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CLINICAL MANAGEMENT UPDATE

Eastern Association for the Surgery of Trauma PracticeManagement Guidelines for Hemorrhage in Pelvic

Fracture—Update and Systematic Review

Daniel C. Cullinane, MD, Henry J. Schiller, MD, Martin D. Zielinski, MD, Jaroslaw W. Bilaniuk, MD,Bryan R. Collier, DO, John Como, MD, Michelle Holevar, MD, Enrique A. Sabater, MD, S. Andrew Sems, MD,

W. Matthew Vassy, MD, and Julie L. Wynne, MD

Background: Hemorrhage from pelvic fracture is common in victims ofblunt traumatic injury. In 2001, the Eastern Association for the Surgery ofTrauma (EAST) published practice management guidelines for the manage-ment of hemorrhage in pelvic trauma. Since that time there have been newpractice patterns and larger experiences with older techniques. The PracticeGuidelines Committee of EAST decided to replace the 2001 guidelines withan updated guideline and systematic review reflecting current practice.Methods: Building on the previous systematic literature review in the 2001EAST guidelines, a systematic literature review was performed to includereferences from 1999 to 2010. Prospective and retrospective studies wereincluded. Reviews and case reports were excluded. Of the 1,432 articlesidentified, 50 were selected as meeting criteria. Nine Trauma Surgeons, anInterventional Radiologist, and an Orthopedic Surgeon reviewed the articles.The EAST primer was used to grade the evidence.Results: Six questions regarding hemorrhage from pelvic fracture wereaddressed: (1) Which patients with hemodynamically unstable pelvic frac-tures warrant early external mechanical stabilization? (2) Which patientsrequire emergent angiography? (3) What is the best test to exclude extrapel-vic bleeding? (4) Are there radiologic findings which predict hemorrhage?(5) What is the role of noninvasive temporary external fixation devices? and(6) Which patients warrant preperitoneal packing?Conclusions: Hemorrhage due to pelvic fracture remains a major cause ofmorbidity and mortality in the trauma patient. Strong recommendations were maderegarding questions 1 to 4. Further study is needed to answer questions 5 and 6.Key Words: Pelvic fracture, Hemorrhage, Angiography, Embolization,External fixator, C-clamp, Temporary pelvic binder, Pelvic packing, Trauma,Intravenous contrast extravasation, Blush, PASG, Pelvic hematoma, FAST,CT scan, Fracture pattern.

(J Trauma. 2011;71: 1850–1868)

STATEMENT OF THE PROBLEMHemorrhage from pelvic fracture is common in victims of

blunt traumatic injury. In 2001, the Eastern Association for theSurgery of Trauma (EAST) published practice managementguidelines for the management of hemorrhage in pelvictrauma.1 Since that time there have been a number of newpractice patterns and larger experiences with older tech-niques. The Practice Guidelines Committee of EAST decidedto update the 2001 EAST guidelines and systematic reviewfor hemorrhage due to pelvic fracture. The design of theproject was to update the previous guideline as well as toevaluate new treatment methods and techniques. Six specificquestions are addressed regarding the management of pelvicfracture hemorrhage:

1. Which patients with hemodynamically unstable pelvicfractures warrant early external mechanical stabilization?

2. Which patients require emergent angiography?3. What is the best test to exclude extrapelvic bleeding?4. Are there radiologic findings which predict hemorrhage?5. What is the role of noninvasive temporary external fixa-

tion devices?6. Which patients warrant preperitoneal packing (PPP)?

PROCESSThe Practice Management Guidelines Committee of

the EAST (www.east.org) developed the process used bythis committee for review and development of practicemanagement guidelines. A computerized search of theNational Library of Medicine MEDLINE database wasundertaken using the OVID interface. English languagecitations were included for the period of 1999 through2010 using the primary search strategy: pelvis, fracturehemorrhage, trauma, and retroperitoneal hematoma. Thedates were selected to allow comprehensive review ofarticles published since the prior systematic review withminimal overlap.

Review articles and case reports were excluded.Moreover, studies not directly addressing hemorrhage withpelvic fracture were excluded. The PubMed Related Arti-cles algorithm was also used to identify additional articlessimilar to the items retrieved by the primary strategy. Ofthe 1,432 articles identified by these two techniques, those

Submitted for publication April 21, 2011.Accepted for publication October 18, 2011.Copyright © 2011 by Lippincott Williams & WilkinsFrom the Departments of Surgery (D.C.C., H.J.S., M.D.Z.) and Orthopedics (S.A.S.),

Mayo Clinic, Rochester, Minnesota; Department of Surgery, Morristown Memo-rial Hospital (J.W.B.), Morristown, New Jersey; Department of Surgery, Vander-bilt University Medical Center (B.R.C.), Nashville, Tennessee; Department ofSurgery, MetroHealth Medical Center (J.C.), Cleveland, Ohio; Department ofSurgery, Mount Sinai Hospital (M.H.), Chicago, Illinois; Department of Radiol-ogy, HIMA-San Pablo Hospital (E.A.S.), Bayamon, Puerto Rico; Department ofSurgery, Evansville Surgical Associates (W.M.V.), Newburgh, Indiana; andDepartment of Surgery, University of Arizona (J.L.W.), Tucson, Arizona.

Presented at the 22nd Annual Scientific Assembly of the Eastern Association forthe Surgery of Trauma, January 16, 2009, Lake Buena Vista, Florida.

Address for reprints: Daniel C. Cullinane, MD, Department of Surgery, Mayo Clinic,200 First St, SW, Rochester, MN 55905; email: [email protected].

DOI: 10.1097/TA.0b013e31823dca9a

1850 The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011

dealing with prospective or retrospective studies wereselected, comprising 50 studies specifically evaluatinghemorrhage associated with pelvic fracture in adult orpediatric patients.

The EAST, “Utilizing evidence based outcome mea-sures to develop practice management guidelines: a primer,”was used as a quality assessment instrument applied todevelop this guideline.2

The workgroup for the Practice Management Guide-lines for Hemorrhage in Pelvic Trauma consisted of nineTrauma Surgeons, an Orthopedic Surgeon specializing intrauma (S.A.S.), and an Interventional Radiologist (E.A.S.)(Table 1). Articles were compiled by the committee chair(D.C.C.) and were distributed among committee members forformal review. Each article was entered into a review datasheet with detailed summaries of the articles. Deficienciesand conclusions not validated by the data were also noted.The reviewers correlated the references with the method-ology established by the Agency for Health policy andResearch of the US Department of Health and HumanService. Each reference was classified as class I, class II,or class III data. There was no class I data found for thesearch period. Fifteen class II articles and 35 class IIIarticles were included in the review. All references werereviewed by at least two committee members for purposesof cross-validation. An evidentiary table was constructedusing the 50 references (Table 2).

Level IThis recommendation is convincingly justifiable based

on the available scientific information alone. It is generallybased on class I data or strong class II evidence may form thebasis for a Level I recommendation. Conversely, weak orcontradictory class I data may not be able to support a LevelI recommendation.

Level IIThis recommendation is reasonably justifiable by avail-

able scientific evidence and strongly supported by expertopinion. It is usually supported by class II data or a prepon-derance of class III evidence.

Level IIIThis recommendation is supported by available data,

but adequate scientific evidence is lacking. It is generallysupported by class III data. This type of recommendationis useful for educational purposes and in guiding futurestudies.

Although there were not any class I references avail-able, four Level I recommendations were made due to thestrong class II data (large retrospective and nonrandomizedprospective data) available for specific questions. Level IIrecommendations were supported by class II data and arejustified by available scientific evidence and strongly sup-ported by expert opinion. Nine Level II recommendationswere made from the available data. Level III recommenda-tions were based on class III data, where adequate scientificevidence is lacking. Twelve Level III recommendations areincluded in these recommendations.

RECOMMENDATIONS

Which Patients With HemodynamicallyUnstable Pelvic Fractures Warrant EarlyExternal Mechanical Stabilization?

1. The use of a pelvic orthotic device (POD) does not seemto limit blood loss in patients with pelvic hemorrhage.Level III recommendation

2. The use of a POD effectively reduces fracture displacement anddecreases pelvic volume. Level III recommendation

Scientific Foundation: Early External StabilizationIt is well known that the volume of the pelvis increases

after a mechanically unstable pelvic fracture (Tile B/C; Table3). This increased pelvic volume in complex pelvic fracturesis thought to reduce the tamponade effect of the retroperito-neal tissues and intrapelvic organs, leading to further bleed-ing into the pelvic space. Baque et al.3 demonstrated a 20%increase in the volume of the pelvis with a 5-cm pubicdiastasis in a cadaver pelvic-fracture model. The iliolumbarvein was noted to be disrupted in 60% of the pelvic fracturescreated, accounting for the venous hemorrhage seen withfractures of the sacroiliac portion of the pelvis. Using com-

TABLE 1. Members of the EAST Hemorrhage in Pelvic Fracture Workgroup

Name Organization/Place Email

Daniel C. Cullinane, MD—Chair Mayo Clinic, Rochester, MN [email protected]

Henry J. Schiller, MD Mayo Clinic, Rochester, MN [email protected]

Jaroslaw W. Bilaniuk, MD Morristown Memorial Hospital, Morristown, NJ [email protected]

Bryan R. Collier, DO Vanderbilt University Medical Center, Nashville, TN [email protected]

John Como, MD MetroHealth Medical Center, Cleveland, OH [email protected]

Michelle Holevar, MD Mount Sinai Hospital, Chicago, IL [email protected]

Enrique A. Sabater, MD HIMA-San Pablo Hospital, Bayamon, PR [email protected]

S. Andrew Sems, MD Mayo Clinic, Rochester, MN [email protected]

W. Matthew Vassy, MD Evansville Surgical Associates, Newburgh, IN [email protected]

Julie L. Wynn, MD University of Arizona, Tucson, AZ [email protected]

Martin D. Zielinski, MD Mayo Clinic, Rochester, MN [email protected]

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011 EAST Pelvic Fracture Guidelines

© 2011 Lippincott Williams & Wilkins 1851

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Cullinane et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011

© 2011 Lippincott Williams & Wilkins1852

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a.20

03;5

4:43

7–44

3



TAB

LE2.

Evid

entia

ryTa

ble

1999

–201

0(c

ontin

ued)

Aut

hor(

s)Y

ear

Tit

leL

evel

ofE

vide

nce

Que

stio

nA

ddre

ssed

Syno

psis

Ref

eren

ce

Gou

rlay

etal

.22

2005

Pel

vic

angi

ogra

phy

for

recu

rren

ttr

aum

atic

pelv

icar

teri

alhe

mor

rhag

e2

2S

tudy

coho

rtof

39pa

tien

tsw

hoha

dre

peat

angi

ogra

phy

for

recu

rren

tpe

lvic

hem

orrh

age.

The

33pa

tien

tsw

ith

apo

siti

vese

cond

angi

ogra

mha

dbl

eedi

ngat

ane

wsi

tein

28(8

5%)

and

atth

epr

evio

usly

embo

lize

dsi

tein

11(3

3%).

All

embo

liza

tion

sat

the

repe

atan

giog

ram

wer

eth

ough

tto

bete

chni

call

ysu

cces

sful

.S

igni

fica

ntri

skfa

ctor

sfo

rre

curr

ent

pelv

icar

teri

alhe

mor

rhag

ear

e(1

)pr

eang

iogr

amhy

pote

nsio

n,(2

)pu

bic

sym

phys

isdi

srup

tion

,(3

)gr

eate

rnu

mbe

rof

inju

red

arte

ries

onin

itia

lar

teri

ogra

m,

(4)

coag

ulop

athy

,an

d(5

)re

quir

em

ore

bloo

dtr

ansf

usio

n.T

heau

thor

sco

nclu

ded

that

pati

ents

wit

hth

ese

char

acte

rist

ics

may

man

ifes

tre

curr

ent

arte

rial

blee

ding

,an

dit

may

bepr

uden

tto

reta

inth

ean

gio

shea

thfo

rup

to72

h

JT

raum

a.20

05;5

9:11

68–

1173

Tak

ahir

aet

al.3

220

01G

lute

alm

uscl

ene

cros

isfo

llow

ing

tran

scat

hete

ran

giog

raph

icem

boli

sati

onfo

rre

trop

erit

onea

lha

emor

rhag

eas

soci

ated

wit

hpe

lvic

frac

ture

32

Rev

iew

ofpa

tien

tsw

how

ent

bila

tera

lan

gioe

mbo

liza

tion

for

pelv

icF

x-re

late

dhe

mor

rhag

efo

und

that

5of

151

pati

ents

(3.3

%)

deve

lope

dgl

utea

lm

uscl

ene

cros

is.

All

had

embo

liza

tion

ofbi

late

ral

inte

rnal

ilia

car

teri

es.

Mor

tali

tyw

as60

%du

eto

seps

is/D

IC

Inju

ry.

2001

;32:

27–3

2

Yas

umur

aet

al.3

320

05H

igh

inci

denc

eof

isch

emic

necr

osis

ofth

egl

utea

lm

uscl

eaf

ter

tran

scat

hete

ran

giog

raph

icem

boli

zati

onfo

rse

vere

pelv

icfr

actu

re

32

8pa

tien

tsun

derw

ent

angi

ogra

phy

for

blee

ding

pelv

icF

xs.

6of

8un

derw

ent

embo

liza

tion

.4

of6

pati

ents

had

bila

tera

lin

tern

alil

iac

embo

liza

tion

s.2

of6

pati

ents

had

bila

tera

lsu

peri

or/i

nfer

ior

glut

eals

embo

lize

d.3

case

sof

tiss

uein

fect

ion,

4ca

ses

ofgl

utea

lne

cros

is,

and

2ca

ses

ofse

psis

.P

atie

nts

unde

rwen

tM

RI

at1

wk

and

4w

k.A

llw

ere

note

dto

have

glut

eal

mus

cle

necr

osis

,an

d2

pati

ents

deve

lope

dne

crot

izin

gso

ftti

ssue

infe

ctio

nne

cess

itat

ing

I&D

JT

raum

a.20

05;5

8:98

5–99

0

Fan

gio

etal

.20

2005

Ear

lyem

boli

zati

onan

dva

sopr

esso

rad

min

istr

atio

nfo

rm

anag

emen

tof

life

-thr

eate

ning

hem

orrh

age

from

pelv

icfr

actu

re

32

32he

mod

ynam

ical

lyun

stab

lepa

tien

tsun

derw

ent

pelv

ican

giog

raph

y,w

hich

was

foll

owed

byem

boli

zati

onin

25ca

ses.

Ang

iogr

aphy

was

succ

essf

ulin

24ca

ses

(96%

).T

here

was

hem

odyn

amic

impr

ovem

ent

in21

(84%

).L

iber

alus

eof

vaso

pres

sors

was

used

duri

ngth

eea

rly

stag

esof

hem

orrh

agic

shoc

kan

ddu

ring

angi

oem

boli

zati

on.

Mor

tali

ty36

%

JT

raum

a20

05;5

8:97

8–98

4

Bro

wn

etal

.62

2005

Doe

spe

lvic

hem

atom

aon

adm

issi

onco

mpu

ted

tom

ogra

phy

pred

ict

acti

vebl

eedi

ngat

angi

ogra

phy

for

pelv

icfr

actu

re?

32,

4R

etro

spec

tive

revi

ewof

37pe

lvic

Fx

pati

ents

who

unde

rwen

tC

Tan

dan

giog

raph

y.It

was

foun

dth

atth

esi

zeof

the

pelv

iche

mat

oma

onC

Tdi

dno

tco

rrel

ate

wit

hac

tive

pelv

icbl

eedi

ngon

angi

ogra

m.

Inad

diti

on,

the

abse

nce

ofa

cont

rast

blus

hdi

dno

tre

liab

lyex

clud

eac

tive

blee

ding

seen

onan

giog

raph

y

Am

Surg

.20

05;7

1:75

9–76

2

Coo

ket

al.1

920

02T

hero

leof

angi

ogra

phy

inth

em

anag

emen

tof

haem

orrh

age

from

maj

orfr

actu

res

ofth

epe

lvis

32,

423

pati

ents

wit

hon

goin

ghy

pote

nsio

nha

dan

giog

ram

wit

hun

stab

lepe

lvic

Fxs

.F

xpa

tter

ndi

dno

tpr

edic

tas

soci

ated

vasc

ular

inju

ry

JB

one

Join

tSu

rg.

2002

;84

:178

–182



TAB

LE2.

Evid

entia

ryTa

ble

1999

–201

0(c

ontin

ued)

Aut

hor(

s)Y

ear

Tit

leL

evel

ofE

vide

nce

Que

stio

nA

ddre

ssed

Syno

psis

Ref

eren

ce

Net

toet

al.6

420

08R

etro

grad

eur

ethr

ocys

togr

aphy

impa

irs

com

pute

dto

mog

raph

ydi

agno

sis

ofpe

lvic

arte

rial

hem

orrh

age

inth

epr

esen

ceof

alo

wer

urol

ogic

trac

tin

jury

32,

449

pati

ents

wit

hpe

lvic

Fx

and

eith

era

uret

hral

orbl

adde

rru

ptur

e.23

had

RU

Gor

cyst

ogra

mpe

rfor

med

befo

reC

T,

and

26ha

dcy

stog

raph

yaf

ter

CT

scan

ning

.P

erfo

rmin

gcy

stog

raph

ybe

fore

CT

was

asso

ciat

edw

ith

cons

ider

atel

ym

ore

inde

term

inat

esc

ans

(N�

9)an

dfa

lse

nega

tive

s(N

�2)

for

pelv

icar

teri

alex

trav

asat

ion.

Con

side

rati

onsh

ould

begi

ven

tope

rfor

min

gre

trog

rade

uret

hrog

raph

yan

dcy

stog

raph

yaf

ter

CT

scan

ning

asth

eyin

terf

ere

wit

hth

ede

tect

ion

ofac

tive

extr

avas

atio

non

CT

JA

mC

oll

Surg

.20

08;

206:

322–

327

Won

get

al.2

520

00M

orta

lity

afte

rsu

cces

sful

tran

scat

hete

rar

teri

alem

boli

zati

onin

pati

ents

wit

hun

stab

lepe

lvic

frac

ture

s:ra

teof

bloo

dtr

ansf

usio

nas

apr

edic

tive

fact

or

32,

4R

etro

spec

tive

revi

ew.

17he

mod

ynam

ical

lyun

stab

lepe

lvic

Fx

pati

ents

unde

rwen

tth

erap

euti

cem

boli

zati

on,

and

3of

the

pati

ents

subs

eque

ntly

died

,fo

ra

mor

tali

tyra

teof

17.6

%.

Blo

odtr

ansf

usio

nra

tebe

fore

embo

liza

tion

asw

ell

asti

me

inte

rval

toem

boli

zati

onw

ere

sign

ifica

ntpr

edic

tors

ofm

orta

lity

,bu

tsi

zeof

CE

was

not.

The

auth

ors

conc

lude

dth

atea

rly

reco

gnit

ion

ofar

teri

alpe

lvic

blee

ding

wit

hea

rly

embo

liza

tion

ises

sent

ial

JT

raum

a.20

00;4

9:71

–75

Hag

iwar

aet

al.2

620

03P

redi

ctor

sof

deat

hin

pati

ents

wit

hli

fe-t

hrea

teni

ngpe

lvic

hem

orrh

age

afte

rsu

cces

sful

tran

scat

hete

rar

teri

alem

boli

zati

on

22,

461

pati

ents

eval

uate

dw

ith

pros

pect

ive

prot

ocol

.13

of61

died

desp

ite

100%

succ

essf

ulan

gioe

mbo

liza

tion

.P

oste

rior

pelv

icbl

eedi

ngan

dA

PA

CH

EII

scor

espr

edic

ted

mor

tali

ty.

Fx

patt

erns

did

not

pred

ict

mor

tali

ty.

Non

surv

ivor

sre

quir

edm

ore

flui

dto

achi

eve

hem

odyn

amic

stab

ilit

y

JT

raum

a.20

03;5

5:69

6–70

3

Cro

ceet

al.6

920

07E

mer

gent

pelv

icfi

xati

onin

pati

ents

wit

hex

sang

uina

ting

pelv

icfr

actu

re2

1,5

186

patie

nts

with

mul

tiple

seve

repe

lvic

Fxs

unde

rwen

tst

abili

zatio

nof

the

pelv

isw

itha

POD

(C-C

lam

p)(9

3)vs

.tem

pora

ryex

tern

alpe

lvic

bind

er(9

3).T

rans

fusi

onre

quir

emen

tsw

ere

redu

ced

with

the

use

ofth

ebi

nder

,as

was

hosp

ital

leng

thof

stay

.The

rew

asno

stat

istic

ally

sign

ifica

ntdi

ffer

ence

inth

em

orta

lity

rate

s.T

heau

thor

sco

nclu

deth

atth

eus

eof

the

bind

erre

duce

str

ansf

usio

nre

quir

emen

tsan

dle

ngth

ofho

spita

lst

ay

JA

mC

oll

Surg

.20

07;

204:

935–

939

Bot

tlan

get

al.7

020

02E

mer

gent

man

agem

ent

ofpe

lvic

ring

frac

ture

sw

ith

use

ofci

rcum

fere

ntia

lco

mpr

essi

on

31,

5O

pen-

book

pelv

icF

xsw

ere

indu

ced

in7

cada

vers

.S

tabi

liza

tion

was

init

iall

ypr

ovid

edw

ith

the

pelv

icsl

ing.

Sub

sequ

entl

y,st

abil

ized

wit

ha

post

erio

rpe

lvic

C-c

lam

p/an

teri

orex

tern

alfi

xato

r.S

tabi

lity

prov

ided

byth

epe

lvic

slin

gw

asdi

rect

lyco

mpa

rabl

eto

that

prov

ided

byth

epo

ster

ior

pelv

icC

-cla

mp,

but

the

slin

gpr

ovid

edon

ly1/

3rd

ofth

efl

exio

n-ex

tens

ion

stab

ilit

yan

d1/

10th

ofth

ein

tern

al-e

xter

nal

rota

tion

stab

ilit

yas

com

pare

dw

ith

the

exte

rnal

fixa

tor.

The

auth

ors

conc

lude

that

the

slin

gis

wel

lsu

ited

for

tem

pora

rily

stab

iliz

atio

nof

the

acut

ely

inju

red

pati

ent

JB

one

Join

tSu

rgA

m.

2002

;84:

43–4

7

Bot

tlan

get

al.7

120

02N

onin

vasi

vere

duct

ion

ofop

en-b

ook

pelv

icfr

actu

res

byci

rcum

fere

ntia

lco

mpr

essi

on

35

Par

tial

lyst

able

and

unst

able

exte

rnal

rota

tion

inju

ries

ofth

epe

lvic

ring

wer

ecr

eate

din

7ca

dave

rs.

Ape

lvic

stra

pw

asap

plie

dat

3di

ffer

ent

leve

lsar

ound

the

pelv

is.

The

stra

pac

hiev

edco

mpl

ete

redu

ctio

nof

sym

phys

isdi

asta

sis

JO

rtho

pT

raum

a.20

02;

16:3

67–3

73



TAB

LE2.

Evid

entia

ryTa

ble

1999

–201

0(c

ontin

ued)

Aut

hor(

s)Y

ear

Tit

leL

evel

ofE

vide

nce

Que

stio

nA

ddre

ssed

Syno

psis

Ref

eren

ce

Tie

man

net

al.1

320

05E

mer

genc

ytr

eatm

ent

ofm

ulti

ply

inju

red

pati

ents

wit

hun

stab

ledi

srup

tion

ofth

epo

ster

ior

pelv

icri

ngby

usin

gth

e“C

-cla

mp”

31

28pa

tient

sw

ithan

unst

able

post

erio

rpe

lvic

ring

Fxha

da

C-c

lam

pap

plie

dim

med

iate

lyaf

ter

diag

nosi

s.T

heav

erag

etim

efr

omtr

aum

ato

C-c

lam

pap

plic

atio

nw

as64

.7m

in(1

0–24

0m

in).

App

licat

ion

ofth

eC

-cla

mp

resu

lted

inst

abili

zatio

nof

BP

and

oxyg

enat

ion

insu

rviv

ors;

inth

eno

nsur

vivo

rgr

oup

(7of

28pa

tient

s)th

ere

was

nost

abili

zatio

nof

BP

orox

ygen

atio

n.T

heau

thor

sco

nclu

deth

atth

eC

-cla

mp

lead

sto

stab

iliza

tion

ofvi

tal

para

met

ers

with

ina

shor

tpe

riod

oftim

e

Eur

JT

raum

a.20

05;3

:24

4–25

1

Kre

iget

al.1

420

05E

mer

gent

stab

iliz

atio

nof

pelv

icri

ngin

juri

esby

cont

roll

edci

rcum

fere

ntia

lco

mpr

essi

on:

acl

inic

altr

ial

31,

516

pati

ents

wit

hpe

lvic

ring

Fxs

had

aP

CC

Dte

mpo

rari

lyap

plie

dun

til

defi

niti

vest

abil

izat

ion

was

prov

ided

.In

the

exte

rnal

rota

tion

grou

p,th

eP

CC

Dsi

gnifi

cant

lyre

duce

dth

epe

lvic

wid

thby

9.9%

�6%

,si

mil

arto

the

10.0

%�

4.1%

redu

ctio

nin

achi

eved

byde

fini

tive

stab

iliz

atio

n.In

the

inte

rnal

rota

tion

grou

p,th

eP

CC

Ddi

dno

tca

use

sign

ifica

ntov

erco

mpr

essi

on.

The

auth

ors

conc

lude

that

aP

CC

Dca

nef

fect

ivel

yre

duce

pelv

icri

ngin

juri

esw

hile

posi

ngm

inim

alri

skfo

rov

erco

mpr

essi

onan

dco

mpl

icat

ions

JT

raum

a.20

05;5

9:65

9–66

4

Gha

emm

agha

mi

etal

.68

2007

Eff

ects

ofea

rly

use

ofex

tern

alpe

lvic

com

pres

sion

ontr

ansf

usio

nre

quir

emen

tsan

dm

orta

lity

inpe

lvic

frac

ture

s

35

Pel

vic

bind

ers

wer

eap

plie

dto

118

pati

ents

wit

hun

stab

lepe

lvic

Fx,

pelv

icF

xin

apa

tien

tol

der

than

55yr

,or

ape

lvic

Fx

asso

ciat

edw

ith

hypo

tens

ion.

The

sepa

tien

tsw

ere

com

pare

dw

ith

hist

oric

alco

ntro

ls.

The

pelv

icbi

nder

had

noef

fect

onm

orta

lity

,ne

edfo

rpe

lvic

angi

oem

boli

zati

on,

or24

-htr

ansf

usio

ns.

The

auth

ors

conc

lude

dth

atea

rly

use

ofpe

lvic

bind

ers

does

not

redu

cehe

mor

rhag

eor

mor

tali

tyas

soci

ated

wit

hpe

lvic

Fxs

Am

JSu

rg.

2007

;194

:720

–72

3

Sto

ver

etal

.420

06T

hree

-dim

ensi

onal

anal

ysis

ofpe

lvic

volu

me

inan

unst

able

pelv

icfr

actu

re3

1A

mod

elw

asde

velo

ped

com

pari

ngin

tact

and

post

frac

ture

pelv

icvo

lum

esin

10ca

dave

rs;

the

pelv

icvo

lum

ew

asca

lcul

ated

usin

gC

T.

The

obse

rved

volu

me

chan

ges

wit

hin

crea

sing

pubi

cdi

asta

sis

wer

esm

alle

rth

anpr

evio

usly

repo

rted

JT

raum

a.20

06;6

1:90

5–90

8

Sad

riet

al.1

120

05C

ontr

olof

seve

rehe

mor

rhag

eus

ing

C-c

lam

pan

dar

teri

alem

boli

zati

onin

hem

odyn

amic

ally

unst

able

pati

ents

wit

hpe

lvic

ring

disr

upti

on

31,

214

hem

odyn

amic

ally

unst

able

pati

ents

wit

hty

pes

Ban

dC

pelv

icri

ngF

xsun

derw

ent

appl

icat

ion

ofpe

lvic

C-c

lam

p.5

pati

ents

rem

aine

din

shoc

kan

dun

derw

ent

angi

o/em

boli

zati

onw

ithi

n24

h.T

hem

orta

lity

rate

ofth

epa

tien

tsw

houn

derw

ent

angi

oem

boli

zati

onw

as14

%).

Alt

houg

hth

eC

-cla

mp

isef

fect

ive

inco

ntro

llin

ghe

mor

rhag

e,ar

teri

alem

boli

zati

onm

aybe

need

edto

rest

ore

hem

odyn

amic

stab

ilit

y

Arc

hO

rtho

ptr

aum

aSu

rg.

2005

;125

:443

–447

Bla

ckm

ore

etal

.85

2003

Ass

essm

ent

ofvo

lum

eof

hem

orrh

age

and

outc

ome

from

pelv

icfr

actu

re3

2,4

CT

scan

sof

592

pati

ents

wit

hpe

lvic

Fx

wer

ere

tros

pect

ivel

yre

view

edto

esti

mat

evo

lum

e.T

hese

esti

mat

esw

ere

then

corr

elat

edw

ith

pelv

icar

teri

albl

eedi

ngdi

agno

sed

byan

giog

raph

y.T

heri

skra

tio

for

pelv

icar

teri

alin

jury

was

4.8

insu

bjec

tsw

ith

�50

0m

Lof

pelv

icF

x-re

late

dhe

mat

oma

com

pare

dw

ith

subj

ects

wit

h�

500

mL

.V

olum

e�

500

mL

was

asso

ciat

edw

ith

high

tran

sfus

ion

requ

irem

ent

(ris

kra

tio

�4.

7)an

dw

ith

any

adve

rse

outc

ome

(ris

kra

tio

�7.

0).

The

auth

ors

conc

lude

that

pelv

iche

mor

rhag

evo

lum

esde

rive

dfr

ompe

lvic

CT

scan

can

pred

ict

the

need

for

pelv

icar

teri

ogra

phy

and

tran

sfus

ions

Arc

hSu

rg.

2003

;138

:504

–50

9



TAB

LE2.

Evid

entia

ryTa

ble

1999

–201

0(c

ontin

ued)

Aut

hor(

s)Y

ear

Tit

leL

evel

ofE

vide

nce

Que

stio

nA

ddre

ssed

Syno

psis

Ref

eren

ce

Baq

ueet

al.3

2005

Ana

tom

ical

cons

eque

nces

of“o

pen

book

”pe

lvic

ring

disr

upti

on.

aca

dave

rex

peri

men

tal

stud

y

31

Bil

ater

alop

en-b

ook

pelv

icF

xsw

ere

crea

ted

in10

cada

vers

.P

elvi

cvo

lum

ew

asde

term

ined

afte

rto

tal

pelv

icex

ente

rati

on.

The

mea

nvo

lum

eof

pelv

icca

vity

was

872.

5m

L(5

80–7

56m

L).

The

aver

age

incr

ease

ofpe

lvic

volu

me

was

20.8

%af

ter

5cm

ofpu

bic

dias

tasi

s.In

60%

,a

lace

rati

onof

the

ilio

lum

bar

vein

occu

rred

afte

r5

cmof

pubi

cdi

asta

sis.

No

arte

rial

lace

rati

onoc

curr

ed.

The

auth

ors

conc

lude

dth

atop

en-b

ook

Fxs

crea

tean

incr

ease

ofpe

lvic

volu

me

that

faci

lita

tes

bloo

ddi

ffus

ion

from

the

pelv

icve

ssel

s.T

heil

iolu

mba

rpe

dicl

ese

ems

tobe

very

vuln

erab

lein

this

type

ofF

x

Surg

Rad

iol

Ana

t.20

05;

27:4

87–4

90

Jow

ett

and

Bow

yer7

220

07P

ress

ure

char

acte

rist

ics

ofpe

lvic

bind

ers

35

10vo

lunt

eers

wer

efi

tted

wit

ha

flex

ible

pres

sure

-se

nsit

ive

sens

orov

erth

esk

inco

veri

ngth

ean

teri

orsu

peri

oril

iac

spin

e,gr

eate

rtr

ocha

nter

and

sacr

um.

Ape

lvic

bind

erw

asth

enap

plie

dan

dti

ghte

ned

acco

rdin

gto

the

man

ufac

ture

rs’

inst

ruct

ions

.T

hepr

essu

res

obta

ined

corr

elat

edin

vers

ely

wit

hB

MI.

The

auth

ors

conc

lude

that

the

pres

sure

sde

velo

ped

betw

een

the

bind

eran

dth

esk

inov

erth

epr

omin

ence

sw

ere

all

grea

ter

than

the

pres

sure

reco

mm

ende

dat

inte

rfac

esto

avoi

dth

ede

velo

pmen

tof

pres

sure

sore

s,su

gges

ting

that

pati

ents

wit

hpe

lvic

Fxs

trea

ted

wit

hte

mpo

rary

pelv

icbi

nder

sar

eat

risk

ofde

velo

ping

pres

sure

sore

s

Inju

ry.

2007

;38:

118–

121

Kat

aoka

etal

.86

2005

Ilia

cve

inin

juri

esin

hem

odyn

amic

ally

unst

able

pati

ents

wit

hpe

lvic

frac

ture

sca

used

bybl

unt

trau

ma

32,

3,6

72pa

tien

tsw

ith

unst

able

pelv

icF

xsw

hopr

esen

ted

insh

ock

wer

ere

view

ed.

36of

61pa

tien

tsre

cove

red

from

shoc

kaf

ter

angi

oem

boli

zati

on.

18of

25w

hodi

dno

tre

cove

rfr

omsh

ock

died

.In

11of

25w

hodi

dno

tre

cove

rfr

omsh

ock

afte

ran

gio/

embo

liza

tion

,tr

ansf

emor

alve

nogr

aphy

was

perf

orm

ed,

reve

alin

gsi

gnifi

cant

veno

usex

trav

asat

ion

in9

(5co

mm

onil

iac

vein

,3

inte

rnal

ilia

cve

in,

and

1ex

tern

alil

iac

vein

).T

heau

thor

sco

nclu

deth

atil

iac

vein

inju

ryis

the

prin

cipa

lca

use

ofhe

mor

rhag

icsh

ock

inpa

tien

tsw

ith

unst

able

pelv

icF

xsan

dth

atve

nogr

aphy

isus

eful

for

iden

tify

ing

thes

ein

juri

es

JT

raum

a.20

05;5

8:70

4–71

0

Ste

phen

etal

.16

1999

Ear

lyde

tect

ion

ofar

teri

albl

eedi

ngin

acut

epe

lvic

trau

ma

32,

4R

etro

spec

tive

revi

ewof

111

pati

ents

wit

hpe

lvic

/ace

tabu

lar

Fxs

w/C

Tsc

an,

incl

udin

gst

able

and

unst

able

pati

ents

.11

pati

ents

had

extr

avas

atio

n.O

btur

ator

arte

ryw

as#1

caus

eof

hem

orrh

age

requ

irin

gem

boli

zati

onw

ith

supe

rior

glut

eal

#2.

CE

was

80%

sens

itiv

ean

d98

%sp

ecifi

cfo

rre

quir

ing

angi

ogra

phy.

The

yco

nclu

deth

atC

Ese

enon

CT

(whe

ther

hem

odyn

amic

ally

stab

leor

unst

able

)re

quir

esan

giog

raph

y,al

thou

ghso

me

hem

orrh

age

wil

lha

vest

oppe

dby

the

tim

ean

giog

raph

yis

unde

rtak

en

JT

raum

a.19

99;4

7:63

8–64

2



TAB

LE2.

Evid

entia

ryTa

ble

1999

–201

0(c

ontin

ued)

Aut

hor(

s)Y

ear

Tit

leL

evel

ofE

vide

nce

Que

stio

nA

ddre

ssed

Syno

psis

Ref

eren

ce

Per

eira

etal

.58

2000

Dyn

amic

heli

cal

com

pute

dto

mog

raph

ysc

anac

cura

tely

dete

cts

hem

orrh

age

inpa

tien

tsw

ith

pelv

icfr

actu

re

32,

4H

elic

alC

Tha

shi

ghN

PV

(99.

6%)

tode

term

ine

need

for

embo

liza

tion

PP

V69

.2%

;th

eref

ore,

appr

opri

ate

for

scre

enin

gpo

lytr

aum

apa

tien

tsw

ith

pelv

icF

xsto

elim

inat

ene

edfo

rem

erge

ntan

gio

embo

liza

tion

.29

0pe

lvic

Fxs

stud

ied

wit

hC

T,

only

13w

ith

CE

.T

hey

reco

mm

end

angi

oin

pati

ents

who

are

unst

able

and

have

CE

Surg

ery.

2000

;128

:678

–68

5

Rya

net

al.5

920

04A

ctiv

eex

trav

asat

ion

ofar

teri

alco

ntra

stag

ent

onpo

st-t

raum

atic

abdo

min

alco

mpu

ted

tom

ogra

phy

32,

4R

etro

spec

tive

revi

ewof

28in

itia

lly

hem

odyn

amic

ally

stab

lepa

tien

tsw

/ext

rava

sati

onon

CT

.S

ensi

tivi

tyw

as87

.5%

,S

peci

fici

tyw

as99

.5%

,P

PV

was

77.8

%,

and

NP

Vw

as99

.8%

.M

orta

lity

for

CE

grou

pw

as64

%an

d13

%fo

rth

ose

wit

hout

.A

utho

rsre

com

men

dan

gio

inpa

tien

tsw

ith

pelv

icF

xsan

dC

Ebe

com

eun

stab

le

Can

Ass

ocR

adio

lJ.

2004

;55

:160

–169

Ruc

hhol

tzet

al.4

520

04F

ree

abdo

min

alfl

uid

onul

tras

ound

inun

stab

lepe

lvic

ring

frac

ture

:is

lapa

roto

my

alw

ays

nece

ssar

y?

21,

2,3,

4,6

Ret

rosp

ecti

vere

view

of80

pati

ents

wit

hty

peB

orC

pelv

icri

ngF

xs.

Flu

idgr

oup

(fre

efl

uid

onin

itia

lF

AS

T)

had

31pa

tien

ts,

all

unde

rwen

tla

paro

tom

y.30

of31

had

anab

dom

inal

sour

ceof

blee

ding

.6

pati

ents

inth

eno

flui

dgr

oup

(n�

49)

wer

ehe

mod

ynam

ical

lyun

stab

le,

and

none

had

anab

dom

inal

sour

ces

ofbl

eedi

ng.

Hem

odyn

amic

ally

unst

able

pati

ents

w/o

free

flui

dre

quir

eea

rly

Ex

fix

stab

iliz

atio

nan

dhe

mod

ynam

ical

lyun

stab

lepa

tien

tsw

ith

apo

siti

veF

AS

Tre

quir

ela

paro

tom

yfi

rst,

retr

oper

iton

eal

pack

ing

asne

eded

,an

dex

fixa

tion

afte

rab

dom

inal

blee

ding

isco

ntro

lled

.F

urth

erim

agin

g(C

Tsc

an)

isne

eded

inhe

mod

ynam

ical

lyst

able

pati

ents

and

pati

ents

w/o

free

flui

dw

hoco

ntin

ueto

beun

stab

leaf

ter

exfi

xati

on

JT

raum

a.20

04;5

7:27

8–28

5

Niw

aet

al.2

420

00T

heva

lue

ofpl

ain

radi

ogra

phs

inth

epr

edic

tion

ofou

tcom

ein

pelv

icfr

actu

res

trea

ted

wit

hem

boli

sati

onth

erap

y

32,

4R

evie

wof

40pa

tien

tsre

quir

ing

angi

ogra

phic

embo

liza

tion

for

pelv

iche

mor

rhag

e.P

lain

pelv

icfi

lms

wer

ere

view

edre

tros

pect

ivel

yfo

rlo

cati

onof

bony

inju

ry(L

orR

isch

iopu

bic

orsa

croi

liac

)an

dF

oley

devi

atio

nto

see

ifhe

mor

rhag

icso

urce

coul

dbe

pred

icte

d.T

heau

thor

sco

nclu

ded

that

inth

ispa

tien

tgr

oup,

plai

nX

-ray

has

81%

sens

itiv

ity

and

91%

spec

ifici

tyin

iden

tify

ing

loca

tion

ofhe

mor

rhag

e.S

elec

tion

bias

ofre

view

ing

only

thos

ere

quir

ing

embo

liza

tion

and

does

not

tohe

lpid

enti

fyth

ose

who

may

requ

ire

embo

liza

tion

Br

JR

adio

l.20

00;7

3:94

5–95

0

Tay

alet

al.4

620

06A

ccur

acy

oftr

aum

aul

tras

ound

inm

ajor

pelv

icin

jury

32,

3,4

Sen

siti

vity

ofF

AS

Tin

pati

ents

wit

hpe

lvic

fx80

.8%

and

spec

ifici

ty86

.9%

.P

PV

72.4

%,

NP

V91

.4%

.O

f21

true

posi

tive

FA

ST

,fr

eefl

uid

was

urin

ein

4.P

ropo

sepe

rito

neal

tap

inhe

mod

ynam

ical

lyun

stab

lepa

tien

tsto

dete

rmin

ew

heth

erfl

uid

isbl

ood

orur

ine

from

blad

der

inju

ry

JT

raum

a.20

06;6

1:14

53–

1457



TAB

LE2.

Evid

entia

ryTa

ble

1999

–201

0(c

ontin

ued)

Aut

hor(

s)Y

ear

Tit

leL

evel

ofE

vide

nce

Que

stio

nA

ddre

ssed

Syno

psis

Ref

eren

ce

Fri

ese

etal

.47

2007

Abd

omin

alul

tras

ound

isan

unre

liab

lem

odal

ity

for

the

dete

ctio

nof

hem

oper

iton

eum

inpa

tien

tsw

ith

pelv

icfr

actu

re

32,

3,4

96pa

tien

tsw

ith

pelv

icF

xan

din

crea

sed

risk

for

hem

orrh

age

(age

�55

,S

BP

�90

mm

Hg

inE

D,

orU

FP

)st

udie

dw

/FA

ST

whe

rere

sult

sco

nfirm

edw

ith

CT

orla

paro

tom

y.In

dete

ctin

gfr

eefl

uid

inpe

rito

neal

cavi

ty,

FA

ST

had

sens

itiv

ity

of26

%,

spec

ifici

ty96

%,

PP

V85

%,

NP

V63

%.

Wit

ha

nega

tive

FA

ST

,a

seco

ndte

stne

eds

tobe

done

:C

Tsc

anin

stab

lepa

tien

ts,

DP

Lin

unst

able

pati

ents

.A

utho

rsco

nclu

deF

AS

Tdo

esno

the

lpde

term

ine

lapa

roto

my

JT

raum

a.20

07;6

3:97

–10

2

Bal

lard

etal

.48

1999

An

algo

rith

mto

redu

ceth

ein

cide

nce

offa

lse-

nega

tive

FA

ST

exam

inat

ions

inpa

tien

tsat

high

risk

for

occu

ltin

jury

.F

ocus

edas

sess

men

tfo

rth

eso

nogr

aphi

cex

amin

atio

nof

the

trau

ma

pati

ent

23,

4P

rosp

ecti

ve,

nonr

ando

miz

edst

udy

ofbl

unt

trau

ma

pati

ents

w/p

elvi

cF

xs,

FA

ST

,an

dsu

bseq

uent

CT

orla

paro

tom

y.T

here

wer

e70

pelv

ictr

aum

apa

tien

tsw

/sen

siti

vity

of24

%an

dsp

ecifi

city

of10

0%an

d13

fals

ene

gati

ves.

The

auth

ors

conc

lude

that

any

pati

ent

wit

hpe

lvic

trau

ma

and

FA

ST

requ

ires

aC

Tsc

anto

eval

uate

for

furt

her

inju

rydu

eto

the

high

fals

e-ne

gati

vera

te

JA

mC

oll

Surg

.19

99;

189:

145–

150

Ham

ill

etal

.51

1999

Pel

vic

frac

ture

patt

ern

pred

icts

pelv

icar

teri

alha

emor

rhag

e3

3,4

Rev

iew

of76

pati

ents

wit

hpe

lvic

Fxs

who

requ

ired

�6

unit

sP

RB

Cin

1st

24h:

(ML

Das

defi

ned

byF

xcl

asse

sA

PC

IIor

III,

LC

III,

VS

,or

Com

bine

dM

echa

nism

)w

assh

own

toco

rrel

ate

wit

hin

crea

sed

need

for

embo

liza

tion

,bu

tse

nsit

ivit

y63

%an

dsp

ecifi

city

44%

.U

nabl

eto

use

pelv

icfx

clas

sto

iden

tify

pati

ents

who

requ

ire

embo

liza

tion

Aus

tN

ZJ

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ore

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orhe

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rhag

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ents

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ture

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Maj

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TAB

LE2.

Evid

entia

ryTa

ble

1999

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0(c

ontin

ued)

Aut

hor(

s)Y

ear

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leL

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nce

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psis

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liza

tion

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etro

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tive

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onan

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and

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ty,

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egr

eate

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oup.

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not

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elat

ion

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and

the

need

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ogra

phy.

Aut

hors

conc

lude

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ite

othe

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port

s,pe

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ern

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used

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term

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ther

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ompe

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orrh

age

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othe

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urce

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raum

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nuss

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ated

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rst

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ient

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din

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ly(1

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only

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dbo

th(3

5).

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ient

sw

ith

both

requ

ired

mor

eP

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anth

ose

wit

hpe

lvic

orac

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ular

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RB

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quir

emen

tseq

ual

betw

een

pelv

ican

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etab

ular

grou

p.W

ithi

npe

lvic

grou

p,44

%of

thos

ew

ith

ML

D(f

xpa

tter

nsL

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I,A

PC

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II,

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mbi

ned)

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ired

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leon

ly8.

5%of

thos

ew

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requ

ired

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BC

JO

rtho

pT

raum

a.20

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07

Lun

sjo

etal

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Ass

ocia

ted

inju

ries

and

not

frac

ture

inst

abil

ity

pred

ict

mor

tali

tyin

pelv

icfr

actu

res:

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ospe

ctiv

est

udy

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0pa

tien

ts

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100

cons

ecut

ive

pati

ents

wit

hpe

lvic

Fx,

mor

tali

ty(9

%).

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vic

Fx

clas

sifi

edas

O(n

oin

stab

ilit

y),

R(r

otat

iona

lin

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ilit

y),

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otat

iona

lan

dve

rtic

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y).

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lvic

fxcl

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fica

tion

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gist

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gres

sion

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lyIS

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bean

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pend

ent

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icto

rof

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tali

ty.

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vic

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erns

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lity

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ther

efor

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tive

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orrh

age

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irin

gan

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raph

y

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ith

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lypr

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lity

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mod

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ture

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ma

data

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vic

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naly

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ors

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ted

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lity

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tter

n(Y

oung

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gess

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dne

edfo

ran

giog

raph

yw

ere

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icti

veof

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tali

ty.

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nsfu

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raph

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ions

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dm

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tive

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ifica

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had

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erra

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ogra

phy,

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noot

her

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ern

tone

edfo

ran

gio

was

foun

d.P

atie

nts

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rwen

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lity

and

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BC

TX

need

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nabl

eto

dem

onst

rate

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atis

tica

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phy

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lity

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rtho

pT

raum

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61

Bal

ogh

etal

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2005

Inst

itut

iona

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acti

cegu

idel

ines

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anag

emen

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re-

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ted

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ishe

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clud

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vic

bind

ing

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heet

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-cla

mp

(PB

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)P

elvi

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gio

wit

hin

90m

in,

and;

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Fw

ithi

n24

h;pa

tien

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eeti

nggu

idel

ines

pre/

post

PG

:A

C67

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00%

;P

B0%

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A30

%/9

3%;

OF

52%

/86%

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orta

lity

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G(3

5%)

and

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%).

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8:77

8–78

2



puted tomography (CT) scanning with mathematical model-ing, Stover et al.4 demonstrated an increase in pelvic volumeof 35% to 40% with a large 10-cm pubic diastasis, again in acadaver model.

Pelvic stabilization has been practiced for a number ofyears in an attempt to control pelvic bleeding by decreasingthe pelvis volume, leading to earlier tamponade. Methods thatclose the pelvic ring are thought to tamponade bleeding bydiminishing the pelvic volume, hastening clotting of thepelvic hematoma.5 Initially, the pneumatic antishock gar-ments (PASG) was used to stabilize the pelvis and decreasethe pelvic volume. In retrospective studies, Flint et al. andothers have demonstrated less blood loss when the PASG wasapplied.6–8 Other studies have questioned the ability ofPASG to limit hemorrhage from pelvic fracture.9,10 PASGhave largely fallen out of favor due to concerns about ab-dominal compartment syndrome and fluid and electrolytecomplications and because they are bulky, difficult to apply,and interfere with physical examination.

External pelvic fixation (EPF) and the pelvic C-clamphave been used more recently in an attempt to reduce pelvicvolume and control hemorrhage associated with pelvic frac-ture. In a study of 14 hemodynamically unstable patients withpelvic fractures, Sadri et al.11 found that blood loss was notstatistically different before/after placement of the pelvicC-clamp. Angiography was required in many of these pa-tients to control hemorrhage. Application of the pelvic C-Clamp is generally done quickly (5 minutes)12although othershave reported that it can take longer, averaging 64 minutes toapply (range, 10–240 minutes).13 When EPF is comparedwith a temporary pelvic binder (TPB) in patients with sacro-iliac fractures, EPF was found to have higher blood transfu-sion needs at 24 hours and 48 hours compared with the TPB.The reduced blood loss has been attributed to the ease andrapidity of TPB application compared with EPF.14

Placement of a C-Clamp or EPF decreases the pelvicvolume by 10% to 20% and reduces pelvic fractures.3,14,15

Whether this leads to less blood loss and better outcomes hasyet to be shown in the literature. The standard use of externalfixation in the initial treatment algorithms of patients withunstable pelvic injuries is common and remains a useful toolin the initial management of these patients.13,16 However,because of their ease of use and fast application, TPBs havelargely replaced the pelvic C-Clamp and EPF for earlymechanical stability in pelvic fracture.TA

BLE

2.Ev

iden

tiary

Tabl

e19

99–2

010

(con

tinue

d)

Aut

hor(

s)Y

ear

Tit

leL

evel

ofE

vide

nce

Que

stio

nA

ddre

ssed

Syno

psis

Ref

eren

ce

Bif

flet

al.8

220

01E

volu

tion

ofa

mul

tidi

scip

lina

rycl

inic

alpa

thw

ayfo

rth

em

anag

emen

tof

unst

able

pati

ents

wit

hpe

lvic

frac

ture

s

21,

2,3,

5R

etro

spec

tive

revi

ewof

143

pati

ents

in“e

arly

grou

p”vs

.73

“lat

egr

oup”

whi

chw

asde

fine

das

befo

rean

daf

ter

the

tim

ew

hen

2or

tho

trau

ma

staf

fw

ere

inth

etr

aum

aba

yfo

rde

cisi

onm

akin

gup

onpa

tien

tar

riva

l.L

ower

rate

ofhy

pote

nsio

n,in

crea

sed

use

ofP

B,

and

impr

oved

mor

tali

ty(3

1%vs

.15

%).

The

rew

ere

nodi

ffer

ence

sin

the

num

ber

ofpa

cked

red

cell

sor

fres

h-fr

ozen

plas

ma

unit

str

ansf

used

.T

here

wer

eno

sign

ifica

ntdi

ffer

ence

sbe

twee

nth

e2

grou

psin

term

sof

the

over

all

com

plic

atio

nra

teor

the

occu

rren

ceof

acut

ere

spir

ator

ydi

stre

sssy

ndro

me,

mul

tipl

eor

gan

fail

ure,

orpn

eum

onia

Ann

Surg

.20

01;2

33:8

43–

850

ISS

,in

jury

seve

rity

scor

e;R

TS

,re

vise

dtr

aum

asc

ore;

CE

,co

ntra

stex

trav

asat

ion;

PR

BC

,pa

cked

red

bloo

dce

lls;

OT

A,

Ort

hope

dic

Tra

uma

Ass

ocia

tion

;A

PC

,an

tero

post

erio

rco

mpr

essi

on;

LC

,la

tera

lco

mpr

essi

on;

DIC

,di

ssem

inat

edin

trav

ascu

lar

coag

ulop

athy

;MR

I,m

agne

tic

reso

nanc

eim

agin

g;I&

D,i

ncis

ion

and

drai

nage

;AP

AC

HE

,acu

teph

ysio

logy

and

chro

nic

heal

thev

alua

tion

;BP

,blo

odpr

essu

re;P

CC

D,p

elvi

cci

rcum

fere

ntia

lcom

pres

sion

devi

ce;

BM

I,bo

dym

ass

inde

x;F

x,fr

actu

re;

CT

,com

pute

dto

mog

raph

y;P

PV

,pos

itiv

epr

edic

tive

valu

e;N

PV

,neg

ativ

epr

edic

tive

valu

e;S

BP

,sys

toli

cbl

ood

pres

sure

;E

D,e

mer

genc

yde

part

men

t;V

S,v

erti

cal

shea

r;M

LD

,maj

orli

gam

ento

usdi

srup

tion

;S

FP

,st

able

frac

ture

patt

ern;

UF

P,

unst

able

frac

ture

patt

ern;

AIS

S,

abbr

evia

ted

inju

ryse

veri

tysc

ore;

PB

,pe

lvic

bind

ing;

PG

,pr

acti

cegu

idel

ine;

OF

,op

erat

ive

pelv

icfi

xati

on;

TX

,tr

ansf

usio

n.Q

uest

ions

:(1

)W

hich

pati

ents

war

rant

earl

yex

tern

alm

echa

nica

lst

abil

izat

ion?

(2)

Whi

chpa

tien

tsre

quir

eem

erge

ntan

giog

raph

y?(3

)W

hat

isth

ebe

stte

stto

excl

ude

extr

a-pe

lvic

blee

ding

?(4

)A

reth

ere

radi

ogra

phic

find

ings

whi

chpr

edic

the

mor

rhag

e?(5

)W

hat

isth

ero

leof

non-

inva

sive

tem

pora

ryex

tern

alfi

xati

onde

vice

s?an

d(6

)W

hich

pati

ents

war

rant

pre-

peri

tone

alpa

ckin

g?

TABLE 3. Tile Classification

Type A Stable pelvic ring injury

Type B Partially stable pelvic ring injury

B1: Open book injury (anteroposterior compression,external rotation)

B2: Lateral compression (internal rotation)

B3: Bilateral injuries

Type C Completely unstable (allows all degrees of translationaldisplacement)



Which Patients Require EmergentAngiography?

1. Patients with pelvic fractures and hemodynamic instability orsigns of ongoing bleeding after nonpelvic sources of bloodloss have been ruled out should be considered for pelvicangiography/embolization. Level I recommendation

2. Patients with evidence of arterial intravenous contrastextravasation (ICE) in the pelvis by CT may require pelvicangiography and embolization regardless of hemodynamicstatus. Level I recommendation

3. Patients with pelvic fractures who have undergone pelvicangiography with or without embolization, who havesigns of ongoing bleeding after nonpelvic sources ofblood loss have been ruled out, should be considered forrepeat pelvic angiography and possible embolization.Level II recommendation

4. Patients older than 60 years with major pelvic fracture(open book, butterfly segment, or vertical shear) should beconsidered for pelvic angiography without regard for he-modynamic status. Level II recommendation

5. Although fracture pattern or type does not predict arterialinjury or need for angiography, anterior fractures are morehighly associated with anterior vascular injuries, whereasposterior fractures are more highly associated with poste-rior vascular injuries. Level III recommendation

6. Pelvic angiography with bilateral embolization seems tobe safe with few major complications. Gluteal muscleischemia/necrosis has been reported in patients with he-modynamic instability and prolonged immobilization orprimary trauma to the gluteal region as the possible cause,rather than a direct complication of angioembolization.Level III recommendation

7. Sexual function in males does not seem to be impairedafter bilateral internal iliac arterial embolization. Level IIIrecommendation

Scientific Foundation: Emergent AngiographyPelvic angiography is useful control of arterial hemor-

rhage associated with pelvic fractures. In many pelvic frac-tures, much of the bleeding is venous in nature, generallyfrom bone fracture edges or the iliolumbar vein. Angiographywith embolization only controls arterial hemorrhage andtherefore is beneficial in only a minority of patients. Indeed,it seems that pelvic angiography is indicated in only 3% to10% of patients with pelvic fracture.17–23 Hemodynamic in-stability associated with pelvic fractures without anothersignificant source of bleeding is an indication for pelvicangiography.18–20,24,25 In a retrospective study of 325 patientsat a Level I trauma center, Starr et al. found that RevisedTrauma Score alone was predictive of the need for angiog-raphy. Age, shock on admission, and fracture pattern did notpredict need for angiography.21

There are several predictors to help determine whichpatients will need angiography. The presence of ICE seen onCT scan has a sensitivity of 60% to 84% and specificity of85% to 98% for the need for pelvic embolization.18 ICE is astrong predictor of need for angioembolization. Fracturepattern alone has not been predictive of who will or will not

require angiography.21,24,26 The combination of age �60 andmajor pelvic fracture is highly associated with need forangiography with embolization (odds ratio, 15) regardless ofthe patient’s hemodynamic status. Indeed, 62% of patientsolder than 60 years requiring angiographic embolization hadnormal vital signs on hospital admission.27 Although hemor-rhage from major pelvic fractures is common, several retro-spective studies contain patients with arterial bleeding fromisolated sacral or acetabular fractures.17 Although fracturetype does not predict need for angiography, in general,anterior fractures are associated with anterior vascular inju-ries, whereas posterior fractures are associated with posteriorvascular injuries.28

Pelvic angiography with embolization seems to be 85%to 97% effective in controlling bleeding. Some patients willcontinue to bleed and require repeat embolization to controlhemorrhage.22,23,29,30 4.6% to 24.3% of patients with either nobleeding seen on the initial angiogram or initially successfulpelvic embolization will require repeat pelvic angiographywith repeat embolization. Independent risk factors for recur-rent pelvic bleeding include transfusing greater than two unitspacked red blood cells per hour before angiography, findingmore than two injured vessels requiring embolization,22

repeated hypotension after initial angiography, absence ofintra-abdominal injury, and persistent base deficit.30 Thestandard embolization technique for an unstable patientbleeding from an internal iliac artery source is to nonselec-tively embolize both internal iliac arteries. In more stablepatients, some operators may attempt more selective embo-lization. However, a study by Fang et al.23 demonstrated thatrecurrent pelvic bleeding also seems to be more commonafter selective embolization than after nonselective treatment,suggesting this practice should be limited.

The safety of pelvic angiography/embolization seemsto be well established in several series.29,31 There are occa-sional reports of femoral artery injury requiring repair andtransient increases in serum creatinine in older patients.27

Cases of gluteal necrosis associated with embolizations seemto be related to primary trauma to the gluteal region alongwith protracted hypotension rather than a direct complicationof embolization.17,32 In one report, six of eight pelvic fracturepatients undergoing bilateral angioembolization for shockshowed magnetic resonance imaging changes consistent withsoft tissue infection or necrosis33 without primary glutealtrauma, suggesting that gluteal muscle ischemia may besubclinical. Ramirez et al.34 examined sexual dysfunction inmales undergoing bilateral internal iliac embolization andfound no difference compared with case-matched pelvic frac-ture patients not undergoing embolization.

What Is the Best Test to ExcludeIntra-Abdominal Bleeding?

1. Focused Assessment with Sonography for Trauma(FAST) is not sensitive enough to exclude intraperito-neal bleeding in the presence of pelvic fracture. Level Irecommendation



2. FAST has adequate specificity in patients with unstablevital signs and pelvis fracture to recommend laparotomyto control hemorrhage. Level I recommendation

3. Diagnostic peritoneal tap (DP)/Diagnostic peritoneal la-vage (DPL) is the best test to exclude intra-abdominalbleeding in the hemodynamically unstable patient. LevelII recommendation

4. In the hemodynamically stable patient with a pelvic fracture,CT of the abdomen and pelvis with intravenous contrast isrecommended to evaluate for intra-abdominal bleeding re-gardless of FAST results. Level II recommendation

Scientific Foundation: Tests to ExcludeIntra-Abdominal Bleeding With Pelvic Fracture

Early detection of hemoperitoneum after blunt abdom-inal injury allows for rapid implementation of decision-making algorithms and decreasing the time to abdominalexploration in patients at high risk for intraperitoneal hemor-rhage. The indications for laparotomy in the patient with apelvic fracture are the same for all trauma patients. Withconcomitant pelvic fracture, differentiating between pelvic-bleeding and intra-abdominal hemorrhage is critical to theinitial decision-making and management of the patient.

Four methods are commonly used to help excludeintra-abdominal bleeding: DPL, ultrasound (FAST), DP, andCT.1 Each test has advantages and disadvantages specific totheir use in patients with pelvic fracture. DPL has been shownto have a high rate of false positives in patients with pelvicfractures.7,35,36 This is thought to be due to a high rate ofred cell diapedesis across the peritoneum. DP withoutlavage performed in the supraumbilical region seems tooffer similar sensitivity as DPL with a lower rate offalse-negative examinations.7,36,37

The FAST has been an effective tool for the evaluationof patients with intra-abdominal injuries and hypoten-sion.38–42 Patients with pelvic fractures are at high risk tohave other associated intra-abdominal injuries as a source ofbleeding.43,44 Although the specificity of the FAST in patientswho have pelvic fractures examination is reasonable as aninitial screening tool (87–100%), the sensitivity of the exam-ination in the presence of a mechanically unstable pelvicfracture (Tile B/C) is unacceptably low.45–48 Ruchholz et al.45

reported 75% sensitivity with concomitant pelvic fracture ina series of patients with type B/C pelvic fractures. Thisfinding was consistent with other reports in the literature.46,48

In a more recent report from a high volume trauma center,Freise et al.47 reported a very low sensitivity of 26% inpatients with pelvic fracture.

Because of the low sensitivity and low negative pre-dictive value of FAST when pelvic fracture is present, CT ofthe abdomen and pelvis with intravenous contrast is recom-mended in patients with pelvic fracture and a negative FASTexamination who are hemodynamically stable. A negativeFAST examination in a patient with pelvic fracture does notaid in determining whether a laparotomy or angiography iswarranted.46–48 Hemodynamically unstable patients with pel-vic fracture and a positive FAST should undergo emergentlaparotomy, whereas hemodynamically normal patients with

pelvic fracture and a positive FAST should receive an ab-dominal/pelvic CT scan.

Are There Radiologic Findings Which PredictHemorrhage?

1. Fracture pattern on pelvic X-ray does not single-handedlypredict mortality, hemorrhage, or the need for angiogra-phy. Level II recommendation

2. Presence/location of hematoma does not predict or ex-clude the need for angiography and possible embolization.Level II recommendation

3. CT of the pelvis is an excellent screening tool to excludepelvic hemorrhage. Level II recommendation

4. Absence of contrast extravasation on CT does not alwaysexclude active hemorrhage. Level II recommendation

5. Pelvic hematoma �500 cm3 in size has an increasedincidence of arterial injury and need for angiography.Level II recommendation

6. Isolated acetabular fractures are as likely to require angiographyas pelvic rim fractures. Level III recommendation

7. If a retrograde urethrocystogram is required, it should beperformed after CT with intravenous contrast. Level IIIrecommendation

Scientific Foundation: Radiographic Predictors ofHemorrhage

Two radiographic modalities have the potential to pro-vide clinically useful information during the evaluation oftraumatic pelvic fractures in the acute setting: pelvic X-rayand CT scan. Several recent studies attempt to correlateradiographic findings to clinical outcomes and specifically theneed for angiography.

The Young-Burgess classification system49 (Table 4)divides pelvic fractures by vector; anteroposterior, lateralcompression, vertical shear, and combined mechanical. Eachtype of fracture is also graded by severity (I, II, and III).Correlating the fracture pattern to the need for angiographyhas shown mixed results. Niwa et al.24 was able to show anassociation. This study was unable to define the cause ofdeath in 20% of their population. Posterior bleeding sourcesseem to correlate with anteroposterior type fractures, whereaslateral compression fractures are more likely to have ananterior (iliac) source of bleeding.28

In an effort to determine whether patients should un-dergo laparotomy or angiography in hemodynamically unsta-ble patients with pelvic fractures, Eastridge et al.50 found thatthose with higher grade or rotationally unstable pelvic frac-tures were more likely to have a pelvic source of bleeding.Patients with rotationally stable fractures were more likely tohave an abdominal source of hemorrhage and thereforeshould have a laparotomy performed as the primary proce-dure. Two studies were able to show a relationship betweenmajor ligamentous disruption and the need for pelvic embo-lization.51,52 The authors concede that, although positive, thecorrelation was too weak to assist in clinical decision-mak-ing. When looking at pelvic fractures outside the pelvic ring,isolated acetabular fractures were shown to have the sameblood transfusion requirements and presumably the need for



angiography.53 Two other studies concluded that injury se-verity score was a better predictor of pelvic hemorrhage thanfracture pattern.50,54 Blackmore et al.55 developed a multiplelogistic regression model that was able to predict the proba-bility of pelvic arterial hemorrhage.55 The model included thefollowing factors: initial hematocrit 30 or less, heart rate 130or greater, and pelvic fracture patterns including obturatorring fracture greater than 1 cm or pubic symphysis diastasisof at least 1 cm. The presence of three or four of these riskfactors was only able to predict pelvic hemorrhage in 66% ofpatients. The remaining studies were unable to correlatepelvic fracture pattern with need for angioemboliza-tion.21,56,57 The available literature suggests that pelvic frac-ture pattern alone is insufficient to predict the need forangioembolization.

CT scanning has become a valuable asset in the acutemanagement of pelvic trauma. Two factors have been studiedto determine the need for angioembolization: ICE and thepelvic hematoma size. The absence of ICE on the admissionCT is an excellent screening test to exclude the presence ofactive arterial hemorrhage and therefore the need for angio-embolization, with the negative predictive values rangingfrom 98.0% to 99.8%.58–60 The presence of ICE, however,has shown varied results. Stephen et al.16 showed that thepositive predictive value of ICE needing angioembolizationwas 80%. The negative predictive value was 98%. Theyconcluded that the presence of ICE was an indication forangiography, regardless of hemodynamic status. Pereira etal.58 demonstrated a lower positive predictive value of 69.2%with ICE. Four of five patients who were hemodynamicallystable with a blush did not require embolization. They rec-ommend angiography only in hemodynamically unstable pa-tients with ICE. Ryan et al.59 reported their experience with18 patients with mechanically unstable pelvic fractures andICE. Nine of these patients underwent angiography for he-modynamic instability of which seven required embolization.The presence of ICE on CT was predicted the site of bleedingfound angiographically in all patients. They concluded thatICE on CT scan with a major pelvic fracture mandatesangiography regardless of hemodynamics. There were nocomplications from angiography reported in these studies.

Other studies have demonstrated a higher mortality ratefrom a delay in angiography.60 Brasel et al.61 retrospectivelyexamined CT scans with ICE and found 90% sensitivity forneeding angiography. They noted, however, that 33% ofpatients without ICE who were hemodynamically unstablealso required angiography. The data suggest that any hemo-dynamically unstable patient with pelvic fractures and ICErequires angiography in the absence of other bleedingsources. When patients are hemodynamically stable, the ev-idence is mixed. In a patient with stable hemodynamics, thedata suggest that angiography may be useful to preventfurther bleeding but may not be required in all patients.61

Need for angiography in hemodynamically stable patientswith ICE from pelvic trauma requires further study to deter-mine its usefulness.

Attempts at correlating the presence and size of a pelvichematoma seen on CT with the need for angiography havebeen undertaken. Brown et al.62 retrospectively studied 37patients who underwent CT and angiography. Contrast ex-travasation during angiography was noted in 83% of patientswithout hematoma (67% of patients with small hematomaand 73% of patients with significant hematoma). Blackmoreet al.55 found that hematomas �500 cm3 had a significantincreased risk ratio of 4.8 for arterial injury at angiography. Ingeneral, the presence of pelvic hematoma is insufficient toalter the indications for angiography and is not a predictor ofneed for transfusion or ongoing blood loss. Large hematomaswith volumes over 500 cm3 may have an increased risk ofarterial injury requiring angiography.

The presence of bladder and urethral injuries withconcomitant pelvic fractures is common. Retrograde urethro-gram (RUG) should be performed before placement of aurinary catheter; however, the sequencing of RUG and CThas been controversial.63 Netto et al.64 was able to show ahigher rate of indeterminate and false-negative CT if RUGwas performed first. This was due to contrast from the RUGinterfering with determining if ICE was present. The detec-tion of hemorrhage needs to take priority over detectingurologic injuries, and therefore CT scan with contrast shouldbe performed before the evaluation of the genitourinary tractin most settings.

TABLE 4. Young-Burgess Classification System

Fracture Type Common Characteristic Differentiating Characteristic

Lateral compression 1 Transverse pubic rami fracture Sacral Compression on side of impact

Lateral compression 2 Transverse pubic rami fracture Crescent (iliac wing) fracture

Lateral compression 3 Transverse pubic rami fracture Contralateral open-book (anteroposterior compression) injury

Anterior-posteriorcompression 1

Symphyseal diastasis (1–2 cm) Slight widening of symphysis and/or sacroiliac (SI) joint,stretched but intact anterior and posterior SI joint ligaments


Symphyseal diastasis or vertical pubic rami fracture Widened SI joint, disrupted anterior SI ligaments withintact posterior SI ligaments


Symphyseal diastasis or vertical pubic rami fracture Complete hemipelvis separation but no vertical displacement,anterior and posterior SI joint ligaments ruptured

Vertical shear Symphyseal diastasis or vertical pubic rami fracture Vertical hemipelvis displacement, usually through SI joint,occasionally through iliac wing or sacrum

Combined mechanism Vertical or transverse pubic rami fractures Combination of patterns; lateral compression with verticalshear or lateral compression with anterior-posterior compression

SI, sacroiliac.



What Is the Role of Noninvasive TemporaryExternal Fixation Devices?

1. TPBs effectively reduce unstable pelvic fractures as wellas definitive stabilization and decrease pelvic volume.Level III recommendation

2. TPBs may limit pelvic hemorrhage but do not seem toaffect mortality. Level III recommendation

3. TPBs work as well or better than emergent EPF in con-trolling hemorrhage. Level III recommendation

Scientific Foundation: Temporary ExternalFixation Devices

Temporary binders have been used to control hemor-rhage from pelvic fractures for many years. Pneumatic anti-shock trousers were one of the early attempts to decrease thepelvic volume and limit hemorrhage. Sheets have been usedfor this task more recently.65–67 Commercial devices haverecently evolved to provide consistent compression in aconvenient prepackaged device. Results from studies of thesecommercial binders have been mixed. In a large study per-formed at Parkland Hospital, the use of a commercial binderhad no effect on transfusion requirements, need for angio-graphic embolization, or mortality when compared with his-torical controls.68 Croce et al. compared the use of EPFplaced in the operation room with TPB placed in the emer-gency department in a series of patients with hemodynami-cally instability and structurally unstable fractures. The use ofthe T-POD (Cybertech Medical, La Verne, CA) reducedblood transfusion needs at 24 hours and 48 hours comparedwith historical controls. Both the groups were in similardegree of shock. The authors attributed the reduced bloodloss to the rapidity of T-POD placement compared with EPF.No differences in mortality were found.69

Evidence suggests temporary binders decrease pelvicvolume with a pelvic fracture and may improve biomechani-cal stability. Bottlang et al.70,71 noted fracture reduction and55% to 61% improvement in biomechanical stability ofpelvic fractures in seven nonembalmed cadavers after appli-cation of an external compression device. In a study of 16patients with mechanically unstable pelvic fractures, Kreig etal.14 demonstrated a 9.9% decrease in pelvic width using aTPB with no complications related to the binder. The dataconfirming efficacy of pelvic binders in controlling hemor-rhage from pelvic fracture remain unclear because of con-flicting studies in the literature.14,68–72

The use of pelvic binders may predispose to skinbreakdown with prolonged use due to high pressure at bonyprominences.72 Shearing force applied when tightening thebinder might result in tissue trauma. Users of these devicesneed to be aware of the risk of pressure induced ischemicwounds. Because of the ease of application, relatively inex-pensive cost, low potential for complications, and benefit topelvic stability, temporary external stabilization devicesshould be considered for emergent application to all hemo-dynamically unstable patients with pelvic injuries.

Which Patients Warrant Retroperitoneal(Preperitoneal) Packing?

1. Retroperitoneal pelvic packing is effective in controllinghemorrhage when used as a salvage technique after an-giographic embolization. Level III recommendation

2. Retroperitoneal pelvic packing is effective in controllinghemorrhage when used as part of a multidisciplinaryclinical pathway including a POD/C-clamp. Level IIIrecommendation

Scientific Foundation: Retroperitoneal PackingEmergent PPP is a newer technique in the trauma

surgeon’s armamentarium. Its use is currently evolving. Orig-inally described in the European literature,73 several Euro-pean centers have described using PPP in combination withexternal mechanical fixation of the pelvis.74–77 Some traumacenters in the United States have adopted this technique andpublished on its use as a first-line therapy in-lieu of angiog-raphy.78 It is reportedly easy to learn.79

The technique involves creating a midline incision 8 cmin length just above the pubis extending toward the umbili-cus.80,81 Skin and subcutaneous tissue is opened in the mid-line, as is the fascia. The bladder is retracted away from thefracture and three laparotomy pads are placed in the retro-peritoneal space on each side toward the iliac vessels. Theprocedure is repeated on the opposite side and the fascia andskin are closed. The procedure can be performed in 20minutes by experienced surgeons.80,81

Cothren et al.78 reported using PPP as part of a clinicalpathway in treating hemorrhage from pelvic fracture. In thisgroup of severely injured patients (injury severity score �55), PPP was performed immediately after placement of aTPB in-lieu of angiography. There were no deaths attributedto hemorrhage after packing along with significantly fewerblood transfusions. This study reported an 83% success ratein controlling hemorrhage in hemodynamically unstable pa-tients who underwent PPP. The other 17% required angiog-raphy. In a follow-up study at their institution, pelvic packingwas found to occur faster than with angiography (45 minutesvs. 130 minutes). There was also a decrease need for trans-fusion. The results of the study are difficult to interpretbecause time to control hemorrhage was significantly differ-ent between the groups.81

PPP seems to have some advantage in controllinghemorrhage, particularly when angiography is unavailable orwould result in significant delay. Future comparative studieswill be needed to directly compare PPP with angiography forthe control of pelvic hemorrhage.

SUMMARYHemorrhage from pelvic fracture remains a difficult

problem facing the trauma surgeon. Today, there have beenmany changes in practice pattern that have been shown topredict and limit hemorrhage in the patient with a pelvicfracture. Biffl et al.82 found that a multidisciplinary team,including an Orthopedic Surgeon, improved outcomes com-pared with historical controls. Institutional guidelines alsohave been shown to improve outcomes and their use is



encouraged to limit variability in care.82–84 Emergent externalfixation and the pelvic C-clamp used to control hemorrhage isnot supported by the available literature. Although they doreduce fractures effectively, they do not seem to limit hem-orrhage based on the available literature. Angiography forcontrol of hemorrhage has come of age and has an importantrole in the treatment of patients with pelvic fracture and issupported by the highest level of evidence. Pelvic angiogra-phy with embolization can be performed bilaterally if neededand even repeated to control bleeding without undo conse-quence. The data on using the FAST examination to excludeintra-abdominal hemorrhage are clear. FAST examination,although highly specific, does not have the sensitivity to ruleout an extrapelvic (abdominal) source of hemorrhage withmajor pelvic fracture. Although X-ray patterns of injury donot seem to predict hemorrhage, the use of CT scan with afinding of ICE is highly predictive of active bleeding andsupported by the literature. The use of pelvic externalfixation and C-Clamps has largely given way to TPBs. Thehope with these devices is that by stabilizing the fracture,bleeding will be limited. Although the data are limited,early studies seem promising. Further studies will beneeded to asses the ability of temporary abdominal bindersto minimize hemorrhage from pelvic fracture. Finally,retroperitoneal packing is an effective tool to limit hem-orrhage in the small studies that have investigated thetechnique. Its role in the management of pelvic hemor-rhage at this time remains unclear and will need directcomparison with angiography in future studies.

REFERENCES1. DiGiacomo JG, Bonadies JA, Cole FJ. Practice management guidelines

for hemorrhage in pelvic fracture [EAST Website], 2001. Available at:http://www.east.org/tpg/pelvis.pdf. Accessed October 1, 2009.

2. Eastern Association for the Surgery of Trauma. Practice ManagementGuidelines for Traum a East Ad Hoc Committee on Guideline Develop-ment. Chicago, IL: EAST; 1998.

3. Baque P, Trojani C, Delotte J, et al. Anatomical consequences of“open-book” pelvic ring disruption: a cadaver experimental study. SurgRadiol Anat. 2005;27:487–490.

4. Stover MD, Summers HD, Ghanayem AJ, Wilber JH. Three-dimensionalanalysis of pelvic volume in an unstable pelvic fracture. J Trauma. 2006;61:905–908.

5. Grimm MR, Vrahas MS, Thomas KA. Pressure-volume characteristicsof the intact and disrupted pelvic retroperitoneum. J Trauma. 1998;44:454–459.

6. Flint LM, Brown A, Richardson JD, Polk HC. Definitive control ofbleeding from severe pelvic fractures. Ann Surg. 1979;189:709–716.

7. Moreno C, Moore EE, Rosenberger A, Cleveland HC. Hemorrhageassociated with major pelvic fracture: a multispecialty challenge.J Trauma. 1986;26:987–994.

8. Batalden DJ, Wickstrom PH, Ruiz E, Gustilo RB. Value of the G suit inpatients with severe pelvic fracture. Controlling hemorrhagic shock.Arch Surg. 1974;109:326–328.

9. Ali J, Qi W. Fluid and electrolyte deficit with prolonged pneumaticanti-shock garment application. J Trauma. 1995;38:612–615.

10. Chang FC, Harrison PB, Beech RR, Helmer SD. PASG: does it help inthe management of traumatic shock? J Trauma. 1995;39:453–456.

11. Sadri H, Nguyen-Tang T, Stern R, Hoffmeyer P, Peter R. Control ofsevere hemorrhage using C-clamp and arterial embolization in hemody-namically unstable patients with pelvic ring disruption. Arch OrthopTrauma Surg. 2005;125:443–447.

12. Richard MJ, Tornetta P. Emergent management of APC-2 pelvic ringinjuries with an anteriorly placed C-Clamp. J Orthop Trauma. 2009;23:322–326.

13. Tiemann AH, Bohme J, Josten C. Emergency treatment of multiplyinjured patients with unstable disruption of the posterior pelvic ring byusing the “C-clamp”: analysis of 28 consecutive cases. Eur J Trauma.2005;31:244–251.

14. Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M.Emergent stabilization of pelvic ring injuries by controlled circumfer-ential compression: a clinical trial. J Trauma. 2005;59:659–664.

15. Galois L, Pfeffer F, Mainard D, Delagoutte JP. The value of externalfixation for unstable pelvic ring injuries. Acta Orthop Belg. 2003;69:321–327.

16. Stephen DJG, Kreder HJ, Day AC, et al. Early detection of arterialbleeding in acute pelvic trauma. J Trauma. 1999;47:638–642.

17. Totterman A, Dormagen J, Madsen JE, Klow NE, Skaga NO,Roise O. A protocol for angiographic embolization in exsanguinatingpelvic trauma: a report on 31 patients. Acta Orthop. 2006;77:462–468.

18. Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC. Externalfixation or arteriogram in bleeding pelvic fracture: initial therapy guidedby markers of arterial hemorrhage. J Trauma. 2003;54:437–443.

19. Cook RE, Keating JF, Gillespie I. The role of angiography in themanagement of haemorrhage from major fractures of the pelvis. J BoneJoint Surg. 2002;84:178–182.

20. Fangio P, Asehnoune K, Edouard A, Smail N, Benhamou D. Earlyembolization and vasopressor administration for management of life-threatening hemorrhage from pelvic fracture. J Trauma. 2005;58:978–984.

21. Starr AJ, Griffin DR, Reinert CM, et al. Pelvic ring disruptions: predic-tion of associated injuries, transfusion requirement, pelvic arteriography,complications, and mortality. J Orthop Trauma. 2002;16:553–561.

22. Gourlay D, Hoffer E, Routt M, Bulger E. Pelvic angiography forrecurrent traumatic pelvic arterial hemorrhage. J Trauma. 2005;59:1168–1173.

23. Fang JF, Shih LY, Wong YC, Lin BC, Hsu YP. Repeat transcatheterarterial embolization for the management of pelvic arterial hemorrhage.J Trauma. 2009;66:429–435.

24. Niwa T, Takebayashi S, Igari H, et al. The value of plain radiographs inthe prediction of outcome in pelvic fractures treated with embolisationtherapy. Br J Radiol. 2000;73:945–950.

25. Wong YC, Wang LJ, Ng CJ, Tseng IC, See LC. Mortality aftersuccessful transcatheter arterial embolization in patients with unstablepelvic fractures: rate of blood transfusion as a predictive factor.J Trauma. 2000;49:71–75.

26. Hagiwara A, Minakawa K, Matsuda T, Murata A, Masuda H, ShimazakiS. Predictors of death in patients with life-threatening pelvic hemorrhageafter successful transcatheter arterial embolization. J Trauma. 2003;55:696–703.

27. Kimbrel BJ, Velmahos GC, Chan LS, Demetriades D. Angiographicembolization for pelvic fractures in older patients. Arch Surg. 2004;139:728–732.

28. Metz CM, Hak DJ, Goulet JA, Williams D. Pelvic fracture patterns andtheir corresponding angiographic sources of hemorrhage. Orthop ClinNorth Am. 2004;35:431–437.

29. Velmahos GC, Toutouzas KG, Vassiliu A, et al. A prospective study onthe safety and efficacy of angiographic embolization for pelvic andvisceral injuries. J Trauma. 2002;53:303–308.

30. Shapiro M, McDonald AA, Knight D, Johannigman JA, Cuschieri J. Therole of repeat angiography in the management of pelvic fractures.J Trauma. 2005;58:227–231.

31. Velmahos GC, Chahwan S, Falabella A, Hanks SE, Demetriades D.Angiographic embolization for intraperitoneal and retroperitoneal inju-ries. World J Surg. 2000;24:539–545.

32. Takahira N, Shindo M, Tanaka K, Nishimaki H, Ohwada T, Itoman M.Gluteal muscle necrosis following transcatheter angiographic embolisa-tion for retroperitoneal haemorrhage associated with pelvic fracture.Injury. 2001;32:27–32.

33. Yasumura K, Ikegami K, Kamohara T, Nohara Y. High incidence ofischemic necrosis of the gluteal muscle after transcatheter angio-graphic embolization for severe pelvic fracture. J Trauma. 2005;58:985–990.



34. Ramirez JI, Velmahos GC, Best CR, Chan LS, Demetriades D. Malesexual function after bilateral internal Iliac artery embolization for pelvicfracture. J Trauma. 2004;56:734–739.

35. Panetta T, Sclafani SGA, Goldstein AS, Phillips TF, Shaftan GW.Percutaneous transcatheter embolization for massive bleeding frompelvic fractures. J Trauma. 1985;25:1021–1029.

36. Evers BM, Cryer HM, Miller FB. Pelvic fracture hemorrhage. ArchSurg. 1989;124:422–424.

37. Flint L, Babikian G, Anders M, Rodriguez J, Steinberg S. Definitivecontrol of mortality from severe pelvic fracture. Ann Surg. 1990;211:703–706.

38. Branney SW, Moore EE, Cantrill SV, Burch JM, Terry SJ. Ultrasoundbased key clinical pathway reduces the use of hospital resources for theevaluation of blunt abdominal trauma. J Trauma. 1997;42:1086–1090.

39. Healey MA, Simons RK, Winchell RJ, et al. A prospective evaluation ofabdominal ultrasound in blunt trauma: is it useful? J Trauma. 1996;40:875–883.

40. Glaser K, Tschmelitsch J, Klingler P, Wetscher G, Bodner E. Ultra-sonography in the management of blunt abdominal and thoracic trauma.Arch Surg. 1994;129:743–747.

41. Liu M, Lee CH, P’eng FK. Prospective comparison of diagnosticperitoneal lavage, computed tomographic scanning, and ultrasonographyfor the diagnosis of blunt abdominal trauma. J Trauma. 1993;35:267–270.

42. Boulanger BR, McLellan BA, Brenneman FD, et al. Emergent abdom-inal sonography as a screening test in a new diagnostic algorithm forblunt trauma. J Trauma. 1996;40:867–874.

43. Eastridge BJ, Burgess AR. Pedestrian pelvic fractures; 5-year experienceof a major urban trauma center. J Trauma. 1997;42:695–700.

44. Allen CF, Goslar PW, Barry M, Christiansen T. Management guidelinesfor hypotensive pelvic fracture patients. Am Surg. 2000;66:735–738.

45. Ruchholtz S, Waydhas C, Lewan U, et al. Free abdominal fluid onultrasound in unstable pelvic ring fracture: is laparotomy always neces-sary? J Trauma. 2004;57:278–285.

46. Tayal V, Nielsen A, Jones AE, Thomason MH, Kellam J, Norton HJ.Accuracy of trauma ultrasound in major pelvic injury. J Trauma.2006;61:1453–1457.

47. Friese RS, Malekzadeh S, Shafi S, Gentilello LM, Starr A. Abdominalultrasound is an unreliable modality for the detection of hemoperito-neum in patients with pelvic fracture. J Trauma. 2007;63:97–102.

48. Ballard RB, Rozycki GS, Newman PG, et al. An algorithm to reduce theincidence of false-negative FAST examinations in patients at high riskfor occult injury. Focused assessment for the sonographic examinationof the trauma patient. J Am Coll Surg. 1999;189:145–150; discussion150–151.

49. Young JWR, Burgess AR. Radiologic Management Of Pelvic RingFractures in Systematic Radiographic Diagnosis. Baltimore: Urban andScwarzenberg; 1987.

50. Eastridge BJ, Starr A, Minei JP, O’Keefe GE, Scalea TM. The impor-tance of fracture pattern in guiding therapeutic decision-making inpatients with hemorrhagic shock and pelvic ring disruptions. J Trauma.2002;53:446–450.

51. Hamill J, Holden A, Civil I. Pelvic fracture pattern predicts pelvicarterial haemorrhage. Aust N Z J Surg. 2000;70:338–343.

52. Fu CY, Wu SC, Chen RJ, et al. Evaluation of pelvic fracture stability andthe need for angioembolization: pelvic instabilities on a plain film havean increased probability of requiring angioembolization. Am J EmergMed. 2009;27:792–796.

53. Magnussen RA, Tressler MA, Obremskey WT, Kregor PJ. Predictingblood loss in isolated pelvic and acetabular high-energy trauma. J Or-thop Trauma. 2007;21:603–607.

54. Lunsjo K, Tadros A, Hauggaard A, Blomgren R, Kopke J, Abu-ZidanFM. Associated injuries and not fracture instability predict mortality inpelvic fractures: a prospective study of 100 patients. J Trauma. 2007;62:687–691.

55. Blackmore CC, Cummings P, Jurkovich GJ, Linnau KF, Hoffer EK,Rivara FP. Predicting major hemorrhage in patients with pelvic fracture.J Trauma. 2006;61:346–352.

56. Sarin EL, Moore JB, Moore EE, et al. Pelvic fracture pattern does notalways predict the need for urgent embolization. J Trauma. 2005;58:973–977.

57. Smith W, Williams A, Agudelo J, et al. Early predictors of mortality inhemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;21:31–37.

58. Pereira SJ, O’Brien DP, Luchette FA, et al. Dynamic helical computedtomography scan accurately detects hemorrhage in patients with pelvicfracture. Surgery. 2000;128:678–685.

59. Ryan MF, Hamilton PA, Chu P, Hanaghan J. Active extravasation ofarterial contrast agent on post-traumatic abdominal computed tomogra-phy. Can Assoc Radiol J. 2004;55:160–169.

60. Evers BM, Cryer HM, Miller FB. Pelvic fracture hemorrhage: prioritiesin management. Arch Surg. 1989;124:422–424.

61. Brasel KJ, K. Pham, Yang H, Christensen R, Weigelt JA. Significance ofcontrast extravasation in patients with pelvic fracture. J Trauma. 2007;62:1149–1152.

62. Brown CVR, Kasotakis G, Wilcox A, Rhee P, Salim A, Demetriades D.Does pelvic hematoma on admission computed tomography predict activebleeding at angiography for pelvic fracture? Am Surg. 2005;71:759–762.

63. Brandes S, Borrelli J. Pelvic fracture and associated urologic injuries.World J Surg. 2001;25:1578–1587.

64. Netto FA, Hamilton P, Kodama R, et al. Retrograde urethrocystographyimpairs computed tomography diagnosis of pelvic arterial hemorrhage inthe presence of a lower urologic tract injury. J Am Coll Surg. 2008;206:322–327.

65. Routt ML Jr, Falicov A, Woodhouse E, Schildhauer TA. Circumferentialpelvic antishock sheeting: a temporary resuscitation aid. J OrthopTrauma. 2006;20:S3–S6.

66. Simpson T, Krieg JC, Heuer F, Bottlang M. Stabilization of pelvic ringdisruptions with a circumferential sheet. J Trauma. 2002;52:158–161.

67. Warme WJ, Todd MS. The circumferential antishock sheet. Mil Med.2002;167:438–441.

68. Ghaemmaghami V, Sperry J, Gunst M, et al. Effects of early use ofexternal pelvic compression on transfusion requirements and mortalityin pelvic fractures. Am J Surg. 2007;194:720–723; discussion 723.

69. Croce MA, Magnotti LJ, Savage SA, Wood GW II, Fabian TC. Emer-gent pelvic fixation in patients with exsanguinating pelvic fractures.J Am Coll Surg. 2007;204:935–939; discussion 940–942.

70. Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergentmanagement of pelvic ring fractures with use of circumferential com-pression. J Bone Joint Surg Am. 2002;84:43–47.

71. Bottlang M, Simpson T, Sigg J, Krieg JC, Madey SM, Long WB.Noninvasive reduction of open-book pelvic fractures by circumferentialcompression. J Orthop Trauma. 2002;16:367–373.

72. Jowett AJL, Bowyer GW. Pressure characteristics of pelvic binders.Injury. 2007;38:118–121.

73. Pohlemann T, Gansslen A, Hufner T, Tscherne H. Extraperitonealpacking at laparotomy. Presented at: OTA-AAST Annual Meeting, Oc-tober 12–14, 2000, San Antonio, Texas.

74. Ertel W, Karim E, Keel M, Trentz O. Therapeutical strategies andoutcome of polytraumatized patients with pelvic injuries. Eur J Trauma.2000;26:278–286.

75. Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe hemor-rhage using C-clamp and pelvic packing in multiply injured patients withpelvic ring disruption. J Orthop Trauma. 2001;15:468–474.

76. Giannoudis PV, Pape HC. Damage control orthopaedics in unstablepelvic ring injuries. Injury. 2004;35:671–677.

77. Totterman A, Madsen JE, Skaga NO, Roise O. Extraperitoneal pelvicpacking: a salvage procedure to control massive traumatic pelvic hem-orrhage. J Trauma. 2007;62:843–852.

78. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, SmithWR. Preperitoneal pelvic packing for hemodynamically unstable pelvicfractures: a paradigm shift. J Trauma. 2007;62:834–839; discussion839–842.

79. Bach A, Bendix J, Hougaard K, Christensen EF. Retroperitoneal packingas part of damage control surgery in a Danish trauma centre—fast,effective, and cost-effective. Scand J Trauma Resusc Emerg Med.2008;16:4.

80. Smith WR, Moore EE, Osborn P, et al. Retroperitoneal packing as aresuscitation technique for hemodynamically unstable patients withpelvic fractures: report of two representative cases and a description oftechnique. J Trauma. 2005;59:1510–1514.

81. Osborn PM, Smith WR, Moore EE, et al. Direct retroperitonealpacking versus pelvic angiography: a comparison of two management



protocols for heamodynamically unstable pelvic fractures. Injury.2009;40:54 – 60.

82. Biffl WL, Smith WR, Moore EE, et al. Evolution of a multidisciplinaryclinical pathway for the management of unstable patients with pelvicfractures. Ann Surg. 2001;233:843–850.

83. Balogh Z, Caldwell E, Heetveld M, et al. Institutional practice guidelineson management of pelvic fracture-related hemodynamic instability: dothey make a difference? J Trauma. 2005;58:778–782.

84. Jeske HC, Larndorfer R, Krappinger D, et al. Management of hemor-rhage in severe pelvic injuries. J Trauma. 2010;68:415–420.

85. Blackmore CC, Jurkovich GJ, Linnau KF, Cummings P, Hoffer EK,Rivara FP. Assessment of volume of hemorrhage and outcome frompelvic fracture. Arch Surg. 2003;138:504–509.

86. Kataoka Y, Maekawa K, Nishimaki H, Yamamoto S, Soma K. Iliac veininjuries in hemodynamically unstable patients with pelvic fracturescaused by blunt trauma. J Trauma. 2005;58:704–710.



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