European Journal of Trauma and Emergency Surgery
Focus on Severe Pelvic Bleeding
Management of Acute Hemorrhage in Pelvic Trauma: An Overview Pol M. Rommens1, Alexander Hofmann1, Martin H. Hessmann2
Abstract Pelvic disruption is a combination of fractures or dislocations of the pelvic ring with trauma of the soft tissues on the inside and outside of this ring. Hemodynamic instability is the result of blood loss out of the fracture fragments, the posterior venous plexus, ruptured pelvic organs, or arterial lesions. In the resuscitation phase, different measures are possible to reduce the volume of the disrupted pelvis and to restore mechanical stability. They are not competitive but complementary. Pelvic binders should be used in the prehospital phase before and during transport. Application of a pelvic C-clamp is restricted to inhospital patients with C-type pelvic ring lesions and with severe and ongoing hemodynamic instability. External fixation is most useful in B-type but also has limited value in C-type injuries. The prerequisite for pelvic packing is the restoration of mechanical stability by pelvic C-clamping or external fixation. It is effective in severe venous bleeding in the small pelvis. Pelvic angiography and selective embolization is performed in patients with active arterial bleeding. These patients can be identified by a convincing clinical picture, by early multislice computed tomography (CT) with contrast-enhanced angiographic technique, or by the persistent need for volume replacement after Cclamping, external fixation, or pelvic packing. Key Words Hemorrhagic shock Æ Management of skeletal injuries in polytrauma Æ Multiple trauma Æ Pelvic fractures Æ Pelvis Æ Management of acute hemorrhage in pelvic trauma Æ Pelvic hemorrhage
1
2
Eur J Trauma Emerg Surg 2010;36:91–9 DOI 10.1007/s00068-010-1061-x
Introduction The pelvic girdle is the largest and strongest entity of the musculoskeletal system. Large forces are needed to disrupt the pelvic ring of a healthy person. Pelvic ring injuries are the result of high-velocity traffic accidents, crush traumas, or falls from great height. The pelvic girdle is covered by large muscle groups, subcutaneous tissue, and skin. It protects the organs of the lower abdomen as well as the neurovascular bundles, which functionally connect the trunk with the lower extremities. These soft tissue structures may be damaged as a result of pelvic fractures and dislocations. They may also be disrupted or torn due to abrupt dislocation of fracture fragments. Soft tissue trauma influences the outcome of pelvic trauma. Vascular trauma and severe blood loss are early dangerous complications of pelvic disruption which must be recognized as soon as possible. Several parallel or consecutive measures of resuscitation are compulsory in order to preserve the patient’s life and minimize morbidity. They will be described in this review. Recognizing the Severity of the Lesion In healthy persons, pelvic ring disruptions only occur after high-energy accidents. Many patients with a pelvic ring lesion are severely injured and many severely injured patients have a pelvic ring lesion. It belongs to the primary survey of every severely injured patient to confirm or exclude a pelvic ring lesion. Examination of the pelvic girdle is performed clinically and radiologically.
Center for Musculoskeletal Surgery, University Medical Center, Johannes Gutenberg-University, Mainz, Germany, Department of Orthopedic and Trauma Surgery, Academic Hospital Fulda, Fulda, Germany.
Received: March 5, 2010; revision accepted: March 14, 2010; Published Online: March 31, 2010
Eur J Trauma Emerg Surg 2010 Æ No. 2 Ó URBAN & VOGEL
91
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
Figure 1. Perineal hemorrhage is a direct indicator of a severe pelvic trauma.
Simultaneous palpation and careful mobilization of both pelvic crests confirms vertical and/or rotational instability. Contusions, abrasions, avulsions, or open wounds on the back, on the buttocks, or in the perineum are direct indices of the amount of traumatic force (Figure 1). Together with the anteroposterior view of the thorax and the lateral view of the cervical spine, the pelvic overview belongs to the first three Xrays taken of every severely injured patient [1]. A good-quality X-ray of the pelvis is only obtained when the patient is undressed lying strictly supine on the table, and when the X-ray beam is directed perpendicular to the symphysis pubis. If clinical and conventional X-ray examinations do not reveal any pathological findings, a major trauma of the pelvis can be excluded and further diagnostic measures postponed. In case of any suspicion, a computed tomography (CT) examination of the pelvis must be performed. With CT of the newest generation, a totalbody CT examination can be performed in less time than necessary for the three conventional X-rays. The amount of information which is available from transverse and multiplanar reconstructions exceeds by far the information of conventional X-rays. Total-body CT is, therefore, increasingly often used as the first-choice diagnostic tool for severely injured patients. Prerequisites are that the CT room is accessible round the clock and the distance to the emergency room is short. When the CT room is near to or situated in the Emergency Department, the severely injured patient is transported directly to it [2]. CT images and conventional X-rays of good quality allow for exact classification of the pelvic lesion. In
92
the classification of Tile [3], a distinction is made between stable (Type A), rotationally unstable (Type B), as well as vertically and rotationally unstable lesions (Type C). In the classification of Burgess, anteroposterior compression, lateral compression, vertical shear, and complex injuries are distinguished [4, 5]. Openbook injuries, vertically unstable lesions, complex and open pelvic injuries are the most dangerous, as they are combined with soft tissue disruptions and retroperitoneal bleeding. Open-book lesions are the result of anteroposterior compression. Typically, there is a rupture with diastasis of the symphysis pubis. In case the diastasis exceeds 2 cm, the ventral sacroiliac ligaments, the sacrospinal, and sacrotuberal ligaments are also torn. The volume of the small pelvis increases when being filled up with blood. Blood loss may be active and continuous [6, 7]. Vertically unstable disruptions are characterized by a complete rupture of the ventral and complete rupture of the dorsal pelvis. There no longer remain any anatomical borders; selftamponade is less likely than in open-book lesions. Moreover, lesions of intrapelvic structures such as the bladder, urethra, nerves, or larger vessels are more frequent [8]. Complex pelvic injuries are defined as pelvic lesions in combination with severe damage of the surrounding soft tissues, lesions of the urogenital tract, or neurovascular compromise of one of the lower extremities [9, 10]. Open pelvic injuries are pelvic fractures with a direct communication with a ruptured skin, vagina, or rectum. The above-mentioned lesions have in common that there may be severe and ongoing blood loss inside and outside the pelvic ring, which endangers the patient’s survival [11, 12]. If recognized early, adequate management can be started accordingly.
Early Management Many severely injured patients have a pelvic ring injury and many patients with pelvic ring lesions are severely injured. There must always be a high index of suspicion of a pelvic lesion when severely injured patients are admitted in our Emergency Departments. Primary treatment must be focused on the hemodynamic situation of the patient. On admission, we are confronted with both hemodynamic and osteoligamentar instabilities. The cause of hemodynamic instability is blood loss out of the fracture fragments, especially of the dorsal pelvic ring. Already more than 30 years ago, Huittinen and Sla¨tis [13] presented a series of 27 postmortem angiographies and dissections after pelvic trauma. They found that leakage from the fractured
Eur J Trauma Emerg Surg 2010 Æ No. 2
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
cancellous bone was the major source of bleeding. Low-pressure blood loss also arises in presacral vessels and the vessels supplying the intrapelvic organs [14]. Arterial bleeding is present in less than 10% of pelvic injuries. The origins of arterial blood loss are the superior or inferior gluteal artery, the obturator artery, or the pudendal artery, all of which run close to bony landmarks of the pelvis [15–17]. If larger vessels such as the external, internal, or common iliac arteries are torn, there is massive blood loss, with a rapidly deteriorating hemodynamic situation. Following the rules of ATLS, resuscitation with early intubation, ventilation, as well as aggressive volume substitution are started. Osteoligamentar and hemodynamic instabilities should be rectified as soon as possible. This stabilization can be done in several ways. Different possibilities with their advantages and limitations will be discussed here.
Pelvic Binder, Pelvic Strap Putting the two hip joints in internal rotation with both legs parallel and the hips and knees in extension will reduce an externally rotated hemipelvis. This reduction can be secured by a circumferential bed sheet (tightened around the pelvic ring or upper legs), a pelvic strap, or a pelvic binder. Their application reduces the volume of the small pelvis and avoids further displacement or dislocation during transport or
manipulation. Commercially available binders for single use are taken for transport from the scene to the first admitting hospital. Clinical trials have proven the efficiency of these devices [17–19]. In a series of 16 patients, controlled circumferential compression significantly reduced the pelvic width in open-book-type injuries and did not cause significant overcompression in lateral-compression-type injuries. In this study, no complications could be detected at all [20]. In a study on ten healthy individuals, the pressures generated over bony prominences under the pelvic binder were measured [21]. In all cases, the pressures exceeded the limit recommended to prevent pressure sores. Therefore, pelvic binders should not be kept in place longer than absolutely necessary and should not be overtightened [21]. A similar device, which reminds us of the MAST trousers, is the pelvic immobilization belt. The belt is composed of two gluteal and one half-size suprapubic chamber, which are inflated after installing the belt around the disrupted pelvis. Inflating the chambers reduces the volume within the belt; the bony pelvis is reduced without collapse of the anterior pelvic ring. The posterior chambers compress the gluteal compartments, preventing bleeding, the anterior chamber compresses soft tissue against the convexity of the lumbosacral spine, producing a tamponade within the pelvis. There is no risk of pressure sores, as the pressure is equally distributed over the whole skin area under the inflated chambers (Figure 2).
Figure 2. The pelvic immobilization belt is composed of two gluteal and one half-size suprapubic chamber, which are inflated after installing the belt around the disrupted pelvis (courtesy of Prof. Baumgaertel, Koblenz, Germany).
Eur J Trauma Emerg Surg 2010 Æ No. 2
93
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
C-Clamp The antishock pelvic clamp was introduced 1991 [22]. This device is used in the emergency room during the resuscitation phase of the severely injured patient with a pelvic disruption combined with severe venous bleeding and hypotension. The idea behind the clamp is to restore the mechanical stability of the dorsal pelvic ring. Two thick pins are placed percutaneously through the gluteal regions at the side of the injured and uninjured hemipelvis. The tip of each pin is inserted into the bone of the dorsal ilium at the level of the sacroiliac joint. The pins are connected to each other via an external fixator. After closed reduction of the dislocated hemipelvis, compression is applied to the dorsal pelvis by tightening the two parts of the clamp [23] (Figure 3). The device has the form of a C and, therefore, is called a C-clamp. As the device compresses the dorsal pelvis, it is useful in patients with complete sacroiliac dislocations or vertically unstable sacral fractures, but not in transiliac instabilities. Reducing fracture or dislocation and restoring mechanical stability, bleeding out of the broken cancellous bone is limited. Blood loss from torn veins of the dorsal venous plexus is also limited by rendering clotting possible. Restoring stability of the dorsal pelvis will not influence blood loss out of torn arteries. Due to the limited number of patients, a large experience with the device does not exist. In 1996, Heini et al. published a first series of 30 cases. This application was hemodynamically effective in 10 out of 18 cases with an acute unstable hemodynamic situation. There were no complications related to the C-clamp application [24].
Figure 3. Two pins, which are connected to a C-shaped external fixator push directly on the dorsal ilium at the level of the sacroiliac joint. Mechanical stability is obtained in the fracture or dislocation of the dorsal pelvis by tightening the two parts of the clamp.
94
Tiemann et al. published a series of 29 patients in which the C-clamp was applied before X-ray of the pelvis was taken. The clamp was effective in all but one patient. Malpositioning of pins, overcompression of the sacrum, secondary pin dislocation with loss of stability, bleeding at the pin insertion site, or minor wound problems have been described in six patients (20.7%) [25]. The C-clamp is an effective device when used in the right technique, at the right time, and in the right patient.
External Fixation External fixation of the broken pelvis has been a wellaccepted technique of provisional or definitive stabilization for decades [26–30]. As with the pelvic binder or C-clamp, it reduces the volume of the small pelvis and creates mechanical stability, which supports blood clotting in the early posttraumatic phase. The application of a pelvic external fixator takes more time than the application of a pelvic binder or a C-clamp. As several skin incisions are needed and pins are drilled into the bone, application is not recommended in a non-sterile environment, as the emergency room is. The patient is transported to the operating theater; the procedure is performed in sterile conditions and with image intensifier control. These prerequisites limit the use of external fixation as a resuscitation maneuver. There are two possible entry portals for the pins: the supraacetabular ilium and the iliac crest at the level of the thick column of bone cephalad to the acetabulum. In anteroinferior fixation, the pins are drilled from the anterior inferior iliac spine towards the posterior inferior iliac spine [30]. In case of anterosuperior fixation, the pins are drilled from the iliac crest between the two tables of the ilium in the direction of the acetabulum [31–33]. Kim et al. compared the stiffness of the two fixator frames in the case of open-book and C-type pelvic ring lesions [34]. They found no significant differences in stiffness between the two frames. Injuries to the lateral femoral cutaneous nerve due to percutaneous pin insertion were not found [34, 35]. For these reasons and because of the easiness of application, the anteroinferior fixator is preferred above the anterosuperior (Figure 4). Pohlemann et al. investigated the stiffness of two types of C-clamps versus supraacetabular external fixator both in B-type and C-type pelvic ring injuries [36]. Whereas all fixation methods could withstand the loading of full body weight bearing in B-type lesions, the external fixator showed no significant holding force in C-type lesions. In their biomechanical investigation, Simonian et al.
Eur J Trauma Emerg Surg 2010 Æ No. 2
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
Pelvic external fixation is adequate for the provisional fixation of B- and C-type lesions without severe bleeding. It reduces pelvic volume and creates a mechanical stability, which helps to reduce bleeding from broken cancellous bone and which enhances the chances of clotting of torn veins of the dorsal venous plexus. It is compulsory in patients who need laparotomy and is strongly recommended in patients who need nailing of the lower extremities. It can be a definitive treatment in B-type lesions and part of the definitive treatment of C-type lesions.
Figure 4. Anteroinferior pelvic external fixator. Two pins are drilled from the anterior inferior iliac spine towards the posterior inferior iliac spine and connected with a simple external fixator frame.
found that the pelvic external fixator realizes less stability in the posterior pelvic ring than the C-clamp; both fixation methods significantly enhance stability in the anterior pelvic ring [37]. Therefore, pelvic external fixation is more useful in rotationally unstable pelvic ring lesions, in which the dorsal pelvic ring is not completely disrupted, than in vertically unstable lesions. In case that lesions in neighboring body regions must be treated operatively at the same time, external fixation of the pelvis is recommended as a protecting stabilization. When urgent laparotomy is needed, external fixation of any unstable pelvic ring lesion is done in advance. Otherwise, retraction of the abdominal muscles during laparotomy will increase external rotation of the injured hemipelvis; additional instability will enhance the risk of retroperitoneal bleeding [38]. The latter may also be the case for patients with femur or tibia fractures, where primary nailing is considered. Hammering a nail into femur or tibia will dislocate fracture fragments of an unstable pelvis. Therefore, the pelvic ring should be stabilized before the nailing procedure is started. Surgical packing of the small pelvis for the treatment of ongoing bleeding can only be successful when pelvic external fixation is carried out beforehand. External fixation and C-clamping create mechanical stability; the fixed bony structures form a resistance to which packing is effective [39]. Contrary to the pelvic binder and C-clamp, the external fixator can remain longer on the pelvic ring. In rotationally unstable lesions, it can be a definitive treatment; in vertically unstable lesions, it can be an adjunct to dorsal internal fixation. In a personal series of 222 pelvic ring lesions, external fixation was part of the definitive treatment in 52% of B-type and in 38% of C-type lesions [40].
Eur J Trauma Emerg Surg 2010 Æ No. 2
Pelvic Packing In some European trauma centers, pelvic packing has been advocated as an additional damage control procedure in posttraumatic pelvic bleeding [39, 41]. The goal is to control bleeding which originates from broken cancellous bone, from the dorsal venous plexus, and from smaller arteries. Packing can be done through an intraperitoneal or extraperitoneal approach. When there are no abdominal lesions, a laparotomy is not needed. Through a short incision above the symphysis pubis, the midline fascial layer between both rectus abdominis muscles is transected. The peritoneum is not opened. Immediately, large amounts of blood and blood clots evacuate from the small pelvis. Because of traumatic dissection and bleeding, it is easy to enter the small pelvis. After drainage of hematoma, several towels are placed in the void of the drained hematoma, typically in the retropubic space or along the medial walls of the posterior columns and acetabulum. As packing is only possible in a stable environment, external fixation or C-clamping of the pelvic ring needs to be done on beforehand. Papakostidis evaluated the results of three larger series [39, 41–43]. Pelvic packing significantly reduced the blood transfusion requirement in all cases. The early mortality rate was 10%, late mortality rate 13%, and the overall mortality 28%. Major complications were infection in 35% and multiple organ failure in 9%. Pelvic packing is clearly a damage control procedure. A second-look operation for the removal of towels, further debridement, and specific suturing of remaining bleeding sources is mandatory. During the second procedure, internal fixation of the anterior pelvis can be done. Packing is also not competitive to pelvic angiography and selective embolization. In the series of Cothren et al., 5 out of 28 patients underwent successful angiography with embolization after pelvic packing because of clinical concern of ongoing bleeding [43]. Suzuki et al. suggest pelvic packing to be done in the operating theater
95
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
during the time of preparation of the angiography suite in patients who remain hemodynamically unstable, despite resuscitation [44].
Pelvic Angiography and Selective Embolization Posttraumatic pelvic bleeding originates from fractures through the cancellous bone of the dorsal pelvis, from the posterior venous plexus, and from arterial bleeding. Venous bleeding and bleeding from broken bone are the major sources of hypovolemia. They are not suitable for angiography and embolization. Arterial bleeding is seen in less than 10% of cases. In a series of 806 patients with pelvic fractures, only 35 (4.3%) underwent angiography and 15 (1.9%) needed selective embolization [15]. The major dilemma in the severely injured is distinguishing patients with ongoing venous bleeding from patients with arterial blood loss. Typically, patients with arterial bleeding present with major pelvic instability due to the large displacement of fracture fragments, reflecting huge energy impact. We must be very careful judging these patients (Figure 5). What are further characteristics of these patients at risk? Jeroukhimov et al. investigated the data of 29 cases in a series of 106 patients with major pelvic trauma who underwent angiography. These patients had a significantly higher pelvic AIS and lower base excess levels on admission. A blood transfusion rate of greater than 0.5 units per hour was found to be a reliable indicator for early angiography [45]. Miller et al. identified repeated episodes of hypotension despite resuscitation as the best indicator for arterial bleeding. Adequate response to initial resuscitation was defined as a sustained (>2 h) improvement of
Figure 5. A 10-year-old boy with unstable pelvic fracture, hemodynamic instability, and rapidly growing hematoma in the right groin. There must be a high index of suspicion of arterial bleeding in this patient.
96
systolic blood pressure to > 90 mm Hg after the administration of less than two or exactly two packed red blood cells. Seventy-three percent of nonresponding patients had a positive angiography [46]. In patients amenable to emergency multislice CT with contrast-enhanced angiographic technique, the diagnosis of active pelvic bleeding can be made early. Contrast extravasation not only confirms but also identifies the source of bleeding thanks to knowledge of the anatomy of the region of the pelvis where the extravasation is noted (Figure 6) [47, 48]. In a large series of patients with pelvic fractures and selective angiography, selective embolization was carried out in 80%. The angiographic success ratio was between 95 and 100%, the clinical success ratio between 81 and 95%, and the global mortality was between 14 and 28% [49–51]. Complications are few but severe: gluteal muscle and skin necrosis or sensitivity problems [52]. While pelvic angiography and selective embolization has proven to be successful, the question remains on what should be done first. Reviewing the literature, preference is guided by the profile of the authors:
Figure 6. Multislice computed tomography (CT) with contrast-enhanced angiographic technique in patient with a combined pelvicacetabular fracture. A large hematoma (large arrow) in the right hemipelvis with displacement of the external iliac artery is visible. There is extravasation of contrast product out of the artery (small arrow).
Eur J Trauma Emerg Surg 2010 Æ No. 2
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
trauma surgeons prefer external fixation or C-clamping followed by pelvic packing, radiologists and general surgeons prefer embolization [46, 53, 54]. Pelvic angiography and selective embolization need specific infrastructure and medical expertise, which must be available on every occasion. It is a complex and timeconsuming procedure and, therefore, cannot be recommended for patients in extremis. Their chance of survival is higher in the hands of surgeons who master several damage control procedures such as pelvic Cclamping, external fixation, and pelvic packing. When patients respond well to resuscitation measures, angiography is not needed or can be postponed. Patients who do not stabilize permanently during resuscitation may benefit from pelvic angiography and selective embolization. However, it should not be used as a firststep procedure in this group. External fixation, which is a compulsory procedure anyhow, should be done first and will control most of the venous bleeding. Pelvic packing is done in patients who do not stabilize after external fixation. Angiography plus embolization is an alternative to pelvic packing. It is a further obligatory step in patients who do not respond well to external fixation followed by packing.
Conclusion Different procedures are available for the acute management of posttraumatic pelvic bleeding. They are not competitive but complementary. They represent different levels of complexity and therapeutic aggressiveness, being appropriate in a specific time slot of resuscitation. In the prehospital phase, pelvic binders are effective in reducing instability of the broken pelvis during transport. During shock-room management and intra-hospital transport, pelvic binders have the same benefit as in the prehospital phase. Because of the dangers of skin necrosis or compartment syndrome, they cannot be applied for longer than a few hours. The pelvic C-clamp is used as a damage control procedure in the emergency room or in the operation theater. It creates high mechanical stability in the dorsal pelvic ring. It is only meaningful in C-type lesions with sacroiliac or trans-sacral instability. External fixation is widely used as the provisional stabilizer of rotational and vertical unstable lesions. It reduces the volume of and creates sufficient stiffness in the pelvic ring for selftamponade and clotting. There is no difference in stiffness between anterosuperior and anteroinferior fixation frames. Pelvic packing creates high local pressure in the small pelvis. The approach to the small pelvis is suprapubic and extraperitoneal. Packing is
Eur J Trauma Emerg Surg 2010 Æ No. 2
performed immediately after external fixation in patients with clinical signs of ongoing bleeding. Pelvic angiography and selective embolization are useful in patients with active arterial bleeding. The right indications can be identified with early multislice computed tomography (CT) with contrast-enhanced angiography or with specific clinical signs. It should not be used as a first-choice procedure. The technique presumes the permanent availability of an adequate infrastructure and specific medical expertise. The clinical success ratio is high. The most suitable patients are those who do not or badly respond to resuscitation measures such as aggressive volume substitution, pelvic C-clamp application, external fixation, or pelvic packing.
Conflict of interest statement The authors declare that there is no actual or potential conflict of interest in relation to this article.
References 1.
Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986;160:445–51. 2. Hessmann MH, Hofmann A, Kreitner KF, Lott C, Rommens PM. The benefit of multislice CT in the emergency room management of polytraumatized patients. Acta Chir Belg 2006;106:500–7. 3. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br 1988;70:1–12. 4. Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 1990;30:848–56. 5. Dalal SA, Burgess AR, Siegel JH, Young JW, Brumback RJ, Poka A, Dunham CM, Gens D, Bathon H. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma 1989;29:981–1000. 6. Moss MC, Bircher MD. Volume changes within the true pelvis during disruption of the pelvic ring—where does the haemorrhage go? Injury 1996;27:S-A21–3. 7. Grimm MR, Vrahas MS, Thomas KA. Pressure–volume characteristics of the intact and disrupted pelvic retroperitoneum. J Trauma 1998;44:454–9. 8. Dyer GSM, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury 2006;37:602–13. 9. Pohlemann T, Gänsslen A, Stief CH. Complex injuries of the pelvis and acetabulum. Orthopäde 1998;27:32–44. 10. Bosch U, Pohlemann T, Haas N, Tscherne H. Classification and management of complex pelvic trauma. Unfallchirurg 1992;95:189–96. 11. Jones AL, Powell JN, Kellam JF, McCormack RG, Dust W, Wimmer P. Open pelvic fractures. A multicenter retrospective analysis. Orthop Clin North Am 1997;28:345–50.
97
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
12.
13.
14. 15.
16. 17.
18.
19.
20.
21. 22. 23. 24.
25.
26. 27.
28. 29. 30.
31.
32. 33.
98
Grotz MR, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis PV. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005;36:1–13. Huittinen VM, Slätis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454–62. White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury 2009;40:1023–30. Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF 3rd. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 1997;43: 395–9. Perez JV, Hughes TM, Bowers K. Angiographic embolisation in pelvic fracture. Injury 1998;29:187–91. Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg Am 2002;84:43–7. Simpson T, Krieg JC, Heuer F, Bottlang M. Stabilization of pelvic ring disruptions with a circumferential sheet. J Trauma 2002;52:158–61. Nunn T, Cosker TD, Bose D, Pallister I. Immediate application of improvised pelvic binder as first step in extended resuscitation from life-threatening hypovolaemic shock in conscious patients with unstable pelvic injuries. Injury 2007;38:125–8. Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma 2005;59:659–64. Jowett AJL, Bowyer GW. Pressure characteristics of pelvic binders. Injury 2007;38:118–21. Ganz R, Krushell RJ, Jakob RP, Küffer J. The antishock pelvic clamp. Clin Orthop Relat Res 1991;267:71–8. Pohlemann T, Culemann U, Tosounidis G, Kristen A. Application of the pelvic C-clamp. Unfallchirurg 2004;107:1185–91. Heini PF, Witt J, Ganz R. The pelvic C-clamp for the emergency treatment of unstable pelvic ring injuries. A report on clinical experience of 30 cases. Injury 1996;27::S-A38–45. Tiemann AH, Böhme J, Josten C. Use of the pelvic clamp in polytraumatised patients with unstable disruption of the posterior pelvic ring. Modified technique – risks – problems. Orthopäde 2006;35:1225–36. Kellam JF. The role of external fixation in pelvic disruptions. Clin Orthop Relat Res 1989;241:66–82. Broos P, Vanderschot P, Craninx L, Reynders P, Rommens P. Internal hemorrhages associated with fractures of the pelvic girdle. Importance of early stabilization using an external fixator. Acta Orthop Belg 1993;59:130–8. Rommens PM. Pelvic ring injuries: a challenge for the trauma surgeon. Acta Chir Belg 1996;96:78–84. Siegmeth A, Müllner T, Kukla C, Vécsei V. Associated injuries in severe pelvic trauma. Unfallchirurg 2000;103:572–81. Gänsslen A, Pohlemann T, Krettek C. A simple supraacetabular external fixation for pelvic ring fractures. Oper Orthop Traumatol 2005;17:296–312. Rommens PM, Hessmann MH. External fixation for the injured pelvic ring. In: Tile M, Helfet DL, Kellam JF, eds. Fractures of the pelvis and acetabulum. Philadelphia: Lippincott Williams and Wilkins, 2003:203–16. Slätis P, Karaharju EO. External fixation of the pelvic girdle with a trapezoid compression frame. Injury 1975;7:53–6. Bircher MD. Indications and techniques of external fixation of the injured pelvis. Injury 1996;27[suppl 2]:B3–19.
34. Kim WY, Hearn TC, Seleem O, Mahalingam E, Stephen D, Tile M. Effect of pin location on stability of pelvic external fixation. Clin Orthop Relat Res 1999;361:237–44. 35. de Ridder VA, de Lange S, Popta JV. Anatomical variations of the lateral femoral cutaneous nerve and the consequences for surgery. J Orthop Trauma 1999;13:207–11. 36. Pohlemann T, Krettek C, Hoffmann R, Culemann U, Gänsslen A. Biomechanical comparison of various emergency stabilization measures of the pelvic ring. Unfallchirurg 1994;97:503–10. 37. Simonian PT, Routt ML Jr, Harrington RM, Tencer AF. Anterior versus posterior provisional fixation in the unstable pelvis. A biomechanical comparison. Clin Orthop Relat Res 1995;310:245–51. 38. Hötker U, Rommens PM. Blunt abdominal trauma and severe pelvic rupture. What to do? Acta Chir Belg 1997;97:65–8. 39. Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001;15:468–74. 40. Rommens PM, Hessmann MH. Staged reconstruction of pelvic ring disruption: differences in morbidity, mortality, radiologic results, and functional outcomes between B1, B2/B3, and C-type lesions. J Orthop Trauma 2002;16:92–8. 41. Tötterman A, Madsen JE, Skaga NO, Røise O. Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. J Trauma 2007;62:843–52. 42. Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability: efficacy of pelvic packing, a systematic review. Injury 2009;40:S53–61. 43. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 2007;62:834–9. 44. Suzuki T, Smith WR, Moore EE (2009) Pelvic packing or angiography: competitive or complementary? Injury 40:343–53. 45. Jeroukhimov I, Ashkenazi I, Kessel B, Gaziants V, Peer A, Altshuler A, Nesterenko V, Alfici R, Halevy A. Selection of patients with severe pelvic fracture for early angiography remains controversial. Scand J Trauma Resusc Emerg Med 2009;17:62. 46. Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC. External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 2003;54:437–43. 47. Westhoff J, Laurer H, Wutzler S, Wyen H, Mack M, Maier B, Marzi I. Interventional emergency embolization for severe pelvic ring fractures with arterial bleeding. Integration into the early clinical treatment algorithm. Unfallchirurg 2008;111:821–8. 48. Pinto A, Niola R, Tortora G, Ponticiello G, Russo G, Di Nuzzo L, Gagliardi N, Scaglione M, Merola S, Stavolo C, Maglione F, Romano L. Role of multidetector-row CT in assessing the source of arterial haemorrhage in patients with pelvic vascular trauma. Comparison with angiography. Radiol Med 2010 [Epub ahead of print] PMID:20082229. 49. Velmahos GC, Toutouzas KG, Vassiliu P, sarkisyan G, Chan LS, Hanks SH, Berne TV, Demetriades D. A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma 2002;53:303–8. 50. Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S. The usefulness of transcatheter arterial embolization for patients with blunt polytrauma showing transient response to fluid resuscitation. J Trauma 2004;57:271–6.
Eur J Trauma Emerg Surg 2010 Æ No. 2
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
51.
Fangio P, Asehnoune K, Edouard A, Smail N, Benhamou D. Early embolization and vasopressor administration for management of life-threatening hemorrhage from pelvic fracture. J Trauma 2005;58:978–84. 52. Yasumura K, Ikegami K, Kamohara T, Nohara Y. High incidence of ischemic necrosis of the gluteal muscle after transcatheter angiographic embolization for severe pelvic fracture. J Trauma 2005;58:985–90. 53. Gänsslen A, Giannoudis P, Pape HC. Hemorrhage in pelvic fracture: who needs angiography? Curr Opin Crit Care 2003;9:515–23. 54. Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review: initial management of blunt pelvic trauma patients with haemodynamic instability. Crit Care 2007;11:204.
Eur J Trauma Emerg Surg 2010 Æ No. 2
Address for Correspondence Prof. Dr. Dr. h.c. Pol M. Rommens Center for Musculoskeletal Surgery University Medical Center Johannes Gutenberg-University Langenbeckstraße 1 55131 Mainz Germany Phone (+49/6131) 17-7292, Fax -4043 e-mail: [email protected]
99
Focus on Severe Pelvic Bleeding
Management of Acute Hemorrhage in Pelvic Trauma: An Overview Pol M. Rommens1, Alexander Hofmann1, Martin H. Hessmann2
Abstract Pelvic disruption is a combination of fractures or dislocations of the pelvic ring with trauma of the soft tissues on the inside and outside of this ring. Hemodynamic instability is the result of blood loss out of the fracture fragments, the posterior venous plexus, ruptured pelvic organs, or arterial lesions. In the resuscitation phase, different measures are possible to reduce the volume of the disrupted pelvis and to restore mechanical stability. They are not competitive but complementary. Pelvic binders should be used in the prehospital phase before and during transport. Application of a pelvic C-clamp is restricted to inhospital patients with C-type pelvic ring lesions and with severe and ongoing hemodynamic instability. External fixation is most useful in B-type but also has limited value in C-type injuries. The prerequisite for pelvic packing is the restoration of mechanical stability by pelvic C-clamping or external fixation. It is effective in severe venous bleeding in the small pelvis. Pelvic angiography and selective embolization is performed in patients with active arterial bleeding. These patients can be identified by a convincing clinical picture, by early multislice computed tomography (CT) with contrast-enhanced angiographic technique, or by the persistent need for volume replacement after Cclamping, external fixation, or pelvic packing. Key Words Hemorrhagic shock Æ Management of skeletal injuries in polytrauma Æ Multiple trauma Æ Pelvic fractures Æ Pelvis Æ Management of acute hemorrhage in pelvic trauma Æ Pelvic hemorrhage
1
2
Eur J Trauma Emerg Surg 2010;36:91–9 DOI 10.1007/s00068-010-1061-x
Introduction The pelvic girdle is the largest and strongest entity of the musculoskeletal system. Large forces are needed to disrupt the pelvic ring of a healthy person. Pelvic ring injuries are the result of high-velocity traffic accidents, crush traumas, or falls from great height. The pelvic girdle is covered by large muscle groups, subcutaneous tissue, and skin. It protects the organs of the lower abdomen as well as the neurovascular bundles, which functionally connect the trunk with the lower extremities. These soft tissue structures may be damaged as a result of pelvic fractures and dislocations. They may also be disrupted or torn due to abrupt dislocation of fracture fragments. Soft tissue trauma influences the outcome of pelvic trauma. Vascular trauma and severe blood loss are early dangerous complications of pelvic disruption which must be recognized as soon as possible. Several parallel or consecutive measures of resuscitation are compulsory in order to preserve the patient’s life and minimize morbidity. They will be described in this review. Recognizing the Severity of the Lesion In healthy persons, pelvic ring disruptions only occur after high-energy accidents. Many patients with a pelvic ring lesion are severely injured and many severely injured patients have a pelvic ring lesion. It belongs to the primary survey of every severely injured patient to confirm or exclude a pelvic ring lesion. Examination of the pelvic girdle is performed clinically and radiologically.
Center for Musculoskeletal Surgery, University Medical Center, Johannes Gutenberg-University, Mainz, Germany, Department of Orthopedic and Trauma Surgery, Academic Hospital Fulda, Fulda, Germany.
Received: March 5, 2010; revision accepted: March 14, 2010; Published Online: March 31, 2010
Eur J Trauma Emerg Surg 2010 Æ No. 2 Ó URBAN & VOGEL
91
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
Figure 1. Perineal hemorrhage is a direct indicator of a severe pelvic trauma.
Simultaneous palpation and careful mobilization of both pelvic crests confirms vertical and/or rotational instability. Contusions, abrasions, avulsions, or open wounds on the back, on the buttocks, or in the perineum are direct indices of the amount of traumatic force (Figure 1). Together with the anteroposterior view of the thorax and the lateral view of the cervical spine, the pelvic overview belongs to the first three Xrays taken of every severely injured patient [1]. A good-quality X-ray of the pelvis is only obtained when the patient is undressed lying strictly supine on the table, and when the X-ray beam is directed perpendicular to the symphysis pubis. If clinical and conventional X-ray examinations do not reveal any pathological findings, a major trauma of the pelvis can be excluded and further diagnostic measures postponed. In case of any suspicion, a computed tomography (CT) examination of the pelvis must be performed. With CT of the newest generation, a totalbody CT examination can be performed in less time than necessary for the three conventional X-rays. The amount of information which is available from transverse and multiplanar reconstructions exceeds by far the information of conventional X-rays. Total-body CT is, therefore, increasingly often used as the first-choice diagnostic tool for severely injured patients. Prerequisites are that the CT room is accessible round the clock and the distance to the emergency room is short. When the CT room is near to or situated in the Emergency Department, the severely injured patient is transported directly to it [2]. CT images and conventional X-rays of good quality allow for exact classification of the pelvic lesion. In
92
the classification of Tile [3], a distinction is made between stable (Type A), rotationally unstable (Type B), as well as vertically and rotationally unstable lesions (Type C). In the classification of Burgess, anteroposterior compression, lateral compression, vertical shear, and complex injuries are distinguished [4, 5]. Openbook injuries, vertically unstable lesions, complex and open pelvic injuries are the most dangerous, as they are combined with soft tissue disruptions and retroperitoneal bleeding. Open-book lesions are the result of anteroposterior compression. Typically, there is a rupture with diastasis of the symphysis pubis. In case the diastasis exceeds 2 cm, the ventral sacroiliac ligaments, the sacrospinal, and sacrotuberal ligaments are also torn. The volume of the small pelvis increases when being filled up with blood. Blood loss may be active and continuous [6, 7]. Vertically unstable disruptions are characterized by a complete rupture of the ventral and complete rupture of the dorsal pelvis. There no longer remain any anatomical borders; selftamponade is less likely than in open-book lesions. Moreover, lesions of intrapelvic structures such as the bladder, urethra, nerves, or larger vessels are more frequent [8]. Complex pelvic injuries are defined as pelvic lesions in combination with severe damage of the surrounding soft tissues, lesions of the urogenital tract, or neurovascular compromise of one of the lower extremities [9, 10]. Open pelvic injuries are pelvic fractures with a direct communication with a ruptured skin, vagina, or rectum. The above-mentioned lesions have in common that there may be severe and ongoing blood loss inside and outside the pelvic ring, which endangers the patient’s survival [11, 12]. If recognized early, adequate management can be started accordingly.
Early Management Many severely injured patients have a pelvic ring injury and many patients with pelvic ring lesions are severely injured. There must always be a high index of suspicion of a pelvic lesion when severely injured patients are admitted in our Emergency Departments. Primary treatment must be focused on the hemodynamic situation of the patient. On admission, we are confronted with both hemodynamic and osteoligamentar instabilities. The cause of hemodynamic instability is blood loss out of the fracture fragments, especially of the dorsal pelvic ring. Already more than 30 years ago, Huittinen and Sla¨tis [13] presented a series of 27 postmortem angiographies and dissections after pelvic trauma. They found that leakage from the fractured
Eur J Trauma Emerg Surg 2010 Æ No. 2
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
cancellous bone was the major source of bleeding. Low-pressure blood loss also arises in presacral vessels and the vessels supplying the intrapelvic organs [14]. Arterial bleeding is present in less than 10% of pelvic injuries. The origins of arterial blood loss are the superior or inferior gluteal artery, the obturator artery, or the pudendal artery, all of which run close to bony landmarks of the pelvis [15–17]. If larger vessels such as the external, internal, or common iliac arteries are torn, there is massive blood loss, with a rapidly deteriorating hemodynamic situation. Following the rules of ATLS, resuscitation with early intubation, ventilation, as well as aggressive volume substitution are started. Osteoligamentar and hemodynamic instabilities should be rectified as soon as possible. This stabilization can be done in several ways. Different possibilities with their advantages and limitations will be discussed here.
Pelvic Binder, Pelvic Strap Putting the two hip joints in internal rotation with both legs parallel and the hips and knees in extension will reduce an externally rotated hemipelvis. This reduction can be secured by a circumferential bed sheet (tightened around the pelvic ring or upper legs), a pelvic strap, or a pelvic binder. Their application reduces the volume of the small pelvis and avoids further displacement or dislocation during transport or
manipulation. Commercially available binders for single use are taken for transport from the scene to the first admitting hospital. Clinical trials have proven the efficiency of these devices [17–19]. In a series of 16 patients, controlled circumferential compression significantly reduced the pelvic width in open-book-type injuries and did not cause significant overcompression in lateral-compression-type injuries. In this study, no complications could be detected at all [20]. In a study on ten healthy individuals, the pressures generated over bony prominences under the pelvic binder were measured [21]. In all cases, the pressures exceeded the limit recommended to prevent pressure sores. Therefore, pelvic binders should not be kept in place longer than absolutely necessary and should not be overtightened [21]. A similar device, which reminds us of the MAST trousers, is the pelvic immobilization belt. The belt is composed of two gluteal and one half-size suprapubic chamber, which are inflated after installing the belt around the disrupted pelvis. Inflating the chambers reduces the volume within the belt; the bony pelvis is reduced without collapse of the anterior pelvic ring. The posterior chambers compress the gluteal compartments, preventing bleeding, the anterior chamber compresses soft tissue against the convexity of the lumbosacral spine, producing a tamponade within the pelvis. There is no risk of pressure sores, as the pressure is equally distributed over the whole skin area under the inflated chambers (Figure 2).
Figure 2. The pelvic immobilization belt is composed of two gluteal and one half-size suprapubic chamber, which are inflated after installing the belt around the disrupted pelvis (courtesy of Prof. Baumgaertel, Koblenz, Germany).
Eur J Trauma Emerg Surg 2010 Æ No. 2
93
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
C-Clamp The antishock pelvic clamp was introduced 1991 [22]. This device is used in the emergency room during the resuscitation phase of the severely injured patient with a pelvic disruption combined with severe venous bleeding and hypotension. The idea behind the clamp is to restore the mechanical stability of the dorsal pelvic ring. Two thick pins are placed percutaneously through the gluteal regions at the side of the injured and uninjured hemipelvis. The tip of each pin is inserted into the bone of the dorsal ilium at the level of the sacroiliac joint. The pins are connected to each other via an external fixator. After closed reduction of the dislocated hemipelvis, compression is applied to the dorsal pelvis by tightening the two parts of the clamp [23] (Figure 3). The device has the form of a C and, therefore, is called a C-clamp. As the device compresses the dorsal pelvis, it is useful in patients with complete sacroiliac dislocations or vertically unstable sacral fractures, but not in transiliac instabilities. Reducing fracture or dislocation and restoring mechanical stability, bleeding out of the broken cancellous bone is limited. Blood loss from torn veins of the dorsal venous plexus is also limited by rendering clotting possible. Restoring stability of the dorsal pelvis will not influence blood loss out of torn arteries. Due to the limited number of patients, a large experience with the device does not exist. In 1996, Heini et al. published a first series of 30 cases. This application was hemodynamically effective in 10 out of 18 cases with an acute unstable hemodynamic situation. There were no complications related to the C-clamp application [24].
Figure 3. Two pins, which are connected to a C-shaped external fixator push directly on the dorsal ilium at the level of the sacroiliac joint. Mechanical stability is obtained in the fracture or dislocation of the dorsal pelvis by tightening the two parts of the clamp.
94
Tiemann et al. published a series of 29 patients in which the C-clamp was applied before X-ray of the pelvis was taken. The clamp was effective in all but one patient. Malpositioning of pins, overcompression of the sacrum, secondary pin dislocation with loss of stability, bleeding at the pin insertion site, or minor wound problems have been described in six patients (20.7%) [25]. The C-clamp is an effective device when used in the right technique, at the right time, and in the right patient.
External Fixation External fixation of the broken pelvis has been a wellaccepted technique of provisional or definitive stabilization for decades [26–30]. As with the pelvic binder or C-clamp, it reduces the volume of the small pelvis and creates mechanical stability, which supports blood clotting in the early posttraumatic phase. The application of a pelvic external fixator takes more time than the application of a pelvic binder or a C-clamp. As several skin incisions are needed and pins are drilled into the bone, application is not recommended in a non-sterile environment, as the emergency room is. The patient is transported to the operating theater; the procedure is performed in sterile conditions and with image intensifier control. These prerequisites limit the use of external fixation as a resuscitation maneuver. There are two possible entry portals for the pins: the supraacetabular ilium and the iliac crest at the level of the thick column of bone cephalad to the acetabulum. In anteroinferior fixation, the pins are drilled from the anterior inferior iliac spine towards the posterior inferior iliac spine [30]. In case of anterosuperior fixation, the pins are drilled from the iliac crest between the two tables of the ilium in the direction of the acetabulum [31–33]. Kim et al. compared the stiffness of the two fixator frames in the case of open-book and C-type pelvic ring lesions [34]. They found no significant differences in stiffness between the two frames. Injuries to the lateral femoral cutaneous nerve due to percutaneous pin insertion were not found [34, 35]. For these reasons and because of the easiness of application, the anteroinferior fixator is preferred above the anterosuperior (Figure 4). Pohlemann et al. investigated the stiffness of two types of C-clamps versus supraacetabular external fixator both in B-type and C-type pelvic ring injuries [36]. Whereas all fixation methods could withstand the loading of full body weight bearing in B-type lesions, the external fixator showed no significant holding force in C-type lesions. In their biomechanical investigation, Simonian et al.
Eur J Trauma Emerg Surg 2010 Æ No. 2
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
Pelvic external fixation is adequate for the provisional fixation of B- and C-type lesions without severe bleeding. It reduces pelvic volume and creates a mechanical stability, which helps to reduce bleeding from broken cancellous bone and which enhances the chances of clotting of torn veins of the dorsal venous plexus. It is compulsory in patients who need laparotomy and is strongly recommended in patients who need nailing of the lower extremities. It can be a definitive treatment in B-type lesions and part of the definitive treatment of C-type lesions.
Figure 4. Anteroinferior pelvic external fixator. Two pins are drilled from the anterior inferior iliac spine towards the posterior inferior iliac spine and connected with a simple external fixator frame.
found that the pelvic external fixator realizes less stability in the posterior pelvic ring than the C-clamp; both fixation methods significantly enhance stability in the anterior pelvic ring [37]. Therefore, pelvic external fixation is more useful in rotationally unstable pelvic ring lesions, in which the dorsal pelvic ring is not completely disrupted, than in vertically unstable lesions. In case that lesions in neighboring body regions must be treated operatively at the same time, external fixation of the pelvis is recommended as a protecting stabilization. When urgent laparotomy is needed, external fixation of any unstable pelvic ring lesion is done in advance. Otherwise, retraction of the abdominal muscles during laparotomy will increase external rotation of the injured hemipelvis; additional instability will enhance the risk of retroperitoneal bleeding [38]. The latter may also be the case for patients with femur or tibia fractures, where primary nailing is considered. Hammering a nail into femur or tibia will dislocate fracture fragments of an unstable pelvis. Therefore, the pelvic ring should be stabilized before the nailing procedure is started. Surgical packing of the small pelvis for the treatment of ongoing bleeding can only be successful when pelvic external fixation is carried out beforehand. External fixation and C-clamping create mechanical stability; the fixed bony structures form a resistance to which packing is effective [39]. Contrary to the pelvic binder and C-clamp, the external fixator can remain longer on the pelvic ring. In rotationally unstable lesions, it can be a definitive treatment; in vertically unstable lesions, it can be an adjunct to dorsal internal fixation. In a personal series of 222 pelvic ring lesions, external fixation was part of the definitive treatment in 52% of B-type and in 38% of C-type lesions [40].
Eur J Trauma Emerg Surg 2010 Æ No. 2
Pelvic Packing In some European trauma centers, pelvic packing has been advocated as an additional damage control procedure in posttraumatic pelvic bleeding [39, 41]. The goal is to control bleeding which originates from broken cancellous bone, from the dorsal venous plexus, and from smaller arteries. Packing can be done through an intraperitoneal or extraperitoneal approach. When there are no abdominal lesions, a laparotomy is not needed. Through a short incision above the symphysis pubis, the midline fascial layer between both rectus abdominis muscles is transected. The peritoneum is not opened. Immediately, large amounts of blood and blood clots evacuate from the small pelvis. Because of traumatic dissection and bleeding, it is easy to enter the small pelvis. After drainage of hematoma, several towels are placed in the void of the drained hematoma, typically in the retropubic space or along the medial walls of the posterior columns and acetabulum. As packing is only possible in a stable environment, external fixation or C-clamping of the pelvic ring needs to be done on beforehand. Papakostidis evaluated the results of three larger series [39, 41–43]. Pelvic packing significantly reduced the blood transfusion requirement in all cases. The early mortality rate was 10%, late mortality rate 13%, and the overall mortality 28%. Major complications were infection in 35% and multiple organ failure in 9%. Pelvic packing is clearly a damage control procedure. A second-look operation for the removal of towels, further debridement, and specific suturing of remaining bleeding sources is mandatory. During the second procedure, internal fixation of the anterior pelvis can be done. Packing is also not competitive to pelvic angiography and selective embolization. In the series of Cothren et al., 5 out of 28 patients underwent successful angiography with embolization after pelvic packing because of clinical concern of ongoing bleeding [43]. Suzuki et al. suggest pelvic packing to be done in the operating theater
95
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
during the time of preparation of the angiography suite in patients who remain hemodynamically unstable, despite resuscitation [44].
Pelvic Angiography and Selective Embolization Posttraumatic pelvic bleeding originates from fractures through the cancellous bone of the dorsal pelvis, from the posterior venous plexus, and from arterial bleeding. Venous bleeding and bleeding from broken bone are the major sources of hypovolemia. They are not suitable for angiography and embolization. Arterial bleeding is seen in less than 10% of cases. In a series of 806 patients with pelvic fractures, only 35 (4.3%) underwent angiography and 15 (1.9%) needed selective embolization [15]. The major dilemma in the severely injured is distinguishing patients with ongoing venous bleeding from patients with arterial blood loss. Typically, patients with arterial bleeding present with major pelvic instability due to the large displacement of fracture fragments, reflecting huge energy impact. We must be very careful judging these patients (Figure 5). What are further characteristics of these patients at risk? Jeroukhimov et al. investigated the data of 29 cases in a series of 106 patients with major pelvic trauma who underwent angiography. These patients had a significantly higher pelvic AIS and lower base excess levels on admission. A blood transfusion rate of greater than 0.5 units per hour was found to be a reliable indicator for early angiography [45]. Miller et al. identified repeated episodes of hypotension despite resuscitation as the best indicator for arterial bleeding. Adequate response to initial resuscitation was defined as a sustained (>2 h) improvement of
Figure 5. A 10-year-old boy with unstable pelvic fracture, hemodynamic instability, and rapidly growing hematoma in the right groin. There must be a high index of suspicion of arterial bleeding in this patient.
96
systolic blood pressure to > 90 mm Hg after the administration of less than two or exactly two packed red blood cells. Seventy-three percent of nonresponding patients had a positive angiography [46]. In patients amenable to emergency multislice CT with contrast-enhanced angiographic technique, the diagnosis of active pelvic bleeding can be made early. Contrast extravasation not only confirms but also identifies the source of bleeding thanks to knowledge of the anatomy of the region of the pelvis where the extravasation is noted (Figure 6) [47, 48]. In a large series of patients with pelvic fractures and selective angiography, selective embolization was carried out in 80%. The angiographic success ratio was between 95 and 100%, the clinical success ratio between 81 and 95%, and the global mortality was between 14 and 28% [49–51]. Complications are few but severe: gluteal muscle and skin necrosis or sensitivity problems [52]. While pelvic angiography and selective embolization has proven to be successful, the question remains on what should be done first. Reviewing the literature, preference is guided by the profile of the authors:
Figure 6. Multislice computed tomography (CT) with contrast-enhanced angiographic technique in patient with a combined pelvicacetabular fracture. A large hematoma (large arrow) in the right hemipelvis with displacement of the external iliac artery is visible. There is extravasation of contrast product out of the artery (small arrow).
Eur J Trauma Emerg Surg 2010 Æ No. 2
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
trauma surgeons prefer external fixation or C-clamping followed by pelvic packing, radiologists and general surgeons prefer embolization [46, 53, 54]. Pelvic angiography and selective embolization need specific infrastructure and medical expertise, which must be available on every occasion. It is a complex and timeconsuming procedure and, therefore, cannot be recommended for patients in extremis. Their chance of survival is higher in the hands of surgeons who master several damage control procedures such as pelvic Cclamping, external fixation, and pelvic packing. When patients respond well to resuscitation measures, angiography is not needed or can be postponed. Patients who do not stabilize permanently during resuscitation may benefit from pelvic angiography and selective embolization. However, it should not be used as a firststep procedure in this group. External fixation, which is a compulsory procedure anyhow, should be done first and will control most of the venous bleeding. Pelvic packing is done in patients who do not stabilize after external fixation. Angiography plus embolization is an alternative to pelvic packing. It is a further obligatory step in patients who do not respond well to external fixation followed by packing.
Conclusion Different procedures are available for the acute management of posttraumatic pelvic bleeding. They are not competitive but complementary. They represent different levels of complexity and therapeutic aggressiveness, being appropriate in a specific time slot of resuscitation. In the prehospital phase, pelvic binders are effective in reducing instability of the broken pelvis during transport. During shock-room management and intra-hospital transport, pelvic binders have the same benefit as in the prehospital phase. Because of the dangers of skin necrosis or compartment syndrome, they cannot be applied for longer than a few hours. The pelvic C-clamp is used as a damage control procedure in the emergency room or in the operation theater. It creates high mechanical stability in the dorsal pelvic ring. It is only meaningful in C-type lesions with sacroiliac or trans-sacral instability. External fixation is widely used as the provisional stabilizer of rotational and vertical unstable lesions. It reduces the volume of and creates sufficient stiffness in the pelvic ring for selftamponade and clotting. There is no difference in stiffness between anterosuperior and anteroinferior fixation frames. Pelvic packing creates high local pressure in the small pelvis. The approach to the small pelvis is suprapubic and extraperitoneal. Packing is
Eur J Trauma Emerg Surg 2010 Æ No. 2
performed immediately after external fixation in patients with clinical signs of ongoing bleeding. Pelvic angiography and selective embolization are useful in patients with active arterial bleeding. The right indications can be identified with early multislice computed tomography (CT) with contrast-enhanced angiography or with specific clinical signs. It should not be used as a first-choice procedure. The technique presumes the permanent availability of an adequate infrastructure and specific medical expertise. The clinical success ratio is high. The most suitable patients are those who do not or badly respond to resuscitation measures such as aggressive volume substitution, pelvic C-clamp application, external fixation, or pelvic packing.
Conflict of interest statement The authors declare that there is no actual or potential conflict of interest in relation to this article.
References 1.
Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986;160:445–51. 2. Hessmann MH, Hofmann A, Kreitner KF, Lott C, Rommens PM. The benefit of multislice CT in the emergency room management of polytraumatized patients. Acta Chir Belg 2006;106:500–7. 3. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br 1988;70:1–12. 4. Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 1990;30:848–56. 5. Dalal SA, Burgess AR, Siegel JH, Young JW, Brumback RJ, Poka A, Dunham CM, Gens D, Bathon H. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma 1989;29:981–1000. 6. Moss MC, Bircher MD. Volume changes within the true pelvis during disruption of the pelvic ring—where does the haemorrhage go? Injury 1996;27:S-A21–3. 7. Grimm MR, Vrahas MS, Thomas KA. Pressure–volume characteristics of the intact and disrupted pelvic retroperitoneum. J Trauma 1998;44:454–9. 8. Dyer GSM, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury 2006;37:602–13. 9. Pohlemann T, Gänsslen A, Stief CH. Complex injuries of the pelvis and acetabulum. Orthopäde 1998;27:32–44. 10. Bosch U, Pohlemann T, Haas N, Tscherne H. Classification and management of complex pelvic trauma. Unfallchirurg 1992;95:189–96. 11. Jones AL, Powell JN, Kellam JF, McCormack RG, Dust W, Wimmer P. Open pelvic fractures. A multicenter retrospective analysis. Orthop Clin North Am 1997;28:345–50.
97
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
12.
13.
14. 15.
16. 17.
18.
19.
20.
21. 22. 23. 24.
25.
26. 27.
28. 29. 30.
31.
32. 33.
98
Grotz MR, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis PV. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005;36:1–13. Huittinen VM, Slätis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454–62. White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury 2009;40:1023–30. Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF 3rd. Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 1997;43: 395–9. Perez JV, Hughes TM, Bowers K. Angiographic embolisation in pelvic fracture. Injury 1998;29:187–91. Bottlang M, Krieg JC, Mohr M, Simpson TS, Madey SM. Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg Am 2002;84:43–7. Simpson T, Krieg JC, Heuer F, Bottlang M. Stabilization of pelvic ring disruptions with a circumferential sheet. J Trauma 2002;52:158–61. Nunn T, Cosker TD, Bose D, Pallister I. Immediate application of improvised pelvic binder as first step in extended resuscitation from life-threatening hypovolaemic shock in conscious patients with unstable pelvic injuries. Injury 2007;38:125–8. Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma 2005;59:659–64. Jowett AJL, Bowyer GW. Pressure characteristics of pelvic binders. Injury 2007;38:118–21. Ganz R, Krushell RJ, Jakob RP, Küffer J. The antishock pelvic clamp. Clin Orthop Relat Res 1991;267:71–8. Pohlemann T, Culemann U, Tosounidis G, Kristen A. Application of the pelvic C-clamp. Unfallchirurg 2004;107:1185–91. Heini PF, Witt J, Ganz R. The pelvic C-clamp for the emergency treatment of unstable pelvic ring injuries. A report on clinical experience of 30 cases. Injury 1996;27::S-A38–45. Tiemann AH, Böhme J, Josten C. Use of the pelvic clamp in polytraumatised patients with unstable disruption of the posterior pelvic ring. Modified technique – risks – problems. Orthopäde 2006;35:1225–36. Kellam JF. The role of external fixation in pelvic disruptions. Clin Orthop Relat Res 1989;241:66–82. Broos P, Vanderschot P, Craninx L, Reynders P, Rommens P. Internal hemorrhages associated with fractures of the pelvic girdle. Importance of early stabilization using an external fixator. Acta Orthop Belg 1993;59:130–8. Rommens PM. Pelvic ring injuries: a challenge for the trauma surgeon. Acta Chir Belg 1996;96:78–84. Siegmeth A, Müllner T, Kukla C, Vécsei V. Associated injuries in severe pelvic trauma. Unfallchirurg 2000;103:572–81. Gänsslen A, Pohlemann T, Krettek C. A simple supraacetabular external fixation for pelvic ring fractures. Oper Orthop Traumatol 2005;17:296–312. Rommens PM, Hessmann MH. External fixation for the injured pelvic ring. In: Tile M, Helfet DL, Kellam JF, eds. Fractures of the pelvis and acetabulum. Philadelphia: Lippincott Williams and Wilkins, 2003:203–16. Slätis P, Karaharju EO. External fixation of the pelvic girdle with a trapezoid compression frame. Injury 1975;7:53–6. Bircher MD. Indications and techniques of external fixation of the injured pelvis. Injury 1996;27[suppl 2]:B3–19.
34. Kim WY, Hearn TC, Seleem O, Mahalingam E, Stephen D, Tile M. Effect of pin location on stability of pelvic external fixation. Clin Orthop Relat Res 1999;361:237–44. 35. de Ridder VA, de Lange S, Popta JV. Anatomical variations of the lateral femoral cutaneous nerve and the consequences for surgery. J Orthop Trauma 1999;13:207–11. 36. Pohlemann T, Krettek C, Hoffmann R, Culemann U, Gänsslen A. Biomechanical comparison of various emergency stabilization measures of the pelvic ring. Unfallchirurg 1994;97:503–10. 37. Simonian PT, Routt ML Jr, Harrington RM, Tencer AF. Anterior versus posterior provisional fixation in the unstable pelvis. A biomechanical comparison. Clin Orthop Relat Res 1995;310:245–51. 38. Hötker U, Rommens PM. Blunt abdominal trauma and severe pelvic rupture. What to do? Acta Chir Belg 1997;97:65–8. 39. Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001;15:468–74. 40. Rommens PM, Hessmann MH. Staged reconstruction of pelvic ring disruption: differences in morbidity, mortality, radiologic results, and functional outcomes between B1, B2/B3, and C-type lesions. J Orthop Trauma 2002;16:92–8. 41. Tötterman A, Madsen JE, Skaga NO, Røise O. Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. J Trauma 2007;62:843–52. 42. Papakostidis C, Giannoudis PV. Pelvic ring injuries with haemodynamic instability: efficacy of pelvic packing, a systematic review. Injury 2009;40:S53–61. 43. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 2007;62:834–9. 44. Suzuki T, Smith WR, Moore EE (2009) Pelvic packing or angiography: competitive or complementary? Injury 40:343–53. 45. Jeroukhimov I, Ashkenazi I, Kessel B, Gaziants V, Peer A, Altshuler A, Nesterenko V, Alfici R, Halevy A. Selection of patients with severe pelvic fracture for early angiography remains controversial. Scand J Trauma Resusc Emerg Med 2009;17:62. 46. Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC. External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 2003;54:437–43. 47. Westhoff J, Laurer H, Wutzler S, Wyen H, Mack M, Maier B, Marzi I. Interventional emergency embolization for severe pelvic ring fractures with arterial bleeding. Integration into the early clinical treatment algorithm. Unfallchirurg 2008;111:821–8. 48. Pinto A, Niola R, Tortora G, Ponticiello G, Russo G, Di Nuzzo L, Gagliardi N, Scaglione M, Merola S, Stavolo C, Maglione F, Romano L. Role of multidetector-row CT in assessing the source of arterial haemorrhage in patients with pelvic vascular trauma. Comparison with angiography. Radiol Med 2010 [Epub ahead of print] PMID:20082229. 49. Velmahos GC, Toutouzas KG, Vassiliu P, sarkisyan G, Chan LS, Hanks SH, Berne TV, Demetriades D. A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma 2002;53:303–8. 50. Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S. The usefulness of transcatheter arterial embolization for patients with blunt polytrauma showing transient response to fluid resuscitation. J Trauma 2004;57:271–6.
Eur J Trauma Emerg Surg 2010 Æ No. 2
Rommens PM et al. Management of Acute Hemorrhage in Pelvic Trauma
51.
Fangio P, Asehnoune K, Edouard A, Smail N, Benhamou D. Early embolization and vasopressor administration for management of life-threatening hemorrhage from pelvic fracture. J Trauma 2005;58:978–84. 52. Yasumura K, Ikegami K, Kamohara T, Nohara Y. High incidence of ischemic necrosis of the gluteal muscle after transcatheter angiographic embolization for severe pelvic fracture. J Trauma 2005;58:985–90. 53. Gänsslen A, Giannoudis P, Pape HC. Hemorrhage in pelvic fracture: who needs angiography? Curr Opin Crit Care 2003;9:515–23. 54. Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J. Clinical review: initial management of blunt pelvic trauma patients with haemodynamic instability. Crit Care 2007;11:204.
Eur J Trauma Emerg Surg 2010 Æ No. 2
Address for Correspondence Prof. Dr. Dr. h.c. Pol M. Rommens Center for Musculoskeletal Surgery University Medical Center Johannes Gutenberg-University Langenbeckstraße 1 55131 Mainz Germany Phone (+49/6131) 17-7292, Fax -4043 e-mail: [email protected]
99
