European Journal of Trauma and Emergency Surgery
Focus on Severe Pelvic Bleeding
Pelvic Fractures: Soft Tissue Trauma Luke P.H. Leenen1
Abstract Severe open injuries of the pelvis go with a high complication, morbidity and mortality rate. A stepwise approach is the way to achieve reasonable results; however, final clinical outcome is in a large number of cases suboptimal. Key Words Hemorrhagic Shock Æ General trauma Æ Multiple trauma Æ Orthopedic trauma Æ Pelvic fractures Æ Polytrauma Æ Polytrauma management including pre-hospital and shockroom Eur J Trauma Emerg Surg 2010;36:117–23 DOI 10.1007/s00068-010-1038-0
Introduction The pelvis is a complex entity. The bony pelvis is wrapped with both muscle and skin and is packed with many soft tissue structures. The structures that have to be evaluated after a pelvic fracture are summarized in Table 1. The pelvis has a complex anatomy with a close interplay between the soft tissue structures and is an important conduit of vital structures to the legs. Moreover, it is the lower border of the abdomen and, therefore, lesions of the pelvis can have an important impact on abdominal structures also. Even the simplest of fractures can have an impact on the closely related organs, e.g., as pubic rami fractures can puncture the bladder, up to the enormity of a traumatic hemipelvectomy with the devastation of virtually every organ in or around the pelvic rim. These are the more or less obscure lesions that should be sought for or excluded in case of a pelvic fracture and addressed adequately. In this article, we deal with every organ or structure on its own and present a comprehensive treatment algorithm for the more complex lesions. 1
Epidemiology Hauschild et al. [1] evaluated the German pelvic trauma database and found in 4,291 registered pelvic fractures, 386 cases with considerable soft tissue injuries. In 36% of these cases, a lesion of the bladder and in 18.9% lesions of the urethra were found. Retroperitoneal hematoma and peri pelvic vessels were severed in 38.6 and 13.7%, respectively. Nerve lesions (sacral plexus) were seen in 18.4 unilateral and 4.9% bilateral fashion. Enteric lesions were found in 11.9% of cases, and a similar figure was seen for skin lesions like the Morel–Lavalle´ injury (see further). From the same database, the authors found that the prognosis of these complex lesions has not changed over the years (21–22% mortality rate). This is in contrast to the noncomplex fractures that showed a reduction of mortality from 6.5 to 3.6%. Moreover, they concluded that the complex pelvic trauma independently demonstrated the highest risk of death in the pelvic fracture group.
Individual Lesions Vascular Damage Pelvic fractures can lead to extensive blood loss. The origin can be the fracture sites, the presacral or prevesical venous plexus, or it can be of arterial nature. Notorious is the retroperitoneal hematoma, which can hold up to 6 l [2]. The risk for extensive blood loss is highest in roll-over trauma and open pelvic fractures [3]. The C-type fractures have the highest risk. Initial treatment is the compression on the fracture sites and tamponade of the intrapelvic bleeding. This can be accomplished with a pelvic binder or a C-clamp [4]. In case insufficient hemodynamic stabilization is achieved, intrapelvic tamponade through a small suprapubic incision can be achieved. Lesions of the larger arteries require surgical intervention; however, currently, angio-embolization can help to control arterial bleeding in a less invasive way [5].
Department of Surgery, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands.
Received: February 16, 2010; revision accepted: March 8, 2010; Published Online: March 31, 2010
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Table 1. Soft tissue structures at risk with a pelvic fracture. Anorectum Bladder Vagina Urethra Nerves/plexus Venous plexus Arterial supply Abdominal wall
Bladder Injury The most common soft tissue lesions accompanying a pelvic fracture is a bladder lesion. As mentioned earlier, Hausschilld et al. [1] found in 36% of cases with soft tissue injuries a bladder rupture. The mechanism can be twofold: as part of a compression injury, from which the fractured pelvic rami are compressed into the bladder and produce a puncture or tearing injury. In C fractures, however, gross tears can occur and, in these lesions, often arise with intraperitoneal bladder injuries. Clinical signs of a bladder rupture can be gross hematuria or inability to void [6]. Both an intraperitoneal and an extraperitoneal rupture can be discerned. The diagnosis is made with a retrograde urethrovesicogram, in which the bladder is filled retrogradely through the urethra [7, 8]. A protocol should be in placed in every Emergency Department. A simple plain pelvic X-ray after filling of the bladder can suffice. The pattern of intraperitoneal and extraperitoneal lesions are different. A second method for diagnosis is through computed tomography (CT) scanning. If the patient received intravenous contrast, resulting in bladder filling, a lesion of the bladder is often obvious from the resulting contrast leakage. A bladder contrast study, however, has a higher diagnostic yield than CT scanning (95.6 vs. 60.6%) [9]. During exploration or in case of a pelvic packing, however, a bladder rupture can be obviated. Making a small incision over the pelvic rim anteriorly looking into the cavum Rezzi might reveal a bladder rupture, as demonstrated in figure 1. Treatment of the bladder lesion depends on the sort of injury. For intraperitoneal lesions, it is obvious that exploration and direct repair should be performed. Care should be taken regarding the vesical triangle with the entrance of the ureters. Also, the bladder neck should be dealt with using special emphasis, as incontinence can result because of inadequate treatment. This part of the bladder should be seen similarly as the urethra (see below). Other parts of the bladder can be
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Figures 1a and 1b. a) Bladder contrast study with signs of bladder injury. b) Bladder rupture found during exploration for pelvic packing.
simply sewn over [7]. Drainage of the bladder should be dealt with. Transurethral drainage goes inevitably with strictures; however, a supra pubic catheter can interfere with the osteosynthesis, possibly done on the anterior side, and is related to a high number of infectious complications [10]. The author favors suprapubic drainage, notwithstanding the high chance of infectious problems, for patient comfort and the possibility of training the bladder after a certain amount of time, when passing urine via the natural method becomes a possibility. Extraperitoneal injuries of the bladder can be dealt with nonoperatively [7]. Adequate drainage, mostly transurethral, suffices. In selected cases, a suprapubic catheter can be used, however, mostly as a result of an
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Figures 2a and 2b. a) Ecchymosis of scrotum and perineum, signifying possible injury to the urethra. b) Retrograde Urethrogram showing lesion of urethra.
open exploration. A drainage period of 6 weeks is recommended, after which a follow-up cystogram should be obtained. In general, the prognosis for bladder injury is good [9]. Urethral Injury The urethra is most at risk in men; however, urethral lesions in pelvic fractures are also described in women [11]. Because of the close proximity and the tight connection of the urethra with the pelvis in every pelvic fracture, a urethral lesion should be suspected. Secondary signs such as blood on the external meatus, however, also ecchymosis in the perineal region (Figure 2a), as well as a high-riding prostate at digital rectal examination are classic signs of a possible urethral injury and should be followed by a contrast urethrogram (Figure 2b). The digital rectal examination is associated with a very low diagnostic yield [12] and additional evaluation should be done. The urethral injury is highly associated with pubic arch fractures [13, 14]. The highest incidence of urethral injuries, 24 times more than in other pelvic fractures, is found in straddle injuries, with diastasis of the sacroiliac joint [14]. This is followed by straddle fractures without sacroiliac distention and Malgaigne’s fracture. Andrich and Mundy [15] evaluated prospectively the nature of urethral injury and concluded that,
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in contrast to earlier observations, part of the urethral sphincter capacity was preserved in a significant number of patients. The treatment of urethral injury is controversial [16–18]. A first single diligent attempt of passing a urethral catheter is generally allowed in experienced hands. If this is not successful, two options remain. This first possibility is to go for an immediate repair; however, the price to be paid is impotence in a high number of cases. The second and currently more popular method is to drain the bladder suprapubically for several months, leaving the lesion alone for a considerable period of time, whereafter secondary reconstruction is considered. The advantage is a lower number of patients suffering from impotence; however, invariably experiencing a urethral stricture and considerable difficulty in reconstructing the anatomical conduit. The origin of impotence, however, is currently thought to be of vascular instead of neurological in nature [16]. Currently, early alignment of the urethra seems to be advantageous [16]. Urethral injury in women can result also in significant sequelae in later years, such as fistulae and sexual and lower urinary tract dysfunction [11]. Anorectal Injury Anorectal injury should be suspected in every pelvic injury, especially with straddle injuries, e.g., in patients who have experienced motorcycle accidents and are
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straddled on the fuel tank. This mechanism separates both iliac pelvic bones and widely tears the pelvic floor open. More subtly, the lesion can be found with compression injuries. Diagnosis can be obvious, with gross bleeding from the anus, signifying a lesion internally; however, diagnosis can also be delayed in more subtle lesions. Formerly, the treatment of the anorectal lesions was rather straightforward with invariably a diversion colostomy to divert the fecal stream [19]. Nowadays, the treatment is more specific, depending on the initial lesion [20–22]. The tendency, however, with severe accompanying injuries and gross contamination, as well as extensive perineal wounds, is to divert the fecal stream [20, 23]. In other cases, direct repair or resection of the injured segment and direct anastomosis is an option [20]. A recent systematic review evaluated the available evidence, but it could not reach a conclusion on the use of a colostomy to prevent pelvic sepsis in open pelvic fractures [24]. Nerve Injury The sequelae of nerve injury accompanying pelvic fractures are manifold. The late results of these lesions will be dealt with in another contribution to this issue. This leaves to say that, mainly in the grossly displaced fractures, the nervous plexus (mostly), the sciatic (seldom), and the femoral nerve injuries have to be expected and ruled out. In most cases, the L4 to S2 segments are involved. Moreover, sacral fractures occur frequently with nerve lesions (40% of cases), as fractures or dislocations involving the sacroIliac joint (57% of cases) [1]. Inability to move the leg when the patient is conscious targets the nerve injury, as does loss of sphincter tone. Especially, the perineal nerve as part of the sciatic injury is at risk and has a poor prognosis [25]. The final result, however, should not be concluded before 2 years after the injury, as in 53% of cases, remission can occur [1]. Morel–Lavallé The Morel–Lavalle´ injury is the severe deglovement of the skin and subcutaneous tissue mostly associated with a roll-over trauma, severely complicating pelvic fractures. These lesions are not easy to treat, as huge wound surfaces with subcutaneous bleeding and, at a later stage, seroma formation complicate an uneventful course. Treatment with vacuum-assisted closure [26] has been advocated, and percutaneous management has also been suggested with good results [27].
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Treatment Protocol of Complex Unstable Open Pelvic Ring Trauma In Table 2, the stepwise approach for the treatment of the complex pelvic trauma is outlined. It is modified from the original protocol published in 1993 [19]. The stepwise approach is depicted in Figure 3. Currently. stability can be obtained, already pre-hospital, depending on the fracture type, with a simple pelvic binder [28, 29]. Disadvantages of this method are the practically unapproachable abdomen and the high pressures obtained under the binder. In the Emergency Department, a C-clamp can be put onto the bony pelvis in order to compress the iliac wings to the sacral bone (Figure 3b). If bleeding persists, packing through an anterior small suprapubic approach can be performed, now with a stable pelvis. In the open pelvis, further evaluation of the injuries can then be done (Figure 3c) and also further contamination control. In case of further hemodynamic instability, an angiographic evaluation should be performed [30] (Figures 3d and 3e). The next step is to debride and wash out the wounds. In case of severe contamination by the fecal stream, a colostomy should be contemplated (Figure 4). After these damage control procedures, reevaluation should take place. Other injuries have to be addressed as well. Thereafter, the patient is transported to the intensive care unit for further resuscitation. In our opinion, early internal fixation of these problematic cases is warranted [19], because optimal stabilization of the fractures can be achieved. Open wounds can be treated with vacuum-assisted closure therapy [26] and repeated debridement. A planned second-look operation until the wounds are consolidated should be considered. Late Results The German polytrauma and pelvis research group evaluated the results of pelvic trauma [1], and another
Table 2. Treatment of complex pelvic trauma. Control the bleeding Obtain stability Packing Lavage/debridement Packing/embolization Control of contamination Colostomy? Bladder repair Suprapubic catheter
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Figures 3a to 3e. a) Highly unstable pelvic fracture after motor cycle crash. b) Initial mechanical stabilization with a C-clamp. c) Severe open pelvic fracture with wounds of the perineal region. d) Arteriogram showing arterial contrast leakage. e) Situation after angio embolization. Patient hemodynamically stable.
German group evaluated chronic pain and disability after pelvic fractures [31]. They invariably conclude that severe open pelvic injuries are associated with a high mortality and morbidity. Siegmeth et al. [32]
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evaluated the late results of associated injuries of severe pelvic trauma and showed that 53.4% of the type B fractures had a good and 47.6% a poor clinical outcome. The C-type fractures were far worse how-
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Conflict of interest statement The author declares that there is no actual or potential conflict of interest in relation to this article.
References 1.
Figures 4a and 4b. a) Patient with a severe open pelvic fracture with anorectal involvement b) Secondary surgery. Packing of the pelvis and abdomen, open abdomen, suprapubic catheter, colostomy to divert fecal stream and external fixator for initial stabilization.
ever, and showed only 15.4% a good outcome and up to 84.6% a poor outcome.
Conclusion Severe open injuries of the pelvis are associated with high complication, morbidity, and mortality rates. A stepwise approach is the way to achieve reasonable results; however, the final clinical outcome is, in a large number of cases, suboptimal.
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Address for Correspondence Luke P.H. Leenen, MD, PhD, FACS Department of Surgery UMC Utrecht Heidelberglaan 100 3584 CX, Utrecht The Netherlands Phone (+31/30) 2508075 Fax -2541344 e-mail:
[email protected]
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