Pelvic ring injuries: Emergency assessment and management

Management of floating hip injury: a review of the literature

Aim

The aim of this study was to provide a comprehensive overview of floating hip injury and attempt to provide a management algorithm.

Methods

PubMed was searched using the terms 'Floating hip' or 'acetabular fracture' and 'Ipsilateral femoral fracture' or 'pelvic fracture' and 'Ipsilateral femoral fracture'. One author performed a preliminary review of the abstracts and references of the retrieved articles.

Results

The mean injury severe score reported was higher than 20. Chest and abdominal injuries, as well as fractures at other sites, were the most common associated injuries. Despite the high disability rate, surgery remained the preferred option for managing these injuries. The surgical timing varied from a few hours to several days and was subjected to the principles of damage control orthopedics. Although, in most cases, fixation of femoral fractures took precedence over pelvic or acetabular fractures, there was still a need to consider the impact of damage control orthopedics, associated injuries, and surgeon's considerations and preferences. Posttraumatic arthritis, neurological deficits, heterotopic ossification, femoral head necrosis, femoral nonunion, and limb inequality were common complications of the floating hip injury.

Conclusions

The severity of such injuries often exceeds that of an isolated injury and often requires specialized multidisciplinary treatment. In the management of these complex cases, the complexity and severity of the injury should be fully assessed, and an appropriate surgical plan should be developed to perform definitive surgery as early as possible, with attention to prevention of complications during the perioperative period.

A cadaveric biomechanical evaluation of anterior posterior compression II injuries

PURPOSE

Pelvic fractures are associated with high morbidity and often require surgical intervention. An Anterior Posterior Compression (APC) II injury consists of disruption at the pubic symphysis and anterior sacroiliac joint. Studies investigating specific ligamentous contributions would aid in development of novel fixation techniques. The objective of this study is to determine the level of pelvic destabilization from progressive soft tissue disruptions associated with APC II injuries.

METHODS

Six fresh-frozen cadaveric pelvises were dissected of soft tissues, preserving joint capsules and ligaments. Each pelvis was secured in a double-leg stance and joint motion was tracked with the specimens cyclically loaded to 60% body weight. Each specimen was measured in the intact state and again following stepwise destabilization to an APC II injury model (PS: sectioned pubic symphysis, IPS JOINT: PS + ipsilateral anterior sacroiliac, sacrotuberous, sacrospinous ligaments sectioned, IPS LIGS: IPS JOINT + ipsilateral interosseous ligaments sectioned, IPS JOINT+CONT ASI: IPS LIGS + contralateral anterior sacroiliac ligament disruption).

RESULTS

Compared to the intact state, there was a statistically significant increase in movement in the IPS JOINT (ipsilateral 177%, p<0.001; contralateral 46%, p<0.005) and IPS JOINT+CONT ASI (ipsilateral 184%, p<0.002; and contralateral 62%, p<0.002) states bilaterally. No significant change was demonstrated in the PS or IPS LIGS state.

CONCLUSION

Disruption of ipsilateral ligamentous structures destabilized both sacroiliac joints. The interosseous and posterior sacroiliac ligaments provide the majority of stability of the sacroiliac joint and will likely benefit most from surgical stabilization.

LEVEL OF EVIDENCE

mechanism-based reasoning.

Morphodynamic study of the corona mortis using the SimLife® technology

PURPOSE

Open book pelvic ring fractures are potentially life-threatening, due to their instability and major hemorrhage risk. During the open reduction and internal fixation, the pelvic approach remains a technical challenge, as the surgeon wants to prevent any iatrogenic damage of the vascular loop located in the retro-pubic area called corona mortis (CMOR). Recently, the cadaver perfused SimLife^® technology has been developed to improve the surgeon training, out of the operating room. This study aimed to compare two models of cadaveric dissection, to assess the interest of the perfused SimLife^® in providing dynamic aspect of anatomy in the identification of CMOR and its topography.

METHODS

Twelve human cadaveric pelvises have been dissected, following two protocols. 12 hemi-pelvises of the dissections were performed without perfusion (Model A), whereas the 12 other hemi-pelvises have been prepared with the SimLife^® pulsatile perfusion (Model B). The prevalence and morphologic parameters determined: length, diameter and distance between the CMOR and the pubic symphysis.

RESULTS

The CMOR has been found in 66.67% of the cases. The length, the diameter, and the distance between the CMOR and the pubic symphysis were significantly higher in model B (respectively p = 0.029, p = 0.01, and p = 0.022).

CONCLUSION

These results suggest that the CMOR is easier to identify and to dissect with the SimLife^® perfusion. As part of the surgical training of any trauma surgeon, this model could help him to keep in mind the CMOR topography, to improve the open book lesion management.

Minimally invasive transiliac anatomical locking plate for posterior pelvic ring injury: A technical trick of the gull wing plate

Posterior pelvic ring injuries commonly involve sacral fractures, which are difficult to reduce and stabilize. Because conservative treatment requires long-term bedrest and leads to unsatisfactory outcomes, surgical intervention is a beneficial option to protect neurological structures and provide sufficient stability for early mobilization. Several studies have investigated a variety of internal fixation techniques, such as iliosacral screws, transiliac bars, spinal instruments, and transiliac plates. The gull wing plate (GWP) is a pre-contoured anatomical locking plate with two cancellous screws (φ6.5 mm) and four locking screws (φ5.0 mm), the design of which is unique among posterior tension-band plates. The GWP provides reliable stability of the posterior construct of the pelvic ring and accelerates rehabilitation. Compared to alternative surgical techniques for posterior fixation, the simple surgical procedure of the GWP is minimally invasive and highly reproducible, which leads to fewer complications and less radiation exposure.

Navigated Percutaneous Sacroiliac Screw Fixation in Unstable Pelvic Ring Fracture

Since the late 1990s, navigation systems have been widely used in a variety of orthopaedic surgical procedures, with the majority of these procedures being complex arthroplasty surgeries and the correction of spinal abnormalities. Navigation systems are, however, infrequently used in trauma cases, especially in unstable pelvic ring fractures. The conventional method of percutaneous sacroiliac screw fixation typically used fluoroscopic image intensifiers to fix unstable pelvic ring fractures. We will examine how navigation systems can be used in trauma situations, particularly those involving unstable posterior pelvic ring fractures and focus on the advantages and disadvantages that we experienced during management.

[Fracture management in polytrauma]

The management of polytrauma patients is a complex multidisciplinary and dynamic task. The early and comprehensive assessment of the clinical condition is of great importance with respect to the timing and the individual decision-making on surgical fracture treatment. Stable patients benefit from early definitive fracture treatment, whereas for unstable patients, the concept of multistage fracture treatment with temporary minimally invasive stabilization has gained wide acceptance. These concepts, known as early total care (ETC) and damage control orthopedics (DCO), have been extended in recent decades by dynamic and injury-adapted treatment protocols, such as early appropriate care (EAC) or safe definitive orthopedic surgery (SDS): Therefore, patients in an initially unclear condition (borderline patients) can now also be treated with an individually adapted care concept as soon as possible.

Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamically Unstable Patients With Pelvic Ring Injuries

OBJECTIVE

To evaluate the outcomes of patients with pelvic ring injuries managed with resuscitative endovascular balloon occlusion of the aorta (REBOA).

DESIGN

Retrospective case series.

SETTING

Academic, Level 1 trauma center in North America.

PATIENTS

Twenty-five patients with disruption of the pelvic ring and hemodynamic instability.

INTERVENTION

Placement of a REBOA device as an adjuvant treatment to trauma resuscitation.

MAIN OUTCOME MEASURE

Death and ischemic-related complications.

RESULTS

The average age of patients was 43 years (range: 17-85). Patients presented with a median lactate of 6.3 mmol/L, systolic blood pressure of 116 mm Hg, heart rate of 121 beats/minute, and injury severity score of 34. The median unit of packed red blood cells received through transfusion in the first 24 hours of hospital admission was 13 (interquartile range: 8-28). Young-Burgess injury patterns included fractures of the following types: 5 lateral compression (LC)-1, 1 LC-2, 8 LC-3, 4 anteroposterior compression-2, and 7 anteroposterior compression-3. Angiography and embolization were performed in 24 (96%) patients. Selective embolization occurred in 18 (72%) patients, with nonselective angiography of the iliac system occurring in 7 (24%) patients. There were 12 (48%) deaths, 7 (28%) patients requiring lower extremity fasciotomy, and 5 (20%) patients requiring lower extremity amputations, and there was 1 (4%) patient requiring thrombectomy.

CONCLUSIONS

REBOA use in pelvic ring injuries is rare and most frequently used in critically ill patients with polytrauma. Successful pelvic embolization can occur in concert with REBOA use; however, the severity of injury is associated with a high complication profile. In this series of 25 patients, in-hospital mortality was 48%. For those patients who survived, 54% experienced a major complication (fasciotomy, amputation, and deep infection). Further investigation is required to evaluate the role REBOA may play in managing these patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Novel resuscitation strategies in patients with a pelvic fracture

Patients with a pelvic ring injury and hemodynamic instability can be challenging to manage with high rates of morbidity and mortality rates. Protocol-based resuscitation strategies are critical to successfully manage these potentially severely injured patients in a well-coordinated manner. While some aspects of treatment may vary slightly from institution to institution, it is critical to identify pelvic injuries and their associated injuries expediently. The first step at the scene of injury or in the trauma resuscitation bay should be the immediate application of a circumferential pelvic sheet or binder, initiation of physiologically optimal fluid resuscitation in the form 1:1:1 (pRBC:FFP:platelets) or whole blood, and to consider TXA as a safe adjunct to treat coagulopathy. Providers should have a very low threshold for emergent operative intervention in the form of pelvic external fixation and/or pelvic packing. This occurs in addition to simultaneous interventions addressing the other possible sources of bleeding in patients demonstrating signs of hemorrhagic shock and failure to respond to early resuscitation and external pelvic tamponade. Finally, while arterial injury is only present in a small percentage of patients with a pelvic ring injury, percutaneous vascular intervention with selective angiography and REBOA have been shown to be efficacious for patients with clinical indicators of arterial injury or who remain hemodynamically unstable despite external pelvic tamponade and packing to address venous bleeding. They should be performed when as early as possible for patients in true extremis limit further hemorrhage and allow resuscitation efforts to continue.

Systematic review of sacroiliac joint motion and the effect of screw fixation

BACKGROUND

Pelvic injuries that disrupt the sacroiliac joints often require surgical intervention to restore stability. Quantitative characterization of sacroiliac motion in response to physiologic loading provides important metrics of adequate fixation in the evaluation of newly emerged fixation techniques. The objective of this study was to systematically review and evaluate biomechanical evidence on the motion of the sacroiliac joint in its normal, destabilized, and stabilized states.

METHODS

We searched the PubMed database for studies available until June 2020 using keywords: sacroiliac, biomechanic*, and fixation. Publications of any in vivo or in vitro biomechanical study that included measurements of the range of motion at the sacroiliac joint were considered.

FINDINGS

We identified and screened 176 total records, and 13 articles of them met inclusion criteria and were used in this review. The average sacroiliac joint range of motion of the intact pelvis was 1.88° in flexion/extension, 0.85° in lateral bending, 1.26° in axial rotation. Of the 13 studies, four reported sacroiliac motion from a destabilized state, while seven reported the motion after stabilization. A forest plot of the stabilized data set in flexion/extension showed that while the heterogeneity was poor, the weighted effect size of the changes from the intact state to the stabilized state was 0.0%.

INTERPRETATION

Quantitative evidence on sacroiliac joint motion relating to pelvic injuries or fixation is limited. Our results indicate that the pooled intact range of motion from the literature may serve as a viable reference to quantify the effectiveness of new stabilization techniques.

LEVEL OF EVIDENCE

Level V, systematic review.

STUDY TYPE

Therapeutic- investigating the results of a treatment.

The effect of preperitoneal pelvic packing for hemodynamically unstable patients with pelvic fractures

PURPOSE

Hemodynamically unstable patients with pelvic fractures still represent a challenge to trauma surgeons and have a very high mortality. This study was designed to explore the effect of the interventions of direct preperitoneal pelvic packing for the hemodynamically unstable pelvic fractures.

METHODS

This retrospective study enrolled 67 cases of severe pelvic fractures with unstable hemodynamics from October 2011 to December 2019. All patients presented in our emergency center and received preperitoneal pelvic packing were included in this study. The indication was persistent systolic blood pressure ≤90 mmHg during initial resuscitation and after transfusion of two units of red blood cells. Patients with hemodynamic stability who need no preperitoneal pelvic packing to control bleeding were excluded. Their demographic characteristics, clinical features, laboratory results, therapeutic interventions, adverse events, and prognostic outcomes were collected from digital information system of electronic medical records. Statistics were described as mean ± standard deviation or medium and analyzed using pair sample t-test or Mann-Whitney U-test.

RESULTS

The patients' average age was 41.6 years, ranging from 10 to 88 years. Among them, 45 cases were male (67.2%) and 22 cases were female (32.8%). Significant difference was found regarding the systolic blood pressure (mmHg) in the emergency department (78.4 ± 13.9) and after preperitoneal pelvic packing in the surgery intensive care unit (100.1 ± 17.6) (p < 0.05). Simultaneously, the arterial base deficit (mmol/L) were significantly lower in the surgery intensive care unit (median -6, interquartile range -8 to -2) than in the emergency department (median -10, interquartile range -14 to -8) (p < 0.05). After preperitoneal pelvic packing, 15 patients (22.4%) underwent pelvic angiography for persistent hypotension or suspected ongoing haemorrhage. The overall mortality rate was 29.5% (20 of 67).

CONCLUSIONS

Preperitoneal pelvic packing, as a useful surgical technique, is less invasive and can be very efficient in early intra-pelvic bleed control.

Hemodynamically unstable pelvic fracture: A damage control surgical algorithm that fits your reality

Pelvic fractures occur in up to 25% of all severely injured trauma patients and its mortality is markedly high despite advances in resuscitation and modernization of surgical techniques due to its inherent blood loss and associated extra-pelvic injuries. Pelvic ring volume increases significantly from fractures and/or ligament disruptions which precludes its inherent ability to self-tamponade resulting in accumulation of hemorrhage in the retroperitoneal space which inevitably leads to hemodynamic instability and the lethal diamond. Pelvic hemorrhage is mainly venous (80%) from the pre-sacral/pre-peritoneal plexus and the remaining 20% is of arterial origin (branches of the internal iliac artery). This reality can be altered via a sequential management approach that is tailored to the specific reality of the treating facility which involves a collaborative effort between orthopedic, trauma and intensive care surgeons. We propose two different management algorithms that specifically address the availability of qualified staff and existing infrastructure: one for the fully equipped trauma center and another for the very common limited resource center.

Optimizing Pelvic X-Ray indication in blunt trauma patients using clinical criteria

OBJECTIVE

to identify a subgroup of blunt trauma patients with very low chance of sustaining pelvic fractures based on clinical criteria.

METHODS

retrospective analysis of the trauma registry data, collected in a period of 24 months. We selected adult blunt trauma patients who had a PXR on admission. The frequency of pelvic fractures was calculated for the following groups: Normal neurological examination at admission (NNE), hemodynamical stability (HS), normal pelvic examination at admission (NPE), less than 60 years old (ID<60) and absence of distracting injuries (ADI). Logistic regression analysis was carried out in order to create a probability model of negative PXR.

RESULTS

an abnormal PXR was identified in 101 (3.3%) out of the 3,055 patients who had undergone a PXR at admission. Out of these, 1,863 sustained a NNE, with 38 positive CXRs (2.0%) in this group. Considering only the 1,535 patients with NNE and HS, we found 28 positive PXRs (1.8%). Out of these, 1,506 have NPE, with 21 abnormal PXRs (1.4%). Of these, 1,202 were younger than 60 y, with 11 positive PXRs (0.9%). By adding all these criteria to the ADI, we found 2 abnormal PXRs in 502 (0.4%) cases. The probability model including all these variables had a 0,89 area under the ROC curve.

CONCLUSIONS

by adding clinical criteria, it is possible to identify a group of trauma patients with very low chance of sustaining pelvic fractures. The necessity of PXR in these patients needs to be reassessed.

Modified internal fixator for anterior pelvic ring fractures versus conventional two-screw fixation

PURPOSE

The present study aims to evaluate the short-term clinical effects and complications of modified three-screw fixation and conventional two-screw fixation for treating anterior pelvic ring fractures.

METHODS

A retrospective study of 51 patients with type B fractures was performed. 25 patients (modified group) were treated with modified three-screw fixation and the other 26 patients (conventional group) with conventional two-screw fixation. Outcome measures included operation time, intraoperative blood loss, hospital stays, postoperative complications and the Majeed score at postoperatively 2 months, 3 months, 1 year and the time of implant removal.

RESULTS

The mean operative times and mean blood loss for modified three-screw fixation versus conventional two-screw fixation bilateral were 54.8 ± 10.7 min versus 32.3 ± 9.9 min, and 153.3 mL versus 550.0 mL (p < 0.001), respectively. However, the Majeed score was better in modified group at postoperatively 2 months (75.6 ± 9.5 vs. 69.7 ± 8.3, p = 0.008) and 3 months (80.3 ± 10.7 vs. 75.1 ± 11.9, p = 0.014). There was no statistical difference between two groups at the time of implant removal (82.1 ± 9.3 vs. 80.9 ± 8.8, p = 0.272) and postoperatively 1 year (83.5 ± 7.8 vs 82.6 ± 8.2, p = 0.723). No patients experienced surgical wound infection, deep vein thrombosis, delayed union or nonunion, implant loosening or rupture. One patient complained of tardive unilateral thigh pain at postoperatively 4 months in conventional group.

CONCLUSIONS

Both modified three-screw fixation and conventional two-screw fixation could ultimately afford satisfactory clinical and radiological outcomes with less complication for anterior pelvic ring fractures. The modified three-screw fixation might have better biomechanical strength and faster pelvic rehabilitation.

Improving the improvisational pelvic circumferential compression technique for open-book pelvic fractures using a simulation model and a sphygmomanometer

BACKGROUND

Open-book pelvic fractures are associated with significant mortality. Emergency management may require a commercial pelvic circumferential compression device to reduce the fracture and compress haemorrhaging pelvic vasculature. Standard, commercial, twin-sized bedsheets are acceptable should commercial devices be unavailable. However, obese victims or personnel with insufficient body strength may impede successful reduction.

OBJECTIVE

To demonstrate the value of an improvisational windlass (intravenous pole) in improving the ability to reduce an open-book pelvic fracture.

METHODS

The Institutional Review Board-approved study involved 28 diverse healthcare students and emergency medicine residents. Each participant's demographic information and physical characteristics were recorded. A METIman was prepared with knee and ankle binding and a sphygmomanometer set at 40 mm Hg placed over the symphysis pubis. Two-person teams were randomly selected to place a bedsheet at greater trochanter level and atop the sphygmomanometer. The bedsheet was secured with maximum effort by the pairs and the pressure recorded. Following this, the pairs inserted an intravenous pole in the knot and torqued the pole to maximum effort and a repeat pressure recorded.

RESULTS

The mean increase in pressure using only the bedsheet was 106.43 mm Hg per team. With bedsheet and intravenous pole, the mean pressure increase was 351.79 mm Hg per team. The difference was statistically significant (independent samples t-test: t = 17.177, p < 0.001, 95% CI (216.65 to 274.07 mm Hg). There was no correlation between pressure increases and the individual physical characteristics of the subjects (r = - 0.183, p = 0.352).

CONCLUSIONS

Regardless of personnel's physical attributes, the addition of an improvisational windlass to a pelvic circumferential compression bedsheet can improve the ability to reduce an open-book fracture, especially in obese victims.

Evaluation of strategies for the treatment of type B and C pelvic fractures: results from the German Pelvic Injury Register

Aims

The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization.

Patients and Methods

The study used data from the German Pelvic Trauma Registry and compared patients undergoing conservative management (n = 2394), surgical treatment (n = 1345) and transpubic surgery, including posterior stabilization (n = 730) with isolated posterior osteosynthesis (n = 405) in non-complex Type B and C fractures that only involved the obturator ring anteriorly. Calculated odds ratios were adjusted for potential confounders. Outcome criteria were intraoperative and general short-term complications, the incidence of nerve injuries, and mortality.

Results

Operative stabilization reduced mortality by 36% (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.42 to 0.98) but the incidence of complications was twice as high (OR 2.04, 95% CI 1.57 to 2.64). Mortality and the incidence of neurological deficits at discharge were no different after isolated posterior or combined anteroposterior fixation. However, the odds of both surgical (98%, OR 1.98, 95%CI 1.22 to 3.22) and general complications (43%, OR 1.43, 95% CI 1.02 to 2.00) were higher in the group with the more extensive surgery.

Conclusion

Operative stabilization is recommended for non-complex unstable pelvic fractures. The need for anterior fixation of obturator ring fractures should, however, be considered critically. Cite this article: Bone Joint J 2018;100-B:973-83.

Current trends in the management of hemodynamically unstable pelvic ring injuries

PURPOSE OF REVIEW

Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries.

RECENT FINDINGS

Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization.

SUMMARY

Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.

A Multidisciplinary Approach to Treating Traumatic Pelvic Fractures: 1.1 www.aornjournal.org/content/cme

Pelvic fractures are traumatic injuries that can be caused by motor vehicle accidents, motorcycle accidents, motor vehicle-related pedestrian injuries, or falls from a significant height. These injuries can be life threatening because of the high vascularity of the pelvis and the difficulty in being able to see bleeding occurring in this area. Traditional approaches to treat pelvic fractures have been pelvic binding, external fixation, and open preperitoneal packing; however, the use of angiography and embolization enables faster pinpointing of the location of the bleeding. Increased use of hybrid ORs for treating traumatic pelvic fractures combines the superior imaging of interventional radiology with an OR that can quickly provide open interventions without needing to move a patient from an interventional radiology suite to another OR. This improvement in technology has combined the resources and knowledge of more diverse disciplines to provide a more centralized approach to improving patient outcomes.

Anterior fracture dislocation of the sacroiliac joint: A case report and literature review

Publications describing the diagnosis and treatment of anterior dislocation of the sacroiliac joint are scarce. We report the case a 19-year-old female at 8 weeks' gestation who presented with anterior fracture dislocation of the right sacroiliac joint, posterior fracture dislocation of the left sacroiliac joint (crescent fracture), and incomplete abortion resulting from high energy trauma. Orthopedic surgery involved standard anterior sacroiliac joint plating using an ilioinguinal approach combined with a modified Stoppa approach. Three attempts at complete abortion failed. Complete abortion was eventually achieved by dilatation and curettage two weeks after orthopedic surgery. Our findings reveal a need to improve techniques for diagnosis and treatment of anterior fracture dislocation of the sacroiliac joint, so greater attention can be paid to the rapid and effective management of associated comorbidities, and those resulting from the initial trauma.

The importance of pelvic ring stabilization as a life-saving measure in pre-hospital - A case report commented by autopsy

Hip fractures with unstable pelvic ring have great morbidity and mortality rates. These fractures result from high energy trauma such as falls from heights, road accidents and collapsing structures or other similar mechanisms of action. We report the case of a 63 years old man, construction worker, who stood inside a ditch during a wall construction when he was surprised by this collapse, which resulted in direct trauma to the right thigh and pelvis. The autopsy revealed diaphysis fracture of the right femur with an open book pelvic fracture with severe hemorrhagic infiltration and hematoma of the pelvic muscles without arterial injury. Bone bleeding and the vascular damage associated with disruption of the sacroiliac ligaments promote a very significant bleeding. Simple maneuvers such as sheet circumferential compression to promote pelvic ring closure are effective on stabilizing and closure of the sacroiliac joint. Hip manipulation of the fracture was performed during the necropsy to demonstrate and prove how a simple sheet contention can promote stabilization of the pelvic ring by closing the sacroiliac joints in open book fractures.

Pelvic trauma: WSES classification and guidelines

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting

Introduction

Exsanguination following trauma is potentially preventable. Extremity tourniquets have been successfully implemented in military and civilian prehospital care. Prehospital control of bleeding from the torso and junctional area’s remains challenging but offers a great potential to improve survival rates. This review aims to provide an overview of potential treatment options in both clinical as preclinical state of research on truncal and junctional bleeding. Since many options have been developed for application in the military primarily, translation to the civilian situation is discussed.

Methods

Medline (via Pubmed) and Embase were searched to identify known and potential prehospital treatment options. Search terms were|: haemorrhage/hemorrhage, exsanguination, junctional, truncal, intra-abdominal, intrathoracic, intervention, haemostasis/hemostasis, prehospital, en route, junctional tourniquet, REBOA, resuscitative thoracotomy, emergency thoracotomy, pelvic binder, pelvic sheet, circumferential. Treatment options were listed per anatomical site: axilla, groin, thorax, abdomen and pelvis Also, the available evidence was graded in (pre) clinical stadia of research.

Results

Identified treatment options were wound clamps, injectable haemostatic sponges, pelvic circumferential stabilizers, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), intra-abdominal gas insufflation, intra-abdominal self-expanding foam, junctional and truncal tourniquets. A total of 70 papers on these aforementioned options was retrieved. No clinical reports on injectable haemostatic sponges, intra-abdominal insufflation or self-expanding foam injections and one type of junctional tourniquets were available.

Conclusion

Options to stop truncal and junctional traumatic haemorrhage in the prehospital arena are evolving and may offer a potentially great survival advantage. Because of differences in injury pattern, time to definitive care, different prehospital scenario’s and level of proficiency of care providers; successful translation of various military applications to the civilian situation has to be awaited. Overall, the level of evidence on the retrieved adjuncts is extremely low.

History of pelvic fracture management: a review

High-energy pelvic fractures represent potentially life-threatening injuries due to the risk of acute exsanguinating retroperitoneal hemorrhage. The first report of a severe pelvic ring disruption dates back to Charles Hewitt Moore’s seminal publication from 1851. Significant advantages in the understanding of injury mechanisms and treatment concepts of pelvic ring injuries evolved in the 20^th century, and provided the basis to current classification-guided treatment and life-saving “damage control” concepts. However, there is a paucity of reports in the current literature focused on the historic background on the treatment of pelvic ring injuries. The present review was designed to summarize the history and evolution of our current understanding of the mechanisms and management strategies for severe pelvic ring injuries (excluding acetabular fractures which represent a different entity outside of the scope of this article).