Ipsilateral fractures of the pelvis and the femur--floating hip? A retrospective analysis of 42 cases

The floating hip injury: a descriptive study and case-control analysis

PURPOSE

A "floating hip" (FH) injury is a rare injury describing the simultaneous ipsilateral fracture of the femur and pelvis or acetabulum (P/A). We describe our experience with patients presenting with FH injuries and compare them to controls with similar P/A fractures but without femoral involvement.

METHODS

Medical records and radiographs of FH patients and controls presenting to our tertiary centre between 2015 and 2020 were reviewed. Follow-up data from outpatient clinical records were also extracted. The control group were extensively matched by age, sex, body mass index, fracture classification and energy of injury.

RESULTS

From 1392 recorded P/A fractures, 42 FH cases were identified (average age 39 years, 78.6% males). The most common femoral fracture was the midshaft (35.7%), followed by the neck of femur (26.2%). 90.5% of FH injuries were due to high-energy mechanisms. 64.3% of P/A fractures, and 100% of femoral fractures were managed surgically. Compared to controls, FH cases were more likely to have additional orthopaedic injuries (73.8% vs. 40.5%, p = 0.002), more total theatre admissions (mean 2.5 vs. 1.19, p < 0.001), longer hospital stays (28.3 vs. 14.9 days, p = 0.02), and a higher rates of post-op complications (53.8% vs. 20%, p = 0.025).

CONCLUSIONS

We report differences in the presentation, management, and outcomes of FH injuries versus controls, even after extensive matching for confounders. These differences may inform future treatment strategies for the FH injury.

Simultaneous ipsilateral floating hip and knee: the double floating extremity-a systematic review and proposal of a treatment algorithm

PURPOSE

To systematically review the currently available existing evidence related to the presentation and management of simultaneous floating hip and knee injuries to identify injury characteristics, treatment strategies, and complications.

METHODS

Data sources: Relevant articles were identified by searching Medline, PubMed, and Google Scholar databases with no language restrictions. Manual searches of other relevant databases (SciELO and grey literature databases) and reference lists of primary articles found from initial searches were also conducted.

STUDY SELECTION

All types of study designs published from January 1st, 2000 to October 1st, 2022 involving skeletally mature patients with simultaneous floating hip and knee injuries were included.

DATA EXTRACTION

Basic information and specific injury-related information were collected.

RESULTS

Eight case reports were included. No study adequately reported the case with sufficient detail to allow other investigators to make inferences, nor was the result properly calculated, nor was the follow-up considered adequate for adequate functional assessment to occur in 80% of the studies.

CONCLUSION

The exact treatment strategy and the follow-up time are not uniform across the included studies; therefore, they are not sufficient to adequately recommend surgical approach, timing of fixation, and fixation method. Our findings warrant the need for better documentation and reporting information about the mode of treatment of simultaneous floating hip and knee injuries.

Medium-term clinical results in patients with floating hip injuries

BACKGROUND

The objective of this study was to evaluate the effectiveness of our strategy for managing floating hip injuries.

METHODS

From January 2014 and December 2019, all patients with a floating hip underwent surgical treatment in our hospital were included in the retrospective study, with a minimum follow-up of 1 year. All patients were managed according to a standardised strategy. Data on epidemiology, radiography, clinical outcomes and complications were collected and analysed.

RESULTS

Twenty-eight patients were enrolled, with an average age of 45 years. The mean follow-up was 36.9 months. According to the Liebergall classification, Type A floating hip injuries predominated (n = 15, 53.6%). Head and chest injuries were the most common associated injuries. When multiple operative settings were required, we prioritized the fixation of the femur fracture at the first operation. The mean time from injury to definitive femoral surgery was 6.1 days, with most (75%) femoral fractures treated with intramedullary fixation. More than half (54%) of acetabular fractures were treated with a single surgical approach. Pelvic ring fixation included isolated anterior fixation, isolated posterior fixation, combined anterior and posterior fixation, of which isolated anterior fixation was the most common. Postoperative radiographs suggested that the anatomic reduction rates of acetabulum and pelvic ring fractures were 54% and 70%, respectively. According to grading system of Merle d'Aubigne and Postel, 62% of patients achieved satisfactory hip function. Complications included delayed incision healing (7.1%), deep vein thrombosis (10.7%), heterotopic ossification (10.7%), femoral head avascular necrosis (7.1%), post-traumatic osteoarthritis (14.3%), fracture malunion (n = 2, 7.1%) and nonunion (n = 2, 7.1%). In the patients with complications described above, only two patients underwent resurgery.

CONCLUSIONS

Although there is no difference in clinical outcomes and complications among different types of floating hip injuries, special attention should be paid to anatomical reduction of the acetabular surface and restoration of the pelvic ring. In addition, the severity of such compound injuries often exceeds that of an isolated injury and often requires specialised multidisciplinary management. Because of no standard guidelines for treatment of such injuries, our experience in the management of such a complex case is to fully assess the complexity of the injury and formulate an appropriate surgical plan based on the principles of damage control orthopaedics.

„Floating Hip“: Epidemiologie und Qualität der Versorgung

Einleitung Bei einer „floating-hip“-Verletzung handelt es sich um eine seltene, in der Behandlung komplexe Fraktur, die das Becken und das ipsilaterale Femur betrifft. Daten und Studien zu diesem Thema sind immer noch spärlich. Die optimale Strategie für die chirurgische Behandlung und damit die daraus resultierende Behandlungsqualität ist nach wie vor umstritten; häufig wird eine „Femur-first“-Strategie bevorzugt. Methoden Retrospektiv wurden Patienten mit einer Beckenfraktur untersucht, die zwischen 2003 und 2017 im Level-I-Traumazentrum der Universität Tübingen behandelt wurden. Patienten mit einer zusätzlichen ipsilateralen Femurfraktur wurden in diesem Kollektiv identifiziert. Wir verglichen die Qualität der Behandlung von Beckenfrakturen zwischen „floating-hip“- und „non-floating-hip“-Beckenfrakturen. Ergebnisse Proximale Femurfrakturen traten bei Beckenringfrakturen häufiger auf (n = 16) als bei Azetabulumfrakturen (n = 1). „Floating-hip“-Verletzungen treten bei jüngeren polytraumatisierten männlichen Patienten häufiger auf. Beckenfrakturen bei „floating-hip“-Verletzungen werden häufiger operiert (62,8% vs. 39,1%; p = 0,003) und der klinische Verlauf ist signifikant länger (27,8 ± 19,3 vs. 19,9 ± 23,1 Tage; p < 0,001). Die Qualität der Behandlung der Beckenfraktur, gemessen an Morbidität (18,6% vs. 14,6%; p = 0,610) und Mortalität (7,0% vs. 2,6%; p = 0,108), zeigt jedoch keine Unterschiede. Schlussfolgerung Verletzungsschwere und Komplexität der Beckenfraktur sind bei „floating-hip“-Verletzungen signifikant höher, ohne jedoch die resultierende Behandlungsqualität zu beeinträchtigen. Eine „Femur-first“-Behandlungsstrategie wird von uns und in der Literatur bevorzugt. In einem Flussdiagramm werden dementsprechende Algorithmen für die Notfallbehandlung und die endgültige Versorgung vorgeschlagen.

Floating hip in polytraumatized patients: complications, mechanism of injury, and surgical strategy

PURPOSE

Floating hip fractures are severe and rare injuries with high complication rate and lack of standard management. The purpose of this retrospective study was to review the outcomes of a case series of polytraumatized patients with floating hip injuries, in order to describe the relationship between complication rate and floating hip injury type, the pathomechanism of injury, and the surgical treatment strategy.

METHODS

Forty-five patients with floating hip injuries were analyzed. Complication rate, mechanism of injury, and surgical strategy (damage control orthopedics, stages of internal fixation) were recorded. Fractures were classified using the Mueller system for floating hips and AO/OTA system for the other fractures.

RESULTS

Of the 45 patients with floating hip injuries, 23 (51.1%) developed complications. The results revealed that the complication rate was associated with the instability and type of the pelvic or acetabular fracture (61-C AO/OTA pelvic fracture [73.3%; p = 0.04], 62-B AO/OTA acetabular fracture [88.8%; p = 0.03]). Vertical shear (VS) pelvic fractures were related to middle-distal femoral fractures and lateral compression/anteroposterior compression (LC/APC) pelvic lesions were associated to proximal femoral fractures (p = 0.012).

CONCLUSIONS

Complications were associated with the severity and instability of the pelvic and acetabular type of fractures. The pathomechanism causing Mueller type B and C floating hip injuries was illustrated. A two-stage "femur first" surgical approach was the preferred one for definite internal fixation of fractures.

Concomitant ipsilateral acetabular and femoral fractures – an appraisal of outcomes and complications in 34 patients

Concomitant ipsilateral femoral and acetabular fractures are complex injuries which result from high-velocity trauma. Surgical treatment is the accepted management of such injuries. The objectives of this study were to evaluate the outcomes and study the complications in patients treated for concomitant ipsilateral acetabular and femoral fractures (type ‘B’ floating hip injuries). This retrospective study was conducted at a tertiary care teaching hospital on patients operated for type B floating hip injuries, who had completed a minimum of one-year follow-up after the surgery and whose complete records were available. Those with floating hip injuries with pelvic fractures were excluded. All patients were operated on the femoral side first, followed by the acetabular side. 34 patients were included ; most of them were young males. A road traffic accident was the most common mode, with a dashboard injury being the most common mechanism of injury. No association between the type of acetabular and femoral fractures was found. The clinical (measured with Harris hip score) and radiological (Matta’s method) outcomes at the latest follow-up were excellent or good in >60% cases and had a significant association with the quality of reduction on the post-operative radiographs. Com- plications were seen in 12 out of the 34 patients. Type B floating hips injuries can be managed well with acceptable short-term results by following a femur first strategy. However, patients must be informed of the possible complications and the probabilities of poorer outcomes when compared to isolated acetabular or femoral fractures.

Functional outcome and health-related quality of life following ipsilateral femoral and acetabular fractures: a retrospective analysis

INTRODUCTION

The combination of ipsilateral femoral and acetabular fractures is known in the literature as the "Floating hip injury". The primary aim of this study is to assess both generic and specific patient-reported outcomes and the factors affecting the quality of life in patients sustaining this injury, while the secondary aim was to assess the injury patterns and the associated complications.

METHODS

A retrospective study including 27 patients according to specific inclusion and exclusion criteria. EQ5D5L and Oxford hip score (OHS) were used. The mean age was 28 years (±10.1 SD) and 21 patients (77.8%) were males. The mean follow-up was 7 years (± 3.1 years SD).

RESULTS

Median OHS was 46.5 (IQR: 31.5-48). The median EQ5D score was 0.919 (95% CI: 0.601-1). The mean EQ5D index value was 0.679 ± 0.442 (95% CI: 0.492-0.865). In this young cohort of patients, this drop in the mean EQ5D index value has led to a loss of a mean of 2.2 Quality-adjusted Life Years (QALYs). Through multivariate analysis, we found that the quality of life was mainly affected by the occurrence of end-stage arthritis, the presence of non-recovered traumatic sciatic nerve injury, and the occurrence of infection.

CONCLUSIONS

Our findings show that the quality of life of those patients was significantly affected. These findings can be beneficial in counselling patients sustaining this complex injury and could be helpful in the discussion of the prognosis and in planning postoperative rehabilitation and support.

Complications and outcomes in 69 consecutive patients with floating hip

BACKGROUND

Floating hip is a rare and potentially serious injury. The objective of this study was to evaluate our management strategy for patients with floating hip.

HYPOTHESIS

A standardized strategy with specialised multidisciplinary management is associated with a low mortality rate.

METHODS

Consecutive patients who had surgery to treat floating hip between January 2010 and December 2019 were included in this single-centre retrospective study. Epidemiological, clinical, and radiological data were collected and analysed. Patients were managed according to a standardised strategy adapted to the haemodynamic status and type of floating hip (type A, femoral and pelvic ring fractures; type B, femoral and acetabular fractures; and type C, femoral, acetabular, and pelvic ring fractures). The clinical outcome at last follow-up was determined by a telephone interview, based on the Majeed and Oxford scores, sports resumption, and work resumption. To assess the radiological outcomes, we applied Matta's criteria for the acetabulum and Tornetta's criteria for the pelvic ring.

RESULTS

We included 69 patients with a mean age of 38.5 years. Among them, 39 (57%) had haemodynamic instability requiring embolisation (n=15, 22%) or multiple blood transfusions (n=24, 35%). Type A injuries predominated (n=57, 83%). The need for multiple blood transfusions was significantly associated with type C floating hip, underlining the risk of heavy bleeding with this injury. Two (3%) patients died. When management was complete, the reduction was anatomical or satisfactory for 76% (13/17) of the acetabula according to Matta's criteria (maximum residual displacement <3mm) and for 85% (56/66) of the pelvic rings according to Tornetta's criteria (maximum residual displacement <10mm). One or more complications occurred in 45 (65%) patients. After a mean follow-up of 5 years, the mean Oxford Hip Score in patients with acetabular fractures was 35.5 and the mean Majeed score in patients with pelvic ring fractures was 71.5. Only 30% of patients were able to resume physical activities at the former level and to return to their former professional activities.

CONCLUSION

Type C floating hip, which combines fractures of the pelvic ring and acetabulum, carries a high risk of bleeding. Special attention should be directed to the reduction of pelvic ring fractures, to avoid malunion. Acetabular fractures that are complex in the Letournel classification carry a risk of imperfect reduction. The results of this study confirm the severity of these rare injuries and the need for specialised multidisciplinary management according to a standardised strategy that is appropriate for the haemodynamic status and type of floating hip (A, B, or C).

LEVEL OF EVIDENCE

IV; retrospective study.

Simultaneous Ipsilateral Floating Hip and Knee: A Complex Combination and Difficult Surgical Challenge

Simultaneous ipsilateral floating hip and floating knee are extremely rare. To the best of our knowledge, only four cases have been described in the literature. This uncommon injury is mostly caused by high-velocity impact and associated with life-threatening lesions. We report a unique case of concomitant ipsilateral floating hip and floating knee following road traffic accident. The patient presented ipsilateral hip dislocation and acetabular, femoral, and tibial fractures associated with chest trauma. The aim of this report is to highlight the severity and rarity of this combination and to describe the therapeutic recommendations.

The term "floating" used in traumatic orthopedics

BACKGROUND

The term "floating" is used in orthopedic literature to describe certain patterns of skeletal injuries that share one common character which is disruption and discontinuity of bones above and below a joint. The first time used in orthopedic literature being in late 1970 to describe a type of elbow injury. Later the word was used increasingly and applied to a variety of injuries affecting the knee, shoulder, hip, forearm, hand, and ankle. Currently, there are about 12 different skeletal injuries described as floating.

OBJECTIVES

The aim of this article was to define the term "floating" used in traumatic orthopedics and to discuss its history, mechanism of injury in each region, treatment and outcomes based on the currently available literature. As there were many separate articles describing different sites of floating injuries, this review aimed to summarize all floating injuries into 1 article.

Ipsilateral Acetabular Fracture with Displaced Femoral Head and Femoral Shaft Fracture: A Complex Floating Hip Injury

Floating hip injuries involving the acetabulum, femoral head, and the femoral shaft are a very rare presentation. A complex floating hip injury comprising of an ipsilateral acetabular fracture associated with a displaced femoral head fracture and a femoral shaft fracture following a high-velocity road traffic accident presented to us where all the fractures were addressed with internal fixation during the primary surgery. Postoperatively, the patient suffered a dislocation of the femoral head which eventually went on to avascular necrosis at 5 months from the initial presentation. Then, the patient underwent a total hip replacement with an acetabular reconstruction following which he went on to have a good functional outcome. Our experience in dealing with such a complex case shows that it is difficult to set a protocol for such injuries and they need to be addressed on a case-to-case basis depending on the complexity of the injury.

Treatment and Complications of Patients With Ipsilateral Acetabular and Femur Fractures: A Multicenter Retrospective Analysis

OBJECTIVES

The purpose of this study was to review the treatment of patients with ipsilateral acetabular and femur fractures to provide descriptive demographic data, injury pattern classification, treatment, and evaluate the complication profile reflective of current practices.

STUDY DESIGN

Multicenter retrospective cohort.

SETTING

Eight Level 1 Trauma Centers.

PATIENTS/PARTICIPANTS

One hundred one patients met inclusion criteria.

INTERVENTION

Surgical treatment of both the acetabular and femur fractures.

MAIN OUTCOME MEASUREMENTS

The complications evaluated include avascular necrosis, heterotopic ossification, posttraumatic arthritis, deep venous thrombosis, pulmonary embolism and superficial/deep infection, fracture union, and secondary surgeries.

RESULTS

Forty-three patients had 31 type fractures (29A; 11B, and 3C), 60 had 32 type (37A, 8B; 15C), and 8 had 33 type (1A, 4B, 3C) femur fractures; 10 patients had combinations involving more than 1 femur fracture pattern. There were 35 62A type fractures, 47 62B, and 19 62C acetabular fractures. Age of 45 or older was associated with marginal impaction (P = 0.001). The aggregate infection rate was 17%. More than 30% of patients required secondary surgeries. The rate of avascular necrosis was higher in acetabular fractures combined with proximal femur fractures (P < 0.05). The rate of deep venous thrombosis was associated with increased age and time to surgical fixation (P < 0.05).

CONCLUSIONS

We report the largest review of the surgical treatment and complications of ipsilateral acetabular and femoral fractures. This study provides useful information regarding the complications and provides some treatment recommendations regarding these injuries.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Floating hip and associated injuries

AIM

To describe our experience in treating patients diagnosed with floating hip injury and to communicate the outcomes achieved and the rate of complications. A secondary aim is to compare the results of this group in terms of quality of life with those of patients presenting with a fracture either of the pelvis or of the acetabulum, but in which the femoral segment is not involved.

PATIENTS AND METHODS

This is a descriptive study of the patients diagnosed with floating hip injury (25 patients) who were treated at our hospital between 2004 and 2007, with a minimum follow-up of seven years. The results are compared with those of a control group of 56 patients diagnosed with an isolated pelvic or acetabular injury. We describe the injuries and the associated lesion. The patients' quality of life was assessed using the EUROQOL tool.

RESULTS

Among the floating hip group of patients, three suffered an additional arterial lesion and were later treated with a supracondylar amputation. Seven patients presented heterotopic ossification. No significant difference was observed between the study and control groups, according to the EUROQOL tool, although the scores for every dimension were lower among the floating hip patients. Among the patients in the control group, the quality of life scores were also affected in every dimension of the EUROQOL scale.

DISCUSSION AND CONCLUSIONS

The addition of a femoral fracture to a pelvic or acetabular injury, the so-called floating hip, is a devastating injury which has an important impact on patients' quality of life, going beyond that experienced by patients with isolated injuries. Nevertheless, our results did not reflect statistically significant differences in the quality of life among the three groups analyzed: isolated fractures, floating hip and floating hip resulting in amputation.

Ipsilateral Acetabular and Femoral Neck and Shaft Fractures

Floating hip injuries and ipsilateral femoral neck and shaft fractures are rare. Additionally, the simultaneous occurrence of these injuries is extremely rare, and only one case report of the simultaneous occurrence of these injuries has been published. Here, we report the case of a patient with ipsilateral acetabular and femoral neck and shaft fractures following a suicide attempt. The patient experienced nonunion of the femoral neck and shaft after the initial operation and therefore underwent reconstruction using a femoral head prosthesis with a long stem and interlocking screws. Our procedure may be used in primary and/or secondary reconstruction for ipsilateral acetabular and femoral neck and shaft fractures.

Vascular complications in floating hip

The so-called floating hip involves a pelvis or an acetabular fracture together with an ipsilateral femur bone fracture. Concurrent injuries are also common in these cases, with the evolution and outcome worse than expected when these fractures exist in isolation. We studied a series of 11 patients with floating hip lesions. They all presented within a general polytrauma diagnosis. Diaphyseal femur fracture together with ipsilateral acetabular fracture was the most common combination. Supracondylar fracture occurred in 3 cases; these patients also had a popliteal vascular injury, and underwent a subsequent vascular repair. Although that treatment was promptly performed by a vascular surgeon, all of these patients in the end underwent an above-knee amputation. Bladder lesion, sciatic nerve injury, myositis ossificans, and skin injuries were also associated with these patients with a floating hip. Although vascular injuries in a floating hip have not been previously described in the literature, in our series these constituted the most severe complication. Whenever a major lower limb vascular injury coexists with a floating hip, prompt vascular repair must be accomplished. However, according to our experience, the nature of these lesions makes any expectation of limb viability very unlikely.

The irreducible floating hip: a unique presentation of a rare injury

A floating hip injury occurs in the setting of poly-trauma and is a rare and difficult problem to manage. Floating hip injuries require vigilant attention not only to the osseous injuries but also the surrounding compartments and soft tissue envelope. We report the case of a 35-year-old male with a lower extremity posterior wall acetabular fracture, ipsilateral femoral shaft fracture and a postero-superior hip dislocation. Closed reduction failed, necessitating an open reduction internal fixation of his hip dislocation and acetabular fracture. The patient then developed a thigh compartment syndrome requiring a fasciotomy. Despite the obvious bony injuries, orthopedic surgeons must be vigilant of the neurovascular structures and soft tissues that have absorbed a great amount of force. A treatment plan should be formulated based on the status of the overlying soft tissue, fracture pattern and the patient's physiologic stability.

Antegrade femoral nailing in acetabular fractures requiring a Kocher-Langenbeck approach

Ipsilateral displaced acetabular and femoral shaft fractures represent a dilemma for orthopedic surgeons because antegrade femoral nailing may complicate a Kocher-Langenbeck acetabular exposure. The goals of this study were to review the results of ipsilateral femoral and acetabular fractures treated with antegrade femoral nailing and a Kocher-Langenbeck approach and to evaluate the assertion that this treatment strategy is associated with increased morbidity. This was a retrospective cohort study at a regional Level I trauma center. Sixteen patients with a femoral fracture treated with antegrade nailing and an ipsilateral acetabular fracture treated with a Kocher-Langenbeck approach were identified. One patient died as a result of his injuries, and 2 were not available for long-term follow-up. One had a deep infection requiring irrigation, debridement, and intraveonous antibiotics. One patient developed a hematoma requiring irrigation and debridement. At final follow-up, 2 patients had no heterotopic ossification about the hip, 4 had Brooker class I heterotopic ossification, 3 had Brooker class II heterotopic ossification, 2 had Brooker class III heterotopic ossification, and 2 patients had Brooker class IV heterotopic ossification requiring excision. Ipsilateral femoral and acetabular fractures represent a rare and severe injury constellation. Antegrade nailing of the femur with ipsilateral Kocher-Langenbeck exposure for fixation of the acetabulum was not associated with excessive rates of wound-healing complications, but the incidence of heterotopic ossification was increased.

Ipsilateral Floating Hip and Floating Knee - A Rare Entity

Introduction:

Ipsilateral floating hip and floating knee are very rare injuries. These injuries so uncommon that only three cases of similar kind have been reported. These injuries are due to high velocity injuries following motor vehicle accidents. Management of such complex injuries is a challenging task even in experienced hands as there are no standard treatment guidelines for such fractures.

Case Report:

We hereby report a 20 yr old male who sustained ipsilateral floating hip and ipsilateral floating knee injuries following motor vehicle accident. Patient was stabilized initially and later taken up for surgery. Patient was treated with interlocking nail for femur and tibia in the same sitting whereas acetabulam fracture was managed conservatively. At five months all the fractures united well with restoration of good range of motion in both hip and knee

Conclusion:

Ipsilateral floating knee and floating hip are very rare injuries seen following high velocity motor vehicle accidents. There are no standard guidelines for treatment of those fractures as only a few cases of similar kind have been reported in literature. Early fixation and aggressive mobilization ensures fracture union and fewer complications.

The floating hip: complications and outcomes

BACKGROUND

To perform a descriptive study of the course, treatment decisions, complications, and outcome of patients suffering simultaneous ipsilateral fractures of the femur and pelvis.

METHODS

Medical records and radiographs of 57 patients were reviewed retrospectively.

RESULTS

The average follow-up was 28 months. Fifteen patients (26%) had an acetabular fracture, 17 (30%) had a pelvic ring fracture, and 25 (44%) had both fractures concomitant with the ipsilateral femoral fracture. Eighty percent of acetabular fractures and 55% of pelvic ring fractures were treated surgically. Femur fractures underwent operation in 94% of cases. When multiple operative settings were used, the femur fracture was always fixed at the first operation. Complications included deep venous thrombosis (DVT) (12%), heterotopic ossification (HO) (34%), femoral head avascular necrosis (AVN) (2%), osteoarthritis (OA) (16%), and traumatic sciatic nerve palsy (33%). At least partial nerve palsy resolution occurred in 53% of patients.

CONCLUSIONS

Ipsilateral injuries to the femur and the pelvis or acetabulum ("floating hip") are severe injuries usually caused by high-energy trauma. The acetabulum and pelvic ring are more commonly fractured together than either alone. The femur fracture will most commonly be addressed first, as in 65% of our cases in which both components were addressed at the same setting, and 100% of cases in which they were addressed in separate settings. Delays of surgery were common because of severity of systemic trauma. Surgeons should be aware of the high incidence of sciatic nerve palsy as well as treatment options and potential complications associated with this devastating combination of injuries.

Pelvic radiography in ATLS algorithms: A diminishing role?

Background

Pelvic x-ray is a routine part of the primary survey of polytraumatized patients according to Advanced Trauma Life Support (ATLS) guidelines. However, pelvic CT is the gold standard imaging technique in the diagnosis of pelvic fractures. This study was conducted to confirm the safety of a modified ATLS algorithm omitting pelvic x-ray in hemodynamically stable polytraumatized patients with clinically stable pelvis in favour of later pelvic examination by CT scan.

Methods

We conducted a retrospective analysis of all polytraumatized patients in our emergency room between 01.07.2004 and 31.01.2006. Inclusion criteria were blunt abdominal trauma, initial hemodynamic stability and a stable pelvis on clinical examination. We excluded patients requiring immediate intervention because of hemodynamic instability.

Results

We reviewed the records of n = 452 polytraumatized patients, of which n = 91 fulfilled inclusion criteria (56% male, mean age = 45 years). The mechanism of trauma included 43% road traffic accidents, 47% falls. In 68/91 (75%) patients, both a pelvic x-ray and a CT examination were performed; the remainder had only pelvic CT. In 6/68 (9%) patients, pelvic fracture was diagnosed by pelvic x-ray. None of these 6 patients was found having a false positive pelvic x-ray, i.e. there was no fracture on pelvic CT scan. In 3/68 (4%) cases a fracture was missed in the pelvic x-ray, but confirmed on CT (false negative on x-ray). None of the diagnosed fractures needed an immediate therapeutic intervention. 5 (56%) were classified type A fractures, and another 4 (44%) B 2.1 in computed tomography (AO classification). One A 2.1 fracture was found in a clinically stable patient who only received CT scan (1/23).

Conclusion

While pelvic x-ray is an integral part of ATLS assessment, this retrospective study suggests that in hemodynamically stable patients with clinically stable pevis, its sensitivity is only 67% and it may safely be omitted in favor of a pelvic CT examination if such is planned in adjunct assessment and available. The results support the safety and utility of our modified ATLS algorithm. A randomized controlled trial using the algorithm can safely be conducted to confirm the results.

Die Morel-Lavallée-Läsion

The Morel-Lavallée lesion is a rare condition that was first described by the French physician Maurice Morel-Lavallée in 1853. The lesion is caused by forces of pressure and shear stress at the borders of subcutaneous tissue to the muscle fascia or bone as they are seen in run-over accidents. It leads to a shear of skin and subcutaneous tissue from the neighboring fascia followed by the development of a blood-filled hollow space at predestined regions of the body. If therapy is insufficient, large areas of necrosis can form, which will negatively influence operative measures. We report about three patients with the diagnosis of a Morel-Lavallée lesion. The history and the impressive clinical findings are demonstrated as well as the differential operative therapy performed, partially with osteosynthesis of accompanying bone injuries. According to the recommendations of the literature known to us, an adjusted therapeutic regime suited to the particular findings was carried out and in all three cases uncomplicated healing can be reported. Our results are in line with the existing recommendations, which are to relieve the soft tissue hematoma in time and sufficiently, and secondly to carry out débridements initially as well as planned second-look operations.