In the “old” days, the recommended management for an unstable pelvis was application of an external fixator. In some textbooks, it was even suggested that this should be done (by orthopedics) in the resuscitation room. High volume trauma centers with ortho residents could actually pull this off, but not many others.
As the idea of pelvic orthotic binders caught on (T-POD, sheeting, etc) and was adopted by prehospital providers, and then trauma teams, the use of initial external fixation dropped off. But the idea that external fixation was the most desirable or most effective lingered on. A study from Memphis finally sheds some light on the answer to this question.
A 10 year retrospective review was carried out on patients presenting with multiple or severe pelvic ring fractures who had early stabilization of the pelvis. Stabilization consisted of external fixation early on, and gradually shifted to pelvic orthotic devices over the study period. They ultimately analyzed outcomes for 93 patients in each treatment group.
The authors found that transfusion needs were dramatically reduced with the orthotic devices (5 units vs 17 units at 24 hours) compared to the orthotics. About a quarter of patients in each group went to angiography, and even in those patients the transfusion need remained lower in the orthotic device group. Hospital length of stay was also significantly shorter in this group (17 vs 24 days). There was no difference in mortality.
Bottom line: Although this is a small, retrospective study it easily showed significant results and will probably never be repeated. Use of a pelvic orthotic device (POD) resulted in less blood replacement and shorter stays in hospital. This technique is simple, cheap and quick, an ideal combination. But does a sheet count as an orthotic device? We don’t know. It’s really cheap, but probably a bit less controlled than a POD. If you have a real POD in your ED or your ambulance, use it. If not, apply the sheet as described below.
Reference: Emergent pelvic fixation in patients with exsanguinating pelvic fractures. JACS 204:935-942, 2007.
The photo on Friday shows a woman who had been run over by her own car. The vehicle had rolled over her pelvis and stopped, requiring extrication. The most likely injury is an open book pelvic fracture with significant diastasis and/or bilateral unstable sacral fractures.
If you see this clinical presentation there are several things you need to do immediately:
Call for blood. Losses will be large, so you may even want to consider activating your massive transfusion protocol.
Call an orthopedic surgeon. External stabilization will be needed to help decrease blood loss.
Consider early intubation for control of pain. You will be doing a lot, and a patient in agony will slow you down. Your patient is already hypovolemic, so plan your drug choices accordingly.
Search for evidence of an open fracture. Do a good rectal and vaginal exam looking for blood.
The pelvic xray is poor quality, but shows the major problem, a 10cm pubic diastasis from the open book pelvis fracture. Wrapping the pelvis may be of some help, but consult your orthopedic surgeon first. This pelvis is probably not connected to the spine anymore, so wrapping may have variable results.
Arterial bleeding from a pelvic fracture is more common than previously thought. The doctor books used to say that 10% of bleeding was arterial and 90% was venous, so angiographic techniques were seldom used unless there was clinical evidence of blood loss.
It looks like arterial bleeding occurs more frequently than we think. Here are tips that help you identify patients at risk:
What type of mechanism caused the fracture? Anterior-posterior compression and vertical shear are the most common.
Are the vital signs stable? If not, rule out the other four likely sources first (chest, abdomen, multiple extremity fractures, external). Then blame the pelvis.
Is the fracture open? Arterial bleeding is very likely.
How old is the patient? Elderly patients are more likely to have arterial bleeding, especially from gluteal artery branches.
What part of the pelvis is broken? If major sacral fractures, SI joint disruption or separation of the symphysis is present, think arterial bleeding.
Are there CT abnormalities? A vascular blush or large hematoma indicates significant bleeding.
The most common bleeding sites are the gluteal and pudendal arteries. The gluteal is in proximity to the SI joint, so this can be torn if the SI joint is damaged or the sacrum is fractured. The pudendal can be injured with ramus fractures, especially when the symphysis is widened.
If the patient can be reasonably stabilized, then a trip to interventional radiology is mandatory. Operative management is not very successful, so patients with blood pressure lability or controllable hypotension should go to IR. All active bleeding and arterial cutoffs should be embolized thoroughly.
Images: On the left is the portable plain image of a vertical shear pelvic fracture. The arrows on the right point to two areas of vascular blush.
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