1. Orthopaedic Trauma Surgery Kentucky Trauma Symposium 2012
Pelvic fracture
Management
Erik Hasenboehler MD
Orthopaedic Trauma Surgery
Baltimore MD
Kentucky Trauma Symposium 2012

3. Subjects Basic Polytrauma management Polytrauma basic science
Pelvis Exam, Stability and managment
Acute treatment of pelvic ring injuries
Open Pelvis fracture

4. and Polytrauma Management
Pelvic fracture
and Polytrauma Management
One goal !!!!!!!
Pelvic ring fractures are mostly caused by high-energy impact, and, therefore, are often related (up to over 60%)
to multiple traumas with chest, abdomen, spine, head and long bones fractures. Thanks to a common goal to safe
the patient’s life improving intensive care and trauma management, survival rates have improved over the years,
but still can range between 5-50%.
Save the patient`s life !

5. ATLS: Structured Trauma Care
Phases of Management
Primary Survey
Resuscitation
Secondary Survey
Definitive Care
Tertiary Survey
Airway
Breathing
Circulation
Disability
Exposure
it is of utmost importance to recognize life threatening injuries of pelvic fractures or other body regions.
Accordingly, it is important to have a structures trauma care based on the ATLS model. However despite
ATLS, many of the recommendations are nonspecific and not adequate for hemorrhage control in patients
with hemodynamically unstable pelvic fractures. Thus secondary to the diversity of pelvic fractures,
if stable or unstable type.
Hemodynamically Unstable Pelvic Fracture Management by Advanced Trauma Life Support Guidelines Results in High Mortality . Orthopedics 2012
Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009

6. Steps of Acute Management
Assess
Physical Exam
Labs, Physiology
Images
Stabilize
Resuscitate
Contain
Sheet/Ex fix/C-clamp
As mentioned a good exam and adequate patient’s resuscitation are vital for the acute pelvic
fracture management and if necessary a pelvic damage control approach should be applied.
Damage control orthopaedics in unstable pelvic ring injuries. P.V. Giannoudis and H.C. Pape, Injury 2004

7. Basic Science of Trauma
First Hit
Primary injury response
Second Hit
Incomplete resuscitation
Hemorrhage
Prolonged surgery
Systemic Inflammatory Synergistic Inflammatory
Just a quick step back to basic trauma science. Most of you have heard the two hit model or second hit phenomenon. This is a widely accepted model that addresses the inflammatory status in the immediate aftermath of trauma with an early systemic inflammatory response, known as the systemic inflammatory response syndrome (SIRS), followed by a counter synergistic inflammatory state known as CARS (counter-regulatory anti-inflammatory response). Improper initial trauma management with incomplete resuscitation, prolonged hemorrhage or surgery can worsen the physiologic first hit adding a second hit, increasing the risks for ARDS and MOF.
Second hit phenomenon: Existing evidence of clinical implications Lasanianos et al Injury 2012

8. Two Hit Model MOF MOF Infection Severe SIRS Moderate SIRS Moderate
Delayed definitive surgery
First
insult
Moderate SIRS
Moderate
immuno-suppression
On a summary graph this would look like this. The first insult activates SIRS followed by a moderate immunnosuppression (CARS). But when the activation of the immunoinflammatory system (First insult) is exaggerated or re-triggered (second insult), the patient may enter a malevolent state of severe SIRS leading to severe immunosuppression with increased risk of adult respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS).
If the initial response is well tolerated, the patient progresses through a moderate period of physiological stress without developing too many complications.
2nd
insult
Severe
immunosuppression
Definitive surgery
EARLY
Infection
MOF
Moore FA and Moore EE. Surg Clin North Am. 1995

9. Secondary Period
Old concept: Day 1, 5-7 (window of opportunity) and after 14 days
Patients operated on day 2-4 vs day 5-8 worse inflammatory changes
Avoid significant surgery on days 2-4 for patients at risk
For more severely injured patients a longer waiting period may be needed
The triggering of a ‘second hit’ mainly depends on the timing of surgical interventions. Although choosing a time point for definitive fixation a few days after trauma can minimizes the risk of this detrimental immunologic response, a delayed fixation can also forward local and systemic complications. Therefore the old concept where patient should have been operated on only at day one, 5-7 window of opportunity where SIRS and CARS overlap or after 14 days when CARS is recovering, is no longer a valid concept.
New evidence has demonstrated that patients can be definitively managed at early stage if stable and well resuscitated, while a controlled approach should be more reserved for the unstable and at extremis patient with higher ISS, pulmonary contusions, multiple injuries and or fractures, severe acidosis or low temperature.
Damage control orthopaedics in unstable pelvic ring injuries. P.V. Giannoudis and H.C. Pape, Injury 2004
Damage control orthopedics: current evidence Lichtea et al CO-Critical Care 2012
Second hit phenomenon: Existing evidence of clinical implications . Lasanianos et al. Injury 2011

10. Pre- Hospital: Devastating injury
Polytrauma patients with pelvic fracture and associated injuries are more likely to expire during the first hours after injury

11. Hospital-Acute/Primary: shock, hypoxia or head injury
Adding a second insult to these patients during the early phase can increase their mortality leading them to

12. Hospital-Secondary/Tertiary: MOF or ARDS

13. Measurable Risk Factors
HD unstable or difficult resuscitation
Under resuscitation
Shock and > 25 units PRBC’s
Thrombocytopenia ( platelets < 90,000)
Hypothermia (< 32° C)
Bilateral lung contusions on initial x-ray
Multiple long bone fractures and truncal AIS >2
Presumed OR time > 6 hours
Exaggerated inflammatory response (IL-6> 800 pg/ml)
Here a summary of all measurable risk factors for unstable patients
Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012
Keel M, Trentz O. Pathophysiology of polytrauma. Injury 2005
Giannoudis PV. Current concepts of the inflammatory response after major trauma: an update. Injury 2003
Tschoeke SK, et al. The early second hit in trauma management augments the proinflammatory immune response to multiple injuries. J Trauma 2007

14. Causes of Death from Pelvis Fractures
< 24 hours: blood loss
> 24 hours: MOF
Exsanguination caused 75% of the deaths 14

15. Orthopaedic Damage Control
“… temporary stabilization of fractures soon after injury, minimizing the operative time, and preventing heat and blood loss.”
In severely injured patients, initial orthopaedic surgery should not be definitive treatment
Definitive treatment delayed until after patients overall physiology improves
Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012

16. Damage Control
The damage control orthopedics concept uses minimally invasive surgical techniques for the primary stabilization of
all major fractures to control hemorrhage and stop the cycle of ongoing immunological impact of unstable long bone
fractures. Similar to the strategy used by the NAVY when controlling damages to a ship to prevent sinking.

17. Minimize the Second Hit
The purpose of DCO is to minimize the Second Hit.

18. Assess
Treatment of pelvic ring injuries is usually a multidisciplinary activity
Trauma, Orthopaedics, Radiology
Urology/Gynecology
Resuming our concept of pelvic fracture management, we have to remember that it is a multidisciplinary management.

19. Lots to bleed Big space to bleed into
The pelvis should be seen as a big space that allows lot of

20. Volume Changes in the True Pelvis During Disruption of the Pelvic Ring – Where does it go?
A change of volume of the true pelvis during a pelvic ring disruption will inevitably increase the intrapelvic space,
allowing for a greater volume increase.
Volume increase - r3
Volume increase 1 – 2L
Moss and Bircher, 1996
Effects of Pelvic Volume Changes on Retroperitoneal and Intra- Abdominal Pressure in the Injured Pelvic Ring: A Cadaveric Model Köher et al 2011

21. Physical Exam OBTAIN INFORMATION FIRST Perform a FULL physical exam
Evaluate lower extremities position Shortening/Rotation
Skin Ecchymosis
Open wound Around the pelvis
!!!!Be alert for open pelvic fractures!!!
Neurovascular exam
Information obtained from emergency medical personnel regarding details of the mechanism of injury and initial
patient presentation may be useful in raising suspicion for a pelvic fracture and the presence of associated injuries.
Using guidelines of ATLS we can obtain relevant information during the primary survey with a full physical exam
OBTAIN INFORMATION FIRST

22. Physical Exam Palpate anterior pelvis Watch for perineal Lacerations
Scrotal/Labial Swelling
Flank Ecchymosis 22

23. Physical Exam Turn the patient!
Turn the patient to not miss significant soft tissue signs, or open wounds communicating with the pelvis.
Rectal and vaginal examination are of utmost importance during the initial evaluation to rule out the presence
of an open fracture and a high-riding prostate may indicate the presence of a periurethral or periprostatic
hematoma oc curring secondary to genitourinary injury.
Turn the patient!

24. Physical Exam Morel-Lavalle lesions Degloving of the flank, thigh
Large dead space
Increased incidence of infection
Don’t underestimate a flank ecchimosis, AKA Morel Lavalle Lesion, which is very often associated
with a pelvic ring injury and a sing for a traumatic degloved dead space that can increase the incidence
of infection.

25. #2: Is the Injury Pattern “Stable” or “Unstable”?
After a full physical exam the pelvis should be assessed for stability

26. Rotational Stability AP Compression Lateral Compression
One Positive Exam Only!
Clinical examination as demonstrated by Gonzalez can be sensitive up to 93% for the identification of
pelvic fracture in the conscious and interactive patient. Palpation of the anterior pelvis may demonstrate
a symphyseal gap indicative of diastasis. Compression testing in the anteror posterior direction through
applied downward pressure on the anterior superior iliac spines (ASISs) and in the lateral direction via
compression of the iliac crests is performed in an effort to identify pelvic rotational instability.
Be aware that pelvic compression should be limited to a single attempt, in an effort to limit repeated
disruption of fracture site clots.
Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg 26

27. Physical Exam Abnormal position of the lower extremity
Watch for abnormal leg positioning, i.e. leg shortening or external rotation, an index for a VS or APC
type pelvic fracture
Abnormal position of the lower extremity

28. Pelvis “Stability”
ALWAYS a combination of x-rays and a clinical exam
A single x-ray is a static view
May have been way more displaced at the time of injury
Assessment of pelvis stability is based on the combination of x-rays and clinical exam. 28

29. Imaging- AP pelvis Part of ATLS
Shows obvious, grossly unstable injuries
Obtain Inlet Outlet views
In an HD unstable patient DO NOT get more films
Part of the standard ATLS trauma radiographs are an anteroposterior (AP) view of the chest, a
lateral view of the cervical spine, and an AP view of the pelvis. The AP of the pelvis can be used
to look for anterior injuries (pubic rami fractures and sym- physis displacement), sacroiliac joint
and sacral fractures, iliac fractures, and L5 transverse process fractures. Additionally inlet and
outlet views of the pelvis should be performed to evaluate anterior posterior displacement of the
SI joint, sacrum, iliac wing or vertical displacement of the hemipelvis. 29

30. Vertical Stability Push pull on leg while palpating the ASIS
A stress view can be performed in the ER setting to assess vertical stability. A push-pull
force is applied through the limb; the hemipelvis is unstable if it moves greater than up to 1 cm. 30

31. CT Scans Blush= embolizable arterial injury!
A CT scan is helpful in evaluating the pelvic ring disruption, the sacroiliac complex to determine if
vertical instability is present and evaluate retroperitoneal hematomas. 31

32. “Stabilizing” Theories
Decreases pelvic volume
Prevents gross motion, clot disruption
Reduces cancellous bony bleeding
The primary goal of pelvic ring stabilizations is to decrease the pelvic ring volume which helps
preventing from further motion, disruption and bleeding. 32

33. Why is Stability Important?
APC 2, 3; LC 3; VS
LC3
The utilization of a pelvis classification helps the treating surgeon develop a management
strategy and predict potential associated injuries and prognosis. There are several classifications
available, such as the Tile, Young and Burgess and the AO-OTA. Here is the Y-B classification which
is based primarily on the mechanism of injury and is currently the most widely used system.
The force vector determines the injury and pelvis instability. Highlighted in red are the most unstable
pelvic fracture patterns with the VS type being the most unstable with vertical displacement of the
hemipelvis secondary to fractures ant and post.
APC2,3 VS 33

34. LCIII- 14% VS - 25% APC II- 25% APC III- 37% Mortality Rate
Among the pelvic fracture types the one with major ligament disruption (APC II/III, LC III, VS) are more
likely to require transfusions, with Patients with APC 3 and VS fractures requiring the most amount of blood.
Magnussen et al. Predicting blood loss in isolated pelvic and acetabular high- energy trauma. J Orthop Trauma. 2007
Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007; 34

35. Transfusion Requirements
Lateral Compression - 3.6
Combined Mechanical- 8.5
Vertical Shear - 9.2
AP Compression
Correlated to RBC units, APC 3 and VS pelvic fx can require up to 15 units of blood.
Hemorrhage occurs up to 75% of patients with high energy injuries
Magnussen et al. Predicting blood loss in isolated pelvic and acetabular high- energy trauma. J Orthop Trauma. 2007
Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007; 35

36. WHAT TO USE TO STABILIZE THE PELVIS
In the emergent setting a number of options for provisional pelvic stabilization are available to help
tamponade bleeding in patients with pelvic fractures who are hemodynamically unstable. pneumatic
anti-shock garment (PASG), wrapping a sheet around the pelvis, or placing a pelvic binder on arrival,
as well as more definitive fixation with an anti-shock pelvic clamp (C-clamp) or traditional anterior external fixation.

37. MAST / PASG
PASG, also known as a military anti-shock trouser, is sometimes still used in the pre-hospital and
emergency room setting to increase blood pressure, reduce pelvic fractures, and tamponade hemorrhage,
however this “stabilization” option should be avoided since a number of problems have occurred including
lower extremity ischemia and compartment syndrome. Further the PASG is bulky, and when in place,
it is difficult to access the abdomen, genitourinary system, and lower extremities

38. Sheet or Binder
what is best a sheet or a binder 38

39. Pelvic Binder Easily applied during resuscitation Portable
The binder is a good, easy and reliable solution, if applied properly 39

40. Acute Management SAM Sling / T-POD / Circumferential Sheet: TOO HIGH!!
It has to be placed at the proper height at the level of the greater trochanter.
TOO HIGH!!
Greater Trochanter!!
Pelvis and Acetabulum
Frontline Treatment

41. Pelvic Sheeting Correct Incorrect Routt et all JOT 2002
Circumferential compression with a sheet around the pelvis is a cheap, very reliable and available
to everyone method for an emergent stabilization of the pelvis reducing the pelvic volume in
open-book pelvis fractures. The sheet should be placed at the level of the greater trochanter and
wrapped tightly around the patient and secured with a clamp or cable ties. A bolster should be
placed under the knees and the lower thighs, and ankles should be bandaged together to help stabilize the pelvis.
Incorrect
Routt et all JOT 2002

42. Traction Alone or in combination with sheet/ binder/ ex fix
Particularly useful for vertical shear injuries
Prevents vertical migration
Traction pins are very useful for vertical shear injuries and can be
applied in combination with any other stabilization. 42

43. Anterior External Fixation Disadvantages
Can cause a different deformity
Poor control of posterior pelvic ring
Pin tract infections
It’s not that easy
External fixation with a front Ex-fix can be placed at two sires, either in the ASIS or AIIS.
This constract is suboptimal in emergent clinical settings since it provides only poor control
of the posterior pelvic ring, it can cause 43

44. Pelvic C-Clamp
Described by Ganz in 1991 the C-Clamp is a very useful and quickly applicable tool for
emergent pelvic stabilization. However, C-clamp application requires an efficient triage
set-up and readily available orthopaedic surgeon.
Ganz R, et al. The antishock pelvic clamp. Clin Orthop Relat Res

45. AIRS: I agree that the incidence of arterial bleeding after high energy pelvic trauma is 10%
Patients with a pelvic fracture who are hemodynamically unstable despite aggressive
fluid resuscitation and mechanical stabilization, may be a candidate for pelvicangiography.
Who among you thinks that ………
Yes
No- I think it is higher

46. Who should get angiography?
Rationale: fracture (cancellous) / venous > 90% arterial < 10%
Pelvic angiography remains a topic of controversy. Its rationale should be based on the fact that bleeding is not only arterial,
but also venous and cancellous. Therefore angio can not controle the venous and bony bleeding. Further taking a patient
back to ANGIO suite can be time consuming and may delay taking a patient back to the OR.

47. Who should get angiography?
Rationale: fracture (cancellous) / venous > 90% arterial < 10%

48. Huittinen VM, Slatis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454–62
Kataoka Y, Maekawa K, Nishimaki H, et al. Iliac vein injuries in hemodynamically unstable patients with pelvic fracture caused by blunt trauma. J Trauma 2005;58:704– 10.
Baque P, Trojani C, Delotte J, et al. Anatomical consequences of ‘‘open-book’’ pelvic ring disruption: a cadaver experimental study. Surg Radiol Anat 2005;27:487–90.
Papadopoulos IN, Kanakaris N, Bonovas S, et al. Auditing 655 fatalities with pelvic fractures by autopsy as a basis to evaluate trauma care. J Am Coll Surg 2006;203:30–43
Huittinen V, Slatis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454—62.
Kadish L, Stein J, Kotler S. Angiographic diagnosis andtreatment of bleeding due to pelvic trauma. J Trauma 1973;13:1083—6.
Motsay GJ, Manlove C, Perry JF. Major venous injury with pelvic fracture. J Trauma 1969;9:343–6.
Patterson FP, Morton KS. The cause of death in fractures of the pelvis. J Trauma 1973;13:849–56.
Peltier LF. Complications associated with fractures of the pelvis. J Bone Joint Surg Am 1965;47:1060–9.
Yosowitz P, Hobson 2nd RW, Rich NM. Iliac vein laceration caused by blunt trauma to the pelvis. Am J Surg 1972;124:91–3.

49. Pohlemann T. et al. Tech Orthop 1994
The technique of retroperitoneal packing has been successfully used in some institutions
since many years. Tamponades are applied in the paravesical and presacral spaces in an
attempt to tamponade the bleeding.
In combination with C-Clamp and ex-fix not only mechanical stability can be provided, but
also pelvic tamponade. The packing is usually changed or removed 48 h after injury.
This technique has demonstrated a Mortality rate of around 25%, compared to Angio which
can reach up to 95%.
Cothren CC, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007
Suzuki T, Smith WR, Moore EE, Pelvic packing or angiography: competitive or complementary? Injury 2009
Ertel W, et al. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001
Tscherne H. et al. Crush injuries of the pelvis. Eur J Surg 2001

50. TREAT THE PATIENT BASED ON HIS NEEDS……. DCO VS ETC
Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012

51. Open Pelvis Fracture
A direct communication of the pelvic injury with the outside world
Open fractures of the pelvis are devastating injuries with a very high mortality rate.
Their defined as a pelvic fracture associated with an open wound communicating
to the outside. Luckly they are very rare.
Dente et al AJS 190, 2005

52. Think of the open pelvis as a marker that something very bad has happened and other things are likely wrong with this patient

53. Open Fractures
Air in the pelvis on XR is an open fx until proven otherwise
Require early I&D
Consider diverting colostomy
Antibiotics
Increased effectiveness if in first 6 hours
2-4% of all pelvic fractures
45% mechanically unstable
> 50% hypotensive on admission
5-45% mortality (most >25%)
Early treatment focusing on an appropriate approach with hemorrhage and sepsis control is essential.
Antibiotics should be given as for any other open fracture, repeat wound debridement should be
considered for heavily contaminated wounds, and diverting colostomy if required for wound control,
is compulsory and safe to reduce the risk for early sepsis and mortality.

54. Open Pelvis Fractures Many potential open wound sites: abdominal wall
thigh
scrotum
vagina
rectum
buttocks
perineum
Wounds can be located at different locations around the pelvis………. Remember to examine the patient and to turn him.

55. Significance of Soft Tissue Injury
In addition to the challenges of a pelvic ring injury you also have
Lost the ability of the retroperitoneum to tamponade bleeding
The open wound allows contamination of the fractures and the soft tissues of the pelvis
Remember that when you are faced with the treatment of an open pelvic fracture, hemorrhage control will be more difficult,
since you will not have the effect of retroperitoneal tamponade and also infections will be higher.
Dente et al AJS 190, 2005
M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

56. Initial Treatment DAMAGE CONTROLE ONLY!!! ATLS
Resuscitation: fluid and blood as needed
Stability: Binder/ sheet/ ex fix/ traction
Bleeding: Stability/ angio/ packing/ resuscitation
Management is very similar to closed pelvic fractures, with damage control as the only treatment in early phase………
DAMAGE CONTROLE ONLY!!!
Dente et al AJS 190, 2005
M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

57. Initial Treatment Soft tissue wounds bleed
Treat the soft tissue wound
Soft tissue wounds bleed
The hematoma is decompressed and draining onto the floor
Pack the soft tissue wounds
Don’t disregard the soft tissue and treat all open wounds… simple packing is a start
Dente et al AJS 190, 2005
M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

58. Mortality decreased to 25%
Initial Treatment
Selective early diverting ileostomy or colostomy
Mortality decreased to 25%
Don’t disregard the soft tissue and treat all open wounds… simple packing is a start
Brenneman FD, Kaytal D, Boulanger BR, et al. Long term outcome in open pelvic fractures. J Trauma 1997
Richardson JD, Harty J, Amin M, Flint LM. Open pelvic fractures. J Trauma 1982
M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

59. Mandatory Physical Exam
Rectal in everyone (injuries up to 64%)
Vaginal exam- especially with anterior ring fractures
Do not ever, ever, ever, ever, ever blow off vaginal bleeding as “that time of the month!!!!!!!!!!!!!”
Dente et al AJS 190, 2005
M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

60. Subsequent Treatment When stable:
Treat the wounds as any other open wound
Consider repeat wound I&D
Plan for definitive fixation if possible
Management is very similar to closed pelvic fractures, with damage control as the only treatment in early phase………
Dente et al AJS 190, 2005
M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

61. Mortality Mortality rate: Early mortality: exsanguinations
Pick a number: % or greater with intraabd. injury
The pelvic injury is directly responsible for a significant percentage of these deaths
Early mortality: exsanguinations
Require more transfusions than closed pelvic fractures
Late mortality: pelvic sepsis
Mortality in open pelvic fracture can be as high as 50% or higher and exsanguination should be remembered as the
cause for early mortality, while sepsis 2/2 contamination as the late mortality cause.
Dente et al AJS 190, 2005
M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

62. Summary Perform a proper exam and evaluate x-rays
Stabilize the patient >>> Find the Bleeding Source(s)
Perform DPL, US and CT if stable
Avoid Laparotomy with direct ligation (100% Mortality)
Pelvis packing vs. Angiography
Decide for DCO vs ETC 62

63. Summary Reassess How much blood has been given?
Has the patient stabilized?
Secondary survey
Associated injuries
Discuss surgical planning with other services
Consider colostomy and SP cath

64. Summary !!!!Have a Protocol!!!!
Institutional guidelines created with agreement of trauma surgeons and ortho surgeons
Listen to Ortho, they know more about these fractures and the potential for blood loss than they do
Protocol will be dependent on availability of angio, OR, surgeon preferences

66. Thank you