Year 2015 Vol. 23 No 4

REVIEWS

Y.G. SHAPKIN, P.A. SELIVERSTOV

STRATEGY FOR SURGICAL TREATMENT OF POLYTRAUMA WITH UNSTABLE PELVIC INJURIES

SBEE HPE "Saratov State Medical University Named after V.I. Razumovsky"
The Russian Federation

A review of the scientific literature identified the main factors influencing the choice of therapeutical strategy in polytrauma with unstable pelvic injuries; the options for surgical treatment as well as the advantages and disadvantages of current methods of continuous intrapelvic hemorrhage stopping, external and internal fixation of the pelvis injuries in polytrauma are also presented.
The high incidence of development of shock, massive interstitial hemorrhage, endogenous intoxication syndrome, hypostatic complications, the importance of an anatomically accurate reconstruction of the pelvic ring for functional outcome require special treatment tactics in polytrauma with pelvic injuries. Fixation of unstable pelvic ring injuries with a fixator and continuous intrapelvic hemorrhage stopping using angiographic arterial embolization, extraperitoneal tamponade in polytrauma proven to be some anti-shock urgent measures. Early surgical fixation of unstable pelvic injuries in polytrauma can prevent the development of endogenous intoxication syndrome, disseminated intravascular coagulation, multiple organ failure, to reduce the frequency of hypostatic complications, mortality rate and to improve functional outcomes. Terms and extent of surgical interventions for pelvic injuries in polytrauma are based on the severity of the patient’s condition, the period of traumatic disease. In patients in critical condition the staged surgical treatment of unstable pelvic injuries with temporary external fixation devices and the subsequent final stabilization of the internal fixator correspond to the concept of "Damage Control" and this allows obtaining maximum benefit from both techniques. Treatment of acetabulum fractures and damages in the structural integrity of the pelvic ring should comply with the treatment principles of intra-articular fractures and requires accurate anatomical reposition and pelvic stability.

Keywords: treatment strategy, polytrauma, unstable pelvic injuries, treatment of intra-articular fractures, hypostatic complications, external fixation, internal fixation
p. 452-459 of the original issue
References
  1. Bondarenko AV, Kruglykhin IV, Plotnikov IA, Voitenko AN, Zhmurkov OA. Osobennosti lecheniia povrezhdenii taza pri politravme [Features of treatment of pelvic injuries in polytrauma]. Politravma. 2014;(3):46-62.
  2. Burkhardt M, Nienaber U, Pizanis A, Maegele M, Culemann U, Bouillon B, Flohé S, Pohlemann T, Paffrath T.Acute management and outcome of multiple trauma patients with pelvic disruptions. Crit Care. 2012 Aug 22;16(4):R163. doi: 10.1186/cc11487.
  3. Stewart KE, Cowan LD, Thompson DM.Changing to AIS 2005 and agreement of injury severity scores in a trauma registry with scores based on manual chart review. Injury. 2011 Sep;42(9):934-39. doi: 10.1016/j.injury.2010.05.033.
  4. Ankin LN, Pipiia GG, Ankin NL. Lechenie povrezhdenii taza u postradavshikh s izolirovannoi i sochetannoi travmoi [Treatment of pelvic injuries in victims with isolated and combined injury]. Vestn Travmatologii i Ortopedii Im NN Priorova. 2007;(3):32-35.
  5. Tiliakov AB, Valiev EIu, Ubaidullaev BS. Primenenie sterzhnevogo apparata vneshnei fiksatsii v kompleksnom lechenii nestabil'nykh perelomov kostei taza pri sochetannoi travme [The use of the rod external fixation in treatment of unstable pelvic fractures in combined injury]. Zhurn Im NV Sklifosovskogo. Neotlozhn Med Pomoshch'. 2014;(2):32-37.
  6. Davis JM, Stinner DJ, Bailey JR, Aden JK, Hsu JR. Factors associated with mortality in combat-related pelvic fractures. J Am Acad Orthop Surg. 2012;20 Suppl 1:S7-12. doi: 10.5435/JAAOS-20-08-S7.
  7. Al-Hassani A, Afifi I, Abdelrahman H, El-Menyar A, Almadani A, Recicar J, Al-Thani H, Maull K, Latifi R.Concurrent rib and pelvic fractures as an indicator of solid abdominal organ injury. Int J Surg. 2013;11(6):483-86. doi: 10.1016/j.ijsu.2013.04.002.
  8. Girshin SG. Klinicheskie lektsii po neotlozhnoi travmatologii [Clinical lectures on emergency traumatology]. Saint-Petersburg, RF: Azbuka, 2004. 544 p.
  9. Khanin MIu, Minasov BSh, Minasov TB, Iakupov RR, Zagitov BG. Ortopedicheskii damage-control pri povrezhdeniiakh taza u patsientov s politravmoi [Orthopedic damage-control in injuries of the pelvis in patients with polytrauma]. Prakt Meditsina. 2011;6(54):122-25.
  10. Marzi I, Lustenberger T. Management of Bleeding Pelvic Fractures. Scand J Surg. 2014 Apr 15;103(2):104-11.
  11. Holstein JH, Culemann U, Pohlemann T. What are predictors of mortality in patients with pelvic fractures? Clin Orthop Relat Res. 2012 Aug;470(8):2090-97. doi: 10.1007/s11999-012-2276-9.
  12. Voronin NI, Borozda IV. Vnutritkanevoe krovotechenie u bol'nykh s sochetannoi travmoi taza. Osnovnye kontseptsii patogeneza, diagnostiki i lecheniia [Interstitial bleeding in patients with combined trauma of the pelvis. The basic concepts of the pathogenesis, diagnosis and treatment]. Dal'nevostochnyi Med Zhurn. 2008;(3):112-15.
  13. Gumanenko EK/red, Kozlova VK. Politravma: travmaticheskaia bolezn', disfunktsiia immunnoi sistemy, sovremennaia strategiia lecheniia [Polytrauma: traumatic disease, immune system dysfunction, modern treatment strategy]. Moscow, RF: GEOTAR-Media. 2008. 608 p.
  14. Pavić R, Margetić P.Emergency treatment for clinically unstable patients with pelvic fracture and haemorrhage. Coll Antropol. 2012 Dec;36(4):1445-52.
  15. Sokolov VA, Bialik EI, Fain AM, Smoliar AN, Evstigneev DV. Lechenie nestabil'nykh povrezhdenii taza na reanimatsionnom etape u postradavshikh s politravmoi [Treatment of unstable pelvic injuries in the intensive care stage, patients with multiple injuries]. Politravma. 2011;(2):30-35.
  16. Kalinkin OG. Itogi mnogoletnego opyta lecheniia postradavshikh s tiazhelymi povrezhdeniiami taza v ostrom i rannem periodakh travmaticheskoi bolezni [The results of many years of experience treating patients with severe pelvic injuries in the acute and early periods of traumatic disease]. Travma. 2013;14(2):80-84.
  17. Gridasova EI. Infuzionno-transfuzionnaia terapiia v lechenii endotoksemicheskogo sindroma u bol'nykh s tiazheloi travmoi taza [Infusion-transfusion therapy in the treatment of endotoxic syndrome in patients with severe pelvic injury]. Travma. 2013;14(5):47-50.
  18. Godzik J, McAndrew CM, Morshed S, Kandemir U, Kelly MP. Multiple lower-extremity and pelvic fractures increase pulmonary embolus risk. Orthopedics. 2014 Jun;37(6):e517-24. doi: 10.3928/01477447-20140528-50.
  19. Smirnov A.A. Operativnoe lechenie vertikal'no-nestabil'nykh povrezhdenii taza (tip S po klassifikatsii AO) [Surgical treatment of vertically unstable pelvic injuries (type C by AO classification)]. Travmatologiia i Ortopediia Rossii. 2012;1(63):73-76.
  20. Kanakaris NK, Angoules AG, Nikolaou VS, Kontakis G, Giannoudis PV. Treatment and outcomes of pelvic malunions and nonunions: a systematic review. Clin Orthop Relat Res. 2009 Aug;467(8):2112-24. doi: 10.1007/s11999-009-0712-2.
  21. Shkoda AS, Pokrovskii KA, Cheremukhin OI, Semenov AIu, Ivashkin AN, Sorokin AA, Fedorov DIu. Optimizatsiia organizatsii lecheniia postradavshikh s sochetannoi travmoi taza [Optimization of the organization of treatment of patients with associated trauma of the pelvis]. Meditsina Nev³dkladnikh Stan³v. 2011;(5):85-89.
  22. Vallier HA, Cureton BA, Ekstein C, Oldenburg FP, Wilber JH. Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity. J Trauma. 2010;69(3):677-84.
  23. Hou Z, Smith WR, Strohecker KA, Bowen TR, Irgit K, Baro SM, Morgan SJ.Hemodynamically unstable pelvic fracture management by advanced trauma life support guidelines results in high mortality. Orthopedics. 2012 Mar 7;35(3):e319-24. doi: 10.3928/01477447-20120222-29.
  24. Spahn DR, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Gordini G, Stahel PF, Hunt BJ, Komadina R, Neugebauer E, Ozier Y, Riddez L, Schultz A, Vincent JL, Rossaint R. Management of bleeding following major trauma: a European guideline. Crit Care. 2007 Apr 24;11(2):414.
  25. Brun J, Guillot S, Bouzat P, Broux C, Thony F, Genty C, Heylbroeck C, Albaladejo P, Arvieux C, Tonetti J, Payen JF. Detecting active pelvic arterial haemorrhage on admission following serious pelvic fracture in multiple trauma patients. Injury. 2014 Jan;45(1):101-6. doi: 10.1016/j.injury.2013.06.011.
  26. Scaglione M, Parchi P, Digrandi G, Latessa M, Guido G. External fixation in pelvic fractures. Musculoskelet Surg. 2010 Nov;94(2):63-70. doi: 10.1007/s12306-010-0084-5.
  27. Wang G, Zhou D, Shen WJ, Xin M, He J, Li Q, Tan G. Management of partial traumatic hemipelvectomy. Orthopedics. 2013 Nov;36(11):e1340-5. doi: 10.3928/01477447-20131021-12.
  28. Hornez E, Maurin O, Bourgouin S, Cotte J, Monchal T, de Roulhac J, Meyrat L, Platel JP, Delort G, Meaudre E, Thouard H.Management of exsanguinating pelvic trauma: Do we still need the radiologist? J Visc Surg. 2011 Oct;148(5):e379-84. doi: 10.1016/j.jviscsurg.2011.09.007.
  29. El-Haj M, Bloom A, Mosheiff R, Liebergall M, Weil YA. Outcome of angiographic embolisation for unstable pelvic ring injuries: Factors predicting success. Injury. 2013 Dec;44(12):1750-5. doi: 10.1016/j.injury.2013.05.017.
  30. Balbachevsky D, Belloti JC, Doca DG, Jannarelli B, Junior JA, Fernandes HJ, Dos Reis FB.Treatment of pelvic fractures - a national survey. Injury. 2014 Nov;45 Suppl 5:S46-51. doi: 10.1016/S0020-1383(14)70021-X.
  31. Abrassart S, Stern R, Peter R. Unstable pelvic ring injury with hemodynamic instability: what seems the best procedure choice and sequence in the initial management? Orthop Traumatol Surg Res. 2013 Apr;99(2):175-82. doi: 10.1016/j.otsr.2012.12.014.
  32. Metsemakers WJ, Vanderschot P, Jennes E, Nijs S, Heye S, Maleux G. Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: outcomes of a single centre experience. Injury. 2013 Jul;44(7):964-68. doi: 10.1016/j.injury.2013.01.029.
  33. Morozumi J, Homma H, Ohta S, Noda M, Oda J, Mishima S, Yukioka T. Impact of mobile angiography in the emergency department for controlling pelvic fracture hemorrhage with hemodynamic instability. J Trauma. 2010 Jan;68(1):90-95. doi: 10.1097/TA.0b013e3181c40061.
  34. Probst C, Probst T, Gaensslen A, Krettek C, Pape HC. Timing and duration of the initial pelvic stabilization after multiple trauma in patients from the German trauma registry: is there an influence on outcome? J Trauma. 2007 Feb;62(2):370-77.
  35. Vallier HA, Wang X, Moore TA, Wilber JH, Como JJ. Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care. J Orthop Trauma. 2013 Oct;27(10):543-51. doi: 10.1097/BOT.0b013e31829efda1.
  36. Böhme J, Höch A, Gras F, Marintschev I, Kaisers UX, Reske A, Josten C. Polytrauma with pelvic fractures and severe thoracic trauma: does the timing of definitive pelvic fracture stabilization affect the clinical course? Unfallchirurg. 2013 Oct;116(10):923-30. doi: 10.1007/s00113-012-2237-5.
  37. Fain AM, Bialik EI, Makedonskaia TP. Vybor optimal'noi taktiki okazaniia pomoshchi postradavshim s tiazhelymi perelomami kostei taza i travmoi nizhnikh mochevyvodiashchikh putei [Selection of the optimal tactics to assist victims with serious fractures of the pelvis and lower urinary tract injury]. Politravma. 2013;(3):30-36.
  38. Menges P, Kessler W, Kloecker C, Feuerherd M, Gaubert S, Diedrich S, van der Linde J, Hegenbart A, Busemann A, Traeger T, Cziupka K, Heidecke CD, Maier S. Surgical trauma and postoperative immune dysfunction. Eur Surg Res. 2012;48(4):180-86. doi: 10.1159/000338196.
  39. Pape HC, Tornetta P 3rd, Tarkin I, Tzioupis C, Sabeson V, Olson SA. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009 Sep;17(9):541-49.
  40. Džupa V, Pavelka T, Taller S. Pelvic ring injury as part of multiple trauma. [Article in Czech]. Rozhl Chir. 2014 May;93(5):292-96.
  41. Culemann U, Oestern HJ, Pohlemann T. [Current treatment of pelvic ring fractures]. [Article in German] Unfallchirurg. 2014 Feb;117(2):145-59; quiz 160-1. doi: 10.1007/s00113-014-2558-7.
  42. Ivanov PA, Fain AM, Smoliar AN, Shchetkin VA. Osobennosti diagnostiki i lecheniia sochetannoi travmy taza [Diagnosis and treatment of associated injuries of the pelvis]. Khirurgiia. Zhurn im NI Pirogova. 2014;(10):64-67.
  43. Hu SB, Xu H, Guo HB, Sun T, Wang CJ.External fixation in early treatment of unstable pelvic fractures. Chin Med J (Engl). 2012 Apr;125(8):1420-24.
  44. Sokolov VA. Mnozhestvennye i sochetannye travmy [Multiple and combined injuries]. Moscow, RF: GEOTAR-Media, 2006. 512 p.
  45. Mardanpour K, Rahbar M.The outcome of surgically treated traumatic unstable pelvic fractures by open reduction and internal fixation. J Inj Violence Res. 2013 Jul;5(2):77-83. doi: 10.5249/jivr.v5i2.138.
  46. Bialik EI, Fain AM. Etapnoe lechenie povrezhdenii v oblasti lonnogo sochleneniia s primeneniem original'nogo fiksatora u postradavshikh s sochetannoi travmoi taza [Staged treatment of injuries in the area of the symphysis pubis with the original lock in victims with concomitant pelvic trauma]. Politravma. 2013;(4):30-34.
  47. Hiesterman TG, Hill BW, Cole PA.Surgical technique: a percutaneous method of subcutaneous fixation for the anterior pelvic ring: the pelvic bridge. Clin Orthop Relat Res. 2012 Aug;470(8):2116-23. doi: 10.1007/s11999-012-2341-4.
  48. Chen HW, Liu GD, Ou S, Zhao GS, Pan J.Treatment of unstable sacral fractures with percutaneous reconstruction plate internal fixation. Acta Cir Bras. 2012 May;27(5):338-42.
  49. Li CL.Clinical comparative analysis on unstable pelvic fractures in the treatment with percutaneous sacroiliac screws and sacroiliac joint anterior plate fixation. Eur Rev Med Pharmacol Sci. 2014;18(18):2704-8.
  50. Donchenko SV, Dubrov VE, Sliniakov LIu, Cherniaev AV, Lebedev AF, Alekseev DV. Algoritm khirurgicheskogo lecheniia nestabil'nykh povrezhdenii tazovogo kol'tsa [The algorithm of surgical treatment of unstable pelvic ring injuries]. Vestn Travmatologii i Ortopedii Im NN Priorova. 2013;(4):9-16.
  51. Enninghorst N, Toth L, King KL, McDougall D, Mackenzie S, Balogh ZJ.Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option. J Trauma. 2010 Apr;68(4):935-41. doi: 10.1097/TA.0b013e3181d27b48
  52. Miliukov AI. Formirovanie taktiki lecheniia postradavshikh s povrezhdeniiami taza [Formation of the tactics of treatment of patients with pelvic injuries]. 2013;(3):22-29.
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Seliverstov Pavel Andreevich
Information about the authors:
Shapkin Y.G. MD, professor, a head of the general surgery chair, SBEE HPE "Saratov State Medical University named after V.I. Razumovsky".
Seliverstov P.A. PhD, an assistant of the general surgery chair, SBEE HPE "Saratov State Medical University named after V.I. Razumovsky".
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