Article 6


Pelvic Trauma: A Diagnostic
And Therapeutic Challenge


Lim Ju Boo


There was another very short summary statement as a cross reference from some papers (‘papers’ means technical papers from proper journals, and does not mean (news)papers please) I was flipping over last evening, published by Maurer in 1993. He said that it was shown that patients with pelvic trauma often have other multiple injuries that cause special problems (1). Well, I thought about this short, but important statement of his, and I decided that I should write and expand on this subject a little more here.

Crush injuries of the pelvis is commonly seen in about 5% of MVA (motor vehicle accidents) fractures in Malaysia (2). There may be also resultant pelvic fractures from vertical force applied by a fall from a height, the transmission of impact energy anterior-posteriorly, and vice-versa (AP/PA/AP), or laterally from a motor vehicle onto a pedestrian. Injuries to the pelvis can give rise to a number of complications, and they include:

Urogenital:

• Intraperitoneal and extraperitoneal rupture of the bladder

• Rupture of the penis and membranous urethra

Vascular:

• Damage to major vessels

• Massive haemorrhage from retropelvic vascular tear involving the iliac, lumbar, and other smaller arteries (blood loss from 1-4 litres)

• Ecchymosis (bruising and bleeding under the skin) may spread high up into pelvic cavity

• Disemination of intravascular clots

• Consumptive Coagulopathy


Neurological:

• Sciatic nerve damage

• Lumbosacral plexus involvement


Intestinal:

• Paralytic ileus (more common)

• Small intestine, colon and rectum (less common)


Others:

• May also involve extensive tear to the liver, spleen, pancreas, heart, lungs, and great vessels, spinal cord and extremities.

The major cause of mortality and morbidity in pelvic fractures may be due to massive haematoma and blood loss (up to 4 litres) from the damaged retropelvic arteries, especially in pelvic diastasis (diastasis means separation of bones at the epiphysis or joints, not amounting to a fracture), e.g. in ‘open book’ fracture of the pelvis where the symphysis pubis is opened out with appreciable sacro-iliac disruption). In major pelvic fractures where there is extensive bleeding, the chances of the casualty going into hypovolaemic shock are real. In such cases, the priority in first-aid is to immobilize the pelvic bone, and prevent shock (Trendelenburg’s position if necessary). If there are resulting haemorrhage shock, the application of anti-shock garments such as MAST suits. (MAST stands for Military (or Medical) Anti-Shock Trousers) can be one of the initial emergency first-aid treatment (to be done by paramedic or first responder if you like) prior to reduction (reduction is a surgical term to mean restoration to normal position) with external fixateur, and massive blood transfusion in a hospital. However the application of MAST or Pneumatic Antishock Garment (PASG) as advocated by some authorities is not without disadvantages and complications. Surprisingly, it has limited use in hypotensive trauma as shown by Mattox, et al. (3). Although, useful as a splint, by its tamponade effect, but it may also elevate intra-abdominal pressure, and hence may also raise intrathoracic pressure. This would cause resulting in difficulties with ventilation, cardiovascular and renal dysfunction as shown by Cullen, et al (4). In order to overcome the problem, a number of pelvic clamps and devices have been tried to reduce, compress, and immobilize the posterior fragments in a pelvic fracture, thus limiting further movement, tear and bleeding from bone fragments as reported by Ganz et al (5). Moreover, if pelvic fractures involve the long bones as well, there is also the risk of fat emboli (Fat Embolism Syndrome) especially in young adults, in whom fat globules from the long bones of the lower extremities (legs) may enter the lungs causing ARDS (Adult Respiratory Distress Syndrome). However all of these clamps require general anaesthesia for their application which in itself may cause complications in the unstable patient.

One special pelvic clamp device to address the massive bleeding, usually originating from hypogastric arterial involvement, associated with pelvic fractures, was invented by none other than Mr (Dr) Abu Hassan Asaari Abdullah, the Chief Traumatologist and Head of the Department of Emergency Medical and Trauma Services of Kuala Lumpur Hospital. This simple device does not require general anaesthesia for its application, and the application is so simple, it makes it possible for all paramedics, first-responders and first aiders to use it. It is a very handy equipment to be included in the list of ambulance equipment. Mr Abu Hassan is also St John Ambulans Malaysia Chief Surgeon, and we are very proud of him. (See foot-note). The immobiliser was invented by him in August, 1996, and was named as Nina Pelvic Immobiliser, after his daughter Sabrina who was born in August, 1990. In a 3 part monograph, he described the indications for early rigid immobilisation of pelvic fracture using the device, its methods of application, and gave its design and the manufacturing technology (1). In an unpublished paper, he reported 20 cases for evaluation in terms of pain relief, haemodynamic status and circulatory effect (blood pressure and pulse rate), changes in pelvic volume, and the reduction of pelvic morphology. More cases are now being studied (personal communication). Syabas to him! He is our local inventor. Besides, I think he is a dynamic Consultant Orthopaedic and Trauma Surgeon.

It is important that a quick and thorough diagnosis as well as therapeutic management according to the special situation and findings is necessary. Effective cooperation of all the different specialists concerned with the management of the patient is mandatory. Massive blood loss immediately after trauma is life-threatening to the patient. To cope with bleeding, all non-invasive measures available should be used. Stable injuries of the pelvis are treated conservatively. In cases of instability, external fixation of the pelvis is mandatory and should be performed as soon as possible. Internal stabilization and osteosynthesis (meaning: surgical fastening of ends of a fractured bone by mechanical means) is another option, bearing in mind the different procedures for the treatment are associated with specific risks and complications.


* Foot-note:

I don’t know how many of you in St. John Ambulance Malaysia are aware that Mr. (Dr) Abu Hassan Asaari Abdullah, a Consultant Traumatologist and Orthopaedic Surgeon and National Consultant to the MOH (Ministry of Health), Malaysia for Emergency Medical and Trauma Services in the country, and the Head of Hospital Kuala Lumpur Emergency Services, is also the Chief Surgeon of St John Ambulans Malaysia. He has invented the Nina Pelvic Immobilizer which he named after his young daughter, Sabrina. With his creative mind, let me take this opportunity to say ‘Syabas’ to this great Malaysian surgeon/inventor of ours. Looking at the fantastic work he has done, from the elaborate Medical Emergency Services set-up at the recent SUKOM Games, to training of First Responders and the Bicycle Medics and Paramedics, to the creation of mobile operating theatres,

Mr. Abu Hassan has literally changed the face of emergency medical services in Malaysia with his innovation and creative mind. Never in the history of Trauma Medicine in Malaysia, has anyone seen someone so visionary and resourceful a person as Mr (Dr) Abu Hassan. He is ambitious, dynamic, and is gifted with visionary ideas on emergency services in Malaysia, and he is on the go all the time. His futuristic vision is the establishment of an Ambulance Service Network for Klang Valley, and eventually nation wide. I hope people in position will support his ideas. I had on a few occasions followed him during his morning ward rounds at the Kuala Lumpur Hospital. One should see him teach during one of his rounds of duty. He is a strict and a good disciplinarian to his staff, a fantastic teacher, and a great surgeon and traumatologist. Not many can teach and explain like him. To add another feature to his cap, he is also an inventor, and he has told me he has invented many other things as well. I take my my hats off to this man. I feel he should get an award for all the work he has done. It will come, but I think his stars are not ripe into position yet. Meantime, we at St John would like to congratulate you a thousand times, Dr. Abu Hassan.



References:


1. Maurer, F. Pelvic Trauma. Aktuelle-Traumatol. (1993 Jul; 23) Suppl 1: 42-9.

2. Abu Hassan, A.A. Early Rigid Immobiliser of Pelvic Fracture using Nina Pelvic Immobilizer. A Monograph, 1998 (Unpublished)

3. Mattox, KL; Bickell W, Pepe; PE. Prospspecting MAST study in 911 patients. J Trauma. (1989), 29:1104.

4. Culllen, DJ; Clyle JP, Teplick R, et al. Cardiovascular pulmonary and renal effects of massively increased intra-abdominal pressure in critically ill patients. Crit Care Med 17:118, 1989.

5. Ganz R, Kroshell RJ, Jakob RP, et al. The anti-shock pelvic clamp. Clin Orthop. (1991), 261:71.