Pre-peritoneal pelvic packing for the management of life-threatening pelvic fractures

  • Patrizio PetroneEmail author
  • Martín Rodríguez-Perdomo
  • Aida Pérez-Jiménez
  • Fahd Ali
  • Collin Everton Montgomery Brathwaite
  • D’Andrea Krista Joseph
Review Article



Pre-peritoneal pelvic packing (PPP) is a technique used for treating pelvic hemorrhage in patients with pelvic fractures and hemodynamic instability after a high-energy trauma representing a life-threatening situation. The aim of this study was to perform a comprehensive review of the literature.


A review of the medical literature was performed, based on the following inclusion criteria: patients sustaining pelvic fractures with hemodynamic instability and the inclusion of PPP as a tool for hemorrhage control. Articles not involving human patients, review articles, surveys, pediatric patients, hemodynamic stability, case reports, and not directly related publications; such as angiography with or without embolization, and REBOA use for hemorrhage control as a primary outcome evaluation were excluded from this search.


Eleven articles out of seventy-seven identified publications between 2008 and 2018 met the inclusion criteria and were included in this review.


PPP is a surgical approach used in life-threatening situations due to pelvic fracture with high risk of death for exsanguination. Performed expediently, good results can be obtained with a decrease in the need for blood products, improved systolic blood pressure, and a decrease in mortality rates overall. This makes PPP an important life-saving tool.


Pelvic fracture Pre-peritoneal pelvic packing Hemodynamic instability 


Compliance with ethical standards

Conflict of interest

Patrizio Petrone, Martín Rodríguez-Perdomo, Aida Pérez-Jiménez, Fahd Ali, Collin Everton Montgomery Brathwaite, and D’Andrea Krista Joseph declare that they have not conflict of interest.


  1. 1.
    Burlew CC. Preperitoneal pelvic packing for exsanguinating pelvic fractures. Int Orthop. 2017;41(9):1825–9.CrossRefGoogle Scholar
  2. 2.
    Moskowitz EE, Burlew CC, Moore EE, Pieracci FM, Fox CJ, Campion EM, et al. Preperitoneal pelvic packing is effective for hemorrhage control in open pelvic fractures. Am J Surg. 2018;215(4):675–7.CrossRefGoogle Scholar
  3. 3.
    Filiberto DM, Fox AD. Preperitoneal pelvic packing: Technique and outcomes. Int J Surg. 2016;33(9):222–4.CrossRefGoogle Scholar
  4. 4.
    Smith W, Williams A, Agudelo J, Shannon M, Morgan S, Stahel P, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;21(1):31–7.CrossRefGoogle Scholar
  5. 5.
    Magnone S, Coccolini F, Manfredi R, Piazzalunga D, Agazzi R, Arici C, et al. Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology—Section of Vascular and Interventional Radiology—and the World Society of Emergency Surgery). World J Emerg Surg 2014;9(1):18.CrossRefGoogle Scholar
  6. 6.
    Cullinane DC, Schiller HJ, Zielinski MD, Bilaniuk JW, Collier BR, Como J, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture—update and systematic review. J Trauma. 2011;71(6):1850–68.PubMedGoogle Scholar
  7. 7.
    Smith WR, Moore EE, Osborn P, Agudelo JF, Morgan SJ, Parekh AA, et al. Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. J Trauma. 2005;59(6):1510–4.CrossRefGoogle Scholar
  8. 8.
    Burlew CC, Moore EE, Smith WR, Johnson JL, Biffl WL, Barnett CC, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg. 2011;212(4):628–37.CrossRefGoogle Scholar
  9. 9.
    Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: a comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury. 2009;40(1):54–60.CrossRefGoogle Scholar
  10. 10.
    Tai DK, Li WH, Lee KY, Cheng M, Lee KB, Tang LF, et al. Retroperitoneal pelvic packing in the management of hemodynamically unstable pelvic fractures: a level I trauma center experience. J Trauma. 2011;71(4):E79–86.CrossRefGoogle Scholar
  11. 11.
    Lustenberger T, Wutzler S, Stormann P, Laurer H, Marzi I. The role of angio-embolization in the acute treatment concept of severe pelvic ring injuries. Injury. 2015;46(Suppl 4):33-8.Google Scholar
  12. 12.
    Ron G, Epstein D, Ben-Galim P, Klein Y, Kaban A, Sagiv S. Extra-peritoneal pressure packing without external pelvic fixation: a life-saving stand-alone surgical treatment. J Emerg Trauma Shock. 2015;8(4):181–7.CrossRefGoogle Scholar
  13. 13.
    Chiara O, di Fratta E, Mariani A, Michaela B, Prestini L, Sammartano F, et al. Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a Propensity Score analysis. World J Emerg Surg. 2016;11:22.CrossRefGoogle Scholar
  14. 14.
    Li Q, Dong J, Yang Y, Wang G, Wang Y, Liu P, et al. Retroperitoneal packing or angioembolization for haemorrhage control of pelvic fractures–quasi-randomized clinical trial of 56 haemodynamically unstable patients with Injury Severity Score ≥ 33. Injury. 2016;47(2):395–401.CrossRefGoogle Scholar
  15. 15.
    Jang JY, Shim H, Jung PY, Kim S, Bae KS. Preperitoneal pelvic packing in patients with hemodynamic instability due to severe pelvic fracture: early experience in a Korean trauma center. Scand J Trauma Resusc Emerg Med. 2016;24:3.CrossRefGoogle Scholar
  16. 16.
    Hsu JM, Yadev S, Faraj S. Controlling hemorrhage in exsanguinating pelvic fractures: utility of extraperitoneal pelvic packing as a damage control procedure. Int J Crit Illn Inj Sci. 2016;6(3):148–52.CrossRefGoogle Scholar
  17. 17.
    Burlew CC, Moore EE, Stahel PF, Geddes AE, Wagenaar AE, Pieracci FM, et al. Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg. 2017;82(2):233–42.CrossRefGoogle Scholar
  18. 18.
    Papadopoulos IN, Kanakaris N, Bonovas S, Triantafillidis A, Garnavos C, Voros D, et al. Auditing 655 fatalities with pelvic fractures by autopsy as a basis to evaluate trauma care. J Am Coll Surg. 2006;203(1):30–43.CrossRefGoogle Scholar
  19. 19.
    Hornez E, Maurin O, Bourgouin S, Cotte J, Monchal T, de Roulhac J, et al. Management of exsanguinating pelvic trauma: do we still need the radiologist? J Visc Surg. 2011;148(5):379.CrossRefGoogle Scholar
  20. 20.
    Yoshihara H, Yoneoka D. Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: trends and in-hospital mortality. J Trauma Acute Care Surg. 2014;76(2):380–5.CrossRefGoogle Scholar
  21. 21.
    Totterman A, Madsen JE, Skaga NO, Roise O. Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. J Trauma. 2007;62(4):843–52.CrossRefGoogle Scholar
  22. 22.
    Correa WO, Batista VGR, Cavalcante EFJ, Fernandes MP, Fortes R, Ruiz GZL, et al. Mortality predictors in patients with pelvic fractures from blunt trauma. Rev Col Bras Cir. 2017;44(3):222–30.CrossRefGoogle Scholar
  23. 23.
    Durkin A, Sagi HC, Durham R, Flint L. Contemporary management of pelvic fractures. Am J Surg. 2006;192(2):211–23.CrossRefGoogle Scholar
  24. 24.
    Croce MA, Magnotti LJ, Savage SA, Wood GW 2nd, Fabian TC. Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg. 2007;204(5):935–42.CrossRefGoogle Scholar
  25. 25.
    Dente CJ, Feliciano DV, Rozycki GS, Wyrzykowski AD, Nicholas JM, Salomone JP, et al. The outcome of open pelvic fractures in the modern era. Am J Surg. 2005;190(6):830–5.CrossRefGoogle Scholar
  26. 26.
    Skitch S, Engels PT. Acute management of the traumatically injured pelvis. Emerg Med Clin North Am. 2018;36(1):161–79.CrossRefGoogle Scholar
  27. 27.
    Tesoriero RB, Bruns BR, Narayan M, Dubose J, Guliani SS, Brenner ML, et al. Angiographic embolization for hemorrhage following pelvic fracture: Is it “time” for a paradigm shift? J Trauma Acute Care Surg. 2017;82(1):18–26.CrossRefGoogle Scholar
  28. 28.
    Cho J, Benjamin E, Inaba K, Lam L, Demetriades D. Severe bleeding in pelvic fractures: considerations in planning damage control. Am Surg. 2018;84(2):267–72.PubMedGoogle Scholar
  29. 29.
    Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, et al. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375–83.CrossRefGoogle Scholar
  30. 30.
    Pohlemann T, Gansslen A, Bosch U, Tscherne H. The technique of packing for control of hemorrhage in complex pelvic fractures. Tech Orthop. 1995;9:267–70.CrossRefGoogle Scholar
  31. 31.
    Monchal T, Hornez E, Coisy M, Bourgouin S, de Roulhac J, Balandraud P. Preperitoneal pelvic packing. J Visc Surg. 2017;154(Suppl 1):57–60.CrossRefGoogle Scholar
  32. 32.
    Glass NE, Burlew CC. Preperitoneal pelvic packing: how and when. Curr Trauma Rep. 2015;1(1):1–7.CrossRefGoogle Scholar
  33. 33.
    Sugrue M, D’Amours SK, Joshipura M. Damage control surgery and the abdomen. Injury. 2004;35(7):642–8.CrossRefGoogle Scholar
  34. 34.
    Sihler KC, Napolitano LM. Complications of massive transfusion. Chest. 2010;137(1):209–20.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Trauma and Acute Care Surgery, Department of SurgeryNYU Winthrop HospitalMineolaUSA

Personalised recommendations