Pressure-volume characteristics of the intact and disrupted pelvic retroperitoneum

Abstract

Hemorrhage is a major cause of mortality in pelvic fractures. Bleeding can be controlled in hypotensive patients by direct ligation, angiographic embolization, pelvic packing, and acute external fixation. Acute application of an external fixator can reduce pelvic volume and reduce bleeding fractures to effect tamponade. This therapy assumes that the pelvis represents a closed space, which clearly is not true anatomically. However, the premise may hold functionally. This study explored the relationship between pressure and volume in the intact and disrupted pelvic retroperitoneum. In cadaveric specimens, the external iliac vein was dissected, ruptured, and cannulated. This method allowed controlled flow of fluid, with simultaneous measurement of pressure, into the intact retroperitoneum. Open book pelvic fractures were created by applying external rotation to the pelvis through the femoral heads. The pressure-volume measurements, without and with external fixation applied, were repeated after the fracture, as well as after a laparotomy. In the intact retroperitoneum, pressures rapidly rose to an average of 30 mm Hg after infusion of 5 liters of fluid. After fracture, up to 20 liters of fluid could be infused at pressures not exceeding 35 mm Hg. External fixation increased pressures approximately 3 mm Hg at low fluid volumes, and approximately 11 mm Hg at the highest fluid volumes. Laparotomy decreased retroperitoneal pressure from approximately 35 mm Hg to approximately 15 mm Hg. The results of the study suggest that low-pressure venous hemorrhage may be tamponaded by an external fixator, given that enough fluid volume is present in the pelvic retroperitoneum. However, external fixation may not generate sufficient pressure to stop arterial bleeding. In any case, it seems that a large volume of fluid must be lost into the pelvis before an external fixator can have much effect on retroperitoneal pressures.