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†
F
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-
3–5
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
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
30,31
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
63
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
Patients who remain in extremis with with a probable retroperitoneal cause in spite of aggressive resuscitative efCan J Surg, Vol. 48, No. 1, February 2005
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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
3.
4.
5.
6.
7.
8.
9. 10.. 10
11.. 11
in patients with pelvic fractures. Orthopæ- dics 1994;17:691-6. McMurtry McMu rtry RY RY,, Walto Walton n D, D, Dickin Dickinson son D, D, Kellam J, Tile M. Pelvic disruption in the polytraumatized patient: a management protocol. Clin Orthop 1980;(151):22-30. Pennal Penn al CF CF, Suther Sutherland land GO. Fractures of the pelvis [motion picture]. Park Ridge (IL):: American (IL) American Academy of Orthop Orthopædic ædic Surgeons film library; 1981. Gertzbe Gert zbein in SD, SD, Chenowe Chenoweth th DR. Occu Occult lt injuries of the pelvic ring. Clin Orthop 1977;(128):202-7. Heini PF PF, Witt Witt J, Ganz R. The The pelvic pelvic Cclamp for the emergency treatment of unstable pelvic ring injuries: a report on clinical experience of 30 cases. Injury 1996; 27:S-A38–45. Witschge Wits chgerr P, Heini Heini PF, PF, Ganz R. [Pelv [Pelvic ic clamps for controlling shock in posterior pelvic ring injuries application, biomechanical aspects and initial clinical results.] Orthopade 1992;21:393-9. Tile M. M. Fractures of the pelvis and acetab- ulum . Baltimore (MD): Williams & Wilkins; 1984. Perry Per ry JF Jr. Jr. Pelvic Pelvic open open fractu fractures. res. Clin Orthop 1980;(151):41-5. Hanson Han son PB, PB, Milne Milne JC, Chapm Chapman an MW. MW. Open fractures of the pelvis. J Bone Joint Joint Surg Br 1991;73B:325-9. Ertell W. Ther Erte Therape apeutic utic stra strategi tegies es and and outoutcome of polytraumatized patients with pelvic injuries: a six year experience. Eur J Trauma 2000;6:278.
12.. Gilliland 12 Gilliland MD, MD, Ward Ward RE, RE, Burton Burton RM, RM, Miller PW, Duke JH. Fractures affecting mortality in pelvic fractures. J Trauma 1982;22:691-3.
Management of pelvic ring injuries
Paterson FP, FP, Morton Morton KS. The cause cause of of 13. Paterson death in fractures of the pelvis. J Trauma Trauma 1973;13:849-56. 14.. Roth 14 Rothenbe enberger rger DA, DA, Fischer Fischer RP, RP, Stra Strate te RG, Velasco R, Perry JF Jr. The mortality associated with pelvic fractures. Surgery 1978;84:356-61. 15.. Sevi 15 Sevitt tt S. Fatal Fatal road road acciden accidents: ts: injuries injuries,, complications and causes of death in 257
jured patients patients with pelvic pelvic ring disruptio disruption. n. J Orthop Orthop Traum Trauma a 2001;15(7):468-74. 30. Abra Abramso mson n D, Scalea Scalea DM, DM, Hitchc Hitchcock ock R, R, Trooskin SZ, Henry SM, Greenspan J. Lactate clearance and survival following Trauma 1993;35:584-8, discusinjury. J Trauma sion 588-9. 31. Mizock BA, Falk JA. Lactic acidosis in criticritical illness. Crit Care Med 1992;20:80-93.
46. Christens Christensen en KS. KS. Pneumat Pneumatique ique antish antishock ock garment (PASG): Do they precipitate lower extremity compartment syndromes? J Trauma Trauma 1986;26:549-55. 47.. Ame 47 Americ rican an Colleg Collegee of Surgeo Surgeons. ns. Advan Advanced ced Trauma Life Support for Doctors. Instruc- tor Course Manual . Chicago (IL): the College; 1997. p. 206-9. 206-9. 48. Bot Bottla tlang ng M, Krieg Krieg JC, JC, Mohr M, M, Simpso Simpson n
BrJr, 1968;55:481-505. 16. subjects. Routt ML JJr,Surg Simonian Simonian PT, Ballmer Ballmer F. A rational approach to pelvic trauma: resuscitation and early definitive stabilization. Clin Orthop 1995;(318):61-73. 17.. Biffl WL, Smith WR, Moore EE, Gonza17 Gonzalez RJ, Morgan SJ, Hennessey T, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg 2001;233(6):843-50. 18. Wrigh rightt CS, McMu McMurtry rtry RY, RY, Pickar Pickard d J. A postmortem review of trauma mortalities — a comparative comparative study. J Trauma 1984; 24:67-8. 19.. Ame 19 America rican n Colleg Collegee of Surgeo Surgeons. ns. Advan Advanced ced Trauma Life Support . 6th ed. Chicago (IL): the College; 1997.
32. Jr, Dua Duane ne TM, TM,LJ Tan G olayBlunt D, Cole Ctrauma ole FJ FJ Weireter Jr, BB, Britt Golay LD. and the role of routine pelvic radiographs: a prospective analysis. J Trauma 2002;53(3):463-8. 33. Guillam Guillamondegu ondeguii OD, OD, Pryor Pryor JP, JP, Gracias Gracias VH, Gupta R, Reilly PM, Schwab CW CW.. Pelvic radiography in blunt trauma resuscitation: a diminishing role. J Trauma 2002;53(6):1043-7. Advanced ced 34. Ame America rican n Colleg Collegee of Surgeo Surgeons. ns. Advan Trauma Life Support course for doctors. Instructors course manual . Chicago (IL): the College; 1997. 35. Kirkpa Kirkpatrick trick AW AW,, McKevitt McKevitt EC. Thoraco Thoraco-lumbar spine fractures: Is there a problem? Can J Surg 2002;45:21-4. 36. Meek S. Fractu Fracture re of the thorac thoracolumb olumbar ar
TS, Madey Emergent management of pelvic ringSM. fractures with use of circumferencial compression. J Bone Joint Surg Am 2002;84(Suppl 2):43-7 2):43-7.. 49. Simpso Simpson n T, T, Krieg Krieg JC, JC, Heuer Heuer F, Bottla Bottlang ng M. Stabilization of pelvic ring disruptions with a circumferencial sheet. J Trauma 2002;52:158-61. 50.. Ro 50 Rout uttt ML ML Jr Jr,, Fal Falic icov ov A, Woo oodh dhou ouse se E, E, Schildhauer TA. Circumferencial pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Orthop Traum Trauma a 2002;16(1):45-8. 51.. Reim 51 Reimer er BL, Butt Butterfie erfield ld SL, SL, Diamond Diamond DL, Young JC, Raves JJ, Cottington E, et al. Acute mortality associated with in juries to the pelvic ring: the role of early patient mobilization and external fixation. J Trauma Trauma 1993;35:671-7.
20. Bickell Bickell WH, WH, Wall Wall MJ, MJ, Pepe Pepe PE, Martin Martin RR, Ginger VF VF,, Allen MK, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-9. 21. Bar Baron on BJ, BJ, Scalea Scalea TM. TM. Acute Acute blood blood loss. loss. Emerg Med Clin N Am 1996;14:35-55. 22. Bou Boulang langer er BR, Kear Kearney ney PA, PA, Brennem Brenneman an FD, Tsuei B, Ochoa J. FAST utilization in 1999: results of a survey of North American Americ an trauma trauma centers. centers. Am Surg Surg 2000; 66:1049-55. 23. Kirkp Kirkpatrick atrick AW AW,, Simons Simons RK, RK, Brown Brown DR, DR, Ng AKT, Nicolaou S. Digital hand-held sonography utilized for the focused assessment with sonography for trauma: a pilot study. Ann Acad Med Singapore 2001;30:577-81. 24. Kir Kirpatr patrick ick AW AW, Simons Simons RK, Brown Brown DR, DR, Nicolaou S, Dulchavsky S. The handheld FAST: experience with hand-held trauma sonography in a level-1 urban trauma center. Injury 2002;33:303-8. 25. Kirk Kirkpatr patrick ick AW AW, Chun R, Brown Brown R, Simons RK. Hypothermia and the trauma patient. Can J Surg 1999;42:33-43. 26. Col Collico licott tt PE, Hugh Hughes es I. Traini Training ng in ad vanced trauma trauma life support. support. JAMA 1980; 243:1156-9. 27.. Davi 27 Daviss JW. JW. The relati relationshi onship p of base base deficit deficit to lactate in porcine hemorrhagic shock and Trauma ma 1994;36:168-72. resuscitation. J Trau 28. Davis JW JW,, Shackfor Shackford d SR, SR, Mackersie Mackersie RC, Hoyt DB. Base deficit as a guide to volume resuscitation. J Trauma 1988;28
spine in major trauma patients. BMJ 1999; 317:1442-3. Heinii PF, Wit Hein Wittt J, Ganz Ganz R. R. The pelvi pelvicc Cclamp for the emergency treatment for the unstable pelvic ring injuries: a report on clinical experience of 30 cases. Injury 1996;27(Suppl 1): S-A38–45. Huittinen Huittin en VM, VM, Slatis Slatis P. Post-m Post-mortem ortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454-62. Batalden Batal den DJ, DJ, Wickst Wickstrom rom PH, PH, Ruiz Ruiz E. Value Va lue of the G suit suit in patients patients with with severe severe pelvic fractures: controlling hemorrhagic shock. Arch Surg 1974;109:326-8. America Ame rican n Colleg Collegee of Surgeo Surgeons. ns. Advan Advanced ced Trauma Life Support manual . Chicago (Ill.): the College; 1989. McSwain McSwa in NE. NE. Pneum Pneumatic atic anti-s anti-shock hock garment: state of the art 1988. Ann Emerg Med 1988;17:506-25. Mattox Mat tox KL, KL, Bickel Bickelll WH, Pepe Pepe PE, PE, ManMangelsdorff AD. Prospective randomized evaluation of antishock MAST in posttraumatic hypotension. J Trauma 1986; 26:779-86. Bickelll WH, Pepe PE, Bailey ML, Wyatt Bickel CH, Mattox KL. Randomized trial of pneumatic antishock garments in the prehospital management of penetrating abdominal injuries. Ann Emerg Med 1987; 16:653-8. Mattox KL, Bickell Bickell W, Pepe PE, Burch Burch J, Feliciano D. Prospective MAST study in Trauma 1989;29:1104-12. 911 patients. J Trauma
52. Burgess Burgess AR, Eastrid Eastridge ge BJ, BJ, Young Young JW JW, Ellison TS, Ellison PS Jr, Poka A, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 1990;30:845-56. 53. Poka A, Libby Libby E. Indic Indication ationss and techtechniques for external fixation of the pelvis. Clin Orthop 1996;(329):54-9. 54. Gylling SF, Wa Ward rd RE, RE, Holcroft Holcroft JW JW, Bray TJ, Chapman MW. Immediate external fixation of unstable pelvic fractures. Am J Surg 1985;150(6):721-4. 55. Kellam JF JF.. The role of extern external al fixation fixation in pelvic disruptions. Clin Orthop 1989; (241):66-82. 56. Slatis P, Karahar Karaharju ju EO. EO. External External fixat fixation ion of unstable pelvic fractures: experience in 22 patients treated with trapezoid compression frame. Clin Orthop 1980;(151): 73-80. 57.. Traft 57 Trafton on PG. PG. Pelvic Pelvic ring injur injuries. ies. Surg Clin North Am 1990;70:655-69. 58. Wild JJ JJ Jr, Hansen JW JW,, Tullos Tullos HS. Unstable fractures of the pelvis treated by external fixation. J Bone Joint Surg Am 1982;64:1010-20. 59.. Mea 59 Mears rs DC. Clin Clinical ical techn techniqu iques es in the pelpel vis. In: Mears DC, editor. editor. External skele- tal fixation . Baltimore (MD): Williams and Wilkins; 1983. p. 342. 60. Kim WY WY,, Hearn Hearn TC, TC, Seleem Seleem O, MahalinMahalingam E, Stephen D, Tile M. Effect of pin location on stability of pelvic external fixation. Clin Orthop 1999;(361):237-44. 61. Gha Ghanay nayem em AJ, Stov Stover er MD, Gold Goldstei stein n JA,
Bellon E, Wilber JH. Emergent treatment of pelvic fractures. Comparison of methods for stabilization. Clin Orthop 1995;(318):75-80.
29.. 29
(10):1464-7. Ertel W, Keel Keel M, Eid Eid K, Platz A, Trentz Trentz O. Control of severe hemorrhage using C-clamp and pelvic packing in multiply in-
37.. 37
38.
39.. 39
40.
41.
42.
43.
44.
Can J Surg, Vol. 48, No. 1, February 2005
55
Mohanty et al
62. Hospodar Hospodar P, P, Ulh R, Traub Traub JA, JA, Keller Keller GS. GS. Effect of fluoroscopy on accuracy of pelvic external fixator pin placement [poster 82]. Orthopædic Trauma Association meeting; 1999 Oct 22–24; Charlotte, NC. 63. Dicks Dickson on KF, Matta Matta JM. Skele Skeletal tal deformideformity following external fixation of the pelvis [paper]. American Academy of Orthopædic Surgeons Annual Meeting; 1998
75. Haan J, Scott Scott J, Boyd-K Boyd-Kranis ranis RL, Ho S, S, Kramer M, Scalea TM. Admission angiography for blunt splenic injury: advantages and pitfalls. J Trau Trauma ma 2001;51:1161-5. 76. Kos X, Franch Franchamps amps JM, Tr Trotte otteur ur G, G, DonDondelinger RF. Radiologic damage control: evaluation of a combined CT and angiography suite with a pivoting table. Cardi- ovasc Intervent Radiol 1999;22:124-9.
88. Velmahos GC, Toutouzas KG, Vassiliu P, P, Sarkisyan G, Chan LS, Hanks SH, et al. A prospective prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma 2002;52(2):303-8. 89. Shen GK, Rappaport W. Control of nonhepatic intra-abdominal hemorrhage with temporary packing. Surg Gynecol Obstet
New Orleans, La. 64. Mar Ganz19–23; R, Krushell Krushell AJ, Jakob Jakob RP, Kuffer RP, Kuffer J. The antishock pelvic clamp. Clin Orthop 1991;(267):71-8. 65.. Egbe 65 Egbers rs HJ, Draij Draijrr F, F, Habemann Habemann D, Zenker W. [Stabilizing the pelvic ring with the external fixator: biomechanical studies and clinical experience.] Ortho- pade 1992;6:363-72. 66.. Wits 66 Witschge chgerr P, Heini Heini P, P, Ganz R. [Pelv [Pelvic ic clamps for controlling shock in posterior pelvic ring injuries: application, biomechanical aspects and initial clinical results.] Orthopade 1992;21:393-9. 67.. Agnew SG, Agel 67 Agel J, Chip Routt Routt ML ML Jr, et al. Preliminary experience with the antishock pelvic clamp: complications and early outcomes [poster]. Orthopædic
77.. Gansslen 77 Ganss len A, Gianno G udisfractures: P, Pape P, Pape Who HC. Hemorrhage iniannoudis pelvic needs angiography? Curr Opin Crit Care 2003;9:515-23. 78. Huit Huittin tinen en VM, Sla Slatis tis P. P. Postm Postmort ortem em anangiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454-62. 79.. O’Nei 79 O’Neill ll PA, Riina J, Sclafani Sclafani S, Tornetta Tornetta P 3rd. Angiographic findings in pelvic fracture. Clin Orthop 1996;(329):60-7. 80. Eastrid Eastridge ge BJ, BJ, Starr Starr A, Minei JP, O’Ke O’Keefe efe GE, Scalea TM. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002;53(3):446-50. 81. Agolini SF, Shah K, Jaffe Jaffe J, Newcom Newcomb b J,
90. 1992;174:411-3. Zama N, N, Fazio Fazio V, Jagelman Jagelman DG, Lavery Lavery IC, Weakley FL, Church JM. Efficacy of pelvic packing in maintaining hemostasis after rectal excision of cancer. Dis Colon Rectum 1998;31(12):923-8. 91. Finan MA, Fiorica JV JV, Hoffman MS, Barton DP, Gleeson N, Roberts WS, et al. Massive pelvic hemorrhagic during gynecologic cancer surgery: “pack and go back.” Gynecol Oncol 1996;62:390-5. 92. Pohlemann T, T, Bosch U, Gansslen A, Tscherne H. The Hannover experience in management of pelvic fractures. Clin Or- thop 1994;(305):69-80. 93. Jones AL, Powell Powell JN, Kellam Kellam JF, McCormack RG, Dust W, Wimmer P. Open pel vic fractures: a multicenter retrospective
Trauma Association meeting; 1996 Sep 26–29; Boston, Mass. Schutzz M, Stock Schut Stockle le R, Hoffm Hoffmann ann R, R, SudSudkamp N, Haas N. Clinical experience with two two types of of pelvic C-clamp C-clampss for unstable pelvic ring injuries. Injury 1996;27 (Suppl 1);S-A46–50. Tile M. Acute Acute pelvic fract fractures: ures: II. Princi Princi-ples of management. J Am Acad Orthop Surg 1996;4(3):152-61. Ghanayem Ghan ayem AJ, Wilber Wilber JH, Liebe Lieberman rman JM, Motta AO. The effect of laparotomy and external fixator stabilization on pelvic volume in an unstable pelvic injury. J Trauma 1995;38:396-401. Barei DP DP,, Bellabarb Bellabarbaa C, Mills WJ, Routt ML Jr. Percutaneous management of unstable pelvic ring disruptions. Injury 2001;32(Suppl 1):S-A33–44. Routt ML Jr, Rou Jr, Nork Nork SE, Mills Mills WJ. WJ. HighHighenergy pelvic ring disruptions. Orthop Clin North Am 2002;33(1):59-72. Kushim Kus himoto oto S, Arai Arai M, Aibosh Aiboshii J, Harada Harada N, Tosaka N, Koido Y, et al. The role of interventional radiology in patients requiring damage control surgery. J Trau- ma 2003;54:171-6. Johnson Johns on JW, JW, Gracias Gracias VH, Gupta R, GuilGuillamondegui O, Reilly PM, Shapiro MB, et al. Hepatic angiography in patients undergoing damage control laparotomy. J Trauma 2002;52:1102-6.
Rhodes M, Reed JF 3rd. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma Trauma 1997;43(3):395-9. Cook RE, RE, Keatin Keating g JF, Gilles Gillespie pie I. The The role of angiography in the management of hemorrhage from major fractures of the pelvis. J Bone Joint Surg Br 2002;84 (2):178-82. Gillilan Gill iland d MG, MG, Ward RE, RE, Flyn Flynn n TC, TC, MilMiller PW, Ben-Menachem Y, Duke JH Jr. Peritoneal lavage and angiography in the management of patients with pelvic fractures. Am J Surg 1992;144:744-7. Moreno Moren o C, Moore EE, Rosen Rosenberge bergerr A, Cleveland HC. Hemorrhage associated with major pelvic fracture: a multidisciplinary challenge. J Trauma 1996;26: 987-94. Everss BM, Cryer Ever Cryer HM, HM, Miller Miller FB. Pelvi Pelvicc fracture hemorrhage: priorities in management. Arch Surg 1989;124:422-4. Panetta Pane tta T, T, Sclafani Sclafani SJ, SJ, Goldstei Goldstein n AS, Phillips TF, Shaftan GW. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 1985;25:1021-9. Ben-Mena BenMenachem chem Y, Col Coldwel dwelll DM, DM, Young Young JW, Burgess AR. Hemorrhage associated with pelvic fractur fractures: es: causes, diagnos is and emergent management. AJR Am J Rœntgeno Rœntgenol l 1991;157(5):1005-14.
analysis. Orthop Clin North Am 1997;28 (3):345-50. 94. Poole GV. GV. Pelvic fractures. In: In: Cameron JL, editor. Current surgical therapy . 6th ed. St. Louis (MO): Mosby; 1998. p. 979-83. 95. Kusmisky RE, Shbeeb I, Makos G, G, Boland JP. Blunt pelviperineal injuries: an expanded role for the diverting colostomy. Dis Colon Rectum 1982;25:787-90. 96. Davidson BS, Simmons Simmons GT, GT, Williamson PR, Buerk CA. Pelvic fractures associated with open perineal wounds: a survivab survivable le injury. J Trauma Trauma 1993;35:36-9. 97.. Faringer PD, Mullins RJ, Feliciano 97 Feliciano PD, Duwelius PJ, Trunkey DD. Selective fecal diversion in complex open pelvic fractures from blunt trauma. Arch Surg Surg 1994;129: 958-63. 98. Pell M, Flynn WJ, Seibel RW. RW. Is colostomy always necessary in the treatment of Trauma 1998;45: open pelvic fractures? J Trauma 371-3. 99.. Allen GA, Hoffman M, 99 M, Roberts HR, Monroe DM 3rd. Recombinant activated factor VII: its mechanism of action and role in the control of hemorrhage. Can J Anæsth Anæs th 2002;49:S7-14. 100.. Martin 100 Martinowitz owitz U, Kenet Kenet G, Segal E, Luboshitz J, Lubetsky A, Ingersley J, et al. Recombinant activated activated factor VII for ad junctivee hemorrhage junctiv hemorrhage control in trauma. trauma. J Trauma 2001;51:431-9.