Treatment Options And Manage Experience Of Open Pelvic Fractures Associated With Anorectal Injuries

Objective To investigate the clinical treatment options and manage experience of open pelvic fractures associated with anorectal injuries.Methods We retrospectively reviewed the medical charts and images of 45 patients who sustained a open pelvic fracture associated with anorectal injuries and were treated at our department between October 1998 and October 2008. The treatment protocols were divided into four steps. First of all, rescuing block and controlling massive hemorrhage were the key points of rescue. Subsequently, sigmoid colon ostomy and debridement were used to deal with anorectal injuries and wounds. The next step was the treatment of pelvic fractures. Last but not least, wounds treatings were dealt with.1, first-aid recovery: To save lives and control of bleeding are the keypoints. Patients after admission, first-aid recovery was implemented immediatly in accordance with ATLS principles. To ensure airway patency and maintain good ventilation, attention should be paid to hemodynamic parameters of patients and two or more large vein channels were set up rapidly. If patients with low blood pressure, we looked for the causes of bleeding carefully and stopped bleeding on the overt wound with oppression in order to ensure effective hemostasis. At the same time, the rapid rehydration, rapid cross matching of blood, and a blood transfusion were done depending on the conditions . Medicines for elevating blood pressure were applied if necessary. As for low life-threatening blood pressure emergencies ,non-cross matching type O blood may be granted to patients in order to obtain hemodynamic stability and prevent the development of shock.Measures taken formerly win the opportunity to further exploratory laparotomy, external fixation, and surgery to stop bleeding. While immediate preliminary assessment of vital signs which including paying attention to head, chest and abdomen injuries, etc was executed. Observeing whether the patency of urethra by catheter inserting ,vaginal examination and urine anal examination were conducted at the same time.It was important to avoid missed diagnosis of injuries associated with pelvic fractures.To save the lives of patients and reduce mortality was the success of first-aid recovery. 45 cases of patients in this group are all received blood transfusion which varied from 400 to 8000 ml,average 2600ml in accordance with the principles of crystal plastic combination .It took us 2～4 hours which was at an average of 2.5 hours to accomplish first-aid recovery. First aid in the recovery process ,there were three cases of death due to hemorrhagic shock, 42 cases which obtained stable hemodynamics and vital signs and entered the next phase of colon ostomy and debridement treatment.2, ostomy and debridement treatment: Under conventional anesthesia, exploratory laparotomy was executed with the help of general surgery doctors.If there were still unstable vital signs, a temporary abdominal aortic cross-clamping techniques was received in advance. Methods: After the femoral artery puncture or longitudinal incision , we placed Forgarty catheter into abdominal aorta whose insertion length was approximately 20～25cm from the inguinal ligament to renal artery below.A balloon filled with 10～15ml water blocked abdominal aorta. The principles of anorectal injury treatment are: 1, 7 cases of intraperitoneal rectal injuries: repairing the damaged recta, making a sigmoid ostomy, and keeping retrorectal space drainage ;2, 23 cases of extraperitoneal rectal injuries:debriding in time,repairing the damaged recta, making a sigmoid ostomy and keeping fully presacral drainage; 3, 12 cases of anal injuries :9 cases of simple sphincter fractures sutured at stage I and kept continuous drainage. 3 cases of serious polluted injuries were debrided and kept fully drainage at stage I and other repairs were left at stage II. Besides anorectal injuries, other injuries treatment in this group included: 5 cases of closed thoracic drainage, splenectomy in 5 cases ,5 cases of small intestinal repair, 28 cases of bladder repair, early urethral realignment traction in 19 cases, 34 cases of cystostomy, 8 cases of vaginal repair,7 cases of internal iliac artery ligation , 8 cases of limb vascular patch or anastomosis. After thorough and careful debridement, open wounds were closed at stage I, delayed stage I depending on the circumstances . Wounds with heavy pollution and bad conditions were closed in stage II.3, pelvic fractures: According to the characteristics of the pelvic fractures,the treatments were executed:a temporary pelvic external fixator fixed in 7 cases. One Tile A stable fracture case received conservative therapy after ostomy and debridement. 41eases with ORIF, accounting for 97. 62 percent of all patients. As for Tile B or Tile C unstable pelvic fractures which were in stable condition through 3～7 days recoveries, the longest from the injury was not more than two weeks,surgical reductions and fixations were executed. They were all performed imaging examinations to define a clear fracture type as well as skeletal tractions and other related pre-operative preparations. 21 cases associated with limb fractures were also received ORIF.4, the latter wound treatment: It was essential for wounds early repairs to maintain the patency of indwelling drainage tube, to use broad-spectrum and drug-sensitive antibiotics, to replace dressings in strict accordance with the principle sterile , and to keep the wounds clean without secondary infections. Results There were 3 deaths of all cases. A total of 42 patients were followed up. The follow up period ranged from 12 to 48 months with an average of 18 months. For anorectal injuries,39 cases obtained satisfactory therapeutic results except 3 cases which had an improvement . According to the Majeed evaluation, the results of pelvic fractures were as followes: 8 cases were excellent, 26 cases were good, 6 cases were fair, and only 2 cases was a failure. The rate of excellency and goodness was 80. 95%. As far as the results of the wound healing: 23 cases were healed at the stage of I or delayed I,16 patients were healed with transferring of skin or flaps of their own at stage II ,2 cases which suffered various degrees of wound infections,obtained acceptable results by intensive dressing changes, drainages and the anti-inflammatory. One patient was dealt with transfering of the right upper femur myocutaneous flap formed by amputation to cover the exposed perineum and translocation bilateral testes translocation into abdominal subcutis respectively at stage I . Scrotum reconstruction and testes reduction were accomplished at stage II .Conclusions As for an open pelvic fracures associated with anorectal injuries case,a good outcome may only be achieved on the basis of the first aid and resuscitation ,aggressive managements of anorectal injuries and proper managements of pelvic fractures taken by orthopaedists in cooperation with multidisciplinary specialists.