Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption

Concomitant severe traumatic brain injury is not associated with increased red blood cell transfusion volumes in patients with pelvic fractures: A retrospective observational study

INTRODUCTION

Traumatic brain injury (TBI)-associated coagulopathy significantly influences survival outcomes in patients with multiple injuries. Severe TBI can potentially affect systemic hemostasis due to coagulopathy; however, there is limited evidence regarding whether the risk of hemorrhage increases in patients with pelvic fractures complicated with TBI. Therefore, through multivariable analysis, we aimed to examine the association between severe TBI and increased blood transfusion requirements in patients with pelvic fractures.

MATERIALS AND METHODS

This retrospective observational study was conducted at a tertiary care facility in Japan. Patients aged 16 years or older with pelvic fractures who were admitted to our intensive care unit between April 2014 and December 2021 were included in the analysis. The patients were categorized into no to mild and severe TBI groups according to whether the Head Abbreviated Injury Scale (AIS) score was 3 or higher. The primary outcome was the number of red blood cell (RBC) units transfused within 24 h after arrival at the hospital. The primary outcome was analyzed using univariable and multivariable linear regression analyses. The covariates used for the multivariable linear regression analysis were age, sex, antithrombotic therapy, mechanism of injury, Pelvic AIS score, and extravasation on contrast-enhanced computed tomography on admission.

RESULTS

We identified 315 eligible patients (221 and 94 in the no to mild and severe TBI groups, respectively). In the univariable analysis, the RBC transfusion volume within 24 h after arrival was significantly higher in the severe TBI group than in the no to mild TBI group (2.53-unit increase; 95 % confidence interval [CI]: 0.46-4.61). However, in the multivariable analysis, no statistically significant association was detected between severe TBI and the RBC transfusion volume within 24 h after arrival at the hospital (0.87-unit increase; 95 % CI: -1.11-2.85).

CONCLUSIONS

Concomitant severe TBI was not associated with increased RBC transfusion volumes in patients with pelvic fractures on multivariable analysis.

The Role for Preperitoneal Pelvic Packing in Low-to-Middle-Income Countries: A 16-Year Experience at a Johannesburg Trauma Unit

INTRODUCTION

Preperitoneal pelvic packing for early pelvic haemorrhage control reduces mortality. Bleeding noted with pelvis fractures is predominantly due to associated venous complex injuries. More studies are advocating for angiography as first-line therapy for haemodynamic instability in pelvic fractures; however, these facilities are not in abundance in middle- and low-income countries. We hypothesized that PPP improves outcomes under these circumstances.

METHODS

Retrospective analysis of data from the patients charts over a period of 16 years from 01 January, 2005 to 31 December, 2020. All patients over the age of 18 years who presented with haemodynamic instability from a pelvic fracture and required PPP were included. The demographics, physiological parameter in emergency department, blood products transfused, morbidity and mortality were analysed.

RESULTS

There were 110 patients identified in the study period who underwent pelvic preperitoneal packing for refractory shock or ongoing bleeding. The majority (75.5%) of patients were men (n = 83). The median age was 38 years. The most common mechanism of injury was pedestrian vehicle collision (51%), followed by motor vehicle collisions (27.3%). The median ISS and NISS were 35 and 40, respectively. The median RTS in ED was 4.8(3-6.8). None of our patients rebleed after pack removal and no one needed repacking or adjunct angioembolization in our study group. The in-hospital mortality rate was 43.6% (n = 48) in patients who underwent preperitoneal pelvic packing. The operating room table mortality was 20% (n = 22/110), and the mortality rate of those who survived to ICU transfer was 29.5% (n = 26/88).

CONCLUSIONS

Pelvic preperitoneal packing has a role in the acute management of haemodynamically abnormal patients with pelvic fractures in our environment. In the absence of immediate angioembolization, preperitoneal packing can be lifesaving.

Standard practice in the treatment of unstable pelvic ring injuries: an international survey

PURPOSE

Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe.

METHODS

A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents).

RESULTS

The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization).

CONCLUSION

The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences' impact on outcomes needs to be further explored.

A fatal retroperitoneal bleeding from iliolumbar artery following open reduction and internal fixation of an unstable pelvic ring injury: A case report

RATIONALE

Retroperitoneal bleedings are the result of injury to parenchymal tissue or vascular structures within retroperitoneal cavity. This may arise spontaneously, as a result of trauma or iatrogenically. Patients usually do not manifest clinically apparent signs and symptoms until a substantial amount of blood loss has occurred. Therefore, it is associated with high morbidity and mortality. Herein we present and discuss a case of fatal iatrogenic retroperitoneal bleeding following open reduction and internal fixation of an unstable pelvic ring injury.

PATIENT CONCERNS

A 66-year-old female patient presented to the Level I regional trauma center with severe pelvic pain after a pedestrian collision by a car.

DIAGNOSES

In initial radiography and computed tomography, she was diagnosed with unstable pelvic ring injury.

INTERVENTIONS

Definitive surgery for open reduction and internal fixation through the anterior approach to the sacroiliac joint and anterior intrapelvic approach was performed on the 8th day after the injury.

OUTCOMES

Patient died 3 days after the surgery due to a massive retroperitoneal bleeding from iliolumbar artery.

LESSONS

Insidious retroperitoneal bleeding from the small vessel may lead to fatal massive retroperitoneal hematoma. Therefore, active retroperitoneal bleeding should be suspected in cases of unexplained unstable hemodynamic status following orthopedic pelvic and acetabular surgery.

Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing

INTRODUCTION

in recent decades, the extraperitoneal pelvic packing technique has been disseminated, but there are still few studies. Thus, it was decided to analyze the results of extraperitoneal pelvic tamponade, in patients with pelvic fracture and shock, in order to identify predictive factors for mortality.

METHODS

a retrospective review of medical records of patients submitted to extraperitoneal pelvic packing was conduced. We analyzed their characteristics, prehospital and emergency room data, pelvic fracture classification, associated and severity injuries, laboratory and imaging exams, data on packing, arteriography, and other procedures performed, complications, hemodynamic parameters, and amount of transfused blood products before and after packing.

RESULTS

data were analyzed from 51 patients, who showed signs of shock from prehospital care, presence of acidosis, with high base deficit and arterial lactate levels. Most patients underwent multiple surgical procedures due to severe associated injuries. The incidence of coagulopathy was 70.58%, and overall mortality was 56.86%. The group of non-surviving patients presented significantly higher age, prehospital endotracheal intubation, and lower Glasgow Coma Scale scores (p<0.05). The same group presented, before and after extraperitoneal pelvic packing, significantly worse hemodynamic parameters of mean arterial pressure, pH, base deficit, hemoglobin, and arterial lactate (p<0.05). The non-surviving group received significantly more units of packed red blood cells, fresh frozen plasma and platelets within 24 hours following extraperitoneal pelvic packing (p<0.05).

CONCLUSION

age and base deficit are independent predictors of mortality in patients submitted to extraperitoneal pelvic packing.

Effect of C-Clamp Application on Hemodynamic Instability in Polytrauma Victims with Pelvic Fracture

Background and Objectives: C-clamp application may reduce mortality in patients with unstable pelvic fractures and hemodynamic instability. Decreasing C-clamp use over the past decades may have resulted from concerns about its effectiveness and safety. The purpose of this study was to document effective hemodynamic stabilization after C-clamp application by means of vital parameters (primary outcome parameter), and the subsequent effect on metabolic indices and volume management (secondary outcome parameters). Materials and Methods: C-clamp application was performed between 2014 and 2021 for n = 13 patients (50 ± 18 years) with unstable pelvic fractures and hemodynamic instability. Vital parameters, metabolic indices, volume management, and the correlation of factors and potential changes were analyzed. Results: After C-clamp application, increases were measured in systolic blood pressure (+15 mmHg; p = 0.0284) and mean arterial pressure (+12 mmHg; p = 0.0157), and a reduction of volume requirements (p = 0.0266) and bolus vasoactive medication needs (p = 0.0081) were observed. The earlier C-clamp application was performed, the greater the effect (p < 0.05; r > 0.6). Heart rate, shock index, and end-tidal CO2 were not significantly altered. The extent of base deficit, hemoglobin, and lactate did not correlate with changes in vital parameters. Conclusions: In the majority of hemodynamically unstable trauma patients not responding to initial fluid resuscitation and severe pelvic fracture, early C-clamp application had an additive effect on hemodynamic stabilization and reduction in volume substitution. Based on these findings, there is still a rationale for considering early C-clamp stabilization in this group of severely injured patients.

Role of pelvic packing in the first attention given to hemodynamically unstable pelvic fracture patients: a meta-analysis

PURPOSE

To evaluate the effectiveness of pelvic packing (PP) in pelvic fracture patients with hemodynamic instability.

MATERIALS AND METHODS

Three databases-PubMed, Embase and the Cochrane Library-were systematically searched to identify studies presenting comparisons between a protocol including PP and a protocol without PP. Mortality, transfusion requirement and length of hospitalization were extracted and pooled for meta-analysis. Relative risk (RR) and standard mean difference (SMD), along with their confidence intervals (CIs), were used as the pooled statistical indices.

RESULTS

Eight studies involving 480 patients were identified as being eligible for meta-analysis. PP usage was associated with significantly reduced overall mortality (RR = 0.61, 95% CI = 0.47-0.79, p < 0.01) as well as reduced mortality within 24 h after admission (RR = 0.42, 95% CI = 0.26-0.69, p < 0.01) and due to hemorrhage (RR = 0.26, 95% CI = 0.14-0.50, p < 0.01). The usage of PP also decreased the need for pre-operative transfusion (SMD = - 0.44, 95% CI = - 0.69 to - 0.18, p < 0.01), but had no influence on total transfusion during the first 24 h after admission (SMD = 0.05, 95% CI = - 0.43-0.54, p = 0.83) and length of hospitalization (ICU stay and total stay).

CONCLUSIONS

This meta-analysis indicates that a treatment protocol including PP could reduce mortality and transfusion requirement before intervention in pelvic fracture patients with hemodynamic instability vs. angiography and embolization. This latter technique could be used as a feasible and complementary technique afterwards.

LEVEL OF EVIDENCE: 3

Complications Following Temporary Bilateral Internal Iliac Artery Ligation for Pelvic Hemorrhage Control in Trauma

Background: Temporary bilateral internal iliac artery ligation (TBIIAL) is an option for surgical control of pelvic hemorrhage after trauma. Concerns persist that complications, particularly gluteal necrosis, following TBIIAL should preclude its use, despite a lack of formal research on TBIIAL complications. This study aimed to define complications following TBIIAL for emergent control of traumatic pelvic bleeding.Study Design: Patients undergoing TBIIAL after blunt trauma (2008-2020) at our level 1 trauma center were included without exclusions. Demographics, clinical/injury data, and outcomes were collected. Descriptive statistics summarized study variables. Multivariable analysis of factors independently associated with mortality after TBIIAL was performed.Results: In total, 77 patients undergoing emergent TBIIAL after blunt trauma were identified. Median age was 46 [IQR 29-63] years. Most patients (n = 70, 91%) were severely injured (ISS ≥16), with 43% undergoing resuscitative thoracotomy prior to TBIIAL. No local complications (gluteal necrosis, iatrogenic injury, fascial dehiscence, surgical site infection) after TBIIAL occurred over the 13-year study period. In the first 28 days after injury, median hospital-, ICU-, and ventilator-free days were 0. Mortality was 70% (n = 54). On multivariable analysis, older age was the only variable independently associated with in-hospital mortality (OR 1.081, P = .028).Conclusion: Zero cases of gluteal necrosis, iatrogenic injury to surrounding structures, or surgical site infection/fascial dehiscence of the exploratory laparotomy occurred over the study period. High concern for gluteal necrosis after TBIIAL in severely injured trauma patients is unfounded and should not prevent a surgeon from obtaining prompt pelvic hemorrhage control with this technique among patients in extremis.

Fatores preditivos de mortalidade em pacientes com fratura de pelve e instabilidade hemodinâmica submetidos ao tamponamento extraperitoneal de pelve

RESUMO Introdução: nas últimas décadas, tem sido difundida a técnica de tamponamento pélvico extraperitoneal, porém ainda existem poucos estudos. Decidiu-se analisar os resultados do tamponamento extraperitoneal de pelve, em pacientes com fratura pélvica e choque, com objetivo de identificar fatores preditivos de mortalidade. Métodos: foi realizada revisão do prontuário dos pacientes submetidos ao tamponamento extraperitoneal de pelve. Foram analisadas as características dos pacientes, dados do atendimento pré-hospitalar e na sala de emergência, classificação da fratura, presença de lesões associadas, exames laboratoriais e de imagem, dados relativos ao tamponamento, e outros procedimentos realizados, complicações, parâmetros hemodinâmicos e quantidade de hemoderivados transfudidos. Resultados: foram analisados os dados de 51 pacientes, com sinais de choque desde o atendimento pré-hospitalar, presença de acidose, elevado déficit de bases e lactato arterial. Houve alta prevalência de lesões graves associadas, requerendo múltiplos procedimentos cirúrgicos. A incidência de coagulopatia foi 70,58% e mortalidade 56,86%. O grupo de pacientes não sobreviventes apresentou idade e intubação orotraqueal pré-hospitalar maiores, e escores na escala de coma de Glasgow menores (p<0,05). O mesmo grupo apresentou, antes e após o tamponamento extraperitoneal de pelve, parâmetros hemodinâmicos menores de pressão arterial média, pH, déficit de bases e hemoglobina, e maior de lactato arterial (p<0,05). O grupo de pacientes não sobreviventes recebeu mais concentrados de hemácias, plasma fresco congelado e concentrado de plaquetas nas 24h seguintes ao tamponamento extraperitoneal de pelve (p<0,05). Conclusão: idade e o excesso de bases são fatores preditivos independentes de mortalidade em pacientes submetidos ao tamponamento extraperitoneal de pelve.

The past, present, and future management of hemodynamic instability in patients with unstable pelvic ring injuries

Pelvic ring injuries presenting in hemorrhagic shock have historically had a mortality rate greater than 30%. To address this high mortality rate our institution has had a multi-disciplinary protocol for hemodynamically unstable pelvic ring injuries since 1993. In 2004, this protocol was revised to prioritize pre-peritoneal pelvic packing over angiography to rapidly control hemorrhage, reduce high-volume blood transfusions, and decrease the number of deaths from acute blood loss. This protocol has been successful in reducing deaths from hemorrhage by 30%. Despite the benefits of such a protocol, many trauma centers are not routinely stabilizing pelvic ring injuries or controlling pelvic hemorrhage. Subsequently, mortality rates remain high with a significant proportion of patients dying from acute blood loss. Trauma centers adhering to multi-disciplinary protocols that allow for rapid stabilization of the pelvis and simultaneous control of multiple sites of hemorrhage in hybrid operative suites are promising future directions for the management of patients with these lethal injuries.

Management and outcomes of open pelvic fractures: An update

BACKGROUND

Open pelvic fractures remain challenging in terms of their management. The purpose of this narrative review was to evaluate the latest advances made in the management of these injuries and report on their clinical outcome.

PATIENTS AND METHODS

A literature review was undertaken focusing on studies that have been published on the management of open pelvic fractures between January 2005 and November 2019. Information extracted from each article include demographics, mechanism of injury, injury severity score (ISS), classification of pelvic ring fracture, classification of open soft tissue, specific injury zone classification, number of cases with hemodynamic instability, number of cases that received blood transfusions, amount of packed red blood cells transfused during the first 24 h, number of cases with anorectal trauma, urogenital injury, number of fecal diversional colostomies and laparotomies, angiographies and embolization, preperitoneal pelvic packings, length of stay in intensive care unit (ICU) and in hospital, and mortality.

RESULTS

Fifteen articles with 646 cases formed the basis of this review. The majority of patients were male adults (74.9%). The mean age was 35.1 years. The main mechanism of injury was road traffic accidents, accounting for 67.1% of the injuries. The mean ISS was 26.8. A mean of 13.5 units of PRBCs were administered the first 24 h. During the whole hospital stay, 79.3% of the patients required blood transfusions. Angiography and pelvic packing were performed in a range of 3%-44% and 13.3%-100% respectively. Unstable types of pelvic injuries were the majority (72%), whilst 32.7% of the cases were associated with anorectal trauma, and 32.6% presented with urogenital injuries. Bladder ruptures were the most reported urogenital injury. Fecal diversional colostomy was performed in 37.4% of the cases. The mean length of ICU stay was 12.5 days and the mean length of hospital stay was 53.0 days. The mean mortality rate was 23.7%.

CONCLUSION

Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. Sufficient blood transfusion, bleeding control, treatments of associated injuries, fracture fixation and soft tissue management remain essential for the reduction of mortality and improved outcomes.

Endovascular Management of Pelvic Trauma

Major pelvic fractures result from high-energy trauma including traffic accidents and falls, which usually leads to multiple injuries complicating the patient's management. Management of these patients requires a coordinated multidisciplinary approach. Transcatheter embolization is a minimally invasive and effective technique to control massive hemorrhage and can be performed using a variety of embolic agents. It has become an accepted first-line management option for retroperitoneal bleeds in many centers. In this article, the indications for endovascular management of hemorrhage from pelvic trauma, the various embolization techniques, and potential complications will be discussed.

The effect of preperitoneal pelvic packing for hemodynamically unstable patients with pelvic fractures

PURPOSE

Hemodynamically unstable patients with pelvic fractures still represent a challenge to trauma surgeons and have a very high mortality. This study was designed to explore the effect of the interventions of direct preperitoneal pelvic packing for the hemodynamically unstable pelvic fractures.

METHODS

This retrospective study enrolled 67 cases of severe pelvic fractures with unstable hemodynamics from October 2011 to December 2019. All patients presented in our emergency center and received preperitoneal pelvic packing were included in this study. The indication was persistent systolic blood pressure ≤90 mmHg during initial resuscitation and after transfusion of two units of red blood cells. Patients with hemodynamic stability who need no preperitoneal pelvic packing to control bleeding were excluded. Their demographic characteristics, clinical features, laboratory results, therapeutic interventions, adverse events, and prognostic outcomes were collected from digital information system of electronic medical records. Statistics were described as mean ± standard deviation or medium and analyzed using pair sample t-test or Mann-Whitney U-test.

RESULTS

The patients' average age was 41.6 years, ranging from 10 to 88 years. Among them, 45 cases were male (67.2%) and 22 cases were female (32.8%). Significant difference was found regarding the systolic blood pressure (mmHg) in the emergency department (78.4 ± 13.9) and after preperitoneal pelvic packing in the surgery intensive care unit (100.1 ± 17.6) (p < 0.05). Simultaneously, the arterial base deficit (mmol/L) were significantly lower in the surgery intensive care unit (median -6, interquartile range -8 to -2) than in the emergency department (median -10, interquartile range -14 to -8) (p < 0.05). After preperitoneal pelvic packing, 15 patients (22.4%) underwent pelvic angiography for persistent hypotension or suspected ongoing haemorrhage. The overall mortality rate was 29.5% (20 of 67).

CONCLUSIONS

Preperitoneal pelvic packing, as a useful surgical technique, is less invasive and can be very efficient in early intra-pelvic bleed control.

A nomogram to predict arterial bleeding in patients with pelvic fractures after blunt trauma: a retrospective cohort study

Background

Pelvic bone fractures are one of the biggest challenges faced by trauma surgeons. Especially, the presence of bleeding and hemodynamic instability features is associated with high morbidity and mortality in patients with pelvic fractures. However, prediction of the occurrence of arterial bleeding causing massive hemorrhage in patients with pelvic fractures is difficult. Therefore, the aim of this study was to develop a nomogram to predict arterial bleeding in patients with pelvic bone fractures after blunt trauma.

Methods

The medical records of 1404 trauma patients treated between January 2013 and August 2017 were retrospectively reviewed. Patients older than 15 years with a pelvic fracture due to blunt trauma were enrolled (n = 148). The pelvic fracture pattern on anteroposterior radiography was classified according to the Orthopedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO) system. Multivariable logistic regression modeling was used to determine the independent risk factors for arterial bleeding. A nomogram was constructed based on the identified risk factors.

Results

The most common pelvic fracture pattern was type A (58.8%), followed by types B (34.5%) and C (6.7%). Of the 148 patients, 28 (18.9%) showed pelvic arterial bleeding on contrast-enhanced computed tomography or angiography, or in the operative findings. The independent risk factors for arterial bleeding were a type B or C pelvic fracture pattern, body temperature < 36 °C, and serum lactate level > 3.4 mmol/L. A nomogram was developed using these three parameters, along with a systolic blood pressure < 90 mmHg. The area under the receiver operating characteristic curve of the predictive model for discrimination was 0.8579. The maximal Youden index was 0.1527, corresponding to a cutoff value of 68.65 points, which was considered the optimal cutoff value for predicting the occurrence of arterial bleeding in patients with pelvic bone fractures.

Conclusions

The developed nomogram, which was based on the initial clinical findings identifying risk factors for arterial bleeding, is expected to be helpful in rapidly establishing a treatment plan and improving the prognosis for patients with pelvic bone fractures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02247-2.

Secondary Angio-Embolization After Emergent Pelvic Stabilization and Pelvic Packing Is a Safe Option for Patients With Persistent Hemorrhage From Unstable Pelvic Ring Injuries

Introduction: In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. While mechanical pelvic ring stabilization and pre-peritoneal pelvic packing are mainly addressing venous bleeding, angio-embolization aims to control arterial bleeding. The goal of the present study was to evaluate the rate of postoperative angio-embolization after mechanical pelvic ring injury stabilization and pre-peritoneal pelvic packing. Bleeding sources detected in the angiography and the patient's outcome were investigated.

Patients and Methods: Retrospective observational cohort study at a single academic level I trauma center, reviewing all patients with pelvic ring injuries admitted from 01/2010 to 12/2019. Patients with emergent mechanical pelvic ring stabilization (supraacetabular external fixator and/or pelvic C-clamp) and direct pre-peritoneal pelvic packing were further analyzed. Patients that underwent postoperative angio-embolization were compared with those that did not. All postoperative angio-embolizations were evaluated with regards to bleeding sources and type of embolization.

Results: During the study period, a total of 39 patients required immediate mechanical pelvic stabilization and direct pre-peritoneal pelvic packing. Of these, 12 patients (30.8%) underwent a postoperative angio-embolization. The following vessels were identified as bleeding sources: superior gluteal artery (n = 6), obturator artery (n = 2), internal pudendal artery (n = 2), unnamed branches of the internal iliac artery (n = 3). A selective embolization was successful in 11 patients; in 1 patient, an unilateral complete occlusion of the internal iliac artery was performed to control the bleeding. Mean time from hospital admission to the surgical procedure was 52.8 ± 14.7 min and the mean time from admission to angio-embolization was 189.1 ± 55.5 min. The in-hospital mortality rate of patients with angio-embolization was 25.0% (n = 3). Of these, 2 patients died due to multiple organ failure and 1 patient due to severe head injury.

Conclusion: Secondary angio-embolization after external pelvic fixation and pre-peritoneal pelvic packing was effective in controlling ongoing bleeding. The most frequently detected bleeding vessel was the superior gluteal artery, which is difficult to surgically address, further highlighting the importance of angio-embolization in the management algorithm.

Resuscitative Endovascular Balloon Occlusion of the Aorta vs Pre-Peritoneal Packing in Patients with Pelvic Fracture

BACKGROUND

Pelvic hemorrhage is potentially lethal despite homeostatic interventions such as pre-peritoneal packing (PP), resuscitative endovascular balloon occlusion of the aorta (REBOA), surgery, and/or angioembolization. REBOA may be used as an alternative/adjunct to PP for temporizing bleeding in patients with pelvic fractures. Our study aimed to compare the outcomes of REBOA and/or PP, as temporizing measures, in blunt pelvic fracture patients. We hypothesized that REBOA is associated with worsened outcomes.

STUDY DESIGN

We performed a 2017 review of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) and identified trauma patients with blunt pelvic fractures who underwent REBOA placement and/or PP before laparotomy and/or angioembolization. Propensity score matching was performed, adjusting for demographics, vitals, mechanism of injury, ISS, each body region-AIS, and pelvic fracture type. Outcomes were complication rates and mortality.

RESULTS

A total of 156 patients (PP: 52; REBOA: 52; REBOA+PP: 52) were matched and included. Mean age was 43 ± 18 years, Injury Severity Score (ISS) was 28 (range 17-32), and 74% were males. Overall mortality was 42%. The 24-hour mortality (25% vs 14% vs 35%; p = 0.042), in-hospital mortality (44% vs 29% vs 54%; p = 0.034), and 4-hour pRBC units transfused (15 [9-23] vs 10 [4-19] vs 16 [9-27]; p = 0.017) were lower in the REBOA group. The REBOA group had faster times to both laparotomy (p = 0.040) and/or angioembolization (p = 0.012). There was no difference between the groups in acute kidney injury, lower limb amputations, or hospital and ICU length of stay among survivors.

CONCLUSIONS

REBOA is a less invasive procedure compared with PP and is associated with improved outcomes. Further clinical trials are needed to define the optimal patient who will benefit from REBOA.

Managing polytrauma patients

Embedding physiological markers into treatment algorithms has helped trauma teams rationalise interventions safely and signifies a departure from the dichotomy of damage control orthopaedics (DCO) and early total care (ETC) to early appropriate care (EAC). This has been shown to reduce length of stay and cost to treating centres. This article seeks to provide a clear summary of current concepts for managing orthopaedic injuries in the multiply injured patient.

[Rare combination injury of traumatic spondylolisthesis of the lumbosacral junction and Malgaigne's C3 fracture of the pelvis : Lessons learned]

This article reports on the case of a rare combination injury of a C3 pelvic ring fracture (Malgaigne's fracture) and simultaneous unstable traumatic spondylolisthesis (Meyerding grade 2) of the lumbosacral spine. The patient had pronounced neurological deficits of the lower extremities and tearing of the thecal sac. The selected primary and secondary surgical treatment algorithm of the polytraumatized patient as well as the course are described and critically discussed on the basis of the sparsely available literature.

Extraperitoneal packing in unstable blunt pelvic trauma: A single-center study

BACKGROUND

Hemodynamically unstable pelvic fractures often require a multi-modal approach including both operative and endovascular management. While an important adjunct in hemorrhage control, time to angioembolization even at the most advanced trauma centers may take hours. Extraperitoneal packing (EPP) is a fast and effective procedure that can immediately address pelvic hemorrhage from the retroperitoneal space in severe pelvic injuries. The aim of this study was to evaluate the efficacy of early EPP, looking at 24 hours and overall mortality, and the hemodynamic impact of EPP in unstable blunt pelvic trauma.

METHODS

All trauma patients admitted to an urban Level I trauma center were evaluated from 2002 to 2018 in a retrospective single-center comparative study. Inclusion criteria were patients 14 years or older who sustained blunt trauma with pelvic fractures and hemodynamic instability. Exclusion criteria were a concomitant head injury (Abbreviated Injury Scale >3) and patients who underwent resuscitative thoracotomy. The patient population was divided into two groups: an EPP group and a no-EPP group. Propensity score matching was used to adjust for differences in baseline characteristics in the two groups: a one-to-one matched analysis using nearest-neighbor matching was performed based on the estimated propensity score of each patient.

RESULTS

Two hundred forty-four patients presented hemodynamically unstable, with a pelvic fracture (180 no-EPP, 64 EPP). With propensity score matching, 37 patients in each group were analyzed. Survival within the first 24 hours was significantly improved in the EPP group (81.1% vs. 59.5%, p = 0.042) and we registered similar results in overall survival rate (78.4% EPP group vs. 56.8% no-EPP group, p = 0.047). Those patients who underwent early EPP (n = 64) were associated with a significant improvement in hemodynamic stability, with a pre-EPP mean arterial pressure of 49.9 mm Hg and post-EPP mean arterial pressure of 70.1 mm Hg (p < 0.01).

CONCLUSION

Extraperitoneal pelvic packing is an effective procedure that can be performed immediately, even within the trauma bay, to improve hemodynamic stability and overall survival in patients who sustain severe blunt pelvic trauma. The early use of EPP can be lifesaving.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Initial experience with the T-Clamp for temporary fixation of mechanically and hemodynamically unstable pelvic ring injuries

In polytrauma patients with unstable pelvic ring injuries, pelvic binders interfere with femoral arterial access and are frequently removed for emergent endovascular and abdominal procedures. The 'trochanteric C-clamp' (T-clamp) is a novel technique described for rapid stabilization of the pelvis without fluoroscopic imaging, while ensuring adequate access to the groin. This case series reports the feasibility and safety following T-clamp application for unstable pelvic ring injuries in patients requiring simultaneous endovascular intervention. Between May 2018 - May 2019, seventeen patients with unstable pelvic ring injuries were treated with a T-clamp in conjunction with other emergent endovascular or intra-abdominal procedures. Nine presented with unstable APC injuries, seven with unstable LC injuries and one with a vertical shear pattern. Complications related to the T-clamp were prospectively collected. Following T-clamp application, there were two cases of intraoperative over-reduction, one of which required exchange for an anterior external fixator. This was the result of a concomitant acetabulum fracture leading to iatrogenic acetabular protrusion secondary to the T-clamp. Twelve cases maintained the T-clamp fixation postoperatively ranging from 1-3 days. One postoperative loss of reduction was noted and required exchange for anterior external fixator. In hemodynamically unstable patients who require emergent endovascular procedures, such as pelvic angiography and REBOA, T-clamp application offers a reasonably safe and effective method for expeditious stabilization of the pelvis while allowing unimpeded access to the abdomen, groin and pelvis. Caution should also be applied in patients with concomitant acetabulum fracture for risk of malreduction. Additionally, its prolonged postoperative use should be limited to patients who are not immediately suitable for fixation of the pelvis.

Preperitoneal Pelvic Packing Is Not Associated With an Increased Risk of Surgical Site Infections After Internal Anterior Pelvic Ring Fixation

OBJECTIVE

To investigate the risk of postoperative surgical site infections after plate fixation of the anterior pelvic ring subsequent to preperitoneal pelvic packing (PPP).

DESIGN

Retrospective observational cohort study.

SETTING

Level I academic trauma center.

PATIENTS

Adult trauma patients with unstable pelvic ring injuries requiring surgical fixation of the anterior pelvic ring.

INTERVENTION

Pelvic plate fixation was performed as a staged procedure after external fixation and PPP/depacking (PPP group; n = 25) or as a single-stage primary internal fixation (control group; n = 87).

MAIN OUTCOME MEASURE

Incidence of postoperative surgical site infections of the pelvic space.

RESULTS

Anterior pelvic plate fixation was performed in 112 patients during a 5-year study period. The PPP group had higher injury severity scores and transfused packed red blood cells than the control group (injury severity score: 46 ± 12.2 vs. 29 ± 1.5; packed red blood cells: 13 ± 10 vs. 5 ± 2; P < 0.05). The mean time until pelvic depacking was 1.7 ± 0.6 days (range: 1-3 days) and 3.4 ± 3.7 days (range: 0-15 days) from depacking until pelvic fracture fixation. Two patients in the PPP group and 8 patients in the control group developed a postoperative infection requiring a surgical revision (8.0% vs. 9.2%; n.s.). Both PPP patients with a pelvic space infection had undergone anterior plate fixation for associated acetabular fractures.

CONCLUSIONS

These data support the safety of the PPP protocol for bleeding pelvic ring injuries due to the lack of increased infection rates after fracture fixation. Caution should be applied when considering PPP in patients with associated acetabular fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Trends and efficacy of external emergency stabilization of pelvic ring fractures: results from the German Pelvic Trauma Registry

PURPOSE

External emergency stabilization (EES) of unstable pelvic fractures reduces haemorrhage and mortality. Available are non-invasive procedures (sheet sling and pelvic binder) and invasive procedures (external fixator and pelvic C-clamp). Nevertheless, there is no recommended standard as to which procedure for EES should be used.

METHODS

Prospectively collected data between 2007 and 2016 from the German Pelvic Trauma Registry were used to evaluate 989 patients with in-hospital EES. Besides age, gender and injury severity score (ISS), the fracture classification was evaluated. Furthermore, the frequency of used EES, time to application, their reported efficacy and the frequencies of change to another EES were investigated.

RESULTS

The use of pelvic binders increased up to 40% while all other procedures decreased in frequency over the 10-year period. The ISS was highest in patients treated with a pelvic C-clamp or combination of pelvic C-clamp and external fixator (p < 0.05). Non-invasive stabilization was applied significantly faster than invasive procedures (p < 0.0001). Overall, the reported efficacy was good (at least 70%) for all procedures but with poorest results for the pelvic binder and best for the external fixator (p < 0.00001). Most change to another EES was found for the sheet sling and pelvic binder.

CONCLUSION

In case of suspected unstable pelvic fracture, an EES should be performed, in case of doubt with a non-invasive EES until imaging and final diagnosis. Which method should be used depends on the individual situation and the available information about the overall injury pattern. Invasive EES are preferable for treatment according to Damage Control Orthopaedics.

Prospective validation of a new protocol with preperitoneal pelvic packing as the mainstay for the treatment of hemodynamically unstable pelvic trauma: a 5-year experience

PURPOSES

Hemodynamically unstable pelvic trauma has been a significant challenge even in most experienced Trauma Centres. In 2011 preperitoneal pelvic packing (PPP) was introduced in our Hospital as the first manoeuvre. This study aims to review overall mortality at 24 h from arrival in the emergency department.

METHODS

A retrospective review of our prospective database was performed considering patients with systolic blood pressure (SBP) < 90 mmHg or with the need for more than 2 Units of packed red blood cells (PRBC) on admission in the emergency department, (ED) and a pelvic fracture. Values were expressed as a median and interquartile range. Continuous variables were compared with the Mann-Whitney test.

RESULTS

Between September 2011 and December 2016, we treated 30 patients. Median age was 51 years (40-65) and Injury Severity Score 36 (34-42). SBP in the ED was 90 (67-99), heart rate was 115 (90-130), Base Excess - 8 (- 11.5/- 4.8), pH 7.23 (7.20-7.28). Median PRBC requirements during the first 24 h (from admission) were 13 Units (8-18.8). Time to emergency treatment was 63 min (51-113). 17 patients (56.6%) underwent angiography after PPP. Overall 24 h mortality was 30%. A comparison between survivors and non-survivors showed no statistically significant differences between groups.

CONCLUSIONS

In our experience, PPP resulted to be quick to perform and effective. No death occurred from direct pelvic bleeding.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

Background

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

Methods

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

Results

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

Conclusions

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.

Current Trends in the Surgical Treatment of Open-Book Pelvic Ring Injuries: An International Survey Among Experienced Trauma Surgeons

INTRODUCTION

In the open-book, rotationally unstable (OTA/AO type 61-B1.1) pelvic ring injury, the posterior sacroiliac complex is believed to remain intact. Therefore, anterior ring stabilization alone has been the standard treatment recommendation. However, treatment failures using this method have caused a reconsideration of this management strategy. Anterior plus posterior fixation is the main alternative. In the absence of any specific new guidelines, the choice of treatment currently relies on the preference of the treating surgeon. The objective of this survey was to determine the relative use of anterior plus posterior fixation, as opposed to the standard anterior fixation alone, for the treatment of open-book pelvic ring injuries.

METHODS

An international group of 176 practicing trauma surgeons experienced in pelvic ring fracture fixation participated in an AO Foundation survey asking for their preferred standard surgical fixation (anterior alone or anterior plus posterior combined) for OTA/AO type 61-B1.1 open-book pelvic fractures.

RESULTS

Anterior plate fixation alone (group 1) was preferred by 56% of the survey participants, and combined anterior plus posterior fixation (group 2) was preferred by 44%. Statistical analysis revealed that group 1 participants were significantly older than group 2 participants (P = 0.03) and had more years of surgical experience (P = 0.02).

CONCLUSIONS

Concern regarding the inadequacy of anterior fixation alone has led many surgeons, especially those more recently in practice, to add posterior fixation, despite limited data to determine its indications. No doubt the OTA/AO type B 1.1 pelvic ring disruption actually represents a wide spectrum of injury. Further study is needed to determine the best fixation method.

Trans-arterial embolisation (TAE) in haemorrhagic pelvic injury: review of management and mid-term outcome of a major trauma centre

BACKGROUND

Management of pelvic fracture associated haemorrhage is often complex with high morbidity and mortality rates. Different treatment options are used to control bleeding with an on-going discussion in the trauma community regarding the best management algorithm.

MAIN BODY

Recent studies have shown trans-arterial embolisation (TAE) to be a safe and effective technique to control pelvic fracture associated haemorrhage. Computed tomography (CT) evidence of active bleeding, haemodynamic instability, and pelvic fracture patterns are amongst important indicators for TAE.

CONCLUSION

Herein, we aim to provide a comprehensive literature review of the effectiveness of TAE in controlling haemorrhage secondary to pelvic fracture according to the indications, technique and embolic agents, and outcomes, whilst incorporating our Level 1 major trauma centre's (MTC) results between 2014-2017.

Factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma: a retrospective study

Background

Blunt pelvic injuries are often associated with pelvic fractures and injuries to the rectum and genitourinary tract. Pelvic fractures can lead to life-threatening hemorrhage, which is a common cause of morbidity and mortality in trauma. Thus, early identification of patients with pelvic fractures at risk severe bleeding requiring urgent hemorrhage control is crucial. This study aimed to investigate early factors predicting the need for hemorrhage control in blunt pelvic trauma.

Methods

The medical records of 1760 trauma patients were reviewed retrospectively between January 2013 and June 2018. We enrolled 187 patients with pelvic fracture due to blunt trauma who were older than 15 years. The pelvic fracture pattern was classified according to the Orthopedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO) classification. A multivariate logistic regression model was used to determine independent predictors of the need for pelvic hemorrhage control intervention.

Results

The most common pelvic fracture pattern was type A (54.5%), followed by types B (36.9%) and C (8.6%). Of 187 patients, 48 (25.7%) required pelvic hemorrhage control intervention. Hemorrhage control interventions were most frequently performed in patients with type B fractures (54.2%). Multivariate logistic regression analysis revealed that type B (odds ratio [OR] = 4.024, 95% confidence interval [CI] = 1.666–9.720, p = 0.002) and C (OR = 7.077, 95% CI = 1.781–28.129, p = 0.005) fracture patterns, decreased body temperature (OR = 2.275, 95% CI = 0.134–0.567, p < 0.001), and elevated serum lactate level (OR = 1.234, 95% CI = 1.061–1.435, p = 0.006) were factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma.

Conclusion

Patients with type B and C fracture patterns on the OTA/AO classification, hypothermia, or an elevated serum lactate level are at risk for bleeding and require pelvic hemorrhage control intervention.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0438-8) contains supplementary material, which is available to authorized users.

Current trends in the management of hemodynamically unstable pelvic ring injuries

PURPOSE OF REVIEW

Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries.

RECENT FINDINGS

Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization.

SUMMARY

Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.

Use of the Pelvic C-Clamp to Mitigate Acute Respiratory Distress Syndrome in a Patient with an Unstable Sacral Fracture

Case

We present the case of a 21-year-old man who fell from a roof, sustaining a displaced sacral fracture with pelvic instability. He developed acute respiratory distress syndrome (ARDS) within 24 hours of injury. Placement of the pelvic C-clamp resulted in rapid resolution of pulmonary dysfunction, allowing for definitive internal fixation.

Conclusion

The C-clamp is most commonly used to control hemorrhage in unstable posterior pelvic ring injuries. Our case demonstrates a rare use of the C-clamp to stabilize the posterior pelvis in a patient with an unstable sacral fracture and ARDS, to rapidly improve pulmonary function prior to definitive surgery.

Severe Bleeding in Pelvic Fractures: Considerations in Planning Damage Control

Severe bleeding due to pelvic fractures may require damage control procedures, such as preperitoneal packing. In many cases, preperitoneal packing is performed without full abdominal exploration. There are concerns that such an approach may miss major iliac vascular injuries or other intraabdominal injuries. This analysis assessed the incidence of iliac vascular and intraabdominal injuries in patients with pelvic fractures. The National Trauma Data Bank was queried for blunt trauma patients. Patients with severe pelvic fractures were observed. Common or external iliac vascular lacerations (CEIVL) and associated intraabdominal injuries were recorded. The study comprised 42,122 patients with pelvic fractures, of which 3,221 (7.6%) were severe pelvic fractures. The incidence of CEIVL in patients with severe pelvic fractures was 10.7 per cent. Patient age greater than or equal to 65 years was an independent predictor of CEIVL. A total of 34.3 per cent of severe pelvic fracture patients had severe associated intraabdominal injuries, including injuries to the bladder (26.5%) and bowel (16.7%). Severe pelvic fractures are associated with a high incidence of iliac vascular and intraabdominal injuries. Preperitoneal pelvic packing without abdominal exploration may miss these injuries.

Effects of the establishment of a trauma center and a new protocol on patients with hemodynamically unstable pelvic fractures at a single institution in Korea

PURPOSE

The aim of this study was to determine whether the outcomes of patients with hemodynamically unstable pelvic bone fractures changed after the introduction of a protocol including extraperitoneal pelvic packing (EPP) and the establishment of a trauma center.

METHODS

We analyzed data of adult patients (≥ 18 years old) with hemodynamically unstable pelvic bone fractures who visited a single trauma center from February 2009 to October 2016. In July 2014, a new protocol for pelvic fractures was implemented, and a trauma center was established. Therefore, patient outcomes were compared by period (period I: pre-protocol vs. period II: post-protocol).

RESULTS

Seventy-nine patients with hemodynamically unstable pelvic bone fractures were recruited. The time to angiographic embolization after arrival at the emergency room decreased significantly in period II when compared to period I (182.9 vs. 268.9 min, respectively, p < 0.001). The time required to intervention, including EPP, also decreased, from 268.9 ± 132.4 min in period I to 141.9 ± 79.9 min in period II (p < 0.001). The overall mortality rate decreased from 47.2% in period I to 23.3% in period II (p = 0.033), and mortality related to hemorrhagic shock in particular, was significantly lowered, from 27.8% in period I to 4.7% in period II (p = 0.009).

CONCLUSIONS

The establishment of a trauma center and the implementation of a new protocol that included EPP were effective in the treatment of patients with hemodynamically unstable pelvic fractures.

Effect of angioembolisation versus surgical packing on mortality in traumatic pelvic haemorrhage: A systematic review and meta-analysis

BACKGROUND

The management of complex pattern of bleeding associated with pelvic trauma remains a big challenge for trauma surgeons. We aimed to conduct a comprehensive meta-analysis to compare the outcomes of angioembolisation and pelvic packing in patients with pelvic trauma.

METHODS

We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the CENTRAL; the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists. The primary outcome was defined as mortality. Combined overall effect sizes were calculated using random-effects models. Results are reported as the odds ratio (OR) and 95% confidence interval (CI).

RESULTS

We identified 3 observational studies reporting a total of 120 patients undergoing angioembolisation (n=60) or pelvic packing (n=60) for pelvic trauma. Reporting of the Injury Severity Score (ISS) was variable, with higher ISS in the pelvic packing group. The risk of bias was low in two studies, and moderate in one. The pooled analysis demonstrated that angioembolisation did not significantly reduce mortality in patients with pelvic trauma compared to surgery (OR=1.99; 95% CI= 0.83-4.78, P=0.12). There was mild between-study heterogeneity (I²=0%, P=0.65).

CONCLUSION

Our analysis found no significant difference in mortality between angioembolisation and pelvic packing in patients with traumatic pelvic haemorrhage. The current level of evidence in this context is very limited and insufficient to support the superiority of a treatment modality. Future research is required.

Bleeding Pelvic Fractures: Updates and Controversies in Acute Phase Management

Background

The management of patients with haemodynamic instability related to pelvic fractures is a major challenge with high mortality and morbidity. The treatment priorities have long been a source of debate. Many advocate emergent external fixation (EX-FIX) as the first line of treatment, whereas another school favours the efficacy of transcatheter arterial embolisation (TAE). Decision-making within the ‘Golden Hour’ in the emergency department (ED) is crucial to patients' ultimate outcome. Our aim was to evaluate the current management pathways in our centre and to review the latest literature.

Methods

We present a 2-year case series (from January 2005 to December 2006) of patients with pelvic ring disruption and haemodynamic instability. Data were collected regarding patients' demographics, fracture patterns according to the Young & Burgess classification, concomitant intra-abdominal injuries, treatment pathway and the response to treatment.

Results

There were 7 patients identified. Five were males and 2 were females, with a mean age of 42 years. Fracture types included 3 lateral compression, 1 anteroposterior compression, 2 vertical shear, and 1 combined mechanism. Four patients had significant intraperitoneal haemorrhage identified by Focused Assessment by Sonography for Trauma (FAST). They all needed laporotomy and pelvic packing, initially or subsequently. EX-FIXs were offered to 6 patients as the primary intervention, and 4 of them subsequently required diagnosis with angiography followed by therapeutic embolisation to restore haemodynamic stability. Only 1 patient underwent a second angiographic study to control the arterial bleeding. Two patients died of severe intra-abdominal injuries within 24 hours after admission.

Conclusion

In patients with pelvic fractures and hypotension, EX-FIX is currently the first line of treatment, with variable efficacy. On the other hand, the high successful embolisation rate and reasonable safety profile of TAE in our patients have been impressive. The latter offers a much better alternative to surgical intervention in selected patients. However, precautions should be taken including proper pelvic stabilisation by non-invasive devices, creation of a safe environment in the angiography suite, and early multidisciplinary decision in the ED.

[Influence of external pelvic stabilization on hemodynamically unstable pelvic fractures]

BACKGROUND

In the treatment of complex pelvic fractures hemorrhage control is of primary importance; however, studies regarding the localization of bleeding are contradictory so that various treatment approaches are recommended. The primary aim of external pelvic compression applied in the trauma room is to reduce the pelvic volume and counteract blood loss through self-induced tamponade. This study examined the influence of external pelvic compression on mortality and outcome in cases of hemodynamically unstable pelvic fractures in a larger number of cases.

MATERIAL AND METHODS

The current study used the TraumaRegister DGU® (TR-DGU) to retrospectively evaluate the records of 104 patients treated between 2002 and 2011. All patients suffered severe injury with an injury severity score (ISS) of at least 16 points. In addition, the patients were hemodynamically unstable with confirmed relevant isolated pelvic injuries. To evaluate the effectiveness of external pelvic compression, patients with and without external pelvic stabilization were compared.

RESULTS

Of the investigated patients 26.9 % died of their injuries and of these the mortality was 78.6 % within the first 6 h of admission to the trauma room. External pelvic stabilization was performed in 45.2 % of patients. The mortality was 19.1 % in patients with external pelvic stabilization and in contrast, the mortality in the group of patients without external pelvic stabilization was 33.3 %. During the course of hospitalization, surviving patients with external pelvic stabilization were significantly more likely to develop sepsis or multiple organ failure and required longer periods of intensive care.

CONCLUSION

External pelvic stabilization seems to be an important instrument for the initial treatment of hemodynamically unstable pelvic fractures and showed a positive effect on patient mortality.

Effect of Retroperitoneal Pelvic Packing on Pelvic Cavity Pressure: A Cadaveric Study

Limited clinical evidence demonstrates the effectiveness of direct retroperitoneal pelvic packing for hemorrhage control in pelvic fractures due to the difficulty in measuring pressure on the pelvic walls within the pelvic cavity after retroperitoneal pelvic packing. Using a cadaver model, the authors aimed to assess whether retroperitoneal pelvic packing generates pressure that exceeds the venous return and arterial pressure in the pelvis. The pressure on the pelvic wall was measured in 5 fresh Japanese cadavers. Sensors were placed at 4 points on the pelvic wall, and the pressure at each point was measured after the insertion of each of 3 sponges, per the procedure originally described for direct retroperitoneal pelvic packing. In each specimen, the average pressure across all 4 points on the pelvic wall increased with the addition of each sponge, reaching 12.3±4.5 mm Hg when all 3 sponges were inserted. Furthermore, the pressure at the pelvic floor and posterior pelvic brim increased significantly, whereas the pressure at the anterior and middle pelvic brim increased nonsignificantly. The results of this study suggest that retroperitoneal pelvic packing provides pressure on the pelvic wall that exceeds the venous pressure and is thus effective for the control of venous hemorrhage in pelvic fractures. Currently, the recommended procedure combines external fixation for venous bleeding, transcatheter arterial embolization, and pelvic packing; however, the authors' results suggest that pelvic packing alone may be effective for controlling venous hemorrhage in pelvic fracture. [Orthopedics. 2017; 40(6);e947-e951.].

Reduced need for extraperitoneal pelvic packing for severe pelvic fractures is associated with improved resuscitation strategies

BACKGROUND

Extraperitoneal pelvic packing (EPP) was introduced at Oslo University Hospital Ulleval (OUHU) in 1994. Published studies from other institutions have advocated its application as a first-line therapy in lieu of angiography. Extraperitoneal pelvic packing is invasive with a high risk of complications, and its role remains an issue of discussion. In line with international trends, an updated massive hemorrhage protocol was implemented at OUHU in 2007. We hypothesized a decreased need for EPP owing to the major changes in resuscitation strategies.

METHODS

Retrospective analysis of data from the OUH Trauma Registry and patient charts for the period 2002-2012 was performed. All pelvic fractures with Abbreviated Injury Severity (AIS) score of 3 or higher and/or transfused during the period before intensive care unit admission regardless of the pelvic AIS were included. The population was analyzed for trends and differences between 2002-2006 (P1) and 2007-2012 (P2). Further analysis was performed on the group of patients transfused five or more units of red blood cells (RBCs).

RESULTS

We included 648 patients (P1, 297; P2, 351). There was no difference in median injury severity score, pelvic AIS, or age between the two periods. Median base deficit on admission was higher in P2 (4.2 vs 3.3 mmol/L; p < 0.01). The EPP rate decreased from P1 to P2 (17-10%; p < 0.01). A similar reduction in the angiography rate (15% vs 9%; p < 0.01) was observed, with a concomitant decrease in hemorrhage-related deaths (10% vs 5%; p = 0.01). The subgroup analysis of patients transfused five or more units of RBCs revealed significant increase in the use of plasma and platelets in P2. Multiple logistic regression models for the subgroup transfused five or more units of RBCs confirm the change in resuscitation strategy to be significantly associated with reduced EPP, and identifying admission in P2 to be associated with a 63% decreased odds ratio for EPP.

CONCLUSIONS

The EPP and angiography rates for exsanguinating pelvic injuries have decreased with improved resuscitation strategies, reducing RBC requirements and hemorrhage-related deaths.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

The use of external fixators in the definitive stabilisation of the pelvis in polytrauma patients: Safety, efficacy and clinical outcomes

OBJECTIVES

To analyse the complications and outcomes (functional/radiographic) of Pelvic External Fixators applied as part of the definitive fixation in polytrauma patients.

DESIGN

A single center retrospective chart review.

SETTING

A level-1 trauma center.

PATIENTS AND METHODS

We reviewed all the polytrauma patients (ISS>16) between 2007 and 2012 that had a PEF applied more than 30days. Complications including infection, aseptic loosening, neurological injury, loss of reduction, non-union and mal-union were recorded. Pelvic asymmetry and Deformity Index (DI) were measured at the immediate postoperative radiographs and final follow-up. The functional outcome at final follow up was estimated using a scale previously reported by Chiou et al.

RESULTS

59 patients with mean age of 38.4 (16 - 81) years and mean ISS score 28 (16- 66) were included. The PEFs were applied for mean duration of 56 (30-104) days. The average follow-up was 403days. 22 injuries were type B and 37 type C (AO/OTA). The most common symptomatic complications were pin site infection in 11 (18.6%) and loosening in 5 (8.5%) cases. 44 (74.5%) patients had satisfactory functional outcome. The immediate post-operative and final asymmetry and DI were compared between the two pelvic injury groups (type B and C fractures). The difference in displacement progression was more for type C injuries (p=0.034) but no correlation to the functional outcome was evident.

CONCLUSION

PEF can be used as definitive alternative stabilization method in specific situations at polytrauma setting. Radiological displacement occurred in both type B and C injuries but the clinical outcome was not correlated to this displacement. Complications related to PEF do not affect the final clinical outcome.

LEVEL OF EVIDENCE

Therapeutic Level III.

A Method of Using a Pelvic C-Clamp for Intraoperative Reduction of a Zone 3 Sacral Fracture

It is challenging to properly reduce pelvic ring injuries that involve a zone 3 sacral fracture. Several open and closed reduction methods have been described. Percutaneous reductions are challenging, and improper reductions can have poor long-term outcomes. The pelvic C-clamp is a tool designed to provide emergency stabilization to patients suffering from c-type pelvic ring injuries. We describe a case in which a patient's open book pelvic ring injury with a zone three sacral fracture is reduced intraoperatively with the use of a pelvic C-clamp and stabilized with transsacral screws.

Pelvic fracture in multiple trauma: A 67-case series

INTRODUCTION

Severe pelvic trauma remains associated with elevated mortality, largely due to hemorrhagic shock.

OBJECTIVE

The main study objective was to test for correlation between fracture type and mortality. The secondary objective was to assess the efficacy in terms of mortality of multidisciplinary management following a decision-tree in multiple trauma victims admitted to a level 1 trauma center.

MATERIAL AND METHODS

Between July 2011 and July 2013, 534 severe trauma patients were included in a single-center continuous prospective observational study. All patients with hemorrhagic shock received early treatment by pelvic binder. Patients with active bleeding on full-body CT or persisting hemorrhagic shock underwent arteriography with or without embolization. Pelvic trauma was graded on the Tile classification. The principle end-point was mortality.

RESULTS

Median age was 40 years (range, 26-48 years), with a 79% male/female sex ratio. Thirty-two of the 67 patients with pelvic trauma (48%) were in hemorrhagic shock at admission. Median injury severity score (ISS) was 36 (range, 24-43). On the Tile classification, 22 patients (33%) were grade A, 33 (49%) grade B and 12 (18%) grade C. Overall mortality was 19%, and 42% in case of hemorrhagic shock. Mortality was significantly higher with Tile C than A or B (58% vs. 9.1% and 12.1%, respectively; P=0.001).

CONCLUSION

Vertical shear fracture (Tile C) was associated with greater mortality from hemorrhagic shock.

LEVEL OF EVIDENCE

IV, case series.

Abbreviated laparotomy or damage control laparotomy: Why, when and how to do it?

The goal of abbreviated laparotomy is to treat severely injured patients whose condition requires an immediate surgical operation but for whom a prolonged procedure would worsen physiological impairment and metabolic failure. Indeed, in severely injured patients, blood loss and tissue injuries enhance the onset of the "bloody vicious circle", triggered by the triad of acidosis-hypothermia-coagulopathy. Abbreviated laparotomy is a surgical strategy that forgoes the completeness of operation in favor of a physiological approach, the overriding preference going to rapidity and limiting the procedure to control the injuries. Management is based on sequential association of the shortest possible preoperative resuscitation with surgery limited to essential steps to control injury (stop the bleeding and contamination), without definitive repair. The latter will be ensured during a scheduled re-operation after a period of resuscitation aiming to correct physiological abnormalities induced by the trauma and its treatment. This strategy necessitates a pre-defined plan and involvement of the entire medical and nursing staff to reduce time loss to a strict minimum.

Management of Pelvic Ring Injuries in Unstable Patients

High-energy pelvic ring injuries can represent life-threatening injuries in the polytraumatized patient, particularly when presenting with hemodynamic instability. These injuries mandate a systematic multidisciplinary approach to evaluation, and timely intervention to address hemorrhage while concomitantly addressing mechanical instability. These pelvic injuries are associated with potentially lethal hemorrhage originating from venous, arterial, and osseous sources. A thorough understanding of anatomy, radiographic findings, and initial physical examination can alert one to the presence of pelvic instability necessitating emergent treatment. The focus is on hemorrhage control, using techniques for skeletal stabilization, angiography, and open procedures to decrease mortality in this high-risk patient population.

Pelvic ring injuries

Pelvic ring injuries exhibit a wide spectrum of severity; at times devastating with potentially serious immediate and long-term consequences. The anatomical and mechanistic basis of the injured pelvis is described. The non-operative and surgical management of pelvic ring disruption in the acute and definitive care settings is discussed. As emphasized here, basic principles, the mechanism of injury and pattern of instability help guide management.

Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a Propensity Score Analysis

Background

An option for emergency control of pelvic hemorrhage is Extra-peritoneal Pelvic Packing (EPP), which addresses the retroperitoneal source of exsanguination in pelvic fractures. The aim of this study was to demonstrate the efficacy of early EPP in reducing mortality due to hemorrhage from pelvic fractures, and to evaluate the impact of packing on transfusion requirements within the first 24 h and ICU length of stay (ICU-LOS).

All data pertaining trauma patients admitted from October 2002 and December 2103 with hemodynamic instability and pelvic fractures were selected from the Hospital Trauma Registry. Patients with severe brain injury and bleeding from extra-pelvic sources were excluded. Patient population was divided into two groups: EPP group, including patients admitted from 2009 to 2013, with EPP as part of the treatment algorithm, and NO-EPP group, from 2002 to 2008, without EPP as atherapeutic option. Descriptive statistical analysis was performed on allpatients. Twenty-five patients of each group with similar features were matched using Propensity Score Analysis (PSA).

Results

Six hundred eighty out of 4659 major trauma (14.6 %) presented a pelvic fracture. In 78 hemodynamically unstable patients (30 in EPP group,48 in NO-EPP group) the major source of bleeding was the pelvis. Among patients selected by PSA early mortality was significantly reduced in EPP group (20 vs 52 %, p = .03) compared to NO-EPP, notwithstanding similar hemodynamic impairment. No difference was observed in transfusion requirements and ICU-LOS.

Conclusions

The EPP is a safe and quick procedure, able to improve hemodynamic stabilization and to reduce acute mortality due to hemorrhage in patients with pelvic fracture, in combination with optimized transfusion protocol. EPP may be useful as a bridge for time-consuming procedures, such as angio-embolization.