Damage control orthopaedics in unstable pelvicring injuries

P.V. Giannoudisa,*, H.C. Papeb

aDepartments of Trauma and Orthopaedic Surgery, St. James’s University Hospital,University of Leeds, Leeds LS9 7TF, UKbHannover Medical School, Hannover, Germany

Introduction

Pelvic fractures account for 3—8% of all skeletalfractures.31,40 They are usually secondary to high-energy trauma with motor vehicle crashes being thecommonest mechanism of injury.

Despite the introduction of organised traumasystems, pelvic ring disruptions continue to be asignificant source of morbidity and mortality ran-ging from 4.8 to 50%.10,14,44 Their management inthe acute setting is challenging to the most experi-enced trauma surgeons and often requires a multi-disciplinary approach involving a variety of special-ties. This is due to the presence of associatedinjuries as the high-energy force applied to thepelvic ring is also distributed to other parts of theskeleton resulting in injuries to other organs.42

Appropriate assessment and treatment of thesefractures is important because it can lead in fewerdeaths and less long-term disability.

Several classification systems have been devel-oped over the years based on fracture location,pelvic stability, injury mechanism and directionof injury force applied.

The Young and Burgess classification system is anexpansion of the original classification developed byPennal and Sutherland where the fractures wereclassified based on the direction of three possibleinjury forces: anterior posterior compression (APC),lateral compression (LC) and vertical shear (VS).8,57

Young and Burgess developed subsets on the LC andAPC injuries to quantify the forces applied. Theyalso added a forth injury force category of com-bined mechanical injury.6 Their classification sys-tem helps with the detection of the posterior ringinjury, predicts local and distant associated inju-ries, resuscitation needs and expected mortalityrates. APC types II and III, lateral compression type

Injury, Int. J. Care Injured (2004) 35, 671—677

KEYWORDS

Orthopaedics;

Pelvic ring injury;

Skeletal fracture

Summary Pelvic ring injuries are often associated with other system injuries andrequire a multidisciplinary approach for their treatment. Early mortality is usuallysecondary to uncontrolled haemorrhage whereas late mortality is due to associatedinjuries and sepsis-induced multiple organ failure. The management of the pelvicfracture should be conceived as part of the resuscitative effort as errors in earlymanagement may lead to significant increases in mortality.

In severely multiple injured patients who are in an ‘unstable’ or ‘in extremis’clinical condition damage control orthopedics is the current treatment of choice.

By performing limited surgical interventions the subsequent reduction in blood lossand transfusion requirements can only be beneficial in these critically ill patients,reducing the risk of developing systemic complications and early mortality.� 2004 Elsevier Ltd. All rights reserved.

*Corresponding author. Tel.: þ44-113-2065084;fax: þ44-113-2065156.

E-mail address: pgiannoudi@aol.com (P.V. Giannoudis).

0020–1383/$ — see front matter � 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.injury.2004.03.003

III, vertical shear (VS) and combined mechanicalinjuries are indicative of major ligament disruption.AP III injuries require the most blood replacement,followed by VS patterns followed by CM followed byLC III injuries.6

Patients with pelvic fractures can be divided intotwo sub-groups. The first of those are patients whosustain stable pelvic fractures with most of theinjury confined to the ligamentous tissues. Manage-ment in these circumstances is confined to recon-struction of the osteo-ligamentous structures on amore semi-elective basis.

In the second group, patients sustain displacedpelvic ring fractures, require emergency haemor-rhage control and a multidisciplinary team approachfor the associated injuries. The overall prevalenceof pelvic fractures presenting with haemodynamicinstability has been reported to range from 2 to20%.4,16,25,32,41,43 Errors in early management maylead to significant increases in mortality. Earlyrecognition and appropriate management ofpatients within this group can therefore offer sig-nificant improvements in outcome.

The management of this specific sub-group ofpatients has evolved over the years to what is knowntoday ‘damage control orthopaedics’.

Control of pelvic instability andhaemorrhage

During the acute phase, the goal of treatment ofhigh-energy pelvic ring disruptions is prevention ofearly death from haemorrhage. The management ofinternal blood loss is paramount initially.

Arterial bleeding (iliac vessels and their branchesto the inferior abdominal viscera and pelvic organs)is a major contributor to haemorrhagic shock inpelvic fractures (Fig. 1). Other sources of bleedinginclude the low-pressure venous plexus and frac-tured cancellous bone surfaces. The retroperito-neum can contain up to 4 L of blood and bleedingwill continue until intra-vascular pressure is over-

come and physiological tamponade has occurred.However, where extensive disruption of the retro-peritoneal muscle compartments has taken placethis can lead to uncontrolled haemorrhage with therisk of exsanguination. This is because the retro-peritoneum is not a closed space and pressureinduced tamponade cannot be expected.20

The first step in restoring haemodynamic stabilityincludes the administration of intravenous crystal-loid fluids and whole blood. When replacement offluid and blood does not stabilise the patient’s vitalsigns, additional steps must be taken. Any subse-quent interventions should be rapid and minimallytraumatic focusing on haemorrhage control andother life saving measures. Complex reconstructivework is delayed until the patient is haemodynami-cally stable and in a better physiological conditionto withstand the additional surgical burden. Avoid-ance of coagulation disturbances, the systemicinflammatory response, adult respiratory distresssyndrome and multiple organ dysfunction syndromeis of paramount importance for reduced mortalityrates.17,18,34

In general terms treatment should be highly case-dependent. Treatment options that should be con-sidered for the emergency haemostasis of patientswith pelvic fractures at risk of exsanguinationinclude the pelvic sling, arterial inflow arrest,external fixation devices, internal fixation, directsurgical haemostasis, pelvic packing, pelvic angio-graphy and embolisation.

Pelvic sling

During the past decade the use of a bed sheet, pelvicsling and pelvic belt for emergency stabilization ofpelvic fractures has found great acceptance as itachieves adequate compression without compro-mising access to the patient.3,9,45

Prophylactic application of these devices at thescene or in the Emergency Department appears tobe satisfactory. Furthermore, they are easy to use,readily available and inexpensive. However, poten-tial disadvantages may be related to soft-tissuepressure and the risk of visceral injury or sacralnerve root compression, though there are noreported complications in the available small clin-ical series.49,53

Arterial inflow arrest

In cases where exsanguination of the patient isimminent, occlusion of the aorta can be used as atemporary measure to control the haemorrhage.This can be performed directly open cross clampingor via percutaneous or open balloon catheterFigure 1 Pelvic fractures and arterial bleeding.

672 P.V. Giannoudis, H.C. Pape

techniques.5 Other authors have reported satisfac-tory control of arterial bleeding with ligation of thehypogastric artery attributing this to the remark-able collateral supply within the pelvis.37,47

External fixator devices

Various external fixation devices have been devel-oped over the years and rely on pin insertion into theiliac crest. An external fixator is probably the mostcommonly used tool worldwide for rapid pelvic ringstabilization providing resuscitative, provisionaland definitive treatment. It is considered as thetreatment of choice especially in cases where asso-ciated extensive soft tissue injuries are presentincluding, bowel and bladder disruptions.51,56

External fixator systems are usually easy to han-dle and can be applied in the trauma room. Theirapplication controls blood loss by direct compres-sion at the fracture site and pressure on the injuredvessels. Correct pin placement is the foundation ofthe pelvic external fixator. Resuscitation framesusually involve the application of two pins per iliaccrest.43,54 Many of the clinical complications asso-ciated with pelvic external fixation are related tothe iliac crest pins and the high rate of secondarydisplacement in type B and C injuries.29

Pelvic C-clamp

The C-clamp consists of two pins is applied on theposterior ilium in the region of the SI joints. Itprovides compression and stability at the posterioraspect of the ring at the point where the greatestbleeding usually occurs and thus provides effectivepelvic tamponade. Its use however may be compro-mised in the presence of fractures of the ilium andtrans-iliac fracture dislocations.15 Potential compli-cations include iatrogenic injury to the gluteal neu-rovascular structures and secondary nerve injury asa result of over-compression in sacral fractures.38

Several reports have highlighted their effectivenessespecially in the acute clinical setting.39,50

Internal fixation

The option of open reduction and internal fixation isconsidered as the procedure of choice for pelvic ringfixation due to clearly superior biomechanicaladvantages. However, in the acute setting andespecially in the ‘extremis’ clinical condition ofthe patient such an approach is not advocated asit is time consuming and often extensile approachesare necessary predisposing the patient to uncontrol-lable haemorrhage, coagulation disturbances andearly mortality. When haemodynamic stability has

been achieved, only then symphyseal plating, ante-rior plating of the SI-joint and application of trans-iliosacral screws is sensible.1,27,46

Direct surgical haemostasis

Direct surgical haemostasis whilst providing a the-oretical advantage, in the real clinical environmentit is not usually feasible as bleeding is often sec-ondary to damaged venous plexuses and control ofhaemorrhage may be unachievable. Furthermoreuncontrolled circumferential stitching and clipapplication, with inadequate visualization, maylead to iatrogenic nerve injuries.2,13

Pelvic angiography and embolisation

Haemodynamic compromise following unstable pel-vic fractures secondary to arterial bleeding is pre-sent in only about 10% of the cases.23,24 The use ofangiographic pelvic vessel embolisation in trau-matic pelvic bleeding remains a topic of intensediscussion. Its efficacy has been questioned as mor-tality figures of up to 50% have been reporteddespite effective bleeding control.7,21 Further-more, as the procedure can be time consuming,management of other associated injuries may beproblematical.

In his study, Cook et al. emphasised the impor-tance of the application of an external fixator priorto pelvic angiography. Out of 23 patients who weresubjected to embolisation, 10 patients died (43%)and 6 of these had their angiography as the primarytherapeutic intervention. Of these, five had frac-tures that would have been stabilized by an externalfixator. The authors recommend external pelvicfixation prior to pelvic angiography.7

In another study, Velmahos et al. reported on 30patients who underwent bilateral internal iliac arteryembolisation. In 17 patients embolisation was per-formed as the primary treatment for haemorrhagecontrol whereas in the remaining 13 patients it wasperformed as a secondary treatment as they had firstundergone laparotomy with unsuccessful control ofthe bleeding. The overall success rate was 97% andthe authors concluded that the procedure appearedto be useful in a selected group of patients.52

Hamill et al. studied 20 out of 76 patients withpelvic trauma who underwent pelvic embolisationwith a primary success rate of 90%. The averagetime from injury to angiography was 5 h (2.3—23 h).In eight patients (40%) a second procedure due toongoing haemorrhage was required, four of thesepatients died.21

In order for pelvic angiography and embolisationto be successful, interventional radiologists familiar

Damage control orthopaedics in unstable pelvic ring injuries 673

with the procedure and dedicated facilities should bereadily available at the receiving hospital minimizingthe time between admission and performance of theprocedure. In recent studies an improved resultshave been reported with the average time to inter-vention decreasing from 17 h 19,22 to 5 h.35

Pelvic packing

The technique of retroperitoneal packing has beensuccessfully used in some institutions where tam-ponades are applied in the paravesical and presacralspaces in an attempt to tamponade bleeding.Immediate posterior pelvic ring stabilization withthe pelvic C-clamp or an external fixator providesmechanical stability for pelvic tamponade and frac-ture reduction leads to a reduction in fracturehaemorrhage. The presacral and paravesical regionsare then packed from posterior to anterior usingstandard surgical techniques. The packing is chan-ged or removed 48 h after injury.

Ertel et al. prospectively analyzed 20 consecu-tive patients with pelvic ring disruption and hae-morrhagic shock. All patients were treated with animmediate pelvic C-clamp followed by laparotomyand pelvic packing in persistent or massive haemor-rhage. The overall mortality rate was 25%. Haemor-rhagic shock was identified by blood lactate levelsat admission, which was on average 5.1 mmol/l. Amean of 33.2 units of blood transfusion wererequired within the first 12 h.12

In another study, 41 patients in an ‘extremis’clinical condition were analysed.11 The average ISSwas 40 and the average volume of blood transfusedwas 33.9 units. Concomitant injuries were commonwith 66% having head injuries, 73% chest injuries,61% abdominal injuries and 88% extremity injuries.Emergency treatment consisted of 9 crash thoraco-tomies, 23 crash laparotomies, 9 aortic clampings tocontrol haemorrhage and 2 pelvic C-clamp applica-tions. Effective angiographic embolisation was per-formed in one patient. The overall mortality rate ofthese patients was 90.2%. The majority of patients(56%) died within 24 h due to persistent haemor-rhagic shock.11

Whilst some authors have attempted to providecomparisons between the efficacy of pelvic packingversus pelvic angiography, one could say that such acomparison is not appropriate.

It is apparent from the data that the two groupsof patients undergoing pelvic packing or embolisa-tion are not comparable. The average time to inter-vention is far lower in the pelvic packing group and asignificantly higher volume of PRBC transfusion wasnecessary for immediate resuscitation. The overallaverage transfusion rate for patients who under-

went embolisation was 1.65 units of blood/h7,21 andthis is in contrast to those who underwent emer-gency pelvic packing, receiving on average 8 units inthe first hour or 12 in the first 2 h.50 These patientsrepresent a group of extremely unstable patientssuffering massive pelvic bleeding with an expect-edly high mortality rate.

Damage control orthopaedics for pelvicfractures with haemodynamicinstability

Mortality from pelvic fractures could be divided toearly, secondary to uncontrolled haemorrhage, andlate due to post-traumatic complications such asARDS/MODS.12,50 It is clear today that the develop-ment of ARDS and MODS is due to multiple altera-tions in inflammatory and immunological functions,which occur shortly after trauma and haemorrhage(first hit phenomena). Traumatic injury leads tosystemic inflammation (Systemic InflammatoryResponse Syndrome or SIRS) followed by a periodof recovery mediated by a counter-regulatory anti-inflammatory response (CARS).33 Severe inflamma-tion may lead to acute organ failure and early deathafter injury but a lesser inflammatory responsefollowed by excessive CARS may induce a prolongedimmunosuppressed state that can also be deleter-ious to the host.

The surgical burden (operative intervention, sec-ond hit phenomena) on the immune response thatoccurs in polytraumatized patients, in addition tothat caused by the primary insult, is considered todayas a critical factor directly affecting the clinicalcourse of the patient.34 Sub-clinical consequencesof the initial trauma and subsequent operative treat-ment could manifest as abnormalities in organfunction, leading to MODS. It is believed todaythat the burden of the second hit should be mini-mized in multiply injured patients with a high risk ofadverse outcome. There is no doubt that prolongedoperative interventions on polytrauma patients canlead to coagulation disturbances and an abnormalimmuno-inflammatory state causing remote organinjury.26,55 In patients with pelvic fractures beingin an ‘unstable’ or ‘extremis’ clinical conditiontherefore, prolonged operative interventions couldinitiate a series of reactions at the molecular levelpredisposing the patient to an adverse outcome. Anysurgical intervention here must be considered imme-diately life saving and should therefore be simple,quick and well performed. Rigid rules relating totiming should be avoided to prevent unnecessarydelay — time is usually critical to survival of thepatient.18 Protocols designed to reduce mortality

674 P.V. Giannoudis, H.C. Pape

should stop bleeding, detect and control associatedinjuries and restore haemodynamics. A staged diag-nostic and therapeutic approach is required. Duringthe first 24 h, death from exsanguination has beenidentified as a major cause of mortality. The severityof bleeding is a crucial hallmark for survival duringthe early period after injury. In young patients whoare able to compensate for extensive blood loss forseveral hours, underestimation of the true haemo-dynamic status can lead to fatal outcome. Because ofthe disastrous haemodynamic conditions of thesepatients, only external devices that are easy to applycan be used effectively. These devices, by externalcompression reduce the intrapelvic volume and cre-ate a tamponade effect against ongoing bleeding.They also restore stability and bone contact to theposterior elements of the pelvis and contribute toblood clotting. Pelvic packing should be consideredin cases where, despite the application of the exter-nal fixator, ongoing bleeding is encountered. In thissituation, angiographic embolisation is both timeconsuming and inhibitive to dynamic assessmentand further treatment. Pelvic packing allows thesimultaneous assessment and treatment of abdom-inal injuries. In the presence of multiple massivebleeding points, tamponade of the areas or tempor-ary aortic compression should be considered. Com-plex reconstructive procedures in the abdomenshould be avoided in the presence of pelvic haemor-rhage. A major splenic rupture usually necessitatessplenectomy. In liver injuries, attention is paid onlyto major vessels and hepatic tamponade is applied.Bowel injuries are clamped and covered and defini-tive treatment performed after the haemodynamicsituation is stabilized.28,30,36,48

Angiographic embolisation is not usually indi-cated in this patient population. However, in caseswhere haemodynamic stability with volume repla-cement can be achieved but ongoing pelvic hae-morrhage is suspected (expanding haematoma)then angiography could be considered as an adjunctto the treatment protocol.

Damage control orthopedics is the current treat-ment of choice for the severely injured patientespecially those with an unstable pelvic ring injuryassociated with haemodynamic instability (Fig. 2).The management of the pelvic fracture should beconceived as part of the resuscitative effort. Bymaintaining circulating blood volume and tissueoxygenation, whilst performing a rapid and limitedsurgical intervention where indicated, the damageinduced by any procedure is minimized. Immediateexternal fixation of the unstable pelvis with pelvicpacking to control pelvic haemorrhage is a practicalapproach in those in extremis and borderlinepatients. Angiographic embolisation can only berecommended in the more stable patient.

The recognized benefits of pelvic fracture stabi-lization are obtained at an early stage. The subse-quent reduction in blood loss and transfusionrequirements can only advantage these criticallyill patients and reduce the risks of developing sys-temic complications.

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Management of Pelvic Fractures

Clinical Condition of Patient

Stable Borderline Unstable In extremis

Cause of haemorrhage

(chest abdomen)?

Re-evaluation

2nd FAST

Stable OR

ORIFORIF

Uncertain/OR

DCO

Ex –Fix C-clamp

Ex-fix/C-clamp

Packing

OR

DCO

If continuously unstable:

Extrapelvic bleeding sources ?

Pelvic haemorrhage

Angiography

Yes No

OR

Repacking /ITU

Figure 2 Damage control orthopaedics (DCO) in unstable pelvic fractures.

Damage control orthopaedics in unstable pelvic ring injuries 675

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