Emergency Medicine · Year 3 · from Emergency Medicine

Case 3: Unstable Pelvic Fracture with Hemorrhage

Patient Demographics

• Age: 45 years
• Sex: Male
• Occupation: Motorcyclist

Mechanism of Injury

Motorcycle collision with SUV. Patient T-boned at intersection, thrown approximately 20 feet. Wearing helmet. Found supine, alert, complaining of severe pelvic pain.

Primary Survey

Airway: Patent, speaking Breathing: RR 24, clear bilaterally, SpO2 95% RA Circulation:

• HR 128, BP 82/56
• Weak peripheral pulses
• Cool, clammy skin
• Scrotal hematoma noted
• Pelvis unstable on gentle AP compression (ONE EXAM ONLY)

Disability: GCS 15, moves all extremities Exposure: Road rash, no open fractures, blood at urethral meatus

Immediate Interventions

1. Pelvic binder applied (sheet/commercial device at level of greater trochanters)
2. Two large-bore IVs
3. Massive Transfusion Protocol activated
4. Foley catheter DEFERRED (blood at meatus - need retrograde urethrogram first)
5. FAST examination

FAST Results

• Negative for free abdominal fluid
• No pericardial effusion

Diagnostic Imaging

Portable Pelvis X-ray:

• Open book pelvic fracture
• Symphysis pubis diastasis >4cm
• Left SI joint disruption
• Type B (AP compression) pattern

CT Pelvis with Contrast:

• Bilateral superior and inferior pubic rami fractures
• Left SI joint disruption
• Active arterial extravasation from left internal iliac artery branch
• Large retroperitoneal hematoma

Retrograde Urethrogram:

• Complete posterior urethral injury
• No contrast entering bladder

Hemorrhage Source in Pelvic Fractures

Three sources:

1. Venous plexus (most common) - responds to binder/packing
2. Arterial (internal iliac branches) - requires embolization
3. Bone surfaces - responds to stabilization

Management Sequence

1. Initial Stabilization:

• Pelvic binder (already applied)
• MTP continued: 4 units PRBC, 4 units FFP, 1 pack platelets
• TXA 1g IV

2. Persistent Hemodynamic Instability:

• Despite binder and blood products
• BP 78/50 after 6 units PRBC

3. Angiography and Embolization:

• IR performed pelvic angiogram
• Left internal iliac artery branches actively bleeding
• Successful Gelfoam embolization
• BP improved to 102/68 post-procedure

4. Urologic Management:

• Suprapubic catheter placed (posterior urethral injury)
• Definitive repair delayed 3 months

5. Orthopedic Management:

• External fixation placed in OR
• Definitive ORIF at day 7

Resuscitation Summary

Young-Burgess Classification

Type B (AP Compression):

• "Open book" injury
• External rotation forces
• Symphysis diastasis
• SI joint involvement
• High association with hemorrhage

Teaching Points

1. Single pelvic exam only: Repeated manipulation worsens bleeding
2. Pelvic binder ASAP: Reduces volume, promotes tamponade
3. Blood at meatus = urethral injury: No Foley until urethrogram
4. Negative FAST doesn't exclude pelvic hemorrhage: Retroperitoneal not seen
5. Angioembolization for arterial bleeding: When unstable despite binder
6. Preperitoneal packing: Alternative if angio not available

Clinical Image

Image Description: AP pelvis radiograph demonstrating an open book pelvic fracture with widening of the pubic symphysis greater than 4cm and disruption of the left sacroiliac joint, consistent with AP compression injury.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Roberto Schubert. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/open-book-pelvic-fracture

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