Pelvis Kırıklarında Güncel Tanı-Tedavi Yaklaşımı
Özet
Genç hastalarda yüksek enerjili travmalar sonucu oluşan deplase pelvis halka kırıkları, arteriyel ve venöz damarların hasar görmesi nedeniyle hayati risk oluşturan ciddi kanamalara ve eşlik eden ek organ yaralanmalarına yol açabilmektedir. Vücudun yük aktarımını üstlenen pelvik anatomide, güçlü bağ dokularının bütünlüğü rotasyonel ve vertikal stabilite açısından büyük önem taşımaktadır. Klinik yaklaşımda İleri Travma Yaşam Desteği ilkeleri benimsenerek hemodinamik durum kontrol altına alınmalı, aktif kanama şüphesinde hızla pelvik kemer uygulanmalı, durdurulamayan arteriyel kanamalarda ise embolizasyon veya intrapelvik tamponad gibi invaziv yöntemler tercih edilmelidir. Yaralanma mekanizmasını doğru analiz etmek adına kontrastlı bilgisayarlı tomografi ve grafilerden faydalanılırken, ürogenital sistem ve sinir pleksusu hasarları da titizlikle incelenmelidir. Literatürde en yaygın kullanılan Young ve Burgess sistemine göre lateral kompresyon, antero-posterior kompresyon, vertikal shear ve kombine mekanizmalı yaralanmalar olarak kategorize edilen bu kırıklarda, instabilite durumuna bağlı olarak erken definitif cerrahi fiksasyon veya eksternal fiksatör gibi geçici mekanik stabilizasyon çözümleri zaman kaybedilmeden hayata geçirilmelidir.
Displaced pelvic ring fractures resulting from high-energy traumas in young patients can lead to life-threatening, severe hemorrhages and accompanying additional organ injuries due to damage to arterial and venous vessels. In the pelvic anatomy, which undertakes the load transmission of the body, the integrity of strong ligaments is of great importance for rotational and vertical stability. In the clinical approach, the hemodynamic status should be controlled by adopting Advanced Trauma Life Support principles, a pelvic binder must be applied rapidly in case of suspected active bleeding, and invasive methods such as embolization or intrapelvic tamponade should be preferred in uncontainable arterial hemorrhages. While contrast-enhanced computed tomography and radiographs are utilized to accurately analyze the injury mechanism, urogenital system and nerve plexus damages must also be meticulously examined. In these fractures, which are categorized as lateral compression, antero-posterior compression, vertical shear, and combined mechanism injuries according to the most commonly used Young and Burgess system in the literature, early definitive surgical fixation or temporary mechanical stabilization solutions such as external fixators must be implemented without losing time depending on the instability status.
Referanslar
Schmal H, Markmiller M, Mehlhorn AT, Sudkamp NP. Epidemiology and outcome of complex pelvic injury. Acta Orthop Belg 2005;71(1):41–47.
McCormack R, Strauss EJ, Alwattar BJ, Tejwani NC. Diagnosis and management of pelvic fractures. Bull NYU Hosp Jt Dis 2010;68(4):281–291.
Ben-MenachemY, Coldwell DM,Young JW, Bur- gess AR. Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management. AJR Am J Roentgenol 1991;157(5):1005–1014.
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures. Injury 2009;40(10): 1023–1030.
Durkin A, Sagi HC, Durham R, Flint L. Contemporary management of pelvic fractures. Am J Surg 2006;192(2):211–223.
Dyer GS, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury 2006;37(7):602–613.
Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture: update and systematic review. J Trauma 2011;71(6):1850–1868.
Jeske HC, Larndorfer R, Krappinger D, et al. Management of hemorrhage in severe pelvic injuries. J Trauma 2010;68(2):415–420.
Figler B, Hoffler CE, Reisman W, et al. Multi-disciplinary update on pelvic fracture associated bladder and urethral injuries. Injury 2012;43(8):1242–1249.
Stambaugh LE 3rd, Blackmore CC. Pelvic ring disruptions in emergency radiology. Eur J Radiol 2003; 48(1):71–87.
Kurylo JC,Tornetta P 3rd. Initial management and classification of pelvic fractures. Instr Course Lect 2012;61:3–18.
Star AJ, Malekzadeh AS. Fractures of the Pelvic Ring. In Rockwood & Green’s Fractures in Adults, 6th Edition. Bucholz RW, Heckman JD, Court-Brown CM (ed). Lippincott Williams & Wilkins Volume 2, Section Four, Chapter 41: 1585 – 1663.
DeLancey J 2008 Anatomy of the pelvis Global Library of Women’s Medicine Available from https://editorial.glowm. com/Potassium.htm?p=glowm.cml%2Fsection_view &articleid=95&fbclid=IwAR3GzIzKPPqJ6LVka3MAL 8uRCOPER3QsmYZiX0xy111Cdv2keUrtgR6Hm8w
Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg 1988;70B:1–12.
Pennal GF, Tile M, Waddell JP, Garside H. Pelvic disruption: assessment and classification. Clin Orthop Relat Res. 1980; (151):12-21.
Langford JR, Burgess AR, Liporace FA, Haidukewych GJ 2013 Pelvic fractures: Part 1. Evaluation, classification, and resuscitation Journal of the American Academy of Orthopaedic Surgeons 21 (8) 448–457
Lee C, Porter K 2007 The prehospital management of pelvic fractures, Emergency Medicine Journal 24 (2) 130–133
Lowth M 2015 Pelvic Fractures Available from https://patient. info/doctor/pelvic-fractures (accessed 21 March 2020)
Langford JR, Burgess AR, Liporace FA, Haidukewych GJ 2013 Pelvic fractures: Part 2. Contemporary indications and techniques for definitive surgical management Journal of the American Academy of Orthopaedic Surgeons 21 (8) 458–468
Chiodo A 2007 Neurologic injury associated with pelvic trauma: Radiology and electrodiagnosis evaluation and their relationships to pain and gait outcome Archives of Physical Medicine and Rehabilitation 88 (9) 1171–1176
BOA 2016 The Management of Urological Trauma Associated with Pelvic Fractures Available from www.boa.ac.uk/ uploads/assets/86c72eff-26aa-4cec-98d1e85cda3 dac6c/bcdaeccf-0cff-4da8-bca1b9519b3a542d/the% 20management%20of%20urological%20trauma%20associ ated%20with%20pelvic%20fractures.pdf (accessed 21 March 2020).
Saxena P, Agrawal A, Sakale H 2014 Introduction to pelvic injury and its acute management Journal of Orthopedics, Traumatology and Rehabilitation 7 (1) 1–7
BOA 2018 The Management of Patients with Pelvic Fractures Available from www.boa.ac.uk/uploads/assets/e0ff512b- 6364-42ef-af23617e1894d8bd/04fe5a18-47a2-46d7- 9aa6cc158825014d/the%20management%20of% 20patients%20with%20pelvic%20fractures.pdf (accessed March 2020).
NICE 2016a Fractures (complex): Assessment and management Available from www.nice.org.uk/guidance/ NG37/chapter/recommendations (accessed 21 March 2020).
Moran CG et al 2018 Changing the System – Major Trauma Patients and Their Outcomes in the NHS (England) 2008– 17 EClinicalMedicine 2–3 (2018) 13-21. doi: https://doi. org/10.1016/j.eclinm.2018.07.001. Available from https:// www.thelancet.com/action/showPdf?pii=S2589-5370% 2818%2930007-5
NICE 2016b Major trauma: Assessment and initial management Available from www.nice.org.uk/guidance/ ng39/chapter/Recommendations (accessed 21 March 2020).
Graf 2018 Unstable Pelvic Fractures Workup Medscape Available from https://emedicine.medscape.com/article/ 1247426-workup (accessed 21 March 2020).
O’Connor TJ, Cole PA 2014 Pelvic insufficiency fractures Geriatric Orthopaedic Surgery & Rehabilitation 5 (4) 178–190
Giannoudis PV et al 2007 Prevalence of pelvic fractures, associated injuries, and mortality: The United Kingdom perspective Journal of Trauma – Injury, Infection and Critical Care 63 (4) 875–883
BOA 2017 Open Fractures Available from www.boa.ac.uk/ uploads/assets/3b91ad0a-9081-4253-92f7d90e8df0 fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open% 20fractures.pdf (accessed 21 March 2020).
Weaver MJ, Bruinsma W, Toney E, Dafford E, Vrahas MS.What are the patterns of injury and displacement seen in lateral compression pelvic fractures? Clin Orthop Relat Res 2012;470(8): 2104–2110.
Osgood GM, Manson TT, O’Toole RV, Turen CH. Combined pelvic ring disruption and acetabular fracture: associated injury patterns in 40 patients. J Orthop Trauma 2013;27(5):243–247.
Stover MD, Mayo KA, Kellam JF. Pelvic ring disruptions. In: Skeletal trauma: basic science, management, and reconstruction. 4th ed. Philadelphia, Pa: Saunders, 2009; 1107–1170.
Tile M, Hearn T, Vrahas MS. Biomechanics. In: Fractures of the pelvis and acetabulum. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2003; 32–45.
Burgess AR, Eastridge BJ,Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 1990;30(7): 848–856.
Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986;160(2): 445–451.
Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma 1989;29(7): 981–1000; discussion 1000–1002.
Gänsslen A, Pohlemann T, Paul C, Lobenhoffer P, Tscherne H. Epidemiology of pelvic ring injuries. Injury 1996;27(suppl 1):S13–S20.
Young JW, Resnik CS. Fracture of the pelvis: current concepts of classification. AJR Am J Roentgenol 1990;155(6):1169–1175.
Scheyerer MJ, Osterhoff G, Wehrle S, Wanner GA, Simmen HP, Werner CM. Detection of posterior pelvic injuries in fractures of the pubic rami. Injury 2012;43(8):1326–1329.
Rogers LF. Pelvic trauma. In: Radiology of skeletal trauma. 3rd ed. Philadelphia, Pa: Churchill Living- stone, 2002; 930–1029.
Starks I, Frost A, Wall P, Lim J. Is a fracture of the transverse process of L5 a predictor of pelvic fracture instability? J Bone Joint Surg Br 2011;93(7): 967–969.
Blackmore CC, Jurkovich GJ, Linnau KF, Cummings P, Hoffer EK, Rivara FP. Assessment of volume of hemorrhage and outcome from pelvic fracture. Arch Surg 2003;138(5):504–508.
Sandler CM, Harris JH Jr, Corriere JN Jr, Toombs BD. Posterior urethral injuries after pelvic fracture. AJR Am J Roentgenol 1981;137(6):1233–1237.
Vaidya R, Colen R, Vigdorchik J, Tonnos F, Sethi A.Treatment of unstable pelvic ring injuries with an internal anterior fixator and posterior fixation: initial clinical series. J Orthop Trauma 2012;26(1): 1–8.
