Fig. 1 Radiograph of anteroposterior compression type pelvic fracture showing significant displacement of the anterior pelvic ring
Courtesy of David J. Hak, MD, MBA, FACS

AAOS Now

Published 11/30/2019
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Terry Stanton

Improving the Odds: OTA Session Addresses Pelvic Ring Fractures

At the Orthopaedic Trauma Association (OTA) Annual Meeting symposium titled, “A Multidisciplinary Approach to Hemodynamically Unstable Pelvic Ring Injuries,” David J. Hak, MD, MBA, FAAOS, FACS, of Hughston Clinic Orthopaedics in Sanford, Fla., addressed challenges in acute pelvic stabilization, including the use of binders and sheeting and external fixation and C clamps, use and misuse of fluoroscopy, and physiologic stabilization.

Moderator Cyril Mauffrey, MD, FAAOS, of Denver Health Medical Center, introduced the session and said that in a discussion of this “fairly controversial topic,” the word multidisciplinary “is key to success in trying to save the lives of patients with these injuries.”

“The problem with this injury is exsanguination,” Dr. Mauffrey said. “When we see patients presenting with this terrible fracture, the biggest issue here is acute bleeding and death from exsanguination.” He noted that there is agreement over three basic factors involved in pelvic fractures, whereas debate arises over the role of angiography and other modalities. “I think that we all agree there is a direct correlation between pressure and volume, hence the use of a pelvic binder and sheets in the early phases of resuscitation and, at times, external fixation. We also know that the golden hour is critical for those patients and that early intervention is crucial. We also know that what kills those patients is usually venous bleeding, not necessarily arterial bleeding. These three factors lean on the side of preperitoneal pelvic packing versus angiography. However, their implementations are not as tangible, and to make sure that those three factors occur, you really need to work in a place that has a trauma-focused culture that is able to focus on patients presenting with hemodynamically unstable pelvic fractures” (Fig. 1).

Although specific approaches to management of pelvic ring injuries may vary, protocols for carrying them out should be standardized and followed, Dr. Mauffrey said. “You want to make sure that you have simple, multidisciplinary protocols that everyone can follow. You also want buy-in from the entire team. You want your trauma team to collaborate with the orthopaedic trauma specialists and buy in to the belief that what you’re doing is the right thing for the patient. You want to establish an excellent team spirit, because there is no way you’re going to be able to intervene in 20 minutes without it. We have to have good lines of communication between the trauma surgeons and orthopaedic trauma surgeons, because there are two teams working together in the operating room (OR), placing external fixator, doing pelvic packing, and whatever needs to be done for the patient.”

Dr. Hak opened his talk by commenting, “In hemodynamically unstable patients with high-energy pelvic fractures, regardless of what we do, a large percentage of them are still dying.” He continued, “And we know that death in the first 24 hours is commonly due to hemorrhage. The source of bleeding when this patient arrives in your emergency department is unknown. It could be from their chest, abdomen, [or] pelvis, and sometimes it can be from all three. It’s worth emphasizing that most of these patients are hemorrhaging due to venous injury, not arterial injury. Eighty percent of the time it is estimated hemorrhage due to venous source, and only 10 percent to 20 percent is it due to arterial source. Of course, you’re going to have some ongoing bleeding from the cancellous bone of the associated pelvic fracture.”

The retroperitoneal space, he noted, can hold as much as four to five liters of blood, “and the bleeding continues into that space until there’s tamponade. In unstable pelvic fractures, these patients cannot tamponade because of the ligamentous disruption.” Dr. Hak described the goals in acute management of this type of pelvic fracture: “You want to reduce the pelvic volume; you want to stabilize the fracture, and, in doing so, you can hopefully stabilize the patient’s blood clot.” Pelvic binders and sheets, he noted, “are easy and quick to apply, they don’t require X-ray or an OR, and they should be placed immediately on at-risk patients.”

Binder findings

On the topic of binders, Dr. Hak referred to a review conducted by the Department of Defense Committee on Tactical Combat Casualty Care, with evidence classified as follows: level A—evidence from multiple randomized trials or meta-analyses; level B—evidence from a single randomized trial or nonrandomized studies; and level C—evidence from expert opinions, case studies, and standards of care.

One of the questions asked was whether binders stabilize the pelvis. “They found that there was level B evidence for stabilization of the pelvis in cadaveric studies, that fracture motion can be stabilized with a pelvic binder, and that the binder should be placed at the level of the pubic symphysis and the greater trochanters.” Dr. Hak said the group found level B evidence that pelvic binders may reduce blood transfusions and lethal hemorrhages compared to other methods. “But they caution that there was likely to have been a selection bias in these studies, and there were no studies of prehospital application of binders. But they said that, often, hemodynamics will improve following binder application.”

On the question of whether binders improve survival rates, the committee found, “There is level C evidence—very weak clinical evidence—that pelvic binders may improve survival after hospital arrival. And it’s noted there was not any literature for them to review on the effectiveness of prehospital application of pelvic binders.”

On the question of whether a pelvic binder can cause harm, Dr. Hak said, the committee reported level C evidence and felt that applying a pelvic binder is unlikely to increase injury or bleeding in a patient who is already bleeding to death. “But prolonged use or overtightening can cause pressure ulceration, so we need to remember these are temporary, not definitive, devices.”

Finally, on the question of which patients should receive a binder, the committee determined that the treatment is appropriate in “any patient suspected of having a pelvic fracture based upon the mechanism of severe blunt-force injury with one or more of the following: pelvic pain, any major lower-limb amputation or near amputation, physical exam findings suggestive of a pelvic fracture, unconsciousness, or shock.”

Sheets and more

Fig. 1 Radiograph of anteroposterior compression type pelvic fracture showing significant displacement of the anterior pelvic ring
Courtesy of David J. Hak, MD, MBA, FACS
Fig. 2 Emergent external fixation stabilization of pelvic fracture
Courtesy of David J. Hak, MD, MBA, FAAOS, FACS

A highly accessible and simple but effective modality is pelvic sheeting. “It doesn’t matter where you are; even facilities without pelvic binders will have sheets,” Dr. Hak said. “This can be equally effective in providing circumferential compression. Another thing to remember is that when these patients arrive and are unconscious, or even if they are not unconscious, they typically have both of their legs externally rotated, and internal rotation can help reduce the pelvis in the absence of associated limb injuries.” Simply taping the feet together addresses this issue.

If external fixation is applied, Dr. Hak emphasized simplicity (Fig. 2). “I think a single pin is enough, as long as you have good purchase in the bone. This is not definitive treatment. We know that you’re going to have poor posterior control, but you don’t want to waste time. I think one of the important roles of being a team player is not to be a prima donna in the OR when everyone is trying to save this patient’s life and you have to open up 12 different trays.”

Use of fluoroscopy should be limited, he cautioned. “Again, that’s more time, more equipment, and potential radiation exposure to individuals who are running from the room to get lead gowns.”

The C clamp has great benefits in improving posterior control of the pelvis, and it is best placed with fluoroscopy to avoid iatrogenic injury, Dr. Hak said. “But, often, you have very limited knowledge of what the injury pattern is. You don’t have the CT scan. You don’t know whether the area where the clamp is going to be placed is comminuted. You don’t have a lot of information.”

On the use of emergent sacroiliac (SI) screw fixation—the “antishock iliac screw”—Dr. Hak said it may be indicated in instances of a wide SI joint, when a C clamp cannot be used, and when anterior external fixation and sheeting are ineffective in reducing the pelvis and controlling bleeding. Alternatively, rather than placing a definitive SI screw, he said, “Think about placing just a short screw so that your threads just go across the SI joint. That way, it doesn’t matter if it’s aimed directly at the sacral foramen; you are ending short of that area.”

These procedures, Dr. Hak said, “need to be done quickly by experienced surgeons so as to not slow down the other resuscitative methods and subsequent care general trauma surgeons need to provide.”

Although attention is understandably focused on stabilization of the bony pelvis, Dr. Hak said, “It is important to remember [that] we also need to be stewards of stabilizing the patient’s physiology, because these patients are facing a lethal triad of coagulopathy (occurring in 25 percent to 40 percent of patients), hypothermia, and acidosis.”
Hypothermia may be addressed by raising the ambient temperature and using thermal blankets or warm forced-air blankets.

Aggressive crystalloid fluid resuscitation is counterproductive, Dr. Hak said. “It leads to continued bleeding from increased intraluminal pressure at the fracture sites, it exacerbates coagulopathy, [and] it dilutes the patient’s native clotting factors. And these fluids are typically cold—even if they’re put through a warmer, they will still contribute to hypothermia.”

Protocols for massive transfusions have improved survival rates; early administration of plasma and platelets is crucial, Dr. Hak said. Pressures and plasmas, platelets, and red blood cells should be administered in a 1:1:1 ratio: “Studies have shown this to have a 50 percent decrease in mortality compared to prior resuscitation methods.”

Be simple and quick

Summarizing the key points, Dr. Hak echoed Dr. Mauffrey’s remarks and said protocols “should focus on stopping the hemorrhage, managing the trauma-induced coagulopathy, identifying the patient’s associated injuries, and restoring the patient’s hemodynamic stability. You are to use a pelvic binder or circumferential compression sheeting in all hemodynamically unstable patients as soon as you arrive. Use simple—which I define as quick—external fixation frames. You should be able to do this in a few minutes. You should be in and out without anybody even knowing you’re there. You need to be a stealthy surgeon who can get that external fixator on in no time. Then tape the feet together; while people are doing other things, simply go to the foot of the bed, grab your roll of tape, and correct that external rotation deformity.”

“You want to avoid coagulopathy exacerbation, you want to avoid hypothermia, and you want to minimize crystalloid infusion. Early transfusion of massive transfusion protocol of plasma, platelets, and packed red blood cells in a 1:1:1 ratio will help save these patients’ lives,” he concluded.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.