ABSTRACT
Up to 13% of patients sustaining blunt pelvic fractures will present in shock. These patients with high-energy pelvic fractures have multiple, coincident sources of potential haemorrhage beyond the pelvis, including the chest and abdomen, with a 30% mortality rate. Attribution of pelvic haemorrhage as the cause of death is confounded by multiple sources of haemorrhage, as well as accompanying traumatic brain injury (TBI) and subsequent multi-system organ failure from high-energy trauma. To save these lives, a comprehensive approach is required to;
1. Identify the pelvis as a primary or contributing source of exsanguinating haemorrhage 2. Intervene quickly to stop the bleeding
Pelvic anatomy and haemorrhage The bony pelvis includes the three paired bones of the pubis, ilium and ischium, and a single sacrum posteriorly; together, they form an antero-inferior tilted bony cavity (Figure 7.1). The bones are connected anteriorly by the ligamentous public symphysis and
Objectives 153 Pelvic anatomy and haemorrhage 153 Damage control for pelvic haemorrhage 155
Technique of pelvis-only extraperitoneal pelvic packing 157 Technique of extraperitoneal pelvic packing via the abdomen 158 Additional reading 160
posteriorly by the sacroiliac joints and multiple ligaments (sacrospinous, sacrotuberous and iliolumbar). When the pubic symphysis and sacroiliac ligaments are disrupted, the volume of the pelvic basin increases and has greater capacity for collecting haemorrhage in the pelvic retroperitoneal space. The pubis has two rami, superior and inferior, that join the ischium to form the obturator foramina. The pelvic cavity not only contains organs of the urogenital and lower gastrointestinal tracts, but also the transiting lower extremity neurovasculature and a dense concentration of blood vessels for the pelvic viscera and muscles. A rich venous plexus, in particular, is tethered to the pelvic walls, posterior and adherent to named arteries, which are vulnerable to laceration with pelvic fractures. Two branches of the internal iliac artery are also at particular risk of laceration with severe pelvic fractures, namely, the superior gluteal and internal pudendal arteries. The fractured surfaces of the pelvic bones themselves can bleed as well. Thus, there are three primary sources of pelvic bleeding after pelvic fracture:
1. Venous plexus (80% of all pelvic bleeding) 2. Arterial branches (10%–15% of open-book pelvic fractures and 75% of
haemodynamically unstable pelvic fractures) 3. Cancellous bony ends of fractures
The pelvis is like a hard pretzel in that one cannot break a pretzel in one place alone: it always breaks in at least two places. Structures (including vasculature) in proximity to the fractures can be injured, especially the pelvic veins. The pelvic cavity pressure is lower than venous and arterial pressures and has a large potential retroperitoneal space for haemorrhage and clot to fill. The pelvic organs are readily compressed or displaced upwards into the abdomen, enabling an even larger potential space to fill with blood. It is rare for the peritoneum overlying the clot and blood to rupture freely into the peritoneum; instead the pelvic peritoneum continues to auto-dissect away from the bony pelvis in all directions (posteriorly, laterally and anteriorly), creating more space for further haemorrhage. Exsanguinating pelvic haemorrhage is typically associated with arterial bleeding in combination with venous haemorrhage.
