- Acute Management of Pelvic Fractures - Damage Control Orthopaedics. High- energy Fractures

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1 Controversies in Orthopaedic Trauma Surgery Eric G. Meinberg, MD Assistant Clinical Professor UCSF/SFGH Orthopaedic Trauma InsKtute - Acute Management of Pelvic Fractures - Damage Control Orthopaedics Acute Management of Pelvic Fractures Low- energy Fractures High- energy Fractures Radiographic EvaluaKon Fall from standing height Simple fracture paoerns Stable ConservaKve treatment Associated with significant problems 75% abdominal or pelvic hemorrhage 12% urogenital injury 8% lumbosacral fracture 60 80% associated fractures 12-25% mortality AP pelvis Inlet and outlet views CT scan +/- reconstrucitons Inlet View Outlet View ClassificaKon Systems Pubic symphysis Sacral and crescent fractures SI joint widening Anterior/posterior displacement Pubic symphysis and rami Sacral fractures Superior displacement 1

2 Tile ClassificaKon Type A fractures Tile ClassificaKon Type B fractures Tile ClassificaKon Type C fractures Do not fracture through pelvic ring All ligaments are intact Avulsion fractures Iliac wing fractures Fracture through pelvic ring Displaced by internal or external rotakon forces Posterior ligaments remain intact Posterior arch maintains some stability Complete disrupkon of ligaments and pelvic floor Posterior and verkcal translakon Stable fracture paoern ParKally stable fracture paoern NO posterior or verkcal displacement Completley unstable hemipelvis Young & Burgess ClassificaKon Stability judged by: Fracture paoern DirecKon of force of injury Knowledge of ligamentous anatomy Young & Burgess ClassificaKon Fracture Types Lateral Compression AP Compression VerKcal Shear Combined Mechanism Lateral Compression LC- 1 Posteriorly applied force Sacral impackon +/- Transverse pubic rami fractures Stable Lateral Compression Lateral Compression AP Compression LC- 2 Anteriorly applied force Posterior disrupkon Ilium fx Sacral impackon fx Posterior ligament disrupkon Ipsilateral ramus fractures +/- RotaKonally unstable VerKcally stable LC- 3 Windswept pelvis External rotakon and disrupkon of contralateral hemipelvis Rollover or crush Unstable APC- 1 <2.5 cm symphysis disrupkon Ramus fractures No posterior injury Stable 2

3 APC- 2 >2.5 cm diastasis Opening of SI joint Floor ligaments torn RotaKonally unstable VerKcally stable AP Compression APC- 3 >2.5 cm symphysis disrupkon Complete rupture of posterior ligaments RotaKonally and verkcally unstable AP Compression Fall from height Significant verkcal forces Anterior and posterior verkcal displacement Unstable VerKcal Shear Combined Mechanism CombinaKon of mulkple mechanisms Significant associated injures Majority are LC- 2 and VS Unstable Incidence of fracture type A. Stable 591 (50%) B. ParKally unstable 331 (28%) APC LC C. Completely unstable 263 (22%) Total Associated Injuries AP compression Pelvic floor disrupkon Intra- pelvic and retroperitoneal vascular injuries Shock, sepsis, ARDS, death 20% mortality Lateral compression Pelvic floor is intact Decreased intra- pelvic bleeding Brain and visceral injuries 7% mortality Immediate Management CircumferenKal pelvic ankshock sheekng system Apply around greater trochanters Maintains conknuous reduckon unkl fixator applied May be lem on in OR Safer than C- clamp or MAST trousers Technique Technique 3

4 Technique Proper Placement? Pelvic Binder Works like a sheet Easy to place by emergency staff Less likely to be over- Kghtened Low risk of skin necrosis Looks official Fast and effeckve way of pelvic stabilizakon Re- establishes pelvic ring and decreases intrapelvic volume Decreases hemorrhage by tamponade, reapproximakng fracture edges, decreasing mokon External FixaKon Temporary fixakon of posterior instability and widening Act as temporary SI screws Applied bedside or OR Allows access to abdomen and pakent Only emergent method to adequately stabilize posterior displacement C- Clamp C- Clamp ApplicaKon C- Clamp ApplicaKon C- Clamp ConsideraKons Not readily available Requires c- arm guidance for placement Contraindicated in ilium fractures May over- compress sacrum fractures SciaKc nerve, gluteal artery injury reported Extraperitoneal Pelvic Packing RaKonale: Only treatment to control bleeding from venous plexus Controls arterial bleeding Enables control of large vessel bleeding Simultaneous treatment of associated abdominal trauma Performed amer reduckon of pelvic volume with fixator 4

5 The Case for Pelvic Packing Ertal et al. JOT, 2001 The Case for Pelvic Packing Ertal et al. JOT, pakents with pelvic disrupkon 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 Ertal et al. JOT, 2001 Pelvic packing in 14 4 pakents died (20%) Lactate levels predicted mortality Preperitonal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures: A Paradigm Shi> Cothren, Osborn, Moore, Morgan, Johnson, Smith, MD Preperitonal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures: A Paradigm Shi> Cothren, Osborn, Moore, Morgan, Johnson, Smith, MD The Journal of TRAUMA 2007 The Journal of TRAUMA 2007 Transfusion requirements Pre packing compared with subsequent 24 hrs were significantly less (12 versus 6; p 0.006) 25% Mortality InsKtuKonal Protocols Biffl et al: J Orthop Trauma 2001 EvoluKon of a mulkdisciplinary clinical pathway for the management of unstable pakents with pelvic fractures Problem ReducKon Mortality 31% - >15% Death by exsanguinakon 9% - > 1% MulK- organ failure 12% - > 1% Death within 24h 16% - > 5% InsKtuKonal Protocols ATLS - idenkfy pelvis as source Temporary pelvic volume reduckon Acute external fixakon +/- trackon Laparotomy +/- pelvic packing Pelvic angiography & embolizakon 5

6 Who should get angiography? Concerns: Venous and fracture (cancellous bone) bleeding account for >90% Arterial bleeding accounts for <10% 2 PaKents. Case 1 30 year old male 1 hour amer motorcycle accident inikal vital signs: blood pressure 100/60 heart rate 100 respiratory rate 40 Acute abdomen, and.. Emergent laparatomy, ex fix, packing Classic IndicaKon Persistent shock despite treatment Ongoing Shock Case 2 angiography embolization 70 year old female Struck by car IniKal responder but ongoing low blood pressure Only injury.. packing External fixator 6

7 IniKal treatment Classic IndicaKons Ongoing hypotension No need for binder Skeletal trackon leg Transfusion 4 units packed cells and 6L crystalloid first 4hrs Persistent shock despite treatment Shock with normal pelvic volume 9 hours post injury: Successful angiographic embolizakon of obturator artery Goal: IdenKfy the 10 % that require embolizakon On Review Value of Contrast Sign Stephen, Kreder, et al: J Trauma 1999 IdenKficaKon of extravasakon on contrast CT that correlated with angiographic findings PredicKve value of a posikve test: 80% PredicKve value of a negakve test: 99% Conclusion: CT contrast extravasajon (CE) represents rapid arterial bleeding Contrast ExtravasaKon (CE) Pereira et al: Surgery 2000 SensiKvity 90% Specificity 99% PosiKve predickve value of embolizakon 98% Significance of Contrast ExtravasaKon Brasel et al: J Trauma 2007 N=604 - > contrast extravasakon in 42 (7%) higher ISS (25 vs 18) mortality (24 vs 6%) 25/ 42 (60%) angiography - > 17 embolized (68%) 6 (1%) CE (- ) - > angio - > 2 embolized (.5%) Clues re: need for angio transfusion requirements contrast extravasakon (CE) age > 60 bladder displacement pelvic hemorrhage volume 7

8 Clues re: need for angio Case 2: 70 yo - hit by car Age transfusion requirements contrast extravasakon (CE) age > 60 bladder displacement pelvic hemorrhage volume Kimbrell et al: Arch Surg 2004 angio 92 pakents - > 55 (60%) embolizakon age > 60: 94% embolizakon (vs 50%) 2/3 pakents > 60 yo = normal admission embolizakon - > 100% efficacy Velmahos J Trauma 2002 Clues re: need for angio Pelvic hemorrhage volume Case - acetabular fracture transfusion requirements contrast extravasakon (CE) age > 60 bladder displacement pelvic hemorrhage volume Blackmore et al: Arch Surg 2003 pelvic hemorrhage volumes > 500cc on CT 5x relakve risk of pelvic arterial injury NB: bladder displacement Successful embolizakon of SGA Renal funckon PotenKal Risks of EmbolizaKon Vassiliu et al: J Am Coll Surg 2002/ J Trauma 2002 N=100 mild, transient creaknine (return to normal 5 d): 5% No risk: age > 60 ISS > 15 shock on arrival high volume contrast (>250ml) elevated creaknine (>1.5 mg/ml) before angio renal injury 8

9 Genitourinary FuncKon Ramirez et al: J Trauma 2004 Male sexual funckon amer bilateral internal iliac artery embolizakon No significant impact vs pakents with pelvic fractures not embolized But PotenKal risks of embolizakon OTA 2008 Acute renal failure Carolinas Medical Center, paper # / 263 angiography (17%) PosiKve predickve contrast extravasakon 85% EmbolizaKon 91% (100% with extravasakon) ComplicaKons: Acute renal failure 9% vs.5% (p=.004) 2 gluteal muscle necrosis 2 acute deep infeckons Gluteal muscle necrosis San Francisco General: #25 88 / 909 angiography (10%) ALL PATIENTS: bilateral internal iliac embolizakon Mortality - 20% Acute complicakons - 20% (18 in 12 pts) Gluteal muscle necrosis- 6% Wound breakdown- 8% Impotence 2% Bladder necrosis 1% Gluteal muscle necrosis Takahira et al: Injury 2001 Gluteal artery embolizakon Inicidence: 5/151 (3%) Average ISS: 46 (26-59) Mortality (sepsis/dic) 3/5 (60%) Shock Trauma: #26 Deep InfecKon EmbolizaKon - > ORIF of acetabular fx 32 /1440 angiography - > 14 embolizakon (1%) deep infeckon 50% (11% non embolized) Angiography/ embolizakon Should be used in a protocol Frequency 10% IndicaKons clues Avoid bilateral internal iliac a. embolizakon Associated risks: acute renal failure gluteal muscle necrosis deep infeckon Damage Control Orthopaedics (DCO) 9

10 60 s to 80 s The pakent is too sick to have surgery 80 s to the 90 s PaKent is too sick NOT to have surgery Origins of damage control Riska 1976 Goris 1982 Meek 1986 Bone 1989 Orthopedic Damage Control temporary stabilizakon of fractures soon amer injury, minimizing the operakve Kme, and prevenkng heat and blood loss. In severely injured pakents, inikal orthopaedic surgery should not be definikve treatment DefiniKve treatment delayed unkl amer pakents overall physiology improves Scalea et al J Trauma 48(4), Damage Control Decompression of body cavikes Bleeding control Repair of hollow viscus injuries StabilizaKon of central fractures Pelvis Femur Decision Making Must Focus on the PaKent as a Whole Orthopaedic Damage Control Avoid worsening the pakents condikon by a major orthopaedic procedure ( 2 nd Hit ) ARDS and MulKple Organ Failure Cascade of inflammatory reackons Exaggerated systemic inflammatory response syndrome (SIRS) ARDS and MulKple Organ Failure (MOF) Two Hit Model Amer injury, pakents inflammatory system is primed and vulnerable to a secondary insult A secondary insult results in an amplified systemic inflammatory response syndrome, culminakng in mulkple system organ failure Moore FA and Moore EE. Surg Clin North Am. 75: 257,

11 ARDS and MulKple Organ Failure 20 years of data at the Hannover Trauma Center suggest that pakents who underwent a major (> 3 hour) operakon on PTD 3 5 had increased mortality Secondary surgical procedure acted as a second hit, exacerbakng the primed systemic inflammatory response Polytrauma Management Days a>er trauma Risk of MOF Second- hit Window of opportunity Risk of sepsis No Severe Pulmonary Injury In pakents without severe chest trauma Early IM nailing reduced the length of ICU stay (7.3 days vs days) Reduced the length of intubakon (5.5 days vs days) In the absence of severe chest trauma primary IM femoral nailing is beneficial Pape HC, et al. J. Trauma. 34: , COTS 2006 ETC JOT 20:6 p Canadian Orthopedic Trauma Society - RCT 315 pakents with 322 femur fractures and polytrauma Randomized to reamed or unreamed nails All were treated within 24hrs - ETC Goal: compare incidence of ARDS with primary nailing with pakents randomized to reamed or non- reamed nails JOT 2006 ETC Conclusions The overall incidence of ARDS was found to be low in primary stabilizakon of femoral sham fractures with IM nailing. Much lower incidence of ARDS and death than the Pape papers all pakents had ETC Concurs with other papers that - ETC is reasonable when the pakent is not unstable or in extremis Severe Pulmonary Injury However, in pakents with severe chest trauma when IM nailing was performed in the first 24 hours Higher incidence of posoraumakc ARDS (33% vs. 7.7%) Higher mortality (21% vs. 4%) Pape HC, et al. J. Trauma. 34: , PaKent CondiKon Clinical Status Categories AddiKonal Factors In Blunt Trauma Stable - I Borderline - II Unstable - III In extremis - IV Som Kssue injuries involving ExtremiKes Lung Abdomen Pelvis Pape HC et al. J Orthop Trauma. 19: 551,

12 Treatment Protocol Temporary External FixaKon Mean Mean OR Kme blood loss External fixakon 35 min. 90 cc Reamed femoral nail 135 min. 400 cc Scalea et al J Trauma 48(4), Temporary External FixaKon 1.7 % infeckon rate One stage conversion considered safe Ex fix on for short Kme (< 2 weeks) No signs of pin site or systemic infeckon No loosening of pins Nowatarski PJ et al. J Bone Joint Surg. 82A: 781, Conclusion : Timing of 2 nd DefiniKve Surgery Avoid days 2 4 amer injury Inflammatory system primed for an exaggerated response Wait unkl day 7 or later DCO Stable vs unstable pakent? Polytrauma patient Temporary IM nail ex fix Early if If unstable Patient Is stable IM nail at 7-14 days Decision Making Must Focus on the PaKent as a Whole Thank You eric.meinberg@ucsf.edu 12