v02 acute mgmt pelvic ring - ota.org mgmt pelvic ring.pdf · the evolution of a multidisciplinary...
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The Acute Management of Pelvic
Ring Injuries
Sean E. Nork, MD
Harborview Medical Center
Original Author: Kyle F. Dickson, MD; Created March 2004
New Author: Sean E. Nork, MD; Revised January 2007
Revised: December 2010
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Pelvic Ring Injuries
High energy
Morbidity/Mortality
Hemorrhage
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Pelvic Ring InjuriesAn unstable pelvic injury may
allow hemorrhage to collect
in the true pelvis as there is
no longer a constraint
which allows tamponade.
The volume was traditionally
assume to be a cylinder
with a volume of 4/3π r3,
However…
Best estimated by a hemi-elliptical sphere(Stover et al, J Trauma, 2006)
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Primary survey: ABC’s
Airway maintenance with cervical spine
protection
Breathing and ventilation
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/environment control: undress
patient but prevent hypothemia
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Considerations for Transfer or Care at a Specialized Center:
Pelvic Fractures
• Significant posterior pelvis instability/displacement on the initial AP X-ray (indicates potential need for ORIF)
• Bladder/urethra injury
• Open pelvic fractures
• Lateral directed force with fractures through iliac wing, sacral ala or foramina
• Open book with anterior displacement > 2.5 cm (value of 2.5 centimeters somewhat arbitrary and controversial with regards to reliability)
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Physical Exam
• Degloving injuries
• Limb shortening
• Limb rotation
• Open wounds
• Swelling &
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Defining Pelvic Stability???
• Radiographic
• Hemodynamic
• Biomechanical (Tile & Hearn)
• Mechanical
“Able to withstand normal
physiological forces without
abnormal deformation”
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Stable or Unstable?
• Single examiner• Use fluoro if available
• Best in experienced hands
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Radiographic Signs of Instability
• Sacroiliac displacement of 5 mm in any plane
• Posterior fracture gap (rather than impaction)
• Avulsion of fifth lumbar transverse process, lateral border of sacrum (sacrotuberous ligament), or ischial spine (sacrospinous ligament)
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Open Pelvic Injuries
• Open wounds extending to the colon, rectum,
or perineum: strongly consider early diverting
colostomy
• Soft-tissue wounds should be aggressively
debrided
• Early repair of vaginal lacerations to minimize
subsequent pelvic abscess
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Urologic Injuries
• 15% incidence
• Blood at meatus or high riding prostate
• Eventual swelling of scrotum and labia
(occasional arterial bleeder requiring surgery)
• Retrograde urethrogram indicated in pelvic
injured patients
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Urologic Injuries
• Intraperitoneal & extraperitoneal bladder ruptures are usually
repaired
• A foley catheter is preferred
• If a supra-pubic catheter it used, it should be tunneled to
prevent anterior wound contamination
• Urethral injuries are usually repaired on a delayed basis
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Sources of Hemorrhage
• External (open
wounds)
Long
Abdominal
• Internal: Chest
•
bones
•
•
Retroperitoneal
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Sources of Hemorrhage
Long
Abdominal
• Internal: Chest
•
bones
•
•
Retroperitoneal
• External (open
wounds)
Chest x-ray
Physical exam, swelling
DPL, ultrasound, FAST
CT scan, direct look
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Shock vs Hemodynamic
Instability
• Definitions Confusing
• Potentially based on multiple factors &
measures
• Lactate
• Base Deficit
• SBP < 90 mmHg
• Ongoing drop in Hematrocrit
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Pelvic Fractures & Hemorrhage• Fracture pattern associated with risk of vascular injury (Young & Burgess)
• External rotation and vertical shear injury patterns at higher risk for a vascular injury that internal rotationpatterns
• APC & VS (antero-posterior compression and vertical shear) at increased
risk of hemorrhage
• Injury patterns that are tensile to N-V structures at increased risk
• (eg iliac wing fractures with GSN extension
Dalal et al, JT, 1989
Burgess et al, JT, 1990
Whitbeck et al, JOT, 1997
Switzer et al, JOT, 2000
Eastridge et al, JT, 2002
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Pelvic Fractures & Hemorrhage:
Young and Burgess Classification
V
eased
Lateral
Compression
(LC)
Anteroposterior
Compression
(APC)
Vertical Shear
(VS)
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Hemorrhage Control: Methods• Pelvic
Containment•
•
•
Sheet
Pelvic Binder
External
Fixation
• Angiography
• Laparotomy
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Circ humferential S eeting
• Supine
• 2 “Wrappers”
• Placement
• Apply
• “Clamper”
• 30 Seconds
1
2
34
Routt et al, JOT, 2002
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Sheet Application
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Sheet Application
Before
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After
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Pelvic Binders
Commercially available.
Placed over the
TROCHANTERS and not
over the abdomen.
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External Fixation
• Location Clinical Application
AIIS Resuscitative
ASIS Augmentative
C-clamp Definitive
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Biomechanics of External Fixation: Anterior
External Fixation
• Open book injuries with posterior ligaments
(hinge) intact:
•
• All designs work
C-type injury patterns
No designs work well (but AIIS frames help more
than ASIS frames)
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Biomechanics of External Fixation:
Considerations
• Pin size
• Number of pins
• Frame design
• Frame location
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AS Frames
• Placed at the
iliac crests
bilaterally
• Not a good
vector for
controlling the
pelvis
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Kim et al, CORR, 1999
AI
• Placed at the AIIS
bilaterally
• At least biomechanically
equivalent, thought to be
superior to ASIS frames
• Patients can sit
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AIIS Frames
Kim et al, CORR, 1999
Placed at the AIIS
bilaterally
At least biomechanically
equivalent, thought to
be superior to ASIS
frames
Patients can sit
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Indications for External Fixation
• Resuscitative (hemorrhage control,
stability)
• To decrease pain in
polytraumatized patients?
• As an adjunct to ORIF
• Definitive treatment (Rare!)
• Distraction frame
• Can’t ORIF the pelvis
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Indications for External Fixation
• Resuscitative (hemorrhage control,
stability)
• To decrease pain in
polytraumatized patients?
• As an adjunct to ORIF
• Definitive treatment (Rare!)
• Distraction frame
• Can’t ORIF the pelvis
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Indications for External Fixation
• To decrease pain in
polytraumatized patients?
• As an adjunct to ORIF
• Definitive treatment (Rare!)
• Distraction frame
• Can’t ORIF the pelvis
• Resuscitative (hemorrhage control,
stability)
Theoretical and a
marginal indication,
but there is literature
support
Barei, D. P.; Shafer, B. L.; Beingessner, D.
M.; Gardner, M. J.; Nork, S. E.; and Routt,
M. L.: The impact of open reduction internal
fixation on acute pain management in unstable
pelvic ring injuries. J Trauma, 68(4): 949-53,
2010.
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Indications for External Fixation
• Resuscitative (hemorrhage control,
stability)
• To decrease pain in
polytraumatized patients?
• As an adjunct to ORIF
• Definitive treatment (Rare!)
• Distraction frame
• Can’t ORIF the pelvis
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Indications for External Fixation
ol,• Resuscitative (hemorrhage contr
stability)
• To decrease pain in
polytraumatized patients?
• As an adjunct to ORIF
• Definitive treatment (Rare!)
• Distraction frame
• If can’t ORIF the pelvis
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Technical Details: ASIS & AIIS Frames
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Pin Orientation: ASIS
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Pin Orientation: AIIS
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Pin Orientations
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Technical Details: ASIS
frames…• Fluoro dependent
• 3 to 5 cm posterior to the ASIS
• Along the gluteus medius pillar
• Incisions directed toward the
anticipated final pin location
• Pin entry at the junction of the lateral
2/3 and medial 1/3 of the iliac crest
(lateral overhang of the crest)
•
• Aim: 30 to 45
degrees (from lateral to
medial)
Toward the hip joint
Consider partial closed reduction first!
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Outlet Oblique Image
• Inner Table
• Outer Table
• ASIS
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Outlet Oblique Image
• Inner Table
• Outer Table
• ASIS
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Confirm Pin Placement
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Technical Details: AIIS
frames…
•
•
ique
on)
ection
onfirm
he
• Fluoro dependent:
• 1. 30/30 outlet/obturator obl
(confirm entry location and directi
2. Iliac oblique (confirm dir
above sciatic notch)
3. Inlet/obturator oblique (c
depth)
• Incisions directed toward t
anticipated final location
• Blunt dissection
• Aim: According to
fluoroConsider partial closed reduction first!
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• Outlet Obturator Oblique Image
Outlet Obturator Oblique Image
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5 degrees too much obturator 5 degrees too little obturator
5 degrees too little outlet5 degrees too much outlet
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5 degrees too much obturator 5 degrees too little obturator
5 degrees too little outlet5 degrees too much outlet
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JUDITH
•2H5U0EY2854
5 / 2 9 / 2 0 0 6 · - ' - - . . .
.
H.M.C. #6
DR. NORK
13:32:44
#0019
fJ
JUDITH HUEY 25028545/29/2006
H.M.C. #6
DR. NORK
13:36:02
#0021
kU 71mR 8.0
Xt 3.45
PEL 2689320
kU 70mR 8.0
Xt 3.55
PEL 2689320 ZIEHM
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• Iliac Oblique Image
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Inlet Obturator Oblique Image
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Outlet Obturator Oblique Image
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Pin Orientation
Inlet (with obturator oblique)
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Pin Orientation
Inlet (with obturator oblique)
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Anti-shock Clamp (C-clamp)
Better posterior pelvis
stabilization
Allows abdominal access
Consider application with
fluoro or in the OR to
prevent poor pin placement
Can be combined with pelvic
packingErtel, W et al, JOT, 2001
![Page 68: V02 Acute Mgmt Pelvic Ring - ota.org Mgmt Pelvic Ring.pdf · The evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed](https://reader033.vdocuments.mx/reader033/viewer/2022050716/5e1565eca2747d6f780df0d9/html5/thumbnails/68.jpg)
Anti-shock Clamp (C-clamp)
Better posterior pelvis
stabilization
Allows abdominal access
Consider application with
fluoro or in the OR to
prevent poor pin placement
Can be combined with pelvic
packing
![Page 69: V02 Acute Mgmt Pelvic Ring - ota.org Mgmt Pelvic Ring.pdf · The evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed](https://reader033.vdocuments.mx/reader033/viewer/2022050716/5e1565eca2747d6f780df0d9/html5/thumbnails/69.jpg)
Anti-shock Clamp (C-clamp)
Better posterior pelvis
stabilization
Allows abdominal access
Consider application with
fluoro or in the OR to
prevent poor pin placement
Can be combined with pelvic
packing
![Page 70: V02 Acute Mgmt Pelvic Ring - ota.org Mgmt Pelvic Ring.pdf · The evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed](https://reader033.vdocuments.mx/reader033/viewer/2022050716/5e1565eca2747d6f780df0d9/html5/thumbnails/70.jpg)
Anti-shock Clamp (C-clamp)
Better posterior pelvis
stabilization
Allows abdominal access
Consider application with
fluoro or in the OR to
prevent poor pin placement
Can be combined with pelvic
packing
![Page 71: V02 Acute Mgmt Pelvic Ring - ota.org Mgmt Pelvic Ring.pdf · The evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed](https://reader033.vdocuments.mx/reader033/viewer/2022050716/5e1565eca2747d6f780df0d9/html5/thumbnails/71.jpg)
Emergent Application
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C-clamp: Anatomical
Landmarks
• “Groove” located on the lateral ilium as
the wing becomes the posterior pelvis
• Allows for maximum compression
• Can be identified without fluoro in
experienced hands
Pohlemann et al, JOT, 2004
• Same (similar location) as the starting
point for an iliosacral screwPin Location
Near IS screw entry point
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Avoid Over-compression in
Sacral Fractures!
Caution…
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Pelvic Packing
• Ertel, W et al, JOT, 2001
• Pohlemann et al, Giannoudis et al,
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Role of Angiography???
• Valuable for arterial only
• Estimated at 5-15%
• Timing (early vs late?)
• Institution dependent
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Role of Angiography???
• Fracture pattern may
predict effectiveness
• Contrast CT suggests
• Effective in retrospective
studies!!!
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Vascular Injuries
• Arterial vs Venous vs
Cancellous
• Unstable posterior ring
association
• Associated fracture
extension into notch
• Role of angiographyCryer et al, JT, 1988
O’Neill et al, CORR, 1996
Goldstein et al, JT, 1994
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Acute Hemipelvectomy….
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Acute Hemipelvectomy….
Rarely required (thankfully)
Life saving indications only
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Acute Hemipelvectomy….
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Retrospective evidence• Hypotensivesuwgitgh estsatbsle…pelvicpattern…
• Proceed to Laparotomy (85% with abdominal hemorrhage)
• Hypotensive with unstable pelvic pattern…
• Proceed to Angio (59% with pEoasstirtiidvgeeaent gali,oJ)T,2002
Contrast enhanced CT very suggestive of arterial source
(40 fold likelihood ratio)
(PPV and NPV of 80%, 98%)
Stephen et al, JT, 1999
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Example of a protocol for management
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Example of a protocol for management• Hypovolemic shock and no response to fluids…
• (+) DPL: 1. Laparotomy (+/- packing with ex fix)
• 2. Angio
• (-) DPL: 1. Sheet/binder/ex-fix (some still crash lap)
• 2. Angio
Hypovolemic shock with response to fluids…
(++) DPL: 1. Laparotomy (+/- packing with ex fix)
2. Ex Fix
3. Angio
(+) DPL: 1. Ex Fix
2. Laparotomy
3. Angio
(-) DPL: 1. Sheet/binder
2. Angio
3. Ex Fix
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Example of a protocol for management
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Protocol for Management
• Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the
management of unstable patients with pelvic fractures. JOT, 2001
5 elements: Immediate trauma surgeon availability (+ Ortho!)
Early simultaneous blood and coagulation products
Prompt diagnosis & treatment of life threatening injuries
Stabilization of the pelvic girdle
Timely pelvic angiography and embolization
Changes: Patients more severely injured (52% vs 35% SBP < 90)
DPL phased out for U/S
Pelvic binders and C-clamps replaced traditional ex fix
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Protocol for Management
• Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the
management of unstable patients with pelvic fractures. JOT, 2001
Mortality decreased
Exsanguination death
MOF
Death (<24 hours)
from 31% to 15%
from 9% to 1%
from 12% to 1%
from 16% to 5%
The evolution of a multidisciplinary clinical pathway, coordinating the resources
of a level 1 trauma center and directed by joint decision making between
trauma surgeons and orthopedic traumatologists, has resulted in improved
patient survival. The primary benefits appear to be in reducing early deaths
from exsanguination and late deaths from multiple organ failure.
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Immediate Percutaneous Fixation
• From Chip Routt, MD
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Summary: Acute Management
• Play well with others (general surgery, urology, interventional radiology,neurosurgery)
• Understand the fracture pattern
• Do something (sheet, binder, ex fix, c-clamp)
• Combine knowledge of the fracture, the patients condition, and the physical exam to decide on the next step
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Thank You
Sean E. Nork, MD
Harborview Medical Center
University of Washington
HMC Faculty
Barei, Beingessner, Bellabarba, Benirschke, Chapman, Dunbar, Hanel,
Hanson, Henley, Krieg, Routt, Sangeorzan, Smith, Taitsman
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Acknowledgment
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