Pelvic fracture

Surgical approach (typical pathways)

• Initial haemorrhage control (often before definitive fixation)
  • Pelvic binder/sheet at greater trochanters (temporary stabilisation, reduces pelvic volume)
  • External fixation (anterior frame) or C-clamp (posterior ring instability) to stabilise pelvis
  • Pre-peritoneal pelvic packing (PPP) for venous/bony bleeding in unstable patients
  • Interventional radiology: pelvic angiography ± embolisation for arterial bleeding (e.g. internal iliac branches)
  • Laparotomy if intraperitoneal bleeding/viscus injury, may combine with PPP
• Definitive fixation (timing depends on physiology: damage control vs early total care)
  • ORIF of pelvic ring and/or acetabulum (plates/screws, percutaneous iliosacral screws)
  • Approaches: anterior (Pfannenstiel/Stoppa/ilioinguinal), posterior (sacroiliac), lateral (acetabular approaches e.g. Kocher-Langenbeck)
  • May require staged procedures, prolonged operative time, significant blood loss risk

Anaesthetic management (typical for pelvic fixation/packing/IR)

• Type of anaesthesia
  • Usually GA (trauma, haemorrhage, multiple injuries, long duration, prone/lateral positioning, need for controlled ventilation)
  • Regional techniques are adjuncts (analgesia) rather than sole anaesthetic in unstable trauma, neuraxial often inappropriate early due to shock/coagulopathy/anticoagulation
• Airway
  • ETT with RSI is common (full stomach, trauma, need for ventilation/PEEP, long cases, prone/lateral positions, massive transfusion)
  • SGA rarely appropriate (aspiration risk, positioning, haemodynamic instability, need for high airway pressures)
• Duration (very variable)
  • Damage control: binder/ex-fix/PPP often 30–120 min, angiography/embolisation 1–3+ h
  • Definitive ORIF pelvic ring/acetabulum commonly 2–6+ h (may be longer if complex/staged)
• How painful?
  • Severe pain from fracture and associated injuries, fixation surgery is highly painful
  • Analgesia: IV opioids ± ketamine, consider regional adjuncts (see below) when safe
• Key intra-op priorities
  • Haemorrhage control + massive transfusion readiness, prevent/treat hypothermia, acidosis, coagulopathy
  • Invasive monitoring (A-line early, large-bore access, consider central access/rapid infuser/cell salvage where appropriate)
  • Positioning risks: prone/lateral, pressure areas, traction, access to airway/lines, potential for major blood loss on turning

Why pelvic fractures matter (anaesthetic relevance)

• Marker of high-energy trauma, frequently associated with polytrauma and occult haemorrhage
• Major haemorrhage: bleeding can be venous (plexus), bony surfaces, or arterial (internal iliac branches)
• Associated injuries: abdominal/retroperitoneal, urogenital (urethra/bladder), lumbosacral plexus, head/chest injuries
• Early death: haemorrhage, later morbidity: sepsis, ARDS, VTE, chronic pain, neurological deficit

Classification (useful patterns and implications)

• Pelvic ring stability matters more than exact label: stable vs unstable (rotational/vertical)
• Mechanism-based patterns (Young–Burgess):
  • AP compression (open-book): pubic symphysis diastasis, higher risk of haemorrhage (increased pelvic volume)
  • Lateral compression: common, may still bleed significantly
  • Vertical shear: highly unstable, major haemorrhage risk
• Acetabular fractures: often require prolonged ORIF, positioning (lateral/prone) and blood loss can be substantial

Initial assessment and resuscitation (ATLS/major trauma approach)

• A–E with early haemorrhage control: treat pelvic fracture as potential major haemorrhage until proven otherwise
• Pelvic binder early if suspected unstable pelvic ring injury (apply at greater trochanters, reassess skin and neurovascular status)
• Permissive hypotension may be considered in uncontrolled haemorrhage without TBI (local protocols), avoid hypotension in TBI
• Massive haemorrhage protocol: balanced component therapy, early TXA (per trauma guidance), calcium replacement, fibrinogen/cryoprecipitate guided by labs/TEG/ROTEM
• Prevent the lethal triad: active warming, warmed fluids/blood, minimise crystalloid, correct coagulopathy and acidosis
• Imaging: eFAST, pelvic X-ray, CT (if stable enough) to define bleeding source and injuries, early IR/surgical consultation

Haemorrhage sources and control (practical exam framework)

• Most bleeding is venous/bony, arterial bleeding less common but important (responds to embolisation)
• Binder/ex-fix reduces pelvic volume and motion → helps venous/bony bleeding
• PPP targets venous/bony bleeding quickly in theatre (damage control)
• Angio-embolisation targets arterial bleeding, requires time, access to IR, and relative physiological tolerance
• REBOA may be used in selected centres for refractory pelvic haemorrhage as a bridge (requires expertise, significant complications)

Anaesthetic considerations: pre-op

• Assume full stomach, anticipate difficult airway (C-spine precautions, facial trauma), plan RSI and backup
• Access: 2 large-bore IVs, consider rapid infuser, early arterial line, consider central access if poor peripheral access/vasopressors/rapid transfusion needs
• Blood: group and save/crossmatch, activate MHP early if unstable, consider cell salvage (contamination considerations in open fractures/bowel injury)
• Labs: ABG/VBG, lactate, Hb, coagulation, fibrinogen, ionised calcium, repeat frequently
• Urogenital injury: avoid urethral catheter if urethral injury suspected (blood at meatus, high-riding prostate, perineal bruising), consider suprapubic catheter after urology input

Anaesthetic considerations: induction and maintenance

• Induction: haemodynamically fragile—use titrated induction (ketamine/etomidate per local practice), early vasopressors, maintain coronary/cerebral perfusion
• Ventilation: lung-protective strategy, consider effects of haemorrhagic shock and transfusion on acid-base, avoid severe hypocapnia (esp. if TBI considerations)
• Monitoring: A-line, temperature, urine output (if safe), frequent ABGs, consider cardiac output monitoring in complex shock
• Transfusion/coagulation: ratio-based initially then goal-directed with TEG/ROTEM, give calcium, consider fibrinogen early if low
• Antibiotics: per open fracture/packing/ORIF protocols, consider tetanus status

Analgesia strategies (acute and perioperative)

• Systemic: IV opioids (careful in shock), paracetamol, cautious NSAIDs (renal injury/bleeding risk), ketamine infusion useful in trauma
• Regional (adjuncts, weigh coagulopathy/anticoagulation/infection/positioning):
  • Fascia iliaca block / femoral nerve block: helps anterior hip/acetabular pain, limited for posterior pelvic ring pain
  • Erector spinae plane (lumbar) or quadratus lumborum blocks: may help flank/iliac crest pain, variable evidence
  • Neuraxial (epidural/spinal): generally avoid in acute unstable pelvic trauma, may be considered later for elective fixation if haemodynamically stable and coagulation normal

Postoperative and critical care

• Many require ICU/HDU: ongoing haemorrhage risk, coagulopathy, ventilation needs, multi-organ support
• VTE prophylaxis: very high risk (pelvic/acetabular fractures), mechanical early, pharmacological when safe (balance bleeding/operative plans)
• Complications: ARDS/TRALI/TACO, hypocalcaemia, hypothermia, AKI, infection, pelvic sepsis (packing), nerve injury, chronic pain
• Rehabilitation and analgesia plan, consider chronic pain referral if neuropathic features

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