CHAPTER II

LITERATURE REVIEW

2. Pelvic Fracture

2.1 Pelvic Anatomy

Pelvic is a ring-like structure made of three bones: sacrum and two innominate bones,
which each consists of ilium, ischium, and pubic. The innominate bones articulate with
sacrum in the posterior of the two sacroiliac joints in the anterior. These bones merge on
the pubic symphysis. Symphysis props the body weight to maintain the pelvic ring
structure.1

The three bones and three joints stabilize the pelvic ring by the ligament structure, in
which the strongest and the most important are the posterior sacroiliac ligament. These
ligaments are made of short oblique fibers spanned across the bulge on the sacrum
posterior to the Spina iliaca posterior superior (SIPS), then merge with Spina anterior iliac
posterior inferior (SIPI). It resembles the longer longitudinal fiber span from the sacrum
lateral to Spina iliaca posterior superior (SIPS), which merges with the sacrotuberous
ligament. The anterior sacroiliac ligament is weaker than the posterior sacroiliac ligament.

Sacrotuberous ligament is a strong band that extends from the posterolateral sacrum and
the dorsal aspect of the posterior iliac spine to the ischial tube. Together with the posterior
sacroiliac ligament, it provides vertical stability to the pelvic. The sacrospinous ligament
extends from the lateral border of the sacrum and coccyx to the sacrotuberous ligament,
entering the sciatic spine. The iliolumbar ligament extends from the fourth and fifth lumbar
transverse process to the posterior iliac crest; the lumbosacral ligament extends from the
fifth lumbar transverse process to the sacral alae.1
Picture 1. Pelvic anatomy

The common iliac artery divides into the external iliac artery, located in the anterior pelvis
above the pelvic rim. The internal iliac artery runs anteriorly and deeply close to the
sacroiliac joints above it. The posterior branches of the internal iliac artery include the
iliolumbar arteries, superior gluteal arteries, and lateral sacral arteries. The superior
gluteal artery travels around to form the larger pelvis, which lies directly above the bone.
The anterior branches of the internal iliac artery include the obturator artery, umbilical
artery, vesical artery, pudendal artery, inferior gluteal artery, rectal artery, and
hemorrhoidal artery. The pudendal and obturator arteries are anatomically related to the
pubic rami and can be injured by fracture or injury to these structures. These arteries and
their accompanying veins can all be damaged during pelvic disruption (figure 2).
Understanding the pelvic anatomy will help the orthopedic surgeon identify which fracture
pattern is more likely to cause direct damage to significant vessels and result in substantial
retroperitoneal bleeding.

2.2 Trauma Mechanism

The trauma mechanism to the pelvic ring consists of:

2.2.1 Antero-Posterior Compression (APC)

It usually occurs as a result of a collision between a pedestrian and a vehicle. The pubic
ramus is fractured, the innominate bone is split and undergoes external rotation,
accompanied by a symphysis tear. This situation is known as an open book injury. The
posterior sacroiliac ligament is partially torn or may be accompanied by a fracture of the
back of the ilium.

2.2.2 Lateral Compression (LC)

Compression from the side will cause cracks in the ring. It occurs when side trauma due to
a traffic accident or a fall from a height is present. In this situation, the front pubic ramus is
fractured on both sides, and there is a strain on the back from the sacroiliac joint or ilium
fracture or pubic ramus fracture on the same side.

2.2.3 Vertical Shear (VS)

The innominate bone goes through vertical movement with fracture of the pubic ramus on
one side and disruption of the sacroiliac joint on the same side. It occurs when a person
falls from height on one leg.

2.2.4 Combined Mechanism (CM)

A more significant trauma that combines the other three traumas above.

2.3 Classification

There are several types of pelvic injury:

2.3.1 Isolated pelvic ring fracture

2.3.1.a) Avulsion fracture

A condition where a muscular contraction pulls off a piece of bone. This fracture is
commonly found in sportspeople and athletes. The Sartorius muscle can pull on the
anterior superior iliac spine, the rectus femoris can draw on the anterior inferior iliac crest,
the adductor longus pulls on a piece of the pubic, and the striated veins pull on parts of the
ischium. Longitudinal which,y subsides within a few months. Avulsion of the ischial
apophysis by the knee muscles rarely results in persistent symptoms, in which case open
reduction and internal fixation are indicated.

2.3.1.b) Direct fracture

A direct hit to the pelvic typically after falling from the height. It may cause an ischial or
iliac bone fracture. The patient needs total bed rest until the pain subdue.

2.3.1.c) Stress fracture

A commonly found fracture on the pubic ramus. No pain is present in severe osteoporosis
and osteomalacia patients. The stress fracture around the sacroiliac joint is harder to
diagnose. It often causes unusual sacroiliac pain to elderly osteoporosis patients.

2.3.2 Pelvic ring fracture

It has long been argued that because of the pelvic rigidity, a fracture in one place of the ring
must be followed in another, except for fractures from immediate smash or fractures in
children whose symphysis and sacroiliac joints are still elastic. But a second fracture is
often absent, either because the fracture is reduced immediately or because the sacroiliac
joint is only partially damaged. In this case, the visible fracture is not displaced and the ring
is stable.

In the displaced fractures or joint damage, and all obvious double-ring fractures, the ring is
unstable. This distinction is of more practical value than classification into single and
multiple ring fractures.

Anteroposterior pressure. A frontal collision during accidents usually causes this injury.

The pubic ramus or the innominate bone is fractured and rotates outward along with the
symphysis. It is known as an "open book" fracture. A portion of the sacroiliac ligament is
partially torn, or there is probably a fracture in the ilium posterior. Lateral pressure from
side to side of the pelvic causes the ring to bend and break. In the anterior pubic rami, one
of both sides is fractured, and a severe sacroiliac strain is found in the posterior or ilium
fracture, either on the same side as the pubic rami fracture or on the opposite side of the
pelvic. A significant shift of the sacroiliac joint causes unstable pelvic.

Vertical twisting occurs the innominate bone on one side shifts vertically. It causes a
vertical fracture, pubic rami fracture, and damage to the sacroiliac region on the same side.
It typically happens when somebody is falling on one foot from the height. It is usually
severe and unstable, with soft tissue tears and retroperitoneal bleeding.

Tile (1988) divided pelvic fractures into stable injuries, rotationally unstable injuries, and
rotational and vertically unstable injuries.

● Type A/Stable: Includes avulsions and fractures of the pelvic ring with little to no
displacement.
○ A1: pelvic fracture not involving the ring
○ A2: stable, with a minimal shift of the ring from the fracture
● Type B: Rotationally unstable but vertically stable. External rotational forces hitting
on one side of the pelvis can be damaging and open the normal symphysis. It is
called open book fracture, where the lateral pressure as an internal rotation force
causes ischiopubic rami on one or both sides, along with posterior injury without
symphysis opening.
○ B1: open book
○ B2: ipsilateral lateral compression
○ B3: contralateral lateral compression (bucket-handle)
● Type C: rotationally and vertically unstable, damage to the rigid posterior ligaments
with injury to one or both sides and vertical displacement of one side of the pelvis,
there may also be a fracture of the acetabulum.
○ C1: unilateral
○ C2: bilateral
○ C3: acetabulum fracture is possible

2.4 Diagnosis

The diagnosis is made when subjective and objective pain is present and the abnormal
movement of the pelvic girdle. Therefore, the pelvis is gently pressed back and medially on
the two anterior superior iliac spines, medially on the two major trochanters, backward on
the pubic symphysis, and medially on the two iliac crests. If this examination causes pain, a
hip fracture should be suspected.
Then look for urinary disorders such as urinary retention or bleeding through the urethra,
as well as a digital rectal exam to assess the sacrum or pubic bone from the inside.

2.4.1 Anamnesis

a. State and time of trauma

b. Last miction
c. Time and amount of the last meal and drink
d. If the patient is a woman, check whether she is pregnant or menstruating
e. Other traumas such as head trauma

2.4.2 Clinical Examination

a. General condition
● Pulse, blood pressure, and respiration
● Look for the possibility of other traumas
b. Local
● Pain assessment
○ Pressure from the side of the pelvic ring
○ Tow on the pelvic ring
● Inspect the perineum for bleeding, swelling, and deformity
● Determine the instability degree of the pelvic ring by the pubic ramus and
symphysis palpation
● Digital rectal exam

X-rays may show pubic rami fracture, ipsilateral or contralateral fracture of the posterior
element, symphysis separation, sacroiliac joint damage, or combinations. CT scan is the
best way to demonstrate the nature of the injury.

2.2 Classification System and Prognostic Values

Several classification systems have been defined to describe pelvic injuries based on the
pelvic disruption nature and stability or the magnitude and direction of the pressure
applied to the pelvis. Each of the classifications has been developed to guide the general
and orthopedic surgeons on the types and possible management difficulties encountered
with each fracture type. As explained by Young and Burgess, the pelvic fracture
classification system is most closely related to the need for resuscitation and the pattern
associated with the injury. This system is based on a standard series of pelvic images and
internal and external images, as described by Pennal et al.4

The Young-Burgess classification divided pelvic disruption into anterior-posterior

compression (APC), lateral compression (LC), vertical shear (VS), and combined
mechanism (CM) injuries (figure 3).

The APC and LC categories were further subclassified from types I–III based on the
increased severity of the injury resulting from significant pressure increase. APC injuries
are caused by an anterior impact to the pelvis, often leading to a symphysis pubis diastase.
An “open book” injury interferes with the anterior sacroiliac ligament and the ipsilateral,
sacrospinal, and sacrotuberous ligaments. APC injury is considered an excellent
radiographic sign for the internal iliac vessels branches aligned closely with the anterior
sacroiliac joint.1

Figure 1. Young-Burgess pelvic fractures classification. A) type I anteroposterior

compression. B) type II anteroposterior compression. C) type III anteroposterior
compression. D) type I lateral compression. E) type II lateral compression. F) type III lateral
compression. G) vertical shear. The arrows on each panel indicate the direction of stress
resulting in a fracture pattern.
LC injury resulting from a lateral collision to the pelvic, twist it on the side of crash toward
the midline. The sacrotuberous and sacrospinal ligaments and the internal iliac vessels are
shortened and are not subjected to tensile strength. Disruption of the named large vessels
(e.g., internal iliac artery, superior gluteal artery) is relatively uncommon in LC injury;
when this occurs, it is suspected to result from the fracture fragment laceration. VS injuries
are distinguished from hemipelvic vertical displacement. Hemipelvic displacement may be
accompanied by severe local vascular injury. The pattern of CM injury includes high-
strength pelvic fractures caused by the combination of two separate stress vectors.

The Young-Burgess pelvic fractures classification and presumed stress vectors have also
been shown to correlate well with organ injury patterns, resuscitation requirements, and
mortality. In particular, increases in mortality have been demonstrated as APC rates
increase. The injury pattern seen in type III APC fractures has been correlated with the
most extensive 24-hour fluid requirements. In a series of 210 consecutive patients with
pelvic fractures, Burgess et al. found that the transfusion requirement for patients with LC
injuries averaged 3.6 units of PRC, compared with an average of 14.8 units for patients with
APC injuries. In the same series, patients with VS injuries had an average of 9.2 units, and
patients with CM injuries had an average transfusion requirement of 8.5 units. The overall
mortality rate in this series was 8.6%. The higher mortality rate was seen in the APC
pattern (20%) and the CM pattern (18%) compared to the LC pattern (7%) and VS pattern
(0%). Burgess et al. noted that blood loss from pelvic injuries resulting from lateral
compression was rare, and the authors attributed death in patients with LC injury to other
causes. The most common identified death cause in this series of patients with LC fractures
was closed head injury.

On the contrary, the identified death cause in patients with APC injuries was a combination
of pelvic and visceral injuries. These findings indicate that recognizing the pelvic fractures
pattern and the appropriate injury pressure direction may help the resuscitation team
anticipate fluid and blood transfusions requirements and aid in immediate initial
assessment and treatment. Patients with complete posterior instability can be prevented
from having heavy bleeding.1

Pelvic Fracture Management

Pelvic Fracture Identification and Management (5)

a. Identifying trauma mechanism that causes possible pelvic fractures, e.g., being
thrown from a motorcycle, crash injury, pedestrians being hit by vehicles,
motorcycle collisions.
b. Examine the pelvic area for ecchymosis, perineal or scrotal hematoma, blood in the
urethral meatus.
c. Examine the legs for length discrepancies or hip rotation asymmetry.
d. Conduct rectum examination, the prostate gland position and mobility, palpable
fractures, or blood in the stool.
e. Conduct vaginal examination, palpate for fracture, uterine size and consistency,
presence of blood. Keep in mind that the patient may be pregnant.
f. If abnormalities are found in B to E, if the trauma mechanism supports pelvic
fractures, perform an AP pelvic X-ray (trauma mechanism may explain the fracture
type).
g. If B to E is normal, palpate the pelvic bones to locate the site of pain.
h. Determine pelvic stability by carefully conducting anterior-posterior and lateral-
medial pressure on the SIAS. Examination of axial mobility by carefully doing leg
push and pull, determine the cranial-caudal stability.
i. Caution for urinary catheterization if there is no contraindication, or conduct a
retrograde urethrogram examination if urethral trauma is suspected.
j. For pelvic X-ray assessment, pay attention to the fracture cases that are often
accompanied by heavy blood loss, for example, fractures that increase the pelvic
volume.
1. Match the patient's identity on the film
2. Systemically check the photo;
 a. Symphysis pubis width - more than 1 cm separation indicates
posterior pelvic trauma.
b. Bilateral superior and inferior pubic ramus integrity
c. Acetabulum integrity, femur capsule and column
d. Ileum symmetry and the sacroiliac joint width
e. Foramen sacrum symmetry with arcuate line evaluation
f. L5 transverse process fracture
3. Note that given the circular form of the pelvic bone, the damage is rarely to
only one place.
4. Note that pelvic volume increasing fractures such as vertical shear and open-
book fracture is often accompanied by heavy bleeding.
k. How to stop bleeding
1. Prevent excessive or repetitive manipulation
2. The lower leg is rotated inward to close the open-book fracture. Place the
pads on the bony prominences and tie the two rotated legs together. This
action will reduce the symphysis shift, reduce the pelvic volume, useful for
temporary measures while waiting for definitive treatment.
3. Install and develop PASG. This tool helps carry/transport patients.
4. Install external pelvic fixator (immediate orthopedic consultation)
5. Apply skeletal traction (immediate orthopedic consultation)
6. Embolization of pelvic vessels via angiography
7. Carry out immediate surgical/orthopedic consultation to determine
priorities
8. Place a sand pillow under the left and right buttocks if no spinal trauma or
other methods to close the pelvis are unavailable.
9. Install the pelvic binder.
10. Arrange for patient transfer to a definitive therapy facility if unable to do so.

2.3 Management Methods

2.3.1 Military Antishock Trousers

Military antishock trousers (MAST) can provide compression and temporary
immobilization to the pelvic rings and lower extremities through air-filled pressure. In the
1970s and 1980s, MAST was recommended to induce pelvic tamponade and increase
venous return to assist resuscitation. However, the use of MAST limits the abdomen
examination and may result in lower extremity compartment syndrome or an increase in
one of these. Although still helpful in stabilizing patients with pelvic fractures, MAST has
mainly been replaced by commercially available pelvic binders.

2.3.2 Pelvic binder and sheet

Circular compression may readily be achieved in the prehospital setting and initially
stabilizes advantage during transport and resuscitation. A folded sheet wrapped in a circle
around the pelvis is cost-effective, non-invasive, and easy to apply. Various commercial
pelvic binders have been invented. A pressure of 180 N seems to provide maximum
effectiveness. One study reported a pelvic binder reduced transfusion requirements,
hospital stay duration, and mortality in patients with APC injuries.

Figure 2. Illustration demonstrating the proper application of a pelvic girdle compression

device (pelvic binder), with an additional buckle (arrow) to control pressure

External rotation of the lower extremities is commonly seen in persons with dispositional
pelvic fractures, and strength acting through the hip joint may contribute to the pelvic
deformity. External rotation correction of the lower extremities can be achieved by
bandaging the knees or feet together, and it can improve pelvic reduction that circular
compressions can achieve.

2.3.3 External Fixation

2.3.3.a) Standard Anterior External Fixation

Several studies have reported the benefits of emergency pelvic external fixation in the
resuscitation of hemodynamically unstable patients with unstable pelvic fractures. Several
factors may cause the beneficial effects of external fixation on pelvic fractures.
Immobilization could limit pelvic displacement during patient movement, decreasing the
possibility of blood clot disruption. In some patterns (e.g., APC II), applying an external
fixator is helpful for pelvic volume reduction. Experimental studies have shown that
reducing “open book” pelvic injuries leads to an increased retroperitoneal pressure, which
may help venous bleeding tamponade. The addition of fracture disposition can relieve the
hemostatic pathway to control bleeding from rough bone surfaces.

2.3.3.b) C-Clamp

Standard external pelvic fixation does not provide adequate posterior pelvic stabilization. It
limits its effectiveness in fracture patterns involving significant posterior disruption or
where the iliac ossis is fractured. Posteriorly applied C-clamps have been developed to
cover this shortcoming. It provides posterior compressive force application past the
sacroiliac joint. Great care must be exercised to prevent iatrogenic injury during
application; The procedure generally has to be performed under fluoroscopy guidance.
Applying C-clamp to the trochanteric region of the femur offers an alternative to standard
anterior external fixation for temporary fixation of APC injuries.1

2.3.4 Angiography

Exploratory angiography should be considered in patients with ongoing unexplained blood

loss after pelvic fracture stabilization and aggressive fluid infusion. The overall prevalence
of patients with pelvic fractures requiring embolization is reported to be <10%. In a recent
series, angiography was performed in 10% of patients with a pelvic fracture.

Elderly patients with a higher Revised Trauma Score are most often to have angiography.
In another study, 8% of the 162 patients reviewed by the authors required angiography.
Embolization was required in 20% of the APC injuries, VS injuries, and complex pelvic
fractures, but only 1.7% of LC injuries. Eastridge et al. reported that 27 of 46 patients with
persistent hypotension and completely unstable pelvic fractures, including APC II, APC III,
LC II, LC III, and VS injuries, had active arterial bleeding (58.7%). Miller et al. found that 19
of 28 patients with persistent hemodynamic instability due to pelvic fractures showed
arterial bleeding (67.9%). In other studies, angiography successfully stopped pelvic artery
bleeding in 86-100% of cases.

Early angiography and subsequent embolization have been shown to improve the
outcomes in patients. Agolini et al. demonstrated that embolization within 3 hours of
arrival resulted in a significantly greater survival rate. Another study found that pelvic
angiography performed within 90 minutes of admission improved survival. However,
aggressive use of angiography may lead to ischemic complications. Angiography and
embolization are ineffective in controlling bleeding from venous and bony injuries, and
venous bleeding causes a greater source of bleeding in high-strength pelvic fractures. Time
spent on angiographic sequences in hypotensive patients without arterial injury may not
be supportive of survival.

2.2.1 Pelvic Wrap

Pelvic wraps were developed to achieve immediate hemostasis and control venous
bleeding caused by pelvic fractures. For more than a decade, trauma surgeons in Europe
have advocated exploratory laparotomy followed by pelvic wrap. The technique is believed
to be particularly useful in severe patients. Ertel et al. demonstrated that multiply-injured
patients with pelvic fractures could be safely managed using C-clamps and pelvic wrap
without arterial embolization. Local wraps are also effective in controlling arterial
bleeding.
2.2.2 Fluid Resuscitation

Fluid resuscitation is considered essential to assess and control the site of bleeding. Two
large-bore (≥16-gauge) intravenous cannulae should be constructed centrally or in the
upper extremity throughout the initial assessment. ≥ 2 L crystalloid solutions should be
administered in 20 minutes or sooner in patients who are in shock. If an adequate blood
pressure response can be obtained, crystalloid infusions can be continued until the specific-
type or generally matched blood is available. Specific-type blood, crossmatched for ABO
and Rh types, can usually be provided within 10 minutes; however, such blood may contain
incompatibility with other minor antibodies. Generally matched and crossmatched blood
carried the least risk of a transfusion reaction but also took the most time to be obtained
(mean 60 minutes). When the crystalloid infusion response is transient, or blood pressure
fails to respond, an additional 2 liters of crystalloid fluid can be administered, and non-
crossmatched universal-type or universal-donor blood (i.e., group O negative) given
immediately.

Lack of response indicates that ongoing blood loss is likely, and angiography and/or
surgical bleeding control may be required.2

2.2.3 Blood Products and Recombinant Factor VII a

Hypotensive patients who do not respond to initial fluid resuscitation require large
volumes of fluids afterward, leading to deficiency of the hemostatic pathway. Therefore, all
such patients should be assumed to require platelets and fresh frozen plasma (FFP).
Generally, 2 or 3 units of FFP and 7-8 units of platelets are required for every 5 L of volume
replacement. Massive blood transfusion carries a potential risk of immunosuppression,
inflammatory effects, and dilutional coagulopathy. The optimal volume and relative
requirements of blood products for resuscitation are controversial. In addition, the number
of PRC transfusions is an independent risk factor for post-injury multi-organ failure.
Several authors have proposed that trauma patients with coagulopathy should primarily be
resuscitated with more aggressive use of FFP, consist of PRC, FFP, and platelets
transfusions in a 1:1:1 ratio to prevent early progression of coagulopathy.
Recombinant factor VIIa (rFVIIa) may be considered as a final intervention if life-
threatening coagulopathy and bleeding persist in addition to other treatments. This is a
usage of off-label rFVIIa. Boffard et al. conducted a multicenter study in which severe
trauma patients who received six units of PRC within 4 hours of admission were
randomized to either rFVIIa treatment or placebo. In the rFVIIa group, the number of blood
cell transfusions was significantly reduced (approximately 2.6 RBC units; P = 0.02), and
there was a trend toward reduced mortality and complications.

2.2.4 Resuscitation status evaluation

The resuscitation endpoint was determined by the combination of laboratory data and
physiologic signs. Hemoglobin level readings are known to be inaccurate during the acute
phase of resuscitation. Common resuscitation endpoints considered normal blood
pressure, decreased heart rate, adequate urine output (≥ 30 mL/hour), and normal central
venous pressure (CVP). However, even after normalization of these parameters, inadequate
tissue oxygenation may persist. Additional laboratory measurements to evaluate tissue
oxygenation include the base, bicarbonate, and lactate deficit. All of those assess anaerobic
glycolysis. The terms base deficit and base excess are used interchangeably. The only
difference is that the base deficit is positive, and the base excess is negative. The normal
base deficit is 0-3 mmol/L; this number is routinely measured through arterial blood gas
(ABG) analysis. A persistent base deficit indicates insufficient resuscitation.

2.2.5 Treatment Algorithm and Survival Rate

Retrospective analysis of outcomes before establishing treatment algorithms dramatically

illustrates the artificial difficulty that these protocols seek to avoid. In one series, the deaths
of 43 patients, representing 60% of the deaths in this series, were attributed either as a
whole or as part of a pelvic fracture. On the 26 patients whose pelvic fracture was
considered the leading cause of death, 24 patients were in shock or had clinical evidence of
hypovolemia on admission, and 18 patients lost blood from their pelvic fracture
immediately after hospital admission.
Some algorithms are too complex that it seems impossible to follow. One reason for this
complexity is the wide variety of causes of shock and the many sources of bleeding in
patients with pelvic fractures. Also, treatment tends to be highly case-dependent. Another
reason is that most treatment algorithms are defined based on the institution’s capability
to develop them. While the underlying principles of these protocols are helpful, it may also
be essential to modify the algorithms to suit each institution’s resources and expert staff.

Patients with high-strength pelvic fractures brought to our institution with hemodynamic
instability were initially given 2 L of crystalloid solution (figure 4). Portable chest
radiographs, together with pelvic and lateral cervical spine radiographs, are examined to
exclude thoracic sources of blood loss. A central venous pressure line is placed, and the
base deficit is measured. Focused abdominal sonography for trauma (FAST) was
performed. If the result is positive, the patient is taken directly to the operating room for an
exploratory laparotomy. An external pelvic fixator is installed, and a pelvic dressing is
performed. Patients who remained hemodynamically unstable underwent pelvic
angiography before being transferred to the ICU.

If hemodynamic stability is restored, the patient is transferred directly to the ICU. The
patient receives continued fluid resuscitation and is warmed up there; Various attempts
were made to normalize the coagulation status. If the patient requires continuous
transfusion in the ICU, the not previously performed angiographic assessment should be
done. rFVIIa should be considered if the patient's condition is against all other
interventions.

If the FAST result is negative, the PRC transfusion is initiated in the emergency department.
If the patient remains hemodynamically unstable while following the second PRC unit, the
patient is taken to the operating room for external pelvic fixation and pelvic wrap. Patients
who remained hemodynamically unstable received pelvic angiography before transfer to
the ICU.

If hemodynamic stability is restored, the patient is transferred directly to the ICU. The
abdomen CT scan can be performed at this time. If the patient requires continuous
transfusion in the ICU, the not previously performed angiographic assessment should be
done.

Figure 4. Algorithm for the treatment of patients with pelvic fractures with hemodynamic
instability.

2.3 Complication

a. Sacroiliac pain is common after an unstable pelvic fracture and sometimes requires
arthrodesis to the sacroiliac joint. Sciatic nerve injuries usually heal but sometimes
require exploration. Severe urethral injury can lead to urethral stricture,
incontinence, and impotence (Apley, 1995).
b. Posterior urethral rupture is mainly caused by pelvic bones fracture. Fractures
involving the pubic ramus or symphysis and causing damage to the pelvic ring may
result in a prostatic-membranaceous urethral tear. Pelvic fractures and blood
vessels tear in the pelvic cavity cause a large hematoma in the rectal cavity so that if
the puboprostatic ligament is torn, the prostate and bladder will be raised to cranial
(Purnomo, 2007). Anterior urethral rupture, injury from the outside that often
causes damage to the anterior urethra, is a straddle injury (groin injury) where the
 urethra is pinched between the pelvic bone and a blunt object. Types of urethral
damage appear as urethral wall contusion, partial rupture, or complete rupture of
the urethral wall. In urethral contusion, the patient complains of per-urethral
bleeding or hematuria. If there is a tear in the corpus spongiosum, a hematoma on
the penis or butterfly hematoma is seen. In this situation, the patient is often unable
to mict. (Purnomo, 2007).
c. Acetabulum fracture. Occurs when the caput femoris is pushed into the pelvis. The
fracture combines the complexity of a pelvic fracture with joint damage. There are
four types of acetabulum fractures: anterior column fractures, posterior column
fractures, transverse fractures, and complex fractures. The clinical picture is
somewhat obscured because there may be other injuries that are more
obvious/distracts from the more urgent pelvic injuries. X-ray examination is
necessary (Apley, 1995).
d. Sacrum and coccyx injuries. A smash from behind or fall on the coccyx may cause a
fracture to the sacrum and coccyx. Extensive bruising and stress pain occurs when
the sacrum or coccyx is palpated from behind or through the rectum. The sensation
may be lost in the distribution of the sacral nerves. X-rays can show; 1) a transverse
fracture on the sacrum that may be accompanied by a forward thrusting of the
lower fragment, 2) a coccyx fracture, sometimes with a forward-cornered lower
fragment, 3) a normal appearance, if the injury is only a strain on the sacrococcygeal
joint (Apley, 1995). If the fracture is displaced, try to reduce it. The lower fragment
can be pushed back through the rectum. A stable reduction means a favorable state.
Thus, the patient can continue normal activities but is advised to use a rubber ring
or Sorbo pad when sitting—sometimes accompanied by complaints of difficulty
urinating (Apley, 1995). Persistent pain, especially during sitting position, is
common after a coccyx injury. If the pain is not relieved by Sorbo pads or by a local
anesthetic injection to the painful area, coccygeal excision may be considered
(Apley, 1995).