>"I am told by my orthopaedic colleagues that the application of a C-clamp ...is not that easy without the use of an Image Intensifier and should be done by an experienced person."
I agree completely. They are especially difficult and dangerous in the case of a comminuted sacral fracture, because the sacrum may be crushed easily. I have also heard of C-clamps being misapplied with the prongs going through the greater sciatic notch into the pelvis.
Images Courtesy of Andrew Burgess, MD, MIEMSS, Univ of Maryland
OTA 1999 Posters
Effect of Fluoroscopy on Accuracy of Pelvic External Fixator Pin Placement
Paul P. Hospodar, MD; Richard L. Ulh, MD; Jeff A. Traub, MD; Greg S. Keller, Albany Medical College, Albany, NY
Introduction: External pelvic fixation is widely used for provisional fixation of a pelvic fracture during resuscitation or as part of definitive anterior stabilization. During the insertion of external fixation pins, faulty placement can contribute to premature loosening of the pins with mechanical failure or pin track infections. Recently, we assessed the role for fluoroscopy to improve the accuracy and reproducibility of pin insertion.
Materials and Methods: Twenty preserved cadavers had two blunt 5-mm external fixator pins inserted per hemipelvis randomly assigned with or without fluoroscopic control. For pins placed with fluoroscopy, an obturator view confirmed the starting position, orientation, and placement. In all cases, an open method with direct visualization and drilled pilot hole was used to place one external fixator pin 2 cm posterior to the anterior superior iliac spine and a second pin at the gluteal ridge. Dissection of cadavers verified pin placement. Pins were characterized as: Type 1 (completely in bone), Type 2 (violating cortical bone with the tip between the pelvic tables), and Type 3 (tip exiting bone completely). We recorded the distance from the starting point to violation of the pelvic tables.
Results: Violation of the pelvic tables occurred with ten of forty pins (25%) without fluoroscopy and five of forty pins (12.5%) with fluoroscopy. Eleven of fifteen pins violated the lateral table. Of the fifteen pins that violated one of the pelvic tables, eight of these occurred with the first sixteen placed. There was no statistical difference between those pins placed with or without fluoroscopy, pins placed anteriorly or posteriorly, or sex of the cadavers. Eleven pin tips were graded as Type 3. These exited one of the pelvic tables an average of 2.4 cm (range 1.2-3.6 cm) from the insertion site.
Discussion and Conclusion: Under optimal conditions with an open technique, one can expect a high rate of errantly placed pins. Most missed pins exited laterally, suggesting a tendency to underestimate the convergence of the iliac wings. This problem reinforces the importance of understanding the anatomy of the pelvis. Though not statistically different, the use of fluoroscopy seems to impart some benefit. Accurate pin placement develops with experience. Therefore, for the orthopaedic surgeon with limited experience, we recommend the use of an open technique with fluoroscopic control.
OTA 1996 Posters - Pelvic Fractures
Preliminary Experience with the Anti-Shock Pelvic Clamp: Complications and Early Outcomes
Samuel G. Agnew, MD, Julie Agel, ATC, M. L. Chip Routt, Jr., MD, Marc F. Swiontkowski, MD
University of Washington Harborview Medical Center, Seattle, Washington
Purpose: A retrospective review of all patients presenting to the Trauma Center from 1989-1994 with concomitant mechanically unstable pelvic fracture and in shock despite adequate fluid resuscitation, was undertaken. Those patients having the clamp applied as a method of resuscitation comprises the population for review.
Methods: Chart review for the time and location of clamp application, and any complication from actual application. Those patients that survived were evaluated with Short Form 36 Health survey instrument to assess outcome at one year.
Data: Ninety-one patients presented to the Trauma Center within 2.5 hours (0.5 - 2.5 hr.) of the accident; all with a hemodynamically and mechanically unstable pelvis fracture despite ongoing fluid resuscitation on arrival. Forty-seven patients (51.6%) survived the transportation to be admitted to the hospital for further resuscitation and care. Nine patients (19%) with an average ISS of 44, required the use of the anti-shock clamp due to persistent hemodynamic instability. The mean time from arrival to clamp application was 90 minutes (25 - 188). The first patients requiring the clamp had application done in the operating room without radiographic assistance. Five patients (55%) underwent simultaneous angiography and embolization at the time of clamp application. Embolization of a named source was accomplished in all five cases: 4 iliac or gluteal vessels and 1 renal artery. The clamp was applied in the operating room in four cases. Complications that occurred did not effect the eventual outcome: 2 cases of pelvic penetration of the stabilizing pins, 1 case of over compression of the clamp during positioning of the device. There were no cases of pin tract infections with the average duration of the clamp being 7 days (1 - 21 days).
The clamp was applied only nine times in the five year review period or approximately once every twenty-nine weeks by six different surgeons. The mechanism of injury was blunt trauma exclusively: Auto-Pedestrian (1), Crushing accident (2), Motorcycle (2), MVA (2), Fall (1), Bicycle (1). The mean age was 38 with range from 17 to 63. Of the nine patients identified one did not survive long enough to be admitted to the hospital having exsanguinated in the angiography suite 27 minutes after arrival. The second patient died of their initial injuries (CHI) within 2 hours of arrival, and the third died of multiple system failure at four days. All had complex pelvic fractures as classified according to Tile: there were four type C1, four type C2, and one type C3. The mechanical instability therefore was both rotational and vertical in all cases.
The acute blood requirements averaged 19.3 units per patient. The in hospital stay ranged from 18 to 489 days, not including rehabilitation admissions.
Discussion: Identification of the early problems-pelvic penetration of stabilization pins (2) in these complex settings led to the subsequent use of fluoroscopy. Application of the clamp could be performed under fluoroscopic guidance, usually facilitated in the angiography suite as simultaneous fluid resuscitation and embolization can be performed if necessary, or in the operating room. The posterior entry point to the pelvis and the externally rotated position of the disrupted hemipelvis create the potential for problems from insertion if not first corrected, or guided by fluoroscopy. The cases of pin penetration both occurred during extremely rapid application as both patients were in extremis at the time. The presence of the clamp did not create a problem with subsequent definitive fracture fixation. Three patients had iliosacral screws placed, and one patient had posterior tension band plating all without sequela. The Short Form 36 survey performed on the six survivors at one year follow up revealed significant physical and social disabilities.
Summary: The anti-shock clamp is a useful component for the treatment of these complex problem patients as it allows the unobstructed view and access to the pelvic vessels and viscera as needed. The learning curve for the device is quite flat given its infrequent use, and the complicated settings for which it is required. The use of the anti-shock clamp may aid in patient resuscitation and stabilization, yet unfortunately heralds a prolonged hospital course and associated financial burdens for those that do survive. Poor outcomes should be anticipated and the patients counseled to this end.