Avi Bhavaraju
Oliver L. Gunter
Presentation
A 45-year-old male was involved in a high-speed motor vehicle collision. He was a restrained driver and required prolonged extrication. During transport, he exhibited altered mental status and was unable to provide any history. On arrival to the emergency department, initial vital signs were pulse 150, blood pressure 60/palp, respiratory rate of 30, and unobtainable oxygen saturations.
He was intubated in the emergency department and resuscitated with crystalloid and blood products. Chest x-ray (CXR) was negative; pelvis x-ray (PXR) showed diastases of the pubic symphysis and the right sacroiliac joint, a left sacral fracture, and pubic rami fractures. Additional injuries included bilateral humerus fractures and a femur fracture (Figure 1).
FIGURE 1 • AP pelvis film obtained in emergency department.
Differential Diagnosis
This patient presents with shock from blunt trauma. The differential diagnosis in this setting includes the following:
1. Hemorrhage
a. Thorax
b. Abdomen
c. Pelvis
d. Retroperitoneum
e. Extremity/long bone
f. External
2. Tension pneumothorax
3. Cardiac tamponade
4. Spinal cord injury
5. Myocardial ischemia or arrhythmia
Workup
Immediate priorities include securing the Airway and assessing Breathing and Circulation (ABCs) in accordance with Advanced Trauma Life Support (ATLS) guidelines. History and physical examination, when available, may alert to the possibility of a pelvic fracture. If the patient is awake and alert, he may complain of pelvic, hip, or lower back pain exacerbated by position or lower-extremity movement. Abnormal rotation or shortening of a lower extremity and instability over the pelvic ring are physical findings indicative of a potential pelvis fracture. Blood at the urethral meatus may indicate bladder or urethral disruption, which occur with high frequency in association with pelvis fractures.
Important laboratory tests include type and screen, complete blood count, electrolytes, coagulation studies, and resuscitation markers (blood gas, lactate, and base deficit).
Screening radiographs in the emergency department are helpful to identify the source of shock. Lateral cervical spine, chest, and pelvis films can help direct resuscitation and treatment plans. Abdominal ultrasound can identify hemoperitoneum, particularly in the setting of blunt trauma. Computerized tomography (CT) is an invaluable diagnostic tool for evaluating multisystem trauma patients. The addition of intravenous contrast makes CT a rapid and sensitive imaging modality to evaluate sources of hemorrhage. Extravasation of contrast in proximity to pelvis fractures may indicate active bleeding that requires further management.
In the patient presented above, CT scan revealed an “open-book” pelvis fracture with 1.5 cm of pubic diastasis, bilateral sacral fractures, a right superior pubic ramus fracture, right sacroiliac diastasis, a left acetabular fracture, and bilateral inferior pubic rami fractures. Active contrast extravasation was seen in the anterior pelvis and around the bladder with a large associated pelvic hematoma (Figures 2 and 3).
FIGURE 2 • Axial CT image showing the left sacral fracture and right SI diastasis.
FIGURE 3 • Axial CT image showing contrast extravasation.
Based on the CT findings and clinical picture suggesting class IV shock, he was resuscitated and taken to interventional radiology for emergent pelvic angiography. Findings included pseudoaneurysms with contrast extravasation from both internal pudendal arteries and the left sacral artery. There were no concurrent intra-abdominal injuries requiring operative intervention. Bilateral internal pudendal artery and left sacral artery coil embolization was completed; the patient was then sent to the ICU for continued resuscitation and stabilization (Figures 4 and 5).
FIGURE 4 • IR image showing right internal iliac pseudoaneurysm.
FIGURE 5 • Postembolization IR image.
Discussion
Once a pelvis fracture has been diagnosed on an anteroposterior pelvis radiograph, additional imaging may further characterize the fracture pattern and identify other associated injuries. Pelvic inlet and outlet views show fractures of the pelvic ring, while oblique projections better demonstrate acetabular injuries. CT imaging of the pelvis with reconstructed views is useful for operative planning and identifies more subtle fractures with high sensitivity.
Pelvis fractures may be classified into five categories based on mechanism and predominant force vectors:
1. Anterior–posterior compression (APC) injuries
2. Lateral compression (LC) injuries
3. Vertical shear injuries
4. Combined mechanical injuries
5. Acetabular fractures
Grading is from one to three in order of increasing severity of ligamentous and bony injuries. Those with significant ligamentous disruption and diastasis are often referred to as “open-book” fractures.
While lower-grade injuries may be managed nonoperatively with weight-bearing (WB) restriction, more severe injuries require surgical stabilization.
The patient in our scenario underwent bilateral percutaneous iliosacral screw fixation to repair his pelvic ring injuries and open reduction and internal fixation of his extremity fractures (Figure 6).
FIGURE 6 • Post-op AP pelvis.
CT scan with IV contrast is a useful imaging modality for patients with multiple injuries. Contrast extravasation indicates active hemorrhage and demonstrates pelvic or retroperitoneal hematomas. Most pelvis fracture–related bleeding will tamponade and cease spontaneously; however, severe injuries may require arteriography and embolization to control hemorrhage.
Disruption of the pelvic ring increases the pelvic volume. In the setting of pelvis fracture–related bleeding, patients may benefit from closed reduction to reduce the pelvic volume and tamponade ongoing hemorrhage. This is achieved with external fixation devices, commercially available pelvic binders, or with a sheet tightly wrapped around the pelvis.
Surgical Approach
The initial management of a patient with pelvic injuries should begin with a thorough assessment according to ATLS guidelines. The mechanism of injury and the physiologic state of the patient determine the subsequent course. For hemodynamically stable patients, the initial management is WB restriction and formal orthopedic evaluation.
Hemodynamically unstable patients must be evaluated and managed systematically. Patients in shock must have the source of hemorrhage identified and controlled in the midst of ongoing resuscitation. Adequacy of resuscitation should be monitored simultaneously. Life-threatining injuries should be addressed in order of severity as they are identified.
Although pelvic injuries can be associated with significant hemorrhage, associated injuries are common and must be evaluated. Screening radiographs can rule out intrathoracic or pelvic injuries. If a pelvis fracture is found, external reduction of the pelvic ring is a useful temporizing maneuver to minimize ongoing bleeding. Abdominal ultrasound can expeditiously identify patients that require immediate laparotomy. Evaluation and splinting of long bone injuries minimizes fracture-related bleeding. Lacerations with significant external hemorrhage can be controlled with external pressure or a tourniqet. If the patient can be stabilized, further imaging may be indicated. CT imaging of the brain, spine, and torso is an invaluable tool (particularly in the setting of polytrauma) with the addition of IV contrast to rule out solid organ injury and bleeding.
Signficant pelvic hemorrhage can be difficult or impossible to control, primarily because of anatomic inaccessibility of the injured vessels. Although external reduction combined with either intra- or extraperitoneal packing may be utilized, arteriography with embolization can selectively embolize individual vessels. This method is obviously preferrable to nonselective operative ligation of one or both internal iliac arteries. An aortogram with bilateral iliac runoff, followed by selective angiography of both internal and external iliac systems is the initial approach taken. If contrast extravasation is seen, selective embolization with coils or foam should be performed. Strong consideration should be given to embolizing vessels that have evidence of vessel spasm or an abrupt cutoff since these usually represent signs of injury. This approach is successful in upward of 80% to 90% of patients. It is essential to continue the resuscitation throughout the hemorrhage control process until appropriate endpoints are met to prevent the lethal combination of hypothermia, coagulopathy, and acidosis. Recurrent instability may require reassessment and repeat angiography to assess for rebleeding. Inability to control pelvic hemorrhage by means of external reduction, pelvic packing, angioembolization, or operative ligation is associated with high mortality (Tables 1 and 2).
TABLE 1. Key Technical Steps
TABLE 2. Potential Pitfalls
Special Intraoperative Considerations
Patients with pelvis fractures undergoing laparotomy require special consideration, as the technique utilized may differ from the standard laparotomy for trauma. If an external compression device is present, exposure can be severely limited, and great care must be taken when deciding to remove this device as the patient may hemorrhage from re-expansion of the pelvic volume. If possible, the standard laparotomy incision should be limited to a supraumbilical incision, as extending below the semilunar line may disrupt anterior extension of a pelvic hemtoma, leading to further hemorrhage. Damage control techniques of rapid control of hemorrhage followed by temporizing measures with delayed reconstruction should be considered for patients who are severely physiologically compromised.
Intraoperative control of pelvic bleeding is technically challenging and often ineffective. Ligation of the hypogastric arteries is one technique to control pelvic arterial bleeding, but may be complicated by difficult exposure and distorted anatomy in the face of an extensive retroperitoneal hematoma. Venous pelvic bleeding usually arises from cancellous bone or the sacral venous plexus, is diffuse in nature, and difficult or impossible to control with ligation. This type of pelvic bleeding is best controlled by tamponade. Management of pelvic bleeding during laparotomy is done by tightly packing the pelvis via an intraperitoneal approach in combination with temporary abdominal closure. Postoperatively, the patient may need to be managed with angiography and embolization if there is continued hemorrhage. Once stabilized, the patient can be returned to the operating room for reexploration. At this time, the pelvic packing can be removed, bowel continuity can be restored, and any additional injuries can be addressed. Definitive closure follows traditional principles of damage control laparotomy. At this point, stabilization of the pelvis fracture, either internal or external, may be considered in conjunction with orthopedics.
Open pelvic fractures deserve special consideration. An open pelvis fracture involves direct communication between a fracture fragment and the rectum, vagina, or skin of the perineum or groin. While open pelvis fractures only account for 5% of all pelvis fractures, the mortality of this injury has been estimated at 50% and can acutely result from uncontrolled bleeding from the fracture site because the wound is open to the enviornment and receives no internal tamponade. Initial management should focus on control of acute hemorrhage and wound management. Associated regional injuries are common and may include injuries to the bladder, urethra, vagina, and anorectum, which may increase the risk of infection and the complexity of subsequent reconstruction. Consideration should be given to fecal and urinary diversion to reduce the risk of pelvic sepsis and to facilitate operative repair of the fractures.
Postoperative Management
Postoperative management of pelvic fractures involves a multifaceted approach to patient care. They key elements to consider are WB status, prophylaxis of deep venous thrombosis (DVT), postoperative complications, and long-term follow-up. Postoperative WB status is highly variable, but most unstable pelvis fractures require several weeks of lower-extremity non–weight bearing.
The incidence of DVT in patients with pelvic trauma is reported as high as 60%. Routine DVT prophylaxis is recommended. DVT prophylaxis may be mechanical (ambulation, sequential compression devices) or chemical (e.g., low molecular weight heparin, coumadin).
The most frequent complication after severe pelvis fracture is sciatic or lumbosacral nerve injury (10% to 15% incidence). Nonunions and malunions also occur. Pain and pelvic or limb deformity are the most common complaints from patients. Females may have higher rates of urinary symptoms, cephalopelvic disproportion, and gynecologic pain.
TAKE HOME POINTS
• Classification of pelvis fractures
LC—grade I, II, III
APC—grade I, II, III
Vertical shear
Combined mechanism
• Imaging modalities
X-rays—AP, inlet, outlet, oblique/judet
CT abdomen/pelvis
IV contrast enhanced to evaluate for intra-abdominal injuries
Noncontrast with thin cuts and reconstructed views
• Initial workup should follow ATLS guidelines.
• High rate of concurrent truncal injuries requires full trauma workup and evaluation.
• Indications for angioembolization
Contrast extravasation on CT
Uncontrolled pelvic hemorrhage identified intraoperatively
Recurrent pelvic hemorrhage
• Orthopedic management pearls
Temporary pelvic stabilization for hemodynamically unstable patients
Bed sheet
Pelvic binder
External fixator
Definitive repair by an orthopedic surgeon
Early initiation of DVT prophylaxis
Limitation of weight bearing as necessary
SUGGESTED READINGS
Burgess AR, Eastridge BJ, Young JW. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990;30(7):848–856.
Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma. 1989;29(7):981–1000.
Davis JW, et al. Western trauma association critical decisions in trauma: management of pelvic fracture with hemodynamic instability. J Trauma. 2008;65:1012–1015.
Geerts WH, Code KJ, Jay RM, et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331:1601–1606.
Guillamondegui OD, et al. Pelvis fractures. In: Cameron J, ed. Current Surgical Therapy. 8th ed. Philadelphia, PA: Mosby Elsevier Science, 2004.