INTRODUCTION

Pelvic fractures result from high-energy injuries and occur in 4% to 10% of patients with blunt trauma [1]. They are associated with concomitant organ injury in 10% to 20% of cases and have a mortality rate of 5% to 15%; however, when hemorrhagic shock is present, mortality increases to 40%. In 90% of cases, pelvic hemorrhage is caused by bleeding from the presacral plexus (venous bleeding) or from bone, while arterial bleeding accounts for the remaining 10% [2]. Pelvic fractures are anatomically classified as pelvic ring disruptions or acetabular fractures [3], reflecting the differing treatment approaches required based on the site of injury. Given the high-energy mechanisms involved, mixed fractures involving both the acetabulum and pelvic ring occur in 5% to 16% of cases [3] and are considered severe, often accompanied by multiple traumas [4]. High-energy trauma that causes pelvic and acetabular fractures can lead to hemorrhagic shock. Traumatic pelvic fractures with hemorrhagic shock present variably and require expeditious treatment, often necessitating a multidisciplinary approach. Treatment options include emergency laparotomy when intra-abdominal bleeding is present, and angioembolization (AE), external fixation, and preperitoneal pelvic packing (PPP) when it is absent [5]. Given its simplicity and rapid execution, PPP has been applied in patients with unstable pelvic fractures, with several studies reporting significant reductions in transfusion requirements and mortality [2]. Here, we report a case in which PPP was applied as a salvage operation for postoperative retroperitoneal bleeding with hemodynamic instability following orthopedic surgery (Kocher-Langenbeck approach) for an acetabular fracture with traumatic pelvic ring injury.

CASE REPORT

A 46-year-old man was admitted to the trauma bay with multiple traumatic injuries following a motor vehicle accident. The patient had no previous surgical history and was not taking any medications. A timeline of the patient’s clinical course is shown in Fig. 1. His initial vital signs were stable (systolic blood pressure [SBP], 157 mmHg; diastolic blood pressure [DBP], 128 mmHg), and imaging evaluation revealed a left hip joint dislocation, left acetabular fracture, left pelvic inferior ramus fracture, left femoral head fracture (Fig. 2), left bimalleolar open fracture, left calcaneal open fracture, and a sternum body fracture. A computed tomography (CT) scan showed a left retroperitoneal hematoma adjacent to the bladder and a left pelvic fracture, but there was no evidence of arterial bleeding, such as contrast extravasation (Fig. 3A). As the patient remained hemodynamically stable during both the primary and secondary surveys, the orthopedic department performed early total care on the day of admission, including a Kocher-Langenbeck approach to the acetabulum and open reduction and internal fixation (ORIF) of the tibia and calcaneus. During the orthopedic surgery, there was no major bleeding event, and the patient was subsequently transferred to the trauma intensive care unit (ICU). Upon returning to the trauma ICU, his vital signs were stable (SBP, 149 mmHg; DBP, 122 mmHg) and his urine output was 80 mL/hr (patient weight, 72 kg), aside from tachycardia (heart rate, 136 beats per minute). However, 2 hours after surgery, he complained of severe left lower abdominal distension and back pain and developed sudden hypotension with an SBP of 74 mmHg. Immediately, 500 mL of plasma solution A was infused, and 2 units of red blood cells were transfused 20 minutes later. Subsequently, a vasopressor infusion (norepinephrine at 0.1 μg/kg/min) was initiated, but these measures did not resolve his hypotension. As his vital signs remained unstable and he became combative, no further imaging could be performed. A postoperative nonenhanced three-dimensional pelvic bone CT revealed a new, massive hematoma in the retroperitoneum with displacement of the bladder (Fig. 3B). Although the rapid onset of hypotension could have resulted from new postoperative arterial bleeding, this was not confirmed by CT imaging, and uncontrolled venous or bone bleeding could not be ruled out. Due to the rapid deterioration of his vital signs, the patient was transferred to the operating room, where a trauma surgeon performed PPP.

A left retroperitoneal space was explored via a low midline incision, and more than 500 mL of hematoma containing fresh blood was immediately drained. After evacuation, continuous oozing of blood was observed in the retroperitoneal space. A local hemostatic agent was promptly applied, and gauze packing was performed in the left retroperitoneal space using two trauma pads (kaolin-based hemostatic gauze) and one laparotomy pad. Following the packing, the bleeding ceased, and the patient was safely transferred to the ICU with vital signs maintained at a heart rate of 100 to 110 beats per minute and an SBP of 120 mmHg without vasopressor support. The total operation time was 20 minutes. Because the patient maintained stable vital signs in the ICU following PPP, without additional vasopressor support or transfusions, a second-look operation was performed 48 hours later. No evidence of arterial or venous bleeding was found when the gauze was removed, and the left retroperitoneal space was reexplored. A Jackson-Pratt drain was inserted into the retroperitoneal space after the application of a local hemostatic agent, and the drain was removed on postoperative day (POD) 5. The patient did not experience recurrent pelvic bleeding during hospitalization, and follow-up imaging on POD 7 showed no acetabular displacement (Fig. 4). There was no surgical site infection in the pelvic area, and the patient was safely discharged on POD 29 with the initial internal fixation maintained and without requiring additional orthopedic surgery.

Ethics statement

Written informed consent for publication of the research details and clinical images was obtained from the patient.

DISCUSSION

PPP is primarily considered an initial treatment modality for trauma patients with pelvic fractures and hemorrhagic shock when there is no evidence of intraperitoneal bleeding [6]. In this case, the patient had combined acetabular and pelvic ring fractures along with a retroperitoneal hematoma; however, his initial vital signs were stable during resuscitation, and his injuries did not initially indicate the need for PPP. Following the Kocher-Langenbeck approach, he developed hemorrhagic shock accompanied by an expansion of the retroperitoneal hematoma. Consequently, PPP was performed as a salvage operation for postoperative retroperitoneal bleeding, achieving immediate hemodynamic stabilization and making this a unique case. Previous studies have primarily applied PPP as the initial treatment for pelvic fractures with hemorrhagic shock. For posterior column acetabular fractures with more than 2 mm displacement, the Kocher-Langenbeck approach is the treatment of choice [4]. Although pelvic and acetabular fractures require different surgical approaches, both injuries can result in significant blood loss due to the extensive, complex venous plexus in the area, often necessitating blood transfusions [7]. Given that the patient also sustained an ipsilateral femoral fracture and hip dislocation, most of the force was directed along the anatomical axis involving the acetabulum and femur rather than the pelvis itself. Thus, it is likely that his hemorrhagic shock resulted from severe retroperitoneal hemorrhage after surgery, rather than from a delayed hemorrhage related to the pelvic ring injury. During the Kocher-Langenbeck approach, the orthopedic surgeon may encounter bleeding from vessels such as the superior gluteal, inferior gluteal, and internal pudendal arteries. Injuries to these arteries can result in fatal bleeding. Because no major bleeding was noted during the initial operation and the Kocher-Langenbeck approach is typically performed on the posterior aspect of the pelvis, the orthopedic surgery itself was unlikely to have contributed to the postoperative bleeding. However, the reduction of the femur during surgery may have caused bleeding from the fractured acetabular and pelvic bones or surrounding vessels. Additionally, minor branches of the superior gluteal, inferior gluteal, or internal pudendal arteries may have been damaged during the procedure, contributing to the expansion of the retroperitoneal hematoma. Although the exact cause of the hemorrhage remains uncertain, PPP appears to have been effective in controlling the bleeding, similar to its use in trauma cases where postoperative hemodynamic instability is accompanied by an expanding retroperitoneal hematoma in the pelvis.

AE is another treatment option for pelvic fractures with hemorrhagic shock [5]. However, due to severe abdominal and back pain the patient was uncooperative. Coupled with profound hypotension (SBP, 70 mmHg) and the absence of evidence for arterial bleeding, the time-consuming AE procedure was not feasible. In our case, the bleeding event occurred at night, and our hospital did not have a 24-hour angiography suite, making AE impractical. One study comparing AE and PPP found that the time from emergency department admission to procedure initiation was approximately twice as long for AE compared to PPP [8]. Moreover, several European trauma centers have successfully performed PPP without AE in hemodynamically unstable patients with pelvic fractures [9], and one study reported no significant difference in mortality between patients treated with and without embolization for pelvic fractures associated with vascular injury [10]. Given the need for rapid intervention and the patient’s sharp deterioration in vital signs, PPP was the more appropriate treatment option compared to AE. PPP offers several advantages, including a shorter operative time and procedural simplicity. However, unlike AE, PPP necessitates careful attention to the risk of wound infection [11], especially since three surgeries (Kocher-Langenbeck approach, PPP, and a second-look operation) were performed at the same site. Consequently, although the patient was at high risk for surgical site infection, no such infection was observed during his hospitalization. Zone 3 resuscitative endovascular balloon occlusion of the aorta (REBOA) is another option for controlling hemorrhage in pelvic fractures with hemorrhagic shock; however, its use is not yet standardized, and studies comparing PPP with REBOA in severe pelvic fractures have reported worse outcomes for the REBOA group [12]. Due to the placement of multiple large gauze packs around the fragile bone at the site of ORIF, there was concern about potential bone displacement from the packing pressure. To date, no studies have reported pelvic bone displacement following PPP, and in our case, the patient did not experience any bone displacement despite the multiple gauze packings around the acetabulum where definitive ORIF was performed. Based on the patient’s clinical course, PPP did not adversely affect short-term prognosis and appears to be a feasible modality for controlling postoperative retroperitoneal bleeding after orthopedic surgery, provided that surgical site infection is carefully monitored.

ARTICLE INFORMATION

Author contributions

Conceptualization: DHK, HC; Methodology: HC, MK, DSL, THH; Project administration: HC, MK; Writing–original draft: DHK; Writing–review & editing: HC, MK, DSL, THH. All authors read and approved the final manuscript.

Conflicts of interest

Hangjoo Cho is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Timeline of the patient's clinical course. ICU, intensive care unit; PSA, plasma solution A; RBC, red blood cell; OR, operating room.

Fig. 2.

Initial three-dimensional pelvic computed tomography scan. (A) Anterior view. (B) Posterior view.

Fig. 3.

Computed tomography (CT) scan. (A) Initial abdominopelvic CT scan. (B) Postoperative pelvic CT scan. Asterisks indicate the location of hematoma.

Fig. 4.

Pelvic anteroposterior x-ray on postoperative day 7.

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