An unstable pelvic ring. The killing fracture.

©2006 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.88B4. 16693 $2.00 J Bone Joint Surg [Br] 2006; 88-B:427-33. An unstable pelvic fracture may be life threatening and can be seen as ‘the killing’ fracture. Even if this is the only injury, it may be a serious problem. In the initial management of this type of fracture, the principles of advanced trauma life support (ATLS) 1 must be observed, with management of the airway and control of breathing as the primary aims, while protecting the cervical spine. Many of these patients have multiple injuries and require definitive control of the airway, mechanical ventilation and drainage with a thoracic tube. Attention must be paid to signs of hypovolaemic shock. This can be a silent killer, as 30% of the blood volume (up to 1500 ml in a 75 kg adult) will be lost before hypotension is noted. Loss of up to this volume from bleeding may only cause tachycardia. If there is hypotension with a systolic blood pressure of 90 mmHg or less, at least 1500 to 2000 ml of blood loss has occurred. Adequate access to the venous system for transfusion and fluid replacement must be achieved in the first hour of management. The primary assessment must focus on possible sources of bleeding, such as external blood loss and internal bleeding in the thorax, abdomen or retroperitoneal space, including disruption of the pelvic ring and multiple longbone fractures, especially of the femoral shaft. Physical examination of the thorax will reveal conditions such as a tension pneumothorax or a massive haemothorax, but the abdomen is more difficult to assess. 2 An anteroposterior (AP) radiograph of the thorax and abdominal ultrasonography should be undertaken without delay. Ultrasonography is a reliable indicator of massive intra-abdominal bleeding, which will necessitate direct surgical intervention by emergency laparotomy. 3 The pelvic rock manoeuvre can demonstrate clinical instability of the pelvic ring, especially when the instability is gross, but an apparently normal examination does not exclude severe pelvic injury. Therefore, an AP view of the pelvic ring should be included in the primary survey in all patients with blunt trauma who have signs of hypovolaemic shock. The treatment of choice in hypovolaemic shock is control of the bleeding. In the ATLS concept, the simple statement of ‘early surgical consultation’ does not reflect the complexity of the control of bleeding due to pelvic ring disruption. In severe pelvic injury there is a high incidence of combined intra-abdominal trauma, which will influence the therapeutic strategies to be followed. 4 After exclusion or control of the intra-abdominal bleeding, it must be determined whether the pelvic bleeding is located in the anterior or the posterior part of the ring, whether it is mainly from the fracture site and whether it is venous or arterial. Systemic adverse effects such as hypothermia, metabolic acidosis and clotting disturbances, which are not uncommon in polytraumatised patients, 5 must be considered as they may play a major part in the therapeutic strategy. In such extreme cases, the concept of damage control surgery should be followed. 6,7