Open Pelvic Fractures - Springer Link

European Journal of Trauma

Focus on Pelvic Trauma

Open Pelvic Fractures Martin Bircher1

Abstract An open pelvic fracture represents one of the most significant insults to the human frame. Anatomically, the skeleton apart, many soft-tissue structures will be damaged requiring a multidisciplinary approach. The management of an open fracture challenges any health care system. This article in no way attempts to provide an ultimate management protocol for such injuries – how patients are managed will depend on the trauma system both locally and nationally. However, certain principles must be observed and a management protocol can be developed for each institution. The essence of ideal treatment of such injuries is urgent transportation to an appropriate institution, rapid resuscitation and assessment with the involvement of senior specialists from a wide spectrum of specialities. Key Words Pelvic fractures Eur J Trauma 2005;31:526–35 DOI 10.1007/s00068-005-2111-z

William the Conqueror – William 1 of England William the Conqueror was a brave and successful warrior but suffered from a very modern affliction i.e., he was grossly obese (Figure 1). In 1087 his wife became frustrated by his size and sent him to a clinic in Rouen to lose weight. On his way he was involved in a skirmish – apparently William could not resist a fight! It is reported that during the course of the small battle, his horse lost its footing and his pelvis was driven against the pummel of his saddle. It was originally reported that he had ruptured his testicle [1]. 5 weeks later he died of septic complications. Probably the scenario was not quite as described. The collision of a heavy man against the pummel of a 1

saddle (or more commonly in the 21st century the tank of a motorcycle) will disrupt the anterior pelvic ring. These injuries are commonly associated with significant genitourinary trauma. Therefore William supposedly sustained a symphyseal separation and bled into his scrotum. The external appearance of swelling and hematoma would have led his Norman doctors to conclude that he had ruptured a testicle. Although a painful condition, it is unusual for such an injury to cause death. A more logical explanation seems to be that William sustained an “internal open pelvic fracture” with disruption of his urethra or bladder. The retroperitoneal hematoma became contaminated leading to his demise from secondary septicemia 5 weeks later. Introduction An open pelvic fracture is a life-threatening injury and challenges any form of system no matter how sophisticated it may be. The patient’s life is immediately under threat from hemorrhage and only younger patients will survive such trauma. Early mismanagement will lead to rapid death from bleeding. In survivors the consequences of poor early decision making can result in months of sepsis, pain and misery. At the center of the problem is the fact that open pelvic fractures represent a spectrum of injury ranging from mild skin grazes that expose the iliac crest through to fractures and dislocations with massive soft-tissue destruction often involving the bowel and bladder and other internal organs. The literature is littered with small studies which draw sweeping conclusions that are tinged with professional and local bias. If a unit has an enthusiastic angiographer available at all times, then their hemorrhage control protocol will be very different to that where such a facility is not available [2]. Likewise if there is a local urologist who believes in one particular method of urologic treatment, then the relevant protocols will be geared toward that mode of treatment [3].

St. Georges Hospital – Orthopaedics, London, UK.

Received: September 14, 2005; revision accepted: October 16, 2005.

European Journal of Trauma 2005 · No. 6 © Urban & Vogel

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Bircher M. Open Pelvic Fractures

Figure 1. William the Conqueror and his trusty steed cracking a few English skulls. N.B. The high pommel of the saddle. I believe Henry was considerably heavier than this when he died in 1087.

When looking at the literature it is important to know whether publications are coming from institutions that take direct referrals or those that only receive patients on a secondary or tertiary basis. Primary “off the street” referrals will include more seriously injured patients. The type of patient that arrives at a primary referral unit will also vary considerably from system to system depending on the sophistication of emergency services and transportation time. Patients whose early management has been delayed or compromised will have to undergo treatment that has to be modified to adapt and deal with septic complications. What is certain is that open pelvic fractures pose a major short-term challenge to the treating team but will also leave the patient with some form of ongoing permanent disability and will result in a large number of patients never returning to work. Management strategies have changed little over the last 2 decades and it is still difficult to extract from the literature an ideal treatment pathway or management protocol. These injuries are so rare and diverse that the only way forward would be to collect data in a large multicenter European study (Euro TARN). Incidence and Mechanism of Injury There is no study from any country that accurately defines the true incidence of open pelvic fractures. Many figures are quoted, the commonest being that open pelvic fractures represent 2–4% of all pelvic injuries [4]. The way these figures are calculated, particularly within the UK, has to be viewed with great caution. Within the UK high-energy complex open pelvic fractures are clas-


sified together with stable pelvic ring fractures in the elderly. The true incidence therefore is lost within an unsophisticated coding system. Another significant problem is the actual definition of an open pelvic fracture. It can be impossible to diagnose an open pelvic fracture on initial reception in the emergency room. Some open fractures are obvious but injuries that involve the bladder or bowel may have no external wounds. This is why one should consider an open pelvic fracture as one where there is connection between the fracture site and either the skin, rectum, vagina or genitourinary system (Figure 2). It has long been appreciated in long bone fractures that the initial grading done in the emergency department often requires modification following the first debridement. The same is true of open pelvic fractures. At initial presentation it is exceptionally difficult to accurately define the extent of the soft-tissue injury. Complex investigations as well as operations and contrast studies may be required to provide a final accurate assessment. Large perineal lacerations and splits are obvious as long as the perineum is inspected but “internal open injuries” may not be apparent. These occur when bone fragments are driven across structures like the urethra or bladder or when sacral fractures are sheered vertically and involve the rectum and sigmoid colon. It is, however, important to recognize that these open fractures immediately require a wider multidisciplinary team for treatment and have potential for much poorer outcomes. Within the German multicenter trial published in 1996 [5] there were 1,722 patients with an overall mortality of 7.9%. The number of open pelvic fractures was difficult to know as the authors used the expression “complex pelvic trauma”. This was quoted at 21% and would have included the open fractures. Clearly the incidence of open pelvic fractures is not that high but the author believes that open injuries are underreported. Within the UK the incidence of true open pelvic fractures is probably lower than that in Germany due to the fact that the UK transportation system from the accident scene to hospital is slow. Many of the more serious fractures at the top end of the spectrum will not survive to reach the accident departments. Classic mechanisms of injury will invariably involve high-energy trauma. Motorcyclists are particularly vulnerable. The classic injury that a motorcyclist may sustain is where he or she is thrown from their vehicle and their lower limb strikes an immovable object. The limb

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a

b

c

Figures 2a to 2c. a) Ordinary AP X-ray of a lady who fell from a horse. She had had polio and sustained a lateral compression injury. Note the minor anterior pelvic fractures. b) Image intensifier film taken in the operating room. Note the spike bone protruding from the left side. c) Cystoscopy of same patient. This is a piece of periosteum sticking through the bladder wall attached to the superior pubic ramus.

is forcibly abducted leading to sheering and tearing of the perineum combined with disruption of the symphysis and sacroiliac joint. This is often described as an internal hemipelvectomy and leads to massive bleeding [6]. A small subgroup of motorcyclists, particularly men, sustain anterior pelvic injuries on the petrol tanks with disruption of the urethra and/or bladder [7]. This secondary group are more at risk of late septic complications. Suicide attempts and falls from great heights produce major fracture displacements which often can involve the posterior sacral skin. The classic H-fracture of the suicide jumper often has degloved skin. This can break down in hospital and lead to a secondary open fracture. The worst mechanism of injury involves crush injuries to the pelvis. In the UK there are still a significant number of serious injuries on building sites which produce bizarre fracturing of the pelvic ring and internal organ disruption. There is usually associated lumbosacral nerve damage and associated comminuted acetabular fractures are often seen on X-ray. Penetrating trauma is becoming more common within Europe but management strategies are very different to that of blunt trauma. Treatment is based on the anatomic location of the injury and the trajectory and velocity of the missile. Skeletal instability is rare but soft-tissue contamination is common, if wounds are not properly managed. It is also reported that open pelvic fractures in children are more common than in adults [8]. The high incidence reported in children reflects potentially that the data is not contaminated with low-energy fracture numbers, which is the case with the adult literature.

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Mortality and Morbidity In the 1970s the quoted mortality of an open pelvic fracture was said to be around 50% [9]. This has thankfully declined and reported rates through the 1990s have dropped to as low as 4.8% [10] but an overall rate of 25% is accepted as the norm. Early death from uncontrolled hemorrhage, head injury and mediastinal rupture, occurs within the first few hours. There is a second peak some weeks later when patients are overwhelmed with multi-organ failure and sepsis. The data on mortality must be studied carefully. A modern primary trauma center within a rapid retrieval system may receive many patients with high injury severity scores. The center may have an unusually high early mortality rate. In centers where transportation times are much longer (or those units working as a secondary referral center), the early mortality may be low. This may, however, be balanced by the fact that they will have a higher peak of death a number of weeks down the line due to septic complications. They may also have poorer long-term outcomes in their survivors. As with any other major musculoskeletal injury death is rarely directly attributable due to the pelvic fracture. In the German multicenter trial it was calculated that the mortality attached to a closed pelvic fracture was as low as 1–2% [5]. An open pelvic fracture, however, will have a much more significant and direct effect on mortality. The residual morbidity as a result of the pelvic ring injury will be associated with both the fracture and the soft-tissue injury. The morbidity attached to the fracture of the pelvic ring is related to areas of mal- or nonunion, leg length discrepancy and pelvic obliquity leading to difficulties with sitting and pain. Chronic pain



may be related to the skeleton but is more commonly due to the crushing of nerves and other soft-tissue structures. Treatment strategies to limit the morbidity associated with the bony injury are relatively straightforward. The primary aim of treatment will focus on anatomic reduction of the skeleton to encourage early union of fractures. The problem is made more difficult with open pelvic fractures in that there is a reluctance to use internal fixation techniques when there is significant contamination. When less rigid internal fixation techniques are used, skeletal stability and healing are less likely to be predictable. The morbidity attached to the soft-tissue injuries includes chronic sepsis, wound dehiscence, skin breakdown, pressure sores and the requirement for multiple plastic surgery procedures. Stable reduction of the skeleton provides the best environment for nerve recovery. There is a high incidence of impotence and sexual dysfunction and in women there is evidence that these patients suffer significant long-term pelvic floor laxity [11]. In the past, Slatis & Huittinen reported lumbosacral

nerve injury rates approaching 50% for bilateral vertical sheer fractures [12]. Although they did not specifically separate the open fractures, within the subgroup of crushed pelvises, the lumbosacral nerve injury rate is even higher. Nerves rarely recover and chronic pain, weakness, paralysis and problems with walking are all too common sequelae. No matter how expert the early management is, patients must be prepared for a number of significant operations and an outcome that cannot be really predicted for 2–3 years. Very few patients return to normality following an open pelvic fracture.

Classification A good classification should help the treating team decide on the management strategy and hopefully give the doctors, the patient and their families some idea of the prognosis and what to expect. Classifications should allow similar groups of patients to be studied to make comparison and assessment of the success of treatment modalities. In the past many classifications have not done this. The open pelvic fracture is Table 1. New assessment system. There are three major groups, A, B and C, which are further probably the best example of classisubdivided into three further sections. In assessing the open pelvic fracture there is a classic fication deficiencies. primary skin lesion with associated other soft-tissue intrapelvic damage. There is also an asThere are excellent classificasociation between the type of soft-tissue injury and the associated bony injury. Although not tested prospectively, this system attempts to define a spectrum of injury from the less serious tion systems defining the bony inju“A” subgroups to the most potentially lethal “C” type injury [14]. ry, e.g., Tile & Burgess [16]. Classifications that have focused on the Open Primary skin lesion Additional soft-tissue injury Bony Tile/A0 classification soft-tissue injury have not associated it with the bony trauma [13]. It is for A1 Penetrating trauma, Dependent on velocity, character of A this reason that a new classification e.g., bullet missile and its path that recognized the spectrum of the A2 “Outside in” injury Superficial skin abrasion A injury to the bone and associated (iliac crest) A3 “Outside in” injury Extensive skin loss and soft-tissue A soft tissues has been proposed. This damage. Soft-tissue cover needed is based on experience over 20 years B1 “Inside out” injury No obvious external soft-tissue B (lateral with a small number of open fracdamage. Bladder, urethral or vaginal compression) tures [14] (Table 1). What has been penetration noted is that there is an association B2 “Inside out” injury Extensive degloving tissues (MorelB (lateral Lavalle). Bladder penetration compression) between the type of skeletal injury, B3 Perineal splits Partial GU injury. Relatively little B (open book) the vector of force and the soft-tissue skin loss. Partial urethral injury. trauma. However, with crush injuPosterior elements often intact ries and penetrating trauma, any C1 Perineal and sacral shear Some skin loss. Bladder/urethral C and split complete lesion. Fecal contamination form of soft-tissue injury is possible. C2 Hemipelvis destabilization Extensive degloving and shearing of C It is for this reason that these subtissues. A continuation of a B2 groups of open pelvic fractures are injury with complete GU lesions, bowel laceration with fecal contamination put at the beginning and end of the C3 Pelvic crush Massive soft-tissue injury both inside C classification. The system requires and out. Complex comminuted bony further evaluation but hopefully, the damage (associated acetabular fractures) formation of a paneuropean Pelvic


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a

b

Figures 3a and 3b. a) Open pelvic crush fracture. Notice the bizarre fracturing and the soft-tissue disruption with gas in the soft tissues. b) Open pelvic fracture with symphyseal separation and sacroiliac injury. Note the subtle gas shadows along the left pelvic brim.

Society over the next few years will allow meaningful data collection and an assessment as to whether or not this type of classification is really useful. This classification is a good starting point and brings together both the soft-tissue and bony injury and recognizes the importance of the open pelvic fracture that can be internal or external. The Ideal Management Scenario Facing a serious open pelvic fracture, i.e., a patient with hemodynamic instability, an unstable pelvic injury with involvement of the bladder and/or bowel, immediate resuscitation protocols must kick into action (Figure 3). The fact that there is an open pelvic fracture immediately complicates the situation and a multidisciplinary team needs to be assembled rapidly. Assuming that an ATLS (Advanced Trauma Life Support) protocol is under way, specific initial management of the open pelvic fracture will involve the general and orthopedic surgeons. There is, however, a requirement at a very early stage, for plastic surgery and urologic input. Radiologists need to be co-opted and involved after the initial primary survey. Such teams unfortunately are rarely put together and quite often, within a stretched health care system, there are not enough senior members of every speciality available. However, the key to success in the treatment of an open pelvic fracture is an experienced balanced multidisciplinary team making rapid decisions. If a team is dominated by one particular speciality then problems will often arise from neglect of the other un-

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derrepresented systems. An ideal scenario would be as follows: Following the injury, patients should be rapidly stabilized and transported to a tertiary center experienced in managing such injuries. Any life-saving procedures that need to be undertaken in the field would have been done. Intravenous access would have been obtained and temporary stabilization of the patient either with sheets, belts or bean-bags would have been undertaken. On arrival a full ATLS protocol should be followed with the main focus on dealing with associated injuries and in particular the circulation. Following establishment of airway and breathing with cervical spine control, any other life-saving procedures should be undertaken including insertion of chest drains. At the same time another team should be working on the pelvis and performing an inspection of the perineum with a macro-debridement removing any foreign debris that is contaminating the area. The patients will have often arrived with their legs tied together, the perineum being hidden. The perineum and posterior skin needs to be inspected at an early stage but this will depend on the situation with the circulation. Unfortunately, many patients arrive at UK centers with unstable pelvic fractures with their legs still spread apart. Bandaging the knees together with a simple crepe bandage often will reduce the pelvis temporarily and assist with hemorrhage control. If there is an open wound in the perineum, then an opportunity should be rapidly undertaken to inspect the anus and carry out a rectal examination. Likewise, a



vaginal inspection is always necessary. The results of such investigations should be noted and the patient’s legs should be approximated after the macro-debridement and insertion of antiseptic coated swabs. Tetanus toxoid cover and broad-spectrum antibiotics should be given. After further inspection of the rest of the skin at the front and back of the pelvis some form of pelvic binder can be applied on a more permanent basis. When these are not available some form of emergency clamp should be applied. It is obviously important at an early stage to measure the urine output. Here there is an early major clinical dilemma. All patients with a displaced pelvic fracture will have swollen scrotum or labia. It is also almost impossible in the acute situation to feel a high-riding prostate. As long as there is no blood at the meatus, it is quite reasonable in this situation to attempt gentle urethral catheterization. No force must be used and introducers are contraindicated. If the catheter passes, then the situation is greatly simplified. However, just because a catheter is successfully draining the bladder does not mean that the urethra or bladder neck is intact. Later on during treatment a peri-catheter urethrogram should be performed to define the integrity of the urethra. We have reported five patients who had partial urethral tears where catheters passed quite normally in the trauma room [15]. If catheterization fails, then it should be abandoned and it should be assumed that the patient has some form of urethral injury. If the patient is stable, then contrast studies can be organized. A suprapubic catheter will be required. It can be exceptionally difficult to insert a suprapubic catheter especially in the situation where there is bladder disruption. The bladder will be empty and there is usually a large anterior hematoma which makes identification of anatomic structures challenging. The insertion of a suprapubic catheter needs to be undertaken by an experienced urologist. Cooperation between the urologist and orthopedic surgeon needs to be immediate and early. Once the bladder has been drained, either via the urethra or suprapubic route, then they will need to discuss at an early stage what form of definitive urologic treatment is going to be undertaken and how the anterior pelvic injury will be definitively stabilized. In the past diagnostic peritoneal lavage was advocated but has been largely superseded by abdominal ultrasound. This is extremely user-dependent and many institutions do not have radiologists immediately available. An inappropriate laparotomy in this situation per-


formed on an unstable patient can tip the balance and lead to sudden exsanguinating hemorrhagic death. If a patient is not responding to resuscitative methods with no other sites of bleeding, other than the pelvis, external fixation combined with laparotomy and packing of the true pelvis can be life-saving. Treatment protocols are available for the management of such difficult patients [4]. In the more extreme circumstances, in an attempt to save life, temporary cross clamping of the aorta may be undertaken. The early decision making is vitally important and hence the need for senior input. If an emergency laparotomy is undertaken, it is important that the orthopedic surgeon be there at the time of toweling and draping with the general surgeon. General surgeons in the UK and USA performing a laparotomy, usually drape the patient perhaps 5–6 cm above the suprapubic area. It is essential that the orthopedic surgeon has access to the pubic symphysis. If contamination is not severe, just by extending the incision inferiorly, a plate or percutaneous screws or a combination of both can be used to stabilize the anterior pelvic ring. The emergency application of a temporary clamp across the symphysis can assist in hemorrhage control. If the patient becomes hemodynamically stable, then the posterior skeletal injury can be treated with percutaneous screws, if sufficient expertise is available. Skeletal stabilization can be obtained and maintained at a very early stage leading to a better environment for soft-tissue recovery. If there is a bowel injury, then fecal diversion needs to be undertaken immediately. If there is a significant wound in the perineum, one must still do a diverting colostomy. Contamination of the wound will inevitably occur and lead to sepsis and a potentially disastrous scenario. An end-colostomy seems preferable but people have advocated a loop diversion. This is technically easier to reverse. Whatever type of colostomy is performed, it must be brought out high and well away from the iliac crest so as not to interfere with surgical sites for secondary pelvic and acetabular reconstruction. It is essential, following the performance of a colostomy, that the distal loop is washed out (Figure 4). This needs to be done with liters and liters of saline. If there is a large rectal defect, great care must be taken in washing out the distal loop. It is possible to flush feces through the rectal wound into the soft tissues. Following diversion of the bowel and urine and other life-saving procedures, thorough debridement and irrigation of the wounds needs to be undertaken. If

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tion. Most of the dissection has usually occurred at the time of the injury. It is also important that the patients are nursed properly. The posterior soft tissues are very fragile and patients need to be turned and moved regularly to prevent the development of pressure sores. Special mattresses need to be used. It is for this reason that early stabilization of the skeleton should be undertaken to assist our nursing colleagues.

Figure 4. Intraoperative picture of patient in Figure 3b. There was a missed perianal laceration. A laparotomy has been performed and a colostomy is being fashioned. The distal loop is being washed out. Following further debridement the incision was extended a few centimeters inferiorly and the symphysis was plated.

packing has been required to control bleeding, then these will be removed in the operating room between 24–48 h. A second debridement will be required. Further management then follows along standard lines depending on the management decisions made by the plastic surgeons, urologists, general surgeons and orthopedic team. If skeletal stabilization has not been undertaken at an early stage and binders are still in position, then further imaging may need to be undertaken. During the initial assessment, a spiral CT would have been done (as long as the patient has a stable blood pressure). It is essential that stable internal fixation should be considered at a very early stage, as this does give the best environment for soft-tissue healing. In the past external fixation and traction has been advocated but fracture fragments still move significantly with this form of stabilization. Internal fixation can be performed with very little further soft-tissue dissec-

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Pitfalls and Delays The Missed Open Fracture Vaginal laceration or penetration is commonly missed. It is usually associated with less severe anterior pelvic fractures. Local sepsis is distressing for the patient but rarely leads to early mortality. More serious open pelvic fractures are missed much more rarely nowadays. Patients who receive good early first aid management who arrive with their legs bound together may not have had a thorough inspection of their perineum. With significant open pelvic disruption there are large dead spaces filled with blood which are ideal culture mediums for bacteria. Infection is exceptionally difficult to eradicate and the price of missing such an injury is high. With a long bone fracture amputation is an option but it is rare to obtain a successful outcome with significant fecal contamination of the pelvic basin. Missed Genitourinary Injuries Again these usually occur with the less serious lateral compression type injuries where injuries are underestimated. If urine is allowed to leak, chronic infection will persist even with the chances of a later development of an infected acetabular fracture. If a potential laceration of the genitourinary system is not taken into account, investigated and any injury in the early part of the management excluded, then these injuries will be missed from time to time. Areas of Controversy Hemorrhage Control In the past, the thought of performing a laparotomy on a patient with a pelvic fracture, was thought to be heresy. This was, however, the situation in the 1960s and 1970s and is not the case now. Today, different sorts of patients are dealt with who are arriving faster from the scene of the accident. Standard hemorrhage control involving keeping the patient still and applying a binder or some form of fixators is usually effective. In patients



that are not responsive then temporary skeletal stabilization, laparotomy and packing the true pelvis, is their only chance. This requires high-level decision making and experience. In some centers angiography is advocated for hemorrhage control. In most institutions, by the time the angiography team has been assembled, the patient will have died from hypovolemic shock. In most centers, angiography is reserved for “tricklers”, i.e., those patients who are hemodynamically fragile but temporarily stable and require blood products on a fairly regular basis over a 24-h period. In centers where angiography is available 24 h a day, 7 days a week, then there will be a role in the early management for angiography. The Genitourinary System At all stages, the management of genitourinary lesions seems to be controversial [3]. Options for management of the urethral injury include primary repair, primary alignment and suprapubic drainage with delayed reconstruction. It seems that primary repair first of all is not appropriate in the early stages and requires a high level of expertise. There seems to be a higher increased risk of sepsis and impotence using this strategy. It is for this reason that there have been recent advocates for primary realignment only. Other units seem to suggest that the best outcomes are being achieved with suprapubic diversion followed by later reconstruction. For any of these strategies to be successful, the pelvic ring must be reduced as perfectly as possible. Large pelvic displacements will not allow the soft tissues to heal and will inevitably lead to longer stricture formation and greater difficulties in secondary urologic reconstruction. A coordinated combined urologic and orthopedic approach should be adopted with the primary goal initially being the measurement of urine output and the second goal being the reduction of the skeleton leading to fracture healing followed by later genitourinary reconstruction. Whether this reconstruction is undertaken in the first few weeks or first few months, very much depends on the urologic advice received at the time. If a suprapubic catheter is inserted without consultation with the orthopedic surgeon and becomes contaminated, definitive reconstruction has a high incidence of sepsis. The sooner the definitive reconstruction is performed when there is a suprapubic catheter in position, the better. A suprapubic catheter can be inserted in such a way to be tunneled well away from suprapubic incisions. Fixation of the symphysis in the acute situation will make access to


the bladder neck and urethra much more awkward for the urologist. A protocol for the management of genitourinary injuries in conjunction with the skeleton should be established and working prior to the arrival of the patient. Internal Fixation In the past internal fixation was controversial and was thought to increase the risk of sepsis. Clearly in the presence of gross fecal contamination with severe soft-tissue disruption early internal fixation may not be indicated. Anterior plating and screws can usually be undertaken without a great deal of further soft-tissue dissection and posterior injuries can often be treated with percutaneous screws. The timing of internal fixation is also controversial. If senior expertise is available, then the earlier it is done the better. Once debridements have rendered areas clean, then internal fixation should not be delayed. There are issues regarding “the second-hit phenomenon”. It is for this reason that with these very unstable skeletal injuries, early expert internal fixation should be undertaken. Having to delay reconstruction for 2–3 weeks removes many of the potential techniques of skeletal reduction and fixation from the treating orthopedic team. Complex acetabular fracture reconstruction should again be undertaken as soon as possible. However, in this situation delay may be necessary as the surgical exposure for acetabular reconstruction is often extensive and the soft tissues can be unpredictable in the early stages. The Late Case Scenario These can be the most difficult challenges within orthopedics. Problems can be divided into septic, skeletal, and soft tissue. Septic Problems These patients, although septic, are the survivors. Urine and feces need to be diverted, if not already carried out. If such procedures have been undertaken but sepsis persists, then further investigations need to be carried out to make sure that diversion is complete. Secondary genitourinary leaks are common. Following the confirmation of successful diversion, further aggressive debridements are necessary. The use of suction dressings may reduce the size of defects. Rotation flaps and muscle transfers can reduce the size and extent of the septic problems. Patients who have been crushed or under-

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gone laparotomies have less options for local muscle flap rotation due to disruption of the local blood supply. Skeletal Problems The major skeletal issue with late presentation is upward migration of the hemipelvis, leg length inequality and problems associated with sitting. If fractures are left to heal in a malrotated and malreduced position, it is impossible to reduce them perfectly at a later date. The state of the soft tissues and the extent of scarring will always influence the point in time when delayed reconstruction can be carried out, but it should be done as early as possible. Strategies involve releases at the front and back of the pelvis with anterior and posterior stabilization. These usually require a three-stage single operation. With less severe deformities associated with chronic pain, anterior and posterior arthrodesis in situ may salvage the situation. If a patient is paralyzed and wheelchair-bound, it is very important to balance the ischial tuberosities to facilitate comfortable sitting. Soft-Tissue Complications a) Lumbosacral nerve injuries rarely recover, and if there is a persistent foot drop, soft-tissue or bony procedures can be undertaken on the foot and ankle to try and improve gait. Patients often elect to just use orthoses but great care must be applied when recommending these. Areas of sensitive skin are very prone to breakdown and ulcer formation. b) Even with successful early treatment some form of delayed genitourinary surgery is required. Ongoing sepsis will delay reconstructive surgery. A high proportion of young men would remain impotent. c) Colostomies need to be closed as soon as possible. Young trauma victims dislike colostomies but assessment of the competence of the anal sphincters is necessary before closure. All areas need to be dry and infection-free. d) The formation of incisional, inguinal and posterior wall hernias is not uncommon. They are usually the result of crushing injuries but can also be a result of surgical procedures. These can be identified early and treated with muscle transfers and/or mesh. e) The protrusion of bone into the vagina is rare but occurs after anterior pelvic tilt fractures that had been left unreduced (Figure 5). Treatment strategies to reduce the rami using periacetabular osteotomies can

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Figure 5. AP pelvis. “Tilt type” fracture with lateral compression injury of the right hemipelvis. Superior and inferior pubic ramus fractures show tilting and protrusion of bone into the vaginal vault on the right side.

be performed. Alternatively, a more simple transvaginal resection of bone can provide symptomatic relief. Conclusion An open pelvic fracture seriously challenges trauma systems, doctors and patients. The open nature of the pelvic injury needs to be recognized early and immediate involvement of all specialities at a senior level will undoubtedly allow for a robust treatment plan to be rapidly formulated. This must lead to a better outcome. A large multicentered data collection is necessary in order to assess the spectrum of injury, the efficacy of treatment and its influence on outcome.

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9. Perry JP. Open pelvic fractures. Clin Orthop 1980;151:12–22. 10. Davidson BS, Simmons GT, Williamson PR, et al. Pelvic fractures with open perineal wounds: a survivable injury. J Trauma 1993;35:36–9. 11. Baessler K, Stanton SL, Bircher MD. Pelvic floor dysfunction in women after pelvic trauma. Int J Eurogynaecol Pelvic Floor Dysfunc 2001;12:Suppl 3:214. 12. Slatis P, Huittinen VM. Double vertical fractures of the pelvis: a report on 160 patients. Acta Clin Scand 1972;138:799. 13. Faringer PD, Mullins RJ, Feliciano PD, et al. Selective fecal diversion in complex open pelvic fractures from blunt trauma. Arch Surg 1994;129:958–63. 14. Bircher M, Hargrove R. Is it possible to classify open fractures of the pelvis? Eur J Trauma 2004;30:74–80. 15. Dunstan E, Bircher M. Urological pitfalls in unstable pelvic fractures. Injury 2000;31:379–83. 16. Tile M, Burgess A. Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg 1996;4:143–51.


Address for Correspondence Martin Bircher St. Georges Hospital – Orthopaedics Blackshaw Road Tooting London SW178QT UK Phone (+44/208) 725-3241 e-mail: [email protected]

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