Initial Management of Complex

Pelvic Fractures

Jeffrey Anderson, MDSaint Mary’s Trauma Center

05 May 2011

Course Objectives

• Identify high risk pelvic fractures

• Attain basic knowledge of biomechanics involved

with pelvic fractures

• Understand initial management strategy for

complex pelvic fractures

• Awareness of potential pitfalls in management

• Understand which patients require angiographic

studies versus exploratory laparotomy

Overview of Problem

• Common: 5-10% of all high-speed MVC

occupants will sustain pelvic fractures

• High incidence of serious associated

injuries

• Highly lethal: some studies show a mortality

approaching 50%

• Good outcomes require a rapid and

multidisciniplary team approach

COURSE OVERVIEW

DILEMMA

Bony Pelvic Anatomy

Pelvic Ligaments

Pelvic Ligaments

PELVIC VASCULAR ANATOMY

PELVIC VASCULAR ANAOTMY

With high impact pelvic

fractures approximately

15-20% of bleeding is

arterial; from branches of

internal iliac arteries

PELVIC STABILITY

• Bony pelvis has no inherent stability

– pelvic stability highly dependent on ligaments

• Symphysis and sacral-iliac ligaments

• Fractures of the pelvis imply high energy forces

• MVC, MCC

• pedestrian vs auto

• fall from height

• pelvis is a bony ring and hence fractures typically occur at

two or more sites

PELVIC STABILITY

• Anterior stability

– Pubic symphysis and pubic bones act as a strut

• sectioning of the symphysis creates a diastasis of less than 2.0

cm

• Posterior stability

– stability depends on integrity of sacroiliac complex

• sectioning of the symphysis and the anterior sacroiliac

ligaments allows symphysis to separate > 2.5 cm

• sectioning of the symphysis and both anterior and posterior

sacroiliac ligaments allows for vertical instability

Pelvic Ligaments

• Major contributor to

pelvic stability• Pubic symphysis

• Anterior and posterior

sacroiliac ligaments

Young and Burgess Classification

of Pelvic Fractures

• Useful in the clinical setting

• Addresses injury mechanism and

• Seeks to quantify forces involved

– anterior posterior compression

– lateral compression

– vertical shear

– combination

• Young and Burgess Classification Pelvic Fractures

– AP compression (APC) - direct anterior force

• Type 1: disruption of pubic symphysis < 2.0 cm

– low energy forces (sports)

– stable

• Type 2: symphysis > 2.0 cm and disruption of

anterior SI ligaments

– high energy, “open book”; MVC, ped vs auto

– unstable

– high risk hemorrhage

• Type 3: symphysis > 2.0 cm and disruption of

anterior and posterior SI ligaments

– very unstable

– highest incidence of major hemorrhage

Anterior-Posterior Compression (APC)

• APC 1

– anterior force of mild-

moderate force (sports)

– symphysis separation

< 2cm

– stretching of anterior

sacroiliac ligaments

– stable fracture

Anterior-Posterior Injury

• Grade I

• Symphysis < 2cm

• SI joints intact

Anterior-Posterior Compression (APC)

• APC 2

– anterior force of high

energy

– “open book”

– symphysis > 2cm

– tearing of sacroiliac

ligaments

– unstable fracture

Anterior-Posterior Compression (APC)

• APC 3

– high energy force

– hemipelvis rotates

externally

– symphysis >2cm

– rupture of anterior &

posterior sacroiliac

ligaments

– highest incidence of

major hemorrhage

– unstable fracture

Open Book Pelvic Fractures

– Symphysis > 2cm

– Disruption SI joint

– High incidence hemorrhage

– Mortality approaches 50%

• Young and Burgess

– lateral compression (LC)

• Type 1: unilateral rami fracture and ipsilateral

sacroiliac compression - stable

• Type 2: unilateral rami fracture and ipsilateral

posterior sacroiliac fracture

– unstable fracture

– high risk for hemorrhage

• Type 3: type 2 plus injury to contralateral

hemipelvis

– unstable fracture

– high risk for hemorrhage

Lateral Compression Fractures

• Type I:

• Pubic rami fracture

• Sacral compression

• stable

• Type 2:

• Pubic rami fracture

• Iliac fracture

• Unstable

• Higher incidence

hemorrhage

Lateral compression fractures

• Bilateral pubic rami fractures

• Sacral deformity / fracture

• Lateral compression type fractures are usually stable and rarely hemodynamically unstable

Lateral Compression (LC)

• LC 3

– bilateral LC 2

– crush type injury

– unstable fracture

Classification Pelvic Fractures

• Young and Burgess

– vertical shear (VS): fall

from a height

• Vertical displacement

of hemipelvis

• unstable

• high incidence of

hemorrhage

VERTICAL SHEAR

• Complete disruption of

hemipelvis

• anterior and posterior

vertical displacement

• fall from a height

• high incidence of pelvic

hemorrhage

• unstable pelvis

UNSTABLE PELVIS

• APC2, APC3, LC2, LC3,

VS, and combination

injuries are all unstable pelvic

fractures and are associated with a

higher incidence of vascular

disruption and hemodynamic

compromise

• this does not imply that bony

instability equates to hemodynamic

instability

Pelvic Fractures

• High energy

– MVC, falls from

height, crush injury

– 75% associated injuries

– 15-25% intra-

abdominal injuries

– often hemodynamically

unstable

– mortality up to 55%

• Low energy

– falls from standing

• Lateral compression

– elderly / osteopenic

– associated injuries

uncommon

– hemodynamically

stable

– mortality < 1%

AP Pelvis Radiograph

• Indicators of potential

vasculature injury:• diastasis symphysis >

2.0 cm

• fractures all 4 rami

• widening SI joint >0.5

cm

• vertical displacement at

the SI joint

COURSE OVERVIEW

High Energy Pelvic Fractures

• MVC, auto-pedestrian, motorcycle accidents

• 5-10% of high speed MVCs will sustain pelvic fractures

• mortality correlates highly to hemodynamic stability

• stable < 4%

• unstable > 50%

• mortality:

• 50% acute hemorrhage

• 25% associated injuries

• 25% sepsis / MODS

• associated injuries: TBI, thoracic, intra-abdominal

Physical findings may indicate pelvic

fractures

• Labial, scrotal, perineal swelling / ecchymosis

• deformities lower extremities

• open wounds - rectal / vaginal blood necessitates

sigmoidoscopy / speculum examinations

• urethral injuries• blood at meatus

• high riding prostate

• scrotal/labial hematoma

• sacral nerve root injuries

• Physical maneuvers to establish pelvic

stability are of questionable benefit

• pelvic rock, springing, compression, distraction are

crude and insensitive

• exacerbate hemorrhage and soft tissue injury

• painful and unnecessary maneuvers

– initial pelvic radiographs better indicator of stability

Routine Pelvic X-rays

• Examination of the pelvis is extremely unreliable;

especially in the obtunded, intoxicated, or obese patients

• Routine A-P pelvic and chest x-ray is still indicated in the

multiply or obtunded injured patient

• Hemorrhage in pelvic fractures:

– Venous bleeding (85%)

• fracture surfaces of cancellous bone

• venous plexuses

– Arterial bleeding (15%) - from branches of the superior

gluteal artery ( fracture through sciatic notch) or other branches of

internal iliac artery

• Most common source of significant hemorrhage in

pelvic fractures is NOT the pelvis

Pelvic Stabilization

• Purpose:• controls non-arterial hemorrhage

• aids in clot formation

• decreases fracture site movement and clot

dislodgement

• decreases volume of pelvis and promotes tamponade

• exact mechanism in which stabilization decreases

hemorrhage has not been elucidated

Pelvic Stabilization

• Three basic methods:• non-invasive techniques

• external fixation

• open reduction / internal fixation

Pelvic Stabilization

• 1. Non-invasive techniques:– Sheet wrap

– Proprietary devices / binders

• Most appropriate in the trauma bay for unstable

pelvic fractures

• temporary measures

• Controls hemorrhage as effectively as external

fixation

Pelvic Stabilization

• Sheet wrap• Inexpensive

• Fast

• Effective

• Temporary

Pelvic Binders

• T POD

– Cost: $125.00

– Fast

– Efficient

– Temporary

T-Pod: Non-invasive Pelvic Stabilization

Pelvic Stabilization

• External fixation devices:• anterior fixation device - ideally suited for “open-book”

deformities

• C-clamp device - ideally suited for posterior disruptions

– unstable pelvic fractures associated with hypotension

– can be placed in the trauma bay, OR, ICU

– should be placed prior to skin incision in patients

needing a laparotomy

– complications / drawbacks:

Pelvic Stabilization

• External Fixation:• “Fast”

• Orthopedic consultation

• Effective

• Typically temporary

External Fixation

• Should be applied as soon as possible with unstable pelvis

• May be applied in trauma bay, OR, or TICU

• Anterior bridging bars placed low over pelvis so as not to interfere with laparotomy incision

• Ideally placed prior to laparotomy

External Fixation

Pelvic Stabilization

• Internal stabilization:• limited value in the

acute setting

– occasionally used in

“open-book”

deformities after

laparotomy in the

stable patient

• reserved for patients

who are

hemodynamically stable

• definitive treatment

• No convincing data to support one method of pelvic stabilization over another in the acute setting:

• all methods equally effective

• T-POD HAS GAINED WIDE EXCETANCE

• But studies do support some form of bony stabilization

• decreases hemorrhage

• decreases transfusion requirements

PRINCIPLES OF ANGIOGRAPHY AND

EMBOLIZATION

• Used to control bleeding that cannot be corrected with

surgery

• Purpose is to slow bleeding rather than create large areas

of ischemia and necrosis

• Limit areas of ischemia and necrosis to smallest extent

possible

• Must be done expeditiously prior to onset of “lethal triade”

Angiography

• HEMORRHAGIC SHOCK:

• Surgically correctable injuries directly to operating room

• Non-surgically correctable injuries to angiographic department

Pelvic Angiogram

Angiography

• Approximately 7-11% of pelvic fractures will require

embolization to control arterial bleeding.

• lateral compression fractures: 2%

• anteroposterior compression: 20%

• vertical shear injury: 20%

• combination: 20%

• Approximately 25-40% of cases will require embolization of more

than one artery

• Segina, D., Agnew,S., OTA Annual Meeting 2000

Angiographic Embolization

• Embolization is only

effective for arterial

source of hemorrhage

-90% effective

When To Transfer to Angiography ?

• IMMEDIATELY:• Patients who are

hemodynamically

unstable as the result of

their pelvic fractures

AND if laparotomy is

not indicated

Hypotension and Associated High

Energy Pelvic Fracture

• Etiology of hypotension will be secondary

to non-pelvic sources at least 50% of time• thorax

• abdomen

• long bone fractures

• externally / at the scene

5 Major Sites of Blood Loss

• Chest

• Abdomen

• Retroperitoneum

• Muscle compartment of thigh

• Injury scene

Problem!

• Where is the source of hemorrhage / hypotension?

– If solely related to the pelvic fracture(s) - then

angiography and embolization is the best and initial

therapeutic option

– If hemorrhage secondary to an abdominal injury then

laparotomy is the best and initial therapeutic option

– If hemorrhage secondary to a thoracic injury then tube

thoracostomy and possibly thoracotomy is indicated

• How to determine source of bleeding?

Diagnosing intra-abdominal hemorrhage

• FAST

• Diagnostic peritoneal lavage (DPL)

• Diagnostic peritoneal tap: supra-umbilical

approach appears to be the most reliable test for intra-

abdominal hemorrhage, which requires laparotomy

• CT scan

• E.A.S.T., Practice Management Guidelines, 2001

Focused Abdominal Sonography for Trauma

• FAST

• Ultrasound examination to

determine presence of free

fluid in the pericardial or

peritoneal cavities

• High sensitivity /

specificity

Diagnostic Peritoneal Lavage

Diagnostic Peritoneal Tap

• Catheter introduced

through a supraumbilical

incision

• 5-10cc gross blood is

positive tap and an

indication for immediate

laparotomy

• 1 liter crystalloid solution

infused

Critical Questions ?

• Which patients warrant early pelvic

stabilization?

• Which patients warrant pelvic angiography

and possible embolization?

• Which patients warrant emergent

laparotomy?

Early Pelvic Stabilization

• Patients with unstable pelvic fractures

associated with hypovolemia

• All patients with “unstable pelvis”

diastasis of symphysis > 2.0

cm

fractures all 4 rami

widening SI joint >0.5 cm

vertical displacement at the

SI joint

Early Angiography

• Pelvic fractures with signs of ongoing hemorrhage after non-pelvic sources of blood loss have been ruled-out

• Patients with pelvic fractures with ongoing hemorrhage that cannot be controlled at laparotomy

• Arterial extravasation noted in pelvis on CT scan

Emergent Laparotomy

• Patients with hypotension and gross blood

in the abdomen or evidence intestinal

perforation

• FAST / DPL are most reliable diagnostic

tests

Initial Management

• initial assessment: “ABCDE’s”

• radiographic assessment: CXR, A-P pelvis, FAST

• hemodynamically unstable patients:

– 50% of patients with severe pelvic fractures are

bleeding from sources other than the pelvis

– associated injuries very common

– determine source of hemorrhage!!

• “patients in hemorrhagic shock with a

surgically correctable lesion should be

transported to the OR”

• “patient in hemorrhagic shock with an

unknown source of bleeding, as well as,

lesions best treated by embolization should

be transported to the angiography suite”

• Bassam, D., Am. Surg., 1998, 862-867

When to perform laparotomy

• Indications for laparotomy in the face of

hypotension and pelvic fractures remain the same

• intra-abdominal hemorrhage

• intestinal perforation

• peritoneal signs

Intraoperative Management

• If laparotomy is required for ongoing bleeding:

• control non-pelvic sources of hemorrhage

• if pelvic bleeding identified; enlarging hematoma

– do not open retroperitoneum

– pack pelvis

– exercise damage control

– escort patient to angiography suite: embolization is the

best method to control pelvic arterial bleeding; effective in

90% of cases

Open Pelvic Fractures

• Fracture site communicates through the skin, rectum,

vagina

• High incidence of associated injuries, mortality approaches

80%

• Vital to make diagnosis early - blood in rectum / vagina

necessitates further evaluation

• basic tenants apply to all open fractures - thorough irrigation

and debridement, prophylactic antibiotics, fracture stabilization

Open Pelvic Fractures

• Treatment same

• Early prophylactic

antibiotics• ancef / gentamycin

http://www.trauma.org/images/articles/exsanguinatingpelvisalgorithm.jpg

CONCLUSION

• Do not delay treatment

• Priorities remain the same: ABCDE’s

• Pelvic stabilization mandatory

• Rule –out other sources of bleeding

• Exploratory laparotomy: indications remain the same

• Angiography / embolization: must be considered

early to mobilize appropriate personnel

• early transfer to a trauma center may be life

saving