A DIAGNOSTIC-THERAPEUTIC ALGORITHM FOR MANAGEMENT OF PELVIC FRACTURES WITH HEMODYNAMIC INSTABILITY

Abstract

Introduction and Objectives: High-energy fractures of the pelvis carry a high mortality and pose a diagnostic and therapeutic challenge in modern orthopaedic trauma. A multidisciplinary approach has reduced mortality in the past two decades. In cooperation with the polytrauma ICU, we have developed a diagnostic-therapeutic algorithm to determine indications for laparotomy, external fixation, and angiography, in terms of clinical evolution and fracture type.

Materials and Methods: This is a retrospective study of 67 patients with pelvic fractures and persistent hae-modynamic instability who were treated in our centre between 1994 and 2002. The following parameters were analyzed: personal data, AIS, ISS, RTS, type of fracture (Young and Burgess classification), associated injuries, haematologic requirements, and degree of adherence to the algorithm in terms of diagnostic and therapeutic measures. The following results variables were examined: mortality, incidence of systemic complications associated with traumatic illness (MOF, ARDS, DIC), and length of hospital stay.

Results: The study involved a total of 67 patients, all with pelvic fractures and persistent haemodynamic instability. Average age was 37.7 years, and average time in the ICU was 13.8 days. In 53.7% of cases, patients were transported to the centre by ambulance, 41.8% by helicopter, and the remaining 4.5% by other means. Adjusted mortality was 25%. External fixation was used on 42 patients (62%) and angiography in 36 (53%). Both techniques were used in combination in 17 patients. Of the 36 patients who underwent angiography, 33 showed positive findings (91.7%). Exploratory laparotomy was required in 23 patients due to positive findings on abdominal ultrasound, which yielded positive results in 20 cases. Mortality in these patients was 45%. Average ISS was 29.

Discussion and Conclusions: Rapid evaluation and a multidisciplinary approach are necessary in handling patients with pelvic fracture and haemodynamic instability. External fixation is a rapid procedure that is safe and simple, permitting the control of haemody-namic instability, which should be considered more as an emergency stabilisation technique than a reconstructive procedure. Abdominal ultrasound is a very sensitive method when deciding whether or not to perform an exploratory laparotomy. In cases with rotational instability of the pelvis, laparatomy should be done only after pelvic fixation. A diagnostic-therapeutic algorithm has been designed for the management of pelvic instability, with particular emphasis on indicators of a poor prognosis.