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Jurnal Ortopedi
Jurnal Ortopedi
The primary goal for the treatment of pelvic fractures in Several studies of
early pelvic fracture treatment have demonstrated beneficial effects, such as
decreased blood transfusion requirements, decreased systemic complications,
decreased hospital stays, and improved patient survival. [19, 20] Secondary
considerations for operative management of pelvic fractures in the acute setting are
the correction or prevention of significant pelvic translational and rotational
deformities that have been associated with poorer clinical outcomes. [4, 16, 42]
Hemorrhage All pelvic fractures are associated with some form of bleeding.
Sources of blood loss include cancellous bone at the fracture site, laceration of
retroperitoneal veins in the pelvis, and laceration of branches of the internal iliac
artery, which accounts for approximately 25% of hemodynamically unstable pelvic
fractures.40,41 It is difficult to determine whether a patient is hemorrhaging from a
venous or an arterial bleed. Arteriography can identify arterial bleeding,
venography shows venous bleeding (although it is difficult to distinguish between
major or minor bleeds), and pelvic CT can show the presence of a hematoma
(which is suggestive of a bleed, but not specific). Huittinen and Sltis42 performed
a cadaveric study of 27 patients with pelvic fractures who died from hemorrhage.
Postmortem anatomic dissection and arteriography of the hypogastric artery was
performed. Extravasation from the hypogastric artery through the cancellous bone
and torn tissues was seen in 23 cadavers. Based upon their findings, Huittinen and
Sltis concluded that accurate reposition of the dislocated pelvic fracture is
preferable to ligation of the hypogastric arteries for control of severe hemorrhage
from pelvic fractures. Early identification of patients with hemorrhage is critical
in management. Although evaluation of patients with blunt abdominal injury,
typically, involves a focused assessment with sonography for trauma (FAST)
exam, in patients with pelvic fractures, a negative exam does not rule out
intraperitoneal hemorrhage. Friese and coworkers43 performed a retrospective
review of 96 patients with pelvic fracture and risk factors for hemorrhage (systolic
blood pressure less than 100 mmHg or an unstable fracture pattern) who underwent
a FAST and either operative exploration or CT scan for confirmation. In the study,
there were 11 true positives, 52 true negatives, two false positives, and 31 false
negatives (sensitivity of 26% and negative predictive value of 63%).43 Clinical
factors can be used to help predict which patients with pelvic fractures are more at
risk of bleeding. Blackmore and associates40 performed a retrospective cohort
study of 627 patients with pelvic fractures (20% of whom had major pelvic
hemorrhage) and identified four predictors of hemorrhage, including an emergency
room hematocrit of less than 30, a pulse greater than 130 BPM, displaced obturator
ring fracture, and pubic symphyseal wide diastasis (greater than 1 cm used for
displacement). Patients with zero predictors had a 2% change of major
hemorrhage, whereas patients with three or more predictors had a greater than 60%
chance of having hemorrhage. In a retrospective review of 382 patients with
isolated pelvic or acetabular fractures, Magneussen and colleagues44 found that
isolated pelvic fractures with major ligament disruption (APC I or II, LC III, VS,
or CMI) were more likely to require transfusions (44%) than other pelvic fractures
(8.5%). Patients with APC 3 and VS fractures required the most amount of blood
(12.6 units and 4.6 units, respectively).
Closed Reduction
1. Allis Method. This consists of traction applied in line with the deformity. The
patient is placed
supine with the surgeon standing above the patient on the stretcher or table.
Initially, the surgeon applies in-line traction while the assistant applies
countertraction by stabilizing the patients pelvis. While increasing the traction
force, the surgeon should slowly increase the degree of flexion to approximately 70
degrees. Gentle rotational motions of the hip as well as slight adduction will often
help the femoral head to clear the lip of the acetabulum. A lateral force to the
proximal thigh may assist in reduction. An audible clunk is a sign of a successful
closedreduction (Fig. 27.6).
2. Stimson Gravity Technique. The patient is placed prone on the stretcher with
the affected leg hanging off the side of the stretcher. This brings the extremity into
a position of hip flexion and knee flexion of 90 degrees each. In this position, the
assistant immobilizes the pelvis, and the surgeon applies an anteriorly directed
force on the proximal calf. Gentle rotation of the limb may assist in reduction (Fig.
27.7). This technique is difficult to perform in the emergency department
3. Bigelow and Reverse Bigelow Maneuvers. These have been associated with
iatrogenic femoral neck fractures and are not as frequently used as reduction
techniques. In the Bigelow maneuver,
the patient is supine, and the surgeon applies longitudinal traction on the limb. The
adducted and internally rotated thigh is then flexed at least 90 degrees. The femoral
head is then levered into the acetabulum by abduction, external rotation, and
extension of the hip. In the reverse Bigelow maneuver, used for anterior
dislocations, traction is again applied in the line of the deformity. The hip is then
adducted, sharply internally rotated, and extended.
Open Reduction
Indications for open reduction of a dislocated hip include:
1. Dislocation irreducible by closed means
2. Nonconcentric reduction
3. Fracture of the acetabulum or femoral head requiring excision or open
reduction and internal fixation
4. Ipsilateral femoral neck fracture
Management after closed or open reduction ranges from short periods of bed
rest to variousdurations of skeletal traction. No correlation exists between
early weight bearing andosteonecrosis. Therefore, partial weight bearing is
advised.
Emergency treatment
Traction with a splint is first aid for a patient with a femoral shaft fracture. It is
applied at the site of the accident, and before the patient is moved. A
Thomassplint, or one of the modern derivations of this practical device, is ideal:
the leg is pulled straight and threaded through the ring of the splint; the shod foot is
tied to the cross-piece so as to maintain traction and the limb and splint are firmly
bandaged together. This temporary stabilization helps to control pain, reduces
bleeding and makes transfer easier. Shock should be treated; blood volume is
restored and maintained, anda definitive plan of action instituted as soon as the
patients condition has been fully assessed.
Definitive treatment
The patient with multiple injuries The association of femoral shaft fractures with
other injuries, including head, chest, abdominal and pelvic trauma, increases the
potential for developing fat embolism, ARDS and
multi-organ failure. The risk of systemic complications can be significantly
reduced by early stabilization of the fracture, usually by a locked intramedullary
nail. However, surgery to introduce a reamed intramedullary nail may produce
untoward effects in those with severe chest injuries, especially when carried out
within 24 hours of the fracture. It is thought the trauma of surgery and blood loss
induces inflammatory changes that may increase both morbidity and mortality
this phenomenon is called the second hit, referring to a second episode of trauma,
albeit surgical, on the patient. Consequently, in the multiply injured patient,
particularly one with severe chest trauma, prompt stabilization with an external
fixator may be wise; the fixator can be exchanged for an intramedullary nail when
the patients condition stabilizes. The timing of this second procedure is
problematic.
Some guidance can be sought from measurement of circulating levels of
interleukin-6, a pro-inflammatory cytokine (Pape, van Griensven et al.2001); when
the levels start to decrease, it should be safe to perform second hit interventions.
Clinically this occurs around 57 days after admission, but this window is by no
means applicable to all patients nor
is it conclusive at this time. Performing the exchange to an intramedullary nailalso
carries the risk of transferring contaminants from pin sites to the intramedullary
nail; the earlier the operation is performed, the lower the risk. In the patient who
spends a protracted period in the intensive care unit, it may be safer to use external
fixation
as definitive treatment, perhaps with a return to theatre later to allow insertion of
new pins to increase the stability of the construct.