Severe pelvic injury: vascular lesions detected by ante- and post-mortem contrast medium-enhanced CT and associations with pelvic fractures

The current state of forensic imaging - post mortem imaging

Over the last few decades, forensic imaging has become an essential part of current forensic practice. The aim of this 4-part review is to provide a comprehensive overview of forensic imaging over the first 25 years of this century. After a brief historic review, this first part details the advantages and limitations of post-mortem imaging for the indications most frequently encountered in daily practice.

Anterior subcutaneous internal fixator (INFIX) versus plate fixation for anterior ring injury in Tile C pelvic fractures: a retrospective study

OBJECTIVES

. The purpose of this study was to compare the reduction effect and clinical outcomes of anterior subcutaneous internal fixation (INFIX) and steel plate-screw internal fixation in the treatment of anterior ring injury in Tile C pelvic fractures.

METHODS

. In this retrospective study, the clinical outcomes of 46 patients treated using INFIX and 44 patients treated with steel plate-screw internal fixation were analyzed and compared. All patients underwent anterior and posterior fixation. The Matta imaging scoring system was used to evaluate the postoperative reduction accuracy; the Majeed scoring system was applied to obtain functional outcomes in clinical follow-up. All potential complications were identified and evaluated accordingly.

RESULTS

Both groups of patients were followed up for a period of 13-36 months, with an average of 27 months. The procedure time and blood loss in the INFIX group were significantly lower than those in the plate group(t = - 2.327, P = 0.023;t = - 4.053, P = 0.000; there was no statistically significant difference in the Majeed score and Matta score between the two groups after surgery (P > 0.05).

CONCLUSIONS

. INFIX treatment for anterior ring injury in Tile C pelvic fractures can achieve good therapeutic effects. Compared to internal fixation with plates and screws, it has advantages such as shorter surgical time and less blood loss. INFIX may be more suitable for obese patients, young women of childbearing age, or patients with urinary system injuries.

Bleeding-Source Exploration in Subdural Hematoma: Observational Study on the Usefulness of Postmortem Computed Tomography Angiography

In a few cases, postmortem computed tomography angiography (PMCTA) is effective in postmortem detection of cortical artery rupture causing subdural hematoma (SDH), which is difficult to detect at autopsy. Here, we explore the usefulness and limitations of PMCTA in detecting the sites of cortical arterial rupture for SDH. In 6 of 10 cases, extravascular leakage of contrast material at nine different places enabled PMCTA to identify cortical arterial rupture. PMCTA did not induce destructive arterial artifacts, which often occur during autopsy. We found that, although not in all cases, PMCTA could show the site of cortical arterial rupture causing subdural hematoma in some cases. This technique is beneficial for cases of SDH autopsy, as it can be performed nondestructively and before destructive artifacts from the autopsy occur.

Team Approach: The Unstable Trauma Patient

» A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.» The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries» Effective and open dialog with consulting specialists is paramount for effective team-based care.» Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.

Outcomes in Blunt vs Penetrating Pelvic Vascular Injuries

OBJECTIVES

The purpose of this study is to determine if there is a difference in outcomes for patients with blunt and penetrating vascular injuries of the pelvis.

METHODS

Data were abstracted from the Trauma Quality Improvement Program database from 2011 to 2015. Patients >18 years with hypogastric, iliac, uterine, or ovarian arterial or venous injuries were included. Individuals with an AIS head or chest score >3 were excluded.

RESULTS

Of the 2559 patients included, the mean age was 43 years (±19), 75.25% were male, and 32.6% had a comorbidity. 64.9% presented with blunt injury (mean ISS of 23 (±12)). 74.9% experienced a complication. The median hospital length of stay (LOS) and ICU LOS were 10 days and 4 days, respectively. 6.7% had an adverse discharge. Mortality occurred in 8.3%. On bivariate analysis, patients who sustained blunt trauma were older (51 vs 31 years), female (32.7% vs 10.1%), had a higher ISS (25.71 vs 17.65), and had a longer hospital LOS (16.65 vs 13.88). Patients with penetrating trauma had an increased chance of complications (78.4% vs 73.0%) and mortality (10.7% vs 7.0%). Multivariate analysis revealed in patients with blunt injuries have more complications (OR: 1.950 CI: 0.886-4.291 P = .097), a lower ISS (OR: 0.919, CI: 0.908-0.930, P < .001, were more likely to have an adverse discharge (OR: 2.05, CI: 1.62-2.60, P = .000), and had a higher risk of mortality (OR: 4.08 CI: 2.78-6.41 P < .000).

CONCLUSION

Patients with blunt pelvic vessel injuries are at risk for an increased number of complications and have a higher risk of mortality. Those who survive are more likely to have an adverse discharge.

Iterative reconstruction improves image quality and reduces radiation dose in trauma protocols; A human cadaver study

Background

Radiation-related cancer risk is an object of concern in CT of trauma patients, as these represent a young population. Different radiation reducing methods, including iterative reconstruction (IR), and spilt bolus techniques have been introduced in the recent years in different large scale trauma centers.

Purpose

To compare image quality in human cadaver exposed to thoracoabdominal computed tomography using IR and standard filtered back-projection (FBP) at different dose levels.

Material and methods

Ten cadavers were scanned at full dose and a dose reduction in CTDIvol of 5 mGy (low dose 1) and 7.5 mGy (low dose 2) on a Siemens Definition Flash 128-slice computed tomography scanner. Low dose images were reconstructed with FBP and Sinogram affirmed iterative reconstruction (SAFIRE) level 2 and 4. Quantitative image quality was analyzed by comparison of contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR). Qualitative image quality was evaluated by use of visual grading regression (VGR) by four radiologists.

Results

Readers preferred SAFIRE reconstructed images over FBP at a dose reduction of 40% (low dose 1) and 56% (low dose 2), with significant difference in overall impression of image quality. CNR and SNR showed significant improvement for images reconstructed with SAFIRE 2 and 4 compared to FBP at both low dose levels.

Conclusions

Iterative image reconstruction, SAFIRE 2 and 4, resulted in equal or improved image quality at a dose reduction of up to 56% compared to full dose FBP and may be used a strong radiation reduction tool in the young trauma population.

Endovascular management of pelvic trauma

Traumatic pelvic injuries are an important group of acquired pathologies given their frequent association with significant vascular compromise. Potentially fatal as a consequence of rapid hemorrhage, achievement of early hemostasis is a priority; endovascular management of traumatic pelvic arterial injuries is an important potential option for treatment. Precipitated by any number of mechanisms of trauma, pelvic vascular injury necessitates timely patient assessment. Variable patterns of arterial injury may result from blunt, penetrating or iatrogenic trauma. Selection of the most appropriate imaging modality is a priority, ensuring streamlined access to treatment. In the case of CT, this is complemented by acquisition of the most appropriate phase of imaging; review of both arterial and delayed phase imaging improves the accuracy of detection of low-flow hemorrhage. In cases where surgical intervention is not deemed appropriate, endovascular treatment provides an alternative means for cessation of hemorrhage associated with pelvic injuries. This may be achieved in a selective or nonselective manner depending on the patient's clinical status and time constraints. Consequently, a detailed understanding of vascular anatomy is essential, including an appreciation of the normal variant anatomy between males and females. Additional consideration must be given to variant anatomy which may co-exist in both sexes. This review article aims to provide a synopsis of endovascular management of pelvic vascular injury. Through case examples, available treatment options will be discussed, including thrombin injection and transcatheter arterial embolization. Furthermore, potential adverse complications of pelvic arterial embolization will be highlighted. Finally, in view of the potential severity of these injuries, a brief overview of initial management of the hemodynamically unstable patient is provided.

Team Approach: Evaluation and Management of Pelvic Ring Injuries

A multidisciplinary approach to the management of pelvic ring injuries has been shown to decrease mortality rates. The primary goals within the emergency room are to assess, resuscitate, and stabilize the patient. The Advanced Trauma Life Support protocol guides the initial assessment of the patient. A pelvic binder or sheet should be applied to help to provide reduction of the fracture and temporary stabilization. The trauma team becomes the primary service for the patient as he or she transitions away from the emergency department. The trauma team must effectively communicate with and serve as the liaison between other specialists as injuries are identified. emodynamic stability should be closely monitored in patients with pelvic ring injuries, involving the assessment of vital signs, imaging findings, and clinical judgment. Angioembolization and peritoneal packing may play a role in helping to control hemorrhage. Urologists should be consulted if a Foley catheter cannot be passed or there is concern for urethral or bladder injury. Further imaging or urologic intervention may be necessary. Orthopaedic surgeons can help to assess the patient, classify the injury, and assist in temporary stabilization while planning definitive fixation.

Roy-Camille Type 3 suicidal jumper's fractures: Case series and review of the literature

Background:

Roy-Camille reported only three patients in their Type 3 posttraumatic transverse sacral fracture (TSF) classification. A modified Roy-Camille classification has been already proposed by other authors suggesting further categorization of the TSFs as partially displaced or completely displaced to predict the rate of neurological recovery following lumbopelvic fixation.

Materials and Methods:

We reported three adult cases of surgical fixation of fracture–dislocation (3A and 3B) of the sacrum due to traumatic injuries and submitted to lumbopelvic posterior reconstruction. A case of a 15-year-old male patient affected by Type 3C with vascular pelvic injury was also reported. A comprehensive literature search was performed on evaluation and management of Type 3 TSFs.

Results:

In Type 3A, there is a minimal anterior dislocation and the reduction is feasible with good chance of recovery. In Type 3B, the anterior dislocation is severe, neurological deficits are present, reduction is difficult, and there is a risk of vascular injury both at the trauma and during the surgical reduction. In Type 3C, the anterior dislocation is massive, and the risk of vascular injury is very high requiring prompt vascular or endovascular treatment. Open reduction and posterior instrumentation are technically feasible in patients affected by Type 3 high TSFs.

Conclusions:

In our opinion, a modified Roy-Camille classification could be useful in the assessment of prognostic and therapeutic aspects of such fractures, In our opinion, a modified Roy-Camille classification could help assess the prognostic and therapeutic aspects of such fractures, in which the severity of the dislocation affects the surgical technique, the chance of neurological recovery, and the patient's life expectancy.

An Automated Deep Learning Method for Tile AO/OTA Pelvic Fracture Severity Grading from Trauma whole-Body CT

Admission trauma whole-body CT is routinely employed as a first-line diagnostic tool for characterizing pelvic fracture severity. Tile AO/OTA grade based on the presence or absence of rotational and translational instability corresponds with need for interventions including massive transfusion and angioembolization. An automated method could be highly beneficial for point of care triage in this critical time-sensitive setting. A dataset of 373 trauma whole-body CTs collected from two busy level 1 trauma centers with consensus Tile AO/OTA grading by three trauma radiologists was used to train and test a triplanar parallel concatenated network incorporating orthogonal full-thickness multiplanar reformat (MPR) views as input with a ResNeXt-50 backbone. Input pelvic images were first derived using an automated registration and cropping technique. Performance of the network for classification of rotational and translational instability was compared with that of (1) an analogous triplanar architecture incorporating an LSTM RNN network, (2) a previously described 3D autoencoder-based method, and (3) grading by a fourth independent blinded radiologist with trauma expertise. Confusion matrix results were derived, anchored to peak Matthews correlation coefficient (MCC). Associations with clinical outcomes were determined using Fisher's exact test. The triplanar parallel concatenated method had the highest accuracies for discriminating translational and rotational instability (85% and 74%, respectively), with specificity, recall, and F1 score of 93.4%, 56.5%, and 0.63 for translational instability and 71.7%, 75.7%, and 0.77 for rotational instability. Accuracy of this method was equivalent to the single radiologist read for rotational instability (74.0% versus 76.7%, p = 0.40), but significantly higher for translational instability (85.0% versus 75.1, p = 0.0007). Mean inference time was < 0.1 s per test image. Translational instability determined with this method was associated with need for angioembolization and massive transfusion (p = 0.002-0.008). Saliency maps demonstrated that the network focused on the sacroiliac complex and pubic symphysis, in keeping with the AO/OTA grading paradigm. A multiview concatenated deep network leveraging 3D information from orthogonal thick-MPR images predicted rotationally and translationally unstable pelvic fractures with accuracy comparable to an independent reader with trauma radiology expertise. Model output demonstrated significant association with key clinical outcomes.

A comparison on the detection accuracy of ante mortem computed tomography vs. autopsy for the diagnosis of pelvic ring injury in legal medicine

A detailed knowledge on the exact morphology of pelvic injuries provided crucial information in understanding the mechanisms of injury and has influence on the natural course and subsequent mortality. However, forensic medical literature investigating pelvic fractures in detail is scarce to date. This case series aims to compare the accuracy in detecting pelvic injuries using autopsy and ante mortem computed tomography (CT). Nineteen deceased patients with CT scans of pelvic fractures were included retrospectively. Pelvic injuries were independently assessed by a board-certified radiologist (R) and a board-certified trauma surgeon (T), both using the ante mortem CT scans, and by a board-certified forensic pathologist using autopsy (A) results without knowledge of the CT scan findings. No patient had died causatively from a pelvic fracture. Most injuries of the pelvis were present in the pubic rami (16/18) and sacral bone (13/18), followed by the sacroiliac joint (9/18) and iliac bone fractures (8/18). Ilium fractures (A:100%;R:67%;T:67%) and injuries of the sacroiliac joint (A:83%;R:50%;T:42%) were best detected via autopsy. The diagnosis of sacral fractures (A:19%;R:94%;T:88%) and fractures of the pubic rami (A:67%;R:96%;T:96%) were most often missed in autopsy. The results show deficits in the assessment of the pelvic injury for both CT and autopsy. Autopsy was superior in detecting injuries of the sacroiliac joint, but inferior in detecting sacral and pubic bone fractures. For an encompassing evaluation of ligamento-skeletal pelvic injuries, the complementary use of both CT and autopsy is recommended.

Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons

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.

Multidetector CT in Vascular Injuries Resulting from Pelvic Fractures: A Primer for Diagnostic Radiologists

Pelvic vascular injuries are typically caused by high-energy trauma. The majority of these injuries are caused by motor vehicle collisions, and the rest are caused by falls and industrial or crush injuries. Pelvic vascular injuries are frequently associated with pelvic ring disruption and have a high mortality rate due to shock as a result of pelvic bleeding. Morbidity and mortality resulting from pelvic vascular injury are due to pelvic hemorrhage and resultant exsanguination, which is potentially treatable and reversible if it is diagnosed early with multidetector CT and treated promptly. The pelvic bleeding source can be arterial, venous, or osseous, and differentiating an arterial (high-pressure) bleed from a venous-osseous (low-pressure) bleed is of paramount importance in stratification for treatment. Low-pressure venous and osseous bleeds are initially treated with a pelvic binder or external fixation, while high-pressure arterial bleeds require angioembolization or surgical pelvic packing. Definitive treatment of the pelvic ring disruption includes open or closed reduction and internal fixation. Multidetector CT is important in the trauma setting to assess and characterize pelvic vascular injuries with multiphasic acquisition in the arterial and venous phases, which allows differentiation of the common vascular injury patterns. This article reviews the anatomy of the pelvic vessels and the pelvic vascular territory; discusses the multidetector CT protocols used in diagnosis and characterization of pelvic vascular injury; and describes the spectrum of pelvic vascular injuries, the differentiation of common injury patterns, mimics, and imaging pitfalls. Online supplemental material is available for this article. ^©RSNA, 2019 See discussion on this article by Dreizin.

Do we really need the arterial phase on CT in pelvic trauma patients?

PURPOSE

To evaluate whether an arterial phase scan improves the diagnostic performance of computed tomography to identify pelvic trauma patients who received angiographic intervention on demand of the trauma surgeon.

METHODS

This retrospective single-center study was performed at an academic Scandinavian trauma center with approximately 2000 trauma admissions annually. Pelvic trauma patients with arterial and portal venous phase CT from 2009 to 2015 were included. The patients were identified from the institutional trauma registry. Images were interpreted by two radiologists with more than 10 years of trauma radiology experience. Positive findings for extravasation on portal venous phase alone or on both arterial and portal venous phase were compared, with angiographic intervention as clinical outcome.

RESULTS

One hundred fifty-seven patients (54 females, 103 males) with a median age of 45 years were enrolled. Sixteen patients received angiographic intervention. Positive CT findings on portal venous phase only had a sensitivity and specificity of 62% and 86%, vs. 56% and 93% for simultaneous findings on arterial and portal venous phase. Specificity was significantly higher for positive findings in both phases compared with portal venous phase only. Applying a threshold > 0.9 cm of extravasation diameter to portal venous phase only resulted in sensitivity and specificity identical to those of both phases.

CONCLUSION

Arterial phase scan in addition to portal venous phase scan did not improve patient selection for angiography. Portal venous phase extravasation size alone may be used as an imaging-based biomarker of the need for angiographic intervention.

Deep learning-based quantitative visualization and measurement of extraperitoneal hematoma volumes in patients with pelvic fractures: Potential role in personalized forecasting and decision support

INTRODUCTION

Admission computed tomography (CT) is a widely used diagnostic tool for patients with pelvic fractures. In this pilot study, we hypothesized that pelvic hematoma volumes derived using a rapid automated deep learning-based quantitative visualization and measurement algorithm predict interventions and outcomes including (a) need for angioembolization (AE), pelvic packing (PP), or massive transfusion (MT), and (b) in-hospital mortality.

METHODS

We performed a single-institution retrospective analysis of 253 patients with bleeding pelvic fractures who underwent admission abdominopelvic trauma CT between 2008 and 2017. Included patients had hematoma volumes of 30 mL or greater, were 18 years and older, and underwent contrast-enhanced CT before surgical or angiographic intervention. Automated pelvic hematoma volume measurements were previously derived using a deep-learning quantitative visualization and measurement algorithm through cross-validation. A composite dependent variable of need for MT, AE, or PP was used as the primary endpoint. The added utility of hematoma volume was assessed by comparing the performance of multivariable models with and without hematoma volume as a predictor. Areas under the receiver operating characteristic curve (AUCs) and sensitivities, specificities, and predictive values were determined at clinically relevant thresholds. Adjusted odds ratios of automated pelvic hematoma volumes at 200 mL increments were derived.

RESULTS

Median age was 47 years (interquartile range, 29-61), and 70% of patients were male. Median Injury Severity Score was 22 (14-36). Ninety-four percent of patients had injuries in other body regions, and 73% had polytrauma (Injury Severity Score, ≥16). Thirty-three percent had Tile/Orthopedic Trauma Association type B, and 24% had type C pelvic fractures. A total of 109 patients underwent AE, 22 underwent PP, and 53 received MT. A total of 123 patients received all 3 interventions. Sixteen patients died during hospitalization from causes other than untreatable (abbreviated injury scale, 6) head injury. Variables incorporated into multivariable models included age, sex, Tile/Orthopedic Trauma Association grade, admission lactate, heart rate (HR), and systolic blood pressure (SBP). Addition of hematoma volume resulted in a significant improvement in model performance, with AUC for the composite outcome (AE, PP, or MT) increasing from 0.74 to 0.83 (p < 0.001). Adjusted unit odds more than doubled for every additional 200 mL of hematoma volume. Increase in model AUC for mortality with incorporation of hematoma volume was not statistically significant (0.85 vs. 0.90, p = 0.12).

CONCLUSION

Hematoma volumes measured using a rapid automated deep learning algorithm improved prediction of need for AE, PP, or MT. Simultaneous automated measurement of multiple sources of bleeding at CT could augment outcome prediction in trauma patients.

LEVEL OF EVIDENCE

Diagnostic, level IV.

Clinical outcomes of blood transfusion to patients with pelvic fracture in the initial 6 h from injury

As part of the treatment of pelvic fracture, major hemorrhage poses a challenge for trauma surgeons. The aim of the present study was to evaluate the clinical outcomes of blood transfusion in the initial 6 h after pelvic fracture, and to define the blood transfusion volume required for each pelvic fracture type. A retrospective cohort study was performed on patients with pelvic fracture at a single Level I Trauma Centre over a 3-year period. A total of 1,297 patients were transported to our trauma centre within 2 h of injury and blood transfusion was administered in the initial 6 h after pelvic fracture. Review of the patients' medical records provided the initial pelvic radiographs and data from emergency department care. Clinical outcomes, including frequency of blood transfusion, blood transfusion volume, injury severity scores and mortality, were evaluated. All pelvic fractures were defined as closed fractures and patients were categorized according to the Arbeit fuer Osteosynthese (AO) classification system. Statistical methods were used to identify trends to provide guidance for clinical prediction. Complete data were available for 497 patients with pelvic fracture, 104 (20.9%) of which received blood transfusion. The blood transfusion volume in the initial 6 h ranged from 0 to 10,000 ml, with a mean of 1,213.94±1354.11 ml. The total mortality rate was 1.8%. Among the patients with C-type pelvic fractures, the frequency of blood transfusion was 59.0% and the mean volume was 2,191.30±1,740.93 ml. The mortality rate for C-type pelvic fractures was 11.43%. The B3 subtype of pelvic fractures had the highest transfusion frequency (53.6%), while the C3 subtype had the largest blood transfusion volume (5,700.00±4,666.90 ml). Patients with type A-C pelvic fractures had a progressively larger mean transfusion volume, transfusion frequency and mortality in the initial 6 h after pelvic fracture. The AO classification system was demonstrated to be a useful tool for the identification of pelvic fracture risk in the present study.

Analysis of early treatment of multiple injuries combined with severe pelvic fracture

PURPOSE

To summarize and analyze the early treatment of multiple injuries combined with severe pelvic fractures, especially focus on the hemostasis methods for severe pelvic fractures, so as to improve the successful rate of rescue for the fatal hemorrhagic shock caused by pelvic fractures.

METHODS

A retrospective analysis was conducted in 68 cases of multiple trauma combined with severe pelvic fractures in recent 10 years (from Jan. 2006 to Dec. 2015). There were 57 males and 11 females. Their age ranged from 19 to 75 years, averaging 42 years. Causes of injury included traffic accidents in 34 cases (2 cases of truck rolling), high falling injuries in 17 cases, crashing injuries in 15 cases, steel cable wound in 1 case, and seat belt traction injury in 1 case. There were 31 cases of head injury, 11 cases of chest injury, 56 cases of abdominal and pelvic injuries, and 37 cases of spinal and limb injuries. Therapeutic methods included early anti-shock measures, surgical hemostasis based on internal iliac artery devasculization for pelvic hemorrhage, and early treatment for combined organ damage and complications included embolization and repair of the liver, spleen and kidney, splenectomy, nephrectomy, intestinal resection, colostomy, bladder ostomy, and urethral repair, etc. Patients in this series received blood transfusion volume of 1200-10,000 mL, with an average volume of 2850 mL. Postoperative follow-up ranged from 6 months to 1.5 years.

RESULTS

The average score of ISS in this series was 38.6 points. 49 cases were successfully treated and the total survival rate was 72.1%. Totally 19 patients died (average ISS score 42.4), including 6 cases of hemorrhagic shock, 8 cases of brain injury, 1 case of cardiac injury, 2 cases of pulmonary infection, 1 case of pulmonary embolism, and 1 case of multiple organ failure. Postoperative complications included 1 case of urethral stricture (after secondary repair), 1 case of sexual dysfunction (combined with urethral rupture), 1 case of lower limb amputation (femoral artery thrombosis), and 18 cases of consumptive coagulopathy.

CONCLUSION

The early treatment of multiple injuries combined with severe pelvic fractures should focus on pelvic hemostasis. Massive bleeding-induced hemorrhagic shock is one of the main causes of poor prognosis. The technique of internal iliac artery devasculization including ligation and embolization can be used as an effective measure to stop or reduce bleeding. Consumptive coagulopathy is difficult to deal with, which should be detected and treated as soon as possible after surgical measures have been performed. The effect of using recombinant factor VII in treating consumptive coagulopathy is satisfactory.

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

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.

Association of pelvic fracture patterns, pelvic binder use and arterial angio-embolization with transfusion requirements and mortality rates; a 7-year retrospective cohort study

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.

Post-mortem computed tomography angiography using left ventricle cardiac puncture: A whole-body, angiographic approach

Post-mortem computed tomography (PMCT) and PMCT angiography (PMCTA) are rapidly becoming effective and practical methods in forensic medicine. In this article, the authors introduce a whole-body PMCTA approach involving left ventricle cardiac puncture. This procedure was performed in 9 males and 3 females. PMCT was performed first. Then a biopsy core needle was used for a percutaneous puncture into the left ventricle through the intercostal area under CT guidance. 1000 mL of contrast media (diatrizoate meglumine and normal saline [0.9%] at 1:2 ratio) was injected at a rate of 50 mL/8 s, followed by CT scan. Visualization of systemic arteries was achieved in 11 cases, while only partial visualization was achieved in 1 case, which may have been related to incomplete thawing of the cadaver. PMCTA results revealed no vascular diseases and abnormalities in 10 victims. Among the 10 victims, 4 post-scan autopsies were performed and found no vascular abnormalities, consistent with the PMCTA results. Autopsy of the other 6 victims were refused by the relatives. PMCTA revealed signs of internal carotid artery aneurysm inside the sphenoid sinus in one victim, which was confirmed by autopsy. PMCTA results of another victim showed signs of stenosis and blockage of the distal part of the right vertebral artery and basilar artery. Thromboembolism of those arteries was found during autopsy. Compared with other existing PMCTA methods for examination of vascular injuries and diseases, this technique involves simple procedures, is less time consuming, has lower associated costs, does not require specialized equipment, provides adequate imaging quality, and is suitable for centres not equipped with cardiopulmonary bypass machines or other specialized equipment.