Orthopedic Injury
Gregory J. Della Rocca
Sean E. Nork
Epidemiology
Blunt and penetrating trauma kills more than 100,000 people in the United States each year, is the leading cause of death in Americans younger than 45 years of age, and results in staggering losses of health in surviving trauma patients, with associated losses of economic productivity [1]. Trauma evacuation systems have improved dramatically over the past few decades, and patients are much more likely to survive injuries that would have resulted in early mortality only 30 to 40 years ago. Many polytraumatized patients sustain orthopedic injuries, such as extremity fractures, pelvic fractures, or dislocations. These need to be recognized and addressed appropriately to minimize consequent morbidity and mortality. A dedicated orthopedic trauma service, specifically constructed to manage patients with complex fractures and dislocations in the setting of other systemic injuries, may be associated with improved outcomes for trauma patients. The orthopedic traumatologist is not only trained in the surgical management of the individual orthopedic injuries, but is also comfortable with functioning as a member of a multidisciplinary team that, of necessity, also includes emergency physicians, abdominal and chest surgeons, neurosurgeons, urologists, and plastic surgeons, to name a few.
Musculoskeletal injuries in trauma patients come in many varieties. Articular (joint) fractures represent complex injuries requiring prolonged reconstruction; although they routinely occur in polytraumatized patients, their management is beyond the scope of this discussion. Long bone (femur, tibia, humerus, forearm) fractures can have direct impact upon a patient’s early mortality and late morbidity. Pelvic fractures are associated with early mortality, and their recognition and acute management is vital as part of the life-saving efforts of the trauma team. Open fractures are associated with the development of sepsis if not properly addressed. Compartment syndrome, a sequela of severe extremity trauma, is a soft-tissue condition that can result in early morbidity, associated with the impact of myonecrosis on renal function, as well as late disability, associated with fibrosis of one or more muscles important for activities of daily living. Venous thromboembolic (VTE) disease is a danger for all trauma patients, and the risk of VTE has been shown to be increased significantly in patients with pelvic and hip fractures. Finally, lesser fractures can have dramatic implications on future function for trauma patients; it has been shown that failure to identify and/or address complex injuries of the foot, for example, is associated with poor long-term outcomes in patients who survive major trauma [2,3].
In this chapter, we will introduce challenges and knowledge associated with multiple problems that affect trauma patients: open fractures, pelvic fractures, long bone fractures, knee dislocations, compartment syndrome, deep venous thrombosis, and neurological injury. It is our goal to discuss orthopedic treatment considerations for all of these trauma sequelae such that they can be integrated into the management of the patient who is the victim of multiple trauma.
Open Fractures
Open fractures, or fractures with associated skin wounds allowing communication of the external environment with the fractured bone surfaces, are present in a high percentage of polytraumatized patients. Frequently, the open fracture wound contains gross contamination, including dirt or vegetable matter, clothing, or glass. These wounds historically are at high risk of infection without adequate and early treatment of the open wound. Management protocols for open fractures are different from those for closed fractures, and considerations regarding timing of definitive stabilization of both types of fractures may differ. The basic treatment protocol for open fractures includes
antibiotic administration, wound debridement, wound irrigation, fracture stabilization, and wound closure or coverage.
antibiotic administration, wound debridement, wound irrigation, fracture stabilization, and wound closure or coverage.
The Gustilo-Anderson classification scheme is the most widely utilized classification for open fractures. It was initially published in 1976 [4]. Type I open fractures are fractures with a clean wound measuring less than 1 cm in length. Type II open fractures are fractures with a laceration measuring more than 1 cm in length and without extensive soft tissue damage. Type III open fractures are fractures with extensive soft tissue damage or an open segmental fracture (a two-level fracture of the same long bone). “Special categories” were created for open fractures associated with vascular injuries, farm injuries, and high-velocity gunshot wounds. Type III fractures, therefore, represented a highly heterogeneous group of severe open fractures; a modification of the classification scheme for type III open fractures, published in 1981, was therefore developed [5]. Type IIIA open fractures have extensive soft tissue damage but adequate soft tissue coverage, or are the result of high-energy trauma irrespective of laceration size. Type IIIB open fractures entail extensive soft tissue loss, periosteal stripping, bone exposure, and massive contamination. No mention of requirement for muscle flap fracture coverage is made by the authors (despite the fact that many of these wounds indeed do require flap coverage); this is a bastardization of the classification that has been propagated over the years [6], although it was suggested by Gustilo himself in a subsequent letter to the editors of the Journal of Bone and Joint Surgery [7]. Type IIIC open fractures are those associated with a vascular injury that (importantly) requires repair; those open fractures associated with arterial injuries that are not repaired do not fall into this type. An important point must be made about this classification scheme: it is best utilized during operative debridement of the open fracture. The presence of a small open wound in the skin may belie the extensive soft tissue injury underneath, leading to a misclassification of the open fracture. However, this may be of relative unimportance, as the reliability of this classification scheme has been questioned [8,9,10].
Antibiotic administration has been shown to be highly effective in decreasing infection rates after open fractures [11]. Short courses of first generation cephalosporins (typically, cefazolin), initiated as soon as possible after injury, appear to be beneficial in limiting infections after open fracture [12]. Aminoglycosides and penicillins are often utilized in the treatment of type III open fractures and highly contaminated open fractures [13], respectively. Older studies have demonstrated that administration of broad-spectrum antibiotics lead to decreased infection rates [14]. However, the scientific evidence for this practice is limited [12]. Administration of aminoglycosides for the treatment of open fractures must be accomplished judiciously to minimize risk of oto- and nephrotoxicity. Quinolone antibiotics, effective against gram-negative bacteria, have been shown to be effective at reducing infection rates for type I and type II open fractures [15], but they may have an adverse effect on fracture healing; this effect has been shown in animal studies [16,17]. Duration of antibiotic administration is a matter of debate. Older recommendations included 72 hours of antibiotic treatment for types I and II open fractures and 120 hours for type III open fractures [18]. However, Dellinger et al. published in 1988 that a single day of antibiotics is as effective as 5-day regimens for preventing infection after open fracture, in a prospective randomized trial [19].
Surgical debridement of open fracture wounds in a complete and expeditious manner is likely the most important factor in successful management. Sharp debridement should be meticulous and methodical. All foreign material is removed. Bone ends should be delivered into the wound, and complete exploration of the injury zone is necessary. Often, long longitudinal extensions of the traumatic wound are necessary for adequate exploration. All tissue which is completely devitalized, including bone fragments devoid of soft tissue attachments, should be removed [20,21]. Judgments related to the removal of large articular (i.e., joint surface) fragments may be required to balance the risk of severe disability with loss of said fragments versus risk of infection with their retention. Devitalized extra-articular fragments can be cleaned and used as a reduction aid intraoperatively if fixation is proceeding immediately, or they may be stored and utilized later if fixation is delayed; these fragments are ultimately discarded [22]. In general, therefore, it is better not to discard bone fragments from open fractures until the patient has arrived in the operating room for definitive management of the open fracture by the orthopedic surgeon.
Wound irrigation generally follows sharp debridement. Little data exists on the type of irrigant, the amount of irrigant, and the method of irrigation that is the best. Irrigation solutions generally are based upon normal saline (0.9% NaCl). Additives historically have included bacitracin, cefazolin, neomycin, soaps, bleach, Betadine, and other antiseptics (such as benzalkonium chloride). Some of these, such as antiseptics, have been shown to be detrimental to wound viability [23]. Antibiotics appear to offer no benefit over normal saline alone [24]. A prospective, randomized study revealed that a nonsterile soap solution demonstrated decreased wound complications and equal efficacy at reducing infection after open fracture as compared to a sterile saline solution containing bacitracin [25]. A recent survey of nearly 1,000 orthopedic surgeons revealed a high preference for saline irrigant [26]. High versus low-pressure lavage for open fracture wounds has also been a source of debate. Although high-pressure lavage has been thought historically to be better for removal of surface bacteria and inorganic material from soft tissues, it is damaging to both soft tissues and bone, and there is some evidence that it can increase bacterial penetration of bone in an animal model [27]. The same survey of 984 orthopedic surgeons who revealed a preference for saline irrigant also revealed a preference for low-pressure lavage for open fracture wounds [26]. No consensus exists on the volume of irrigant. Protocols vary between institutions and even within institutions, based upon surgeon preference. Up to 9 liters of irrigant are utilized in some centers, but there is no scientific evidence upon which a recommendation can be based. Ultimately, it is the opinion of most surgeons that wound debridement is the most critical aspect of treating open fracture wounds, and that the irrigation component of this treatment is of relatively less importance.
Methods of fixation for open fractures are variable. Historically, acute open reduction and internal fixation of open fractures was contraindicated, without good scientific evidence. However, the Harborview group in Seattle demonstrated that acute open reduction and internal fixation of open ankle fractures is a safe and effective method of treatment [28]. External fixation is relatively rapid and fixation points can be kept out of the zone of injury. Mobilization of fracture ends can be accomplished at the time of future debridement, if necessary, and staged open reduction and internal fixation with external fixator removal is safe and effective [29,30,31]. Plate or nail fixation at the time of irrigation and debridement is also safe and effective [28,32], but limits the surgeon’s ability to re-displace bone ends for wound exploration if repeat debridement is indicated.
Early wound closure or coverage is preferred, as this appears to limit the infection of open fracture wounds [33]. Acute primary closure of open fracture wounds after debridement and fixation, if possible, has been shown to be a safe method of treatment [34]. Early coverage of open fracture wounds that
are unable to be closed primarily has also been shown to be safe and effective [35]. Adjuncts to wound closure, especially in the setting of skin tension, include “pie-crusting” of skin about the wound(s) [36] or performing open wound management with a vessel loop closure technique to re-approximate wound edges [37] and/or use of negative pressure wound dressings [38,39]. Also, if doubts about the safety of closure at the time of initial debridement and fixation persist, then open wound management and repeat debridement are appropriate until closure or coverage is considered safe. This may be a consideration for significantly contaminated wounds at the time of presentation, or open fracture wounds in polytraumatized patients [33]. Negative pressure wound dressings can be utilized successfully for open fracture wounds as a bridge to delayed closure with successful reduction of infection rates in some series [40], or as a bridge to delayed free tissue transfer with reduction of infection rates as compared to traditional dressings [41], perhaps allowing for a possible reduction in need for free tissue transfer [42]. However, this may be a limited process, and earlier wound closure or flap coverage may reduce infection rates over late wound closure or coverage, despite utilization of the negative pressure dressing [43].
are unable to be closed primarily has also been shown to be safe and effective [35]. Adjuncts to wound closure, especially in the setting of skin tension, include “pie-crusting” of skin about the wound(s) [36] or performing open wound management with a vessel loop closure technique to re-approximate wound edges [37] and/or use of negative pressure wound dressings [38,39]. Also, if doubts about the safety of closure at the time of initial debridement and fixation persist, then open wound management and repeat debridement are appropriate until closure or coverage is considered safe. This may be a consideration for significantly contaminated wounds at the time of presentation, or open fracture wounds in polytraumatized patients [33]. Negative pressure wound dressings can be utilized successfully for open fracture wounds as a bridge to delayed closure with successful reduction of infection rates in some series [40], or as a bridge to delayed free tissue transfer with reduction of infection rates as compared to traditional dressings [41], perhaps allowing for a possible reduction in need for free tissue transfer [42]. However, this may be a limited process, and earlier wound closure or flap coverage may reduce infection rates over late wound closure or coverage, despite utilization of the negative pressure dressing [43].
An ongoing source of debate in the management of open fractures relates to the timing of debridement. A standard benchmark that has been propagated internationally is that open fractures should undergo urgent irrigation and debridement procedures within 6 hours. However, this benchmark has recently been questioned, as it appears to have little scientific evidence supporting it. In a seminal article on treatment of open fractures, Patzakis and Wilkins demonstrated no relationship between time from injury to surgical debridement of open fractures and subsequent development of infection [14]. A recent prospective, observational study of open fracture patients across eight trauma centers in the United States also failed to show a correlation between time to surgical debridement and the risk of infection of open fracture wounds [44]. Although urgency of treatment for open fractures associated with massive contamination, vascular injury, and/or limb crush is evident, routine emergent management does not appear to be required for open fractures, and after-hours surgery done in a hurried fashion by under-experienced practitioners and teams may result in an increased rate of minor complications [45]. However, it is generally accepted by orthopedic surgeons internationally that open fracture treatment does not represent an elective practice [46].
Table 167.1 Mangled Extremity Severity Score (MESS) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The polytraumatized patient who sustains high-energy open fractures of the extremities occasionally is a candidate for amputation. Properly indicated, a well-executed amputation can be a life-saving procedure which has the potential to shorten rehabilitation times associated with prolonged reconstruction of the mangled extremity. The debate often centers on whether a limb might be amenable to salvage versus amputation at the time of the trauma patient’s arrival to the hospital. Errors in judgment regarding this problem have the potential to affect a patient’s outcome significantly, both physiologically and psychologically. It should be noted that short-term and intermediate-term outcomes reveal similar levels of disability between limb salvage patients and amputees after major lower extremity trauma [47,48], perhaps indicating that one practice is not routinely better than another. Multiple assessment tools have been developed to assist surgeons with making decisions regarding limb salvage versus amputation, including the Mangled Extremity Severity Score (MESS) [49,50] (Table 167.1). However, many of these tools are mediocre at best with regard to their predictive value, as demonstrated by the Lower Extremity Assessment Project (LEAP) [51,52]. A historically held indication for acute amputation in the setting of a mangled extremity, the lack of plantar foot sensation, has been refuted
by the LEAP study team; many patients presenting with absent plantar foot sensation recovered it completely over time, indicating that the most tibial nerve injuries are neurapraxias (as opposed to complete disruptions) [53]. Ultimately, each injured patient must be carefully scrutinized, and no particular physical examination finding or trauma scale has been shown to be absolutely predictive of the success or failure of attempts at limb salvage. Therefore, thoughtful interpretation of trauma scores is imperative prior to making the choice between salvage and amputation for the mangled extremity in the traumatized patient.
by the LEAP study team; many patients presenting with absent plantar foot sensation recovered it completely over time, indicating that the most tibial nerve injuries are neurapraxias (as opposed to complete disruptions) [53]. Ultimately, each injured patient must be carefully scrutinized, and no particular physical examination finding or trauma scale has been shown to be absolutely predictive of the success or failure of attempts at limb salvage. Therefore, thoughtful interpretation of trauma scores is imperative prior to making the choice between salvage and amputation for the mangled extremity in the traumatized patient.
Pelvic Fractures
Evaluation
The pelvic ring, functionally, is a rigid ring, despite the fact that it comprises three bones—two hipbones and the sacrum—with three articulations—two sacroiliac joints and the pubic symphysis. It is designed to distribute the weight of the torso, arms, and head onto the legs for normal bipedal ambulation. The pelvis contains the acetabulae, which represent the articulations with the lower extremities, and the lumbosacral junction, representing the articulation with the spine. The sacroiliac joints and pubic symphysis are thought to have minimal motion, and are connected by stout ligaments. In some cases, incompetence of these joints can lead to laxity and chronic pain, which may occur after trauma, complicated vaginal birth in females, or in an idiopathic manner [54,55]. Further ligamentous connection between the posterior and anterior pelvis is provided by the sacrospinous and sacrotuberous ligaments. The transverse processes of the fifth lumbar vertebra are attached to the posterior iliac crests by the iliolumbar ligaments.
Disruption of the pelvic ring in young patients requires a high-energy mechanism, such as a motor vehicle crash or fall from a significant height. As the pelvis functionally is a rigid ring, the discovery of a single break in that ring should prompt careful scrutiny for at least one other break. For example, pubic ramus fractures, in the anterior aspect of the pelvic ring, may be obvious on plain radiographs, but associated sacral fractures may not be readily apparent on plain radiographs due to the overlying bowel gas, radio-opaque contrast agents in the bowel or bladder, or bony anatomy. They may be visible on CT scanning. A high index of suspicion must be maintained. It should also be emphasized that acetabular fractures of a transverse nature (not isolated wall or column fractures) often represent a component of a pelvic ring disruption, and suspicion that such disruption has occurred should be maintained when these acetabular fracture types are present.
Multiple classification schemes exist that describe various aspects of pelvic ring injuries. The Young and Burgess classification is perhaps the most commonly utilized descriptive scheme for pelvic ring injuries, in which they are classified as anteroposterior compression (APC) injuries, lateral compression (LC) injuries, vertical shear (VS) injuries, and “complex patterns” [56]. The Young and Burgess classification can be helpful for identification of other problems that can be associated with the pelvic ring injury, such as increased incidence of head trauma with LC injuries and of abdominal and chest trauma with APC injuries [57], and it can be somewhat predictive of transfusion requirements in trauma patients [58]. Other commonly utilized classification schemes include the Tile classification [59] and the AO/Orthopedic Trauma Association classification [60]. No pelvic fracture classification scheme, however, possesses all seven of the following requisites for universally applicable schemes: ease of use, prognostic value (outcomes), descriptive value (describe the injury), therapeutic value (direct treatment), research value (allows direct comparison between groups), intra-observer reliability, and inter-observer reliability.
Orthopedic examination of the pelvic fracture patient is similar to the orthopedic examination of all polytraumatized patients, covering the entire musculoskeletal system in a methodical manner. Focused examination of the pelvis includes observation of limb deformity; abnormal limb rotation or shortening in the setting of pelvis injury may be secondary either to pelvic deformity or to hip dislocation (with or without associated acetabular fracture), or to extra-pelvic lower extremity fracture. Skin about the pelvis, including about the perineum, must be carefully examined for lacerations that can be associated with open pelvic fractures. Open wounds may be present within folds of skin, and a thorough examination is necessary. Lacerations may lurk within the fold of skin inferior to the scrotum in males, and examination of this area cannot be neglected. Extensive ecchymoses should be noted; these may be indicative of degloving injuries. Digital rectal examination is also required to detect occult open fractures into the rectum, and (chaperoned) vaginal examination is also required in women to detect open fractures violating the vaginal vault. Speculum examination is not generally performed in the trauma bay. Blood emanating from the anus or vagina can be an indicator of open pelvic fracture. Urethral disruptions can also occur with pelvic fracture, and blood at the urethral meatus can be indicative of such an injury. Manual palpation of the pelvis and gentle compression of the iliac crests may detect abnormal motion or crepitus associated with an unstable disruption of the pelvic ring, although this manipulation lacks sensitivity and specificity [61]. Pelvic manipulations must be undertaken judiciously; unstable pelvic ring disruptions can cause life-threatening hemorrhage, which can be exacerbated by repeated examinations. Repeated examinations also can induce severe patient discomfort. A neurovascular examination of both legs, as well as examination of anal sphincter tone and of the bulbocavernosus reflex, is routine.
Standard radiography of the pelvis begins with the anteroposterior view. The inlet radiograph, with the beam tilted approximately 40° caudad, can detect anteroposterior translation of the hemipelvis and rotational hemipelvic deformities. The outlet radiographs, with the beam tilted approximately 40° cephalad, can detect “vertical” translation (more often, a flexion deformity) of the hemipelvis and is useful for visualizing sacral fractures. Judet radiographs, with the patient or x-ray beam tilted approximately 45° to either side, are reserved for patients with acetabular fractures detected on anteroposterior radiographs. Computed tomography (CT) has become routine for polytraumatized patients, and provides extensive information regarding the bony anatomy of a pelvic fracture and/or dislocation. In the setting of pelvic and acetabular fractures, CT scanning is also invaluable for planning of the surgical reconstruction. The CT scan is of limited utility, however, for acetabular fractures if the hip remains dislocated during the scan. Therefore, it is desirable to reduce fracture-dislocations of the hip (acetabulum) prior to CT scanning of the pelvis for adequate delineation of fracture anatomy and for preoperative planning.
Acute Management
Pelvic fracture patients often have multiple associated injuries, all of which may contribute to the overall physiological condition of the patient. Early mortality of patients with pelvic fractures may be related to patient age and occurs as a result of catastrophic hemorrhage, head injury, or multiple organ system
failure [62,63]. As the pelvic fracture may contribute directly to morbidity and mortality, early stabilization is preferred. This stabilization may be performed at the scene of the injury by emergency medical personnel, by the application of a circumferential sheet, pelvic binder, or other compressive garment. Sheets are readily available, inexpensive, and easy to apply [64]. The personnel applying the sheet should do their best to avoid wrinkling the sheet, which may cause skin compromise [65]. Overcompression of the pelvic ring is avoided, as the exact nature of the pelvic injury is unknown; overcompression of certain types of unstable fracture patterns may lead to laceration of the bladder, rectum, vagina, or other intrapelvic structures. Although circumferential pelvic wraps may assist with patient transport and comfort and can successfully reduce some types of pelvic ring disruptions [66], a recent study failed to demonstrate decreases in mortality, transfusion requirements, or the need for pelvic angiography by their use [67].
failure [62,63]. As the pelvic fracture may contribute directly to morbidity and mortality, early stabilization is preferred. This stabilization may be performed at the scene of the injury by emergency medical personnel, by the application of a circumferential sheet, pelvic binder, or other compressive garment. Sheets are readily available, inexpensive, and easy to apply [64]. The personnel applying the sheet should do their best to avoid wrinkling the sheet, which may cause skin compromise [65]. Overcompression of the pelvic ring is avoided, as the exact nature of the pelvic injury is unknown; overcompression of certain types of unstable fracture patterns may lead to laceration of the bladder, rectum, vagina, or other intrapelvic structures. Although circumferential pelvic wraps may assist with patient transport and comfort and can successfully reduce some types of pelvic ring disruptions [66], a recent study failed to demonstrate decreases in mortality, transfusion requirements, or the need for pelvic angiography by their use [67].
Upon arrival at the trauma center, all circumferential clothing (including pelvic wraps/binders) is removed to allow for examination of the lower abdomen and pelvis. Binders or wraps can easily be re-applied after examination. Large-bore intravenous access is necessary for fluid resuscitation. Keeping patients warm avoids coagulopathy. Although pelvic fractures may be associated with catastrophic hemorrhage, ongoing hemodynamic instability can arise from a number of causes unrelated to the specific pelvic injury. A full assessment of the patient is required. “Open book” (i.e., anteroposterior compression) injuries of the pelvis can be treated with reapplication of a circumferential wrap. Grossly unstable pelvic injuries can be treated provisionally with the application of skeletal traction, on the same side(s) of the pelvic injury(ies), through either the distal femur or the proximal tibia as the side of pelvic instability. Skeletal traction is also used routinely in the provisional stabilization of acetabular fractures prior to definitive treatment in the operating room; traction can minimize contact of the femoral head with rough acetabular fracture edges.
Pelvic external fixation can be utilized in a resuscitative fashion. External fixator application is difficult, but possible, in the trauma bay. An experienced orthopedic surgeon should perform external fixation of the pelvis, if indicated, to avoid inaccurate pin placement and associated cutout of pins from the iliac crests or injury to the intrapelvic or gluteal structures [68]. Factors that increase difficulty for the application of anteriorly based external fixators can be the rotational deformity and/or instability of one or both hemipelves. Anteriorly based pelvic external fixators are not good at controlling completely unstable posterior pelvic ring disruptions, and reduction of the anterior pelvic ring may be associated with further displacement of the posterior pelvic ring in some circumstances [69]. The antishock “C-clamp” has also been utilized successfully for emergent stabilization of the unstable pelvic ring disruptions [70]. It was designed to be placed posteriorly, with the clamp engaging the posterolateral ilia and exerting compression. The connecting frame can be rotated out of the way to allow for access to the abdomen or perineum. Dangers of application of the C-clamp, especially by inexperienced practitioners, can include fracture and/or penetration of one or both ilia or aberrant placement of one or both ends of the clamp through the greater sciatic notch(es) [71]. The C-clamp has also been applied successfully to the anterior pelvic ring as a resuscitative aid [72].
Patients with pelvic ring disruptions may demonstrate hemodynamic instability that is refractory to volume resuscitation. An ongoing search for sources of blood loss is vital. A recent publication demonstrated that, at a single trauma center, 21% of patients with pelvic fractures and hemodynamic instability (systolic blood pressure < 90 mm Hg) refractory to a 2 L bolus of saline ultimately expired, and 75% of those patients expired as a result of exsanguination [73]. Unstable pelvic fractures are more highly associated with pelvic hemorrhage than are stable pelvic fractures. Therefore, investigation of other potential sources of hemorrhage is vital, especially in the hemodynamically unstable trauma patient with a stable pelvic fracture pattern [74]. Patients with unstable anteroposterior compression injuries have been demonstrated to require massive transfusions, followed by those patients with vertical shear or complex mechanism pelvic ring disruptions, and lastly by those with lateral compression injuries [58,75]. However, fracture pattern may not always be indicative of transfusion requirements or the need for angiographic arterial embolization [76].
The hemodynamically unstable patient with a pelvic ring disruption may have significant fracture-associated hemorrhage. Pelvic fracture-associated bleeding comes from three sources: fracture surfaces, lacerated or ruptured veins, or lacerated or ruptured arteries. Fracture surfaces may not be a source of ongoing massive blood loss, and therefore may contribute negligibly to hemodynamic instability [77]. Distinguishing between major sources of pelvic hemorrhage—arterial or venous—represents a challenging but important task, and prior studies have examined multiple factors that may be associated with successful angiographic embolization, used for arterial hemorrhage, including patient age, trauma scores, shock on arrival to the trauma center, and fracture pattern [78]. Venous hemorrhage after pelvic fracture can be adequately treated with pelvic stabilization, either by circumferential pelvic wrap or by external fixation, while arterial hemorrhage can be addressed with angiographic embolization [79]. Transient response to initial resuscitation, lack of response to provisional pelvic stabilization, and presence of a contrast blush on pelvic CT scanning are all thought to be indicative of arterial hemorrhage that may be amenable to angiographic embolization [80,81].
Pelvic packing has been used for control of severe hemorrhage in hemodynamically unstable patients. It has been proposed that packing may be a more reliable method of treating severe pelvic fracture-associated hemorrhage than angiographic embolization with regard to controlling continued hemorrhage and limiting patient death due to exsanguination [82]. Angiography may also be delayed, and emergency stabilization of the fracture along with or without pelvic packing may be more reliable at controlling severe fracture-associated hemorrhage [83]. Another recent series documented a 30-day survival rate for pelvic fracture patients treated with extraperitoneal pelvic packing of 72%, and subsequent angiography was successful in detecting arterial hemorrhage in 80% of the patients after packing. Immediate increases in systolic blood pressure after packing were also noted [84]. Importantly, both angiography and pelvic packing must be used in a judicious fashion; this will help minimize complications related to both (such as gluteal necrosis).
Genitourinary injuries occur in a small subset of patients with pelvic fracture. This frequency has been shown to approximate 4.6% in a recent study of the U.S.A. National Trauma Data Bank [85]. Another recent study estimated a genitourinary injury rate of 6.8% in pelvic fractures; importantly, 23% of these injuries were missed at the time of initial evaluation [86]. Bladder injuries can also be seen in conjunction with acetabular fractures [87]. Urological injuries most commonly take the form of urethral disruption, extraperitoneal bladder rupture, or intraperitoneal bladder rupture. Diagnosis is often by retrograde cystourethrogram, with careful attention to post-drainage images to detect bladder ruptures not detectable when the bladder is filled with contrast [88]. Urethral disruption appears to occur distal to the urogenital diaphragm, contrary to classical teaching [89]. Primary realignment, when possible, is accomplished endoscopically followed by threading
of the urinary catheter by the Seldinger technique [90]. This repair may be accomplished at the time of pelvic fracture repair, using a team approach [91]. Routine use of suprapubic catheters in the management of urethral disruptions is discouraged, as it may increase the rate of infection, especially in the setting of open reduction and internal fixation of anterior pelvic ring injuries [92]. Bladder injuries are more commonly extraperitoneal. Nearly all present with gross hematuria. Intraperitoneal bladder ruptures are generally treated with surgical exploration, to delineate the extent of injury fully, and with Foley (preferred if open reduction and internal fixation of the pelvic ring fractures will be accomplished) or suprapubic catheters. Extraperitoneal ruptures may be managed with Foley catheters; the bulk of these require no formal repair [93]. However, if open reduction and internal fixation of the pelvic fracture is planned, then primary repair of the extraperitoneal rupture is also accomplished at the same time, with a low infection rate [91]. Use of suprapubic catheters is not required if large-bore Foley catheters are employed after repair of bladder ruptures.
of the urinary catheter by the Seldinger technique [90]. This repair may be accomplished at the time of pelvic fracture repair, using a team approach [91]. Routine use of suprapubic catheters in the management of urethral disruptions is discouraged, as it may increase the rate of infection, especially in the setting of open reduction and internal fixation of anterior pelvic ring injuries [92]. Bladder injuries are more commonly extraperitoneal. Nearly all present with gross hematuria. Intraperitoneal bladder ruptures are generally treated with surgical exploration, to delineate the extent of injury fully, and with Foley (preferred if open reduction and internal fixation of the pelvic ring fractures will be accomplished) or suprapubic catheters. Extraperitoneal ruptures may be managed with Foley catheters; the bulk of these require no formal repair [93]. However, if open reduction and internal fixation of the pelvic fracture is planned, then primary repair of the extraperitoneal rupture is also accomplished at the same time, with a low infection rate [91]. Use of suprapubic catheters is not required if large-bore Foley catheters are employed after repair of bladder ruptures.
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