Injury of pelvis and extremities

Pelvic injuries due to anatomical structural features are a big problem. In the elderly, the most frequent cause of pelvic damage is a drop from the height of its own growth.

The most significant fractures occur with more severe effects, such as car accidents or a fall from a high altitude. In this case, the nature of injuries can be combined, and injuries are severe (ISS> 16 points). In isolated form, prevalence is low. Indications for hospitalization in the intensive care unit can be trauma, accompanied by violations of vital functions - disorders of hemodynamics, shock.

ICD-10 code

• S30 Superficial injury of abdomen, lower back and pelvis
• S31 Open wound of abdomen, lower back and pelvis
• S32 Fracture of the lumbosacral spine and pelvic bones
• S33 Dislocation, sprain and damage to the capsular-ligament apparatus of the lumbar spine and pelvis
• S34 Trauma of nerves and lumbar spinal cord at the level of the abdomen, lower back and pelvis
• S35 Injury of blood vessels at abdominal, lower back and pelvis level
• S36 Trauma of abdominal organs
• S37 Pelvic injuries
• S38 Crushing injury and traumatic amputation of part of abdomen, lower back and pelvis
• S39 Other and unspecified injuries of abdomen, lower back and pelvis

Epidemiology of pelvic injuries

In peacetime, the main cause of injuries, especially those associated with high mortality, is considered an accident. According to official statistics, in Russia in 2006, as a result of an accident, 32,621 people were killed. This indicator increased by 4% in comparison with 2005. Among all types of accidents, pedestrian attacks predominate, especially in large settlements.

[1], [2], [3]

Structure of severe injuries of limbs and pelvis

• Accident, driver, passengers (50-60%),
• injury from falling from a motorcycle (10-20%),
• Accident at the impact on the pedestrian (10-20%),
• fall from the height (katatrava) (8-10%),
• compression (3-6%).

According to the American colleagues, the frequency of limb injuries does not exceed 3%. It is necessary to distinguish between fractures (fractures) of limbs and the pelvis. With pelvic injuries (according to literature sources) the mortality rate is 13-23%. The main cause of the onset of an unfavorable outcome is massive hemorrhage. In the structure of mortality in a later period, the development of complications is considered important. According to international data, there is no gender difference.

Reasons for hospitalization in the ICU

E To the most frequent complications in the fracture of the pelvic bones are the injuries of the pelvic organs and, as a consequence, the development of bleeding. In addition, fractures of the pelvic bones significantly increase the incidence of embolic complications, which is also observed in fractures of tubular bones.

High lethality (approximately 10% in adults and about 5% in children). Bleeding is the immediate cause of death of at least half of those affected with fractures of the pelvic bones. Retroperitoneal hemorrhage and secondary infectious complications are the main predictors of death in children and adults with this type of trauma.

With arterial hypotension at the prehospital stage with fractures of the pelvic bones, mortality can reach 50%.

According to statistical data, with an open fracture of the limbs, an increase in the lethality to 30% is noted.

Causes of pelvic injury

In connection with the anatomical features for the onset of pelvic trauma, it is necessary to exert great kinetic energy. It should be noted that the greater the impact force, the more often injuries of the pelvic bones are accompanied by damage to the pelvic organs (bladder, damage to the scrotum organs, in women - the uterus, ovaries).

Children have the most common causes of injury in road accidents - driving a car on a pedestrian (60-80%) and damage while in the car (20-30%).

[4], [5], [6]

Classification of pelvic injuries

Fracture of pelvic bones

• Edge fracture - fractures of the aorta of the iliac bones, ischiatic tubercles, coccyx, transverse fracture of the sacrum below the sacroiliac joint, ilium
• Fracture of pelvic ring without disruption of its continuity
• Single or bilateral fracture of the same pubic bone branch
• Single or bilateral fracture of the ischium bones
• Fracture of one branch of pubic bone on one side and sciatic bone - on the other
• Damage to the discontinuity of the pelvic ring
• Vertical fracture of the sacrum or fracture of the lateral mass of the sacrum
• Rupture of the sacroiliac joint
• Vertical fracture of the ilium
• Fracture of both branches of the pubic bone from one or both sides
• Fracture of pubic and ischium bone from one or both sides (a butterfly-like fracture)
• Symphysis rupture
• Damage with simultaneous disruption of the continuity of the front and rear semirings (Malgen type)
• Two-sided fracture of the Malgens type - the front and rear half rings are damaged on both sides
• One-sided or vertical fracture of the Malgens type - a fracture of the anterior and posterior half-rings on one side
• The oblique, or diagonal, Malgens-type fracture is a fracture of the front half-ring on one side and the rear half on the other
• Rupture of the sacroiliac joint and symphysis
• The combination of a symphysis rupture with a fracture of the posterior half-ring or a combination of a rupture of the sacroiliac joint with a fracture of the anterior pelvic half of the pelvis
• Fracture of the acetabulum
• Fracture of acetabular margin, may be accompanied by posterior upper hip dislocation
• Fracture of the bottom of the acetabulum can be accompanied by a central dislocation of the femur - displacement of its head inward towards the pelvic cavity
• When the tubular bones are damaged, open and closed fractures are distinguished, with displacement and without displacement

[7], [8], [9], [10]

Complications of skeletal trauma and fractures of pelvic bones

• Hemorrhagic and traumatic shock.
• Fat embolism.
• Sepsis.
• Pulmonary embolism.
• Compartment syndrome of the extremities.
• Stress-ulcers of the gastrointestinal tract.
• Diagnosis and prevention of complications.
• Hemorrhagic shock.

Shock is the adaptive response of the body to trauma. It should be borne in mind that hypotension in case of blood loss is considered a predictor of the onset of an unfavorable outcome. In addition to this recommend:

• injured with violation of the integrity of the pelvic ring with hemorrhagic shock - fixation and stabilization of pelvic fractures,
• victims without disruption of the integrity of the pelvic ring with unstable hemodynamics - early angiographic embolization or surgery.

[11], [12], [13]

Fat embolism

The frequency of development is unknown (diagnosis can be difficult on the background of the clinical picture of the underlying disease). Mortality is 10-20% and increases with concomitant severe pathology, a decrease in functional reserves and in the elderly affected.

[14], [15], [16], [17], [18]

Anamnesis

• Injury of long tubular bones or pelvis, including orthopedic interventions.
• Parenteral administration of lipids.
• Prior administration of glucocorticoids.

[19]

Physical examination

• The cardiovascular system is a sudden and constant tachycardia.
• The appearance of tachypnea, dyspnoea, progression of hypoxemia in the background of mechanical ventilation after 12-72 hours.
• The appearance of fever with hectic temperature rises.
• A generalized petechial rash, especially pronounced in the armpits in 25-50% of cases.
• Increasing encephalopathy.
• Hemorrhages on the retina (with fatty inclusions) - when examining the fundus.

Differential diagnostics

• PE.
• Thrombocytopenic purpura.

[20], [21], [22]

Laboratory research

• Gas composition of blood (pay attention to the increase in the fraction of dead space).
• Hematocrit, platelets and fibrinogen (thrombocytopenia, anemia and hyperfibrinogenemia).
• Urine detection of fatty inclusions (often seen in the injured after an injury).

Instrumental data

• On the control radiographs, bilateral infiltrates are observed, occurring 24-48 hours after the development of the clinical picture.
• CT of the lungs.
• MRI is insensitive for the diagnosis of fat embolism syndrome, but it can detect subsegmental defects in lung tissue.
• With transcranial Doppler, the symptoms of embolism are detected only 4 days after the appearance of a pronounced clinic.
• Echocardiography is of diagnostic value with a functioning oval window in adult patients.

Treatment

Providing adequate oxygen transport, ventilation, ARDS treatment, stabilization of hemodynamics, adequate vollemic status, prevention of deep vein thrombosis, stress ulcers, nutritional status, cerebral edema.

Timely carrying out of an operative intervention on stabilization of a fracture (see the protocol of surgical treatment).

Pharmacological therapy from specific treatment, except for the use of anticoagulants, proved the effectiveness of the use of methylprednisolone (in studies, the duration and dose are not determined).

Thrombosis of deep veins and PE

Since any prophylaxis of deep vein thrombosis and PE is associated with side effects of the drugs used, a group of patients is isolated, for which the risk of using therapy will be lower than the risk of developing thromboembolic complications. There are no unambiguous recommendations in this regard in the literary sources. For clinical use, the following systematized review of the EAST Practice Parameter Workgroup for DVT Prophylaxis is offered.

Risk

Category of evidence A

• the older age group is a risk factor (it is not specified at what exact age the risk increases substantially),
• an increase in ISS and hemotransfusion therapy are risk factors in some studies, but meta-analysis does not show an increase in risk as a major factor,
• fractures of tubular bones, pelvic bones, and CCI in studies show a high incidence of deep vein thrombosis and thromboembolic complications.

Use of low doses of heparin for the prevention of DVT / PE

Category of evidence B

• there is evidence that heparin in a small dose is considered a preventive agent at high risk.

Category of evidence C

• those who are at risk of rebleeding or hemorrhaging are considered to be decisive, the use of heparin (even in low doses) is not recommended. Prevention of PE is decided individually taking into account the risk.

Use of tight bandaging of the lower limbs for the prevention of DVT / PE

Category of evidence B

• There is insufficient evidence to suggest that tight bandaging reduces the risk of PE in combination with trauma

Category of evidence C

• in the category of victims with spine trauma, isolated studies show their effectiveness,
• for those affected, whose lower extremities can not be fixed by bandaging, the use of a muscular pump can somewhat reduce the risk of PE.

The use of low molecular weight heparins for the prevention of DVT / PE

Category of evidence B

• low molecular weight heparins are used for the prophylaxis of DVT in patients with the following pelvic fracture traumas, which require surgical fixation or prolonged bed rest (> 5 days), complex fractures of the lower limb (open or multiple in one limb), requiring an operative fixation or prolonged bed rest mode (> 5 days), spinal cord injury with complete or incomplete motor paralysis.

Category of evidence C

• victims with polytrauma receiving anticoagulant and antiplatelet therapy should (for prevention of PE) receive low molecular weight heparins,
• the possibility of using low-molecular heparins or anticoagulants for oral administration is considered a few weeks after injury in patients with high risk of DVT (elderly patients with pelvic injuries, spinal cord injuries, prolonged bed rest (> 5 days), and patients with long hospitalization or planned long term recovery function),
• low molecular weight heparins have not been adequately studied in the case of intracerebral hemorrhage with intracerebral hemorrhage. They are not recommended for use when installing or removing an epidural catheter.

The role of cava filters for the treatment and prevention of PE

Category of evidence A

• traditional indications for the installation of a cava filter the presence of PE despite the full anticoagulant therapy, a high risk of developing DVT and contraindications for anticoagulant therapy, the likelihood of DVT and massive bleeding, despite the therapy, an increase in the thrombus mass (s) in the ileo-femoral vein, despite to moderate hypocoagulation.

Category of evidence B

• Extended indications for the installation of a cava filter in patients with DVT or PE is a large flotation thrombus in the iliac vein, after massive PE, the subsequent embolus may be fatal during or after surgical embobectomy.

Category of evidence C

• the installation of a cava filter in patients with a high risk of pulmonary embolism or DVT after trauma is provided under the following circumstances
• The impossibility of conducting anticoagulant therapy with a high risk of bleeding,
• with a positive one or more responses in the following paragraphs,
• severe closed craniocerebral trauma (Glasgow coma score <8),
• incomplete anatomical break of the spinal cord with para- or tetraplegia,
• complex pelvic fractures with fractures of tubular bones,
• comminuted fractures of tubular bones.

The role of ultrasound diagnosis and venography in PE and DGD

Category of evidence A

• Duplex scanning of the vessels of the extremities is prescribed to patients with trauma without the use of venography.

Category of evidence B

• indications for venography - a dubious result in the Doppler study.

Category of evidence C

• dopplerography is performed with all injuries of limbs with suspected thrombosis,
• repeated dopplerographic studies are necessary for the detection of deep vein thrombosis in patients with asymptomatic clinical picture This method in dynamics has less sensitivity compared to venography,
• magnetic resonance venography for thrombosis of the iliac vessels in the pelvic examination, where the sensitivity of Doppler ultrasound is even lower.

Compartmental syndrome of conical

The limbity syndrome (KSC) is not considered to be the immediate cause of death in injured persons with limb injuries. It must be diagnosed as early as possible, without waiting for the development of necrosis. This significantly reduces the risk of complications, allows you to maintain the limb, avoiding amputation, reduces disability.

The reason for the formation of compartmental syndrome is the increase in pressure in the myofascicular spaces of the extremities. The immediate cause of increased pressure is the edema of the elements of the myofascicular spaces, mainly the muscle mass. In the etiological structure of this syndrome, the following conditions are noted for electric trauma, the use of anti-shock suits, crash syndrome, certain types of regional anesthesia, arthroscopy, severe deep vein thrombosis, etc. Cases of KSK as a result of iatrogenic causes are described. Diagnosis is based on the identification of risk factors. In the clinical picture, the pain syndrome, the severity of which increases over time, despite the adequate analgesia, the appearance of hyperesthesia, weakness or hypertension from the affected limb.

Pain is worse with passive muscle movement. Observe hyperesthesia when involved in the pathological process of nerve plexuses. It should be noted that with such a symptomatology, the diagnosis is difficult in patients with sedation. In such cases, an objective examination of the palpation of the pulse on the distal artery, the pallor of the skin, helps. From the instrumental methods of diagnosis, research aimed at studying nerve conduction, MRI is used. Other diagnostic methods have controversial data (sensitivity, specificity). From laboratory methods, tests for creatinine kinase, myoglobin, are used, which increase in the late stage.

Treatment

Decompression is the main factor that affects the functional result. Irreversible damage to the nerves and muscles occurs in 6-12 hours. Only 31% of patients who undergo fasciotomy within 12 hours after the onset of CCC have residual neuromuscular deficiency. Conversely, 91% of patients with CSF operated in more than 12 hours have a residual neurological deficit, and 20% of patients need amputation. Out of 125 fasciotomies with CSC, amputation was performed in 75% of cases due to delayed fasciotomy, incomplete or inadequate fascial decompression.

Of additional methods of therapy after the fasciotomy, HBO is recommended as a method aimed at rescuing muscle cells and nerve trunks (level of evidence E).

Complications of KSK neuropathy of various degrees as a result of ischemia, muscle necrosis, fibrosis, contractures, rhabdomyolysis and, as a consequence, the development of arthritis, which in this situation significantly worsens the prognosis.

[23], [24], [25], [26]

Prevention of stress ulcers

It should be noted that the prolonged infusion of H2-receptor blockers of histamine is more effective than bolus injections.

Diagnosis of pelvic and limb injuries

In most cases, with an isolated character of the lesion, the diagnosis is unquestionable even in a clinical examination. Diagnosis of complications is mandatory, especially with indications for transfer to the intensive care unit, because symptoms of life-threatening conditions predominate in the clinical picture, and in this connection it is performed with the initiation of intensive therapy.

Fractures of tubular bones are not difficult to diagnose. However, vigilance and timely therapy are necessary in the development of complications.

[27], [28], [29]

Examination

The primary purpose of a primary examination is to immediately find life-threatening conditions. The exclusion factor is the instability of hemodynamics, which requires intensive therapy, since the development of hypotension in pelvic injuries leads to high lethality.

In anamnesis, they study the presence of allergies, previous surgical interventions, chronic pathology, the time of the last meal, and the circumstances of the trauma.

Later on they study:

• the anatomical location of the wound and the type of wounding projectile, the time of the impact (additional data on the trajectory, the position of the body) with gunshot lesions of the limbs,
• The distance from which the injury was received (height at fall, etc.). With gunshot lesions, it must be remembered that when a close shot is transmitted a greater amount of kinetic energy,
• prehospital assessment of the magnitude of blood loss (as accurately as possible),
• the initial level of consciousness (assessed on the Glasgow coma scale). When transporting from the prehospital stage, it is necessary to determine the amount of care and reaction of the victim to the therapy.

[30], [31], [32], [33]

Additional continuous monitoring

• Level of blood pressure, heart rate in dynamics
• Body temperature, rectal temperature
• Saturation of hemoglobin with oxygen
• Assessment of the level of consciousness with a combination of damage

[34], [35], [36]

Additional diagnostics

• Radiography of the chest and abdominal cavity (if possible standing)
• Ultrasound of the abdominal cavity and pelvic cavity
• Gases of arterial blood
• Lactate content in blood plasma, deficiency of bases and anionic difference as indices of tissue hypoperfusion. The use of esophageal dopplerography as an instrumental non-invasive indicator of the vollemic status
• Coagulogram (APTTV, PTI)
• The content of glucose in blood plasma, creatinine, residual nitrogen, calcium and magnesium - in the blood serum
• Determination of blood type
• Women in the unconscious state determine a pregnancy test

[37], [38], [39]

Detailed inspection

It must be remembered that it is possible that a detailed examination and a complete laboratory test are carried out together with intensive therapy.

[40], [41], [42], [43], [44]

Physical examination

When examining the local status, attention is paid to pathological mobility, while the study should be careful and excludes further damage.

X-ray studies

Survey radiography. Be sure to perform chest radiography. It is carried out and with the development of complications (pneumonia, PE, fat embolism).

Radiography of the damaged segments of the upper and lower extremity belt and pelvis with its damage. The use of this method requires knowledge of radiological methods for certain types of fractures. This requires the involvement of qualified personnel from the departments of radiation diagnostic methods.

Radiocontrast studies of the urinary tract. Urethrorrhagia, abnormal position of the prostate or its mobility in digital rectal examination, hematuria - signs of damage to the urinary tract or genitals. Urethrography is performed to diagnose damage to the urethra. The intraperitoneal and extraperitoneal rupture of the bladder can be detected with the help of cystography, the radiopaque substance is injected through the Foley catheter. Renal damage and retroperitoneal hematomas are diagnosed with CT scans of the abdomen, which is performed for each patient with hematuria and stable hemodynamics.

CT is performed in cases of damage to the pelvic organs and for the exclusion of retroperitoneal hematomas. For radiodiagnosis of fractures of bones, it is sufficient to perform radiography of the limbs.

Angiography is prescribed when ultrasound does not show signs of continued bleeding. In addition, when performing this study, it is possible to embolize the vessel to stop bleeding.

Indications for consultation of other specialists

For successful therapeutic and diagnostic tactics, the joint work of the teams of resuscitation, thoracic and abdominal surgery departments, as well as diagnostic units (ultrasound, CT, angiosurgery, endoscopic surgeries) is necessary. With any suspicions of an urethra injury, urologist consultation is necessary.

Better assistance to the victim will be in a highly specialized medical institution. If the territorial principle is not observed, the forecast is deteriorating, especially in unstable victims.

Treatment of pelvic and limb injuries

With all pelvic injuries and fractures of the tubular bones, hospitalization is necessary because of the development of possible complications. Indications for being in the ICU are violations of vital functions.

Medication

The main components of therapy for victims with fractures of tubular bones, damage to the pelvis.

Analgesics

Perform adequate analgesia, applying regional methods of anesthesia. Victims with a skeletal trauma need more pain relief than patients after orthopedic surgery. In this regard, in the acute period, the most effective use of intravenous opioids. To control effectiveness, it is recommended to use dynamic scales for subjective pain assessment.

[45], [46], [47]

Antibacterial drugs

Antibiotic therapy is prescribed to all those affected with fractures of pelvic bones and tubular bones, as well as fractures that are accompanied by a violation of the integrity of the skin (open fractures), as patients with such fractures are at high risk of developing septic complications.

Given the different frequency of their development, such victims are divided into three types:

• Type I Fractures of bones with a breach of skin integrity not more than 1 cm deep. The cutaneous wound is clean.
• Type II Open fractures with lesion of the skin more than 1 cm, not accompanied by crushing soft tissues.
• Type III Double open fractures, or fractures with traumatic amputation, as well as massive destruction of the muscle mass.
  • III A - soft tissues are not detached from the bone fragment, soft to the touch and not tense.
  • III B - exfoliation of soft tissues from the periosteum and their contamination.
  • III C - soft tissue disorders associated with impaired arterial blood flow.

Indications for antibiotic therapy:

• antibacterial preparations for preventive purposes are administered as soon as possible after trauma and / or intraoperatively (spectrum - Gram-positive microorganisms). When the wound is contaminated with soil, anti-clostridial preparations are prescribed.
• for type I and type II, antibiotics can be canceled 12 hours after the injury. In type III antibiotic therapy is continued for at least 72 hours, provided that it begins no later than 24 hours after the injury.
• immunoprophylaxis. In addition to using serums with open wounds, polyvalent immunoglobulins are recommended to improve long-term treatment outcomes.

Other groups of drugs are used for symptomatic therapy. It should be noted that many of the drugs traditionally used have not proven to be effective in research.

[48], [49], [50], [51], [52], [53], [54], [55], [56]

Anesthetics

The volume of the anesthetic aid depends on the patient's clinical condition and is performed according to all the rules of anesthesiology. At fractures of extremities ideal, in the absence of contraindications, consider the application of regional methods of anesthesia. In case of injuries to the upper extremity belt, it is also possible to install a catheter for prolonged analgesia. When an anesthetic aid is provided to victims with unstable fractures of the pelvis, it is necessary to provide fixation of the pelvis prior to the administration of muscle relaxants, since protective muscle tone can be the only mechanism that restrains the divergence of bone structures.

[57]

Surgical treatment of pelvic injuries

The volume of surgical intervention and the way of fixing the fracture is determined by orthopedists-traumatologists. It should be borne in mind that early fixation of the fracture reduces the risk of complications.

Timely fixing allows you to reduce the bed-day, the cost of treatment and reduces the likelihood of developing infectious complications.

Forecast of pelvic and limb injuries

According to the world data, the level of scores on the TRISS scale is considered as prognostic. To assess the severity of the damage, the ISS scale is used. Severe is considered to be a trauma, which by the number of points> 16 with the stratification of the victim.

[58], [59]