Damage control orthopaedics in unstable pelvic

ring injuries
P.V. Giannoudis
a,
*, H.C. Pape
b
a
Departments of Trauma and Orthopaedic Surgery, St. Jamess University Hospital,
University of Leeds, Leeds LS9 7TF, UK
b
Hannover Medical School, Hannover, Germany
Introduction
Pelvic fractures account for 38% of all skeletal
fractures.
31,40
They are usually secondary to high-
energy trauma with motor vehicle crashes being the
commonest mechanism of injury.
Despite the introduction of organised trauma
systems, pelvic ring disruptions continue to be a
signicant source of morbidity and mortality ran-
ging from 4.8 to 50%.
10,14,44
Their management in
the acute setting is challenging to the most experi-
enced trauma surgeons and often requires a multi-
disciplinary approach involving a variety of special-
ties. This is due to the presence of associated
injuries as the high-energy force applied to the
pelvic ring is also distributed to other parts of the
skeleton resulting in injuries to other organs.
42
Appropriate assessment and treatment of these
fractures is important because it can lead in fewer
deaths and less long-term disability.
Several classication systems have been devel-
oped over the years based on fracture location,
pelvic stability, injury mechanism and direction
of injury force applied.
The Young and Burgess classication system is an
expansion of the original classication developed by
Pennal and Sutherland where the fractures were
classied based on the direction of three possible
injury forces: anterior posterior compression (APC),
lateral compression (LC) and vertical shear (VS).
8,57
Young and Burgess developed subsets on the LC and
APC injuries to quantify the forces applied. They
also added a forth injury force category of com-
bined mechanical injury.
6
Their classication sys-
tem helps with the detection of the posterior ring
injury, predicts local and distant associated inju-
ries, resuscitation needs and expected mortality
rates. APC types II and III, lateral compression type
Injury, Int. J. Care Injured (2004) 35, 671677
KEYWORDS
Orthopaedics;
Pelvic ring injury;
Skeletal fracture
Summary Pelvic ring injuries are often associated with other system injuries and
require a multidisciplinary approach for their treatment. Early mortality is usually
secondary to uncontrolled haemorrhage whereas late mortality is due to associated
injuries and sepsis-induced multiple organ failure. The management of the pelvic
fracture should be conceived as part of the resuscitative effort as errors in early
management may lead to signicant increases in mortality.
In severely multiple injured patients who are in an unstable or in extremis
clinical condition damage control orthopedics is the current treatment of choice.
By performing limited surgical interventions the subsequent reduction in blood loss
and transfusion requirements can only be benecial in these critically ill patients,
reducing the risk of developing systemic complications and early mortality.
2004 Elsevier Ltd. All rights reserved.
*Corresponding author. Tel.: 44-113-2065084;
fax: 44-113-2065156.
E-mail address: pgiannoudi@aol.com (P.V. Giannoudis).
00201383/$ see front matter 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2004.03.003
III, vertical shear (VS) and combined mechanical
injuries are indicative of major ligament disruption.
AP III injuries require the most blood replacement,
followed by VS patterns followed by CM followed by
LC III injuries.
6
Patients with pelvic fractures can be divided into
two sub-groups. The rst of those are patients who
sustain stable pelvic fractures with most of the
injury conned to the ligamentous tissues. Manage-
ment in these circumstances is conned to recon-
struction of the osteo-ligamentous structures on a
more semi-elective basis.
In the second group, patients sustain displaced
pelvic ring fractures, require emergency haemor-
rhage control and a multidisciplinary teamapproach
for the associated injuries. The overall prevalence
of pelvic fractures presenting with haemodynamic
instability has been reported to range from 2 to
20%.
4,16,25,32,41,43
Errors in early management may
lead to signicant increases in mortality. Early
recognition and appropriate management of
patients within this group can therefore offer sig-
nicant improvements in outcome.
The management of this specic sub-group of
patients has evolved over the years to what is known
today damage control orthopaedics.
Control of pelvic instability and
haemorrhage
During the acute phase, the goal of treatment of
high-energy pelvic ring disruptions is prevention of
early death from haemorrhage. The management of
internal blood loss is paramount initially.
Arterial bleeding (iliac vessels and their branches
to the inferior abdominal viscera and pelvic organs)
is a major contributor to haemorrhagic shock in
pelvic fractures (Fig. 1). Other sources of bleeding
include the low-pressure venous plexus and frac-
tured cancellous bone surfaces. The retroperito-
neum can contain up to 4 L of blood and bleeding
will continue until intra-vascular pressure is over-
come and physiological tamponade has occurred.
However, where extensive disruption of the retro-
peritoneal muscle compartments has taken place
this can lead to uncontrolled haemorrhage with the
risk of exsanguination. This is because the retro-
peritoneum is not a closed space and pressure
induced tamponade cannot be expected.
20
The rst step in restoring haemodynamic stability
includes the administration of intravenous crystal-
loid uids and whole blood. When replacement of
uid and blood does not stabilise the patients vital
signs, additional steps must be taken. Any subse-
quent interventions should be rapid and minimally
traumatic focusing on haemorrhage control and
other life saving measures. Complex reconstructive
work is delayed until the patient is haemodynami-
cally stable and in a better physiological condition
to withstand the additional surgical burden. Avoid-
ance of coagulation disturbances, the systemic
inammatory response, adult respiratory distress
syndrome and multiple organ dysfunction syndrome
is of paramount importance for reduced mortality
rates.
17,18,34
In general terms treatment should be highly case-
dependent. Treatment options that should be con-
sidered for the emergency haemostasis of patients
with pelvic fractures at risk of exsanguination
include the pelvic sling, arterial inow arrest,
external xation devices, internal xation, direct
surgical haemostasis, pelvic packing, pelvic angio-
graphy and embolisation.
Pelvic sling
During the past decade the use of a bed sheet, pelvic
sling and pelvic belt for emergency stabilization of
pelvic fractures has found great acceptance as it
achieves adequate compression without compro-
mising access to the patient.
3,9,45
Prophylactic application of these devices at the
scene or in the Emergency Department appears to
be satisfactory. Furthermore, they are easy to use,
readily available and inexpensive. However, poten-
tial disadvantages may be related to soft-tissue
pressure and the risk of visceral injury or sacral
nerve root compression, though there are no
reported complications in the available small clin-
ical series.
49,53
Arterial inow arrest
In cases where exsanguination of the patient is
imminent, occlusion of the aorta can be used as a
temporary measure to control the haemorrhage.
This can be performed directly open cross clamping
or via percutaneous or open balloon catheter Figure 1 Pelvic fractures and arterial bleeding.
672 P.V. Giannoudis, H.C. Pape
techniques.
5
Other authors have reported satisfac-
tory control of arterial bleeding with ligation of the
hypogastric artery attributing this to the remark-
able collateral supply within the pelvis.
37,47
External xator devices
Various external xation devices have been devel-
oped over the years and rely on pin insertion into the
iliac crest. An external xator is probably the most
commonly used tool worldwide for rapid pelvic ring
stabilization providing resuscitative, provisional
and denitive treatment. It is considered as the
treatment of choice especially in cases where asso-
ciated extensive soft tissue injuries are present
including, bowel and bladder disruptions.
51,56
External xator systems are usually easy to han-
dle and can be applied in the trauma room. Their
application controls blood loss by direct compres-
sion at the fracture site and pressure on the injured
vessels. Correct pin placement is the foundation of
the pelvic external xator. Resuscitation frames
usually involve the application of two pins per iliac
crest.
43,54
Many of the clinical complications asso-
ciated with pelvic external xation are related to
the iliac crest pins and the high rate of secondary
displacement in type B and C injuries.
29
Pelvic C-clamp
The C-clamp consists of two pins is applied on the
posterior ilium in the region of the SI joints. It
provides compression and stability at the posterior
aspect of the ring at the point where the greatest
bleeding usually occurs and thus provides effective
pelvic tamponade. Its use however may be compro-
mised in the presence of fractures of the ilium and
trans-iliac fracture dislocations.
15
Potential compli-
cations include iatrogenic injury to the gluteal neu-
rovascular structures and secondary nerve injury as
a result of over-compression in sacral fractures.
38
Several reports have highlighted their effectiveness
especially in the acute clinical setting.
39,50
Internal xation
The option of open reduction and internal xation is
considered as the procedure of choice for pelvic ring
xation due to clearly superior biomechanical
advantages. However, in the acute setting and
especially in the extremis clinical condition of
the patient such an approach is not advocated as
it is time consuming and often extensile approaches
are necessary predisposing the patient to uncontrol-
lable haemorrhage, coagulation disturbances and
early mortality. When haemodynamic stability has
been achieved, only then symphyseal plating, ante-
rior plating of the SI-joint and application of trans-
iliosacral screws is sensible.
1,27,46
Direct surgical haemostasis
Direct surgical haemostasis whilst providing a the-
oretical advantage, in the real clinical environment
it is not usually feasible as bleeding is often sec-
ondary to damaged venous plexuses and control of
haemorrhage may be unachievable. Furthermore
uncontrolled circumferential stitching and clip
application, with inadequate visualization, may
lead to iatrogenic nerve injuries.
2,13
Pelvic angiography and embolisation
Haemodynamic compromise following unstable pel-
vic fractures secondary to arterial bleeding is pre-
sent in only about 10% of the cases.
23,24
The use of
angiographic pelvic vessel embolisation in trau-
matic pelvic bleeding remains a topic of intense
discussion. Its efcacy has been questioned as mor-
tality gures of up to 50% have been reported
despite effective bleeding control.
7,21
Further-
more, as the procedure can be time consuming,
management of other associated injuries may be
problematical.
In his study, Cook et al. emphasised the impor-
tance of the application of an external xator prior
to pelvic angiography. Out of 23 patients who were
subjected to embolisation, 10 patients died (43%)
and 6 of these had their angiography as the primary
therapeutic intervention. Of these, ve had frac-
tures that would have been stabilized by an external
xator. The authors recommend external pelvic
xation prior to pelvic angiography.
7
In another study, Velmahos et al. reported on 30
patients who underwent bilateral internal iliac artery
embolisation. In 17 patients embolisation was per-
formed as the primary treatment for haemorrhage
control whereas in the remaining 13 patients it was
performed as a secondary treatment as they had rst
undergone laparotomy with unsuccessful control of
the bleeding. The overall success rate was 97% and
the authors concluded that the procedure appeared
to be useful in a selected group of patients.
52
Hamill et al. studied 20 out of 76 patients with
pelvic trauma who underwent pelvic embolisation
with a primary success rate of 90%. The average
time from injury to angiography was 5 h (2.323 h).
In eight patients (40%) a second procedure due to
ongoing haemorrhage was required, four of these
patients died.
21
In order for pelvic angiography and embolisation
to be successful, interventional radiologists familiar
Damage control orthopaedics in unstable pelvic ring injuries 673
with the procedure and dedicated facilities should be
readily available at the receiving hospital minimizing
the time between admission and performance of the
procedure. In recent studies an improved results
have been reported with the average time to inter-
vention decreasing from 17 h
19,22
to 5 h.
35
Pelvic packing
The technique of retroperitoneal packing has been
successfully used in some institutions where tam-
ponades are applied in the paravesical and presacral
spaces in an attempt to tamponade bleeding.
Immediate posterior pelvic ring stabilization with
the pelvic C-clamp or an external xator provides
mechanical stability for pelvic tamponade and frac-
ture reduction leads to a reduction in fracture
haemorrhage. The presacral and paravesical regions
are then packed from posterior to anterior using
standard surgical techniques. The packing is chan-
ged or removed 48 h after injury.
Ertel et al. prospectively analyzed 20 consecu-
tive patients with pelvic ring disruption and hae-
morrhagic shock. All patients were treated with an
immediate pelvic C-clamp followed by laparotomy
and pelvic packing in persistent or massive haemor-
rhage. The overall mortality rate was 25%. Haemor-
rhagic shock was identied by blood lactate levels
at admission, which was on average 5.1 mmol/l. A
mean of 33.2 units of blood transfusion were
required within the rst 12 h.
12
In another study, 41 patients in an extremis
clinical condition were analysed.
11
The average ISS
was 40 and the average volume of blood transfused
was 33.9 units. Concomitant injuries were common
with 66% having head injuries, 73% chest injuries,
61% abdominal injuries and 88% extremity injuries.
Emergency treatment consisted of 9 crash thoraco-
tomies, 23 crash laparotomies, 9 aortic clampings to
control haemorrhage and 2 pelvic C-clamp applica-
tions. Effective angiographic embolisation was per-
formed in one patient. The overall mortality rate of
these patients was 90.2%. The majority of patients
(56%) died within 24 h due to persistent haemor-
rhagic shock.
11
Whilst some authors have attempted to provide
comparisons between the efcacy of pelvic packing
versus pelvic angiography, one could say that such a
comparison is not appropriate.
It is apparent from the data that the two groups
of patients undergoing pelvic packing or embolisa-
tion are not comparable. The average time to inter-
vention is far lower in the pelvic packing group and a
signicantly higher volume of PRBC transfusion was
necessary for immediate resuscitation. The overall
average transfusion rate for patients who under-
went embolisation was 1.65 units of blood/h
7,21
and
this is in contrast to those who underwent emer-
gency pelvic packing, receiving on average 8 units in
the rst hour or 12 in the rst 2 h.
50
These patients
represent a group of extremely unstable patients
suffering massive pelvic bleeding with an expect-
edly high mortality rate.
Damage control orthopaedics for pelvic
fractures with haemodynamic
instability
Mortality from pelvic fractures could be divided to
early, secondary to uncontrolled haemorrhage, and
late due to post-traumatic complications such as
ARDS/MODS.
12,50
It is clear today that the develop-
ment of ARDS and MODS is due to multiple altera-
tions in inammatory and immunological functions,
which occur shortly after trauma and haemorrhage
(rst hit phenomena). Traumatic injury leads to
systemic inammation (Systemic Inammatory
Response Syndrome or SIRS) followed by a period
of recovery mediated by a counter-regulatory anti-
inammatory response (CARS).
33
Severe inamma-
tion may lead to acute organ failure and early death
after injury but a lesser inammatory response
followed by excessive CARS may induce a prolonged
immunosuppressed state that can also be deleter-
ious to the host.
The surgical burden (operative intervention, sec-
ond hit phenomena) on the immune response that
occurs in polytraumatized patients, in addition to
that caused by the primary insult, is considered today
as a critical factor directly affecting the clinical
course of the patient.
34
Sub-clinical consequences
of the initial trauma and subsequent operative treat-
ment could manifest as abnormalities in organ
function, leading to MODS. It is believed today
that the burden of the second hit should be mini-
mized in multiply injured patients with a high risk of
adverse outcome. There is no doubt that prolonged
operative interventions on polytrauma patients can
lead to coagulation disturbances and an abnormal
immuno-inammatory state causing remote organ
injury.
26,55
In patients with pelvic fractures being
in an unstable or extremis clinical condition
therefore, prolonged operative interventions could
initiate a series of reactions at the molecular level
predisposing the patient to an adverse outcome. Any
surgical intervention here must be considered imme-
diately life saving and should therefore be simple,
quick and well performed. Rigid rules relating to
timing should be avoided to prevent unnecessary
delay time is usually critical to survival of the
patient.
18
Protocols designed to reduce mortality
674 P.V. Giannoudis, H.C. Pape
should stop bleeding, detect and control associated
injuries and restore haemodynamics. A staged diag-
nostic and therapeutic approach is required. During
the rst 24 h, death from exsanguination has been
identied as a major cause of mortality. The severity
of bleeding is a crucial hallmark for survival during
the early period after injury. In young patients who
are able to compensate for extensive blood loss for
several hours, underestimation of the true haemo-
dynamic status can lead to fatal outcome. Because of
the disastrous haemodynamic conditions of these
patients, only external devices that are easy to apply
can be used effectively. These devices, by external
compression reduce the intrapelvic volume and cre-
ate a tamponade effect against ongoing bleeding.
They also restore stability and bone contact to the
posterior elements of the pelvis and contribute to
blood clotting. Pelvic packing should be considered
in cases where, despite the application of the exter-
nal xator, ongoing bleeding is encountered. In this
situation, angiographic embolisation is both time
consuming and inhibitive to dynamic assessment
and further treatment. Pelvic packing allows the
simultaneous assessment and treatment of abdom-
inal injuries. In the presence of multiple massive
bleeding points, tamponade of the areas or tempor-
ary aortic compression should be considered. Com-
plex reconstructive procedures in the abdomen
should be avoided in the presence of pelvic haemor-
rhage. A major splenic rupture usually necessitates
splenectomy. In liver injuries, attention is paid only
to major vessels and hepatic tamponade is applied.
Bowel injuries are clamped and covered and deni-
tive treatment performed after the haemodynamic
situation is stabilized.
28,30,36,48
Angiographic embolisation is not usually indi-
cated in this patient population. However, in cases
where haemodynamic stability with volume repla-
cement can be achieved but ongoing pelvic hae-
morrhage is suspected (expanding haematoma)
then angiography could be considered as an adjunct
to the treatment protocol.
Damage control orthopedics is the current treat-
ment of choice for the severely injured patient
especially those with an unstable pelvic ring injury
associated with haemodynamic instability (Fig. 2).
The management of the pelvic fracture should be
conceived as part of the resuscitative effort. By
maintaining circulating blood volume and tissue
oxygenation, whilst performing a rapid and limited
surgical intervention where indicated, the damage
induced by any procedure is minimized. Immediate
external xation of the unstable pelvis with pelvic
packing to control pelvic haemorrhage is a practical
approach in those in extremis and borderline
patients. Angiographic embolisation can only be
recommended in the more stable patient.
The recognized benets of pelvic fracture stabi-
lization are obtained at an early stage. The subse-
quent reduction in blood loss and transfusion
requirements can only advantage these critically
ill patients and reduce the risks of developing sys-
temic complications.
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Management of Pelvic Fractures
Clinical Condition of Patient
Stable Borderline Unstable In extremis
Cause of haemorrhage
(chest abdomen)?
Re-evaluation
2
nd
FAST
Stable OR
ORIF ORIF
Uncertain/OR
DCO
Ex Fix C-clamp
Ex-fix/C-clamp
Packing
OR
DCO
If continuously unstable:
Extrapelvic bleeding sources ?
Pelvic haemorrhage
Angiography
Yes No
OR
Repacking /ITU
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