intra-abdominal hemorrhage should be assessed with diagnostic peritoneal aspiration (DPA) and/or focused assessment with sonography for trauma (FAST). Early noninvasive stabilization of the pelvis followed by angiography within 90 minutes are recommended if intra-abdominal hemorrhage is not found. Recent care was assessed in a historical cohort of patients, identified in a prospectively maintained trauma registry, between June 1999 and December 2001. Investigations, interventions, and times were then compared with the new guidelines. The delivery of care to 30 patients (mortality 37%, mean ISS 37.8 ± 20.9) was studied. Compared with the new guidelines, the abdominal assessment rate with DPA and/or FAST was 53% and early (< 90 minutes) angiography rate was 38%. A form of pelvic external stabilization was applied in 27% of cases. Noninvasive pelvic stabilization was not performed at all. The recent care of hemodynamically unstable pelvic fracture patients was not in line with newly developed guidelines. There is an opportunity to markedly improve the rates of initial assessment of the abdomen, pelvic stabilization, and early angiography.


Pelvic Fracture Pelvic Ring Pelvic Trauma Pelvic Hemorrhage Unstable Pelvic Fracture 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    McMurtry, R, Walton, D, Dickenson, D,  et al. 1980Pelvic disruption in the polytraumatized patientClin. Orthop.1512230PubMedGoogle Scholar
  2. 2.
    Panetta, T, Sclafani, SGA, Goldstein, AS,  et al. 1985Percutaneous transcatheter embolisation for massive bleeding from pelvic fracturesJ. Trauma2510211029PubMedGoogle Scholar
  3. 3.
    Moreno, C, Moore, EE, Rosenberger, A,  et al. 1986Haemorrhage associated with major pelvic fractureJ. Trauma26987989PubMedGoogle Scholar
  4. 4.
    Flint, L, Babikian, G, Anders, M,  et al. 1990Definitive control of mortality from severe pelvic fractureAnn. Surg.211703707PubMedGoogle Scholar
  5. 5.
    Gruen, RJ, Peitzman, AB 1994The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fracturesJ. Trauma36706713PubMedGoogle Scholar
  6. 6.
    Eastridge, BJ, Starr, A, Minei, JP,  et al. 2002The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptionsJ. Trauma53446451PubMedGoogle Scholar
  7. 7.
    Miller, PR, Moore, PS, Mansell, E,  et al. 2003External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhageJ. Trauma54437443PubMedGoogle Scholar
  8. 8.
    Ben-Menachem, Y, Coldwell, DM, Young, JW,  et al. 1991Hemorrhage associated with pelvic fracturesAm. J. Roentgenol.15710051014Google Scholar
  9. 9.
    Ali, J, Howard, M, Williams, J 2002Is attrition of ATLS acquired skills affected by trauma patient volume?Am. J. Surg.183142145CrossRefPubMedGoogle Scholar
  10. 10.
    Grimshaw, JM, Russell, IT 1993Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluationsLancet34213171322CrossRefPubMedGoogle Scholar
  11. 11.
    Caldwell E, Sugrue M, Johansson K, et al. South Western Sydney Area Health Service Regional Trauma Registry Report on 5 Years 1995 to 1999. ISBN 1 875909 88 5.2000Google Scholar
  12. 12.
    Burgess, AR, Tile, M 1991Fractures of the pelvisRockwood, CAGreen, DP eds. Fractures in AdultsLippincottPhiladelphia13991442Google Scholar
  13. 13.
    National Health and Medical Research Council. A guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines, Sydney, National Health and Medical Research Council, 1999Google Scholar
  14. 14.
    American College of Surgeons. ATLS Instructor Course Manual, Book 1, 6th edition, Chicago, American College of Surgeons, 1997Google Scholar
  15. 15.
    Hamill, J, Holden, A, Paice, R,  et al. 2000Pelvic fracture pattern predicts arterial hemorrhageANZ J. Surg.70338343CrossRefGoogle Scholar
  16. 16.
    Sugrue, M 2002Diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL)Handbook of Trauma Care: Liverpool Hospital Trauma ManualD’Amours SK, Sugrue M, Russell R, Nocera NGraphitypeSydneyGoogle Scholar
  17. 17.
    Farquhar, CM, Kofa, EW, Slutsky, JR 2002Clinicians’ attitudes to clinical practice guidelines: a systematic reviewMed. J. Aust.177502506PubMedGoogle Scholar
  18. 18.
    The Eastern Association for the Surgery of Trauma Web site. Scholar
  19. 19.
    AMA. Office of Quality Insurance & Health Care Organisations. Attributes to Guideline Development of Practice Parameters, Chicago, American Medical Association, 1990Google Scholar
  20. 20.
    Looser, KG, Crombie, HD,Jr 1976Pelvic fractures: an anatomic guide to severity of injury: review of 100 casesAm. J. Surg.132638642CrossRefPubMedGoogle Scholar
  21. 21.
    Cryer, HM, Miller, FB, Evers, EM,  et al. 1988Pelvic fracture classification: correlation with hemorrhageJ. Trauma28973980PubMedGoogle Scholar
  22. 22.
    Poole, GV, Ward, EF 1994Causes of mortality in patients with pelvic fracturesOrthopedics17691696PubMedGoogle Scholar
  23. 23.
    Klein, SR, Saroyan, M, Baumgartner, F,  et al. 1992Management strategy of vascular injuries associated with pelvic fracturesJ. Cardiovasc. Surg.33349357Google Scholar
  24. 24.
    Clarke, JR, Trooskin, SZ, Doshi, PJ,  et al. 2002Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutesJ. Trauma52420425PubMedGoogle Scholar
  25. 25.
    Tile, M 1988Pelvic ring fractures: should they be fixed?J. Bone Joint Surg. Br.70112PubMedGoogle Scholar
  26. 26.
    Dalal, SA, Burgess, AR, Siegel, JH,  et al. 1989Pelvic fracture in multiple trauma: classification by mechanism in key to pattern of organ injury, resuscitative requirements and outcomeJ. Trauma299811002PubMedGoogle Scholar
  27. 27.
    Poole, GV, Ward, EF, Muakkassa, FS,  et al. 1991Pelvic fracture from major blunt traumaAnn. Surg.213532539PubMedGoogle Scholar
  28. 28.
    Velmahos, GC, Toutouzas, K, Vassiliu, P,  et al. 2002A prospective study on the safety and efficacy of angiographic embolisation for pelvic and visceral injuriesJ. Trauma53303308PubMedGoogle Scholar
  29. 29.
    Agolini, SF, Shah, K, Jaffe, J,  et al. 1997Arterial embolisation is a rapid and effective technique for controlling pelvic fracture hemorrhageJ. Trauma43395399PubMedGoogle Scholar
  30. 30.
    Biffl, WA, Smith, WR, Moore, EE,  et al. 2001Evolution of a multidisciplinary clinical pathway for the management of haemodynamically unstable patients with a pelvic fractureAnn. Surg.233843850CrossRefPubMedGoogle Scholar
  31. 31.
    Velmahos, GC, Chahwan, S, Falabella, A,  et al. 2000Angiographic embolisation for intraperitoneal and retroperitoneal injuriesWorld J. Surg.24539545CrossRefPubMedGoogle Scholar
  32. 32.
    Resnik, CS, Stackhouse, DJ, Shanmuganathan, K,  et al. 1992Diagnosis of pelvic fractures in patients with acute pelvic trauma: efficacy of plain radiographsAm. J. Roentgenol.158109112Google Scholar
  33. 33.
    Robertson, DD, Sutherland, CJ, Chan, BW,  et al. 1995Depiction of pelvic fractures using 3D volumetric holography: comparison of plain X-ray and CTJ. Comput. Assist. Tomogr.19967974Google Scholar
  34. 34.
    Grant, PT 1990The diagnosis of pelvic fractures by ‘springing’Arch. Emerg. Med.7178182PubMedGoogle Scholar
  35. 35.
    Nunes, LW, Simmons, S, Hallowell, MJ,  et al. 2001Diagnostic performance of trauma US in identifying abdominal or pelvic free fluid and serious abdominal or pelvic injuryAcad. Radiol.8128136CrossRefPubMedGoogle Scholar
  36. 36.
    Rozycki, GS, Ballard, R, Feliciano, DV,  et al. 1998Surgeon performed ultrasound for the assessment of truncal injuriesAnn. Surg.228557567CrossRefPubMedGoogle Scholar
  37. 37.
    Stephen, DJ, Kreder, HJ, Day, AC,  et al. 1999Early detection of arterial bleeding in acute pelvic traumaJ. Trauma47638642PubMedGoogle Scholar
  38. 38.
    Shanmuganathan, K, Mirvis, SE, Sover, ER 1993Value of contrast enhanced CT in detecting active haemorrhage in patients with blunt abdominal or pelvic traumaAm. J. Roentgenol.1616569Google Scholar
  39. 39.
    Simpson, T, Krieg, JC, Heuer, F,  et al. 2002Stabilisation of pelvic ring disruptions with a circumferential sheetJ. Trauma52158161PubMedGoogle Scholar
  40. 40.
    Broos, P, Vanderschot, P, Crannx, L,  et al. 1992The operative treatment of pelvic ring fracturesInt. Surg.77303308PubMedGoogle Scholar
  41. 41.
    Kellam, JF 1989The role of external fixation in pelvic disruptionsClin. Orthop.2416682PubMedGoogle Scholar
  42. 42.
    Routt, MLC, Simonian, PT, Ballmer, F 1995A rational approach to pelvic traumaClin. Orthop.3186174PubMedGoogle Scholar
  43. 43.
    Kaufman, JA, Waltman, AC 1997Angiographic Management of Hemorrhage in Pelvic FracturesBaum, SPentecost, M eds. Abrams Angiography–Interventional Radiologyvol 3Lippincott-RavenPhiladelphia86983Google Scholar
  44. 44.
    Siegel, JH, Rivkind, AI, Dalal, S,  et al. 1990Early physiologic predictors of injury severity and death in multiple traumaArch. Surg.125498508PubMedGoogle Scholar
  45. 45.
    Ertel, W, Keel, M, Eid, K,  et al. 2001Control of severe haemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruptionJ. Orthop. Trauma15468474CrossRefPubMedGoogle Scholar
  46. 46.
    Allen, CF, Goslar, PW, Barry, M,  et al. 2000Management guidelines for hypotensive pelvic fracture patientsAm. Surg.66735738PubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2004

Authors and Affiliations

  • Martin J. Heetveld
    • 1
  • Ian Harris
    • 2
  • Glen Schlaphoff
    • 3
  • Zsolt Balogh
    • 4
  • Scott K. D’Amours
    • 4
  • Michael Sugrue
    • 4
  1. 1.Trauma Unit, Department of SurgeryAcademic Medical CenterAmsterdamThe Netherlands
  2. 2.Department of OrthopaedicsLiverpool HospitalLiverpool BCAustralia
  3. 3.Department of Interventional RadiologyLiverpool HospitalLiverpool BCAustralia
  4. 4.Department of TraumaLiverpool HospitalLiverpool BCAustralia

Personalised recommendations