1
|
Patterson JT, Mayfield CK, Gary JL, Chung P, Hasegawa IG, Becerra JA. Pelvic binder radiography detects occult instability in cadaveric simulated lateral compression type I (LC1) pelvic fractures. Injury 2023; 54:111067. [PMID: 37777368 DOI: 10.1016/j.injury.2023.111067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
OBJECTIVES Occult instability in minimally displaced lateral compression (LC) pelvic ring injuries may have clinical relevance for treatment. We describe two novel LC pelvis fracture stress examinations - pelvic binder stress radiography (PBR) and pelvic binder stress bladder manometry (PBM) - which do not require sedation, anesthesia, patient transport, or radiation of personnel. METHODS A biomechanical study was performed with five fresh elderly cadavers. Sequential osteotomies of the pelvis simulated increasingly unstable LC pelvis fracture patterns (OTA/AO 61A2.2, 61B1.1a, 61B1.1b, 61B2.1). Compressive force was quantitatively applied using a pelvic binder and scale. Pelvis fracture displacement was measured on AP and inlet fluoroscopic views. Pelvic bladder pressure (PBM) was measured using a Foley catheter as a water column. RESULTS Fracture displacement strongly correlated with force applied (R2=0.600-0.963). PBR discriminated between simulated LC injuries. Mean displacement of 61B1.1b injuries >1cm was observed at 3.8kg on AP view and 5kg on inlet view. Mean displacement of 61B1.1a injuries >1cm was observed at 8.2kg on AP view and 9.3kg on inlet view. 61A2.2 injuries did not displace >1cm at forces up to 10kg. >95% of 61B1.1a and 61B1.1b injuries displaced >1cm at 10kg. PBM moderately correlated with force applied (R2=0.517-0.842) but did not discriminate between LC injuries. CONCLUSIONS PBR is feasible, precisely quantified occult mechanical instability in simulated LC pelvis fractures in response to reproducible applied force, and discriminated between simulated LC pelvis fractures. PBM did not discriminate between simulated LC fractures. A clinical trial to validate the safety and efficacy of PBR for assessing occult instability in LC pelvis fracture is warranted.
Collapse
Affiliation(s)
- Joseph T Patterson
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery.
| | - Cory K Mayfield
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Joshua L Gary
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Phillip Chung
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Ian G Hasegawa
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Jacob A Becerra
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| |
Collapse
|
2
|
Altamirano-Cruz MA, Velarde JE, Valderrama-Molina CO, Azi M, Belangero WD, Bidolegui F, Carabelli GS, Gómez A, Pires RE, Xicará JA, Giordano V. Availability and use of resources for emergency fracture care of pelvic trauma associated with haemorrhagic shock in Latin America: A cross-sectional study. Injury 2023; 54 Suppl 6:110733. [PMID: 38143149 DOI: 10.1016/j.injury.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/14/2023] [Accepted: 04/12/2023] [Indexed: 12/26/2023]
Abstract
Determining the true availability of resources and understanding the level of training of surgeons involved in the treatment of patients with pelvic fractures and haemorrhagic shock is critical. In the herein study, the availability of technical, technological, and human resources for the care of this injury in Latin America region was analysed, and the preferences of orthopaedic trauma surgeons when performing interventions for the diagnosis and treatment of patients with pelvic trauma and associated haemorrhagic shock was described. A cross sectional web-based survey containing questions on knowledge, attitudes, and practices with respect to imaging resources, emergency pelvic stabilization methods, and interventions used for bleeding control was sent to 948 Latin America orthopaedic trauma surgeons treating pelvic fractures in the emergency department. Differences between regional clusters, level of training, type of hospital, and pelvic surgery volume were assessed. 368 responses were obtained, with 37.5% of respondents reporting formal training in pelvic surgery and 36.0% having available protocol for managing these patients. The most frequently used interventions were the supra-acetabular pelvic external fixator and pelvic packing. Limited hospital and imaging resources are available for the care of patients with pelvic trauma and associated haemorrhagic shock throughout Latin America. In addition, the training of orthopaedic trauma surgeons dealing with this type of injury and the volume of pelvic surgeries per year is heterogeneous. It should be urgently considered to develop management protocols adapted to Latin America according to the availability of resources, as well as to promote training in this severe life-threatening traumatic condition.
Collapse
Affiliation(s)
| | | | | | - Matheus Azi
- Departamento de Ortopedia, Hospital Manoel Victorino, Secretaria Estadual de Saúde do Estado da Bahia, Salvador, Brazil
| | - William Dias Belangero
- Departamento de Ortopedia, Reumatologia e Traumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas UNICAMP, Campinas, SP, Brazil
| | - Fernando Bidolegui
- Servicio de Ortopedia y Traumatologia, Hospital Sirio-Libanes, ECICARO, Buenos Aires, Argentina
| | - Guido Sebastián Carabelli
- Sector de Trauma, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos E. Ottolenghi", Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Amparo Gómez
- Servicio Ortopedia, Hospital Universitario de la Samaritana, Bogota, Colombia
| | - Robinson Esteves Pires
- Departamento do Aparelho Locomotor, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - José Arturo Xicará
- Centro Universitario de Occidente, Universidad de San Carlos de Guatemala, Quetzaltenango, Guatemala; Cruz Roja Guatemalteca, Delegación Quetzaltenango, Quetzaltenango, Guatemala
| | - Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brazil; Clínica São Vicente, Rede D'or São Luiz, Rio de Janeiro, RJ, Brazil
| |
Collapse
|
3
|
DeKeyser GJ, Taylor MA, Allen JD, Firoozabadi R, Githens M, Kleweno CP. The EMS stress view: occult pelvic instability revealed by pre-hospital pelvic binder placement. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03601-2. [PMID: 37289243 DOI: 10.1007/s00590-023-03601-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 05/23/2023] [Indexed: 06/09/2023]
Abstract
PURPOSE To describe and evaluate the serendipitous pelvic binder stress radiographs of lateral compression type (LC) pelvic ring injuries. METHODS This was a retrospective case series performed at a single, level I academic trauma center from 2016 to 2018. All patients presenting with a minimally displaced LC pelvic ring injury were reviewed (< 10 cm displacement on static pelvic radiographs). Patients with X-rays (XR) in a pelvic binder (EMS stress) and with the pelvic binder removed were included. Pelvic ring stability was determined by attending surgeon evaluation of EMS stress radiographs versus static XR of the pelvis. Patients were treated non-operatively and allowed to weight bear or taken to the operating room for exam under anesthesia (EUA) and potential operative fixation. Clinical success of treatment was determined by evaluation of further displacement at the completion of their most recent follow-up. RESULTS Thirty-seven patients of the initial 398 reviewed met inclusion criteria. Fourteen of 37 patients (38%) were categorized as stable with no significant pelvis displacement seen on EMS stress and were treated non-operatively without further sequelae (4.6 months mean follow-up). The remaining 23/37 (62%) were treated operatively. Occult instability was identified on EMS stress in 14 (61%) of those 23 patients and the remainder were determined to be unstable based upon fracture pattern or EUA. All patients went on to successful treatment without significant pelvic deformity (7.8 months mean follow-up). CONCLUSION The EMS stress XR is a valuable, opportunistic evaluation in LC pelvic ring injuries. This evaluation is a useful diagnostic adjunct to alert the provider that additional stress imaging may be indicated to evaluate for occult pelvic ring instability.
Collapse
Affiliation(s)
- Graham J DeKeyser
- Department of Orthopaedic Surgery, Oregon Health & Sciences University, Portland, OR, USA
| | - Mario A Taylor
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA
| | - Jerad D Allen
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Reza Firoozabadi
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA
| | - Michael Githens
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA
| | - Conor P Kleweno
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA.
| |
Collapse
|
4
|
Chavez MA, Weinberg JA, Jacobs JV, Soe-Lin H, Chapple KM, Ryder M, Conley I, Bogert JN. Commonly performed pelvic binder modifications for femoral access may hinder binder efficacy. Am J Surg 2022; 224:1464-1467. [PMID: 35623945 DOI: 10.1016/j.amjsurg.2022.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/06/2022] [Accepted: 04/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pelvic fractures are common and potentially life-threatening. Pelvic circumferential compression devices (PCCD) can temporize hemorrhage, but more invasive strategies that involve femoral access may be necessary for definitive treatment. The aim of our study was to evaluate the efficacy of PCCDs reducing open book pelvic fractures when utilizing commonly described modifications and placement adjustments that allow for access to the femoral vasculature. METHODS Open book pelvic fractures were created in adult cadavers. Three commercially available PCCDs were used to reduce fractures. The binders were properly placed, moved caudally, or moved cranially and modified. Fracture reduction rates were then recorded. RESULTS The pelvic fracture was completely reduced with every PCCD tested when properly placed. Reduction rates decreased with improper placement and modifications. CONCLUSION Modifying PCCD placement to allow femoral access decreased the effectiveness of these devices Clinicians should be aware of this possibility when caring for critically injured trauma patients with pelvic fractures.
Collapse
Affiliation(s)
- Marin A Chavez
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Jordan A Weinberg
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Jordan V Jacobs
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Hahn Soe-Lin
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Kristina M Chapple
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Madison Ryder
- Ira A. Fulton School of Engineering at Arizona State University, 699 S. Mill Ave. Tempe, Arizona, 85281, United States
| | - Ian Conley
- Ira A. Fulton School of Engineering at Arizona State University, 699 S. Mill Ave. Tempe, Arizona, 85281, United States
| | - James N Bogert
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States.
| |
Collapse
|
5
|
Pelvic Ring Resuscitation Pathways. J Orthop Trauma 2022; 36:294-297. [PMID: 35727006 DOI: 10.1097/bot.0000000000002107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 02/02/2023]
Abstract
A 35 year-old female is injured in a high-speed motor vehicle collision in which her car is struck on the driver's side by a distracted driver. The patient is unable to self-extricate from the vehicle and she is confused at the scene. She comes directly to the trauma bay via EMS and a binder is placed in transit for suspicion of a pelvic ring injury. Upon presentation she has a GCS of 14 due to confusion, and an initial pressure of 87/50. Workup does not disclose an associated head, chest or abdominal injury and the anteroposterior pelvis radiograph demonstrates a windswept pelvis injury pattern. Despite being transfused 4 units of whole blood, her hypotension does not improve. Please describe your institution's advanced resuscitation protocol and management of this scenario, and provide the rational and support for it.
Collapse
|
6
|
Resuscitative endovascular balloon occlusion of the aorta in pelvic ring fractures: The Denver Health protocol. Injury 2021; 52:2702-2706. [PMID: 32057458 DOI: 10.1016/j.injury.2020.01.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/24/2020] [Accepted: 01/28/2020] [Indexed: 02/02/2023]
Abstract
Patients presenting with hemodynamic instability associated with pelvic fractures continue to have very high mortality and surgeons continue to seek damage control strategies that may improve survival. Strategies usually require massive transfusion, immediate pelvic stabilization and another adjunctive maneuver's such as angioembolization or preperitoneal pelvic packing to prevent hemorrhagic death. One current intervention that has regained some popularity in lieu of resuscitative thoracotomy is the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). This requires some manner of femoral arterial access to insert a balloon into the aorta and increase central blood pressure (cardiac and cerebral perfusion) and control active pelvic bleeding. Based on several animal models and an increasing number of publications, many US level I trauma centers have now opted to use REBOA in carefully selected patients showing signs of near cardiac arrest from non-compressible torso hemorrhage. Description of the current advances in aortic occlusion using catheter-based technology in the setting of severe shock for non-compressible torso hemorrhage from pelvic ring fracture is the purpose of this report.
Collapse
|
7
|
Epidemiologic, Postmortem Computed Tomography-Morphologic and Biomechanical Analysis of the Effects of Non-Invasive External Pelvic Stabilizers in Genuine Unstable Pelvic Injuries. J Clin Med 2021; 10:jcm10194348. [PMID: 34640366 PMCID: PMC8509371 DOI: 10.3390/jcm10194348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 11/25/2022] Open
Abstract
Unstable pelvic injuries are rare (3–8% of all fractures) but are associated with a mortality of up to 30%. An effective way to treat venous and cancellous sources of bleeding prehospital is to reduce intrapelvic volume with external noninvasive pelvic stabilizers. Scientifically reliable data regarding pelvic volume reduction and applicable pressure are lacking. Epidemiologic data were collected, and multiple post-mortem CT scans and biomechanical measurements were performed on real, unstable pelvic injuries. Unstable pelvic injury was shown to be the leading source of bleeding in only 19%. All external non-invasive pelvic stabilizers achieved intrapelvic volume reduction; the T-POD® succeeded best on average (333 ± 234 cm3), but with higher average peak traction (110 N). The reduction results of the VBM® pneumatic pelvic sling consistently showed significantly better results at a pressure of 200 mmHg than at 100 mmHg at similar peak traction forces. All pelvic stabilizers exhibited the highest peak tensile force shortly after application. Unstable pelvic injuries must be considered as an indicator of serious concomitant injuries. Stabilization should be performed prehospital with specific pelvic stabilizers, such as the T-POD® or the VBM® pneumatic pelvic sling. We recommend adjusting the pressure recommendation of the VBM® pneumatic pelvic sling to 200 mmHg.
Collapse
|
8
|
Circumferential Pelvic Antishock Sheeting. J Orthop Trauma 2021; 35:S24-S25. [PMID: 34227598 DOI: 10.1097/bot.0000000000002173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
Pelvic ring fractures range from low-energy falls in the elderly to high-energy mechanisms in young patients. These injuries can be a significant cause of morbidity and mortality and are frequently associated with additional injuries. Hemorrhage and resultant hemodynamic instability are often associated with high-energy injuries and require prompt management. Circumferential pelvic antishock sheeting is an effective and readily available tool for reducing pelvic volume at the accident scene or in the emergency department, while still allowing access to the abdomen and lower extremities for ongoing resuscitation. This article, and the associated instructional video, reviews the indications and proper technique for placing a pelvic sheet.
Collapse
|
9
|
Kazley JM, Potenza MA, Marthy AG, Arain AR, O'Connor CM, Czajka CM. Team Approach: Evaluation and Management of Pelvic Ring Injuries. JBJS Rev 2021; 8:e0149. [PMID: 33006457 DOI: 10.2106/jbjs.rvw.19.00149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A multidisciplinary approach to the management of pelvic ring injuries has been shown to decrease mortality rates. The primary goals within the emergency room are to assess, resuscitate, and stabilize the patient. The Advanced Trauma Life Support protocol guides the initial assessment of the patient. A pelvic binder or sheet should be applied to help to provide reduction of the fracture and temporary stabilization. The trauma team becomes the primary service for the patient as he or she transitions away from the emergency department. The trauma team must effectively communicate with and serve as the liaison between other specialists as injuries are identified. emodynamic stability should be closely monitored in patients with pelvic ring injuries, involving the assessment of vital signs, imaging findings, and clinical judgment. Angioembolization and peritoneal packing may play a role in helping to control hemorrhage. Urologists should be consulted if a Foley catheter cannot be passed or there is concern for urethral or bladder injury. Further imaging or urologic intervention may be necessary. Orthopaedic surgeons can help to assess the patient, classify the injury, and assist in temporary stabilization while planning definitive fixation.
Collapse
Affiliation(s)
- Jillian M Kazley
- 1Divisions of Orthopaedic Surgery (J.M.K., A.R.A., C.M.O., and C.M.C.), Emergency Medicine (M.A.P.), and General Surgery (A.G.M.), Albany Medical Center, Albany, New York
| | | | | | | | | | | |
Collapse
|
10
|
Marmor M, El Naga AN, Barker J, Matz J, Stergiadou S, Miclau T. Management of Pelvic Ring Injury Patients With Hemodynamic Instability. Front Surg 2020; 7:588845. [PMID: 33282907 PMCID: PMC7688898 DOI: 10.3389/fsurg.2020.588845] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/12/2020] [Indexed: 12/28/2022] Open
Abstract
Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.
Collapse
Affiliation(s)
- Meir Marmor
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Ashraf N El Naga
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jordan Barker
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jacob Matz
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | | | - Theodore Miclau
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| |
Collapse
|
11
|
Jones CB. WITHDRAWN: Vertical shear pelvic ring injuries: Management algorithm. Injury 2020:S0020-1383(20)30073-5. [PMID: 32061357 DOI: 10.1016/j.injury.2020.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 02/02/2023]
Abstract
The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
Collapse
Affiliation(s)
- Clifford B Jones
- Orthopaedic Surgery Division Chief, Dignity Health Medical Group, Phoenix AZ, United States; St Joseph's Orthopaedic Surgery, McCauley Office Building Suite 800, 500 West Thomas Road, Phoenix AZ 85013, United States; Creighton Medical School-Phoenix, United States.
| |
Collapse
|
12
|
Bakhshayesh P, Risling DH, Enocson A. Three Dimensional Quality Assessments of Applied Pelvic Binders. Bull Emerg Trauma 2019; 7:156-161. [PMID: 31198805 PMCID: PMC6555219 DOI: 10.29252/beat-070211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: To assess the quality of applied pelvic binders using three dimensional computer tomography (3D CT). Methods: A local trauma registry was used to identify patients with pelvic fractures after high-energy trauma during 2011-2015. A 3D CT reconstruction was made from the initial trauma computer tomography images to assess the level of application, symmetricity of the binder and achieved fracture reduction. An acceptable application of the pelvic binder was deemed if it was at the trochanteric level, symmetric and minimized residual displacement. Results: We found 73 patients with a pelvic fracture and a pelvic binder on the initial trauma CT-scan. The mean (±SD) age of the patients was 46±17 years and 40% (n=29) were females. The median ISS score was 38 (IQR;29-50), the mean systolic blood pressure on arrival was 106±46 mmHg and the median GCS on arrival was 14 (IQR;7-15). We found that 59% (n=43) of the binders were correctly applied (symmetric at the trochanteric level, symmetrical and with acceptable residual displacement of the fracture). The 30-day mortality was higher in patients with non-correct application 17% (n=5/30) compared to patients with correct application of the pelvic binder 9.3% (n=4/43) however this was not statistically significant (p=0.562). Conclusion: A substantial number of patients had non-correct application of pelvic binders. Future studies using 3D technique are encouraged to further investigate clinical impacts of non-appropriate application of pelvic binders.
Collapse
Affiliation(s)
- Peyman Bakhshayesh
- Imperial College London, Department of Cancer and Surgery, Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | | | - Anders Enocson
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm Sweden
| |
Collapse
|
13
|
He Y, Qiu D, Zhou D, Li L, Wang B, Wang L. Treatment of Partial Traumatic Hemipelvectomy: A Study of 21 Cases. J Bone Joint Surg Am 2019; 101:e36. [PMID: 31045672 DOI: 10.2106/jbjs.18.00877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Partial traumatic hemipelvectomy (THP) is a catastrophic and life-threatening injury caused by high-energy impact. With advances in prehospital resuscitative techniques, more patients now survive this disastrous injury; however, the management of partial THP still lacks well-established therapeutic protocols. The purpose of this study was to present our experience in managing partial THP in a level-I trauma center. METHODS We retrospectively reviewed the medical records of 21 consecutive patients with partial THP. The key points of successful treatment are hemorrhage control, proper decision-making regarding amputation, treatment of associated injuries, and infection control. Data on patient demographics, injury characteristics, surgical management, and outcomes were recorded and analyzed. RESULTS Eight female and 13 male patients with a mean age of 31.3 years met the diagnostic criteria. The mean follow-up was 51.9 months. Of 17 surviving patients, 7 underwent primary amputation; limbs were successfully preserved in 4; and 6 patients underwent secondary amputation because of infection, organ dysfunction, and limb necrosis. Two patients died during resuscitation, and 2 patients died after amputation. Phantom limb pain, infection, and skin flap necrosis were the major postoperative complications. CONCLUSIONS THP requires cooperative multidisciplinary emergency diagnosis and treatment, early surgical intervention, and definitive treatment. Rapid resuscitation, adequate hemostasis, early amputation, and repeated debridement may improve survival. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Yu He
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China.,Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Daodi Qiu
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| | - Dongsheng Zhou
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| | - Lianxin Li
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| | - Bomin Wang
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| | - Lubo Wang
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| |
Collapse
|
14
|
Abstract
OBJECTIVE Pelvic binders may hinder radiologic assessment of pelvic instability after trauma, and avulsive injuries can potentially unmask instability in this setting. We compare the performance of MDCT for the detection of pelvic disruptions in patients with binders to a matched cohort without binders, and we assess the utility of avulsive injuries as signs of pelvic instability. MATERIALS AND METHODS MDCT examinations of 56 patients with binders were compared with MDCT examinations of 54 patients without binders. Tile grading by an experienced orthopedic surgeon was used as the reference standard (A, stable; B, rotationally unstable; C, rotationally and vertically unstable). Two radiologists performed blinded reviews of CT studies in two reading sessions (sessions 1 and 2). In session 1, Tile grade was predicted on the basis of established signs of instability, including pubic symphysis and sacroiliac (SI) joint widening. In session 2, readers could change the Tile grade when avulsive injuries were seen. Diagnostic performance for predicting rotational instability and vertical instability was assessed. RESULTS In the binder group, AUCs under the ROC curves for rotational instability increased from fair (0.73-0.77) to good (0.82-0.89) when avulsive signs were considered. In the control group, AUCs were good in both sessions. AUCs for vertical instability were fair with binders in both sessions. Agreement with the reference standard increased from fair (0.30-0.32) to moderate (0.46-0.54) when avulsive signs were considered in the binder group but were in the moderate range for both sessions in the control group. Combined evaluation for inferolateral sacral fractures, ischial spine fractures, and rectus abdominis avulsions resulted in optimal discrimination of rotational instability. CONCLUSION Evaluation for avulsive signs improves MDCT sensitivity for the detection of rotational instability but not vertical instability in patients with binders.
Collapse
|
15
|
Abstract
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.
Collapse
Affiliation(s)
- Matthew I Rudloff
- Department of Orthopaedic Surgery, Campbell Clinic, University of Tennessee, 1211 Union Avenue, Suite 500, Memphis, TN 38002, USA.
| | - Kostas M Triantafillou
- University Orthopedic Surgeons, University of Tennessee Medical Center, 320 Kingston Ct, Knoxville, TN 37919, USA
| |
Collapse
|
16
|
Abstract
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.
Collapse
|
17
|
Bakhshayesh P, Boutefnouchet T, Tötterman A. Effectiveness of non invasive external pelvic compression: a systematic review of the literature. Scand J Trauma Resusc Emerg Med 2016; 24:73. [PMID: 27193135 PMCID: PMC4870770 DOI: 10.1186/s13049-016-0259-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/03/2016] [Indexed: 12/18/2022] Open
Abstract
Introduction Pelvic fractures might carry a significant risk of bleeding. A wide variety of pelvic binders together with pelvic sheets are available and offer an adjunct to the initial management of poly-trauma patients with pelvic injuries. These devices are collectively referred to as pelvic circumferential compression devices (PCCDs). The aim of this study was to review the literature for evidence pertinent to the efficacy and safety of PCCDs. Methods Using the PRISMA guidelines a systematic search on PubMed, Web of Science, CINAHL, Embase and Scopus was carried out. Articles included were in English language and published between 1999 and 2015. Studies included were appraised with narrative data synthesis. Results Seven articles addressed mechanical properties of non-invasive external mechanical devices, six articles focused on physiological aspects, and three studies evaluated the pressure characteristics of these devices. We found 4 case reports regarding adverse effects. None of the studies identified addressed the cost effectiveness or pain relief issues related to the use of PCCDs. Conclusions Based on available literature, PCCDs are widely used in the initial management of patients with suspected pelvic bleeding. There is evidence to suggest that external compression reduces disrupted pelvic rings. There are some complications reported following application of PCCDs. Hemorrhagic source and physiological effectiveness of PCCDs needs to be addressed in future studies. In the meantime judicious application of PCCDs will continue to be recommended.
Collapse
Affiliation(s)
- Peyman Bakhshayesh
- Department of Orthopaedics, Karolinska University Hospital, Karolinksa vägen, 17176, Solna, Stockholm, Sweden.
| | - Tarek Boutefnouchet
- University Hospital Coventry and Warwickshire, Clifford bridge road, Coventry, CV2 2DX, UK
| | - Anna Tötterman
- Department of Orthopaedics, Karolinska University Hospital, Karolinksa vägen, 17176, Solna, Stockholm, Sweden
| |
Collapse
|
18
|
Prasarn ML, Horodyski M, Schneider PS, Pernik MN, Gary JL, Rechtine GR. Comparison of skin pressure measurements with the use of pelvic circumferential compression devices on pelvic ring injuries. Injury 2016; 47:717-20. [PMID: 26777467 DOI: 10.1016/j.injury.2015.11.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 11/18/2015] [Accepted: 11/22/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Pelvic circumferential compression devices are commonly used in the acute treatment of pelvic fractures for reduction of pelvic volume and initial stabilisation of the pelvic ring. There have been reports of catastrophic soft-tissue breakdown with their use. The aim of the current investigation was to determine whether various pelvic circumferential compression devices exert different amounts of pressure on the skin when applied with the force necessary to reduce the injury. The study hypothesis was that the device with the greatest surface area would have the lowest pressures on the soft-tissue. METHODS Rotationally unstable pelvic injuries (OTA type 61-B) were surgically created in five fresh, whole human cadavers. The amount of displacement at the pubic symphysis was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). The T-POD, Pelvic Binder, Sam Sling, and circumferential sheet were applied in random order for testing. The devices were applied with enough force to obtain a reduction of less than 10mm of diastasis at the pubic symphysis. Pressure measurements, force required, and contact surface area were recorded with a Tekscan pressure mapping system. RESULTS The mean skin pressures observed ranged from 23 to 31kPa (173 to 233mm of Hg). The highest pressures were observed with the Sam Sling, but no statistically significant skin pressure differences were observed with any of the four devices (p>0.05). The Sam Sling also had the least mean contact area (590cm(2)). In greater than 70% of the trials, including all four devices tested, skin pressures exceeded what has been shown to be pressure high enough to cause skin breakdown (9.3kPa or 70mm of Hg). CONCLUSIONS Application of commercially available pelvic binders as well as circumferential sheeting commonly results in mean skin pressures that are considered to be above the threshold for skin breakdown. We therefore recommend that these devices only be used acutely, and definitive fixation or external fixation should be performed early as patient physiology allows. There may be some advantage of use of a simple sheet given its low cost, versatility, and ability to alter contact surface area.
Collapse
Affiliation(s)
- Mark L Prasarn
- Dept. of Orthopaedics and Rehabilitation, University of Texas, Houston, TX, USA.
| | - MaryBeth Horodyski
- Dept. of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Prism S Schneider
- Dept. of Orthopaedics and Rehabilitation, University of Texas, Houston, TX, USA
| | - Mark N Pernik
- Dept. of Orthopaedics and Rehabilitation, University of Texas, Houston, TX, USA
| | - Josh L Gary
- Dept. of Orthopaedics and Rehabilitation, University of Texas, Houston, TX, USA
| | | |
Collapse
|
19
|
Sinha S, Ellicott H, Gee E, Steel A. A bed sheet is not as effective as a pelvic circumferential compression device in generating pelvic compression in patients with a suspected pelvic fracture. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408614568831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The Advanced Trauma Life Support protocol for emergent management of pelvic ring disruptions includes advising circumferential application of a bed sheet. A number of purpose-designed pelvic circumferential compression devices are commercially available. We assessed whether the Advanced Trauma Life Support-recommended simple bed sheet was able to generate the same pelvic pressure as provided by a pelvic circumferential compression device. Methods A healthy volunteer was laid supine on an examination trolley and a pressure transducer was placed overlying the volunteer’s greater trochanters. Two pelvic compression devices, a commercially available SAM Pelvic Sling II™ and a standard hospital bed sheet, were applied single handedly. The SAM Sling was applied according to the manufacturer’s instructions and the bed sheet was applied in the way the participant felt best. The pressures generated at the level of the greater trochanters were measured at 2 min. The mean of the left and right pressures was recorded. Following removal of the first device, the second device was then placed and the pressures were again recorded at 2 min. Results Twelve participants completed the study. The mean (standard deviation) pressure generated by the SAM sling was 107 (28.4) mmHg and by the bed sheet 54 (26.3) mmHg; the SAM sling generated significantly greater pressure ( p < 0.0001). A variety of different methods for applying the bed sheet were observed. Conclusion In patients with a suspected pelvic fracture, a bed sheet is unable to reliably generate pressures approaching those of a commercially available pelvic circumferential compression device.
Collapse
Affiliation(s)
- Shrestha Sinha
- Anaesthetic Department, Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn, UK
| | - Helen Ellicott
- Anaesthetic Department, Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn, UK
| | - Ed Gee
- Orthopaedic Department, Manchester Royal Infirmary, Manchester, UK
| | - Alistair Steel
- Anaesthetic Department, Queen Elizabeth Hospital NHS Foundation Trust, King’s Lynn, UK
| |
Collapse
|
20
|
Auston DA, Simpson RB. Initial Treatment of "Pelvic Injuries" with Commercially Available Pelvic Binders Results in Displacement of Acetabular Fractures: A Report of Three Cases. JBJS Case Connect 2015; 5:e20. [PMID: 29252574 DOI: 10.2106/jbjs.cc.n.00073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CASES Three hemodynamically stable patients with displaced acetabular fractures were treated with commercially available pelvic binders after blunt trauma. In two of the patients, placement of the binder corresponded with transfer from a community hospital to a tertiary care facility. CONCLUSION The pelvic binder is an increasingly utilized portable device that can provide lifesaving tamponade in patients with hemodynamically unstable pelvic injuries. However, incorrect application of the device may expose patients to unnecessary morbidity. This report demonstrates the need to establish appropriate guidelines and provide training for first responders and community physicians who are likely to encounter these fractures in the acute setting.
Collapse
Affiliation(s)
- Darryl A Auston
- Department of Orthopedic Surgery, SUNY Upstate Medical University, 750 East Adams Street, Suite 4400, Syracuse, NY 13210. .
| | | |
Collapse
|
21
|
The orthopedic damage control in pelvic ring fractures: when and why-a multicenter experience of 10 years' treatment. JOURNAL OF ACUTE DISEASE 2014. [DOI: 10.1016/s2221-6189(14)60044-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
22
|
Prasarn ML, Conrad B, Small J, Horodyski M, Rechtine GR. Comparison of circumferential pelvic sheeting versus the T-POD on unstable pelvic injuries: A cadaveric study of stability. Injury 2013; 44:1756-9. [PMID: 23810452 DOI: 10.1016/j.injury.2013.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 05/28/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Commercially available binder devices are commonly used in the acute treatment of pelvic fractures, while many advocate simply placing a circumferential sheet for initial stabilization of such injuries. We sought to determine whether or not the T-POD would provide more stability to an unstable pelvic injury as compared to circumferential pelvic sheeting. METHODS Unstable pelvic injuries (OTA type 61-C-1) were surgically created in five fresh, lightly embalmed whole human cadavers. Electromagnetic sensors were placed on each hemi-pelvis. The amount of angular motion during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). Either a T-POD or circumferential sheet was applied in random order for testing. The measurements recorded in this investigation included maximum displacements for sagittal, coronal, and axial rotation during application of the device, bed transfer, log-rolling, and head of bed elevation. RESULTS There were no differences in motion of the injured hemi-pelvis during application of either the T-POD or circumferential sheet. During the bed transfer, log-rolling, and head of bed elevation, there were no significant differences in displacements observed when the pelvis was immobilized with either a sheet or pelvic binder (T-POD). CONCLUSIONS A circumferential pelvic sheet is more readily available, costs less, is more versatile, and is equally as efficacious at immobilizing the unstable pelvis as compared to the T-POD. We advocate the use of circumferential sheeting for temporary stabilization of unstable pelvic injuries.
Collapse
|
23
|
Pizanis A, Pohlemann T, Burkhardt M, Aghayev E, Holstein JH. Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques. Injury 2013; 44:1760-4. [PMID: 23916903 DOI: 10.1016/j.injury.2013.07.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 05/19/2013] [Accepted: 07/06/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Emergency devices for pelvic ring stabilization include circumferential sheets, pelvic binders, and c-clamps. Our knowledge of the outcome of these techniques is currently based on limited information. METHODS Using the dataset of the German Pelvic Trauma Registry, demographic and injury-associated characteristics as well as the outcome of pelvic fracture patients after sheet, binder, and c-clamp treatment was compared. Outcome parameters included transfusion requirement of packed red blood cells, length of hospital stay, mortality, and incidence of lethal pelvic bleeding. RESULTS Two hundred seven of 6137 (3.4%) patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets, binders, or c-clamps. In most cases, c-clamps (69%) were used, followed by sheets (16%), and binders (15%). The median age was significantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs. 47 vs. 42 years, p=0.01). Sheet wrapping was associated with a significantly higher incidence of lethal pelvic bleeding compared to binder or c-clamp stabilization (23% vs. 4% vs. 8%). No significant differences between the study groups were found in sex, fracture type, blood haemoglobin concentration, arterial blood pressure, Injury Severity Score, the incidence of additional pelvic packing and arterial embolization, need of red blood cell transfusion, length of hospitalisation, and mortality. CONCLUSIONS The data suggest that emergency stabilization of the pelvic ring by binders and c-clamps is associated with a lower incidence of lethal pelvic bleeding compared to sheet wrapping. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- A Pizanis
- Department of Trauma, Hand, and Reconstructive Surgery, University of Saarland, Kirrberger Strasse 1, 66421 Homburg, Germany
| | | | | | | | | |
Collapse
|
24
|
Rajab TK, Weaver MJ, Havens JM. Videos in clinical medicine. Technique for temporary pelvic stabilization after trauma. N Engl J Med 2013; 369:e22. [PMID: 24152281 DOI: 10.1056/nejmvcm1200383] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Taufiek K Rajab
- From the Department of Surgery (T.K.R., J.M.H.), the Orthopedic Trauma Service (M.J.W.), and the Division of Trauma, Burns, and Surgical Critical Care (J.M.H.), Brigham and Women's Hospital, and the Department of Surgery, Harvard Medical School (T.K.R., M.J.W., J.H.) - both in Boston
| | | | | |
Collapse
|
25
|
Fu CY, Wu YT, Liao CH, Kang SC, Wang SY, Hsu YP, Lin BC, Yuan KC, Kuo IM, Ouyang CH. Pelvic circumferential compression devices benefit patients with pelvic fractures who need transfers. Am J Emerg Med 2013; 31:1432-6. [PMID: 23972479 DOI: 10.1016/j.ajem.2013.06.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 06/26/2013] [Accepted: 06/27/2013] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Patients with pelvic fracture usually require transfers to trauma centers for additional advanced treatment. Patient safety during the transfer should always be a priority. The noninvasive pelvic circumferential compression device (PCCD) can reportedly provide a tamponade effect, which reduces hemorrhage. In the present study, we evaluated the feasibility and efficiency of PCCD in patients with pelvic fracture who required transfer to trauma centers. MATERIALS AND METHODS In the present study, we aimed to evaluate patients with pelvic fractures who were transferred from other hospitals. We investigated and compared the characteristics of these types of patients with and without pretransfer PCCD. We compared 2 groups (with and without pretransfer PCCD) of patients under different situations (unstable pelvic fracture, stable pelvic fracture, or indicated for transcatheter arterial embolization). We also analyzed the characteristics of patients with unstable pelvic fracture who were initially evaluated as having stable pelvic fracture primarily before being transferred. RESULTS During the 53-month period, we enrolled 585 patients in the study. The patients with unstable pelvic fractures who received pretransfer PCCDs required significantly fewer blood transfusions (398.4 ± 417.6 mL vs 1954.5 ± 249.0 mL, P < .001), shorter intensive care unit length of stay (LOS; 6.6 ± 5.2 days vs 11.8 ± 7.7 days, P = .024), and shorter hospital LOS (9.4 ± 7.0 days vs 19.5 ± 13.7 days, P = .006) compared with patients who did not receive the pretransfer PCCD. The stable patients who received pretransfer PCCDs required significantly fewer blood transfusions (120.2 ± 178.5 mL vs 231.8 ± 206.2 mL, P = .018) and had shorter intensive care unit LOS (1.7 ± 3.3 days vs 3.4 ± 2.9 days, P = .029) and shorter hospital LOS (6.8 ± 5.1 days vs 10.4 ± 7.6 days, P = .018) compared with patients who did not receive the pretransfer PCCD. CONCLUSION Pelvic circumferential compression devices benefit patients with pelvic fracture who need to be transferred to trauma centers. Pretransfer PCCDs appeared to be a feasible and safe procedure during the transfer. In discussions between the referring physicians and the receiving physicians, we recommend using pretransfer PCCDs.
Collapse
Affiliation(s)
- Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Jain S, Bleibleh S, Marciniak J, Pace A. A national survey of United Kingdom trauma units on the use of pelvic binders. INTERNATIONAL ORTHOPAEDICS 2013; 37:1335-9. [PMID: 23420325 DOI: 10.1007/s00264-013-1828-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 02/05/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE Major pelvic injuries resulting from high-energy trauma require emergency hospital treatment, and part of the initial management includes mechanical stabilisation of the pelvis. Controversies include binder position, use in lateral compression injuries and application during radiological assessment. We present the results of a survey of both emergency department and orthopaedic specialties. METHODS A telephone survey of all 144 trauma units in the UK accepting adult pelvic trauma patients was carried out in July 2012. The duty registrar for the emergency and orthopaedic departments was contacted and asked to complete a questionnaire. RESULTS A response rate of 100% was achieved. Pelvic binders were available for use in approximately three quarters of the trauma units surveyed. Eight-five emergency department (59%) and 79 orthopaedic (54.9%) registrars had been given training on pelvic binder application. Fifty-six emergency department (38.9%) and 114 orthopaedic (79.1%) registrars identified the level of the greater trochanters as the most suitable position for the binder. Forty-five emergency department (31.3%) and 58 orthopaedic (40.3%) registrars used pelvic binders in suspected lateral compression injuries. One hundred and twenty-six emergency department (87.5%) and 113 orthopaedic (78.5%) registrars would not release the binder during radiological assessment of the pelvis in a haemodynamically stable patient. CONCLUSION There is great variability in practice amongst trauma units in the UK. Training must be formalised and provided as a mandatory part of departmental induction. The use of standardised treatment algorithms in trauma units and the Advanced Trauma and Life Support (ATLS) framework may help decision making and improve patient survival rates.
Collapse
Affiliation(s)
- Sameer Jain
- Department of Trauma & Orthopaedic Surgery, Scarborough General Hospital, Woodlands Drive, Scarborough, North Yorkshire YO12 6QL, UK.
| | | | | | | |
Collapse
|
27
|
External contention for pelvic trauma: is 1 sheet enough? Am J Emerg Med 2013; 31:442.e1-3. [DOI: 10.1016/j.ajem.2012.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 05/13/2012] [Indexed: 11/22/2022] Open
|
28
|
Tonetti J. Management of recent unstable fractures of the pelvic ring. An update conference supported by the Club Bassin Cotyle. (Pelvis-Acetabulum Club). Orthop Traumatol Surg Res 2013; 99:S77-86. [PMID: 23380433 DOI: 10.1016/j.otsr.2012.11.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 11/23/2012] [Indexed: 02/02/2023]
Abstract
Traumatic injury to the pelvic ring is a result of high energy trauma in young patients. These osteo-ligamentous injuries are associated with numerous lesions including retroperitoneal hematoma, urogenital, cutaneous and neurological (lumbosacral plexus). The goal of initial management is to restore vital indicators, urinary excretion function and protect the patient from infectious complications. An emergency decisional algorithm helps manage haemodynamic instability. Initial bone and ligament procedures should reduce displacement and make it possible for the patient the wait until his condition is stable enough for definitive surgical fixation. The goal of surgical treatment is to avoid nonunion and malunion. Stable fixation of the posterior arch after reduction favors union. Different techniques can be used by the posterior, anterior ilio-inguinal or lateral percutaneous approaches. Anterior fixation is discussed to improve reduction and increase the stability obtained with a posterior procedure. Anterior external fixation is useful to temporarily reinforce posterior stabilization.
Collapse
Affiliation(s)
- J Tonetti
- Service de chirurgie orthopédique et traumatologie, hôpital Michallon,Grenoble cedex 09, France.
| |
Collapse
|
29
|
Gänsslen A, Heidari N, Weinberg AM. Fractures of the pelvis in children: a review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 23:847-61. [PMID: 23412229 DOI: 10.1007/s00590-012-1102-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 10/03/2012] [Indexed: 12/01/2022]
Abstract
Trauma is the leading cause of death in children. Pelvic ring injuries account for 0.3-4% of all paediatric injuries. The pattern of fractures differs to that seen in adults as it is more ductile. Pelvic ring injuries tend to be more stable as the relatively thick periosteum restricts bony displacement. Intrapelvic viscera are not well protected and can sustain injury in the absence of pelvic fractures. These injuries have traditionally been treated non-operatively. In this paper, we comprehensively review the literature and propose a protocol for treatment taking into consideration associated organ injuries, hemodynamic status of the patient, patient's age, type of fracture and the stability of the pelvic ring.
Collapse
Affiliation(s)
- Axel Gänsslen
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum der Stadt, Wolfsburg, Sauerbruchstraße 7, 38440, Wolfsburg, Germany
| | | | | |
Collapse
|
30
|
Comparison of external fixation versus the trauma pelvic orthotic device on unstable pelvic injuries: a cadaveric study of stability. J Trauma Acute Care Surg 2012; 72:1671-5. [PMID: 22695439 DOI: 10.1097/ta.0b013e31824526a7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Most institutions treating pelvic fractures use some method of acute mechanical stabilization. This typically involves use of pelvic binders or circumferential sheeting, and/or external fixation. The comparative value of these different modalities is controversial. We hypothesized that an external fixator would provide more stability to an unstable pelvic injury than a commercially available binder device (trauma pelvic orthotic device [T-POD]). METHODS Unstable pelvic injuries (Tile C) were surgically created in five fresh whole human cadavers. Electromagnetic sensors were placed on the same position of each hemipelvis. The amount of angular motion during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device. Maximum displacements were recorded during application of the stabilizing devices, bed transfer, logrolling, and head-of-bed elevation. External fixation frames were constructed by placing two 5.0-mm half pins into the iliac crest and then connected them with a 10-mm curved bar. The T-POD device was placed at the level of the greater trochanters as per manufacturer's recommendations. RESULTS While logrolling the patient and performing bed transfers, the T-POD conferred more stability in all planes of motion, although this did not reach statistical significance. During elevation of the head of the bed, the T-POD allowed less motion in the sagittal and coronal planes but permitted equivalent motion in axial rotation. These differences were not statistically significant. CONCLUSION There were no significant differences in stability conferred by an external fixator or a T-POD for unstable pelvic injuries. We advocate acute, temporary stabilization of pelvic injuries with a binder device and early conversion to internal fixation when the patient's medical condition allows.
Collapse
|
31
|
Toth L, King KL, McGrath B, Balogh ZJ. Efficacy and safety of emergency non-invasive pelvic ring stabilisation. Injury 2012; 43:1330-4. [PMID: 22677220 DOI: 10.1016/j.injury.2012.05.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Revised: 01/04/2012] [Accepted: 05/14/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Urgent non-invasive pelvic ring stabilisation (pelvic binding, PB) in shocked patients is recommended by state and institutional guidelines regardless of the fracture pattern. The purpose of this study was to determine the adherence to the guidelines, efficacy of the technique and identification of potential adverse effects associated with PB. PATIENTS AND METHODS A 41-month retrospective analysis of the prospective pelvic fracture database was undertaken at a level 1 trauma centre. High-energy pelvic fractures were included in the analysis with exclusion of the A type injuries (AO/OTA classification) and patients who were dead on arrival. Collected data included patient demographics, injury severity score, fracture classification, application and timing of PB, associated injuries, physiological parameters, resuscitation fluids and outcomes. Pre and post-PB radiographs were reviewed. The potential effects of the PB on soft tissue (femoral vessel, bladder and rectal injury) complications were assessed by independent experts. RESULTS 115 patients with high-energy B and C type pelvic ring injuries were included. Thirty-six (31%) patients presented in haemorrhagic shock on arrival. A total of 43 pelvic bindings were performed, 18 of them on shocked patients. The adherence to the guidelines was 50% (18/36) overall. Analysing fracture types of shocked patients the adherence was: B1 80%, B2 20%, B3 20%, C1 66%, C2 86%, C3 33%. The alignment of the pelvis was improved or perfect on post-PB radiographs in 68% and had not changed in 21%. In some cases of B2 and B3 type injuries the PB increased the deformity after application (11%). There were 10 deaths (8.7%) in the study group, with 4 deaths attributed to acute pelvic bleeding. Two of these had PB applied and two were identified as potential for improvement. One femoral artery injury, four bladder injuries and three rectum injuries were identified in patients who had PB applied. Association between the PB and these injuries is unlikely. CONCLUSION The adherence to the guidelines should be improved with further education and system development. The good effect of the technique was evident on radiographs. Although in some lateral compression fracture patterns the deformity increased, no hazards were associated with the use of PB.
Collapse
Affiliation(s)
- Laszlo Toth
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, NSW 2310, Australia
| | | | | | | |
Collapse
|
32
|
Hoffmann MF, Jones CB, Sietsema DL. Persistent impairment after surgically treated lateral compression pelvic injury. Clin Orthop Relat Res 2012; 470:2161-72. [PMID: 22278851 PMCID: PMC3392399 DOI: 10.1007/s11999-012-2247-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recently, fixation of lateral compression (LC) pelvic fractures has been advocated to improve patient comfort and to allow earlier mobilization without loss of reduction, thus minimizing adverse systemic effects. However, the degree of acceptable deformity and persistence of disability are unclear. QUESTIONS/PURPOSES We determined if (1) injury pattern; (2) demographics; (3) final posterior displacement; (4) L5/S1 involvement; (5) associated injuries; and (6) time influence outcome measurements, sexual dysfunction, and pain. METHODS We retrospectively reviewed 119 patients with unstable LC injuries treated surgically between 2000 and 2010. There were 52 males and 67 females; mean age was 39 years with a mean body mass index of 27 kg/m(2). All patients underwent clinical examination and radiographic imaging for instability and accompanying injuries. We obtained Short Musculoskeletal Function Assessment (SMFA). The minimum followup was 12 months (mean, 33 months; range, 12-100 months). RESULTS SMFA subscores were not affected by injury pattern and demographics. Posterior reduction was less than 5 mm with persistent displacement in 99 of 119 (83%). Displacement of 5 to 10 mm did not affect any SMFA subscore at any time interval. Patients with additional lower extremity injuries had worse SMFA scores. Function improved with time. A visual analog scale pain score of 4 or more at 6 months predicted pain and overall SMFA score at last followup. CONCLUSIONS Unstable LC pelvic ring injuries result in persistent disability based on validated outcome measurements. Near anatomical reduction can be achieved and maintained. While our findings need to be confirmed in studies with high rates of followup, patients with unstable LC pelvic injuries should be counseled concerning the possibility of some degree of persistent disability. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Martin F. Hoffmann
- Grand Rapids Medical Educational Partners, Grand Rapids, MI USA ,Asklepios Klinik St Georg, Hamburg, Germany
| | - Clifford B. Jones
- Orthopaedic Associates of Michigan, Grand Rapids, MI USA ,Michigan State University, 230 Michigan Street NE, Suite 300, Grand Rapids, MI 49503 USA
| | - Debra L. Sietsema
- Orthopaedic Associates of Michigan, Grand Rapids, MI USA ,Michigan State University, 230 Michigan Street NE, Suite 300, Grand Rapids, MI 49503 USA
| |
Collapse
|
33
|
Abstract
AbstractOrthopedic injuries are predominant among combat casualties, and carry the potential for significant morbidity. An expert consensus process (Prehospital care of military orthopedic trauma: A consensus meeting, Israel Defense Forces Medical Corps, May 2003) was used to create guidelines for the treatment of these injuries by military prehospital providers. The consensus treatment guidelines developed by experienced orthopedic trauma personnel from leading trauma centers in Israel are presented in this paper.For victims with open fractures, the first priority is hemorrhage control. Splinting, irrigation, and wound care should be performed while waiting for transport, or, in any scenario, in the case of an isolated limb injury. The use of traction splints was advocated for both the rapid transport scenario (up to one hour from the time of injury to arrival at the hospital) and the delayed transport scenario. In the urban setting, traction splints may not be necessary. Any victim experiencing pelvic pain following a high-energy mechanism of injury should be presumed to have an unstable pelvic fracture, and a sheet should be tied around the pelvis. The panel agreed that field-reduction of dislocations should be avoided by the medical officer unless it is anticipated that the patient will need to go through a long evacuation chain and the medical officer is familiar with specific reduction techniques.
Collapse
|
34
|
|
35
|
Karadimas EJ, Nicolson T, Kakagia DD, Matthews SJ, Richards PJ, Giannoudis PV. Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature. INTERNATIONAL ORTHOPAEDICS 2011; 35:1381-90. [PMID: 21584644 DOI: 10.1007/s00264-011-1271-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Accepted: 04/20/2011] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the relation between pelvic fracture patterns and the angiographic findings, and to assess the effectiveness of the embolisation. METHODS This retrospective study, included patients with pelvic fractures and angiographic evaluation. Demographics, Injury Severity Score (ISS), associated injuries, embolisation time, blood units needed, method of treatment and complications were recorded and analysed. Fractures were classified according to the Burgess system. RESULTS Between 1998 and 2008, 34 patients with pelvic fractures underwent angiographic investigation. Twenty six were males. The mean age was 41 years. Twenty-seven were motor vehicle accidents and seven were falls. There were 11 anterior posterior (APC) fractures, 12 lateral compression (LC), eight vertical shear (VS) patterns and three with combined mechanical injuries. The median ISS was 33.1 (range 5-66). From the 34 who underwent angiography, 29 had positive vascular extravasations. From them, 21 had embolisation alone, two had vascular repair and embolisation, five required vascular repair alone and one patient died while being prepared for embolisation. Five cases were re-embolised. The findings suggested that AP fractures have a higher tendency to bleeding compared with LC fractures. Both had a higher chance of blood loss compared to VS and complex fracture patterns. We reported 57 additional injuries and 65 fractures. The complications were: one non lethal pulmonary embolism, one renal failure, one liver failure, one systemic infection, two deep infections and two psychological disorientations. Seven patients died in hospital. CONCLUSION Control of pelvic fracture bleeding is based on the multidisciplinary approach mainly related to hospital facilities and medical personnel's awareness. The morphology of the fracture did not have a predictive value of the vascular lesion and the respective bleeding.
Collapse
|
36
|
|
37
|
Stress radiograph to detect true extent of symphyseal disruption in presumed anteroposterior compression type I pelvic injuries. ACTA ACUST UNITED AC 2010; 69:880-5. [PMID: 20938276 DOI: 10.1097/ta.0b013e3181efbad5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The differentiation between anteroposterior compression (APC)-I and APC-II pelvic fracture patterns is critical in determining operative versus nonoperative treatment. We instituted a protocol in which a stress examination was performed for patients presenting with an APC-I injury diagnosed with static radiographs to reveal the true extent of the injury. METHODS During a 4-year study period, we performed 22 stress radiographs in patients with a presumed APC-I injury, which showed symphyseal diastasis ≥ 1.0 cm but <2.5 cm on initial anteroposterior (AP) radiographs of the pelvis or on axial images of the pelvis on computed tomography (CT) scans. In the operating room, a radiopaque marker of known diameter was placed on the skin over the pubic symphysis. A direct AP load was manually applied to both anterior superior iliac spines, and diastasis of the pubic symphysis was measured on stress fluoroscopic images. RESULTS The mean distance of symphyseal diastasis was 1.8 cm on the AP radiographs, 1.4 cm on the CT scans, and 2.5 cm on fluoroscopic images under a stress examination. Six of 22 patients (27.2%) demonstrated a symphyseal diastasis of >2.5 cm during the stress examination, which changed their treatment from nonoperative to operative. CONCLUSIONS Measurements of symphyseal diastasis can significantly vary depending on the radiographic modality (CT vs. plain films) and during application of a stress force. The use of stress examination under general anesthesia in the acute setting of pelvic injury can be beneficial in accurately diagnosing the severity of injury and choosing appropriate treatment.
Collapse
|
38
|
Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity. ACTA ACUST UNITED AC 2010; 69:677-84. [PMID: 20838139 DOI: 10.1097/ta.0b013e3181e50914] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although the benefits of acute stabilization of long bone fractures are recognized, the role of early fixation of unstable pelvis and acetabular fractures is not well-defined. The purpose of this study was to review complications and hospital course of patients treated surgically for pelvis and acetabulum fractures. We hypothesized that early definitive fixation would reduce morbidity and decrease length of stay. METHODS Six hundred forty-five patients were treated surgically at a level I trauma center for unstable fractures of the pelvic ring (n = 251), acetabulum (n = 359), or both (n = 40). Mean age was 40.5 years, and mean Injury Severity Score (ISS) was 25.6 (range 9-66). They were retrospectively reviewed to determine complications including acute respiratory distress syndrome (ARDS), pneumonia, deep vein thrombosis, pulmonary embolism, multiple organ failure (MOF), infections, and reperations. RESULTS Definitive fixation was within 24 hours of injury in 233 patients (early, mean 13.4 hours) and >24 hours in 412 (late, mean 99.2 hours). Twenty-nine patients (12.4%) had complications after early fixation versus 81 (19.7%) after late, p = 0.006. Length of stay and intensive care unit days were 10.7 days versus 11.6 days (p = 0.26) and 8.1 days versus 9.9 days (p = 0.03) for early and late groups, respectively. With ISS >18 (n = 165 early [ISS 32.7]; n = 253 late [ISS 33.1]), early fixation resulted in fewer pulmonary complications (12.7% versus 25%, p = 0.0002), less ARDS (4.8% versus 12.6%, p = 0.019), and less MOF (1.8% versus 4.3%, p = 0.40). Rates of complications, pulmonary complications, deep vein thrombosis, and MOF were no different for patients with pelvis versus acetabulum fractures. In patients receiving ≥ 10U packed red blood cells (n = 41 early, n = 56 late) early fixation led to fewer pulmonary complications (24% versus 55%, p = 0.002), less ARDS (12% versus 25%, p = 0.09), and MOF (7.3% versus 14%, p = 0.23). Two hundred ten patients had some chest injury (32.6%). Chest injury with Abbreviated Injury Scores ≥ 3 was present in 46 (19.7%) of early and 78 (18.9%) of late patients (p = 0.44) and was associated with pulmonary complications in 26.1% versus 35.9%; ARDS in 15.2% versus 23.1%; and MOF in 6.5% versus 6.4%, respectively (all p > 0.20). However, chest injury with Abbreviated Injury Scores ≥ 3 was independently associated with more complications including ARDS (20.2% versus 3.3%, p < 0.0001), other pulmonary complications (32.3% versus 10.4%, p < 0.0001), and MOF (6.5% versus 1.2%, p = 0.0016), regardless of timing of fixation. CONCLUSIONS Early fixation of unstable pelvis and acetabular fractures in multiply injured patients reduces morbidity and length of intensive care unit stay, which may decrease treatment costs. Further study to ascertain the effects of associated systemic injuries and the utility of physiologic and laboratory parameters during resuscitation may delineate recommendations for optimal surgical timing in specific patient groups.
Collapse
|
39
|
Abstract
Acute traumatic pelvic ring injuries are associated with life-threatening hemorrhage related to pelvic instability. Rapid and effective methods to mechanically stabilize the pelvic injury are often a prerequisite for patient survival. Most of these methods have significant disadvantages because of either difficult application or limited efficacy. Pelvic antishock clamp placement is difficult and dangerous, and circumferential pelvic antishock sheeting is not universally effective in reducing and stabilizing the pelvic ring. We describe a technique of acute posterior pelvic ring reduction and stabilization using a percutaneously inserted iliosacral screw as a resuscitation adjunct.
Collapse
|
40
|
The Second Lebanon War—Preparedness, Functioning, and Analyzing Data of Injuries Presenting to the Trauma Unit at the Rambam Health Care Campus. Prehosp Disaster Med 2010. [DOI: 10.1017/s1049023x00023220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
41
|
Abstract
Unstable pelvic ring injuries are associated with an increased mortality rate, most commonly from severe hemorrhage. Circumferential pelvic antishock sheeting has proven effective for rapidly stabilizing the pelvic ring and has become an integral part of resuscitation protocols. Acute antishock sheet placement frequently results in patient hemodynamic stabilization and an accurate pelvic reduction. In these situations, we describe a technique of maintaining the pelvic sheet position for continued use as a reduction aid and using working portals to insert definitive percutaneous pelvic implants.
Collapse
|
42
|
Spanjersberg WR, Knops SP, Schep NWL, van Lieshout EMM, Patka P, Schipper IB. Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: a systematic review of literature. Injury 2009; 40:1031-5. [PMID: 19616209 DOI: 10.1016/j.injury.2009.06.164] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 06/12/2009] [Accepted: 06/22/2009] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pelvic fractures can cause massive haemorrhage. Early stabilisation and compression of unstable fractures is thought to limit blood loss. Reposition of fracture parts and reduction of pelvic volume may provide haemorrhage control. Several non-invasive techniques for early stabilisation have been proposed, like the specifically designed pelvic circumferential compression devices (PCCD). The purpose of this systematic review was to investigate current evidence for the effectiveness and safety of non-invasive PCCDs. METHODS To investigate current literature the search string: "pelvi* AND fract* AND (bind* OR t-pod OR tpod OR wrap OR circumferential compression OR sling OR sheet)" was entered into EMBASE, PubMed (Medline), PiCarta, WebofScience, Cochrane Online, UptoDate, CINAHL, and Scopus. All scientific publications published in indexed journals were included. RESULTS The search resulted in 17 included articles, none of which were level I or II studies. One clinical cohort study (level III) and 1 case-control study (level IV) were found. These showed a significant reduction of pelvic volume after applying a PCCD, without an effect on outcome. Other included literature consisted of 4 case series (level V). Two biomechanical analysis studies of fractures in human cadavers showed pelvic stabilisation and effective volume reduction by PCCD, especially when applied around the greater trochanters. Finally, 7 case reports (level VI) and 3 expert opinions (level VII) were identified. These case reports suggested complications such as pressure sores and nerve palsy. CONCLUSION PCCDs seem to be effective in early stabilisation of unstable pelvic fractures. However, prospective data concerning mortality and complications is lacking. Some complications, like pressure sores have been described.
Collapse
Affiliation(s)
- Willem R Spanjersberg
- Erasmus MC, University Medical Center Rotterdam, Department of Surgery-Traumatology, 3000 CA Rotterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
43
|
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury 2009; 40:1023-30. [PMID: 19371871 DOI: 10.1016/j.injury.2008.11.023] [Citation(s) in RCA: 165] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 10/15/2008] [Accepted: 11/07/2008] [Indexed: 02/02/2023]
Abstract
Bleeding pelvic fractures that result in haemodynamic instability have a reported mortality rate as high as 40%. Because of the extreme force needed to disrupt the pelvic ring, associated injuries are common and mortality is usually from uncontrolled haemorrhage from extra-pelvic sources. Identifying and controlling all sources of bleeding is a complex challenge and is best managed by a multi-disciplinary team, which include trauma surgeons, orthopaedic surgeons and interventional radiologists. Once the pelvis is identified as the major source of haemorrhage, component therapy reconstituting whole blood should be used and the pelvic region wrapped circumferentially with a sheet or pelvic binder. Patients at risk for arterial bleeding who continue to show haemodynamic instability despite resuscitative efforts should undergo immediate arteriography and embolisation of bleeding pelvic vessels. If this is unavailable or delayed, or the patient has other injuries (i.e., head, chest, intra-abdominal, long bone), external fixation and pelvic packing, performed concomitantly with other life-saving procedures, may be used to further reduce pelvic venous bleeding. If however, the patient remains haemodynamically labile without apparent source of blood loss, transcatheter angiographic embolisation should be attempted to locate and stop pelvic arterial bleeding. Institutional practice guidelines have been shown to reduce mortality and should be developed by all centres treating pelvic fractures.
Collapse
Affiliation(s)
- Christopher E White
- Institute of Surgical Research, Fort Sam Houston, Fort Sam Houston, TX 78234, USA.
| | | | | |
Collapse
|
44
|
Abstract
Emergent life-saving treatment is required for high-energy pelvic fracture with associated hemorrhage and hemodynamic instability. Advances in prehospital, interventional, surgical, and critical care have led to increased survival rates. Pelvic binders have largely replaced military antishock trousers. The availability and precision of interventional angiography have expanded considerably. External pelvic fixation can be rapidly applied, often reduces the pelvic volume, and provides temporary fracture stabilization. Pelvic packing, popularized in Europe, is now used in certain centers in North America. The use of standardized treatment algorithms may improve decision making and patient survival rates. Active involvement of an experienced orthopaedic surgeon in the evaluation and care of these critically injured patients is essential.
Collapse
|
45
|
Abstract
OBJECTIVE Can anteriorly placed pelvic C-clamps be used successfully in the emergent management of APC-2 pelvic fractures? DESIGN Prospective cohort. SETTING Level 1 trauma center. PATIENTS A single-surgeon series of 24 patients with an anteroposterior compression type 2 pelvic fracture. INTERVENTION Application of an anteriorly placed pelvic C-clamp within 2 hours of presentation. MAIN OUTCOME MEASUREMENTS Response to hypotension, complications related to pin placement, application time, and symphyseal reduction measured on anteroposterior radiograph. RESULTS Twenty-four patients with a mean age of 29 years (14-58 years) had an APC-2 pelvic fracture diagnosed by an anteroposterior radiograph of the pelvis on presentation. All patients were emergently managed with an anteriorly placed C-clamp applied in the emergency room (10), angiography suite (9), or operating room (5). Eleven patients presented with hypotension (systolic blood pressure <90 mm Hg) and had an average elevation of their blood pressure of 23 mm Hg (10-44 mm Hg). The symphyseal separation was reduced from a mean of 4.5 cm (3-9 cm) to <2 cm in all cases and to <1 cm in 21 of 24 cases. Complications included 1 misdiagnosis of an APC-3 injury and 2 cases in which the clamp became dislodged when the patients were rolled in the intensive care unit. Thirteen patients required laparotomy or angiography for further management after the C-clamp was applied. The C-clamp was easily draped out of the field for both procedures. CONCLUSIONS The pelvic C-clamp can be placed anteriorly as a part of the early management of APC-2 pelvic fractures with a short application time in a variety of patient care areas.
Collapse
|
46
|
Abstract
OBJECTIVE To study the deformity of acutely injured unstable pelves before and after emergent application of an anterior external fixator. DESIGN Retrospective. SETTING Large pelvic fracture referral practice. PATIENTS Eleven of 151 patients referred to our institution after emergent application of an external fixator by the referring orthopaedist before transfer who were hemodynamically unstable and had a mechanically unstable pelvic injury with pre-external fixator radiographs and post-external fixator radiographs adequate to determine pelvic deformity. MAIN OUTCOME MEASUREMENTS We reviewed all available radiographs both before and after placement of the external fixator (the anterior-posterior, inlet, outlet, and computed tomography), determining whether the external fixator improved or worsened the deformity. RESULTS Although many deformities existed, we found that application of an anterior frame consistently worsened this deformity. Seven of the 11 patients (64%) had worsening of the posterior cephalad translation or posterior diastasis despite apparent improvement anteriorly on the anterior-posterior radiograph. "External fixator deformity," defined as increased flexion and/or internal rotation of the hemipelvis, also occurred in 8 of 11 patients (73%). After placement of the external fixator, all patients displayed greater than 1 cm of either posterior cephalad translation or posterior diastasis (average 3.4 cm, range 1.3-4.6 cm). CONCLUSIONS Due to the forces placed on the pelvis during application of an anterior external fixator by the surgeon, an external fixator deformity may occur (flexed and internally rotated hemipelvis). Furthermore, most patients had an increase in posterior cephalad translation or posterior diastasis with placement of an external fixator. The surgeon should be aware of the potential of increasing the pelvic deformity when applying an emergent anterior external fixator.
Collapse
|
47
|
Catastrophic myonecrosis following circumferential pelvic binding after massive crush injury: A case report. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.injury.2009.01.101] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
48
|
Abstract
External rotation of the disrupted hemipelvis is a common deformity after pelvic ring trauma, especially in anteroposterior compression injury patterns. This displacement is associated with significant pelvic hemorrhage. Emergent closed reduction techniques are necessary to diminish the potential pelvic volume, provide temporary stability, and allow tamponade with clot formation. Circumferential pelvic antishock sheeting is effective but may be cumbersome, especially in patients with truncal obesity. In such scenarios, circumferential pelvic area sheeting does not always achieve a complete reduction. We present a technique of internal rotation and taping of the lower extremities as an alternative or supplemental pelvic closed reduction method.
Collapse
|
49
|
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury 2009; 40:343-53. [PMID: 19278678 DOI: 10.1016/j.injury.2008.12.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 12/09/2008] [Indexed: 02/02/2023]
Abstract
Pelvic angiography is an established technique that has evolved into a highly effective means of controlling arterial pelvic haemorrhage. The current dominant paradigm for haemodynamically unstable patients with pelvic fractures is angiographic management combined with mechanical stabilisation of the pelvis. However, an effective rapid screening tool for arterial bleeding in pelvic fracture patients has yet to be identified. There is also no precise way to determine the major source of bleeding responsible for haemodynamic instability. In many pelvic fracture patients, bleeding is from venous lacerations which are not effectively treated with angiography to fractured bony surfaces. Modern pelvic packing consists of time-saving and minimally invasive techniques which appear to result in effective control of the haemorrhage via tamponade. This review article focuses on the recent body of knowledge on angiography and pelvic packing. We propose the optimal role for each modality in trauma centres.
Collapse
Affiliation(s)
- Takashi Suzuki
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado at Denver School of Medicine, 777 Bannock Street, Denver, CO 80204, USA
| | | | | |
Collapse
|
50
|
Western Trauma Association Critical Decisions in Trauma: Management of Pelvic Fracture With Hemodynamic Instability. ACTA ACUST UNITED AC 2008; 65:1012-5. [DOI: 10.1097/ta.0b013e318189a836] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|