Contemporary Management of Pelvic Fractures

The American Journal of Surgery 192 (2006) 211–223 Review Contemporary management of pelvic fractures

Alan Durkin, M.D.a, H. Claude Sagi, D.O.b, Rodney Durham, M.D., F.A.C.S.a, Lewis Flint, M.D., F.A.C.S.a,*

aDepartment of Surgery, University of South Florida, Tampa, FL, USA bOrthopedic Trauma Service, Florida Orthopedic Institute, Tampa, FL, USA

Manuscript received July 12, 2005; revised manuscript May 1, 2006

Abstract Background: Pelvic fractures occur when there is high kinetic energy transfer to the patient such as would be expected in motor vehicle crashes, auto-pedestrian collisions, motorcycle crashes, falls, and crush injuries. High-force impact implies an increased risk for associated injuries to accompany the pelvic fracture, as well as signiﬁcant mortality and morbidity risks. Choosing the optimum course of diagnosis and treatment for these patients can be challenging. The purpose of this review is to supply a contemporary view of the diagnosis and therapy of patients with this important group of injuries. Methods: A comprehensive review of the medical literature, focusing on publications produced in the last 10 years, was undertaken. The principal sources were found in surgical, orthopedic, and radiographic journals. Conclusions: The central challenge for the clinician evaluating and managing a patient with a pelvic fracture is to determine the most immediate threat to life and control this threat. Treatment approaches will vary depending on whether the main threat arises from pelvic fracture hemorrhage, associated injuries, or both simultaneously. Functional outcomes in the long-term depend on the quality of the rigid ﬁxation of the fracture, as well as associated pelvic neural and visceral injuries. © 2006 Excerpta Medica Inc. All rights reserved.

Keywords: Pelvic fracture; Angiography; External ﬁxation; Open-book fracture; Trauma

Pelvic fractures are serious injuries associated with a ligaments. Posteriorly, the sacrum is situated between the diverse assortment of morbidities. Mortality rates for right and left iliac portions of the innominate bones patients sustaining pelvic fractures range from 10% to forming the bilateral sacra-iliac (SI) joints, which are 50% depending, for the most part, on the severity of secured by the dorsal and ventral components of the SI pelvic fracture bleeding and the presence of associated ligaments. Additional ligaments providing structural sup- injuries to the brain, thorax, and abdomen [1– 4]. port for the pelvis and the contained visceral structures are the bilateral sacra-tuberous and sacra-spinous ligaments (Fig. 1). Because of the inherent bony instability of Pertinent Anatomy the pubic symphysis and SI joints, the integrity of the pelvic ring depends completely on the strength of these Three bones combine to form the pelvic ring. The 2 ligaments. Fractures that result in separation of the pubic innominate bones arise from the fusion of the embryonic symphysis and SI joints imply that damage to the sup- pubis, ilium, and ischium to the midline sacrum, which is porting ligaments has occurred. Besides supplying struc- the caudal end of the axial skeleton. The acetabulum, or tural support for the bony pelvis, the ligaments supply a hip socket, is located at the center of the fusion site where stable compartment for the vascular, neural, and visceral the embryonic bones join. structures contained within the pelvis. These critical The pelvic bones unite anteriorly in the midline via the functions of the ligaments explain why ligamentous dis- articulation between the pubic bones and the symphyseal ruption is associated with increased short and long term morbidity [5]. * Corresponding author. PO Box 1289, Suite G-417, Tampa, FL 33601. The iliac arterial and venous trunks pass near the Tel.: ϩ1-813-844-4248; fax: 813-844-7576. ventral aspect of the SI joints bilaterally (Fig. 2). Dis- E-mail address: lﬂ[email protected] ruption of the SI joints and associated ligaments in-

Table 1 Etiologies of pelvic fractures in descending order of frequency Motorcycle crash Vehicle-pedestrian collision Side impact motor vehicle collision Fall Ͼ 15 feet Motor vehicle crash

Epidemiology of Pelvic Fracture

In decreasing order of frequency, pelvic fractures are caused by motorcycle crashes, auto-pedestrian collisions, falls, and motor vehicle crashes [6]. Crush injuries may also cause pelvic fracture (Table 1). As the incidence of high-velocity motor vehicle crashes increases, so does Fig. 1. Pelvic anatomy showing the supporting sacratuberous ligaments. the incidence of pelvic fracture. Side impact with lateral force transfer and vehicle incompatibility (small vehicles impacted by large vehicles) are the main risk factors for creases the risk of vascular injury and resultant hemor- pelvic fracture morbidity and mortality [7–9]. rhage, which usually arises from the anterior and posterior divisions of the internal iliac vessels. We have, however, observed injury to the main trunk of the exter- Pre-hospital Management nal iliac artery in 2 instances due to acetabular fracture with femoral head protrusion into the pelvis. Information gleaned from witnesses at the crash scene The bladder and urethra are located immediately pos- in addition to data from pre-hospital care professionals terior to the pubic symphysis and the rectum lies imme- regarding patient presentation and examination ﬁndings diately ventral to the sacrum. The intimate association of may raise the suspicion for pelvic injury. Uniform pre- these viscera with the pelvic skeleton increases the risk of hospital transport protocols are helpful and improve ef- injury when pelvic fracture occurs. ﬁciency of early injury care and the delivery of the The pubic symphysis is the weakest link in the pelvic patient to the appropriate hospital. Appropriate immobi- ring, supplying only 15% of the inherent pelvic stability. lization, airway protection, and initial circulatory support The SI joints are the strongest in the body, relying pri- with expedient transport are the main goals. Application marily on the posterior SI ligaments to resist vertical and of the pneumatic anti-shock garment (MAST) is an op- anterior-posterior (AP) displacement. Being a ring struction to assist with stabilization of the fracture. However, ture, disruption and displacement in one area implies a this device is associated with inherent complications and second disruption in another part of the ring. many pre-hospital care systems no longer use the MAST.

Initial Assessment

The multiple-injury patient is at risk for thoracic, intra-abdominal, soft tissue, pelvic, and extremity hemorrhage. Once the primary survey is completed, the airway is secured and a search for sources of controllable bleeding begins. Radiographs of the chest and pelvis may assist in localizing a bleeding site. The focused abdominal ultrasound for trauma (FAST) can detect intraperitoneal fluid. A positive FAST in an unstable patient is an indication for exploration of the abdomen [10]. Diagnos- tic peritoneal lavage (DPL) may be helpful where ongoing bleeding is suspected and the FAST is equivocal. In patients with known or suspected pelvic fracture, DPL is done via a supra-umbilical entry point to minimize the Fig. 2. Major pelvic arteries and veins course near the sites of bone and chance for piercing the pelvic hematoma and producing a ligament disruption. false positive result. If the DPL is grossly positive (Ͼ8 A. Durkin et al. / The American Journal of Surgery 192 (2006) 211–223 213 mL of blood aspirated on entry into the peritoneum), Table 3 operative exploration is indicated. Clinical signs that suggest an increased risk of ongoing pelvic The sequence of assessments outlined in the Advanced fracture bleeding Trauma Life Support course (American College of Sur- 1. Pre-hospital hypotension geons, Chicago, IL) is helpful for organizing an approach 2. Admission base deficit Ն 5 3. Persistent tachycardia in face of normal oxygenation and adequate to managing potentially unstable trauma patients. This pain control sequence is not helpful in determining hemodynamic 4. Recurrent hypotension during resuscitation instability for individual patients. Individual hemody- 5. Requirement for Ͼ 6 U blood during first 24 hours namic measurements are snapshots in time and by them- selves are not helpful. Hemodynamic trends are helpful and the time required in the trauma resuscitation area to shear (VS) injury (see classification below). Gonzales et make a decision as to hemodynamic stability is a worth- al [12] documented that clinical examination in conscious while investment. patients who could comply with the physical examination yielded a 90% sensitivity for the diagnosis of pelvic fracture. The addition of the AP pelvic radiograph will Early Detection and Management of permit accurate identification and initial classification of Associated Injuries the fracture type. Other observations may yield valuable insight as to the As a result of the energy required to cause pelvic presence and amount of bleeding from the pelvic frac- fracture, injuries to other areas are commonly encoun- ture. The presence of scrotal/labial hematoma and the tered. The thorax, long bones, brain, abdominal organs, presence of blood at the urethral meatus indicate, indi- and spine are most frequently involved. An early decision rectly, the extent of injury. The presence of blood in the to explore the pleural space or peritoneum when bleeding vaginal vault and/or in the rectal lumen helps to define or intestinal injury is suspected will reduce the risk of the presence of open pelvic fracture, which is associated death or serious complications. Most of the time, this with serious infectious morbidity. The rectal examination decision can be made during the primary survey. More will also disclose the “high riding” prostate, indicative of extensive diagnostic procedures can be postponed until periprostatic and periurethral hematoma associated with bleeding is controlled. pelvic hemorrhage and genitourinary injury. When ongoing bleeding has been controlled or ex- An accurate neurologic examination is often difficult cluded on clinical grounds, the secondary survey focuses to obtain secondary to the patient’s inability to cooperate on identifying the pelvic injuries that may contribute to with the examination. Because the sciatic nerve and the blood loss or complications [11]. Clinical findings that branches of the sacral plexus are subject to injury with are suggestive of pelvic fracture are listed in Table 2. A pelvic fracture, it is important to document neurologic listing of clinical evidence suggestive of pelvic fracture function if possible. Recording the presence of rectal tone bleeding is provided in Table 3. Clinical evaluation of the and the bulbocavernosus reflex is important. Distal motor pelvis can document pelvic instability when AP and lat- and sensory function at the foot and ankle should be as- eral compression on the iliac wings produces pain or sessed where possible. Table 4 lists motor groups and func- rotational instability. A gap in the pubic symphysis may tion tests for the nerves passing through the pelvis to the also be palpable. External rotation and shortening of 1 of lower extremity. the lower extremities is a sign of “open-book” or vertical Patients who arrive hemodynamically stable or who be- come immediately stable with initial fluid infusion may be safely moved to receive further diagnostic studies. The Table 2 Pelvic fracture clinical examination trauma team leader must decide which diagnostic maneu- ver(s) are safest and most appropriate given the clinical 1. Does the patient have pelvic pain? circumstances. 2. Are there neurologic deficits involving sciatic, femoral, or obturator nerves? Computed tomographic (CT) scanning is useful in 3. Are there contusions, ecchymoses, or abrasions at or near the bony gauging the amount of pelvic hemorrhage that has oc- prominences of the pelvis? 4. Are there ecchymoses of the scrotum or perineum? 5. Is there blood at the urethral meatus? Table 4 6. Is there blood in or around the rectum and is the prostate normal? Functions of the nerves supplying the lower extremity that pass in 7. Are there open wounds of the groin, buttock, or perineum? proximity to pelvic fractures 8. Is there a leg length difference or is the resting position of one leg Neural origin of lower extremity motor function different from the other? 9. Is there pain or abnormal pelvic motion on compression of the L1/2: hip flexors anterior iliac spines, lateral compression of the iliac crests, rotation of L3/4: quadriceps/knee extension the lower extremity, or hip flexion-extension? L4/5: ankle and toe dorsiflexion 214 A. Durkin et al. / The American Journal of Surgery 192 (2006) 211–223

Table 5 Tile classiﬁcation of pelvic fractures Type A: Pelvic ring stable a) A1: fractures not involving the ring (i.e. avulsions, iliac wing or crest fractures b) A2: stable minimally displaced fractures of the pelvic ring Type B: Pelvic ring rotationally unstable, vertically stable a) B1: open book b) B2: lateral compression, ipsilateral c) B3: lateral compression, contralateral or bucket handle–type injury Type C: Pelvic ring rotationally and vertically unstable a) C1: unilateral b) C2: bilateral c) C3: associated with acetabular fracture

curred. CT is also helpful in planning the strategy for Fig. 3. Lateral compression pelvic fracture. Pubic rami fractures are often definitive fixation of the fracture(s). The presence of a present with this mechanism. contrast blush seen on CT, strongly suggests, even in stable patients, ongoing bleeding and the need for ther- apeutic angiography. more comprehensive and serves primarily to provide a widely accepted and standardized classification system for data collection and reporting [16]. Classification of Pelvic Fractures Treatment is based on accurate assessment of the resultant injury and instability pattern. It is important to remem- Classification of pelvic fractures and dislocations re- ber 2 points: first, that the posterior pelvic ring injury de- quires adequate plain radiography (AP, inlet, and outlet fines ultimate stability; and second, although in an intact x-rays) and thin-cut (3-mm) CT scanning. If possible, the pelvis the anterior ring (symphysis) supplies only 10% to AP pelvis film is obtained prior to bladder catheterization 15% of the total stability, in an unstable pelvis where there and cystography to avoid obscuring landmarks. The pur- is complete disruption of the posterior ring, stabilization of poses of classifying pelvic fracture are to provide a common the anterior ring contributes significantly to the strength of language to facilitate communication among medical pro- the reconstruction and maintenance of reduction. Possible fessionals caring for the patient and to provide a means for posterior ring injuries are iliac wing fractures, SI disloca- relating clinical findings to prognosis. Several classification tions, and sacral fractures. Possible anterior ring injuries are schemes are currently employed, but all have evolved from rami fractures and symphyseal disruptions. Pelvic injuries the early work performed by Pennal et al [13] and Tile [14] can include any combination of anterior and posterior inju- (Table 5). The most widely utilized classification scheme is ries, unilateral or bilateral. that of Burgess et al [15], which focuses on the mechanism Lateral compression fractures are the most commonly of injury (Table 6). The classification system put forth by encountered. At the time lateral forces are applied, the the Orthopaedic Trauma Association (OTA) and Associa- impacted hemipelvis is pushed into the contralateral tion for the Study of Internal Fixation (AO-ASIF) group is hemipelvis. This usually involves rami fractures anteriorly with a sacral impaction iliac wing fracture. This type of injury is rotationally unstable but usually vertically stable Table 6 (Fig. 3). Young-Burgess classification of pelvic fractures AP compression (APC) injuries result in the commonly Lateral compression (LC): anterior injury-rami fractures termed “open-book” pelvis (Fig. 4). The impact causes a) LC I: sacral fracture on side of impact external rotation of 1 or both hemi-pelves, with the fulcrum b) LC II: crescent fracture on side of impact c) LC III: type I or II injury on side of impact with contralateral or point of rotation being the SI joints. The first point of open-book injury failure is the symphysis pubis. As increasing external rota- Anterior-posterior compression (APC): anterior injury ϭ symphysis tion is applied, the sacrotuberous, sacrospinous, and anterior diastasis/rami fractures SI ligaments fail under tension. Anterior SI ligament dis- a) APC I: minor opening of symphysis and SI joint anteriorly ruption is present when there is more than 2.5 cm of dias- b) APC II: opening of anterior SI, intact posterior SI ligaments c) APC III: complete disruption of SI joint tasis of the symphysis. With further external rotation, the Vertical Shear (VS type) posterior SI ligaments ultimately fail as well. When this Vertical dislplacement of hemipelvis with symphysis diastasis or rami stage is reached, all of the supporting ligaments of the pelvic fractures anteriorly, iliac wing, sacral facture or SI dislocation ring are disrupted in addition to the pelvic floor and perineal posteriorly musculature. Combination (CM type): any combination of above injuries VS injuries are the most unstable and usually encompass A. Durkin et al. / The American Journal of Surgery 192 (2006) 211–223 215

showed with postmortem angiography that pelvic fracture hemorrhage results most frequently from the venous structures and bleeding bone edges. This hemorrhage stops in most patients secondary to tamponade from increasing tissue pressure in the pelvic retroperitoneal space. However, in patients who died of pelvic fracture hemorrhage, single or multiple arterial lacerations were more likely to be present. Arterial bleeding can overcome the tamponade effect of the retroperitoneal tissues, leading to shock; this is the most common cause of death related to the pelvic fracture itself. Arterial bleeding usually arises from branches of the internal iliac system with the superior gluteal and pudendal arteries being the most commonly identified source. As outlined above, bleeding and hemorrhage from pelvic fracture alone is and should be a diagnosis of exclusion. Once resuscitation is underway and a search for thoracic Fig. 4. A variant of the anterior compression fracture, the open-book pelvic and abdominal bleeding has been completed, further anal- fracture, is illustrated, showing a wide pubic symphysis separation and ysis of the fracture pattern can be performed to see if this associated bilateral disruption of the posterior pelvic ring. may be the cause of ongoing blood loss. However, the radiographic representation of the fracture alone is inade- some form of rotational injury as well. In these cases, a quate for determining the risk of ongoing hemorrhage since cranially directed force shears the hemi-pelvis causing se- only the current degree of displacement is visible and not vere skeletal, muscular, and ligamentous disruption. The that which occurred at the time of impact. Metz et al [18] iliac crest of the injured hemi-pelvis is seen to be riding documented an equal number of arterial bleeding sites seen cephalad compared to the contralateral side, often with a on angiography in patients with anterior-posterior compres- fracture of the ipsilateral transverse process of L5 (Fig. 5). sion and lateral compression injury patterns. The take-home Significant urogenital, vascular, and neurological injury message is that severe bleeding can occur in all fracture is accompanied by the APC and VS injuries due to the patterns and the whole clinical picture should dictate clini- stretch and traction placed on these structures as the injuring cal strategy rather than just the radiograph. forces are applied. Supporting this assertion is a report by Miller et al [19] which suggested that patients could be chosen for pelvic angiography based on the recurrence of hypoten- Diagnosis of Pelvic Fracture Bleeding sion within 2 hours of an initially successful resuscitation. They discovered that active arterial bleeding oc- Bleeding secondary to vascular lacerations and bone curred in 73% of patients selected by these means. Details edge bleeding is the most important life-threatening prob- of our preferences and treatment strategies are diagrammed lem due to pelvic fractures. Huittinen and Slatis [17], in a in the accompanying algorithm and discussed in the follow- classic contribution to the field of pelvic fracture care, ing section (see Appendix 1). If pelvic fracture bleeding is suspected, patients get blood transfusions as needed. Four to six units of blood may be given before venous bleeding subsides. CT scans of the pelvis may allow quantification of the volume of blood loss and may disclose a contrast “blush” indicating active arterial bleeding.

Treatment of Pelvic Fracture Hemorrhage—Persistent Controversies

Fortunately, most bleeding from pelvic fracture arises from torn small- and medium-sized veins and edges of fractured bone. These sites will usually stop by natural hemostatic mechanisms if patient cardiovascular function, blood volume, and coagulation status are kept within acceptable limits. We transfuse all patients who do Fig. 5. Vertical shear pelvic fracture. not immediately stabilize after 2000 mL of balanced salt 216 A. Durkin et al. / The American Journal of Surgery 192 (2006) 211–223 solution. If a patient requires transfusion of more than 4 This approach is also supported in a report by Gansslen et al U of blood, support of coagulation with fresh-frozen [25]. plasma infusion is begun. Platelets are given to keep the Potential drawbacks to the use of external fixation are the platelet count above 100,000/␮L. For patients with per- need for expert orthopedic surgery support, which must be sistent bleeding, controversy has continued concerning readily available soon after the patient arrives at the defin- the desirability of efforts to reduce pelvic volume and itive care facility. Specific training is needed for successful stabilize bone edges versus the use of selective angiog- application of external fixation devices. Indeed, there have raphy and embolization or emergent surgical exploration been reports of pelvic visceral injury following application with packing. There is a large body of evidence to sug- of external fixation devices [26,27]. Some surgeons feel gest that closure of symphysis pubis separations with strongly that application in the operating room (rather than reduction of pelvic volume improves the prospect of in the resuscitation area) using sterile technique and image tamponade of pelvic bleeding. Holding bone edges so intensifier control is necessary for safe placement of exter- that motion is minimized is intuitively appealing as a nal fixators. Because of these concerns and the availability means of stopping hemorrhage. The time-honored tenet of other devices for pelvic compression, application of ex- of fracture care— “splint them where they lie”—is an ternal fixators for persistent hemodynamic instability in the example of the long-held conviction that immobilization resuscitation area has not been universally accepted. of fractures controls bleeding around fracture sites and The application of a folded bed sheet anchored ante- improves pain control. riorly by towel clips can reduce pelvic volume and can be Reports of the efficacy of the MAST supported this applied safely and quickly in the emergency room by care- concept for the management of bleeding due to pelvic givers who are not trained orthopedic surgeons. The bed fracture [20,21]. This device served 3 potential functions: sheet is applied in a straight transverse fashion, with the first, it returned blood from the lower extremities to the primary force vector being delivered to the greater trochan- central vascular system; second, it could close, at least ters. Recently, Bottlang et al [28] reported an adjustable fabric device for pelvic compression, which is now com- partially, open-book type injuries; and third, it stabilized mercially available (T-Pod, Bio-cybernetics International, the pelvis. Brotman et al [22] discussed the shortcomings La Verne, CA). and failures of the MAST, particularly the fact that the One potential hazard of applying external compression garment had to be partially or completely removed to devices is overcorrection of the fracture. This is particularly allow access to the abdomen in patients who required true in fractures where the posterior ring is completely abdominal exploration, as well as reports of compartment unstable. Compression of the ilium with overcorrection can syndrome and skin necrosis following use of the device, result in injury to the neurovascular and pelvic visceral hindered acceptance of this approach. structures. Thus, in conscious, responsive patients, careful The adoption of aggressive fracture fixation strategies assessment of neurovascular status is essential prior to and pioneered by European trauma surgeons accelerated in- following the application of any pelvic fixation device in terest in early application of external fixation for control addition to follow-up radiographs. Another complication of of bleeding, and several experienced orthopedic trauma external compression devices such as sheets or pelvic bind- surgeons currently support using early external fixation ers is the development of pressure ulceration and full-thick- as a means of controlling pelvic bleeding. Although some ness skin necrosis and slough. These devices are often assert that external fixation is superior to angiography for employed in critically ill patients who will spend many days control of bleeding, no head-to-head comparison has in the intensive care unit. If the binder is successful at been done. controlling pelvic hemorrhage and is left in place for more Two basic types of external skeletal fixation are currently than 48 hours because of fear of recurrent bleeding, the employed: anterior frames (which are applied percutane- potential for major skin and soft tissue problems is signif- ously to the iliac bones either above the acetabulum or into icant [29]. the iliac crest) and pelvic clamps (which are applied to the For patients who have persistent hemodynamic instabil- posterior iliac fossae at the iliac groove) [23]. Both devices ity despite pelvic compression, appropriate resuscitation, can be positioned so that access to the abdomen is possible. and exclusion of thoracic, abdominal, and extremity hem- Anterior frames function by internally rotating and restoring orrhage, expeditious clinical decisions are necessary. The 2 alignment to an externally rotated pelvis (an open book) but options at this point are angiographic embolization of pre- only if the posterior ring is intact. Pelvic clamps apply an sumed pelvic arterial bleeding versus open exploration and internal vector that translates the hemi-pelvis medially and packing. The lack of readily available experts in angiogra- thus does not rely on an intact posterior ring. Ertel et al [24] phy obviously limits any radiologic approach. Experienced reported use of the c-clamp in patients with severe pelvic trauma surgeons have reported instances of death during bleeding and noted that laparotomy with pelvic packing was angiography in desperately ill patients who were actively occasionally needed when the c-clamp failed to control bleeding. Rather than delay hemostatic efforts in an unstable bleeding. Their overall mortality due to bleeding was 25%. patient when angiography is not immediately available, A. Durkin et al. / The American Journal of Surgery 192 (2006) 211–223 217 laparotomy with pelvic packing prior to angiography is bleeding is best accomplished by a multidisciplinary team preferable. approach with choices as to the strategy for optimizing the The choice of angiography versus external fixation or critical clinical decisions made on the basis of availability of pelvic compression is made based on a careful assessment local resources and clearly agreed upon protocols for man- of the fracture pattern and resources available at each hos- agement. pital and agreement, in advance, as to which specialists will participate in the management of pelvic fracture with hemorrhage. Commitment to immediate availability is critical Diagnosis and Management of Genitourinary Injuries from all specialists involved. If the fracture pattern is not in Patients With Pelvic Fracture amenable to compression, then angiography should be sought. If the fracture pattern is amenable to compression, Injuries to the bladder and urethra are common with then at least a trial of sheet wrapping or pelvic binder is pelvic fractures, with an incidence as high as 15% to 20% indicated. These basic tenets are well outlined in the prac- [36–38]. Because of the significant force required to rupture tice management guidelines promulgated by the Eastern a hollow viscus within the pelvis, mortality can be as high Association for the Surgery of Trauma [30]. 22% to 34% when pelvic fractures are accompanied by a It is occasionally necessary to employ angiographic tech- bladder rupture [39]. Bladder injuries tend to cluster in those niques of hemorrhage control in patients who are actively patients with a lateral compression mechanism, while ure- bleeding from arterial sources and who are hemodynami- thral injury is seen with both anterior compression and cally unstable. In these patients, it is important that all of the lateral compression mechanisms. life support capability present in the operating room is The clinical finding most consistently observed after available for use in the angiography suite. A full comple- bladder injury is gross hematuria, which is present in 95% ment of anesthesia personnel and equipment for monitoring, of patients. The remaining 5% of patients will have micro- and the presence of rapid infusers for the delivery of warmed scopic hematuria. Patients with gross hematuria and pelvic blood, blood products, and fluids, as well as the constant fracture are evaluated carefully for urethral injury or bladder presence of the trauma surgeon, are essential for clinical rupture, as discussed below. The presence of a pelvic frac- success. ture, particularly combined with penile and scrotal ecchy- Trans-femoral angiography offers the opportunity to iden- mosis, should raise suspicion for a bladder and/or urethral tify bleeding points and stop bleeding using selective em- injury. When bladder injury is suspected, contrast cystog- bolization. Concern has been expressed, especially by Hak raphy is performed in stable patients following placement of [31], that many patients who undergo angiography do not a Foley catheter. Stable patients who are to undergo CT have active bleeding sites visualized. With improved patient scanning can have CT cystography as described by Peng selection, as noted below, the number of positive studies has et al [40]. Properly performed CT cystography is equally as progressively increased. In some cases of multiple bilateral accurate as conventional cystography. Extraperitoneal blad- bleeding points, filling of the internal iliac vessels bilater- der injury is treated, usually, with Foley catheter drainage. ally with embolic material has been utilized. Necrosis of Intraperitoneal bladder rupture is treated with exploration pelvic viscera such as the rectum is a risk of bilateral and suture closure. Suprapubic catheterization is not usually internal iliac occlusion. Sexual dysfunction, a feared long- necessary, but when indicated, placement of the catheter term complication of bilateral internal iliac occlusion, has must take into account the potential for contamination of not been regularly observed [32]. There is, apparently, a anterior internal fixation. The suprapubic catheter may pre- small chance of tissue necrosis in patients who have under- vent the use of a suprapubic incision approach for skeletal gone definitive pelvic fixation following angiography via fixation of the pelvic fracture. Where this approach to skel- large “extensile exposure” incisions. So far, these reports etal fixation is contemplated, another option for bladder have been single case experiences. drainage such as endoscopic placement of a transurethral Patients older than 60 years are more likely to have catheter should be considered. arterial bleeding in conjunction with pelvic fracture, and The classic findings of abnormal position of the prostate, increasing mortality risk as age rises has been well docu- inability to void, and blood at the urethral meatus are seen mented [33,34]. The demonstration of bleeding sites is com- in a minority of patients. Lowe et al [41] documented that mon when angiography is used in these patients, perhaps the appearance of these symptoms and signs is a function of due to aging of the vessels and atherosclerosis. Despite the interval between injury and evaluation. Patients seen successful angiography, mortality remains significant in this early after injury are unlikely to manifest clear-cut clinical group at 11% to 15%. Similar findings were reported by evidence of bladder or urethra injury. A high index of Velmahos et al [35], who observed a higher frequency of suspicion is necessary. positive angiograms in patients over 55 years of age. Re- Clinical examination and pelvic x-rays are obtained and, current bleeding after embolization occurred in 6% of their based on these, a decision to attempt bladder catheterization patients after “successful” embolization. is made. When pelvic fracture is present, catheterization It is clear that successful management of pelvic fracture should be attempted by a clinician experienced in passing 218 A. Durkin et al. / The American Journal of Surgery 192 (2006) 211–223

Table 7 lacerations communicating with pelvic fracture sites may be Steps for performing an retrograde urethrogram found along the course of the iliac crest, in the groin, and in 1. Carefully insert bladder catheter the perineum, and should raise the suspicion of rectal or 2. Cease insertion immediately for any resistance to passage or drainage vaginal injury. During the acute evaluation of genitourinary of thick blood or thick bloody urine injury in the patient with a pelvic fracture, a careful digital 3. Withdraw catheter until 4 cm of catheter is in penile urethra 4. Inflate catheter balloon with 3 mL saline rectal is mandatory and a vaginal examination, if the patient 5. Inject 15–20 mL of water-soluble contrast can be comfortably positioned, is highly desirable. Palpable 6. Obtain oblique pelvis x-ray vaginal lacerations indicate open pelvic fracture. Occasion- ally, rectal lacerations can also be palpated but, in the majority, the most consistent finding indicating rectal injury in the patient with pelvic fracture is the finding of blood in catheters in patients with urethral injury. Unless there is the rectal lumen. easy and unobstructed passage of the catheter into the blad- Vaginal speculum examination and proctoscopic exam- der, efforts at passing the catheter are stopped and a contrast ination are postponed until it is safe to place the patient in urethrogram is obtained by inflating the Foley catheter bal- the lithotomy or lateral decubitus position. Speculum and loon in the penile urethra with 2 to 3 mL of saline and sigmoidoscopic examinations, when they may be safely instilling 10 to 15 mL of water-soluble contrast material done, supplement the careful digital vaginal and rectal and obtaining an oblique film of the pelvis. Table 7 lists examination. Pelvic and anal sphincter muscle damage the steps in performing retrograde contrast urethrography may accompany perineal lacerations. Evaluation for fecal (RUG). The grading scale for urethral injury as promulgated continence is not an emergency diagnostic procedure for by the American Association for the Surgery of Trauma is patients with pelvic fracture. Damage to the anal sphinc- shown in Table 8 [42]. ter with a perineal laceration suggests the need for di- Failure to pass contrast into the bladder indicates urethral verting colostomy. Fecal diversion is done selectively disruption. Extravasation of contrast into the surrounding based on the position of the laceration (perineal lacerations soft tissues may be observed. Cephalad displacement of the will usually require diversion and groin lacerations may bladder by the pelvic hematoma with passage of the contrast sometimes require diversion). When fecal soilage of an into the bladder is the finding typical of stretch injury to the open wound is possible, diversion is performed to reduce urethra with continuity maintained. Endoscopic placement the chance of pelvic wound infection. Five patients with of a transurethral bladder drainage catheter is indicated, perineal lacerations in Brenneman’s series did not undergo where possible, to facilitate management and later repair. fecal diversion and all suffered serious infectious compli- When transurethral catheterization of the bladder is not cations. possible, open or ultrasound-guided percutaneous suprapu- Plans for definitive repair of the pelvic fracture need to bic cystography is indicated. be understood before the decision to perform fecal diversion Despite the short length of the urethra in women, is made so that best placement of the ostomy can be assured. anterior compression fractures and VS injuries associated Supraumbilical placement of the ostomy is preferred to with perineal injury cause urethral tears in women. Blood minimize contamination of the incisions used for skeletal around the urethral orifice and lacerations of the vaginal fixation. If colostomy is to be performed, it should be done introitus suggest an elevated risk of this injury. Most ure- within the first 6 to 8 hours following injury to reduce the thral injuries in women are amenable to treatment with incidence of sepsis and death [46]. Foley catheter drainage. Wounds of the perineum, anorectum, and vagina are Open, frequent, and frank communication among the managed using open techniques with repeated dressing specialists providing care for the patient with pelvic fracture changes/irrigations using general anesthesia as necessary. is necessary to make certain that the choices and sequencing of interventions lead to an optimal outcome. Table 8 American Association for the Surgery of Trauma urethral injury severity scale Open Pelvic Fractures Grade Designation Clinical findings Open pelvic fractures occur when there is communica- 1 Contusion Blood at meatus, RUG normal tion between a fracture fragment and the skin or a pelvic 2 Stretch injury Elongation of urethra, no extravasation 3 Partial disruption Extravasation, contrast in bladder visceral cavity. These injuries are observed in 4% to 5% of 4 Complete disruption Extravasation, no contrast in bladder, patients with pelvic fracture [43]. The incidences of pelvic Ͻ2 cm separation infection including soft tissue infection and osteomyelitis, 5 Complete disruption Complete transection, Ͼ2 cm as well as high mortality and long-term disability, are raised separation or extension into vagina or in patients with open pelvic fracture as documented in the prostate reports by Brenneman et al [44] and Raffa et al [45]. Skin RUG ϭ retrograde contrast urethrography. A. Durkin et al. / The American Journal of Surgery 192 (2006) 211–223 219

These wounds are usually allowed to heal by secondary a combined anterior and posterior approach was then ac- intention in order to maintain an open tract to the fracture complished (Fig. 7). Earlier clinical studies have shown no site. Our bias is that maintaining an open tract offers some difference between 2-hole plates and multi-hole plates; protection against infection, but data to support this bias however, newer data suggest that 2-hole plates may have a are not available. Similarly, there is no convincing evidence higher reoperation rate and incidence of pelvic mal-reduc- that antibiotic treatment, either systemically, by topical ap- tion. External fixation approaches may be used for pelvic plication, or by irrigation, lowers pelvic infection rate or fractures, as well as internal fixation approaches. The ad- osteomyelitis. Groin and iliac crest wounds are managed vantages of external fixations are that these can be easily selectively. Some of these are amenable to early closure if applied to pubic rami fractures as well as symphysis dis- contamination and tissue damage are not severe. ruption. Moreover, the devices can be applied in the emergency room, intensive care unit, or operating room. External fixators can be applied when contamination from abdominal Principles of Definitive Fixation of Pelvic Fractures and genitourinary injuries makes internal fixation approaches hazardous. Finally, external fixation devices can The basic tenets of pelvic fracture fixation are: be removed in the clinic or office setting. A disadvantage of external fixation is that there is an external device, which 1. With complete instability of the posterior ring (i.e., interferes with positioning, sitting, and clothing. Pin site the posterior SI ligaments are disrupted), anterior fix- care and infection can be problematic, particularly with ation alone is inadequate. obese patients. Finally, it is more difficult to obtain and 2. With complete instability of the posterior ring and maintain an anatomic reduction of the anterior pelvic ring vertical instability, any posterior fixation should be with external fixation devices. supplemented with some form of anterior stabili- Similarly, there are advantages and disadvantages to zation. internal fixation. The advantages include the absence of 3. With partial instability of the pelvic ring (i.e., the interference with positioning, sitting, or with clothing posterior SI ligaments are intact), anterior fixation and that there are no attendant problems of pin site care. alone is adequate and full weight-bearing may be One disadvantage is that internal fixation cannot be em- permitted. ployed when there is contamination of the operative field. An additional disadvantage is that formal reoperation is necessary if the fixation hardware must be removed. Disruptions of the Pubic Symphysis Finally, internal fixation potentially limits pelvic relax- ation in women during childbirth. The options for stabilizing symphyseal disruptions in- Fixation options are essentially the same for pubic clude anterior external fixators or internal fixation with ramus fractures as for pubic symphysis diastasis. How- plate and screws. Available data from biomechanical ever, internal fixation with plating does not carry the studies have shown that there is no significant difference same long-term obstetrical or hardware failure sequelae. between external or internal fixation of the pelvis for con- Retrograde medullary ramus screws represent a novel trolling the symphysis [47,48]. In addition, there is signifi- technique that allows percutaneous application of inter- cant improvement in pelvic stability when posterior fixation nal fixation of the ramus fracture; however, a closed is augmented with some form of anterior fixation in VS percutaneous reduction must be possible. injury patterns [49]. Fig. 6 shows the CT image of an open-book pelvic fracture complicated by ongoing bleeding, which was controlled angiographically. Fixation using Fixation of Posterior Pelvic Fractures

Iliac wing fractures can be fixed with the patient prone via a posterior approach with an incision along the crest and elevation of the gluteal musculature from the outer table of the ilium, or supine via an anterior approach with the lateral window of the ilioinguinal or Smith-Peterson exposures of the inner table. Depending on the fracture pattern and the patient’s condition and/or associated injuries, one approach may offer advantages over the other. As a general rule, the anterior approach is better tolerated by the patient and associated with less blood loss. How- ever, if the iliac wing fracture is very posterior (Fig. 8), Fig. 6. CT image of an open-book fracture shows disruption of iliac wing then exposure of both sides of the fracture and applica- at the SI joint. tion of fixation may be difficult. 220 A. Durkin et al. / The American Journal of Surgery 192 (2006) 211–223

Fig. 7. Open-book fracture is shown post ﬁxation using combined anterior and posterior approaches.

Fig. 9. The iliac wing fracture is pictured after fixation. Usually, a single pelvic reconstruction plate or lag screw along the crest supplemented with a second reconstruction plate or lag screw at the level of the pelvic brim acetabular procedures are performed. The disadvantages or sciatic buttress will suffice in neutralizing deforming include the fact that the procedure requires dissection and forces until healing has occurred (Fig. 9). placement of fixation onto the sacral ala, which places the The SI joint can be approached from either anterior or L5 nerve root at risk. Trans-iliac bars or plates are associ- posterior as described above, but it is often easier to ated with two disadvantages; one is that the fixation hard- reduce the SI joint and apply reduction clamps from ware crosses the normal contra-lateral SI joint. In addition, posterior. Attention must be paid to closing the anterior on thin patents, fixation can be prominent and bothersome, aspect of the SI joint, which can be difficult from the occasionally causing skin breakdown. posterior approach. Fixation options include iliosacral A particularly difficult fracture pattern is the crescent screws, anterior SI plating, and posterior trans-iliac plat- fracture associated with posterior SI joint and ligament ing or compression rods; however, biomechanical studies disruption. This injury involves a fracture of the iliac have not shown any significant differences among these wing posteriorly that starts at the crest and exits into the techniques [50 –53]. SI joint. A variable-sized fragment of posterior crest The main disadvantage to iliosacral screw fixation is containing the posterior superior iliac spine remains at- that experienced surgeons and excellent intraoperative tached to the sacral ala via the posterior SI ligaments. fluoroscopic quality with clear imaging are essential to This constant fragment can be used as an aid to reduction success [54 –56]. as it is located anatomically. Standard fixation involves a Anterior plating to achieve fixation of pelvic fractures is superiorly placed reconstruction plate along the crest particularly useful if additional ipsilateral anterior pelvic/ with supplemental lag screws from the posterior inferior iliac spine into the sciatic buttress just above the greater notch. As the constant fragment becomes smaller, this injury approaches an SI dislocation, and consideration must be given to supplemental SI screws or plates. The topic of sacral fractures encompasses a whole discussion. Suffice it to say that these injuries, depending on fracture pattern, can be regarded as pelvic ring injuries or spinal injures. In addition, sacral fractures often involve some form of neurologic deficit, either unilateral peripheral nerve root (as in the case of VS injuries) or cauda equina lesions (as in the case of transverse fractures that involve the central spinal canal). Occasionally, the L5/S1 joint is disrupted and the stability of the lumbosacral junction is compromised. All of these issues Fig. 8. Plain radiograph of the pelvis shows an iliac wing fracture. need to be taken into consideration when treating sacral A. Durkin et al. / The American Journal of Surgery 192 (2006) 211–223 221

bilization of the pelvic fracture and mobilization of the patient, as well as numerous reports citing improved outcome with anatomic reduction of the posterior ring, continued to provide the impetus to develop more rigid and stable posterior fixation constructs [63,64]. Supplemental fixation of the anterior aspect of the pelvic ring has been shown to provide further biomechanical stability in the case of the vertically unstable hemi-pelvis. Whether this is in the form of an external fixator or symphyseal plate seems to be of little signifi- cance; however, more orthopedic trauma surgeons are moving toward routine use of symphyseal plates that can be placed at the time of exploratory laparotomy, and do not give rise to the attendant pin-site complications seen Fig. 10. CT image shows a sacral fracture that was associated with severe with external fixators. nerve damage. Early outcome studies support the position that the long- term functional results are improved if reduction with less than 1 cm of combined displacement of the posterior ring is fractures. Fig. 10 illustrates a CT image of a sacral obtained, especially with pure dislocations of the SI com- fracture causing both neural and skeletal damage. plex. Fractures of the posterior ring tend to do better, pre- Fixation largely depends on what is disrupted, i.e. the sumably because bone healing can restore initial strength pelvic ring, the lumbosacral junction, or both. Some and stability, SI dislocations rely purely on ligamentous sacral fractures that arise from lateral compression inju- healing and scar formation, and these patients tend to fair ries result in impaction of the ala and may be inherently worse in terms of short- and long-term problems with pain stable, not requiring any fixation. Other fractures that are unstable will incorporate some form of posterior fixation and ambulation when compared to patients with other frac- as outlined above. ture patterns. However, despite seemingly anatomic (or near anatomic) reductions, more recent clinical outcome studies have shown that with modern fixation techniques, a substantial Clinical Outcomes of Pelvic Fracture Fixation proportion of patients continue to have poor outcomes with chronic posterior pelvic pain [65,66]. This is likely related Stabilization of unstable pelvic injuries has only recently evolved to include early internal fixation and res- to multiple confounding factors: toration of anatomic relations. Prior to the 1980s, very 1. Trauma patients often have a borderline socioeco- little was understood regarding the biomechanics and nomic status with poor social and financial support contributions to stability of the various pelvic bony and groups. ligamentous structures. As recently as the 1970s, many 2. Extensive soft tissue damage and associated long- pelvic ring disruptions were treated with nonoperative bone and extremity fractures. techniques; generally skeletal traction and pelvic slings 3. Associated neurologic, visceral, and urogenital inju- to prevent excessive cephalad migration of the hemi- ries with dyspareunia, sexual dysfunction, and incon- pelvis. However, many clinicians have documented the tinence prolong recovery and rehabilitation time with high incidence of poor functional outcome and chronic loss of job, home, and family relationships. pain in patients with vertically unstable pelvic fractures treated nonoperatively [57– 60]. The results of these and Outcome studies after fixation of pelvic injuries are dif- other studies provided the impetus to pursue operative ficult to interpret because of poor follow-up, heterogeneity means to achieve and maintain anatomic reduction. of the injury pattern, associated visceral and neurologic Operative stabilization began with anteriorly placed injury, and the lack of a reliable outcome measure for pelvic external fixators alone, which were found to be nearly ring injuries. Debate continues regarding the definition of totally ineffective at controlling vertical and posterior adequate reduction of the pelvic ring and how mal-reduction displacement of the posterior aspect of the ring. Clinical affects functional outcome, if at all. Recent clinical outcome outcome studies with the use of external fixators subse- studies have shown that with current fixation techniques, a quently found that results were not improved over non- substantial proportion of patients continue to have poor operative management and, in fact, traction and pelvic outcomes with chronic posterior pelvic pain despite seem- sling alone may have been more successful at treating ingly anatomic reductions and healing, with less than 50% this unstable injury [61,62]. returning to previous level of function and work status Improved short-term patient outcome with early sta- [67,68]. 222 A. Durkin et al. / The American Journal of Surgery 192 (2006) 211–223

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