See also:

Trauma – primary survey
Trauma – secondary survey
Trauma – tertiary survey
Fractures of the Pelvic Ring and Acetabulum

Key Points

1. Pelvic fractures are high energy injuries and are likely to be associated with multiple other injuries
2. Pelvic fractures can cause massive haemorrhage into the pelvis leading to shock
3. If an unstable pelvic fracture is suspected, perform manual stabilisation of the pelvis whilst a binder is placed as a matter of urgency

Background

Pelvic fractures

• Rare in children
• Usually caused by high energy mechanism of injury
• Can cause disruption of pelvic blood vessels, leading to massive pelvic haemorrhage and shock
• Can also be associated with life-threatening abdominal, genitourinary, spinal, thoracic and intracranial injuries    

Pelvic bleeding

• Mainly venous
• Often retroperitoneal, requiring a high index of suspicion given occult location

Pelvic binders

• May help manage shock by reducing blood loss from an unstable pelvic fracture

Assessment

History

High risk mechanism, often involving crush injury

• Motor vehicle collision, additional risk features include ejection, lateral impact, rollover or fatalities in the same collision
• Pedestrian vs car, bicycle vs car collision
• Fall from height (typically >3 m, also consider mechanism and age)
• Heavy object fall onto patient eg horse, quad bike

Examination

Perform a primary survey

• Haemodynamic compromise may present with the following signs: Tachycardia (bradycardia late sign), hypotension, prolonged capillary refill, evidence of end organ hypoperfusion eg GCS <15

Assess for signs of pelvic injury

• Bruising, wounds, asymmetry, deformity of abdomen, pelvis or lower limbs
• Tenderness along iliac crests, pubic symphysis, sacroiliac joints, ischial tuberosities, lumbosacral spine
• Rectal or vaginal bleeding, blood at the urethral meatus, scrotal bruising

Assess for pelvic instability by gentle compression of iliac crests. This should only be done once, preferably by the most senior clinician. Avoid if there is obvious pelvic instability, or if already planning imaging of the pelvis with CT or XR. “Springing” or rocking of the pelvis is contraindicated as it can increase bleeding

The secondary survey may identify significant injuries associated with pelvic fracture

• Use caution when log rolling the patient, defer if risk of worsening an unstable pelvis

Management

• Resuscitate if haemodynamically unstable
• If unstable pelvic fracture is suspected, commence manual stabilisation of pelvis whilst a pelvic binder is placed as a matter of urgency.
• If binder placement is indicated, it should generally be applied before intubation
• A binder should be available in advance if mechanism of injury and pre-hospital findings are suggestive of possible pelvic injury

Indications for pelvic binder application flowchart

Pelvic binder application

• Apply at level of greater trochanters

• If placed too high (ie over iliac crests) the binder will not be effective and pelvic injury may be exacerbated
• Proprietary pelvic binders include SAM Pelvic Sling™, T-POD™ and Prometheus Pelvic Splint™. There is little evidence favouring one proprietary binder over another.  Some binders may be cut to length (eg T-POD™ and Prometheus Pelvic Splint™), others come in several sizes (SAM Pelvic Sling™). Refer to user guide for sizing instructions. If available binders are too large for the child, use a sheet as shown below
• If there are no lower limb fractures, tie the feet together with a figure of eight knot around the ankles with a bandage or sling. This will increase internal rotation of the hip and may assist tamponading pelvic bleeding

Circumferential sheet method

• Place folded sheet under child at the level of the greater trochanters
• Cross and twist the ends of the sheet over the pubic symphysis
• Two team members pull the sheet firmly, aiming to distribute force evenly over greater trochanters, take care to brace the patient so they are not moved unnecessarily
• Secure sheet in place with clamps as shown below. Plastic clamps are preferable if available, as metal clamps can obscure X-rays and CT

Investigations

• AP pelvic X-ray
• Point of care ultrasound (FAST) is controversial in paediatric trauma and of limited utility in diagnosis of pelvic fractures. Application of a pelvic binder should not be delayed to perform FAST
• Urgent angio-embolisation or operative intervention may be required if child does not improve haemodynamically following application of pelvic binder and resuscitation, consider CT and seek advice from paediatric trauma specialist

Imaging for suspected pelvic injury flowchart

 Pelvic binder removal

• In a child with an unstable pelvic fracture, a binder should remain in place until definitive stabilisation procedure. On occasion the binder may worsen haemodynamic instability by increasing distraction at the fracture site (eg lateral compression fractures). If this is suspected, it may be beneficial to loosen or even remove the binder. This should be done in consultation with orthopaedics and with senior clinician oversight
• Children need careful monitoring for deterioration on removal of pelvic binder, in an area capable of resuscitation. An unstable fracture can be fully reduced by the binder, causing it not to be seen on x-ray or CT. If deterioration occurs, reapplication of the binder and further imaging is required
• Binders may cause abrasions and pressure sores, and should be removed at earliest opportunity when there is no evidence of fracture
• Consultation with the orthopaedic team is recommended prior to removal of the binder in children with stable pelvic fractures

Process for pelvic binder removal

Consider transfer when:

• All children with major trauma should be transferred to a major trauma service for definitive management. This should be done in consultation with the local pre-hospital and inter-hospital transfer guidelines
• The child requires care beyond the comfort level of the hospital

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Additional resources

RCH Paediatric trauma manual- Pelvic fractures

Last updated March 2024