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Welcome back to Behind the Knife. Big T trauma. This is Patrick Georgoff and man. Am I excited to be here? It's been a crazy few days at Behind the Knife. We've been working our tails off.

Just today, I had meetings regarding our trauma surgery video. Atlas is something totally new. It's never been done before. Amazing footage. We have 1.8 terabytes of footage that we're working through to try to clean up and make something amazing for you all. We have a BTK sutra kit and not time board that we're working on. It's got fantastic videos for both right-handed and left-handed students and trainees. We're very excited about that.

We're also cranking away on a massive medical student and advanced practice provider curriculum. And if we've got a brand new website with a company in Android and iPhone apps coming out sometime next year, but we're digging it deep into that as well. It's all really great stuff.

We are here to follow that up with the Big T trauma series. As always, I am joined by my former co-fellows at the home of Big T trauma University of Texas in Houston, Dr. Teddy Puzio, who is faculty at UT and assistant program director for the acute care fellowship and Dr. Jason Brill now in Hawaii and the trauma medical director for United States, Indo-Pacific Command gentlemen. Welcome.

Hey Patrick.

Now, if you guys are listeners, if you like trauma and you haven't already listened to the rest of our Big T trauma series, I want to encourage you to check it out on our website under the listen tab. If you click listen, you can sort by topic or series.

We've covered resuscitative thoracotomy, trauma pitfalls, solid organ injury, gun violence, complex cases, transfusion medicine. The list goes on and on and on. That's not even half of them.

So check it out if you're a big fan of trauma. And today we're going to discuss pelvic trauma, specifically hemodynamically unstable pelvic fractures. This is such an important topic because these patients can be really, really challenging to care for because they're super sick and their countless forks in the road when it comes to their management are they stable enough for the CT scan.

Do I need a binder for this fracture? Should I be in the OR right now or am I okay to wait for IR? What about checking for a genital urinary injuries? There's just a lot to consider.

And pelvic fractures with hemorrhage are deadly and they remain so for quite some time Jason, just how deadly are these injuries?

Yeah, so fairly deadly was the short answer all comers with unstable pelvic fractures experience mortality rates around 8 to 9% and those are in very large series elderly patients experience even higher mortality rates 20 to 40% in some modern series. So very deadly overall.

Now, unfortunately, those rates really haven't improved over the last several decades, at least not in the larger data sets. And part of that is probably due to the high energy mechanism involved in crushing or opening a pelvis.

So there are usually many other injuries associated with an unstable pelvis. And beyond that, the anatomy of the pelvis can be a real issue. Teddy, can you speak to that?

Yeah, I think you're talking about the venous plexus that covers the most of the inferior aspect of the pelvis, especially the posterior elements and the sacrum. So a tear in that venous plexus can result in significant bleeding audible at times, as we like to say, it's a low pressure, but high volume network.

And there are lots of collaterals and it can continue to supply blood to the, you know, the vessels, even though you think you're getting control, there's a lot of collaterals you got to think about.

And we'll return to that specific issue when we talk about IR intervention in a minute.

Yeah. And, you know, it's important to remember that we think 80 to 85% of pelvic hematomas are actually venous in nature.

Yeah, super important number. And Teddy, on the anatomy subject, are there any other classification systems we should discuss before we talk about how we evaluate these sick patients?

Yeah, so when we think about classification, you know, there are several, of course, just like a lot of different things, but the most common system used to classify pelvic fractures is the young and Burgess system.

Now, to us non orthopedic surgeons, this classification system is a little confusing or a lot confusing, honestly, but it describes both the fracture pattern with the impact mechanism, but also has degrees and severity.

Fortunately, it doesn't really matter that much to us as trauma surgeons, all of the nuances, as multiple studies have really failed to demonstrate a consistent correlation between injury pattern and mortality, or even a need for hemorrhage control.

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