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Erik Hasenboehler MD Orthopaedic Trauma Surgery Baltimore MD Kentucky Trauma Symposium 2012 Pelvic fracture Management.

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Presentation on theme: "Erik Hasenboehler MD Orthopaedic Trauma Surgery Baltimore MD Kentucky Trauma Symposium 2012 Pelvic fracture Management."— Presentation transcript:

1 Erik Hasenboehler MD Orthopaedic Trauma Surgery Baltimore MD Kentucky Trauma Symposium 2012 Pelvic fracture Management

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3 Subjects  Basic Polytrauma management  Polytrauma basic science  Pelvis Exam, Stability and managment  Acute treatment of pelvic ring injuries  Open Pelvis fracture

4 Save the patient`s life ! One goal !!!!!!! Pelvic fracture and Polytrauma Management

5 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 Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009

6 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

7 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

8 Two Hit Model First insult 2 nd insult Moderate SIRS Severe SIRS Moderate immuno- suppression Severe immunosuppression MOF Infection Definitive surgery EARLY Delayed definitive surgery Moore FA and Moore EE. Surg Clin North Am. 1995

9 Secondary Period  Old concept: Day 1, 5-7 (window of opportunity) and after 14 days 2-4  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 Damage control orthopedics: current evidence Lichtea et al CO-Critical Care Second hit phenomenon: Existing evidence of clinical implications. Lasanianos et al. Injury 2011

10 Pre- Hospital: Devastating injury

11 Hospital-Acute/Primary: shock, hypoxia or head injury

12 Hospital-Secondary/Tertiary: MOF or ARDS

13 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

14  < 24 hours: blood loss  > 24 hours: MOF  Exsanguination caused 75% of the deaths Causes of Death from Pelvis Fractures

15 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

16 Damage Control

17 Minimize the Second Hit

18 Assess  Treatment of pelvic ring injuries is usually a multidisciplinary activity  Trauma, Orthopaedics, Radiology  Urology/Gynecology

19  Lots to bleed  Big space to bleed into

20 Volume Changes in the True Pelvis During Disruption of the Pelvic Ring – Where does it go?  Volume increase - r 3  Volume increase 1 – 2L 1.Moss and Bircher, Effects of Pelvic Volume Changes on Retroperitoneal and Intra- Abdominal Pressure in the Injured Pelvic Ring: A Cadaveric Model Köher et al 2011

21 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

22 Physical Exam  Palpate anterior pelvis  Watch for perineal Lacerations  Scrotal/Labial Swelling  Flank Ecchymosis

23 Physical Exam  Turn the patient!

24 Physical Exam  Morel-Lavalle lesions  Degloving of the flank, thigh  Large dead space  Increased incidence of infection

25 #2: Is the Injury Pattern “Stable” or “Unstable”?

26 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

27 Physical Exam Abnormal position of the lower extremity

28 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

29 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

30 Vertical Stability  Push pull on leg while palpating the ASIS

31 CT Scans  Blush= embolizable arterial injury!

32 “Stabilizing” Theories  Decreases pelvic volume  Prevents gross motion, clot disruption  Reduces cancellous bony bleeding

33 Why is Stability Important?  APC 2, 3; LC 3; VS LC3 APC2,3 VS

34 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 Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;

35 Transfusion Requirements  Lateral Compression  Combined Mechanical- 8.5  Vertical Shear  AP Compression 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 Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;

36 WHAT TO USE TO STABILIZE THE PELVIS

37 MAST / PASG

38 Sheet or Binder

39 Pelvic Binder  Easily applied during resuscitation  Portable

40 Pelvis and Acetabulum Frontline Treatment Acute Management  SAM Sling / T-POD / Circumferential Sheet: Greater Trochanter!! TOO HIGH!!

41 Pelvic Sheeting Routt et all JOT 2002

42 Traction  Alone or in combination with sheet/ binder/ ex fix  Particularly useful for vertical shear injuries  Prevents vertical migration

43 Anterior External Fixation Disadvantages  Can cause a different deformity  Poor control of posterior pelvic ring  Pin tract infections  It’s not that easy

44 Pelvic C-Clamp Ganz R, et al. The antishock pelvic clamp. Clin Orthop Relat Res

45 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

46 Who should get angiography? Rationale: fracture (cancellous) / venous > 90% arterial < 10%

47 Who should get angiography? Rationale: fracture (cancellous) / venous > 90% arterial < 10%

48  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.

49 1.Cothren CC, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma Suzuki T, Smith WR, Moore EE, Pelvic packing or angiography: competitive or complementary? Injury 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 Tscherne H. et al. Crush injuries of the pelvis. Eur J Surg 2001 Pohlemann T. et al. Tech Orthop 1994

50 Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012 TREAT THE PATIENT BASED ON HIS NEEDS……. DCO VS ETC

51 Open Pelvis Fracture  A direct communication of the pelvic injury with the outside world Dente et al AJS 190, 2005

52 Think of the open pelvis as a marker that something very bad has happened and other things are likely wrong with this patient

53 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%)

54 Open Pelvis Fractures Many potential open wound sites:  abdominal wall  thigh  scrotum  vagina  rectum  buttocks  perineum

55 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 Dente et al AJS 190, 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

56 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 Dente et al AJS 190, 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

57 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 Dente et al AJS 190, 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

58 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 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 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 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

59 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 Dente et al AJS 190, 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

60 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 Dente et al AJS 190, 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

61 Mortality  Mortality rate:  Pick a number: % 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 Dente et al AJS 190, 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005 M.R.W. Grotz et al Open pelvic fractures: epidemiology, current concepts of management and outcome Injury 2005

62 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

63 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

64 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

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66 Thank you


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