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Difficulty: HardOrthopedic Surgery

Arriving at the trauma center via helicopter emergency medical services is a 28-year-old male who was involved in a high-speed motorcycle collision. On initial assessment, the patient is lethargic and pale. Vital signs show a temperature of 36.5°C (97.7°F), heart rate of 142/min, blood pressure of 76/40 mm Hg, and respiratory rate of 28/min. The airway is patent, and breath sounds are equal bilaterally. The abdomen is soft and non-distended. Pelvic examination reveals mechanical instability to gentle anteroposterior compression. Blood is noted at the urethral meatus. A focused assessment with sonography for trauma (FAST) demonstrates no free fluid in the peritoneal, pericardial, or pleural spaces. Which of the following is the most appropriate next step in the management of this patient?

  1. Application of a circumferential pelvic binderAnswer
  2. B
    Transfer to the radiology suite for a computed tomography scan of the abdomen and pelvis
  3. C
    Immediate transport to the operating room for an exploratory laparotomy
  4. D
    Performance of a retrograde urethrogram
  5. E
    Intravenous administration of broad-spectrum antibiotics

Answer

The most appropriate next step is the application of a circumferential pelvic binder.
The patient is in profound hemorrhagic shock resulting from an unstable pelvic ring fracture. The venous plexus and cancellous bone surfaces within the pelvis can rapidly bleed massive volumes into the retroperitoneum. Because the FAST exam is negative, major intraperitoneal bleeding is ruled out, confirming the retroperitoneum as the source of shock. The immediate life-saving priority is to mechanically close the pelvic ring using a circumferential pelvic binder. Placed correctly over the greater trochanters, the binder reduces the true volume of the pelvis, stabilizes the fracture fragments, and creates a tamponade effect against the bleeding venous structures. This step must precede any further diagnostic imaging or urologic evaluation.

Step-by-Step Solution

1
Identify the primary physiologic threat to the patient's life.
The patient exhibits severe tachycardia (142/min) and hypotension (76/40 mm Hg), placing him in Class IV hemorrhagic shock.
Recognizing the severity of shock dictates that management must immediately focus on the 'C' (Circulation) of the ATLS protocol.
2
Localize the primary source of hemorrhage based on clinical findings.
Clear breath sounds and a negative FAST exam rule out massive intrathoracic and intraperitoneal bleeding. The mechanically unstable pelvis indicates a severe pelvic ring disruption.
The pelvis can hide up to 4 liters of blood in the retroperitoneal space due to venous plexus tearing and cancellous bone bleeding.
3
Determine the most critical intervention to address the bleeding source.
Mechanical stabilization of the pelvis is required immediately.
A circumferential pelvic binder reduces pelvic volume, opposing the fracture fragments and promoting the tamponade of retroperitoneal venous bleeding.

Key Concept

In a hemodynamically unstable patient with a pelvic ring fracture and a negative FAST exam, the immediate next step is mechanical stabilization with a pelvic binder to control retroperitoneal hemorrhage.
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Topics

Orthopedic Surgery

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