From a surgical management perspective, A-type injuries are unlikely to be a source of major bleeding while B type and specifically C types are increasingly life-threatening. After initial assessment, primary radiology, and consideration of the response to initial resuscitation, pelvic fractures can be considered by the mechanical stability resulting from the injury and the resultant hemodynamic response (Table 28-2).
Table 28-2 Principles of Management of Major Pelvic Ring Injuries
When considered in this way the orthopedic care follows a logical pattern. The essential contribution of the orthopedic surgeon is to assess the injury with regard to the local and associated problems it will produce and to provide pelvic mechanical stability when required. Clearly, the hemodynamically stable patient with a stable pelvic ring injury does not require major active orthopedic management although it should be noted that even the most apparently simple injury can rarely cause local bleeding and transfusion may be required.11 The hemodynamically stable patient with a mechanically unstable pelvic ring injury needs early but nonemergent surgery to restore mechanical stability to the pelvis for pain relief, normal daily care, and mobilization. Hemodynamically unstable patients need emergent care to restore their physiologic stability. If the pelvis is mechanically stable, orthopedic intervention has little to offer, either there is an extrapelvic cause for the bleeding or hemostasis should be obtained by provision of appropriate clotting factors and platelets or angiographically.
3 The patient in hemorrhagic shock with a major unstable pelvic ring is a very different problem.11,12 Early coordinated multidisciplinary care is essential with appropriate resuscitation within an established massive transfusion protocol. It is well established that the site of hemorrhage in most bleeding major pelvic fractures is from the fractured bone surfaces and extensive soft tissue injury, and rarely from major named arteries. Fortunately, the majority of this will slow significantly or stop when skeletal stability is achieved. Unfortunately, rapid stabilization of the pelvic ring is a major expert intervention at best and is commonly not easily achievable in the acute bleeding situation. Initial reduction, stability and some local tamponade is provided by a pelvic binder. In critical cases it should not be removed without an available alternative method to provide stability. Internally rotating the hips, slightly flexing the knees and binding the legs at the thigh should also be used if possible and provides additional effective control. The provision of early pelvic fixation or a primary angiographic approach depends on local expertise and protocol. Recently, a move to emergent operative provision of skeletal stability and packing of bleeding areas has entered practice and is suggested to be a major advance.2,3 This considers the major bleeding pelvic injury similar to a bleeding liver and where local hemostasis can rarely be achieved and general hemorrhage control with packing for local pressure and provision of appropriate clotting factors is essential. For the severe pelvic injury, a systematic protocol with pelvic stabilization and packing at the end of an appropriate decision-making tree is essential.2,3 Emphasizing the importance of not getting out of control or reacting too late, “The Denver Protocol”2,3 begins with a patient with shock, a pelvic ring injury, and a failure to respond to 2 L of crystalloid resuscitation and 2 units of blood transfusion (Algorithm 28-1). The essential principle is early aggressive surgical management for hemorrhage control with preperitoneal packing and rapid blood and factor replacement before the patient becomes grossly coagulopathic. From the orthopedic point of view, restoring skeletal stability is a critical part of this process and close cooperation with the general traumatologist is essential.
Figure 28-1. A–C: Young and Burgess and Tile (AO-OTA) classifications of pelvic fractures (from Wiss DA. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Wolters Kluwer Health; 2012.)
The procedure of packing a pelvis for hemorrhage is not complicated and well within the capabilities of most surgeons but some form of pelvic bony stability has to be achieved first to give a solid base to pack into. In the emergency situation this commonly means the application of an anterior external fixation frame although if available and possible, internal fixation has many advantages. Occasionally, emergency provision of posterior stability with emergent percutaneous sacroiliac fixation or application of a “C clamp” can be dramatically effective in restoring stability and markedly slowing bleeding. Preperitoneal packing is done through a small anterior incision just above the pubis. After separating the rectus muscles (which may be avulsed from the pubis), the cavity created by the trauma is entered, the hematoma evacuated and rapid mechanical stability obtained (often temporarily, with an immediate anterior clamp across the pubis). The cavity is then packed with as many packs required. These should be placed as far back into the true pelvis as possible. The hematoma cavity created by the injury will be obvious and it is not required or desirable to extend the dissection outside this area but it is essential to get the packs right to the back of the cavity. Assuming hemostasis is achieved, the packs are left in, often for 48 hours and under an open but sealed abdomen before they are changed or simply removed depending on the physiologic response.
Complicated Pelvic Injuries – Open Fractures or Associated Visceral Injury
The initial assessment of any patient with a pelvic fracture must include an inspection of the perineum with rectal and vaginal examination to check for complex open injuries or associated urologic injuries. Open pelvic fractures and those complicated by damage to the local viscera need specific treatment based on the wound or specific visceral damage sustained.13,14 While the mortality and complexity increases with the risk of contamination and infection the orthopedic principles of open fracture care remain the same. Any open fracture is considered contaminated and dealt with along the principles described below of debridement and lavage, establishment of bony stability and early, healthy soft tissue cover as required. However, in major pelvic injuries there is usually a massive trauma cavity where contamination and infection would prove fatal. Aggressive decontamination and protection of this extensive zone of injury from further contamination by diversion of the fecal stream may be essential.
Algorithm 28-1. The Denver Protocol for management of major pelvic fractures. (Reproduced with permission and copyright © of the British Editorial Society of Bone and Joint Surgery. Mauffrey C, Cuellar DO 3rd, Pieracci F, et al. Strategies for the management of hemorrhage following pelvic fractures and associated trauma-induced coagulopathy. Bone Joint J 2014;96(9):1143–1154.)
Complex urologic injuries are commonly seen with specific patterns of pelvic fracture. A significant APC injury is commonly associated with an extraperitoneal bladder rupture of the anterior bladder wall directly in line with the plane of injury. LC injuries may be associated with urethral tears as the inferior ramus cuts the male membranous urethra as it is forced across the midline by the injury. In all cases the presence of hematuria or blood at the meatus is the pathognomonic sign of injury and necessitates appropriate investigation and joint management with the urologic service. Again from the orthopedic point of view no soft tissue reconstruction can work without an underlying stable bony skeleton to support the repair and prevent reinjury. In many situations, the best access the urologist will have is at the time of the primary bony stabilization and early urologic repair or diversion avoids many problems. While a staged urologic procedure may be required, very early combined surgery has much to recommend it.
The Orthopedic Management of Major Polytrauma
4 Major trauma is a surgical problem, and the essence of management is to take control and stay in control of the trauma and do no further iatrogenic harm. From the orthopedic point of view, this means that it is essential to gain control by stabilizing the skeleton. This understanding has developed through quite opposite phases to now consider all elements of the injury and physiologic priorities. The management protocols have focused on the changing opinions about stabilization of the femur fracture which has become the index injury in this regard. Essentially, despite the development of long-bone nailing by Kuntscher15 in the 1940s, through till the late 1980s most Western surgeons believed that seriously injured patients were “too sick to operate on” and used traction devices as the primary mode of treatment for major fractures. Concern that this was not the best mode of treatment led to the term “Horizontal Crucifixion” and several early publications15–17 suggesting a major advantage of early surgical stabilization of the fractures, specifically with femoral nailing. Johnson18 confirmed this effect and showed that it appeared to be greater the more severely the patient was injured and in 1989 Bone19 published his landmark paper, a prospective randomized trial of early against late femoral nailing after severe injury. Essentially he showed that there was a major advantage in early nailing and the pendulum swung to enthusiastic universal early skeletal stabilization after polytrauma. The patient was now considered “too sick not to operate on” and a management philosophy now termed “Early Total Care” developed. This practice was soon questioned, specifically in Germany where the orthopedic trauma surgeon is closely involved with intensive care and inevitably observed the combined effect of other injures. Pape et al.20 again considering the femur, looked specifically at the effect of early and late femoral nailing in severe polytrauma and showed the deleterious effect of an associated chest injury in association with femur fractures treated by early reamed nailing. While statistically the effect seemed more related to the chest injury than the nailing, this alerted the profession to the combination effect of these injuries and stimulated an outpouring of research looking at the general and immunologic effects of orthopedic procedures and specifically of reaming the femur.21–36 Eventually, a concept of the general effects of polytrauma and bony injury has become more widely accepted and a concept of the appropriate surgery (damage control orthopedics – DCO) for the most severely injured patients developed.
Essential Damage Control Surgery in Orthopedics
Damage control in orthopedics means taking control of the musculoskeletal elements of the injury without creating an increased trauma load due to increased surgical bleeding or a lengthy surgery associated with definitive care of complex fractures (Fig. 28-2). After essential hemorrhage and wound management this involves restoring major skeletal stability usually by the rapid application of external fixators. The basic physiologic parameters are then normalized in a critical care environment unit and definitive stabilization is delayed until the peritraumatic immunologic storm has settled.25,26,28,29 The most critical element is the speed and accuracy of the initial surgery as the critical injured patient cannot tolerate a long orthopedic procedure. However, it cannot be underemphasized how important the principle of establishing early skeletal stability remains; this was the major lesson of the early Johnson/Bone papers18,19 and has never been disputed, the issue is not if, but how this is obtained. In situations where the patient can tolerate it, there are major advantages in early definitive skeletal stabilization. The question is, how do we identify which patients are too sick and for what? Long orthopedic procedures and protracted bleeding must be avoided and nailing the femur seems to be particularly excessively stimulating. A variety of parameters have been investigated to help with this decision.25 Measurement of interleukin-6 (IL6)24 has not achieved its initial promise and today a spectrum of parameters considering the patient’s general condition are commonly used.30 This essentially means close communication and protocol agreement with the anesthetic/general trauma team but is primarily a surgical decision as the anesthetic team is less likely to be trauma specialized. Basic parameters to be considered include the hemoglobin/hematocrit, ventilation parameters, platelet count and coagulation studies, patient temperature and a measure of acidosis, usually the lactate level. The latter has been widely used as measure of resuscitation and as the primary decision-making parameter by many orthopedic surgeons. Initially, a level of 2.5 mmol/L was considered the value above which surgery should not proceed but the more recent work from Vallier et al.30 has suggested a lactate level of 4 mmol/L is a safe cutoff. However, surgical decision making in critical illness does not occur in isolation and improvements in early resuscitation and critical care management mean constant reappraisal and probably another future swing in the pendulum (Table 28-3).
Figure 28-2. Early damage control of extensive limb injuries with external fixation.
Table 28-3 Essential Priorities in Orthopedic Damage Control
Special Polytrauma Situations – Head Injury
The orthopedic priorities change in specific scenarios the most obvious being the associated head injury. When the brain is at risk the primary aim is to maintain cerebral oxygenation and cerebral perfusion pressure (CPP); accordingly, orthopedic procedures especially those that would lead to bleeding, swings in blood pressure and thus episodes of reduced CPP should be avoided. However, there are definite advantages in having a stable skeleton and being able to sit the patient up which will help oxygenation and general critical care such that after appropriate discussions bony stabilization at the right time is strongly indicated.37,38
Special Polytrauma Situations – Chest Injury and Femur Fractures
The effect of the chest injury is discussed above. It was emphasized by Pape and Tscherne and innumerable papers that followed.20 While multiple studies have shown the advantages of early skeletal stabilization there is no doubt that the lungs are vulnerable to further insults after injury, and that the acute lung injury can be worsened by fat embolization especially during femoral canal instrumentation. While improvements in reamer design reduce canal pressurization and smaller nails have been advocated, delaying definitive nailing for 4 to 5 days after initial external fixation in the most critical patient is probably the standard of care. The effect seems to be dose dependent such that the patient with bilateral femur fractures is at a significantly increased risk and some surgeons avoid bilateral femoral nailing at the same time even in healthy patients.39–42
Specific Orthopedic Scenarios
5 The ongoing septic effect of major wounds can be critical. In the first instance, debridement of necrotic tissue from the trauma is essential and commonly inadequately done at the initial surgery. Wounds will never stabilize until adequately debrided and when associated with fractures will not heal until bony stability has been established. The management of complex open fractures is described below; in polytrauma cases the principles remain the same but the ability to obtain early soft tissue cover is compromised by the patient’s general situation.
Table 28-4 Open Fracture Surgical Principles
ORTHOPEDIC TRAUMA SURGERY TO SAVE LIMBS
Open Fracture Principles
Open fractures can range from simple to destructive injuries but in all the important feature is that the fracture hematoma communicates with the outside environment and the fracture is thus potentially contaminated. As such, their specific management revolves around limiting the chance of this contamination converting to established infection. General measures include the provision of tetanus cover, early broad spectrum antibiotics, early splintage, wound dressing, and specific surgical management. The latter is designed to reduce the degree of contamination, to remove necrotic or threatened tissue likely to become infected and to protect the limb by making it unlikely to develop further infection due to an unstable open wound (Tables 28-4 and 28-5).
Appropriate and adequate open fracture debridement is one of the most difficult surgical procedures, it should not be relegated to inexperienced staff and if possible not attempted at night unless the limb is very seriously threatened. The whole zone of injury must be assessed and all dead and dying tissue removed, only nerve and vessel must be preserved and poor muscle specifically removed. Any free bone or fragments attached by flimsy soft tissue should also be removed and the resulting defect dealt with accordingly, although only rarely is a significant defect produced. Wound extensions need to be placed with specific consideration for the later closure and must not make the soft tissue reconstruction more complex. An adequate appropriate debridement must be performed the first time. Repeated debridements “to make sure” are a result of an inadequate initial operation and massively increase delay and the infection rate. This should be avoided at all costs.
6 Establishing early bone stability is essential, and ideally the definitive bone stabilization should be performed at the primary procedure. This reduces the chance of late infection and facilitates the subsequent soft tissue reconstruction. In truth, the ability to perform an adequate debridement and the best bony reconstruction depends directly on the orthopedic surgeons’ confidence in the subsequent soft tissue closure and thus the working relationship with the plastic surgery team. While soft tissue reconstruction is often delayed for practical reasons there is excellent evidence that the earlier a healthy closure is obtained the better. This is true to the extent that the best data in the most complex (IIIb) injuries are with immediate flap cover after an adequate initial debridement and definitive bony reconstruction as one primary procedure (Fig. 28-3). Few units can achieve this at primary presentation, such that definitive debridement, fracture stabilization, and appropriate soft tissue assessment at the primary procedure followed by definitive soft tissue cover at the second visit to the OR (at about 48 hours) after the patient has been appropriately counseled are probably the best achievable standard. Cooperative care with the plastic surgical service from the start is essential.44–49
Table 28-5 Open Fracture Classification (after Gustillo & Anderson43)