The Hemodynamically Unstable Pelvic Fracture

Peter N Thompson MD Attending Trauma Surgeon Atlanticare

Disclosures

• None financial

• I am not an orthopedic surgeon

• Emergency Department presentation

• Multidisciplinary approach and needs

Pelvic Fractures • Common: e.g. 9% of blunt traumas possess,

6%of these associated with mortality—so 1/20 pelvic ring injuries are lethal

• Mortality due to hemorrhage—40%, or constellation of pelvic and associated injuries e.g. head trauma—30%

• Overall incidence increasing with aging population

ATLS• Advanced Trauma Life Support—American College of Surgeons

• “Audience”—providers engaging in care of the traumatically injured patient

• Systematic approach to trauma patient

• Increasing emphasis on pelvic injury/treatment

• Concept of “golden hour”

• Once again, touches on multiple disciplines

• Someone needs to “captain the ship”

Overview/Objectives• Anatomy

• Fracture Anatomy/Injury Patterns

• Diagnosis

• Management modalities/options

• Suggested treatment algorithms

• Cases

Anatomy• Three fused bones in the hemi-pelvis—pubic, ischium,

iliac—referred to as “innominate”

• Bony pelvis comprised of innominate (L and R) and sacrum

• These bones are not fused but held in place by strong ligaments at sacroiliac joints and the pubic symphysis as well as “bridging” ligaments

• Horizontal platform to accept spine and lower extremities

Anatomy

• Arteries—external and internal iliac, branches including the superior and inferior gluteal

• Associated veins

• Major nerve trunks to pelvis and lower extremity

• Pelvic organs—genital, urinary, rectal/anal

Fracture Anatomy

• To organize our professional conversations fracture classifications have been developed

• Consider (1)vectors of inciting force, (2)anatomic disruption, (3)stability/instability—vertical and rotational

• Tile and Young—Burgess Classifications

Vector of Force Applied

• Lateral Compression—impact from side, “t-boned”

• Anterior-posterior Compression—frontal impact, straddle injury

• Vertical shear—fall from height, vertical vector

Stability

• Vertical

• Rotational

Fracture Anatomy

• If one can correlate injury vector, degree of anatomic disruption, and issues of stability with an understanding of non-bony anatomy and associations one can approach the patient in the most logical way

Diagnosis• Studies have shown that in an appropriate patient

physical exam is sensitive and specific in assessing for pelvic injury

• Physical exam—GENTLE medial compression, A-P compression, SI palpation, Perineal/Rectal assessment

• DO NOT manipulate in such a way to worsen bleeding

• Obviates need for imaging

Diagnosis/Treatment• UNSTABLE PATIENT

• ATLS Primary Survey—ABCDE

• Assume C—circulation/cardiovascular

• Resuscitate—volume, blood—blood products

• Where??—field, chest, abdomen, pelvis, long bone fractures

• Assess in order while resuscitate

• Primary survey—CXR and Pelvic Films mandatory in blunt trauma

Diagnostic Imaging• Plain A-P film

• Accept false negative rate in more subtle injuries

• One is looking for gross disruptions to guide management decisions in the UNSTABLE patient

• Inlet/outlet views not usually needed—we are not looking for subtleties

• CT Scan is not part of primary survey

CT Scan• Assumes the patient a “responder” in the

emergency setting, even if transiently

• Shows soft tissues, hematomas, other organs, active bleeding, bony relationships

• Now with 3-D reconstructions and formatting—clear understanding

• Sensitive and specific

Treatment• ABCDE of ATLS Primary Survey

• If exam and X-rays indicate “significant” pelvic injury must rule in or rule out other contributing site(s) of hemorrhage—essentially the abdomen

• This will guide the treatment pathway—as per algorithms

• Prioritize what can be done and the order thereof

Treatment—Initial• Bleeding sources—bones, arteries, veins

• The normal pelvis is a tight confined space/volume

• Displaced fractures cause loss of domain, increase volume, mobility of fragments thus contributing to ongoing blood loss—volume and mobility

• Restricting bony movement, reducing the volume, may help control bleeding from bony and venous sources

• Arterial bleeding (major) is high pressure, large vessel and will usually require more definitive intervention

YIKES!• ATLS

• HEMORRHAGE!

• RESUSCITATE!—WHILE YOU DIAGNOSE

• TEAM APPROACH

• BLOOD and BLOOD PRODUCTS 1:1:1 or 1:2:1

• MASSIVE TRANSFUSION PROTOCOL

• MINIMIZE CRYSTALLOID

• LARGE BORE IV ACCESS, LEVEL1TRANSFUSERS/WARMERS, PRESSURE BAGS

Initial Treatment—ER

• Decrease Pelvic Volume/Reduce Mobility

• Binders—sheet/manufactured device (t-pod)

• External fixation—C-clamp

• Aortic Occlusion—REBOA

Binders• Decrease movement and volume

• Most useful in “open-book” type fracture, less so in lateral compression (volume often reduced)

• Fracture type specific—may make worse—iliac wing

• Duration—can get skin necrosis, temporizing, <24 hours

• Simple sheet, T-pod

• Apply at trochanters—can cause abdominal compression if too high

• Moderate pressure

C-clamp

• Placed in ED

• Posterior Stabilization

• Rotates

• Temporary

Aortic Occlusion Balloon

• Aortic Occlusion Balloon placed percutaneously through introducer system via femoral artery

• Several deployment positions

• Lower to occlude distal aorta/major pelvic inflow

• Temporizing measure

OPERATING ROOM MANAGEMENT

• Exploratory Laparotomy—damage control, stop hemorrhage

• Pelvis—does one plunge into pelvis, break into ?tamponade?

• Exercise caution—major shunts e.g. common or external iliac artery injury—rapidly expanding hematoma

• ?? Bilateral internal iliac artery ligation??

• Best to do as little as possible

Pelvic Packing• Operative intervention

• One wants to maintain integrity of peritoneum and tamponade effect of pressure

• Packs placed extraperitoneally and need to be in the deep posterior pelvis/presacral area

• Incision can be vertical or transverse

• Can accompany a laparotomy yet kept anatomically separate

• Another temporizing measure

Angiography/Embolization• No clear predictive factors guiding patient

selection for angiography for or against

• E. g. “25%” negative, +CT blush in stable patient may be clinically insignificant

• Hemodynamic instability, no other clear source, or “recognized unstable anatomy, higher grade, large hematoma, call IR

• Better negative than too late

IR Caveats!• The “Captain” controls all but the procedure itself

• Must have ongoing complete resuscitative efforts and support—essentially a full OR team and capability

• Nurses, techs, equipment—infusers, monitors, ventilators, transfusion services

• Surgical team present throughout, directing and driving care

Angiography

• Bilateral “damage control” internal iliac artery occlusion with temporizing gel foam--tolerated

• Selective angiography—more time consuming, more definitive

External Fixation

• Realign anatomy controlling/decreasing bony movement and decreasing/restoring pelvic volume

• Usually temporizing—internal, definitive performed later

Associated Injuries

• Genital/urinary injuries

• Ano/rectal injuries

Genital Urinary

• Male—perineal, meatal blood—retrograde urethagram

• Hematuria—cystogram (somewhat CT scan directed)

Ano-rectal

• “Open pelvic fracture”—high association with mortal outcome

• If perineal/anal/rectal injury—diversion of fecal stream

Summary Treatment

• Algorithms

• Must know YOUR system, capabilities, and tailor your management accordingly

Treatment “Summary” for Unstable Patient

• ATLS Protocol

• Assess chest, long bones—treat and splint as needed while continuing resuscitative efforts

• (+) Pelvic fracture

• (?) Abdomen—FAST, DPL or OR

• Call IR and prepare

• Binder

• REBOA

• If OR—add preperitoneal packing while there

• If IR—call Ortho preemptively

• After IR—Ortho, ex fix

Clinical Case # 1• 57 yo male, pedestrian struck by motor vehicle

• Presents GCS 15, complaining of R shoulder, L LE pain

• PMH NIDDM, the rest unclear, no prior surgical history

• BP 99/60, P 83, RR 24

• PE consistent with hemorrhagic shock

ATLS—lets go!!• Team approach!

• Anesthesia—RSI after getting quick verbal history

• Large bore IVs, R SCV Cordis catheter, transfuse blood in trauma bay via Level 1 transfuser

• All adjuncts in place and moving ahead—Foley catheter, OGT

• ABCDE

Where is the blood?• No external bleeding

• CXR—no explanation for shock state

• No long bone fractures

• Abdomen—FAST unsatisfactory—DPL/OR or CT scan

• Pelvis—open book pelvic fracture

• Binder and STAT MASS

Decision• Evaluate the abdomen as source—binder in place

• “Transient responder”

• Given all factors—CT scan and continue vigorous resuscitation

• DO NOT “abandon” patient

• Call IR—mobilize that team

• “Heads up” call to Orthopedics

Hospital Course• Trauma Bay—evaluate, resuscitate

• CT scan—diagnose

• IR suite—arterial embolization

• OR—external fixation

• To ICU to further resuscitate

Hospital Course 2• By morning…..35 units PRBC, 16 units FFP, 3 platelet packs

• HD #4 ORIF

• HD #6 compartment syndrome/fasciotomy

• HD #6 L LE DVT…complete to IVC, mechanical thrombectomy (limited), IVC filter

• HD #11 Debridement of L LE fasciotomy site tissue

• HD #12 Transferred to higher Level Center to advanced orthopedics/plastics

Hospital Course 3

• L LE with loss of motor sensory function

• Tissue loss—extent not defined

• ARF—dialysis dependent

• Continued transfusion requirements throughout.

Clinical Case 2• 18 y o male head on MVC to tree

• L LE deformity

• Signs and symptoms of shock

• GCS 15

• No significant PMH, PSH

• 18 y o but morbidly obese

ATLS• RSI after obtaining history

• Again—team approach

• IV Access—during Cordis attempts—suspect pelvic fracture—anatomy “off”

• CXR o k, no blood in field reported, L femur deformity

• Pelvic film—open book pelvic fracture

• PE—rectal blood and stool

Decision• Evaluate abdomen—know there are two other causes of

blood loss, hypotension, but must evaluate abdomen

• FAST “seems” negative

• Too large to DPL

• Unstable

• Patient taken to OR to further assess abdomen—DP ”analysis”

• On way to OR, notify IR, Orthopedics

Decision/Treatment 2• OR—limited peritoneal peek—enough to say NOT the source of

significant bleeding, instability

• Close only skin

• TO IR suite from OR

• Angioembolization performed R pelvis bleeding

• Patient taken to OR from IR suite

• External fixation L femur, pelvis

• Completion laparotomy, diverting loop ileostomy for rectal injury

Hospital Course• HD #1—31 units PRBC, 24 units FFP, 5 platelet packs

• Urine initially grossly bloody, not intraperitoneal rupture as per OR

• Ultimately urethral injury diagnosed

• Pelvic infection/perineal infection

• Three month course, ICU/floor

• Ultimately transferred to rehab facility

BUT

• In the end complex life threatening injuries

• Require team approach to get through the immediate period

• Even then extremely challenging to ultimately get the patient to recover to satisfactory level of function