Arch Orthop Trauma Surg (1992) 111 : 293-295
Achv°°fOrthopaedic ndTrauma Surgery © Springer-Verlag 1992
Traumatic hemipelvectomy A case report a n d c o m m e n t s on associated injuries G. Dendrinos, D. Koronias, and G. Papagiannopoulos First Orthopaedic Department, Athens General Hospital, Athens, Greece
Summary. The twenty-fifth reported case of survival following traumatic hemipelvectomy is presented. Our patient is the fourth female survivor and the second who escaped associated injuries to either the genito-urinary system or the rectum.
Traumatic hemipelvectomy is a rare but most challenging injury to confront the trauma surgeon. Few victims of this avulsion of the pelvis survive the initial resuscitation period. Only 24 survivors were found reported in the literature at the time of this writing [1-15]; only three of these were females. This devastating injury is usually associated with injuries to the urinary system and the anal region, which were seen in 18 and 19 of the 24 reported patients respectively. We present a new case of a female survivor of traumatic hemipelvectomy who escaped both urinary and anal injuries.
At operation all the vascular and neurological structures of the left lower limb were noted to have been severed and the traumatic partial amputation was completed. Thorough debridement of the wound was carried out and the wound was partially closed with loose sutures. Neither colostomy nor laparotomy were considered necessary. Post-operatively the patient was transferred to the intensive care unit, where she stayed for 4 days. During the first 24 h she was given a total of twelve units of blood. On the 7th post-operative day the patient became pyrexial and discharge from the perineal end of the wound was noted, containing Enterobacter. The infection was treated successfully by drainage of the wound and intravenous antibiotics (Primaxin 500 mg × 4). Three weeks later secondary closure of the wound was carried out. The fractures of the left humerus and both ulnae were internally fixed on this occasion. The patient was later moved to the rehabilitation department of our hospital where she underwent intensive mobilisation and was supplied with a specially made artificial limb. At follow-up i year later she was actively up and about but not adapting well to her prosthesis: she was able to walk with the prosthesis for a long distance, but preferred to use crutches. She was back at her job working as a secretary and did not appear to be experiencing major psychological problems.
Case report
Discussion
A 26-year-old female was hit by a car whilst riding her motocycle. The car came at her at high speed from the opposite direction. She was transported to the Athens Regional General Hospital and arrived approximately 30 rain after the accident. The patient was conscious on admission but she had very low blood pressure. Immediate resuscitation was started using peripheral and central venous infusion. She had multiple compound fractures of the left lower limb and an almost complete separation of this limb from the pelvis. The radiographs of the pelvis revealed avulsion of the sacroiliac joint leaving a piece of iliac bone attached to the sacrum, and a fracture through the obturator foramen leaving a piece of pubic bone also intact (Fig. 1). The radiological examination also showed fractures of the right pubic rami, a supracondylar fracture of the left humerus, fractures of both ulnar shafts and multiple comminuted fractures of the left femur and the left tibia. The left limb was attached to the trunk only by a small skin bridge and parts of the gluteal muscles. The peritoneum was exposed but intact and there was no visceral injury. Rectal examination revealed no damage to the anus. There was no injury to either the urinary tract or to the genitalia. An intravenous pyelogram carfled out prior to operation did not reveal any pathological findings (Fig. 2).
Our patient is the twenty-fifth (fourth female) reported survivor of traumatic hemipelvectomy. This injury is rare but most devastating, not only because of the mag-
Correspondence to: George Dendrinos, M.D., Messinias 17, Halandri, G R 152 34, Athens, Greece
Fig.1. Radiograph showing the level of the traumatic amputation
294
Fig. 2. Pre-operative intravenous pyelogram showing the urinary
tract to be intact Fig. 3a, b. Final appearance of the patient after wound healing
nitude of the pelvic trauma, but also because of the associated injuries to other systems, the most common being to the gentiourinary and the gastrointestinal tracts [4]. Control of haemorrhage with adequate fluid and blood transfusion is the initial determinant of survival. This volume replacement and further evaluation of associated injuries should be completed before direction of attention to the pelvic wound. The life of this woman was saved by the quick action of the ambulance crew and the accident unit physicians, who compressed and successfully clamped the bleeding iliac vessels. The type of the wound should also be discussed. After complete avulsion of limbs, as in our case, bleeding usually stops as result of retraction of vessels, whereas incomplete avulsion holds torn vessels apart and may require surgical hemipelvectomy to save life [5]. The second major determinant of survival is the severity of the associated injuries. It has been repeatedly stated that any injury to the rectum or to the distal colon should be treated by diverting colostomy [7]. Similarly, injuries to the urinary tract should be treated with proximal diversion of the urinary stream. Associated injuries to the genitalia, rectum, peritoneum, or intraperitoneal viscera were present in the majority of the previous 24 cases so far reported. Thus, absence of this type of injury is rare, and significantly increased our patient's chances of survival. Very careful attention must be paid to any associated musculoskeletal and neurological injuries to the other extremities, since these injuries will have a significant in-
fluence on the patient's potential for long-term rehabilitation. In our case the surgical treatment of the upper limb fractures was delayed due to the patient's poor general condition and the risk of expansion of the perineal infection. Despite this delay, however, the excellent longterm result of these operations eventually allowed the best possible rehabilitation of the patient. The plane of the hemipelvectomy was also unusual in our case, running through the obturator foramen. Klasen and Ten Duis [4] have reported that this remaining extra piece of bone is useful in acting as a support for the artificial limb. However, this did not apply in the case of our patient, since she preferred to use crutches instead of her prosthesis. The last determinant of succesful outcome in patients with traumatic hemipelvectomy is their ability to adapt psychologically to the injury [8]. Because most of these patients are young and vigorous, their ages in reported cases ranging from 7 to 32 years, reaction to the disability and disfigurement resulting from the injury will be profound (Fig. 3). Thus, management of patients with traumatic hemipelvectomy should include early consultation with and continuous care by a psychiatrist. However, as the literature and the present report indicate, many of these badly injured patients can be successfully rehabilitated to an active and productive role in life. Finally, it should be underlined that the management of patients with traumatic hemipelvectomy requires extraordinary efforts and cooperation from a team consisting of general surgeon, urologist, psychiatrist, orthopaedist, physiotherapist and dedicated nursing personnel. References
1. Dauisi FJ, Stromberg BV (1985) Traumatic hemipelvectomy. Plast Reconstr Surg 76 : 945-947
295 2. Evans RN Jr, Foss FE (1984) Traumatic hemipelvectomy in combination with traumatic amputation of an upper extremity. J Trauma 24 : 342-345 3. Johanson H, Olerud S (1971) Traumatic hemipelvectomy in a ten-year-old boy. J Bone Joint Snrg [Am] 53 : 170-172 4. Klasen HJ, Ten Duis HJ (1989) Traumatic hemipelvectomy. J Bone Joint Surg [Br] 71 : 219-295 5. Maull KI, Sachatello CR, Ernst CB (1977) The deep perineal laceration - an injury frequently associated with open pelvic fractures: a need for aggressive surgical management. A report of 12 cases and review of the literature. J Trauma 17 : 685-696 6. McLean EM (1962) Avulsion of the hindquarter. J Bone Joint Surg [Br] 44: 384-385 7. Meester GL, Myerley WH (1975) Traumatic hemipelvectomy: case report and literature review. J Trauma 15 : 541-545 8. Moore WM, Brown JJ, Haynes JL, Viamontes L (1987) Traumatic hemipelvectomy. J Trauma 27 : 570-572 9. Oppenheim WL, Tricker J, Smith RB (1977) Traumatic hemipelvectomy - the tenth survivor: a case report and review of literature. Injury 9: 307-312
10. Orcutt TW, Emerson CW Jr, Rhamy RK, Cocke W Jr (1974) Reconstruction and rehabilitation following traumatic hemipelvectomy and brachial plexus injury. J Trauma 14 : 695-704 11. Rondriguez-Morales G, Phillips T, Conn AK, Cox EF (1983) Traumatic hemipelvectomy: report of two survivors and review. J Trauma 23 : 615-620 12. Siemens R, Flint LM Jr (1977) Traumatic hemipelvectomy: a case report. J Trauma 17 : 245-247 13. Turnbull H (1978) A case of traumatic hindquarter amputation. Br J Surg 65 : 390-392 14. Wade FV, Macksood W A (1965) Traumatic hemipelvectomy: a report of two cases with rectal involvement. J Trauma 5 : 554-562 15. Wand JS (1990) Traumatic hemipelvectomy without visceral injury. J Bone Joint Surg [Br] 72: 327-328
Received December 18, 1990
Achv°°fOrthopaedic ndTrauma Surgery © Springer-Verlag 1992
Traumatic hemipelvectomy A case report a n d c o m m e n t s on associated injuries G. Dendrinos, D. Koronias, and G. Papagiannopoulos First Orthopaedic Department, Athens General Hospital, Athens, Greece
Summary. The twenty-fifth reported case of survival following traumatic hemipelvectomy is presented. Our patient is the fourth female survivor and the second who escaped associated injuries to either the genito-urinary system or the rectum.
Traumatic hemipelvectomy is a rare but most challenging injury to confront the trauma surgeon. Few victims of this avulsion of the pelvis survive the initial resuscitation period. Only 24 survivors were found reported in the literature at the time of this writing [1-15]; only three of these were females. This devastating injury is usually associated with injuries to the urinary system and the anal region, which were seen in 18 and 19 of the 24 reported patients respectively. We present a new case of a female survivor of traumatic hemipelvectomy who escaped both urinary and anal injuries.
At operation all the vascular and neurological structures of the left lower limb were noted to have been severed and the traumatic partial amputation was completed. Thorough debridement of the wound was carried out and the wound was partially closed with loose sutures. Neither colostomy nor laparotomy were considered necessary. Post-operatively the patient was transferred to the intensive care unit, where she stayed for 4 days. During the first 24 h she was given a total of twelve units of blood. On the 7th post-operative day the patient became pyrexial and discharge from the perineal end of the wound was noted, containing Enterobacter. The infection was treated successfully by drainage of the wound and intravenous antibiotics (Primaxin 500 mg × 4). Three weeks later secondary closure of the wound was carried out. The fractures of the left humerus and both ulnae were internally fixed on this occasion. The patient was later moved to the rehabilitation department of our hospital where she underwent intensive mobilisation and was supplied with a specially made artificial limb. At follow-up i year later she was actively up and about but not adapting well to her prosthesis: she was able to walk with the prosthesis for a long distance, but preferred to use crutches. She was back at her job working as a secretary and did not appear to be experiencing major psychological problems.
Case report
Discussion
A 26-year-old female was hit by a car whilst riding her motocycle. The car came at her at high speed from the opposite direction. She was transported to the Athens Regional General Hospital and arrived approximately 30 rain after the accident. The patient was conscious on admission but she had very low blood pressure. Immediate resuscitation was started using peripheral and central venous infusion. She had multiple compound fractures of the left lower limb and an almost complete separation of this limb from the pelvis. The radiographs of the pelvis revealed avulsion of the sacroiliac joint leaving a piece of iliac bone attached to the sacrum, and a fracture through the obturator foramen leaving a piece of pubic bone also intact (Fig. 1). The radiological examination also showed fractures of the right pubic rami, a supracondylar fracture of the left humerus, fractures of both ulnar shafts and multiple comminuted fractures of the left femur and the left tibia. The left limb was attached to the trunk only by a small skin bridge and parts of the gluteal muscles. The peritoneum was exposed but intact and there was no visceral injury. Rectal examination revealed no damage to the anus. There was no injury to either the urinary tract or to the genitalia. An intravenous pyelogram carfled out prior to operation did not reveal any pathological findings (Fig. 2).
Our patient is the twenty-fifth (fourth female) reported survivor of traumatic hemipelvectomy. This injury is rare but most devastating, not only because of the mag-
Correspondence to: George Dendrinos, M.D., Messinias 17, Halandri, G R 152 34, Athens, Greece
Fig.1. Radiograph showing the level of the traumatic amputation
294
Fig. 2. Pre-operative intravenous pyelogram showing the urinary
tract to be intact Fig. 3a, b. Final appearance of the patient after wound healing
nitude of the pelvic trauma, but also because of the associated injuries to other systems, the most common being to the gentiourinary and the gastrointestinal tracts [4]. Control of haemorrhage with adequate fluid and blood transfusion is the initial determinant of survival. This volume replacement and further evaluation of associated injuries should be completed before direction of attention to the pelvic wound. The life of this woman was saved by the quick action of the ambulance crew and the accident unit physicians, who compressed and successfully clamped the bleeding iliac vessels. The type of the wound should also be discussed. After complete avulsion of limbs, as in our case, bleeding usually stops as result of retraction of vessels, whereas incomplete avulsion holds torn vessels apart and may require surgical hemipelvectomy to save life [5]. The second major determinant of survival is the severity of the associated injuries. It has been repeatedly stated that any injury to the rectum or to the distal colon should be treated by diverting colostomy [7]. Similarly, injuries to the urinary tract should be treated with proximal diversion of the urinary stream. Associated injuries to the genitalia, rectum, peritoneum, or intraperitoneal viscera were present in the majority of the previous 24 cases so far reported. Thus, absence of this type of injury is rare, and significantly increased our patient's chances of survival. Very careful attention must be paid to any associated musculoskeletal and neurological injuries to the other extremities, since these injuries will have a significant in-
fluence on the patient's potential for long-term rehabilitation. In our case the surgical treatment of the upper limb fractures was delayed due to the patient's poor general condition and the risk of expansion of the perineal infection. Despite this delay, however, the excellent longterm result of these operations eventually allowed the best possible rehabilitation of the patient. The plane of the hemipelvectomy was also unusual in our case, running through the obturator foramen. Klasen and Ten Duis [4] have reported that this remaining extra piece of bone is useful in acting as a support for the artificial limb. However, this did not apply in the case of our patient, since she preferred to use crutches instead of her prosthesis. The last determinant of succesful outcome in patients with traumatic hemipelvectomy is their ability to adapt psychologically to the injury [8]. Because most of these patients are young and vigorous, their ages in reported cases ranging from 7 to 32 years, reaction to the disability and disfigurement resulting from the injury will be profound (Fig. 3). Thus, management of patients with traumatic hemipelvectomy should include early consultation with and continuous care by a psychiatrist. However, as the literature and the present report indicate, many of these badly injured patients can be successfully rehabilitated to an active and productive role in life. Finally, it should be underlined that the management of patients with traumatic hemipelvectomy requires extraordinary efforts and cooperation from a team consisting of general surgeon, urologist, psychiatrist, orthopaedist, physiotherapist and dedicated nursing personnel. References
1. Dauisi FJ, Stromberg BV (1985) Traumatic hemipelvectomy. Plast Reconstr Surg 76 : 945-947
295 2. Evans RN Jr, Foss FE (1984) Traumatic hemipelvectomy in combination with traumatic amputation of an upper extremity. J Trauma 24 : 342-345 3. Johanson H, Olerud S (1971) Traumatic hemipelvectomy in a ten-year-old boy. J Bone Joint Snrg [Am] 53 : 170-172 4. Klasen HJ, Ten Duis HJ (1989) Traumatic hemipelvectomy. J Bone Joint Surg [Br] 71 : 219-295 5. Maull KI, Sachatello CR, Ernst CB (1977) The deep perineal laceration - an injury frequently associated with open pelvic fractures: a need for aggressive surgical management. A report of 12 cases and review of the literature. J Trauma 17 : 685-696 6. McLean EM (1962) Avulsion of the hindquarter. J Bone Joint Surg [Br] 44: 384-385 7. Meester GL, Myerley WH (1975) Traumatic hemipelvectomy: case report and literature review. J Trauma 15 : 541-545 8. Moore WM, Brown JJ, Haynes JL, Viamontes L (1987) Traumatic hemipelvectomy. J Trauma 27 : 570-572 9. Oppenheim WL, Tricker J, Smith RB (1977) Traumatic hemipelvectomy - the tenth survivor: a case report and review of literature. Injury 9: 307-312
10. Orcutt TW, Emerson CW Jr, Rhamy RK, Cocke W Jr (1974) Reconstruction and rehabilitation following traumatic hemipelvectomy and brachial plexus injury. J Trauma 14 : 695-704 11. Rondriguez-Morales G, Phillips T, Conn AK, Cox EF (1983) Traumatic hemipelvectomy: report of two survivors and review. J Trauma 23 : 615-620 12. Siemens R, Flint LM Jr (1977) Traumatic hemipelvectomy: a case report. J Trauma 17 : 245-247 13. Turnbull H (1978) A case of traumatic hindquarter amputation. Br J Surg 65 : 390-392 14. Wade FV, Macksood W A (1965) Traumatic hemipelvectomy: a report of two cases with rectal involvement. J Trauma 5 : 554-562 15. Wand JS (1990) Traumatic hemipelvectomy without visceral injury. J Bone Joint Surg [Br] 72: 327-328
Received December 18, 1990
