History of pelvic fracture management: a review
© Stahel and Hammerberg. 2016
Received: 17 February 2016
Accepted: 29 April 2016
Published: 4 May 2016
High-energy pelvic fractures represent potentially life-threatening injuries due to the risk of acute exsanguinating retroperitoneal hemorrhage. The first report of a severe pelvic ring disruption dates back to Charles Hewitt Moore’s seminal publication from 1851. Significant advantages in the understanding of injury mechanisms and treatment concepts of pelvic ring injuries evolved in the 20th century, and provided the basis to current classification-guided treatment and life-saving “damage control” concepts. However, there is a paucity of reports in the current literature focused on the historic background on the treatment of pelvic ring injuries. The present review was designed to summarize the history and evolution of our current understanding of the mechanisms and management strategies for severe pelvic ring injuries (excluding acetabular fractures which represent a different entity outside of the scope of this article).
KeywordsPelvic fracture History Management strategies Retroperitoneal bleeding Damage control
The ‘Malgaigne era’ (19th century)
In the absence of radiographic imaging, accurate diagnosis in the 19th century was established by physical exam. Malgaigne described palpation and manipulation to reveal crepitation at the fracture site, and careful estimation of the height of the iliac crest to help rule out a more common fracture pattern associated with lower extremity shortening, i.e. a fracture of the femoral neck. Malgaigne noted that vertically displaced pelvic fractures were often accompanied by impairment or complete loss of lower extremity function. The ‘key’ to successful management of these injuries was the restoration and maintenance of lower extremity length. To this end, Malgaigne advocated an accurate closed reduction maneuver, aided by vaginal and/or rectal palpation. The reduction maneuver was followed by maintenance in a modified traction bed, with application of a pelvic sling, for a minimum of 45 to 50 days. As many patients could not tolerate the prolonged immobilization in traction, most fractures healed with significant limb shortening. Malgaigne noted that many patients would not survive this severe injury, and understood that there was a significant association between this fracture pattern, bleeding, and visceral injuries. The more fortunate patients who survived the initial injury remained at significant risk of delayed suppuration and sepsis, which was likely the result of contaminated open fracture wounds and associated visceral injuries. Therefore, those patients who survived had a grim prognosis in general. As Malgaigne observed: “If life is preserved, lameness is very apt to ensue.”
Charles Hewitt Moore’s case report (1851)
The ‘Holdsworth era’ (early 20th century)
Classification-guided management (20th/21st century)
The first clinically relevant systematic classification of pelvic fractures, based on the mechanism of injury, was described by Pennal and Sutherland in 1961 . This system defines three distinct categories of pelvic ring injuries: (1) avulsion fractures, (2) ‘stable’ fractures, and (3) ‘unstable’ fractures, and attempts to correlate injury severity with outcomes. Dunn and Morris later revisited the non-operative concept for the management of pelvic ring injuries and dislocations, based on the Pennal/Sutherland classification system .
In 1980, Pennal and Tile introduced the aspect of fracture stability to the original Pennal/Sutherland classification and incorporated mechanisms and vectors of injury . The Pennal/Tile classification furthermore served as a basis for therapeutic decision-making and management protocols of pelvic ring injurie . Currently used classification systems are largely based on the seminal publications by Tile, Pennal, and Sutherland. For example, the AO/OTA classification for pelvic ring injuries  is mainly based on Marvin Tile’s original classification system from 1980, and the classification by Young & Burgess  is based on the original Pennal/Sutherland description from 1961. Both the Tile and Young & Burgess classification systems are still widely used in the 21st century for decision-making and guidance of therapeutic protocols in the acute management of patients with pelvic ring disruptions [18, 19].
By the middle part of the 20th century, with a growing number of high-speed motor vehicle accidents, it had become clear that pelvic fractures were involved in a significant number of fatal injuries, mostly related to exsanguinating retroperitoneal hemorrhage . At this time, resuscitation strategies were in their infancy, and there was ongoing debate regarding the appropriate sequence and surgical priorities in the acute management of pelvic hemorrhage . The role of the orthopaedic surgeon in the acute management and resuscitation of patients with pelvic ring disruptions continued to grow in the second half of the 20th century. External fixation of pelvic ring injuries was introduced and applied increasingly in the early management of hemodynamically unstable patients [22–24]. The underlying theory was that external fixation might decrease ongoing blood loss by eliminating motion at the fracture site. In addition, by reducing ‘open book’ injuries, external fixation was thought to reduce the intrapelvic volume and to help reducing retroperitoneal blood loss .
While there are some early reports from the 1950s on internal fixation for acute pelvic fractures , the majority of pelvic ring injuries were managed non-operatively at the time. During the second half of the 20th century, treatment protocols moved beyond conservative treatment strategies, as a number of surgeons began to recommend surgical fixation for selected pelvic ring injuries. Marvin Tile was a pioneer in this field and he used his own classification system to guide treatment recommendations . Initially, definitive internal fixation was reserved for vertically unstable fractures . However, into the 1980s, indications for definitive internal fixation were broadened to include rotationally unstable fractures as well [27–29]. The notion that surgical fixation of unstable pelvic ring injuries allows early mobilization of patients and provides superior clinical outcomes became prevalent towards the end of the 20th century in North American and European countries [30, 31]. This experience solidified the concept of early internal fixation of unstable pelvic ring injuries as a new international standard of care in the 21st century.
Significant progress has been made in recent years in the acute management of severe pelvic ring disruptions by mitigating the risk of acute exsanguinating hemorrhage and associated post-injury mortality. The historic evolution related to our understanding of underlying injury mechanisms has provided the basis for classification-guided management strategies for high-energy pelvic injuries. Future innovations on the horizon include less-invasive management strategies, e.g. by early definitive care with percutaneous fixation of unstable pelvic ring disruptions, and bedside point-of-care resuscitation of hemorrhagic shock and post-injury coagulopathy which represents the current “frontier” of cutting-edge research in the 21st century [32–38].
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