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Pelvic trauma

Key sources
The following summarized guidelines for the evaluation and management of pelvic trauma are prepared by our editorial team based on guidelines from the Eastern Association for the Surgery of Trauma (EAST/AOTA 2023), the European Association of Urology (EAU 2023; 2022), the Pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma (ABC-T 2023; 2019), the World Society of Emergency Surgery (WSES/AAST 2020; 2019), the Society of Interventional Radiology (SIR 2020), the Eastern Association for the Surgery of Trauma (EAST 2019; 2011), the World Society of Emergency Surgery (WSES 2017), and the American Urological Association (AUA 2014).
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Guidelines

1.Classification and risk stratification

WSES classification: the WSES (WSES) classification divides pelvic ring injuries into three classes:
minor (WSES grade I) comprising hemodynamically and mechanically stable lesions. WSES grade I includes Anterior-Posterior Compression I and Lateral Compression I hemodynamically stable pelvic ring injuries
moderate (WSES grade II, III) comprising hemodynamically stable and mechanically unstable lesions. WSES grade II includes Anterior-Posterior Compression II-III and Lateral Compression II-III hemodynamically stable pelvic ring injuries. WSES grade III includes Vertical Shear and Combined Mechanism hemodynamically stable pelvic ring injuries
severe (WSES grade IV) comprising hemodynamically unstable lesions independently from mechanical status. WSES grade IV includes any hemodynamically unstable pelvic ring injuries
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2.Diagnostic investigations

Physical examination
As per WSES 2017 guidelines:
Perform perineal and rectal digital examination in patients with a high suspicion of rectal injuries.
B
Perform proctoscopy in patients with a positive rectal examination.
B

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  • Laboratory testing

  • FAST ultrasound

  • Pelvic radiography

  • CT

  • Retrograde urethrocystography

  • Pelvic angiography

3.Diagnostic procedures

Diagnostic peritoneal lavage: diagnostic peritoneal lavage is the best test to exclude intra-abdominal bleeding in hemodynamically unstable patients.
B

4.Medical management

Pain management
Consider administering NSAIDs (such as ketorolac) for pain management in adult patients with a traumatic fracture.
C
Insufficient evidence to recommend the preferential use of either selective NSAIDs (COX-2 inhibitors) or nonselective NSAIDs.
I

5.Nonpharmacologic interventions

Pelvic binders: as per WSES 2017 guidelines, apply pelvic binders to stabilize the pelvic ring and decrease the amount of pelvic hemorrhage in patients with pelvic fractures who are undergoing initial resuscitation.
A
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More topics in this section

  • Pelvic orthotic devices

6.Therapeutic procedures

Retroperitoneal pelvic packing: as per ABC-T 2023 guidelines, perform temporary extraperitoneal packing when bleeding is ongoing and/or when angioembolization cannot be achieved promptly. Consider combining extraperitoneal packing with open abdominal surgery when necessary.
B

More topics in this section

  • Pelvic angioembolization

  • REBOA

7.Surgical interventions

Timing of surgery: as per WSES 2017 guidelines, resuscitate hemodynamically unstable patients and coagulopathic patients prior to proceeding with definitive pelvic fracture fixation.
B
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More topics in this section

  • Damage-control surgery

  • External pelvic fixation

  • Internal pelvic fixation

8.Specific circumstances

Patients with kidney injury, evaluation, AAST/WSES: obtain eFAST to detect intra-abdominal free fluid.
A
recognize that eFAST has low sensitivity and specificity in kidney trauma.
B
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More topics in this section

  • Patients with kidney injury (management)

  • Patients with ureteral injury

  • Patients with bladder injury

  • Patients with urethral injury