Pelvic Fractures and Indications for Pelvic Packing: An Update

  • Nicole L. Werner
  • Clay Cothren BurlewEmail author
Trauma Surgery (J. Diaz, Section Editor)
Part of the following topical collections:
  1. Trauma Surgery


Purpose of review

Patients with hemodynamically unstable pelvic fractures have a high mortality from pelvic hemorrhage. The purpose of this paper is to review preperitoneal pelvic packing (PPP) as an approach for these patients, including recent outcomes, and evaluation of treatment algorithms including angioembolization and resuscitative endovascular balloon occlusion of the aorta (REBOA).

Recent findings

There are no randomized clinical trials comparing PPP to other methods for controlling pelvic hemorrhage. The largest retrospective series, reporting on 128 patients, had a mortality rate of 21% and showed a reduction of blood transfusions after external fixation and PPP; smaller series and a meta-analysis also demonstrate similar results.


PPP with external pelvic fixation should be adopted as the first-line intervention for patients with pelvic fractures who remain hemodynamically unstable despite blood transfusion. It takes a lesser time to achieve hemorrhage control than angioembolization and directly addresses the primary source of pelvic fracture-related bleeding.


Pelvic fracture Pelvic packing Preperitoneal pelvic packing Trauma Hemorrhage 


Compliance with Ethical Guidelines

Conflict of interest

Nicole L. Werner and Clay Cothren Burlew declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

The article contains a retrospective evaluation of human patients performed by the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Demetriades D, Karaiskakis M, Toutouzas K, Alo K, Velmahos G, Chan L. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg. 2002;195(1):1–10.CrossRefGoogle Scholar
  2. 2.
    Sathy AK, Starr AJ, Smith WR, Elliott A, Agudelo J, Reinert CM, et al. The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients. J Bone Joint Surg Am. 2009;91(12):2803–10. Scholar
  3. 3.
    Verbeek DO, Sugrue M, Balogh Z, Cass D, Civil I, Harris I, et al. Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice. World J Surg. 2008;32(8):1874–82. Scholar
  4. 4.
    Starr AJ, Griffin DR, Reinert CM, Frawley WH, Walker J, Whitlock SN, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma. 2002;16(8):553–61.CrossRefGoogle Scholar
  5. 5.
    Gustavo Parreira J, Coimbra R, Rasslan S, Oliveira A, Fregoneze M, Mercadante M. The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures. Injury. 2000;31(9):677–82.CrossRefGoogle Scholar
  6. 6.
    Lunsjo K, Tadros A, Hauggaard A, Blomgren R, Kopke J, Abu-Zidan FM. Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients. J Trauma. 2007;62(3):687–91. Scholar
  7. 7.
    • Costantini TW, Coimbra R, Holcomb JB, Podbielski JM, Catalano R, Blackburn A et al. Current management of hemorrhage from severe pelvic fractures: results of an American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg. 2016;80(5):717–23; discussion 23–5. Multi-center trial reporting current practices in the United States for managing pelvic fractures. CrossRefGoogle Scholar
  8. 8.
    Heetveld MJ, Harris I, Schlaphoff G, Balogh Z, D’Amours SK, Sugrue M. Hemodynamically unstable pelvic fractures: recent care and new guidelines. World J Surg. 2004;28(9):904–9.CrossRefGoogle Scholar
  9. 9.
    Perkins ZB, Maytham GD, Koers L, Bates P, Brohi K, Tai NR. Impact on outcome of a targeted performance improvement programme in haemodynamically unstable patients with a pelvic fracture. Bone Joint J. 2014;96(8):1090–7. Scholar
  10. 10.
    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. Scholar
  11. 11.
    Huittinen VM, Slatis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery. 1973;73(3):454–62.PubMedGoogle Scholar
  12. 12.
    Pohlemann T GA, Hufner T, Tscherne H. Extraperitoneal packing at laparotomy. OTA-AAST Annual Meeting. 2000.Google Scholar
  13. 13.
    Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma. 2001;15(7):468–74.CrossRefGoogle Scholar
  14. 14.
    Ertel WEK, Keel M, Trentz O. Therapeutical strategies and outcome of polytraumatized patients with pelvic injuries a six-year experience. Eur J Trauma. 2000;26:278–86.CrossRefGoogle Scholar
  15. 15.
    Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury. 2004;35(7):671–7. Scholar
  16. 16.
    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
  17. 17.
    Pizanis A, Pohlemann T, Burkhardt M, Aghayev E, Holstein JH. Emergency stabilization of the pelvic ring: clinical comparison between three different techniques. Injury. 2013;44(12):1760–4. Scholar
  18. 18.
    Prasarn ML, Horodyski M, Conrad B, Rubery PT, Dubose D, Small J, et al. Comparison of external fixation versus the trauma pelvic orthotic device on unstable pelvic injuries: a cadaveric study of stability. J Trauma Acute Care Surg. 2012;72(6):1671–5. Scholar
  19. 19.
    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. Scholar
  20. 20.
    Ghanayem AJ, Wilber JH, Lieberman JM, Motta AO. The effect of laparotomy and external fixator stabilization on pelvic volume in an unstable pelvic injury. J Trauma. 1995;38(3):396–400 discussion-1.CrossRefGoogle Scholar
  21. 21.
    • Burlew CC. Preperitoneal pelvic packing: A 2018 EAST master class video presentation. J Trauma Acute Care Surg. 2018;85(1):224–8. Provides a detailed description and video demonstration of preperitoneal pelvic packing. CrossRefGoogle Scholar
  22. 22.
    Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007;62(4):834–9. discussion 9–42.CrossRefPubMedGoogle Scholar
  23. 23.
    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):628–35. discussion 35–7.CrossRefPubMedGoogle Scholar
  24. 24.
    •• 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. The largest series of patients with hemodynamically unstable pelvic fractures treated with preperitoneal pelvic packing and external fixation. CrossRefGoogle Scholar
  25. 25.
    Shim H, Jang JY, Kim JW, Ryu H, Jung PY, Kim S, et al. Effectiveness and postoperative wound infection of preperitoneal pelvic packing in patients with hemodynamic instability caused by pelvic fracture. PLoS ONE. 2018;13(11):e0206991. Scholar
  26. 26.
    Cheng M, Cheung MT, Lee KY, Lee KB, Chan SC, Wu AC, et al. Improvement in institutional protocols leads to decreased mortality in patients with haemodynamically unstable pelvic fractures. Emerg Med J. 2015;32(3):214–20. Scholar
  27. 27.
    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. Journal Emerg Trauma Shock. 2015;8(4):181–7. Scholar
  28. 28.
    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 Injury Sci. 2016;6(3):148–52. Scholar
  29. 29.
    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. Scholar
  30. 30.
    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. Scholar
  31. 31.
    Napolitano LM, Kurek S, Luchette FA, Anderson GL, Bard MR, Bromberg W, et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. J Trauma. 2009;67(6):1439–42. Scholar
  32. 32.
    Coccolini F, Stahel PF, Montori G, Biffl W, Horer TM, Catena F, et al. Pelvic trauma: ESES classification and guidelines. World J Emerg Surg. 2017;12:5. Scholar
  33. 33.
    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. Scholar
  34. 34.
    Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF 3rd. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma. 1997;43(3):395–9.CrossRefGoogle Scholar
  35. 35.
    Panetta T, Sclafani SJ, Goldstein AS, Phillips TF, Shaftan GW. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma. 1985;25(11):1021–9.PubMedGoogle Scholar
  36. 36.
    Ben-Menachem Y. Pelvic fractures: diagnostic and therapeutic angiography. Instr Course Lect. 1988;37:139–41.PubMedGoogle Scholar
  37. 37.
    Chu CH, Tennakoon L, Maggio PM, Weiser TG, Spain DA, Staudenmayer KL. Trends in the management of pelvic fractures, 2008-2010. J Surg Res. 2016;202(2):335–40. Scholar
  38. 38.
    Tanizaki S, Maeda S, Matano H, Sera M, Nagai H, Ishida H. Time to pelvic embolization for hemodynamically unstable pelvic fractures may affect the survival for delays up to 60 min. Injury. 2014;45(4):738–41. Scholar
  39. 39.
    Balogh Z, Caldwell E, Heetveld M, D’Amours S, Schlaphoff G, Harris I, et al. Institutional practice guidelines on management of pelvic fracture-related hemodynamic instability: do they make a difference? J Trauma. 2005;58(4):778–82.CrossRefGoogle Scholar
  40. 40.
    •• 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? The J Trauma Acute Care Surg. 2017;82(1):18–26. Large retrospective review of patients with pelvic fractures who underwent pelvic angiography over a 10 year period, evaluating outcomes and times to treatment. CrossRefGoogle Scholar
  41. 41.
    Schwartz DA, Medina M, Cotton BA, Rahbar E, Wade CE, Cohen AM, et al. Are we delivering two standards of care for pelvic trauma? Availability of angioembolization after hours and on weekends increases time to therapeutic intervention. J Trauma Acute Care Surg. 2014;76(1):134–9. Scholar
  42. 42.
    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. Scholar
  43. 43.
    Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009;40(4):343–53. Scholar
  44. 44.
    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. Scholar
  45. 45.
    Morrison JJ, Galgon RE, Jansen JO, Cannon JW, Rasmussen TE, Eliason JL. A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. J Trauma Acute Care Surg. 2016;80(2):324–34. Scholar
  46. 46.
    Moore LJ, Brenner M, Kozar RA, Pasley J, Wade CE, Baraniuk MS, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg. 2015;79(4):523–30. discussion 30–2.CrossRefPubMedGoogle Scholar
  47. 47.
    Martinelli T, Thony F, Declety P, Sengel C, Broux C, Tonetti J, et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures. J Trauma. 2010;68(4):942–8. Scholar
  48. 48.
    Morrison JJ, Percival TJ, Markov NP, Villamaria C, Scott DJ, Saches KA, et al. Aortic balloon occlusion is effective in controlling pelvic hemorrhage. J Surg Res. 2012;177(2):341–7. Scholar
  49. 49.
    Tran TL, Brasel KJ, Karmy-Jones R, Rowell S, Schreiber MA, Shatz DV, et al. Western Trauma Association Critical Decisions in Trauma: management of pelvic fracture with hemodynamic instability-2016 updates. J Trauma Acute Care Surg. 2016;81(6):1171–4. Scholar
  50. 50.
    •• Tang J, Shi Z, Hu J, Wu H, Yang C, Le G et al. Optimal sequence of surgical procedures for hemodynamically unstable patients with pelvic fracture: a network meta-analysis. Am J Emerg Med. 2018. Meta-analysis studying the optimal sequence of surgical procedures for hemodynamically unstable pelvic fractures. CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.The Ernest E. Moore Shock Trauma Center, Denver Health Medical CenterUniversity of Colorado School of MedicineDenverUSA

Personalised recommendations