5604 SJS103210.1177/1457496914525604I. Marzi, T.

LustenbergerScandinavian Journal of Surgery X(X)

REVIEW Scandinavian Journal of Surgery 103: 104111, 2014

Management of Bleeding Pelvic Fractures

I. Marzi, T. Lustenberger

Department of Trauma, Hand and Reconstructive Surgery, University Hospital, Goethe University Frankfurt
am Main, Germany

Abstract

Introduction: In patients with severe pelvic fractures, exsanguinating hemorrhage

represents the major cause of death within the first 24 h. Despite advances in management,
the mortality rate in these patients remains significantly high. Recently, multiple treatment
algorithms have been proposed for patients with severe pelvic fractures; however, the
optimal modalities in particular in the hemodynamically unstable patient are still a
matter of lively debate.This review article focuses on the recent body of knowledge on
the different treatment options in patients with severe pelvic fractures and proposes the
possible role of each modality in the management of these patients.
Methods: The MEDLINE database was searched for medical literature addressing the
management of severe pelvic fractures with specific attention given to recent, clinically
relevant publications.
Results: Angiography and embolization have emerged as excellent methods for addressing
arterial bleeding. Mechanical pelvic stabilization and surgical hemostasis by pelvic packing,
on the other hand, may effectively control venous bleeding and bleeding from the fractured
bony surface. However, since there is no precise way to determine the major source of
bleeding that is responsible for the hemodynamic instability, controversy remains over the
timing and optimal order of angiography, mechanical pelvic stabilization, and packing.
Conclusions: The authors own approach to these patients includes angiographic
embolization as a first-line treatment only in hemodynamically stable patients with an
arterial blush seen in the computed tomography scan, indicating acute arterial bleeding.
Hemodynamically unstable patients are immediately transferred to the operating room,
where pelvic packing and mechanical stabilization of the pelvic ring are carried out.
Optionally, a subsequent postoperative angio-embolization is performed if signs of
further bleeding remain present.
Key words: Pelvic ring fracture; management; hemodynamic instability; angiography; embolization; pelvic
packing; external fixation; pelvic C-clamp

Correspondence:
I. Marzi
Department of Trauma, Hand, and Reconstructive
Surgery
University Hospital
Goethe University Frankfurt am Main
Theodor-Stern-Kai 7
D-60590 Frankfurt/Main
Germany
Email: marzi@trauma.uni-frankfurt.de
 Bleeding pelvic fractures
Introduction
Pelvic fractures represent a significant challenge for
the trauma surgeon in terms of life-threat and func-
tional outcome. The complex anatomic relations that
exist within the bony pelvis put a myriad of structures
at risk when the pelvis is broken. An increased recog-
nition of pelvic fractures as a marker of injury severity,
as well as improved algorithms for resuscitation, skel-
etal fixation, and critical care monitoring, has done
much to advance the care of these often severely
injured patients (1). However, the mortality still
remains significantly high; the overall mortality rate
of patients with any pelvic fracture ranges between
5% and 10% (24), in hemodynamically unstable pel-
vic fractures, it is up to 60% (57), and in patients with
open pelvic fracture as high as 70% as a result of the
loss of the self-tamponade effect (8).
While, in recent years, a wide variety of strategies
to treat the hemodynamically unstable patient with
pelvic fractures have been proposed (2, 918), there is
still no clear consensus as to the best management
strategy for these patients. Basically, two different fun-
damental treatment modalities have been advocated
to address a persistent hemodynamic instability due
to pelvic fractures: angiography with sequential
embolization controlling arterial hemorrhage versus
pelvic packing, which mainly controls venous bleed-
ing and bleeding from the fracture sites. However, the
establishment of gold standard treatment guidelines is
difficult due to the associated multisystem injury pat-
tern in these patients.
Methods
This review article describes trends in the initial man-
agement of hemodynamically compromised patients
with severe pelvic fractures, including the evolving
concept of pre-peritoneal pelvic packing and angio-
embolization. The MEDLINE database was searched
for medical literature with specific attention given to
recent, clinically relevant publications.
RESULTS
Identifying Pelvic Hemorrhage
Early identification of those patients with pelvic frac-
tures who are at highest risk for pelvic bleeding is
imperative. In general, patients with an injury that
increases the bony volume of the pelvis (open book
fractures) are much more likely to have significant
bleeding than those with injuries that reduce the vol-
ume of the pelvis (lateral compression fractures) (1).
However, severe bleeding can occur in all pelvic frac-
ture patterns, and, unfortunately, there is a poor corre-
lation between the radiologically estimated severity of
the pelvic fracture and the need for emergent hemosta-
sis (2, 3, 10, 1517). In children, the incidence of life-
threatening bleeding from pelvic or acetabular
fractures seems to be very low (19). Therefore, the
physiological status of the patient rather than the pel-
vic X-ray should dictate the early resuscitation man-
agement. Sequential measurements of base deficit and
105
lactate levels in the early phase may help estimating
the severity of pelvic hemorrhage. In the study by Abt
et al. (20), base deficit levels measured within 1 h of
admission best predicted severe bleeding and early
mortality. Salim et al. (21) suggested that a sacroiliac
joint disruption, female gender, and the duration of
hypotension (systolic blood pressure <100 mmHg)
would reliably indicate ongoing bleeding requiring
angiographic embolization. Blackmore etal. (22) found
an emergency department hematocrit of 30 or less, a
pulse rate of 130 or greater, displaced obturator ring
fracture, and pubic symphysis diastasis to be good pre-
dictors of major pelvic hemorrhage. Miller et al. (15)
suggested that patients should be taken to the angiog-
raphy suite based on the recurrence of hypotension
within 2 h of an initially successful resuscitation.
Pelvic Binder/Sheet Wrapping
Pelvic binders, tied around the greater trochanter to
apply pressure with internal rotation of the legs, are
simple to apply, cost-effective, and of non-invasive
character. Biomechanical studies on cadaveric speci-
mens provided evidence of effective pelvic reduction
with binders tensioned to 140200 N in open book or
anterior posterior compression injuries (2325). There
has been little study of clinical outcome measures,
although there are some data to support improved
hemodynamic status with binder use in the immediate
resuscitative period (11, 26). Croce etal. (11) compared
stabilization with a pelvic binder to emergent pelvic
external fixation and found a significantly reduced
transfusion requirement in the pelvic binder group at
24 and 48 h. Length of hospital stay and mortality were
reduced in the binder group, although this did not
reach statistical significance. Virtually all the advan-
tages of the pelvic binders can be achieved by using
something as simple as a bedsheet; however, a recent
study comparing different stabilization techniques
found pelvic binders to be superior to sheet wrapping
in addressing significant pelvic bleeding (27). In addi-
tion, a correct positioning of the pelvic binder has to be
performed (28). Downsides of the binder include skin
necrosis and pressure ulcerations as the time of the
binder application increases. Tissue damage, sufficient
to cause pressure sores and skin necrosis, is believed to
occur when a contact pressure above 9.3 kPa is sus-
tained continuously for more than 23 h (29). This
threshold was found to be exceeded at the binderskin
interface at the anterior superior iliac spine, greater tro-
chanters, and sacrum in a study on 10 healthy individ-
uals (30). The polytraumatized patient is likely to be at
increased risk of soft-tissue damage due to systemic
factors promoting tissue breakdown (31). However, up
to now, there is no clear evidence how long a pelvic
binder can be safely maintained and how often it
should be released periodically to relieve and clinically
inspect the soft-tissues.
External Fixation
Pelvic anterior external fixators are easy to handle and
can be applied rapidly in 1520 min by placing the
106 I. Marzi, T. Lustenberger
pins in the iliac crest or in the supra-acetabular bones
(4, 32). They are in particular efficient in B-type frac-
tures (open book fractures and lateral compression
fractures). In C-type fractures (vertical shear frac-
tures), they can stabilize the anterior pelvic ring in
addition to a C-clamp. In children, they are generally
used for all types of stabilization (33). Experimental
studies, however, have shown that external fixation
provides only a small pelvic volume change, and thus,
external fixation is thought to contribute to hemostasis
primarily by decreasing bony motion at the fracture
site, re-opposing the fracture fragments, and allowing
stable clot formation (34, 35). Disadvantages of the
external fixation include the inability to sufficiently
stabilize the posterior pelvic ring and pin site infec-
tions, which can compromise subsequent definitive
open reduction and internal fixation.
Pelvic C-Clamp
The pelvic C-clamp is a specific form of external fixa-
tion. As it first has been described by Ganz etal. (36),
it can be used posteriorly for direct reduction of verti-
cally and rotationally unstable fractures. By exerting
transverse compression across the sacroiliac joint, the
basis for effective pelvic tamponade is achieved (37
40). Ertel etal. (12, 13) from the Zurich group reported
their experiences in managing multiple injured
patients with severe pelvic fracture by application of a
C-clamp and pelvic packing. They concluded that the
combination of a pelvic C-clamp and packing can
effectively control pelvic hemorrhage in patients in
extremis (12, 13). In an analysis of 28 patients, Tiemann
et al. (41) reported their experience using the pelvic
C-clamp for emergency treatment of patients with
unstable disruption of the posterior pelvic ring.
Overall, seven (25%) patients died. The surviving
patients showed blood circulation stabilization as well
as consolidation of the oxygenation level 6 h after
C-clamping. Five hours after the use of the C-clamp,
the number of required blood units decreased signifi-
cantly (41). The use of the pelvic C-clamp, however, is
limited to a subset of indications, and requires often a
completion by an anterior external fixator or an ante-
rior plate in C-type fractures. In fractures of the ilium
and in trans-iliac fracture dislocations, the C-clamp is
not applicable; in children, the application of a
C-clamp is dangerous and should be avoided (33).
Pelvic Angiography
Patients who remain hemodynamically unstable after
appropriate fluid resuscitation and mechanical stabi-
lization of the pelvis are possible candidates for pel-
vic angiography. Further indications for performing a
pelvic angiography include contrast medium extrava-
sation on the arterial phase of the computed tomogra-
phy (CT) scan (4, 18, 42). The identification of a
contrast blush on the CT scan has been shown to have
an accuracy of 98% for identifying patients requiring
embolization (43).
While vascular lesions in pelvic fractures are
thought to be more frequently of venous (90%, mostly
lesions of the presacral or prevesical veins) than
arterial origin (10%), in cases of hemodynamic insta-
bility, arterial lesions are much more frequent, and a
higher incidence of arterial extravasation is found in
these instances. Eastridge etal. (7) reported that 58.7%
of patients with both persistent hypotension and a
severely unstable pelvic fracture had arterial bleed-
ing. Likewise, in the study by Miller etal. (15), 67.9%
of patients with persistent hemodynamic compro-
mise demonstrated arterial bleeding. In the early
report by Agolini et al. (9), of 806 patients admitted
with pelvic fractures, 35 underwent pelvic angiogra-
phy, and 15 (1.9%) required embolization. Bleeding
was successfully stopped in all of the patients embo-
lized. Embolization within 3 h of arrival resulted in a
significantly greater survival rate (14% vs 75% if angi-
ography was performed after 3 h) (9). Velmahos etal.
(44) recently reported on 100 patients evaluated by
angiography for bleeding from major pelvic fractures
or solid visceral organ injuries. In total, 80 patients
were embolized due to hemodynamic instability,
active contrast extravasation, or indirect signs of vas-
cular injury. Angiographic embolization was safe and
effective in 95% of these patients (44). Based on these
results, early angiography and embolization have
been recommended by many authors to improve
patient outcome (7, 9, 45).
However, there are a number of drawbacks to angi-
ography mentioned in the literature, and none of the
investigators recommend the indiscriminate use of
angiography in all hemodynamically unstable patients
with pelvic fracture. Angiography is a time-consuming
procedure precluding the simultaneous performance
of other diagnostic or therapeutic interventions, it
requires the immediate availability of a skilled inter-
ventional radiologist and associated technical staff,
and involves the transportation of a severely injured
patient to an angiography suite. In one series, 20% of
hemodynamically unstable patients with pelvic frac-
tures suffered cardiopulmonary arrest during angiog-
raphy and could not be resuscitated (46). Furthermore,
multiple authors have pointed out that considerable
delays exist in the performance of angiography (rang-
ing from 50 min to 5.5 h), which may not be tolerated
by hemodynamically unstable patients (4, 9, 10, 18). In
a multicenter review of 11 major trauma centers in
Australia and New Zealand describing the manage-
ment practice of hemodynamically unstable pelvic
trauma patients, only 14.7% of the pelvic angiogra-
phies were performed within 90 min of arrival (47).
Considering these downsides, the question of which
patients should undergo angiography and the most
appropriated timing of angiography with respect to
other treatment options remains a matter of contro-
versy and one of the most difficult aspects of the man-
agement in these patients.
Pelvic Packing
For the past decade, European trauma surgeons in
particular have recommended exploratory laparot-
omy followed by pelvic packing (12, 13, 37, 38). The
rationale behind pelvic packing derives from the fact
 Bleeding pelvic fractures
that the source of pelvic bleeding in the majority of
cases has been identified as predominantly venous.
Posterior pelvic ring stabilization with a pelvic
C-clamp or an external fixator provides mechanical
stability for the pelvic tamponade and fracture
reduction leads to a reduction in fracture hemor-
rhage. Ertel etal. (12, 13) reported success in control-
ling both arterial and venous bleeding by tightly
packing the pelvis. However, the initially described
transabdominal approach for pelvic packing
included the disadvantage of opening the poten-
tially intact peritoneum with disruption of the pelvic
hematoma, and therefore disrupting the tamponade
effect of the retroperitoneal space (4). To minimize
these downsides of pelvic packing via the transperi-
toneal approach, the retroperitoneal method has
recently been described (48). Not violating the intra-
peritoneal space and leaving the peritoneum intact,
the presacral and paravesical regions are packed
from posterior to anterior using three sponges on
each side. In the study by Cothren etal. (5), using the
technique of pre-peritoneal pelvic packing in hemo-
dynamically unstable patients not responding to 2
units of packed red blood cells (PRBCs), no deaths
were reported as a result of acute blood loss. In their
study, angio-embolization was only used in 4 of 24
non-responders as a rescue intervention after every-
thing else has failed. They concluded that packing is
an effective method that can quickly control pelvic
bleeding and can serve as a triage tool for emergent
angiography (5). In a study of 40 hemodynamically
unstable patients with pelvic ring fractures, external
pelvic fixation in combination with direct retroperi-
toneal pelvic packing effectively stabilized the
hemodynamic situation and significantly reduced
post-procedure blood transfusion (6).
There are, however, as well disadvantages of pel-
vic packing. Compared to angiography, it is a rela-
tively invasive procedure, it may not be completely
effective for control of bleeding from large-bore
arteries, and there is the necessity of a reoperation
for removal of the packs 2448 h following the first
operation.
Pelvic Angiography Versus Pelvic Packing
It is difficult to compare the effectiveness of pelvic
angiography and packing, mainly because the pub-
lished reports included patient cohorts with different
severity and complexity of their injuries. In particular,
the patients undergoing pelvic packing represented a
group of extremely unstable patients with massive
pelvic bleeding. However, both treatment modalities
are important techniques to improve patient outcome
in bleeding pelvic fractures, and they are not antago-
nistic but should be seen as complementary. Our own
experience shows that ongoing signs of bleeding fol-
lowing pelvic packing and mechanical pelvic stabili-
zation indicate the need for a pelvic angiography on
the way from the operating room to the intensive care
unit (ICU) (manuscript in preparation). Angio-
embolization of small bleeding arteries will then stop
blood loss definitely as indicated in an illustrated case
(Fig. 1).
107
The Hemodynamically Unstable Patient:
Abdomen or Pelvis First?
Severe pelvic fractures commonly occur in associa-
tion with other significant injuries, in particular in the
abdomen. In the study by Ertel etal. (13), analyzing
41 patients in an extremis clinical condition, 61% of
the patients demonstrated concomitant abdominal
injuries. Therefore, the hemodynamically unstable
patient with a severe pelvic fracture presents a par-
ticularly difficult dilemma with regard to the deter-
mination of intra- versus retroperitoneal blood loss.
In unstable patients with a positive focused assess-
ment sonography for trauma (FAST) exam, it is pru-
dent to perform a laparotomy to treat intra-abdominal
bleeding, however, having in mind that performing a
laparotomy may increase pelvic volume and directly
aggravate pelvic hemorrhage due to the decompres-
sion of the retroperitoneum. Nevertheless, clearly, not
all intra-abdominal injuries require emergency lapa-
rotomy and retroperitoneal blood in the FAST exam
should not automatically lead to a laparotomy, as ret-
roperitoneal hematomas often come from the pelvic
fracture. Some authors, therefore, recommend the use
of diagnostic angiography to identify ongoing blood
loss and to achieve hemostasis with embolization.
However, this is only possible in hemodynamically
stable patients. Angiography is usually not indicated
in patients in uncontrolled hemodynamic conditions
where immediate surgical interventions are required.
In these combined situations, laparotomy and pelvic
packing should be performed which further allows
the simultaneous assessment and treatment of
abdominal injuries. In the presence of multiple mas-
sive bleeding points, tamponade of these areas or
even temporary aortic compression can be carried out
(14). Furthermore, a closure of the abdomen in order
to close both compartments at least temporarily seems
wise.
The Authors ApproachThe Frankfurt
Algorithm
The authors general approach to the patient with
pelvic fracture is based on the patients hemody-
namic stability and the patients response to volume
resuscitation (Fig. 2, further developed from (18)
considering the type of pelvic fracture additionally
(Table 1)).
The evaluation of the trauma pattern and the initial
management strictly follows the Advanced Trauma
Life Support (ATLS) guidelines. Surgeon-performed
FAST is performed in the emergency room upon
arrival. Further assessment includes plain radiographs
of the chest and pelvis. In parallel, a definitive airway
is obtained (liberal intubation in patients with severe
pelvic trauma) and a large-bore intravenous access is
established (preferably large-bore central catheters).
In terms of volume resuscitation, 2 L of crystalloid
solution is administered followed by PRBCs and fresh
frozen plasma (FFP) in the hemodynamically unstable
patient. For temporary mechanical fracture stabiliza-
tion, a pelvic binder is placed on arrival if it has
not been done in the pre-hospital phase. Constant
108 I. Marzi, T. Lustenberger

Fig. 1. (A) A 74-year-old man sustained a complex pelvic trauma with an anterio-posterior compression and vertical shear injury. A pelvic
sling was placed in a local hospital. Within 1 h of the accident, the patient arrived in severe hemorrhagic shock in the level-I-trauma
center. Mechanical stabilization of the pelvis was performed by posterior application of a pelvic C-clamp and an anterior external fixator.
Retroperitoneal pelvic packing and a suture of the urinary bladder were carried out additionally.(B) Due to signs of further slow, but
continuous bleeding postoperatively, a selective pelvic angiography was performed and demonstrated multiples contrast blushes from
bleeding branches of the internal iliac artery. (C) Following superselective embolization, the patient was hemodynamically completely
stable. (D) The definitive pelvic osteosynthesis was carried out on hospital day 6.

reassessment of the patients hemodynamic status is
performed in order to avoid late recognition of a
bleeding patient.
The non-responder
If the patients systolic blood pressure remains less
than 90 mmHg despite administration of 2 L of crys-
talloid solution and 2 units of PRBC, the patient is con-
sidered as a non-responder. These patients are not
amenable to further diagnostic procedures and
undergo urgent exploration, pre-peritoneal pelvic
packing, and mechanical stabilization of the pelvic
fracture (pelvic C-clamp and anterior external fixator).
During pelvic packing, associated injuries that con-
tribute to mortality, such as intra-abdominal hemor-
rhage, hemo-pneumothoraces, and long bone
fractures, are simultaneously assessed and treated
with damage control techniques. In case of persistent
hemodynamic instability with ongoing need of vol-
ume resuscitation following surgery, a subsequent
angiography is performed. If extravasation of contrast
is seen, selective embolization with coils or foam is
performed. Evidence of vessel spasm or abrupt cutoffs
of vessels are likewise seen as signs of injury and
embolization is carried out. If the patient stabilizes
after angio-embolization, the patient then gets com-
pletion of the trauma evaluation including CT scans
and any needed plain radiographs (case report; Fig. 1).
The responder
Patients adequately responding to fluid boluses and
holding the systolic blood pressure > 90 mmHg after
 Bleeding pelvic fractures 109

Primary Survey according to ATLS

Anteroposterior X-Ray of chest and pelvis, FAST, Blood gas analysis
Intubation, large-bore i.v. access, decompression of chest/pericard
Fluid resuscitation (cristalloids, PRBC), mechanical pelvic stabilisation (pelvic binder)

Re-Evaluation

non-responder transient-responder responder

Emergency operation Multislice CT with contrast media

No contrast blush Contrast blush

Angio-Embolization

ICU or required surgical procedures (osteosynthesis / pelvic packing)

Fig. 2. Emergency department algorithm in patients with severe pelvic fracture.

PRBC: packed red blood cell; FAST: focused assessment sonography for trauma; ATLS: Advanced Trauma Life Support; ICU: intensive
care unit.

Table 1
Initial management of patients with pelvic trauma.

Injury Primary phase life saving procedures Secondary phase urgent procedures

Stable, minor dislocated pelvic

ring injuries (Type-A fractures)

 upture of the pubis symphysis

R Anterior external fixator in case of Plate osteosynthesis
(open book injury, Type B1) ongoing bleeding
Alternative: anterior external fixator

 ateral compression fracture

L In case of dislocation: dorsal plate
(Type B2), rotational instability and screw osteosynthesis

Alternative: anterior external fixator

Vertical shear injury with/without Pelvic C-clamp and/or anterior Anterior and/or posterior
rotational instability (Type-C external fixator stabilization in case of ongoing
fracture), sacrum fracture bleeding

administration of 2 L of crystalloid solution and if
necessary 2 units of PRBC undergo contrast-enhanced
CT scan evaluation following the primary survey. In
case of contrast extravasation, a pelvic angiography
with embolization is subsequently performed with
the pelvic binder in place. Patients with ongoing
need of volume replacement to achieve hemody-
namic stability, with ongoing suspicion of pelvic
hemorrhage following angio-embolization, or with
the need for a mechanical stabilization of the pelvic
ring are urgently transferred to the operating room
for pelvic stabilization and pre-peritoneal pelvic
packing.
The transient responder
Similar to the responder, in the patient with at
least temporarily achieved hemodynamic stability by
volume resuscitation (blood pressure > 90 mmHg,
however, only with continuous volume replacement),
110 I. Marzi, T. Lustenberger
an additional multi-slice CT scan with contrast is per-
formed andaccording to the resultsfollowed by
angiography, surgical damage control procedures,
and/or ICU admission similar to the responder sit-
uation.
Although these treatment algorithms describe the
authors standard practice in the management of
patients with severe pelvic fractures, the care of any
patient must be individualized with alteration of this
schema for associated injuries.
Conclusion
In hemodynamically unstable patients with pelvic
fractures, early exsanguination and the late sequela of
shock and massive transfusion represent the major
cause of death. The initial decision depends on the
shock status of the patient. In non-responders, only a
direct transfer to the operating room, pelvic packing,
mechanical stabilization of the pelvic ring, and option-
ally a subsequent angio-embolization is possible. The
decision of whether pelvic angiography or pelvic
packing should be performed depends on the careful
assessment of the patients hemodynamic status and
the result of the contrast media-enhanced CT scan.
Angiographic embolization as a first-line treatment is
reasonable only in transient responders and in
responders with an arterial blush seen in the CT scan,
indicating acute arterial bleeding. The pelvic binder
should remain in place until a definitive surgical stabi-
lization is performed.
Declaration of Conflicting Interests
The authors hereby declare that they have no conflicts of
interest to disclose.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
References
1. Scalea TM, Stein DM, OToole RV: Pelvic fractures. In:Feliciano
DV, Mattox KL, Moore EE(Eds). Trauma, 6th ed. McGraw-Hill
Medical : New York, 2008, pp. 759788.
2. Biffl WL, Smith WR, Moore EE et al: Evolution of a mul-
tidisciplinary clinical pathway for the management of
unstable patients with pelvic fractures. Ann Surg 2001;233:
843850.
3. Starr AJ, Griffin DR, Reinert CM etal: Pelvic ring disruptions:
prediction of associated injuries, transfusion requirement,
pelvic arteriography, complications, and mortality. J Orthop
Trauma 2002;16:553561.
4. Suzuki T, Smith WR, Moore EE: Pelvic packing or angiography:
competitive or complementary? Injury 2009;40:343353.
5. Cothren CC, Osborn PM, Moore EE et al: Preperitonal pelvic
packing for hemodynamically unstable pelvic fractures: a para-
digm shift. J Trauma 2007;62:834839 (discussion 839842).
6. Osborn PM, Smith WR, Moore EE etal: Direct retroperitoneal
pelvic packing versus pelvic angiography: a comparison of two
management protocols for haemodynamically unstable pelvic
fractures. Injury 2009;40:5460.
7. Eastridge BJ, Starr A, Minei JP et al: The importance of frac-
ture pattern in guiding therapeutic decision-making in patients
with hemorrhagic shock and pelvic ring disruptions. J Trauma
2002;53:446450 (discussion 450451).
8. Grotz MR, Allami MK, Harwood P etal: Open pelvic fractures:
epidemiology, current concepts of management and outcome.
Injury 2005;36:113.
9. Agolini SF, Shah K, Jaffe J etal: Arterial embolization is a rapid
and effective technique for controlling pelvic fracture hemor-
rhage. J Trauma 1997;43:395399.
10. Cook RE, Keating JF, Gillespie I: The role of angiography in the
management of haemorrhage from major fractures of the pelvis.
J Bone Joint Surg Br 2002;84:178182.
11. Croce MA, Magnotti LJ, Savage SA etal: Emergent pelvic fixa-
tion in patients with exsanguinating pelvic fractures. J Am Coll
Surg 2007;204:935939 (discussion 940942).
12. Ertel W, Keel M, Eid K etal: Control of severe hemorrhage using
C-clamp and pelvic packing in multiply injured patients with
pelvic ring disruption. J Orthop Trauma 2001;15:468474.
13. Ertel W, Eid K, Keel M etal: Therapeutical strategies and out-
come of polytraumatized patients with pelvic injuries. Eur J
Trauma Emerg Surg 2000;26:278286.
14. Giannoudis PV, Pape HC: Damage control orthopaedics in
unstable pelvic ring injuries. Injury 2004;35:671677.
1 5. Miller PR, Moore PS, Mansell E et al: External fixa-
tion or arteriogram in bleeding pelvic fracture: ini-
tial therapy guided by markers of arterial hemorrhage.
J Trauma 2003;54:437443.
16. Sarin EL, Moore JB, Moore EE etal: Pelvic fracture pattern does
not always predict the need for urgent embolization. J Trauma
2005;58:973977.
17. Velmahos GC, Chahwan S, Falabella A et al:Angiographic
embolization for intraperitoneal and retroperitoneal injuries.
World J Surg 2000;24:539545.
18. Westhoff J, Laurer H, Wutzler S etal: Interventional emergency
embolization for severe pelvic ring fractures with arterial bleed-
ing. Integration into the early clinical treatment algorithm.
Unfallchirurg 2008; 111:821828.
19. Tuovinen H, Sderlund T, Lindahl J et al: Severe pelvic frac-
ture-related bleeding in pediatric patients: does it occur? Eur J
Trauma Emerg Surg 2012;38(2):163169.
20. Abt R, Lustenberger T, Stover J et al: Base excess determined
within one hour of admission predicts mortality in patients
with severe pelvic fractures and severe hemorrhagic shock. Eur
J Trauma Emerg Surg 2009;35(5):429436.
21. Salim A, Teixeira PG, DuBose J etal: Predictors of positive angi-
ography in pelvic fractures: a prospective study. J Am Coll Surg
2008;207:656662.
22. Blackmore CC, Cummings P, Jurkovich GJ et al: Predicting
major hemorrhage in patients with pelvic fracture. J Trauma
2006;61:346352.
23. DeAngelis NA, Wixted JJ, Drew J etal: Use of the trauma pelvic
orthotic device (T-POD) for provisional stabilisation of anterior-
posterior compression type pelvic fractures: a cadaveric study.
Injury 2008;39:903906.
24. Spanjersberg WR, Knops SP, Schep NW etal: Effectiveness and
complications of pelvic circumferential compression devices in
patients with unstable pelvic fractures: a systematic review of
literature. Injury 2009;40:10311035.
25. Bottlang M, Krieg JC, Mohr M etal: Emergent management of
pelvic ring fractures with use of circumferential compression. J
Bone Joint Surg Am 2002;84(Suppl. 2):4347.
26. Nunn T, Cosker TD, Bose D et al: Immediate application of
improvised pelvic binder as first step in extended resuscitation
from life-threatening hypovolaemic shock in conscious patients
with unstable pelvic injuries. Injury 2007;38:125128.
27. Pizanis A, Pohlemann T, Burkhardt M etal: Emergency stabili-
zation of the pelvic ring: clinical comparison between three dif-
ferent techniques. Injury 2013;44:17601764.
28. Fleiter N, Reimertz C, Lustenberger T et al: Importance of
the correct placement of the pelvic binder for stabilisation of
haemodynamically compromised patients. Z Orthop Unfall
2012;150:627629.
 Bleeding pelvic fractures
29. Hedrick-Thompson JK: A review of pressure reduction device
studies. J Vasc Nurs 1992;10:35.
30. Jowett AJ, Bowyer GW: Pressure characteristics of pelvic bind-
ers. Injury 2007;38:118121.
31. Vohra RK, McCollum CN: Pressure sores. BMJ 1994;309:853
857.
32. Riemer BL, Butterfield SL, Diamond DL etal: Acute mortality
associated with injuries to the pelvic ring: the role of early patient
mobilization and external fixation. J Trauma 1993;35:671675
(discussion 676677).
33. Jakob H, Lustenberger T, Schneidmller D et al: Pediatric
polytrauma management. Eur J Trauma Emerg Surg
2010;36(4):325338.
34. Ghanayem AJ, Wilber JH, Lieberman JM etal: The effect of lapa-
rotomy and external fixator stabilization on pelvic volume in
an unstable pelvic injury. J Trauma 1995; 38:396400 (discussion
400401).
35. Grimm MR, Vrahas MS, Thomas KA: Pressure-volume charac-
teristics of the intact and disrupted pelvic retroperitoneum. J
Trauma 1998;44:454459.
36. Ganz R, Krushell RJ, Jakob RP etal: The antishock pelvic clamp.
Clin Orthop Relat Res 1991;(267):7178.
37. Gansslen A, Giannoudis P, Pape HC: Hemorrhage in pel-
vic fracture: who needs angiography? Curr Opin Crit Care
2003;9:515523.
38. Pohlemann T, Bosch U, Gansslen A etal: The Hannover experi-
ence in management of pelvic fractures. Clin Orthop Relat Res
1994;(305):6980.
39. Sadri H, Nguyen-Tang T, Stern R etal: Control of severe hemor-
rhage using C-clamp and arterial embolization in hemodynami-
cally unstable patients with pelvic ring disruption. Arch Orthop
Trauma Surg 2005;125:443447.
40. Lustenberger T, Meier C, Benninger E etal: C-clamp and pelvic
packing for control of hemorrhage in patients with pelvic ring
disruption. J Emerg Trauma Shock 2011;4:477482.
111
41. Tiemann AH, Boehme J, Josten C: Emergency treatment of mul-
tiply injured patients with unstable disruption of the posterior
pelvic ring by using the C-clamp. Eur J Trauma Emerg Surg
2005;31:244251.
42. Davis JW, Moore FA, McIntyre RC Jr et al: Western trauma
association critical decisions in trauma: management of
pelvic fracture with hemodynamic instability. J Trauma
2008;65:10121015.
43. Pereira SJ, OBrien DP, Luchette FA et al: Dynamic helical
computed tomography scan accurately detects hemorrhage in
patients with pelvic fracture. Surgery 2000;128:678685.
44. Velmahos GC, Toutouzas KG, Vassiliu P et al: A prospective
study on the safety and efficacy of angiographic embolization
for pelvic and visceral injuries. J Trauma 2002;53:303308 (dis-
cussion 308).
45. Balogh Z, Caldwell E, Heetveld M et al: Institutional practice
guidelines on management of pelvic fracture-related hemo-
dynamic instability: do they make a difference? J Trauma
2005;58:778782.
46. Niwa T, Takebayashi S, Igari H etal: The value of plain radio-
graphs in the prediction of outcome in pelvic fractures treated
with embolisation therapy. Br J Radiol 2000;73:945950.
47. Verbeek D, Sugrue M, Balogh Z et al: Acute management of
hemodynamically unstable pelvic trauma patients: time for
a change? Multicenter review of recent practice. World J Surg
2008;32:18741882.
48. Smith WR, Moore EE, Osborn P et al: Retroperitoneal pack-
ing as a resuscitation technique for hemodynamically
unstable patients with pelvic fractures: report of two represent-
ative cases and a description of technique. J Trauma 2005;59:
15101514.
Received: October 18, 2013
Accepted: January 19, 2014