FORMATION OF TACTICS OF TREATMENT OF PATIENTS WITH PELVIC INJURIES Milyukov A.Y.
BACKGROUND
Locomotorium injuries are among the most severe injuries, because of high lethality (20-80 %), disability (50-90 %) and complications. The data from the world-wide literature gives evidence of increase in the total amount of pelvic injuries (10-22 %) compared to the total amount of trauma patients. Compared to the other skeletal fractures this rate is up to 20 % [1, 3, 7, 9, 17]. Severe pelvic injuries are accompanied by shock and massive intratissual bleeding. It is associated with the specific features, with necessity of special tactics of management. Up to the present time in the specialized literature we have not seen any information about formation of management tactics for patients with pelvic injuries, with consideration of relation between severity of general state, severity of injury and required volume of injury restoration [6, 8, 10, 11]. There are a lot of controversial moments in X-ray visualization of pelvic injuries. Such injuries are not compatible with special positions, because body rotations in patients with severe pelvic trauma are not allowed. Therefore, in many clinics the standard examination includes different multi-view pelvic radiographs, and diagnostics of injuries to the posterior semi-ring is performed according to indirect signs. Rarely CT diagnostics is used, but in the following days [6, 16, 18].
One of the most wide-spread techniques of treatment is conservative one. It has such limitations as absence of rigid fixation, difficulty of reposition, long period of bed rest, decreased mobility of patient and associated complications: thrombophlebitis, pneumonia, bed sores and hypotrophy. Although surgical methods of treatment allow precise reducing of bone fragments and faster beginning of patient activization, their use for severe ill patients in traumatic disease period is limited with injury possibility and danger of severe complications [2, 4, 14]. Large percent of unsatisfactory outcomes (20-100 %) is indicative of irrational use of surgical and conservative methods of treatment in acute and early periods of traumatic disease [5, 12, 13, 15].
Considering above mentioned facts it is clear that formation of tactics of treatment of patients with pelvic injuries requires development of model of specialized medical aid.
Objective – to develop, to give scientific credence and to perform clinical implementation of specialized medical aid model for patients with isolated, multiple and concomitant pelvic injuries based on the medical diagnostic algorithms and innovative methods oriented to improvement of outcomes of treatment.
MATERIALS, METHODS AND STUDY DESIGN
The study includes ten year period from 2000 till 2010. 690 patients were treated under our supervision. They were evaluated prospectively and were included into the main group. The control group included 792 patients who were treated in the leading multi-profile facilities of the region. They were included into retro- and prospective analysis (Fig. 1).
Figure 1
Study design
The mean age of the patients of the main group was 38.5 ± 12.59, in the control one – 36.9 ± 13.1 (M ± σ). The main proportion of the patients is men. The main group included 503 men (72.8 %) and 187 women (27.2 %), the control group – 609 (76.8 %) and 183 (23.2 %). The distribution of the patients according to the criteria for injured pelvic segments is shown in the table.
Table
Distribution of patients into groups
|
Pelvic segments |
Main group |
Control group | ||
|
n |
% |
n |
% | |
|
pelvic ring |
421 |
61 |
470 |
59.4 |
|
acetabulum |
169 |
24.5 |
230 |
29 |
|
combination of both segments |
100 |
14.5 |
92 |
11.6 |
|
Total: |
690 |
100 |
792 |
100 |
Note: total chi-square = 5.359, df = 2, p = 0.068.
RESULTS AND DISCUSSION
Considering the fact that pelvic fracture appears during impact of significant differently directed external force, it is difficult to predict the types of combinations in such patients. And taking into account impossibility of two equal injuries, like two equal men, then their volume of injuries is different. Therefore, diagnostic and curative measures for each patient will be individual both for time and volume of restoration. These are the key factors for definition of management tactics. In this regard we formulated and introduced the integral term: injured structures restoration volume (ISRV). This is a possibility of realization of diagnostic and curative measures oriented to restoration of anatomic integrity and functioning of a segment with consideration of evaluation of severity of injury and severity of general state of patient. Formation of a segment depends on injury severity and general state of patient.
Injury severity evaluation consists of assessment of injury severity according to ISS (Injury Severity Score, Baker et al., 1974) and results of X-ray diagnostics. Severity of patient’s general state was evaluated with APACHE III (Acute Physiology And Chronic Health Evaluation, W.A. Knaus, 1989). The multidisciplinary approach to treatment of pelvic injuries requires intermutual assessment of severity of an initial injury, severity of patient’s general state and necessary volume of restoration of injured structures. All three factors are in strong interrelation, with close correlations. In case of low points according to ISS the statistic significant correlation coefficient with the sum of APACHE III points was identified beginning from the third day of treatment. It is conditioned by the fact that ISRV in these patients was performed early, as general state of patients allowed it. In case of high points of ISS the statistic significant correlation coefficient of the sum of APACHE III points is observed from the first day. Over time the sum of APACHE III points in patients with high ISS values decreased progressively on the 5th day. At the same time it was not observed in the patients with low ISS points. The differences in dynamics of changes in points are associated with the fact that the patients with high sum of ISS and APACHE III points required more time for compensation of physiologic state.
X-ray diagnostics of pelvic injuries has its own features, because these injuries are associated with syndrome of mutual burdening, disguise of symptoms of separate injuries and inacceptability of special positions, because of inadmissibility of body and pelvic rotations. Only anterior-posterior (AP) view is sufficient for rude estimation of pelvic injuries in acute period, additional examination is required further, because many pelvic injuries remain unrecognized. With AP X-ray diagnostics of posterior pelvic ring is carried out according to indirect signs. Therefore, in many clinics the standard examination includes multi-view pelvic radiographs. Unstable fractures of pelvic ring and all acetabular injuries require detalization, which is possible with multispiral computer tomography of pelvis which allows to visualize ring shape of pelvis, state of retroperitoneal space, hip joint, as well as to compose full picture of injuries. We think that in suspicion of unstable pelvic injury the examination is performed as early as possible. It’s possible in patients with different degree of severity owing to adequate anesthesiology. The terms of examination depend not only on hemodynamics. The contradiction is ongoing bleeding. Certainly, during transportation to place of examination and during its carrying out the basic life support is provided. All placements of patient to the examination table are performed in supine position, in antishock pneumosuit or on the special transport mattress on which patients stay during examination.
We perform AP view, tomography and their combination. It is necessary to perform two-dimensional reconstruction in anterior, sagittal and horizontal planes, three-dimensional (3D) reconstruction, which creates the full picture of an injury through the dimensional visualization, summarizing technique for image processing, which allows to receive the entire image of fragments, their relation between each other and with joint space, specific 3D reconstruction (Hardware), which is able to show metal constructions without bone image shading, and MR-angiography. Spiral scanning has the following advantages compared to subsequent one:
1. Short time of examination (10-15 minutes).
2. Possibility of reconstruction of any layer from scanned volume.
3. Possibility of scanning of extensive anatomic regions during one examination.
If a number of additional injuries in the anterior ring identified by us was not so significant (additionally 6 % of injuries were identified), then this number is significant for the posterior ring (difference in 54.2 %). The amount of unrecognized injuries to the hip joint is more significant. There were 41.4 % of unrecognized injuries in the region of the acetabulum, 56.7 % of unrecognized injuries to femoral head. Capsular ligamentous injuries were not visualized in 100 % of the cases. With AP view one can only suppose, for example, in case of femur head dislocation. One can say that more than half of injuries to the pelvic ring (60.2 %) and 40-100 % of hip joint injuries are not visualized with AP view.
Considering that formation of volume of restoration of injured structures depends on degree of identified correlations between evaluation of general state severity with APACHE III and evaluation with ISS and X-ray diagnostics, we developed the algorithm of treatment of patients with pelvic injuries (Fig. 2).
Figure 2
Algorithm of treatment of patients with pelvic injuries
We distinguish three groups of patients:
1. Stable (compensated) – patients with ISS < 17, APACHE III < 62. Often such patients have no clinical signs of shock or they have shock of 1st degree. Breathing is independent. Body temperature is not less than 36.6°C.
2. Indeterminate (intermediate) – patients with ISS 17-25, APACHE III 62-93. Such patients are in shock state. They are able to shortly sustain the systolic blood pressure within 80-100 mm Hg. Tachypnea, tachycardia and body temperature not less than 35°C are observed.
3. Unstable (non-compensated) – patients with ISS > 25, APACHE III > 93. They are not able to sustain the systolic blood pressure > 90 mm Hg in heart rate < 100, central venous pressure < 5 cm H2O, diuresis < 30 ml/h, despite of adequate infusion therapy and blood transfusion during the first two hours. This category also includes patients with absence of vital signs, with body temperature not exceeding 35°C or with severe shock because of uncontrolled bleeding.
For patients with uncompensated state all necessary cardiac pulmonary resuscitation procedures and life-saving operations are performed. Any reconstructive surgery is delayed until hemodynamic stabilization is achieved. In such situations emergent hemostasis must be performed without risk of exsanguinations, with use of external fixation techniques: pelvic belt, pneumosuit “Kashtan”, direct surgical hemostasis, pelvis packing. Injured segments are preferable to leave in transportation mechanic or pneumatic splints. We performed pelvis packing in cases of laparotomy for intraabdominal bleeding, when “chimney effect” or opened injuries happened. In open fractures of pelvis hemostasis (even temporary) is quite difficult, and surgeons have little time in reserve for its realization. Therefore, in such situations use of all available means are justified.
Clinical case
The Patient Ch., age of 19 (medical history #3970\05, 17396\05). A trolley hit him to pelvis area during his work in the undermine. Diagnosis on admission: “Polytrauma, open pelvic injury, type S3: open dislocation-fracture in the sacroiliac joint and in the pubic symphysis to the right; open fracture of right iliac bone, open dislocation of the right hip joint; non-complete disruption of the right lower extremity. Extensive lacerated wound in the right half of the pelvis with injury to femoral artery, vein, sciatic and femoral nerves, soft tissue crushing. Closed injury to sacroiliac joint to the left. Closed fracture of L4-L5 transverse processes to the right. Perineal rupture with injury to the rectum and urethra. Acute blood loss. Shock of 3 degree. ISS = 57 (non-compensated general state) (Fig. 3).
Figure 3
Open pelvic injury Ñ3: A – plain AP view; B – wound appearance
A
B
In the ICU the temporary hemostasis was performed by means of clipping of vessels. Constant hemostasis was achieved by means of ligation with sutures (Fig. 4).
Figure 4
Surgery stage. Temporary stabilization of pelvis with external fixation device, wound packing
The patient had little chances of survival, unless rapid hemostasis and adequate resuscitation were not performed. Tight packing of the wound was technically achievable only after stabilization of pelvis halves with external fixation device with any minimal diastasis. Despite of significant contamination of the wound with coal dust and clothes remains, the removal of the debris and contact preparation with antiseptic solutions were not performed. The arterial pressure was stabilized at the background of continuous cardiac pulmonary resuscitation and infusion transfusion therapy. Besides, epicystostomy and colostomy were performed in the end of the first 24 hours. Wound dressing was not performed during the following days. APACHE III was 135. After 24 hours after admission the full removal of the right lower extremity at the level of disruption was carried out (right hemipelvectomy) (Fig. 5).
Figure 5
Stage of hemipelvectomy. Pelvic radiograph after surgery
During the following several weeks the patient was in the ICU. The dynamic changes in APACHE III were slow, but positive. There were no reconstructive surgeries at the stage of intensive care. After general state stabilization the patient was transferred to the traumatology unit for symptomatic therapy, staged necrectomy and autodermoplasty (Fig. 6).
Figure 6
A – one month after trauma; B – 3 months after trauma; C – 4 years after trauma
Angiography with following embolization of vessels for patients in uncompensated state is unlikely reasonable, because systolic pressure does not exceed 40-60 mm Hg, and possibility of identification of a deactivated vessel is minimal. At the stage of continuing resuscitation the minimal surgical interventions are allowed: thoracocentesis, laparoscopy, and, if needed, thoracotomy and laparotomy. Wounds are irrigated with antiseptic solutions only. Aseptic dressings and single apposition suture are applied. We do not perform amputations, replantations and osteosynthesis during this period. If course of resuscitation measures is favorable this period takes up to 20-24 hours, and staged change of pelvis pneumofixation and large segments to fixation with rod devices in stabilization mode or to C-brace is performed (Fig. 7).
Figure 7
Variants of fixation of unstable pelvis: A – C-brace; B – external fixation device; C – pneumosuit
The stage of intermediate state is characterized by improvement in all vital functions. Therefore, a possibility for extension of medical diagnostic measures appears. The whole period has the close relation between duration of planned surgeries, examination and general state. Gradually we extend use of external fixation and perform final osteosynthesis, which has an advantage in view of low invasiveness. It is not desirable to perform operations lasting more than 2-3 hours, and single-step (simultaneous) surgeries performed by two or three teams of surgeons. Any worsening in clinical state or physiologic parameters should result in rapid, repetitive evaluation and development of appropriate plan of treatment.
For patients in compensated state surgical treatment can be single-step or final, but individual in each case. In case of concomitant injury the priority in sequence was given to diagnostics of the most severe injury. In most cases pelvic injuries combined with traumatic brain injury, fractures of long bones, rib fractures, injuries to parenchymatous organs and urinary system. Conditionally we divided all concomitant injuries into 2 groups: 1st group – injuries with possibility of decompensation of general state in case of delay in treatment (injuries to all organs of chest, abdomen, kidneys, unstable pelvic injuries, extensive wounds, multiple rib fractures in combination with clavicle fracture); 2nd group – injuries without worsening of general state in case of treatment delay (fractures of segments, stable pelvis, non-complicated fractures of the spine, urethra disruption, nerve injuries, mild traumatic brain injury, thermal injury of I-II degree).
The offered tactics of specialized medical aid for patients with pelvic injuries decreased the total mortality to 5.22 %, and to 21.8 % for severe injuries. The terms of in-hospital treatment reduced to 16.83 ± 12.01 for mild injuries and to 33.99 ± 19.79 days for severe injuries to the pelvic ring, to 25.86 ± 13.96 days for acetabular fractures, and to 36.15 ± 21.16 days for combinations of these injuries. Primary disability decreased to 13.4 %.
The results of treatment of the patients with pelvic injuries with use of the assessment scales and the instrumental methods are considered as positive ones in 78.1 % of the cases with pelvic ring injury and in 71.6 % with acetabular injuries.
CONCLUSION:
1. For determination of tactics of treatment of pelvic injuries the medical diagnostic algorithms are necessary. In uncompensated general state (ISS ≥ 17, APACHE III ≥ 62) only bleeding arrest and external fixation of the pelvis are carried out. In subcompensated or compensated general state (ISS < 17, APACHE III < 62) the different techniques of surgical and conservative treatment are used depending on characteristics of pelvic injury. They are based on rational combination of methods of AP view and tomography. Multispiral computer tomography for patients with severe pelvic injury is a method of choice, because of high information capacity and brief carrying out.
2. The developed model of rendering specialized medical aid for patients with isolated, multiple and concomitant pelvic injuries is based on the maximally possible realization of volume of restoration of injuries. Formation of this volume determines severity of an injury and general state in emergent and planned order. It is appropriate to assess the severity of patient’s state using APACHE III, evaluation of injury severity – with ISS and with results of roentgen diagnostics.