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MINERVA ORTOPEDICA E TRAUMATOLOGICA
A Journal on Orthopedics and Traumatology
ORTHOPEDIC TRAUMA UPDATE PART I
Minerva Ortopedica e Traumatologica 2009 October;60(5):403-29
When to operate on pelvic fractures?
Benneker L. M., Keel M.
Department for Orthopedic Surgery, Inselspital, University of Bern, Switzerland
Pelvic and acetabular fractures account for 3-8% of all skeletal injuries and have among these the highest mortality rates as they are often associated with severe bleeding and major intra-abdominal and thoracic injuries. Most common causes are motor vehicle accidents (57%), pedestrians hit by motor vehicles (18%), motorcycle accidents (9%), falls (9%), crush injuries (4%) and sports/recreational accidents (3%). In general the injuries can be divided into two groups with high energy trauma resulting in pelvic ring disruptions, luxation fractures of the hip joint and spino-pelvic dissociation on the one hand and low energy trauma with acetabular, symphyseal or sacral fractures in the elderly patient with osteoporosis on the other hand. Even after implementing Advanced Trauma Life Support (ATLS©) principles in many trauma centers fractures of the pelvis still have a high mortality rate of approximately 15% (range 3-30%) for all type of fractures, approximately 27% (range 10-42%) when hemodynamic instability is present and up to 50-60% for open pelvic fractures. In patients who die from hemorrhage, 62% is due to pelvic hemorrhage and 38% is due to associated external, intrathoracic and intra-abdominal hemorrhage sources. The complex situation of the polytraumatized patient require a interdisciplinary approach with management algorithms adopted to the local and individual situation that can sometimes differ from the usual priorities of fracture treatment as restoration of stability and anatomy. The following overview addresses the priorities of treatment principles in the special situation of pelvic fractures that ultimately dictate the indications for surgery: 1) control of hemorrhage; 2) control of contamination; 3) decompression in case of neurological compromise; 4) stability; 5) anatomical reduction. Whereas the first three priorities are part of the initial emergency management that are embedded in the initial management algorithms, stability and anatomical reduction are of less importance in the acute treatment but nevertheless important for the final healing and long-term outcome. The treatment algorithms and recommendations presented are based on review of the literature mainly of the past two decades, own research and preferences from the authors’ own institution.