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Acute Management of Pelvic Ring Injuries

Kyle F. Dickson, MD
Chief of Orthopaedics, Charity Hospital Director of Orthopaedic Trauma Tulane University
Created March 2004

Primary survey
A. B.

Airway maintenance with cervical spine protection Breathing and ventilation

C. D. E.

Circulation with hemorrhage control Disability: Neurologic status Exposure/environment control: undress patient but prevent hypothemia

Transfer Criteria for Pelvic Fractures


Posterior instability/displacement
Initial AP x-ray

Bladder/urethra injury Open pelvic fractures Lateral directed force with fractures through iliac wing, sacral ala or foramina

Transfer (cont.)

Open book with anterior displacement > 2.5 cm Acetabular fractures


> 1 mm articular step off on any view Lack of parallelism of femoral head and roof Displacement of wall or column

Factors Increasing Mortality


Type of pelvic ring injury


Posterior disruption

High ISS
Tile, 1980 McMurty, 1980

Hemorrhagic shock on admission


Gilliland, 1982

Factors Increasing Mortality


Requirement for large quantities of blood


24 u vs. 7 u, McMurty, 1980

Perineal lacerations, open fractures


Hanson, 1991

Associated injuries
Head & abdominal, 50% mortality

Age
Looser, 1976

Extremely High Energy Injuries with a Large Number and Variety of Associated Injuries

Associated Injuries
Long bone injuries Knee injuries Foot injuries

Morel Lavalle Lesion (Skin Degloving)


Infected in 1/3 of cases Require thorough debridement prior to definitive surgery

Example of Small Inadequate Debridement with Subsequent Infection

Open Pelvic Injuries


Colon, rectum, or perineum Early diverting colostomy Soft-tissue wounds aggressively debrided Early repair of vaginal lacerations minimize subsequent pelvic abscess

Team Approach

Help with thorough debridement of entire extent of the hematoma

Team Approach (cont.)

Direct the general surgeon for a transverse colostomy vs. descending colostomy to prevent possible wound contamination of an anterior approach

Colostomy is Indicated for Any Open Injury Where the Fecal Stream Will Contact the Open Area

Urologic Injuries

15% incidence Blood at meatus or high riding prostate Eventual swelling of scrotum and labia (occasional arterial bleeder requiring surgery)

Urologic (cont.)

Retrograde urethrogram indicated in pelvic injured patients but insure hemodynamic stability or embolization may be difficult due to dye extravasation

Urologic (cont.)

Intra & extra peritoneal bladder ruptures are repaired Foley preferred supra-pubic catheter tunneled to prevent ant. wound contamination

Urologic (cont.)

Urethral injuries are repaired on a delayed basis

Neurologic Damage

L5 & S1, most common L2 to S4 possible Dependent on location of fracture and amount of displacement

Denis, CORR 1988

Sacral Fractures Neurologic Injury


Lateral to foramen 6% injury Through foramen 28% injury Medial to foramen 57% injury

Pohlemann, CORR 1994

Amount of displacement move important then location

Neurologic Injury

Careful exam may need decompression of sacral foramen if progressive loss of neural function May take up to 3 years for recovery

Orthopaedic Surgeons Initial Role

Stabilization of pelvic hemorrhage


Traction Anti-shock garments External fixation Open packing & ligation

Referral to center for appropriate fixation

Hemodynamically unstable Patient Fluid resuscitation (causes of hypovolemia) Other causes: external bleeding (i.e. open fractures -- sterile dressing) Hemothorax --- (chest tube) closed fractures (i.e. femur ---- traction eventual early reduction and fixation) coagulopathies (hypothermia, low calcium, acidosis) Intra-abdominal Bleeding Assess: ultrasound CT supraumbilical peritoneal lavage negative AP Pelvis & physical exam Emergency Mechanically stable pelvis Mechanically unstable pelvis External fixator Small Other causes of hypotension: cardiac quadriplegia or spinal injury terminal brain injury hypothermia Patient unstabl e Patien t stable look for other causes laparotomy
(should not delay emergency laparotomy)

positive

AP Pelvis & physical exam

Mechanically stable pelvis

Mechanically unstable pelvis Angiograph y on standby

External fixator

Assess retroperitoneal hemorrhage Large and expanding hematom a Surgical ligation & packing Patient unstable Patient stable

Patient unstabl e

Angiographic embolization

Patien t stable

Hemodynamically unstable Patient


Fluid resuscitation (causes of hypovolemia)

Other causes:
external bleeding (i.e. open fractures -- sterile dressing) Hemothorax --- (chest tube) closed fractures (i.e. femur ---- traction eventual early reduction and fixation) coagulopathies (hypothermia, low calcium, acidosis)

Intra-abdominal Bleeding Assess:


ultrasound CT supraumbilical peritoneal lavage

Negative

Positive

Negative

AP Pelvis & Physical Exam

Mechanically stable pelvis

Mechanically unstable pelvis

Other causes of hypotension:


cardiac quadriplegia or spinal injury terminal brain injury hypothermia

External fixator

Patient unstable Other causes

Patient stable

Positive

AP Pelvis & Physical Exam

Mechanically unstable pelvis

Mechanically stable pelvis

Emergency laparotomy

External fixator (should not delay emergency laparotomy)

Angiography on standby

Positive
Assess retroperitoneal hemorrhage

Small
look for other causes

Large and expanding hematoma Surgical ligation & packing Patient unstable Patient stable Patient stable

Patient unstable

Angiographic embolization

Etiology of Hypovolemic Shock


Intra-thoracic bleeding Intra-peritoneal bleeding


Ultrasound Peritoneal tap CT

Retroperitoneal bleeding

Shock (cont.)

Blood loss from open wounds Bleeding if closed extremity fracture

Burgess, J Trauma 1990


Mortality 8.6% 2/210 pelvic injury patients where pelvic injury was primary cause of death Contributed 10/210

Hemorrhage Control

Average blood replacement (units)


LC = 3.6 AP = 14.8 VS = 9.2 CM = 8.5

Mortality
3% hemodynamically stable patients 38% unstable patients

Burgess (cont.)

LC head injury major cause of death APC pelvic and visceral injury major cause of death

Force Vector with Clinic Utilization


LC1 and LC2 50% brain injury LC3 (windswept pelvis rollover/crush)
60% retroperitoneal hematoma 40% lower extremity fracture 20% bowel injury 0% brain injury

Force (cont.)

AP3 (comprehensive posterior instability)


67% shock 59% sepsis 37% death 18.5% ARDS

Force (cont.)

Vertical shear
63% shock 56% brain injury 25% splenic injury 25% death 23% lung injury

Coagulopathy

Hypothermia Ca2 (blood citrate) Acidotic

Prolonged Hypovolemia

Aggravate pulmonary contusion Head and visceral injuries Increased sepsis Adult respiratory distress syndrome (ARDS) Multiple organ failure

Only patients with mechanical instability can have hemodynamic instability related to the pelvic injury

Force Vectors

Lateral compression Anterior posterior compression Vertical shear

Radiographic Signs of Instability


Sacroiliac displacement of 5 mm in any plane Posterior fracture gap (rather than impaction) Avulsion of fifth lumbar transverse process, lateral border of sacrum (sacrotuberous ligament), or ischial spine (sacrospinous ligament)

Hemorrhage (cont.)

Skeletal traction External fixation Mast suit Embolization Surgical stabilization with packing Towel clamp with sheet

Hemorrhage (cont.)

Contributes to 60% of deaths Retroperitoneal veins 20% arterial injury

Slatis & Huittinen, 1972

147 cadavers, double vertical pelvic fractures


84-88% bone bleeders 46% incidence at nerve lesion 57% multiple nerve roots

Possible Arterial Bleeders in Pelvic Injuries


Iliolumbar artery Superior gluteal artery Lateral sacral artery Internal iliac artery Internal pudendal (active bleeding most commonly found)

Anterior External Fixator vs. Posterior External Fixator

Anterior Frame

Safer and easier to apply May not give the necessary posterior support Indication acutely for a mechanically and hemodynamically unstable pelvis injury

Posterior Clamp

Same indications Advantages, posterior stabilization Contraindications: Iliac wing fracture or comminution of sacrum (over compression)

External fixation is a resuscitative fixation and cannot be used as the definitive fixation in completely unstable pelvic injuries.

Patient NJ

VS initially attempted to be treated with anterior plate and ex-fix with hardware failure 3 stage pelvic reconstruction ( ant. post ant. 2 yr follow-up Auburn football player)

External Fixation Placement


Must understand the 3-D deformity Reduce the posterior complex (do not just squeeze anterior symphysis together)

External Fixation Placement (cont.)


Retroperitoneal space is massive (30L with only 3 mmHg) Stabilization is from holding hemipelvis stable not reducing pelvic volume

Pin Placement Anterior Frame


Glut. Medius tubercle Follow contour of iliac wing 2 - 2.5 cm post. To ASIS

Anterior (cont.)

K-wires helpful for inner and outer cortex Starting drill hole than let pin find direction Traction and close pelvis posteriorly

Dickson, JOT 2001


16/151 unstable pelvic injuries referred with external fixator as initial treatment Review AP, inlet, outlet, and CT before and after external fixator

Reduction

67% (8/12) worsening of posterior complex 30% (3/10) loss of reduction Average maximum displacement 3 cm (range 1.5 cm 5.4 cm)

Indications for Angiography


Unexplained blood loss after stabilization and aggressive resuscitation Pulselessness extremity

Surgical

Stabilization with internal fixation of pelvis Stabilization of hemodynamic instability with surgical packing of retroperitoneal space rare

The Pelvis is a Place to Work Not a Place to Play

Acknowledgement
Joel Matta, Jim Pohlemann, Mark Vrahas

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