Pelvic Fractures


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Pelvic Fractures


G. Yves Laflamme MD FRCS(c)1, Jonah Hébert‐Davies MD FRCS(c),c2 and Dominique M. Rouleau MD MSc FRCS(c)1


1Sacré‐Coeur Hospital, University of Montreal, Montreal, QC, Canada


2Harborview Medical Center, University of Washington, Seattle, WA, USA


Clinical scenario



  • A 37‐year‐old woman is severely injured in a motor vehicle accident and is brought to the Emergency Department with complaints of pelvic pain.
  • She is unresponsive to initial volume resuscitation.
  • On examination, her left and right thighs are swollen and bruised. Blood pressure is 90/60 with tachycardia of 130/min.
  • The neurological exam, the chest x‐ray, and the abdominal ultrasound are negative.

Top three questions



  1. During the initial management of patients with suspected pelvic bleeding, does the application of an invasive external fixator provide superior pelvic hemorrhage control when compared to a noninvasive external pelvic binder (PB)?
  2. For patients with ongoing pelvic bleeding after resuscitation, does giving priority to pre‐peritoneal pelvic packing (PPP), before angioembolization (AE), reduce mortality?
  3. In pelvic fracture patients at high risk of bleeding and pulmonary embolism (PE), is mechanical thromboprophylaxis or even prophylactic inferior vena cava (IVC) filter insertion safer than a chemical strategy?

Question 1: During the initial management of patients with suspected pelvic bleeding, does the application of an invasive external fixator provide superior pelvic hemorrhage control when compared to a noninvasive external pelvic binder (PB)?


Rationale


Temporary stabilization is crucial for the survival of patients with a life‐threatening pelvic ring injury. Until recently, urgent application of external fixation was widely used. Experimental studies have shown that the retroperitoneal compartment is an open space1 and that the tamponade effect of the pelvis is minimal. According to the ATLS (acute trauma life support )guidelines, a PB should be applied before mechanical fixation.


Clinical comment


During the immediate resuscitative period, the trauma team can quickly wrap a simple bedsheet around her pelvis and thighs before the orthopedic surgeon arrives. Blood pressure and heart rate improve dramatically 10 minutes post application.


Available literature and quality of the evidence



  • Level I–II: 0 randomized controlled trials (RCT).
  • Level III: 3 case‐controls.
  • Level III and IV: 2 systematic reviews.

Findings


Two systematic reviews have been published on the effectiveness of circumferential pelvic compression devices for unstable pelvic fractures.2,3 The most recent, published in 2016, found sufficient evidence to suggest that external compression mechanically reduces disrupted pelvic rings. Although the short‐term physiological effectiveness of PB has been shown, the long‐term outcome regarding mortality remains unclear.2 Similar conclusions were reported in the other systematic review that included 17 articles with only one level III study. Authors concluded that, although PB appears to be effective, there was a lack of prospective data.3


A trauma registry analysis by Croce et al. compared external fixators to PB in a cohort of 186 patients and found a lower mortality rate in the PB group but the results were not statistically significant (p = 0.011).4 However, blood transfusions at 24 (4.9 vs 17.1 units) and 48 hours (6 vs 18.6 units) were statistically lower for the PB group than for the external fixation group (p <0.0001). In a retrospective study of 585 patients treated with and without PB upon arrival at a trauma center, Fu et al. reported a significant reduction in transfusion rates (398 ± 417 ml vs 1954 ± 249 ml, p = 0.006) and a shorter intensive care length of stay (6.6 vs 11.8 days, p = 0.02).5 Another retrospective analysis on 118 patients treated with PB upon patient arrival and continued for 24 to 72 hours, compared them with historical controls in the preceding year (n = 119).6 PB had no effect on mortality (23% vs 23%, p = 0.92), need for pelvic AE (11% vs 15%, p = 0.35), or 24‐hour transfusions (5.2 ± 10.0 vs 4.6 ± 9.0 U, p = 0.64).


Resolution of clinical scenario


In the hemodynamic unstable pelvic fracture, evidence suggests (overall quality: low):



  • Emergent stabilization of the pelvis is beneficial.
  • External fixation is not superior to noninvasive stabilization devices. Therefore, we recommend the immediate application of a PB during resuscitation from life‐threatening hypovolemic shock in patients with unstable pelvic injuries.

Question 2: For patients with ongoing pelvic bleeding after resuscitation, does giving priority to pre‐peritoneal pelvic packing (PPP), before angioembolization (AE), reduce mortality?


Rationale


Reducing blood loss is crucial for the survival of patients with a pelvic injury and hemodynamic instability. In conjunction with bone stabilization, there are two possible methods of hemorrhage control: PPP and AE. Guidelines currently provide contradictory recommendations over which treatment should be preferred.


Clinical comment


After temporary hemodynamic stabilization, the patient undergoes a secondary drop in blood pressure to 85/50. Repeated secondary survey does not reveal any other source of bleeding. The general surgeon wants to perform PPP while the orthopedic team would prefer beginning with AE. Following a publication from the American Association for Surgery of Trauma, embolization (10%) is used much more frequently than PPP (5%) to control bleeding in unstable pelvic injuries in the USA,7 whereas PPP is more frequently reported in European literature. The most common complication for PPP is infection in 15% of cases. The unique complications reported for embolization are ischemia of the gluteus muscles and those related to IV contrast.8


Available literature and quality of the evidence



  • Level I–II: 1 RCT
  • Level III: 2 case‐controls.
  • Level IV: 2 retrospective studies of prospective database.

Findings

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Pelvic Fractures

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