KY Trauma Symposium

Report
Pelvic fracture
Management
Erik Hasenboehler MD
Orthopaedic Trauma Surgery
Baltimore MD
Kentucky Trauma Symposium 2012
Subjects
 Basic Polytrauma management
 Polytrauma basic science
 Pelvis Exam, Stability and managment
 Acute treatment of pelvic ring injuries
 Open Pelvis fracture
Pelvic fracture
and Polytrauma Management
One goal !!!!!!!
Save the patient`s life !
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
Second hit phenomenon: Existing evidence of clinical implications
Lasanianos et al Injury 2012
Systemic Inflammatory
Synergistic Inflammatory
Two Hit Model
Severe
SIRS
First
insult
MOF
Delayed definitive surgery
Moderate SIRS
2nd
insult
Definitive surgery
EARLY
Moderate
immunosuppression
Severe
immunosuppression
Infection
Moore FA and Moore EE. Surg Clin North Am. 1995
MOF
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 2012
3. 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
Causes of Death from Pelvis
Fractures
 < 24 hours: blood loss
 > 24 hours: MOF
 Exsanguination caused 75% of the deaths
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, 1996
2. 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
Acute Management
 SAM Sling / T-POD / Circumferential Sheet:
TOO HIGH!!
Greater Trochanter!!
Pelvis and Acetabulum
Frontline Treatment
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
arterial
< 10%
> 90%
Who should get angiography?
Rationale:
fracture (cancellous) / venous
arterial
< 10%
> 90%

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.
Pohlemann T. et al.
Tech Orthop 1994
1.
Cothren CC, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007
3.
2. Suzuki T, Smith WR, Moore EE, Pelvic packing or angiography: competitive or complementary? Injury 2009
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 2001
4. Tscherne H. et al. Crush injuries of the pelvis. Eur J Surg 2001
TREAT THE PATIENT BASED ON
HIS NEEDS……. DCO VS ETC
Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012
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

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