Session X - Pelvis

Emergent Management of APC 2 Pelvic Ring Injuries with an Anteriorly Placed C-Clamp

Paul Tornetta, III, MD; Marc Richard, MD;

Boston University Medical Center, Boston, Massachusetts, USA

Purpose: Mechanical external stabilization of skeletally unstable pelvic fractures has been demonstrated to be beneficial to patients. It is most advantageous in "open book" injuries associated with tearing of the pelvic floor and significant venous bleeding. Many methods are possible, including the use of wrap sheets, specially made binders, and external fixation. Standard anterior frames are difficult to place in the emergency department and can be obtrusive to angiographers and surgeons. Sheets and binders work well for short periods of time, but cannot be maintained for more than a few hours, and they hinder some procedures. The C-clamp is useful in that it achieves bony purchase, affording a strong reduction moment and allows for angiography and celiotomy without interference. We report on a series of patients with APC2 "open book" injuries treated emergently with an anteriorly placed pelvic C-clamp within the first hour after presentation.

Methods: Twenty-four patients with an average age of 29 years (range, 14 to 58) who arrived with APC 2 injuries were emergently managed in the emergency department (10), angiography suite (9,) or the operating room (5) with an anteriorly placed C-clamp within the first hour after arrival. The tongs were placed in the gluteus ridge three finger breadths directly inferior to the anterior superior iliac spine with the patient in the supine position through a 1.5-cm stab wound under local anesthesia. The legs were bound together or held internally rotated during clamp placement to aid in the reduction.

Results: The application time was less than 5 minutes in all patients. Eleven patients had hypotension, and there was an average elevation of their blood pressure of 23 mm after clamp placement. Two patients died (1 abdominal bleeding, 1 head injury). Ten patients went on to angiography and 3 to laparotomy. The pelvic clamp was easily draped out of the field for both procedures. The symphyseal separation was reduced from an average of 4.5 cm (range, 3 to 9) to less than 2 cm in all cases and less than 1 cm in 21 of 24 cases. All clamps were removed by 72 hours. Complications included one misdiagnosis of an APC3 injury in a hemodynamically unstable patient who eventually succumbed to her head injury. In two cases, the clamp became dislodged when patients were rolled in the intensive care unit and required retightening. No other complications occurred during placement of the clamp anteriorly. The clamps were maintained during definitive fixation in most cases until after the symphysis was exposed and a reduction was achieved with a bone tenaculum.

Conclusion: Anterior placement of the pelvic C-clamp is a fast (< 5 minutes) and effective method of emergent management for APC 2 type injuries and has a low complication rate. We recommend the use of the pelvic C-clamp in an anterior position for "open book" APC 2 injuries, particularly in hemodynamically unstable patients and those requiring other procedures such as angiography, celiotomy, or fixation of other skeletal injuries.