Pelvic and extremity trauma

Pelvic injuries are a big problem due to the anatomical features of the structure. In older people, the most common cause of pelvic injuries is a fall from one's own height.

The most significant fractures occur with more severe impacts, such as car accidents or falls from a great height. The nature of the damage may be combined, and the injuries severe (ISS> 16 points). In isolated form, the prevalence is low. Indications for hospitalization in intensive care units may be injuries accompanied by disturbances of vital functions - hemodynamic disorders, 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 lumbosacral spine and pelvic bones
• S33 Dislocation, sprain and injury of the capsular-ligamentous apparatus of the lumbar spine and pelvis
• S34 Injury of nerves and lumbar spinal cord at abdomen, lower back and pelvis level
• S35 Injury of blood vessels at abdomen, lower back and pelvis level
• S36 Injury of abdominal organs
• S37 Injury of pelvic organs
• S38 Crushing 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 trauma

In peacetime, road accidents are still considered the main cause of injuries, especially those associated with high mortality. According to official statistics, 32,621 people died in road accidents in Russia in 2006. This figure has increased by 4% compared to 2005. Among all types of road accidents, pedestrians are the most common, especially in large populated areas.

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Structure of severe injuries of the limbs and pelvis

• Road accident, driver, passengers (50-60%),
• injury from falling from a motorcycle (10-20%),
• Road accidents involving a collision with a pedestrian (10-20%),
• fall from a height (catatrauma) (8-10%),
• compression (3-6%).

According to American colleagues, the frequency of limb injuries does not exceed 3%. It is necessary to distinguish between injuries (fractures) of the limbs and pelvis. In case of pelvic injuries (according to literary sources), the mortality rate is 13-23%. The main reason for the onset of an unfavorable outcome is massive blood loss. In the structure of mortality in the later period, the development of complications is considered important. According to international data, there are no differences by gender.

Reasons why hospitalization in the intensive care unit is necessary

E The most common complications of pelvic bone fractures include damage to the pelvic organs and, as a consequence, the development of bleeding. In addition, pelvic bone fractures significantly increase the incidence of embolic complications, which are also observed in tubular bone fractures.

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

In case of arterial hypotension at the pre-hospital stage, mortality in case of pelvic bone fractures can reach 50%.

According to statistics, in case of open fractures of the extremities, the mortality rate increases to 30%.

Causes of pelvic trauma

Due to anatomical features, the occurrence of pelvic trauma requires the impact of high kinetic energy. It should be noted that the greater the force of impact, the more often pelvic bone injuries are accompanied by damage to the pelvic organs (bladder, damage to the scrotum organs, in women - the uterus, ovaries).

The most common causes of injury in road accidents for children are a car hitting a pedestrian (60-80%) and injuries while in a car (20-30%).

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Classification of pelvic injuries

Pelvic bone fracture

• Marginal fracture - fractures of the iliac spines, ischial tuberosities, coccyx, transverse fracture of the sacrum below the sacroiliac joint, ilium
• Fracture of the pelvic ring without disruption of its continuity
• Unilateral or bilateral fracture of the same branch of the pubic bone
• Unilateral or bilateral fracture of the ischial bones
• Fracture of one branch of the pubic bone on one side and the ischium on the other
• Injuries with disruption of the continuity of the pelvic ring
• Vertical sacral fracture or lateral mass sacral fracture
• Sacroiliac joint rupture
• Vertical fracture of the ilium
• Fracture of both branches of the pubic bone on one or both sides
• Fracture of the pubic and ischium bones on one or both sides (butterfly fracture)
• Symphysis rupture
• Damage with simultaneous disruption of the continuity of the anterior and posterior half rings (Malgenya type)
• Bilateral Malgenya fracture - the anterior and posterior half rings are damaged on both sides
• Unilateral or vertical fracture of the Malgen type - fracture of the anterior and posterior half rings on one side
• Oblique, or diagonal, fracture of the Malgen type - a fracture of the anterior half-ring on one side and the posterior half-ring on the other
• Sacroiliac joint and symphysis rupture
• Combination of symphysis rupture with fracture of the posterior semi-ring or combination of rupture of the sacroiliac joint with fracture of the anterior semi-ring of the pelvis
• Acetabular fracture
• A fracture of the acetabulum rim may be accompanied by a posterosuperior dislocation of the hip
• A fracture of the bottom of the acetabulum may be accompanied by a central dislocation of the hip - displacement of its head inward towards the pelvic cavity
• In case of damage to tubular bones, open and closed fractures are distinguished, with and without displacement.

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Complications of skeletal trauma and pelvic fractures

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

Shock is an adaptive response of the body to trauma. It is necessary to take into account that hypotension during blood loss is considered a predictor of an unfavorable outcome. In addition to this, it is recommended:

• for victims with a violation of the integrity of the pelvic ring with hemorrhagic shock - fixation and stabilization of pelvic ring fractures,
• for victims without a violation of the integrity of the pelvic ring with unstable hemodynamics - early angiographic embolization or surgical intervention.

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Fat embolism

The incidence rate is unknown (diagnosis may be difficult given the clinical picture of the underlying disease). Mortality is 10-20% and increases with concomitant severe pathology, decreased functional reserves, and in older victims.

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Anamnesis

• Trauma to long bones or pelvis, including orthopaedic procedures.
• Parenteral administration of lipids.
• Prior administration of glucocorticoids.

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Physical examination

• Cardiovascular system - sudden and persistent tachycardia.
• The appearance of tachypnea, dyspnea, and progression of hypoxemia against the background of mechanical ventilation after 12-72 hours.
• The appearance of fever with hectic temperature rises.
• Generalized petechial rash, especially pronounced in the axillae in 25-50% of cases.
• Increasing encephalopathy.
• Retinal hemorrhages (with fatty inclusions) - during examination of the fundus.

Differential diagnostics

• TELA.
• Thrombocytopenic purpura.

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Laboratory research

• Blood gas composition (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 found in victims of trauma).

Instrumental data

• Control radiographs show bilateral infiltrates that appear 24-48 hours after the development of the clinical picture.
• CT scan of the lungs.
• MRI is insensitive for the diagnosis of fat embolism syndrome, but can detect subsegmental lung tissue defects.
• With transcranial Doppler ultrasonography, symptoms of embolism are detected only 4 days after the onset of pronounced clinical symptoms.
• EchoCG has diagnostic value in the presence of a functioning oval window in adult patients.

Treatment

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

Timely implementation of surgical intervention to stabilize the fracture (see surgical treatment protocol).

Pharmacological therapy from specific treatment, in addition to the use of anticoagulants, the effectiveness of the use of methylprednisolone has been proven (duration and dose were not determined in studies).

Deep vein thrombosis and pulmonary embolism

Since any prevention of deep vein thrombosis and pulmonary embolism is associated with side effects of the drugs used, a group of patients is identified for whom the risk of using therapy will be lower than the risk of developing thromboembolic complications. There are no unambiguous recommendations on this matter in the literature. The following systematic review is proposed for clinical use: EAST Practice Parameter Workgroup for DVT Prophylaxis.

Risk

Evidence Category A

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

Use of low-dose heparin for the prevention of DVT/PE

Category of evidence B

• There is evidence that low-dose heparin is considered a prophylactic agent in high-risk situations.

Evidence Category C

• For victims in whom the risk of rebleeding or blood loss is considered to be critical, 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 extremities for the prevention of DVT/PE

Category of evidence B

• there is insufficient evidence to conclude that tight bandaging reduces the risk of PE in combined trauma •

Evidence Category C

• in the category of victims with spinal injuries, isolated studies show their effectiveness,
• For victims whose lower limbs cannot be immobilized with bandages, the use of a muscle pump may somewhat reduce the risk of PE.

Use of low molecular weight heparins for the prevention of DVT/PE

Category of evidence B

• Low molecular weight heparins are used to prevent DVT in patients with the following injuries: pelvic fractures requiring surgical fixation or prolonged bed rest (>5 days), complex lower limb fractures (open or multiple in one limb) requiring surgical fixation or prolonged bed rest (>5 days), spinal cord injury with complete or incomplete motor paralysis.

Evidence Category C

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

The role of cava filters in the treatment and prevention of pulmonary embolism

Category of evidence A

• traditional indications for cava filter placement are the presence of pulmonary embolism despite full anticoagulant therapy, high risk of developing DVT and contraindications to anticoagulant therapy, the likelihood of DVT and massive bleeding despite therapy, an increase in the mass of thrombus(es) in the ileofemoral vein despite moderate hypocoagulation.

Category of evidence B

• expanded indications for placement of a cava filter in patients with DVT or PE large floating thrombus in the iliac vein, after massive PE subsequent embolus may be fatal during or after surgical embolectomy.

Evidence Category C

• The installation of a cava filter in patients with a high risk of PE or DVT after trauma is considered under the following circumstances
• impossibility of anticoagulant therapy with a high risk of bleeding,
• if one or more of the following points are answered positively,
• severe closed head injury (Glasgow Coma Scale score <8),
• incomplete anatomical interruption 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 diagnostics and venography in PE and DVT

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 - questionable result in Doppler examination.

Evidence Category C

• Dopplerography is performed for all limb injuries with suspected thrombosis,
• Repeated Doppler studies are necessary to detect deep vein thrombosis in patients with an asymptomatic clinical picture. This method has lower sensitivity in dynamics compared to venography,
• Magnetic resonance venography for iliac vascular thrombosis in pelvic examination, where the sensitivity of Dopplerography is even lower.

Horseshoe compartment syndrome

Limb compartment syndrome (LCS) is not considered a direct cause of mortality in victims with limb injuries. It should be diagnosed as early as possible, without waiting for necrosis to develop. This significantly reduces the risk of complications, allows preserving the limb, avoiding amputation, and reduces disability.

The cause of compartment syndrome is increased pressure in the myofascicular spaces of the extremities. The immediate cause of increased pressure is edema of the elements of the myofascicular spaces, mainly the muscle mass. The following conditions are noted in the etiological structure of this syndrome: electrical trauma, the use of anti-shock suits, crush syndrome, some types of regional anesthesia, arthroscopy, severe deep vein thrombosis, etc. Cases of CSC due to iatrogenic causes have been described. Diagnostics is based on the identification of risk factors. The clinical picture includes pain syndrome, the severity of which increases over time, despite adequate analgesia, the appearance of hyperesthesia, weakness or hypertonia on the part of the affected limb.

The pain increases with passive muscle movement. Hyperesthesia is observed when nerve plexuses are involved in the pathological process. It should be noted that with such symptoms, diagnosis is difficult in patients under sedation. In such cases, an objective examination helps palpation of the pulse on the distal artery, pallor of the skin. Instrumental diagnostic methods include conducting studies aimed at studying nerve conduction, MRI. Other diagnostic methods have controversial data (sensitivity, specificity). Laboratory methods include tests for creatinine kinase, myoglobin, which increase in the late stage.

Treatment

Decompression is the major factor affecting the functional outcome. Irreversible damage to nerves and muscles occurs after 6-12 hours. Only 31% of patients who undergo fasciotomy within 12 hours of the start of CSC have residual neuromuscular deficit. In contrast, 91% of patients with CSC operated on more than 12 hours later have residual neurological deficit, and 20% of patients require amputation. Of 125 fasciotomies performed in CSC, 75% of cases resulted in amputation due to delayed fasciotomy, incomplete or inadequate fascial decompression.

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

Complications of CSC include neuropathy of varying degrees as a result of ischemia, muscle necrosis, fibrosis, contractures, rhabdomyolysis and, as a consequence, the development of acute renal failure, which in this situation significantly worsens the prognosis.

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Prevention of stress ulcers

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

Diagnosis of pelvic and limb injuries

In most cases, with an isolated nature of the injury, the diagnosis is not in doubt even during a clinical examination. Diagnosis of complications is mandatory, especially when there are indications for transfer to the intensive care unit, since the clinical picture is dominated by symptoms of life-threatening conditions, and therefore it is carried out when intensive therapy has begun.

Fractures of tubular bones are not difficult to diagnose. However, vigilance and timely therapy are necessary if complications develop.

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Survey

The main goal of the initial examination is to immediately find life-threatening conditions. The exclusion factor is hemodynamic instability, which requires intensive care, since the development of hypotension in pelvic injuries leads to high mortality.

The anamnesis includes the presence of allergies, previous surgeries, chronic pathology, time of the last meal, and circumstances of the injury.

Further study:

• anatomical location of the wound and type of projectile, time of impact (additional data regarding trajectory, body position) in case of gunshot wounds to the extremities, pelvic injuries,
• the distance from which the injury was sustained (height of fall, etc.). In case of gunshot wounds, it is necessary to remember that a close shot transfers a greater amount of kinetic energy,
• pre-hospital assessment of the amount of blood loss (as accurately as possible),
• initial level of consciousness (assessed using the Glasgow Coma Scale). During transportation from the pre-hospital stage, it is necessary to determine the amount of assistance and the victim's response to the therapy being administered.

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Additional continuous monitoring

• Blood pressure and heart rate dynamics
• Body temperature, rectal temperature
• Saturation of hemoglobin with oxygen
• Assessment of the level of consciousness in case of combined injury

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Additional diagnostics

• Chest and abdominal X-ray (standing if possible)
• Ultrasound of the abdominal cavity and pelvic cavity
• Arterial blood gases
• Plasma lactate content, base deficit and anion gap as indicators of tissue hypoperfusion. The use of esophageal Dopplerography as an instrumental non-invasive indicator of volemic status is considered promising
• Coagulogram (APTT, PTI)
• The content of glucose in blood plasma, creatinine, residual nitrogen, calcium and magnesium in blood serum
• Blood group determination
• A pregnancy test is performed on women in an unconscious state

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Detailed inspection

It is important to remember that a situation may arise where a detailed examination and complete laboratory testing are carried out in conjunction with intensive therapy.

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Physical examination

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

X-ray examinations

Survey radiography. Chest radiography is mandatory. It is also performed in the event of complications (pneumonia, pulmonary embolism, fat embolism).

Radiography of damaged segments of the upper and lower limb girdle and the pelvis in case of its damage. The use of this method requires knowledge of radiographic positions for certain types of fractures. This requires the involvement of qualified personnel from the departments of radiological diagnostic methods.

X-ray contrast studies of the urinary tract. Urethrorrhagia, abnormal position of the prostate or its mobility during digital rectal examination, hematuria are signs of damage to the urinary tract or genitals. Urethrography is performed to diagnose damage to the urethra. Intraperitoneal and extraperitoneal rupture of the bladder can be detected using cystography, a radiopaque substance is introduced through a Foley catheter. Kidney damage and retroperitoneal hematomas are diagnosed using abdominal CT, which is performed on each patient with hematuria and stable hemodynamics.

CT is performed in cases of damage to the pelvic organs and to exclude retroperitoneal hematomas. For radiation diagnostics of bone fractures, X-rays of the extremities are sufficient.

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

Indications for consultation with other specialists

Successful treatment and diagnostic tactics require joint work of teams from intensive care units, thoracic and abdominal surgery, as well as diagnostic units (ultrasound, CT, angiosurgery, endoscopic rooms). Any suspicion of urethral injury requires consultation with a urologist.

A more qualitative assistance to the victim will be provided in a highly specialized medical institution. If the territorial principle is not observed, the prognosis worsens, especially in unstable victims.

Treatment of pelvic and limb injuries

All pelvic injuries and tubular bone fractures require hospitalization due to the development of possible complications. Indications for stay in the intensive care unit are disorders of vital functions.

Drug treatment

The main components of therapy for victims with fractures of tubular bones and pelvic injuries.

Analgesics

Provide adequate analgesia using regional pain relief methods. Victims with skeletal trauma require more pain relief than patients after orthopedic surgery. In this regard, intravenous opioids are considered the most effective in the acute period. To monitor the effectiveness, it is recommended to use dynamic scales for subjective pain assessment.

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Antibacterial drugs

Antibacterial therapy is prescribed to all victims with fractures of the pelvic bones and tubular bones, as well as fractures that are accompanied by a violation of the integrity of the skin (open fractures), since 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 Bone fractures with a breach of skin integrity no more than 1 cm deep. The skin wound is clean.
• Type II Open fractures with damage to the skin of more than 1 cm, not accompanied by crushing of 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 separated from the bone fragment, soft to the touch and not tense.
  • III B - detachment of soft tissues from the periosteum and their contamination.
  • III C - soft tissue lesions associated with impaired arterial blood flow.

Indications for antibacterial therapy:

• Antibacterial drugs are administered for prophylactic purposes as soon as possible after injury and/or intraoperatively (spectrum - gram-positive microorganisms). If the wound is contaminated with soil, anticlostridial drugs are prescribed.
• For types I and II, it is recommended to discontinue antibiotics 12 hours after the injury. For type III, antibacterial therapy is continued for at least 72 hours, provided that it is started no later than 24 hours after the injury.
• immunoprophylaxis. In addition to using serums for open wounds, polyvalent immunoglobulins are recommended to improve long-term treatment results.

Other groups of drugs are used for symptomatic therapy. It should be noted that many traditionally used drugs have not proven their effectiveness in studies.

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Anesthetic support

The volume of anesthesia depends on the clinical condition of the victim and is performed according to all the rules of anesthesiology. In case of limb fractures, the use of regional methods of anesthesia is considered ideal, in the absence of contraindications. In this case, in case of injuries to the upper limb girdle, it is also possible to install a catheter for long-term analgesia. When performing anesthesia in victims with unstable pelvic fractures, it is necessary to provide for fixation of the pelvis before the introduction of muscle relaxants, since protective muscle tone may be the only mechanism that restrains the divergence of bone structures.

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Surgical treatment of pelvic injuries

The scope of surgical intervention and the method of fixing the fracture are determined by orthopedic traumatologists. It is necessary to take into account that early fixation of the fracture reduces the risk of complications.

Timely fixation allows to reduce the length of hospital stay, the cost of treatment and reduces the likelihood of developing infectious complications.

Prognosis of pelvic and limb injuries

According to global data, the TRISS score is considered prognostic. The ISS scale is used to assess the severity of injury. A trauma is considered severe if it scores >16 points when stratifying the victim.

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