Management of pelvic injuries in hemodynamically unstable polytrauma patients - Challenges and current updates

Abstract

Pelvic injuries are notorious for causing rapid exsanguination, and also due to concomitant injuries and complications, they have a relatively higher mortality rate. Management of pelvic fractures in hemodynamically unstable patients is a challenging task and has been variably approached. Over the years, various concepts have evolved, and different guidelines and protocols were established in regional trauma care centers based mainly on their previous experience, outcomes, and availability of resources. More recently, damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation are being employed in the management of these unstable injuries, without clear consensus or guidelines. In this background, we have performed a computerized search using the Cochrane Database of Systematic Reviews, Scopus, Embase, Web of Science, and PubMed databases on studies published over the past 30 years. This comprehensive review aims to consolidate available literature on the current epidemiology, diagnostics, resuscitation, and management options of pelvic fractures in polytraumatized patients with hemodynamic instability with particular focus on damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation.

Keywords: External fixation; Management; Pelvic fractures; Pelvic injury; Polytrauma.

Fig. 1

Anteroposterior radiograph showing anteroposterior compression injury of pelvis with pubic diastasis and bilateral sacroiliac joint widening.

Fig. 2

FAST scan done in a polytrauma patient as a part of initial assessment, demonstrating fluid in hepatorenal pouch.plain

Fig. 3

The anatomy of pelvic cavity can be compared to that of an ellipsoid. The volume of blood it can accommodate is calculated by formula V = 4/3π R1R2R3 where R1 is the height, R2 is the mediolateral length and R3 is the anteroposterior width of the cavity.

Fig. 4

a) Whole body CT scan done in a polytrauma patient showing liver laceration of size 6 × 1 cm in the 4th lobe (organ injury scale grade 3), b) significant presacral hematoma indicating an underlying sacrum fracture or sacroiliac joint disruption which causes massive internal bleeding due to rupture of presacral venous plexus leading to hemodynamic instability.

Fig. 5

Pelvic EXFIX with pins through a) Iliac crest, b) supra acetabular area and c) anterior inferior iliac spine.

Fig. 6

Algorithmic approach used to manage pelvic injuries in polytrauma at the authors center.

Fig. 7

A 36-year-old gentleman with a history of motor vehicle accident was shifted to the hospital in 2 h following injury. On arrival patient was conscious, oriented, hemodynamically unstable, with a pulse rate of 148/min, blood pressure of 86/40 mmHg and SPo2 of 88%. Following initial resuscitation with 1 L crystalloid infusion, immediate hemostatic resuscitation was performed with 2 units of packed red blood cells, fresh frozen plasma and platelets administered in a 1:1:1 ratio. On clinical examination he had a) an open wound over distal 3rd of thigh along with perineal laceration. Per-rectal examination showed absence of muscle tone and a proximal rectal injury was clinically suspected. Once patient achieved hemodynamical stability, E-FAST done which was negative. b)Preoperative plain radiographs showed pubic diastasis with right sided sacroiliac joint disruption, comminuted fracture of right distal femur (type III B open), c) Whole body CT scan done as a part of polytrauma protocol showed presacral hematoma more on right side indicating an underlying sacrum fracture or sacroiliac joint disruption. In addition, surgical emphysema was noted along the right lateral abdominal wall with air fluid level in lower abdomen, tracking into perineum and right upper thigh with tracking of air up to right hemiscrotum. In view of unstable pelvic injury with an associate extremity injury, damage control surgery (exfix for femur ,pelvis and Laparotomy) was performed, d) Plain radiograph following EXFIX of pelvis and knee spanning external fixation for distal femur. Laparotomy revealed a rectal tear for which proximal sigmoid loop colostomy was done and wounds over the perineum, right distal thigh were debrided. e) Clinical picture showing laparotomy wound and colostomy stump. Postoperatively the patient was shifted to ICU for observation. Serum lactate normalization time was 24 h from 8.3 mmol/lit to 2.24 mmol/lit. On 3rd postoperative day f) definitive fixation of pelvis in the form of pubic symphysis plating and percutaneous sacroiliac fixation for the right sacroiliac joint was done. On 7th postoperative day definitive fixation (Exfix removal and retrograde nailing) of distal femur was done.