CHAPTER 121: Pelvic Ring Injuries and Extremity Trauma

KEY POINTS

• Hemorrhage from pelvic injuries is frequently underestimated, leading to delayed diagnosis and treatment.

• Pelvic ring injuries are commonly associated with other significant injuries resulting in major morbidity and mortality.

• Initial management of pelvic injuries requires hemorrhage control and volume resuscitation.

• Provisional acute stabilization of the pelvis using a binder or external fixation is a key element in the initial control of hemorrhage from pelvic fractures.

• Extremity fractures, though frequently not life threatening, require accurate diagnosis and appropriate management to prevent significant disability and morbidity.

• Complications of extremity injuries, such as compartment syndrome and neurovascular compromise, can best be detected by a high index of suspicion, careful assessment, and institution of appropriate preventive measures.

• Knowledge of the mechanism of injury is important in predicting the type and severity of extremity injuries.

PELVIC RING INJURIES

Patients sustaining major pelvic and extremity trauma frequently are managed in the ICU setting. These patients may present with significant hemodynamic abnormality owing to their associated injuries, and this can be compounded by inadequate resuscitation resulting from underestimation of the volume of blood loss associated with such injuries. The following information is provided to assist the intensivist in understanding extremity and pelvic ring injuries, thus allowing early diagnosis with prompt and appropriate management aimed at preventing major morbidity and mortality.

Significant force is required to sustain an injury to the pelvic ring. In various epidemiologic studies, mortality rates of up to 25% have been reported, depending on the pattern and severity of the pelvic injury.^1,2 While the direct cause of death is usually attributed to a head or thoracic injury,³ pelvic bleeding significantly contributes to this high rate of mortality. There is an increased risk of mortality in association with open pelvic fractures, a high injury severity score (ISS), or concomitant head, thoracic, abdominal, or neurologic injury.⁴ The incidence of associated injuries is relatively common (Table 121-1).³ A team approach is required to treat trauma victims adequately, including the trauma team leader, surgical team (general, thoracic, orthopedic, and neurosurgery), and intensivist.

ANATOMY

The pelvis is composed of the two innominate bones (hemipelvis) and the sacrum joined anteriorly by the pubic symphysis and posteriorly by the anterior and posterior sacroiliac ligaments, as well as the interosseous sacroiliac ligaments. Within the pelvic floor, the pelvis is further reinforced by the sacrospinous and sacrotuberous ligaments, as well as the muscles and fascia of the pelvic floor (Fig. 121-1).