Pelvic fracture Management Erik Hasenboehler MD Orthopaedic Trauma Surgery Baltimore MD Kentucky Trauma Symposium 2012 Subjects Basic Polytrauma management Polytrauma basic science Pelvis Exam, Stability and managment Acute treatment of pelvic ring injuries Open Pelvis fracture Pelvic fracture and Polytrauma Management One goal !!!!!!! Save the patient`s life ! ATLS: Structured Trauma Care Phases of Management Primary Survey Resuscitation Secondary Survey Definitive Care Tertiary Survey Airway Breathing Circulation Disability Exposure 1. Hemodynamically Unstable Pelvic Fracture Management by Advanced Trauma Life Support Guidelines Results in High Mortality . Orthopedics 2012 2. Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009 Steps of Acute Management Assess Physical Exam Labs, Physiology Images Stabilize Resuscitate Contain Sheet/Ex fix/C-clamp Damage control orthopaedics in unstable pelvic ring injuries. P.V. Giannoudis and H.C. Pape, Injury 2004 Basic Science of Trauma First Hit Primary injury response Second Hit Incomplete resuscitation Hemorrhage Prolonged surgery Second hit phenomenon: Existing evidence of clinical implications Lasanianos et al Injury 2012 Systemic Inflammatory Synergistic Inflammatory Two Hit Model Severe SIRS First insult MOF Delayed definitive surgery Moderate SIRS 2nd insult Definitive surgery EARLY Moderate immunosuppression Severe immunosuppression Infection Moore FA and Moore EE. Surg Clin North Am. 1995 MOF Secondary Period Old concept: Day 1, 5-7 (window of opportunity) and after 14 days Patients operated on day 2-4 vs day 5-8 worse inflammatory changes Avoid significant surgery on days 2-4 for patients at risk For more severely injured patients a longer waiting period may be needed 1. Damage control orthopaedics in unstable pelvic ring injuries. P.V. Giannoudis and H.C. Pape, Injury 2004 2. Damage control orthopedics: current evidence Lichtea et al CO-Critical Care 2012 3. Second hit phenomenon: Existing evidence of clinical implications . Lasanianos et al. Injury 2011 Pre- Hospital: Devastating injury Hospital-Acute/Primary: shock, hypoxia or head injury Hospital-Secondary/Tertiary: MOF or ARDS Measurable Risk Factors HD unstable or difficult resuscitation Under resuscitation Shock and > 25 units PRBC’s Thrombocytopenia ( platelets < 90,000) Hypothermia (< 32° C) Bilateral lung contusions on initial x-ray Multiple long bone fractures and truncal AIS >2 Presumed OR time > 6 hours Exaggerated inflammatory response (IL-6> 800 pg/ml) •Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012 •Keel M, Trentz O. Pathophysiology of polytrauma. Injury 2005 •Giannoudis PV. Current concepts of the inflammatory response after major trauma: an update. Injury 2003 •Tschoeke SK, et al. The early second hit in trauma management augments the proinflammatory immune response to multiple injuries. J Trauma 2007 Causes of Death from Pelvis Fractures < 24 hours: blood loss > 24 hours: MOF Exsanguination caused 75% of the deaths Orthopaedic Damage Control “… temporary stabilization of fractures soon after injury, minimizing the operative time, and preventing heat and blood loss.” In severely injured patients, initial orthopaedic surgery should not be definitive treatment Definitive treatment delayed until after patients overall physiology improves Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012 Damage Control Minimize the Second Hit Assess Treatment of pelvic ring injuries is usually a multidisciplinary activity Trauma, Orthopaedics, Radiology Urology/Gynecology Lots to bleed Big space to bleed into Volume Changes in the True Pelvis During Disruption of the Pelvic Ring – Where does it go? Volume increase - r3 Volume increase 1 – 2L 1. Moss and Bircher, 1996 2. Effects of Pelvic Volume Changes on Retroperitoneal and Intra- Abdominal Pressure in the Injured Pelvic Ring: A Cadaveric Model Köher et al 2011 Physical Exam Perform a FULL physical exam Evaluate lower extremities position Shortening/Rotation Skin Ecchymosis Open wound Around the pelvis !!!!Be alert for open pelvic fractures!!! Neurovascular exam OBTAIN INFORMATION FIRST Physical Exam Palpate anterior pelvis Watch for perineal Lacerations Scrotal/Labial Swelling Flank Ecchymosis Physical Exam Turn the patient! Physical Exam Morel-Lavalle lesions Degloving of the flank, thigh Large dead space Increased incidence of infection #2: Is the Injury Pattern “Stable” or “Unstable”? Rotational Stability AP Compression Lateral Compression One Positive Exam Only! Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg. 2002. Physical Exam Abnormal position of the lower extremity Pelvis “Stability” ALWAYS a combination of x-rays and a clinical exam A single x-ray is a static view May have been way more displaced at the time of injury Imaging- AP pelvis Part of ATLS Shows obvious, grossly unstable injuries Obtain Inlet Outlet views In an HD unstable patient DO NOT get more films Vertical Stability Push pull on leg while palpating the ASIS CT Scans Blush= embolizable arterial injury! “Stabilizing” Theories Decreases pelvic volume Prevents gross motion, clot disruption Reduces cancellous bony bleeding Why is Stability Important? APC 2, 3; LC 3; VS LC3 APC2,3 VS Mortality Rate LCIII- 14% VS - 25% APC II- 25% APC III- 37% •Magnussen et al. Predicting blood loss in isolated pelvic and acetabular high- energy trauma. J Orthop Trauma. 2007 •Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007; Transfusion Requirements Lateral Compression - 3.6 Combined Mechanical- 8.5 Vertical Shear - 9.2 AP Compression - 14.8 Hemorrhage occurs up to 75% of patients with high energy injuries •Magnussen et al. Predicting blood loss in isolated pelvic and acetabular high- energy trauma. J Orthop Trauma. 2007 •Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007; WHAT TO USE TO STABILIZE THE PELVIS MAST / PASG Sheet or Binder Pelvic Binder Easily applied during resuscitation Portable Acute Management SAM Sling / T-POD / Circumferential Sheet: TOO HIGH!! Greater Trochanter!! Pelvis and Acetabulum Frontline Treatment Pelvic Sheeting Routt et all JOT 2002 Traction Alone or in combination with sheet/ binder/ ex fix Particularly useful for vertical shear injuries Prevents vertical migration Anterior External Fixation Disadvantages Can cause a different deformity Poor control of posterior pelvic ring Pin tract infections It’s not that easy Pelvic C-Clamp Ganz R, et al. The antishock pelvic clamp. Clin Orthop Relat Res. 1991. AIRS: I agree that the incidence of arterial bleeding after high energy pelvic trauma is 10% 1. Yes 2. No- I think it is higher Who should get angiography? Rationale: fracture (cancellous) / venous arterial < 10% > 90% Who should get angiography? Rationale: fracture (cancellous) / venous arterial < 10% > 90% Huittinen VM, Slatis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454–62 Kataoka Y, Maekawa K, Nishimaki H, et al. Iliac vein injuries in hemodynamically unstable patients with pelvic fracture caused by blunt trauma. J Trauma 2005;58:704– 10. Baque P, Trojani C, Delotte J, et al. Anatomical consequences of ‘‘open-book’’ pelvic ring disruption: a cadaver experimental study. Surg Radiol Anat 2005;27:487–90. Papadopoulos IN, Kanakaris N, Bonovas S, et al. Auditing 655 fatalities with pelvic fractures by autopsy as a basis to evaluate trauma care. J Am Coll Surg 2006;203:30–43 Huittinen V, Slatis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454—62. Kadish L, Stein J, Kotler S. Angiographic diagnosis andtreatment of bleeding due to pelvic trauma. J Trauma 1973;13:1083—6. Motsay GJ, Manlove C, Perry JF. Major venous injury with pelvic fracture. J Trauma 1969;9:343–6. Patterson FP, Morton KS. The cause of death in fractures of the pelvis. J Trauma 1973;13:849–56. Peltier LF. Complications associated with fractures of the pelvis. J Bone Joint Surg Am 1965;47:1060–9. Yosowitz P, Hobson 2nd RW, Rich NM. Iliac vein laceration caused by blunt trauma to the pelvis. Am J Surg 1972;124:91–3. Pohlemann T. et al. Tech Orthop 1994 1. Cothren CC, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007 3. 2. Suzuki T, Smith WR, Moore EE, Pelvic packing or angiography: competitive or complementary? Injury 2009 Ertel W, et al. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001 4. Tscherne H. et al. Crush injuries of the pelvis. Eur J Surg 2001 TREAT THE PATIENT BASED ON HIS NEEDS……. DCO VS ETC Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012 Open Pelvis Fracture A direct communication of the pelvic injury with the outside world Dente et al AJS 190, 2005 Think of the open pelvis as a marker that something very bad has happened and other things are likely wrong with this patient Open Fractures Air in the pelvis on XR is an open fx until proven otherwise Require early I&D Consider diverting colostomy Antibiotics Increased effectiveness if in first 6 hours 2-4% of all pelvic fractures 45% mechanically unstable > 50% hypotensive on admission 5-45% mortality (most >25%) Open Pelvis Fractures Many potential open wound sites: abdominal wall thigh scrotum vagina rectum buttocks perineum Significance of Soft Tissue Injury In addition to the challenges of a pelvic ring injury you also have Lost the ability of the retroperitoneum to tamponade bleeding The open wound allows contamination of the fractures and the soft tissues of the pelvis •Dente et al AJS 190, 2005 •M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 Initial Treatment ATLS Resuscitation: fluid and blood as needed Stability: Binder/ sheet/ ex fix/ traction Bleeding: Stability/ angio/ packing/ resuscitation DAMAGE CONTROLE ONLY!!! •Dente et al AJS 190, 2005 •M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 Initial Treatment Treat the soft tissue wound Soft tissue wounds bleed The hematoma is decompressed and draining onto the floor Pack the soft tissue wounds •Dente et al AJS 190, 2005 •M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 Initial Treatment Selective early diverting ileostomy or colostomy Mortality decreased to 25% •Brenneman FD, Kaytal D, Boulanger BR, et al. Long term outcome in open pelvic fractures. J Trauma 1997 •Richardson JD, Harty J, Amin M, Flint LM. Open pelvic fractures. J Trauma 1982 •M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 Mandatory Physical Exam Rectal in everyone (injuries up to 64%) Vaginal exam- especially with anterior ring fractures Do not ever, ever, ever, ever, ever blow off vaginal bleeding as “that time of the month!!!!!!!!!!!!!” •Dente et al AJS 190, 2005 •M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 Subsequent Treatment When stable: Treat the wounds as any other open wound Consider repeat wound I&D Plan for definitive fixation if possible •Dente et al AJS 190, 2005 •M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 Mortality Mortality rate: Pick a number: 0- 50 % or greater with intraabd. injury The pelvic injury is directly responsible for a significant percentage of these deaths Early mortality: exsanguinations Require more transfusions than closed pelvic fractures Late mortality: pelvic sepsis •Dente et al AJS 190, 2005 •M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 Summary Perform a proper exam and evaluate x-rays Stabilize the patient >>> Find the Bleeding Source(s) Perform DPL, US and CT if stable Avoid Laparotomy with direct ligation (100% Mortality) Pelvis packing vs. Angiography Decide for DCO vs ETC Summary Reassess How much blood has been given? Has the patient stabilized? Secondary survey Associated injuries Discuss surgical planning with other services Consider colostomy and SP cath Summary !!!!Have a Protocol!!!! Institutional guidelines created with agreement of trauma surgeons and ortho surgeons Listen to Ortho, they know more about these fractures and the potential for blood loss than they do Protocol will be dependent on availability of angio, OR, surgeon preferences Thank you