Demographics
10% of Blunt Trauma Cases
3-8% of all skeletal fxs
Occur due to heavy force transfers:
- Lateral impact MVC
- Auto vs. Ped
- Motorcycle crashes
- Falls >15 ft
5-20% overall mortality
Related to:
- Pelvic hemorrhage
- Associated injuries
Risk increased with:
- Advanced age (osteoporosis)
- Female gender (ligamentous laxity)
Anatomy
3 Bones: R Ilium, Sacrum, L Ilium
Each ilium results of fusion of iliac, pubus and ischium
Ligaments:
- Anterior sacroiliac
- Posterior sacroiliac
- Sacrospinous
- Sacrotuberous
- Iliolumbar
Pubic symphysis <1cm = normal, 1-2.5 cm = stable, >2.5cm = unstable
15% of pelvic bleeds are due to major arterial bleeding sites (internal pudendal arteries)
85% of pelvic bleeding is venous
Extremely hard to control surgically
Responsive to tamponade effect from undisrupted peritoneum
Neighboring Pelvic Structures:
Lower urinary tract
GYN organs
Rectum
Nerves
Postmortum angiographic & anatomic dissection study.
U of Helsinki - 27 blunt trauma pts between 1969-71
In only three patients could a lesion to a main artery be identified
Extravasation of congealed contrast medium from both the fractured cancellous bone and from the torn vessels in adjacent soft tissue hampered identification of the various arteries involved
Early and accurate repositioning of the posterior fracture would press the cancellous bone fragments together and serve the same purpose, that is, reduced hemorrhage from the damaged area
Dissection revealed injury to the neural elements in 13 specimens, usually on the ventral aspect of the sacroiliac joint
--Shifted to staying out of pelvic hematomas
Pelvis - Physical examination
ABC’s
Careful Inspection
AP and Lateral Compression
Learn how to examine instability
Neurologic examination
Distal pulses +/-APIs
Inspection:
Scrotal Hematoma
Blood at Meatus
Open wounds
Roll the patient
Rectal +/- vaginal exam - Location of prostate
Morelle lesions -
Abnormal rotation of limb without gross instability
Pelvic Instability - posterior, then lateral compression
Tenderness may be the only sign
Biomechanics
By definition, a ringed structure cannot be disrupted by blunt force in one place only
Radiographic Evaluation
Pelvis X-ray
- Plumb line spine line up with pubic symphysis
- Transverse line across femoral plane
- Circle centered around those lines of middle of pelvis
- Good cortical lines around outside of bone
- Ileoischeal line and ileopectinate lines
- Pubic symphysis <1cm = normal, 1-2.5 cm = stable, >2.5cm = unstable
Ortho often gets 5-view xrays
2D and 3D CT Reconstruction
CT has added a new dimension to the determination of displacement in pelvic ring injuries and is the best method of visualizing lesions of the sacroiliac complex. It is especially useful in identifying fractures of the sacrum, clearly showing those that are compressed or impacted due to lateral compression, rather than gaping and unstable. 3.0mm cuts or thinnner provide satisfactory detail of bony pelvis.
Patterns of Deformity
Lateral Compression (Windswept pelvis) - assoc. c Head/chest trauma
Open book - associated with abdominal injury and hemorrhage
Vertical Shear - assoc. c Hemorrhage
Pelvic Fx Classification
Lateral compression 1
- Transverse pubic rami fracture
- Sacral compression on side of impact
Lateral compression 2
- Transverse pubic rami fracture
- Crescent (iliac wing) fracture
***Does not benefit from sheet compression
Lateral compression 3
- Transverse pubic rami fracture
- Contralateral open-book (anteroposterior compression) injury
Anterior-posterior compression 1
- Symphyseal diastasis (1-2cm)
- Slight widening of symphysis and/or SI joint, stretched but intact anterior and posterior SI joint ligaments
Anterior-posterior compression 2
- Symphyseal diastasis or vertical pubic rami fracture
- Widened SI joint, disrupted anterior SI ligaments with intact posterior SI ligaments
Anterior-posterior compression 3
- Symphyseal diastasis or vertical pubic rami fracture
- Complete hemipelvis separation but no vertical displacement, anterior and posterior SI joint ligaments ruptured
***Highest bleeding
Vertical Shear
- Symphyseal diastasis or vertical pubic rami fracture
- Vertical hemipelvis displacement, usually through SI joint, occasionally through iliac wing or sacrum
Combined mechanism
- Vertical or transverse pubic rami fractures
- Combination of patterns; lateral compression with vertical shear or lateral compression with anterior-posterior compression
LC3, APC2&3, VS, and combined indicate major ligament disruption
Average Transfusion Requirements (u pRBCs)
- Lateral Compression 3.6 U pRBC
- Open Book 14.8 U pRBC
- Vertical Shear 9.2 U pRBC
- Combined 8.5 U pRBC
Most likely to bleed: APC 3 > VS > Comb > LC3
Fracture pattern alone does not predict: mortality, hemorrhage risk, need for angiography
Isolated acetabular fractures have equal risk of bleeding as pelvic ring fractures
Fx Classification Limitations
50% of pts c significant pelvic arterial bleeding have relatively minor or even non-displaced Fxs on XR
Significant % of pts c displaced Fxs have minimal hemorrhage.
Evaluation therefore requires a composite approach: injury mechanism, fracture severity, physiologic data
Bleeding in Stable Pelvic Fxs
Incidence of significant bleeding = 5%
3 Predictors:
- Initial SB < 90
- Initial Hgb < 10
- Pelvic hematoma on CT
Don’t forget about things that bleed most commonly!!
•Scalp
•Chest
•Abdomen
•Extremities
•Pelvis
–Fracture bleeding
–Venous plexus
–Arterial hemorrhage
Means of Control
Pelvic Wrap
Pelvic External Fixation
Angioembolization
Operative
- preperitoneal packing
- iliac artery ligation
Pelvic Wrapping
-Remove clothes
-Apply over broad area centered around greater trochanters
-No wrinkles / twisting
-Manually reduce
-Clamp Sheet
-Time of Removal?
Other Pelvic wrapping techniques
- MAST trousers (debunked)
- Pelvic circumfrential compression devices (PCCDs)
- Pelvic binder: velcro-backed with shoelace closing - tighten to "two fingers"
- SAM-Sling: sized to fit, fasten with auto-stop buckle that limits compression
- T-POD: velcro-backed with pulley system pull-tab (chambers prefered)
Comparing means of control
Best stabilization with least tension obtained at level of greater trochanters, also caused least IAP increase at level 1
60 percent decrease in instability (to IR/ER and Flex/Ext) with pelvic sling
C clamp worse than sheet
Ex-fix most stable but potential to cause further harm
Examined safety of applying pelvic sling to “unidentified” pelvic fracture
–Type II LC (worst-case) created on 8 cadavers
–Pelvic inlet area and IR displacement NOT significantly changed
Croce et al. J Am Coll Surg (2007)
Retrospective case-control on 186 patient over 10 years with hemodynamically unstable pelvic fractures
Compared T-POD (n 93) with emergent external pelvic fixation (n 93)
Evaluated transfusions, hospital stay, VAP, and mortality
T-Pod Advantages:
–Reduced transfusion requirements, VAP, and hospital stay
–Trend toward decreased mortality
–Similar efficacy for controlling fracture site and pelvic hemorrhage (based on equal number of pelvic angio pts)
–Time from injury to ex-fix or POD placement was NOT provided & slightly higher ISS in EPF group
Tan et al, Injury (2010)
Case series investigating the effect of the T-POD on hemodynamic stability and reducing pelvic volume
T-POD applied to 15 patients with prehospital untreated unstable pelvic fracture with signs of hypovolemic shock
Heart rate, blood pressure, and symphyseal diastasis measured before and after application
Results:
–Symphyseal diastasis was significantly reduced - 41.7mm to 12.4 mm, p 0.01
–MAP increased significantly - 64.7 mmHg to 81.2 mmHg, p 0.04
–Heart Rate significantly decreased - 106 to 93 beats per minute
–No side effects seen: no skin necrosis or compartment syndrome (maximum use 48 hrs)
Conclusions:
–Treatment of unstable pelvic fractures is based on quick stabilization of the pelvis
–The T-POD causes a significant improvement in circulatory parameters
–It is effective in temporarily stabilizing pelvic ring injuries in hemodynamically unstable patients
DeAngelis, French BG, et al. Injury (2008)
Conclusions:
–Non-invasive means of provisional pelvic stabilization during the initial resuscitative period appears to be the optimal approach - Safer, more time effective, technically simpler
–T-POD reduces the symphyseal diastasis in APC type pelvic fractures more effectively than a circumferential bed sheet
Cautions:
–Controlling skin-device interface pressure is important to prevent the development of sores
–Increased pressure with thinner patients (lower BMI)
–Do NOT keep binder in place longer than absolutely necessary
–Check pressure areas regularly if extended use required
Gardmer et al. JOT (2009)
Internal Rotation and Taping of the Lower Extremity for Closed Pelvic Reduction
Technique paper describing internal rotation and taping of lower extremity as alternative or supplemental closed pelvic reduction method
Especially useful when: truncal obesity, degloving injury with compromised pelvic skin, open fractures, colorectal or bladder injuries, femoral catheters
Typical sites include anterior thighs and feet – avoiding subcutaneous bones
Clean site with alcohol than allow dry
4-in-wide foam tape –Several bands applied smoothly
Assess tape sites frequently –“never over 24 hrs”, remove once reduction is stabilized
PODs
Early stabilization and compression of unstable pelvic fractures is critical. PCCDs effectively reduce symphyseal diastasis and are a reasonable option for temporary stabilization of these injuries.
FASTER FIXATION = KEY ADVANTAGE
The majority of patients with ongoing bleeding have an arterial source
Angioembolization in HD Unstable Pelvic Trauma
Necessary in 3-10%
85-97% effective at controlling pelvic arterial bleeding
5-25% require repeat angioembolization
Technique
Proximal embolization favored, Easier, More effective
Additional Indications (other than unstable)
Blush (60-84% sensitive, 60-98% specific of Angio need)
Large Hematoma (> 500 cm3)
Age > 60 + Major Fx (ie: open book, butterfly segment, lateral shear)
Complications
Renal Failure
Gluteal Claudication (rare and likely more related to injury)
Trash Can (Pelvic Necrosis)
Sexual Dysfunction (rare and likely more related to injury)
Extrapelvic Hemorrhage
Scalp - clinical exam
Chest - CXR
Abdomen - FAST, DPA or CT
Extremities - Clinical exam
FAST in Pelvic Trauma
Focused Abdominal Sonography for Trauma
Advantages - non-invasive, rapid, potential for serial exams
Disadvantages - significant learning curve, problems, training, equipment, sensitivity, user dependent
Not sensitive enough to exclude intraperitoneal bleeding (25-75%)
If FAST is negative DPA enhances sensitivity to help r/o significant intraperitoneal bleeding source
FAST is specific enough in unstable patients to indicate Ex-lap (87-100%)
In stable patients CT recommended regardless of FAST results
Diagnostic Peritoneal Lavage
Traditional parameters: >5cc gross blood, >100,000 RBCs
--> RBC diapedesis from pelvis decreases specificity of DPL but not DPA
Supraumbilical DPA: better sensitivity than FAST, Better specificity than DPL, ~sensitivity to DPL
Intraperitoneal Bleeding Evaluation with Pelvic Fx
Stable --> CT A/P -->
+Hemoperitoneum --> treat as indicated for abdominal bleeding
+Pelvic blood, pelvic blush, >500 cc hematoma or major fracture in pt>60 --> consider pelvic angio
Unstable --> FAST
Positive--> Ex-lap
Negative-->DPA
Positive--> ex-lap
Negative --> eval for other sources --> consider angioembolization
Preperitoneal Packing
Step 1 - 6 to 8 cm midline incision starting at pubus
Step 2 - Blunt digital dissection to open preperitoneal space for packing (pelvic hematoma often facilitates this
Step 3 - Three laparotomy pads are placed on each side of the bladder, deep within the preperitoneal space, and the fascia is closed with O-PDS and skin with staples
Performed concurrently with or after Ex-Fix
Separate from Lap incision
Suprapubic before fascial closure if needed
Laps out in 48 hr
Outcomes
Limited data available currently
Improved outcomes with severely injured (mean ISS 55) in Colorado
Good option in unstable pt not responsive to wrapping / fixation and Angio not available
DC Ligation of Internal IIiac Arteries
Means of Control
•Pelvic Wrap
•Pelvic Fixation
•Angioembolization
•Operative
Pelvic Fixation
Fixation rare prior to 1970s
1980-90s: Benefits of ORIF documented.
Current standard in stable pts = early ORIF
Damage Control Ortho – Pros & Cons
•Early mobilization
•Decreased LOS
•Better Function
•Decreased SIRS
•Decreased PRBCs
•Decreased ARDS
Literature suggests that early definitive treatment may be used safely for most patients with multiple injuries. however, a subgroup of patients with multiple injuries may benefit from
Definitive ORIF within 4-14 days
Morel-Lavallee Lesions
Initial description in 1860s
Modern description by Letournel in 23/275 (8%) acetabular fxs
Internal hip degloving injury
•Clinical Dx: Skin hypermobility,ecchymosis, abrasions
•Radiologic Dx: SQ fluid collection
•Morel-Lavalle Lesions
•Treatment
•Open Pelvic Fx
•Emergent Irrigation and Debridement
•Bedside washout if necessary
•Optimal Washout in OR
•Be smart and aggressive with debridements
–Do not leave dead muscle
–Remove all debris
–Consider diverting colostomy when rectum involved
–Provide skeletal stability when possible
–Abx
•Pelvic Fx & Lower Urinary Tract Injuries
•Urethral injury
•Urethral Injuries
•Dx: Retrograde urethrogram
•Urethral Injuries - Management
•Stable pt : early realignement & endoscopic repair
- decreased stricture rate
- earlier return to spontaneous voiding
- less sexual dysfunction
•Unstable pt: suprapub cath & interval perineal urethroplasty
•Pelvic Fx & Lower Urinary Tract Injuries
•Bladder Injury
•Bladder Injury
•Extraperitoneal – foley
•Intraperitoneal – operative closure