HEMIPELVECTOMY FOR TRAUMA: CASE REPORT Robert J. Smith, MD Memphis, Tennessee
This report documents a patient with an open pelvic fracture with gross contamination and partial avulsion of soft tissues with transection of femoral artery and vein, femoral nerve, and a stretch injury to the sciatic nerve. Initially, an attempt was made to treat with above-knee amputation, but due to massive soft tissue loss, this was not feasible. A left hemipelvectomy was done with closure of the wound. The patient required 14 units of blood. He was discharged and is now ambulatory with a prosthesis. Key words * hemipelvectomy * open pelvic fracture* control of vessels * debridement with pulsator Trauma is the leading cause of death in people under the age of 38 in the United States; motor vehicle accidents account for the majority of these deaths. With the recent establishment of good emergency medical services, many patients now arrive at the emergency room who previously died at the scene of the accident. Presented at the 93rd Annual Convention and Scientific Assembly of the National Medical Association; July 30-August 4, 1988; Los Angeles, Calif. Requests for reprints should be addressed to Dr Robert J. Smith, 1067 E Raines Rd, Memphis, TN 30116. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
Patients with transection of major vessels, open pelvic fractures, and open chest injuries occasionally arrive at the emergency room; some of these patients can be saved. The pelvis forms a bony basket to protect the viscera. The major function of the pelvis, in addition to protection, is support of the spine in sitting and erect positions. The lines of forces of weight bearing form two arches-the femorosacral arch and the tie arch (pubic arches) anteriorly. When a fracture occurs at one place in the bony ring, there is an accompanying break in another part of the ring.' Pelvic bone fractures are an important contributing factor to the death of patients treated for high-velocity deceleration injuries. The primary problems in caring for patients with pelvic fractures include: * life-threatening associated injuries, * large open wounds communicating with the pelvic fracture, * hemorrhaging, and * associated rectal and urinary tract damage. At St Louis University, Naam et a12 reported 102 patients with major pelvic fractures. Thirteen had open fractures of the pelvis. Five patients died for a mortality rate of 38%. Four of the deaths were caused by sepsis. Helling3 reported 75 patients with significant trauma leading to pelvic fractures. Fifty-eight (77%) suffered additional injuries, including other fractures, chest and 265
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HEMIPELVECTOMY
.s..
I
I
Figure 1. X-ray of pelvis after control of vessels. Note gravel and debris in wounds.
Figure 2. Open comminuted fractures of left leg. abdominal injuries, and soft tissue injuries. Richardson et a14 reported 37 patients with open pelvic fractures, with only one death. They listed the critical elements of management of these fractures as follows: * control of hemorrhage, * debridement of soft tissue injury and amputation, if 266
Figure 3. Artist's sketch of amputated specimen.
needed, * recognition and treatment of associated injuries of the genitourinary system, and * dressing wounds in the operating room. In this series, two patients had emergency hemipelvectomies. The average amount of blood used was 15 units during the first week, ranging as high as 66 units in the first 48 hours. Lipkowitz and colleagues5 reported a case of traumatic hemipelvectomy in a 7-year-old child and reviewed the literature. They emphasized the necessity to fully evaluate the injury and consider the potential for a viable, functional, extremity versus a large septic wound that may require later revision and amputation. The patient presented with an open pelvic fracture with wide separation of the pubic symphysis and sacrum, extensive disruption of soft tissues in the inguinal area, and avulsion of the external iliac vessels and the sciatic nerve. The patient was rehabilitated with a prosthesis and was able to ride a bicycle 6 months after the injury. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
HEMIPELVECTOMY
///i Figure 5. Illustration showing posterior extent of wound.
Figure 4. Illustration showing anterior extent of open pelvic fracture.
CASE REPORT On November 25, 1986, a 26-year-old man was riding a motorcycle and was struck by a tractor trailer truck. He was reportedly thrown 30 feet through grass, dirt, and gravel. En route to the hospital, the attending surgeon kept hand pressure on the left groin. The patient received 5000 cc of fluid and 1 unit of type-specific blood. Upon arrival, it was decided the patient would be resuscitated in the operating room. His initial hemoglobin was 6 g, and his hematocrit was 18%. In the OR, two large bore lines were inserted and general endotracheal anesthesia was initiated. A large open partially avulsed wound was present, beginning 4 cm anterior to the anus and extending laterally superior from the anterior iliac spine to the lateral lumbar area. All soft tissues and muscles for approximately 12 inches were exposed and bulging out of the wound. The femoral artery, vein, and nerve were completely transected. Previous examination in the emergency room revealed that the patient had no sensation or movement in the left lower extremity. The left femoral artery and vein were located and controlled with vascular clamps. At this point, the anesthesiologist was allowed to catch up his resuscitation until the patient had a blood pressure of 90 mm Hg. Radiographs were taken on the table (Figure 1). The femur was fractured in two areas, with one JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
portion protruding from the wound. The tibia and fibula also showed markedly comminuted fractures. Radiograph of the pelvis showed separation of the symphysis pubis and a fracture of the left ilium extending into the acetabulum and dislocation of the left hip (Figure 2). The wound was contaminated with grass, dirt, gravel, and stool. The patient had an indwelling catheter that was draining light yellow urine. It was decided that an above-knee amputation was mandatory. The femur was transected about three inches from the acetabulum, and the remainder of the posterior thigh muscles were amputated. Hemostasis was achieved. The wound was then irrigated with 3000 cc of saline containing triple antibiotic solution. The pulsator was used, and all dirt, gravel, and contaminated tissue was cleaned and debrided. At this point, it was noted that the wound would not close. The femur was then disarticulated from the acetabulum, and the ilium was grasped with bone-holding forceps and removed subperiosteally (Figures 3, 4, and 5). At this point, all drapes, instruments, and gowns were changed. The wound was again irrigated and hemostasis secured. The lateral flaps containing iliotibial tract and skin were loosely approximated using no. 2 Mersilene sutures with bolsters. A large hemovac suction drain was inserted and a bulky dressing applied. The patient received 14 units of blood on the table and remained in critical condition at the end of the procedure. Three hours after surgery, the patient had evidence of bleeding from the wound and was taken back to surgery. The wound was reexplored, the clot removed, and the skin was closed again. At this point, the patient had received 8 units of platelets, which aided in clotting. Over the next week, he developed acute respiratory distress 267
HEMIPELVECTOMY
He was followed over the next few months, referred to a prosthetic shop, and is now ambulatory with a prosthesis (Figure 6). Acknowledgments The author thanks Drs Fred Myers, William Jekot, and Scott Caudle for help in the surgical management of this case, and Dorothy J. Smith and Terry M. Benford for editorial and manuscript assistance; and Joseph Martin, photographer, Methodist Hospital, for his help.
Figure 6. Perineal wound healing per primam at 6 weeks.
syndrome, but responded to treatment. By March 9, 1987, the patient was transferred from the intensive care unit to a surgery floor. His wound continued to heal without any sign of infection. He was discharged on March 20, 1987, to return to the office.
268
Literature Cited 1. Tile MD. Pelvic fractures: operative versus non-operative treatment. Orthop Clin North Am. 1980; 1:425-465. 2. Naam NH, Brown WH, Hurd R, Burdge E, Kaminski D. Major pelvic fractures. Arch Surg. 1983;1 18:611-686. 3. Helling T. Complication of pelvic fractures in the victims of major trauma. Mo Med. 1983;80:683-686. 4. Richardson JD, Harty J, Amin M. Open pelvic fractures. J Trauma. 1982;22:533-538. 5. Lipkowitz G, Phillips T, Coren C, Spero C, Glassberg K, Velcek FT. Hemipelvectomy: a lifesaving operation in severe open pelvic injury in childhood. J Trauma. 1983;25:823-827.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
This report documents a patient with an open pelvic fracture with gross contamination and partial avulsion of soft tissues with transection of femoral artery and vein, femoral nerve, and a stretch injury to the sciatic nerve. Initially, an attempt was made to treat with above-knee amputation, but due to massive soft tissue loss, this was not feasible. A left hemipelvectomy was done with closure of the wound. The patient required 14 units of blood. He was discharged and is now ambulatory with a prosthesis. Key words * hemipelvectomy * open pelvic fracture* control of vessels * debridement with pulsator Trauma is the leading cause of death in people under the age of 38 in the United States; motor vehicle accidents account for the majority of these deaths. With the recent establishment of good emergency medical services, many patients now arrive at the emergency room who previously died at the scene of the accident. Presented at the 93rd Annual Convention and Scientific Assembly of the National Medical Association; July 30-August 4, 1988; Los Angeles, Calif. Requests for reprints should be addressed to Dr Robert J. Smith, 1067 E Raines Rd, Memphis, TN 30116. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
Patients with transection of major vessels, open pelvic fractures, and open chest injuries occasionally arrive at the emergency room; some of these patients can be saved. The pelvis forms a bony basket to protect the viscera. The major function of the pelvis, in addition to protection, is support of the spine in sitting and erect positions. The lines of forces of weight bearing form two arches-the femorosacral arch and the tie arch (pubic arches) anteriorly. When a fracture occurs at one place in the bony ring, there is an accompanying break in another part of the ring.' Pelvic bone fractures are an important contributing factor to the death of patients treated for high-velocity deceleration injuries. The primary problems in caring for patients with pelvic fractures include: * life-threatening associated injuries, * large open wounds communicating with the pelvic fracture, * hemorrhaging, and * associated rectal and urinary tract damage. At St Louis University, Naam et a12 reported 102 patients with major pelvic fractures. Thirteen had open fractures of the pelvis. Five patients died for a mortality rate of 38%. Four of the deaths were caused by sepsis. Helling3 reported 75 patients with significant trauma leading to pelvic fractures. Fifty-eight (77%) suffered additional injuries, including other fractures, chest and 265
i_:~.
HEMIPELVECTOMY
.s..
I
I
Figure 1. X-ray of pelvis after control of vessels. Note gravel and debris in wounds.
Figure 2. Open comminuted fractures of left leg. abdominal injuries, and soft tissue injuries. Richardson et a14 reported 37 patients with open pelvic fractures, with only one death. They listed the critical elements of management of these fractures as follows: * control of hemorrhage, * debridement of soft tissue injury and amputation, if 266
Figure 3. Artist's sketch of amputated specimen.
needed, * recognition and treatment of associated injuries of the genitourinary system, and * dressing wounds in the operating room. In this series, two patients had emergency hemipelvectomies. The average amount of blood used was 15 units during the first week, ranging as high as 66 units in the first 48 hours. Lipkowitz and colleagues5 reported a case of traumatic hemipelvectomy in a 7-year-old child and reviewed the literature. They emphasized the necessity to fully evaluate the injury and consider the potential for a viable, functional, extremity versus a large septic wound that may require later revision and amputation. The patient presented with an open pelvic fracture with wide separation of the pubic symphysis and sacrum, extensive disruption of soft tissues in the inguinal area, and avulsion of the external iliac vessels and the sciatic nerve. The patient was rehabilitated with a prosthesis and was able to ride a bicycle 6 months after the injury. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
HEMIPELVECTOMY
///i Figure 5. Illustration showing posterior extent of wound.
Figure 4. Illustration showing anterior extent of open pelvic fracture.
CASE REPORT On November 25, 1986, a 26-year-old man was riding a motorcycle and was struck by a tractor trailer truck. He was reportedly thrown 30 feet through grass, dirt, and gravel. En route to the hospital, the attending surgeon kept hand pressure on the left groin. The patient received 5000 cc of fluid and 1 unit of type-specific blood. Upon arrival, it was decided the patient would be resuscitated in the operating room. His initial hemoglobin was 6 g, and his hematocrit was 18%. In the OR, two large bore lines were inserted and general endotracheal anesthesia was initiated. A large open partially avulsed wound was present, beginning 4 cm anterior to the anus and extending laterally superior from the anterior iliac spine to the lateral lumbar area. All soft tissues and muscles for approximately 12 inches were exposed and bulging out of the wound. The femoral artery, vein, and nerve were completely transected. Previous examination in the emergency room revealed that the patient had no sensation or movement in the left lower extremity. The left femoral artery and vein were located and controlled with vascular clamps. At this point, the anesthesiologist was allowed to catch up his resuscitation until the patient had a blood pressure of 90 mm Hg. Radiographs were taken on the table (Figure 1). The femur was fractured in two areas, with one JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
portion protruding from the wound. The tibia and fibula also showed markedly comminuted fractures. Radiograph of the pelvis showed separation of the symphysis pubis and a fracture of the left ilium extending into the acetabulum and dislocation of the left hip (Figure 2). The wound was contaminated with grass, dirt, gravel, and stool. The patient had an indwelling catheter that was draining light yellow urine. It was decided that an above-knee amputation was mandatory. The femur was transected about three inches from the acetabulum, and the remainder of the posterior thigh muscles were amputated. Hemostasis was achieved. The wound was then irrigated with 3000 cc of saline containing triple antibiotic solution. The pulsator was used, and all dirt, gravel, and contaminated tissue was cleaned and debrided. At this point, it was noted that the wound would not close. The femur was then disarticulated from the acetabulum, and the ilium was grasped with bone-holding forceps and removed subperiosteally (Figures 3, 4, and 5). At this point, all drapes, instruments, and gowns were changed. The wound was again irrigated and hemostasis secured. The lateral flaps containing iliotibial tract and skin were loosely approximated using no. 2 Mersilene sutures with bolsters. A large hemovac suction drain was inserted and a bulky dressing applied. The patient received 14 units of blood on the table and remained in critical condition at the end of the procedure. Three hours after surgery, the patient had evidence of bleeding from the wound and was taken back to surgery. The wound was reexplored, the clot removed, and the skin was closed again. At this point, the patient had received 8 units of platelets, which aided in clotting. Over the next week, he developed acute respiratory distress 267
HEMIPELVECTOMY
He was followed over the next few months, referred to a prosthetic shop, and is now ambulatory with a prosthesis (Figure 6). Acknowledgments The author thanks Drs Fred Myers, William Jekot, and Scott Caudle for help in the surgical management of this case, and Dorothy J. Smith and Terry M. Benford for editorial and manuscript assistance; and Joseph Martin, photographer, Methodist Hospital, for his help.
Figure 6. Perineal wound healing per primam at 6 weeks.
syndrome, but responded to treatment. By March 9, 1987, the patient was transferred from the intensive care unit to a surgery floor. His wound continued to heal without any sign of infection. He was discharged on March 20, 1987, to return to the office.
268
Literature Cited 1. Tile MD. Pelvic fractures: operative versus non-operative treatment. Orthop Clin North Am. 1980; 1:425-465. 2. Naam NH, Brown WH, Hurd R, Burdge E, Kaminski D. Major pelvic fractures. Arch Surg. 1983;1 18:611-686. 3. Helling T. Complication of pelvic fractures in the victims of major trauma. Mo Med. 1983;80:683-686. 4. Richardson JD, Harty J, Amin M. Open pelvic fractures. J Trauma. 1982;22:533-538. 5. Lipkowitz G, Phillips T, Coren C, Spero C, Glassberg K, Velcek FT. Hemipelvectomy: a lifesaving operation in severe open pelvic injury in childhood. J Trauma. 1983;25:823-827.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
