Unstable Pelvis Research Articles

Western Trauma Association Critical Decisions in Trauma: Management of Pelvic Fracture With Hemodynamic Instability

SUMMARY Patients with hemodynamic instability and pelvic frac-ture remain a significant challenge in management. A mul-tidisciplinary approach has been shown to have the bestoutcomes. The algorithm outlined above represents the ef-forts of the Western Trauma Association Critical Decisions inTrauma Ad Hoc Committee based on the best evidence avail-able and expert opinion. Prospective validation of this algo-rithm is recommended. REFERENCES 1. Moreno C, Moore EE, Rosenberger A, Cleveland HC. Hemorrhageassociated with major pelvic fracture: a multispecialty challenge. J Trauma. 1986;26:987–994.2. Smith W, Williams A, Agudelo J, et al. Early predictors of mortalityin hemodynamically unstable pelvis fractures. J Orthop Trauma. 2007;21:31–37.3. Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, SmithWR. Preperitonal pelvic packing for hemodynamically unstablepelvic fractures: a paradigm shift. J Trauma. 2007;62:834–839;discussion 839–842.4. Gilliland MD, Ward RE, Barton RM, Miller PW, Duke JH. Factorsaffecting mortality in pelvic fractures.

Single-Leg-Stance Radiographs in the Diagnosis of Pelvic Instability

In the nonacute setting, the diagnosis of pelvic instability is difficult. Patients who present with pelvic pain may have underlying instability. The purpose of the present study was to report the effectiveness of single-leg-stance radiographs in the diagnosis of pelvic instability in a consecutive series of patients presenting with pelvic pain. Thirty-eight consecutive patients (twenty-four women and fourteen men) ranging in age from eighteen to seventy-eight years who presented with pelvic pain and a history of injury (twenty-seven), childbirth (seven [four primiparous and three multiparous]), or osteopenia (four) were evaluated with a visual analog scale pain score and a standard series of radiographs in an attempt to identify pelvic instability. The average time from the onset of symptoms to the evaluation was forty-one months (range, six weeks to twenty-seven years). Each patient was evaluated with supine anteroposterior, inlet, and outlet pelvic radiographs; a standing anteroposterior pelvic radiograph; and two single-leg-standing pelvic radiographs (one with the patient standing on the left leg and one with the patient standing on the right leg). A positive finding was defined as >or=0.5 cm of vertical translation measured at the symphyseal bodies between the two single-leg-stance radiographs. Of the thirty-eight patients, twenty-five demonstrated pelvic instability (average, 1.98 cm; range, 0.5 to 5 cm). With the numbers available, the average visual analog scale pain score for the patients with a stable pelvis was not significantly different from that for the patients with an unstable pelvis (6.4 +/- 2.9 compared with 7.3 +/- 1.9; p = 0.28). Standing anteroposterior and single-leg-stance pelvic radiographs aid in the diagnosis of pelvic instability more effectively than do the standard three radiographs of the pelvis made in the supine position or a standing anteroposterior radiograph of the pelvis alone. Additional studies will be needed to correlate this instability with clinical symptoms. Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Repetitive posterior iliac crest autograft harvest resulting in an unstable pelvic fracture and infected non-union: case report and review of the literature

Fractures of the pelvic ring have been well studied, and the biomechanical relationship between the anterior and posterior elements is an important concept to understand these complex injuries. The vast majority of these injuries are due to trauma. However, in rare circumstances, autogenous bone graft harvesting may lead to an unstable pelvic ring. In this case report, we describe a rare complication in a 70-year old female patient who developed an unstable pelvis and an infected non-union secondary to repeated posterior iliac graft harvest. The orthopaedic surgeon should be aware of this detrimental complication associated with extensive or repeated posterior iliac crest graft harvest.

Early Predictors of Mortality in Hemodynamically Unstable Pelvis Fractures

To determine reliable, early indicators of mortality and causes of death in hemodynamically unstable patients with pelvic ring injuries. This was a retrospective review of a prospective pelvic database. In all, 187 hemodynamically unstable patients with pelvic fractures (persistent systolic blood pressure <90 mm Hg after receiving 2 L of intravenous crystalloid) admitted from April 1998 to November 2004 were included. Intervention was Level 1 Trauma Center-Pelvis Fracture standardized protocol. Main outcome measurements were: Injury Severity Score (ISS), Revised Trauma Score (RTS), age, blood transfusion, mortality, and multisystem organ failure (MOF). Group 1 (39 patients) did not survive their injury. Group 2 (148 patients) survived their injury. Fracture pattern (chi(2) = 9.1, P = 0.33), and treatment with angiography/embolization (chi(2) = 0.054, P = 0.84) were not predictive of death. Patients requiring more blood had a statistically significant higher mortality rate. The ISS (t = -5.62, P < 0.001), RTS (t = 6.10, P < 0.001), age >60 years old (chi(2) = 5.4, P = 0.03), and transfusion (t = -2.70, P = 0.010) were statistically significant independent predictors of mortality. A logistic regression analysis and receiver operating characteristic curves indicated that of these variables, RTS was the most predictive independent variable. However, a model including all four variables was superior at predicting mortality. Most deaths were attributed to exsanguination (74.4%) or MOF (17.9%). Predictors of mortality in pelvis fracture patients should be available early in the course of treatment in order to be useful. Death within 24 hours was most often a result of acute blood loss while death after 24 hours was most often caused by MOF. Improved survival will depend upon the evolution of early hemorrhage control and resuscitative strategies in patients at high mortality risk.

Preperitoneal pelvic packing in the child with an unstable pelvis: a novel approach

Combined external pelvic fixation and preperitoneal pelvic packing may represent a revolutionary management strategy for mechanically unstable pelvis fractures in critically injured patients.

Appropriate Use of CT in the Diagnosis of Bladder Rupture

42-year-old man sustained a pelvic crush injury t work. On physical examination, he had an untable pelvis, normal digital rectal examination, and o blood at the urethral meatus. Placement of a rethral catheter returned gross blood. Multiple elvic fractures were seen on CT. Injury to the uriary bladder was not seen on cystographic phase T images with the urethral catheter clamped (A). formal CT cystogram revealed an extraperitoneal ladder rupture (B, arrow). The CT cuts are idenical, demonstrating the importance of the formal ystogram. The bladder injury was managed with rethral catheter decompression. Two weeks after is injury, repeat cystography found no extravasaion and the catheter was removed. Bladder injury occurs in approximately 10% of atients with pelvic fractures from blunt trauma. ross hematuria in the presence of pelvic fractures s an absolute indication for cystography. Alhough the cystographic phase of a CT scan may emonstrate bladder injury, this is not a sufficient iagnostic test. Because CT scanning has become outine in the evaluation of the hemodynamically table patient with an unstable pelvis, a retrograde T cystogram should be performed if the integrity f the bladder is in question. This is done by filling he bladder with 350 mL of 4% contrast through he urethral catheter (which is subsequently lamped). When used properly, this technique has ensitivity and specificity of 95% and 100%, espectively.

Skin Breakdown Following Circumferential Pelvic Antishock Sheeting

Hemodynamic instability in the setting of high-energy blunt trauma is a challenging clinical scenario. Rapid provisional stabilization of the unstable pelvis is advisable because it reduces ongoing blood loss and pain by imparting bone and soft tissue stability as well as reducing pelvic volume. The use of a standard bed sheet has become a popular choice for achieving temporary stability of the pelvis through a technique that has been called circumferential pelvic antishock sheeting. Although we have found circumferential pelvic antishock sheeting to be a valuable tool in our institution, we describe a case of skin compromise that precluded complete internal fixation of a complex pelvic ring/acetabular fracture.

Appropriate Use of CT In the Diagnosis of Bladder Rupture

42-year-old man sustained a pelvic crush injury t work. On physical examination, he had an untable pelvis, normal digital rectal examination, and o blood at the urethral meatus. Placement of a rethral catheter returned gross blood. Multiple elvic fractures were seen on CT. Injury to the uriary bladder was not seen on cystographic phase T images with the urethral catheter clamped (A). formal CT cystogram revealed an extraperitoneal ladder rupture (B, arrow). The CT cuts are idenical, demonstrating the importance of the formal ystogram. The bladder injury was managed with rethral catheter decompression. Two weeks after is injury, repeat cystography found no extravasaion and the catheter was removed. Bladder injury occurs in approximately 10% of atients with pelvic fractures from blunt trauma. ross hematuria in the presence of pelvic fractures s an absolute indication for cystography. Alhough the cystographic phase of a CT scan may emonstrate bladder injury, this is not a sufficient iagnostic test. Because CT scanning has become outine in the evaluation of the hemodynamically table patient with an unstable pelvis, a retrograde T cystogram should be performed if the integrity f the bladder is in question. This is done by filling he bladder with 350 mL of 4% contrast through he urethral catheter (which is subsequently lamped). When used properly, this technique has ensitivity and specificity of 95% and 100%, espectively.

Anterior Fixation Techniques on Unstable Pelvic Ring Injury

Purpose: We reviewed the clinical result of two techniques of anterior fixation method for unstable pelvic ring injuries, which are external and internal fixation. Materials and Methods: A retrospective clinical analysis was performed on 33 cases which had been operated from September 1998 to February 2003. Mean follow-up period is 29 months (range, 12-54 months). Previous to anterior fixation percutaneous iliosacral screw fixation was applied on iliosacral joint in Type C injury. After then plate and screw fixation were done in 17 cases and external fixation in 16 cases as an anterior fixation method. The patient’™s functional outcome was evaluated by Postel score and comparison between two groups was performed. Results: In external fixator group the complaints are long duration of application of external fixator, excessive scar formation due to pin tract infection, pain and discomfort (Postel score 9.9; range, 8-11) due to malunion. In internal fixation group all of them showed more than good result and satisfactory to the postoperative condition and clinically (Postel score 11.6; range, 10-12). Conclusion: An open reduction and internal fixation technique is better than external fixation for the treatment of injured anterior pelvic ring in unstable pelvis fracture.

Noninvasive reduction of open-book pelvic fractures by circumferential compression.

To determine the efficacy and optimal application parameters of circumferential compression to reduce external rotation-type pelvic fractures. Biomechanical investigation on human cadaveric specimens. Biomechanics laboratory. Partially stable and unstable external rotation injuries of the pelvic ring (OTA classification 61-B1 and 61-C1) were created in seven human cadaveric specimens. A prototype pelvic strap was applied subsequently at three distinct transverse levels around the pelvis. Circumferential pelvic compression was induced by gradual tensioning of the strap to attempt complete reduction of the symphysis diastasis. Pelvic reduction was evaluated with respect to strap tension and the strap application site. The effect of circumferential compression on intraperitoneal pressure and skin-strap interface pressure was measured. A successive increase in circumferential compression consistently induced a gradual decrease in symphysis diastasis. An optimal strap application site was determined, at which circumferential compression most effectively yielded pelvic reduction. The minimum strap tension required to achieve complete reduction of symphysis diastasis was determined to be 177 +/- 44 Newtons and 180 +/- 50 Newtons in the partially stable and unstable pelvis, respectively. Application of circumferential compression to the pelvic soft tissue envelope with a pelvic strap was an efficient means to achieve controlled reduction of external rotation-type pelvic fractures. This study derived application parameters with direct clinical implication for noninvasive emergent management of traumatic pelvic ring disruptions.

Effect of logistic and medical emergency resources on fatal outcome of severe trauma

122 cases of patients who died in sequel of an accident (recruitment period 1993/94, mean ISS 40 +/- 19) in reach of air rescue base Dresden, Germany, were examined. Data were assessed from autopsy protocol and the protocol of the physician who treated on scene. We analyzed the time course of the emergency, the scheduled emergency medical service and the quality of prehospital diagnosis and therapy by the emergency team. The mean response time was 8.1 +/- 5.9 min, the mean distance between EMS bases und incident location 5.9 +/- 5.7 km. In 94.4% of all cases a mobile intensive care unit--with an emergency physician as crew member--was on scene, in 5.6% a paramedic car. Air rescue by helicopter, including an emergency physician, was performed only in 8.7% of all cases although a helicopter was available in 54% of all accidents. Mechanisms of injury were traffic accident (71.4%), fall (14.3), 5.9% accident on building site, shot and stab injuries (5.9%) and burns (1.7%). 82 patients reached the emergency room alive (67.2% mean ISS 37 +/- 18). Only 26% of all patients were transported directly to a level I trauma center. Mean survival time of all 122 patients was 146 +/- 30.4 h. Severe head injury described by autopsy protocol was diagnosed on scene in 82%. Preclinical treatment was:intubation and ventilation (63%), O2 insufflation (17.4%), no specific treatment (19.6%). Severe thoracic trauma was diagnosed in 54%. Preclinical treatment was:intubation and ventilation (64.8%), O2 application (18.8%), no specific treatment (16.2%). Severe thoracic trauma with hemato-pneumothorax (n = 26) was recognized by the emergency physician in 65.6%, specific therapy (application of chest drain) was performed in 7.1%. Preclinical diagnosis rates concerning abdominal trauma were 29% and 27.8% in case of unstable pelvis fracture. Hemorrhagic shock related to these injuries was found in 44.2%, mean resuscitation volume applicated in these cases was 960 +/- 610 ml. Typical faults in diagnosis and treatment were underestimating of severe trunk trauma and non-consistent use of invasive treatment procedures. Primary transport of the severely injured patient to a level I trauma center by helicopter was performed only rarely.

Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion.

To evaluate the effectiveness of the use of iliosacral screw fixation in the management of the vertically unstable pelvis. Retrospective analysis with clinical follow-up of patients to assess functional outcome. Thirty-eight vertically unstable pelvic fractures were treated using iliosacral screw fixation. Anterior fixation was by means of plating in sixteen pelves and by external fixation in fifteen pelves. Four pelves had no anterior fixation. Complications were recorded and radiographs were analyzed to classify fractures and identify screw misplacement and malunion. Twenty-six patients had a functional evaluation. Five patients (13 percent) suffered a pulmonary embolus in the early postoperative period, one of which was fatal, a hospital mortality of 2.6 percent. Screw misplacement occurred in five patients but there were no adverse sequelae. In thirty-four cases with radiographic follow-up, malunion was noted in fifteen cases (44 percent). A lower rate of malunion (36 percent) was noted with internal fixation of the anterior lesion. Of twenty-six patients with long-term follow-up, only four (15 percent) had no pain. Sacroiliac fusion for pain was performed in three patients (11 percent). Twelve patients (46 percent) returned to their preinjury occupation, six patients (23 percent) changed occupation, and nine patients (30 percent) had not yet returned to work by last follow-up. Iliosacral screw fixation is a useful method of fixation in the vertically unstable pelvis but needs to be augmented by rigid anterior fixation to minimize malunion.

Open pelvic fracture--an indication for laparotomy?

Open pelvic fractures are rare and account for 1-5% of all pelvic fractures. Mortality rates of 50% and even more have been reported. Bleeding and septic complications are the major causes of death. In our retrospective study from 1974 to 1996 the data of 40 patients were analyzed. Five patients died (12.5%); 28 survivors could be investigated with a mean follow-up of 10 years. It is concluded that the comparably low mortality rate is due to a standardized treatment protocol. The main principles of management are emergency stabilization of the unstable pelvis and early laparotomy.

Acute Pelvic Fractures: II. Principles of Management.

The past two decades have seen many advances in pelvic-trauma surgery. Provisional fixation of unstable pelvic-ring disruptions and open-book fractures with a pelvic clamp or an external frame with a supracondylar pin has proved markedly beneficial in the resuscitative phase of management. In the completely unstable pelvis, external clamps and frames can act only as provisional fixation and should be combined with skeletal traction. The traction pin is usually used only until a definitive form of stabilization can be applied to keep the pelvic ring in a reduced position. If the patient is too ill to allow operative intervention, the traction pin can remain in place with the external frame as definitive treatment. Symphyseal disruptions and medial ramus fractures should be plated at the time of laparotomy. Lateral ramus fractures can usually be controlled with external frames. A role has been suggested for percutaneous retrograde fixation of the superior pubic ramus; however, the benefits to be gained may not be enough to outweigh the serious risks of penetrating the hip, and this technique should therefore be used only by surgeons trained in its performance. The techniques for posterior fixation are becoming more standardized, but all still carry significant risks, especially to neurologic structures.

Effects of method of internal fixation of symphyseal disruptions on stability of the pelvic ring

This study tested different methods of internal fixation of a symphyseal disruption, in comparison with the mechanics of the intact pelvis. Unembalmed cadaveric pelves were tested in simulated bilateral stance in a servohydraulic materials-testing machine. Motion of the superior and inferior pubic symphysis, and at two lefels of the posterior sacroiliac complex, was measured using high resolution displacement transdsucers. The fixations tested were (1) double plating (4.5 mm reconstruction plates), (2) wire loops around two 6.5 mm, fully threaded cancellous screws, and (3) an absorbable suture material (polydioxanone). Each pelvis was first tested intact, recording displacements in response to a cyclic axial load up to a maximum of 500 N applied through the proximal sacrum. The pubic symphysis was then sectioned and the sacrum fractured to produce an unstable pelvis (Tile C-type). Recordings were then repeated, following fixation of the sacral fructure with lag screws and sequential fixation of the symphysis with each of the test methods. The results from eight pelves revealed that internally fixed symphyseal motion was generally greater than intact, regardless of fixation method. The superior symphysis was usually compressed, while there was distraction inferiorly. Wiring resulted in significantly less symphyseal motion than the other methods ( P<0.02), provided four loops were used, reducing the separation inferiorly. There was no significant difference in sacral fracture motion between the three methods. The results indicate that in osteoporotic bone, as used in this study, symphyseal wiring is best able to oppose the tensile loads in the inferior symphysis that are associated with bilateral stance loading. These biomechanical findings must be interpreted within the broader context of surgical management of these complex injuries.

Fixation of the pubic symphysis

Internal fixation of a disrupted pubic symphysis is an attractive option when this injury is a component of an unstable pelvis. Posterior stability is also required and may be provided by residual ligamentous integrity or by separate posterior repair, depending on the patient's injury. Open reduction internal fixation of the symphysis can be done through a midline laparotomy or a Pfannenstiel incision. A two-hole dynamic compression plate with fully threaded 6.5-mm cancellous screws is recommended. External fixation may be preferable initially if emergency stabilization is needed to control hemorrhage and the abdomen is not already open.

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This study tested different methods of internal fixation of a symphyseal disruption, in comparison with the mechanics of the intact pelvis. Unembalmed cadaveric pelves were tested in simulated bilateral stance in a servohydraulic materials-testing machine. Motion of the superior and inferior pubic symphysis, and at two lefels of the posterior sacroiliac complex, was measured using high resolution displacement transdsucers. The fixations tested were (1) double plating (4.5 mm reconstruction plates), (2) wire loops around two 6.5 mm, fully threaded cancellous screws, and (3) an absorbable suture material (polydioxanone). Each pelvis was first tested intact, recording displacements in response to a cyclic axial load up to a maximum of 500 N applied through the proximal sacrum. The pubic symphysis was then sectioned and the sacrum fractured to produce an unstable pelvis (Tile C-type). Recordings were then repeated, following fixation of the sacral fructure with lag screws and sequential fixation of the symphysis with each of the test methods. The results from eight pelves revealed that internally fixed symphyseal motion was generally greater than intact, regardless of fixation method. The superior symphysis was usually compressed, while there was distraction inferiorly. Wiring resulted in significantly less symphyseal motion than the other methods (P<0.02), provided four loops were used, reducing the separation inferiorly. There was no significant difference in sacral fracture motion between the three methods. The results indicate that in osteoporotic bone, as used in this study, symphyseal wiring is best able to oppose the tensile loads in the inferior symphysis that are associated with bilateral stance loading. These biomechanical findings must be interpreted within the broader context of surgical management of these complex injuries.