Original Article
Modified Classification and Repair of Perineal Soft Tissue Injuries Associated with Open Pelvic Fractures Guo Fu, MD, PhD1, Dong Wang, MD, PhD1 Bengang Qin, MD, PhD1 Jianping Xiang, MD, PhD1 Jian Qi, MD, PhD1 Ping Li, MD, PhD1 Qingtang Zhu, MD, PhD1 Xiaolin Liu, MD, PhD1 Jiakai Zhu, MD1 Li-Qiang Gu, MD, PhD1 1 Department of Microsurgery and Trauma Surgery, The First Affiliated
Hospital of Sun Yat-sen University, Guangzhou, China
Both Drs Guo Fu and Dong Wang contributed to the article equally.
Address for correspondence Li-Qiang Gu, MD, PhD, Department of Microsurgery and Trauma Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China (e-mail: [email protected]).
J Reconstr Microsurg 2015;31:12–19.
Abstract
Keywords
► open pelvic fractures ► soft tissue injuries ► classification
Background This study describes a modified classification and management protocol for perineal soft tissue injuries associated with pelvic fractures. Methods A total of 11 patients with perineal soft tissue injuries associated with open pelvic fractures were studied retrospectively. The patients were classified into three types based on the area of defect: type A (urogenital zone), type B (anal zone), and type C (both urogenital and anal zones). Each type included the following subclasses: A1 (without urethra injuries), A2 (with urethra injuries), B1 (without anorectal injuries), B2 (with anorectal injuries), C1 (with types A1 and B1), C2 (with types A2 and B1), C3 (with types A1 and B2), and C4 (with types A2 and B2). The management protocol was planned according to the individual classifications. Protocol A1 (for type A1) involved skin graft or myocutaneous flap transplantation. Protocol A2 (for type A2) involved the same protocol combined with urine diversion. Protocol B1 (for type B1) involved skin graft or myocutaneous flap transplantation. Protocol B2 (for type B2) involved the same management combined with fecal diversion. Protocol C involved the correspondent protocol used for each subtype of type C. Results Out of the 11 patients, there were 5, 3, and 3 cases of types A, B, and C, respectively. One patient died due to sepsis, and the wounds of the remaining patients healed well. No anal incontinence had occurred. Conclusions Perineal soft tissue injuries associated with pelvic fractures can be classified into three types, and the management protocol can be planned according to the classification.
An open pelvic fracture is one of the most severe orthopedic injuries and is typically associated with a high mortality rate.1 Death from this injury is often caused by exsanguination in the early period or by sepsis in later stages.2–4 Perineal soft tissue injuries are often associated with open pelvic fractures, and patients may develop severe local infection or sepsis,
especially when there is a fistula formation between the fracture site and the rectum or the bladder.5,6 The management protocol for such injuries includes hemorrhage control, fecal or urine diversion, fracture stabilization, and wound coverage.7 The evaluation of soft tissue defects is based on their depth and area, the type of associated fracture, and its
received January 8, 2014 accepted after revision February 23, 2014 published online September 16, 2014
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1386616. ISSN 0743-684X.
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treatment priority. The severity of perineal soft tissue injuries is evaluated by clinical examination based on the wound size, depth, feces or urine contamination, and location. The selection of appropriate pelvic ring fixation and ensuring accurate classification of the injury and proper soft tissue repair are mandatory aspects of treatment. Fecal and urinary diversion is an important component of minimizing the risk of infectious complications; however, the indications for fecal and urinary diversion remain controversial. In contrast, early radical debridement and provisional negative pressure wound therapy (NPWT) coverage is widely acknowledged as a reliable approach for the protection of large perineal wounds to prevent infection, stimulate granulation tissue formation, and reduce the area requiring flap coverage, thus improving the success of any subsequent surgery and reducing postoperative complications.8–10 A reliable and clinically relevant classification system for open pelvic fracture is of great importance for clinical care and future research. Such a system provides an effective means of combining similar injuries, distinguishing patterns, and stratifying injury severity.11 The currently available classification systems for grading open pelvic fractures are based on soft tissue or ligamento-osseous injury.7,11–16 However, a classification method for grading the degree of perineal soft tissue injury associated with an open pelvic fracture does not currently exist. Therefore, further studies are needed to design a treatment strategy to avoid complications. The objective of the present study is to outline a more specific classification and relevant management protocol for perineal soft tissue injuries associated with pelvic fractures, and to discuss the indications of fecal and urinary diversion.
Patients and Methods A total of 13 patients were admitted to the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China, between January 2005 and April 2012, with open pelvic fractures. Data regarding demographics, pattern of fracture, mechanism of injury, concurrent or associated injuries, injury severity score (ISS), treatment, and complications were collected. Pelvic fractures in this study were classified according to the Tile classification.13 All open pelvic fractures were directly communicating with the overlying soft tissue. The inclusion criterion was a perineal soft tissue injury associated with a pelvic fracture. Patients were excluded from this study if the soft tissue defect could be closed in a single-stage procedure after debridement or if no consent was obtained. The medical ethical committee at the authors’ institution approved this study before its commencement, and an informed consent was obtained from each patient upon hospitalization.
Classification and Management Protocol After arrival at the hospital, all patients were immediately treated according to the advanced trauma life support guidelines.17 The main treatments included emergency resuscitation, colostomy formation, external fixation of fractures, repeated debridement with pulsatile irrigation, and vacuum
Fu et al.
sealing drainage (VSD). A broad-spectrum antibiotic therapy was administered to all patients at presentation, and further antibiotic treatment was adapted to the bacterial cultures and drug sensitivity tests of samples obtained from open wounds. Urgent consultations with urologists and colorectal surgeons were obtained to rule out vaginal and rectal injuries. We developed a modified classification of perineal soft tissue injuries based on our experience of the surgical anatomical requirements and the characteristics of injuries. From the functional perspective, the perineal region can be divided into the urogenital and anal zones, with the urogenital zone located anteriorly and the anal zone located posteriorly. Injuries to this region usually cause urethral tear or anorectal rupture. Type A perineal soft tissue injuries involve the anterior perineal triangle area (urogenital zone) and can be divided into two subtypes: A1 (wounds that cross through the skin and involve the subcutaneous fat without urethral injury) and A2 (wounds that extend into underlying fascia with urethra injuries). Type B injuries involve the posterior triangle area (anal zone) and can be divided into subtypes B1 (wounds that cross through the skin and involve the subcutaneous fat without anorectal injuries) and B2 (wounds that extend into underlying fascia, and flap avulsions or degloving with anorectal injuries). Type C injuries involve the entire perineal area with both urogenital and anal zone defects, and can be divided into subtypes C1 (types A1 and B1), C2 (types A2 and B1), C3 (types A1 and B2), and C4 (types A2 and B2). The management protocols were planned according to the classification. Protocol A1 (for type A1) involves skin graft or myocutaneous flap transplantation, whereas protocol A2 (for type A2) involves the same protocol combined with urine diversion. Protocol B1 (for type B1) involves skin graft or myocutaneous flap transplantation, and protocol B2 (for type B2) involves the same management combined with fecal diversion. Second-stage procedures involve gracilis muscle transposition to reconstruct the function of the internal anal sphincter (IAS) and colostomy takedown. Protocol C involves the corresponding protocols used for each subtype of type C (►Table 1).
Soft Tissue Management There were two stages in soft tissue management. In the first stage, the wound was radically debrided and covered by VSD for 5 to 7 days. For wounds with local tissue necrosis and infection, debridement included elimination of ischemic and irreparably damaged tissues, as well as the removal of foreign substances and opening of dead space. The VSD technique is an efficient drainage system in which comprehensive drainage is achieved under high vacuum. It promptly and thoroughly eliminates seepage, pus, and necrotic tissues from the drainage area to achieve “zero accumulation.”18 After the debridement, a VSD sponge was trimmed to fit the wounds without a dead space or vacuum leak. Further debridement and repeat VSD were performed after 5 to 7 days if necessary. In most cases, external fixation was used as temporary stabilization. In the second stage of treatment, the VSD was removed, debridement was performed again, and deep tissue injuries were repaired if possible. A reparative free Journal of Reconstructive Microsurgery
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Classification of Perineal Soft Tissue Injuries
Classification of Perineal Soft Tissue Injuries
Fu et al.
Table 1 The classification and treatment protocol Type
Characteristics of injuries
Repair protocols
A
Urogenital zone injuries
A1
Without urethral injury
Skin graft or flap transplantation without cystostomy
A2
With urethral injury
Skin graft or flap transplantation with cystostomy
B
Anal zone injuries
B1
Without anorectal injury
Skin graft or flap transplantation without colostomy
B2
With anorectal injury
Skin graft or flap transplantation with colostomy
C
Both urogenital zone and anal zone injuries
C1
With neither urethral nor anorectal injuries
Skin graft or flap transplantation
C2
With urethral but without anorectal injuries
Skin graft or flap transplantation with only cystostomy
C3
With anorectal but without urethral injuries
Skin graft or flap transplantation with only colostomy
C4
With both urogenital and anorectal injuries
Skin graft or flap transplantation with both colostomy and cystostomy
myocutaneous flap was transplanted or skin grafting was performed. During the initial procedure, debridement was performed and broad-spectrum antibiotic therapy was administered. External fixation was changed to definitive internal fixation in those cases with intact surgical field. Once the wounds were clean and granulation tissue was formed, the appropriate flaps or skin grafts were selected based on the individual wound. Split-thickness skin grafts from the abdomen were needed in some cases where the donor site could not be closed with suturing after flap harvest. The remaining wounds surrounding the transplanted flaps were covered with split-thickness skin from the scalp or abdomen. For patients with IAS injuries, gracilis muscle transposition was performed. After discharge, the patients were followed up for at least 6 months to monitor the clinical outcome measures, including postoperative complications, pelvic bone union, and IAS function. Furthermore, radiography and clinical observation were used to investigate the stage of healing of pelvic fractures for determining the timings of weight bearing and removal of external fixators. External fixators were removed 3 to 6 months after bone union.
Results Out of the 11 patients included in this study, 9 were men and 2 were women, with an average age of 24.8 years (range, 11–40 years). The cause of injury was traffic accidents (nine cases), falling from a height (one case), and crushing (one case). Two patients were transferred to our hospital 5 days after their accident, and the other patients were admitted to our institution immediately after their accident. The average ISS of patients was 27.7 (range, 15–41). Patient management was conducted according to the priority of the various injuries. The average length of stay in the intensive care unit was 8.2 days (range, 4–12 days), and length of hospital stay averaged 52.9 days (range, 22–106 days). Nine of the 11 patients received a blood transfusion (average, 11.7 units; range, 7–19 units) in the first 24 hours. Journal of Reconstructive Microsurgery
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Two patients had a full-cut urethral injury, and one patient had bladder injuries. In three patients, the anal canal and surrounding rectal tissues were dissected on both sides of the pelvic floor. The rectum had dissected and separated from the tissue around the anus, resulting in loss of integrity of the internal and external anal sphincter muscles. Two patients had fractures in other areas such as the femoral neck, radius, humerus, and tibia. According to the Tile classification, one case was rated as type A, six as type B, and four as type C. External fixation for definite stabilization was used in 10 of the 11 patients, including 4 vertically and 6 rotationally unstable fractures. In one patient, external fixation was changed to internal fixation in the second operation. Among the 11 patients, there were 5, 3, and 3 cases of types A, B, and C injuries, respectively. The subtypes of patients are shown in ►Tables 2 and 3. The smallest wound size at admission was 5 cm in diameter and the largest was 21 cm. The wound bases were irregular in structure, and most of the wounds had deep extensions featuring cavities and pockets. VSD is an efficient drainage system for the protection of large wounds and its efficiency embodies its comprehensive drainage and thorough drainage under high vacuum. It can prevent infection, stimulate granulation, reducing postoperative complications, and improving the success of subsequent surgery.19 During treatment with the VSD system, the dressing was changed once every 5 days; weekly wound measurements were obtained during the VSD dressing changes. Decreases in the sizes of the wounds were detected each week at the rate of approximately 0.5 to 1 cm in depth and 5 to 10% in wound diameter. Beginning at an average of 17 days ( 5.9 days) after injury, the wound could be covered by a skin graft or flap transfer, and debridement was performed as necessary. After confirming absence of infection in and around the open pelvic fracture, the fractures were stabilized using internal fixation or external fixation. One patient died from sepsis-related multiple organ failure on the 6th day after injury. Among the remaining 10 patients, 1 underwent an above-knee amputation of the right lower extremity. Full-length skin grafts were applied in two
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Classification of Perineal Soft Tissue Injuries
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Case
Pelvic fx classification
Perineal soft tissue classification
Age (y)
ISS
Complications
1
B
A1
11
20
N/A
2
B
A1
17
28
N/A
3
B
C4
33
37
Wound infection
4
B
A1
23
24
N/A
5
B
B1
22
15
N/A
6
B
C1
40
27
N/A
7
B
B2
24
36
Wound infection
8
B
A1
15
22
N/A
9
B
B1
31
34
Right leg amputation
10
B
C3
38
41
N/A
11
B
A1
19
21
N/A
Abbreviations: fx, fracture; ISS, injury severity score; N/A, not applicable.
cases. The flaps used in this study were anterolateral femoral flaps (five cases) and gracilis myocutaneous flaps (three cases). Eight patients were treated with a local myocutaneous flap, six of which were anterolateral thigh flaps. Three of the eight patients underwent a pedicle gracilis myocutaneous flap transfer to repair soft tissue defects, and two of these showed recovery of IAS function with gracilis muscle transposition. Infection occurred in varying degrees in the perineal wounds. In six of the eight patients, primary healing was achieved, and secondary stage healing was achieved in two cases after debridement and VSD treatment. All the surviving patients were discharged upon resolution of their wounds. All patients underwent postoperative follow-up of 16.5 months (range, 6–48 months). Radiography showed that
bone union was achieved 3 to 6 months postoperatively. The two patients with recovery of IAS function during follow-up showed no anal incontinence. No patients who experienced fecal diversion developed complications related to either the colostomy creation or the subsequent takedown (refer to the typical cases: ►Figs. 1 and 2).
Discussion Open pelvic fracture is one of the most devastating injuries in orthopedic trauma and is associated with high mortality and poor outcome in the long term.20 Patients who had experienced considerable high-energy trauma were at a high risk of experiencing multiple concomitant injuries to the bladder,
Table 3 The data of patients (contd) Case
Hospital stay (d)
ICU stay
Associated injury
Reconstruction
Blood transfusion
1
29
9
Head
VSD þ skin graft
7
2
70
7
N/A
VSD þ ALT flap
12
3
106
12
Left hand injury þ urethral incision
Gracilis muscle to IAS
8
4
56
4
Right humerus fx
ALT flap
13
5
22
8
N/A
VSD þ skin graft
17
6
41
5
Fibula fracture
ALT flap
16
7
61
11
N/A
VSD þ gracilis muscle to IAS
14
8
57
8
N/A
VSDþ
10
9
59
9
Hemo/pneumothorax þ lung contusion þ flail chest
ALT flap
8
10
6
6
N/A
VSD þ ALT flap
8
11
37
7
N/A
ALT flap
16
Abbreviations: ALT, anterior lateral thigh; fx, fracture; IAS, internal anal sphincter; ICU, intensive care unit; N/A, not applicable; VSD, vacuum sealing drainage. Journal of Reconstructive Microsurgery
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Table 2 The data of patients
Classification of Perineal Soft Tissue Injuries
Fu et al.
Fig. 1 A 39-year-old man who was involved in a traffic accident presented to our institution. (A) The pelvic fracture pattern of the patient was Tile C1 and the perineal soft tissue defect was classified as type B2. (B) An external fixator was applied, and colostomy was created. (C) In the first operation, the perineal wound was sutured after debridement. During the second operation (14 days postoperatively), the wound was not healed. (D) A gracilis myocutaneous flap was created to reconstruct the function of the IAS. (E and F) The external fixator was removed, and the symphysis pubis diastasis was treated by ORIF. (G) Fourteen days after the second operation, the wound was adequately healed and the patient was able to walk with assistance. Closure of the colostomy was performed without any complications, and the patient regained normal defecation function within 5 months postoperatively. IAS, internal anal sphincter; ORIF, open reduction and internal fixation.
urethra, rectum, or distal colon, as well as perineal soft tissue defects. As compared with patients having closed pelvic fractures, those having pelvic fractures associated with perineal injuries have a higher rate of complications, including sepsis, pelvic abscess formation, acute respiratory distress syndrome, multiorgan system failure, and death.21 In these situations, “damage control” orthopedic surgery is the mandatory first step. The perineal area is the most commonly injured soft tissue in open pelvic fractures.22,23 A systematic classification of perineal soft tissue injury associated with pelvic fracture is important in stratifying injury severity, facilitating treatment guidelines for surgical reconstruction, predicting complications, and assessing prognosis. Perineal soft tissue injuries should be classified according to their location, and the repair protocol should be based on the anatomical location of the injury. In this study, the modified classification of perineal soft tissue injuries defined three types of injuries that could be further subclassified according to the occurrence of urethral tear or anorectal rupture (►Table 1). Several classification schemes are used for the clinical evaluation of open pelvic fractures. The most widely used scheme is the Gustilo–Anderson classification.24 This system, Journal of Reconstructive Microsurgery
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which was based on open tibial fractures, has been used successfully for more than 35 years.25 However, significant problems and shortcomings have been identified with respect to its reliability and reproducibility.11 Based on the Gustilo–Anderson classification, the Classification and Outcomes Committee of the Orthopedic Trauma Association (OTA) has developed a new classification for open fractures; the new classification overcomes some of these shortcomings.26 This new classification is composed of five categories: skin injury (S), muscle injury (M), arterial injury (A), bone loss (B), and contamination (C).11 This classification is not feasible for evaluating perineal soft tissue injuries and the necessity of urinary or fecal diversion. Generally, fecal diversion and subsequent colostomy takedown are recommended for patients with perineal soft tissue injuries. Although, fecal diversion is of great importance to avoid the risk of sepsis and wound contamination, the complications of this procedure are still significant.27,28 Jones et al15 divided open pelvic fractures into three classes: class 1, stable pelvic ring; class 2, unstable pelvic ring and no rectal or perineal wound; and class 3, unstable pelvic ring with a rectal or perineal wound. In this classification, the use of a diverting colostomy was recommended for class 3 fractures. Faringer et al reported
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Fu et al.
Fig. 2 (A and B) A 22-year-old man presented with destructive injury to the external genitalia and severe perineal soft tissue defects after a motor vehicle crash. (C and D) The pelvic fracture pattern was Tile B3 and the perineal soft tissue defect was classified as type C2. A suprapubic cystostomy was performed and an external fixator was applied after wound debridement. (E) The perineal wound was temporarily covered with a VSD. (F–H) Five days postoperatively, an anterior lateral thigh flap was placed. (I) Two weeks postoperatively, the wound had healed.
that open pelvic fractures can be classified as either zone I (perineum, anterior pubis, medial buttock, and posterior sacrum), zone II (medial thigh and groin crease), or zone III (posterolateral buttock and iliac crest). The indications for mandatory fecal diversion included deep lacerations of the anus or rectum, large-sized soft tissue wounds in immediate proximity to the anus, or large avulsion flaps with associated ischemic tissue in the pelvic area.14,29 However, there has been disagreement about the indications. For example, Woods et al concluded that in patients with open pelvic fractures, fecal diversion is not associated with a lower incidence of abdominopelvic infections.27 Our results indicate that fecal diversion is not mandatory for patients without anorectal injury (type B1, C1, and C2). In our study, two patients with anorectal tears underwent colostomy, three patients with soft tissue injuries in the anal zone but no anorectal tear did not require fecal diversion, and only one patient experienced a wound infection. Aggressive debridement was performed for all patients, and early wound coverage was achieved in all cases. However, for types B2, C3, and C4 injuries, a colostomy and secondary stage reconstruction of the IAS are mandatory.
In our study, an associated rectal injury was not diagnosed until 2 days postoperatively. For one patient, digital rectal examination (DRE) performed in the emergency room showed negative findings. After the initial procedure, fresh blood was observed in the anus. A second DRE also revealed fresh blood. Subsequently, rectoscopy identified a tear in the rectal wall, and the patient underwent exploratory laparotomy, rectum repair, and colostomy creation. Therefore, for patients with open pelvic fractures, a careful history and physical examination are of great importance to rule out suspected rectal and vaginal injuries. Physical examination should include a thorough abdominal examination, inspection of the perineum, and DRE, with vaginal examination in female patients.30 However, it should be noted that a lack of physical findings does not rule out an intra-abdominal injury. The development of peritonitis or localized sepsis may not be immediately apparent; therefore, further evaluation or close observation is necessary depending on the index of suspicion. The diagnostic evaluation of rectal impalement injuries should include proctosigmoidoscopy to properly examine the rectal mucosa for perforation. Bladder injury should be Journal of Reconstructive Microsurgery
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Classification of Perineal Soft Tissue Injuries
Classification of Perineal Soft Tissue Injuries
Fu et al.
excluded by using cystoscopy or cystography in patients with hematuria.5 In addition, vaginoscopy should be performed routinely in female patients.31 In our study, both the patient’s overall condition and the severity of wounds were critical. Therefore, early closure and reconstruction of the wound was not suitable in these cases. Repeated debridement and negative vacuum drainage were often used to decrease necrotic tissue formation. Reconstruction procedures can be initiated only after necrotic tissue is debrided and the infection is controlled. The final result for many patients is lower extremity amputation and loss of pelvic floor muscles; this results in abdominal gas and fecal or urinary incontinence, possibly necessitating a secondary reconstructive procedure.32 Treatment of open pelvic fractures combined with perineal soft tissue injuries should aim to prevent infection, cover the wound, and definitively fix the fracture. Most patients with these types of injuries are hypothermic, acidotic, and experiencing coagulopathic disorders. Patients in this condition cannot tolerate a lengthy operation. High impact wounds should receive early and aggressive debridement; it is therefore recommended to perform immediate “damage control” surgery, followed by a definitive surgery 24 to 48 hours later. Rectal and anal sphincter damage often accompanies these injuries, and these injuries should be left open with good drainage provided. Colostomy reversal may be possible within 4 to 6 weeks without adverse outcomes. Historically, suprapubic catheters have been used during open bladder repair. However, recent literature supports the use of transurethral catheter decompression in patients with intraperitoneal bladder injury.10–12 Extraperitoneal bladder rupture may be managed with urethral catheterization alone and close observation.12,13 A cystogram should be performed after 10 to 14 days of bladder repair to determine if the catheter can be safely removed. Our results showed that a diverting colostomy can be avoided for patients in whom IAS and intra-abdominal injuries can be ruled out. However, the appropriate use of negative pressure wound closure systems such as VSD is always important for wound management. In recent years, negative pressure wound closure systems have been widely used for injuries in the perineal region.5–10 The clinical application of NPWT with the VSD has proved to be a very efficient closure technique for our patients.
References 1 Grotz MR, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis
2
3
4
5
6
7
8
9
10
11
12 13
14
15
16
17 18
Conclusion A classification for grading the degree of perineal soft tissue injuries associated with open pelvic fractures is necessary in clinical practice. In this retrospective study, we found that perineal soft tissue injuries associated with pelvic fractures could be accurately classified into three types with further subclassification. Injuries were classified based on the location, depth, and size of soft tissue defects and associated injuries to surrounding organs. This classification may help surgeons to make treatment priority decisions and determine an appropriate management plan according to the repair protocol. Journal of Reconstructive Microsurgery
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20
21
22
PV. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005;36(1):1–13 Black EA, Lawson CM, Smith S, Daley BJ. Open pelvic fractures: the University of Tennessee Medical Center at Knoxville experience over ten years. Iowa Orthop J 2011;31:193–198 Hanson PB, Milne JC, Chapman MW. Open fractures of the pelvis. Review of 43 cases. J Bone Joint Surg Br 1991;73(2): 325–329 Mohanty K, Musso D, Powell JN, Kortbeek JB, Kirkpatrick AW. Emergent management of pelvic ring injuries: an update. Can J Surg 2005;48(1):49–56 Durrant JJ, Ramasamy A, Salmon MS, Watkin N, Sargeant I. Pelvic fracture-related urethral and bladder injury. J R Army Med Corps 2013;159(Suppl 1):i32–i39 Lunsjo K, Abu-Zidan FM. Does colostomy prevent infection in open blunt pelvic fractures? A systematic review. J Trauma 2006;60(5): 1145–1148 Brenneman FD, Katyal D, Boulanger BR, Tile M, Redelmeier DA. Long-term outcomes in open pelvic fractures. J Trauma 1997; 42(5):773–777 Labler L, Trentz O. The use of vacuum assisted closure (VAC) in soft tissue injuries after high energy pelvic trauma. Langenbecks Arch Surg 2007;392(5):601–609 Ozer MT, Coskun AK, Ozerhan IH, et al. Use of vacuum-assisted closure (VAC™) in high-energy complicated perineal injuries: analysis of nine cases. Int Wound J 2011;8(6):599–607 Milcheski DA, Zampieri FM, Nakamoto HA, Tuma P Jr, Ferreira MC. Negative pressure wound therapy in complex trauma of perineum. Rev Col Bras Cir 2013;40(4):312–317 Agel J, Evans AR, Marsh JL, et al. The OTA open fracture classification: a study of reliability and agreement. J Orthop Trauma 2013; 27(7):379–384, discussion 384–385 Bircher M, Eng FE, Hargrove R. Is it Possible to Classify Open Fractures of the Pelvis? Eur J Trauma 2004;30(2):74–79 Pennal GF, Tile M, Waddell JP, Garside H. Pelvic disruption: assessment and classification. Clin Orthop Relat Res 1980;(151): 12–21 Faringer PD, Mullins RJ, Feliciano PD, Duwelius PJ, Trunkey DD. Selective fecal diversion in complex open pelvic fractures from blunt trauma. Arch Surg 1994;129(9):958–963, discussion 963– 964 Jones AL, Powell JN, Kellam JF, McCormack RG, Dust W, Wimmer P. Open pelvic fractures. A multicenter retrospective analysis. Orthop Clin North Am 1997;28(3):345–350 Agel J, Rockwood T, Barber R, Marsh JL. Potential predictive ability of the orthopedic trauma association open fracture classification. J Orthop Trauma 2014;28(5):300–306 Wilson RF. Current status of advanced trauma life support training. Ann Emerg Med 1981;10(4):226–227 Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38(6):563–576, discussion 577 Qu J, Yan R, Wang L, et al. Free dermatoplasty combined with vacuum sealing drainage for the treatment of large-area soft tissue defects accompanied by bone exposure in the lower leg. Exp Ther Med 2013;5(5):1375–1380 Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg 2005;190(6): 830–835 Duchesne JC, Bharmal HM, Dini AA, et al. Open-book pelvic fractures with perineal open wounds: a significant morbid combination. Am Surg 2009;75(12):1227–1233 Kottmeier SA, Wilson SC, Born CT, Hanks GA, Iannacone WM, DeLong WG. Surgical management of soft tissue lesions associated with pelvic ring injury. Clin Orthop Relat Res 1996;(329):46–53
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
18
Classification of Perineal Soft Tissue Injuries
Fu et al.
28 Ghanayem AJ, Wilber JH, Lieberman JM, Motta AO. The effect of
trauma centers. Am J Surg 1992;163(3):283–287 Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984;24(8):742–746 Gustilo RB. Management of open fractures. An analysis of 673 cases. Minn Med 1971;54(3):185–189 Orthopaedic Trauma Association: Open Fracture Study Group. A new classification scheme for open fractures. J Orthop Trauma 2010;24(8):457–464 Woods RK, O’Keefe G, Rhee P, Routt ML Jr, Maier RV. Open pelvic fracture and fecal diversion. Arch Surg 1998;133(3): 281–286
laparotomy and external fixator stabilization on pelvic volume in an unstable pelvic injury. J Trauma 1995;38(3):396–400, discussion 400–401 Richardson JD, Harty J, Amin M, Flint LM. Open pelvic fractures. J Trauma 1982;22(7):533–538 Mangiante EC, Graham AD, Fabian TC. Rectal gunshot wounds. Management of civilian injuries. Am Surg 1986;52(1):37–40 Kumar BA, Chojnowski AJ. Open pelvic fractures with vaginal laceration: an unusual clinical feature. Injury 2000;31(1):68–70 Mundy AR, Andrich DE. Pelvic fracture-related injuries of the bladder neck and prostate: their nature, cause and management. BJU Int 2010;105(9):1302–1308
24
25 26
27
29 30 31 32
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
23 Sinnott R, Rhodes M, Brader A. Open pelvic fracture: an injury for
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Modified Classification and Repair of Perineal Soft Tissue Injuries Associated with Open Pelvic Fractures Guo Fu, MD, PhD1, Dong Wang, MD, PhD1 Bengang Qin, MD, PhD1 Jianping Xiang, MD, PhD1 Jian Qi, MD, PhD1 Ping Li, MD, PhD1 Qingtang Zhu, MD, PhD1 Xiaolin Liu, MD, PhD1 Jiakai Zhu, MD1 Li-Qiang Gu, MD, PhD1 1 Department of Microsurgery and Trauma Surgery, The First Affiliated
Hospital of Sun Yat-sen University, Guangzhou, China
Both Drs Guo Fu and Dong Wang contributed to the article equally.
Address for correspondence Li-Qiang Gu, MD, PhD, Department of Microsurgery and Trauma Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou 510080, China (e-mail: [email protected]).
J Reconstr Microsurg 2015;31:12–19.
Abstract
Keywords
► open pelvic fractures ► soft tissue injuries ► classification
Background This study describes a modified classification and management protocol for perineal soft tissue injuries associated with pelvic fractures. Methods A total of 11 patients with perineal soft tissue injuries associated with open pelvic fractures were studied retrospectively. The patients were classified into three types based on the area of defect: type A (urogenital zone), type B (anal zone), and type C (both urogenital and anal zones). Each type included the following subclasses: A1 (without urethra injuries), A2 (with urethra injuries), B1 (without anorectal injuries), B2 (with anorectal injuries), C1 (with types A1 and B1), C2 (with types A2 and B1), C3 (with types A1 and B2), and C4 (with types A2 and B2). The management protocol was planned according to the individual classifications. Protocol A1 (for type A1) involved skin graft or myocutaneous flap transplantation. Protocol A2 (for type A2) involved the same protocol combined with urine diversion. Protocol B1 (for type B1) involved skin graft or myocutaneous flap transplantation. Protocol B2 (for type B2) involved the same management combined with fecal diversion. Protocol C involved the correspondent protocol used for each subtype of type C. Results Out of the 11 patients, there were 5, 3, and 3 cases of types A, B, and C, respectively. One patient died due to sepsis, and the wounds of the remaining patients healed well. No anal incontinence had occurred. Conclusions Perineal soft tissue injuries associated with pelvic fractures can be classified into three types, and the management protocol can be planned according to the classification.
An open pelvic fracture is one of the most severe orthopedic injuries and is typically associated with a high mortality rate.1 Death from this injury is often caused by exsanguination in the early period or by sepsis in later stages.2–4 Perineal soft tissue injuries are often associated with open pelvic fractures, and patients may develop severe local infection or sepsis,
especially when there is a fistula formation between the fracture site and the rectum or the bladder.5,6 The management protocol for such injuries includes hemorrhage control, fecal or urine diversion, fracture stabilization, and wound coverage.7 The evaluation of soft tissue defects is based on their depth and area, the type of associated fracture, and its
received January 8, 2014 accepted after revision February 23, 2014 published online September 16, 2014
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1386616. ISSN 0743-684X.
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treatment priority. The severity of perineal soft tissue injuries is evaluated by clinical examination based on the wound size, depth, feces or urine contamination, and location. The selection of appropriate pelvic ring fixation and ensuring accurate classification of the injury and proper soft tissue repair are mandatory aspects of treatment. Fecal and urinary diversion is an important component of minimizing the risk of infectious complications; however, the indications for fecal and urinary diversion remain controversial. In contrast, early radical debridement and provisional negative pressure wound therapy (NPWT) coverage is widely acknowledged as a reliable approach for the protection of large perineal wounds to prevent infection, stimulate granulation tissue formation, and reduce the area requiring flap coverage, thus improving the success of any subsequent surgery and reducing postoperative complications.8–10 A reliable and clinically relevant classification system for open pelvic fracture is of great importance for clinical care and future research. Such a system provides an effective means of combining similar injuries, distinguishing patterns, and stratifying injury severity.11 The currently available classification systems for grading open pelvic fractures are based on soft tissue or ligamento-osseous injury.7,11–16 However, a classification method for grading the degree of perineal soft tissue injury associated with an open pelvic fracture does not currently exist. Therefore, further studies are needed to design a treatment strategy to avoid complications. The objective of the present study is to outline a more specific classification and relevant management protocol for perineal soft tissue injuries associated with pelvic fractures, and to discuss the indications of fecal and urinary diversion.
Patients and Methods A total of 13 patients were admitted to the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China, between January 2005 and April 2012, with open pelvic fractures. Data regarding demographics, pattern of fracture, mechanism of injury, concurrent or associated injuries, injury severity score (ISS), treatment, and complications were collected. Pelvic fractures in this study were classified according to the Tile classification.13 All open pelvic fractures were directly communicating with the overlying soft tissue. The inclusion criterion was a perineal soft tissue injury associated with a pelvic fracture. Patients were excluded from this study if the soft tissue defect could be closed in a single-stage procedure after debridement or if no consent was obtained. The medical ethical committee at the authors’ institution approved this study before its commencement, and an informed consent was obtained from each patient upon hospitalization.
Classification and Management Protocol After arrival at the hospital, all patients were immediately treated according to the advanced trauma life support guidelines.17 The main treatments included emergency resuscitation, colostomy formation, external fixation of fractures, repeated debridement with pulsatile irrigation, and vacuum
Fu et al.
sealing drainage (VSD). A broad-spectrum antibiotic therapy was administered to all patients at presentation, and further antibiotic treatment was adapted to the bacterial cultures and drug sensitivity tests of samples obtained from open wounds. Urgent consultations with urologists and colorectal surgeons were obtained to rule out vaginal and rectal injuries. We developed a modified classification of perineal soft tissue injuries based on our experience of the surgical anatomical requirements and the characteristics of injuries. From the functional perspective, the perineal region can be divided into the urogenital and anal zones, with the urogenital zone located anteriorly and the anal zone located posteriorly. Injuries to this region usually cause urethral tear or anorectal rupture. Type A perineal soft tissue injuries involve the anterior perineal triangle area (urogenital zone) and can be divided into two subtypes: A1 (wounds that cross through the skin and involve the subcutaneous fat without urethral injury) and A2 (wounds that extend into underlying fascia with urethra injuries). Type B injuries involve the posterior triangle area (anal zone) and can be divided into subtypes B1 (wounds that cross through the skin and involve the subcutaneous fat without anorectal injuries) and B2 (wounds that extend into underlying fascia, and flap avulsions or degloving with anorectal injuries). Type C injuries involve the entire perineal area with both urogenital and anal zone defects, and can be divided into subtypes C1 (types A1 and B1), C2 (types A2 and B1), C3 (types A1 and B2), and C4 (types A2 and B2). The management protocols were planned according to the classification. Protocol A1 (for type A1) involves skin graft or myocutaneous flap transplantation, whereas protocol A2 (for type A2) involves the same protocol combined with urine diversion. Protocol B1 (for type B1) involves skin graft or myocutaneous flap transplantation, and protocol B2 (for type B2) involves the same management combined with fecal diversion. Second-stage procedures involve gracilis muscle transposition to reconstruct the function of the internal anal sphincter (IAS) and colostomy takedown. Protocol C involves the corresponding protocols used for each subtype of type C (►Table 1).
Soft Tissue Management There were two stages in soft tissue management. In the first stage, the wound was radically debrided and covered by VSD for 5 to 7 days. For wounds with local tissue necrosis and infection, debridement included elimination of ischemic and irreparably damaged tissues, as well as the removal of foreign substances and opening of dead space. The VSD technique is an efficient drainage system in which comprehensive drainage is achieved under high vacuum. It promptly and thoroughly eliminates seepage, pus, and necrotic tissues from the drainage area to achieve “zero accumulation.”18 After the debridement, a VSD sponge was trimmed to fit the wounds without a dead space or vacuum leak. Further debridement and repeat VSD were performed after 5 to 7 days if necessary. In most cases, external fixation was used as temporary stabilization. In the second stage of treatment, the VSD was removed, debridement was performed again, and deep tissue injuries were repaired if possible. A reparative free Journal of Reconstructive Microsurgery
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Classification of Perineal Soft Tissue Injuries
Classification of Perineal Soft Tissue Injuries
Fu et al.
Table 1 The classification and treatment protocol Type
Characteristics of injuries
Repair protocols
A
Urogenital zone injuries
A1
Without urethral injury
Skin graft or flap transplantation without cystostomy
A2
With urethral injury
Skin graft or flap transplantation with cystostomy
B
Anal zone injuries
B1
Without anorectal injury
Skin graft or flap transplantation without colostomy
B2
With anorectal injury
Skin graft or flap transplantation with colostomy
C
Both urogenital zone and anal zone injuries
C1
With neither urethral nor anorectal injuries
Skin graft or flap transplantation
C2
With urethral but without anorectal injuries
Skin graft or flap transplantation with only cystostomy
C3
With anorectal but without urethral injuries
Skin graft or flap transplantation with only colostomy
C4
With both urogenital and anorectal injuries
Skin graft or flap transplantation with both colostomy and cystostomy
myocutaneous flap was transplanted or skin grafting was performed. During the initial procedure, debridement was performed and broad-spectrum antibiotic therapy was administered. External fixation was changed to definitive internal fixation in those cases with intact surgical field. Once the wounds were clean and granulation tissue was formed, the appropriate flaps or skin grafts were selected based on the individual wound. Split-thickness skin grafts from the abdomen were needed in some cases where the donor site could not be closed with suturing after flap harvest. The remaining wounds surrounding the transplanted flaps were covered with split-thickness skin from the scalp or abdomen. For patients with IAS injuries, gracilis muscle transposition was performed. After discharge, the patients were followed up for at least 6 months to monitor the clinical outcome measures, including postoperative complications, pelvic bone union, and IAS function. Furthermore, radiography and clinical observation were used to investigate the stage of healing of pelvic fractures for determining the timings of weight bearing and removal of external fixators. External fixators were removed 3 to 6 months after bone union.
Results Out of the 11 patients included in this study, 9 were men and 2 were women, with an average age of 24.8 years (range, 11–40 years). The cause of injury was traffic accidents (nine cases), falling from a height (one case), and crushing (one case). Two patients were transferred to our hospital 5 days after their accident, and the other patients were admitted to our institution immediately after their accident. The average ISS of patients was 27.7 (range, 15–41). Patient management was conducted according to the priority of the various injuries. The average length of stay in the intensive care unit was 8.2 days (range, 4–12 days), and length of hospital stay averaged 52.9 days (range, 22–106 days). Nine of the 11 patients received a blood transfusion (average, 11.7 units; range, 7–19 units) in the first 24 hours. Journal of Reconstructive Microsurgery
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Two patients had a full-cut urethral injury, and one patient had bladder injuries. In three patients, the anal canal and surrounding rectal tissues were dissected on both sides of the pelvic floor. The rectum had dissected and separated from the tissue around the anus, resulting in loss of integrity of the internal and external anal sphincter muscles. Two patients had fractures in other areas such as the femoral neck, radius, humerus, and tibia. According to the Tile classification, one case was rated as type A, six as type B, and four as type C. External fixation for definite stabilization was used in 10 of the 11 patients, including 4 vertically and 6 rotationally unstable fractures. In one patient, external fixation was changed to internal fixation in the second operation. Among the 11 patients, there were 5, 3, and 3 cases of types A, B, and C injuries, respectively. The subtypes of patients are shown in ►Tables 2 and 3. The smallest wound size at admission was 5 cm in diameter and the largest was 21 cm. The wound bases were irregular in structure, and most of the wounds had deep extensions featuring cavities and pockets. VSD is an efficient drainage system for the protection of large wounds and its efficiency embodies its comprehensive drainage and thorough drainage under high vacuum. It can prevent infection, stimulate granulation, reducing postoperative complications, and improving the success of subsequent surgery.19 During treatment with the VSD system, the dressing was changed once every 5 days; weekly wound measurements were obtained during the VSD dressing changes. Decreases in the sizes of the wounds were detected each week at the rate of approximately 0.5 to 1 cm in depth and 5 to 10% in wound diameter. Beginning at an average of 17 days ( 5.9 days) after injury, the wound could be covered by a skin graft or flap transfer, and debridement was performed as necessary. After confirming absence of infection in and around the open pelvic fracture, the fractures were stabilized using internal fixation or external fixation. One patient died from sepsis-related multiple organ failure on the 6th day after injury. Among the remaining 10 patients, 1 underwent an above-knee amputation of the right lower extremity. Full-length skin grafts were applied in two
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Classification of Perineal Soft Tissue Injuries
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15
Case
Pelvic fx classification
Perineal soft tissue classification
Age (y)
ISS
Complications
1
B
A1
11
20
N/A
2
B
A1
17
28
N/A
3
B
C4
33
37
Wound infection
4
B
A1
23
24
N/A
5
B
B1
22
15
N/A
6
B
C1
40
27
N/A
7
B
B2
24
36
Wound infection
8
B
A1
15
22
N/A
9
B
B1
31
34
Right leg amputation
10
B
C3
38
41
N/A
11
B
A1
19
21
N/A
Abbreviations: fx, fracture; ISS, injury severity score; N/A, not applicable.
cases. The flaps used in this study were anterolateral femoral flaps (five cases) and gracilis myocutaneous flaps (three cases). Eight patients were treated with a local myocutaneous flap, six of which were anterolateral thigh flaps. Three of the eight patients underwent a pedicle gracilis myocutaneous flap transfer to repair soft tissue defects, and two of these showed recovery of IAS function with gracilis muscle transposition. Infection occurred in varying degrees in the perineal wounds. In six of the eight patients, primary healing was achieved, and secondary stage healing was achieved in two cases after debridement and VSD treatment. All the surviving patients were discharged upon resolution of their wounds. All patients underwent postoperative follow-up of 16.5 months (range, 6–48 months). Radiography showed that
bone union was achieved 3 to 6 months postoperatively. The two patients with recovery of IAS function during follow-up showed no anal incontinence. No patients who experienced fecal diversion developed complications related to either the colostomy creation or the subsequent takedown (refer to the typical cases: ►Figs. 1 and 2).
Discussion Open pelvic fracture is one of the most devastating injuries in orthopedic trauma and is associated with high mortality and poor outcome in the long term.20 Patients who had experienced considerable high-energy trauma were at a high risk of experiencing multiple concomitant injuries to the bladder,
Table 3 The data of patients (contd) Case
Hospital stay (d)
ICU stay
Associated injury
Reconstruction
Blood transfusion
1
29
9
Head
VSD þ skin graft
7
2
70
7
N/A
VSD þ ALT flap
12
3
106
12
Left hand injury þ urethral incision
Gracilis muscle to IAS
8
4
56
4
Right humerus fx
ALT flap
13
5
22
8
N/A
VSD þ skin graft
17
6
41
5
Fibula fracture
ALT flap
16
7
61
11
N/A
VSD þ gracilis muscle to IAS
14
8
57
8
N/A
VSDþ
10
9
59
9
Hemo/pneumothorax þ lung contusion þ flail chest
ALT flap
8
10
6
6
N/A
VSD þ ALT flap
8
11
37
7
N/A
ALT flap
16
Abbreviations: ALT, anterior lateral thigh; fx, fracture; IAS, internal anal sphincter; ICU, intensive care unit; N/A, not applicable; VSD, vacuum sealing drainage. Journal of Reconstructive Microsurgery
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Table 2 The data of patients
Classification of Perineal Soft Tissue Injuries
Fu et al.
Fig. 1 A 39-year-old man who was involved in a traffic accident presented to our institution. (A) The pelvic fracture pattern of the patient was Tile C1 and the perineal soft tissue defect was classified as type B2. (B) An external fixator was applied, and colostomy was created. (C) In the first operation, the perineal wound was sutured after debridement. During the second operation (14 days postoperatively), the wound was not healed. (D) A gracilis myocutaneous flap was created to reconstruct the function of the IAS. (E and F) The external fixator was removed, and the symphysis pubis diastasis was treated by ORIF. (G) Fourteen days after the second operation, the wound was adequately healed and the patient was able to walk with assistance. Closure of the colostomy was performed without any complications, and the patient regained normal defecation function within 5 months postoperatively. IAS, internal anal sphincter; ORIF, open reduction and internal fixation.
urethra, rectum, or distal colon, as well as perineal soft tissue defects. As compared with patients having closed pelvic fractures, those having pelvic fractures associated with perineal injuries have a higher rate of complications, including sepsis, pelvic abscess formation, acute respiratory distress syndrome, multiorgan system failure, and death.21 In these situations, “damage control” orthopedic surgery is the mandatory first step. The perineal area is the most commonly injured soft tissue in open pelvic fractures.22,23 A systematic classification of perineal soft tissue injury associated with pelvic fracture is important in stratifying injury severity, facilitating treatment guidelines for surgical reconstruction, predicting complications, and assessing prognosis. Perineal soft tissue injuries should be classified according to their location, and the repair protocol should be based on the anatomical location of the injury. In this study, the modified classification of perineal soft tissue injuries defined three types of injuries that could be further subclassified according to the occurrence of urethral tear or anorectal rupture (►Table 1). Several classification schemes are used for the clinical evaluation of open pelvic fractures. The most widely used scheme is the Gustilo–Anderson classification.24 This system, Journal of Reconstructive Microsurgery
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which was based on open tibial fractures, has been used successfully for more than 35 years.25 However, significant problems and shortcomings have been identified with respect to its reliability and reproducibility.11 Based on the Gustilo–Anderson classification, the Classification and Outcomes Committee of the Orthopedic Trauma Association (OTA) has developed a new classification for open fractures; the new classification overcomes some of these shortcomings.26 This new classification is composed of five categories: skin injury (S), muscle injury (M), arterial injury (A), bone loss (B), and contamination (C).11 This classification is not feasible for evaluating perineal soft tissue injuries and the necessity of urinary or fecal diversion. Generally, fecal diversion and subsequent colostomy takedown are recommended for patients with perineal soft tissue injuries. Although, fecal diversion is of great importance to avoid the risk of sepsis and wound contamination, the complications of this procedure are still significant.27,28 Jones et al15 divided open pelvic fractures into three classes: class 1, stable pelvic ring; class 2, unstable pelvic ring and no rectal or perineal wound; and class 3, unstable pelvic ring with a rectal or perineal wound. In this classification, the use of a diverting colostomy was recommended for class 3 fractures. Faringer et al reported
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Fu et al.
Fig. 2 (A and B) A 22-year-old man presented with destructive injury to the external genitalia and severe perineal soft tissue defects after a motor vehicle crash. (C and D) The pelvic fracture pattern was Tile B3 and the perineal soft tissue defect was classified as type C2. A suprapubic cystostomy was performed and an external fixator was applied after wound debridement. (E) The perineal wound was temporarily covered with a VSD. (F–H) Five days postoperatively, an anterior lateral thigh flap was placed. (I) Two weeks postoperatively, the wound had healed.
that open pelvic fractures can be classified as either zone I (perineum, anterior pubis, medial buttock, and posterior sacrum), zone II (medial thigh and groin crease), or zone III (posterolateral buttock and iliac crest). The indications for mandatory fecal diversion included deep lacerations of the anus or rectum, large-sized soft tissue wounds in immediate proximity to the anus, or large avulsion flaps with associated ischemic tissue in the pelvic area.14,29 However, there has been disagreement about the indications. For example, Woods et al concluded that in patients with open pelvic fractures, fecal diversion is not associated with a lower incidence of abdominopelvic infections.27 Our results indicate that fecal diversion is not mandatory for patients without anorectal injury (type B1, C1, and C2). In our study, two patients with anorectal tears underwent colostomy, three patients with soft tissue injuries in the anal zone but no anorectal tear did not require fecal diversion, and only one patient experienced a wound infection. Aggressive debridement was performed for all patients, and early wound coverage was achieved in all cases. However, for types B2, C3, and C4 injuries, a colostomy and secondary stage reconstruction of the IAS are mandatory.
In our study, an associated rectal injury was not diagnosed until 2 days postoperatively. For one patient, digital rectal examination (DRE) performed in the emergency room showed negative findings. After the initial procedure, fresh blood was observed in the anus. A second DRE also revealed fresh blood. Subsequently, rectoscopy identified a tear in the rectal wall, and the patient underwent exploratory laparotomy, rectum repair, and colostomy creation. Therefore, for patients with open pelvic fractures, a careful history and physical examination are of great importance to rule out suspected rectal and vaginal injuries. Physical examination should include a thorough abdominal examination, inspection of the perineum, and DRE, with vaginal examination in female patients.30 However, it should be noted that a lack of physical findings does not rule out an intra-abdominal injury. The development of peritonitis or localized sepsis may not be immediately apparent; therefore, further evaluation or close observation is necessary depending on the index of suspicion. The diagnostic evaluation of rectal impalement injuries should include proctosigmoidoscopy to properly examine the rectal mucosa for perforation. Bladder injury should be Journal of Reconstructive Microsurgery
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Classification of Perineal Soft Tissue Injuries
Classification of Perineal Soft Tissue Injuries
Fu et al.
excluded by using cystoscopy or cystography in patients with hematuria.5 In addition, vaginoscopy should be performed routinely in female patients.31 In our study, both the patient’s overall condition and the severity of wounds were critical. Therefore, early closure and reconstruction of the wound was not suitable in these cases. Repeated debridement and negative vacuum drainage were often used to decrease necrotic tissue formation. Reconstruction procedures can be initiated only after necrotic tissue is debrided and the infection is controlled. The final result for many patients is lower extremity amputation and loss of pelvic floor muscles; this results in abdominal gas and fecal or urinary incontinence, possibly necessitating a secondary reconstructive procedure.32 Treatment of open pelvic fractures combined with perineal soft tissue injuries should aim to prevent infection, cover the wound, and definitively fix the fracture. Most patients with these types of injuries are hypothermic, acidotic, and experiencing coagulopathic disorders. Patients in this condition cannot tolerate a lengthy operation. High impact wounds should receive early and aggressive debridement; it is therefore recommended to perform immediate “damage control” surgery, followed by a definitive surgery 24 to 48 hours later. Rectal and anal sphincter damage often accompanies these injuries, and these injuries should be left open with good drainage provided. Colostomy reversal may be possible within 4 to 6 weeks without adverse outcomes. Historically, suprapubic catheters have been used during open bladder repair. However, recent literature supports the use of transurethral catheter decompression in patients with intraperitoneal bladder injury.10–12 Extraperitoneal bladder rupture may be managed with urethral catheterization alone and close observation.12,13 A cystogram should be performed after 10 to 14 days of bladder repair to determine if the catheter can be safely removed. Our results showed that a diverting colostomy can be avoided for patients in whom IAS and intra-abdominal injuries can be ruled out. However, the appropriate use of negative pressure wound closure systems such as VSD is always important for wound management. In recent years, negative pressure wound closure systems have been widely used for injuries in the perineal region.5–10 The clinical application of NPWT with the VSD has proved to be a very efficient closure technique for our patients.
References 1 Grotz MR, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis
2
3
4
5
6
7
8
9
10
11
12 13
14
15
16
17 18
Conclusion A classification for grading the degree of perineal soft tissue injuries associated with open pelvic fractures is necessary in clinical practice. In this retrospective study, we found that perineal soft tissue injuries associated with pelvic fractures could be accurately classified into three types with further subclassification. Injuries were classified based on the location, depth, and size of soft tissue defects and associated injuries to surrounding organs. This classification may help surgeons to make treatment priority decisions and determine an appropriate management plan according to the repair protocol. Journal of Reconstructive Microsurgery
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20
21
22
PV. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005;36(1):1–13 Black EA, Lawson CM, Smith S, Daley BJ. Open pelvic fractures: the University of Tennessee Medical Center at Knoxville experience over ten years. Iowa Orthop J 2011;31:193–198 Hanson PB, Milne JC, Chapman MW. Open fractures of the pelvis. Review of 43 cases. J Bone Joint Surg Br 1991;73(2): 325–329 Mohanty K, Musso D, Powell JN, Kortbeek JB, Kirkpatrick AW. Emergent management of pelvic ring injuries: an update. Can J Surg 2005;48(1):49–56 Durrant JJ, Ramasamy A, Salmon MS, Watkin N, Sargeant I. Pelvic fracture-related urethral and bladder injury. J R Army Med Corps 2013;159(Suppl 1):i32–i39 Lunsjo K, Abu-Zidan FM. Does colostomy prevent infection in open blunt pelvic fractures? A systematic review. J Trauma 2006;60(5): 1145–1148 Brenneman FD, Katyal D, Boulanger BR, Tile M, Redelmeier DA. Long-term outcomes in open pelvic fractures. J Trauma 1997; 42(5):773–777 Labler L, Trentz O. The use of vacuum assisted closure (VAC) in soft tissue injuries after high energy pelvic trauma. Langenbecks Arch Surg 2007;392(5):601–609 Ozer MT, Coskun AK, Ozerhan IH, et al. Use of vacuum-assisted closure (VAC™) in high-energy complicated perineal injuries: analysis of nine cases. Int Wound J 2011;8(6):599–607 Milcheski DA, Zampieri FM, Nakamoto HA, Tuma P Jr, Ferreira MC. Negative pressure wound therapy in complex trauma of perineum. Rev Col Bras Cir 2013;40(4):312–317 Agel J, Evans AR, Marsh JL, et al. The OTA open fracture classification: a study of reliability and agreement. J Orthop Trauma 2013; 27(7):379–384, discussion 384–385 Bircher M, Eng FE, Hargrove R. Is it Possible to Classify Open Fractures of the Pelvis? Eur J Trauma 2004;30(2):74–79 Pennal GF, Tile M, Waddell JP, Garside H. Pelvic disruption: assessment and classification. Clin Orthop Relat Res 1980;(151): 12–21 Faringer PD, Mullins RJ, Feliciano PD, Duwelius PJ, Trunkey DD. Selective fecal diversion in complex open pelvic fractures from blunt trauma. Arch Surg 1994;129(9):958–963, discussion 963– 964 Jones AL, Powell JN, Kellam JF, McCormack RG, Dust W, Wimmer P. Open pelvic fractures. A multicenter retrospective analysis. Orthop Clin North Am 1997;28(3):345–350 Agel J, Rockwood T, Barber R, Marsh JL. Potential predictive ability of the orthopedic trauma association open fracture classification. J Orthop Trauma 2014;28(5):300–306 Wilson RF. Current status of advanced trauma life support training. Ann Emerg Med 1981;10(4):226–227 Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38(6):563–576, discussion 577 Qu J, Yan R, Wang L, et al. Free dermatoplasty combined with vacuum sealing drainage for the treatment of large-area soft tissue defects accompanied by bone exposure in the lower leg. Exp Ther Med 2013;5(5):1375–1380 Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg 2005;190(6): 830–835 Duchesne JC, Bharmal HM, Dini AA, et al. Open-book pelvic fractures with perineal open wounds: a significant morbid combination. Am Surg 2009;75(12):1227–1233 Kottmeier SA, Wilson SC, Born CT, Hanks GA, Iannacone WM, DeLong WG. Surgical management of soft tissue lesions associated with pelvic ring injury. Clin Orthop Relat Res 1996;(329):46–53
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
18
Classification of Perineal Soft Tissue Injuries
Fu et al.
28 Ghanayem AJ, Wilber JH, Lieberman JM, Motta AO. The effect of
trauma centers. Am J Surg 1992;163(3):283–287 Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984;24(8):742–746 Gustilo RB. Management of open fractures. An analysis of 673 cases. Minn Med 1971;54(3):185–189 Orthopaedic Trauma Association: Open Fracture Study Group. A new classification scheme for open fractures. J Orthop Trauma 2010;24(8):457–464 Woods RK, O’Keefe G, Rhee P, Routt ML Jr, Maier RV. Open pelvic fracture and fecal diversion. Arch Surg 1998;133(3): 281–286
laparotomy and external fixator stabilization on pelvic volume in an unstable pelvic injury. J Trauma 1995;38(3):396–400, discussion 400–401 Richardson JD, Harty J, Amin M, Flint LM. Open pelvic fractures. J Trauma 1982;22(7):533–538 Mangiante EC, Graham AD, Fabian TC. Rectal gunshot wounds. Management of civilian injuries. Am Surg 1986;52(1):37–40 Kumar BA, Chojnowski AJ. Open pelvic fractures with vaginal laceration: an unusual clinical feature. Injury 2000;31(1):68–70 Mundy AR, Andrich DE. Pelvic fracture-related injuries of the bladder neck and prostate: their nature, cause and management. BJU Int 2010;105(9):1302–1308
24
25 26
27
29 30 31 32
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
23 Sinnott R, Rhodes M, Brader A. Open pelvic fracture: an injury for
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