Advertisement

Modern Strategies for the Management of High-Energy Pelvic Fractures in the Twenty-First Century

  • Philip F. Stahel
  • Ernest E. Moore
Chapter

Abstract

High-energy pelvic fractures continue to represent a major challenge in trauma management due to the high rates of post-injury mortality of around 30–40% in the modern peer-reviewed literature. The main root cause of potentially preventable mortality relates to the delayed recognition of the extent of retroperitoneal hemorrhage and post-injury coagulopathy. Current management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta (REBOA) for patients “in extremis” in conjunction with point-of-care guided resuscitation for post-injury coagulopathy. There is increasing international consensus regarding the benefits of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing (PPP), and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from exsanguinating retroperitoneal hemorrhage. Modern classification systems provide guidance for grading of injury mechanisms and risk stratification of patients with hemodynamically unstable pelvic ring injuries in order to support protocol-driven acute resuscitation strategies and improved outcomes in this highly vulnerable patient cohort.

References

  1. 1.
    Peltier LF. Joseph Francois Malgaigne and Malgaigne’s fracture. Surgery. 1958;44(4):777–84.PubMedGoogle Scholar
  2. 2.
    Stahel PF, Hammerberg EM. History of pelvic fracture management: a review. World J Emerg Surg. 2016;11:18.CrossRefGoogle Scholar
  3. 3.
    Brand RA. Biographical sketch: Charles Hewitt Moore, FRCS (1821-1870). Clin Orthop Relat Res. 2012;470(8):2075–6.CrossRefGoogle Scholar
  4. 4.
    Brand RA. Biographical sketch: Frank Wild Holdsworth, FRCS (1904-1969). Clin Orthop Relat Res. 2012;470(8):2083–4.CrossRefGoogle Scholar
  5. 5.
    Young JW, Resnik CS. Fracture of the pelvis: current concepts of classification. AJR Am J Roentgenol. 1990;155(6):1169–75.CrossRefGoogle Scholar
  6. 6.
    Fakler JKM, Stahel PF, Lundy DW. Classification of pelvic ring injuries. In: Smith WR, Ziran BH, Morgan SJ, editors. Fractures of the pelvis and acetabulum. New York: Informa Healthcare; 2007. p. 11–25.CrossRefGoogle Scholar
  7. 7.
    Tile M. Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg. 1996;4(3):143–51.CrossRefGoogle Scholar
  8. 8.
    Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–133.CrossRefGoogle Scholar
  9. 9.
    Osterhoff G, Scheyerer MJ, Fritz Y, Bouaicha S, Wanner GA, Simmen HP, Werner CM. Comparing the predictive value of the pelvic ring injury classification systems by Tile and by Young and Burgess. Injury. 2014;45(4):742–7.CrossRefGoogle Scholar
  10. 10.
    Mauffrey C, Cuellar DO 3rd, Pieracci F, Hak DJ, Hammerberg EM, Stahel PF, Burlew CC, Moore EE. Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy. Bone Joint J. 2014;96-B(9):1143–54.CrossRefGoogle Scholar
  11. 11.
    Stahel PF, Mauffrey C, Smith WR, McKean J, Hao J, Burlew CC, Moore EE. External fixation for acute pelvic ring injuries: decision making and technical options. J Trauma Acute Care Surg. 2013;75(5):882–7.CrossRefGoogle Scholar
  12. 12.
    Alton TB, Gee AO. Classifications in brief: Young and Burgess classification of pelvic ring injuries. Clin Orthop Relat Res. 2014;472(8):2338–42.CrossRefGoogle Scholar
  13. 13.
    Halawi MJ. Pelvic ring injuries: Emergency assessment and management. J Clin Orthop Trauma. 2015;6(4):252–8.CrossRefGoogle Scholar
  14. 14.
    Stahel PF, Burlew CC, Moore EE. Current trends in the management of hemodynamically unstable pelvic ring injuries. Curr Opin Crit Care. 2017;23(6):511–9.CrossRefGoogle Scholar
  15. 15.
    Coccolini F, Stahel PF, Montori G, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:5.CrossRefGoogle Scholar
  16. 16.
    Bakhshayesh P, Boutefnouchet T, Totterman A. Effectiveness of non invasive external pelvic compression: a systematic review of the literature. Scand J Trauma Resusc Emerg Med. 2016;24:73.CrossRefGoogle Scholar
  17. 17.
    Stahel PF, Heyde CE, Wyrwich W, Ertel W. Current concepts of polytrauma management: from ATLS to “damage control”. Orthopade. 2005;34(9):823–36.CrossRefGoogle Scholar
  18. 18.
    Kashuk JL, Moore EE, Sawyer M, et al. Postinjury coagulopathy management: goal directed resuscitation via POC thrombelastography. Ann Surg. 2010;251(4):604–14.CrossRefGoogle Scholar
  19. 19.
    Stahel PF, Moore EE, Schreier SL, Flierl MA, Kashuk JL. Transfusion strategies in postinjury coagulopathy. Curr Opin Anaesthesiol. 2009;22(2):289–98.CrossRefGoogle Scholar
  20. 20.
    Gonzalez E, Moore EE, Moore HB, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg. 2016;263(6):1051–9.CrossRefGoogle Scholar
  21. 21.
    Rossaint R, Bouillon B, Cerny V, et al. Management of bleeding following major trauma: an updated European guideline. Crit Care. 2010;14(2):R52.CrossRefGoogle Scholar
  22. 22.
    Abramson D, Scalea TM, Hitchcock R, Trooskin SZ, Henry SM, Greenspan J. Lactate clearance and survival following injury. J Trauma. 1993;35(4):584–8; discussion 588–589.CrossRefGoogle Scholar
  23. 23.
    Davis JW, Parks SN, Kaups KL, Gladen HE, O’Donnell-Nicol S. Admission base deficit predicts transfusion requirements and risk of complications. J Trauma. 1996;41(5):769–74.CrossRefGoogle Scholar
  24. 24.
    Burlew CC, Moore EE, Moore FA, Coimbra R, McIntyre RC Jr, Davis JW, Sperry J, Biffl WL. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012;73(6):1359–63.CrossRefGoogle Scholar
  25. 25.
    Manzano Nunez R, Naranjo MP, Foianini E, Ferrada P, Rincon E, Garcia-Perdomo HA, Burbano P, Herrera JP, Garcia AF, Ordonez CA. A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients. World J Emerg Surg. 2017;12:30.CrossRefGoogle Scholar
  26. 26.
    Davidson AJ, Russo RM, Reva VA, et al. The pitfalls of REBOA: risk factors and mitigation strategies. J Trauma Acute Care Surg. 2018;84(1):192–202.Google Scholar
  27. 27.
    Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE, Stahel PF. Direct retroperitoneal pelvic packing versus pelvic angiography: a comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury. 2009;40(1):54–60.CrossRefGoogle Scholar
  28. 28.
    Burlew CC, Moore EE, Smith WR, Johnson JL, Biffl WL, Barnett CC, Stahel PF. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg. 2011;212(4):628–35; discussion 627–635CrossRefGoogle Scholar
  29. 29.
    Chiara O, di Fratta E, Mariani A, Michaela B, Prestini L, Sammartano F, Cimbanassi S. Efficacy of extra-peritoneal pelvic packing in hemodynamically unstable pelvic fractures, a Propensity Score Analysis. World J Emerg Surg. 2016;11:22.CrossRefGoogle Scholar
  30. 30.
    Pohlemann T, Culemann U, Gansslen A, Tscherne H. Severe pelvic injury with pelvic mass hemorrhage: determining severity of hemorrhage and clinical experience with emergency stabilization. Unfallchirurg. 1996;99(10):734–43.CrossRefGoogle Scholar
  31. 31.
    Ertel W, Keel M, Eid K, Platz A, Trentz O. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma. 2001;15(7):468–74.CrossRefGoogle Scholar
  32. 32.
    Lustenberger T, Meier C, Benninger E, Lenzlinger PM, Keel MJ. C-clamp and pelvic packing for control of hemorrhage in patients with pelvic ring disruption. J Emerg Trauma Shock. 2011;4(4):477–82.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Koller H, Balogh ZJ. Single training session for first time pelvic C-clamp users: correct pin placement and frame assembly. Injury. 2012;43(4):436–9.CrossRefGoogle Scholar
  34. 34.
    Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009;40(4):343–53.CrossRefGoogle Scholar
  35. 35.
    Hou Z, Smith WR, Strohecker KA, Bowen TR, Irgit K, Baro SM, Morgan SJ. Hemodynamically unstable pelvic fracture management by advanced trauma life support guidelines results in high mortality. Orthopedics. 2012;35(3):e319–24.PubMedGoogle Scholar
  36. 36.
    Burlew CC, Moore EE, Stahel PF, Geddes AE, Wagenaar AE, Pieracci FM, Fox CJ, Campion EM, Johnson JL, Mauffrey C. Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg. 2017;82(2):233–42.CrossRefGoogle Scholar
  37. 37.
    Platz A, Friedl HP, Kohler A, Trentz O. Surgical management of severe pelvic crush injuries. Helv Chir Acta. 1992;58(6):925–9.PubMedGoogle Scholar
  38. 38.
    Smith WR, Moore EE, Osborn P, Agudelo JF, Morgan SJ, Parekh AA, Cothren C. Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. J Trauma. 2005;59(6):1510–4.CrossRefGoogle Scholar
  39. 39.
    Glass NE, Burlew CC, Hahnhaussen J, Weckbach S, Pieracci FM, Moore EE, Stahel PF. Early definitive fracture fixation is safely performed in the presence of an open abdomen in multiply injured patients. J Orthop Trauma. 2017;31(12):624–30.CrossRefGoogle Scholar
  40. 40.
    Moore EE, Burlew CC, Pieracci F, Stahel PF. Preperitoneal pelvic packing for acute hemorrhage control. https://www.vumedi.com/video/pelvic-packing-surgery-live-real-time-instructional-video/. Accessed 15 Dec 2017.
  41. 41.
    Fakler JKM, Pallister I, Stahel PF. Surgical approaches for pelvic ring injuries. In: Smith WR, Ziran BH, Morgan SJ, editors. Fractures of the pelvis and acetabulum. New York: Informa Healthcare; 2007. p. 87–98.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Philip F. Stahel
    • 1
  • Ernest E. Moore
    • 2
  1. 1.Rocky Vista University, College of Osteopathic MedicineParkerUSA
  2. 2.Department of SurgeryUniversity of Colorado, School of Medicine, Denver Health Medical CenterDenverUSA

Personalised recommendations