Traumatic Hemipelvectomy

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January 10, 2013
Edward Smith

Traumatic hemipelvectomies are rare traumatic injuries with a forty percent mortality rate. It happens when half of the pelvis from the pubic symphysis to the sacroiliac joint is pulled away from the rest of the body in an open or closed injury. Because this is a situation that often results in death, it is important for the trauma team to do angiography to assess the circulation to the area, x-rays to determine the extent of the fracture and possibly a CT scan of the pelvis to determine what the injury looks like in three dimensions. Only aggressive surgical treatment can save the person’s life.

Because prehospital care has gotten so good, more and more people are arriving to the trauma centers alive rather than dead. This is a very unstable fracture with ligamentous injury and bony injury with external bleeding in some cases. The pelvic neurovascular bundle is usually destroyed, affecting sensation to the affected, partially-amputated leg.

In one study, the literature was reviewed for cases extending up to 1995. About 48 surviving individuals were found with a hemipelvectomy. Another review looked at 2002 cases treated at the medical school in Hannover from 1972-1994. They found 11 traumatic hemipelvectomy cases with only 4 survivors. The purpose of this study was to look at the various treatment standards used in these cases and how the treatment standard affected the survivability of the patient.

All available clinical data and radiological data were reviewed to look at EMT treatment and ER treatment, other injuries the patient sustained and the exact cause of death, including any complications of the injury. Survivors were watched from 2 to 7 years on average following the trauma. All patients needed therapy for shock in the emergency room, which included manual compression of the wound and immediate closure of blood vessels by the surgeons. Even so, four patients died within the first four hours due to uncontrollable bleeding. Another 3 patients died between two days and five weeks after the event because of septic shock or hemorrhagic shock.

In four patients, there was an attempt to salvage the limb and in three of these cases, the patients died early on. The remaining case required a secondary hemipelvectomy due to paralysis of the leg and ongoing sepsis. In patients that had a primary surgical completion of the hemipelvectomy, three out of four patients survived the surgery and later issues. The worst patient outcome had secondary completion of the hemipelvectomy; the patient had social deterioration and drug abuse as primary medical histories.

It was decided that it was important to have excellent prehospital management of shock and immediate transfer to a trauma facility. While in the hospital, the patient needed surgical correction of bleeding and excellent debridement. Surgical treatment of the injury should include the surgical completion of the hemipelvectomy for the best possible chances of survival. Limb saving procedures only endanger the life and health of the patient. Doing early and frequent second look operations help minimize wound healing issues seems to save lives also. Psychological support is necessary.