Unstable pelvic ring injury with hemodynamic instability: What seems the best procedure choice and sequence in the initial management?

SummaryIntroductionMost fatalities related to pelvic ring injuries occur early and are caused by massive retroperitoneal bleeding. The objective of our study is to determine the optimal sequence of surgical procedures to restore hemodynamic stability in patients with unstable pelvic ring injuries.Patients and methodsThis was a retrospective review of all patients with pelvic fractures and hemodynamic instability admitted to our level 1 trauma center between January 1998 and December 2008. We entered into our polytrauma database the following patient characteristics: age, sex, mechanism of injury, Injury Severity Score (ISS), classification of injury, timing of operative intervention, and type of operative procedures. Patients were divided into four groups (according to the sequence of surgical procedures performed within 24hours following admission), as follows: group 1: patients treated with external fixation only; group 2: patients receiving external fixation followed by angiography; group 3: patients receiving external fixation followed by laparotomy±angiography; and group 4: patients treated by immediate laparotomy or angiography before skeletal fixation.ResultsEighty of 136 patients admitted with a pelvic fracture were classified, as unstable AO/OTA type B or C pelvic ring injury, and 70/80 were hemodynamically unstable. Eight patients died shortly after arrival and two remained stable without requiring any early procedure. Sixty patients went immediately to the operating room. Twenty-nine patients were placed in group 1 with 100% survival, 12 in group 2 with 91% survival, 11 in group 3 with 82% survival, and eight patients placed in group 4 with 0% survival (P