Acute management

Pelvic fracture APC


Pelvic hemorrhage




Constantini et al J Trauma Acute Care Surg 2016

- multi-centred prospective study of 1339 patients with pelvic fractures at Level 1 trauma centers

- overall mortality 9%

- pelvic trauma with shock has 30% mortality


Dente et al Am J Surg 2005

- 44 open pelvic fractures

- overall mortality 45%

- concurrent intra-abdominal injury 89% mortality

- pelvic sepsis 60% mortality


EMST / ATLS principles


Blood transfusion protocols

1:1:1 Plasma / Platelets / RBC


Transexamic acid

Loading dose 1g over 10 min then infusion of 1g over 8 h


Abdominal FAST scan to identify intra-abdominal bleeding


Rectal and vaginal examination


Patients in persistent shock despite blood transfusion (systolic 70 - 80 mmHg) go to operating room


Provisional Stabilization in the Emergency Room




Reduce pelvic volume and stabilize pelvic ring




Sheet / Pelvic Binder/ C-clamp




Pizanis et al Injury 2013

- 207 patients treated with sheet (16%) v pelvic binder (15%) v C-clamp (69%)

- higher incidence of lethal bleeding with sheet (23%) v pelvic binder (4%) v C clamp (8%)


Audretsch et al Sci Rep 2021

- compared 40 patients with type C fractures with no stabilization v pelvic binder v C-clamp

- shorter time to application with pelvic binder

- no evidence of advantage of C-clamp over pelvic binder


Schmal et al Injury 2019

- use of C-clamp resulted in 5 fold increase infection for subsequent SI joint screws


Pelvic binder


Simple, easy to use

Apply over greater trochanter


Pelvic binder 1Pelvic binder 2Pelvic binder


APC pre binderAPC post binder

APC fracture pre- and post binder (note improper position cranial to trochanters)


C clamp


C Clamp 1C clamp 2C clamp 3C clamp 4




Contra-indicated in iliac wing fracture / can over compression in cases with sacral comminution




AO foundation technique

Synthes surgical technique PDF


Entry point of steinmann pins

- intersection of 2 lines

- line parallel with femur / line back from ASIS


Management of hemodynamically unstable pelvic fractures


Sources of hemorrhage


Arterial bleeders 15%


Abboud et al BMC Emerg Med 2021

- CTa of 127 consecutive pelvic fractures

- 12% had intra-pelvic arterial bleeders

- most common:  obturator artery / superior gluteal / inferior gluteal arteries

- others: internal iliac / internal pudendal / fifth lumbar / lateral sacral / ilio-lumbar

- APC > Vertical shear > LC


Venous bleeding 85%


Presacral or lumbar venous plexus

Fracture site




External fixation + extra-peritoneal pelvic packing

Pelvic angiography + embolisation


Pelvic packing versus Angiography


In the hemodynamically unstable patient with a bleeding pelvic fracture

- early pelvic packing and external fixation

- +/- subsequent embolization as needed


Osborn et al Injury 2016

- RCT of 56 patients with hemodynamically unstable pelvic ring fractures

- pelvic angiography (ANGIO) versus retroperitoneal pelvic packing (PACK)

- median time to ANGIO was 102 minutes versus 77 minutes to PACK

- 9/27 (33%) ANGIO patients required packing for persistent bleeding

- 6/29 (21%) in the PACK group required angio for persistent bleeding

- 2 patients in ANGIO group died from exsanguination

- 0 patients in PACK group died from exsanguination


Chiara et al World J Emerg Surg 2017

- 78 patients with hemodynamically unstable pelvic fractures where pelvic was major source of bleeding

- extra-peritoneal packing reduced mortality from 50% to 20%


Tai et al J Trauma 2011

- hemodynamically unstable pelvic fractures

- treated with angiography versus packing +/- subsequent angiography as needed

- mortality 70% in ANGIO group versus 36% in PACK and subsequent angio group


Li et al J Orthop Traumatol 2022

- meta-analysis of packing v angiography

- 8 studies and 480 patients

- packing thought to reduced mortality and transfusion


Retro-peritoneal packing + external fixation


Pelvic packing


Vumedi video of peritoneal packing


Packs need to be removed at 48 hours due to infection risk

Ensure bladder decompressed with foley catheter


Retroperitoneal packing 1Retroperitoneal packing 2

Retroperitoneal packing in unstable patient with pubic diastasis and pelvic bleeding


Pelvic ex fixPelvic ex fix 2


External fixation technique




Hemodynamically unstable patients

Anterior pelvic ring injuries

Can be definitive treatment for those with open or visceral injuries precluding anterior internal fixation




Iliac crest frame


Supra-acetabular frame

- pins in AIIS

- requires fluoroscopy


Technique iliac crest


Vumedi video sawbones iliac crest external fixation


Vumedi video intra-operative iliac crest external fixation


Technique supra acetabular


AO foundation pelvic supra acetabular external fixation technique


Vumedi video supra acetabular external fixation


Pelvic ex fix 1Pelvic ex fix 2


Pelvic ex fix 3Pelvic ex fix 4