Erik Hasenboehler MD Orthopaedic Trauma Surgery

Baltimore MD Kentucky Trauma Symposium 2012

Pelvic fracture Management

Subjects

Basic Polytrauma management Polytrauma basic science Pelvis Exam, Stability and

managment Acute treatment of pelvic ring injuries Open Pelvis fracture

Save the patient`s life !

One goal !!!!!!!

Pelvic fracture and Polytrauma Management

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

Systemic Inflammatory

Synergistic Inflammatory

Second hit phenomenon: Existing evidence of clinical implications Lasanianos et al Injury 2012

Two Hit Model

Firstinsult

2nd

insult

Moderate SIRS

Severe SIRS

Moderateimmuno-

suppression

Severeimmunosuppression

MOF

MOFInfection

Definitive surgeryEARLY

Delayed definitive surgery

Moore FA and Moore EE. Surg Clin North Am. 1995

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 20123. 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

< 24 hours: blood loss

> 24 hours: MOF

Exsanguination caused 75% of the deaths

Causes of Death from Pelvis Fractures

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 bleedBig 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, 19962. 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 - 14.8Hemorrhage 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

Pelvis and AcetabulumFrontline Treatment

Acute Management

SAM Sling / T-POD / Circumferential Sheet:

Greater Trochanter!!

TOO HIGH!!

Incorrect

Correct

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. Yes2. No- I think it is higher

Who should get angiography?

Rationale:

fracture (cancellous) / venous > 90%

arterial < 10%

Who should get angiography?

Rationale:

fracture (cancellous) / venous > 90%

arterial < 10%

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.

1. Cothren CC, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007

2. Suzuki T, Smith WR, Moore EE, Pelvic packing or angiography: competitive or complementary? Injury 20093. 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 20014. Tscherne H. et al. Crush injuries of the pelvis. Eur J Surg 2001

Pohlemann T. et al. Tech Orthop 1994

Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012

TREAT THE PATIENT BASED ON HIS NEEDS……. DCO VS ETC

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