5/29/2014 Controversies in • Hemodynamically unstable Orthopaedic Trauma Surgery pelvic fractures • Damage Control Eric G. Meinberg, MD • Orthopaedics Associate Clinical Professor • Open Fracture UCSF/SFGH Orthopaedic Trauma Institute Management Low-energy Fractures • Fall from standing height Management of Hemodynamically – Simple fracture patterns Unstable Pelvic Fractures – Stable – Conservative treatment 1
5/29/2014 Lateral Compression High-energy Fractures LC-3 • Associated with significant problems • ‘Windswept pelvis’ • External rotation and – 75% abdominal or pelvic hemorrhage disruption of – 12% urogenital injury contralateral hemipelvis – 8% lumbosacral fracture • Rollover or crush – 60 – 80% associated fractures • Unstable – 12-25% mortality AP Compression AP Compression APC-1 APC-2 • <2.5 cm symphysis • >2.5 cm diastasis disruption • Opening of SI joint • Ramus fractures • Floor ligaments torn • No posterior injury • Rotationally unstable • Vertically stable • Stable 2
5/29/2014 AP Compression Vertical Shear APC-3 • >2.5 cm symphysis • Fall from height disruption • Significant vertical • Complete rupture of forces posterior ligaments • Anterior and posterior • Rotationally and vertical displacement vertically unstable • Unstable Combined Mechanism Associated Injuries AP compression • Pelvic floor disruption • Combination of • Intra-pelvic and retroperitoneal vascular injuries multiple mechanisms • Shock, sepsis, ARDS, death • Significant associated • 20% mortality injures Lateral compression • Majority are LC-2 and • Pelvic floor is intact VS • Decreased intra-pelvic bleeding • Unstable • Brain and visceral injuries • 7% mortality 3
5/29/2014 Immediate Management Technique • In the field or trauma bay • Pelvic binder or bedsheet • Apply around greater trochanters • Maintains continuous reduction until fixator applied (up to 72h safe) • May be left on in OR for other procedures Technique Technique 4
5/29/2014 Proper Placement? Pelvic Binder • Works like a sheet • Easy to place by emergency staff • Less likely to be over- tightened • Low risk of skin necrosis • Looks ‘official’ C-Clamp External Fixation • Fast and effective way of pelvic stabilization • Temporary fixation of posterior instability and widening • Re-establishes pelvic ring • Act as temporary SI screws and decreases intrapelvic • Applied bedside or OR volume • Allows access to abdomen and patient • Only emergent method to • Decreases hemorrhage by adequately stabilize tamponade, posterior displacement reapproximating fracture edges, decreasing motion 5
5/29/2014 C-Clamp Application C-Clamp Application Extraperitoneal Pelvic Packing C-Clamp Considerations • Rationale: – Only treatment to control • Not readily available bleeding from venous plexus – Controls arterial bleeding • Requires c-arm guidance for placement – Enables control of large vessel bleeding • Contraindicated in ilium fractures – Simultaneous treatment of associated abdominal trauma • May over-compress sacrum fractures • Performed after reduction • Sciatic nerve, gluteal artery injury reported of pelvic volume with fixator 6
5/29/2014 The Case for Pelvic Packing The Case for Pelvic Packing Ertal et al. JOT, 2001 Ertal et al. JOT, 2001 • 20 patients with pelvic disruption • Mean ISS 41.2 • C-clamp applied in the ER • Lactate q30 min. • Pelvic packing for persistent bleeding (non decreasing lactate) The Case for Pelvic Packing Preperitonal Pelvic Packing for Hemodynamically Unstable Ertal et al. JOT, 2001 Pelvic Fractures: A Paradigm Shift • Pelvic packing in 14 Cothren, Osborn, Moore, Morgan, Johnson, Smith, MD • 4 patients died (20%) The Journal of TRAUMA 2007 • Lactate levels predicted Transfusion requirements Pre – packing compared with subsequent 24 hrs were mortality significantly less (12 versus 6; p 0.006) 7
5/29/2014 Preperitonal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures: A Paradigm Shift Cothren, Osborn, Moore, Morgan, Johnson, Smith, MD The Journal of TRAUMA 2007 25% Mortality Institutional Protocols • Biffl et al: J Orthop Trauma 2001 • Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures Problem Reduction • Mortality 31% ->15% • Death by exsanguination 9% -> 1% • Multi-organ failure 12% -> 1% • Death within 24h 16% -> 5% 8
5/29/2014 Institutional Protocols Who should get angiography? • ATLS - identify pelvis as source • Temporary pelvic volume reduction • Concerns: • Acute external fixation +/- – Venous and fracture (cancellous bone) bleeding traction account for >90% • Laparotomy +/- pelvic packing – Arterial bleeding accounts for <10% • Pelvic angiography & embolization Case 1 • 30 year old male • 1 hour after motorcycle accident 2 Patients…. • initial vital signs: • blood pressure 100/60 • heart rate 100 • respiratory rate 40 • Acute abdomen, and….. 9
5/29/2014 Emergent laparatomy, ex fix, packing Ongoing ‘Shock’ Classic Indication • Persistent shock despite treatment embolization angiography packing External fixator 10
5/29/2014 Case 2 • 70 year old female • Struck by car • Initial responder but ongoing low blood pressure • Only injury….……. Initial treatment Classic Indications • No need for • Persistent shock binder despite treatment • Skeletal traction leg • Shock with normal • Transfusion 4 pelvic volume units packed cells and 6L crystalloid first 4hrs 11
5/29/2014 ‘Clues’ re: need for angio Ongoing hypotension • transfusion requirements • contrast extravasation (CE) 9 hours post injury: • Successful angiographic • age > 60 embolization of obturator • bladder displacement artery – ‘pelvic hemorrhage volume’ ‘Clues’ re: need for angio Extravasation • transfusion requirements • Identification of • contrast extravasation (CE) ‘extravasation’ on • age > 60 contrast CT that • bladder displacement correlated with angiographic findings – ‘pelvic hemorrhage volume’ 12
5/29/2014 Age ‘Clues’ re: need for angio • transfusion requirements Kimbrell et al: Arch Surg 2004 • angio 92 patients -> 55 (60%) embolization • contrast extravasation (CE) • age > 60: 94% embolization (vs 50%) • age > 60 • 2/3 patients > 60 yo = normal BP @ admission • bladder displacement • embolization -> 100% efficacy – ‘pelvic hemorrhage volume’ Velmahos J Trauma 2002 Case - acetabular fracture Successful embolization of SGA 13
5/29/2014 Angiography/ embolization • Should be used in a protocol – Frequency ≈10% Damage Control Orthopaedics • Indications (DCO) • ‘clues’ • Avoid bilateral internal iliac a. embolization • Associated risks: – acute renal failure – gluteal muscle necrosis – deep infection 60 ’s to 80’ s 80 ’s to the 90’ s “The patient is too sick to have surgery” “Patient is too sick NOT to have surgery” • Riska 1976 • Goris 1982 • Meek 1986 • Bone 1989 14
5/29/2014 Orthopedic Damage Origins of “damage control” Control “… temporary stabilization of fractures soon after injury, minimizing the operative time, and preventing heat and blood loss.” • In severely injured patients, initial orthopaedic surgery should not be definitive treatment • Definitive treatment delayed until after patients overall physiology improves Scalea et al J Trauma 48(4), 2000. Damage Control Decision Making Must Focus on the • Decompression of body cavities Patient as a “Whole” • Bleeding control • Repair of hollow viscus injuries • Stabilization of central fractures – Pelvis – Femur 15
5/29/2014 ARDS and Multiple Organ Failure Orthopaedic Damage Control • Avoid worsening the patients condition by a major Cascade of inflammatory reactions orthopaedic procedure (“2 nd Hit”) Exaggerated systemic inflammatory response syndrome (SIRS) ARDS and Multiple Organ Failure (MOF) ARDS and Multiple Organ Failure No Severe Pulmonary Injury • 20 years of data at the Hannover Trauma Center suggest that patients who • In patients without severe chest trauma underwent a major (> 3 hour) operation – Early IM nailing reduced the length of ICU stay on PTD 3 – 5 had increased mortality (7.3 days vs. 18.0 days) • Secondary surgical procedure acted as a – Reduced the length of intubation (5.5 days vs. “second hit” , exacerbating the primed 11.0 days) systemic inflammatory response • In the absence of severe chest trauma primary IM femoral nailing is beneficial Pape HC, et al. J. Trauma. 34: 540 – 657, 1993. 16
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