- Discussion:
-
arterial anatomy of lower limbs:
- massive retroperitoneal hemorrhage may result from bony fragments and lacerated blood vessels, leading to coagulopathy and exsanguination;
-
associated injuries:
- upto 40 % of pts who have a pelvic frx will have an intra-abdominal source of bleeding that contributes to mortality and morbidity after blunt trauma;
-
evaluation of hematuria:
- references:
-
Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients.
-
arterial bleeding:
- massive blood loss usually occurs from injury to
superior gluteal artery or anterior branches of the internal iliac artery;
-
superior gluteal injury occurs because of its relation to
SI joint;
- internal pudendal artery injury occurs from sharp fascia of piriformis;
- less often occurs injury to lateral sacral artery in disruptions of posterior portion of pelvic ring;
- arterial injuries are uncommon & usually seen w/ open pelvic frx;
- arterial injuries occur most often in APC -
Type II &
Type III
- arterial bleeding is amenable to a variety of
embolization techniques;
-
magnitude of bleeding:
- magnitude of blood loss often goes unrecognized;
- retroperitoneal space may accumulate upto 4 liters of blood before venous tamponade occurs;
- w/ 3-cm pubic symphysis diastasis will cause doubling of normal volume of pelvis, which would allow several units of addition blood to accumulate
before a tamponade effect occurs;
- w/ posterior instability, avg blood loss is > 15 units
pRBC compared to avg of 5 pRBC required for pelvic frx w/o posterior instability;
- always consider need for
FFP inaddition to
pRBC in cases of massive blood loss;
- CT Scan:
- CT scanning has become an alternative to peritoneal lavage for the diagnosis of intra-abdominal hemorrhage;
- references:
-
Contrast-enhanced CT accurately detects hemorrhage in torso trauma: direct comparison with angiography.
- Management Options:
-
blood product menu and
medical management of bleeding;
-
angiography & embolization
- in pelvic fractures, selective angiography may aid in the dx of of
superior gluteal artery lacteration;
- during the angiography, the artery may be embolized thru the diagnostic cannula, avoiding a pelvic exploration;
- if one is using the anterior or posterior approaches to the acetabulum using trochanteric osteotomy,
superior gluteal vessels must be intact in
order to avoid necrosis of
medius &
minimus;
- this is becuase origin and insertion of muscles is detached in these approaches;
- if acetabular fracture involves a displaced frx of
sciatic notch preoperative angiography is advised to ensure that the neurovascular pedicle is intact;
-
laparotomy to control hemorrhage:
-
external fixators to control bleeding:
-
mechanical reduction of pelvic volume:
- pelvic volume can be closed down by wrapping a sheet around the pelvis, and then sequentially twisting a "broom stick" to the tied ends until the sheet tightens;
- taping the knees and ankles together;
- antishock ("C") clamps;
- careful not to overtighten the clamp;
- references:
-
Circumferential pelvic antishock sheeting: a temporary resuscitation aid.
-
Pelvic emergency clamps: anatomic landmarks for a safe primary application.
-
Clinical experience with two types of pelvic C-clamps for unstable pelvic ring injuries.
-
Biomechanical comparison of various emergency stabilization measures of the pelvic ring.
-
Emergent treatment of pelvic fractures. Comparison of methods for stabilization.
-
Institutional practice guidelines on management of pelvic fracture-related hemodynamic instability: do they make a difference?
-
Skin breakdown following circumferential pelvic antishock sheeting: a case report.
-
Innominosacral dissociation: mechanism of injury as a predictor of resuscitation requirements, morbidity, and mortality.
-
The trochanteric C-clamp for provisional pelvic stability.
Pelvic Fractures: Causes, Diagnosis, and Emergent Management.
Management strategy of vascular injuries associated with pelvic fractures.
Diagnosis and treatment of retroperitoneal hematoma in multiple trauma patients.
Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management.
Hemorrhage associated with major pelvic fracture: a multispecialty challenge.
Retroperitoneal hematomas of traumatic origin.
Retroperitoneal hematomas of traumatic origin.
Year Book: Pelvic Fracture Classification: Correlation With Hemorrhage.
Pelvic ring disruptions: effective classification system and treatment protocols.
Hemodynamic Instability Following an Avulsion of the Corona Mortis Artery Secondary to a Benign Pubic Ramus Fracture.
