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Zorluk: OrtaOrthopedic Surgery

A 29-year-old male is transported to the emergency department following a high-speed motorcycle collision where he was thrown from the vehicle. Upon arrival, the patient is confused and diaphoretic. Vital signs show a temperature of 36.5°C (97.7°F), heart rate of 138/min, blood pressure of 78/40 mmHg, and respiratory rate of 26/min. Primary survey reveals a patent airway and equal breath sounds bilaterally. The abdomen is soft, non-distended, and non-tender to palpation. Bedside focused assessment with sonography for trauma (FAST) reveals no free fluid in the intraperitoneal space or pericardium. Pelvic examination demonstrates a significant scrotal hematoma and mechanical instability with gentle anterior-posterior compression. Neurologic examination shows intact motor function in both lower extremities, and dorsalis pedis pulses are palpable but faint bilaterally. Which of the following is the most appropriate next step in management?

  1. Application of a pelvic circumferential compression deviceCevap
  2. B
    Computed tomography scan of the abdomen and pelvis
  3. C
    Exploratory laparotomy
  4. D
    Immediate internal fixation of the pelvic ring
  5. E
    Administration of broad-spectrum intravenous antibiotics

Cevap

Application of a pelvic circumferential compression device
The correct answer is the application of a pelvic circumferential compression device (pelvic binder or sheet). This patient is in hypovolemic shock following high-energy blunt trauma and has a mechanically unstable pelvic ring on physical examination. Hemorrhage associated with pelvic fractures most commonly originates from the presacral venous plexus and cancellous bone, leading to massive retroperitoneal bleeding. A negative FAST exam makes significant intraperitoneal hemorrhage highly unlikely. Therefore, the immediate priority is to apply a pelvic binder centered over the greater trochanters. This simple, non-invasive maneuver reduces the internal pelvic volume, apposes bleeding fracture ends, and promotes the tamponade of venous hemorrhage, temporarily stabilizing the patient while preparing for definitive management such as pelvic angiography for embolization or preperitoneal packing.

Adım Adım Çözüm

1
Identify the patient's hemodynamic status.
The patient is in hemorrhagic shock, evidenced by significant hypotension and tachycardia.
Vital signs dictate the urgency and algorithm for acute trauma management.
2
Evaluate the primary survey and FAST exam results in the context of the physical exam.
The FAST exam is negative, ruling out massive intraperitoneal hemorrhage, while the physical exam shows marked pelvic instability and hematoma.
This localizes the likely source of life-threatening bleeding to the retroperitoneum, associated with an unstable pelvic ring fracture.
3
Determine the appropriate immediate intervention for suspected pelvic hemorrhage.
Non-invasive stabilization with a pelvic binder is indicated as the first step.
A circumferential binder reduces pelvic volume, promotes venous tamponade, and mechanically stabilizes the fracture before definitive management.

Anahtar Kavram

In a hemodynamically unstable patient with an unstable pelvic fracture and a negative FAST exam, the immediate next step is the application of a pelvic binder to reduce pelvic volume and control retroperitoneal venous hemorrhage.
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