AANA Journal Course
Update for nurse anesthetists
Perioperative considerations in major orthopedic
trauma: Pelvic and long bone fractures
David D. Rose, CRNA, MAEd
David W. Rowen, CRNA, MSNA
Sacramento, California
Although pelvic fractures constitute a small percentage of
total orthopedic injuries, they are associated with the high-
est mortality rate. Pelvic fractures, along with long bone
fractures, frequently are the result of significant blunt
trauma often encountered in high-speed motor vehicle acci-
dents. However, other types of trauma can cause these dev-
astating injuries.
Early recognition and a high index of suspicion are nec-
essary to ensure that effective and aggressive resuscitation
is instituted immediately. Expeditious assessment in the
emergency department and care of the patient with pelvic
and long bone fractures will greatly enhance the ongoing
resuscitation in the operating room. Potentially life-threat-
ening associated injuries in these patients make resuscita-
tion even more challenging. Therefore, a basic knowledge of
the mechanisms of injury, early treatment in the emergency
department, and the factors that affect intraoperative man-
agement will help optimize the outcome for patients with
these injuries. This course describes the perioperative con-
cerns and the evaluation and treatment of a patient with a
pelvic or a long bone fracture.
Key words: Long bone fracture, orthopedic trauma, pelvic
fracture.
Objectives
Upon completion of this course, the reader should be
able to:
1. Describe how the mechanism of injury aids in the
diagnosis of pelvic fractures.
2. Detect the potential for hemorrhage and other
associated life-threatening injuries in the patient
with a pelvic fracture.
* The American Association of Nurse Anesthetists is accredited as a provider of continuing education in nursing by the American Nurses Credentialing
Center Commission on Accreditation. The AANA Journal course will consist of 6 successive articles, each with objectives for the reader and sources for
additional reading. At the conclusion of the 6-part series, a final examination will be printed in the AANA Journal. Successful completion will yield the
participant 6 CE credits (6 contact hours), code number: 24623, expiration date: July 31, 2003.
1
*6 CE Credits
3. Identify the preoperative treatment of the patient
with pelvic and long bone fractures in the emer-
gency department and how it relates to anesthetic
care.
4. Describe the perioperative management of a
patient with a pelvic or a long bone fracture.
5. Describe the significance of adequate volume
resuscitation and the ongoing evaluation of that
resuscitation in the patient with pelvic and long
bone fracture.
Introduction
Pelvic fractures constitute 3% of all fractures and are
the most serious orthopedic injury, with a mortality
rate of 50%.1 Pelvic and long bone fractures usually are
the result of blunt trauma and are the third most com-
monly encountered fatal injury from motor vehicle
accidents.2 Death usually occurs from exsanguination
or as a result of other lethal injuries. Pelvic fractures
also may occur with sharp trauma such as in gunshot
wounds and explosions. Patients who are admitted
with pelvic fractures often have associated life-threat-
ening injuries to the head, thoracoabdominal area, and
upper and lower extremities that affect their resuscita-
tion and eventual outcome.3 Early recognition and
aggressive resuscitation are vital to survival after this
devastating injury. This article briefly reviews the
mechanisms of injury that result in pelvic and long
bone fractures, followed by the pathophysiology asso-
ciated with these injuries. Finally, an overview of peri-
operative resuscitation strategies is given.
AANA Journal/April 2002/Vol. 70, No. 2 131
 Table 1. Apparent weights of the organs of the human
body during impact at various velocities
Apparent weight (kg)
Organ (actual
weight in kg) 36 km/h 72 km/h 108 km/h
Spleen (0.25) 2.5 10
Heart (0.35) 3.5 14
Encephalon (1.5) 15 60
Liver (1.8) 18 72
Blood (5.0) 50 200
Whole body (70) 700 2,800 6,300
(Published with permission from Besson A, Saegesser F. Color Atlas of Chest
Trauma and Associated Injuries. Vol 1. Oxford, United Kingdom: Blackwell
Science LTD; 1983:96.)
Mechanisms of injury
The gravitational forces that result in a pelvic fracture
from motor vehicle collisions, pedestrian vs automobile
accidents, and falls produce additional potentially
lethal injuries. They may include hemopneumothorax,
cardiac tamponade, and intra-abdominal hemorrhage.
Upper and lower extremity fractures and intracranial
trauma also are common injuries.3
Frontal impact collisions are the most common
automobile accident and result in a rapid deceleration.
The apparent weight of the human body is increased
significantly, based on the velocity at which it is travel-
ing, and can have a dramatic influence on the severity
of the injuries sustained (Table 1). Frontal impact
trauma associated with motorcycles and bicycles occurs
with similar injury patterns. However, these victims are
more vulnerable and absorb most of the transmitted
forces that result in significant soft tissue damage.1,4,5
The lateral impact collision has the potential for life-
threatening trauma. This mechanism of injury can
cause severe upper and lower body trauma that may
include cervical spine and thoracoabdominal injuries
and fractures to the humerus, pelvis, acetabulum, and
femur. The lateral impact mechanism accounts for
nearly half of all traumatic aortic ruptures, resulting in
a high mortality rate for this mechanism of injury.4
A trimodal injury pattern is seen in pedestrian vs
automobile trauma. Many of the victims of pedestrian
trauma are children or senior citizens. Adults hit by
cars sustain pelvic, acetabular, and lower extremity
fractures from striking the bumper and grill. Additional
thoracoabdominal trauma results when the upper torso
hits the hood and windshield. Head and upper extrem-
ity injury occurs when the body hits the ground. Trun-
cal injury should always be suspected when a pedes-
trian is admitted with head and lower extremity
injuries due to trauma.5
132 AANA Journal/April 2002/Vol. 70, No. 2
Figure. Anatomy of the pelvis
Aorta
Common
Iliolumbar Fracture
iliac artery
artery
Inferior
gluteal artery
22.5 Superior
gluteal artery
31.5 External
iliac artery
135
Superior
162 vesical artery
Inferior
vesical artery
450
Obturator
artery
Lateral
Middle rectal sacral artery
artery
Inferior Fractures
pudendal artery
(Published with permission from Brotman S, Soderstrom CA, Oster-Granite M,
et al. Management of severe bleeding in fractures of the pelvis. Surgery,
Gynecology, and Obstetrics. 1981;153:825.)
One of the most common causes of nonfatal injuries
is falls, which also are categorized as blunt injury
because of the abrupt change in velocity. The contact
surface and the change in velocity determine the injury
severity. Survival from a fall depends on the distance
traveled. The median lethal dose (LD50) is estimated to
be 4 stories (14.4 m), and the LD90 is 7 stories (25.2 m).5
The same principles of energy transference that gov-
ern blunt trauma apply to sharp trauma or gunshot and
high-velocity missiles. The degree of tissue damage
depends on the amount of energy transferred to the tis-
sue from the projectile, the time for the energy transfer,
and the surface area to which the energy is transferred.
The most important factor in determining damage of a
projectile is its velocity. The formula for kinetic energy
[Kinetic Energy = (Mass Velocity 2)/2] demonstrates
that doubling the velocity quadruples the kinetic
energy. Therefore, high-velocity projectiles will pro-
duce the most significant damage.5
Because of the bony anatomy and blood supply to
the pelvis, uncontrollable bleeding is likely when a
fracture occurs (Figure 1). Expected hemorrhage vol-
umes have been reported to be more than 1,000 mL
from humerus and femoral shaft fractures and more
than 1,500 mL from pelvic fracture.6 In 1 study, a
human cadaveric model demonstrated the pressure-
volume characteristics between an intact and a dis-
rupted pelvis. Although the pressure rapidly rose after
the administration of 5 L of lactated Ringers solution in
the intact retroperitoneum, infusion of as much as 20 L
of lactated Ringers solution did not elevate the
retroperitoneal pressure in the disrupted pelvic model.7
Table 2. Characteristics of pelvic fractures with appropriate examination and associated injury

Sign Examination Injury

Flank/buttocks contusion Visual and palpation Hemorrhage
Leg length discrepancy Visual Pelvic fracture
Scrotal hematoma Visual Urethral injury, with anterior
pelvic ring injury
Blood at urethral meatus Visual Urethral injury, with anterior
pelvic ring injury
Vaginal bleeding Vaginal with speculum Bowel injury
Rectal bleeding Anoscopy Bowel injury
Movement of pelvis Anterior-posterior pressure* Unstable fracture
Deformity of the pelvis Visual, anterior-posterior pressure Stable vs unstable fracture

*Anterior-posterior pressure is applied with hands over the anterior-superior iliac spines.

This study illustrates the potential for significant vol- Table 3. Classifications by associated injuries with
ume sequestration when the pelvic ring is disrupted, pelvic fractures
and findings are consistent with clinical data that show
the potential for severe blood loss. Significant bleeding Class I (potential for hemorrhage)
of the lower extremities also has been reported as a 1
Fractures meeting the Cryer criterion
result of arterial injury associated with other open frac-
Open-book injury/sprung pelvis
tures. Patients who sustain blunt trauma with bilateral
femur fractures often have additional life-threatening Open pelvic fractures
injuries that may include closed head and thoracoab- Class II (potential for genitourinary complications)
dominal injuries, pelvic fractures, and a higher risk of Pubic symphysis subluxation
adult respiratory distress syndrome and death.8 Straddle fracture
1
Evaluation and diagnosis Malgaigne fracture
Advanced trauma life support protocols are helpful in Bucket handle fracture
smaller and rural hospitals with limited personnel to Open-book injury/sprung pelvis
ensure a stepwise progression of trauma care. In
Class III (potential for orthopedic complications)
trauma centers, however, a team approach to resuscita-
Double breaks anywhere in the pelvic ring
tion is established and more comprehensive parallel
treatment is maintained. It is extremely important that Class IV (potential for neurologic complications)
the trauma patient is evaluated early and a high index Sacral fractures
of suspicion maintained until a pelvic fracture has been Acetabular fractures
ruled out.
Class V (uncomplicated)
Computed tomography scanning of the abdomen
Avulsion fractures
may be indicated for patients who are suspected of sus-
taining intra-abdominal injury but have stable vital Ischial body fractures
signs. If, however, the patient is hemodynamically Iliac wing fractures
unstable, evaluation for intra-abdominal injury is Single pubic/ischial rami and double unilateral
required, either by diagnostic peritoneal lavage or by rami fractures
abdominal ultrasound called focused assessment with Coccyx fracture
sonography for trauma. The latter modality permits
rapid, noninvasive assessment of the trauma patient in
unstable condition and identifies patients with fluid in have been developed to diagnose and categorize pelvic
the abdominal cavity. fractures.9 While informative to orthopedic surgeons,
Physical examination reveals distinguishing charac- these classifications are based on injury patterns and
teristics in patients with a pelvic fracture (Table 2). provide little clinically useful information to anesthesia
Numerous classification schemes and nomenclature care providers. A newer scheme has been established

AANA Journal/April 2002/Vol. 70, No. 2 133

 that classifies pelvic fractures based on the potential for
hemorrhage and associated injuries and actually may
help in the perioperative anesthetic management of the
patient1 (Table 3).
If a patient has an unstable pelvic fracture that is
contributing to hemodynamic instability, external fixa-
tion before surgery has been advocated. This procedure
may reduce the potential volume space by stabilizing
the pelvic fracture.10 However, an adverse result is that
the external device can be an obstruction to the sur-
geons during abdominal surgery and has been reported
to cause nerve damage.1,10-12
Another technique that has been advocated either
before or as an alternative to surgery is angiographic
embolization. Although effective for controlling arterial
hemorrhage, embolization fails to abate venous bleed-
ing, which accounts for the hemorrhage in 80% of
pelvic trauma.11 The use of embolization before surgery
in a patient who is hypovolemically unstable must be
weighed seriously against the possibility of underresus-
citation during the procedure.
Anesthetic management in the operating room
The hemodynamically unstable patient who presents to
the operating room requires immediate aggressive
treatment. A team approach to the anesthetic manage-
ment is imperative. Resuscitation of a blunt trauma
patient with an associated pelvic fracture is without a
doubt one of the most challenging anesthesia cases. In
addition, there are multiple anesthetic considerations
that require almost simultaneous evaluation and man-
agement. Therefore, a team approach cannot be
stressed enough. The primary goal of aggressive resus-
citation is hinged on effective volume replacement and
the ongoing evaluation of that replacement.
The treatment goal of fluid management centers
around sufficient circulating volume and effective oxy-
gen transport to already hypoxic tissues. Appropriate
vascular access is paramount in optimizing resuscita-
tive efforts. An arterial catheter provides necessary
information regarding arterial blood gases (ABGs), lac-
tate, base deficit, hemoglobin, and hematocrit to guide
fluid management. The type of crystalloid and colloid
used depends on the practice and philosophy of the
institution.
There are data in the trauma literature that support
the use of lactated Ringers solution over normal saline
for crystalloid replacement.13 These data suggest that in
massive hemorrhage, significantly more physiologic
derangement and mortality occurred with normal saline
than with lactated Ringers solution. In addition, colloid
replacement with hetastarch solutions, albumin, and
blood components will be necessary. One comprehensive
review of blunt trauma patients with an associated pelvic
134 AANA Journal/April 2002/Vol. 70, No. 2
fracture demonstrated the need for early aggressive col-
loid and crystalloid use in the first hour of resuscitation.9
Compounding the resuscitative efforts are the asso-
ciated injuries that result from blunt trauma. Manage-
ment of head trauma in tandem with the significant
hypotension from intra-abdominal and pelvic injury is
a formidable challenge. Cerebral perfusion pressure
(Cerebral Perfusion Pressure = Mean Arterial Pressure
Intracranial Pressure) should be maintained at 70 mm
Hg or higher to prevent cerebral ischemia.14-16 Until a
ventriculostomy is placed, vigorous attempts should be
made to maintain the mean arterial pressure at 90 mm
Hg.14 Associated brain injury with pelvic and intra-
abdominal trauma is ominous and is associated with a
high mortality rate (50%).1,2,9,11-16
There is evidence that supports better outcome with
the early treatment of pelvic and lower extremity frac-
tures in patients with associated head trauma.17 Early
fixation does not increase the number of or the severity
of adverse cerebral events and significantly decreases
pulmonary complications when hypotension and
hypoxia are avoided.17,18 In addition, a recent outcome
study revealed that early fixation of acetabular fractures
(within 24 hours) resulted in a lower incidence of mul-
tiple organ failure and improved functional outcome.19
Collateral damage from associated blunt trauma had a
more significant impact on the outcome of care in the
intensive care unit than did early fixation. Further-
more, delaying fixation did not improve the outcome of
the injured brain.20 Still, some believe that early fixa-
tion has a greater risk of increased fluid requirements,
hypotension, hypoxia, and secondary brain injury.21,22
External fixation of unstable femur fractures to
decrease bleeding as a bridge to intramedullary nailing
has been advocated as a form of orthopedic damage
control.23 Finally, new evidence has been reported that
major lower extremity surgery increases the inflamma-
tory, fibrinolytic, and coagulative cascades.24 This can
exacerbate an established coagulopathic situation and
further add to the inflammatory response.
The most challenging aspect of intraoperative anes-
thetic management is the ongoing fluid resuscitation.
Frequent ABG assessment provides necessary informa-
tion for the tempo of volume replacement. Colloid
replacement requirements are known to be exceedingly
high.10,11,25 A rate-limiting step in the exploration, repair,
and resuscitation is the coagulopathy associated with
blunt trauma and massive transfusion, which is defined
as more than 10 units of packed red blood cells.11,26
Normally, a delicate balance is maintained between
coagulation and fibrinolysis. This balance is disrupted by
many factors including the coagulation cascade, comple-
ment activation, endothelial damage, capillary leak, and
fibrinolysis. Disseminated intravascular coagulation
Table 4. Laboratory tests used for making the diagnosis of disseminated intravascular coagulation (DIC)
Test Normal value
INR 0.75-1.19
PT 17-25 s
aPTT 25-35 s
3 3
Platelets 150-450,000 mm
Fibrinogen 200-400 mg/dL
FDP < 10 /mL
D-dimer < 200 mg/mL
Most DIC panels include INR, aPTT, platelet count, fibrinogen, and either FDP or D-dimer.
aPTT = Activated partial thromboplastin time
FDP = fibrin degradation products
INR = International normalized ratio
(Adapted from Henry JB. Clinical Diagnosis and Management by Laboratory Methods. 18th ed. Philadelphia, Pa: WB Saunders; 1991:1377.)
(DIC) can occur as a result of blunt trauma, significant
blood loss, and massive transfusion. Disseminated
intravascular coagulation results in the consumption of
the coagulation factors and platelets, fibrinolysis, and
generalized bleeding.27,28 A DIC panel should be ordered
when massive transfusion states occur (Table 4). An
adjunct to a DIC panel is the thromboelastogram. A
thromboelastogram provides a dynamic picture of the
entire clotting process, measuring the speed of clot for-
mation, retraction, lysis, and consistency. A DIC panel, a
thromboelastogram, or both can help avoid the shot-
gun approach of blindly giving multiple products dur-
ing massive transfusions.28 Because coagulation studies
often lag behind in providing useful, timely data, it is
necessary to confirm that coagulopathy exists. Observa-
tion of the operative field also will provide clinical evi-
dence of microvascular bleeding, indicating ongoing
coagulopathy.
Another factor that has a direct impact on patient
outcome is hypothermia. Coagulopathy that results
from hypothermia is well documented.11,29 Hypother-
mia causes a reduction in coagulation and enzymatic
activity. In addition, fibrinolysis is enhanced and pro-
thrombin and partial thromboplastin times are pro-
longed significantly.30 Reduced cardiac function also
has been shown to occur with hypothermia.30 Specific
warming techniques should concentrate on the operat-
ing room environment and on fluid replacement. Nor-
mothermia should be a primary perioperative goal, not
only for its effect on coagulation, but also for its signif-
icant improvement of oxygen delivery.
A leftward shift in the oxyhemoglobin dissociation
curve decreases oxygen delivery by decreasing the
amount of oxygen released at the cellular level. This
Result Treatment
Fresh frozen plasma
Fresh frozen plasma
Fresh frozen plasma
< 40,000 mm
Platelets
(1 unit/10 kg in adult)
< 200 mg/dL Cryopercipitate
(1 bag/10 kg)
Fresh frozen plasma
Fresh frozen plasma
comes at a time when oxygen extraction is increased to
meet the demands of the hypotensive patient.31 There-
fore, the combination of hypothermia and hypotension
can have devastating results if measures are not taken
to evaluate the resuscitative efforts.
Measurement of ABGs provides an excellent evalua-
tion of oxygenation and perfusion status. FIO2 should
remain at 1.0 (100%) until the first ABG is obtained.
Changes following the initial ABG are done based on
the magnitude of the injuries sustained and the level of
resuscitation required. Base deficit and the lactate level
are excellent markers for assessing fluid resuscitative
efforts. In a recent study of hypotensive patients with
pelvic fractures, key indicators for resuscitation were
base deficit and blood pressure.32 Hypotensive patients
with a base deficit of 5 or less had a significantly
higher mortality rate. In addition, patients who left the
emergency department with a systolic blood pressure of
90 mm Hg or lower were more likely to die.32
In a retrospective review of 2,954 trauma patients,
the base deficit was used to predict transfusion require-
ments.33 The need for transfusion increased with wors-
ening base deficit, as did the incidence of adult respira-
tory distress syndrome, renal failure, coagulopathy, and
multiple organ failure. However, some rely on the lac-
tate level as the most sensitive indicator of successful
resuscitation.34 Using both the lactate level and the
base deficit as a guide to fluid replacement is advisable.
It is well established that the retroperitoneum has a
capacity of up to 4 L.11 Bleeding will continue unabated
until the venous pressure is overcome and tamponade
occurs.7,10,11 The patient in hemodynamically unstable
condition will need an emergency exploratory laparo-
tomy for damage control of large vessel and solid organ
AANA Journal/April 2002/Vol. 70, No. 2 135
 bleeding.1,10,11 Volume replacement remains the main-
stay of resuscitation for these patients.
Besides solid organ hemorrhage that accounts for
much of the blunt intra-abdominal injury, open pelvic
fractures may result in life-threatening rectal trauma.
Instability of a pelvic fracture and the presence of rectal
injury are the 2 factors that correlate with increased mor-
bidity and mortality.35 Fecal diversion with a colostomy
should be considered in patients with open pelvic frac-
ture, extensive tissue damage, and perineal wounds.35,36
No discussion of orthopedic injuries is complete
without including the risk for fat embolism. This is
especially true in the case of unstable pelvic and lower
extremity fracture. The incidence of fat embolism syn-
drome (FES) in isolated long bone fractures is 3% to
4%, with a significant mortality rate of between 10%
and 20%.35 Trauma patients with multiple injuries who
are male, between the ages of 20 and 30, and in hypo-
volemic shock are at the highest risk.37,38
The clinical and laboratory signs of FES are classi-
fied as major and minor39 (Table 5). For FES to be pos-
itively diagnosed, at least 1 major and 4 minor signs
must be present. The symptoms usually occur 12 to 40
hours after the injury, with decreased arterial oxygen
tension the most common laboratory abnormality.37,38
Fulminant FES has occurred within hours of trauma,
resulting in severe hypoxemia, respiratory failure, and
significant neurological deficit. Disseminated intravas-
cular coagulation also has been associated with FES.
The treatment of FES is first directed at early recog-
nition of the signs of the syndrome. Prompt volume
resuscitation for patients who are hypovolemic is criti-
cal. Early fracture stabilization and fixation has been
shown to decrease the risk of FES. Ventilator support is
needed in the more severe, fulminant cases of FES. One
case report described the movement of large-diameter
fat emboli through a patent foramen ovale that was
documented by Doppler.39 The foramen ovale is patent
in as many as 34% of the population and may be the
cause of the systemic manifestations associated with
FES.39 Perioperative transesophageal echocardiography
is an effective technique for monitoring for fat emboli
and has been used successfully to detect fat emboli in
approximately 40% of patients undergoing major
orthopedic procedures.41
Conclusion
Major orthopedic injuries that involve the pelvis and
long bones usually are associated with significant addi-
tional trauma that may involve the head, chest, and
abdomen. Understanding the mechanism of the injury
pattern is valuable for predicting associated life-threat-
ening conditions. Early evaluation and a high index of
suspicion for pelvic injury should be maintained in the
136 AANA Journal/April 2002/Vol. 70, No. 2
Table 5. Criteria for the diagnosis of fat embolism
syndrome first described by Gurd40*
Major criteria
Subconjunctival/axillary petechiae
Hypoxemia (PaO2 < 60 mm Hg with FiO2 < 0.4)
Central nervous system depression
(disproportionate to hyoxemia)
Pulmonary edema
Minor criteria
Tachycardia (> 110 beats per minute)
Hyperthermia
Retinal fat emboli
Urinary fat globules
Decreased platelet count/hematocrit
(unexplained)
Increased erythrocyte sedimentation rate
Fat globules in the sputum
*At least 1 major and 4 minor signs must be present to meet the criteria for fat
embolism syndrome.
hypotensive patient. Aggressive resuscitation is essen-
tial for survival.
Perioperative management is directed at ongoing
volume resuscitation previously instituted in the emer-
gency department. In addition, continuous warming
techniques must be used, and ongoing evaluation of
resuscitative efforts are imperative. Steps to prevent
DIC or early recognition of the syndrome should it
occur are an important part of the anesthetic plan.
Finally, there are very few trauma experiences that
are as challenging as a high-speed motor vehicle acci-
dent with blunt trauma and associated pelvic and long
bone fractures. The first thought should be to get help!
This can be from a fellow anesthesia care provider or an
operating room nurse. These cases are extremely labor
intensive and require an extra pair of hands (or 2 or 3)!
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AUTHORS
David D. Rose, CRNA, MAEd, is chief nurse anesthetist, Department of
Anesthesiology and Pain Medicine, University of California Davis Med-
ical Center, Sacramento, Calif.
David W. Rowen, CRNA, MSNA, is senior nurse anesthetist,
Department of Anesthesiology and Pain Medicine, University of Califor-
nia Davis Medical Center, Sacramento, Calif, and a doctoral student at
the University of California San Francisco.
AANA Journal/April 2002/Vol. 70, No. 2 137