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1168 PART 10: The Surgical Patient

requiring prolonged operative procedures, the use of massive amounts
of crystalloids and blood transfusions leading to hypothermia and hypo- • Initial management of pelvic injuries requires hemorrhage control
coagulable states. Treatment should be directed at correction and pre- and volume resuscitation.
vention of these precipitating factors. A high index of suspicion should • Provisional acute stabilization of the pelvis using a binder or external
be maintained in order to predict the onset of this condition so that fixation is a key element in the initial control of hemorrhage from
preventive measures and early diagnosis will result in better outcomes. pelvic fractures.
• Extremity fractures, though frequently not life threatening, require
accurate diagnosis and appropriate management to prevent signifi-
KEY REFERENCES cant disability and morbidity.
• Brasel KJ, Borgstrom DC, Meyer P, Weigelt JA. Predictors of out- • Complications of extremity injuries, such as compartment syndrome
https://kat.cr/user/tahir99/
come in blunt diaphragm rupture. J Trauma. 1996;41:484. and neurovascular compromise, can best be detected by a high
• Demetriades D, Asensio JA, Valmahos G, et al. Complex problems index of suspicion, careful assessment, and institution of appropriate
in penetrating neck trauma. Surg Clin North Am. 1996;76:661. preventive measures.
• Diebel LN, Wilson RF, Dulchavsky SA, et al. Effect of increased • Knowledge of the mechanism of injury is important in predicting
intraabdominal pressure on hepatic arterial, portal venous and the type and severity of extremity injuries.
hepatic microcirculatory blood flow. J Trauma. 1992;33:279.
• Fabian TC, Croce MA, Pritchard FE, et al. Planned ventral her-
nia: staged management for abdominal wall defects. Ann Surg.
1994;219:643. PELVIC RING INJURIES
• Fabian TC, Davis KA, Gavant ML, et al. Prospective study of Patients sustaining major pelvic and extremity trauma frequently are
blunt aortic injury: helical CT is diagnostic and anti-hypertensive managed in the ICU setting. These patients may present with signifi-
therapy reduces rupture. Ann Surg. 1998;227:606. cant hemodynamic abnormality owing to their associated injuries, and
• Kisat M, Morrison JJ, Hashmi ZG, Efron DT, Rasmussen TE, this can be compounded by inadequate resuscitation resulting from
Haider AH. Epidemiology and outcomes of non-compressible underestimation of the volume of blood loss associated with such
torso hemorrhage. J Surg Res. 2013;184(1):414-421. injuries. The following information is provided to assist the intensivist
• Mee SL, McAninch JW, Robinson AL, et al. Radiographic assess- in understanding extremity and pelvic ring injuries, thus allowing early
diagnosis with prompt and appropriate management aimed at preventing
ment of renal trauma: a 10-year prospective study of patient selec- major morbidity and mortality.
tion. J Urol. 1989;141:1095. Significant force is required to sustain an injury to the pelvic ring. In
• Pachter HL, Knudson MM, Esrig B, et al. Status of nonoperative various epidemiologic studies, mortality rates of up to 25% have been
management of blunt hepatic injuries in 1995: a multicenter expe- reported, depending on the pattern and severity of the pelvic injury. While
1,2
rience with 404 patients. J Trauma. 1996;40:31. the direct cause of death is usually attributed to a head or thoracic injury,
3
• Powell M, Courcoulas A, Gardner M, et al. Management of blunt pelvic bleeding significantly contributes to this high rate of mortality.
splenic trauma, significant differences between adults and chil- There is an increased risk of mortality in association with open pelvic
dren. Surgery. 1997;122:654. fractures, a high injury severity score (ISS), or concomitant head, thoracic,
4
• Shapiro MB, Jenkins DH, Schwab CW, et al. Damage control: abdominal, or neurologic injury. The incidence of associated injuries is
3
collective review. J Trauma. 2000;49:969. relatively common (Table 121-1). A team approach is required to treat
• Sheldon GF, Lim RC, Yee ES, et al. Management of injuries to the trauma victims adequately, including the trauma team leader, surgical
team (general, thoracic, orthopedic, and neurosurgery), and intensivist.
■ ANATOMY
porta hepatis. Ann Surg. 1985;202:539.
The pelvis is composed of the two innominate bones (hemipelvis) and
REFERENCES the sacrum joined anteriorly by the pubic symphysis and posteriorly by
the anterior and posterior sacroiliac ligaments, as well as the interos-
Complete references available online at www.mhprofessional.com/hall seous 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).
Running over the sacral ala and into the pelvis are the common iliac
CHAPTER Pelvic Ring Injuries artery and vein, bifurcating to the external and internal iliac vessels
above and below the pelvic brim, respectively. These vessels run close
121 and Extremity Trauma to the innominate bones, thus making them vulnerable to injury with
any disruption of the pelvic ring. In particular, there is a plexus of veins
Allan Liew running along the walls of true pelvis below the pelvic brim that is
Wade Gofton
Steven Papp
TABLE 121-1 incidence of Associated injuries With Pelvic Ring injury
Hemodynamically unstable 15%
KEY POINTS Closed head injury 66%
• Hemorrhage from pelvic injuries is frequently underestimated, Thoracic injury 25%
leading to delayed diagnosis and treatment. Abdominal injury 20%
• Pelvic ring injuries are commonly associated with other significant Urologic injury 20%
injuries resulting in major morbidity and mortality.
Lumbosacral injury 8%

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