Pelvic Fracture – Generic notions for the general surgeon
Abstract
The pelvic fracture consists on a clinical entity that can represent grave danger, mainly when associated to major mechanic instability, which reflects the amount of energy transferred during trauma. The high mortality of pelvic fracture is a reason for concern to the medical staff involved in its management, because its multiple needs, in terms of assessment and treatment. The general surgeon is often responsible for patients with this kind of trauma, be it for the associated injuries, or in the management of the severe trauma patient in shock. So, he needs a set of knowledge about this issue that helps him in decision making. In this paper, we review the management needs for this severe patients, focusing on the main causes of mortality:
1. Hemorrage: a management algorithm is proposed, based on the actual resources of our country and hospitals;
2. Sepsis: stating the importance of the early management in preventing complica-
tions, and the need of a multidisciplinar approach.
Keywords: Multiple trauma, Pelvis, Pelvic fractures, Management of mechanically unstable pelvic fractures, Hemorrhagic shock, Sepsis
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References
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Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW: The Injury Severity Score revisited. J Trauma 1988; 28(1): 69-77
Balogh Z, King K, Mackay P, McDougall D, Mackenzie S, Evans Lyons T, Deane S: The Epidemiology of Pelvic ring fractures: a population-based study J Trauma 2007 Nov; 63(5):1066-73
Wubben RC: Mortality rate of pelvic fracture patients. Wisconsin Medical Journal 1996; 95(10):702-4.
Brenneman FD, Katyal D, Boulanger BR, Tile M, Redelmeier DA. Long-term outcomes in open pelvic fractures. Journal of Trauma-Injury Infection & Critical Care 1997; 42(5):773-7
Tile M: Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br 1988; 70: 1-12
Dalal S, Burgess A, Siegel J, Young J, Brumback R, Poka A et al: Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. J Trauma 1989 Jul; 29(7): 13-20
Rommens PM, Hofmann A, Hessmann MH: Management of acute hemorrhage in pelvic trauma: an overview. Eur J Trauma & Emergency Surgery 2010 Apr; 36(2): 91-99
Poole GV, Ward EF: Causes of mortality in patients with pelvic fractures. Orthopedics 1994; 17(8): 691-6
Grotz MRW, Gummerson NW, Gansslen A, Petrowsky H, Keel M, Allami MK: Staged management and outcome of combined pelvic and liver trauma. An international experience of the deadly duo. Injury 2006; 37(7): 642-51.
Hauschild O, Strohm PC, Culemann U, Pohlemann T, Suedkamp NP, Koestler W, et al. Mortality in patients with pelvic fractures: Results from the German pelvic injury register. Journal of Trauma-Injury Infection & Critical Care 2008; 64(2): 449-55.
Sanchez-Tocino JM, Turegano-Fuentes F, Perez-Diaz D, Sanz-Sanchez M: Fracturas de pelvis graves, lesiones asociadas e inestabilidad hemo-dinámica: incidencia, manejo y pronóstico en nuestro medio. Cir Esp, 2007; 81 (6): 316-23
Cryer HM, Miller FB, Evers BM, Rouben LR, Seligson DL: Pelvic fracture classification: correlation with hemorrhage. Journal of Trauma-Injury Infection & Critical Care 1988; 28(7): 973-80.
Moreno C, Moore E, Rosenberger A, Cleveland H: Hemorrhage associated with major pelvic fracture: a multispeciality challenge. J Trauma 1986 Nov; 26 (11): 532-539
Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J: Clinical Review: Initial management of blunt pelvic trauma patients with haemodynamic instability. Critical Care; Vol 11/1: 204-213
Davis JW, Moore FA, McIntyre RC Jr, Cocanour CS, Moore EE, West MA: Western trauma association critical decisions in trauma: management of pelvic fracture with hemodynamic instability. J Trauma 2008, Nov; 65(5): 1012-5
Peterson N, Scardiglia J (editors): ATLS Student Manual 8 th Edition. ACS COT 2008
Tayal V, Nielsen A, Alan E, Michael H, Kellam J, Norton J: Accuracy of trauma ultrasound in major pelvic injury. J Trauma, 2006, Dec; 61(6): 1453-1457
Friese RS, Malekzadeh S, Shafi S, Gentiello L, Starr A: Abdominal Ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture. J Trauma, 2007, Jul; 63(6): 97-102
Chiara O, Cimbanassi S, Castelli F, Spagnolo R, Girotti P, Pizzilli G, Pitidis A, Andreani S, Pugliese R, Capitani D: Protocol-driven approach of bleeding abdominal and pelvic trauma. World J Emer Surgery 2006, 1:17-26
Ballard RB, Rozycki JS, Newman PJ, Cubillos JE, Salomone JP, Feliciano DV et al: An algorithm to reduce the incidence of false negative FAST examinations in patients at high risk of occult injuries. J Am Coll Surg 1999, 189: 145-150
Boulanger BR, McLellan BA, Brenneman FD, Ochoa J, Kirkpatrick AW: Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. J Trauma 1999, 42: 1086-1090
Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE et al: Direct retroperitoneal pelvic packing versus pelvic angiography: a comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury 2009, 40: 54-60
White CE, Hsu JR, Holcomb JB: Haemodynamically unstable pelvic fractures. Injury 2009, 40: 1023-1030
Miller P, Moore P, Mansell E, Meredith W, Chang M: External Fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 2003, 54 (3): 437-443
Lustenberger T, Meier C, Benninger E, Lenzlinger PM, Keel MJB: C-clamp and pelvic packing for control of hemorrhage in patients with pelvic ring disruption. J Emerg Trauma Shock, 2011; 4 (4): 477-482
Totterman A, Madsen JE, Skaga NO, Roise O: Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. J Trauma 2007,62 (4): 843-52
E Hornez. Management of exsanguinating pelvic trauma: do we still need the radiologist? J Visc Surgery, 2011; 148: e379-e384
Cothren CC, Osborn PM, Moore E: Preperitoneal packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 2007; 62: 834-42
Bach A, Bendix J, Hougaard K, Christensen EF: Retroperitoneal packing as part of damage control surgery in a Danish trauma centre – fast, effective, and cost-effective Scandinavian. J Trauma Resus Emerg Medicine 2008, 16: 4-8
Scalea TM: Extraperitoneal Pelvic Packing. Apresentação Pessoal: “The Arizona Trauma and Acute Care Consortium Second Annual Symposium” Nov 2010: http://www.aztracc.org/videos/abdomen/extra-peritoneal-pelvic-packing
Eastridge, Brian J, Starr A, Joseph P, O’Keefe G. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002; 53(3): 446-451, Editor comment by Tom Scalea, Baltimore, Maryland
Hui –Yi Chen, Jeon-Hor Chen, Yung-Fang Chen, Iuan-Hong Tzeng, Hsein-Jar Chiang, Hung-Yang Chuang et al. Arterial embolization for controlling life-threatning traumatic pelvic hemorrhage. Mid Taiwan J Med 2009;14(1): 16-26
T Suzuki, W R Smith, E Moore. Pelvic packing or angiography: competitive or complementary? Injury 40:343-53
Luke P H Leenen. Pelvic Fractures: soft tissue trauma Eur J Trauma & Emergency Surgery, 2010, Apr; 36(2):117-123
Jones A, Powell J, Kellam J, McCormack R, Dust W, Wimmer P. Open pelvic fractures: a multicenter retrospective analysis. Orthop Clin N Am 1997;28(3): 345-50
Pell M, Flynn W J Jr, Seibel R W Is colostomy always necessary in the treatment of open pelvic fractures? J Trauma 1998 Aug; 45(2): 371-3.
Lunsjo K, Abu-Zidan FM. Does colostomy prevent infection in open blunt pelvic fractures? A systematic review. J Trauma 2006 May;60(5):1145-8.
Martin H Hessman, Marcus Rickert, Alexander Hofmann, Pol M Rommens, Michael Buhl Outcome in pelvic ring fractures. Eur J Trauma & Emergency Surgery, 2010, Apr; 36(2):124-130.
Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW: The Injury Severity Score revisited. J Trauma 1988; 28(1): 69-77
Balogh Z, King K, Mackay P, McDougall D, Mackenzie S, Evans Lyons T, Deane S: The Epidemiology of Pelvic ring fractures: a population-based study J Trauma 2007 Nov; 63(5):1066-73
Wubben RC: Mortality rate of pelvic fracture patients. Wisconsin Medical Journal 1996; 95(10):702-4.
Brenneman FD, Katyal D, Boulanger BR, Tile M, Redelmeier DA. Long-term outcomes in open pelvic fractures. Journal of Trauma-Injury Infection & Critical Care 1997; 42(5):773-7
Tile M: Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br 1988; 70: 1-12
Dalal S, Burgess A, Siegel J, Young J, Brumback R, Poka A et al: Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. J Trauma 1989 Jul; 29(7): 13-20
Rommens PM, Hofmann A, Hessmann MH: Management of acute hemorrhage in pelvic trauma: an overview. Eur J Trauma & Emergency Surgery 2010 Apr; 36(2): 91-99
Poole GV, Ward EF: Causes of mortality in patients with pelvic fractures. Orthopedics 1994; 17(8): 691-6
Grotz MRW, Gummerson NW, Gansslen A, Petrowsky H, Keel M, Allami MK: Staged management and outcome of combined pelvic and liver trauma. An international experience of the deadly duo. Injury 2006; 37(7): 642-51.
Hauschild O, Strohm PC, Culemann U, Pohlemann T, Suedkamp NP, Koestler W, et al. Mortality in patients with pelvic fractures: Results from the German pelvic injury register. Journal of Trauma-Injury Infection & Critical Care 2008; 64(2): 449-55.
Sanchez-Tocino JM, Turegano-Fuentes F, Perez-Diaz D, Sanz-Sanchez M: Fracturas de pelvis graves, lesiones asociadas e inestabilidad hemo-dinámica: incidencia, manejo y pronóstico en nuestro medio. Cir Esp, 2007; 81 (6): 316-23
Cryer HM, Miller FB, Evers BM, Rouben LR, Seligson DL: Pelvic fracture classification: correlation with hemorrhage. Journal of Trauma-Injury Infection & Critical Care 1988; 28(7): 973-80.
Moreno C, Moore E, Rosenberger A, Cleveland H: Hemorrhage associated with major pelvic fracture: a multispeciality challenge. J Trauma 1986 Nov; 26 (11): 532-539
Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J: Clinical Review: Initial management of blunt pelvic trauma patients with haemodynamic instability. Critical Care; Vol 11/1: 204-213
Davis JW, Moore FA, McIntyre RC Jr, Cocanour CS, Moore EE, West MA: Western trauma association critical decisions in trauma: management of pelvic fracture with hemodynamic instability. J Trauma 2008, Nov; 65(5): 1012-5
Peterson N, Scardiglia J (editors): ATLS Student Manual 8 th Edition. ACS COT 2008
Tayal V, Nielsen A, Alan E, Michael H, Kellam J, Norton J: Accuracy of trauma ultrasound in major pelvic injury. J Trauma, 2006, Dec; 61(6): 1453-1457
Friese RS, Malekzadeh S, Shafi S, Gentiello L, Starr A: Abdominal Ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture. J Trauma, 2007, Jul; 63(6): 97-102
Chiara O, Cimbanassi S, Castelli F, Spagnolo R, Girotti P, Pizzilli G, Pitidis A, Andreani S, Pugliese R, Capitani D: Protocol-driven approach of bleeding abdominal and pelvic trauma. World J Emer Surgery 2006, 1:17-26
Ballard RB, Rozycki JS, Newman PJ, Cubillos JE, Salomone JP, Feliciano DV et al: An algorithm to reduce the incidence of false negative FAST examinations in patients at high risk of occult injuries. J Am Coll Surg 1999, 189: 145-150
Boulanger BR, McLellan BA, Brenneman FD, Ochoa J, Kirkpatrick AW: Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. J Trauma 1999, 42: 1086-1090
Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE et al: Direct retroperitoneal pelvic packing versus pelvic angiography: a comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury 2009, 40: 54-60
White CE, Hsu JR, Holcomb JB: Haemodynamically unstable pelvic fractures. Injury 2009, 40: 1023-1030
Miller P, Moore P, Mansell E, Meredith W, Chang M: External Fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 2003, 54 (3): 437-443
Lustenberger T, Meier C, Benninger E, Lenzlinger PM, Keel MJB: C-clamp and pelvic packing for control of hemorrhage in patients with pelvic ring disruption. J Emerg Trauma Shock, 2011; 4 (4): 477-482
Totterman A, Madsen JE, Skaga NO, Roise O: Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. J Trauma 2007,62 (4): 843-52
E Hornez. Management of exsanguinating pelvic trauma: do we still need the radiologist? J Visc Surgery, 2011; 148: e379-e384
Cothren CC, Osborn PM, Moore E: Preperitoneal packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 2007; 62: 834-42
Bach A, Bendix J, Hougaard K, Christensen EF: Retroperitoneal packing as part of damage control surgery in a Danish trauma centre – fast, effective, and cost-effective Scandinavian. J Trauma Resus Emerg Medicine 2008, 16: 4-8
Scalea TM: Extraperitoneal Pelvic Packing. Apresentação Pessoal: “The Arizona Trauma and Acute Care Consortium Second Annual Symposium” Nov 2010: http://www.aztracc.org/videos/abdomen/extra-peritoneal-pelvic-packing
Eastridge, Brian J, Starr A, Joseph P, O’Keefe G. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002; 53(3): 446-451, Editor comment by Tom Scalea, Baltimore, Maryland
Hui –Yi Chen, Jeon-Hor Chen, Yung-Fang Chen, Iuan-Hong Tzeng, Hsein-Jar Chiang, Hung-Yang Chuang et al. Arterial embolization for controlling life-threatning traumatic pelvic hemorrhage. Mid Taiwan J Med 2009;14(1): 16-26
T Suzuki, W R Smith, E Moore. Pelvic packing or angiography: competitive or complementary? Injury 40:343-53
Luke P H Leenen. Pelvic Fractures: soft tissue trauma Eur J Trauma & Emergency Surgery, 2010, Apr; 36(2):117-123
Jones A, Powell J, Kellam J, McCormack R, Dust W, Wimmer P. Open pelvic fractures: a multicenter retrospective analysis. Orthop Clin N Am 1997;28(3): 345-50
Pell M, Flynn W J Jr, Seibel R W Is colostomy always necessary in the treatment of open pelvic fractures? J Trauma 1998 Aug; 45(2): 371-3.
Lunsjo K, Abu-Zidan FM. Does colostomy prevent infection in open blunt pelvic fractures? A systematic review. J Trauma 2006 May;60(5):1145-8.
Martin H Hessman, Marcus Rickert, Alexander Hofmann, Pol M Rommens, Michael Buhl Outcome in pelvic ring fractures. Eur J Trauma & Emergency Surgery, 2010, Apr; 36(2):124-130.
Published
2014-01-17
How to Cite
PEREIRA, Jorge.
Pelvic Fracture – Generic notions for the general surgeon.
Revista Portuguesa de Cirurgia, [S.l.], n. 26, p. 21-30, jan. 2014.
ISSN 2183-1165.
Available at: <https://revista.spcir.com/index.php/spcir/article/view/319>. Date accessed: 19 apr. 2024.
Section
Review Article
