Pelvic Ring Injuries: Clinical Guidelines

List of Abbreviations

AO — aortic balloon occlusion;

EFS — external fixation system;

AG — angiography;

BP – blood pressure;

AE — angioembolization;

PPX — preperitoneal pelvic packing;

IL — interleukin;

CT – computed tomography;

ICU — intensive care unit;

RCT — randomized controlled trial;

ROTEM — rotational thromboelastometry;

X-ray — pelvic radiography;

RUG — retrograde urethrogram;

PB — pelvic binder;

TEG — thromboelastography;

LOE — level of evidence;

TBI — traumatic brain injury;

REBOA — resuscitative endovascular balloon occlusion of the aorta;

AIS — Abbreviated Injury Scale;

APC — anteroposterior compression injuries;

ATLS – Advanced Trauma Life Support;

BD — base deficit;

CM — combined mechanism injuries;

DCO — Damage Control Orthopaedics;

DSA — Digital Subtraction Angiography;

EAST — The Eastern Association for the Surgery of Trauma;

eFAST — extended Focused Assessment with Sonography for Trauma;

ISS — Injury Severity Score;

LC — lateral compression injuries;

REBOA — resuscitative endovascular balloon occlusion of the aorta;

iREBOA — intermittent REBOA;

pREBOA — partial REBOA;

VS — vertical shear injuries;

WSES — World Society of Emergency Surgery.

Terms and Definitions

Apophyseolysis — injury to the growth plate located between the apophysis and its parent bone.

External fixation system (EFS) — an orthopedic device comprising an implant (transosseous or extracortical element reaching and penetrating the bone) and an external (non-implantable) support connecting bone fragments via elements protruding through soft tissues and skin during the treatment of fractures, pseudoarthrosis, or gradual lengthening (deformity correction) of a segment.

Internal fixation device — an orthopedic implant placed on the bone beneath the patient's soft tissues to connect bone fragments in the treatment of fractures, deformities, or pseudoarthrosis.

High-energy trauma — injuries resulting from high kinetic energy impact

Hemostasis — a sequence of tightly regulated processes that maintain blood in a fluid state and induce the rapid formation of a local thrombus at the site of vascular injury.

Hypoperfusion — poor microcirculation, inadequate blood supply to a specific organ: brain, kidneys, etc.

Catatrauma — a type of injury sustained from falling from a height.

Hemodynamic instability — according to the Advanced Trauma Life Support (ATLS) protocol, a condition defined by the following signs: blood pressure <90 mm Hg and pulse >120 bpm, signs of skin vasoconstriction (cold, clammy skin, decreased capillary refill), hypothermia, altered mental status, and/or tachypnea [25, 26].

Unstable pelvic injuries — pelvic injuries accompanied by disruption of the pelvic ring integrity with fragment displacement and pathological mobility. Depending on the mechanism of injury, vertically unstable and rotationally unstable fractures may occur. Vertically unstable injuries present with complete disruption of the posterior complex with vertical displacement of a hemipelvis. Rotationally unstable injuries involve incomplete disruption of the posterior complex while maintaining the connection between the hemipelvis and the axial skeleton, accompanied by rotational displacement of the ilium in the horizontal and sagittal planes.

Stable pelvic injuries — pelvic injuries not accompanied by disruption of the pelvic ring integrity, and fractures without fragment displacement or pathological mobility.

Verneuil's sign — pain in the region of injury upon transverse compression of the pelvic bones.

Larrey's sign — pain at the site of pelvic bone fracture when the iliac crests are manually pulled apart.

Decreased capillary refill — the appearance of a persistent white spot on the skin of the patient's dorsum of the foot or hand after finger pressure; observed in vascular insufficiency of the distal extremities and impaired sympathetic innervation.

Fixation stability — the resistance of the system to external loads, allowing it to maintain constant relative orientation of fragments and optimal distance or direct contact between them.

Pelvis — the bony ring formed by two hip bones, the sacrum, and the coccyx. The pelvis serves as a support for the trunk and lower extremities and houses several internal organs.

Fixation — a state in which relative or complete immobilization of fragments is achieved, ensuring relative or absolute stability.

Shock — a stereotyped, phase-developing pathological process resulting from neurohumoral regulation disorders caused by extreme stimuli (mechanical trauma, burn, electrical injury, etc.) and characterized by a drastic reduction in tissue blood supply disproportionate to metabolic needs, hypoxia, and depression of body functions.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Pelvic fracture — a disruption of the integrity of pelvic bones under the influence of external impacts or traumatic factors.

Sacroiliac joint dislocation — disruption of the congruence of the articular surfaces of the ilium and sacrum caused by a mechanical factor.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Pelvic ring injuries typically result from high-energy impact, which is the primary mechanism of injury (low-energy pelvic injuries occur in elderly patients and those with bone diseases). High-energy injuries include catatrauma, sports injuries, motor vehicle accidents (pedestrian, driver, passenger, motorcyclist, bicyclist), and crushing by a vehicle or massive object [1, 5]. Up to 15% of patients with pelvic bone fractures are admitted to the hospital emergency department in shock, and up to one-third of them die [10, 25]. The causes of death in most cases are massive hemorrhage, irreversible consumption coagulopathy, and exhaustion of the body's compensatory reserves.

Pelvic ring injuries disrupt its integrity, stability, and in some cases lead to a subsequent increase in intrapelvic volume. Increased volume, particularly in open-book type injuries associated with soft tissue and vascular damage, promotes increased bleeding into the retroperitoneal space due to a reduction in the "biological tamponade" effect (the pelvic cavity and retroperitoneal space can hold up to several liters of blood) and can lead to hemodynamic compromise [7, 15, 25]. Some authors define normal hemodynamics as the absence of a need for infusion therapy or blood transfusion to maintain blood pressure (BP), as well as the absence of signs of hypoperfusion; on the other hand, hemodynamic stability is a state in which stable BP or improved parameters are achieved with infusion therapy, reaching a BP >90 mm Hg and pulse <100 bpm [23, 25].

1.3 Epidemiology of the Disease or Condition

Management of pelvic ring injuries is one of the most challenging problems in musculoskeletal surgery, with a prevalence of 3–5% of all injuries [1–4, 25]. High-energy pelvic fractures are most common in young patients and are characterized by a high total Injury Severity Score (ISS, 25–48 points) [3, 25]. Pelvic injuries are associated with high mortality, particularly in patients with unstable injuries and significant displacement, leading to acute hemodynamic compromise due to rapid exsanguination from massive retroperitoneal bleeding [1, 2, 4, 5].

Pelvic bone fractures in the pediatric population account for 0.4–4% of all skeletal injuries in children, or 4.2 cases per 100,000 children, according to various sources. Avulsion injuries due to tension of muscle groups attached to the apophyseal regions of the pelvic ring predominate in children. Unstable pelvic ring injuries in children are typically caused by high-energy mechanisms resulting from motor vehicle accidents and falls from height [210].

1.4 Features of Coding the Disease or Condition

S30.0 Contusion of lower back and pelvis.

S32.1 Fracture of sacrum.

S32.2 Fracture of coccyx.

S32.3 Fracture of ilium.

S32.30 Closed fracture of ilium.

S32.4 Fracture of acetabulum.

S32.5 Fracture of pubis.

S32.7 Multiple fractures of lumbar spine and pelvis.

S32.70 Closed multiple fractures of lumbar spine and pelvis.

S32.8 Fractures of other and unspecified parts of lumbar spine and pelvis.

S33.2 Luxation of sacroiliac joint and sacrococcygeal symphysis.

S33.4 Traumatic rupture of pubic symphysis [pubic symphysis rupture].

S33.6 Sprain and strain of capsule-ligamentous apparatus of sacroiliac joint.

S33.7 Sprain and strain of capsule-ligamentous apparatus of other and unspecified parts of lumbar spine and pelvis.

T91.2 Sequelae of other fractures of thorax and pelvis.

1.5 Classification of the disease or condition

The treatment strategy for patients with pelvic trauma is determined not by the presence of a fracture per se, but by the degree and direction of fragment displacement [25]. Classifications that combine the mechanism of injury, the primary direction of the traumatic force, and typical pelvic ring injuries (anteroposterior compression, APC; lateral compression, LC; vertical shear, VS; combined mechanism, CM) allow predicting the individual response in terms of severity: mild, moderate, and severe, and, importantly, the hemodynamic status.

According to the World Society of Emergency Surgery (WSES) classification, pelvic ring injuries are divided into 3 classes [25]:

Mild pelvic injuries: WSES grade I includes APC-I, LC-I, and pelvic ring injuries in hemodynamically stable patients.

Moderate pelvic injuries:

• WSES grade II includes APC II-III and LC II-III mechanically unstable pelvic ring injuries in hemodynamically stable patients.

• WSES grade III includes VS and CM mechanically unstable pelvic ring injuries in hemodynamically stable patients.

Severe pelvic injuries: WSES grade IV includes any pelvic ring injuries in hemodynamically unstable patients, regardless of mechanical stability.

The classification presented in Table 1 takes into account the Young-Burgess classification (Fig. 1), hemodynamic status, and associated injuries.

Table 1. World Society of Emergency Surgery (WSES) classification of pelvic injuries

Figure 1. Young-Burgess classification of pelvic injuries

The AO classification, which distinguishes three types of fractures, is generally accepted.

• Type A stable pelvic ring injuries with osteoligamentous integrity of the posterior pelvic ring and intact pelvic floor; the pelvis will not displace under physiological loads.

• Type B rotationally unstable pelvic ring injuries with partially preserved stability of the posterior pelvic ring.

• Type C translationally unstable pelvic ring injuries with disruption of all posterior osteoligamentous structures and pelvic floor injury. The direction of displacement (vertical, posterior, distractive, excessive rotation) plays a subordinate role. The pelvic ring is disrupted anteriorly and posteriorly, and the affected side is unstable.

In children and adolescents, in addition to the classifications mentioned above, avulsion fractures, which represent apophyseolyses, should be noted. Most commonly, these injuries, classified as simple or type A, occur in the region of the anterior superior and anterior inferior iliac spines, and less frequently at the ischial tuberosity.

Complicated pelvic ring injuries are pelvic injuries associated with severe soft tissue trauma, injury to pelvic hollow organs, vascular injury, and/or urinary tract injury. It is also necessary to distinguish between open and closed pelvic injuries. The following pelvic ring injuries should be considered open.

• primarily open pelvic ring injury, when there is communication between the injury site and the skin and/or vaginal mucosa and/or anorectal region;

• closed pelvic ring injury with performed minor pelvis packing to stop bleeding;

• closed pelvic ring injury with documented contamination of the retroperitoneal space resulting from intra-abdominal trauma.

In contrast, pelvic ring injuries with isolated bladder or urethral trauma should be considered complicated rather than open injuries. Open pelvic injuries carry a high mortality rate (approximately 45%) due to associated intra-abdominal injuries with the risk of acute exsanguination, as well as delayed sepsis.

Identification of unstable pelvic ring injuries

Instability, particularly of the posterior pelvic ring, is accompanied by a tendency toward massive hemorrhage from the presacral venous plexus. In this case, it is important to differentiate between isolated mechanical instability of the pelvic ring and hemodynamic instability, although both may occur simultaneously. If signs of pelvic instability are present, the hemodynamic status must be closely monitored. Pelvic ring instability should be assessed by applying pressure to the iliac wing, which results in inward or outward displacement. In cases of translational (vertical and horizontal) instability, craniocaudal mobility in the horizontal plane or anteroposterior mobility in the sagittal plane may be observed. In addition to an increased risk of hemorrhage, pelvic ring instability can lead to further complications such as thrombosis and secondary injuries to nerves, vessels, and pelvic organs. The latter may result from the primary trauma and must be ruled out during the diagnostic evaluation of patients with unstable pelvic injuries. Stabilization of the pelvic ring should be performed as early as possible. Depending on the patient's condition, this may be a rapid damage control orthopedics (DCO) procedure using external fixation or primary definitive internal fixation (which is more labor-intensive). However, there is a general consensus that mechanical stabilization (regardless of the method) has the highest priority and ideally should be performed at the scene of the injury. Hemostasis is of equally high priority and should be performed according to available alternatives.

Signs of pelvic ring instability can be identified on plain pelvic radiographs. These include, for example, widening of the pubic symphysis or sacroiliac joints. Horizontal or vertical displacement of the iliac wings should also be considered a sign of instability. It should be kept in mind that the displacement is often much greater at the time of injury than during diagnosis. Therefore, a fracture of the L5 transverse process should be evaluated as a sign of instability in the presence of a pelvic ring injury, even if there is no iliac wing displacement. It should also be noted that a properly positioned pelvic binder or belt may mask pelvic ring instability. The direction of pelvic ring instability is important for classification. If only rotational instability is present, it is a type B injury. If there is instability in both the vertical and horizontal planes, it is a type C injury.

1.6 Clinical presentation of the disease or condition

The assessment of pelvic injury severity should be based on the mechanism of injury (especially in high-energy trauma, which is more common in mechanical injuries) and physical examination findings aimed at identifying and analyzing traumatic foci of the pelvic ring, detecting intra-pelvic hemorrhage from retroperitoneal or perineal hematomas, or rectal/urethral bleeding [1, 25]. The clinical presentation upon examination is significant: forced position of the patient; external rotation of the feet; semi-flexed position of the legs at the hip and knee joints (Volkovich sign); pelvic asymmetry; limb shortening. Of particular importance is the analysis of skin and soft tissue integrity, the damage to which indicates an open fracture.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Comment: It should be noted that only unstable pelvic ring injuries are accompanied by hemodynamic instability. The diagnostic workflow in the trauma bay should be standardized and optimized to avoid delays in definitive hemorrhage control. It has been demonstrated that the time from injury to arrival in the operating room is inversely correlated with the survival of patients with intra-pelvic hemorrhage [25].

Criteria for establishing the diagnosis/condition:

1. Complaints: pain, pelvic deformity, bruising, inability to move the legs, impaired weight-bearing capacity of the extremity(ies).

2. History: presence of trauma.

3. Physical examination: Palpation reveals: tenderness at the site of the pelvic fracture; pain aggravated by weight-bearing and lower extremity movements; positive Larrey sign; positive Verneuil sign; positive sticking heel sign (Gorynevsky sign), forced position of the lower extremities (Volkovich sign), tenderness upon palpation (Marx sign), reverse gait sign (Lozinsky sign), Zyryanova signs, Lelly maneuver (pelvic ring stress test) may be useful in assessing pelvic ring stability, but it should be performed with caution as it can occasionally exacerbate bleeding due to bone fragment displacement [25]. It is recommended to perform a radiographic examination, especially in patients with hemodynamic instability, limiting it to an external inspection and medical history. A careful vaginal and rectal examination, as well as inspection of the urethra prior to catheter insertion, should be performed. In avulsion fractures in children, weight-bearing capacity of the lower extremity on the affected side may be preserved in combination with a limp. Depending on the location of the injury, specific movements associated with the contraction of a muscle attached to the apophysis cause pain projected to the site of apophysiolysis ( ischial tuberosity, anterior superior iliac spines).

4. Laboratory tests: Laboratory parameters may be normal in mild injuries; in unstable injuries assessed dynamically: decreased hemoglobin and erythrocyte counts, elevated leukocyte count and ESR, elevated lactate, changes in acid-base status, blood gas parameters, and thromboelastography.

5. Instrumental examination:

Radiography in the anteroposterior view, additional pelvic inlet view (X-ray tube angled at 30–45°) and pelvic outlet view (X-ray tube angled at 30–45°). For acetabular fractures, to clarify the diagnosis and determine treatment tactics when pelvic CT is unavailable, additional radiographic projections are recommended: oblique, iliac, and obturator views. For iliac and obturator views, it is not recommended to position the patient by rotating the torso or the X-ray tube by 30–45 degrees right and left as described in the classical method by E. Letournel; the same images can be obtained by angling the central X-ray beam without changing the patient's pelvic position. This technique avoids additional trauma and worsening of the patient's condition.

Computed tomography (CT) of the pelvic bones. It is recommended for any suspected pelvic bone injury (if technically available). In polytrauma, pelvic CT is an integral part of pan-CT imaging, i.e., total skeletal tomography. FAST ultrasound: Performed on an emergency basis as rapid diagnostics to detect hematomas and ongoing hemorrhage

2.1 Complaints and Anamnesis

Complaints and medical history are described in Section 2 "Criteria for Establishing the Diagnosis/Condition".

2.2 Physical Examination

Physical examination findings are described in Section 2 "Criteria for Establishing the Diagnosis/Condition".

• Assessment of the following parameters in patients with suspected pelvic bone injuries for diagnostic purposes is recommended to be performed no later than 1 hour after hospital admission, with the results mandatorily documented in the medical records:

  • assessment of somatic status;

  • visual and palpation assessment of local status;

  • blood pressure measurement;

  • body temperature measurement;

  • assessment of the risk of venous thromboembolic complications [202, 209, 217, 252, 253].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

2.3 Laboratory Diagnostics

Comment: Routine laboratory tests allow assessment of the patient's general condition upon admission and implementation of drug therapy. However, hemoglobin and hematocrit levels lack sensitivity in the early assessment of the severity of traumatic shock [29].

Comment: Sensitive laboratory markers of ongoing bleeding include serum lactate and base deficit levels obtained from arterial blood gas analysis. Serum lactate and base deficit are sensitive diagnostic markers that allow assessing the degree of traumatic and hemorrhagic shock, as well as monitoring the response to ongoing intensive care [25].

Comment: The presence of coagulopathy should be detected early using bedside tests such as TEG and ROTEM. These tests enable targeted goal-directed fluid and blood component therapy and improve survival outcomes following pelvic trauma [25].

2.4 Instrumental Diagnostics

Comments: In cases of hemodynamic instability, an extended focused assessment with sonography for trauma (FAST) is performed to identify or exclude other sources of bleeding in the chest and abdominal cavities. [7] Guidelines from the Eastern Association for the Surgery of Trauma (EAST) indicate that the extended FAST (eFAST) lacks sufficient sensitivity to rule out pelvic hemorrhage; however, this method is considered appropriate for ruling out the need for laparotomy in unstable patients [25].

Comments: Major injury patterns associated with hemodynamic instability include sacral fractures, "open-book" fractures, and vertical shear fractures of the hemipelvis (APC II-III, LC II-III, and VS). However, pelvic radiography alone is often insufficient to predict bleeding or determine the need for angiography, let alone mortality. Pelvic radiography is important not only for assessing hip dislocation, but also for evaluating the vertical displacement (subluxation/dislocation) of the hemipelvis to correctly perform the appropriate reduction maneuver. Notably, obtaining radiographs should not delay interventions aimed at correcting life-threatening consequences. The sensitivity and specificity of this diagnostic method (reported variably by different authors) are relatively low (50–68% and 98%, respectively), and the false-negative rate is high (32%), particularly in low-energy injuries and non-displaced or minimally displaced fractures. It should be noted that hemodynamic instability occurs only in unstable pelvic injuries accompanied by massive disruption of the pelvic ring. For this reason, some authors suggest omitting pelvic radiography in stable patients. Early pelvic stabilization and prompt planning of the subsequent management and diagnostic algorithm are essential for accurate morphological assessment of the injury. In hemodynamically stable patients without pelvic ring instability, hip dislocation, or positive physical examination findings who are scheduled for a CT scan, pelvic radiography may be omitted [25, 34].

Comments: Computed tomography of the pelvic bones is the gold standard for diagnosing pelvic trauma and allows the detection of soft tissue injuries [34].

Comments: Two key factors to consider when making clinical decisions and referring a patient for pelvic angiography are the presence of contrast extravasation on contrast-enhanced CT and the size of the pelvic hematoma on unenhanced CT. CT has a 98% accuracy in identifying patients with active extravasation; however, the absence of contrast extravasation on CT does not always rule out active intrapelvic bleeding.

2.5 Other Procedures

Comments: Diagnosis of urethral injuries is quite challenging during initial assessment. About 23% of such injuries are not diagnosed in a timely manner [14, 25]. Symptoms that may accompany urethral injuries include perineal/scrotal hematoma, blood discharge from the external urethral meatus, deformation of the urinary bladder contours in the presence of an intrapelvic hematoma, and unstable pelvic injuries. Insertion of a transurethral catheter without other preliminary examinations in patients with pelvic trauma may be associated with severe consequences, either as an acute complete urethral rupture or as the development of a chronic stricture, impotence, and urinary incontinence [14, 25]. For this reason, ATLS guidelines, the World Health Organization, and several authors [14, 25] have suggested performing a retrograde urethrogram (RUG) prior to urethral catheterization. RUG is recommended in the presence of local clinical symptoms or if there are signs of rupture on plain radiographs, especially in the presence of severe soft tissue injury, displacement of bone fragments, or multiple fractures [14, 25]. In the case of a positive RUG result or when there is a high degree of suspicion for urethral injury, epicystostomy with delayed cystography is recommended [14, 25]. MRI appears promising in identifying the type of injury and can be an effective method in combination with RUG or as an alternative to RUG, but only in stable patients [14, 25]. However, the sequence of performing RUG and urethrocystography with contrast-enhanced CT has not been defined [2, 25]. Performing RUG prior to CT may increase the rate of indeterminate or false-negative CT results [2, 25]. For this reason, in cases of suspected urethral injury, delayed contrast-enhanced CT scanning with urological evaluation is recommended, provided the patient's hemodynamic status allows it [2, 25].

The high incidence of anorectal injuries necessitates a thorough examination of the anorectal region. First and foremost, perineal and digital rectal examinations should be performed to detect the presence of blood, assess rectal wall laxity, and determine if the prostate is non-palpable. If the rectal examination is positive, rigid proctoscopy should be seriously considered [3].

Comment: The high incidence of anorectal injuries necessitates a thorough examination of the anorectal region. First and foremost, perineal and digital rectal examinations should be performed to detect the presence of blood and assess rectal wall laxity.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Basic principles in the management of pelvic trauma

Treatment of pelvic ring injuries, and correspondingly for all polytrauma patients, requires a special emphasis on physiology; decisions made can be more effective with a comprehensive assessment of anatomy, the mechanical consequences of the trauma, and their physiological manifestations. In everyday clinical practice, initial decisions are made based on the assessment of the patient's clinical status and the presence of associated injuries and pelvic ring disruption. The primary goal of treatment is the restoration of disrupted physiology, while the main objectives are stopping bleeding and stabilizing hemodynamics, restoring the mechanical integrity and stability of the pelvic ring, correcting coagulation disorders, preventing the development of complications (septic, urogenital, intestinal, vascular, sexual dysfunction, gait disorders), and finally, definitive stabilization, reduction, and fixation of acetabular fractures [25].

3.2 Conservative treatment

Comment: Activity level depends on severity — 1, 2, 3.

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comment: At the same time, the device does not interfere with other surgical interventions, as it can be moved to the abdomen or thighs if necessary. Further development of this area in traumatology has led to the creation of pin fixation systems that can be used for all types of unstable fractures and acetabular injuries. This allows for the rapid resuscitation of the patient and their transfer for specialized care. However, the installation of pin systems requires specific skills and mandates special training. In cases of vertical displacement of the hemipelvis, reduction is necessary prior to the placement of fixation elements. In some cases, the most effective approach is a combination of percutaneous iliosacral stabilization with cannulated screws and the application of external fixation devices to the anterior pelvic ring. Such a combination, in skilled hands, has significant advantages over the application of external fixation devices to the posterior pelvic ring.

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comment: External fixation devices (a set of components and parts for an external fixation apparatus) with such a mechanism of action, applied to the posterior pelvic ring, usually have a C-shape similar to those proposed by Ganz [99]. In lateral compression injuries and iliac wing fractures, the application of external fixation devices (a set of components and parts for an external fixation apparatus) of this type is contraindicated.

Comment: In this patient position, the antagonist muscles balance each other out to a greater extent than in any other positioning. Furthermore, relaxation of the iliopsoas muscle significantly reduces pressure on the fragments of the anterior pelvic ring, decreasing pain impulses from the fracture sites. Consequently, the risk of secondary displacement of bone fragments is substantially reduced, and pain intensity decreases. In forced conservative treatment of vertically unstable injuries or during the preoperative period, skeletal traction on the side of the posterior disruption is mandatory.

3.2.1. Use of a pelvic binder in the management of pelvic injuries in hemodynamically unstable patients

Comment: The pelvic binder can be "improvised" (e.g., a sheet) or a standard specialized device. To apply a pelvic binder correctly, it should be wrapped around the greater trochanters and the pubic symphysis; tightening it secures the pelvic fracture and brings the lower extremities together, which helps reduce the internal volume of the pelvis. Standard pelvic binders are more effective at stabilizing fragments and reducing pelvic hemorrhage than improvised ones. However, in resource-limited settings or when standard devices are unavailable, an improvised pelvic binder can be effective and safe [25].

A pelvic binder is contraindicated in lateral compression injuries and acetabular fractures.

Comment: Non-invasive external pelvic compression devices (pelvic binders) should be removed as soon as physiologically feasible and replaced with an external fixation device or definitive pelvic stabilization, if indicated. Pelvic binders should be positioned with caution in pregnant women and elderly patients. In patients with a pelvic binder in place, early transfer off the spine board significantly reduces the likelihood of pressure ulcers, whenever possible. If the binder is not removed in a timely manner and is applied with excessive force, complications may develop within 2–3 hours (skin necrosis and pressure ulcers, especially in the elderly). If indicated, the pelvic binder should be replaced by surgical stabilization of the pelvic ring (application of external fixation devices [reusable external orthopedic fixation system] after radiodiagnostics and initiation of intensive care). The pelvic binder should not be left in place overnight, even if definitive early surgical treatment is planned [25].

3.3 Surgical treatment

Comment: If treatment of the patient at the medical institution is not feasible, transfer to a level I or II trauma center must be arranged [209].

Comment: In rotationally and vertically unstable injuries, synthesis of the anterior and posterior segments of the pelvic ring must be performed. For acetabular floor fractures and central displacement, closed reduction with the application of fixation devices anchored to the pelvis and femur is most effective. This design subsequently allows for minimally invasive percutaneous osteosynthesis of both columns with cannulated screws. Skeletal traction is indicated in the preoperative period for acetabular fractures solely for immobilization, but requires double traction in the event of central displacement of fragments and the femoral head. If surgical treatment is impossible due to somatic indications or technical issues, the application of external fixation devices (reusable external orthopedic fixation system) with fixation points on the pelvis and femur with the best possible reduction is indicated. If treatment of the patient at the medical institution is not feasible, transfer to a level I or II trauma center must be arranged.

Comment: In case of femoral head protrusion into the lesser pelvis, the displacement must be corrected emergently and in a single stage under adequate anesthesia, followed by the application of external fixation devices (reusable external orthopedic fixation system) with fixation points on the pelvis and femur. If modern surgical care and the performance of these interventions are not available for such patients, the patient must be transferred to a level 1 trauma center or a medical institution with the infrastructure and trained personnel to perform such interventions.

3.3.1 Endovascular Balloon Occlusion of the Aorta (REBOA) in Pelvic Ring Injuries in Patients with Hemodynamic Instability

Endovascular balloon occlusion of the aorta (REBOA) is considered as an alternative to open surgery in patients with hemodynamic instability [48–51]. REBOA and other endovascular and hybrid trauma management (EVTM) techniques are increasingly used in the general structure of care for various injuries, including pelvic hemorrhage, and are now included in care algorithms in major trauma centers [6, 25, 48–50, 52–58].

Comment: REBOA is regarded as a "bridge to surgery" and, in pelvic hemorrhage, as an alternative to resuscitative thoracotomy followed by open surgery or angioembolization (or both methods) for definitive hemostasis. This involves the use of all the aforementioned methods in the early treatment of patients and may require the presence of a cardiovascular surgeon on the polytrauma care team [52, 69, 70]. REBOA can be performed in Zone I (above the celiac trunk or in the descending thoracic aorta) or Zone III (infrarenal), but not in Zone II (pararenal), where balloon inflation is not recommended due to the risk of visceral organ ischemia. When performing manipulations in a hemodynamically unstable patient in the shock trauma room, percutaneous or open surgical access to the femoral artery or ultrasound-guided access may be time-consuming. In severe pelvic injuries, vascular injuries are possible, with a higher risk in elderly patients with calcified vessels. Today, most trauma specialists use REBOA only in critically ill patients with multiple sources of hemorrhage as a "bridge" before definitive damage control surgery [25].

3.3.2 Preperitoneal Pelvic Packing in Pelvic Injuries in Patients with Hemodynamic Instability

The main source of acute retroperitoneal hemorrhage in patients with hemodynamic instability and pelvic ring injuries is venous bleeding (in 80–90% of cases) from the presacral and paravesical venous plexuses, as well as from bleeding cancellous bone surfaces in the area of sacral, iliac fractures, and the presacral plexuses of the sacroiliac joint [25, 77]. Arteries are the source of intrapelvic hemorrhage in only 10–20% of cases. Arterial bleeding can cause hemodynamic instability despite mechanical pelvic stabilization [25, 78] and is accompanied by venous bleeding in almost 100% of cases [25, 46, 79].

Comment: Preperitoneal pelvic packing (PPP) is considered a rapid and easily performable intervention [4, 25, 79] that can be carried out both in the operating room and in the trauma bay [4, 25]. However, it should be kept in mind that PPP is effective only when the pelvic ring is stabilized.

Comment: In unstable pelvic ring injuries in patients with hemodynamic instability, PPP should be performed after external fixation of the pelvic ring if hemodynamic instability persists. In extremely critical conditions, pelvic ring stabilization can be rapidly achieved by applying a pelvic binder. The additional placement of rolled surgical towels beneath the binder allows for compression in case of sacroiliac joint disruption. Some patients with ongoing hemorrhage and/or persistent indications for blood transfusion after pelvic packing are recommended to undergo subsequent (secondary) angioembolization [25].

3.3.3 External pelvic fixation for pelvic ring injuries in patients with hemodynamic instability

The biomechanics of pelvic injuries and the underlying mechanism determine the indications for external fixation [25, 58, 95]. The choice and assembly of the device depend on the type of injury, available equipment, operating room facilities, and the surgeon's experience. It must be remembered that in vertical instability, anterior pelvic ring fixators do not maintain the reduction of the posterior segments, which requires either a combination of external fixation devices (reusable external orthopedic fixation system) or the insertion of cannulated screws.

Comment: Indications for emergency stabilization of the pelvic ring with external fixation devices are:

• vertically unstable pelvic ring injuries,

• rotationally unstable injuries with an increased pelvic volume,

• bilateral injuries.

When determining the indications and technique for external pelvic fixation, one should proceed from the Young-Burgess classification of pelvic injuries. Unstable pelvic traumas resulting from anteroposterior compression (APC-II/APC-III) and lateral compression (LC-II/LC-III) must be fixed with anterior devices by inserting Schanz pins into the iliac wings or supra-acetabularly. Although pin insertion into the iliac wings is simpler and allows for rapid frame installation in a damage control setting, the pull-out resistance of Schanz pins inserted in this zone is extremely low, leading to a high risk of device instability and loss of reduction [25, 96].

3.3.4 Definitive surgical fixation of pelvic ring injuries

Anatomical reduction and stable fixation of rotationally and vertically unstable pelvic injuries are prerequisites for early functional rehabilitation. There is a general consensus that pelvic fractures and dislocations with posterior ring instability require internal fixation [25, 95, 121]. In vertically unstable and bilateral fractures, fixation of the anterior segments alone is insufficient and requires osteosynthesis of the posterior segments. The decision regarding open or closed reduction, as well as the choice of implant, depends on the available fixators, equipment, and the operating surgeon's experience. Plate osteosynthesis, intramedullary osteosynthesis, the use of an external fixation device as a definitive treatment method, and transpedicular constructs are possible, especially when spinal canal decompression and spino-pelvic dissociation reduction are necessary.

GCP CLE 4Grade of Recommendation C (Level of Evidence 4)

Comment: Methods of internal surgical fixation include:

• open reduction and internal fixation of the pubic symphysis with plates,

• minimally invasive percutaneous screw fixation using iliosacral screws to stabilize unstable sacral fractures and sacroiliac joint disruptions,

• minimally invasive percutaneous screw fixation of other pelvic ring fractures in the absence of interfragmentary interposition,

• osteosynthesis of the iliac wing with plates and screws,

• spino-pelvic fixation (referred to as "triangular osteosynthesis" when combined with iliosacral screws)

• posterior plating to stabilize posterior ring injuries, including vertically unstable sacral fractures.

Comments. In patients with lateral compression, osteosynthesis of the anterior pelvic segments using external (reusable external orthopedic fixation system) or implantable devices (non-absorbable sterile internal orthopedic fixation system using plates/screws***) is indicated in the presence of concomitant visceral injury, laparotomy, severe fragment displacement, or the need for early mobilization to treat other skeletal injuries within the polytrauma framework.

Comments. Regarding unstable type B and C pelvic ring injuries in adolescents aged 12 years and older, no studies have been conducted to prove the efficacy of alternative therapeutic and surgical tactics used for adult patients. Surgical care for children with unstable pelvic injuries should be provided in multidisciplinary pediatric facilities using modern principles of reduction and osteosynthesis [212, 213].

3.3.5 Optimal timing for definitive internal pelvic fixation

The selection of optimal timing for definitive internal fixation of unstable pelvic trauma remains a subject of debate [25, 138–145].

Comment: It has been established that performing brief early primary pelvic fixation reduces the incidence of multiple organ failure and lowers mortality [25, 148]. Furthermore, it was shown that the rate of postoperative complications when performing definitive osteosynthesis between the 2nd and 4th days after trauma is significantly higher than when surgery is delayed until the 6th to 8th days after trauma [25, 149].

3.3.6 Staged surgical management in severe traumatic brain injury

Severe traumatic brain injury (TBI) is frequently encountered in polytrauma patients presenting with concomitant pelvic trauma. Currently, there are no universally accepted treatment protocols for severe combined head and pelvic injuries. One of the most critical aspects is the combination of pelvic fractures with hemorrhage and subsequent coagulopathy, which exacerbates the course of TBI through secondary bleeding and the subsequent progression of hemorrhagic contusion foci in a vicious circle [25].

Comments: Careful monitoring of the course of traumatic brain injury with potential early repeat CT scanning in cerebral perfusion mode may yield favorable outcomes [25, 150]. As a rule, neurosurgeons are concerned about potential additional brain damage resulting from blood pressure fluctuations observed during osteosynthesis surgery [25, 150]. Overall, this leads to doubts regarding the tactics and additional delay required to stabilize the patient and prepare them for surgery [25, 150].

3.4. Postoperative pain management

• To ensure adequate pain relief in patients with pelvic bone fractures, it is recommended to use multimodal analgesia, which may include nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol**, gabapentinoids, and immediate-release opioids, taking into account age restrictions in the instructions for medical use; if its administration is not feasible, monomodal analgesia should be used [211–213].

GCR ALOE 2Grade of Recommendation A (Level of Evidence – 2)

Comments: It is necessary to ensure adequate analgesia for the patient with a fracture prior to any manipulations and throughout the entire period of fracture treatment, the duration of which varies significantly depending on the chosen management strategy. When performing analgesia in a hospital setting, it is necessary to take into account prescriptions made at the emergency medical care stage. In the acute period of trauma, for the purpose of analgesia, it is necessary to ensure proper immobilization of fragments using a vacuum splint, a vacuum mattress, or an external fixation device.

Among pharmacological strategies, the current consensus is the use of multimodal analgesia (MMA), which involves the use of several analgesic drugs (opioid and non-opioid) with different mechanisms of action, as well as non-pharmacological interventions aimed at targeting peripheral and/or central parts of the nervous system [214]. This combination allows for more effective pain relief by enhancing the effects of various drugs, which in most cases leads to a reduction in the frequency of prescriptions and/or doses of opioid analgesics. Thus, MMA improves the risk profile of each drug while providing synergistic pain control using different drug classes. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**, gabapentinoids, regional anesthesia (single injection or placement of peripheral nerve catheters), local injections, and opioids [212, 215].

In modern scientific literature, authors emphasize the use of the lowest effective doses of opioids for the shortest possible period, avoiding extended-release opioids. As an adjuvant during MMA, a single perioperative administration of #dexamethasone** can be used, which provides a significant reduction in pain syndrome [211].

It must be borne in mind that the duration of parenteral administration of most NSAIDs (ketorolac**, ketoprofen**, diclofenac**) is limited to two days, which requires timely switching of the patient to oral administration, changing the drug, or coordinating further use with the medical commission. The specific choice of local anesthesia method and medicinal products is made by the attending physician individually in accordance with the patient's characteristics, local protocols, and the equipment of the medical organization.

When prescribing analgesic therapy for children, a single dose should be chosen taking into account the child's weight and age. Preference should be given to analgesics with oral or rectal administration routes, avoiding intramuscular injections.

Recommended analgesic medications are listed in Appendices A3.1-A3.3

3.5. Surgical antibiotic prophylaxis

• In the surgical treatment of patients with pelvic bone fractures, it is recommended to perform surgical antibiotic prophylaxis (SAP) for surgical site infections by a single preoperative administration of an antibacterial drug to reduce the risk of infectious complications [218].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments. In accordance with international clinical guidelines for the prevention of surgical site infections [217, 219], the objective of SAP is to establish bactericidal concentrations of the antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The necessity of SAP is determined by the surgical wound class of the upcoming procedure: SAP is not required for "clean" surgical wounds not associated with the placement of orthopedic and metal implants. SAP should be performed for clean-contaminated and contaminated surgical wounds, as well as for "clean" surgical wounds involving the placement of orthopedic and metal implants. For infected ("dirty") wounds, SAP is not indicated; instead, antibiotic therapy is administered.

• In patients with pelvic bone fractures, it is recommended to use first- and second-generation (I and II) cephalosporins (cefazolin**, cefuroxime**) as the primary drugs for surgical antibiotic prophylaxis during surgical interventions in traumatology and orthopedics, and glycopeptide antibiotics (vancomycin**) or lincosamides (#clindamycin**) as alternatives in case of beta-lactam antibiotic intolerance [217].

GGR CLeE 5Grade of Recommendation C (Level of Evidence – 5)

Comments. For patients with an unburdened allergic history and without significant risk factors for methicillin-resistant staphylococci carriage, first- and second-generation (I and II) cephalosporins (cefazolin**, cefuroxime**) are used for SAP prevention and are administered intravenously 30 to 60 minutes before skin incision. In case of beta-lactam intolerance, a combination of vancomycin** with one of the fluoroquinolones (ciprofloxacin**, #levofloxacin**) administered over at least 60 minutes starting the IV infusion 2 hours before incision, or #clindamycin** should be prescribed. When significant risk factors for methicillin-resistant staphylococci (MRS) carriage are present, the SAP regimen must include an antibiotic with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of the antibiotic is sufficient for effective prophylaxis. For prolonged procedures or massive blood loss, an additional intraoperative dose of the antibiotic should be administered (the estimated time for intraoperative administration is two half-lives after the preoperative dose). Administering an antibiotic after wound closure in the operating room is inappropriate even if drains are in place.

Single doses of main antibacterial drugs for SAP in adult traumatology and orthopedic surgeries: cefazolin** 2 g (for patient weight ≥120 kg — 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow IV infusion, ciprofloxacin** 400 mg, #levofloxacin** 500 mg [216].

Single doses for children should be calculated based on actual weight: cefazolin** 30 mg/kg, cefuroxime** 50 mg/kg, #clindamycin** 10 mg/kg, vancomycin** 15 mg/kg; the use of fluoroquinolones during the period of musculoskeletal system development is contraindicated due to the risk of arthropathy [216, 255, 256].

Comments. In cases of open fractures, prophylactic antibiotic administration is effective in preventing early infection, and the drug should be administered as soon as possible after trauma. Cefazolin** is the antibiotic of choice, but for patients with open high-energy fractures with displacement and segmental loss, major vessel injury, and heavily contaminated wounds, expanding the spectrum of prescribed antibiotics to cover gram-negative pathogens is advisable. In such cases, adding #gentamicin** (at a dose of 6 mg/kg once daily) to cefazolin** may be considered for adult patients [220, 221]. An alternative to this combination may be #ampicillin+sulbactam** (at a dose of 3.0 g every 8 hours for 3 days) [221], the latter being particularly relevant in case of the risk of clostridial infection. According to the majority of researchers, in Gustilo-Anderson type III open fractures, antibiotics should not be continued for more than 72 hours after soft tissue wound closure.

• In the surgical treatment of patients with pelvic bone fractures, it is recommended to perform surgical site infection antibiotic prophylaxis for a duration of no more than 24 hours [223].

GCR ALEL 1Grade of Recommendation A (Level of Evidence – 1)

Comments: In accordance with the regulations currently in force in the Russian Federation (SanPiN 3.3686-21) and clinical guidelines [223], to achieve an effective concentration of the antibacterial drug in tissues and blood serum at the time of skin incision, antibiotics for the prevention of surgical site infection should be administered intravenously within 30 to 60 minutes before the skin incision, with vancomycin** administered within 2 hours before the incision. The maximum duration of prophylactic antibiotic administration should not exceed 24 hours after the end of surgery. In most cases, a single dose of an antibiotic is sufficient for effective prophylaxis. Additional doses should be administered during prolonged surgeries when the half-life of the administered antibiotic has elapsed since the preoperative dose, creating a risk of the antibiotic concentration dropping below the bactericidal level and increasing the risk of surgical site infection (SSI).

3.6. Prophylaxis of venous thromboembolism

• For patients undergoing conservative treatment for pelvic fractures, it is recommended to carry out the prevention of venous thromboembolic events (VTE) using pharmacological and (or) mechanical methods of prevention [225,226].

GCR ALeE 3Grade of Recommendation A (Level of Evidence 3).

Comment: In the conservative treatment of pelvic fractures, preference should be given to pharmacological (medical) methods of VTE prevention [225,226]. The use of low molecular weight heparins (LMWH) from the heparin group (ATX group code B01AB) is preferred [225]. Recommended doses, frequency, and route of administration are presented in Appendix A3.4.

Mechanical methods of prevention include elastic and (or) intermittent sequential pneumatic compression of the lower extremities. Other non-drug prevention methods include early mobilization and activation of the patient, and therapeutic exercises.

• For patients undergoing conservative treatment for pelvic fractures, it is recommended to prescribe prophylaxis early using low molecular weight heparins from the heparin group (ATX group code B01AB) (within the first 24 hours after injury) [226].

GGR BLEL 3Grade of Recommendation B (Level of Evidence 3)

Comment: Recommended intervals between the prophylactic use of anticoagulants and neuroaxial interventions are given in Appendix A3.5.

• For patients undergoing conservative treatment for pelvic fractures, it is recommended to provide prolonged antithrombotic prophylaxis (more than 1 month) [227, 228].

GGR BLEL 3Grade of Recommendation B (Level of Evidence 3)

• For patients undergoing surgical treatment for pelvic fractures, it is recommended to carry out VTE prevention as early as possible (within the first 24 hours after injury) using low molecular weight heparins from the heparin group (ATX group code B01AB) once hemostasis is achieved and there is a low risk of bleeding [229,230].

GGR BLEL 3Grade of Recommendation B (Level of Evidence 3)

• For patients undergoing surgical treatment for pelvic fractures, it is recommended to carry out pharmacological VTE prevention for at least 4 weeks. It is recommended to consider extending pharmacological prophylaxis for the entire period of maintained immobilization (more than 4 weeks) [227,228,231,232].

GGR BLEL 3Grade of Recommendation B (Level of Evidence 3)

Issues of VTE prevention in trauma and orthopedic patients are discussed in detail in the 2022 methodological recommendations [233] and the 2023 recommendations of Russian experts [234].

3.7. Diet therapy

No specific dietary therapy has been developed.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Rehabilitation of patients with pelvic trauma, regardless of the treatment method, begins after the cessation of bleeding and stabilization of hemodynamics, and the restoration of the mechanical integrity and stability of the pelvic ring [199, 202, 237, 252].

Individual publications have demonstrated the effectiveness of rehabilitation in the postoperative period, but there are no unified rehabilitation protocols for surgical treatments of pelvic ring fractures [236-238, 243]. The main issue is the timing of verticalization and permissible axial load on the extremities after surgical treatment. This issue is decided individually in conjunction with the operating physician and depends on the stability of the fracture and pelvic ring fixation, but requires further study and scientific justification [236-237, 241, 246].

Comments: in the conservative treatment of pelvic ring fractures, immobilization is carried out with the patient in the supine position on a functional bed or with a large bolster under the knee joints, flexing the legs at the knee (125⁰-135⁰) and hip joints (35⁰-40⁰) with hip abduction of about 10⁰ [199, 202].

A physical and rehabilitation medicine (PRM) physician/exercise therapy specialist draws up an individual rehabilitation program prescribing exercise therapy means: breathing exercises, isometric exercises for the thigh muscles, gluteal muscles, lumbar spine muscles, dynamic exercises for the knee and ankle joints, and dynamic exercises for the upper extremities. Therapeutic gymnastics is an important component of the conservative treatment of patients with pelvic ring injuries accompanied by multiorgan disorders associated with restricted motor activity and prolonged horizontal positioning of patients. This condition can lead to musculoskeletal, respiratory, endocrine-metabolic, and cardiovascular disorders [248].

From the first days, to reduce pain, local cold pack cryotherapy, electrotherapy, and magnetotherapy are prescribed [250, 252].

The duration of bed rest depends on the number and location of pelvic ring fractures and is determined by the attending physician for up to 3–6 weeks.

Two weeks after a repeat consultation with the PRM physician/exercise therapy specialist, exercises with resistance and additional movement weighting are prescribed, along with manual massage of the lower extremities, which is necessary to prepare the patient for verticalization. After adaptation to the upright position, patients are taught to walk with crutches or a walker [245, 252].

Comments: Upon discharge from the hospital, the PRM physician/exercise therapy specialist gives recommendations to the patient on continuing rehabilitation at home, introduces the exercise program necessary to strengthen the muscles of the pelvic floor, lumbar spine, and lower extremities, and determines the approximate timing for permissible axial loading on the extremities and full-weight-bearing walking.

The duration of walking with auxiliary support devices is determined individually depending on the type of pelvic ring injury and the pain syndrome. The criterion for discontinuing additional load-bearing devices is the absence of pain in the fracture area during walking [244, 246].

Comments: from the 1st–2nd day after surgery, the PRM physician/exercise therapy specialist draws up an individual rehabilitation program prescribing exercise therapy and physical therapy: static, dynamic, breathing, and general conditioning exercises for all muscle groups, ideomotor exercises, active movements of the toes and knee joints, and isometric tensions of the lower leg and thigh muscles. From the 3rd–4th day after surgery (if the patient's general condition allows), isometric tensions of the pelvic girdle, thigh, and lower leg muscles [239, 241, 248, 250]. There are isolated publications on the use of bedside passive mechanotherapy using the MOTOmed letto2 device and electrical stimulation [250].

From the first days after surgery, to reduce pain, cold pack cryotherapy and TENS are prescribed [239, 241].

Two weeks after a repeat consultation with the PRM physician/exercise therapy specialist, provided the patient's general condition is satisfactory, resistance and weight exercises are prescribed to strengthen the lower extremity muscle groups, which are recommended to be performed at home after discharge from the hospital [239, 241, 251].

Verticalization of the patient is carried out on days 2–4 after surgery [239-241]. The issue of axial loading and the duration of walking with auxiliary support devices is decided individually in conjunction with the operating surgeon [236, 237, 239].

Comments: surgical fixation of the fracture allows early verticalization of the patient and walking with auxiliary support devices, and therefore discharge from the hospital. The outpatient (home) rehabilitation program is drawn up by a PRM/exercise therapy physician and includes physical exercises with increasing load on the lower limb girdle muscles: dynamic exercises with resistance and weights, static exercises, and gait training with partial weight bearing on the limbs. The duration of the rehabilitation period, or the permissibility of full weight-bearing on the legs, is determined by the time required for fracture healing, ranging from 3 to 6 months [242, 242, 244, 249, 251].

Comments: from the first day after fixation of fractures with external fixation devices, the PRM/exercise therapy physician draws up a rehabilitation program prescribing therapeutic gymnastics: general tonic exercises, breathing exercises, assisted and active dynamic exercises for the distal leg joints, isometric exercises for the thigh, pelvic floor, and lumbar spine muscles, and ideomotor exercises for the hip joints.

From the second day after surgery, the patient is verticalized and trained in locomotion using crutches or a walker [247, 251, 252].

Comments: upon discharge from the hospital, the PRM/exercise therapy physician draws up a rehabilitation program prescribing therapeutic gymnastics: free, weighted, and resisted dynamic exercises for the lower limbs, gluteal muscles, and pelvic floor muscles, which must be performed at home with a gradual increase in load and procedure duration. The program is carried out until the external fixation device is removed.

Comments: after removal of the external fixation device, the PRM/exercise therapy physician determines the degree of functional impairment and, depending on the severity of the motor deficit, draws up an outpatient rehabilitation program. Physical exercises, passive and active mechanotherapy, balance and gait training, muscle electrical stimulation, ultrasound therapy, manual/underwater massage, physical exercises in water, and therapeutic swimming are prescribed [242, 249, 250].

Comment: Medical physical therapy. From the first day, passive movements in the hip joint are performed with support for the thigh and lower leg within the limits determined by pain intensity. They slowly transition to active movements.

Straight leg raise is strictly contraindicated. Mechanotherapy can be used. When traction is used, physical therapy for bone fractures is started only after the removal of traction. Getting out of bed and weight-bearing. Single pelvic ring fractures. With sufficient stability — pool gymnastics from the 10th day. From the 3rd–4th week, walking on crutches or with a walker is initiated. Load is increased after 6 weeks. With instability in the sacroiliac joint, patients are mobilized at the 9th week. Acetabular fractures. With stable osteosynthesis, patients are mobilized on the 2nd–3rd day (without axial load on the damaged joint). Graduated weight-bearing is allowed at the 13th week. Load is increased after 6 weeks under X-ray control. Full weight-bearing is allowed after 4–6 months. In case of femoral head injury, the question of weight-bearing is decided individually.

In pelvic fractures, the lower limb on the affected side is placed on a damping device for skeletal traction (Böhler splint) without applying actual skeletal traction. In sacral and coccygeal fractures, the patient is placed in the "frog" position (according to N.M. Volkovich) for 2–4 weeks.

5. Prevention and Dispensary Observation

Prevention of pelvic injuries does not differ from that of other injuries: compliance with safety rules by the patient and implementation of measures to create a trauma-safe environment by the state, in particular, the use of engineering and technical support for high-risk areas with active and passive citizen protection measures (road lighting, ice control, maintenance of vehicles in good working order, equipping them with passive safety features), and the creation of a trauma-safe environment in enterprises.

6. Organization of Medical Care

Indications for hospital admission.

The presence of pelvic ring injuries or suspicion of such injuries based on the mechanism of injury is an indication for emergency admission to a multidisciplinary hospital equipped with a shock trauma room or ICU (preferably a level II or I trauma center).

If the medical organization lacks a specialized shock trauma room or ICU, as well as the capability to provide specialized care to patients with pelvic ring and acetabular injuries, anti-shock measures must be performed in the ICU, pelvic ring stabilization should be carried out using a binder or, if possible, external fixation devices, followed by evacuation of the patient to a level I or II trauma center where the infrastructure and trained personnel are available to provide such care.

Indications for patient discharge from a medical organization:

1. Outpatient treatment of mild pelvic injuries not requiring surgical treatment;

2. After definitive stabilization of the pelvic ring and restoration of the patient's ability to self-care in the absence of hemodynamic disturbances and a smooth postoperative course.

7. Additional Information

Mortality, lethality, and treatment outcomes. Pelvic injuries, especially open ones, can lead to complications with significant functional impairments: urinary and fecal incontinence, impotence, dyspareunia, residual motor deficits, perineal and pelvic abscesses, chronic pain, and vascular complications such as thrombosis and embolism [1, 3, 25].

The majority (44.7%) of deaths due to pelvic trauma occur on the day of injury, and the main factors correlating with mortality are age, ISS injury severity score, pelvic ring instability, wound size and degree of contamination, rectal injury, colostomy creation, number of transfused blood components, AIS head injury severity, and base deficit in blood gas analysis upon admission [3, 5, 25].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Bortulev P.I., Candidate of Medical Sciences, National Medical Research Center of Children's Traumatology and Orthopedics

2. named after G.I. Turner of the Russian Ministry of Health, Saint Petersburg.

3. Geroyeva I.B., MD, Professor, Federal State Budgetary Institution "N.N. Priorov National Medical Research Center of Traumatology and Orthopedics" of the Russian Ministry of Health, Moscow.

4. Gorbatyuk D.S., Candidate of Medical Sciences, Trauma and Orthopedic Surgeon, Department for Function Implementation of the National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov, Moscow, member of ASOR.

5. Donchenko S.V., Candidate of Medical Sciences, Head of Traumatology Department No. 27, City Clinical Hospital named after S.P. Botkin of the Moscow Healthcare Department, Moscow

6. Dubrov V.E., Doctor of Medical Sciences, Professor, Chief freelance specialist traumatologist-orthopedist of the Moscow Healthcare Department, Head of the Department of General and Specialized Surgery, Faculty of Fundamental Medicine, Lomonosov Moscow State University,

7. Moscow, member of ASOR.

8. Zlobina Yu.S., Candidate of Medical Sciences, Head of the Organizational and Methodological Department for Traumatology and Orthopedics, Moscow Healthcare Department.

9. Zorin V.I., PhD, Associate Professor, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Ministry of Health of Russia, St. Petersburg.

10. Kleymeneva E.B., Doctor of Medical Sciences, Professor, Deputy Director for Quality and Information Technology, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Ministry of Health of the Russian Federation, Moscow.

11. Lazarev A.F., Doctor of Medical Sciences, Professor, Professor of the Department of Traumatology and Orthopedics

12. National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov, Moscow, member of ASOR.

13. Litvina E.A., Doctor of Medical Sciences, Supervisor of the First-Level Trauma Center of the Clinic of City Clinical Hospital named after M.P. Konchalovsky of the Moscow Healthcare Department, Professor of the Russian Medical Academy of Continuous Professional Education, Moscow

14. Mironov A.N., Head of Traumatology Department No. 1, City Clinical Hospital No. 13 of the Moscow Healthcare Department, Moscow.

15. Nazarenko A.G., Doctor of Medical Sciences, Professor of the Russian Academy of Sciences, Director of the National Medical Research Center of Traumatology and Orthopedics

16. named after N.N. Priorov of the Ministry of Health of the Russian Federation, Moscow, Vice-President of ASOR.

17. Otdelenov V.A., Candidate of Medical Sciences, Head of the Department of Rational Pharmacotherapy and Drug Supply Analysis, National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov of the Ministry of Health of the Russian Federation, Moscow.

18. Solod E.I., Doctor of Medical Sciences, Professor, Head of the Function Implementation Department

19. National Medical Research Center of Traumatology and Orthopedics named after N.N. Priorov, member of ASOR.

Conflict of interest.

The working group on drafting clinical guidelines for the treatment of pelvic ring injuries has no conflicts of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

• Medical specialists:

  • trauma and orthopedic surgeons;

  • surgeons;

  • pediatric surgeons;

  • anesthesiologists-intensivists;

  • urologists;

  • obstetricians-gynecologists;

  • coloproctologists;

  • cardiovascular surgeons;

  • endovascular surgeones / specialists in X-ray endovascular diagnostics and treatment;

  • radiologists;

  • ultrasound diagnostics physicians;

  • functional diagnostics physicians;

  • emergency medicine physicians;

  • district general practitioners;

  • general practitioners (family physicians).

• Paramedics.

• Chief physicians (heads) of medical organizations.

• Deputy heads (managers) of medical organizations.

• Heads (managers) of a structural subdivision (department, unit, laboratory, office, squad, etc.) of a medical organization who are medical specialists.

• Heads (chief physicians, managers) of a structural subdivision engaged in medical activities in another organization.

Methods used for evidence collection/selection

The development of these clinical guidelines was based on the guideline document "Pelvic Trauma: World Society of Emergency Surgery (WSES) Classification and Guidelines" (2017) in a Russian adapted translation [25]. Methodology: "A bibliographic search was conducted in the MEDLINE, SCOPUS, and EMBASE databases for the period from January 1980 to December 2015 using keyword combinations with the Boolean operators "AND/OR": pelvis, pelvic, injuries, trauma, resuscitation, sacral, bone screws, fractures, external fixation, internal fixation, anterior and posterior fixation, hemodynamic instability/stability, tamponade, pubic symphysis, angioembolization, pelvic belt, aortic, balloon, occlusion, resuscitative, definite, stabilization. There were no search parameter restrictions. The study time frame was chosen to ensure full access to clinical studies, consensus conferences, comparative studies, congresses, clinical guidelines, government publications, multicenter studies, systematic reviews, meta-analyses, large case series, original articles, and randomized controlled trials. Case reports and small case series were excluded. Not a single randomized controlled trial was found (one randomized controlled trial [19] was found during the preparation of these clinical guidelines — italics ours). Narrative reviews were also analyzed to identify suitable studies."

Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Level of evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The update mechanism for clinical guidelines involves their systematic review — at least once every three years, as well as upon the emergence of new evidence-based data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or when justified additions/comments to previously approved clinical guidelines arise, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1. Guidelines for pain management in major musculoskeletal trauma (surgical interventions for long bone fracture fixation or complex articular fracture, extensive soft tissue trauma, major surgery, etc.) in adults

The table presents analgesic medications and their dosage regimens in accordance with the Clinical Guideline for Pain Management in Acute Musculoskeletal Trauma [213].

Appendix A3.2. Guidelines for pain management in musculoskeletal trauma without surgery (closed fractures, superficial wounds, etc.) in adults

The table presents analgesic medications and their dosage regimens in accordance with the Clinical Guideline for Pain Management in Acute Musculoskeletal Trauma [213].

Appendix A3.3 Analgesic dosage regimen for children

¹ In children under 12 years of age, morphine** is preferred when opioid analgesics need to be prescribed, as the use of tramadol** is associated with a higher risk of adverse reactions [257,258].

² Not recommended for use in children, as its metabolite accumulates in the body and provokes seizures upon repeated administration [259].

Appendix A3.4. Recommended dosage regimen of low-molecular-weight heparins for the prevention of high-risk VTE in conservative treatment and orthopedic surgery in adult patients at high risk of VTE

The table is compiled based on the instructions for medical use of parenteral anticoagulants.

It should be noted that spinal or epidural anesthesia can only be performed 12 hours after the administration of a low-molecular-weight heparin dose and no earlier than 4–6 hours after the administration of unfractionated heparin (meanwhile, APTT or ACT values must be within the normal range) [235].

Appendix A3.5. Recommended intervals between prophylactic anticoagulant administration and neuraxial interventions [12]

Time intervals between neuraxial intervention and anticoagulant administration are presented in accordance with the European Guidelines on Perioperative VTE Prophylaxis [12].

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

In cases of pelvic ring injuries, emergency hospitalization to a hospital is indicated to rule out life-threatening conditions such as internal bleeding and pelvic organ trauma. After examinations (radiography, abdominal and pelvic ultrasound), the treatment method is determined: conservative (for mild injuries) and surgical (for moderate and severe injuries). Conservative treatment involves positioning therapy or skeletal traction with prolonged bed rest for 2–2.5 months. Surgical treatment includes hemostasis methods and primary stabilization by applying external fixation devices. Subsequently, once the patient's condition stabilizes, the approach transitions to definitive stabilization using external fixation devices (reusable external orthopedic fixation systems) or internal implants (non-absorbable, sterile internal orthopedic fixation systems using plates/screws).

Pelvic injuries may also be accompanied by injuries to intrapelvic organs, which requires surgical treatment. One-stage or staged treatment of bladder and urethral ruptures can be used: closure of bladder ruptures, urethroplasty, or creation of an epicystostomy followed by subsequent bladderoplasty with closure of the bladder wall defect.

The use of surgical treatment methods for the pelvic ring allows for early mobilization of both young and elderly patients. Patients are mobilized with crutches/walkers 5–7 days after surgery, provided there are no contraindications related to the patient's general condition, and walking with assistive support is prescribed for a period of 2–3 months.

Control radiographs are performed at 2–3 months, based on which the physician decides on expanding the orthopedic regimen.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1 — Injury Severity Score

Abbreviated Injury Scale (AIS) [208]

Developer website: https://www.aaam.org/abbreviated-injury-scale-ais/

Type (underline): rating scale

Purpose: assessment of injury severity.

Content: a system of scoring criteria for assessing injury severity

Key (interpretation): 

The politrauma severity (Injury Severity Scale — ISS) in points is equal to the sum of the squares of the AIS severity scores of the three most severe injuries across the following six body regions <*>:

1. head and neck;

1. face;

2. chest

2. abdomen, retroperitoneal space, and pelvic contents;

3. extremities and pelvic girdle

4. external injuries

<*> Note: the division of body regions according to ISS does not correspond to the AIS division.

Polytrauma severity assessment criteria (Injury Severity Score — ISS) [209]:

1. mild: less than 17 points;

2. stable: 17–25 points;

3. borderline: 26–40 points;

4. critical: more than 40 points.

Example of ISS politrauma severity calculation:

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