3Subjects Basic Polytrauma management Polytrauma basic science Pelvis Exam, Stability and managmentAcute treatment of pelvic ring injuriesOpen Pelvis fracture
4and Polytrauma Management Pelvic fractureand Polytrauma ManagementOne goal !!!!!!!Pelvic ring fractures are mostly caused by high-energy impact, and, therefore, are often related (up to over 60%)to multiple traumas with chest, abdomen, spine, head and long bones fractures. Thanks to a common goal to safethe patient’s life improving intensive care and trauma management, survival rates have improved over the years,but still can range between 5-50%.Save the patient`s life !
5ATLS: Structured Trauma Care Phases of ManagementPrimary SurveyResuscitationSecondary SurveyDefinitive CareTertiary SurveyAirwayBreathingCirculationDisabilityExposureit is of utmost importance to recognize life threatening injuries of pelvic fractures or other body regions.Accordingly, it is important to have a structures trauma care based on the ATLS model. However despiteATLS, many of the recommendations are nonspecific and not adequate for hemorrhage control in patientswith hemodynamically unstable pelvic fractures. Thus secondary to the diversity of pelvic fractures,if stable or unstable type.Hemodynamically Unstable Pelvic Fracture Management by Advanced Trauma Life Support Guidelines Results in High Mortality . Orthopedics 2012Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009
6Steps of Acute Management AssessPhysical ExamLabs, PhysiologyImagesStabilizeResuscitateContainSheet/Ex fix/C-clampAs mentioned a good exam and adequate patient’s resuscitation are vital for the acute pelvicfracture management and if necessary a pelvic damage control approach should be applied.Damage control orthopaedics in unstable pelvic ring injuries. P.V. Giannoudis and H.C. Pape, Injury 2004
7Basic Science of Trauma First HitPrimary injury responseSecond HitIncomplete resuscitationHemorrhageProlonged surgerySystemic Inflammatory Synergistic InflammatoryJust a quick step back to basic trauma science. Most of you have heard the two hit model or second hit phenomenon. This is a widely accepted model that addresses the inflammatory status in the immediate aftermath of trauma with an early systemic inﬂammatory response, known as the systemic inﬂammatory response syndrome (SIRS), followed by a counter synergistic inflammatory state known as CARS (counter-regulatory anti-inflammatory response). Improper initial trauma management with incomplete resuscitation, prolonged hemorrhage or surgery can worsen the physiologic first hit adding a second hit, increasing the risks for ARDS and MOF.Second hit phenomenon: Existing evidence of clinical implications Lasanianos et al Injury 2012
8Two Hit Model MOF MOF Infection Severe SIRS Moderate SIRS Moderate Delayed definitive surgeryFirstinsultModerate SIRSModerateimmuno-suppressionOn a summary graph this would look like this. The first insult activates SIRS followed by a moderate immunnosuppression (CARS). But when the activation of the immunoinﬂammatory system (First insult) is exaggerated or re-triggered (second insult), the patient may enter a malevolent state of severe SIRS leading to severe immunosuppression with increased risk of adult respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS).If the initial response is well tolerated, the patient progresses through a moderate period of physiological stress without developing too many complications.2ndinsultSevereimmunosuppressionDefinitive surgeryEARLYInfectionMOFMoore FA and Moore EE. Surg Clin North Am. 1995
9Secondary PeriodOld concept: Day 1, 5-7 (window of opportunity) and after 14 daysPatients operated on day 2-4 vs day 5-8 worse inflammatory changesAvoid significant surgery on days 2-4 for patients at riskFor more severely injured patients a longer waiting period may be neededThe triggering of a ‘second hit’ mainly depends on the timing of surgical interventions. Although choosing a time point for definitive fixation a few days after trauma can minimizes the risk of this detrimental immunologic response, a delayed fixation can also forward local and systemic complications. Therefore the old concept where patient should have been operated on only at day one, 5-7 window of opportunity where SIRS and CARS overlap or after 14 days when CARS is recovering, is no longer a valid concept.New evidence has demonstrated that patients can be definitively managed at early stage if stable and well resuscitated, while a controlled approach should be more reserved for the unstable and at extremis patient with higher ISS, pulmonary contusions, multiple injuries and or fractures, severe acidosis or low temperature.Damage control orthopaedics in unstable pelvic ring injuries. P.V. Giannoudis and H.C. Pape, Injury 2004Damage control orthopedics: current evidence Lichtea et al CO-Critical Care 2012Second hit phenomenon: Existing evidence of clinical implications . Lasanianos et al. Injury 2011
10Pre- Hospital: Devastating injury Polytrauma patients with pelvic fracture and associated injuries are more likely to expire during the first hours after injury
11Hospital-Acute/Primary: shock, hypoxia or head injury Adding a second insult to these patients during the early phase can increase their mortality leading them to
13Measurable Risk Factors HD unstable or difficult resuscitationUnder resuscitationShock and > 25 units PRBC’sThrombocytopenia ( platelets < 90,000)Hypothermia (< 32° C)Bilateral lung contusions on initial x-rayMultiple long bone fractures and truncal AIS >2Presumed OR time > 6 hoursExaggerated inflammatory response (IL-6> 800 pg/ml)Here a summary of all measurable risk factors for unstable patientsDamage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012Keel M, Trentz O. Pathophysiology of polytrauma. Injury 2005Giannoudis PV. Current concepts of the inflammatory response after major trauma: an update. Injury 2003Tschoeke SK, et al. The early second hit in trauma management augments the proinflammatory immune response to multiple injuries. J Trauma 2007
14Causes of Death from Pelvis Fractures < 24 hours: blood loss> 24 hours: MOFExsanguination caused 75% of the deaths14
15Orthopaedic 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 treatmentDefinitive treatment delayed until after patients overall physiology improvesDamage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012
16Damage ControlThe damage control orthopedics concept uses minimally invasive surgical techniques for the primary stabilization ofall major fractures to control hemorrhage and stop the cycle of ongoing immunological impact of unstable long bonefractures. Similar to the strategy used by the NAVY when controlling damages to a ship to prevent sinking.
17Minimize the Second Hit The purpose of DCO is to minimize the Second Hit.
18AssessTreatment of pelvic ring injuries is usually a multidisciplinary activityTrauma, Orthopaedics, RadiologyUrology/GynecologyResuming our concept of pelvic fracture management, we have to remember that it is a multidisciplinary management.
19Lots to bleed Big space to bleed into The pelvis should be seen as a big space that allows lot of
20Volume Changes in the True Pelvis During Disruption of the Pelvic Ring – Where does it go? A change of volume of the true pelvis during a pelvic ring disruption will inevitably increase the intrapelvic space,allowing for a greater volume increase.Volume increase - r3Volume increase 1 – 2LMoss and Bircher, 1996Effects of Pelvic Volume Changes on Retroperitoneal and Intra- Abdominal Pressure in the Injured Pelvic Ring: A Cadaveric Model Köher et al 2011
21Physical Exam OBTAIN INFORMATION FIRST Perform a FULL physical exam Evaluate lower extremities position Shortening/RotationSkin EcchymosisOpen wound Around the pelvis!!!!Be alert for open pelvic fractures!!!Neurovascular examInformation obtained from emergency medical personnel regarding details of the mechanism of injury and initialpatient presentation may be useful in raising suspicion for a pelvic fracture and the presence of associated injuries.Using guidelines of ATLS we can obtain relevant information during the primary survey with a full physical examOBTAIN INFORMATION FIRST
23Physical Exam Turn the patient! Turn the patient to not miss significant soft tissue signs, or open wounds communicating with the pelvis.Rectal and vaginal examination are of utmost importance during the initial evaluation to rule out the presenceof an open fracture and a high-riding prostate may indicate the presence of a periurethral or periprostatichematoma oc curring secondary to genitourinary injury.Turn the patient!
24Physical Exam Morel-Lavalle lesions Degloving of the flank, thigh Large dead spaceIncreased incidence of infectionDon’t underestimate a flank ecchimosis, AKA Morel Lavalle Lesion, which is very often associatedwith a pelvic ring injury and a sing for a traumatic degloved dead space that can increase the incidenceof infection.
25#2: Is the Injury Pattern “Stable” or “Unstable”? After a full physical exam the pelvis should be assessed for stability
26Rotational Stability AP Compression Lateral Compression One Positive Exam Only!Clinical examination as demonstrated by Gonzalez can be sensitive up to 93% for the identification ofpelvic fracture in the conscious and interactive patient. Palpation of the anterior pelvis may demonstratea symphyseal gap indicative of diastasis. Compression testing in the anteror posterior direction throughapplied downward pressure on the anterior superior iliac spines (ASISs) and in the lateral direction viacompression of the iliac crests is performed in an effort to identify pelvic rotational instability.Be aware that pelvic compression should be limited to a single attempt, in an effort to limit repeateddisruption of fracture site clots.Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg26
27Physical Exam Abnormal position of the lower extremity Watch for abnormal leg positioning, i.e. leg shortening or external rotation, an index for a VS or APCtype pelvic fractureAbnormal position of the lower extremity
28Pelvis “Stability”ALWAYS a combination of x-rays and a clinical examA single x-ray is a static viewMay have been way more displaced at the time of injuryAssessment of pelvis stability is based on the combination of x-rays and clinical exam.28
29Imaging- AP pelvis Part of ATLS Shows obvious, grossly unstable injuriesObtain Inlet Outlet viewsIn an HD unstable patient DO NOT get more filmsPart of the standard ATLS trauma radiographs are an anteroposterior (AP) view of the chest, alateral view of the cervical spine, and an AP view of the pelvis. The AP of the pelvis can be usedto look for anterior injuries (pubic rami fractures and sym- physis displacement), sacroiliac jointand sacral fractures, iliac fractures, and L5 transverse process fractures. Additionally inlet andoutlet views of the pelvis should be performed to evaluate anterior posterior displacement of theSI joint, sacrum, iliac wing or vertical displacement of the hemipelvis.29
30Vertical Stability Push pull on leg while palpating the ASIS A stress view can be performed in the ER setting to assess vertical stability. A push-pullforce is applied through the limb; the hemipelvis is unstable if it moves greater than up to 1 cm.30
31CT Scans Blush= embolizable arterial injury! A CT scan is helpful in evaluating the pelvic ring disruption, the sacroiliac complex to determine ifvertical instability is present and evaluate retroperitoneal hematomas.31
32“Stabilizing” Theories Decreases pelvic volumePrevents gross motion, clot disruptionReduces cancellous bony bleedingThe primary goal of pelvic ring stabilizations is to decrease the pelvic ring volume which helpspreventing from further motion, disruption and bleeding.32
33Why is Stability Important? APC 2, 3; LC 3; VSLC3The utilization of a pelvis classification helps the treating surgeon develop a managementstrategy and predict potential associated injuries and prognosis. There are several classificationsavailable, such as the Tile, Young and Burgess and the AO-OTA. Here is the Y-B classification whichis based primarily on the mechanism of injury and is currently the most widely used system.The force vector determines the injury and pelvis instability. Highlighted in red are the most unstablepelvic fracture patterns with the VS type being the most unstable with vertical displacement of thehemipelvis secondary to fractures ant and post.APC2,3VS33
34LCIII- 14% VS - 25% APC II- 25% APC III- 37% Mortality Rate Among the pelvic fracture types the one with major ligament disruption (APC II/III, LC III, VS) are morelikely to require transfusions, with Patients with APC 3 and VS fractures requiring the most amount of blood.Magnussen et al. Predicting blood loss in isolated pelvic and acetabular high- energy trauma. J Orthop Trauma. 2007Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;34
35Transfusion Requirements Lateral Compression - 3.6Combined Mechanical- 8.5Vertical Shear - 9.2AP CompressionCorrelated to RBC units, APC 3 and VS pelvic fx can require up to 15 units of blood.Hemorrhage occurs up to 75% of patients with high energy injuriesMagnussen et al. Predicting blood loss in isolated pelvic and acetabular high- energy trauma. J Orthop Trauma. 2007Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;35
36WHAT TO USE TO STABILIZE THE PELVIS In the emergent setting a number of options for provisional pelvic stabilization are available to helptamponade bleeding in patients with pelvic fractures who are hemodynamically unstable. pneumaticanti-shock garment (PASG), wrapping a sheet around the pelvis, or placing a pelvic binder on arrival,as well as more definitive fixation with an anti-shock pelvic clamp (C-clamp) or traditional anterior external fixation.
37MAST / PASGPASG, also known as a military anti-shock trouser, is sometimes still used in the pre-hospital andemergency room setting to increase blood pressure, reduce pelvic fractures, and tamponade hemorrhage,however this “stabilization” option should be avoided since a number of problems have occurred includinglower extremity ischemia and compartment syndrome. Further the PASG is bulky, and when in place,it is difficult to access the abdomen, genitourinary system, and lower extremities
38Sheet or Binderwhat is best a sheet or a binder38
39Pelvic Binder Easily applied during resuscitation Portable The binder is a good, easy and reliable solution, if applied properly39
40Acute Management SAM Sling / T-POD / Circumferential Sheet: TOO HIGH!! It has to be placed at the proper height at the level of the greater trochanter.TOO HIGH!!Greater Trochanter!!Pelvis and AcetabulumFrontline Treatment
41Pelvic Sheeting Correct Incorrect Routt et all JOT 2002 Circumferential compression with a sheet around the pelvis is a cheap, very reliable and availableto everyone method for an emergent stabilization of the pelvis reducing the pelvic volume inopen-book pelvis fractures. The sheet should be placed at the level of the greater trochanter andwrapped tightly around the patient and secured with a clamp or cable ties. A bolster should beplaced under the knees and the lower thighs, and ankles should be bandaged together to help stabilize the pelvis.IncorrectRoutt et all JOT 2002
42Traction Alone or in combination with sheet/ binder/ ex fix Particularly useful for vertical shear injuriesPrevents vertical migrationTraction pins are very useful for vertical shear injuries and can beapplied in combination with any other stabilization.42
43Anterior External Fixation Disadvantages Can cause a different deformityPoor control of posterior pelvic ringPin tract infectionsIt’s not that easyExternal fixation with a front Ex-fix can be placed at two sires, either in the ASIS or AIIS.This constract is suboptimal in emergent clinical settings since it provides only poor controlof the posterior pelvic ring, it can cause43
44Pelvic C-ClampDescribed by Ganz in 1991 the C-Clamp is a very useful and quickly applicable tool foremergent pelvic stabilization. However, C-clamp application requires an efficient triageset-up and readily available orthopaedic surgeon.Ganz R, et al. The antishock pelvic clamp. Clin Orthop Relat Res
45AIRS: I agree that the incidence of arterial bleeding after high energy pelvic trauma is 10% Patients with a pelvic fracture who are hemodynamically unstable despite aggressivefluid resuscitation and mechanical stabilization, may be a candidate for pelvicangiography.Who among you thinks that ………YesNo- I think it is higher
46Who should get angiography? Rationale: fracture (cancellous) / venous > 90% arterial < 10%Pelvic angiography remains a topic of controversy. Its rationale should be based on the fact that bleeding is not only arterial,but also venous and cancellous. Therefore angio can not controle the venous and bony bleeding. Further taking a patientback to ANGIO suite can be time consuming and may delay taking a patient back to the OR.
47Who should get angiography? Rationale: fracture (cancellous) / venous > 90% arterial < 10%
48Huittinen VM, Slatis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454–62Kataoka 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;203:30–43Huittinen 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.
49Pohlemann T. et al. Tech Orthop 1994 The technique of retroperitoneal packing has been successfully used in some institutionssince many years. Tamponades are applied in the paravesical and presacral spaces in anattempt to tamponade the bleeding.In combination with C-Clamp and ex-fix not only mechanical stability can be provided, butalso pelvic tamponade. The packing is usually changed or removed 48 h after injury.This technique has demonstrated a Mortality rate of around 25%, compared to Angio whichcan reach up to 95%.Cothren CC, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007Suzuki T, Smith WR, Moore EE, Pelvic packing or angiography: competitive or complementary? Injury 2009Ertel W, et al. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001Tscherne H. et al. Crush injuries of the pelvis. Eur J Surg 2001
50TREAT THE PATIENT BASED ON HIS NEEDS……. DCO VS ETC Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012
51Open Pelvis FractureA direct communication of the pelvic injury with the outside worldOpen fractures of the pelvis are devastating injuries with a very high mortality rate.Their defined as a pelvic fracture associated with an open wound communicatingto the outside. Luckly they are very rare.Dente et al AJS 190, 2005
52Think of the open pelvis as a marker that something very bad has happened and other things are likely wrong with this patient
53Open FracturesAir in the pelvis on XR is an open fx until proven otherwiseRequire early I&DConsider diverting colostomyAntibioticsIncreased effectiveness if in first 6 hours2-4% of all pelvic fractures45% mechanically unstable> 50% hypotensive on admission5-45% mortality (most >25%)Early treatment focusing on an appropriate approach with hemorrhage and sepsis control is essential.Antibiotics should be given as for any other open fracture, repeat wound debridement should beconsidered for heavily contaminated wounds, and diverting colostomy if required for wound control,is compulsory and safe to reduce the risk for early sepsis and mortality.
54Open Pelvis Fractures Many potential open wound sites: abdominal wall thighscrotumvaginarectumbuttocksperineumWounds can be located at different locations around the pelvis………. Remember to examine the patient and to turn him.
55Significance of Soft Tissue Injury In addition to the challenges of a pelvic ring injury you also haveLost the ability of the retroperitoneum to tamponade bleedingThe open wound allows contamination of the fractures and the soft tissues of the pelvisRemember that when you are faced with the treatment of an open pelvic fracture, hemorrhage control will be more difficult,since you will not have the effect of retroperitoneal tamponade and also infections will be higher.Dente et al AJS 190, 2005M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005
56Initial Treatment DAMAGE CONTROLE ONLY!!! ATLS Resuscitation: fluid and blood as neededStability: Binder/ sheet/ ex fix/ tractionBleeding: Stability/ angio/ packing/ resuscitationManagement is very similar to closed pelvic fractures, with damage control as the only treatment in early phase………DAMAGE CONTROLE ONLY!!!Dente et al AJS 190, 2005M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005
57Initial Treatment Soft tissue wounds bleed Treat the soft tissue woundSoft tissue wounds bleedThe hematoma is decompressed and draining onto the floorPack the soft tissue woundsDon’t disregard the soft tissue and treat all open wounds… simple packing is a startDente et al AJS 190, 2005M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005
58Mortality decreased to 25% Initial TreatmentSelective early diverting ileostomy or colostomyMortality decreased to 25%Don’t disregard the soft tissue and treat all open wounds… simple packing is a startBrenneman FD, Kaytal D, Boulanger BR, et al. Long term outcome in open pelvic fractures. J Trauma 1997Richardson JD, Harty J, Amin M, Flint LM. Open pelvic fractures. J Trauma 1982M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005
59Mandatory Physical Exam Rectal in everyone (injuries up to 64%)Vaginal exam- especially with anterior ring fracturesDo not ever, ever, ever, ever, ever blow off vaginal bleeding as “that time of the month!!!!!!!!!!!!!”Dente et al AJS 190, 2005M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005
60Subsequent Treatment When stable: Treat the wounds as any other open woundConsider repeat wound I&DPlan for definitive fixation if possibleManagement is very similar to closed pelvic fractures, with damage control as the only treatment in early phase………Dente et al AJS 190, 2005M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005
61Mortality Mortality rate: Early mortality: exsanguinations Pick a number: % or greater with intraabd. injuryThe pelvic injury is directly responsible for a significant percentage of these deathsEarly mortality: exsanguinationsRequire more transfusions than closed pelvic fracturesLate mortality: pelvic sepsisMortality in open pelvic fracture can be as high as 50% or higher and exsanguination should be remembered as thecause for early mortality, while sepsis 2/2 contamination as the late mortality cause.Dente et al AJS 190, 2005M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005
62Summary Perform a proper exam and evaluate x-rays Stabilize the patient >>> Find the Bleeding Source(s)Perform DPL, US and CT if stableAvoid Laparotomy with direct ligation (100% Mortality)Pelvis packing vs. AngiographyDecide for DCO vs ETC62
63Summary Reassess How much blood has been given? Has the patient stabilized?Secondary surveyAssociated injuriesDiscuss surgical planning with other servicesConsider colostomy and SP cath
64Summary !!!!Have a Protocol!!!! Institutional guidelines created with agreement of trauma surgeons and ortho surgeonsListen to Ortho, they know more about these fractures and the potential for blood loss than they doProtocol will be dependent on availability of angio, OR, surgeon preferences