Trauma - Pelvic injury

Key points

• Pelvic fractures are high-energy injuries and are likely to be associated with multiple other injuries.
• They can cause massive haemorrhage into the pelvis leading to shock; pelvic bleeding is mainly venous and often retroperitoneal.
• If an unstable pelvic fracture is suspected, the pelvis is stabilised manually while a pelvic binder is placed urgently, generally before intubation.
• The binder is applied at the level of the greater trochanters; placed over the iliac crests it is ineffective and may worsen the injury.
• Springing or rocking the pelvis is contraindicated because it can increase bleeding.

Overview

This Royal Children's Hospital Melbourne guideline covers the recognition and emergency management of pelvic injury in children, with a focus on pelvic binders, imaging and binder removal. Pelvic fractures are rare in children, are usually caused by a high-energy mechanism and can be associated with life-threatening abdominal, genitourinary, spinal, thoracic and intracranial injuries.

Assessment

High-risk mechanisms often involve crush injury: motor vehicle collisions (especially with ejection, lateral impact, rollover or fatalities), pedestrian or cyclist struck by a car, falls from height (typically over 3 m) and heavy objects such as a horse or quad bike falling onto the child. During the primary survey, haemodynamic compromise may show as tachycardia (bradycardia is a late sign), hypotension, prolonged capillary refill or end-organ hypoperfusion such as GCS below 15. Signs of pelvic injury include bruising, wounds, asymmetry or deformity, tenderness over the iliac crests, pubic symphysis, sacroiliac joints, ischial tuberosities or lumbosacral spine, and rectal or vaginal bleeding, blood at the urethral meatus or scrotal bruising. Instability is tested only once, by gentle compression of the iliac crests, preferably by the most senior clinician, and is avoided if instability is obvious or imaging is already planned. Log rolling needs caution.

Applying a pelvic binder

A binder should be available in advance when the mechanism and pre-hospital findings suggest pelvic injury. There is little evidence favouring one proprietary binder over another. If the available binders are too large, a circumferential sheet is used: a folded sheet is placed under the child at the greater trochanters, crossed and twisted over the pubic symphysis, pulled firmly by two team members and secured with clamps, preferably plastic, as metal clamps can obscure X-ray and CT. If there are no lower limb fractures, the feet are tied together with a figure-of-eight bandage around the ankles to increase internal rotation of the hip.

Investigations and binder removal

An AP pelvic X-ray is used; point-of-care ultrasound (FAST) is controversial in paediatric trauma and of limited value for pelvic fractures. If the child does not improve after binder application and resuscitation, urgent angio-embolisation or surgery may be needed; CT is considered and paediatric trauma specialist advice sought. In an unstable fracture the binder stays until definitive stabilisation, but it occasionally worsens instability (for example in lateral compression fractures), when loosening or removal is decided with orthopaedics and senior oversight. Binders can cause abrasions and pressure sores and are removed as early as possible when there is no evidence of fracture.

Frequently asked questions

Should binder placement wait for a FAST scan?

No. Application of a pelvic binder should not be delayed to perform FAST.

Why is monitoring needed after the binder is removed?

A binder can fully reduce an unstable fracture so that it is not seen on X-ray or CT; removal is done in an area capable of resuscitation, and if the child deteriorates the binder is reapplied and further imaging is performed.

Where should children with major trauma be treated?

All children with major trauma should be transferred to a major trauma service for definitive management, in line with local pre-hospital and inter-hospital transfer guidelines.

Source

The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Trauma - Pelvic injury. Last updated March 2024. Endorsed by the Paediatric Improvement Collaborative (PIC). Summary prepared by Medpresso from the original guideline; it is not a substitute for the full text or for medical advice.