V. Axial Skeleton Injuries in an Austere Environment

CPT Jeanne Patzkowski, M.D.
CPT Chad Krueger, M.D.
 
 
A. Describe the initial management, resuscitation, and stabilization of pelvic fractures
 
Pelvic Fractures
I. Epidemiology
            A. High energy mechanism of injury requires instantaneous deceleration of 30 mph to injure pelvic ring
            B. Large association with other injuries including head, chest, abdomen, and extremity trauma
                        1. more than 80% of patients with unstable pelvis fractures will have additional musculoskeletal injuries in civilian literature1

                        2. Injury Severity Score (ISS) (figure 1. Injury severity score.3) is more predictive of mortality than pelvic fracture type
                        3. however, the presence of pelvic ring fracture is an independent risk factor for mortality in blunt trauma2
                                  a.other independent risk factors of mortality are patient age, Glasgow Coma Scale, and blood pressure at time of admission2

            C. Increased incidence of penetrating pelvic trauma as compared to civilian trauma2 (see figure 2, figure 3, figure 4. Penetrating pelvic injuries.)
II. Initial management
            A. Initial evaluation, resuscitation, and stabilization are concurrent events managed by a multidisciplinary team consisting of combat medics, emergency physicians, general surgeons, orthopaedic surgeons, intensivists, anesthesiologists, interventional radiologists, and critical care nurses
            B. Remove wounded from hostile environment (echelon I) – diagnosis and treatment often have to wait until wounded and first responder are out of immediate danger
            C. Primary advanced trauma life support (ATLS) survey (echelon I and above)
                        1. airway
                        2. breathing
                        3. circulation
                        4. neurologic disability
                        5. exposure
            D. Secondary ATLS survey (echelon II and above)
                        1. find all injuries and sources of hemorrhage
                                    a. high rate of associated injuries to head, thorax, abdomen, and other extremities
                                    b. thorough physical exam necessary to identify all injuries and sites of bleeding
                                                i. pelvic springing/rock
                                                            (A). alternating compression and distortion over iliac wings to detect pelvic ring instability
                                                            (B). poor predictor of presence or absence of pelvic fracture
                                                            (C). may dislodge adherent clot and exacerbate hemorrhage     
                                                            (D). painful
                                                            (E). should be avoided
                                                ii. findings suggestive, but not specific for pelvic fracture
                                                            (A). limb length discrepancy
                                                            (B). rotational or bony deformity of lower extremity
                                                            (C). superficial hematoma in scrotum, thigh, or above inguinal ligament
                                                            (D). bony prominence, hematoma, or tenderness on rectal exam
                                                            (E). Morel-Lavallée lesion
                                                                        (I). degloving of lateral proximal thigh (over greater trochanter) due to subcutaneous hematoma formation
                                                                        (II). increased risk of poor wound healing and infection
                                                                        (III). associated with high energy acetabulum fractures
                                    c. initial radiographic survey – know radiographic limitations at present level of care
                                                i. echelon II: plain radiographs, ultrasound
                                                ii. echelon III: CT scan
                        2. aggressive search for open wounds (see figure 5. Examination for open pelvic wounds.)
                                    a. external
                                                i. blood at urethral meatus
                                                ii. scrotal/labial lacerations
                                                iii. perineal lacerations or hematoma
                                                iv. retrograde urethrogram to assess for urologic injuries in the stable patient
                                    b. internal
                                                i. rectal exam
                                                            (A). rigid proctoscopy and sigmoidoscopy
                                                            (B). high-riding prostate
                                                            (C). blood
                                                            (D). rectal wall weakness
                                                ii. vaginal exam
                                                            (A). formal speculum exam
                                                            (B). focus on introitus
                                                                        (I). look for lacerations near opening as well as along side-walls
                                                                        (II). conventional speculum exam designed to evaluate cervix may miss these areas
            E. Diagnostic evaluation
                        1. limited diagnostic modalities available at echelon II
                                    a. plain radiography – AP pelvis – may underestimate severity of injury and likelihood of instability
                                    b. hand held ultrasound – FAST exam
                                                i. FAST exam is not sensitive enough to exclude intraperitoneal bleeding in with a pelvic fracture4
                                                ii. however, specificity is high enough that, if positive, laparotomy should be performed4
                                    c. diagnostic peritoneal lavage
                                                i. high incidence of false positives with pelvic fratures
                        2. CT scan available at echelon III and above and only appropriate for hemodynamically stable patients        
                                    a. CT scan with contrast is recommended for hemodynamically unstable patients regardless of FAST results4               
            F. Provisional stabilization of pelvis once pelvic fracture suspected (echelon II and above)
                        1. sheet – may place at echelon I if available and tactical situation allows
                        2. binder (see figure 6. Pelvic binder clinical photo.) – may place at echelon I if available and tactical situation allows
                        3. external fixator ( echelon II and above)


                                                                                     (CONTINUED)

The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense or the U.S. Government.

Materials and support for The Disaster Preparedness Toolbox is provided by Lt Col. Ky Kobayashi, MD. and Col. Benjamin Kam, MD.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, April 15, 2014 10:39 am