Bleeding is a well-recognized complication of severe pelvic fracture. Certain fracture patterns, usually with significant involvement of the posterior portions of the ring, are associated with significant bleeding. Most of these fractures are unstable to some degree.
Stable pelvic fractures (those that do not require internal or external fixation) are not generally prone to a large amount of bleeding. However, it can occur on occasion, and surgeons at the Massachusetts General Hospital have devised a simple prediction system so patients more likely to bleed can be identified and monitored more closely.
They retrospectively looked at their stable pelvic fracture population over 5+ years. A total of 391 patients with stable pelvic injury were identified. Of those, 280 never required transfusion and 111 did. Of the latter, only 15 bled from their stable pelvic fractures.
The authors found the following three significant indicators of bleeding from stable pelvic fractures:
- Admission hematocrit < 30%
- Pelvic hematoma on CT
- Any systolic blood pressure < 90 mm Hg
Bottom line: This is a simple, retrospective study with low numbers. However, the three indicators commonly indicate significant early bleeding in any trauma patient, so it makes sense to apply it here, too. If a patient meets one or two criteria, consider monitoring in the ICU and consider angiography. If all three or met, strongly consider appropriate intervention (angiography if good blood pressures can be maintained, or fixation and/or preperitoneal packing if not).
Reference: Predictors of bleeding from stable pelvic fractures. Arch Surg 146(4):407-411, 2010.
Arterial bleeding from a pelvic fracture is more common than previously thought. The doctor books used to say that 10% of bleeding was arterial and 90% was venous, so angiographic techniques were seldom used unless there was clinical evidence of blood loss.
It looks like arterial bleeding occurs more frequently than we think. Here are tips that help you identify patients at risk:
- What type of mechanism caused the fracture? Anterior-posterior compression and vertical shear are the most common.
- Are the vital signs stable? If not, rule out the other four likely sources first (chest, abdomen, multiple extremity fractures, external). Then blame the pelvis.
- Is the fracture open? Arterial bleeding is very likely.
- How old is the patient? Elderly patients are more likely to have arterial bleeding, especially from gluteal artery branches.
- What part of the pelvis is broken? If major sacral fractures, SI joint disruption or separation of the symphysis is present, think arterial bleeding.
- Are there CT abnormalities? A vascular blush or large hematoma indicates significant bleeding.
The most common bleeding sites are the gluteal and pudendal arteries. The gluteal is in proximity to the SI joint, so this can be torn if the SI joint is damaged or the sacrum is fractured. The pudendal can be injured with ramus fractures, especially when the symphysis is widened.
If the patient can be reasonably stabilized, then a trip to interventional radiology is mandatory. Operative management is not very successful, so patients with blood pressure lability or controllable hypotension should go to IR. All active bleeding and arterial cutoffs should be embolized thoroughly.
Images: On the left is the portable plain image of a vertical shear pelvic fracture. The arrows on the right point to two areas of vascular blush.