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Fokin AA, Wycech Knight J, Tharp ME, Brinton KC, Gallagher PK, Xie JF, Weisz RD, Puente I. Pelvic fractures in blunt trauma patients: A comparative study. World J Orthop 2024; 15:418-434. [PMID: 38835686 PMCID: PMC11145966 DOI: 10.5312/wjo.v15.i5.418] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 05/15/2024] Open
Abstract
BACKGROUND Pelvic fractures (PF) with concomitant injuries are on the rise due to an increase of high-energy trauma. Increase of the elderly population with age related comorbidities further complicates the management. Abdominal organ injuries are kindred with PF due to the proximity to pelvic bones. Presence of contrast blush (CB) on computed tomography in patients with PF is considered a sign of active bleeding, however, its clinical significance and association with outcomes is debatable. AIM To analyze polytrauma patients with PF with a focus on the geriatric population, co-injuries and the value of contrast blush. METHODS This retrospective cohort study included 558 patients with PF admitted to level 1 trauma center (01/2017-01/2023). Analyzed variables included: Age, sex, mechanism of injury (MOI), injury severity score (ISS), Glasgow coma scale (GCS), abbreviated injury scale (AIS), co-injuries, transfusion requirements, pelvic angiography, embolization, laparotomy, orthopedic pelvic surgery, intensive care unit and hospital lengths of stay, discharge disposition and mortality. The study compared geriatric and non-geriatric patients, patients with and without CB and abdominal co-injuries. Propensity score matching was implemented in comparison groups. RESULTS PF comprised 4% of all trauma admissions. 89 patients had CB. 286 (52%) patients had concomitant injuries including 93 (17%) patients with abdominal co-injuries. Geriatric patients compared to non-geriatric had more falls as MOI, lower ISS and AIS pelvis, higher GCS, less abdominal co-injuries, similar CB and angio-embolization rates, less orthopedic pelvic surgeries, shorter lengths of stay and higher mortality. After propensity matching, orthopedic pelvic surgery rates remained lower (8% vs 19%, P < 0.001), hospital length of stay shorter, and mortality higher (13% vs 4%, P < 0.001) in geriatric patients. Out of 89 patients with CB, 45 (51%) were embolized. After propensity matching, patients with CB compared to without CB had more pelvic angiography (71% vs 12%, P < 0.001), higher embolization rates (64% vs 22%, P = 0.02) and comparable mortality. CONCLUSION Half of the patients with PF had concomitant co-injuries, including abdominal co-injuries in 17%. Similarly injured geriatric patients had higher mortality. Half of the patients with CB required an embolization.
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Affiliation(s)
- Alexander A Fokin
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Joanna Wycech Knight
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL 33316, United States
| | - Madison E Tharp
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Kyler C Brinton
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Phoebe K Gallagher
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Justin Fengyuan Xie
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Russell D Weisz
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
| | - Ivan Puente
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, FL 33431, United States
- Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL 33316, United States
- Herbert Wertheim College of Medicine, Department of Surgery, Florida International University, Miami, FL 33199, United States
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Jo WL, Chung YG, Shin SH, Lim JH, Kim MS, Yoon DK. Structural analysis of customized 3D printed plate for pelvic bone by comparison with conventional plate based on bending process. Sci Rep 2023; 13:10542. [PMID: 37386116 PMCID: PMC10310805 DOI: 10.1038/s41598-023-37433-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023] Open
Abstract
Pelvic bone fracture is highly complex, and its anatomical reduction is difficult. Therefore, patient-specific customized plates have been developed using three-dimensional (3D) printing technology and are being increasingly used. In this study, the reduction status in five representative pelvic fracture models was compared between two groups: the 3D printing plate (3DP) group using a patient-specific 3D printed plate after virtual reduction and the conventional plate (CP) group using a conventional plate by manual bending. The 3DP and CP groups included 10 and 5 cases, respectively. The fractured models were reduced virtually and their non-locking metal plates were customized using 3D printing. The process of contouring the conventional plates to fit the contact surface of the bone with the bending tool was conducted by an experienced pelvic bone trauma surgeon. The reduction and fixation achieved using the two different plate groups was compared, and the significance of differences in the results was analyzed using paired t-tests, after verifying the normality of data distribution. The vertex distances between the surface of the bone and the contact surface of the plate were significantly lower in the 3DP group than in the CP group (0.407 ± 0.342 and 2.195 ± 1.643, respectively, P = 0.008). Length and angular variations, which are measurements of the reduction state, were also lower in the 3DP group than in the CP group (length variation: 3.211 ± 2.497 and 5.493 ± 3.609, respectively, P = 0.051; angular variation: 2.958 ± 1.977 and 4.352 ± 1.947, respectively, P = 0.037). The customized 3D printed plate in the virtual reduction model provided a highly accurate reduction of pelvic bone fractures, suggesting that the customized 3D printed plate may help ensure easy and accurate reduction.
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Affiliation(s)
- Woo-Lam Jo
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 222, Banpo-Daero, Seocho-Gu, Korea
| | - Yang-Guk Chung
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 222, Banpo-Daero, Seocho-Gu, Korea.
| | - Seung-Han Shin
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 222, Banpo-Daero, Seocho-Gu, Korea
| | - Jae-Hak Lim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 222, Banpo-Daero, Seocho-Gu, Korea
| | - Moo-Sub Kim
- Industrial R&D Center, KAVILAB Co. Ltd., 06693, Seoul, Republic of Korea
| | - Do-Kun Yoon
- Industrial R&D Center, KAVILAB Co. Ltd., 06693, Seoul, Republic of Korea
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Marchand LS, Sepehri A, Hannan ZD, Zaidi R, DuBose JJ, Morrison JJ, O'Toole RV, Slobogean GM. Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamically Unstable Patients With Pelvic Ring Injuries. J Orthop Trauma 2022; 36:74. [PMID: 34050079 DOI: 10.1097/bot.0000000000002191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the outcomes of patients with pelvic ring injuries managed with resuscitative endovascular balloon occlusion of the aorta (REBOA). DESIGN Retrospective case series. SETTING Academic, Level 1 trauma center in North America. PATIENTS Twenty-five patients with disruption of the pelvic ring and hemodynamic instability. INTERVENTION Placement of a REBOA device as an adjuvant treatment to trauma resuscitation. MAIN OUTCOME MEASURE Death and ischemic-related complications. RESULTS The average age of patients was 43 years (range: 17-85). Patients presented with a median lactate of 6.3 mmol/L, systolic blood pressure of 116 mm Hg, heart rate of 121 beats/minute, and injury severity score of 34. The median unit of packed red blood cells received through transfusion in the first 24 hours of hospital admission was 13 (interquartile range: 8-28). Young-Burgess injury patterns included fractures of the following types: 5 lateral compression (LC)-1, 1 LC-2, 8 LC-3, 4 anteroposterior compression-2, and 7 anteroposterior compression-3. Angiography and embolization were performed in 24 (96%) patients. Selective embolization occurred in 18 (72%) patients, with nonselective angiography of the iliac system occurring in 7 (24%) patients. There were 12 (48%) deaths, 7 (28%) patients requiring lower extremity fasciotomy, and 5 (20%) patients requiring lower extremity amputations, and there was 1 (4%) patient requiring thrombectomy. CONCLUSIONS REBOA use in pelvic ring injuries is rare and most frequently used in critically ill patients with polytrauma. Successful pelvic embolization can occur in concert with REBOA use; however, the severity of injury is associated with a high complication profile. In this series of 25 patients, in-hospital mortality was 48%. For those patients who survived, 54% experienced a major complication (fasciotomy, amputation, and deep infection). Further investigation is required to evaluate the role REBOA may play in managing these patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S Marchand
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Aresh Sepehri
- University of British Columbia, Vancouver, BC, Canada
| | - Zachary D Hannan
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Raza Zaidi
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Joseph J DuBose
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Jonathan J Morrison
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Gerard M Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
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Marchand LS, Sepehri A, Hannan ZD, Zaidi SM, Bangura AT, Morrison JJ, Manson TT, Slobogean GP, O’Hara NN, O’Toole RV. Pelvic Ring Injury Mortality: Are We Getting Better? J Orthop Trauma 2022; 36:81-86. [PMID: 34128497 PMCID: PMC8669037 DOI: 10.1097/bot.0000000000002210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS/PARTICIPANTS A total of 3314 patients with pelvic ring injuries who presented to a single referral center from 1999 to 2018 were included in the study. INTERVENTION Pelvic ring management, years 1999-2006 versus years 2007-2018. MAIN OUTCOME MEASUREMENTS In hospital mortality. Other examined variables included change in patient demographics, fracture characteristics, date of injury, associated injuries, length of hospital stay, Abbreviated Injury Severity Score. RESULTS The composite mortality rate was 6.5% (214/3314). The earliest cohort presented a mortality rate of 9.1% [111/1224; 95% confidence interval (CI), 7.6%-10.8%] compared with the more recent cohort mortality rate of 4.9% (103/2090; 95% CI, 4.1%-5.9%). Overall mortality was significantly lower in the more recent period, a risk difference of 4.1% (95% CI, 2.3%-6.1%; P < 0.01). After adjusting for age and Abbreviated Injury Severity Score of the brain, chest, and abdomen, the mortality reduction was more pronounced with an adjusted risk difference of 6.4% (95% CI, 4.7%-8.1%; P < 0.01). CONCLUSION Significant improvement in the mortality rate of pelvic ring injuries has been demonstrated in recent years (4.9% vs. 9.1%) and the difference is even large when accounting for known confounders. Improvement appears to coincide chronologically with changes in trauma resuscitation and implementation of adjuvant treatments for managing patients with severe hemorrhagic shock. Although the exact benefit of each treatment awaits further research, these data might indicate improved care over time for these difficult patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S. Marchand
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aresh Sepehri
- University of British Columbia, Department of Orthopaedic Surgery, Vancouver, BC, Canada
| | - Zachary D. Hannan
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Syed M.R. Zaidi
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abdulai T. Bangura
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan J. Morrison
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Theodore T. Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathan N. O’Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert V. O’Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
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Chung HJ, Kim DS, Kwon HY, Bae KS, Park J. Risk Factors for Mortality Associated With Pelvic Fractures at a Level I Trauma Center. Orthopedics 2021; 44:e724-e728. [PMID: 34618632 DOI: 10.3928/01477447-20211001-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pelvic bone fractures are usually caused by high-energy trauma and are often accompanied by organ injuries. For hemodynamically unstable patients with pelvic bone fractures, knowing the anatomic type of fracture-whether it is a pelvic ring injury or an acetabular fracture-might be helpful in prioritizing treatment. A total of 302 patients with pelvic bone fractures who received treatment at the authors' level I trauma center between March 1, 2015, and February 28, 2017, were included in this study. Patients with pelvic bone fractures were enrolled in the Korea Trauma Data Bank and classified by anatomic type of pelvic bone fracture: pelvic ring injury, acetabular fracture, or combined fractures. The authors used t tests to analyze survival and death groups and multivariate regression to analyze mortality factors. Different types of pelvic bone fractures had significantly different mortality rates (P<.001). Forty-four (22.6%) of 195 patients with pelvic ring injuries and 6 (18.8%) of 32 patients with combined fractures died. Meanwhile, only 1 of 75 patients with isolated acetabular fractures died (1.3%). The mortality rate was lowest for type A pelvic ring injuries (8.2%) and highest for type C pelvic ring injuries (68.2%). The difference was statistically significant (P<.001). It is commonly acknowledged that age, combined injuries, higher Injury Severity Score, and lower initial systolic blood pressure are risk factors for mortality, but research has shown that classification and anatomic type of pelvic bone fracture are also highly related. [Orthopedics. 2021;44(6):e724-e728.].
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Zingg T, Uldry E, Omoumi P, Clerc D, Monier A, Pache B, Moshebah M, Butti F, Becce F. Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons. Eur Radiol 2020; 31:1517-1525. [PMID: 32901303 PMCID: PMC7880942 DOI: 10.1007/s00330-020-07247-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/24/2020] [Accepted: 08/31/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To assess the interobserver reliability (IOR) of the Tile classification system, and its potential influence on outcomes, for the interpretation of CT images of pelvic fractures by radiologists and surgeons. METHODS Retrospective data (1/2008-12/2016) from 238 patients with pelvic fractures were analyzed. Mean patient age was 44 years (SD 20); 66% were male. There were 54 Tile A, 82 Tile B, and 102 Tile C type injuries. The 30-day mortality rate was 15% (36/238). Six observers, three radiologists, and three surgeons with different levels of experience (attending/resident/intern) classified each fracture into one of the 26 second-order subcategories of the Tile classification. Weighted kappa coefficients were used to assess the IORs for the three main categories and nine first-order subcategories. RESULTS The overall IORs of the Tile system for the main categories and first-order subcategories were moderate (kappa = 0.44) and fair (kappa = 0.31), respectively. IOR was fair to moderate among radiologists, but only fair among surgeons. By level of training, IOR was moderate between attendings and between residents, whereas it was only fair between interns. IOR was moderate to substantial (kappa = 0.56-0.70) between the radiology attending and resident. Association of the Tile fracture type with 30-day mortality was present based on two out of six observer ratings. CONCLUSIONS The overall IOR of the Tile classification system is only fair to moderate, increases with the level of rater experience and is better among radiologists than surgeons. In the light of these findings, results from studies using this classification system must be interpreted cautiously. KEY POINTS • The overall interobserver reliability of the Tile pelvic fracture classification is only fair to moderate. • Interobserver reliability increases with observer experience and radiologists have higher kappa coefficients than surgeons. • Interobserver reliability has an impact on the association of the Tile classification system with mortality in two out of six cases.
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Affiliation(s)
- Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Emilie Uldry
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrick Omoumi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Daniel Clerc
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Arnaud Monier
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Basile Pache
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mohammed Moshebah
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio Butti
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Kwong WY, Yang MLC, Wong OF, Lui CT, Tsui KL. Epidemiological study of major pelvic fracture in Hong Kong and analysis of predictors for mortality. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919856218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives and Background Pelvic fracture causes significant mortality and morbidities. The purpose of this study is to identify the characteristics of patients with pelvic fracture in Hong Kong and to determine the factors predicting mortality. The result could help to identify high-risk patients who might benefit from more intensive evaluation and intervention. Method: Five hundred and eight patients (age > 12 years old) with pelvic fractures were identified from the trauma registries of four designated trauma centres in Hong Kong from 1 January 2005 to 31 December 2012. Patient baseline characteristics and outcomes were analysed. Stepwise logistic regression was performed to identify independent clinical predictors for mortality. Result: Mean age was 45.4 ± 19.2 years, 43.3% were female, mean length of hospital stay was 27.9 ± 42.4 days and mean length of intensive care unit stay was 4.8 ± 6.8 days. Injury severity score was 28.9 ± 18.7, revised trauma score was 7.2 ± 2 and 30-day mortality was 20.9%. Stepwise logistic regression identified patient’s age, presenting systolic blood pressure, initial Glasgow Coma Scale, injuries to the thoracic and abdominal regions, first base excess and the volume of red blood cell transfusion required within the first 6 h to be independent risk factors predicting mortality. Conclusion: Pelvic fracture is associated with significant risk of mortality in major trauma patients. Clinical characteristics obtained during emergency department resuscitation can help in selecting patients for timely aggressive interventions.
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Affiliation(s)
- Wing Yan Kwong
- Department of Accident and Emergency, Queen Elizabeth Hospital, Jordan, Hong Kong
| | - Marc LC Yang
- Department of Accident and Emergency, Queen Elizabeth Hospital, Jordan, Hong Kong
| | - Oi Fung Wong
- Department of Accident and Emergency, North Lantau Hospital, Tung Chung, Hong Kong
| | - Chun Tat Lui
- Department of Accident and Emergency, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | - Kwok Leung Tsui
- Department of Accident and Emergency, Tuen Mun Hospital, Tuen Mun, Hong Kong
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Leach SET, Skiadas V, Lord CE, Purohit N. Pelvic fractures: experience of pelvic ring fractures at a major trauma centre. Clin Radiol 2019; 74:649.e19-649.e26. [PMID: 31153596 DOI: 10.1016/j.crad.2019.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
Abstract
In this review, we discuss the imaging classification of pelvic ring fractures in the context of our experience of reporting trauma computed tomography (CT) in a major trauma centre. Pelvic ring fractures are potentially significant injuries with risk of significant haemorrhage and morbidity. This review details the use of classification systems in determining the mechanism and severity of injury, with discussion of the features of the Young and Burgess classification system. We demonstrate the different types of pelvic ring fracture with examples from trauma CT, and with reference to the distribution and frequency of these injuries in trauma patients. This review will allow the reader to assess trauma CT for significant pelvic ring injury and identify features of instability.
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Affiliation(s)
- S E T Leach
- Southampton General Hospital, Tremona Road, Southampton, Hampshire SO16 6YD, UK.
| | - V Skiadas
- Southampton General Hospital, Tremona Road, Southampton, Hampshire SO16 6YD, UK
| | - C E Lord
- Southampton General Hospital, Tremona Road, Southampton, Hampshire SO16 6YD, UK
| | - N Purohit
- Southampton General Hospital, Tremona Road, Southampton, Hampshire SO16 6YD, UK
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Kachlik D, Vobornik T, Dzupa V, Marvanova Z, Toupal O, Navara E, Stevulova N, Baca V. Where and what arteries are most likely injured with pelvic fractures?: The Influence of Localization, Shape, and Fracture Dislocation on the Arterial Injury During Pelvic Fractures. Clin Anat 2019; 32:682-688. [PMID: 30873674 DOI: 10.1002/ca.23372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/04/2019] [Accepted: 03/13/2019] [Indexed: 12/27/2022]
Abstract
Blood vessels passing through pelvic region come into intimate contact with pelvic bone and can be injured by the sharp edges of the dislocated fracture fragments. The aim of the study was to evaluate the influence of localization, shape, and dislocation of individual pelvic ring bones' fractures on arterial injuries. The study group consisted of 474 patients enrolled in a 1-year prospective multicenter study. The pattern of pelvic fracture lines was characterized and recorded on a planar diagram of the subjected side of the pelvis. The diagram was subdivided into 11 designated areas. Frequency of injury at each 11 areas was recorded. The course of individual arteries in the 11 areas was also recorded in relation to each type of pelvic fractures. Out of the 474 investigated patients, the highest proportion of fractures occurred in the areas of the superior (62%) and inferior (59%) ramus of the pubis as well as in the lateral part of the sacrum (19%). These locations can be associated with injuries of the external iliac, obturator, internal iliac, and aberrant obturator arteries. The highest risk of arterial injuries was associated with vertically displaced fractures in the middle part of the superior and inferior pubic rami, along the ischial ramus, in the apex of the greater sciatic notch and in the vicinity of the ventral part of the sacroiliac joint, where the artery runs at a distance of less than 1 cm from the bone. Clin. Anat. 32:682-688, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tomas Vobornik
- Department of Orthopedics and Traumatology, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Valer Dzupa
- Department of Orthopedics and Traumatology, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic.,Center for Integrated Study of Pelvis, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zuzana Marvanova
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondrej Toupal
- Department of Orthopedics and Traumatology, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Eduard Navara
- Department of Orthopedics and Traumatology, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Nikoleta Stevulova
- Department of Orthopedics and Traumatology, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Vaclav Baca
- Department of Orthopedics and Traumatology, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic.,Department of Health Care Studies, College of Polytechnics Jihlava, Jihlava, Czech Republic
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10
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The pelvic fracture - Indicator of injury severity or lethal fracture? Injury 2018; 49:1568-1571. [PMID: 29909925 DOI: 10.1016/j.injury.2018.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/11/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Presence of pelvic fractures in trauma patients has previously been related to high mortality. However, there are controversies on whether pelvic fractures are the underlying cause of death or if it is rather an indicator of injury severity. We aimed to assess whether the presence of pelvic fracture increased mortality among a cohort of trauma patients or if it was simply an indicator of severe injury. MATERIAL AND METHODS Karolinska University Hospital is the largest trauma centre in Sweden. The hospital is linked to the Swedish National Trauma Registry, "SweTrau". Registry data was collected for the period January 2013 until December 2015 with a one year further follow-up regarding mortality. Patients in the pelvic fracture group were compared to the non-pelvic fracture group and regression analysis was performed adjusting for factors that could possibly affect mortality. RESULTS Univariable analysis showed that pelvic fracture was associated with an increased mortality, OR 2.4 (CI 1.3-3.4). Multivariable analysis showed that the presence of a pelvic fracture was not associated with an increased 30-day mortality (OR 0.5, CI 0.2-0.9), while factors as Shock (OR 7.1, CI 4.6-10.9), GCS < 9 (OR 6.2, CI 3.9-9.8), ISS > 15 (OR 12.4, CI 8.1-18.9), Age >60 (OR 3.2, CI 2.1-4,9) and ASA 3-4 (OR 4.7, CI 3.1-7.3) were associated with an increased 30-day mortality. Factors affecting 1-year mortality was analysed in the same way and the results were similar. CONCLUSION Presence of pelvic fractures in trauma patients is not correlated to increased mortality when adjusted for Age, ISS, ASA, GCS and Shock.
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Abstract
OBJECTIVE To determine whether certain patterns of pelvic ring injury are associated with more frequent intrauterine fetal demise (IUFD). DESIGN Retrospective review. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Of 44 pregnant patients with pelvic and/or acetabular fractures, 40 had complete records that allowed determination of fetal viability. χ2 tests were used for categorical variables (Fisher exact tests when expected cell counts were fewer than 5), and t tests were used for continuous variables. MAIN OUTCOME MEASUREMENTS Fetal or maternal death. RESULTS Sixteen patients had isolated acetabular fractures, 25 had isolated pelvic ring injuries, and 3 had acetabular fractures with concomitant pelvic ring injuries. Maternal and fetal mortality were 2% and 40%, respectively. No patients with isolated acetabular fractures experienced IUFD, compared with 68% (15/22) of those with isolated pelvic ring injuries (P < 0.0001). Eight (53%) of 15 IUFDs were associated with lateral compression (LC)-I pelvic ring injuries (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 61-B2). Of the 13 LC-I pelvic ring injuries, 8 (62%) resulted in IUFD. Pelvic ring stability, Young-Burgess classification, and operative treatment were not associated with IUFD. Maternal Glasgow Coma Scale (average 13.2) and Injury Severity Score (average 18.2) at admission were predictive of IUFD. CONCLUSIONS The most frequent pelvic fractures in gravid trauma patients are LC-I. Although the rate of maternal mortality was low, the risk of IUFD was quite high (40%). LC-I pelvic ring injuries often had catastrophic outcomes, with IUFD in 62% of cases. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Agri F, Bourgeat M, Becce F, Moerenhout K, Pasquier M, Borens O, Yersin B, Demartines N, Zingg T. Association of pelvic fracture patterns, pelvic binder use and arterial angio-embolization with transfusion requirements and mortality rates; a 7-year retrospective cohort study. BMC Surg 2017; 17:104. [PMID: 29121893 PMCID: PMC5680776 DOI: 10.1186/s12893-017-0299-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 10/13/2017] [Indexed: 12/13/2022] Open
Abstract
Background Pelvic fractures are severe injuries with frequently associated multi-system trauma and a high mortality rate. The value of the pelvic fracture pattern for predicting transfusion requirements and mortality is not entirely clear. To address hemorrhage from pelvic injuries, the early application of pelvic binders is now recommended and arterial angio-embolization is widely used for controlling arterial bleeding. Our aim was to assess the association of the pelvic fracture pattern according to the Tile classification system with transfusion requirements and mortality rates, and to evaluate the correlation between the use of pelvic binders and arterial angio-embolization and the mortality of patients with pelvic fractures. Methods Single-center retrospective cohort study including all consecutive patients with a pelvic fracture from January 2008 to June 2015. All radiological fracture patterns were independently reviewed and grouped according to the Tile classification system. Data on patient demographics, use of pelvic binders and arterial angio-embolization, transfusion requirements and mortality were extracted from the institutional trauma registry and analyzed. Results The present study included 228 patients. Median patient age was 43.5 years and 68.9% were male. The two independent observers identified 105 Tile C (46.1%), 71 Tile B (31.1%) and 52 Tile A (22.8%) fractures, with substantial to almost perfect interobserver agreement (Kappa 0.70-0.83). Tile C fractures were associated with a higher mortality rate (p = 0.001) and higher transfusion requirements (p < 0.0001) than Tile A or B fractures. Arterial angio-embolization for pelvic bleeding (p = 0.05) and prehospital pelvic binder placement (p = 0.5) were not associated with differences in mortality rates. Conclusions Tile C pelvic fractures are associated with higher transfusion requirements and a higher mortality rate than Tile A or B fractures. No association between the use of pelvic binders or arterial angio-embolization and survival was observed in this cohort of patients with pelvic fractures.
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Affiliation(s)
- Fabio Agri
- Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Department of Emergency Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Mylène Bourgeat
- Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Kevin Moerenhout
- Department of Orthopedic Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Mathieu Pasquier
- Department of Emergency Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Olivier Borens
- Department of Orthopedic Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Bertrand Yersin
- Department of Emergency Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Tobias Zingg
- Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
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Yano S, Aoki Y, Watanabe A, Nakajima T, Takazawa M, Hirasawa H, Takahashi K, Nakagawa K, Nakajima A, Takahashi H, Orita S, Eguchi Y, Suzuki T, Ohtori S. Less invasive lumbopelvic fixation technique using a percutaneous pedicle screw system for unstable pelvic ring fracture in a patient with severe multiple traumas. J Neurosurg Spine 2016; 26:203-207. [PMID: 27716018 DOI: 10.3171/2016.7.spine16323] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pelvic ring fractures are defined as life-threatening injuries that can be treated surgically with external or internal fixation. The authors report on an 81-year-old woman with an unstable pelvic fracture accompanying multiple traumas that was successfully treated with a less invasive procedure. The patient was injured in a traffic accident and sustained a total of 20 fractures, including pelvic ring, bilateral rib, and lumbar transverse processes fractures, and multiple fractures of both upper and lower extremities. The pelvic ring fracture was unstable with fractures of the bilateral sacrum with right sacroiliac disruption, right superior and inferior pubic rami, left superior pubic ramus, and ischium. During emergency surgery, bilateral external fixation was applied to the iliac crest to stabilize the pelvic ring. Second and third surgeries were performed 11 and 18 days after the first emergency surgery, respectively, to treat the multiple fractures. At the third surgery, the pelvic ring fracture was stabilized surgically using a less invasive posterior fixation technique. In this technique, 2 iliac screws were inserted on each side following an 8-cm midline posterior incision from the S-1 to S-3 spinous process, with the subcutaneous tissue detached from the fascia of the paraspinal muscles. The S-2 spinous process was removed and 2 rods were connected to bilateral iliac screws to stabilize the bilateral ilium in a switchback fashion. A crosslink device was applied to connect the 2 rods at the base of the S-2 spinous process. Following pelvic fixation, percutaneous pedicle screws were inserted into L-4 and L-5 vertebral bodies on both sides, and connected to the cranial rod connecting the bilateral iliac screws, thus completing the lumbopelvic fixation. The postoperative course was favorable with no postoperative complications. At the 10-month follow-up, bone union had been achieved at the superior ramus of the pubis, the patient did not complain of pain, and her activities of daily life returned to preinjury status. Unstable pelvic ring fractures need to be sufficiently stabilized for good surgical outcome. However, to avoid postoperative complications, a less invasive treatment is preferred, particularly in cases with poor general condition. This procedure is less invasive and provides sufficient stabilization to the unstable pelvic ring fracture, and thus is the ideal surgical procedure for such cases.
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Affiliation(s)
- Sei Yano
- Departments of 1 Orthopaedic Surgery and
| | - Yasuchika Aoki
- Departments of 1 Orthopaedic Surgery and.,Departments of 2 General Medical Science and
| | - Atsuya Watanabe
- Departments of 1 Orthopaedic Surgery and.,Departments of 2 General Medical Science and
| | - Takayuki Nakajima
- Departments of 1 Orthopaedic Surgery and.,Departments of 2 General Medical Science and
| | - Makoto Takazawa
- Departments of 1 Orthopaedic Surgery and.,Departments of 2 General Medical Science and
| | - Hiroyuki Hirasawa
- Emergency and Critical Care Medicine, Eastern Chiba Medical Center, Togane
| | - Kazuhisa Takahashi
- Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city; and
| | - Koichi Nakagawa
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | - Sumihisa Orita
- Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city; and
| | - Yawara Eguchi
- Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city; and
| | - Takane Suzuki
- Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city; and
| | - Seiji Ohtori
- Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba-city; and
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Correlation between Pelvic Bone Fracture Site and Arterial Embolization in Severe Trauma Patients: A Retrospective Study in a Single Korean Institute. Trauma Mon 2016. [DOI: 10.5812/traumamon.33461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Pelvic ring injuries exhibit a wide spectrum of severity; at times devastating with potentially serious immediate and long-term consequences. The anatomical and mechanistic basis of the injured pelvis is described. The non-operative and surgical management of pelvic ring disruption in the acute and definitive care settings is discussed. As emphasized here, basic principles, the mechanism of injury and pattern of instability help guide management.
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16
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Wang H, Robinson RD, Moore B, Kirk AJ, Phillips JL, Umejiego J, Chukwuma J, Miller T, Hassani D, Zenarosa NR. Predictors of early versus late mortality in pelvic trauma patients. Scand J Trauma Resusc Emerg Med 2016; 24:27. [PMID: 26964737 PMCID: PMC4785731 DOI: 10.1186/s13049-016-0220-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 03/04/2016] [Indexed: 11/22/2022] Open
Abstract
Background Risks of predicting time-related in-hospital mortality varies in pelvic trauma patients. We aim to identify potential independent risks predictive of time-related (early versus late) mortality among pelvic trauma patients. Methods Local trauma registry data from 2004 through 2013 were reviewed. Mortality causes and timing of death were investigated. Multivariate logistic regression identified independent risks predictive of early versus late mortality in pelvic trauma patients while adjusting for patient demographics (age, sex, race), clinical variables (initial vital signs, mental status, injury severity, associated injuries, comorbidities), and hospital outcomes (surgical interventions, crystalloid resuscitations, blood transfusions). Results We retrospectively collected data on 1566 pelvic trauma patients with a mortality rate of 9.96 % (156/1566). Approximately 74 % of patients died from massive hemorrhage within the first 24 h of hospitalization (early mortality). Revised trauma score (RTS), injury severity score (ISS), initial hemoglobin, direct transfer to operating room, and blood transfusion administration in the Emergency Department were considered independent risk factors predictive of early mortality. Age, ISS, and Glasgow Coma Scale (GCS) were deemed risk factors predictive of death after 24 h (late mortality). Discussion Given the fact of a substantial number of patients died within the first 24 h of hospital arrival, it is reasonable to consider the first 24 h of hospitalization as the appropriate window within which early mortality may be expected to occur in pelvic trauma patients. The risk factors associated with massive hemorrhage were strong predictors of early mortality, whereas late mortality predictors were more closely linked with comorbidities or in-hospital complications. Conclusions While risk factors predictive of early versus late mortality vary, ISS seems to predict both early and late mortality accurately in pelvic trauma patients.
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Affiliation(s)
- Hao Wang
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA.
| | - Richard D Robinson
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA
| | - Billy Moore
- Research Institute, JPS Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Alexander J Kirk
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA
| | | | - Johnbosco Umejiego
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA
| | - Joseph Chukwuma
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA
| | - Tyler Miller
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA
| | - Donna Hassani
- University of South Florida, Morsani College of Medicine, 12901 Bruce B. Downs Blvd., MDC061, Tampa, FL, 33612-4799, USA
| | - Nestor R Zenarosa
- Research Institute, JPS Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
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Reynard FA, Flaris AN, Simms ER, Rouvière O, Roy P, Prat NJ, Damizet JG, Caillot JL, Voiglio EJ. Kendrick's extrication device and unstable pelvic fractures: Should a trochanteric belt be added? A cadaveric study. Injury 2016; 47:711-6. [PMID: 26867981 DOI: 10.1016/j.injury.2016.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/14/2015] [Accepted: 01/22/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Pre-hospital pelvic stabilisation is advised to prevent exsanguination in patients with unstable pelvic fractures (UPFs). Kendrick's extrication device (KED) is commonly used to extricate patients from cars or crevasses. However the KED has not been tested for potential adverse effects in patients with pelvic fractures. The aim of this study was to examine the effect of the KED on pubic symphysis diastasis (SyD) with and without the use of a trochanteric belt (TB) during the extraction process following a MVC. MATERIALS AND METHODS Left-sided "open-book" UPFs were created in 18 human cadavers that were placed in seven different positions simulating pre-extraction and extraction positions using the KED with and without a TB in two different positions (through and over the thigh straps). The SyD was measured using anteroposterior radiographs. The effects of the KED with and without TB, on the SyD, were evaluated. RESULTS The KED alone resulted in a non-significant increase of the SyD compared to baseline, whereas the addition of a TB to the KED resulted in a significant reduction of the SyD (p<0.001). The TB through the straps provided a significantly better reduction than the TB over the straps in the extracted position (p<0.05). CONCLUSION Our study demonstrated that a TB in combination with the KED on UPFs is an effective way to achieve early reduction. The addition of the TB in combination with the KED could be considered for Pre-Hospital Trauma Life Support (PHTLS) training protocols.
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Affiliation(s)
- Floran A Reynard
- University of Lyon, Université Lyon 1, Faculté de Médecine Lyon Est, Laboratoire d'Anatomie, UMR T9405, F-69003 Lyon, France
| | - Alexandros N Flaris
- University of Lyon, Université Lyon 1, Faculté de Médecine Lyon Est, Laboratoire d'Anatomie, UMR T9405, F-69003 Lyon, France; Hospices Civils de Lyon, Unit of Emergency Surgery, Centre Hospitalier Lyon-Sud, F-69495 Pierre-Bénite, France; Protypon Neurological-Neuromuscular Center, Thessaloniki, Greece
| | - Eric R Simms
- Hospices Civils de Lyon, Unit of Emergency Surgery, Centre Hospitalier Lyon-Sud, F-69495 Pierre-Bénite, France; Tulane University School of Medicine, New Orleans, LA, USA
| | - Olivier Rouvière
- Hospices Civils de Lyon, Department of Urinary and Vascular Radiology, Hôpital Edouard Herriot, F-69437 Lyon, France
| | - Pascal Roy
- University of Lyon, Université Lyon 1, CNRS, UMR5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, F-69622 Villeurbanne, France
| | - Nicolas J Prat
- Institut de Recherche Biomédicale des Armées, SMCF, F-91223 Brétigny sur Orge, France
| | - Jean-Gabriel Damizet
- Service de Santé et de Secours Médical, Service d'Incendie et de Secours du Rhône et de la Métropole de Lyon, F-69421 Lyon, France
| | - Jean-Louis Caillot
- Hospices Civils de Lyon, Unit of Emergency Surgery, Centre Hospitalier Lyon-Sud, F-69495 Pierre-Bénite, France
| | - Eric J Voiglio
- University of Lyon, Université Lyon 1, Faculté de Médecine Lyon Est, Laboratoire d'Anatomie, UMR T9405, F-69003 Lyon, France; Hospices Civils de Lyon, Unit of Emergency Surgery, Centre Hospitalier Lyon-Sud, F-69495 Pierre-Bénite, France; Service de Santé et de Secours Médical, Service d'Incendie et de Secours du Rhône et de la Métropole de Lyon, F-69421 Lyon, France.
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Ismail HD, Lubis MF, Djaja YP. The Outcome of Complex Pelvic Fracture after Internal Fixation Surgery. Malays Orthop J 2016; 10:16-21. [PMID: 28435542 PMCID: PMC5333698 DOI: 10.5704/moj.1603.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Introduction: Complex pelvic fracture, which has a very high mortality and even higher morbidity, needs internal fixation surgery as an integral part for its management. It was necessary to conduct a study regarding outcome of complex pelvic fractures after internal fixation surgery. Material & Method: Twenty-six patients with complex pelvic fractures that had been treated with internal fixation surgery during 2011-2014 were enrolled. These patients had an open pelvic fractures or Tile type B or C pelvic fracture who had undergone internal fixation surgery with at least 6 months follow-up. Evaluation of the morbidity and functional scoring was performed using Majeed and Hannover Score. Results and Discussions: Average of age was 31 years old and follow up time was 25 months. There were 7 patients with open pelvic fracture and 19 with closed fracture. Excellent Majeed Score were found on 78.6% cases in Tile B fractures and 50% in Tile C. Good Hannover Score was found in 64.3% Tile B cases and 80% Tile C cases. Fracture type was statistically insignificant with acquired sexual dysfunction (p>0.05), but significant with the chronic pain (p=0,.017). We also found that urogenital injury is associated with sexual dysfunction (p=0.005). Conclusions: The outcome of complex pelvic fracture after internal fixation surgery was excellent. More than 90% patients got an excellent and good result on Majeed Score, and also very good and good result on Hannover Score.
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Affiliation(s)
- H D Ismail
- Department Orthopaedics and Traumatology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta
| | - M F Lubis
- Department Orthopaedics and Traumatology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta
| | - Y P Djaja
- Department Orthopaedics and Traumatology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta
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Improved Survival After Pelvic Fracture: 13-Year Experience at a Single Trauma Center Using a Multidisciplinary Institutional Protocol. J Orthop Trauma 2016; 30:22-8. [PMID: 26360539 DOI: 10.1097/bot.0000000000000443] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyze pelvic fracture mortality rates before and after initiation of a multidisciplinary pelvic fracture protocol. DESIGN Retrospective database analysis. SETTING Prospective data from our Level-I National Trauma Registry of The American College of Surgeons (NTRACS) database. PATIENTS/PARTICIPANTS A total of 1682 trauma patients with pelvic fractures from 2000 to 2013 were compared with a control group of 42,629 without pelvic fractures. INTERVENTION Initiation of a multidisciplinary institutional protocol to guide the initial management of trauma patients with pelvic fractures. MAIN OUTCOME MEASUREMENTS Patients were grouped into 3 periods (group 1: 2000-2003, group 2: 2004-2007, group 3: 2008-2013). Multivariate logistic regression analysis was conducted to assess associations between mortality and age, shock (systolic blood pressure less than or equal to 90 mm Hg), head injury (Glasgow Coma Scale less than or equal to 8), Injury Severity Score (ISS), and time period. RESULTS Unadjusted mortality rates decreased [12.5%-11.0% (P = 0.72)]; however, ISS increased [19.1-22.7 (P < 0.01)]. Age, shock, head injury, increasing ISS, and earlier period were significantly associated with mortality. Adjusted mortality decreased over time [odds ratio for 2000-2003 vs. 2008-2013: 2.05, 95% confidence interval = (1.26, 3.33) and odds ratio for 2004-2007 vs. 2008-2013: 1.71, 95% confidence interval = (1.09, 2.67)]. From 2000 to 2003, an unstable fracture pattern in the healthiest cohort significantly increased mortality compared with the stable fracture pattern cohort (8.6% and 0.0%, P < 0.01). In subsequent intervals, there was no statistically significant association between stable versus unstable fracture patterns and mortality. CONCLUSIONS Adjusted pelvic fracture mortality rates have significantly decreased over time. In the healthiest patients with unstable pelvic fractures, the mortality rate is now similar to that of patients with stable fracture patterns. With sustained institutional effort to address pelvic fractures, mortality rates can be diminished. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Cha YH, Sul YH, Kim HY, Choy WS. Correlation between Young and Burgess Classification and Transcatheter Angiographic Embolization in Severe Trauma Patients. JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.3.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Young Hoon Sul
- Department of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
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Ruatti S, Guillot S, Brun J, Thony F, Bouzat P, Payen JF, Tonetti J. Which pelvic ring fractures are potentially lethal? Injury 2015; 46:1059-63. [PMID: 25769199 DOI: 10.1016/j.injury.2015.01.041] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/23/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE Global mortality of polytraumatised patients presenting pelvic ring fractures remains high (330%), despite improvements in treatment algorithms in Level I Trauma Centers. Many classifications have been developed in order to identify and analyse these pelvic ring lesions. However, it remains difficult to predict intra-pelvic haemorrhage. The aim of this study was to identify pelvic ring anatomical lesions associated with significant blood loss, susceptible to lead to life-threatening haemorrhage. MATERIAL AND METHOD This study focused on a retrospective analysis of patients' medical files, all of whom were admitted to one of the shock rooms of Grenoble University Hospital, France, between January 2004 and December 2008. Treatment was given according to the institutional algorithm of the Alps Trauma Center and Emergency North Alpine Network Trauma System (TRENAU). Different hemodynamical parameters at arrival were measured, and the fractures were classified according to Young and Burgess, Tile, Letournel and Denis. One hundred and ninety seven patients were analysed. They were subdivided into two groups, embolised (Group E) and non-embolised (Group NE). RESULTS Group NE included 171 patients with a mean age of 40.2 ± 8.7 years (15-90). Group E included 26 patients with a mean age of 41.6 ± 5.3 years (18-67). Twenty-six patients died during the initial treatment phase. Eleven belonged to Group E and 15 to Group NE. Mortality was significantly higher in Group E (42.3% vs 8.8% in Group NE) (p < 0.05). There were significantly many more Tile C unstable fractures in Group E (p = 0.0014), and anterior lesions, according to Letournel, with pubic symphysis disruption were significantly more likely to lead to active bleeding treated by selective embolisation (p = 0.0014). Posterior pelvic ring lesions with iliac wing fracture and transforaminal sacral fractures (Denis 2) were also more frequently associated with bleeding treated by embolisation (p = 0.0088 and p = 0.0369 respectively). DISCUSSION/CONCLUSION It appears that in our series the primary identification and classification of osteo-ligamentous lesions (according to Letournel and Denis' classifications) allows to anticipate the importance of bleeding and to adapt the management of patients accordingly, in order to quickly organise angiography with embolisation.
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Affiliation(s)
- S Ruatti
- Hôpital Michallon, Alps Trauma Centre, University Hospital, Department of Orthopaedic and Trauma Surgery, BP 217 X, 38043 Grenoble Cedex 09, France.
| | - S Guillot
- Hôpital Michallon, Alps Trauma Centre, University Hospital, Department of Anesthesia and Intensive Care, BP 217 X, 38043 Grenoble Cedex 09, France
| | - J Brun
- Hôpital Michallon, Alps Trauma Centre, University Hospital, Department of Anesthesia and Intensive Care, BP 217 X, 38043 Grenoble Cedex 09, France
| | - F Thony
- Hôpital Michallon, Alps Trauma Centre, University Hospital, Department of Radiology and Medical Imagery, BP 217 X, 38043 Grenoble Cedex 09, France
| | - P Bouzat
- Hôpital Michallon, Alps Trauma Centre, University Hospital, Department of Anesthesia and Intensive Care, BP 217 X, 38043 Grenoble Cedex 09, France
| | - J F Payen
- Hôpital Michallon, Alps Trauma Centre, University Hospital, Department of Anesthesia and Intensive Care, BP 217 X, 38043 Grenoble Cedex 09, France
| | - J Tonetti
- Hôpital Michallon, Alps Trauma Centre, University Hospital, Department of Orthopaedic and Trauma Surgery, BP 217 X, 38043 Grenoble Cedex 09, France
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Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: trends and in-hospital mortality. J Trauma Acute Care Surg 2014; 76:380-5. [PMID: 24398776 DOI: 10.1097/ta.0b013e3182ab0cde] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Unstable pelvic fracture is predominantly caused by high-energy blunt trauma and is associated with a high risk of mortality. The epidemiology in the United States is largely unknown. The purpose of this study was to examine the epidemiology of unstable pelvic fracture based on patient and hospital demographics in the United States during the last decade. METHODS The Nationwide Inpatient Sample was used to identify patients who were hospitalized with unstable pelvic fracture from 2000 to 2009, using the International Classification of Diseases--9th Rev.--Clinical Modification (ICD-9-CM) codes. The primary outcome parameter consisted of analyzing the temporal trends of in-hospital admissions for unstable pelvic fracture and the associated in-hospital mortality. The data were stratified by demographic variables, including age, sex, race, and hospital region in the United States. RESULTS From 2000 to 2009, there were 24,059 patients in total; among these, 1,823 (7.6%) had open fractures, and 22,236 (92.4%) had closed fractures. The population growth-adjusted incidence was stable over time (p = 0.431). The incidence was the lowest in the northeastern region. The in-hospital mortality rate in patients with unstable pelvic fracture was 8.3% (21.3% for open fracture, 7.2% for closed fracture) and remained stable over time (p = 0.089). The in-hospital mortality rate was higher in several subgroups of patients, such as older patients, male patients, African-American patients, and patients in the northeastern region. CONCLUSION During the last decade, the incidence of unstable pelvic fracture has remained stable over time in the United States. The in-hospital mortality rate in patients with unstable pelvic fracture was 8.3% and remained stable over time. The rate in patients with an open fracture was approximately three times higher than that in patients with a closed fracture. The incidence was the lowest, but the in-hospital mortality rate was the highest in the northeastern region compared with the other three regions. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Osterhoff G, Scheyerer MJ, Fritz Y, Bouaicha S, Wanner GA, Simmen HP, Werner CML. Comparing the predictive value of the pelvic ring injury classification systems by Tile and by Young and Burgess. Injury 2014; 45:742-7. [PMID: 24360744 DOI: 10.1016/j.injury.2013.12.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 10/21/2013] [Accepted: 12/02/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Radiology-based classifications of pelvic ring injuries and their relevance for the prognosis of morbidity and mortality are disputed in the literature. The purpose of this study was to evaluate potential differences between the pelvic ring injury classification systems by Tile and by Young and Burgess with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries. PATIENTS AND METHODS Two-hundred-and-eighty-five consecutive patients with pelvic ring fractures were analyzed for mortality within 30 days after admission, number of blood units and total volume of fluid infused during the first 24h after trauma, the Abbreviated Injury Severity (AIS) scores for head, chest, spine, abdomen and extremities as a function of the Tile and the Young-Burgess classifications. RESULTS There was no significant relationship between occurrence of death and fracture pattern but a significant relationship between fracture pattern and need for blood units/total fluid volume for Tile (p<.001/p<.001) and Young-Burgess (p<.001/p<.001). In both classifications, open book fractures were associated with more fluid requirement and more severe injuries of the abdomen, spine and extremities (p<.05). When divided into the larger subgroups "partially stable" and "unstable", unstable fractures were associated with a higher mortality rate in the Young-Burgess system (p=.036). In both classifications, patients with unstable fractures required significantly more blood transfusions (p<.001) and total fluid infusion (p<.001) and higher AIS scores. CONCLUSIONS In this first direct comparison of both classifications, we found no clinical relevant differences with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries.
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Affiliation(s)
- Georg Osterhoff
- Division of Trauma Surgery, University Hospital Zurich, Switzerland.
| | - Max J Scheyerer
- Division of Trauma Surgery, University Hospital Zurich, Switzerland
| | - Yannick Fritz
- Division of Trauma Surgery, University Hospital Zurich, Switzerland
| | - Samy Bouaicha
- Division of Trauma Surgery, University Hospital Zurich, Switzerland
| | - Guido A Wanner
- Division of Trauma Surgery, University Hospital Zurich, Switzerland
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Gabbe BJ, Esser M, Bucknill A, Russ MK, Hofstee DJ, Cameron PA, Handley C, de Steiger RN. The imaging and classification of severe pelvic ring fractures: Experiences from two level 1 trauma centres. Bone Joint J 2013; 95-B:1396-401. [PMID: 24078539 DOI: 10.1302/0301-620x.95b10.32134] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We describe the routine imaging practices of Level 1 trauma centres for patients with severe pelvic ring fractures, and the interobserver reliability of the classification systems of these fractures using plain radiographs and three-dimensional (3D) CT reconstructions. Clinical and imaging data for 187 adult patients (139 men and 48 women, mean age 43 years (15 to 101)) with a severe pelvic ring fracture managed at two Level 1 trauma centres between July 2007 and June 2010 were extracted. Three experienced orthopaedic surgeons classified the plain radiographs and 3D CT reconstruction images of 100 patients using the Tile/AO and Young-Burgess systems. Reliability was compared using kappa statistics. A total of 115 patients (62%) had plain radiographs as well as two-dimensional (2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and eight patients (4.3%) had no available images. The plain radiograph was limited to an anteroposterior pelvic view. Patients without imaging, or only plain films, were more severely injured. A total of 72 patients (39%) were imaged with a pelvic binder in situ. Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17) and Young-Burgess (Kappa 0.09 to 0.21) was low, and insufficient for clinical and research purposes. Severe pelvic ring fractures are difficult to classify due to their complexity, the increasing use of early treatment such as with pelvic binders, and the absence of imaging altogether in important patient sub-groups, such as those who die early of their injuries.
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Affiliation(s)
- B J Gabbe
- Monash University, Department of Epidemiology and Preventive Medicine, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia
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Hasankhani EG, Omidi-Kashani F. Treatment outcomes of open pelvic fractures associated with extensive perineal injuries. Clin Orthop Surg 2013; 5:263-8. [PMID: 24340145 PMCID: PMC3858096 DOI: 10.4055/cios.2013.5.4.263] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 05/10/2013] [Indexed: 11/11/2022] Open
Abstract
Background The main causes of death in patients with open pelviperineal injuries are uncontrollable bleeding and pelvic sepsis. The aim of this study was to evaluate the management outcomes of open pelvic fractures associated with extensive perineal injuries. Methods We retrospectively studied 15 cases with open pelvic fractures associated with extensive perineal injuries (urethral and anal canal laceration) admitted between August 2006 and September 2010. Mechanism of injury, Injury Severity Score, associated injuries, hemodynamic status on arrival, resuscitation and transfusion requirements, operative techniques, intra- and postoperative complications, length of intensive care unit and hospital stay, and mortality were recorded in a computerised database for further evaluation and analysis. Results The male to female ratio was 12:3 with an average age of 38.6 years (ranged, 11 to 65 years). The average packed red blood cell units used were 8 units (ranged, 4 to 21 units). All patients were initially transferred to the operating room for colostomy, radical debridement and fixation of the pelvic fracture by an external fixator. One patient had acute renal failure, which improved with medical treatment and 2 patients (13.3%) died, one with type III anteroposterior compression fracture due to hemorrhagic shock and the other due to septicemia. Conclusions Open pelvic fractures with extensive perineal injuries are associated with high mortality rates. Early diagnosis and appropriate treatment, including reanimation, colostomy, cystostomy, vigorous and repeated irrigation and debridement, and fixation by an external fixator can improve the outcomes and reduce the mortality rate.
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Affiliation(s)
- Ebrahim Ghayem Hasankhani
- Orthopedic Department, Orthopedic Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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Abstract
OBJECTIVES Combined pelvic ring disruptions and acetabular fractures are thought to be uncommon. Our objectives were to characterize concomitant injury patterns and to compare them with historically observed rates for each injury in isolation. DESIGN Retrospective review comparing a study group with historical controls. Fracture patterns were compared with our institution's isolated injury patterns and with isolated injury patterns of other published series. SETTING Level I academic medical center. PATIENTS Between 1997 and 2001, 854 pelvic ring disruptions and 457 acetabular fractures were evaluated. Forty patients sustained combined injuries. INTERVENTION None. MAIN OUTCOME MEASUREMENTS Fracture patterns, Injury Severity Scores, and mortality rates. RESULTS Our series of combined injuries included 5% posterior wall fractures. This was significantly different from the 30% incidence of posterior wall fractures among isolated acetabular fractures at our institution (P < 0.006). No posterior column or posterior column with associated posterior wall fractures occurred. Fifty-three percent of the patients sustained anterior-posterior compression pelvic ring injuries, exceeding our center's 19% norm for isolated pelvic ring injuries (P < 0.001). For combined injuries, the mean injury severity score was 27.9 and the overall mortality rate was 13%. Early death occurred in 19% of patients with combined anterior-posterior compression injuries and 6% with lateral compression injuries. CONCLUSIONS Patients with combined pelvic and acetabular injuries have multiple system injuries and high Injury Severity Scores. Fracture patterns differ from those observed with isolated injuries. Posterior acetabular fractures are uncommon components. Anterior-posterior compression pelvic injuries seem much more frequent in cases of combined injuries than isolated injuries and are associated with high mortality rates. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Gabbe BJ, de Steiger R, Esser M, Bucknill A, Russ MK, Cameron PA. Predictors of mortality following severe pelvic ring fracture: results of a population-based study. Injury 2011; 42:985-91. [PMID: 21733513 DOI: 10.1016/j.injury.2011.06.003] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 06/03/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic disruption of the pelvic ring is uncommon but is associated with a high risk of mortality. These injuries are predominantly due to high energy blunt trauma such as a fall from height, road or workplace trauma, and severe associated injuries are prevalent, increasing the complexity of managing this patient group. The aim of this population-based study was to investigate predictors of mortality following severe pelvic ring fractures managed in an inclusive, regionalised trauma system. METHODS Cases aged≥15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based statewide Victorian State Trauma Registry for analysis. Patient demographic, prehospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated. RESULTS There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged≥65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15-34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), whilst patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres). CONCLUSIONS The findings highlight the importance of effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.
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Affiliation(s)
- Belinda J Gabbe
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
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Young-Burgess classification of pelvic ring fractures: does it predict mortality, transfusion requirements, and non-orthopaedic injuries? J Orthop Trauma 2010; 24:603-9. [PMID: 20871246 DOI: 10.1097/bot.0b013e3181d3cb6b] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The objectives of this study were to evaluate the ability of the Young-Burgess classification system to predict mortality, transfusion requirements, and nonorthopaedic injuries in patients with pelvic ring fractures and to determine whether mortality rates after pelvic fractures have changed over time. DESIGN Retrospective review. SETTING Level I trauma center. PATIENTS One thousand two hundred forty-eight patients with pelvic fractures during a 7-year period. INTERVENTION None. MAIN OUTCOME MEASUREMENTS Mortality at index admission, transfusion requirement during first 24 hours, and presence of nonorthopaedic injuries as a function of Young-Burgess pelvic classification type. Mortality compared with historic controls. RESULTS Despite a relatively large sample size, the ability of the Young-Burgess system to predict mortality only approached statistical significance (P = 0.07, Kruskal-Wallis). The Young-Burgess system differentiated transfusion requirements--lateral compression Type 3 (LC3) and anteroposterior compression Types 2 (APC2) and 3 (APC3) fractures had higher transfusion requirements than did lateral compression Type 1 (LC1), anteroposterior compression Type 1 (APC1), and vertical shear (VS) (P < 0.05)--but was not as useful at predicting head, chest, or abdomen injuries. Dividing fractures into stable and unstable types allowed the system to predict mortality rates, abdomen injury rates, and transfusion requirements. Overall mortality in the study group was 9.1%, unchanged from original Young-Burgess studies 15 years previously (P = 0.3). CONCLUSIONS The Young-Burgess system is useful for predicting transfusion requirements. For the system to predict mortality or nonorthopaedic injuries, fractures must be divided into stable (APC1, LC1) and unstable (APC2, APC3, LC2, LC3, VS, combined mechanism of injury) types. LC1 injuries are very common and not always benign (overall mortality rate, 8.2%).
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29
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Patients with pelvic fracture: what factors are associated with mortality? Int J Emerg Med 2010; 3:299-304. [PMID: 21373296 PMCID: PMC3047881 DOI: 10.1007/s12245-010-0224-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 07/19/2010] [Indexed: 10/30/2022] Open
Abstract
BACKGROUND Pelvic fracture is one of the major injuries that lead to death in patients who sustain high-impact injuries such as road traffic accidents and falls from height. AIMS This study aims to look at the epidemiology and the significant predictors of mortality in victims with pelvic fracture presenting to the emergency department (ED) of an urban Asian city. METHODS This was a retrospective data analysis of all trauma patients with pelvic fracture who were treated at the ED of an urban adult hospital in Singapore from April 2001 to December 2004. Student's t-test and χ(2) test were used in statistical analysis where appropriate. RESULTS The study included 179 consecutive patients. Sixty-four percent of patients were males, and 71% of patients were in the 20-49-year-old age group. Road traffic accidents and falls from height were the two most common mechanisms of injury. Mortality rate was 37%. Pelvic fracture severity, shock and coma at presentation, and the presence of concurrent head and chest injuries were associated with increased mortality. Gender, other mechanisms of injury and other concomitant injuries were not associated with increased mortality. CONCLUSIONS The mortality rate of trauma patients with pelvic fracture continues to be high. In such patients, predictors of mortality are the severity of the pelvic fracture, the presence of coma, shock, and head and chest injuries.
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Pelvic ring fractures are an independent risk factor for death after blunt trauma. ACTA ACUST UNITED AC 2010; 68:930-4. [PMID: 20386286 DOI: 10.1097/ta.0b013e3181cb49d1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND It is unknown whether pelvic ring fracture is an independent predictor of death after blunt trauma. Few previous studies have attempted to analyze whether the high death rate observed in association with pelvic ring injury is secondary to the pelvic ring injury or merely related to many other injuries that typically are sustained in such cases. Our hypothesis was that pelvic ring fracture is an independent risk factor for death, even after accounting for the risk of death from other associated injuries. METHODS We reviewed the records of 31,550 patients who presented with blunt trauma at our Level I trauma center from 1995 to 2002. We analyzed our prospectively collected database and excluded any patient who was missing more than one demographic parameter (n = 414, 1.3% of the data set). Our study group consisted of 1,017 patients with pelvic ring fractures and 30,119 patients with blunt trauma without pelvic ring fractures. Multiple logistic regression analysis was conducted to account for the relative contribution of associated clinical criteria to mortality. A mortality model was then designed by using the regression analysis, allowing us to compare a calculated chance of death for each patient in the study group. We then compared the expected number of deaths of patients with pelvic injury with the actual number of observed deaths in that data set. Additionally, we conducted a second statistical analysis with which we compared the death rate of our pelvic ring fracture population (n = 1,017) with a matched subgroup (n = 1,017) from our patient population without pelvic ring fractures (n = 30,119). RESULTS The presence of pelvic ring fracture was found to be an independent risk factor for mortality in the blunt trauma population based on both statistical methods (odds ratios, 1.9 [p < 0.001] and 2.1 [p < 0.0007]). Other significant predictors of mortality included patient age, Injury Severity Score, Glasgow Coma Scale score, systolic blood pressure and respiratory rate at admission, and several medical comorbidities. CONCLUSION The presence of pelvic ring fracture seems to represent a clinically significant independent risk factor for mortality, even after accounting for the association with potentially severe additional body system injuries.
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Ramirez DWE, Schuette JJ, Knight V, Johnson E, Denise J, Walker AR. Necessity of routine pelvic radiograph in the pediatric blunt trauma patient. Clin Pediatr (Phila) 2008; 47:935-40. [PMID: 18567696 DOI: 10.1177/0009922808320598] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pelvic radiographs are obtained frequently in pediatric blunt trauma. The authors hypothesize that there are clinical indicators that can predict pelvic fracture on a pelvic radiograph in the pediatric blunt trauma patient with a Glasgow Coma Scale score of 14 or 15. METHODS A retrospective case-control study of 33 patients with pelvic fractures and 63 patients without pelvic fractures was performed. RESULTS 8 evaluated clinical indicators showed that pelvic contusions and abrasions (P = .026), hip/pelvic pain (P<.001), abdominal pain and distension (P = .006), back pain (P = .080), hip held in rotation at presentation (P = .026), and femur deformity/pain (P = .002) were independently predictive of pelvic fracture. In combination, absence of hip/pelvic pain, pelvic contusions and abrasions, abdominal pain/distension, and femur deformity/pain showed a negative predictive value of 87%. CONCLUSION Clinical indicators may be useful in determining the need for pelvic radiographs in awake and alert pediatric blunt trauma patients.
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Affiliation(s)
- Dana W E Ramirez
- Johns Hopkins Department of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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32
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Stein DM, O'Toole R, Scalea TM. Multidisciplinary approach for patients with pelvic fractures and hemodynamic instability. Scand J Surg 2008; 96:272-80. [PMID: 18265853 DOI: 10.1177/145749690709600403] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The hemodynamically unstable patient with a pelvic fracture presents a diagnostic and therapeutic challenge. The care of these patients requires a unique multidisciplinary approach with input and expertise from many different specialists. An understanding of pelvic anatomy and fracture patterns can help guide the diagnostic evaluation and treatment plan. The initial management of these patients must focus on rapid airway and hemorrhage control while preparing for ongoing blood loss. Rapid temporary fracture stabilization with simple bedside modalities is crucial in limiting additional blood loss. An exhaustive search must also be performed to evaluate for concomitant injuries that commonly accompany major pelvic fractures and the treatment of these other injuries must be appropriately prioritized. For patients who are unresponsive to standard resuscitation and bedside attempts at limiting hemorrhage, angiographic embolization is often utilized as the next step to attain hemodynamic stability. The key to successful management of these patients lies in the careful coordination of different specialists and the expertise that each brings to the clinical care of the patient.
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Affiliation(s)
- D M Stein
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland 21201, USA
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Linnau KF, Blackmore CC, Kaufman R, Nguyen TNH, Routt ML, Stambaugh LE, Jurkovich GJ, Mock CN. Do initial radiographs agree with crash site mechanism of injury in pelvic ring disruptions? A pilot study. J Orthop Trauma 2007; 21:375-80. [PMID: 17620995 DOI: 10.1097/bot.0b013e31809d5983] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Direction of injury force inferred from pelvic radiographs may be used in trauma care to predict associated injuries and guide intervention. Our objective was to compare injury direction determined from anteroposterior (AP) pelvic radiographs with injury forces determined from crash site investigation. MATERIALS AND METHODS We studied all 28 subjects from the Crash Injury Research Engineering Network (CIREN) database who met inclusion criteria of pelvic ring disruption, single-event crash, restrained front-seat occupant, diagnostic-quality pelvic radiography, and complete crash investigation data. Assessment of diagnostic quality of pelvic radiography was made by 2 radiologists who were blinded to all other subject information. Crash site investigation data included principal direction of force (PDOF), crash magnitude, and passenger compartment intrusion. An orthopedic trauma surgeon and a fellowship-trained emergency radiologist independently assessed the pelvic radiographs to determine the injury PDOF and the Young-Burgess and Tile fracture classifications, with disputes resolved by an additional emergency radiologist. Agreement between injury forces and pelvic radiographs was assessed using the kappa statistic. RESULTS The PDOF was anterior in 9 (32%) and lateral in 19 (68%) subjects. The readers agreed with the crash primary direction of force in 21 (75%) subjects (kappa=0.42). In subjects with lateral PDOF, agreement was 89% (17/19) compared to 44% for anterior PDOF (4/9). Interobserver agreement for the Young and Tile classification schemes was moderate (weighted kappa 0.44 and 0.54, respectively). CONCLUSION Crash site investigation and pelvic radiography may provide conflicting information about primary direction of injuring forces. Presumed anterior impact based on PDOF is not in consistent agreement with the pattern of injury evident on the AP pelvic radiograph.
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Affiliation(s)
- Ken F Linnau
- Department of Radiology, Harborview Medical Center, Seattle, Washington 98104-2499, USA
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Tötterman A, Madsen JE, Skaga NO, Røise O. Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. ACTA ACUST UNITED AC 2007; 62:843-52. [PMID: 17426538 DOI: 10.1097/01.ta.0000221673.98117.c9] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe the method of extraperitoneal pelvic packing (EPP), and to assess the impact of EPP on outcome in severely hemodynamically unstable patients after blunt pelvic trauma. METHODS Of 661 patients treated for pelvic trauma, 18 underwent EPP as part of our protocol with the intent to control massive pelvic bleeding and constituted the study population. Data retrospectively collected from the medical records and from the Ullevål Trauma Registry included demographics, fracture classification, additional injuries, blood transfusions, surgical interventions, angiographic procedure, physiologic parameters, and survival. RESULTS Survival rate within 30 days was 72% (13/18), and correlated inversely to the age of the patient (p = 0.038). Only one of the nonsurvivors died of exsanguination. A significant increase in systolic blood pressure (BP) (p = 0.002) was observed immediately after EPP. Angiography performed after EPP was positive for arterial injury in 80% of patients. All types of pelvic ring fractures were represented. CONCLUSIONS EPP as part of a multi-interventional resuscitation protocol might be life saving in patients with life-threatening pelvic injury who are exsanguinating. However, the high rate of arterial injuries seen after EPP indicates that the procedure should be supplemented with angiography once the patient is sufficiently stabilized to tolerate transportation to the angiography suite.
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Affiliation(s)
- Anna Tötterman
- Orthopedic Centre, Ullevål University Hospital, Oslo, Norway.
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Stein DM, O'Connor JV, Kufera JA, Ho SM, Dischinger PC, Copeland CE, Scalea TM. Risk Factors Associated with Pelvic Fractures Sustained in Motor Vehicle Collisions Involving Newer Vehicles. ACTA ACUST UNITED AC 2006; 61:21-30; discussion 30-1. [PMID: 16832246 DOI: 10.1097/01.ta.0000222646.46868.cb] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite advances in automotive safety, pelvic fractures caused by motor vehicle collisions remain a significant cause of mortality, morbidity, and functional disability. This study was designed to evaluate epidemiologic and biomechanic risk factors associated with pelvic fractures resulting from motor vehicle collisions. We utilized the Crash Injury Research Engineering Network (CIREN) database to identify these risk factors in newer vehicles. METHODS Data were prospectively collected at the ten CIREN centers from 1996 to 2005. Specific data were then abstracted on all patients, biomechanic crash characteristics, and injuries sustained. Patients involved in a frontal or near-side lateral impact with pelvic fractures were compared with those without. Univariate analysis was performed using a chi2 analysis. Logistic regression was used to identify significant risk factors in a multivariate analysis to control for confounding associations. RESULTS Of the 1,851 patients studied, 511 (27.6%) had a pelvic fracture. The overall mortality was 17%. Injury specific factors associated with pelvic fracture were higher Injury Severity Score (ISS) and fatality of the patient. Biomechanic factors associated with the risk of pelvic fracture included; no airbag deployment (p < 0.001), smaller vehicle (p = 0.05), and lateral deformation location (p < 0.001). When stratified by vehicle deformation location, logistic regression models revealed statically significant variables in a frontal impact which included; higher body mass index, higher ISS, large patient vehicle, no seatbelt use, and higher deltaV. For near-side lateral impacts, multivariate analysis revealed statistically significant variables of lower body mass index, higher ISS, female sex, small vehicle size, and higher deltaV. CONCLUSIONS Even in newer vehicles with federally mandated safety features, pelvic fractures remain a common injury. Pelvic fractures may serve as a marker of crash severity and specific crash characteristics are associated with pelvic fractures. Lateral crashes are significantly more likely to result in a pelvic fracture and, therefore, prevention of pelvic fractures should focus on improving occupant safety in near-side lateral impacts. Recognition of other associations should lead researchers to further investigate causative factors that will ultimately result in improved vehicle design.
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Affiliation(s)
- Deborah M Stein
- Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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