Multidisciplinary Management of Blunt Pelvic Trauma

Abstract

Pelvic fractures account for ∼3% of all fractures and usually occur in patients with polytrauma. Pelvic fractures usually indicate high energy transfer and a significant mechanism of injury, and they can involve massive hemorrhage. For this reason, mortality from pelvic trauma is high, ranging from 40% to 60% among patients in shock, and up to 90% in patients considered to be in extremis. Multidisciplinary approaches in the treatment of patients with pelvic fractures have resulted in improved outcomes for these complex and challenging injuries. In this article, we describe a case of a pediatric patient who suffered severe pelvic fracture with massive hemorrhage, requiring a multidisciplinary approach for control of hemorrhage and definitive repair of injuries.

Objectives: Upon completion of this article, the reader will be able to identify the multidisciplinary approach in the evaluation and management of patients with significant pelvic fractures including combined surgical and endovascular management.

Accreditation: Tufts University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit: Tufts University School of Medicine designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Case Presentation

A 14-year-old boy with no significant past medical history presented to the hospital by paramedics following a motor vehicle collision. He was found to have significant deformity of the right hip, with right lower extremity significantly shorter than the left. He was hemodynamically stable at the time. His anteroposterior (AP) pelvis radiograph demonstrated a complex right acetabular fracture with marked dislocation of the femoral head into the pelvis. There were also comminuted fractures of the right iliac wing, pubic rami, and sacral ala (Fig. 1). Computed tomography (CT) scan of the abdomen and pelvis demonstrated free intra-abdominal fluid and air, as well as a comminuted, severely displaced pelvic fracture with active extravasation of contrast in multiple locations in the distribution of the left internal iliac artery (Fig. 2).

Figure 1.

Anteroposterior pelvic radiograph demonstrates a complex right acetabular fracture with marked dislocation of the femoral head into the pelvis. There were also comminuted fractures of the right iliac wing, pubic rami, and sacral ala.

Figure 2.

Computed tomography scan. (A) Axial and (B) coronal reconstructions of the pelvis demonstrated severely displaced pelvis fracture with active extravasation of contrast in the distribution of the left internal iliac artery (arrow).

Diagnosis

Comminuted and severely displaced pelvic fractures with active hemorrhage from the left internal iliac artery distribution.

Treatment

The patient was taken to the operating room for emergent exploratory laparotomy to control potential intra-abdominal hemorrhage. While the patient was in the operating room, the angiography team was activated. No significant intra-abdominal hemorrhage was identified intraoperatively. A rectal injury was identified, but due to concern for uncontrolled hemorrhage from loss of a tamponade effect, the decision was made not to open the retroperitoneal space for reduction of the pelvis fracture and repair of rectal injury. Instead, the patient's abdomen was packed, and he was taken to the interventional radiology suite for angiography and pelvic embolization.

In the interventional radiology suite, a 21-gauge micropuncture needle was used to enter the right common femoral artery. A 0.018-inch wire was advanced into the aorta. Under fluoroscopy, the needle was removed and a micropuncture sheath was inserted. A 0.035-inch wire was inserted, and the micropuncture sheath was exchanged for a 4F sheath. A 4F pigtail catheter was placed in the aorta, and an aortogram was performed. The catheter was pulled back to the aortic bifurcation, and a pelvic arteriogram was performed. Contrast extravasation was noted from tributaries of the left internal iliac artery (Fig. 3). The pigtail catheter was exchanged for a 4F Cobra 2 catheter, which was advanced into the left internal iliac artery over a 0.035-inch hydrophilic wire. An arteriogram was performed, and further superselection was obtained with a 0.035-inch hydrophilic wire to the origin of the bleed. A slurry of Gelfoam (Pfizer, New York, NY) and contrast was instilled until hemostasis was achieved. This was followed by placement of four 4 mm × 3mm Tornado microcoils (Cook Medical, Inc., Bloomington, IN). Following embolization, a left common iliac arteriogram was performed; no further contrast extravasation was noted (Fig. 4).

Figure 3.

(A and B) Iliac angiography, anteroposterior projection midarterial phase, demonstrates active extravasation from tributaries of the left internal iliac artery (arrow). No other regions of active extravasation were identified.

Figure 4.

Anteroposterior angiographic image, midarterial phase, after embolization with Gelfoam and coil demonstrates control of hemorrhage.

After successful embolization, the patient returned to the operating room where open reduction of the left acetabular fracture was performed. An external fixation device was placed, and peritoneal pelvic packing was performed to control venous hemorrhage. The abdomen was closed temporarily; the patient returned to the operating room 2 days later for removal of pelvic packing and proximal diversion of stool with a Hartman procedure. The pelvic injuries required multiple operations for definitive repair. He did well and was discharged from the hospital on hospital day 24. He returned 6 months later for reversal of his colostomy and is currently doing well. He is followed closely by the orthopedic service for surveillance of avascular necrosis of the right femoral head.

Discussion

Pelvic fractures commonly result from motor vehicle collisions or falls from significant height, and they tend to have a male preponderance. There is a bimodal distribution, with patients in the third, fourth, and fifth decades sustaining injury from high energy trauma, and elderly patients sustaining injury from fall-induced fractures secondary to osteoporosis.

There are three common injury patterns involved in pelvic fractures. These include anteroposterior compression (APC), lateral compression, and vertical shear injuries. However, any pelvic ring injury may result in major hemorrhage. For example, APC compression injuries do not commonly cause arterial injury but may tear the retroperitoneal pelvic venous plexus or pelvic floor musculature. Pelvic volume is increased and can accommodate an increased volume of blood, hindering a tamponade effect. Three major bleeding sites can result in life-threatening shock including fractured cancellous bone surface and venous and arterial lacerations. Usually, most bleeding in pelvic fractures is secondary to venous plexus injury; however, arterial sources can result in catastrophic hemorrhage. The management of each of these sources of injuries is different: mechanical stabilization of fractures, promotion of the tamponade effect for venous bleeding, and embolization of arterial bleeding sources. The major pelvic arterial supply to the pelvis arises from branches of the internal iliac artery. Additionally, arteries adjacent to bone are prone to injury from displaced fractures including the superior gluteal, internal pudendal, and the obturator arteries.

The initial assessment of the trauma patient follows the American College of Surgeons Advance Trauma Life Support guidelines. During the initial assessment, mechanical instability of the pelvis can be assessed with manipulation of the pelvis. Once instability of the pelvis is confirmed, no further manipulation should be done because it may disrupt any formed clot and cause further hemorrhage. A single AP pelvis radiograph can easily be performed to confirm fractures. The patient should also be assessed for scrotal/perineal hematoma, blood at the urethral meatus, or a high-riding prostate for indication of urinary tract injury. Laceration of the perineum, vagina, rectum, or buttocks would suggest an open pelvic fracture. In a hemodynamically unstable patient with an unstable pelvic fracture, a pelvic binder should be placed as soon as possible to reduce the pelvic volume and potentially reduce further blood loss.^1,2,3 Alternatively, an external pelvic fixation device or pelvic C-clamp can be placed. However, placement of these devices requires expertise and is time consuming. In one study of patients with sacroiliac injury, placement of external pelvis fixation was associated with a higher blood transfusion requirement compared with placement of a temporary pelvic binder.³ Due to the ease and rapidity of pelvic binder placement, pelvic binders have largely replaced external pelvic fixation and C-clamp devices for early mechanical stabilization of the pelvis.

Emergent pelvic angiography and embolization is indicated in patients with pelvic fractures and hemodynamic instability, or signs of ongoing hemorrhage when other sources of bleeding have been ruled out. In a retrospective study of 325 patients, the Revised Trauma Score alone was found to be predictive of the need for angiography.⁴ There are exceptions, however. In patients with pelvic fracture and hemodynamic instability, with a concomitant intra-abdominal source of hemorrhage found by Focus Assessment with Sonography for Trauma, the intra-abdominal hemorrhagic source should be addressed first with a laparotomy, followed by pelvic angiography and embolization.

In hemodynamically stable patients with pelvic fractures, a CT scan of the abdomen and pelvis should be performed to evaluate for associated intra-abdominal injuries and detection of intravenous contrast extravasation. In determining the need for pelvic embolization, the presence of contrast extravasation seen on CT has a sensitivity of 60 to 80% and specificity of 85 to 98%.^5,6 Intravenous contrast extravasation, therefore, is a strong predictor of the need for pelvic embolization. Another predictor of the need for pelvic embolization is age >60 years; in fact, 62% of patients >60 years requiring angiography and subsequent embolization have normal vital signs on hospital admission.⁷ It is also important to note that fracture pattern alone is not predictive of need for pelvic angiography and embolization.^8,9 However, it is generally agreed that anterior fractures are associated with anterior vascular injuries, whereas posterior fractures are associated with posterior vascular injuries.¹⁰

Angiography for pelvic fractures allows both selective embolization of bleeding arteries and nonselective embolization of the more proximal internal iliac arteries. Multiple bleeding sites from bilateral internal iliac artery branches are sometimes identified, especially in hemodynamically unstable patients. In these cases, nonselective bilateral internal iliac artery embolization (“shotgun embolization”) with gelatin sponge from the internal iliac artery trunk has been advocated. In patients who are hemodynamically stable or who respond to initial fluid resuscitation, selective embolization offers a minimally invasive method of treatment that may obviate the need for further intervention or blood transfusion. However, a study by Fang et al demonstrated that recurrent bleeding is more common after selective embolization than following nonselective treatment.¹¹ Therefore, the decision for selective embolization should be carefully considered. Recurrent hemorrhage requiring repeat angiography occurs in 5 to 24% of patients.^12,13,14 Independent risk factors for recurrent hemorrhage are transfusion of >2 units of packed red blood cells per hour prior to embolization, more than two bleeding vessels, recurrent hypotension after initial embolization, absence of intra-abdominal injuries, and persistent base deficit.^12,13,14

There are several downsides in performing angiography. In some patients, access to the femoral artery is difficult due to obesity, hematoma, hypotension, degloving injuries, or overlying pelvic fixation devices. Complications such as hematoma at the arterial puncture site, femoral artery thrombosis, subintimal dissection, and pseudoaneurysm have been reported. Although cases of gluteal necrosis have been reported, they seem to be related to direct trauma to the gluteal region along with protracted hypotension rather than a direct complication of embolization.^15,16 In a retrospective case-controlled study from a single level I trauma institution, we demonstrated that there was no significant difference in skin necrosis, sloughing, pelvic perineal infection, or nerve injury in pelvic trauma patients who underwent internal iliac artery embolization compared with those who did not undergo embolization.¹⁷

An alternative to pelvic embolization is preperitoneal pelvic packing (PPP). This involves accessing the retroperitoneal space through a transverse or midline incision, with subsequent packing of laparotomy pads posteriorly in the bilateral pelvis along the iliac vessels. This technique originated in Europe and was adopted by some trauma centers in the United States. Cothren et al reported the use of PPP immediately after placement of a pelvic binder in-lieu of angiography in severely injured patients.¹⁸ They reported no deaths attributed to hemorrhage, and control of hemorrhage was successful in 83% of the patients. The remaining 17% of patients required pelvic embolization. In their follow-up study, they demonstrated that PPP was associated with a decrease in the transfusion requirement, whereas embolization was not. However, they also found that the time to PPP was significantly shorter than the time to angiography (45 minutes versus 130 minutes).¹⁹ The result of this study is difficult to interpret because the time to hemorrhage control was so much different between the two groups. However, it is safe to conclude that PPP is a good option for unstable patients with pelvic fracture if angiography is not readily available.

In summary, pelvic fracture can be associated with significant pelvic hemorrhage, and the mortality of patients with pelvic fracture remains high. The treatment of patients with severe pelvic fracture can be challenging, and successful management of these patients often requires a multidisciplinary approach.

Teaching Points

• Most bleeding in pelvic fractures is secondary to venous plexus injury; however, arterial sources can result in catastrophic hemorrhage.

• When multiple bleeding sites from bilateral internal iliac artery branches are identified in hemodynamically unstable patients, nonselective bilateral internal iliac artery embolization with gelatin sponge is advocated. In hemodynamically stable patients, selective embolization offers a minimally invasive method of treatment that may obviate the need for further intervention or blood transfusion.

• Emergent pelvic angiography and embolization is indicated in patients with pelvic fractures and hemodynamic instability or signs of ongoing hemorrhage when other sources of bleeding have been ruled out.

• Management of patients with pelvic fractures often requires a multidisciplinary approach.