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成人创伤患者的严重骨盆骨折

Authors
Clay Cothren Burlew, MD
Ernest E Moore, MD
Section Editor
Heidi L Frankel, MD, FACS
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Translators
张绍东, 副主任医师，副教授

引言

严重骨盆骨折患者给创伤小组带来很多挑战。骨盆损伤常伴有其他危及生命的损伤，有关其全方位处理尚未达成普遍共识。在美国目前的处理流程中，对于初始复苏后骨骼稳定，以及采用腹膜前盆腔填塞和血管栓塞术进行出血控制的时间规定不统一。我们建议对血流动力学不稳定患者行早期固定和盆腔填塞，而血管栓塞术仅用于行盆腔填塞后仍有盆腔源性出血的非凝血病患者。采用创伤外科医生、骨科医生、血管介入科医生、麻醉科医生和输血机构的多学科方法，可优化严重骨盆骨折的处理。

本文将总结重度骨盆骨折的治疗方法，包括控制持续出血。骨盆骨折患者的诊断和初始创伤处理将在别处讨论。 (参见“骨盆创伤：初步评估与处理”)

解剖学注意事项

骨盆钝性损伤可产生复杂的骨折，常导致中度到重度的出血。Young-Burgess分类法按照力向量将骨盆骨折分为：侧方挤压(lateral compression, LC)骨折、前/后挤压(anterior/posterior compression, APC)骨折或垂直剪力(vertical shear, VS)骨折(图 1和表 1) [1,2]。在每种类型中，根据韧带损伤、骨折和半骨盆整体移位的程度，又进一步将骨盆损伤分为Ⅰ型(较轻度)到Ⅲ型(最严重)。然而，患者的骨折表现可能并不完全遵从某一单独的类型；也可能出现LC、APC和VS的组合。较高级别的骨折，特别是APC型和VS型，出现血流动力学不稳，需要输血和干预的情况更常见。 (参见“骨盆创伤：初步评估与处理”，关于‘骨折类型’一节)

在美国矫形外科协会/骨科创伤协会的分类系统中，骨盆骨折也可被分为生物力学稳定型或不稳定型[3]。不稳定型骨盆骨折要求骨盆环存在2处或更多处断裂。需注意的是，骨盆骨折的生物力学不稳并不一定意味着血流动力学就稳定。骨折块和韧带不稳可能导致骨盆旋转不稳(部分稳定型骨盆，B型)或旋转垂直不稳(完全不稳定型骨盆，C型)(图 2)。总的来说，APCⅠ、Ⅱ型及LCⅠ、Ⅱ、Ⅲ型损伤被认为是旋转不稳定型，而APCⅢ、VS型和复合型损伤被认为旋转和垂直都不稳定。

造成软组织损伤的骨折被称为“开放性”骨折；然而，这种破损可发生在直肠、阴道或皮肤，这些相关损伤会使处理变复杂。 (参见下文‘相关软组织损伤的处理’)

                 

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Literature review current through: 2017-06 . | This topic last updated: 2016-04-19.
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References
Top
  1. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986; 160:445.
  2. Young, JWR, Burgess, AR. Fractures of the pelvis. In: Imaging in Trauma and Critical Care, Mirvis SE, Young JWR (Eds), Williams & Wilkins, Baltimore 1992. p.382.
  3. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma 1996; 10 Suppl 1:v.
  4. Huittinen VM, Slätis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery 1973; 73:454.
  5. Advance trauma life support, 8, American College of Surgeons, Chicago 2009..
  6. Giannoudis PV, Grotz MR, Tzioupis C, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma 2007; 63:875.
  7. Lunsjo K, Tadros A, Hauggaard A, et al. Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients. J Trauma 2007; 62:687.
  8. Charbit J, Millet I, Martinez O, et al. Does the size of the hemoperitoneum help to discriminate the bleeding source and guide therapeutic decisions in blunt trauma patients with pelvic ring fracture? J Trauma Acute Care Surg 2012; 73:117.
  9. Pizanis A, Pohlemann T, Burkhardt M, et al. Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques. Injury 2013; 44:1760.
  10. Pehle B, Nast-Kolb D, Oberbeck R, et al. [Significance of physical examination and radiography of the pelvis during treatment in the shock emergency room]. Unfallchirurg 2003; 106:642.
  11. Ruchholtz S, Waydhas C, Lewan U, et al. Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary? J Trauma 2004; 57:278.
  12. Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma 1995; 39:375.
  13. Dolich MO, McKenney MG, Varela JE, et al. 2,576 ultrasounds for blunt abdominal trauma. J Trauma 2001; 50:108.
  14. Friese RS, Malekzadeh S, Shafi S, et al. Abdominal ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture. J Trauma 2007; 63:97.
  15. Tayal VS, Nielsen A, Jones AE, et al. Accuracy of trauma ultrasound in major pelvic injury. J Trauma 2006; 61:1453.
  16. Guillamondegui OD, Pryor JP, Gracias VH, et al. Pelvic radiography in blunt trauma resuscitation: a diminishing role. J Trauma 2002; 53:1043.
  17. Berg EE, Chebuhar C, Bell RM. Pelvic trauma imaging: a blinded comparison of computed tomography and roentgenograms. J Trauma 1996; 41:994.
  18. McCormick JP, Morgan SJ, Smith WR. Clinical effectiveness of the physical examination in diagnosis of posterior pelvic ring injuries. J Orthop Trauma 2003; 17:257.
  19. Gonzalez RP, Fried PQ, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg 2002; 194:121.
  20. Duane TM, Tan BB, Golay D, et al. Blunt trauma and the role of routine pelvic radiographs: a prospective analysis. J Trauma 2002; 53:463.
  21. Brasel KJ, Pham K, Yang H, et al. Significance of contrast extravasation in patients with pelvic fracture. J Trauma 2007; 62:1149.
  22. Diamond IR, Hamilton PA, Garber AB, et al. Extravasation of intravenous computed tomography scan contrast in blunt abdominal and pelvic trauma. J Trauma 2009; 66:1102.
  23. Verbeek DO, Zijlstra IA, van der Leij C, et al. Management of pelvic ring fracture patients with a pelvic "blush" on early computed tomography. J Trauma Acute Care Surg 2014; 76:374.
  24. Poole GV, Ward EF. Causes of mortality in patients with pelvic fractures. Orthopedics 1994; 17:691.
  25. Scalea, TM, Stein, DM, O'Toole, RV. Pelvic Fractures. In: Trauma, 6, Feliciano, DV, Mattox, KL, Moore, EE (Eds), McGraw-Hill, New York 2008. p.759.
  26. Cestero RF, Plurad D, Green D, et al. Iliac artery injuries and pelvic fractures: a national trauma database analysis of associated injuries and outcomes. J Trauma 2009; 67:715.
  27. Frykberg, ER, Schinco, MA. Peripheral vascular injuries. In: Trauma, 6, Feliciano, DV, Mattox, KL, Moore, EE (Eds), McGraw-Hill, New York 2008. p.941.
  28. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma 2005; 59:1314.
  29. Scott DJ, Eliason JL, Villamaria C, et al. A novel fluoroscopy-free, resuscitative endovascular aortic balloon occlusion system in a model of hemorrhagic shock. J Trauma Acute Care Surg 2013; 75:122.
  30. Morrison JJ, Percival TJ, Markov NP, et al. Aortic balloon occlusion is effective in controlling pelvic hemorrhage. J Surg Res 2012; 177:341.
  31. Burlew CC, Moore EE, Smith WR, et al. Preperitoneal pelvic packing/external fixation with secondary angioembolization: optimal care for life-threatening hemorrhage from unstable pelvic fractures. J Am Coll Surg 2011; 212:628.
  32. Spahn DR, Cerny V, Coats TJ, et al. Management of bleeding following major trauma: a European guideline. Crit Care 2007; 11:R17.
  33. Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury 2009; 40:343.
  34. Biffl WL, Smith WR, Moore EE, et al. Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures. Ann Surg 2001; 233:843.
  35. Cothren CC, Osborn PM, Moore EE, et al. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 2007; 62:834.
  36. Hamill J, Holden A, Paice R, Civil I. Pelvic fracture pattern predicts pelvic arterial haemorrhage. Aust N Z J Surg 2000; 70:338.
  37. Costantini TW, Bosarge PL, Fortlage D, et al. Arterial embolization for pelvic fractures after blunt trauma: are we all talk? Am J Surg 2010; 200:752.
  38. Gourlay D, Hoffer E, Routt M, Bulger E. Pelvic angiography for recurrent traumatic pelvic arterial hemorrhage. J Trauma 2005; 59:1168.
  39. Toth L, King KL, McGrath B, Balogh ZJ. Factors associated with pelvic fracture-related arterial bleeding during trauma resuscitation: a prospective clinical study. J Orthop Trauma 2014; 28:489.
  40. Eastridge BJ, Starr A, Minei JP, et al. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002; 53:446.
  41. Pereira SJ, O'Brien DP, Luchette FA, et al. Dynamic helical computed tomography scan accurately detects hemorrhage in patients with pelvic fracture. Surgery 2000; 128:678.
  42. Miller PR, Moore PS, Mansell E, et al. External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 2003; 54:437.
  43. Brown CV, Kasotakis G, Wilcox A, et al. Does pelvic hematoma on admission computed tomography predict active bleeding at angiography for pelvic fracture? Am Surg 2005; 71:759.
  44. Blackmore CC, Jurkovich GJ, Linnau KF, et al. Assessment of volume of hemorrhage and outcome from pelvic fracture. Arch Surg 2003; 138:504.
  45. Salim A, Teixeira PG, DuBose J, et al. Predictors of positive angiography in pelvic fractures: a prospective study. J Am Coll Surg 2008; 207:656.
  46. Köhler D, Sellei RM, Sop A, et al. Effects of pelvic volume changes on retroperitoneal and intra-abdominal pressure in the injured pelvic ring: a cadaveric model. J Trauma 2011; 71:585.
  47. Croce MA, Magnotti LJ, Savage SA, et al. Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg 2007; 204:935.
  48. Jowett AJ, Bowyer GW. Pressure characteristics of pelvic binders. Injury 2007; 38:118.
  49. Ertel, W, Karim, E, Keel, M, Trentz, O. Therapeutic strategies and outcome of polytraumatized patients with pelvic injuries. Eur J Trauma 2000; 26:278.
  50. Ochsner MG, Knudson MM, Pachter HL, et al. Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis. J Trauma 2000; 49:505.
  51. Mason WT, Khan SN, James CL, et al. Complications of temporary and definitive external fixation of pelvic ring injuries. Injury 2005; 36:599.
  52. Taeger G, Ruchholtz S, Waydhas C, et al. Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma 2005; 59:409.
  53. Stahel PF, Mauffrey C, Smith WR, et al. External fixation for acute pelvic ring injuries: decision making and technical options. J Trauma Acute Care Surg 2013; 75:882.
  54. Ertel W, Keel M, Eid K, et al. Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 2001; 15:468.
  55. Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury 2004; 35:671.
  56. Smith WR, Moore EE, Osborn P, et al. Retroperitoneal packing as a resuscitation technique for hemodynamically unstable patients with pelvic fractures: report of two representative cases and a description of technique. J Trauma 2005; 59:1510.
  57. Pohlmann, T, Gansslen, A, Hufner, T, Tscherne, H. Extraperitoneal packing at laparotomy. OTA-AAST Annual Meeting 2000.
  58. Panetta T, Sclafani SJ, Goldstein AS, et al. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 1985; 25:1021.
  59. Rossaint R, Duranteau J, Stahel PF, Spahn DR. Nonsurgical treatment of major bleeding. Anesthesiol Clin 2007; 25:35.
  60. Starr AJ, Griffin DR, Reinert CM, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma 2002; 16:553.
  61. Niwa T, Takebayashi S, Igari H, et al. The value of plain radiographs in the prediction of outcome in pelvic fractures treated with embolisation therapy. Br J Radiol 2000; 73:945.
  62. Jeske HC, Larndorfer R, Krappinger D, et al. Management of hemorrhage in severe pelvic injuries. J Trauma 2010; 68:415.
  63. O'Neill PA, Riina J, Sclafani S, Tornetta P 3rd. Angiographic findings in pelvic fractures. Clin Orthop Relat Res 1996; :60.
  64. Suzuki T, Kataoka Y, Minehara H, et al. Transcatheter arterial embolization for pelvic fractures may potentially cause a triad of sequela: gluteal necrosis, rectal necrosis, and lower limb paresis. J Trauma 2008; 65:1547.
  65. Yasumura K, Ikegami K, Kamohara T, Nohara Y. High incidence of ischemic necrosis of the gluteal muscle after transcatheter angiographic embolization for severe pelvic fracture. J Trauma 2005; 58:985.
  66. DuBose J, Inaba K, Barmparas G, et al. Bilateral internal iliac artery ligation as a damage control approach in massive retroperitoneal bleeding after pelvic fracture. J Trauma 2010; 69:1507.
  67. Naam NH, Brown WH, Hurd R, et al. Major pelvic fractures. Arch Surg 1983; 118:610.
  68. Sinnott R, Rhodes M, Brader A. Open pelvic fracture: an injury for trauma centers. Am J Surg 1992; 163:283.
  69. Moore FA, McKinley BA, Moore EE, et al. Inflammation and the Host Response to Injury, a large-scale collaborative project: patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006; 61:82.
  70. Menaker J, Stein DM, Scalea TM. Incidence of early pulmonary embolism after injury. J Trauma 2007; 63:620.
  71. Smith W, Williams A, Agudelo J, et al. Early predictors of mortality in hemodynamically unstable pelvis fractures. J Orthop Trauma 2007; 21:31.
  72. Mucha P Jr, Welch TJ. Hemorrhage in major pelvic fractures. Surg Clin North Am 1988; 68:757.
  73. Heetveld MJ, Harris I, Schlaphoff G, et al. Hemodynamically unstable pelvic fractures: recent care and new guidelines. World J Surg 2004; 28:904.
  74. Demetriades D, Karaiskakis M, Toutouzas K, et al. Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 2002; 195:1.
  75. Gustavo Parreira J, Coimbra R, Rasslan S, et al. The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures. Injury 2000; 31:677.
  76. Verbeek DO, Sugrue M, Balogh Z, et al. Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice. World J Surg 2008; 32:1874.
  77. Hauschild O, Strohm PC, Culemann U, et al. Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma 2008; 64:449.