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Emergency Management of Pelvic Fractures

Mark Emerton

 Many protocols for the management of patients with unstable pelvic # and haemodynamic instability have been developed. They primarily offer guidance for the timing of external fixation, angiography and laparotomy for the control of haemorrhage. The decision to apply an external fixator, according to protocols, appears to be simple. Patients with an unstable pelvis and haemodynamic instability require pelvic stabilisation to control haemorrhage. However, unnecessary procedures increase morbidity and mortality and it is therefore important that they are performed on appropriate patients at the correct phase of treatment. Identification of these patients is not always straightforward.

Deciding which patients are 'unstable' both haemodynamically and mechanically is critical to successful management. A system of haemodynamic assessment is suggested, dividing patients into groups, depending on their response to initial resuscitation. These groups are:

  1. Stable responder

  2. Transient responder

  3. Minimal responder

  4. Non-responder

  5. Continued bleeder

This assessment relies on continued 'dynamic evaluation' following repeated bolus resuscitation. The concept of the 'primary clot' in establishing haemorrhage control is useful particularly when dealing with patients in groups 2 - 5. The selection of patients with persistent haemodynamic instability is hopefully simplified with this approach.

The classification of pelvic fractures is complicated.  However, during resuscitation a rapid judgement of pelvic stability is all that is required. Emergency room clinical and radiographic assessment is usually sufficient to achieve this. Tile's classification into stable and rotational or multiplanar instability is most useful.

The principal behind the use of external fixation is to close bleeding fracture surfaces and allow the primary clot to form in a mechanically stable situation. Reduction of pelvic volume and improving tamponade have been suggested as advantages but probably have little role in haemorrhage control.

Application of the external fixator requires careful technique to avoid complication and reduction of the fracture must be done with care to avoid posterior displacement. The design of anterior frames is not critical to success and they all provide similar/sufficient stability. The posterior C clamp is not widely used in the UK or USA but the principle behind its use addresses the underlying problem more directly than an anterior frame.

The use of laparotomy and angiography is controversial. Most units in the UK and USA will rely on angiography in all patients who are transiently stable. Abdominal assessment can be difficult with DPL or CT offering different pros and cons. The literature suggests that major arterial bleeding occurs in a small percentage but clinical experience suggests otherwise and angiography is frequently helpful and is usually performed before laparotomy unless the patient is in extremis. Laparotomy should not be performed without an ex-fix since the anterior abdominal wall contributes significantly to pelvic stability and pelvic packing requires it. Packing the pelvis is a difficult technique in which precise packing of the pre-sacral and pre-vesical fascial spaces is performed.

Unstable pelvic fractures in unstable patients carries a significant mortality, which increase with concomitant injury. Precise selection of patients for external fixation will reduce unnecessary complications and allow definitive treatment to be performed in virgin territory.



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