Managing severe (and open) pelvic disruption

Open pelvic fractures are a rare yet catastrophic injury pattern, often resulting from high-energy trauma such as motor vehicle collisions, motorcycle accidents, and pedestrian impacts. They account for only 2%-4% of all pelvic fractures, but their severity lies in the complex anatomy of the pelvis and its associated structures, including the vasculature, bowel, bladder, and genital organs. Mortality rates range from 15% to 50%, with some studies reporting rates as high as 70% in cases involving severe perineal or rectal injuries. These injuries pose two main risks to survival: hemorrhagic shock in the acute phase and pelvic sepsis during the later phases of recovery. Acute hemorrhage can occur from arterial injury (eg, internal iliac arteries), venous plexuses, or bony sources. Delayed deaths are often caused by sepsis due to fecal contamination of wounds or infected hematomas. Additionally, these fractures are often associated with other life-threatening injuries, including intra-abdominal trauma, genitourinary disruptions, and neurovascular compromise, further complicating their management. Management of these injuries has evolved significantly with advancements in hemorrhage control techniques such as preperitoneal pelvic packing and resuscitative endovascular balloon occlusion of the aorta. A multidisciplinary approach is essential to address the multifaceted challenges posed by these injuries.