Immediate management of a stable patient with unstable pelvis

Key points

• In unstable pelvic fractures, hemodynamic stability should be a diagnosis by exclusion: the more unstable the fracture, the higher the risk of bleeding, and stability is only a temporary state.
• A pelvic binder should be standard as early as possible, including before hospital, in high-impact blunt trauma regardless of the mechanism; it must sit over both greater trochanters and never above the symphysis pubis.
• An immediate one-stage contrast-enhanced CT scan is the appropriate test for bleeding in stable patients, but because of radiation, plain X-rays should be considered when there is reasonable suspicion that no unsafe bleeding is going on.
• External fixation is mainly indicated for open fractures, and for closed ones when definitive osteosynthesis is delayed by the patient's general condition; when possible, immediate percutaneous sacroiliac screws give excellent results, even in open fractures.
• In open pelvic fractures, a broad-spectrum antibiotic should be given as early as possible, preferably within 1 h of the accident.

Overview

This EFORT Open Reviews instructional course review offers a strategy for diagnosing and treating an unstable pelvic fracture once the patient is known to be hemodynamically stable. Because all patients in hemorrhagic shock were stable until they became unstable, the authors stress early ring closure, careful imaging choices and prompt fixation. It is a narrative review drawing on the literature and the authors' experience, not a graded guideline.

Hemodynamic assessment and imaging

A sustained systolic blood pressure below 80–90 mm Hg after vasoactive drugs is considered a sign of active bleeding, and a heart rate above 100–110 beats per minute in a trauma patient indicates hemodynamic instability; coagulation tests and lactate are also useful. An abdominal CT exposes the patient to 10–20 mSv versus 0.01–0.1 mSv for a chest X-ray, and the literature reports 20–40% negative scans, so CT should be even more restrictive in children. Imaging is preferably done with the binder on, but if an unstable fracture is suspected, the binder should be released just during the CT scan, as an open-book injury can be missed with it in place.

Classification and bleeding risk

The Young and Burgess and AO-Tile classifications link mechanism, displacement and bleeding risk. Lateral compression closes the ring, so severe bleeding is not expected; anteroposterior trauma opens the ring and can tear the presacral and retropubic venous plexuses; vertical injuries are nearly always followed by major bleeding. Type A fractures should not carry a major bleeding risk, whereas anteroposterior type B fractures with more than 2.5 cm of opening or bilateral injuries, and mainly type C fractures, may cause instability.

Stabilization options

The pelvic binder is considered the gold standard for closing the ring; it is not harmful in a stable pelvis but can cause skin sores if kept on for more than 2–3 days, and the legs should be kept together with the feet in internal rotation. External fixator pins should never be placed in the iliac crest; one 5–7 mm pin on each side above the hip joint, at the level of the anteroinferior iliac spine, gives robust purchase. A C-clamp can stabilize the posterior ring when the iliac bone is intact, but pin positioning is difficult and pins can migrate, and a binder is as efficient and preferred whenever possible. Definitive surgery within 72 h usually seems safe, and acute transiliac-transsacral screws can shorten this time.

Special situations and medication

Intraperitoneal bladder injuries usually need surgical repair, whereas extraperitoneal ones can be managed with a transurethral catheter; anorectal trauma is present in more than 30% of open fractures and may need a diverting colostomy. Elderly patients could represent 40% of trauma admissions by 2050, and in pregnancy X-rays should guide care where possible, with CT if needed after interdisciplinary assessment. Dose-adjusted intravenous morphine is needed for pain in high-energy trauma.

Frequently asked questions

Is a patient who is stable on arrival safe from bleeding?

Not necessarily. Stability is a temporary concept, and an occult bleeding source may cause later instability, so stability should be a diagnosis by exclusion.

Should the pelvic binder stay on during imaging?

Generally yes, but if an unstable fracture is suspected, it should be released only during the CT scan, once the patient is positioned, so that an open-book injury is not missed.

Does tranexamic acid help?

A British Orthopaedic Association consensus advises intravenous tranexamic acid, ideally within 1 h of injury; a Cochrane review found low-certainty evidence of fewer transfusions up to 30 days but no difference in all-cause mortality.

Source

Cano JR, Bogallo JM, Ramirez A, Guerado E. Immediate management of a stable patient with unstable pelvis. EFORT Open Rev 2024;9(5). doi:10.1530/EOR-24-0055. Open access. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.