21.1

Pelvic Injuries

Chapter 21

Pelvic Injuries

Introduction

 Injuries of the pelvis are an uncommon battlefield injury.

 Blunt injuries may be associated with major hemorrhage and

early mortality.

 Penetrating injuries to the skeletal pelvis are usually

associated with abdominopelvic organ injury.

Blunt Injuries

 Patterns and mechanisms are the same as those seen in

civilian blunt trauma.

ο Lateral compression injuries are marked by internal

rotation or midline displacement of the hemipelvis.

ο Anterior posterior injuries demonstrate external rotation

of the hemipelvis.

ο Vertical shear injuries have cephalad displacement of the

hemipelvis.

 Increasing degrees of displacement in any direction are

associated with greater risk of hemorrhage.

ο Anterior posterior injuries with complete disruption of all

sacroiliac ligaments represent an internal hemipelvectomy

and have the greatest potential for hemorrhage.

Early pelvic stabilization can control hemorrhage and

reduce mortality. This is particularly true in an austere

environment with limited blood replacement products and

other treatment resources.

 Open injuries require early recognition and prompt treatment

to prevent high mortality due to early hemorrhage and late

sepsis.
21.2

Emergency War Surgery

 Diagnosis.

ο Physical examination demonstrates instability of the pelvis

when manual pressure is applied to the iliac crests.

ο Leg length difference, scrotal or labial swelling/

ecchymosis, or abrasions over the pelvis raise suspicion

for pelvic ring injury.

ο Perineum, rectum, and vaginal vault must be evaluated

for lacerations to rule out an open injury.

ο Radiograph (AP pelvis, and when possible, inlet and outlet

views) confirm the diagnosis. Computed tomography (CT)

defines the location of injury more accurately.

ο Bladder and urethral injuries are suspected when blood is

present at the meatus or in the urine, or when a Foley

catheter cannot be passed. Retrograde urethrogram and

cystography confirm the diagnosis.

 Treatment.

ο Hemorrhage control.

♦ Mechanical stabilization.

◊ Tying a sheet or placing a binder around the pelvis

at the level of the greater trochanters.

◊ Bean bags or sand bags.

◊ Lateral decubitus positioning with the affected side

dependent.

External fixator placement in the iliac crests allows for

the most direct control of the pelvis.

♦ Angiography is a useful adjunct, but is not usually

available in the deployed environment.

♦ As a last resort, retroperitoneal packing may be

attempted, but will expend tremendous resources and

is often unsuccessful.

ο Open blunt injuries require:

♦ Immediate hemorrhage control by packing.

♦ Aggressive and thorough debridement.

♦ Pelvic stabilization.

♦ Diverting colostomy in the presence of wounds at risk

for fecal soilage.
21.3

Pelvic Injuries

ο Definitive internal pelvic stabilization (plates, screws,

among others) is done outside of the combat zone.

Missile and fragmentation wounds can cause fracture of

the pelvis.

 The pelvis usually remains stable.

 The colon, small intestine, rectum, and the genitourinary tracts must all be assessed for associated injury.

 Major hemorrhage can result from injury to the iliac

vessels.

Penetrating Injuries

 Evaluation.

ο Diagnosis of associated injuries may require exploratory

laparotomy.

ο Fractures should be assessed with radiographs and CT

scans, when available, to rule out extension into the hip

and acetabulum.

 Treatment.

ο Control hemorrhage.

ο Control hollow visceral injury.

ο Debride wounds and fractures.

For combined hollow-viscus and acetabulum /hip joint

injuries, the joint is contaminated and must be explored

and treated as described in Chapter 24, Open Joint

Injuries.

 Technique of pelvic external fixator placement (Fig. 21-1).

ο Prep the iliac crests.

ο Place a 2-cm horizontal incision over the iliac crest, 2

fingerbreadths proximal or medial ventral to the anterior

superior iliac crest.

ο Bluntly dissect to the iliac crest.

ο To determine the angle of the pelvis, first slide a guide pin

between the muscle and the bone along the inner table of

the iliac wing, no deeper than 3–4 cm.
21.4

Emergency War Surgery

Fig. 21-1. Pelvic external fixator placement.

Failure to properly determine the angle of the iliac wing

leads to inadequate fixation and may cause significant

complications.

ο Locate the junction of the middle and medial thirds of the

thickness of the iliac crest with the tip of a 5-mm external

fixator pin.

ο Paralleling the guide pin, begin drilling the pin into the crest.

ο Drill between the inner and outer tables to a depth of about

4 cm, aiming generally towards the greater trochanter.

Only gentle pressure should be applied once the pin

threads have engaged, to allow for the pin to guide itself

between the tables.

ο A second pin is inserted 1–2 cm more posteriorly on the crest.

ο Check the stability of each pin. If unsatisfactory, attempt

reinsertion by aiming between the tables.

ο Place pins in the contralateral iliac crest in the same

manner.

ο Reduce the pelvis by applying pressure on the pelvis (not

the pins!) and connect the external fixator pins with bar(s)

across the abdomen and pelvis to maintain reduction.