Modified Classification and Repair of Perineal Soft Tissue Injuries Associated with Open Pelvic Fractures

Abstract

Background This study describes a modified classification and management protocol for perineal soft tissue injuries associated with pelvic fractures.

Methods A total of 11 patients with perineal soft tissue injuries associated with open pelvic fractures were studied retrospectively. The patients were classified into three types based on the area of defect: type A (urogenital zone), type B (anal zone), and type C (both urogenital and anal zones). Each type included the following subclasses: A1 (without urethra injuries), A2 (with urethra injuries), B1 (without anorectal injuries), B2 (with anorectal injuries), C1 (with types A1 and B1), C2 (with types A2 and B1), C3 (with types A1 and B2), and C4 (with types A2 and B2). The management protocol was planned according to the individual classifications. Protocol A1 (for type A1) involved skin graft or myocutaneous flap transplantation. Protocol A2 (for type A2) involved the same protocol combined with urine diversion. Protocol B1 (for type B1) involved skin graft or myocutaneous flap transplantation. Protocol B2 (for type B2) involved the same management combined with fecal diversion. Protocol C involved the correspondent protocol used for each subtype of type C.

Results Out of the 11 patients, there were 5, 3, and 3 cases of types A, B, and C, respectively. One patient died due to sepsis, and the wounds of the remaining patients healed well. No anal incontinence had occurred.

Conclusions Perineal soft tissue injuries associated with pelvic fractures can be classified into three types, and the management protocol can be planned according to the classification.

Keywords

open pelvic fractures - soft tissue injuries - classification

Both Drs Guo Fu and Dong Wang contributed to the article equally.

• References

• 1 Grotz MR, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis PV. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005; 36 (1) 1-13
• 2 Black EA, Lawson CM, Smith S, Daley BJ. Open pelvic fractures: the University of Tennessee Medical Center at Knoxville experience over ten years. Iowa Orthop J 2011; 31: 193-198
• 3 Hanson PB, Milne JC, Chapman MW. Open fractures of the pelvis. Review of 43 cases. J Bone Joint Surg Br 1991; 73 (2) 325-329
• 4 Mohanty K, Musso D, Powell JN, Kortbeek JB, Kirkpatrick AW. Emergent management of pelvic ring injuries: an update. Can J Surg 2005; 48 (1) 49-56
• 5 Durrant JJ, Ramasamy A, Salmon MS, Watkin N, Sargeant I. Pelvic fracture-related urethral and bladder injury. J R Army Med Corps 2013; 159 (Suppl. 01) i32-i39
• 6 Lunsjo K, Abu-Zidan FM. Does colostomy prevent infection in open blunt pelvic fractures? A systematic review. J Trauma 2006; 60 (5) 1145-1148
• 7 Brenneman FD, Katyal D, Boulanger BR, Tile M, Redelmeier DA. Long-term outcomes in open pelvic fractures. J Trauma 1997; 42 (5) 773-777
• 8 Labler L, Trentz O. The use of vacuum assisted closure (VAC) in soft tissue injuries after high energy pelvic trauma. Langenbecks Arch Surg 2007; 392 (5) 601-609
• 9 Ozer MT, Coskun AK, Ozerhan IH , et al. Use of vacuum-assisted closure (VAC™) in high-energy complicated perineal injuries: analysis of nine cases. Int Wound J 2011; 8 (6) 599-607
• 10 Milcheski DA, Zampieri FM, Nakamoto HA, Tuma Jr P, Ferreira MC. Negative pressure wound therapy in complex trauma of perineum. Rev Col Bras Cir 2013; 40 (4) 312-317
• 11 Agel J, Evans AR, Marsh JL , et al. The OTA open fracture classification: a study of reliability and agreement. J Orthop Trauma 2013; 27 (7) 379-384 , discussion 384–385
• 12 Bircher M, Eng FE, Hargrove R. Is it Possible to Classify Open Fractures of the Pelvis?. Eur J Trauma 2004; 30 (2) 74-79
• 13 Pennal GF, Tile M, Waddell JP, Garside H. Pelvic disruption: assessment and classification. Clin Orthop Relat Res 1980; (151) 12-21
• 14 Faringer PD, Mullins RJ, Feliciano PD, Duwelius PJ, Trunkey DD. Selective fecal diversion in complex open pelvic fractures from blunt trauma. Arch Surg 1994; 129 (9) 958-963 , discussion 963–964
• 15 Jones AL, Powell JN, Kellam JF, McCormack RG, Dust W, Wimmer P. Open pelvic fractures. A multicenter retrospective analysis. Orthop Clin North Am 1997; 28 (3) 345-350
• 16 Agel J, Rockwood T, Barber R, Marsh JL. Potential predictive ability of the orthopedic trauma association open fracture classification. J Orthop Trauma 2014; 28 (5) 300-306
• 17 Wilson RF. Current status of advanced trauma life support training. Ann Emerg Med 1981; 10 (4) 226-227
• 18 Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38 (6) 563-576 , discussion 577
• 19 Qu J, Yan R, Wang L , et al. Free dermatoplasty combined with vacuum sealing drainage for the treatment of large-area soft tissue defects accompanied by bone exposure in the lower leg. Exp Ther Med 2013; 5 (5) 1375-1380
• 20 Dente CJ, Feliciano DV, Rozycki GS , et al. The outcome of open pelvic fractures in the modern era. Am J Surg 2005; 190 (6) 830-835
• 21 Duchesne JC, Bharmal HM, Dini AA , et al. Open-book pelvic fractures with perineal open wounds: a significant morbid combination. Am Surg 2009; 75 (12) 1227-1233
• 22 Kottmeier SA, Wilson SC, Born CT, Hanks GA, Iannacone WM, DeLong WG. Surgical management of soft tissue lesions associated with pelvic ring injury. Clin Orthop Relat Res 1996; (329) 46-53
• 23 Sinnott R, Rhodes M, Brader A. Open pelvic fracture: an injury for trauma centers. Am J Surg 1992; 163 (3) 283-287
• 24 Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24 (8) 742-746
• 25 Gustilo RB. Management of open fractures. An analysis of 673 cases. Minn Med 1971; 54 (3) 185-189
• 26 Orthopaedic Trauma Association: Open Fracture Study Group. A new classification scheme for open fractures. J Orthop Trauma 2010; 24 (8) 457-464
• 27 Woods RK, O'Keefe G, Rhee P, Routt Jr ML, Maier RV. Open pelvic fracture and fecal diversion. Arch Surg 1998; 133 (3) 281-286
• 28 Ghanayem AJ, Wilber JH, Lieberman JM, Motta AO. The effect of laparotomy and external fixator stabilization on pelvic volume in an unstable pelvic injury. J Trauma 1995; 38 (3) 396-400 , discussion 400–401
• 29 Richardson JD, Harty J, Amin M, Flint LM. Open pelvic fractures. J Trauma 1982; 22 (7) 533-538
• 30 Mangiante EC, Graham AD, Fabian TC. Rectal gunshot wounds. Management of civilian injuries. Am Surg 1986; 52 (1) 37-40
• 31 Kumar BA, Chojnowski AJ. Open pelvic fractures with vaginal laceration: an unusual clinical feature. Injury 2000; 31 (1) 68-70
• 32 Mundy AR, Andrich DE. Pelvic fracture-related injuries of the bladder neck and prostate: their nature, cause and management. BJU Int 2010; 105 (9) 1302-1308