A protocolised approach provides a favourable outcome in patients with severe pelvic trauma

INTRODUCTION

Pelvic fractures (PFs) occur in about 10% of patients with major trauma and are markers of injuries resulting from a major force, leading to polytrauma in about 20% of patients with PFs.¹ The majority of PFs present as isolated bony fractures, while 10% present as multiple complex fractures with marked haemodynamic instability, causing a mortality of up to 50%.² With improved management protocols, there has been an improvement in the mortality rate of pelvic fractures in the past 2 decades; however, mortality in complex PF remains high.^3-5 The outcome of patients with pelvic trauma depends on many factors such as haemodynamic status at presentation, injury pattern, associated injuries, management protocols, etc. Institutional management protocols vary depending on the availability of resources and expertise and use mainly endovascular techniques.^6,7 We analysed our experience with a protocol for the management of pelvic trauma using surgical haemostatic techniques and the outcomes over 5 years.

METHODS

This retrospective observational study was done in the division of trauma surgery at a level 1 trauma centre. Our high-volume trauma centre has an average annual footfall of about 75 000 patients. Clinical case records of all the trauma patients are maintained prospectively in an electronic database. All patients with PFs admitted from January 2014 to December 2018, were included in the study. Patients <18 years of age and on anticoagulant medications were excluded from the study.

Demographic profile, clinical details, imaging findings, operative details and outcome of all the recruited patients were analysed. PFs were classified according to the Young Burgess Classification into four types of injuries: lateral compression (LC), anteroposterior compression (APC), vertical shear (VS) and combined (COM). Haemodynamically stable patients with stable PFs were managed non-operatively. Operative interventions were done in haemodynamically unstable patients or patients with concomitant intra-abdominal or extra-abdominal injuries requiring surgery.

Our protocol

All patients with trauma who present to the emergency department (ED) are triaged and resuscitated according to the Advanced Trauma Life Support (ATLS) protocols. After initial assessment, stable patients undergo further evaluation, imaging and management according to the diagnosed injuries. Haemodynamically unstable patients in whom PF is considered to be the main source of exsanguinating haemorrhage, undergo application of pelvic circumferential compression devices in the ED, exploratory laparotomy, control of haemorrhage and contamination from other intra-abdominal injuries, if any, and bilateral ligation of internal iliac arteries (BLIIA), preperitoneal pelvic packing (PPP) with or without external fixator placement for PFs (Fig 1).⁸

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FIG 1.

Management protocol of pelvic fractures ATLS advanced trauma life support BLIIA bilateral ligation of internal iliac arteries

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The concurrent resuscitation consists of initial transfusion using major haemorrhage protocol followed by coagulation assessment guided transfusion of blood products. Interventional radiology with embolization is done in haemodynamically stable patients with contrast blush/extravasation or pseudoaneurysm on contrast-enhanced computed tomography scans detected during the secondary survey. Patients who survive for 24–48 hours and remain haemodynamically stable are re-explored for possible pack removal. The following course consists of further management and surgical intervention for PFs and other associated injuries, if required.

All quantitative variables are reported using mean and standard error or median and range. The data were analysed using the Statistical Package for the Social Sciences (SPSS, IBM, Ver 23). Student t-test for univariate variables and Chi-square test were used to compare the means. The Institutional Ethics Committee approved the study.

RESULTS

During the study period, of 30 523 trauma patients 568 patients (1.86%) with PFs were admitted; of them, 67 patients were excluded due to their age (<18) or pre-existing known bleeding disorders. Hence, 501 patients with PFs were included in the study (Fig 2).

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FIG 2.

Flow chart showing study design

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Men were a large proportion with a male:female ratio of 4:1 and a mean (SD) age of 34 (13.1) years. Road traffic injuries (RTIs) were the most common cause (362; 72.3%) followed by falls from heights (90; 18%). Injuries associated with train travel accounted for a minority of PFs (25; 5%).

The mean (SD) injury severity score (ISS) and revised trauma score (RTS) were 17.37 (8.31) and 7.41 (1.04), respectively. The majority of patients (422; 84.8%) were haemodynamically stable at the initial assessment on arrival to the emergency resuscitation bay. The rest (79 [15.2%]) were haemodynamically unstable and transferred directly to the operating room (Table 1).

Focused assessment with sonography in trauma (FAST) was positive in 188 (37.5%) patients. The pelvic compression test (PCT) was positive in only half of the patients with PFs.

DISCUSSION

Management of pelvic trauma is complex as in most cases, these are polytrauma patients requiring multidisciplinary intervention. Our results provide the results of a management protocol in a resource-limited setting where facilities such as a hybrid operating room and resuscitative endovascular balloon occlusion of the aorta (REBOA) were not available.

The estimated incidence of PF in the present study was 1.86%. Available literature shows a similar incidence pattern from 0.82% to 2.82%.^5,9 A higher incidence of 3% to 17.9% has also been reported in different series.^1,10,11 This difference could be due to the selective referral of patients with higher ISS and unstable PF to our level 1 trauma centre. Patients with isolated and undisplaced fractures are usually not referred to us. Even if they do reach us, after an initial assessment and management, patients with such injuries are often discharged from the ED.

RTIs are the most common cause of PFs, accounting for around 60%, followed by falls from height.^1,10,11 We also found similar results, with RTIs in 72.3% of patients, followed by falls from height in 18% of patients. We observed a peculiar mechanism of injury in the form of train-associated injuries in 4.8% of patients. Such injuries occur due to trespassing over railway tracks, non-availability of automatic door closing in train compartments leading to injuries during boarding and deboarding running trains and at unmanned railway crossings. Such injuries can be reduced by better infrastructure, technological advancement and strict implementation of road traffic and railway protection rules.

PCT is commonly done in the ED to diagnose PFs clinically. It is subjective with inter-observer variability and is difficult to elicit in patients with a low Glasgow coma scale or other distracting injuries. The sensitivity and specificity of PCT have been reported to be 100% and 93%, respectively, for diagnosing unstable PFs (Tile B and C) in conscious patients.¹² We could diagnose PFs using PCT in only 50% of all patients irrespective of haemodynamic status. This may be because the majority of PFs were due to low-velocity trauma primarily causing non-displaced fractures without any haemodynamic instability (85%).

The utility of FAST examination in PFs is limited. In our study, FAST was positive in only one-third of patients, which may be due to associated intraperitoneal injuries. Similar results were reported by Verbeek et al.¹³ The mean ISS in our study was 17.3. Giannoudis et al. reported that one-third of patients in their series had ISS >15. Similar results were reported in a series of 1545 patients with PFs.¹ It indicates that PFs are often associated with other injuries. Chest injuries are the most commonly reported associated injury in 10%–40% of cases.^9,10,14 the most common associated injuries in our series were long bone fractures and chest injuries. We found associated concomitant intra-abdominal injuries in 18.6% of patients, similar to the study by Gänsslen et al.¹⁰

Concomitant head injury was present in 11.2% of patients, well within the reported range of between 10% and 35% in patients with PFs.^3,5,9 However, we could not correctly evaluate the head injuries in 29 patients as they were haemodynamically unstable and were directly taken to the operation theatre and later died. In our study, 5.5% of patients had associated bladder or urethral injuries. This is consistent with a reported incidence of 6% of associated bladder and urethral injuries in the literature.¹ Patients with pelvic trauma require immediate operative intervention to control bleeding due to PFs or associated injuries. About 56.5% (283/501) of patients required operative intervention in our study. Of 283 patients, 58 patients required operative intervention for haemodynamically unstable PFs, while in 225 patients, the operative intervention was required for associated injuries. Hence, PFs are a marker for a major force of impact on the patient. Most studies have reported LC as the most common type of PF followed by APC.^5,9 We also noted a similar trend in our series.

PFs are a major source of haemorrhage. The reported incidence of haemodynamic instability in patients with PFs ranges from 5% to 50%. This wide range is because there is no uniformity in the literature about the definition of haemodynamic instability. Hermans et al. used the ATLS classification of haemorrhagic shock and reported approximately 50% of their patients with class 2, 3 and 4 shock being haemodynamically unstable at presentation.¹⁵ We used the same criteria and found that 38.9% of patients were haemodynamically unstable at presentation. However, 79 (15.2%) patients remained haemodynamically unstable even after initial resuscitation and required urgent damage control surgery. Damage control surgery for pelvic bleeding was done in 56 (11.2%) patients, while 23 (4%) patients required damage control surgery for associated intra-abdominal injuries. We did not have a hybrid operating room at our centre. We did BLIIA and PPP in haemodynamically unstable patients due to PFs. We observed gluteal claudication after BLIIA in only 4 patients.

In our study, the mean hospital and ICU stays were 14.3 and 3.3 days, respectively. Similar results were reported in the literature.¹⁵

Even after many advances in trauma care, mortality associated with PFs remains high. Poole and Ward reported mortality related to pelvic trauma to be 14.3%.¹⁶ We had a mortality rate of 15.7%, with haemorrhagic shock being the most common cause in 50% of patients, followed by sepsis and head injury. In a comparative study of outcomes of PF survivors and non-survivors, the most common cause of mortality was massive bleeding from the pelvic region.¹⁷ Chong et al. found that one-third of patients with PFs died of pelvic haemorrhage and pelvis-related injury.¹⁸ Elderly patients with pelvic trauma were associated with higher mortality than younger patients.¹⁹

Comparative analysis between survivors and non-survivors showed that higher grades of shock and higher ISS predicted poor outcomes in patients with PFs. Gilliland et al. compared the outcome of survivors and non-survivors in pelvic trauma. They found ISS, head injury, initial blood pressure, haemoglobin and partial thromboplastin time to be associated with mortality (p<0.001).²⁰ Many studies have reported that old age, higher ISS, systolic blood pressure <90 mmHg and RTS <7.8 are associated with increased mortality.^13,14,21,22 The ISS was reported to be the most important factor for mortality after pelvic trauma and not the type of pelvic instability.²³ Manson et al. reported higher mortality in the unstable PF group (11.5%) than in the stable PF group (7.9%).²² We also found similar results when comparing the mortality between unstable PFs and stable PFs.