PPP is a rapid method for controlling pelvic fracture-related hemorrhage that can supplant the need for emergent angiography. There is a significant reduction in blood product transfusion after PPP, and this approach appears to reduce mortality in this select high-risk group of patients.

No abstract

T he optimal management strategy for unrelenting hemorrhage produced by unstable pelvic fractures remains controversial. The basic cornerstones of modern pelvic fracture management in North America are early identification, resuscitation with blood and blood products, treatment of associated injuries, and control of pelvic bleeding with a combination of mechanical stabilization and arterial embolization. 1-6 The published European approach has emphasized packing of the pelvis through an abdominal approach and direct arterial control instead of angiography. 7,8 Considering that more than 85% of bleeding from major pelvis fractures is venous in origin, 8,9 we have recently used mechanical stabilization followed by direct retroperitoneal packing to control life-threatening hemorrhage due to unstable pelvic fractures in patients arriving at the hospital in hemorrhagic shock. To our knowledge, direct packing via a retroperitoneal approach to control pelvic fracture bleeding has not been previously described in the English-language literature. We present two illustrative cases. Although the injury mechanisms and fracture patterns were disparate, both patients survived emergent operative intervention relying on retroperitoneal packing with C-clamp reduction of the pelvic volume. Herein, we discuss the acute management of these patients and provide a detailed technical description of the key operative maneuvers. CASE 1S.W. is a 48-year-old male line worker who sustained an unrestrained fall of approximately 50 feet from a power line. He was initially transported and treated at an outlying facility for hemodynamic instability from a mechanically unstable pelvic fracture with a presenting blood pressure (BP) of 84/40 mm Hg. His initial hematocrit was 34.8%. He remained hemodynamically unstable with a systolic blood pressure (SBP) less than 90 mm Hg, despite having his pelvis bound with a sheet across the greater trochanters and receiving two units of packed red blood cells (PRBCs). Emergent transport of the patient to our facility was arranged.On arrival to our Level I trauma center, the patient's BP was 104/70 mm Hg with a pulse of 154 bpm and a Glasgow Coma Scale (GCS) score of 15. Laboratory values included a base deficit of -11 meq/L. Ultrasound examination was negative for free fluid in the abdominal cavity. Other injuries included a small right hemopneumothorax, fractures of ribs 7 to 12 on the right, T7 to T9 and L1 to L3 transverse process fractures. Trauma anteroposterior radiograph and CT scan of the pelvis showed a Young and Burgess APC III fracture and a right Denis type II sacral fracture AO (Arbeitsgemeinschaft fur Osteosynthesefragen)/OTA (Orthopaedic Trauma Association) Pelvic Fracture Classification, type C1-3a2) (Fig. 1, A and B). The patient was intubated urgently and consequently a complete neurologic examination was unable to be performed. Computed tomography scans of the head, chest, and abdomen confirmed a right hemopneumothorax but no head or intra-abdominal injury. Despite receiving an additional ...

Level III, retrospective comparative series.

IMPORTANCE Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist.OBJECTIVE To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. DESIGN, SETTING, AND PARTICIPANTSThis open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers.INTERVENTIONS A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. MAIN OUTCOMES AND MEASURESThe primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. RESULTSThe analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections.CONCLUSIONS AND RELEVANCE Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin.