Pelvic fracture

[Olav Røise]

I agree with Ken Mattox. I introduced extrapelvic packing in Oslo in 1994
and it has been part of our pelvic bleeding protocol ever since.

So as the patient is haemodynamically unstable this would be the option in
this case.  First the fracture should be stabilized with the binder or sheet
around the trochanter region and kept in place during the surgical procedure
of damage control. 

For the urethral injury I would not have put the catheter in before the
urethra was cleared by an urethra-graphy.  It is known that catheter can put
a partial rupture into a total disruption. I would not focus on the urethra
before the pelvic bleed is under controll. 

With regard to the possible rectal injury we are doing a
rectal/sigmoidoscopy to exclude injury. We have seen false negative contrast
exam. of the rectum. This has of low priority and should not be done before
control of the bleed. Eventually a sigmoidotomy shoul be done - keeping in
mind the later reconstruction of the pelvis - and talk to the pelvic surgeon
to avoid incision conflict for later reconstruction of the pelvis 



With kind regards,

Olav

Olav Røise

Division of Neuroscience and Muscoloskeletal Medicine, Ullevaal University
Hospital, Oslo

Cellular phone;+4790895062
E-mail;olro at uus.no or; olav.roise at medisin.uio.no 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of KMATTOX at aol.com
Sent: 27. oktober 2007 15:44
To: trauma-list at trauma.org
Cc: ccm-l at ccm-l.org
Subject: Re: Pelvic fracture

 
In a message dated 10/27/2007 5:39:42 A.M. Central Daylight Time,  
hpb.surgery at gmail.com writes:

1.  Pelvic fracture + suspected ongoing retro peritoneal venous bleed,  what
surgical strategy would you employ?
2. If a rectal tear is  suspected, without any perioneal trauma, how would
you
de-function, loop  colostomy? Or end colostomy and mucous fistula? Would you
try and establish  the site of perforation - on-table flexible
sigmoidoscopy
etc.?



I agree with Bjorn regarding the excessive fluid administration.  
 
The patient appears to be hemodynamically stable.    If  unstable, then one 
of several tactics to impede ongoing blood loss is  indicated.   I have
never 
been totally satisfied with arterial  embolization for control of venous 
bleeding.    I also have not  been satisfied with external fixation to
reduce blood 
loss.   The  orthopedic community is mixed in its support of external  
fixation.    The new extra peritoneal packing as reported from  Europe and
from a 
couple of centers in the United States bears  watching.    I might have 
considered such a procedure in this  patient.   It is a temporizing ("damage
control") 
tactic.  
 
With the case as you describe, I would consider going to OR for an  
examination under anesthesia, looking mainly at the rectum.     For this one
does not 
need to do a flexible sigmoidoscopy, as it is only the  rectum which is of 
concern.     This can be done with a  straight short scope.     Even a full 
thickness injury might  be missed, but your CT description is suggestive of
a rectal 
 injury.     I would strongly consider a LOOP colostomy, but  to be sure
that 
the distal stoma is totally defunctionalized, unless the patient  is obese 
and the mesentery is foreshortened and to do a loop would create  vascular 
compromise to the exteriorized segment.       If the patient's pelvis was 
operatively repaired, and he did not become  febrile, I would study the
distal rectum 
via the loop colostomy and if NO LEAK,  I would consider closing this
colostomy 
at the first  hospitalization.   
 
k



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