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Evolution of management strategies for unstable pelvic ring injuries over the past 40 years: a systematic review

Patient Safety in Surgery volume 18, Article number: 38 (2024) Cite this article

Abstract

Background

Hemodynamically unstable pelvic ring fractures from high-energy trauma are critical injuries in trauma care, requiring urgent intervention and precise diagnostics. With ongoing advancements in trauma management, treatment strategies have evolved, with some techniques becoming obsolete as new ones emerge. This study aimed to evaluate changes and trends in treatment algorithms for these injuries over approximately 40 years.

Methods

A systematic review of PubMed and EMBASE was conducted to include articles published over roughly four decades that presented visual treatment algorithms or workflows for managing unstable pelvic ring fractures. Identified algorithms were categorized by publication period and analyzed by initial assessment, diagnostic methods, pelvic stabilization, and hemorrhage control interventions.

Results

The search identified 5,434 publications, of which 32 met the inclusion criteria. 75% of these studies were published between 2011 and 2022, reflecting a growing focus on standardization, particularly in Europe, North America, and Asia. Physiological assessment remains essential in the initial management of hemodynamically unstable pelvic ring fractures, guiding resuscitation and influencing the selection of intervention and imaging. The use of pelvic binders or sheets has risen steadily, highlighting their role in hemorrhage control and temporary stabilization. CT scans and angiography have largely replaced pelvic X-rays in diagnostic protocols, becoming preferred radiological methods alongside focused assessment with sonography for trauma (FAST). Pelvic stabilization remains critical, with external fixation being the most commonly used technique, showing an upward trend in recent years. Laparotomy, pelvic packing, and angioembolization continue to play vital roles in hemorrhage management. Emerging techniques, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), anterior subcutaneous internal fixation (INFIX), and rescue screws, are increasingly included in treatment algorithms, while diagnostic peritoneal lavage (DPL) has become obsolete and is no longer listed in these algorithms.

Conclusions

This review provides foundational insights toward the standardization of initial treatment for hemodynamically unstable pelvic ring fractures and holds significant importance in enhancing the consistency and efficiency of treatment. Future research should focus on accumulating higher-quality evidence to evaluate the effectiveness of standardized protocols and explore the applicability of new treatment methods.

Background

Hemodynamically unstable pelvic ring fractures from high-energy trauma are among the most severe cases in trauma surgery, posing significant risks to patient survival due to massive hemorrhage from major pelvic vessels, which requires prompt and appropriate intervention in the acute phase [1, 2]. It is recommended that each patient with a pelvic ring injury is considered as a potential candidate for a “hidden shock” symptomatic until further diagnostics can disprove the possibility of retroperitoneal blood loss, which can initially be masked by the patient’s compensation mechanism [3]. While timely initial management has been shown to improve survival rates [4], treating these fractures remains complex, involving multiple diagnostic and therapeutic steps that demand swift and accurate decision-making in clinical settings.

Despite the critical nature of this management, the standardization of initial treatment procedures and approaches remains insufficient, and treatment often depends on individual clinician judgment [5]. To address these inconsistencies, various medical facilities have implemented flowcharts designed to standardize initial treatment approaches, aiming to streamline decision-making and improve patient outcomes in emergency settings [6]. These structured pathways not only enhance transparency and care quality by reducing variability but also promote consistent adherence to essential steps.

However, research indicates substantial differences in flowchart content and structure across institutions, potentially affecting treatment uniformity [7]. The ongoing evolution of treatment techniques and diagnostic tools further complicates standardization, as newer flowcharts may lack clear criteria or sufficient supporting evidence, suggesting a need for continual refinement [8].

This systematic review aims to evaluate the development of initial treatment flowcharts for hemodynamically unstable pelvic ring fractures, analyzing variations over time to support future standardization efforts. By synthesizing current practices, this review seeks to lay the groundwork for a standardized approach, ultimately enhancing trauma care decision-making and clinical guidelines.

Methods

The reporting of this systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (http://www.prisma-statement.org/).

Eligibility criteria

A systematic review was conducted to identify all relevant publications regarding the initial management of patients with pelvic ring fractures associated with hemodynamic instability due to trauma. Only original articles written in English, German, or Japanese were included, that present flowcharts or visual treatment algorithms for the emergency management of unstable pelvic ring injuries. Exclusion criteria included studies on pediatric patients, isolated sacral fractures, military-related fractures, case reports, case series, reviews, editorials, studies without a clear description of treatment timing, studies not focused on emergency care, low-quality studies, and studies involving navigated or robotic-assisted procedures (as these are not applicable to emergency settings). In cases where multiple studies with flowcharts were published by the same institution or hospital, only the most recent publication was included in the analysis, and earlier studies from the same institution were excluded.

Information sources and search strategy

The Medline and EMBASE databases were searched to cover the period from January 1, 1980, to December 31, 2022. The final search was performed on February 25, 2023. The search strategy included a combination of controlled vocabulary terms (MeSH/Emtree terms) and regular search terms, connected using Boolean operators. Truncation was applied to account for plural forms and alternate spellings, and careful attention was paid to include all relevant synonyms. Filters were applied to exclude inappropriate article types. The full list of search terms is provided in Supplementary File 1. In addition, the reference lists of selected studies and relevant reviews were screened to identify additional sources. The search results were organized and deduplicated using Clarivate™ EndNote™ version 20.

Study selection

Titles and abstracts of the identified articles were independently screened by KS, FKLK, and LE. KS and FKLK cross-checked the extracted data, and any disagreements were resolved through personal discussion. Full texts of potentially eligible studies were retrieved through the university’s central library via respective publishers.

Data extraction

Data extraction was conducted solely from the figures in the flowcharts/algorithms presented in the papers, and no data were extracted from the main text of the articles. The extracted items were categorized into five major areas: “Paper Information,” “Initial Management,” “Diagnostic Methods,” “Pelvic Stabilization,” and “Interventions for Hemorrhage Control.”

For “Paper Information,” the author names, paper title, journal name, year of publication, and country were extracted. Temporal trends in publication were also evaluated. Specifically, articles were stratified according to their publishing dates as follows: 1980 to 1985, each subsequent 5-year period after 1986, and the period from 2021 to 2022. This resulted in a 6-year period for 1980–1985 and a 2-year period for 2021–2022. The average number of publications per year for each period was assessed. The number of publications by region was also analyzed. For “Initial Management”, “Diagnostic Methods”, “Pelvic Stabilization”, and “Interventions for Hemorrhage Control”, the presence of each respective procedure or method in the flowcharts was evaluated. The presence or absence of these elements was recorded as “Yes,” “No,” or “UNK = Unknown”, “NA = Not Applicable”. The results were further analyzed by dividing them into four periods: 1980–2010, 2011–2015, 2016–2020, and 2021–2022, and the proportions for each response were calculated for these time frames.

The specific items extracted for “Initial Management” included:

  • Was the stability of the fracture assessed?

  • Was the patient’s physiology taken into account?

  • Were other sources of bleeding (from other body regions/injuries) ruled out?

  • Was a pelvic binder or sheet applied?

  • Were resuscitation efforts described?

For “Diagnostic Methods”, the following items were evaluated:

  • Focused Assessment with Sonography for Trauma (FAST).

  • Diagnostic Peritoneal Lavage (DPL).

  • X-ray of the pelvis.

  • Computed Tomography scan (CT-scan).

  • Angiography.

For “Pelvic Stabilization”, the following items were included:

  • Was any form of pelvic fixation/stabilization was performed (excluding pelvic binders or sheets)?

  • External fixation.

  • C-clamp.

  • Anterior subcutaneous internal fixation (INFIX).

  • Rescue screws.

  • Open reduction and internal fixation (Definitive fixation) (ORIF).

For “Interventions for Hemorrhage Control”, the following items were extracted:

  • Laparotomy.

  • Pelvic packing.

  • Angioembolization.

  • Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA).

Results

Study selection

The flowchart detailing the study selection process is presented in Fig. 1. A systematic search of the Medline database yielded 1,932 results, and an additional 3,465 records were identified through EMBASE. Furthermore, 37 additional records were identified from other sources. After removing 1,213 duplicates, 4,221 records were screened, with 3,811 records excluded. Of the remaining 410 full-text articles assessed, 369 were excluded due to the absence of flowcharts addressing initial treatment or early management. Of the 41 remaining studies, 9 duplicate studies from the same institution were excluded, leaving 32 studies that were ultimately included in this review [9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40].

Fig. 1
figure 1

Flowchart of this systematic review

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Paper information

Information regarding all included studies is provided in Table 2 in Appendix. A total of 32 studies published between 1980 and 2022 met the inclusion criteria and were included in this review. The number of studies incorporating flowcharts for initial treatment and management has increased in recent years, with 24 studies published between 2011 and 2022, accounting for 75% of the total. The number of publications during the four time periods used in subsequent evaluations—1980–2010, 2011–2015, 2016–2020, and 2021–2022—were 8, 7, 10, and 7, respectively. Moreover, the trend of increasing publications per year has become more pronounced in recent years, with an average of 3.5 studies published annually in the 2021–2022 period (Fig. 2). Additionally, when categorizing the institutions where treatments were conducted by region, Europe accounted for 14 studies, followed by North America with 8, Asia with 7, the Middle East with 2, and South America with 1 (Table 1).

Table 1 Regional distribution of treatment institutions
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Fig. 2
figure 2

Annual number of publications featuring flowcharts on initial management, assessment, and treatment

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Initial management

The results of the evaluation items related to initial management are presented in Table 3 in Appendix; Fig. 3. Fracture stability assessment was documented in 50.0% (16/32), physiological assessment in 100% (32/32), ruling out other bleeding sources in 31.3% (10/32), pelvic binder or sheet application in 68.8% (22/32), and resuscitation measures in 53.1% (17/32).

Fig. 3
figure 3

Initial management

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Regarding fracture stability assessment, no marked changes were observed across different time periods. Physiological assessment was consistently included in all flowcharts across all time periods. In contrast, exclusion of other bleeding sources exhibited considerable variation between time periods, with no clear trend observed. The use of pelvic binders or sheets showed a steady increase over time, reaching 100% (7/7) in the 2021–2022 period. Documentation of resuscitation efforts also saw a notable increase after 2011.

Diagnostic method

The results related to diagnostic methods are presented in Table 4 in Appendix; Fig. 4. FAST was used in 81.2% of the studies (26/32), DPL in 15.6% (5/32), pelvic X-ray in 56.3% (18/32), CT scan in 74.2% (23/31), and angiography in 87.1% (27/31).

Fig. 4
figure 4

Diagnostics methods

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FAST was consistently used across all time periods, with a particularly notable increase after 2011. DPL was used to some extent in the early stages, but it was no longer included in flowcharts after 2016. Regarding radiological diagnostics, until 2015, there was no marked difference in the usage rates between pelvic X-ray and CT scan; however, after 2016, the use of CT scan increased. Angiography maintained a high usage rate across all time periods, and in the 2021–2022 period, both CT scan and angiography were included in 100% of the flowcharts (6/6).

Pelvic stabilization

The results related to pelvic stabilization are presented in Table 5 Appendix; Fig. 5. Including papers where details were not explicitly mentioned, some form of pelvic fixation was documented in 78.1% (25/32) of the flowcharts. Specifically, external fixation was noted in 56.3% (18/32), C-Clamp in 9.4% (3/32), INFIX in 6.3% (2/32), rescue screws in 3.1% (1/32), and ORIF in 25.0% (8/32). External fixation was the most frequently documented method of fixation. Additionally, there was a tendency for the usage of external fixation to increase over time.

Fig. 5
figure 5

Pelvic stabilization

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Interventions for hemorrhage control

The results related to interventions for hemorrhage control are presented in Table 6 Appendix; Fig. 6. Laparotomy was documented in 78.1% (25/32) of the studies, pelvic packing in 62.5% (20/32), angioembolization in 56.3% (18/32), and REBOA in 18.8% (6/32). Laparotomy showed relatively high usage rates across all time periods. Although some cases of pelvic packing were categorized as “UNK,” its documentation has markedly increased since 2011. The use of angioembolization showed no evident variation across the different periods. REBOA was first documented after 2016, and its use has been increasing in recent years.

Fig. 6
figure 6

Interventions for Hemorrhage Control

Full size image

Discussion

Based on this systematic review of treatment algorithms for pelvic ring injuries we conclude the following main findings:

  • The number of publications featuring initial treatment flowcharts for hemodynamically unstable pelvic ring fractures has risen in recent years, reflecting a growing interest in standardization, primarily from institutions in Europe, North America, and Asia.

  • Physiological assessment remains essential in the initial management of hemodynamically unstable pelvic ring fractures, as it guides the decision-making process for resuscitation measures.

  • The recommendation for the use of pelvic binders or sheets has progressively increased over recent years, underscoring their perceived value in flowcharts for hemorrhage control and temporary pelvic stabilization.

  • CT scans and angiography have increasingly replaced pelvic X-rays in diagnostic protocols, ultimately becoming more commonly radiological method alongside FAST, while pelvic X-rays remain an important tool for assessing patients with unstable conditions.

  • Pelvic stabilization remains a critical aspect of trauma management, with various methods reported; however, external fixation continues to be the most frequently utilized technique, showing an increasing trend in usage in recent years.

  • Laparotomy, pelvic packing, and angioembolization continue to play essential roles in managing hemorrhage in hemodynamically unstable patients with pelvic fractures, while the use of REBOA has notably increased in recent years.

Initial management

The assessment of fracture stability is included in approximately half of the flowcharts across all periods. In contrast, physiological assessment appears in 100% of the flowcharts, as understanding vital signs and levels of consciousness is essential for determining emergency severity and stabilizing hemodynamics, and plays a critical role in establishing the initial treatment plan. Similarly to the assessment of fracture stability, the exclusion of other bleeding sources is not frequently included in flowcharts during any period. This pattern may suggest that such evaluations are commonly performed by clinicians without requiring explicit mention in the flowcharts. Including too many details in the flowchart risks complicating it and potentially delaying the primary objectives of rapid initial management and treatment. However, in life-threatening conditions, even basic evaluations like fracture stability and the exclusion of bleeding from other sources might be overlooked. According to Pfeifer et al., the clearance process for fracture fixation in polytrauma patients prioritizes initial physiological stabilization but also necessitates a rapid assessment of fracture and other organ status as part of a comprehensive evaluation [41]. Therefore, the inclusion of elements such as fracture stability assessment and the exclusion of other bleeding sources within the flowcharts may be worth considering, provided they do not lead to overcomplication or confusion.

The use of pelvic binders and sheets has been on the rise, with every flowchart in the literature from 2021 to 2022 including references to them. Research on cadavers has suggested that pelvic binders significantly increase intrapelvic pressure, which helps minimize venous bleeding [42]. While improper placement has been reported as an issue [43], including them in flowcharts is considered beneficial for hemorrhage control and temporary pelvic stabilization [44]. Documentation on resuscitation has notably increased since 2011, and similar to fracture stability assessment and bleeding exclusion, including these aspects without overly complicating the flowchart may be worth considering.

Diagnostic method

FAST was included in over 80% of the flowcharts and became particularly prominent in publications from 2011 onward. Since its introduction in the 1990s, FAST has become a rapid and effective diagnostic tool in trauma care [45], which explains its lower usage rate in earlier years. According to Smith and Wood, the sensitivity and specificity of FAST scans for blunt trauma are as high as 93.1% and 100%, respectively, underscoring its utility in quickly assessing unstable patients and guiding initial treatment [46]. This high accuracy makes FAST an essential component of the flowcharts for rapidly diagnosing and stabilizing pelvic fractures accompanied by hemodynamic instability. On the other hand, DPL appears in a smaller proportion of flowcharts and has not been included at all since 2016. This aligns with reports indicating that DPL usage has declined with the increasing adoption of FAST [47]. Given that FAST is a non-invasive and quick diagnostic method, it suggests that DPL is unlikely to be frequently used in the future.

Pelvic X-rays appear in approximately 50% of flowcharts across all periods, indicating a role in the initial assessment of pelvic ring fractures with hemodynamic instability, though not necessarily as a primary diagnostic priority. This may be attributed to the increased use of more advanced imaging modalities, such as CT scans, which offer superior diagnostic capabilities. While pelvic X-ray remains an integral part of the ATLS assessment, a retrospective study by Hilty et al. indicates that in hemodynamically stable patients with a clinically stable pelvis, its sensitivity is only 67%, and it may safely be omitted in favor of pelvic CT if such adjunctive imaging is planned and available [48]. However, in physiologically highly unstable patients, pelvic X-ray might still be required to expedite initial assessment and facilitate rapid decision-making. CT scan inclusion in flowcharts has increased significantly, from 50% in 1980–2010 to universal inclusion in 2021–2022. The improvements in CT technology and its enhanced speed and diagnostic precision underscore its growing importance in assessing pelvic fractures, identifying hemorrhage sources, and establishing treatment plans. Angiography has also been consistently included and mentioned separately from CT imaging in a high percentage of flowcharts across all periods, highlighting its value in rapidly identifying and controlling bleeding in cases of hemodynamically unstable pelvic ring fractures. Nowadays, angiography is usually integrated in the emergency CT scans, allowing for more rapid and accurate assessment of trauma, including arterial injuries, and providing a more effective diagnostic approach compared to performing them separately [49]. Considering the above, it is recommended that FAST, CT scans, and Angiography be included in flowcharts as evaluation methods, provided that the facility’s resources and human capital allow.

Pelvic stabilization

Pelvic fixation is included in high frequency across all periods, reflecting its consistent role as a critical intervention for hemodynamically unstable pelvic ring fractures. Pelvic stabilization reduces intrapelvic bleeding and lowers the risk of hemorrhagic shock, confirming its efficacy [50]. External fixation is the most commonly used stabilization technique, largely due to its relatively rapid implementation and less demanding training requirements compared to other methods [5]. On the other hand, techniques such as C-Clamp, INFIX, rescue screws, and ORIF require more advanced skills and specialized expertise, and as a result, are typically limited to select facilities. For instance, C-Clamp is effective for posterior pelvic stabilization in patients with hemodynamic instability, yet its application requires specific training to avoid potential complications [51]. Similarly, rescue screws play a critical role in sacroiliac joint stabilization in emergency cases; however, inadequate training can increase the risk of screw misplacement and associated nerve injury [52]. Because these methods are not always clearly defined in flowcharts, definitive conclusions are challenging. However, pelvic stabilization, especially through external fixation, remains crucial in initial treatment, and including these approaches in flowcharts is recommended. Furthermore, external fixation and C-Clamp are commonly used as temporary measures for pelvic stabilization, while INFIX, rescue screws, and ORIF are primarily used for definitive fixation. These techniques are systematically incorporated into several flowcharts according to the treatment phase and the patient’s physiology according to the safe definitive surgery concept (SDS) [53].

Interventions for hemorrhage control

Laparotomy is frequently included in all periods and remains the primary method for hemorrhage control in pelvic ring fractures. In contrast, pelvic packing was rarely mentioned in publications from 1980 to 2010, but its inclusion has increased significantly in more recent literature. Pelvic packing may not always be explicitly noted in the flowcharts, as it is often described within the context of laparotomy. Angioembolization is slightly less frequently included than pelvic packing, likely due to the specialized skills and resources required for its implementation. Both preperitoneal packing and angioembolization have been shown to be effective in controlling bleeding in hemodynamically unstable pelvic fracture patients, but meta-analyses suggest no significant difference in mortality between the two, highlighting the need for further evidence [54]. REBOA first appeared in the flowcharts in 2016 and has gradually gained traction as an emerging method for temporarily controlling bleeding through balloon occlusion [55]. These findings suggest that while laparotomy continues to be positioned as the standard treatment method, pelvic packing follows closely in terms of usage rate. Additionally, newer techniques such as REBOA are on the rise, and these methods are anticipated to contribute to the standardization of future flowcharts.

Limitation

This review has several limitations. First, as it is based on past literature, it may not fully reflect actual clinical outcomes or the latest technologies. In particular, if new technologies or protocols have been introduced, their effects may not be represented. Additionally, variations in the algorithms present another limitation. The algorithms reviewed differed in both specific details and holistic structure, with some steps in certain algorithms being indicative but not consistently standardized; as a result, these steps were not uniformly included in this analysis. Furthermore, it remains unclear whether the effectiveness of the flowcharts can be uniformly applied across all facilities. Future research should focus on validating these flowcharts with real clinical data and developing flexible guidelines that can be adapted to the unique conditions of different facilities.

Conclusions

This review provides foundational insights toward the standardization of initial treatment for hemodynamically unstable pelvic ring fractures and holds significant importance in enhancing the consistency and efficiency of treatment. The development of standardized flowcharts has the potential to contribute to improved patient outcomes and higher quality of care by unifying diagnostic procedures and establishing appropriate treatment protocols, representing a crucial step in refining clinical guidelines. Furthermore, future research should focus on accumulating higher-quality evidence to evaluate the effectiveness of standardized protocols and explore the applicability of new treatment methods.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

CT-scan:

Computed Tomography scan

DPL:

Diagnostic Peritoneal Lavage

FAST:

Focused Assessment with Sonography for Trauma

INFIX:

Anterior Subcutaneous Internal Fixation

ORIF:

Open Reduction and Internal Fixation

REBOA:

Resuscitative Endovascular Balloon Occlusion of the Aorta

SDS:

Safe Definitive Surgery

X-ray:

X-radiation

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Author notes

  1. Felix Karl-Ludwig Klingebiel and Roman Pfeifer contributed equally to this work.

Authors and Affiliations

  1. Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistr. 100, Zurich, 8091, Switzerland

    Kenichi Sawauchi, Yannik Kalbas, Zygimantas Alasauskas, Valentin Neuhaus, Hans-Christoph Pape, Felix Karl-Ludwig Klingebiel & Roman Pfeifer

  2. Harald-Tscherne Laboratory for Orthopaedic and Trauma Research, University of Zurich, Raemistr. 100, Zurich, 8091, Switzerland

    Kenichi Sawauchi, Luca Esposito, Yannik Kalbas, Zygimantas Alasauskas, Valentin Neuhaus, Hans-Christoph Pape, Felix Karl-Ludwig Klingebiel & Roman Pfeifer

  3. Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo- ku, Kobe, 650-0017, Japan

    Kenichi Sawauchi

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Contributions

K.S.: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. L.E.: Data curation, Investigation, Writing – review & editing. Y.K.: Conceptualization, Methodology, Writing – review & editing. Z.A.: Methodology, Writing – review & editing. V.N.: Methodology, Writing – review & editing. H.-C.P.: Conceptualization, Project administration, Supervision, Writing – review & editing. F.K.L.K.: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. R.P.: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – review & editing. All the authors have read and approved the final article.

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Correspondence to Kenichi Sawauchi.

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Supplementary Information

Appendix

Appendix

Table 2 Summary of included studies
Full size table
Table 3 Evaluation of initial management items
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Table 4 Evaluation of diagnostic methods
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Table 5 Evaluation of pelvic stabilization methods
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Table 6 Evaluation of interventions for hemorrhage control
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Sawauchi, K., Esposito, L., Kalbas, Y. et al. Evolution of management strategies for unstable pelvic ring injuries over the past 40 years: a systematic review. Patient Saf Surg 18, 38 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13037-024-00421-z

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Keywords

Patient Safety in Surgery

ISSN: 1754-9493