Traumatic hemipelvectomy: an appeal for primary completion

Abstract

Traumatic hemipelvectomy (TH) is a rare and extremely severe injury of the pelvic area, which is often life-threatening and associated with a high mortality rate. Individual treatment is focused on the pelvic fracture and the type of accompanying injuries. The management of these severely injured patients places a considerable challenge on the resuscitation team. Patient management should be aggressive from the start. Current literature is focused predominantly on survivors, with only few case series providing possible treatment recommendations. Aggressive initial treatment is focused on standardized damage-control procedures during the prehospital, emergency room, and initial surgical phase to prevent exsanguination and contamination; a massive transfusion protocol should also be initiated immediately to address traumatic coagulopathy. Standard vascular treatment addresses the vascular injury. Colostomy is often recommended for adequate soft-tissue trauma management. Attempts at limb salvage often result in higher complications rates with non-functional limbs compared with completion of the TH. Thus, in cases of critical ischemia and identified relevant sacral nervous plexus injury during initial debridement in predominantly open injuries, primary completion of the hemipelvectomy is recommended. Level of Evidence: IV.

Keywords: Case report; Debridement; Management; Traumatic hemipelvectomy.

Fig. 1

A 28-year-old male patient sustained a traumatic hemipelvectomy (TH) following a high-speed motorcycle accident. Due to haemodynamic instability, the patient was taken directly to the operating room without imaging. a Clinical photograph illustrating the extent of the primary large traumatic wound on the right hemipelvis with < 50% soft tissue connection between the trunk and lower extremity prior to amputation. Exploration revealed a complete disruption of the hemipelvis from the axial skeleton, discontinuity of the main blood flow by complete avulsion of femoral vessels, avulsion of the nerves, and ruptures of the colon and small intestine. b Computed tomography of the pelvis following hemipelvectomy revealed a small remnant of the right pubic bone and disruption of the contralateral sacroiliac joint. c Clinical photograph of the patient standing 1 year post-trauma