Mubarak M Abdelkerim
MBBS MCh Orth FRCSI FRCSEd FRSM(UK)FICS (USA)
Hemodynamic Instability in Patients
with Pelvic Fractur...
Objectives:
 Epidemiology & Relevance
 Anatomical Review
 Classification Systems
 Hemorrhage Control
 Management
Pelvic Fractures: Epidemiology
 ~3% of all fractures in ED
 50-60% secondary to MVA
 Motorcycle crashes ~15%
 Car vs. ...
Mechanism of Injury
Patient demographics
Associated Injuries
Predictors of mortality
Pelvic Anatomy
 Anterior Support:
 ~40% of strength
 Symphysis pubis
 Fibrocartilaginous joint covered by ant & post s...
Vascular Anatomy
 Vessels lie closely
adherent to posterior
pelvic walls
 Most common cause of
bleeding is venous
 Most...
History & Physical
 ABC’s & initial stabilization
 AMPLE Hx
 Most important feature is mechanism
 Destot’s sign:
 Hem...
Imaging
 Plain films
 AP
 Inlet view / Outlet view
 Judet view (oblique)
 AP alone ~90% sensitive; combined w/ inlet ...
FAST/CT/Total Body CT
• Initial clinical experience with a 64-MDCT
whole-body scanner in an emergency department:
better t...
Classification Systems:
 Most common are Tile and Young systems
 Tile Classification system:
 Advantages
 Comprehensiv...
Classifications and the Risk of Bleeding
• Young-Burgess classification has less inter and inter-
observer reliability
• I...
Tile Classification System
 Type A: Stable pelvis: post
structures intact
 A1: avulsion injury
 A2: iliac wing or ant a...
Tile Classification System
 Type B: Partially
stable pelvis:
incomplete posterior
structure disruption
 B1: open-book in...
Tile Classification System
 Type C: Unstable pelvis:
complete disruption of
posterior structures
 C1: unilateral
 C2: b...
Young Classification System:
 Lateral Compression
 (50%) – transverse # of
pubic rami, ipsilateral or
contralateral to p...
Young Classification System:
 AP Compression (25%)
 Symphyseal and / or
Longitudinal Rami Fractures
 APC I – slight wid...
Young Classification System:
 Vertical Shear (5%)
 Symphyseal diastasis or
vertical displacement
anteriorly and posterio...
Tile &Burgess
Young: Morbidity & Mortality
Fracture
Type
Severe
Bleeding
Bladder
Rupture
Urethral
Injury
Urethral
Injury
LC - I 0.5% 4% ...
Comparing The Predictive Value Of The Pelvic Ring Injury By Young And Burgess
And Tile
Georg Osterhoff Max J.Scheyerer et ...
Immediate Action
• During primary survey pelvic binders should be used despite the fact there is no
conclusive evidence fr...
Sources Of Bleeding
• Arteries,veins,cancellous bone
• Retroperitoneal haematoma - up to 4 liters mostly from venous
plexu...
Resuscitation
• Packed RBCS,FFP and platelets
• The optimal ratio of these components is still under research
• Supporting...
Physical Exam
• Degloving injuries
• Limb shortening
• Limb rotation
• Open wounds
• Swelling & hematoma
Clinical Tips
• Presence of blood in the urethra
• Bleeding per vagina
• Edema of the labia
• Leak of urine from the rectum
Management
 Stable vs Unstable patient
 Stable pt:
 Conservative Tx (bed rest  slow wt bearing)
 Tile: A1, A2, A3 (co...
Management: Unstable Patient
 ABC’s, resuscitation
 Evaluate for site(s) of blood loss
 FAST, CT
 Laparotomy if indica...
The Risk of Bleeding
• Metz et al demonstrated that APC are associated with posterior
bleeding and LC with anterior bleedi...
Imaging
• Plain pelvis and chest radiographs ,FAST, selective CT(ATLS)
• Total body CT with split-dose IV contrast
• The e...
Pelvic Ring Injuries
An unstable pelvic injury may
allow hemorrhage to collect in
the true pelvis as there is no
longer a ...
Defining Pelvic Stability?
• Radiographic
• Hemodynamic
• Mechanical
“Able to withstand
normal physiological
forces withou...
Radiographic Signs of Instability
•Sacroiliac displacement of 5 mm in any
plane
•Posterior fracture gap (rather than
impac...
Stable or Unstable?
• Single examiner
• Use fluoro if available
• Best in experienced hands
• External fixator device to the iliac crest easy to apply, but there is
a risk of infection
• Pelvic c-clamp on the poste...
Shock VS Hemodynamic
Instability
• Definitions Confusing
• Potentially based on multiple factors & measures
• Lactate
• Ba...
Sheet Application
Sheet Application
Before
After
Pelvic Binders
Commercially available.
Placed over the trochanters
and not over the abdomen.
Circumferential Sheeting
• Supine
• 2 “Wrappers”
• Placement
• Apply
• “Clamper”
• 30 Seconds
1
2
3
4
Routt et
al, JOT, 20...
Indications for External Fixation
• Resuscitative (hemorrhage
control, stability)
• To decrease pain in
polytraumatized pa...
External Fixation
Location
AIIS
ASIS
C-clamp
Clinical Application
Resuscitative
Augmentative
Definitive
Anti-shock Clamp (C-clamp)
Better posterior
pelvis
stabilization
Allows abdominal
access
Consider
application with
fluoro ...
Emergent Application
C-clamp: Anatomical Landmarks
• Same (similar location) as the starting point
for an iliosacral screw
• “Groove” located o...
Avoid Over-
compression in
Sacral
Caution…
Control Of Bleeding
•The use of a sacroiliac screw has been reported by Gardner
as having a resuscitation role (the anti-s...
Role of Angio
•Valuable for arterial only
•Estimated at 5-15%
•Timing (early vs late?)
•Institution dependent
Role of Angiography???
• Fracture pattern may predict
effectiveness
• Contrast CT suggests
• Effective in retrospective
st...
Complications of AE
 Gluteal claudication
 Pelvic Necrosis
 Renal failure
 Although effective in controlling bleeding ...
Preperitoneal Pelvic Packing
 In Europe (PPP/EF),
 2011,Clay C Burlew et al (75 out of 1,245) concluded
that this method...
PPP
Pelvic Packing
• Ertel, W et al, JOT, 2001
• Pohlemann et al, Giannoudis et al,
Summary
• Play well with others (general surgery, urology, interventional
radiology, neurosurgery)
• Understand the fractu...
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
Pelvic fracure with haemodynamic instability
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Pelvic fracure with haemodynamic instability

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this is a talk about the ongoing debate of what to do in the management of pelvic fractures with haemodynamic instability
a revision of literature to see the best sequence of events ..

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Pelvic fracure with haemodynamic instability

  1. 1. Mubarak M Abdelkerim MBBS MCh Orth FRCSI FRCSEd FRSM(UK)FICS (USA) Hemodynamic Instability in Patients with Pelvic Fractures
  2. 2. Objectives:  Epidemiology & Relevance  Anatomical Review  Classification Systems  Hemorrhage Control  Management
  3. 3. Pelvic Fractures: Epidemiology  ~3% of all fractures in ED  50-60% secondary to MVA  Motorcycle crashes ~15%  Car vs. pedestrian ~15%  Falls 10-30%  Crush injuries ~5%  Mortality 6-10%; Inc’s to ~50% in unstable pt  Tends to occur in setting of multi-system injury therefore often other serious injuries  Complications:  Hemorrhage, neurological injury, deformity, GU injury, GI injury
  4. 4. Mechanism of Injury
  5. 5. Patient demographics
  6. 6. Associated Injuries
  7. 7. Predictors of mortality
  8. 8. Pelvic Anatomy  Anterior Support:  ~40% of strength  Symphysis pubis  Fibrocartilaginous joint covered by ant & post symphyseal ligaments  Pubic rami  Posterior Support:  ~60% of strength  Sacroiliac complex  Sacroiliac ligaments  Iliolumbar ligaments  Pelvic floor  Sacrospinous ligament  Sacrotuberous ligament  Pelvic diaphragm
  9. 9. Vascular Anatomy  Vessels lie closely adherent to posterior pelvic walls  Most common cause of bleeding is venous  Most commonly injured arteries are superior gluteal and internal pudendal
  10. 10. History & Physical  ABC’s & initial stabilization  AMPLE Hx  Most important feature is mechanism  Destot’s sign:  Hematoma above inguinal ligament or scrotum  Grey-Turner’s sign  Earle’s sign:  Presence of bony prominence, palpable hematoma, or tender # line on DRE  Blood at urethral meatus / vaginal introitus  Examine pelvis only once  Sensitivity of exam 93% vs. 87% for AP pelvis  Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5
  11. 11. Imaging  Plain films  AP  Inlet view / Outlet view  Judet view (oblique)  AP alone ~90% sensitive; combined w/ inlet / outlet views ~94% sensitive  Limited in ability to clearly delineate posterior injuries  Pelvic films are NOT necessary in pts with normal physical exam + GCS >13  At least one study shows clinical exam reliable in EtOH  Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5  CT scans  Evaluates extent of posterior injury better  Superior imaging of sacrum and acetabulum  More detailed info about associated injuries
  12. 12. FAST/CT/Total Body CT • Initial clinical experience with a 64-MDCT whole-body scanner in an emergency department: better time management and diagnostic quality • Rieger, Michael MD; Czermak, Benedikt MD; El Attal, Rene MD; Sumann, Günther MD; Jaschke, Werner MD; Freund, Martin MD • Journal of Trauma volume 66-3 march 2007 648-657
  13. 13. Classification Systems:  Most common are Tile and Young systems  Tile Classification system:  Advantages  Comprehensive  Predicts need for operative intervention  Disadvantages  Does NOT predict morbidity or mortality  Young Classification System:  Advantages  Based on mechanism of injury  predicts associated injury  Estimates mortality  Disadvantages  Excludes more minor injuries
  14. 14. Classifications and the Risk of Bleeding • Young-Burgess classification has less inter and inter- observer reliability • It is well correlated with the mechanism, the amount of energy, the concomitant injuries and transfusion requirements
  15. 15. Tile Classification System  Type A: Stable pelvis: post structures intact  A1: avulsion injury  A2: iliac wing or ant arch #  A3: transverse sacrococcygeal #
  16. 16. Tile Classification System  Type B: Partially stable pelvis: incomplete posterior structure disruption  B1: open-book injury  B2: lateral compression injury  B3: contralateral / bucket handle injuries
  17. 17. Tile Classification System  Type C: Unstable pelvis: complete disruption of posterior structures  C1: unilateral  C2: bilateral w/ one side Type B, one side Type C  C3: bilateral Type C
  18. 18. Young Classification System:  Lateral Compression  (50%) – transverse # of pubic rami, ipsilateral or contralateral to posterior injury  LC I – sacral compression on side of impact  LC II – iliac wing # on side of impact  LC III – LC-I or LC-II on side of impact w/ contralateral APC injury
  19. 19. Young Classification System:  AP Compression (25%)  Symphyseal and / or Longitudinal Rami Fractures  APC I – slight widening of the pubic symphysis and/or anterior SI joint  APC II – disrupted anterior SI joint, sacrotuberous, and sacrospinous ligaments  APC III – complete SI joint disruption w/ lateral displacement and disruption of sacrotuberous and sacrospinous ligaments
  20. 20. Young Classification System:  Vertical Shear (5%)  Symphyseal diastasis or vertical displacement anteriorly and posteriorly  Combined Mechanism Combination of injury patterns
  21. 21. Tile &Burgess
  22. 22. Young: Morbidity & Mortality Fracture Type Severe Bleeding Bladder Rupture Urethral Injury Urethral Injury LC - I 0.5% 4% 2% 2% LC – II 36% 7% 0% 0% LC – III 60% 20% 20% 20% APC – I 1% 8% 12% 12% APC – II 28% 11% 23% 23% APC – III 53% 14% 36% 36% VS 75% 15% 25% 25% CM 58% 16% 21% 21%
  23. 23. Comparing The Predictive Value Of The Pelvic Ring Injury By Young And Burgess And Tile Georg Osterhoff Max J.Scheyerer et al Injury, 2013
  24. 24. Immediate Action • During primary survey pelvic binders should be used despite the fact there is no conclusive evidence from the literature to support these binders decrease the need for transfusion, embolization and improve mortality rates but they decrease the pelvic volume. • Prolonged use can cause trochanteric ulcers, also the secondary survey is difficult while the binder is on. Chesser T.J,Cross AM,(the use of pelvic binders in the emergent management of potential pelvic trauma Injury2012,43:667-9 Ghaemmaghami V,Sperry J.Friese R,et al .effects of early use of external pelvic compression on transfusion requirements and mortality in pelvic fractures.American Journal of surgery 2007:204:935-9.
  25. 25. Sources Of Bleeding • Arteries,veins,cancellous bone • Retroperitoneal haematoma - up to 4 liters mostly from venous plexus and cancellous fractured bone • Damage control resuscitation is to keep the patient hypotensive and prevent (coagulopathy,acidosis and hypothermia) • Permissive resuscitation is to keep SBP at 90 mmhg and thus preventing excessive exsanguination and at the same time organs are perfused • Several questions need to be answered since there is no evidence supporting this strategy
  26. 26. Resuscitation • Packed RBCS,FFP and platelets • The optimal ratio of these components is still under research • Supporting the fibrinolytic system is achieved by giving tranexamic acid • Military application of TXA in trauma emergency,Archives Of Surgery 2012:147:113-9
  27. 27. Physical Exam • Degloving injuries • Limb shortening • Limb rotation • Open wounds • Swelling & hematoma
  28. 28. Clinical Tips • Presence of blood in the urethra • Bleeding per vagina • Edema of the labia • Leak of urine from the rectum
  29. 29. Management  Stable vs Unstable patient  Stable pt:  Conservative Tx (bed rest  slow wt bearing)  Tile: A1, A2, A3 (coccyx #’s only)  Young: APC – I, LC – I, some LC – II  Unstable pt:  Tile B & C / Young APC & VS = high energy injuries  Require surgical management  Timing & methods for stabilization controversial
  30. 30. Management: Unstable Patient  ABC’s, resuscitation  Evaluate for site(s) of blood loss  FAST, CT  Laparotomy if indicated  Options for patients not requiring laparotomy:  Sheet around pelvis.  External fixator.  Early ORIF  Angiographic embolization  Early antibiotics for open # (cefazolin & gent)
  31. 31. The Risk of Bleeding • Metz et al demonstrated that APC are associated with posterior bleeding and LC with anterior bleeding. • ISS and the associated injuries and not the fracture type have been found to represent a better mortality predictor • the extravasation of iv contrast and the size of pelvic haematoma have been correlated to bleeding and the need for angiography • Associated Injuries and Not Fracture Instability Predict Mortality in Pelvic Fractures: A Prospective Study of 100 Patients • Lunsjo, Karl MD, PhD; Tadros, Ayman FRCS; Hauggaard, Anders MD; Blomgren, Rolf MD; Kopke, John MD; Abu-Zidan, Fikri M. MD, FRCS, PhD,-Journal of TraumaVol62(3)March 2007-pages 687-691.
  32. 32. Imaging • Plain pelvis and chest radiographs ,FAST, selective CT(ATLS) • Total body CT with split-dose IV contrast • The effects of this approach comported to the conventional ATLS protocol has not been established • Several studies have shown that time spent in CT is not a prohibiting factor in patient management in modern trauma centers and have emphasized the efficiency of total body CT • Wumbte,Quaisser C,Balling et al.(Whole-body CT- improves trauma care in patients requiring surgery after multiple trauma )Emergency Medicine Journal: 2009:66:648-57.
  33. 33. Pelvic Ring Injuries An 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)
  34. 34. Defining Pelvic Stability? • Radiographic • Hemodynamic • Mechanical “Able to withstand normal physiological forces without abnormal deformation”
  35. 35. 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)
  36. 36. Stable or Unstable? • Single examiner • Use fluoro if available • Best in experienced hands
  37. 37. • External fixator device to the iliac crest easy to apply, but there is a risk of infection • Pelvic c-clamp on the posterior ilium in the SIJ creates a tamponade effect (?Iliac fractures) • Injuries to the superior gluteal neuromuscular bundle • Internal fixation superior but time consuming (extremis) • Direct surgical control theoretically easy - uncontrolled circumferential stitching and clip application with inadequate visualization may lead to iatrogenic nerve injuries • Pelvic angiography and embolization
  38. 38. Shock VS Hemodynamic Instability • Definitions Confusing • Potentially based on multiple factors & measures • Lactate • Base Deficit • SBP < 90 mmHg • Ongoing drop in Hematocrit • Response to fluid challenge
  39. 39. Sheet Application
  40. 40. Sheet Application Before
  41. 41. After
  42. 42. Pelvic Binders Commercially available. Placed over the trochanters and not over the abdomen.
  43. 43. Circumferential Sheeting • Supine • 2 “Wrappers” • Placement • Apply • “Clamper” • 30 Seconds 1 2 3 4 Routt et al, JOT, 2002
  44. 44. 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 Theoretical and a marginal indication, bu t 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
  45. 45. External Fixation Location AIIS ASIS C-clamp Clinical Application Resuscitative Augmentative Definitive
  46. 46. 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
  47. 47. Emergent Application
  48. 48. C-clamp: Anatomical Landmarks • Same (similar location) as the starting point for an iliosacral screw • “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 Pin Location Near IS screw entry point
  49. 49. Avoid Over- compression in Sacral Caution…
  50. 50. Control Of Bleeding •The use of a sacroiliac screw has been reported by Gardner as having a resuscitation role (the anti-shock iliosacral screw-Journal Of Orthopaedic Trauma 2010-24:e86-9) •The best means to control haemorrhage after skeletal stabilization is a subject of a vivid debate!!!!! •According to Gullinane DC, and co-workers in their systemic review (Journal Of Trauma 2011:71:1850-68) arterial embolization should be strongly recommended:
  51. 51. Role of Angio •Valuable for arterial only •Estimated at 5-15% •Timing (early vs late?) •Institution dependent
  52. 52. Role of Angiography??? • Fracture pattern may predict effectiveness • Contrast CT suggests • Effective in retrospective studies!!!
  53. 53. Complications of AE  Gluteal claudication  Pelvic Necrosis  Renal failure  Although effective in controlling bleeding (arterial)but published series didn’t show decrease in necessity for blood product resuscitation  Clay C Burley 2011 American College of Surgeons
  54. 54. Preperitoneal Pelvic Packing  In Europe (PPP/EF),  2011,Clay C Burlew et al (75 out of 1,245) concluded that this method eliminates the question of OR and IR.  Concurrent operations can be done fixed  Less than 15% require angio-embolization  AE should be complementary procedure for life threatening haemorrhage control following PPP/EF
  55. 55. PPP
  56. 56. Pelvic Packing • Ertel, W et al, JOT, 2001 • Pohlemann et al, Giannoudis et al,
  57. 57. Summary • Play well with others (general surgery, urology, interventional radiology, neurosurgery) • Understand the fracture pattern • Do something (sheet, binder, ex fix, c-clamp) call OR/IR . • Combine knowledge of the fracture, the patients condition, and the physical exam to decide next steps

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