Erik Hasenboehler MD Orthopaedic Trauma Surgery Baltimore MD Kentucky Trauma Symposium 2012

1. Pelvic fracture Management Erik Hasenboehler MD Orthopaedic Trauma Surgery Baltimore MD Kentucky Trauma Symposium 2012

3. Subjects Basic Polytrauma management Polytrauma basic science Pelvis Exam, Stability and managment Acute treatment of pelvic ring injuries Open Pelvis fracture

4. Pelvicfracture and Polytrauma Management One goal !!!!!!! Save the patient`s life !

5. ATLS: Structured Trauma Care Hemodynamically Unstable Pelvic Fracture Management by Advanced Trauma Life Support Guidelines Results in High Mortality . Orthopedics 2012 Stahel PF, Smith WR, Moore EE. Current trends in resuscitation strategy for the multiply injured patient. Injury. 2009 Phases of Management Primary Survey Resuscitation Secondary Survey Definitive Care Tertiary Survey Airway Breathing Circulation Disability Exposure

6. Steps of Acute Management • Assess • Physical Exam • Labs, Physiology • Images • Stabilize • Resuscitate • Contain • Sheet/Ex fix/C-clamp Damage control orthopaedics in unstable pelvic ring injuries. P.V. Giannoudis and H.C. Pape, Injury 2004

7. Basic Science of Trauma Second hit phenomenon: Existing evidence of clinical implications Lasanianos et al Injury 2012 • First Hit • Primary injury response • Second Hit • Incomplete resuscitation • Hemorrhage • Prolonged surgery Systemic Inflammatory Synergistic Inflammatory

8. Two Hit Model MOF Severe SIRS Delayed definitive surgery First insult Moderate SIRS Moderate immuno-suppression 2nd insult Severe immunosuppression Definitive surgery EARLY Infection MOF Moore FA and Moore EE. SurgClin North Am. 1995

9. Secondary Period Damage control orthopaedics in unstable pelvic ring injuries. P.V. Giannoudis and H.C. Pape, Injury 2004 Damage control orthopedics: current evidence Lichtea et al CO-Critical Care 2012 Second hit phenomenon: Existing evidence of clinical implications . Lasanianos et al. Injury 2011 • Old concept: Day 1, 5-7 (window of opportunity) and after 14 days • Patients operated on day 2-4vs day 5-8 worse inflammatory changes • Avoid significant surgery on days 2-4 for patients at risk • For more severely injured patients a longer waiting period may be needed

10. Pre- Hospital: Devastating injury

11. Hospital-Acute/Primary: shock, hypoxia or head injury

12. Hospital-Secondary/Tertiary: MOF or ARDS

13. Measurable Risk Factors • Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012 • Keel M, Trentz O. Pathophysiology of polytrauma. Injury 2005 • Giannoudis PV. Current concepts of the inflammatory response after major trauma: an update. Injury 2003 • Tschoeke SK, et al. The early second hit in trauma management augments the proinflammatory immune response to multiple injuries. J Trauma 2007 • HD unstable or difficult resuscitation • Under resuscitation • Shock and > 25 units PRBC’s • Thrombocytopenia ( platelets < 90,000) • Hypothermia (< 32° C) • Bilateral lung contusions on initial x-ray • Multiple long bone fractures and truncal AIS >2 • Presumed OR time > 6 hours • Exaggerated inflammatory response (IL-6> 800 pg/ml)

14. Causes of Death from Pelvis Fractures < 24 hours: blood loss > 24 hours: MOF Exsanguination caused 75% of the deaths

15. Orthopaedic Damage 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 Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012

16. Damage Control

17. Minimize the Second Hit

18. Assess • Treatment of pelvic ring injuries is usually amultidisciplinaryactivity • Trauma, Orthopaedics, Radiology • Urology/Gynecology

19. Lots to bleed Big space to bleed into

20. Volume Changes in the True Pelvis During Disruption of the Pelvic Ring – Where does it go? Moss and Bircher, 1996 Effects of Pelvic Volume Changes on Retroperitoneal and Intra- Abdominal Pressure in the Injured Pelvic Ring: A Cadaveric Model Köher et al 2011 Volume increase - r3 Volume increase 1 – 2L

21. Physical Exam OBTAIN INFORMATION FIRST • Perform a FULL physical exam • Evaluate lower extremities position Shortening/Rotation • Skin Ecchymosis • Open wound Around the pelvis • !!!!Be alert for open pelvic fractures!!! • Neurovascular exam

22. Physical Exam Palpate anterior pelvis Watch for perineal Lacerations Scrotal/Labial Swelling Flank Ecchymosis

23. Physical Exam • Turn the patient!

24. Physical Exam • Morel-Lavalle lesions • Degloving of the flank, thigh • Large dead space • Increased incidence of infection

25. #2: Is the Injury Pattern “Stable” or “Unstable”?

26. Rotational Stability AP Compression Lateral Compression One Positive Exam Only! Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg. 2002.

27. Physical Exam Abnormal position of the lower extremity

28. Pelvis “Stability” • ALWAYS a combination of x-rays and a clinical exam • A single x-ray is a static view • May have been way more displaced at the time of injury

29. Imaging- AP pelvis Part of ATLS Shows obvious, grossly unstable injuries Obtain Inlet Outlet views In an HD unstable patient DO NOT get more films

30. Vertical Stability Push pull on leg while palpating the ASIS

31. CT Scans Blush= embolizable arterial injury!

32. “Stabilizing” Theories Decreases pelvic volume Prevents gross motion, clot disruption Reduces cancellous bony bleeding

33. Why is Stability Important? APC 2, 3; LC 3; VS LC3 APC2,3 VS

34. Mortality Rate LCIII- 14% VS - 25% APC II- 25% APC III- 37% • Magnussen et al. Predicting blood loss in isolated pelvic and acetabular high- energy trauma. J Orthop Trauma. 2007 • Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;

35. Transfusion Requirements Lateral Compression - 3.6 Combined Mechanical- 8.5 Vertical Shear - 9.2 AP Compression - 14.8 Hemorrhage occurs up to 75% of patients with high energy injuries • Magnussen et al. Predicting blood loss in isolated pelvic and acetabular high- energy trauma. J Orthop Trauma. 2007 • Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;

36. WHAT TO USE TO STABILIZE THE PELVIS

37. MAST / PASG

38. Sheet or Binder

39. Pelvic Binder Easily applied during resuscitation Portable

40. Acute Management SAM Sling / T-POD / Circumferential Sheet: TOO HIGH!! Greater Trochanter!! Pelvis and Acetabulum Frontline Treatment

41. Pelvic Sheeting Correct Incorrect Routt et all JOT 2002

42. Traction Alone or in combination with sheet/ binder/ ex fix Particularly useful for vertical shear injuries Prevents vertical migration

43. Anterior External Fixation Disadvantages Can cause a different deformity Poor control of posterior pelvic ring Pin tract infections It’s not that easy

44. Pelvic C-Clamp Ganz R, et al. The antishock pelvic clamp. ClinOrthopRelat Res. 1991.

45. AIRS: I agree that the incidence of arterial bleeding after high energy pelvic trauma is 10% • Yes • No- I think it is higher

46. Who should get angiography? Rationale: fracture (cancellous) / venous > 90% arterial < 10%

47. Who should get angiography? Rationale: fracture (cancellous) / venous > 90% arterial < 10%

48. Huittinen VM, Slatis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454–62 Kataoka Y, Maekawa K, Nishimaki H, et al. Iliac vein injuries in hemodynamically unstable patients with pelvic fracture caused by blunt trauma. J Trauma 2005;58:704–10. Baque P, Trojani C, Delotte J, et al. Anatomical consequences of ‘‘open-book’’ pelvic ring disruption: a cadaver experimental study. SurgRadiolAnat 2005;27:487–90. Papadopoulos IN, Kanakaris N, Bonovas S, et al. Auditing 655 fatalities with pelvic fractures by autopsy as a basis to evaluate trauma care. J Am CollSurg2006;203:30–43 Huittinen V, Slatis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973;73:454—62. Kadish L, Stein J, Kotler S. Angiographic diagnosis andtreatment of bleeding due to pelvic trauma. J Trauma 1973;13:1083—6. Motsay GJ, Manlove C, Perry JF. Major venous injury with pelvic fracture. J Trauma 1969;9:343–6. Patterson FP, Morton KS. The cause of death in fractures of the pelvis. J Trauma 1973;13:849–56. Peltier LF. Complications associated with fractures of the pelvis. J Bone Joint Surg Am 1965;47:1060–9. Yosowitz P, Hobson 2nd RW, Rich NM. Iliac vein laceration caused by blunt trauma to the pelvis. Am J Surg 1972;124:91–3.

49. Pohlemann T. et al. Tech Orthop 1994 Cothren CC, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007 Suzuki T, Smith WR, Moore EE, Pelvic packing or angiography: competitive or complementary? Injury 2009 Ertel W, et al. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001 Tscherne H. et al. Crush injuries of the pelvis. Eur J Surg 2001

50. TREAT THE PATIENT BASED ON HIS NEEDS……. DCO VS ETC Damage control orthopedics: current evidence, Lichte et al CO-Critical Care 2012