Frosch K-H, Hingelbaum S, Dresing K, Roessler M, Stürmer K M
Klinik für Unfallchirurgie, Plastische und Wiederherstellungschirurgie, Georg-August-Universität, Robert-Koch-Strasse 40, 37075 Göttingen.
Unfallchirurg. 2007 Jun;110(6):521-7. doi: 10.1007/s00113-007-1228-4.
The anatomic region on the lateral cortex of the ileum, where a palpable groove is formed by angulations of the lateral cortex of the iliac wing, is recommended as the insertion point for the pelvic emergency clamp by many authors. In our opinion this technique often leads to an incomplete closure of the anterior pelvic ring as well as to bacterial contamination of the access for the sacroiliac joint screw fixation and is accompanied by a risk for nerve and vessel injuries. To reduce these risks the pelvic clamp was placed at a supra-acetabular location. The goal of our study was to report on our experiences with the supra-acetabular position of the pelvic emergency clamp and to compare our results with the current literature.
From September 1998 to February 2006 the pelvic emergency clamp was applied in 15 polytraumatized patients (9 male, 6 female), with a mean age of 46 years (19-93) and a mean injury severity score (ISS) of 40 points (25-66) with mechanically and hemodynamically unstable pelvic ring fractures. According to the AO classification the injury pattern was type B2 in four cases, type B3 in one case, type C1 in seven cases, type C2 in two cases and type C3 in one case. The pelvic clamp was percutaneously applied 2-3 cm cranial to the acetabular roof. The duration from hospital admission until the pelvic emergency clamp was applied amounted to an average of 54 min (15-150); the procedure itself was performed in all cases in less than 15 min. The mean Hb at arrival in the emergency department was 7.4 (2.4-13.8) mg/dl and the mean systolic blood pressure 69 (0-130) mmHg.
In 14 patients a complete closure of the anterior and posterior pelvic ring could be achieved; in 1 patient an overcompression of the anterior pelvic ring was observed. Four patients died due to massive bleeding. Three patients with isolated pelvic ring fractures became hemodynamically stable within 20 min after treatment with the supra-acetabular pelvic clamp. Nine patients needed additional emergency surgery because of intracerebral, intrathoracic or intra-abdominal injuries. On average in the first 6 h, 36.7 (9-175) units of erythrocyte concentrates and 34.5 (4-200) units of fresh frozen plasma were transfused.
The supra-acetabular pelvic clamp leads to a homogeneous force distribution to the pelvic ring and enables complete closure of the anterior and posterior pelvic ring in unstable pelvic fractures. Reduction of the intrapelvic volume and compression of the posterior pelvic ring can thus be achieved. Risks for intrapelvic perforation or injuries of vessels and nerves are low. No bacterial contamination of the access for the sacroiliac screw fixation occurs. To avoid overcompression of the unstable pelvic ring, manual or radiological control of the closure of the ventral pelvic ring is necessary.
许多作者推荐将回肠外侧皮质上的解剖区域作为骨盆紧急钳的插入点，该区域由髂骨翼外侧皮质的成角形成可触及的凹槽。我们认为，这种技术常常导致骨盆前环闭合不完全，以及骶髂关节螺钉固定入路的细菌污染，并且伴有神经和血管损伤的风险。为降低这些风险，将骨盆钳放置于髋臼上方位置。我们研究的目的是报告骨盆紧急钳髋臼上方位置的应用经验，并将我们的结果与当前文献进行比较。
1998年9月至2006年2月，对15例多发伤患者（9例男性，6例女性）应用骨盆紧急钳，平均年龄46岁（19 - 93岁），平均损伤严重度评分（ISS）为40分（25 - 66分），均为机械性和血流动力学不稳定的骨盆环骨折。根据AO分类，损伤类型为B2型4例，B3型1例，C1型7例，C2型2例，C3型1例。经皮将骨盆钳置于髋臼顶上方2 - 3 cm处。从入院到应用骨盆紧急钳的平均时间为54分钟（15 - 150分钟）；所有病例手术操作本身均在15分钟内完成。到达急诊科时的平均血红蛋白为7.4（2.4 - 13.8）mg/dl，平均收缩压为69（0 - 130）mmHg。
14例患者实现了骨盆前后环的完全闭合；1例患者出现骨盆前环过度压缩。4例患者因大出血死亡。3例单纯骨盆环骨折患者在应用髋臼上方骨盆钳治疗后20分钟内血流动力学变得稳定。9例患者因脑、胸或腹部损伤需要额外的急诊手术。平均在最初6小时内，输注红细胞浓缩液36.7（9 - 175）单位，新鲜冰冻血浆34.5（4 - 200）单位。
髋臼上方骨盆钳可使骨盆环受力均匀分布，能够实现不稳定骨盆骨折时骨盆前后环的完全闭合。从而可减少盆腔容积并压缩骨盆后环。盆腔内穿孔或血管及神经损伤的风险较低。不会发生骶髂螺钉固定入路的细菌污染。为避免不稳定骨盆环过度压缩，需要对骨盆前环的闭合进行手法或影像学控制。
