Date: Wed, 26 Apr 2000 07:23:17 -0500

From: Adam Starr

Subject: Pelvic Fx Fatality

Maybe this data will stimulate some discussion on pelvic fracture care.

Between Nov 97 and Nov 99, we treated 324 closed pelvic ring disruptions at Parkland.

36 of them died. Of these 36, 20 had severe head injuries (GCS<8). Most of them (17) had GCS=3 on arrival. I expect the head injury is what killed these folks.

Of the 16 remaining, 9 had severe brain injuries visible on CT, with Head AIS > 3. Here again, I think the head injury is the likely cause of death.

Of the 7 remaining people, 5 had Chest AIS >3 or Abdomen AIS > 3. They either had a severe chest injury or a severe belly injury.

We had only 2 fatalities in people with pelvic fracture and no head, chest or belly injury. One of these patients had an LC-1 (Tile A), the other had an LC-3 (Tile C).

We do not use pelvic external-fixators. Should we be using them?

Reply at: Orthopaedic Trauma Association forum

Date: Thu, 27 Apr 2000 11:37:18 EDT


I have also reviewed mortality and pelvic ring disruptions over the past 10 years at the University of New Mexico in conjunction with our trauma general surgeons and found a 9% fatality rate. 1/3 had major other injuries including head injury and typically died in the first few hours and the head injury was assessed as the cause of death. The presence of a pelvic ring disruption increased the liklihood of a life threatening head injury by a factor of 5. 1/3 of deaths had multiple system injuries and died of multi system organ failure typically 3-10 days later. 1/3 had pelvic ring as their major injury and either died in the first 24 hours (?hemorrhage) or 3-10 days later (infection from major open fractures, Morel lesion...) I do believe pelvic ring disruption is a cause of death and is also a marker for more severe injuries.

I also believe (although without hard data) that external fixation is often beneficial in resuscitation of patients with pelvic ring disruption and reduces the mortality rate.

Date: Thu, 27 Apr 2000 14:22:04 -0500

From: Adam Starr, Dallas

That's the thing - I'm not sure if application of an ex-fix alters the outcome. I understand the principle of tamponade, and the idea that fracture fragment motion could elute inflammatory mediators that make the patient sick. I just don't know if placing an anterior ex-fix changes that.

Which fracture patterns do you feel benefit from application of an ex-fix? I suppose you could make a case for APC-2 types. Will an anterior ex-fix frame alter the clinical course of an APC-3 ring disruption? A Tile C?

I have no experience with "pelvic clamps" such as the Ganz clamp. I've seen some awful Xrays of misplaced Ganz clamps, but I assume most of them would be placed correctly. So maybe they work.

On the flip side, I've seen many external fixators placed on fractures inappropriately. My question is, what is driving all these orthopods to place these ex-fixes? Patients with LC-1's don't need an ex-fix, do they?

Date: Sat, 29 Apr 2000 13:36:52 +0300

From: Anton V. Vakulenko

Dear List Members,

Regarding pelvic fractures: do you use internal fixation for such injuries? All of us commonly use internal fixation for acetabular fractures but what about other pelvic fractures, particularly with pelvic ring disruption?

Sincerely, Anton V. Vakulenko

Date: Sun, 30 Apr 2000 13:15:25 -0700

From: John Ruth

Regarding pelvic fractures: do you use internal fixation for such injuries?

Yes routinely for all symphyseal disruptions (>3 cm. diastasis) and all displaced and by definition unstable SI disruptions or sacral fractures. Other types based on Type, patient condition and ability to mobilize.

Date: Sat, 29 Apr 2000 22:40:51 -0400

From: Fred Barrick


Do you use anything to immobilize the pelvis?

I am getting away from using an exfix for pelvic ring disruptions---for many of the reasons that you have cited. Sometimes we will use a sheet wrapped around the pelvic region and tightened with a makeshift turnbuckle.

E. Frederick Barrick, MD, Director of Orthopaedic Trauma, Inova Fairfax Hospital, Falls Church, VA

Date: Date: Mon, 01 May 2000 12:22:43 -0500

From: Adam Starr


Regarding pelvic fractures: do you use internal fixation for such injuries?

Yes, we use internal fixation for pelvic fracture stabilization.

At our center, we've gotten away from anterior ex-fix frames, but I'm not sure if that's the right approach, since there are no randomized trials comparing the use of ex-fix vs. no ex-fix for resuscitation.

As far as definitive pelvic fracture stabilization goes, we tend to use percutaneous screws whenever possible. Sacroiliac joint injuries, iliac wing fractures and pubic ramus fractures are all amenable to percutaneous screw techniques. (Recently, we stabilized a symphysis pubis diastasis with a percutaneous screw. Our series of 1 is doing well so far!).

Many pelvic fracture surgeons feel strongly that open reduction and internal fixation yields better results than percutaneous techniques. I disagree. But, maybe one of them will chime in and give you his/her opinion.

Adam Starr, Dallas, Texas

Date: Mon, 01 May 2000 12:24:54 -0500

From: Adam Starr


Do you use anything to immobilize the pelvis?

Yes, I use a sheet, too. At Parkland, we've started using a "butt binder", a cloth wrap that goes around the waist and tightens via a pulley system. You can pull it really tight, and it closes the ring down, at least in the APC 2 types.

Adam Starr. Dallas, Texas

Date: Mon, 01 May 2000 12:33:00 -0500

From: Adam Starr

John Ruth,

Yes routinely for all symphyseal disruptions (>3 cm. diastasis) and all displaced and by definition unstable SI disruptions or sacral fractures. Other types based on Type, patient condition and ability to mobilize.

That raises an interesting point - how displaced is "displaced"?

What sort of criteria should we use to define "instability" in the pelvic ring? Is a non-displaced vertical, transforaminal sacral fracture unstable? Potentially unstable?

Should we use pain as an indicator of instability? Or should we try to assess stability more objectively? Like with "push-pull" films, or maybe even by an exam in the OR, under fluoroscopy?

Should we put the patient to sleep to assess stability under fluoro? How hard should we push those fragments? And what if we displace a non-displaced tranforaminal fracture? I guess we'd know that it was unstable, at least, but what about those nerve roots?

Adam Starr, Dallas, Texas

Date: Mon, 1 May 2000 17:28:03 -0700

From: John Ruth

- how displaced is "displaced"?

It is my feeling after nonoperatively treating complete, nonimpacted sacral fractures Zones 1 or 2 and watching them displace over time, that all are potentially unstable and should be stabilized. If they can be mobilized closed and fixed percutaneously then that is a very good option. With respect to a general statement on percutaneous vs. ORIF of pelvic ring injuries, it is my feeling that when dealing with SI dislocation or SI fracture dislocations an anatomic reduction is most important and this is best achieved with an open approach. My preference is a posterior approach with debridement of the joint and anatomic reduction with stabilization using ileosacral screws. My question is whether there is any biomechanical data to support the use of 1 or 2 screws?

Date: Mon, 01 May 2000 20:59:30 -0400

From: Kevin Pugh

I am not aware of any biomechanical data on the use of 1 vs 2 screws, but there exists an abundance of data about the available room in the S1 pedicle for the placement of more than 1 screw. In many (most, in my opinion) people, there is only enough room to place one screw safely without coming close to the foramina at some point in it's path.

Kevin Pugh, Columbus, OH

Date: Tue, 02 May 2000 11:39:58 +0200

From: Robin Peter

Fatality after unstable pelvic ring fracture is highest within the first hours after trauma and often related to vascular injuries and retroperitoneal exsanguination. Mechanical stabilization of the ring is haemodynamically beneficial. Early stabilization of the ring can be made by the paramedics on the site of trauma using a belt of some sort.

In the Geneva area, we have trained the paramedics to first recognize such cases and to use a Velcro-Strap-Belt, developed here, which they carry as a standard piece of equipment.

The 15 cm wide belt is easy to set on, lightweight, reusable & cheap.

First experiences are good. The device is now adopted by helicopter rescue in Switzerland and elsewhere also.

We published our first experiences in: Vermeulen B, Peter R, Hoffmeyer P, Unger PF. Prehospital stabilization of pelvic dislocations: a new strap belt to provide temporary hemodynamic stabilization [In Process Citation]. Swiss Surg 1999;5(2):43-6.

Our preferred fixation method is internal fixation.

Date: Tue, 2 May 2000 10:38:29 -0500

From: Anglen, Jeffrey

Fatality after unstable pelvic ring fracture is highest within the first hours after trauma and often related to vascular injuries and retroperitoneal exsanguination. Mechanical stabilization of the ring is haemodynamically beneficial.

I think we are all familiar with this theory, by where's the proof?


Date: Tue, 02 May 2000 08:11:43 -0500

From: Adam Starr


Does your study include any data on the mortality seen in pelvic fracture patients before and after the binders came into use?

Adam Starr, Dallas, Texas

Date: Tue, 02 May 2000 17:17:32 +0200

From: Robin Peter


We were not able to compare mortality with and without using the belt and can only guess the device is beneficial. Following observation may support this.

Patients presenting with a major pelvic ring instability (B or C), who are brought in alive equipped with the belt, usually get the AP pelvis xRay taken with the belt still in place. Major pelvic displacements or instabilities usually appear on xRays only after removal of the belt in the ER. This tends to prove that in these patients, the belt kept the pelvis reduced and stable prior to admission.

Robin Peter, Geneva, Switzerland

Date: Tue, Tue, 02 May 2000 13:12:26 -0500

From: Adam Starr


I agree the binders can do a nice job holding the pelvic ring in a more normal position. Does that help tamponade the bleeding, though? I wish we knew. We're using binders here at Parkland, too. I imagine they're very similar to what you use - a wide cloth strap held by velcro and fastened by strings and pulleys - I just wish I had some data that proved that they work.

Adam Starr, Dallas, Texas

Date: Wed, 3 May 2000 00:19:44 +0100

From: Karim Brohi

We've also been using a pelvic sling (velcro/neoprene combination) at the Royal London Hospital for around 10 years. I'm not sure that it offers any particular benefit over a triangular bandage but it works. We also have moved away from external fixation which is a waste of time, usually not indicated for the given fracture pattern, and nobody really knows how to put one on quickly without image intensifiers, in ER, late at night. But you can be sure "it'll only take 5 minutes" ;-)

Ben Vermeulen and I have talked at some length about the pelvic belt and it's value, especially pre-hospitally. It, and our experience with it, was presented at the British Trauma Society meeting in 1998 - and I think the abstract was published in Injury in 1999 sometime.

As to the original posting, yes a lot of these patients had head injuries and die from complications, although a lot of them die because they are hyper-resucitated to "perfuse the brain" and die from ex-sanguination.

We have found it much more revealing to compare the mortality of those patients with unstable-pattern pelvic fractures who arrive shocked with those who are stable on arrival. 5 years ago our mortality for pelvic fracture patients (AIS 4 or 5) arriving with a BP<100 was around 50%. You don't want to know what it was for patients with a combined pelvic and intra-peritoneal injury requiring laparotomy.

We have dealt with the problem pretty aggressively but the mortality is still 15-25%, and there are still serious flaws in the management of these injuries.

Karim Brohi FRCS FRCA BSc, Dept of Surgery, Homerton Hospital, Trauma & Critical Care unit, Royal London Hospital,

Date: 05/03/00 11:58PM

From: Chip Routt

Thanks Karim. Your candid comments based on your experience are refreshing and appreciated.

These challenging clinical situations are quite variable and dynamic. They demand various and skilled resources.

Resuscitation and treatment "protocols" function as foundation, and should be very flexible - responding to (and anticipating) each patient's unique and evolving scenario, among other details.

The chance for success only begins with a realistic, cooperative, experienced, available, and dedicated team approach.

Comprehensive discussions of these difficult patients are well beyond the scope of this forum.

I'm amazed at how any people "developed" these "new" antishock circumferential pelvic wrapping techniques nearly simultaneosly, and in just the past decade! Fantastic.

Be available, keep it simple early, get experienced help, make it perfect and stable using the appropriate technique for the specific ring disruption...and then good luck!

We still have a great amount of work to do in this area.

M.L. Chip Routt, Jr., M.D., Harborview Medical Center. Seattle, Washington, USA

Date: Thursday, May 04, 2000 7:02 AM

From: Adam Starr

I'm amazed at how any people "developed" these "new" antishock circumferential pelvic wrapping techniques nearly simultaneosly, and in just the past decade! Fantastic."

That's right!

We're trying to figure out a way to market the ones we use. We even have a catchy name - "The Parkland Butt Binder".

(I suppose you could call them "Seattle Slings" or something up there - but make sure to include us in the deal).

I figure the royalties made off the "Butt Binder" will allow me to retire early to a life of leisure....I just need to learn how to play golf and I'm all set.

Adam Starr, Esq., Dallas, Texas

Date: Sat, 6 May 2000 22:42:21 -0500

From: Kyle Dickson, MD


I haven't checked my email in over a month (extremely swamped) and I saw your name a bunch of times and was worried you were promoting that percutaneous thing that I can't mention. For years I've thought too many ex fixes are going on the pelvis (ex fix deformities and malunions presented at the academy and accepted in jot and published in corr respectively). Furthermore, I think that it is rare for the pelvis to cause death. The question is with your numbers is how many pelvic injuries did you not see that maybe went to the morgue. I believe the number may be a little higher. I do use the ganz clamp rarely and in a few selected cases the results have been dramatic with a rise pressure. To see this response you must have one of those unstable pelvic injuries and must see and apply a fixator to the patient within the 1st hour. Once you see it you'll be a believer. I also was shown your texas squeezer with a nice note from charlie. The problem I have in new orleans is that we make them bigger here with more cushon and I can't get the velcro to hold. Hope things are going well. Take care

kyle dickson