Emerg Management of Pelvic Ring Injury an Update

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Trauma and Critical Care Traumatologie Traum atologie et soins critiques

Emergent management management of pelvic ring injuries: an update Khitish Mohanty, MD;* Damian Musso, MD;* James N. Powell, MD;* John B. Kortbeek, MD;† Andrew And rew W. Kir Kirkpa kpatri trick, ck, MD†

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ractures of the pelvic ring comprise about 2% of all fractures, but the incidence is increasing due to increasing numbers of high-speed vehicular crashes and suicide attempts.1 Mortality associated with isolated pelvic injury, independent of severity, has been reported to be low: 1%–2%.2  Among multiply injured victims of  blunt trauma, however, almost 20%

ary team of trained personnel with a defined treatment protocol. Multidisciplinaryy clinical-pathwa Multidisciplinar clinical-pathway  y  and coordinated joint decision-making improves patient survival.17  A  postmortem study by Wright and colleagues18 has shown that the average ISS of patients dying from pelvic fractures was much higher in patients treated by a protocol of care than in

emerges. They are used worldwide for systematic management of multiply injured patients, and continue to be the most useful guidelines. The primary survey emphasizes immediate assessment of the airway  and breathing while maintaining spinal precautions. Attention is then focused on the cardiovascular system. Quickly identifying the site of hem-

those treated a “non-system” approach on anwith ad-hoc basis. As the understanding of these potentially fatal injuries improves, priorities of  early management of pelvic ring in juries are evolvin evolving. g. This This review review article article summarizes the current trend in emergent management of pelvic fractures, based on available evidence. A  protocol designed to facilitate organized and systematic care of the serious pelvic fracture in multi-system trauma is proposed.

orrhage in the hemodynamically unstable patient is both critical and time-dependant. Although volume resuscitation is generally begun after intravenous (IV) access has been established, it is only an adjunct to aggressive hemorrhage control.20,21 It is important to note that volume resuscitation without hemorrhage control is ineffective and may lead to secondary iatrogenic complications such as hypothermia and coagulopathy. Hemorrhage control consists of  stopping external bleeding by direct pressure and expeditiously determin-

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have injurieswhen to theclosed pelvicpelvic ring. ring In this group, disruption is associated with multiple injuries, the mortality rate rises to 10%–15%.6–8 Pelvic fractures associated with intra-cranial mass lesions or notable abdominal injuries have mortality rates as high as 50%.3 The mortality associated with open pelvic fractures has been shown to be 30%– 50%.9,10 The parameters that predict mortality are age, injury severity score (ISS) and the existence of severe hemorrhage.11 Exsanguinating hemorrhage is the

Advanced trauma life-support

major cause of death12–16 in the first 24 ing whether surgery or other interand the primary survey hours after trauma. Immediate  venti ons are require  ventions required d for intern internal al recognition of hemorrhagic shock  Upon arrival in the emergency decontrol of bleeding. If the patient and effective control of bleeding partment, patients should be resuscishows signs of hypovolemia, a thormust be pivotal in every resuscitation tated according to the guidelines of  ough and systematic search must be effort. Appropriate recognition and the Advanced Trauma Life Support initiated to identify the source of  management of serious pelvic fracCourse (ATLS) of the American bleeding. Plain radiographs of the tures is also integral to resuscitative College of Surgeons’ Committee on chest (CXR) and pelvis are obtained strategy. Management of these po- Trauma.19  ATLS protocols are sub- at this stage. Optimally, this is foltentially lethal injuries requires expe-  ject to period periodic ic review review and and revision revision as lowed by an evaluation for intradited stabilization by a multidisciplin- new clinical and basic science data abdominal bleeding, through either From the *Department of Trauma and Orthopædics, and the †Departments of Critical Care Medicine and Surgery, Foothills  Hospital, Calgary, Alta. Accepted for publication May 28, 2004  Correspondence to: Dr. Andrew W. Kirkpatrick, Department of Surgery, Foothills Medical Centre, 1403–29th St. NW, Calgary AB  T2N 2T9; fax 403 944944-1277; 1277; andrew andrew.kirkpa .kirkpatrick@c trick@calgaryh algaryhealthre ealthregion.ca  gion.ca  © 2005 Canadian Medical Association

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diagnostic peritoneal lavage (DPL) loss. A very low hematocrit may also or, increasingly, a focused assessment suggest massive blood loss, but nor with sonography sonography for traum traumaa (FAST (FAST)) mal hematocrit does not rule out exam.22  We conceptu conceptualize alize this exam shock. In young patients, estimations as a simple extension of the physical of arterial blood pressure, central venexamination.23,24 ous pressure, hemoglobin and hemaIdeally, major blood losses into a tocrit have been shown to be unreliahemothorax or the peritoneal cavity  ble markers of shock.26  will thus be detected by either the  A base base deficit deficit with metab metabolic olic acidacidCXR or the FAST. Retroperitoneal osis, as estimated from arterial blood blood loss associated with a pelvic gas analysis, can be obtained quickly, fracture will not be definitively de-  which is useful in estima estimating ting the tected through this algorithm, but severity of shock and an important can often be inferred when a severely  trend to follow.27,28 Ertel and associdisplaced pelvic fracture is seen via xates29 have also emphasized lactate rays and the chest radiograph and clearance as an accurate way to quanabdominal studies are reassuring. tify both the degree of hemorrhagic Computed tomography (CT) is shock and the probability of survival. undeniably the most accurate means Lactate levels are believed to better to identify peritoneal and especially  correlate with total oxygen debt, retroperitoneal injuries, but the CT  which ulti ultimatel matelyy depen depends ds on the suite is an unsafe environment for the magnitude of hypoperfusion and

tients with no obvious site of hemorrhage, careful clinical examination  of  the pelvis is mandatory even when radiographs look normal or a pelvic image demonstrates a stable fracture configuration. A hurriedly taken anteroposterior view of the pelvis in the trauma room is often inadequate and may fail to reveal posterior injury of  the pelvic ring. Physical examination of the pelvis should include thorough inspection of the flanks, lower abdomen, groin, perineum and buttocks to detect any wounds or bruises. The genitals and rectum should be inspected carefully to detect any  blood at the urethral meatus or in the rectal vault, and to assess for a highriding prostate. In the presence of  signs suggestive of a genito-urinary  injury, insertion of a urinary catheter should be avoided, and a retrograde

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unstable traumainpatient. An essential consideration resuscitating these patients is thermal control, with a strict avoidance of early hypothermia,  which exacerbates traumatic coagulopathies.25

hemorrhagic shock.clinical In signs the early  resuscitative phase, and symptoms, along with measurement of hourly urine output, continue to be the most practical indicators of  systemic perfusion.

Initial assessment of pelvic injury

Fracture stability

The 2 most important factors that If pelvic radiographs reveal obvious direct further management of pelvic radiological instability of the ring, injury are the patient’s hemodynamic aggressive physical examination with status and stability of the pelvic ring. compression and distraction will not Careful and thorough assessment of  provide additional information on inboth parameters can be life-saving,  jury severity, severity, but but rather could could potenand may direct systematic management priorities.

tially cause further injury or aggravate bleeding. Recently, investigators such as Duane32 and Guillamondegu Guillamondeguii33 and Hemodynamic status their respective groups have questioned the need for routine pelvic raHypovolemia should be carefully  diographs in awake and alert patients, evaluated and hemorrhagic shock diin whom clinical examination would agnosed and graded promptly. Spebe reliable. As in spinal fractures, cific attention should be paid to ashowever, many if not most severely  sessing the pulse and respiratory rates injured patients have confounding and the state of skin circulation circulation.. Relyfactors such as head or neurologic ining solely on systolic blood pressure  juries  juries,, intoxication, intoxication, or other distract distract-may be misleading, as up to 30% of a ing injuries that make the physical patient’s blood volume must be lost examination unreliable.34–36 Thus, in order to incur hypotension. Tachyscreening radiographs of the pelvis cardia and cool peripheries are early  are recommended and continue to be indicators, and a narrowed pulse presan adjunct to resuscitation. sure may suggest significant blood In hemodynamically unstable pa50

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urethrogram performed. Orthopedic assessment should also note any clinical deformity of  the pelvis, limb-length discrepancy or malrotation. The pelvis is tested for rotational instability with pelvic compression and distraction tests. A push –pull test, in which the examiner palpates both iliac crests while and an assistant provides telescoping forces to the ipsilateral lower limb, will help to find vertical instability. In patients who are both hemodynamically and mechanically unstable, and in whom the major bleeding is thought to be related to the pelvic fracture, external stabilization of the pelvis becomes the first priority. Because the main sources of bleeding are most frequently the presacral venous plexus (80%)37,38 and fractured bony surfaces, external stabilization decreases the hemorrhage by reducing the volume of the pelvic basin and approximating the fracture ends. Pneumatic antishock garments

The pneumatic antishock garment (PASG) or medical antishock trouser (MAST) can be helpful for immediate mechanical stabilization at an accident scene.39 “Prehospital” personnel can

 

Management of pelvic ring injuries

apply these garments promptly to fa- techniques. Potential complications cilitate transfer to the trauma centre.40 include skin necrosis if left in place The PASG may provide an initial retoo long or applied too tightly. In distribution of blood from the limb lateral compression injuries with to the trunk and restrict the expantransforaminal sacral fractures, possi41 sion of a pelvic hematoma. ble visceral or neural injury may ocIn multiply injured patients with cur if applied too vigorously.50 In both blunt and penetrating trauma,  vertically unstable pelvic fracture fractures, s, a however, randomized trials have not supracondylar skeletal traction pin shown a survival benefit for use of the should be introduced; note also that 42–44 MAST garment. It is also unsuit- to bring the affected hemipelvis level able for long periods of application before applying a pelvic binder, some because of the risk of compartment 25–30 pounds pounds (about (about 11–14 11–14 kg) of  45,46 syndrome. It impedes access to longitudinal traction is required. limbs and abdomen, making assess At prese present, nt, the only evid evidence ence availavailment of the patient in the emergency  able on the efficacy of pelvic binders room more difficult. Currently, the is anecdotal. Nevertheless this safe, role of PASG and MAST is limited. noninvasive method seems to be a logical first resuscitative step with a Pelvic binders serious pelvic fracture, to provide early hemorrhage control before consiCircumferential pelvic binders or dering invasive methods. sheets are gradually anterior external fixationreplacing (AEF) as the method of choice of immediate external stabilization, and currently form part of the ATLS protocol.47 These binders are noninvasive, simple to apply, inexpensive and can be applied at a prehospital stage. Biomechanical studies48  with pel vic sheets applied applied around the greater greater trochanters troch anters and and tensioned tensioned to 180 N have demonstrated their effectiveness. It has been shown that simple application of this sling increases pelvic stability by 61% in response to

ponade, and by decreasing bony motion at the fracture site, allowing clots to stabilize.59 The anterior pelvic frame can be applied in the trauma bay, intensive care unit (ICU) or operating room (OR) in around 20–30 minutes. Fixator pins can be placed percutaneously or with an open technique. There are 2 common sites of pelvic pin placement; in emergency situations the high route (directly between the 2 tables of the iliac crest) is preferable to the low route (the supraacetabular area between the anterior inferior and the anterior superior iliac spine). Biomechanical studies60 have shown that the low pin location has greater rigidity and pull-out strength; but in the trauma bay, placement of  pins in the low route without guidance by fluoroscopy can be danger-

ous and is not recommended. In juries to the lateral cutaneous nerve of the thigh and intra-articular pin Immediate AEF of an unstable pelvic placement have been reported.55,60 injury has been the mainstay of acute In the high route, stab incisions stabilization for the past few decades. for pin placement are made 1 fingerReimer and coworkers51 reduced breadth behind the ASIS (Fig. 1). mortality rates from 22% to 8% by  The natural overhang of the outer adding acute AEF to their hospital table of the iliac crest is taken into resuscitation protocol. Based on their consideration; the drill guide has to results, they concluded that skeletal be placed along the inner two-thirds stabilization of pelvic injury should of the crest. After opening the cortex be viewed as a part of resuscitation of the ilium with the drill, a 5-mm rather than reconstruction. Burgess threaded pin is directed toward the and colleagues52 and others53,54 have greater trochanter and inserted into Anterior external fixation

rotational stress and 55%, flexion–exalso documented decreased transfuthe ilium. Two pins, placed in a contension. Although the same study 48 sion needs and reduced mortality   verging manner, are usually used in found this method to be less rigid  with the the use of anterior anterior externa externall fixa- each iliac crest and are connected by  than AEF, it has nonetheless been tor. Subsequent investigators52,53,55–58 bars. Manual force is used to reduce shown to reduce unstable pelvic frachave also recommended immediate the pelvic fracture before tightening tures radiologically and to improve application of external fixation for he- of the bars, which are positioned to patients’ hemodynamic status.49 modynamically modynamica lly unstable patients, and allow access to the abdomen and To perform this method of stabi- consider it a life-saving procedure. permit flexion of the hip. 53 lization, either an ordinary broad Some investigators have advised The pelvic fractures most amenasheet can be tied at the level of the prophylactic stabilization with anter- ble to this form of treatment are the greater trochanter, or a commercial ior external fixator(s) in all patients open book fracture, and the unstable pelvic binder can be used or a MAST. demonstrating bony instability, as shear type when combined with lonIt must be positioned appropriately  even those patients who are initially  gitudinal traction. Lateral compresor be moveable when required, to hemodynamically stable on presentasion injuries incur fewer benefits provide access to the entire abdomen tion may decompensate later. The anfrom this method.55  AEF should be and groin. terior fixator is thought to contribute applied after discussion with the genClinical judgement and reassessto hemostasis by maintaining a reeral surgical team, illustrating the imment are important in using these duced pelvic volume, allowing tam- portance of multidisciplinary comCan J Surg, Vol. 48, No. 1, February 2005

 

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munication. Its judicious use before strated worsening of posterior deforof the dorsal border of the femur laparotomy can both reduce further mity in patients treated with AEF. (Fig. 2). Once both pins are placed, bleeding and prevent hypotension the clamp is assembled and can be from decompression of the tampon- C–clamps swivelled on its axis to permit access ade effect upon opening the abdomieither to the legs or abdomen. 61 nal wall. Ghanayem and associates To deal with posteriorly unstable C-clamp application can not only  have demonstrated in cadavers that fractures, Ganz and coauthors64 de- be difficult difficult but dangerou dangerouss in cases of  the abdominal wall provides stability   veloped  veloped a pelvic C-clamp, now availavail- comminuted sacral fractures: neuroby means of a tension band effect, able in most trauma units. It acts like  vascular  vascul ar injury can occur due to and that performing a laparotomy  a simple carpenter’s clamp and can crushing of the sacrum. Agneu and may further destabilize an open book  exert transverse compression directly  associates67 have reported pelvic penpelvic injury and increase pelvic volacross the sacroiliac joint. Experimen- etration of the stabilizing pins and ume. The potential mechanical eftal data64 have shown that an average overcompression of the clamps. The fects of leaving the abdominal fascia compress compression ion force of 3 342 42 N can be prongs of the C-clamp can be misopen after a laparotomy, as is comapplied to the area of this joint. applied and have been accidentally  monly done in the “damage control” These clamps have been used ther- placed into the true pelvis through approach to intra-abdominal injury, apeutically in hemodynamically un- the greater sciatic notch. remains unknown but is worthy of  stable patients, and prophylactically in Two types of pelvic clamps are further study. stable patients with unstable pelvicavailable. Schutz and coworkers68 The application of AEF requires ring disruptions. Hemodynamic stacompared use of the AO and ACE training and can be difficult to ac- tus and fracture reduction have been (Depuy International, Leeds, UK) 64 complish in the trauma room. It is shown to improve in both groups. pelvic clamps in 9 cases of posterior hard maintain a sterileofenvironment,toand contamination the pin tracts can jeopardize definitive care of pelvic fractures. Pins can easily be misplaced, which could contribute to premature loosening and mechanical failure. Hospodar and coworkers62 have reported pin misplacement of up to 25% without use of fluoroscopy.  Anterior  Anter ior extern external al fixators fixators can be be diffidifficult to apply in obese persons and can impede access to the abdomen and groin. And most importantly, AEF can aggravate the posterior instability  in an unstable fracture configuration. Dickson and Matta

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have demon-

Mechanically technically, posterior device isand better than an an-a 55,65 terior one. In experienced hands the posterior device is faster and safer to apply, and its position can be easily modified to allow access to the abdomen for the general surgeon. The C-clamp is generally applied in the emergency department, if possible with the aid of an image intensifier. Witschger and colleagues66 have described the typical site for pin placement to be at the point of intersection of a line from the posterior to the anterior superior iliac spine, with

injuries to the pelvis, achieving factory primary compression andsatisstability in all cases with either clamp, but found the ACE clamp to be less stable rotationally due to its design.  Although potenti potentially ally life-s life-saving, aving, these devices should be applied by an experienced surgeon, and considered only in cases of posteriorly unstable pelvic fractures accompanied by hemodynamic instability.

the extension of the longitudinal axis

ring disruptions with a pelvic clamp

FIG. 1. Anterior fixator placed using the high route for pin placement, with 2 pins for each iliac crest. 52

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Acute fracture fixation

Provisional fixation of unstable pelvic-

FIG. 2. Application of C-clamp with pins placed at line of intersection of a line from the posterior superior iliac spine to the anterior superior iliac spine with the extension of the longitudinal axis of the dorsal border of the femur.

 

Management of pelvic ring injuries

or an external frame with a supracon- sacroiliac joint or sacral fractures, dylar pin has proved markedly ben-  with the advantage of minimal diseficial in the resuscitative phase of  section and a reduction in wound management. If the patient is too ill complications.71,72 to allow a more invasive intervention, i ntervention, traction pins can remain in place with Angiography the external frame as definitive treatment. If, however, the patient under- Interventional angiographic procegoes a laparotomy to deal with visdures are increasingly being used as ceral injuries, symphyseal disruption adjuncts to hemorrhage control in and medial ramus fractures should be cases of solid-organ trauma. 73–75  As plated at the same time. Because neiexperience and familiarity increases, ther blood loss nor operative time are many patients are having intervengreatly increased, combining these tional radiological procedures instead repairs decreases the risk of compliof formal surgical intervention.73,76 cations in a patient who is already  Similarly, the role of pelvic angiogracompromised.69 phy is evolving in a selected group of   A role has has been sugge suggested sted for for per- patients with pelvic fractures. cutaneous fixation; however, only   Although the source of bleeding surgeons appropriately trained should is non-arterial in most cases, arterial use this technique. Open surgery  injury can account for hemodynamic provides the opportunity for direct instability in 10%–20% of patients.77,78

thermally stable patients who remain in shock after exploratory laparotomy  and surgical control of all other sources of bleeding. Overall requirements for angiography have been shown to be between 5% and 15%.83–85 The > 40% mortality mortality rate reported in these patients indicates the relatively severe nature of the injury and its associated poor prognosis. Open surgical exploration of arterial bleeding is not recommended: access to the iliac arteries is difficult to gain, and disruption of the pelvic hematoma and consequential loss of tamponade effect can produce massive, uncontrollable and often fatal bleeding.86,87 Pelvic angiography is typically  performed in a designated suite by a trained interventional radiologist, although the resuscitative suite of the future is likely to have both operative

 visua  visualizati lization, on, to butallow is often put off for  Vario us arteries that cross theobturapelvis,, pelvis several days maturation of   Various including the internal iliac, the pelvic hematoma: acute entrance tor, superior gluteal and pudendal armay disrupt early tamponade.70 teries, have been found to be the Percutaneous pelvic fixation tech- cause of bleeding in these fractures. 79 niques allow for acute and definitive Patients who remain hemodynamictreatment of anterior and posterior ally labile after external stabilization pelvic ring injuries, without extensive and other resuscitative measures but dissection. Their success relies on achave no major intraperitoneal bleedcurate closed reduction, excellent ining are potential candidates for pelvic traoperative imaging and correct paangiography. Eastridge and coautient selection. thors80 reported a 60% mortality rate  Accurate  Accura te early pelvic stabiliza stabilization tion in patients with unstable pelvic fracdiminishes pain and hemorrhage, tures who underwent laparotomy beprovides better patient nursing and fore angiography, and suggested that

and interventional radiological capabilities. Sites of extravasation of arterial contrast are identified and selectively cannulated with Gelfoam or stainless steel coils.82 In practice, angiography has some drawbacks. It is time-consuming and currently requires transfer of a se verely injur injured, ed, unstab unstable le patient patient to the angiography suite, which may hamper resuscitative efforts. It also requires the availability of a skilled radiologist. When anatomical studies suggest the main source of hemorrhage to be non-arterial, the expec-

comfort, and allows early mobilization. Fixation can be performed acutely, even as a component of the patient’s resuscitation. Early inter vention improves the likeli likelihood hood of a closed reduction, since the pelvic hematoma is compliant. Operative blood loss is minimal and wound complications are unusual. Minimally invasive anterior ring fixation includes external fixation  with retro retrograde grade or ante anterograd rogradee screws in the medulla of the superior ramus. Closed reduction and fixation  with percutaneuous percutaneuous sacroiliac sacroiliac screw screwss offers definitive stable fixation for many posterior pelvic ring injuries, such as fracture/dislocation of the

ted yield of angiography is low.81 Nevertheless, numerous investigators have reported the benefits of angiography in selected cases. We believe that pelvic angiography remains an important option in management of these life-threatening injuries, and can be diagnostic as well as therapeutic in patients in shock with no obvious cause of hemorrhage. In trained hands, angiography has been shown to be a safe procedure.88

angiography should be considered before laparotomy and packing. Agolini and associates,81 in a large series of 806 patients, reported on 35 who underwent pelvic angiography: 15 of  the 35 required embolization, which  was successf successful ul in all cases. Cook’s group82 reported a 15% rate of angiography in a series of 150 patients  with unstable pelvic fractures. They  concluded that the morphology of  the fracture was unreliable as a guide to the associated vascular injury. Other indications for pelvic angiography include the incidental discovery of an arterial “blush” in a contrast CT scan in an apparently stable patient, and as a last-ditch effort in

Pelvic packing

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Open fractures forts should not be transported to a centre. The complementary roles of  distant angiography suite, especially  newer hemostatic adjuncts such as 77 if delay is involved. These are often Potentially lethal injuries with a reporrecombinant factor VII also deserve 93 patients at risk for abdominal comted mortality rate of 30%–50%, open further study.99,100  A system of care partment syndrome, and who therefractures of the pelvis by definition  with a mutu mutually ally agreed agreed-upo -upon n proto proto-fore need an open peritoneal cavity  communicate with the rectum, the col would reduce confusion and exfor adequate cardiovascular physiolo-  vagina,  vagina, or the out outside side env environ ironmen mentt by  by  pedite resuscitation, which would gic support after surgery. disruption of the skin. They are often certainly improve outcomes in these Such patients undergoing laparoassociated with disruption of the pelseverely injured patients. tomy for an identifiable intraperi-  vic floor, leading to loss of tamp tamponontoneal cause of hemorrhage should ade and persistent bleeding. Clinical Competing interests: Drs. Kortbeek and be assessed for an expanding pelvic suspicion of an open fracture and any  Kirkpatrick serve on a Trauma Advisory Board for Novo Nordisk (makers of Factor VIIa), for hematoma. The true pelvis should be rectal or vaginal bleeding mandate a  which they have have received compensation. compensation. packed at that time if the hematoma thorough examination, proctoscopic, has ruptured; the pelvic hematoma is sigmoidoscopic or by speculum. References otherwise not opened routinely. The Classically, an open pelvic fracture true pelvis should be packed with prompts recommendations for colos1. Pohlem Pohlemann ann T. T. Pelvic Pelvic ring ring injuries injuries:: assessassesslarge abdominal swabs and the tomy to prevent soft-tissue sepsis in ment and concepts of surgical manage wound closed closed over the packs to crean expanded perineum.94–96 It has rement. Chapter 4.4 4.4 in: Rüedi TP, TP, Murphy  97  WM, eds.  AO pri princip nciples les of fract fracture ure man-  ate tamponade. The packs are recently been suggested that fecal diagement . Stuttgart (Germany): Thieme moved or changed in a second pro-  vers  version ion in an an open open pelvic pelvic frac fracture turess ca can n Publishing Group; 2000. p. 391–413. cedure at 24–48 hours. be applied selectively, according to 2. Poole GV GV, Ward Ward EF. EF. Causes Causes of mortalit mortality  y 

The hemostasis efficacy of after pelvic packing to  wound. the actual ofence the of achieve hepatic, colo woun d. In location the experience the experi ocutaneous f Pell and 98 rectal and gynecologic surgery is well coauthors, anterior wounds of the documented.89–91 This approach is groin, anterior thigh, iliac crest or practised prac tised in some some European European trau trauma ma pubis do not require diversion. centres. Ertel29 and Pohlemann92 and In addition to hemorrhage contheir respective groups have shown trol and stabilization of the pelvic promising results with laparotomy  ring, meticulous debridement of the and packing prior to considering pel-  woun  wound d and admin administrat istration ion of broa broadd vic angiography angiography;; however, all their spectrum antibiotics are required. In patients were either in extremis  or in open pelvic fractures with continuing severe shock at presentation. This hemorrhage, packing can be lifetechnique seems particularly applicasaving. These patients need careful ble to patients with multiple hemor- ICU monitoring of hemodynamic rhagic sources, both intra- and retro- and wound status, and may need serperitoneal, whose visceral injuries mandated a laparotomy as the first operative resuscitative measure. The rationale behind pelvic packing derives from the fact that the ma jor source source of of hemorrha hemorrhage ge from pelvic ring injury is venous. Ertel’s group29 reported success in controlling both arterial and venous bleeding by tightly packing the pelvis. Although pelvic packing has not often been used in North America, we feel it should be considered when patients are in ongoing shock but clinical and radiological features of arterial injury, such as an expanding groin hematoma or a fracture traversing the greater sciatic notch, are absent. 54

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ial and radical debridement along  with changes of packs every 24– 24–48 48 hours hou rs (packs (packs left > 48 h may themthemselves potentiate pelvic sepsis). 8 If  bleeding recurs upon pack removal, the pelvis should be repacked. In conclusion, lack of consensus persists among trauma surgeons on a standardized sequence of resuscitative steps for serious pelvic fractures. European centres generally prefer the more radical approach of laparotomy  and direct packing, whereas North  American  Amer ican centres centres rely more on angiographic embolization. Exploration of these issues is hindered by the extreme complexity of the patients and the limited numbers seen by any one

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