Dealing with unstable pelvic fractures and mangled extremities

Thus far in 2010, earthquakes in Haiti, Chile, China, and Mexico (Baja California) have exposed many volunteer orthopaedists to conditions and situations not frequently seen in a private practice. Some of these injuries, however, are similar to those incurred in combat, and military orthopaedists have developed guidelines that can help the general orthopaedist make quality decisions when confronted with unusual trauma.

Saving a life
“Hemodynamically unstable pelvic fracture is one of the few injuries that can really get our blood pressure up as the patient’s blood pressure is falling,” explained Lt. Col. Michael T. Charlton, MD, USAF. “I hope to demystify the one injury in which we as orthopaedists can, with our actions, save a life.”

The first things to keep in mind, he said, are approaching the fracture in a systematic and methodical manner and maintaining good communication among all the different services involved. To that end, he encourages all surgeons to seek out the institutional protocols at their own hospitals regarding such injuries, and if there aren’t any, to take steps to put a protocol into place.

A series of questions can be used to guide the orthopaedist to the proper course of action. Asking questions such as, “Did the patient improve following provisional stabilization?” and, “Is the injury from a high energy or low energy mechanism?” can help the surgeon assess the patient’s condition in a methodical manner.

“As orthopaedic surgeons, our primary role in the trauma bay is to assess that pelvic fracture first,” he said. “The general surgeons and the trauma surgeons are dealing with advanced trauma life support and performing other lifesaving maneuvers. But as orthopaedic surgeons, the one thing that we can contribute in the immediate period following a traumatic pelvic ring injury is to stabilize it.”

Stabilization is usually done using a sheet or a binder, but it’s important to remember that sheets and binders can lead to necrosis during prolonged use.

“If the patient continues to be hemodynamically unstable after placement of the sheet or binder, you have to determine whether an arterial injury could be the cause of the ongoing bleeding,” he explained.

If so, he said, the surgeon can address the situation surgically, with retroperitoneal packing, or using a minimally invasive approach such as embolization. According to Dr. Charlton, both are viable options.

“If the patient is going to the operating room anyway for another injury that the general surgeon will be dealing with—either an abdominal or intrathoracic injury—the orthopaedist is probably the best suited to do retroperitoneal packing in conjunction with other lifesaving surgical procedures,” he said. “But if the patient has no other injuries, and the pelvic injury is thought to be the cause of the ongoing bleeding, and the institutional resources are available for an expedient angiography, then a minimally invasive approach is appropriate.”

“Make yourself small”
According to MAJ Joseph R. Hsu, MD, the patient’s physiology should be the orthopaedist’s primary concern in an acute trauma situation.

“As orthopaedic surgeons, we tend to consider anatomy first,” he said. “Even though a patient could be dying, we may be thinking, ‘How can we salvage the limb?’ But you have to save the patient before anything else.”

To that end, Dr. Hsu offers a lesson he learned from working in a military setting: Make yourself small, by staying out of the way of the critical care surgeon and his or her team, and taking up as little space and as few resources as possible in the operating room.

“If the patient has a combined vascular and orthopaedic injury, there are often turf battles over who should go first—the vascular surgeon or the orthopaedic surgeon,” he said. “Do you reperfuse the limb, or do you stabilize it first? In the military, we have learned to all go together. As the orthopaedic surgeon, however, you have to make yourself small. Although the orthopaedic procedures may end up ultimately driving the patient’s functional outcome, the patient won’t have a chance at any outcome if the general and vascular surgeons aren’t able to do their jobs.”

Dr. Hsu explained that, although patients will live or die based on their head, chest, and abdominal injuries, extremity injuries account for the greatest proportion of disabilities in those who survive. Therefore, one of the most difficult decisions an orthopaedic surgeon may make in an acute setting is whether or not to salvage an injured limb. If the patient cannot be resuscitated to the point where limb reconstruction is possible, amputation may be necessary. Another factor that may affect the decision to amputate is the condition of the terminal extremity.

“This is my opinion only,” he said. “The main anatomical concern for me—with limb salvage—is the terminal extremity. If the patient won’t have a good hand or a good foot, then limb salvage may not be worthwhile.

“The hand is very different from the foot. A partial terminal extremity for the hand is still very useful, even if it’s just two fingers. But if the patient won’t have a useable foot; if the foot itself is not going to be a good weight-bearing extremity…that’s a concern. Other factors that may have affected the decision to salvage in the past—such as bone and muscle loss, or sensation—aren’t as great a challenge now, according to the evidence.”

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Editor’s Note: This is the second article covering the symposium on “Damage Control for the General Orthopaedic Surgeon: Getting Your Patient Safely to the Traumatologist,” which was held at the 2010 AAOS Annual Meeting. The previous article focused on issues surrounding open fractures and compartment syndrome.