Overview
Definition:
A Zone III pelvic hematoma refers to a significant collection of blood in the retroperitoneal space, typically extending from the iliac vessels and sacral plexus, associated with pelvic ring disruptions
These hematomas are often large, poorly demarcated, and difficult to control due to the extensive vascular supply of the pelvic bones and associated venous plexuses.
Epidemiology:
Occurs in approximately 20-40% of patients with severe pelvic ring injuries, particularly those with open book or vertical shear fractures
They are associated with high morbidity and mortality rates, estimated at 30-60% if not managed promptly and effectively.
Clinical Significance:
Zone III pelvic hematomas pose a significant threat to life due to massive hemorrhage, hemodynamic instability, and potential for secondary organ damage
Prompt recognition and aggressive management are crucial for patient survival and for minimizing long-term complications and disability
Understanding their management is a core competency for trauma surgeons preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Hypotension or shock
Tachycardia
Abdominal distension
Pelvic pain
Decreased urine output
Signs of blood loss: pallor, diaphoresis
May be obscured by other injuries or sedation.
Signs:
Pelvic instability (rocking test positive)
Abdominal tenderness or guarding
Flank ecchymosis (grey-turner sign) or scrotal/labial ecchymosis (strangulation sign) may develop late
Rectal or vaginal examination may reveal a palpable mass or blood
Palpable pulsatile mass in lower abdomen or flank suggests arterial source.
Diagnostic Criteria:
No specific formal diagnostic criteria
diagnosis is primarily clinical and radiological
Based on mechanism of injury (high-energy trauma), pelvic ring instability, and evidence of hemodynamic compromise in the presence of a pelvic fracture
CT angiography is the gold standard for confirmation and characterization.
Diagnostic Approach
History Taking:
Mechanism of injury is paramount (fall from height, vehicular collision)
Hemodynamic status (blood pressure, heart rate)
Previous medical history (anticoagulation use, coagulopathy)
Volume of blood loss
Duration of symptoms.
Physical Examination:
Rapid primary survey focusing on ABCDEs
Thorough secondary survey including detailed abdominal and pelvic examination
Assess for pelvic instability carefully to avoid exacerbating hemorrhage
Check for perineal, scrotal, or labial ecchymosis
Perform rectal and vaginal examination.
Investigations:
Complete Blood Count (CBC): Monitor hemoglobin and hematocrit
may be normal initially due to fluid resuscitation
Coagulation profile (PT, aPTT, INR): Essential to identify coagulopathies
Type and Screen/Crossmatch: Essential for anticipating blood transfusion requirements
CT Angiography: Gold standard to identify bleeding vessels, hematoma size and location, and associated injuries
Pelvic X-ray: To assess pelvic ring disruption and guide initial management.
Differential Diagnosis:
Intra-abdominal hemorrhage from other sources (solid organs, bowel)
Ruptured abdominal aortic aneurysm
Large subcutaneous hematoma
Urological or gynecological bleeding unrelated to pelvic fracture.
Management
Initial Management:
Aggressive resuscitation with intravenous fluids and blood products (packed red blood cells, fresh frozen plasma, platelets in a 1:1:1 ratio)
Hemodynamic stabilization is the priority
Temporary pelvic stabilization with a pelvic binder or external fixator to tamponade bleeding and reduce further displacement
Prompt consultation with trauma surgery, interventional radiology, and orthopedic surgery.
Medical Management:
Reversal of anticoagulation if indicated
Correction of coagulopathy with fresh frozen plasma, cryoprecipitate, or prothrombin complex concentrate
Transfusion of packed red blood cells to maintain hemoglobin > 7-8 g/dL
Administration of tranexamic acid within 3 hours of injury to reduce bleeding.
Surgical Management:
Indications include hemodynamic instability refractory to resuscitation and angioembolization, suspected arterial injury not amenable to embolization, or massive venous hemorrhage
Options include: 1
Angiographic embolization: Preferred first-line intervention for arterial bleeding
2
Pelvic packing: Temporary control of venous and capillary bleeding by packing the retroperitoneum
3
Definitive surgical exploration: Ligation of bleeding vessels (internal iliac artery ligation), direct repair of injuries, or definitive pelvic fixation
Often requires a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, and interventional radiologists.
Supportive Care:
Continuous hemodynamic monitoring (arterial line, central venous pressure)
Mechanical ventilation if required
Strict fluid balance monitoring
Pain management
Deep vein thrombosis prophylaxis
Nutritional support
Intensive care unit admission.
Complications
Early Complications:
Exsanguination and death
Hemorrhagic shock
Organ hypoperfusion
Acute kidney injury
Compartment syndrome
Fat embolism syndrome.
Late Complications:
Chronic pain
Limp and gait disturbances
Neurological deficits (pudendal nerve injury)
Sexual dysfunction
Chronic pelvic instability
Infection
Pseudoaneurysm formation.
Prevention Strategies:
Early recognition of pelvic fractures and associated injuries
Prompt and aggressive resuscitation
Timely pelvic stabilization
Judicious use of pelvic packing and angioembolization
Careful surgical technique during exploration to minimize further bleeding
Early identification and management of coagulopathies.
Prognosis
Factors Affecting Prognosis:
Severity of pelvic ring injury
Degree of hemorrhage and hemodynamic stability
Presence of associated injuries (head, thoracic, abdominal)
Timeliness and effectiveness of management interventions (resuscitation, embolization, surgery)
Age and comorbidities of the patient.
Outcomes:
With prompt and effective management, survival rates can be improved significantly
However, patients may still experience long-term functional deficits and pain
Mortality rates remain high for unstable Zone III hematomas requiring emergent surgical control.
Follow Up:
Long-term follow-up is essential, typically managed by orthopedic surgery and rehabilitation specialists
This includes monitoring for pain, functional recovery, and potential late complications
Serial imaging may be required to assess healing and stability.
Key Points
Exam Focus:
Zone III hematomas are retroperitoneal and associated with high-energy pelvic fractures
Angiography with embolization is the primary treatment for arterial bleeding
Pelvic packing is crucial for venous/capillary oozing and in unstable patients awaiting definitive fixation
Hemodynamic stability is paramount.
Clinical Pearls:
Never underestimate the bleeding potential of pelvic fractures
A negative initial FAST exam does not rule out pelvic hemorrhage
Consider tranexamic acid early
Pelvic binders should be applied quickly to tamponade bleeding
Reassess the need for pelvic packing or embolization if the patient remains hemodynamically unstable despite initial resuscitation.
Common Mistakes:
Delaying resuscitation and blood transfusion
Performing pelvic external fixation before controlling hemorrhage
Failing to consider angioembolization for arterial bleeding
Inadequate management of coagulopathy
Disregarding the need for pelvic packing in hemodynamically unstable patients with venous oozing.