Strategies for surgical treatment of multiple trauma including pelvic fracture. Review of the literature

Objective. In the management of multiply injured patients the question of the optimal time point for surgical treatment of individual injuries still remains open. Especially in severely injured patients with pelvic fractures, this decision differs between rapid surgical interventions in life-threatening situations or time-consuming reconstructive surgery. Besides the "early" operative treatment, i.e., within the first 24 h after trauma, the"late," i.e., definitive or secondary surgical fracture stabilization, exists.The following study represents a review of the current recommendations in the literature concerning the optimal time and fracture management of multiply injured patients with pelvic fracture. Methods. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches), reviewed, and classified into evidence levels (I to 5 according to the Oxford system). Results. According to the literature there is consensus on "early" operative stabilization of multiply injured patients with hemodynamically and mechanically unstable pelvic fractures, open pelvic fractures, or complex pelvic trauma. External fixation and the pelvic C-clamp are the methods of choice in emergency situations, whereas currently internal fracture fixation is only proposed in exceptional circumstances. In contrast, the point in time for the secondary definitive fracture stabilization remains controversially discussed. This discussion ranges from the postulation that extensive definitive fracture treatment be avoided during days 2-4 after trauma to the recommendation that definitive internal fixation of pelvic fractures be undertaken early, i.e., within the 1st week after trauma. Conclusion. Basically, the principles of trauma management of multiply injured patients with life-threatening hemorrhage from mechanically unstable pelvic fractures are divided into two main time periods. On the one hand, there is the emergency stabilization of the pelvic ring as the most important goal within the acute period to control the bleeding, at least with extraperitoneal tamponade if necessary. On the other hand, once the hemorrhaging has been stopped, the"late"and definitive internal fracture stabilization of the pelvis should be performed depending on the fracture pattern.