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ORTHOPAEDIC TRAUMA

PELVIC TRAUMA

 

 

Exsanguinating Pelvic Trauma

Part of the Exsanguinating Pelvic Injury Symposium

From: Tony Joseph,
          President, Australasian Trauma Society,
          Royal North Shore Hospital, Sydney, Australia
Date: 26.05.1999 01:15 GMT

We recently had a case of a pedestrian run over by own car and suffered major pelvic fractures ( ant and post), a liver laceration and major chest injuries. The Surgical team decided that there was no major thoracic or abdominal souce of bleeding although a FAST or DPL was not done. The Orthopaedic team decided that pelvic angiography and embolisation was the way to go for control of the major pelvic bleeding.

The patient was initially stable after intubation, fluid and blood resuscitation, but became very unstable in the Angio suite and had a hypovolaemic arrest in radiology. She was resuscitated with fluids, blood and adrenaline and the radiologist was then able to complete the angio ( after about an hour) and successfully embolise 2 major arterial bleeders.

She then went to the OT and had Ext Fixateurs appllied and eventually had a laparotomy which revealed a liver laceration which the surgeons tell me was not a major source of blood loss. Unfortunately she had a further cardiac arrest on the operating table and was not able to be resuscitated.

Can anyone tell me if there are any Randomised controlled trials out there which compare External or Internal Fixation of Unstable Pelvic fractures v Pelvic Angio / embolisation for the major shocked patient with ongoing bleeding. Is there a place for taking this patient straight to the OT for application of Ext Fix and laparotomy with packing of the pelvis? Is there any evidence for this which I believe is done in some Trauma Centres in Europe. Sorry its a bit long winded but we were unable to obtain consensus at out trauma audit

 

From: Eric Frykberg,
          Jacksonville, Florida
Date: 15.05.1999 02:05 GMT

Only a minority of pelvic fractures will be benefitted by reduction and ex-fix--internal fixation has NO place in the emrgency management of unstable patients with pelvic fractures. These are the open-book type fractures in which ex-fix will reduce the volume of the pelvis and effectively tamponade most bleeding.

First--intraperitoneal bleeding must be actively excluded by DPL or U/S (of course you can not CT an unstable patient)--if positive, patient must immediately undergo laparotomy to control that bleeding--if negative, or after control of intraperitoneal bleeding and still unstable, the patient must undergo angioembolization.

Pelvic reduction should NOT ever have to be done in the Operating Room in the acute care phase--either apply a C-clamp fixator in the trauma center (takes 5 minutes) or simply apply a MAST trousers or wrap a bedsheet around the pelvis and pull it tight--I've used all and they are very effective IF the fracture is of the type amenable to it--your question seems to indicate you think all pelvic fractures will benefit from reduction to stop bleeding--this is not true, and time should not be wasted (lives, either) trying this useless maneuver on all patients, especially in the O.R.

The case you described was flawed from the beginning, in not first excluding and taking care of the most likely and life threatening source of bleeding in these patients. Several articles advocating these tenets have been published in the J of Trauma over the past decade.

From: Andrew H. Schmidt, M.D
          Faculty, Dept. of Orthopedic Surgery, Hennepin County Medical Center
          Assistant Professor, University of Minnesota
Date: 27.05.1999 02:51 GMT

Patients with hemodynamic collapse and unstable pelvic ring injuries are very difficult to manage. Blood loss is from four potential sources:

1) Fractured bone surfaces, which are quite vascular and will bleed significantly. This blood loss is exacerbated by continued movement of the bone fragments, which limits the ability of clot to adhere to the cancellous bone.

2) The pelvic venous plexus - this is low pressure and will generally tamponade as long as the retroperitoneum is not opened. This is the usual source of vascular bleeding and responds well to fluid resuscitation.

3) Arterial injury - usually branches of the superior gluteal artery, although the internal iliac vessels or any other vessel traversing the pelvis may be injured. Pelvic arterial injuries are rare (about 15% of cases) and the yield from pelvic angiography is low.

4) Extra-pelvic sources of bleeding. Actually, the major threat of life-threatening bleeding on patients with pelvic disruption are vascular injuries outside the pelvis. (Ochsner MG Jr, Champion HR, Chambers RJ, Harviel JD. Pelvic fracture as an indicator of increased risk of thoracic aortic rupture. The Journal of Trauma, 1989; 29:1376-9.)

Successful management requires attention to several factors:

1) Immediate and aggressive fluid resuscitation. (Gruen GS, Leit ME, Gruen RJ, Peitzman AB. The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fractures. The Journal of Trauma, 1994; 36: 706-11.)

2) Provision of temporary pelvic stability by tightly wrapping a sheet or bean bag about the pelvis, secured with a towel clip. It is quite amazing what this simple maneuver can do to provide temporary stability during patient transport.

3) The pelvic ring injury should be classified according to mechanism, as discussed in several papers by Burgess at Shock Trauma in Baltimore:

Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma 29: 981-1000, 1989.

Gokcen EC, Burgess AR, et al. Pelvic fracture mechanism of injury in vehicular trauma patients. The Journal of Trauma, 1994; 36:789-95.

If the patient is does not respond to fluid, and has both evidence of chest trauma and a high risk pelvic fracture (e.g. type 3 anterior posterior compression), then immediate angiography of the chest, abdomen, and pelvis is warranted. It is possible for an experienced trauma team to apply an anterior ex fix in the emergency department, or more likely, in the angio suite while the radiology team is getting prepared. If the patient has a low risk injury (e.g. stable lateral compression), then application of an external fixator should be done first.

I am not aware of any good comparative studies as you ask. However, there are several good papers that address the topic :

Routt ML, Simonian PT, Ballmer F. A rational approach to pelvic trauma. Resuscitation and early definitive stabilization. Clinical Orthopaedics and Related Research, 1995; 318: 61-74.

Perez JV, Hughes TMD, Bowers K. Angiographic embolisation in pelvic fracture. Injury 29: 187-191, 1998.

Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF. Arterial embolization is a rapid and effective technique for controlling pelvic hemorrhage. The Journal of Trauma, 1997; 43:395-9.

Ben-Menachem Y, Coldwell DM, Young JWR, Burgess AR. Hemorrhage associated with pelvic fracture: causes, diagnosis, and emergent management. American Journal of Radiology, 1991; 157: 1005-14.

Cryer H, Miller FB, Evers BM, Rouben LR, Seligson DL. Pelvic fracture classification: correlation with hemorrhage. The Journal of Trauma, 1988; 28: 973-80.

 

From: Ian Civil,
         Auckland, New Zealand
Date: 27.05.1999 09:39 GMT

I don't believe there have been (or perhaps could be) any randomised controlled trials. There are many non-patient variables, particularly skills and application of the orthopaedic surgeons and skill and application of the radiologist. It also depends on the configuration of the pelvic fracture. We would concur with the general approach taken in your case EXCEPT it is mandatory that the patient have FAST or DPL to exclude significant intra-abdominal bleeding prior to taking the patient to angio. In your case I imagine this would have been positive and we would have therefore taken the patient to the OR, done a damage control procedure, asked the Orthos for their opinion (+/- action) and then taken the patient to angio. If the FAST/DPL was macroscopically negative we would have taken the patient to angio.

This IS contentious and I don't believe I have ever heard or read from a group that convinced me they had the RIGHT answer. Otherwise we would all be doing the same thing. You might be interested in our latest contribution on this subject:

"Pelvic Fracture Haemorrhage - Indications for Embossing" J. Hamill, R. Paice, I Civil Aust NZ J Surg 69, Supplement A89"

From: Tim Coats
          Senior Lecturer in Accident & Emergency,
          Royal London Hospital, London
Date: 17.05.1999 11:27 GMT

This is a problem that we do not yet have an answer for. Our classic mechanism is a cyclist crushed by a lorry turning left. This gives a fairly isolated pelvis/abdo injury that all too frequently 'talks and dies'.

Treatment depends on both the fracture configuration, haemodynamic stability and facilities available (I do not have instant access to interventional radiology 24 hours a day - it often takes an hour or two to get set up).

Fixation followed by laparotomy and packing of the pelvis is often used here. I would suggest this would be a good approach if the abdomen was already open for correction of intra-abdominal bleeding (as in Tony's reply), simply because in most centres doing a laparotomy then moving to the angio suite would take a significant amount of time.

How about:

Severe cardiovascular instability + free fluid on FAST = laparotomy, fixation and packing.

Severe cardiovascular instability + no free fluid = (angio + embolisation) or (laparotomy, fixation and packing) depending on local expertise / facilities.

Cardiovascular stable + free fluid = CT abdo pelvis.

Cardiovascular stable + no free fluid = CT abdo pelvis.

Karim - I seem to remember you did a rather good presentation on this topic. Would you agree? (I mean agree with the above, rather than agree that your presentation was rather good!). How could an RCT in this area be organised? Anyone on the list interested in developing a trial protocol? Tim.

 

From: Eric Frykberg,
          Jacksonville, Florida
Date: 27.05.1999 12:02 GMT

Tim-- No one has instant access to such procedures, and no one on this list claimed to--in faact, several studies in the U.S. have shown that even in the most active trauma centers the average time to get an angio is 90 to 120 minutes--

Otherwise I agree with the algorithm you presented--except that in open book type fractures a C-clamp or wrapping a bed sheet around the patient for quick ex fix would be done in the trauma center first thing

 

From: Tim Coats
          Senior Lecturer in Accident & Emergency,
          Royal London Hospital, London
Date: 27.05.1999 15:30 GMT

I had just finished my last posting when we had a patient in with a crushed pelvis. This reminded me that I had forgotten to mention the pelvic C clamp. This is great for compressing the pelvis and can be put on in the resuscitation room. It does not have the problem of distraction of the posterior fragments that can be caused by a conventional iliac exfix.

Also I had forgotten to mention the elasticated pelvic belt that we use for unstable patients in the pre-hospital phase - little hard evidence, but it reduces the fracture marvellously in some patients (but can also cause posterior distraction).

Other vital factor that I missed - preserve clot! Use a minimum of patient movement. No rolling (leave back exam for later). Also stop anyone who wants to try and 'spring' the pelvis. This is a useless examination.

(The patient had palpable carotid, no BP recordable, small abdominal free fluid on ultrasound, multiple other injuries, chest OK, GCS 13 before intubation. Pelvic C and fluid resuscitation. Repeat ultrasound after 20 minutes showed free fluid much increased, so to theatre for damage control laparotomy and packing of pelvis).

 

From: Avery Nathans
          Fellow, Trauma and Critical Care,
          Harborview Medical Center, Seattle, WA
Date: 28.05.1999 01:50 GMT

I don't know how the surgical team can decide that evaluation of the abdomen (DPL/US) is unwarranted and send the patient straight to angio. There are many publications supporting and outlining the strategies for prioritizing the management of combined (potential) intraabdominal and pelvic bleeding and all require some assessment of the abdomen.

If this patient would have died in angio from uncontrolled intraabdominal bleeding the surgical team would not have a leg to stand on.

 

From: G. Brattebo MD
          Haukeland Hospital Norway
Date: 28.05.1999 09:35 GMT

<<
Only a minority of pelvic fractures will be benefitted by reduction and ex-fix-........... These are the open-book type fractures in which ex-fix will reduce the volume of the pelvis and effectively tamponade most bleeding.
>>

So putting on an ex.fix. in the resusc.room is not advocated?

<<
First--intraperitoneal bleeding must be actively excluded by DPL or U/S (of course you can not CT an unstable patient)--if positive, patient must immediately undergo laparotomy to control that bleeding--if negative, or after control of intraperitoneal bleeding and still unstable, the patient must undergo angioembolization. Pelvic reduction should NOT ever have to be done in the Operating Room in the acute care phase--either apply a C-clamp fixator in the trauma center (takes 5 minutes) or simply apply a MAST trousers or wrap a bedsheet around the pelvis and pull it tight--I've used all and they are very effective IF the fracture is of the type amenable to it--
>>

For the skilled surgeon putting on an ex.fix shouldn't take more than some minutes either, which could be done simultaneously while doing the lap. & packing.

From: Ian Civil,
         Auckland, New Zealand
Date: 28.05.1999 12:00 GMT

Dear Andrew,

You seem to be arguing against yourself here. I would highly debate your comment under (3). 90% of patients on whom we undertake arteriography have arterial bleeding. I refer to my previous post.

 

From: Eric Frykberg,
          Jacksonville, Florida
Date: 28.08.1999 13:11 GMT

Ian--

That is our experience as well--I suspect that the difference is best reconciled by differences in patient selection--those with low rates of positive angios are those who are not at all selective and take all cases to angio--it should only be those who are unstable with no intraperitoneal blood, or after fixing intraperitoneal bleeding--most cases do not require angio--so we should all review our criteria for angio in this setting--and I suspect many of us do not have criteria, and just use the panic shotgun approach

Eric

 

From: Andrew H. Schmidt, M.D
          Faculty, Dept. of Orthopedic Surgery, Hennepin County Medical Center
          Assistant Professor, University of Minnesota
Date: 28.05.1999 14:10 GMT

Clearly, you are selecting your patients for angiography well and I suspect that you are only performing this on a small subset of your patients. My point number 3) was that of the entire group of patients with pelvic ring injuries and hypotension on presentation, only a small proportion (about 15%) actually have arterial injury (see Agolini SF et al, Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 43(3) p395-9).

The majority have venous bleeding that responds well to fluid resuscitation and immobilization of the pelvis. It remains very difficult to determine which patient may actually have arterial injury - that demands a careful assessment of the mechanism of injury, the pattern of displacement of the pelvis on radiographs, and an assessment of other likely sources of bleeding.

 

From: Pret Bjorn,
          Bangor, ME, USA
Date: 28.05.1999 17:06 GMT

This is an interesting and timely discussion for me; we labored for months to develop a triage and treatment protocol for unstable pelvic fractures (or unstable patients with pelvic fractures) only to discover that our orthopaedists had widely varying levels of experience and comfort with emergency external fixation; moreover, our case saturation -- a large handful annually -- doesn't help.

Our leading trauma orthopod is advocating the TSPF (Twin-Size Percale Fixator), and it seems an ideal solution: quick and low-tech, non-operative, no moving parts, wash with whites, tumble dry medium. Only minor questions remain: regular or fitted? Hospital corners? But I digress...

Thanks for all of the well-articulated posts on this thread.

(Sorry to mislead -- your response is further evidence that my sense of humor is not for everyone, if anyone. The "TSPF" is a bed sheet, tied snug around the pelvic ring. I've heard much about the c-clamp, here on the list & elsewhere (Len Jacobs at Hartford has been using it for several years), but we don't have one. Frankly, it seems like it would be a little ungainly in the CT room, etc.)

 

From: Phil Munro,
          Glasgow, Scotland
Date: 29.05.1999 10:07 GMT

We had a pedestrian knockdown with a L flail, R peumothorax and unstable pelvis fracture this week. Blood pressure unrecordable on arrival. Had rapid fluid and blood, bilateral chest drains and a blanket tied round pelvis. FAST negative including pericardial view. The blanket was replaced with an Ex-Fix put on in the resus room but BP remained 75/50 despite continuing blood transfusion. Where to now? We had arranged angiography but it was argued he was too unstable for this and that he required admission to ITU to be "filled up" with blood until the bleeding stopped.

Should we have gone directly to angiography as planned despite the BP, OR for laparotomy and packing, or ITU for rewarming, massive transfusion and "stabilisation"?

 

From: Eric Frykberg,
          Jacksonville, Florida
Date: 29.05.1999 14:13 GMT

<< For the skilled surgeon putting on an ex.fix shouldn't take more than some minutes either, which could be done simultaneously while doing the lap. & packing. G. Brattebo MD >>

Dr Brattebo--
I'm sorry but I ahve heard this so often in my 20 years of dealing with these cases I have to condemn such philosophy!

The classic moan of the Orthopods--"oh, it will only take me 5 minutes....etc etc etc" And 2 hours later thay are still flailing around!

There is NO earthly reason why it is necessary to be in the OR to apply an ex-fix immediately in the acute care phase for hemodynamic instability, no matter how quickly it can be done (and again--it is NEVER as quick as they say!)--that is a simple fact, and it is unchanged by the conjecture that it may be done quickly--even if true, doing it in the trauma center without the time and waste of resources of needlessly going to the OR for this is CLEARLY less use of time and quicker--this can't be argued.

The only time fixation of a pelvic fracture should be done in the OR is in the stable patient who has already undergone all acute phase evaluation and management--and this is generally days later in bad fractures with hemodynamic instability.

 

From: Eric Frykberg,
          Jacksonville, Florida
Date: 29.05.1999 14:47 GMT

<< This is an interesting and timely discussion for me; we labored for months to develop a triage and treatment protocol for un-stable pelvic fractures (or un-stable patients with pelvic fractures) only to discover that our orthopaedists had widely varying levels of experience and comfort with emergency external fixation; moreover, our case saturation -- a large handful annually -- doesn't help. >>

Pret-- An important discovery on your part--and it should show you that for that reason, the Orthopods should not be involved in emrgent ex-fix unless you are lucky enough to have one in your facility with the necessary interest and experience with this trauma--the Trauma team should be able to do this very quickly in the trauma center with the C-clamp device or a bedsheet, IF it is one of that small minority who actually need such emergent fixation--which, again, most do not!

It is the same as we discovered for getting urologists involved in GU trauma, or cardiac surgeons in chest or cardiac trauma--forget it! By the time they arrive, and finish their piddling like this is some elective case, things are already over--one way or the other! If a trauma surgeon or ER physician cannot take care of any immediately lifethreatening problem themselves, and must depend on calling in specialists who generally have little interest or experience with trauma, they should not be doing trauma! Pure and simple--and if your own experience you describe above does not convince you of that, then nothing will!

This is not a criticism of those specialists--it is a matter of needing to act quickly. In fact, those specialists are an important part of all trauma centers, but not for immediate life-threatening problems--that is our responsibility

From: Tony Joseph,
          Royal North Shore Hospital, Sydney, Australia
Date: 31.05.1999 03:04 GMT

Dear All

Thank you for your responses which reflect as I suspected a lot of experience in the management of these injuries but not much in the way of controlled studies which again is not surprising. I am told by my orthopaedic colleagues that the application of a C-clamp in the correct position in the Resuscitation Bay above the acetabulum in order to obtain posterior closure is not that easy without the use of an Image Intensifier and should be done by an experienced person.I would be interested to know how much experiece is out there with these clamps, who puts them on and how successful they are.

It seems that all agree that control of any obvious intraperitoneal bleeding is clearly of paramount importance, but where one goes from there assuming that there has been adequate oxygenation and fluid / blood resuscitation remains unclear.

Embolisation may be a good option in the 15% with arterial bleeding, but what is the best approach in the other 85% with retroperitoneal venous bleeding? Is there a place in the haemodynamically unstable patient at laparotomy for opening the retroperitoneal haematoma , packing it and tying off the Internal Iliac Arteries if necessary.

I still feel uncomfortable about sending a haemodynamically unstable patient to the Angio Suite as it is not the best place to perform a resuscitation.

I think Tim Coats and Ian Civil provided a commonsense approach and perhaps their proposals could be the basis for an international study?

From: Andrew H. Schmidt, M.D
          Assistant Professor, University of Minnesota
Date: 28.05.1999 14:10 GMT

> I am told by my orthopaedic colleagues that the application of a C-clamp ...is
> not that easy without the use of an Image Intensifier and should be done by an
> experienced person.

I agree completely. They are especially difficult and dangerous in the case of a comminuted sacral fracture, because the sacrum may be crushed easily. I have also heard of C-clamps being misapplied with the prongs going through the greater sciatic notch into the pelvis.

> what is the best approach in the other 85% with
> retroperitoneal venous bleeding?

The majority of these will respond to fluid and provisional stabilization of the pelvis. Selective angiography in those that don't respond is appropriate.

> I think Tim Coats and Ian Civil provided a commonsense approach and perhaps
> their proposals could be the basis for an international study?

Agreed.

 

From: Eric Frykberg,
          Jacksonville, Florida
Date: 31.05.1999 13:14 GMT

<< I am told by my orthopaedic colleagues that the application of a C-clamp in the correct position in the Resuscitation Bay above the acetabulum in order to obtain posterior closure is not that easy without the use of an Image Intensifier and should be done by an experienced person >>

Tony--

This just is not true--again, get the specialist involved and the piddling and screwing around start.

The key at this point is not to get perfect placement and alignment but to stop the hemorrhage!

<< but what is the best approach in the other 85% with retroperitoneal venous bleeding? >>

You are imagining a situation that happens rarely if at all--if the patient is stable after intraperitoneal bleeding control, of course there is no issue A small number of times I have seen evidence of hemodynamic instability continue after intraperitoneal bleeding control and angioembolization AND fracture fixation(if indicated)--which again are the steps to follow after the belly is taken care of if further bleeding still occurs. In every case, this stopped once the patient was warmed, acidosis reversed and coagulation factors restored, and was presumably from venous bleeding.

Venous bleeding almost always stops on its own and is rarely a problem (except in the open book or open perineal fractures where there is no chance for tamponade), If you have continued evidence of bleeding even at that point--first, write it up and publish it! Then go back over everything again, rechecking CT or U/S of the abdomen, fracture fixation and re-do a pelvic angio, keep on top of temp, acidosis and coags--DO NOT reoperate in some misguided attempt to control retroperitoneal pelvic bleeding surgically--you'll make the patient worse if not be the coup de grace!

<< Should we have gone directly to angiography as planned despite the BP, OR for laparotomy and packing, or ITU for rewarming, massive transfusion and "stabilisation"? >>

Phil,

Absolutely! The treatment for ongoing hemorrhage is NOT transfusion or "resuscitation"-- it is to STOP THE HEMORRHAGE!

Would you first take a ruptured spleen to the ICU to "resuscitate" before doing your splenectomy to "stabilize" the patient first?? How about a gunshot wound to the neck with a BP of 50-60? Would your efforts be to first stop the bleeding or "resuscitate" in the ICU to stabilize enough to take the patient to surgery?

The above approach defies all logic that you yourself would follow in any other scenario. Pelvic fracture hemorrhage is somewhat different in that surgery is not the way to stop it--angioembolization is clearly the treatment of choice, and this has come from long years of experience with the hazards and futility of operative management obviously an experience that the above physicians are completely unaware of. Sending an unstable patient to angio is generally something we should not do, but this paradigm is changing as interventional angio is becoming more proven of benefit in various scenarios, and this is one of those exceptions--this is one of those scenarios, like the ruptured spleen and GSW neck above in which the ONLY way to "stabilize" is to immediately stop the bleeding! And angio is the best way to do that once intraperitoneal bleeding is excluded or stopped when you are dealing with a fractured pelvis--it is no different than sending an unstable patient with a ruptured spleen to the OR--to the best place to stop the bleeding

 

From: Tim Coats
          Royal London Hospital, London
Date: 01.06.1999 09:47 GMT

>Should we have gone directly to angiography as planned despite the BP, OR
>for laparotomy and packing, or ITU for rewarming, massive
> transfusion and "stabilisation"?

Yes. You need to stop the bleeding. Resuscitation will not achieve this (may even make it worse). Transfer to ITU for stabilisation is likely to lead to patient death (if not immediately they will probably die from the results of massive transfusion).

I would suggest give FFP and cryoprecipitate (BEFORE knowing the results of the coag screen - it will be abnormal), warm the patient (coag system works better), look at the xray to see if a C-clamp would help, use minimum of patient movement throughout (preserve clot). Then move direct to angio if this is set up. If no immediate access to interventional radiology (many UK hospitals receiving major trauma are not set up for rapid interventional radiology) consider laparotomy and packing (some patients will die as soon as you open the abdomen, with release of tamponade from anterior abdominal wall).

Some radiologists have a real problem with patients dying in their department. As with death on the operating table this is sometimes simply an unavoidable consequence of optimum management.

From: Ian Civil,
         Auckland, New Zealand
Date: 01.06.1999 11:03 GMT

Dear Phil,

You have done everything right BUT I would be very confident that this patient has arterial bleeding. "Filling him up" prior to angiographic control of haemorrhage will do nothing constructive but cause a huge pelvic haematoma, an abdominal compartment syndrome, and the patient will still need angio. Why not sell the concept "take the ICU to the radiology suite"

Maybe in the future we will have facilities that allow surgery, interventional radiology, and intensive care all in the same location.

 

From: Karim Brohi
Date: 02.06.1999 00:46 GMT

Well, I thought I would get in on the act. There are some basic principles & decisions in the management of these injuries.

Q. Who needs emergent pelvis stabilization?

The HAEMODYNAMICALLY un-stable patient with a MECHANICALLY un-stable pelvis (and only this group)

Q. How do I know which fracture is mechanically unstable?

X-ray - not repeated springing of the iliac crests. This also springs open & closed whatever veins & arteries are trying so hard to clot off. The pure open-book type fracture (Tile B) is stabilised better with an anterior ex-fix than a posterior C-clamp. All the other unstables benefit from posterior stabilisation (C-clamp). A triangular bandage / pelvis sling MAY accomplish both of these to some extent. Oh and stop log-rolling too.

If you don't know which fracture is which - learn. Have a look at the trauma imagebank which has Tile & AO classifications. www.trauma.org/imagebank/imagebank.html

Q. What am I trying to achieve with stabilization?

Ahh, glad you asked. Just what you say. Stabilisation - not anatomical reduction of the fracture. Once a blood vessel is torn it probably stays torn and does not repair itself too quickly. However, you probably (A) protect what clot has formed, (B) aid new clot formation and (C) prevent further harm. You may also provoke some degree of tamponade by closing connective tissue spaces which will help stabilise a venous bleed but not arterial ones.

Q. OK I have stabilised the pelvis but still bleeding a lot!

bleeding from somewhere else?
No.
you sure?
Yes.
Sure sure?
Yes.
Checked for intraperitoneal free fluid?
Yes.

OK If you have stablised the pelvis & have done what you can to control venous bleeding the patient needs angiographic embolization of an arterial bleeder. This is one of the few instances where you are allowed (my permission) to send an un-stable patient to the angio suite (Zone 3 neck injuries may be the only other).

Q. I have done a DPL/USS/Tricorder reading and there is free fluid in the intraperitoneal cavity, where do I go now?

To theatre for a laparotomy, for a concomitant intraperitoneal organ injury. If the patient needs a laparotomy, he or she is in big trouble. There are few surgical options after opening the abdomen releases 'tamponade' on a retroperitoneal haematoma which is expanding in front of your eyes:

A. Open the haematoma and ligate one/both internal iliacs - this invariably results in death and is one of the most scary surgical procedures ever & I think should be discarded immediately

B. Pack the pelvis. - It is very difficult to pack a structure which gets bigger as you push things into it. This is the un-stable pelvis. Therefore the pelvis must be stabilised prior to packing. This can be done with external-fixation/C clamp but may just as effectively be performed with a triangular bandage when there is no experienced orthopod around.

C. Angiography. - If you have packed the pelvis, stopped the intraperitoneal haemorrhage (Damage Control) and the patient is still bleeding this is arterial from the pelvis and the patient can be transferred secondarily from OR to the angio suite for embolisation.

Q. Anything else I should be doing?

Yes,

Q. What?

Aggressively treating coagulopathy & hypothermia - Not aggressively fluid resuscitating - maintaining brain perfusion is probably fine until the bleeding has stopped.

Q. Does all this make any difference?

I think so. A coordinated approach to these injuries, with minimal messing around is the only way to save these patients. Over the first few years of the HEMS service at the Royal London, patients admitted with an intra-peritoneal AIS of 4 or more and AIS 4+ pelvis had a 50% mortality (ie. ISS > 32), and of those who arrived in resus hypotensive (SBP <90), 90% died.

Since the arrival of interested, able orthopaedic staff and recognition and institution of the above principles that figure is around 15%.

PS. Eric, any idea of data on the utility of ultrasound for identification of free fluid in the presence of a large retroperitoneal haematoma? Karim

 

From: Ian Civil,
         Auckland, New Zealand
Date: 02.06.1999 05:25 GMT

Karim,

Do you have any allergy to the Young/Burgess classification of pelvis fractures. We have found that mechanically unstable pelvic fractures on this classification (APC II/III, LC III, VS, Combined mechanical) have a significant association with need for embolisation using the Auckland Hospital algorothm.

Ian Civil

 

From: Karim Brohi
Date: 02.06.1999 23:36 GMT

Ian,

Nope, I accept that Young & Burgess is used & is useful, although I have difficulty sometimes with fracture classifications based on mechanism of injury - which can create conflicts with the given mechanism. The Y&B classification is also available on the imagebank. I think you'll find that anatomically Tile correlates well with Y&B.

Karim