Pelvic fracture related hematoma - emergency treatment and bleeding control

Unstable pelvic fractures present significant challenges in trauma care due to the risk of massive haemorrhage from arterial, venous, and osseous sources. Rapid identification of the bleeding origin is critical for targeted intervention. This multicentre retrospective study evaluated the use of the Pelvic Vascular Injury Score (P-VIS) and CT-based volumetric assessment (Kothari's method) for early detection and classification of pelvic vascular injury (PVI) in severely injured patients.

Data from January 2021 to December 2022 were collected from three German Level I Trauma Centres. Adult patients (18-75 years) with Tile type B or C pelvic ring injuries, ISS ≥ 16, haemodynamic instability (SBP ≤ 100 mmHg), and solid intrapelvic hematomas ≥ 100 ml on CT were included. Hematoma size was estimated using Kothari's formula and validated with planimetric volumetry for volumes ≥ 500 ml. Clinical data (including bloodwork, pelvic stabilization method, need for blood transfusion, haemorrhage therapy, mortality etc.) was acquired and compared. P-VIS was applied pre- or peri-hospital to predict likelihood of PVI.

Among 229 eligible patients, 56 exhibited pelvic haemorrhage (median 233 ml). Significant bleeding ≥ 500 ml occurred in 1.7% of cases and correlated strongly with arterial injury (probability 45%) and transfusion requirement (risk ratio 4.7). Arterial bleeding accounted for 26.8% of cases, which is notably higher than the 10-20% typically reported in the literature; venous and fracture-surface bleeding made up the remaining 73.2%. P‑VIS ≥ 6 markedly increased the likelihood of vascular injury. Multivariate analysis identified arterial bleeding, ISS, and coagulopathy as independent predictors of mortality. Pelvic packing was performed in 16.1%, endovascular embolization in 5.4%, and external fixation in 27.1% of cases. Mortality was 30.3%, and was significantly higher in patients with arterial injury and severe shock (p < 0.001).

Most pelvic haemorrhages were small to moderate in volume and venous or osseous in origin, but arterial injury-though less common-was associated with high mortality and blood loss. The Kothari method offered rapid, approximate volume estimation, guiding prioritization for angiography when > 500 ml. The P-VIS proved useful for early triage, with most patients scoring ≥ 3 indicating moderate to high risk for PVI. Combining mechanical stabilization with targeted haemorrhage control (packing for venous, embolization/stenting for arterial) improved outcomes.

Early structured assessment using P-VIS and CT-based volume estimation supports timely identification of pelvic vascular injury and appropriate intervention. Angioembolization or application of covered stent grafts should be first-line for arterial bleeding in stable patients, while pelvic packing remains effective for venous sources. Integrating these tools into trauma algorithms can optimize management of unstable pelvic fractures and improve survival.