Current management of severe pelvic and perineal trauma

Abstract

Mortality associated with pelvic and perineal trauma (PPT) has fallen from 25% to 10% in the last decade thanks to progress accomplished in medical, surgical and interventional radiology domains (Dyer and Vrahas, 2006) [1]. The management strategy depends on the hemodynamic status of the patient (stable, unstable or extremely unstable). Open trauma requires specific treatment in addition to control of bleeding. All surgical centers can be confronted some day with patients with hemorrhagic PPT and for this reason, all surgeons should be familiar with the initial management. In expert centers, management of patients with severe PPT is complex, multidisciplinary and often requires several re-interventions. Obstetrical and sexual trauma, also requiring specific management, will not be dealt with herein.

Pelvic trauma: WSES classification and guidelines

“…Principal mechanisms of injuries that cause a pelvic ring fracture are due to a high energy impact as fall from height, sports, road traffic collision (pedestrian, motorcyclist, motor vehicle, cyclist), person stuck by vehicles [1, 5]. Ten to fifteen percent of patients with pelvic fractures arrive to the ED in shock and one third of them will die reaching a mortality rate in the more recent reports of 32% [10].…”

“…Principal veins injured are presacral plexus and prevescical veins, and the principals arteries are anterior branches of the internal iliac artery, the pudendal and the obturator artery anteriorly, and superior gluteal artery and lateral sacral artery posteriorly [7, 11]. Others sources of bleeding include bones fractures [1]. Among the different fracture patterns affecting the pelvic ring each has a different bleeding probability.…”

“…In cases of high-grade injuries, thoraco-abdominal associated injuries can occur in 80%, and others local lesions such as bladder, urethra (1.6-25% of cases), vagina, nerves, sphincters and rectum (18–64%), soft tissues injuries (up to 72%). These injuries should be strongly suspected particularly in patients with perineal hematoma or large soft tissue disruption [1, 3, 14]. These patients need an integrate management with other specialists.…”

“…Pelvic trauma (PT) is one of the most complex management in trauma care and occurs in 3% of skeletal injuries [1–4]. Patients with pelvic fractures are usually young and they have a high overall injury severity score (ISS) (25 to 48 ISS) [3].…”

“…Patients with pelvic fractures are usually young and they have a high overall injury severity score (ISS) (25 to 48 ISS) [3]. Mortality rates remain high, particularly in patients with hemodynamic instability, due to the rapid exsanguination, the difficulty to achieve hemostasis and the associated injuries [1, 2, 4, 5]. For these reasons, a multidisciplinary approach is crucial to manage the resuscitation, to control the bleeding and to manage bones injuries particularly in the first hours from trauma.…”