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Roszman AD, John DQ, Patch DA, Spitler CA, Johnson JP. Management of open pelvic ring injuries. Injury 2023; 54:1041-1046. [PMID: 36792402 DOI: 10.1016/j.injury.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/18/2023] [Accepted: 02/02/2023] [Indexed: 02/17/2023]
Abstract
Open pelvic ring injuries are rare clinical entities that require multidisciplinary care. Due to the scarcity of this injury, there is no well-defined treatment algorithm. As a result, conflicting evidence surrounding various aspects of care including wound management and fecal diversion remain. Previous studies have shown mortality reaching 50% in open pelvic ring injuries, nearly five times higher than closed pelvic ring injuries. Early mortality is due to exsanguinating hemorrhage, while late mortality is due to wound sepsis and multiorgan system failure. With advancements in trauma care and ATLS protocols, there has been an improved survival rate reported in published case series. Major considerations when treating these injuries include aggressive resuscitation with hemorrhage control, diagnosis of associated injuries, prevention of wound sepsis with early surgical management, and definitive skeletal fixation. Classification systems for categorization and management of bony and soft tissue injury related to pelvic ring injuries have been established. Fecal diversion has been proposed to decrease rates of sepsis and late mortality. While clear indications are lacking due to limited studies, previous studies have reported benefits. Further large-scale studies are necessary for adequate evaluation of treatment protocols of open pelvic ring injuries. Understanding the role of fecal diversion, avoidance of primary closure in open pelvic ring injuries, and importance of well-coordinated care amongst surgical teams can optimize patient outcomes.
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Affiliation(s)
- Alexander D Roszman
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Devin Q John
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - David A Patch
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Joey P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
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Kazley JM, Potenza MA, Marthy AG, Arain AR, O'Connor CM, Czajka CM. Team Approach: Evaluation and Management of Pelvic Ring Injuries. JBJS Rev 2021; 8:e0149. [PMID: 33006457 DOI: 10.2106/jbjs.rvw.19.00149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A multidisciplinary approach to the management of pelvic ring injuries has been shown to decrease mortality rates. The primary goals within the emergency room are to assess, resuscitate, and stabilize the patient. The Advanced Trauma Life Support protocol guides the initial assessment of the patient. A pelvic binder or sheet should be applied to help to provide reduction of the fracture and temporary stabilization. The trauma team becomes the primary service for the patient as he or she transitions away from the emergency department. The trauma team must effectively communicate with and serve as the liaison between other specialists as injuries are identified. emodynamic stability should be closely monitored in patients with pelvic ring injuries, involving the assessment of vital signs, imaging findings, and clinical judgment. Angioembolization and peritoneal packing may play a role in helping to control hemorrhage. Urologists should be consulted if a Foley catheter cannot be passed or there is concern for urethral or bladder injury. Further imaging or urologic intervention may be necessary. Orthopaedic surgeons can help to assess the patient, classify the injury, and assist in temporary stabilization while planning definitive fixation.
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Affiliation(s)
- Jillian M Kazley
- 1Divisions of Orthopaedic Surgery (J.M.K., A.R.A., C.M.O., and C.M.C.), Emergency Medicine (M.A.P.), and General Surgery (A.G.M.), Albany Medical Center, Albany, New York
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Gabbe BJ, Stewart I, Veitch W, Beck B, Cameron P, Russ M, Bucknill A, Steiger RD, Esser M. Long-term outcomes of major trauma with unstable open pelvic fractures: A population-based cohort study. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620933203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims The aims of this study were to describe the profile and longer-term outcomes of major trauma patients with unstable open pelvic fractures. Patients and methods An observational study was performed using data from the population-based Victorian State Trauma Registry. Adult (≥16 years) major trauma patients who had sustained an unstable open pelvic fracture between 1 July 2010 and 30 June 2017 in Victoria (Australia) were included. Patient demographics, injury event, severity and management data were extracted. Patients were followed up at 6, 12 and 24 months post-injury to collect information about health status, function and return to work. Results There were 67 patients. The mean (SD) age was 41.4 (18.3) years, and 66% were male. Seventy-six per cent were road traffic injuries, 96% were managed at Level 1 trauma centres and all were multi-trauma patients. A third were Tile C fractures and 80% underwent surgical stabilisation of the pelvic injury. Eighty per cent were admitted to intensive care. The in-hospital mortality rate was 9%. Most (89%) survivors were discharged to an inpatient rehabilitation facility. The proportion classified as ‘severe disability’ on the Glasgow Outcome-Scale Extended declined from 38% at 6 months to 19% at 24 months. The overall three-level EuroQoL five-dimensional instrument score increased with time indicating better health status, and 50% of patients returned to work by 24 months. Conclusions Major trauma with unstable, open pelvic fracture is rare. Low in-hospital mortality was observed. Most survived to hospital discharge and outcomes improved with time post-injury, but 75% of patients experienced persistent pain and ongoing mobility and activity restrictions.
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Affiliation(s)
- Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, UK
| | - Ian Stewart
- Department of Orthopaedic Surgery, The Alfred, Prahran, Australia
| | - William Veitch
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Faculty of Medicine, Laval University, Quebec City, Canada
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Emergency and Trauma Centre, The Alfred, Melbourne, Australia
| | - Matthias Russ
- Department of Orthopaedic Surgery, The Alfred, Prahran, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Andrew Bucknill
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Australia
- Department of Surgery, University of Melbourne, Parkville, Australia
| | - Richard de Steiger
- Department of Surgery, University of Melbourne, Parkville, Australia
- Department of Surgery, Epworth Healthcare, Richmond, Australia
| | - Max Esser
- Department of Orthopaedic Surgery, The Alfred, Prahran, Australia
- Department of Surgery, Monash University, Melbourne, Australia
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