英文：严重骨盆骨折的修复

Resuscitation of Resuscitation of Severe Pelvic FracturesSevere Pelvic Fractures ������������������������ MuMu--Shun Huang, M.DShun Huang, M.D.. Veterans General HospitalVeterans General Hospital--TaipeiTaipei Surgical Division, Surgical Division, Emergency Department Emergency Department National YangNational Yang--Ming Medical Ming Medical UniversityUniversity �� greatestgreatest mortalitymortality ratesrates ofof skeletalskeletal injuryinjury �� RetroperitonealRetroperitoneal bleedingbleeding �� highlyhighly vascularisedvascularised cancellouscancellous bonebone �� highhigh associationassociation withwith otherother injuriesinjuries �� overalloverall pelvicpelvic fracturefracture mortalitymortality:: 1616%% �� closedclosed pelvicpelvic fracturefracture andand hemodynamicalhemodynamical instabilityinstability mortalitymortality:: 2727%% �� openopen pelvicpelvic fracturefracture mortalitymortality:: 5555%% Pelvic FracturesPelvic Fractures ��haemorrhagehaemorrhage inin 4242%% causecause ofof mortalitymortality ��6262%% isis duedue toto pelvicpelvic bleedingbleeding ��3838%% isis duedue toto otherother bleedingbleeding sources,sources, chest,chest, abdomen,abdomen, externalexternal ��headhead injuryinjury:: 3232%% causecause ofof mortalitymortality ��sepsissepsis && MOFMOF:: 1414%% causecause ofof mortalitymortality Mortality in Pelvic FracturesMortality in Pelvic Fractures Time Time is a Critical Factoris a Critical Factor ��Delayed access to definitive trauma Delayed access to definitive trauma carecare ��Injury: discovery, access, EMT, Injury: discovery, access, EMT, transportationtransportation, , ERER, , trauma team trauma team activationactivation, , trauma surgeontrauma surgeon, ATLS, , ATLS, consultation; OR, ICU consultation; OR, ICU High Index of SuspicionHigh Index of Suspicion �� PelvicPelvic tendernesstenderness �� PelvicPelvic instabilityinstability -- gentlegentle compressioncompression;; OnceOnce �� Haematuria/bloodHaematuria/blood atat urinaryurinary meatusmeatus �� Abdominal/pelvicAbdominal/pelvic bruisingbruising �� FlankFlank bruisingbruising �� Perineal/scrotalPerineal/scrotal haematomahaematoma Resuscitation of Resuscitation of Severe Pelvic FracturesSevere Pelvic Fractures Primary SurveyPrimary Survey �� AAirway maintenance with Cirway maintenance with C--spine spine controlcontrol �� BBreathing and ventilationreathing and ventilation �� CCirculation with hemorrhage controlirculation with hemorrhage control ��determinedetermine sourcesource ofof bleedingbleeding ?? ��controlcontrol ofof bleedingbleeding ?? P r ov isiona l P el v ic St a b il iz a t ion P r ov isiona l P el v ic St a b il iz a t ion �Dallas binder �G-Suit �Kendrick extrication device �Geneva belt �London splint U r et hr a l inj ur iesU r et hr a l inj ur ies �� Posterior(75%)with pelvic fracturesPosterior(75%)with pelvic fractures �� A n terior(2 5%)with strad d le in j uryA n terior(2 5%)with strad d le in j ury �� W om en (rare)W om en (rare) B l a dder inj ur iesB l a dder inj ur ies �� I n traperiton eal(2 0 %); E x traperiton eal(8 0 %)I n traperiton eal(2 0 %); E x traperiton eal(8 0 %) �� 9 59 5--1 0 0 % have g ross hem aturia1 0 0 % have g ross hem aturia �� Presen ce of pelvic fracture n ot helpful in Presen ce of pelvic fracture n ot helpful in d ecid in g whom to in vestig ated ecid in g whom to in vestig ate Name the 2 major complications that Name the 2 major complications that are d irectly related to pelv ic f ractu reare d irectly related to pelv ic f ractu re ��1 . H em orrhag e! ! !1 . H em orrhag e! ! ! ��2 . U rolog ic I n j ury2 . U rolog ic I n j ury ��Bladder ruptureBladder rupture ��U reth ral tearU reth ral tear �Pelvic fractures b ad �A sso ciated in j uries very b ad ! A ssociated I nju ries in P elv ic F ractu resA ssociated I nju ries in P elv ic F ractu res Severe Severe H em o rrh a g e ( % )H em o rrh a g e ( % ) B l a d d er R u p t u re B l a d d er R u p t u re ( % )( % ) U ret h ra l I n j u ry U ret h ra l I n j u ry ( % )( % ) L CL C --II 0. 50. 5 4 . 04 . 0 2 . 02 . 0 L CL C --IIII 3 63 6 7 . 07 . 0 00 L CL C --IIIIII 6 06 0 2 02 0 2 02 0 A PA P --II 11 88 1212 A PA P --IIII 2 82 8 1111 2 32 3 A PA P --IIIIII 5 35 3 1414 3 63 6 V SV S 7 57 5 1515 2 52 5 M i x edM i x ed 5 85 8 1616 2 12 1 Young JWR, Burgess AR: Radiologic Management of Pelvic Ring Fractures: Systematic Radiologic D iagnosis. Baltimore: U rb an & Sch w arz enb erg, 1 9 8 7 A ssociated I nju ries in P elv ic F ractu resA ssociated I nju ries in P elv ic F ractu res �� H em orrhag e (75%)H em orrhag e (75%) �� U rolog ic I n j ury (1 2 %)U rolog ic I n j ury (1 2 %) �� N eurolog ic I n j ury (8 %)N eurolog ic I n j ury (8 %) �� G y n ecolog ic I n j ury G y n ecolog ic I n j ury ( va g i n a l l a c m c w i t h a n t eri o r f x )( va g i n a l l a c m c w i t h a n t eri o r f x ) �� T horacic aorta T horacic aorta (8x blunt abd trauma)(8x blunt abd trauma) �� R upture of d iaphrag mR upture of d iaphrag m �� R ectal I n j uryR ectal I n j ury Browner BD, Levine AM, Jupiter JB, Trafton PB. Skeletal Trauma. Vol 1. 2nd Browner BD, Levine AM, Jupiter JB, Trafton PB. Skeletal Trauma. Vol 1. 2nd ed. Ph iladelph ia: W B Saunders C o; 19 9 8 .ed. Ph iladelph ia: W B Saunders C o; 19 9 8 . Hem or r ha ge in P el v ic F r a ct ur esHem or r ha ge in P el v ic F r a ct ur es �� Lack muscular wall for postLack muscular wall for post--traumatic traumatic constrictionconstriction �� Rely on Rely on intact peritoneumintact peritoneum to contain & to contain & tamponadetamponade �� Primary cause of deathPrimary cause of death �� Retroperitoneal space can accommodate Retroperitoneal space can accommodate 6 L6 L �� Three sourcesThree sources �� ArterialArterial: angiographic embolization or ligation: angiographic embolization or ligation �� VenousVenous: packing or ext. fixation; or limited ORIF: packing or ext. fixation; or limited ORIF �� OsseousOsseous: C: C--clamp or ext. fixation; or limited ORIFclamp or ext. fixation; or limited ORIF PrioritiesPriorities 55. Open tibial fracture. Open tibial fracture 44. Hollow organ perforation. Hollow organ perforation 33. + Retroperitoneal hematoma . + Retroperitoneal hematoma → → ?? 33. + Intra. + Intra--abdominal bleeding abdominal bleeding →→ splenectomysplenectomy 22. + Tension pneumothorax . + Tension pneumothorax →→ chest tube chest tube thoracostomythoracostomy 11. Severe facial trauma . Severe facial trauma →→ cricothyroidotomycricothyroidotomy Pelvic Ring Fractures Pelvic Ring Fractures = High Energy Blunt Trauma= High Energy Blunt Trauma 10 G : 3 6 K m / h : 5 M f a l l i n g �� 150 to 200 G forces150 to 200 G forces �� 150 l b p erson x 150 G 150 l b p erson x 150 G = 22, 500 l b s = 22, 500 l b s or 11. 25 ton sor 11. 25 ton s ������������������������������������������������Hypovolemic ShockHypovolemic Shock � �� � � �� �� � � �� �� � � �� �� � � �� �� � � �� �� � � �� �� � � �� �� � � � ����� � �� � �� � �� � ������ � �� � �� � �� � � 7070 � � � �� � � �� � � �� � � � � � � �� � � �� � � �� � � � ������ ������ ������ ������ � � � (ml) 7 50 7 50 -1 50 0 1 50 0 -2 0 0 0 > 2 0 0 0 � � � � (% ) � 1 5% 15%-3 0 % 3 0 %-4 0 % > 4 0 % � < 1 0 0 > 10 0 > 12 0 > 14 0 � � � � � � �� �� �� � � � � � � � � � � �� �� �� � � � � � � � � 1 4 -2 0 2 0 -3 0 3 0 -4 0 > 3 5 � � � (ml/ h ) > 3 0 2 0 -3 0 5-1 5 � � � � � � ! " # $ % & ' & ' ( ) ( ) * + � ,(3 : 1 - . ) Crystalloid Crystalloid C ry s talloid / � , C ry s talloid / � , 01� , 3 : 1 - . 2 3 4 5 6 ���(1) � � � � � � � � ( � � 3 : 1) (2 )������ ���( � � 3 : 1 ) ������50%��� � � � � �� �� �� � � � � Young & Burgess ClassificationYoung & Burgess Classification ��Lateral compression (50%) Lateral compression (50%) ��AP compression/open book (25%)AP compression/open book (25%) ��Vertical Shear (5%) Vertical Shear (5%) ��Combination (20%)Combination (20%) Tile ClassificationTile Classification �� Type A Type A –– s t a b l es t a b l e �� Type B Type B –– v er t i c a l l y s t a b l e, r o t a t i o n a l l y u n s t a b l ev er t i c a l l y s t a b l e, r o t a t i o n a l l y u n s t a b l e �� Type C Type C –– u n s t a b l e ( r o t a t i o n a l l y + v er t i c a l l y)u n s t a b l e ( r o t a t i o n a l l y + v er t i c a l l y) Stable or Unstable Fractures?Stable or Unstable Fractures? �� StableStable fracturesfractures occuroccur whenwhen thethe pelvicpelvic fracturesfractures inin onlyonly oneone place,place, oror whenwhen simplesimple chipchip oror avulsionavulsion fracturesfractures areare presentpresent.. �� AA bonebone avulsionavulsion involvesinvolves aa tendontendon separatingseparating fromfrom itsits attachmentattachment onon thethe bonebone.. UnstableUnstable fracturefracture == HemodynamicallyHemodynamically UnstableUnstable Severe Pelvic Severe Pelvic FractureFracture On ImpactOn Impact:: A 28 year old A 28 year old male motorcyclist traveling male motorcyclist traveling approx 60 mph intercepts approx 60 mph intercepts an automobile which an automobile which ignores a stoplightignores a stoplight.. OTA-AAS T C o m b i n e d An n u a l M e e t i n g Y e a r 2 0 0 0 http://www.trauma.org/ortho/maincase.html E R R esu scitationE R R esu scitation �� The patient has received 2500 cc The patient has received 2500 cc crystalloid, the 4th of 10 units of PRBC crystalloid, the 4th of 10 units of PRBC and 1 unit of FFP is ordered. and 1 unit of FFP is ordered. �� Abdominal ultrasound shows hypoechoic Abdominal ultrasound shows hypoechoic stripe in the Morison's pouch (positive for stripe in the Morison's pouch (positive for internal bleedinginternal bleeding).). What is the What is the most likely sourcemost likely source of ongoing pelvic bleeding of ongoing pelvic bleeding �� Fracture surfaces (fractured cancellous Fracture surfaces (fractured cancellous bone): bone): External Fixation; C clampExternal Fixation; C clamp �� IntraIntra--abdominal bleeding: Liver, Spleen, abdominal bleeding: Liver, Spleen, Mesentery injuries: Mesentery injuries: LaparotomyLaparotomy or or Angiographic EmbolizationAngiographic Embolization �� Posterior venous plexus :Posterior venous plexus : PackingPacking �� Arterial: Internal iliac artery: Arterial: Internal iliac artery: Angiographic Angiographic EmbolizationEmbolization �� Retroperitoneal hematoma: Retroperitoneal hematoma: PackingPacking CT in Pelvic FracturesCT in Pelvic Fractures �� Specific indications for pelvic CT Specific indications for pelvic CT ��Acetabular fracturesAcetabular fractures ��All potential or recognized sacral fracturesAll potential or recognized sacral fractures ��All potential or recognized SI injuriesAll potential or recognized SI injuries ��Question of instabilityQuestion of instability �� Patient must be hemodynamically stablePatient must be hemodynamically stable Hunter JC, Brandser EA, Tran KA. Pelvic and acetabular trauma. Radiol Hunter JC, Brandser EA, Tran KA. Pelvic and acetabular trauma. Radiol Clin North Am. 1997;35:559Clin North Am. 1997;35:559--590.590. The Pelvic CThe Pelvic C--clampclamp Image courtesy of Kenneth Johnson, MD, V and erb i l t U ni v Med C tr, N ashv i l l e G anz , M. D. , Clinical Orthopaedics and Related Research N o. 2 6 7 , June 1 9 9 1 . p p . 7 1 -7 8 Angiographic EmbolizationAngiographic Embolization �� The patient is The patient is transferred to the transferred to the angiography suite angiography suite within 30 minutes, within 30 minutes, hemorrhage from the hemorrhage from the left obturator artery is left obturator artery is identified and identified and embolized. BP 100/70, embolized. BP 100/70, pulse 100, Lab: Hct 17, pulse 100, Lab: Hct 17, Plt 91K, INR 1.26, PTT Plt 91K, INR 1.26, PTT 44.344.3 Image courtesy of S tev en O l son, MD, U C Dav i s, S acramento A vascular clamp was placed A vascular clamp was placed across the origin of the left across the origin of the left internal iliac arteryinternal iliac artery C ase sub mi tted b y S al S cl afani Retroperitoneal Pelvic PackingRetroperitoneal Pelvic Packing �� Mostly the origin of Mostly the origin of hemorrhage is diffuse hemorrhage is diffuse -- either from the venous either from the venous plexus or the fracture plexus or the fracture site. site. �� The presacral and The presacral and paravesical region is paravesical region is packed using standard packed using standard surgical lap packs (4surgical lap packs (4--8 8 packs). packs). P o h l e m a n n T; U nfal l chi rurgi sche Kl i ni k d er Med i z i ni schen H ochschul e H annov er D am ag e Contr ol L ap ar otom yD am ag e Contr ol L ap ar otom y �� Decisive/timelyDecisive/timely interventionintervention �� AvoidAvoid lethallethal triadtriad ��HypothermiaHypothermia ��AcidosisAcidosis ��CoagulopathyCoagulopathy �� Remember fracture stabilisation/reductionRemember fracture stabilisation/reduction �� EmbolizationEmbolization toto c ontr olc ontr ol h ae mor r h ag eh ae mor r h ag e Case R ep or t Case R ep or t �� Emergency room service Emergency room service a t T a ip ei V et era ns G enera l H osp it a la t T a ip ei V et era ns G enera l H osp it a l �� O n a rriva lO n a rriva l -- P a in over a b d omen a nd b ot h h ip sP a in over a b d omen a nd b ot h h ip s -- C onsciou sC onsciou s��cl ea r cl ea r -- V it a l signV it a l sign�� T P R 3 6 . 2 / 1 2 0 / 1 8 , T P R 3 6 . 2 / 1 2 0 / 1 8 , B P 8 0 / 5 0 mmH gB P 8 0 / 5 0 mmH g P h y sical E x am .P h y sical E x am . �� D i f f u s e a b d o m i n a l t en d er n es s w i t h D i f f u s e a b d o m i n a l t en d er n es s w i t h m u s c l e g u a r d i n g a n d r eb o u n d i n g pa i nm u s c l e g u a r d i n g a n d r eb o u n d i n g pa i n �� M u l t i pl e a b r a s i o n i n c l u d i n g L L QM u l t i pl e a b r a s i o n i n c l u d i n g L L Q �� L a c er a t i o n : l a t er a l a s pec t o f r i g h tL a c er a t i o n : l a t er a l a s pec t o f r i g h t h em ih em i --s c r o t u m , n o h em a t u r i a a f t er u r i n a r ys c r o t u m , n o h em a t u r i a a f t er u r i n a r y F o l ey c a t h et er i z a t i o nF o l ey c a t h et er i z a t i o n I m ag ing S tu d y I m ag ing S tu d y �� E R s o n o g r a m : P el v i c h em a t o m a w i t h f l u i d E R s o n o g r a m : P el v i c h em a t o m a w i t h f l u i d a c c u m u l a t i o na c c u m u l a t i o n �� K U B & XK U B & X --r a y o f P el v i s : F r a c t u r e o f l ef t i l i a c r a y o f P el v i s : F r a c t u r e o f l ef t i l i a c w i n g , l ef t a c et a b u l u m , b i l a t er a l i s c h i u m . w i n g , l ef t a c et a b u l u m , b i l a t er a l i s c h i u m . O b l i t er a t ed c o n t o u r o v er ps o a s m u s c l e a n d O b l i t er a t ed c o n t o u r o v er ps o a s m u s c l e a n d k i d n eysk i d n eys H osp ital Cou r se H osp ital Cou r se �� A t ER :A t ER : --B . P . imp roved a f t er f l u id resu scit a t ion B . P . imp roved a f t er f l u id resu scit a t ion C ryst a l l oid sol u t ion: 2 0 0 0 mLC ryst a l l oid sol u t ion: 2 0 0 0 mL C ol l oid sol u t ion: 5 0 0 mLC ol l oid sol u t ion: 5 0 0 mL P R B C : 4 UP R B C : 4 U H osp ital Cou r se ( cont. ) H osp ital Cou r se ( cont. ) �� E x pl o r a t i v e L a pa r o t o m y, 1 2E x pl o r a t i v e L a pa r o t o m y, 1 2 --1 01 0 --2 0 0 3 :2 0 0 3 : -- I n t r a per i t o n ea l h em a t o m a ( 5 0 0 m L )I n t r a per i t o n ea l h em a t o m a ( 5 0 0 m L ) -- O b v i o u s r et r o per i t o n ea l h em a t o m a d i s s ec t i n g t o O b v i o u s r et r o per i t o n ea l h em a t o m a d i s s ec t i n g t o pel v i c r eg i o n . pel v i c r eg i o n . -- Z o n e I I I r et r o per i t o n ea l b l eed i n gZ o n e I I I r et r o per i t o n ea l b l eed i n g -- P er f o r a t i o n o f j ej u n u m , 5 0 c m a n d 7 0 c m P er f o r a t i o n o f j ej u n u m , 5 0 c m a n d 7 0 c m a pa r t f r o m t h e l i g a m en t o f Tr i et za pa r t f r o m t h e l i g a m en t o f Tr i et z w i t h m es en t er i c h em o r r h a g ew i t h m es en t er i c h em o r r h a g e H osp ital Cou r se ( cont. )H osp ital Cou r se ( cont. ) �� E x pl o r a t i v e L a pa r o t o m y o n 1 2E x pl o r a t i v e L a pa r o t o m y o n 1 2 --1 01 0 --2 0 0 3 :2 0 0 3 : ( C o n t . ) 5 : 3 5 P M t o 9 P M( C o n t . ) 5 : 3 5 P M t o 9 P M -- R ec t o s i g m o i d j u n c t i o n w i t h s er o s a t ea r , l a t er a l R ec t o s i g m o i d j u n c t i o n w i t h s er o s a t ea r , l a t er a l per i t o n eu m l a c er a t i o n w i t h b l eed i n gper i t o n eu m l a c er a t i o n w i t h b l eed i n g -- R epa i r o f i n t es t i n a l per f o r a t i o n a n d b l eed er s R epa i r o f i n t es t i n a l per f o r a t i o n a n d b l eed er s -- R epa i r o f s c r o t a l l a c er a t i o n R epa i r o f s c r o t a l l a c er a t i o n H osp ital Cou r se ( cont. )H osp ital Cou r se ( cont. ) �� 1 0 P M , 1 21 0 P M , 1 2 --1 11 1 --2 0 0 32 0 0 3 -- JJ--P d r a i n a g e o v er r ec t oP d r a i n a g e o v er r ec t o --s i g m o i d j u n c t i o n : s i g m o i d j u n c t i o n : f r es h b l o o d , > 9 0 0 m L , t o t a l l y f r es h b l o o d , > 9 0 0 m L , t o t a l l y -- C o n t i n u o u s w o u n d o o z i n gC o n t i n u o u s w o u n d o o z i n g -- F l u i d s u ppl em en t a n d P R B C 2 UF l u i d s u ppl em en t a n d P R B C 2 U �� E m er g en t pel v i c a n g i o g r a ph y &E m er g en t pel v i c a n g i o g r a ph y & a n g i o g r a ph i c em b o l i z a t i o n w i t h G el f o a m a n g i o g r a ph i c em b o l i z a t i o n w i t h G el f o a m XX--r ay of P elv is r ay of P elv is 1 21 2 --2 52 5 --2 0 0 3 2 0 0 3 Conclu sionConclu sion •• O pt i m a l t h er a py i n t h e f a c e o f b l eed i n g pel v i c O pt i m a l t h er a py i n t h e f a c e o f b l eed i n g pel v i c f r a c t u r e r eq u i r es ea r l y d et er m i n a t i o n o f t h e f r a c t u r e r eq u i r es ea r l y d et er m i n a t i o n o f t h e pr es en c e o f a r t er i a l b l eed i n g s o t h a t pr es en c e o f a r t er i a l b l eed i n g s o t h a t a n g i o g r a ph i c em b o l i z a t i o n c a n b e r a pi d l y a n g i o g r a ph i c em b o l i z a t i o n c a n b e r a pi d l y o b t a i n ed o b t a i n ed �� P riorit y of l a p a rot imy a nd a ngiogra p h y w a s P riorit y of l a p a rot imy a nd a ngiogra p h y w a s d iscu ssed b a sed on p el vic f ra ct u re p a t t ern d iscu ssed b a sed on p el vic f ra ct u re p a t t ern a nd / or resp onse t o init ia l resu scit a t ion. a nd / or resp onse t o init ia l resu scit a t ion.