Unstable pelvic ring injury with hemodynamic instability: What seems the best procedure choice and sequence in the initial management?

Introduction: Most fatalities related to pelvic ring injuries occur early and are caused by massive retroperitoneal bleeding. The objective of our study is to determine the optimal sequence of surgical procedures to restore hemodynamic stability in patients with unstable pelvic ring injuries. Patients and methods: This was a retrospective review of all patients with pelvic fractures and hemodynamic instability admitted to our level 1 trauma center between January 1998 and December 2008. We entered into our polytrauma database the following patient characteristics: age, sex, mechanism of injury, Injury Severity Score (ISS), classification of injury, timing of operative intervention, and type of operative procedures. Patients were divided into four groups (according to the sequence of surgical procedures performed within 24 hours following admission), as follows: group 1: patients treated with external fixation only; group 2: patients receiving external fixation followed by angiography; group 3: patients receiving external fixation followed by laparotomy +/- angiography; and group 4: patients treated by immediate laparotomy or angiography before skeletal fixation. Results: Eighty of 136 patients admitted with a pelvic fracture were classified, as unstable AO/OTA type B or C pelvic ring injury, and 70/80 were hemodynamically unstable. Eight patients died shortly after arrival and two remained stable without requiring any early procedure. Sixty patients went immediately to the operating room. Twenty-nine patients were placed in group 1 with 100% survival, 12 in group 2 with 91% survival, 11 in group 3 with 82% survival, and eight patients placed in group 4 with 0% survival (P < 0.001). Conclusions: The management of hemorrhagic instability linked to pelvic ring disruption involves a sequence of therapeutic events, which is more important than the events themselves. Pelvic bone stabilization by pelvic clamp or external fixator followed by arteriography seems to be the more secure. Angiographic embolization is the method of choice whenever haemodynamic instability coexists with an unstable pelvic disruption. Laparotomy and packing are restricted to extreme severe cases in remote hospitals with skillful surgeons! Actually aortic balloon is a good solution to control uncontrollable bleeding.