HYPOTENSIVE PELVIC FRACTURES

Raj R. Gandhi, MD, PhD, FACS, FCCM Trauma Medical Director, JPS Health System Associate Professor of Surgery University of North Texas Health Science Center Fort Worth, Texas DISCLOSURES

 AAMA Board  GETAC Trauma Systems  NCTTRAC Past Chair  SCCM committees  EAST guideline committee  Texas TQIP Medical Director INTRODUCTION

Background Definition Diagnosis Treatment BACKGROUND

No change in incidence from 2000 to 2009, 8.3% mortality, closed fractures 1/3 of the deaths from bleeding Preventable deaths Usually high energy mechanism Incidence 0.02%, 1-3% of skeletal fx 20-40 years of age and greater than 65 CLASSIFICATION: YOUNG AND BURGESS

•Anterior-posterior compression (APC)

• Lateral compression (LC) •Vertical shear (VS) •Combined mechanisms (CM) •Associated with resuscitation needs APC anteriorly directed force “Open Book” APC  APC-I injury - from low- to moderate-energy forces and < 2 cm widening of the pubic symphysis; the SI joint (SIJ) is ligamentously intact  APC-II injury - higher-energy injuries tearing of anterior SI ligaments, and the sacrotuberous and sacrospinous ligaments, with the posterior SI ligaments remaining intact; the pubic symphysis diastasis greater than 2 cm; fractures are rotationally unstable and associated with neurovascular injuries, soft tissue complications, and hemorrhage  APC-III injury - high-energy injuries; the hemipelvis rotates externally, the posterior sacrospinous ligaments are disrupted, and complete ligamentous dissociation of the involved hemipelvis to the axial skeleton; highest rate of neurovascular complications and blood loss APC LC

LC injuries lateral impact of innominate bone, with internal rotation of the pelvis toward the midline. The sacrotuberous, sacrospinous, and internal iliac vessels are. LC injuries are further classified into three subtype LC

 LC-I injury - The most common, elderly population, transverse fracture of the anterior ring and a cancellous impaction fracture of the sacrum posteriorly; the impaction fracture often goes unidentified; low-energy and stable

 LC-II injury - greater laterally applied force and result in posterior fracture dislocation of the SIJ (crescent fracture [16] ); ligamentous disruption of the inferior portion of the SIJ and a vertical fracture of the posterior ilium that extends from the middle of the SIJ and exits the iliac crest; the posterior superior iliac spine remains attached to the sacrum via the superior portion of the posterior ligamentous complex; the remaining anterior fragment is more mobile to internal rotation but stable to external rotation and vertical forces

 LC-III injury - laterally directed force on one side of the pelvis and is trapped against an immobile object on the contralateral side, the result being a lateral compression injury pattern on the side of the laterally directed force and an external rotation injury on the contralateral side; the ligamentous injury pattern observed on the contralateral side is the same as that in the APC injuries, with disruption of the sacrospinous, sacrotuberous, and anterior SI ligaments; most hemorrhages observed in these fractures occur on the side contralateral to the injury force, where tensile forces are acting VS

VS injury Anteriorly, involves the pubic symphysis, and fractures through the pubic rami. Posteriorly, the force through SIJ, complete disruption joint. VS DIAGNOSIS Plain radiographs CT Pelvis, 3-D reconstruction CT Pelvis with contrast Labs: CBC, Plt, Lytes, LFT, pregnancy test, PT/PTT, TEG, Toxicology screen, T&C EAST GUIDELINES No Level 1 Recommendations Level 2 Recommendations Patients with evidence of unstable fractures of the pelvis associated with hypotension should be considered for some form of external pelvic stabilization. Patients with evidence of unstable pelvic fractures who warrant laparotomy should receive external pelvic stabilization prior to laparotomy incision.

EAST GUIDELINES  Patients with a major pelvic fracture who have signs of on going bleeding after non-pelvic sources of blood loss have been ruled out should be considered for pelvic angiography and possible embolization.  Patients with major pelvic fracture who are found to have bleeding in the pelvis, which cannot be adequately controlled at laparotomy, should be considered for pelvic angiography and possible embolization.  Patients with evidence of arterial extravasation of intravenous contrast in the pelvis by computed tomography should be considered for pelvic angiography and possible embolization.

EAST GUIDELINES Patients with hypotension and gross blood in the abdomen or evidence of intestinal perforation warrant emergent laparotomy. The diagnostic peritoneal tap appears to be the most reliable diagnostic test for this purpose. Urgent laparotomy is warranted for patients who demonstrate signs of continued intra-abdominal bleeding after adequate resuscitation, or evidence of intestinal perforation. TREATMENT

ABCDE’s 1:1:1 resuscitation Unstable VS with open book Pelvic binder Intra-abdominal injury?

TREATMENT

If interventional radiology available then embolization Pre-peritoneal packing External fixation Internal Iliac artery ligation PRE-PERITONEAL PACKING

SUMMARY

Hemodynamically unstable pelvic fractures have a high mortality Mortality can be decreased with control of hemorrhage THANKS

Dr. Carlos Brown and Team My Partners My staff

REFERENCES J Trauma Acute Care Surg. 2014 Feb;76(2):380-5. doi: 10.1097/TA.0b013e3182ab0cde. Medscape, accessed 5/29/2016, Unstable Pelvic Fractures EAST (J Trauma. 2011;71: 1850 – 1868)