1.11 Open pelvic fracture
1 Introduction
Open pelvic ring fractures are rare, accounting for only 2–4% of pelvic fractures [1]. These fractures are potentially devastating, often involving injury to nerves, vascular structures, and hollow viscera. Historically high mortality rates of up to 50% have been associated with these fractures, and although some improvements have been demonstrated in more recent studies, high mortality rates averaging approximately 18% are still reported [1]. Modern techniques of wound care and fracture fixation as well as abdominal and urological surgery are aimed at improving these outcomes.
The surgeon has three goals when treating patients with open pelvic fractures: limit ongoing hemorrhage, manage wounds to decrease the risk of infection, and stabilize the pelvis to promote fracture healing, mobilization, and long-term function.
2 Classification
The bone injury associated with open pelvic fractures is classified the same way as closed pelvic ring injuries, as described in Chapter 1.3, section 1. The AO/OTA Fracture and Dislocation Classification/Tile classification (fracture types A, B, and C) [2] and the Young-Burgess classification (anteroposterior compression [APC], lateral compression [LC], vertical shear, and combined mechanical instability) [3, 4] are both widely used and helpful in managing open pelvic fractures. Differentiating iliac wing fractures that do not disrupt the pelvic ring from pelvic ring fractures is useful because iliac wing fractures are likely to have better outcomes.
Identifying patients at risk for acute life-threatening hemorrhage is particularly important with open pelvic ring injuries. As with all pelvic ring fractures, pelvic bleeding can originate from several sources, including venous bleeding, arterial hemorrhage, and bone surfaces. In open fractures bleeding also may originate from the open lacerations themselves, which likely increases hemorrhage risk by negating the tamponade effect of a closed soft-tissue envelope around and expanding hematoma in a closed fracture [5]. The Young-Burgess classification [3, 4] can be used for both open and closed fractures and provides guidance in identifying which injuries are at risk for substantial hemorrhage [4]. Recent work [6] has validated this classification for predicting transfusion requirements in the first 24 hours.
Young-Burgess APC fracture types II and III (AO/OTA types B1 and C) and LC type III injuries (AO/OTA type B3) are at particularly high risk for hemorrhage [4, 6, 7]. Surgeons must locate the anatomical area responsible for hemorrhage, and the open pelvis is just one of several candidates. Unstable pelvic ring injuries (APC types II and III, [AO/OTA types B1 and C] and LC types II and III [AO/OTA types B3 and C]) are associated with higher rates of hemorrhage and suggest the pelvis as a more likely source of bleeding [8]; however, significant clinical judgment is still needed because patients with these injuries have complex clinical presentations, often with many injuries that have potential to account for hemorrhage and hemodynamic instability.
Not only should the pelvic fracture be classified but also the open wound should be classified because the location and severity of the wound typically are crucial in planning management. Many surgeons use the Gustilo-Anderson classification, even though it was not originally described for pelvic ring injuries [9]. Due to the high-energy mechanism of this injury, most open wounds associated with pelvic fractures are classified as type III [1, 10].
Faringer et al [11] described a wound classification specific to open pelvic fractures that divides the wound into three zones based on location. Zone I consists of the perineum, anterior pubis, median buttocks, and posterior sacrum. Zone II consists of the thigh or groin crease. Zone III consists of the iliac crest and more lateral buttocks. Zone I injuries are thought to be particularly problematic with regard to both diagnosis and management. Although this classification has not gained widespread clinical use, identifying the location and amount of wound contamination is clearly important in managing these patients.
Although most open pelvic fracture wounds are obvious, some are not. Accurate diagnosis and classification of wounds include logrolling the patient to examine the sacrum and posterior buttocks, abducting the hips to examine the groin crease and perineum, and then examining the vagina and rectum ( Fig 1.11-1 , Fig 1.11-2 ). Likewise, any laceration around the pelvis should be thoroughly assessed. A laceration about a high-energy pelvic ring injury should be considered an open fracture that tracks to bone.
Vaginal or rectal bleeding associated with a pelvic fracture typically requires further assessment to rule out open pelvic fracture. Digital vaginal examination is performed followed by speculum examination if an injury is suspected based on bleeding from the vaginal vault or if wounds are found on digital examination. Consultation with an obstetrics/gynecological specialist may be required. Similarly important is a digital rectal examination, followed by examination by a general surgeon using rigid sigmoidoscopy if rectal injury is suspected. Pelvic ring injuries that are open into the vagina or rectum may be missed; thus, vigilance is required to avoid this possibility. Computed tomographic (CT) scans should be carefully evaluated to look for air in the soft tissues around the pelvis as indication of an occult open fracture.
3 Initial management
Initial management of open pelvic fractures should follow the principles of open fracture management to limit the risk of infection, specifically prompt initiation of intravenous antibiotics, aggressive resuscitation in an attempt to limit hypoperfusion to tissues [12–14], and debridement of open wounds once the patient is stabilized and adequately resuscitated. Open pelvic wounds should be debrided at the earliest opportunity but not before acute resuscitation efforts and identification and diagnosis of potentially life-threatening injuries.
Initial management of open pelvic fractures also should follow the principles for acute management of pelvic ring injuries in the polytrauma patient, as described in Chapter 1.4, section 1, and include aggressive resuscitation and identification of sources of bleeding. Open pelvic ring injuries are commonly associated with hemodynamic instability, and use of emergency closed reduction using a pelvic binder or sheet along with skeletal traction is common [15, 16]. This simple intervention can dramatically improve hemodynamic stability. X-rays can be obtained after the binder is applied to verify adequate fracture reduction, as would be done for a closed fracture. The typical algorithm for hemodynamic instability and pelvic fracture should be followed similar to that for a closed injury [14].
In addition to the typical acute management of pelvic ring disruptions, large pelvic wounds should be emergently and aggressively packed in an effort to tamponade bleeding in open pelvic fractures to help prevent or treat hemorrhagic shock. Massive wounds should not be allowed to hemorrhage without an immediate attempt at packing the wound to limit bleeding ( Fig 1.11-3 , Fig 1.11-4 ). A large amount of packing can be required, and ten or more sterile laparotomy pads can be easily packed into a large pelvic wound. Although use of pelvic packing in patients with closed pelvic ring injuries and hemodynamic instability is controversial [17], packing of open wounds in the emergency department for patients with open traumatic pelvic wounds is not controversial and should be a high priority.
4 Preoperative planning
Preoperative planning for open pelvic ring injuries may differ from that for closed injuries based on the location and nature of the traumatic wound. A small anterior wound with minimal contamination might be treated similarly to a closed injury; however, a massive, contaminated anterior wound ( Fig 1.11-5 ) may require a completely different surgical approach; plate fixation may be abandoned for external fixation in an attempt to limit exposure of the metal implants to a potentially highly contaminated open wound.
Management of open pelvic injuries also often requires close collaboration with specialists from general surgery and urology because of the high rate of intraabdominal injuries in these patients. Ideally, the location and need for any potential laparotomy incisions, colostomy placement, or suprapubic tubes can be determined in a collaborative decision-making process involving all operative services with the goal of minimizing the risk of surgical-site infection associated with incisions for orthopedic surgery.
5 Surgical techniques
Traumatic wounds associated with open pelvic fractures vary from small clean wounds to massive contaminated wounds ( Fig 1.11-5 ). Given the amount of energy and typical mechanism needed to create an open pelvic wound, larger wounds are fairly common. Situations in which patients have massive contaminated wounds cause a substantial shift from typical surgical treatment algorithms used for closed fractures.
These large wounds tend to evolve over days to weeks. Tissue that appears initially viable will not remain so, thus necessitating multiple debridement procedures to obtain a viable soft-tissue bed. A further complication is that open injuries may require debridement of structures that orthopedic trauma surgeons do not frequently operate on, including the bladder, vagina, penis, scrotum, and rectum. Close collaboration with general surgery, urology, and obstetrics/gynecology may be needed to obtain optimal results. Thus, it may be advantageous to have multiple different surgical services collaborate on the debridement.
Debridement occurs at a pace dictated by wound status and the patient′s overall physiology. Massive and severely contaminated wounds initially may be debrided daily if the patient can tolerate the physiological insult. Debridement typically is done every 48 hours until a viable soft-tissue envelope is obtained.
Some open pelvic fracture wounds can be closed primarily but many cannot ( Fig 1.11-5 ). Local or free soft-tissue coverage is difficult in these patients, and large wounds often can be managed with negative-pressure wound therapy. Negative-pressure wound therapy is first placed in the operating room and eventually in the hospital unit at intervals from 3–5 days. Once the wound bed has filled in with granulation tissue, it is skin-grafted.
5.1 Access
5.1.1 Approach
Definitive surgical technique differs from that of similar bone injury in a closed pelvic ring injury based on the nature and location of the wound. Small wounds may have no effect on technique, whereas massive wounds may completely change the type of fixation and strategy of the approach. For patients with massive and/or contaminated wounds, open pelvic fracture fixation ideally is accomplished through an approach that does not involve the wound itself to avoid contamination and bacterial colonization of metallic fracture fixation implants; however, this is not always possible. Traumatic wounds do not necessarily align with typical surgical wounds, which may require use of a typical approach to avoid small skin bridges.
5.1.2 Open iliac wing fractures
Open iliac wing fractures typically are approached through the open fracture wound for debridement, with the wound extended along the course of the iliac crest for reduction and fixation, if needed. The lateral window of the ilioinguinal approach typically provides excellent exposure to the inner table of the iliac wing and is adequate for treating most iliac wing fractures [18]. Trauma wounds may strip the musculature from the outer aspect of the ilium; this interval may be used for reduction and fixation if already created by the injury. If the wound is severely contaminated or if the surgeon wishes to limit the overall metallic fixation burden in the wound in an attempt to reduce risk of subsequent surgical site infection, percutaneous methods of fixation may be more appropriate. Some argued against primary closure for these wounds [19]. Closed iliac fractures are commonly treated nonoperatively at many centers, so the surgeon should keep in mind the possibility of debridement without fixation of the wound as disruption of the iliac wing alone does not typically disrupt pelvic stability.
Related posts:
1.15.2 Insufficiency fractures of the pelvis: operative management
1.13 Urological injuries in pelvic ring trauma: assessment and management in male patients
1.15.1 Insufficiency fractures of the pelvis: metabolic and nonoperative workup
1.12 Pelvic ring disruption in women: genitourinary and obstetrical implications
1.10 Lumbosacral instability and stabilization
1.14 Injury to the pelvis in pediatric patients: the immature skeleton
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