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Complete traumatic hemipelvectomy resulting from roadside guardrail penetration of a motor vehicle
Injury Extra (2005) 36, 454—457
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CASE REPORT
Complete traumatic hemipelvectomy resulting from roadside guardrail penetration of a motor vehicle§,§§ David S. Kauvar *, Toney W. Baskin, Roman A. Hayda, R. Russell Martin Departments of General Surgery, Trauma/Critical Care, and Orthopaedics; Rehabilitation, Brooke Army Medical Center, San Antonio, TX, USA Accepted 22 March 2005
Introduction In 2002, there were 106,000 motor vehicle crashes involving roadside guardrails in the United States. These represented 1.7% of the total number of crashes, and resulted in 35,000 injuries and over 1000 fatalities.6 Guardrails are designed to protect vehicle occupants from injury in the event of a crash, and when crashes involve guardrail impact, they tend to result in low rates of vehicle occupant injury and fatality.2,4,6 These barriers do have the potential to cause injury, however, and roadside guardrails are erected in locations where the danger of a motor vehicle collision with the guardrail itself is deemed to be outweighed by the risk of striking the guarded object, or area.2,5 Though, there is an § Presented at the Gary Wratten U.S. Army Surgical Symposium, San Antonio, TX, 19—20 May 2003. §§ The opinions or assertions contained herein are the private views of the authors and not to be construed as official or reflecting the views of the Department of Defense or United States Government. The authors are employees of The U.S. government. This work prepared as part of their official duties and, as such, there is no copyright to be transferred. * Corresponding author at: MCHE-SDG, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA. Tel.: +1 210 9160439; fax: +1 210 9162202. E-mail address: [email protected] (D.S. Kauvar).
acknowledged potential for vehicle occupant injury caused by impact with a guardrail, the phenomenon is uncommon and pertinent data are not collected by federal or state transportation authorities. We present a case of complete traumatic hemipelvectomy resulting from guardrail penetration of a motor vehicle during a high-speed crash.
Case report A 26-year-old female was the restrained passenger in a rollover motor vehicle crash at high speed. As the car rolled over, the roadside guardrail entered the passenger compartment, amputating the patient’s right hemipelvis and causing a left knee dislocation and an open fracture of the tibia. Extrication of the patient took 1 h, but the three other occupants of the vehicle were unharmed. The patient arrived at our trauma centre in severe haemorrhagic shock, but without evidence of thoracoabdominal or head trauma. There was a large soft tissue defect at the hemipelvectomy site (Fig. 1) and pelvic radiography revealed an absent right hemipelvis, from the level of the right sacroiliac joint (Fig. 2). She was taken immediately to the operating room where damage-control surgery was
1572-3461/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.03.021
Complete traumatic hemipelvectomy resulting from roadside guardrail penetration of a motor vehicle 455
Figure 1 Photograph demonstrating hemipelvectomy site with huge soft tissue and bony defecits and gross contamination. Foley catheter is in urethra. Abdomen is packed open.
´bperformed. Her initial operation consisted of de ridement and packing of the pelvic wound, irrigation and external fixation of the tibial fracture (Fig. 3) and manual knee reduction. Simultaneously, laparotomy with diverting colostomy, ligation of the
Figure 2 Initial pelvic radiograph demonstrating the absence of the bony structures of the right hemipelvis.
right internal and external iliac arteries, and right iliac vein repair and distal ligation were performed; the abdomen was then packed open. The patient left the operating room hypothermic (33 8C) and acidotic (pH 6.70). Her haematocrit after 10 units of packed red blood cells was 18. She experienced a cardiac arrest from which she was resuscitated. Rewarming, correction of the coagulopathy and resuscitation continued in the intensive care unit. A long critical care course ensued, with multiple ´breturn trips to the operating room for further de ridement and irrigation of her abdomen, pelvis, and leg. Her wounds became colonized with a resistant strain of Pseudomonas, which intermittently caused local infection and resulted in wound sepsis requiring parenteral antibiotics. Given the loss of her entire right lower extremity, preservation of her left was an important goal in her continuing care. An external fixator, followed by an Ilizarov frame, were applied. The soft tissue defect of the leg was treated with negative pressure wound therapy (V.A.C. TherapyTM, Kinetic Concepts, Inc, San Antonio, TX, USA), and was definitively covered by a radial forearm free fasciocutaneous flap on day 20 post-injury. With her clinical condition steadily
456
D.S. Kauvar et al.
Figure 3 Postoperative photograph of left leg on the day of injury demonstrating extensive soft tissue defect over severely comminuted fracture.
improving, V.A.C. TherapyTM was also applied to the pelvic wound. A sacral decubitus ulcer developed due to prolonged immobility, and this and the remaining pelvic soft tissue defect were definitively covered, in consultation with the plastic surgery service, using a lumbar fasciocutaneous rotational flap and a split-thickness skin graft on day 70 postinjury. During her long initial inpatient course, the patient developed post-traumatic stress disorder and severe phantom limb pain. Frequent consultations with the rehabilitative medicine, behavioural medicine, and anaesthesia pain services were vital in the patient’s care. She was transferred to a rehabilitation facility, where she participated in daily physical and occupational therapy. Despite efforts to preserve her left leg, infected non-union of the tibia prompted through-knee amputation 7 months following the injury. She now lives at home and independently performs all routine self and home care tasks.
Discussion This case illustrates the central importance of the mechanism of penetration of the passenger compartment by the guardrail in determining the pattern and severity of injury in such crashes. Guardrail intrusion in this case caused a most severe injury, a very proximal traumatic amputation with complete extremity neurovascular disruption and severe soft tissue injury. The patient arrived in haemorrhagic
shock from her arterial and venous injuries, a condition worsened by the time of prolonged extrication from the vehicle, secondary to guardrail entrapment. The safety and efficacy profile of roadside guardrails is an active area of governmental and private research.2—5,7 A meta-analysis of 32 studies determined that the presence of roadside guardrails decreases both the rate and severity of the sequelae of motor vehicle crashes.2 Mizuno and Kajzer studied crash conditions in Japan and demonstrated that, of fixed objects impacted in single-vehicle collisions, guardrails resulted in the lowest fatality rate.4 Regular reports by the United States Department of Transportation attest to the efficacy of roadside guardrails in the prevention of injury and fatality in crashes.6 Despite their benefits, roadside guardrails can, as evidenced by this case, be the primary mechanism of severe, even life-threatening, injuries in motor vehicle crashes. To this end, roadside guardrail design is undergoing continued examination and improvement, and novel designs that stray from the traditional steel ‘‘W’’ beam devices (so named for the cross-sectional appearance) are being tested and fielded. Much of this research is geared towards improvements in guardrail design to prevent vehicle rollover, not penetration. One aspect of guardrail design that appears to have had a positive impact in preventing vehicle penetration has been the development of the guardrail end treatment, or terminal. Originally, roadside guardrails were blunt-ended, with no attempt made
Complete traumatic hemipelvectomy resulting from roadside guardrail penetration of a motor vehicle 457
to soften the profile of the tip of the device. This predisposed them to vehicle penetration in various types of collisions. The blunt end was then superseded by the ‘‘turndown’’ of the terminus of the guardrail into the ground; however, this design created a tendency for vehicles to vault upwards and rollover, as the down turned terminal acted as a ramp in many cases. Finally, various end treatments for roadside guardrails were developed to decrease the likelihood of vehicle penetration in the event of guardrail impact. These devices are designed to control deceleration after impact and to deflect the guardrail away from the vehicle. The most successful of these devices, the ET-2000, was designed at the Texas Transportation Institute and is currently used in 47 states, has been involved in numerous crashes, and is estimated to have prevented over 1200 deaths, or severe injuries.1 Motor vehicle impact with roadside guardrails is inevitable, but improvements in both guardrail and vehicle designs have the potential to prevent such occurrences from causing severe injury. Continued research into the improvement of guardrail construction with an emphasis on preventing vehicle penetration can undoubtedly help to mitigate the severity of injuries resulting from impact with these necessary barriers.
Acknowledgements The authors wish to thank John Armstrong, MD of the Brooke Army Medical Center department of general surgery and James Ficke, MD of the department of orthopaedic surgery for their contributions to this manuscript.
References 1. Anonymous ET2000 Improves Roadside Safety, Texas Transportation Institute, College Station, available at: http://tti. tamu.edu/product/ror/et2000.stm. 2. Elvik R. The safety value of guardrails and crash cushions: a meta-analysis of evidence from evaluation studies. Accid Anal Prev 1995;27:523—49. 3. Lambert JH, Baker JA, Peterson KD. Decision aid for allocation of transportation funds to guardrails. Accid Anal Prev 2003;35:47—57. 4. Mizuno K, Kajzer J. Compatibility problems in frontal, side, single car collisions and car-to-pedestrian accidents in Japan. Accid Anal Prev 1999;31:381—91. 5. NHTSA New guardrail guidelines will enhance highway safety, USDOT, Washington, 1998. 6. NHTSA NHTSA Traffic Safety Facts, USDOT, Washington, 2002. 7. RSRG Crashworthiness and roadside safety at Worcester Polytechnic Institute, Worchester Polytechnic Institute, Worchester, 2001.
www.elsevier.com/locate/inext
CASE REPORT
Complete traumatic hemipelvectomy resulting from roadside guardrail penetration of a motor vehicle§,§§ David S. Kauvar *, Toney W. Baskin, Roman A. Hayda, R. Russell Martin Departments of General Surgery, Trauma/Critical Care, and Orthopaedics; Rehabilitation, Brooke Army Medical Center, San Antonio, TX, USA Accepted 22 March 2005
Introduction In 2002, there were 106,000 motor vehicle crashes involving roadside guardrails in the United States. These represented 1.7% of the total number of crashes, and resulted in 35,000 injuries and over 1000 fatalities.6 Guardrails are designed to protect vehicle occupants from injury in the event of a crash, and when crashes involve guardrail impact, they tend to result in low rates of vehicle occupant injury and fatality.2,4,6 These barriers do have the potential to cause injury, however, and roadside guardrails are erected in locations where the danger of a motor vehicle collision with the guardrail itself is deemed to be outweighed by the risk of striking the guarded object, or area.2,5 Though, there is an § Presented at the Gary Wratten U.S. Army Surgical Symposium, San Antonio, TX, 19—20 May 2003. §§ The opinions or assertions contained herein are the private views of the authors and not to be construed as official or reflecting the views of the Department of Defense or United States Government. The authors are employees of The U.S. government. This work prepared as part of their official duties and, as such, there is no copyright to be transferred. * Corresponding author at: MCHE-SDG, 3851 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA. Tel.: +1 210 9160439; fax: +1 210 9162202. E-mail address: [email protected] (D.S. Kauvar).
acknowledged potential for vehicle occupant injury caused by impact with a guardrail, the phenomenon is uncommon and pertinent data are not collected by federal or state transportation authorities. We present a case of complete traumatic hemipelvectomy resulting from guardrail penetration of a motor vehicle during a high-speed crash.
Case report A 26-year-old female was the restrained passenger in a rollover motor vehicle crash at high speed. As the car rolled over, the roadside guardrail entered the passenger compartment, amputating the patient’s right hemipelvis and causing a left knee dislocation and an open fracture of the tibia. Extrication of the patient took 1 h, but the three other occupants of the vehicle were unharmed. The patient arrived at our trauma centre in severe haemorrhagic shock, but without evidence of thoracoabdominal or head trauma. There was a large soft tissue defect at the hemipelvectomy site (Fig. 1) and pelvic radiography revealed an absent right hemipelvis, from the level of the right sacroiliac joint (Fig. 2). She was taken immediately to the operating room where damage-control surgery was
1572-3461/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.03.021
Complete traumatic hemipelvectomy resulting from roadside guardrail penetration of a motor vehicle 455
Figure 1 Photograph demonstrating hemipelvectomy site with huge soft tissue and bony defecits and gross contamination. Foley catheter is in urethra. Abdomen is packed open.
´bperformed. Her initial operation consisted of de ridement and packing of the pelvic wound, irrigation and external fixation of the tibial fracture (Fig. 3) and manual knee reduction. Simultaneously, laparotomy with diverting colostomy, ligation of the
Figure 2 Initial pelvic radiograph demonstrating the absence of the bony structures of the right hemipelvis.
right internal and external iliac arteries, and right iliac vein repair and distal ligation were performed; the abdomen was then packed open. The patient left the operating room hypothermic (33 8C) and acidotic (pH 6.70). Her haematocrit after 10 units of packed red blood cells was 18. She experienced a cardiac arrest from which she was resuscitated. Rewarming, correction of the coagulopathy and resuscitation continued in the intensive care unit. A long critical care course ensued, with multiple ´breturn trips to the operating room for further de ridement and irrigation of her abdomen, pelvis, and leg. Her wounds became colonized with a resistant strain of Pseudomonas, which intermittently caused local infection and resulted in wound sepsis requiring parenteral antibiotics. Given the loss of her entire right lower extremity, preservation of her left was an important goal in her continuing care. An external fixator, followed by an Ilizarov frame, were applied. The soft tissue defect of the leg was treated with negative pressure wound therapy (V.A.C. TherapyTM, Kinetic Concepts, Inc, San Antonio, TX, USA), and was definitively covered by a radial forearm free fasciocutaneous flap on day 20 post-injury. With her clinical condition steadily
456
D.S. Kauvar et al.
Figure 3 Postoperative photograph of left leg on the day of injury demonstrating extensive soft tissue defect over severely comminuted fracture.
improving, V.A.C. TherapyTM was also applied to the pelvic wound. A sacral decubitus ulcer developed due to prolonged immobility, and this and the remaining pelvic soft tissue defect were definitively covered, in consultation with the plastic surgery service, using a lumbar fasciocutaneous rotational flap and a split-thickness skin graft on day 70 postinjury. During her long initial inpatient course, the patient developed post-traumatic stress disorder and severe phantom limb pain. Frequent consultations with the rehabilitative medicine, behavioural medicine, and anaesthesia pain services were vital in the patient’s care. She was transferred to a rehabilitation facility, where she participated in daily physical and occupational therapy. Despite efforts to preserve her left leg, infected non-union of the tibia prompted through-knee amputation 7 months following the injury. She now lives at home and independently performs all routine self and home care tasks.
Discussion This case illustrates the central importance of the mechanism of penetration of the passenger compartment by the guardrail in determining the pattern and severity of injury in such crashes. Guardrail intrusion in this case caused a most severe injury, a very proximal traumatic amputation with complete extremity neurovascular disruption and severe soft tissue injury. The patient arrived in haemorrhagic
shock from her arterial and venous injuries, a condition worsened by the time of prolonged extrication from the vehicle, secondary to guardrail entrapment. The safety and efficacy profile of roadside guardrails is an active area of governmental and private research.2—5,7 A meta-analysis of 32 studies determined that the presence of roadside guardrails decreases both the rate and severity of the sequelae of motor vehicle crashes.2 Mizuno and Kajzer studied crash conditions in Japan and demonstrated that, of fixed objects impacted in single-vehicle collisions, guardrails resulted in the lowest fatality rate.4 Regular reports by the United States Department of Transportation attest to the efficacy of roadside guardrails in the prevention of injury and fatality in crashes.6 Despite their benefits, roadside guardrails can, as evidenced by this case, be the primary mechanism of severe, even life-threatening, injuries in motor vehicle crashes. To this end, roadside guardrail design is undergoing continued examination and improvement, and novel designs that stray from the traditional steel ‘‘W’’ beam devices (so named for the cross-sectional appearance) are being tested and fielded. Much of this research is geared towards improvements in guardrail design to prevent vehicle rollover, not penetration. One aspect of guardrail design that appears to have had a positive impact in preventing vehicle penetration has been the development of the guardrail end treatment, or terminal. Originally, roadside guardrails were blunt-ended, with no attempt made
Complete traumatic hemipelvectomy resulting from roadside guardrail penetration of a motor vehicle 457
to soften the profile of the tip of the device. This predisposed them to vehicle penetration in various types of collisions. The blunt end was then superseded by the ‘‘turndown’’ of the terminus of the guardrail into the ground; however, this design created a tendency for vehicles to vault upwards and rollover, as the down turned terminal acted as a ramp in many cases. Finally, various end treatments for roadside guardrails were developed to decrease the likelihood of vehicle penetration in the event of guardrail impact. These devices are designed to control deceleration after impact and to deflect the guardrail away from the vehicle. The most successful of these devices, the ET-2000, was designed at the Texas Transportation Institute and is currently used in 47 states, has been involved in numerous crashes, and is estimated to have prevented over 1200 deaths, or severe injuries.1 Motor vehicle impact with roadside guardrails is inevitable, but improvements in both guardrail and vehicle designs have the potential to prevent such occurrences from causing severe injury. Continued research into the improvement of guardrail construction with an emphasis on preventing vehicle penetration can undoubtedly help to mitigate the severity of injuries resulting from impact with these necessary barriers.
Acknowledgements The authors wish to thank John Armstrong, MD of the Brooke Army Medical Center department of general surgery and James Ficke, MD of the department of orthopaedic surgery for their contributions to this manuscript.
References 1. Anonymous ET2000 Improves Roadside Safety, Texas Transportation Institute, College Station, available at: http://tti. tamu.edu/product/ror/et2000.stm. 2. Elvik R. The safety value of guardrails and crash cushions: a meta-analysis of evidence from evaluation studies. Accid Anal Prev 1995;27:523—49. 3. Lambert JH, Baker JA, Peterson KD. Decision aid for allocation of transportation funds to guardrails. Accid Anal Prev 2003;35:47—57. 4. Mizuno K, Kajzer J. Compatibility problems in frontal, side, single car collisions and car-to-pedestrian accidents in Japan. Accid Anal Prev 1999;31:381—91. 5. NHTSA New guardrail guidelines will enhance highway safety, USDOT, Washington, 1998. 6. NHTSA NHTSA Traffic Safety Facts, USDOT, Washington, 2002. 7. RSRG Crashworthiness and roadside safety at Worcester Polytechnic Institute, Worchester Polytechnic Institute, Worchester, 2001.