The optimal management strategy for unrelenting hemorrhage produced by unstable pelvic fractures remains controversial. The basic cornerstones of modern pelvic fracture management in North America are early identification, resuscitation with blood and blood products, treatment of associated injuries and control of pelvic bleeding with a combination of mechanical stabilization and arterial embolization. The published European approach has emphasized packing of the pelvis through an abdominal approach and direct arterial control instead of angiography.

Considering that >85% of bleeding from major pelvis fractures is venous in origin, we have recently used mechanical stabilization followed by direct retroperitoneal packing to control life-threatening hemorrhage due to unstable pelvic fractures arriving to the hospital in hemorrhagic shock. To our knowledge, direct packing via a retroperitoneal approach to control pelvic fracture bleeding has not been previously reported in North America. We present two illustrative cases. Although the injury mechanisms and fracture patterns were disparate, both patients survived emergent operative intervention relying on retroperitoneal packing with C-clamp reduction of the pelvic volume. Herein, we discuss the acute management of these patients, and provide a detailed technical description of the key operative maneuvers.

Case 1

S.W. is a 48 year-old male line worker who sustained an unrestrained fall of approximately fifty feet from a power line. He was initially transported and treated at an outlying facility for hemodynamic instability from a mechanically unstable pelvic fracture with a presenting blood pressure (BP) of 84/40 mmHg. He remained hemodynamically unstable with a systolic blood pressure (SBP) less than 90 mmHg despite having his pelvis bound with a sheet and receiving two units of packed red blood cells (PRBCs).

On arrival to our center, the patient?s BP was 104/70 mmHg with a pulse of 154/min. Laboratory values included a base deficit of -11 meq/L. Ultrasound examination was negative for free fluid in the abdomen. Trauma anteroposterior radiographs of the pelvis showed a Young and Burgess APC III fracture and a right Denis type II sacral fracture. Despite receiving an additional two units of PRBCs, the patient continued to have tachycardia greater than 150/min and the blood pressure decreased to 80/40. He was taken emergently to the operating room for external fixation with a C-clamp and pelvic packing.  A C-clamp (DePuy, Warsaw, IN) was placed in the posterior position as described by Browner without fluoroscopic imaging. The retroperitoneum was then opened via an 8cm midline incision. Venous bleeding was noted coming from the right posterior pelvis. the true pelvis was directly packed using our proposed technique. The total time for the operative procedure was 22 minutes. The patient departed the operating room 67 minutes after his arrival in the emergency department. 

The patient was taken to the surgical intensive care unit for further resuscitation. At ninety-six hours post-admission the patient underwent definitive pelvic surgery with anterior and posterior fixation. He received a total of six units of PRBCs and was discharged from the hospital after 13 days to a rehabilitation facility with normal cognitive functioning.

Case 2

J.R. is a ten year-old male who was thrown from a horse and dragged for approximately fifty feet before being extricated. He was emergently transported to an outside facility via air evacuation; and intubated enroute; he had a right femoral shaft fracture and an open pelvis fracture. His lab values included a base deficit of -10 meq/L. Treatment at the outside hospital consisted of administration of two units of PRBCs, two units of FFP and binding of his pelvis with a sheet.

On arrival at our center the patient?s vital signs were a SBP of 90 mmHg and a pulse of 128/min. Other injuries noted were a large perineal laceration with an associated rectal tear and transected posterior urethra. Anteroposterior pelvic radiograph showed a Young and Burgess APC III pelvic fracture. Ultrasound examination showed no free fluid in the abdomen. Despite receiving a further two units of PRBCs his SBP dropped below 90 mmHg and he was taken emergently to the operating room for combined C-clamp placement, pelvic packing and laparotomy. There was significant venous bleeding from the open perineal wound. The perineal wound was packed and retroperitoneal packing was performed through an 8 cm midline incision. Venous bleeding from the right hemipelvis was noted upon opening the retroperitoneum. Laparotomy with diverting sigmoid colostomy, and suprapubic catheter placement were performed. The packing and external fixation procedure consumed 19 minutes. The patient left the operating room after percutaneous plate fixation of his femur and urologic assessment 2 hours and 39 minutes after arrival in the emergency room.

He was then taken to the surgical intensive care unit for further resuscitation. Six days after admission he was taken for definitive internal and external fixation of his anterior and posterior pelvis. He received a total of nine units of PRBCs and two units of FFP during his hospital stay. He subsequently underwent delayed rectal and urethral reconstruction and rehabilitation.

Surgical Technique

The patient is positioned supine. In cases in which mechanical stabilization is judged to be advantageous, a C-clamp or external Fixator is placed using standardized techniques. An 8 cm midline incision is made extending caudally from the symphysis pubis in a cephalad direction. Skin and subcutaneous tissue are sharply incised and the fascia anterior to the rectus abdominis is exposed. The fascia is divided in the midline, the length of the incision. Care is taken to protect the bladder during incision as in some cases of symphyseal disruption; the bladder may be pressed against the posterior aspect of the abdominal wall. The bladder is gently retracted to one side with a malleable retractor and the pelvic brim is gently palpated from the symphysis in a posterior direction toward the sacroiliac joint. In most cases, the fascial connections of the overlying tissue will have been dissected free by the force of the injury. Care should be taken to palpate for any aberrant vascular connections between the obturator and iliac systems to avoid avulsing these vessels (the Corona Mortis). The pelvic brim is not visualized through the approach. After the brim has been palpated as posterior as the surgeon can reach, three laparotomy sponges are placed sequentially deep to the brim. the first is placed on a sponge stick posterior just below the sacroiliac joint. The second is placed anterior to the first sponge at a point corresponding to the middle of the pelvic brim. The third sponge is placed in the retropubic space just deep and lateral to the bladder. The bladder is then retracted to the opposite side and the sequence is repeated  until both sides of the pelvis are symmetrically packed with three sponges each. The packs should all be below the pelvic brim in the true pelvis. At this point, any bleeding evident upon opening of the retroperitoneum will have stopped. If bright red bleeding was noted initially, consideration should be given to subsequent pelvic angiography either via a laparotomy by the trauma surgeon or percutaneously by the interventional radiologist. The outer fascia is closed with a single layer running suture to seal the compartment and the skin incision is stapled. The total time for the packing procedure should be under 20 minutes. If laparotomy is required, it should follow the closure of the retroperitoneal fascia in order to preserve the anatomic integrity of the compartments and to allow for tamponade in the retroperitoneum. Laparotomy prior to pelvic packing may result in a difficult approach into the retroperitoneum and prolong the overall procedure time. As in the abdomen, the pelvic packing should be removed or exchanged at 24-48 hours. Packing should be removed carefully with saline added to moisten the packs and lessen blood clot disruption.

Discussion

Despite advances in management, the mortality associated with unstable pelvis fractures remains high. The current emphasis on embolization does not take into account the potential mortality of venous bleeding which is likely present even when arterial injury occurs. Strategies for control of venous bleeding consist of external fixation to enhance pelvic stability and promote intrapelvic tamponade with graded resuscitation to prevent coagulopathy. The addition of direct packing to control venous bleeding is logical and has been used effectively in trauma surgery ?Damage Control?, oncologic, gynecologic surgery, and by Orthopaedic trauma surgeons during pelvic and acetabular surgery.

In our experience, the procedure can be performed quickly and the bleeding encountered when the retroperitoneum is opened is controllable. The advantage to the patient is that the volume of ongoing venous bleeding is decreased early in the course, allowing the surgical team to concentrate treatment on associated injuries. The decreased overall blood loss reduces the duration of shock and the incidence of multisystem organ failure (MOF). However, to be effective, pelvic packing should be performed early in the course of resuscitation, preferably within the first hour of treatment. Following packing the patient with persistent arterial bleeding should undergo pelvic angiography or surgical exploration in order to gain direct arterial control.