Surviving On-Call: Sorting Out the Unstable Patient with an Unstable Pelvic Ring Injury

The responsibility of on-call duty is no small task, regardless of your subspecialty interests, experience level or years in practice. Few patients challenge our on-call abilities more than the unstable patient with an unstable pelvic ring disruption. Over the past few decades, on-call orthopaedic surgeons have evolved from reactive clinicians, tasked with caring for whoever survives until morning, to being active participants in the initial evaluation and resuscitation team. No longer is memorizing the Young-Burgess (or Pennal-Tile) classification and knowing how to apply a pelvic external fixation device viewed as being sufficiently prepared.

With that said, here are several key points to remember if you are on call for patients with potentially unstable pelvic ring injuries:

1. Minutes matter: Show up quickly to evaluate the patient, and have a carefully-considered management algorithm prepared long before you are assigned on-call duty.
2. Check the film:  Look at the initial plain pelvic film to determine whether the injury shows a “volume expanding” (open book injury) or a “volume diminishing” (lateral compression) pattern.
3. Wrap it up:  Apply a circumferential pelvic wrap (sheet or binder) for patients with “volume expanding” injuries to reduce the potential true pelvic volume available for pelvic-related hemorrhage, and also to provide comfort.
4. Seek instability: Never assume that any pelvic ring injury is stable until you have actually seen the initial plain pelvic radiograph and examined the patient. Especially for those with minimally-displaced fractures, instability is easily identified by manually compressing at the iliac crests towards the midline (unstable injuries will collapse and cause pain).
5. Warm them up:  Cold contributes to coagulopathy.
6. Fill them up:  Insert an intra-osseus catheter, if necessary, to facilitate volume resuscitation when routine venous access is difficult.

Put simply, to make a positive impact on overall outcomes in this challenging patient population, keep it simple and make a plan before disaster strikes.

Milton “Chip” Routt, MD
[email protected]

DISCLAIMER: Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion or endorsement on the part of the officers or the members of WOA unless such opinion or endorsement is specifically stated. Materials may be reproduced only if Touches and the Western Orthopaedic Association are credited.

 

Surviving On-Call: Sorting Out the Unstable Patient with an Unstable Pelvic Ring Injury