Drew A. Bednar, M.D., FRCSC,
Division of Orthopaedic Surgery, Department of Surgery, Faculty of Health Sciences
McMaster University
Hamilton, ON

Introduction
Open fractures of the pelvis are devastating injuries. Traditional orthopaedic teaching^1,2,3 holds that the mortality rate in this injury is approximately 50%. Early pelvic ring closure and primary diversional colostomy are proposed as the primary required elements of care needed to optimize survival.  

Fractures of the pelvis are rare, comprising only 3%⁴ of fracture injuries. Open pelvic fractures represent only 0.6%⁵ of these, being rare enough lesions to have escaped discussion in the most recent AO manual^4,5.

The literature on management of open pelvic fractures is limited. A Medline search on this topic specifically tailored to eliminate the term "book" as in "open book" in January 2003 produced only 28 references^6-33.

This literature suggests that, while the principles of primary pelvic ring closure and early diversional colostomy are strongly supported, early vascular intervention may in fact be the key to survival for many hemodynamically unstable open pelvic fracture patients.

What does the Literature Say - 1970's and 1980's
The first cohort series of open pelvic fractures is that of Raffa and Christensen6,who in 1976 reported on 26 cases treated from 1965-1975 at UCSF. Their Introduction discusses the then-current literature on rectal injury describing good results with early fecal diversion and distal segment washout, referring to anecdotal previous reports of rectal injury associated with pelvic fracture.

They report 26 cases complicated by a variety of vaginal, perineal, rectal, buttock and hip wounds including seven missle wounds and three compound fractures of the ilium. This retrospective report proposes no particular care protocol for these cases and does not mention issues of pelvic volume reduction or osteosynthesis of the pelvis. Eliminating the 10 cases of wounds outside the perineum, they found all 16 of their index cases to have suffered blunt trauma with a frontal (as opposed to lateral) impact mechanism. The complex nature of this extreme trauma is supported by the finding of nine cases of visceral rupture and one ruptured diaphragm in this group, as well as the average requirement for 33.6 units of blood transfusion. They consider this injury to be the result of a forced hyperabduction of the leg stopping just short of traumatic hemipelvectomy (Figure 1) as was first proposed in a case report by Chapman¹⁴ in 1974. All eight with extensive perineal or rectal wounds had primary diversional colostomy and five died. Of the eight with lesser wounds fully three died. There were 81% septic complications.



Next in 1978 is Rothenberg's report⁷ of 22 cases in a series of 604 pelvic fracture cases from Minneapolis St Paul. Again the mortality is 50%. Massive hemorrhage was the major primary cause of death. Suggested treatment includes "identifying and repairing major vessel injury" after primary volume resuscitation.

Rothenberger et al's⁸ later sub-analysis of major vascular injuries associated with pelvic fractures found that the majority of these were pedestrian injuries with open pelvic fractures compounded through the perineum. Common or external iliac veins were disrupted in seven cases, the corresponding arteries in two. Three cases had both arterial and venous disruptions. In no case was there disruption of the internal iliac system. Mortality was 83%. Survivors were salvaged by direct control and /or repair of the vascular injuries.

The next citation is that of Perry⁸ who, in 1980, reported retrospectively on 31 cases treated in Minneapolis-St. Paul from 1970 through 1978. Again this series includes no protocol and no mention of pelvic volume reduction or ORIF. Mortality was 42% (13/31) and included 10 early deaths, five of which were related to vascular injuries and five that were septic. Only two patients had no other major injury. Six (19%) had major vascular injuries involving the common iliac, external iliac, or common femoral vessels. There were an average of 18 units transfused (max. 130) in these patients and 10 of 11 hypogastric artery ligation patients died. In this paper, "Discussions" suggest that proximal (infrarenal) control of the arterial circulation with cross-clamping and controlled distal exploration might be indicated. Angiography is given cursory mention, being recognized as only marginally useful in cases of damage to the greater vessels. "If major vessel injury is suspected on clinical grounds…then surgical exploration and vascular repair are mandatory if survival is to be achieved". To prevent late sepsis, "Patients with perineal, vaginal or rectal lacerations…require diverting colostomy…(and the) distal limb…should be irrigated at the time…"

⁹. These authors describe a graduated approach to the management of hemorrhage (failed packing leading to the application of MAST pants, then on to include angiography if instability or bleeding continued for six hours or more, with hemipelvectomy performed as required) that produced the then-astounding survival rate of 94.5%! Only three cases (less than 10%) required angiography. Two patients could not be stabilized short of hemipelvectomy, and both survived.

In all these articles the suggestion, validated prospectively by Richardson et al, is that a vascular protocol is the key to survival in this most devastating of "orthopaedic" injuries!

Richardson et al's experience confirms the urgency of primary fecal diversion. Of colostomies done within 48 hours of injury only 10% became infected. Delay to 48-72 hours resulted in a 50% infection rate, and colostomy after 72 hours was completely ineffectual (100%). All eight patients presenting with intact but flaccid sphincters in this series regained functional rectal tone.

Treatment of these pelvic fractures was bed rest with pelvic slings applied to correct any diastasis. There was no osteosynthesis. Two patients had external fixators applied to their pelvic ring injuries. This is the first reported application of direct skeletal stabilization in these injuries, and again the "Discussions" in this article are fascinating. The importance of pelvic volume reduction in limiting venous bleeding is recognized, but "…archaic devices such as pelvic slings and things like that…" are argued against in favor of the new fixation devices. Despite this very dated bony care protocol, fully 29 of 35 (80%) of survivors went on to return to work.

By 1982, all the rudiments of a standard care protocol are reported. First, the fracture is recognized by Raffa and Christensen6 as an incomplete traumatic hemipelvectomy with frequently associated major visceral and vascular damage rather than a simple passage of bone through flesh. The importance and key timing of diversional colostomy to prevent sepsis from fecal contamination of major perineal wounds, but not of lesser wounds about the iliac wing or hip, is multiply described^6,8 Control of venous bleeding by direct packing and reduction of pelvic ring volume are standard. The problem of associated major vascular injury is recognized^7,11 and the survival rate is nearly doubled by attention to associated major vascular injuries9.

What does the Literature Say - 1990's
The balance of the literature to date^12-32 serves only to reiterate what is already known. Survival rates and the frequency of sepsis are variable, fluctuating when the lessons of earlier literature may not have been optimally applied. Brenneman et al¹⁹ document the sequelae and compromised late functional outcome of these often devastating injuries.

Bottlang et al³³ have recently addressed the question of whether simply wrapping of the pelvis can effectively reduce pelvic ring volume in a cadaver model, and found good efficacy. This suggests that neither "high-tech" external fixation devices nor early open osteosynthesis are necessary in the acute resuscitation of these injuries.

Conclusion - This May be a Solved Injury!
The literature accordingly suggests an orderly and staged approach to these injuries for optimal survival and the avoidance of pelvic sepsis.

First, recognize that lateral-impact injuries causing direct compounding of the iliac wing or hip area without perineal damage are somewhat lesser injuries than the frontal-impact pathology so well described by Raffa and Christensen⁶. While these are still undoubtedly high-energy injuries requiring aggressive application of ATLS protocol, they are not at risk for late pelvic sepsis and do not generally require diversional colostomy.

In managing the incomplete traumatic hemipelvectomy that true open pelvis fractures represent, first external bleeding from open wounds should be controlled with packing and venous bleeding should be tamponaded by closure of the pelvic ring. Primary pelvic ring displacement in these injuries may be considerable (Figure 2). Pelvic ring closure can be effectively accomplished by application of a simple sling or strap.

ATLS protocol should be applied concomitantly to facilitate the detection and optimal care of associated injuries.

As soon as the patient has been stabilized and any coagulopathy reversed, early diversional colostomy with distal segment washout should be performed.

In cases where relative stability can be achieved but where there is either ongoing bleeding with requirement for continuous transfusions or loss of major distal extremity pulses/perfusion, emergency angiography followed by urgent primary surgical repair of ruptured vessels is indicated.

In cases where hemodynamic stability cannot be achieved, emergency infrarenal aortic cross-clamping may be lifesaving and can facilitate the controlled repair of damaged vascular structures.

References

Massive pubic and pelvic diastasis is common in open pelvic fractures.

Structured care and prospective reporting on open pelvic fractures begin in 1982 with Richardson et al's presentation of 37 cases treated between 1976 and 1981 from Louisville, Kentucky

Figure 1. Hyperabduction mechanism of pelvic injury Illustration from Raffa and Christensen6 showing the frontal impact/limb hyperabduction mechanism of most open pelvis fractures (reproduced with permission).

The "Discussions" in this article, given modern perspective, are truly fascinating. With regard to ongoing bleeding, they advise for the aggressive packing of venous sites and against the direct exploration of arterial bleeding for fear of precipitating catastrophic venous hemorrhage. For "expanding arterial" retroperitoneal hematoma we are advised to close, perform angiography and later return to the OR to attempt arterial vascular control and/or repair, with the probable requirement to split the symphysis pubis to access the hypogastric (internal iliac) artery.

1. Kellam J.F., Browner B.D. Fractures of the Pelvic Ring. In; Browner B.D, Jupiter J.B., Levine A.M., Trafton P.G., eds. Skeletal Trauma. Philadelphia, WB Saunders, 1992, pp. 893-4.
   
   
2. Mears D.C., Rubash H.E. Acute Resuscitation of the Patient with a Pelvic Ring or Acetabular Fracture. In; Mears D.C., Rubash H.E. Pelvic and Acetabular Fractures. Thorofare, New Jersey; Slack, 1986, p. 169.
   
   
3. Bucholz R.W., Claudi B. Complex fractures of the Pelvis. In; Meyers M.H., ed. The Multiply Injured Patient with Complex Fractures. Philadelphia; Lea & Febiger, 1984, p. 208.
   
   
4. Clifford, R.P. Open Fractures. In; Rüedi T.P., and Murray W.M., eds. AO Principles of Fracture Management. Thieme: Stuttgart-New York, 2000.
   
   
5. Pohlemann T. Pelvic Ring Injuries. In; Rüedi T.P., and Murray W.M., eds. AO Principles of Fracture Management. Thieme: Stuttgart-New York, 2000, pp. 391-414.
   
   
6. Raffa J., Christensen N.M. Compound fractures of the pelvis. Am J Surg (1976);132:282-286.
   
   
7. Rothenberger D.A., Velasco R., Strate R., Fischer R.P., Perry J.F. Open pelvic fracture: A lethal injury. J Trauma 1978;18:184-187.
   
   
8. Rothenberger D.A., Fischer R.P., Perry J.F. Major vascular injuries secondary to pelvic fractures: An unsolved clinical problem. Am J Surg 1978:136:660-662.
   
   
9. Perry J.F. Pelvic open fractures. Clin. Orthop. (1980);151:41-49.
   
   
10. Richardson J.D., Harty J., Amin M., Flint L.M. Open pelvic fractures. J Trauma 1982;22(7):533-538.
    
    
11. Chapman M. Management of Pelvic Fractures. West Med J 120:421, 1974.
    
    
12. Leenen L.P., van der Werken C., Schoots F., Goris R.J. Internal fixation of open unstable pelvic fractures. J Trauma-Injury Infection & Critical Care 1993;35(2):220-5.
    
    
13. Jones A.L., Powell J.N., Kellam J.F., McCormack R.G., Dust W., Wimmer P. Open pelvic fractures. A multicenter retrospective analysis. Ortho Clin 28(3):345-50, 1997.
    
    
14. Woods R.K., O'Keefe G., Rhee P., Rout M.L. Jr., Maier R.V. Open Pelvic Fracture and Fecal Diversion. Arch Surg 133(3):281-6, 1998.
    
    
15. Pell M., Flynn W.J., Seibel R.W. Is Colostomy Always Necessary in the Treatment of Open Pelvic Fractures? J Trauma-Injury Infc'n Crit Care 45(2):371-1, 1998.
    
    
16. Rout M.L. Jr., Nork S.E., Mills W.J. High-energy pelvic ring disruptions. Orthop Clinics 2002;33(1):59-72.
    
    
17. Ferrera P.C., Hill D.A. Good outcomes of pelvic fractures. Injury 1999;30(3):187-190.
    
    
18. Rowe V.L., Hughes S., Freeman M.B., Stevens S.L., Enderson B.L., Goldman M.H. Limb ischemia secondary to open pelvic fractures: a rare combination. Tennessee Medicine 1999;92(4):137-9.
    
    
    
19. Brenneman F.D., Katyal D., Boulanger B.R., Tile M., Redelmeier D.A. Long-term outcomes in open pelvic fractures. J Trauma-Injury Infection & Critical Care 1997;42(5):773-7.
    
    
20. Brunicardi F.C., Scalea T.M., Bernstein M.O., Sclafani S.S., Phillips T.F. Air embolism during pulsed saline irrigation of an open pelvic fracture: case report. J Trauma-Injury Infection & Critical Care 1989;29(5):700-1.
    
    
21. Sheldon G.F, Winestock D.P. Hemorrhage from open pelvic fracture controlled intraoperatively with balloon catheter. J Trauma-Injury Infection & Critical Care 1978:18(1):68-70.
    
    
22. Maull K.I., Sachatello C.R., Ernst C.B. The deep perineal laceration - an injury frequently associated with open pelvic fractures: a need for aggressive surgical management. A report of 12 cases and review of the literature. J Trauma-Injury Infection & Critical Care 1977;17(9):685-96.
    
    
23. Henry S.M., Tornetta P. 3rd, Scalea T.M. Damage control for devastating pelvic and extremity injuries. Surg Clin North Amer 1997;77(4):879-95.
    
    
24. Promes J.T., Morris J.A. Jr. Open pelvic fracture: delayed diagnosis. J Tennessee Med Assn 1996;89(1):13-4.
    
    
25. Faringer P.D., Mullins R.J., Feliciano P.D., Duwelius P.J., Trunkey D.D. Selective fecal diversion in complex open fractures from blunt trauma. Arch Surg 1994;129(9):958-63.
    
    
26. McHenry C.R., Jacobs D.C. Pelvic hematoma necessitans - a delayed complication of massive hemorrhagic pelvic fracture: case report. J Trauma-Injury Infection & Critical Care 1994;36(6):887-9.
    
    
27. Davidson B.S., Simmons G.T., Williamson P.R., Buerk C.A. Pelvic fractures associated with open perineal wounds: a survivable injury. J Trauma-Injury Infection & Critical Care 1993;35(1):36-9.
    
    
28. Sinnott R., Rhodes M., Brader A. Open pelvic fracture: an injury for trauma centers. Am J Surg 1992 163(3):283-7.
    
    
29. Kelley J.E., Valle A., Burns R.P. Open pelvic fracture: a multidisciplinary injury. J Tennessee Med Assn 1991;84(9):438-40.
    
    
30. Hanson P.B., Milne J.C., Chapman M.W. Open fractures of the pelvis. Review of 43 cases. J Bone Joint Surg(Br) 1991;73(2):325-9.
    
    
31. Govender S., Sham A., Singh B. Open pelvic fractures. Injury 1990 21(6):373-6.
    
    
32. Fox M.A., Mangiante E.C., Fabian T.C., Voeller G.R., Kudsk K.A. Pelvic fractures: an analysis of factors affecting prehospital triage and patient outcome. Southern Med Assn J 1990 83(7):785-8.
    
    
33. Bottlang M., Simpson T., Sigg J., Krieg J.C., Madley S.M., Long W.B. Noninvasive reduction of open-book pelvic fractures by circumferential compression. J Ortho Trauma Ass'n 2002;16(6):367-73.