Erik Hasenboehler MD Orthopaedic Trauma Surgery
Baltimore MD Kentucky Trauma Symposium 2012
Pelvic fracture Management
Subjects
Basic Polytrauma management
Polytrauma basic science
Pelvis Exam, Stability and managment
Acute treatment of pelvic ring injuries
Open Pelvis fracture
Save the
patient`s life !
One
goal !!!!!!!
Pelvic fracture and Polytrauma Management
ATLS: Structured Trauma Care
Phases of Management
Primary Survey Resuscitation Secondary Survey Definitive Care Tertiary Survey
Airway Breathing Circulation Disability Exposure
1. Hemodynamically Unstable Pelvic Fracture Management by Advanced Trauma Life Support Guidelines Results in High Mortality . Orthopedics 2012
2. Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009
Steps of Acute Management
Assess Physical Exam Labs, Physiology Images
Stabilize Resuscitate
Contain Sheet/Ex fix/C-clamp
Damage control orthopaedics in unstable pelvic ring injuries. P.V. Giannoudis and H.C. Pape, Injury 2004
Basic Science of Trauma
First Hit Primary injury
response
Second Hit Incomplete
resuscitation Hemorrhage Prolonged surgery
Systemic Inflammatory
Synergistic Inflammatory
Second hit phenomenon: Existing evidence of clinical implications Lasanianos et al Injury 2012
Two Hit Model
Firstinsult
2nd
insult
Moderate SIRS
Severe SIRS
Moderateimmuno-
suppression
Severe
immunosuppression
MOF
MOFInfection
Definitive surgery
EARLY
Delayed definitive surgery
Moore FA and Moore EE. Surg Clin North Am. 1995
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
1. Damage control orthopaedics in unstable pelvic ring injuries. P.V. Giannoudis and H.C. Pape, Injury 2004
2. Damage control orthopedics: current evidence Lichtea et al CO-Critical Care 20123. Second hit phenomenon: Existing evidence of clinical implications . Lasanianos et al.
Injury 2011
Pre- Hospital: Devastating injury
Hospital-Acute/Primary: shock,
hypoxia or head injury
Hospital-Secondary/Tertiary: MOF or ARDS
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)
• 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
< 24 hours: blood loss
> 24 hours: MOF
Exsanguination caused 75% of the deaths
Causes of Death from Pelvis Fractures
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
Damage Control
Minimize the Second Hit
Assess
Treatment of pelvic ring injuries is
usually a multidisciplinary activity
Trauma, Orthopaedics, Radiology
Urology/Gynecology
Lots to bleed
Big space to bleed into
Volume Changes in the True Pelvis During Disruption of the Pelvic Ring – Where does it go?
Volume increase - r3
Volume increase 1 – 2L
1. Moss and Bircher, 19962. Effects of Pelvic Volume Changes on Retroperitoneal and Intra- Abdominal Pressure in the Injured Pelvic
Ring: A Cadaveric Model Köher et al 2011
Physical Exam
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
OBTAIN INFORMATION FIRST
Physical Exam
Palpate anterior pelvis Watch for perineal
Lacerations Scrotal/Labial Swelling Flank Ecchymosis
Physical Exam
Turn the patient!
Physical Exam
Morel-Lavalle lesions Degloving of the flank, thigh Large dead space Increased incidence of infection
#2: Is the Injury Pattern “Stable” or “Unstable”?
Rotational Stability
AP Compression
Lateral Compression
One Positive Exam Only!
Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll
Surg. 2002.
Physical Exam
Abnormal position of the lower extremity
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
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
Vertical Stability
Push pull on leg while palpating the ASIS
CT Scans
Blush= embolizable arterial injury!
“Stabilizing” Theories
Decreases pelvic volume
Prevents gross motion, clot disruption
Reduces cancellous bony bleeding
Why is Stability Important?
APC 2, 3; LC 3; VS
LC3
APC2,3
VS
Mortality Rate
LCIII- 14%VS - 25%APC II- 25%APC III- 37%
• 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;
Transfusion Requirements
Lateral Compression - 3.6 Combined Mechanical-
8.5 Vertical Shear - 9.2
AP Compression - 14.8
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;
WHAT TO USE TO STABILIZE THE PELVIS
MAST / PASG
Sheet or Binder
Pelvic Binder
Easily applied during resuscitation
Portable
Pelvis and AcetabulumFrontline Treatment
Acute Management
SAM Sling / T-POD / Circumferential Sheet:
Greater Trochanter!!
TOO HIGH!!
Incorrect
Correct
Pelvic Sheeting
Routt et all JOT 2002
Traction
Alone or in combination with sheet/ binder/ ex fix
Particularly useful for vertical shear injuries
Prevents vertical migration
Anterior External Fixation Disadvantages
Can cause a different deformity
Poor control of posterior pelvic ring
Pin tract infections
It’s not that easy
Pelvic C-Clamp
Ganz R, et al. The antishock pelvic clamp. Clin Orthop Relat Res. 1991.
AIRS: I agree that the incidence of arterial bleeding after high energy pelvic trauma is 10%
1. Yes
2. No- I think it is higher
Who should get angiography?
Rationale:
fracture (cancellous) / venous > 90%
arterial < 10%
Who should get angiography?
Rationale:
fracture (cancellous) / venous > 90%
arterial < 10%
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.
1. Cothren CC, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007
2. Suzuki T, Smith WR, Moore EE, Pelvic packing or angiography: competitive or complementary? Injury 20093. 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 20014. Tscherne H. et al. Crush injuries of the pelvis. Eur J Surg 2001
Pohlemann T. et al. Tech Orthop 1994
Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012
TREAT THE PATIENT BASED ON HIS NEEDS……. DCO VS ETC
Open Pelvis Fracture
A direct communication
of the pelvic injury with
the outside world
Dente et al AJS 190, 2005
Think of the open pelvis as a
marker that something very bad
has happened and other things
are likely wrong with this patient
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%)
Open Pelvis Fractures
Many potential open wound sites:
abdominal wall thigh scrotum vagina rectum buttocks perineum
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
• Dente et al AJS 190, 2005• M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and
outcome Injury 2005
Initial Treatment
ATLS
Resuscitation: fluid and blood as needed
Stability: Binder/ sheet/ ex fix/ traction
Bleeding: Stability/ angio/ packing/ resuscitation
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
Initial Treatment
Treat the soft tissue wound Soft tissue wounds bleed The hematoma is
decompressed and draining onto the floor
Pack the soft tissue wounds
• Dente et al AJS 190, 2005• M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and
outcome Injury 2005
Initial Treatment
Selective early diverting ileostomy or colostomy
Mortality decreased to 25%
• 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
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
Subsequent Treatment
When stable: Treat the wounds as any
other open wound Consider repeat wound I&D Plan for definitive fixation if
possible
• Dente et al AJS 190, 2005• M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and
outcome Injury 2005
Mortality
Mortality rate: Pick a number: 0- 50 % 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
• Dente et al AJS 190, 2005• M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and
outcome Injury 2005
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
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
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
Thank you