The application of the WSES classification system for open pelvic fractures-validation and supplement from a nationwide data bank

Polymicrobial infection presenting as non-clostridial gas gangrene in a patient with an open pelvic ring fracture accompanied by abdominal evisceration: a case report

Background

Open pelvic fractures are rare but represent a serious clinical problem with high mortality rates. Acute mortality is often associated with hemorrhage, whereas delayed mortality is most often associated with sepsis and multiple organ failure. We report a case of Wang's classification of type II open pelvic ring fracture with hemorrhagic shock and septic shock from gas gangrene.

Case Description

A healthy 41-year-old man presented with an open pelvic ring fracture and a laceration in the lower abdomen sustained at an ironworks. His hemodynamic status was unstable. Pelvic ring stabilization with an external fixator, ligation of the median sacral and bilateral internal iliac arteries, partial resection of the ileum, appendectomy, and intra-abdominal pelvic packing were performed. Seven days after the injury, he developed a single spike fever of 39.8 ℃ with a significant pus discharge from the open wound around his groin. A computed tomography scan revealed an accumulation of gas around the sacroiliac joint, in the abdominal cavity, and the adductors and gluteus maximus muscles caused by non-clostridial gas gangrene. We performed surgical debridement three times and initiated vancomycin administration. Hyperbaric oxygen therapy was also initiated as an adjunctive therapy. The patient could walk with a cane 5 months after the injury.

Conclusions

We described a multidisciplinary case of a patient with a Wang type II open pelvic fracture who required emergent damage control and subsequently developed anaerobic sepsis. Bleeding was controlled by packing gauze into the intraperitoneal cavity and applying external fixation to the pelvic ring. However, it is important to administer prophylactic antibiotics against anaerobic bacteria and to detect subsequent infections early when packing gauze into the intraperitoneal cavity in patients with open pelvic fractures.

Management of Pelvic Trauma

Pelvic fractures are common after blunt trauma with patients' presentation ranging from stable with insignificant fractures to life-threatening exsanguination from unstable fractures. Often, hemorrhagic shock from a pelvic fracture may go unrecognized and high clinical suspicion for a pelvic source lies with the clinician. A multidisciplinary coordinated effort is required for management of these complex patients. In the exsanguinating patient, hemorrhage control remains the top priority and may be achieved with external stabilization, resuscitative endovascular balloon occlusion of the aorta, preperitoneal pelvic packing, angiographic intervention, or a combination of therapies. These modalities have been shown to reduce mortality in this challenging population.