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Treat pelvic, acetabular fractures carefully to reduce liability risk

By Douglas W. Lundy, MD, and James P. Stannard, MD

To many orthopaedic surgeons, the mere mention of pelvic or acetabular fractures gives rise to images of severe trauma such as a motorcyclist with a badly displaced both-column acetabular fracture, or a patient in hypovolemic shock due to an open-book pelvic fracture or other traumatic injuries.

Orthopaedic surgeons in private practice rarely see injuries of this magnitude, and they quickly, happily, and appropriately refer such patients to orthopaedic trauma surgeons whenever possible.

The intent of this article, therefore, is not to discuss the esoteric details of these complex fractures, but to review the conundrums associated with the more common pelvic and acetabular fractures seen in emergency departments across the country.

A quick word on the more severe injuries, however, is appropriate. Fortunately, patients with significant pelvic trauma are often transported to a trauma center where they can be treated by a well-prepared team of trauma surgeons and staff. Advanced Trauma Life Support protocols aptly describe the methods of evaluation and resuscitation of trauma patients. Because the hemorrhage associated with an open-book pelvic fracture can be considerable and life-threatening, patients with a severe anteroposterior compression (APC) injury with diastasis of the symphysis and sacroiliac joint(s) should be immediately stabilized, using one of several methods to decrease pelvic volume. These methods include pelvic binders, MAST trousers, a C-clamp, or wrapping a sheet around the pelvis.

Although external fixation is still occasionally used as a “resuscitation frame,” pelvic binders are easily applied and have largely replaced resuscitation frames. In addition, an anteriorly placed external fixator cannot completely control the posterior pelvic ring. Interventional radiologists are becoming much more facile in the use of arteriography for pelvic fractures, and most trauma centers use their services very early in the care of the pelvic-trauma patient in hypovolemic shock.

DVT prophylaxis

One of the most troubling issues in the treatment of pelvic and acetabular fractures is prophylaxis of deep vein thrombosis (DVT). Patients with pelvic and acetabular fractures are at high risk for DVT, and it is imperative that the treating surgeon recognizes this possible condition and its potentially catastrophic outcome. There are no universally accepted guidelines for the use of prophylaxis for DVT in patients with pelvic injuries or for the duration of the prophylactic treatment. The value of routine screening for thrombosis has been questioned as well.

Because the risk for DVT is present, however, the treating surgeon should thoughtfully consider the risks and benefits of prophylaxis and discuss them with the patient. This conversation should be well documented in the medical record.

Many orthopaedic trauma surgeons recommend mechanical prophylaxis (sequential compression devices) prior to surgery to decrease the risks of intra-operative bleeding from pharmacologic DVT prophylaxis. Warfarin sodium or low molecular weight heparin should be initiated postoperatively or when clinically appropriate.

Lateral compression injury

The lateral compression (LC) injury pattern is the most common type of pelvic fracture. This injury is sustained by a lateral force to the iliac wing, causing an internal rotation deformity to the affected hemipelvis. The LC injury is commonly sustained during a “T-bone” motor vehicle collision when the occupant is struck on the side during impact. This injury pattern is less likely to produce uncontrolled hemorrhage than the APC or vertical shear injuries.

LC pelvic injuries are frequently seen in community hospital emergency departments across the country, and they are often treated nonsurgically. Because the internal rotation deformity of the injured hemipelvis may impinge on the bladder and anterior pelvic contents, these injuries should be thoroughly imaged with anteroposterior, inlet, and outlet pelvic radiographs, and CT scans if appropriate. Patients with a significant deformity should be informed of the risks and benefits of open reduction and internal fixation versus nonsurgical treatment.

Posterior wall fracture

Many orthopaedic surgeons who would never consider operating on a badly displaced both-column acetabular fracture may feel comfortable surgically treating a patient with a posterior wall fracture. Interestingly, of the 10 types of acetabular fractures, the posterior wall fracture is often associated with the highest incidence of posttraumatic arthritis.

When operating on a posterior wall acetabular fracture, the surgeon must make certain that the internal fixation is appropriately stabilizing the fracture. At the same time, the surgeon must ensure that the fixation does not penetrate the joint. If the surgeon later detects intra-articular hardware, the patient should be returned to the operating room for screw removal. A screw that is in the bottom of the acetabular fovea, however, may provide excellent stability and will not affect the joint viability.

(Left) This is a patient who was seen after being crushed between two vehicles. He has bilateral sacroiliac injuries with disruption of the symphysis, bilateral acetabular fractures with a left hip dislocation. (Right) This is a both-column acetabular fracture after open reduction and internal fixation.

Dislocated hip

Reduction maneuvers for a dislocated hip should be undertaken as soon as possible within the scope of the patient’s resuscitation. If the patient has medial displacement of the femoral head through a comminuted acetabular fracture, closed reduction and traction should be instituted expeditiously. Postreduction radiographs also should be obtained to document the reduction of the hip.

The treating orthopaedic surgeon should take care to document the presence or absence of nerve function prior to and after the reduction of a dislocated hip. Because these patients are often in significant pain and may have concomitant injuries that distract from the recognition of nerve injury, the status of nerve function should be well documented in the medical record. The sciatic nerve should be carefully protected during the posterior approach and reduction of posterior acetabular fractures.

Assess the situation, refer when needed

Closed acetabular fractures without associated irreducible hip dislocations and pelvic fractures in hemodynamically stable patients are generally not surgical emergencies. The trauma surgeon should be afforded whatever time neces sary to evaluate the patient and maximize the overall medical status. The treating orthopaedic surgeon should assess both the patient’s injury as well as his or her own ability to successfully operate on the injury in the hospital system in which the surgeon practices. If the patient’s interests are best served by transferring the patient to an orthopaedic surgeon who specializes in pelvic trauma surgery, such a referral is entirely appropriate, providing that the initial surgeon has instituted “first aid” treatment and resuscitation.

In our experience, patients are extremely appreciative of the orthopaedic surgeon who first stabilized their pelvic injury, and they understand the importance of initial emergency fracture care. Pelvic and acetabular fractures can be among the most challenging injuries to treat. Surgeons who are uncomfortable with treating these types of fractures should therefore be encouraged to transfer the patients appropriately.

References

Borer DS, Starr AJ, Reinert CM, Rao AV, Weatherall P, Thompson D, Champine J, Jones AL. The effect of screening for deep vein thrombosis on the prevalence of pulmonary embolism in patients with fractures of the pelvis or acetabulum: A review of 973 patients. J Orthop Trauma 2005;19:92-95.

Matta JM.: Fractures of the acetabulum: Accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78:1632-1645.

Douglas W. Lundy, MD, is a member of the AAOS Medical Liability Committee and practices at Resurgens Orthopaedics in Atlanta.

James P. Stannard, MD, is Professor and Chief, Section of Orthopaedic Trauma, Department of Surgery, University of Alabama at Birmingham.

Mar/Apr 2007 AAOS Now
http://www.aaos.org/news/bulletin/marapr07/managing10.asp