OTA-AAST Pelvic Fx Symposium 2000

Pelvic Injury Cases

Hemodynamically Unstable Pelvic Injury Case submitted by Eric Frykberg, MD - Shands Jacksonville

HISTORY OF PRESENT ILLNESS: The patient is a 44-year-old white male restrained driver who reportedly lost control of his vehicle and went down an embankment. Reportedly, there was a loss of consciousness at the scene and a GCS of 6. GCS was 14 on arrival with positive ETOH on breath. The patient had no complaints.

PAST MEDICAL HISTORY: Included hypertension, pulmonary embolism and right lower extremity DVT. Positive ETOH. Unknown tetanus.

PAST SURGICAL HISTORY: Positive for Greenfield filter placed.

MEDICATIONS: The patient was on Coumadin and unknown blood pressure medications times two.

ALLERGIES: No known allergies.

PHYSICAL EXAMINATION: The patient is a well-developed white male who presented on a back board in a c-collar. Pulse rate was 86, BP consistently 85-95 mmHg systolic.

The patient was normocephalic with a 3 centimeter right scalp laceration at the hair line. Pupils equally round and reactive to light and accommodation, extraocular movements intact. Pupils were 5 mm. to 3 mm. bilaterally. TMs were clear. There was no mid-face instability.

There were no step-offs noted with palpation of the cervical spine. Trachea was midline. Lungs were clear to auscultation bilaterally. A tachycardic rhythm with normal S1 and S2 and no murmurs was noted. Abdominal exam with positive bowel sounds, soft, nontender and nondistended. Rectal examination was without sphincter tone. Brown stool was heme-negative.

The left ankle showed obvious non-crepitant deformity. Sensation to pin-prick appeared intact to approximately the L4 (the mid-right knee) in the right lower extremity. There was no sensation distal to this point on the right. The right lower extremity had no tone or strength. He moved the left lower extremity on command and spontaneously. Glasgow Coma Scale of 14. Cranial nerves II-XII were intact.

Initial Studies:

AP Chest

Mediastinal View

Pelvic AP

Pelvic AP

Pelvic AP

A 3-view cervical spine series - negative. Chest x-ray suggestive of mediastinal widening . Ultrasound showed no abdominal fluid. A pelvis x-ray - a right sacroiliac joint fracture and pubic diastasis. Thoracic and lumbar spine films - negative. Xray of left ankle shows a bimalleollar fracture.

Initial Labs: ETOH - 218. H&H 13.8 and 41.4, PTT 23.8, PT 19.3 with an INR of 2.8.

Initial Measures: The pubic diastasis was immediately reduced in the trauma center by wrapping a sheet around his pelvis and pulling tight.

Initial Measures:

S/P Sheet Application

This led to immediate improvement in blood pressure to 110 mmHg systolic. A left pneumothorax was found and left anterior chest tube thoracostomy was performed without complication. The right forehead laceration was irrigated and closed.

An Orthopaedic consultation was obtained . The Orthopedic Service planned internal operative stabilization of the pelvic fracture and the left pilon fracture after the patient was cleared by the Trauma Service and deemed stable for such extended procedures.

The patient was taken directly to the angiography suite for aortic arch and pelvic angiograms as prompted by the widened mediastinum, pelvic fracture, and hemodynamic instability.

Angiography:

Aortic Arch

Pelvis

Embolization
Lt Hypogastric

The patient was found to have a thoracic-aortic rupture at the isthmus. It was decided initially to non-operatively manage the aortic injury. The pelvic angiogram was initially interpreted as negative. After further review, it was felt the patient might be bleeding from the pelvis. The patient was taken back to the angiography suite and embolization of the left pudendal branches was performed.

After consultation with Cardiothoracic Surgery, it was felt the patient would benefit most from surgical repair of the aortic injury. The patient was taken to the operating room by Cardiothoracic Surgery where the aortic laceration was repaired. The patient tolerated the procedure well.

HOSPITAL COURSE: Repeat lower extremity examinations and films revealed a right calcaneus fracture. Repeated neurologic exams showed no deterioriation of neurologic status below the level of L4.

On the third hospital day, after being stabilized in the SICU, the patient was cleared by the Trauma Team and Critical Care Team for a return of the patient to the operating room for orthopedic treatment of his pelvic, left pilon and right calcaneus fractures. The patient tolerated the procedures well. He was placed on appropriate antibiotics postoperatively.

Orthopaedic
Procedures:

Pelvic ORIF

The hospital course was complicated by ARDS. The patient spiked temperatures to 103.1 and grew out Hemophilus influenza from the sputum. He was on p.o. Zosyn to combat the pulmonary infection and was placed on TPN. A Dobbhoff tube was placed and the patient remained intubated. An arterial line was placed to monitor the patient's cardiovascular function which gradually improved as did his pulmonary status and the patient was weaned from the ventilator. He was switched to Levaquin for his Hemophilus in the sputum.

The patient was taken back to surgery by the Orthopedic Service to augment the pelvic stabilizing procedure. The patient's electrolytes were followed daily and were replaced and adjusted as necessary. His chest tube was removed on 09/13/99 with no return of pneumothorax. The patient was switched to Unasyn and was continued on TPN until tube feeds reached goal. His lines were changed out.

The patient was again taken to the OR by orthopedics for review and revision of his previous surgeries with additional screws being applied to his pelvis. The patient also developed a decubitus ulcer of his left foot during his hospital course. His H&H were followed and addressed accordingly. The patient's mental status improved and he was an 11T and slowly was weaned off the ventilator. The patient continued to improve and was transferred from the Step-Down Unit to the floor. He had ORIF of his right calcaneal fracture by orthopedics and tolerated the procedure well. He was placed on a regular diet and was continued on Ancef postoperatively. He had good bowel movements. Hypertension was controlled on clonidine t.i.d. On twentieth hospital day, it was deemed the patient was stable for discharge to rehabilitation.

DISPOSITION: The patient is discharged to the Rehab Unit with orthopedic follow up. The patient's discharge planning included a regular diet with Boost supplementation t.i.d. He was non weightbearing on the bilateral lower extremities. The patient was on clonidine, Tylox, Surfak, 240 mg q.d. and Lovenox subcu.