Which pelvic ring fractures are potentially lethal?

Operatively treated high-energy blunt pelvic ring injuries and surgical site infections - A retrospective assessment based on a prospective registry

INTRODUCTION

High-energy pelvic ring injuries (PRI) are severe, life-threatening trauma conditions which might require complex surgical management. One of the major complications associated with these injuries is the development of surgical site infections (SSI) which significantly impact patient outcomes. This study aimed to evaluate the rate of SSI in patients undergoing surgical fixation of high-energy blunt PRI and identify the key predisposing factors.

METHODS

A retrospective review of patients treated for high-energy blunt PRI was conducted using the prospectively filled institutional Severely Injured Patients' Registry, focusing on the rate of SSI following surgical fixation. The multifactorial nature of infection risk was analyzed, with particular attention to the type of injury, surgical technique, external fixation devices' usage and the germs encountered.

RESULTS

A SSI rate of 10,5 % (12 out of 114 patients) was encountered among the study population. The primary SSI risk factor was PRI complexity; 83.3 % of patients with SSI had an AO/OTA type C fracture and 16.7 % a type B fracture, while 43.1 % of patients without SSI had a type C fracture and 56.9 % a type B fracture (p = 0.008). Additionally, SSI patients had a trend to have higher extremities/pelvis AIS and higher ISS, and to have been more often treated with a transient pelvic fixation device including supra-acetabular external fixator.

CONCLUSION

These findings emphasize the need for a comprehensive infection prevention strategy in high-energy PRI patients, especially in complex cases. A multidisciplinary approach is of outmost importance and should include surgical techniques with meticulous soft tissue handling, proper implant selection and aggressive post-operative wound care. Despite external fixation devices being related to certain cases of SSI, their life-saving potential during the initial management phase should be carefully weighed against this risk.

High-energy blunt pelvic ring injuries and pre-hospital pelvic binder applications - A retrospective assessment based on a prospective registry

INTRODUCTION

Application of a pelvic binder in the pre-hospital settings is a crucial step of high-energy blunt pelvic ring injury (PRI) management protocols. The aim of this retrospective cohort study was to evaluate the percentage of pre-hospital pelvic binder's applications in high-energy blunt type B or C PRI patients managed at a single level I trauma center, and to assess its impact on the medical resource requirements and patients' outcomes.

METHODS

The institutional Severely Injured Patients' Registry was screened for patients meeting the following inclusion criteria: (1) high-energy blunt PRI; (2) admission between 2014.01.01 and 2022.12.31; (3) age ≥16 years; and (4) available computed tomography of the pelvis. Exclusion criteria were: (1) death before admission; (2) low-energy injury; (3) penetrating, blast and electrical injuries; and (4) secondary transfers. Study variables, including pre-hospital application of a pelvic binder and demographic, clinical, management and outcome data were extracted from the registry. Additionally, AO/OTA classifications were determined.

RESULTS

A consecutive series of 262 patients was included into the final analysis. Of these, 58.8 % received a pre-hospital pelvic binder (PPB), increasing from type A (45.1 %) to type B (57.8 %) and type C (73.7 %). Pre-hospital hemodynamic instability was a major factor triggering the use of PPB in high-energy blunt type B PRI patients with PPB in 76.9 % of the cases with hemodynamic instability vs. 51.3 % of the cases without hemodynamic instability (p = 0.009). This difference was not statistically significant for high-energy blunt type C PRI patients (82.8 % vs. 64.3 %, p = 0.200). The presence of a physician on the trauma site contributed to the increased percentage of PRI managed with PPB from 43.5 % to 67.3 % in type B PRI (p = 0.011), and from 50 % to 77.1 % in type C PRI (p = 0.257). This study showed an increased need for packed red blood cells (PRBC) transfusions in subgroups treated with PPB and no statistically significant differences in term of intensive care unit (ICU) and total hospital length of stay and complications between high-energy blunt type B or C PRI patients with or without PPB. Comparison of mortality rates in patients with and without PPB showed a trend towards lower mortality rates with PPB in patients with AIS extremity participating in at least 50 % of the total ISS.

CONCLUSION

In the ideal pre-hospital scenario, every high-energy blunt type B or C PRI patient should be managed with a PPB. Continuous pre-hospital team training and information is crucial to achieve this goal. The preparation of Emergency Department and ICU who admit a patient with PPB should include a sufficient number of PRBC ready for transfusion. Mortality rates did not seem to be affected by PPB, except for a trend towards lower mortality rates in patients in whom their PRI was the major component of the global severity of their injury. This might point out the critical and positive effect of PPB in high-energy blunt PRI patients.

Control of Haemorrhage in Orthopaedic Trauma

This paper aims to outline current practices and examine promising new advancements in the modern management of haemorrhage in orthopaedic trauma. Many prehospital and perioperative haemorrhage control strategies and techniques have been available to clinicians for multiple decades, yet our understanding and utilisation of these practices continues to be refined and optimised. There is a particular focus in this article on issues related to resuscitation and coagulation in trauma. We examine the complex mechanisms that lead to coagulopathy in trauma patients as well as the transformative effect tranexamic acid has had in limiting blood loss. We also explore some emerging technologies such as endovascular interventions and clot-stabilising dressings and devices that are likely to have a significant impact going forward.

Damage-control orthopedics or early total care: What you need to know

ABSTRACT

Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.

Effectiveness of pelvic circumferential compression device for lower body trauma: Insights from a Japan Trauma Data Bank retrospective study

Aim

Pelvic ring fractures (PRFs) due to high-energy trauma often result in severe bleeding and high mortality. Pelvic circumferential compression devices (PCCD) are widely used to stabilize PRF and decrease bleeding. However, evidence supporting their effectiveness is still inconclusive.

Methods

We conducted an observational study using the Japan Trauma Data Bank (JTDB) from 2019 to 2021. Patients with blunt lower body trauma aged 15 years or older were included. We used propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) to evaluate the association of PCCD and mortality.

Results

Of the 74,393 patients in the database, 235 PCCD group and 23,429 control group were analyzed. After PSM, 231 patients in both groups were enrolled. Crude analysis indicated significantly higher in-hospital mortality in the PCCD group (odds ratio (OR) = 3.8 [95% CI = 2.51-5.75]). However, PSM and IPTW analysis indicated that PCCD was associated with decreased in-hospital mortality (PSM: OR = 0.79 [0.43-1.42]; IPTW: OR = 0.73 [0.62-0.86]). In a subgroup analysis of the IPTW analysis, PCCD fitting resulted in increased in-hospital mortality in the group without PRF (OR = 2.08 [1.91-2.27]), a decrease in stable PRF (OR = 0.74 [0.6-0.91]), and a further decrease in unstable PRF (OR = 0.18 [0.12-0.27]). Additional factors, such as a fall from a height, a fall downstairs, and pre-hospital PCCD placement also influenced the treatment effect.

Conclusion

The present, large, registry-based study found that PCCD reduced mortality in patients with a lower body injury, especially those with an unstable PRF.

Treatment of Fracture-Related Infection after Pelvic Fracture

BACKGROUND

The management of pelvic fractures is a significant challenge. Surgical site infection can result in the need for revision surgery, cause functional impairment, and lead to a prolonged length of stay and increased treatment costs. Although reports on fracture-related infection (FRI) after pelvic fracture fixation are sparsely reported in the literature, it is a serious complication. This study analysed patients with FRIs after pelvic fracture regarding patient characteristics, treatment strategies, and an evaluation of risk factors for FRI.

METHODS

In this retrospective single-centre study, FRI was diagnosed based on clinical symptoms of infection and a positive culture of a bacterial infection. Depending on the severity and acuteness of the infection, osseous stabilization was restored either via implant retention (stable implant, no osteolysis), exchange (loose implant or bony defect), or external fixation (recurrence of infection after prior implant retaining revision). Healing of infection was defined as no sign of recurring infection upon clinical, radiological, and laboratory examination in the last follow-up visit.

RESULTS

The FRI rate in our patient population was 7.5% (24/316). In 8/24 patients, the FRI occurred within the first three weeks after initial surgery (early) and 16/24 presented with a late onset of symptoms of FRI. A strategy of debridement, antibiotics, and implant retention (DAIR) was successful in 9/24 patients with FRI after pelvic fracture. A total of 10 patients required an exchange of osteo-synthetic implants, whereof three were exchanged to an external fixator. In five patients, we removed the implant because the fracture had already consolidated at the time of revision for infection. A total of 17/24 patients had a poly-microbial infection after a pelvic fracture and 3/24 patients died from post-traumatic multi-organ failure within the first 6 months after trauma. There were no cases of persistent infection within the remaining 21 patients.

CONCLUSIONS

Although poly-microbial infection is common in FRI after pelvic fracture, the recurrence rate of infection is relatively low. A complex pelvic trauma with significant soft tissue injury is a risk factor for recurrent infection and multiple revisions. A strategy of DAIR can be successful in patients with a stable implant. In cases with recurrent infection or an unstable fracture site, the exchange of implants should be considered.

Performance Assessment of Out-of-Hospital Use of Pelvic Circumferential Compression Devices for Severely Injured Patients in Switzerland: A Nationwide Retrospective Cross-Sectional Study

BACKGROUND

Patients with severe pelvic fractures carry a greater risk of severe bleeding, and pelvic compression devices (PCCD) are used to stabilize the pelvis on the pre-hospital scene. The aim of this study was to describe the use of PCCD in the pre-hospital setting on a nationwide scale (Switzerland) and determine the sensitivity, specificity and rates of over- and under-triage of the current application practices. The secondary objective was to identify pre-hospital factors associated with unstable pelvic fractures.

METHODS

Retrospective cross-sectional study using anonymized patient data (1 January 2015-31 December 2020) from the Swiss Trauma Registry (STR). Based on AIS scores, patients were assigned a unique principal diagnosis among three categories (unstable pelvic fracture-stable pelvic fracture-other) and assessed for use or not of PCCD. Secondarily, patient characteristics, initial pre-hospital vital signs, means of pre-hospital transport and trauma mechanism were also extracted from the database.

RESULTS

2790 patients were included for analysis. A PCCD was used in 387 (13.9%) patients. In the PCCD group, 176 (45.5%) had an unstable pelvic fracture, 52 (13.4%) a stable pelvic fracture and 159 (41.1%) an injury unrelated to the pelvic region. In the group who did not receive a PCCD, 214 (8.9%) had an unstable pelvic fracture, 182 (7.6%) a stable pelvic fracture and 2007 (83.5%) an injury unrelated to the pelvic region. The nationwide sensitivity of PCCD application was 45.1% (95% CI 40.1-50.2), the specificity 91.2% (95% CI 90-92.3), with both over- and under-triage rates of 55%. The prevalence of unstable fractures in our population was 14% (390/2790). We identified female sex, younger age, lower systolic blood pressure, higher shock index, pedestrian hit and fall ≥3 m as possible risk factors for an unstable pelvic fracture.

CONCLUSIONS

Our results demonstrate a nationwide both over- and under-triage rate of 55% for out-of-hospital PCCD application. Female gender, younger age, lower blood pressure, higher shock index, pedestrian hit and fall >3 m are possible risk factors for unstable pelvic fracture, but it remains unclear if those parameters are relevant clinically to perform pre-hospital triage.

Predictive Factors for the Application of Pelvic Binders in the Prehospital Setting

OBJECTIVES

Early pelvic binder placement in the field stabilizes pelvic fractures and tamponades potential hemorrhage within the pelvis. Despite known risk factors for pelvic fracture, it remains challenging to quickly triage and correctly apply a pelvic binder. We aim to develop a prediction model that exclusively uses prehospital criteria to inform the decision to place a pelvic binder.

METHODS

The trauma registry was used to identify all trauma patients admitted to an urban Level I trauma center between January 2013 and December 2017. Variables collected included patient demographics, mechanism of injury, prehospital vital signs, and the presence of a pelvic fracture. Participants were randomly assigned to a training group (70%) or a validation group (30%). Univariate analyses were used to identify significant predictors for use in multivariate predictive models.

RESULTS

A total of 8,480 (65% male; median age 49; median ISS 9) and 3,676 (65% male; median age 48; median ISS 9) trauma patients were randomly assigned to the training and validation groups, respectively. Univariate analysis showed significant likelihood of pelvic fracture associated with female sex, hemodynamic instability (initial systolic blood pressure < 90 mmHg), blunt injury type, specific mechanisms of injury (motor vehicle collision, motorcycle collision, pedestrian struck by motor vehicle, crushing injury, and riding an animal), impact location, and position in vehicle. Multivariate models adjusting for blunt type injury, hemodynamic instability, impact location, and position in vehicle showed that presence of two or more of these risk factors is significantly associated with presence of pelvic fracture.

CONCLUSION

Establishing select prehospital criteria for the empiric application of pelvic binders for patients in the field with blunt injuries, hemodynamic instability, frontal or side motor vehicle collision impact, and non-front seat passenger may improve outcomes among patients with pelvic fractures.

Prehospital accuracy of (H)EMS pelvic ring injury assessment and the application of non-invasive pelvic binder devices

BACKGROUND

Pre-hospital application of a non-invasive pelvic binder device (NIPBD) is essential to increase chances of survival by limiting blood loss in patients with an unstable pelvic ring injury. However, unstable pelvic ring injuries are often not recognized during prehospital assessment. We investigated the prehospital (helicopter) emergency medical services ((H)EMS)' accuracy of the assessment of unstable pelvic ring injuries and NIPBD application rate.

METHODS

We performed a retrospective cohort study on all patients with a pelvic injury transported by (H)EMS to our level one trauma centre between 2012 and 2020. Pelvic ring injuries were included and radiographically categorized using the Young & Burgess classification system. Lateral Compression (LC) type II/III -, Anterior-Posterior (AP) type II/III - and Vertical Shear (VS) injuries were considered as unstable pelvic ring injuries. (H)EMS charts and in-hospital patient records were evaluated to determine the sensitivity, specificity and diagnostic accuracy of the prehospital assessment of unstable pelvic ring injuries and prehospital NIPBD application.

RESULTS

A total of 634 patients with pelvic injuries were identified, of whom 392 (61.8%) had pelvic ring injuries and 143 (22.6%) had unstable pelvic ring injuries. (H)EMS personnel suspected a pelvic injury in 30.6% of the pelvic ring injuries and in 46.9% of the unstable pelvic ring injuries. An NIPBD was applied in 108 (27.6%) of the patients with a pelvic ring injury and in 63 (44.1%) of the patients with an unstable pelvic ring injury. (H)EMS prehospital diagnostic accuracy measured in pelvic ring injuries alone was 67.1% for identifying unstable pelvic ring injuries from stable pelvic ring injuries and 68.1% for NIPBD application.

CONCLUSION

The (H)EMS prehospital sensitivity of unstable pelvic ring injury assessment and NIPBD application rate is low. (H)EMS did not suspect an unstable pelvic injury nor applied an NIPBD in roughly half of all unstable pelvic ring injuries. We advise future research on decision tools to aid the routine use of an NIPBD in any patient with a relevant mechanism of injury.

Management of high-energy blunt pelvic ring injuries: A retrospective cohort study evaluating an institutional protocol

INTRODUCTION

High-energy blunt pelvic ring injuries with hemodynamic instability are complicated by a high mortality rate (up to 32%). There is no consensus on the best management strategy for these injuries. The aim of this study was to evaluate the high-energy blunt pelvic ring injury management protocol implemented in the authors' institution.

PATIENTS AND METHODS

This retrospective cohort study was performed in an academic level I trauma center. The institutional protocol incorporates urgent pelvic mechanical stabilization of hemodynamically unstable patients not responding to a pelvic belt, fluids, and transfusions. If hemodynamic instability persists, angiography ± embolization is performed. Adult patients sustaining a high-energy blunt pelvic ring injury between 2014.01.01 and 2019.12.31 were included in the study. The primary outcome was mortality at 1, 2, 30 and 60 days. The secondary outcomes were the number of packed red blood cell units transfused during the first 24 h, intensive care unit stay, and total hospitalization length of stay.

RESULTS

192 high-energy blunt pelvic ring injury patients were analyzed. Of these, 71 (37%) were hemodynamically unstable, and 121 (63%) were stable. The overall in-hospital mortality of the hemodynamically unstable and stable groups was 20/71 (28.2%) and 4/121 (3.3%) respectively (p<0.001). Cumulative mortality rates for hemodynamically unstable patients were 15.5% at day 1, 16.9% at day 2, 26.8% at day 30 and 28.2% at day 60, and for hemodynamically stable patients, rates were 0% at day 1 and 2, 2.5% at day 30 and 3.3% at day 60. Unstable patients required a higher number of packed red blood cell units than stable patients during the first 24 h (5.1 vs. 0.1; p<0.001). Intensive care unit length of stay and total hospitalization duration was 11.25 and 37.4 days for unstable patients and 1.9 and 20.9 days for stable patients (p<0.001).

CONCLUSIONS

For both hemodynamically unstable and stable patients, the institutional protocol showed favorable mortality rates when compared to available literature. Comparative studies are needed to determine the management strategies with the best clinical outcome and survival.

Routine Postoperative Computed Tomography Scans Following Posterior Pelvic Fixation of Pelvic Ring Fractures: A Survey of (OTA) Orthopaedic Traumatologists

OBJECTIVE

To assess practices related to ordering computed tomography (CT) scans routinely after posterior pelvic ring fixation and revision surgery rates.

DESIGN

A 20-question cross-sectional survey.

PARTICIPANTS

Fellowship-trained orthopaedic traumatologists.

MAIN OUTCOME MEASUREMENTS

(1) Percentage of surgeons ordering a routing postoperative CT after posterior pelvic ring fixation, (2) Revision surgery rates based on routine CT scan results.

RESULTS

Responses were received from 57 surgeons. Practices varied regarding postoperative CT scans, with 20 surgeons (35%, group A) routinely ordering them and 37 surgeons (65%, group B) not ordering them on all patients. Group A were younger and with less years of experience than those in Group B. Most group A surgeons report a revision surgery rate of <1% based on results of the postoperative CT. Group A report routine postoperative scans were obtained to assess reduction, instrumentation placement, and for educational purposes. Group B did not obtain routine postoperative CTs because of the following: unlikely to change postoperative treatment course, adequate reduction and instrumentation placement assessed intraoperatively and by postoperative radiographs, and increased radiation exposure and cost to patients. Group B did report obtaining postop CT scans on select patients, with postoperative neurological deficit being the most common indication.

CONCLUSIONS

The routine use of postoperative CTs following posterior fixation of pelvic ring fractures is a controversial topic. Although we recognize the role for postoperative CT scans in select patients, our study questions the clinical utility of these scans in all patients and in conclusion do not recommend this protocol.

Preoperative arterial embolization and wound complications after resection of malignant bone tumor in the pelvis: a nationwide database study

BACKGROUND

Massive intraoperative blood loss is common in pelvic malignant bone tumor surgery, and preoperative arterial embolization may be used in selected cases. Preoperative arterial embolization reportedly increases wound complications in pelvic fracture surgery, but little evidence is available regarding pelvic bone tumor surgery.

METHODS

Using a Japanese nationwide database (Diagnosis Procedure Combination database), we searched for patients who underwent pelvic malignant bone tumor surgery between July 2010 and March 2018. The primary endpoint was wound complications, defined as any wound requiring re-operation, negative pressure wound therapy or both. Univariate analyses (the chi-squared test for categorical variables, the unpaired t-test for continuous variables) and multivariate logistic regression analyses were performed to examine the association between preoperative arterial embolization and wound complications.

RESULTS

Among the 266 eligible patients, 43 (16%, 43/266) underwent embolization and 69 (26%, 69/266) developed wound complications. In the univariate analyses, preoperative arterial embolization (P < 0.001), duration of anesthesia (P < 0.001), the volume of blood transfusion (P < 0.001) and duration of indwelling drain tube (P < 0.001) were associated with wound complications. In the multivariate logistic regression analysis, preoperative arterial embolization was significantly associated with wound complications (odds ratio, 3.92; 95% confidence interval, 1.80-8.56; P = 0.001).

CONCLUSIONS

Preoperative arterial embolization may be associated with increased wound complications after pelvic malignant tumor surgery.

Screw misplacement in percutaneous posterior pelvic iliosacral screwing with and without navigation: A prospective clinical study of 174 screws in 127 patients

BACKGROUND

Recent studies of iliosacral screw fixation performed using intraoperative navigation systems have shown promising results. The Surgivisio Platform is a new-generation three-dimensional intraoperative navigation tool that has been used at our institution for 2years. The aim of this prospective study was to assess the contribution of navigation in terms of iliosacral screw positioning accuracy and of radiation exposure, by comparing outcomes with vs. without navigation.

HYPOTHESIS

Navigation allows more accurate percutaneous iliosacral screw positioning regardless of the type of screw fixation (with sacral dysmorphism and/or cemented screw fixation and/or multiple screw fixation).

MATERIALS AND METHODS

Between January 2018 and December 2019, consecutive patients who underwent percutaneous iliosacral screw fixation of pelvic ring fractures without vertical instability were included in this single-centre prospective study. Screw position accuracy was evaluated by postoperative high-resolution computed tomography (HRCT). Operative time, radiation dose, and complications were recorded.

RESULTS

We included 127 patients with 174 iliosacral screws, of which 129 were positioned under fluoroscopic guidance and 45 using navigation. According to the modified Gras classification, 7% (12/174) of the screws were incorrectly positioned and 2% (4/174) required repositioning. The frequency of screw malposition was not significantly different between the fluoroscopy and navigation groups (8.5%, 11/129 vs. 2.2%, 1/45, respectively; p=0.19). However, screw position in dysmorphic sacra was significantly better with navigation (p=0.04), whereas no significant difference in final screw position was found for cemented or multiple screw implantations. In the navigation group, the operative time was significantly longer (28.2min vs. 21.6min, p=0.003), and the mean dose-area product significantly greater (6.6Gy·cm² vs. 4.9Gy·cm², p=0.02). The complication rates were not different between the two groups.

CONCLUSION

In patients who have pelvic ring fractures without vertical instability, navigation of percutaneous iliosacral screw placement using the Surgivisio Platform improves screw positioning in dysmorphic sacra, at the cost of a longer operative time and greater radiation exposure of the patient.

LEVEL OF EVIDENCE

II, prospective study.

Risk Factors for Mortality Associated With Pelvic Fractures at a Level I Trauma Center

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.].

Epidemiology Of Pelvic Ring Fractures and Injuries: A Retrospective Study

BACKGROUND: Despite relatively rare occurrence in trauma victims, pelvic fractures have a high risk of mortality and morbidity. AIM: This study was conducted to study epidemiology of patients with pelvic ring injuries in a level 1 trauma center in Kazakhstan. METHODS: This is a descriptive cross-sectional study within a single institution. In the period of 2014–2017, we encountered 212 patients with pelvic fractures. About 92% of them had concomitant injures due to a high-energy trauma. Measures were compared using the SPSS 20.0 program. RESULTS: The mean age was 34.5. Pelvic fractures are more often verified in males. The most common mechanism of injury was road traffic injuries and falls from heights. The highest recovery rates were observed for type B fractures, but mortality was highest for type C fractures. The average length of hospital stay was 18.71 days. Non-surgical treatment was used in 62.3% of patients, external fixation device was imposed as an emergency intervention in 64.2% (n = 136) of patients. CONCLUSIONS: Overall most patients with pelvic fractures had multiple injuries and the mortality rate was 7.1%. Non-surgical treatment was most commonly used. Type C fractures had significantly fatal outcome.

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.

Minimally invasive triangular lumboiliac and iliosacral fixation of posterior pelvic ring injuries with vertical instability: Technical note

To date, no strong consensus exists on the best way to treat posterior pelvic ring injuries when there is no neurological deficit. Various fixation methods have been described; more recently, constructs that combine lumboiliac and iliosacral fixation have been introduced. This type of fixation is mainly indicated in cases of spinopelvic dissociation with large displacement of fracture fragments in the sagittal plane. However, these techniques are associated with postoperative complications, particularly infections and severe skin complications. This led us to propose a minimally invasive lumboiliac and iliosacral fixation technique for posterior pelvic ring injuries. The procedure is done with the patient prone. It consists of pedicle screw insertion into L4 or L5 and screw fixation of the ilium with fluoroscopy guidance; intraoperative distraction can be done depending on the amount of displacement. An iliosacral screw is then inserted percutaneously to allow reduction in the transverse plane and yield a triangular construct. In the five patients that we have operated using this technique, the mean preoperative vertical displacement was 11.9±6.9mm (SD) (min 1.3, max 19.7) versus 3.7±3.2mm (min 0.3, max 6.7) postoperatively and the mean preoperative frontal displacement was 7.5±3.7mm (min 4.2, max 12.4) versus 2.5±2.0mm (min 0.3, max 4.3) postoperatively. Minimally invasive iliosacral and lumboiliac fixation is an option for treating posterior pelvic ring fractures free of neurological deficit and especially spinopelvic dissociation.

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.

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense

Background

The most common cause of death in cases of pelvic trauma is exsanguination caused by associated injuries, not the pelvic injury itself. For patients with relatively isolated pelvic trauma, the impact of vascular injury severity on outcome remains unclear. We hypothesized that the severity of the pelvic vascular injury plays a more decisive role in outcome than fracture pattern complexity.

Methods

Medical records of patients with pelvic fracture at a single center between January 2016 and December 2017 were retrospectively reviewed. Those with an abbreviated injury scale (AIS) score ≥ 3 in areas other than the pelvis were excluded. Lateral compression (LC) type 1 fractures and anteroposterior compression (APC) type 1 fractures according to the Young-Burgess classification and ischial fractures were defined as simple pelvic fractures, while other fracture types were considered complicated pelvic fractures. Based on CT, vascular injury severity was defined as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling/extravasation). Patient demographics, clinical parameters, and outcome measures were compared between the groups.

Results

Severe vascular injuries occurred in 26 of the 155 patients and were associated with poorer hemodynamics, a higher injury severity score (ISS), more blood transfusions, and a longer ICU stay (3.81 vs. 0.86 days, p = 0.000) and total hospital stay (20.7 vs. 10.1 days, p = 0.002) compared with minor vascular injuries. By contrast, those with complicated pelvic fractures (LC II/III, APC II/III, vertical shear, and combined type fracture) required a similar number of transfusions and had a similar length of ICU stay as those with simple pelvic fractures (LC I, APC I, and ischium fracture) but had a longer total hospital stay (13.6 vs. 10.3 days, p = 0.034). These findings were similar even if only patients with ISS ≥ 16 were considered.

Conclusions

Our results indicate that even in patients with relatively isolated pelvic injuries, vascular injury severity is more closely correlated to the outcome than the type of anatomical fracture. Therefore, a more balanced classification of pelvic injury that takes both the fracture pattern and hemodynamic status into consideration, such as the WSES classification, seems to have better utility for clinical practice.

Pelvic circumferential compression devices for prehospital management of suspected pelvic fractures: a rapid review and evidence summary for quality indicator evaluation

BACKGROUND

Pelvic fractures, especially when unstable, may cause significant haemorrhage. The early application of a pelvic circumferential compression device (PCCD) in patients with suspected pelvic fracture has established itself as best practice. Ambulance services conduct corresponding performance measurement. Quality indicators (QIs) are ideally based on high-quality evidence clearly demonstrating that the desirable effects outweigh the undesirable effects. In the absence of high-quality evidence, best available evidence should be combined with expert consensus.

OBJECTIVES

The aim of the present study was to identify, appraise and summarize the best available evidence regarding PCCDs for the purpose of informing an expert panel tasked to evaluate the validity of the following QI: A patient with suspected pelvic fracture has a PCCD applied.

METHODS

A rapid review of four databases was conducted to identify relevant literature published up until 9 June 2020. Systematic reviews, experimental, quasi-experimental and observational analytic studies written in English were included. One author was responsible for study selection and quality appraisal. Data extraction using a priori extraction templates was verified by a second reviewer. Study details and key findings were summarized in tables.

RESULTS

A total of 13 studies were assessed to be eligible for inclusion in this rapid review. Of these, three were systematic reviews, one was a randomized clinical trial (crossover design), two were before-after studies, and seven were retrospective cohort studies. The systematic reviews included mostly observational studies and could therefore not be considered as high-level evidence. Overall, the identified evidence is of low quality and suggests that PCCD may provide temporary pelvic ring stabilization and haemorrhage control, although a potential for adverse effects exists.

CONCLUSION

Given the low quality of the best available evidence, this evidence would need to be combined with expert consensus to evaluate the validity of a related quality indicator before its implementation.

Sacral fractures: issues, challenges, solutions

Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma.This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation.Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction.Herein, we present issues, challenges and solutions related to the management of sacral fractures. Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064.

Part 1: Outcome of Posterior Pelvic Ring Injuries and Associated Prognostic Factors - A Five-Year Retrospective Study of One Hundred and Sixty Five Operated Cases with Closed Reduction and Percutaneous Fixation

PURPOSES

The aim of this study was to evaluate: 1. the outcome of pelvic ring fractures treated by closed reduction and percutaneous fixation, 2. the prognostic factors associated with a poor quality reduction, 3. the prognostic factors associated with ilio-sacral screws misplacement and 4. the prognostic factors associated with nonunion.

METHODS

Data from medical charts for all patients admitted with unstable posterior pelvic ring injuries from 2009 to 2013 were extracted. A total of 165 patients with a mean age of 40 years were included. One hundred and five patients were reviewed at a mean of 32 months of follow-up. The prognostic factors analyzed were clinical and radiological factors. Tile B and Tile C pelvic ring fractures were compared and analyzed separately. Then specific statistical analysis was performed using a logistic regression model to eliminate confusion factors.

RESULTS

An excellent or good clinical result was achieved for 94 patients (90%). An excellent or good reduction was achieved for 141 patients (85%). Nonunion rate, smoking patients, bad reductions, age of patients and ISS score were significantly higher in Tile C group. To eliminate confusion factors we used a multivariate analysis logistic regression model. Only unstable vertical bilateral posterior injuries (Tile C2 and C3) were independent prognostic factors for unsatisfactory reduction (p = 0.001; OR = 4.72; CI 95% [2.08-16.72]). Screw misplacement was recorded for 30 patients (16%) and sacral dysmorphia was an associated prognostic factor (p = 0.0001; OR = 15.6; CI95% [3.41-98.11]). Nonunion was recorded for ten patients (6%) and smoking was an associated prognostic factor (p = 0.01, OR = 5.12; CI95% [1.1-24.1]).

CONCLUSIONS

Posterior pelvic ring fractures treated by closed reduction and percutaneous fixation are associated with excellent/good clinical results if excellent/good reduction and bone healing are achieved without screw misplacement. Bilateral unstable vertical posterior pelvic ring injuries, and sacral dysmorphia are risk factors for bad quality reduction and screw misplacement respectively.

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.

Posterior transiliac plating in vertically unstable sacral fracture

The aim of the present technical note is to describe the posterior transiliac plating method. Acute-phase clinical and radiological results in a continuous series of 10 vertically unstable fractures are presented. Reduction was good or excellent in 70% of cases, and clinical results were good or excellent in 80% on Hannover and Majeed scores, with mean Majeed score of 71.8±17. Complications comprised 3 cases of early postoperative sepsis requiring surgical lavage, and 4 cases of hardware removal due to discomfort. At last follow-up, consolidation was systematic. Reduction was more difficult with longer time to surgery and greater initial displacement. Posterior transiliac plating provided immediately effective fixation in vertically unstable pelvic fracture.

Effectiveness of anterior subcutaneous internal fixation (INFIX) in the management of potentially infected pelvis fractures

BACKGROUND

Anterior plating is the treatment of choice in anterior pelvic ring fractures. In certain situations where pelvis fracture is associated with open wound, infection, abdominal injury or bladder injury - internal fixation with plate is contraindicated. Conventionally, external fixation is done in such cases. However, External Fixation is associated with pin tract infection, pin loosening, difficult wound care and less patient compliance. The present study was conducted to evaluate a possible 'middle path' between the two procedures.

METHODS

A prospective study was conducted from July 2017 to December 2019.18 adult patients with risk of infection were treated with INFIX. The patients' data was collected on presentation, preoperatively, intra-operatively and post operatively. The patients were followed up with serial radiographs. Functional status was assessed using Iowa Pelvis Score. After radiological union, implant removal was performed. The patients were followed up for a minimum of 6 months after the removal surgery.

RESULTS

The average age of patients in present study was 39.55 years with a male predominance. 16 out of 18 patients were polytrauma cases with ISS more than 15.50% patients had Lateral Compression type of fracture. Radiological union was seen at an average of 3.5 months. After removal, 78% patients had excellent outcome and 22% patients had good outcome. The complications observed were LFCN irritation (27.78%) and asymptomatic heterotopic ossification (22%).

CONCLUSION

Present study concludes that INFIX produces excellent outcome in pelvis fractures with risk of infection where anterior plating is contraindicated.

CT-guided fixation of pelvic fractures after high-energy trauma, by interventional radiologists: technical and clinical outcome

OBJECTIVE

The aim of our study was to evaluate screw placement accuracy, safety, complications, and clinical outcomes including functional and pain score, in 32 patients treated with CT-guided pelvic ring fixation after high-energy trauma.

MATERIALS AND METHODS

Consecutive patients who were treated by CT-guided fixation of sacral or acetabular fractures after high-energy trauma were included. All procedures were performed under general anesthesia, with dual CT and fluoroscopic guidance, by interventional radiologists. Fractures were minimally displaced or reduced unstable posterior pelvic ring disruptions, with or without sacroiliac disjunction (Tile B or C) and minimally displaced acetabular fractures. The primary outcome evaluated was screw accuracy. Secondary outcomes included patient radiation exposure, duration of the procedure, complications, clinical functional score (Majeed score), and pain scale (VAS, visual analog scale) evaluation during a follow-up period from 4 to 30 months postoperatively.

RESULTS

Thirty-two patients were included (mean age 46) and 62 screws were inserted. Screw placement was correct in 90.3% of patients (95% of screws). Mean procedure duration was 67 min and mean patient radiation exposure was 965 mGy cm. Mean follow-up was 13 months and no complications were observed. The mean Majeed score at final follow-up was 84/100 and the mean VAS was 1.6/10.

CONCLUSION

This technique is an effective and safe procedure in specific cases of pelvic ring and acetabulum fractures. It allows accurate screw placement in a minimally invasive manner, leading to effective management of poly-traumatized patients.

KEY POINTS

• CT-guided pelvic ring fixation, including sacroiliac and acetabular fractures, is an effective and safe procedure. • It allows accurate and minimally invasive screw placement, leading to effective management of poly-traumatized patients. • Multidisciplinary cooperation is essential to ensure efficiency and safety.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Early management of severe pelvic injury (first 24 hours)

OBJECTIVE

Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject.

DESIGN

A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation; SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence; SFMU) in collaboration with the French Society of Radiology (Société Française de Radiologie; SFR), French Defence Health Service (Service de Santé des Armées; SSA), French Society of Urology (Association Française d'Urologie; AFU), the French Society of Orthopaedic and Trauma Surgery (Société Française de Chirurgie Orthopédique et Traumatologique; SOCFCOT), and the French Society of Digestive Surgery (Société Française de Chirurgie digestive; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE^® methodology.

RESULTS

The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ± ), 11 have a low level of evidence (Grade 2 ± ).

CONCLUSIONS

Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture.

Bilateral Internal Iliac Artery Embolization Results in an Unacceptably High Rate of Complications in Patients Requiring Pelvic/Acetabular Surgery

OBJECTIVES

To assess complication rates in patients undergoing open reduction internal fixation (ORIF) of pelvic/acetabular fractures with and without pelvic angiography embolization (PAE).

DESIGN

Retrospective case series.

SETTING

Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

One hundred eleven patients with pelvic or acetabular fractures that required orthopaedic fixation.

INTERVENTION

Retrospective analysis of outcomes in patients who underwent ORIF of pelvic/acetabular fractures with and without PAE.

MAIN OUTCOME MEASUREMENTS

Comparison of surgical wound infections, necrosis, and/or fracture nonunions between the PAE group and a control group (no PAE).

RESULTS

Final study groups consisted of 50 patients in the PAE group and 61 patients in the control group. Ninety-six percent of patients underwent nonselective PAE. Significantly higher complications were noted in the PAE group than in the control group (20% compared with 4.9%; P = 0.020). In addition, posterior surgical approaches combined with internal iliac artery embolization represented the highest complication rate.

CONCLUSIONS

Patients requiring PAE and pelvic/acetabular ORIF should undergo a multidisciplinary treatment approach with the trauma surgeon, interventional radiologist, and orthopaedic surgeon before PAE being performed to decrease complications and avoid nonselective bilateral internal iliac artery embolization.

LEVEL OF EVIDENCE

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

Current trends in the management of hemodynamically unstable pelvic ring injuries

PURPOSE OF REVIEW

Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries.

RECENT FINDINGS

Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization.

SUMMARY

Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.

Acute Management of the Traumatically Injured Pelvis

Severe pelvic trauma is a challenging condition. The pelvis can create multifocal hemorrhage that is not easily compressible nor managed by traditional surgical methods such as tying off a blood vessel or removing an organ. Its treatment often requires reapproximation of bony structures, damage control resuscitation, assessment for associated injuries, and triage of investigations, as well as multimodality hemorrhage control (external fixation, preperitoneal packing, angioembolization, REBOA [resuscitative endovascular balloon occlusion of the aorta]) by multidisciplinary trauma specialists (general surgeons, orthopedic surgeons, endovascular surgeons/interventional radiologists). This article explores this complex clinical problem and provides a practical approach to its management.

Intra-pelvic pressure changes after pelvic fracture: A cadaveric study quantifying the effect of a pelvic binder and limb bandaging over a bolster

INTRODUCTION

Unstable pelvic fractures can be life-threatening due to catastrophic haemorrhage. Non-invasive methods of reducing and stabilising these injuries include pelvic binder application and also lower limb bandaging over a knee-flexion bolster. Both of these methods help close the pelvic ring and should tamponade bleeding. This study aimed to quantify the intra-pelvic pressure changes that occurred with 3 different manoeuvres: lower limb bandaging over a bolster; a Trauma Pelvic Orthotic Device (T-POD) pelvic binder, and a combination of both.

METHODS

Following a pilot study with 2 soft embalmed cadavers, a formal study with 6 unembalmed cadavers was performed. For each specimen an unstable pelvic injury was created (OA/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3-4cm manometric water-filled balloon was placed in the retropubic space and connected to a 50ml syringe and water manometer via a 3-way tap. A baseline pressure of 8cmH₂O (equating to the average central venous pressure) was used for each cadaver. Steady intra-pelvic pressures (more reliably reflecting the pressures achieved following an intervention) were used in the subsequent statistical analysis, using R statistical language and Rstudio. Paired t-test or Wilcoxon's rank sum test were used (depending on the normality of the dataset) to determine the impact of each intervention on the intra-pelvic pressure.

RESULTS

The mean steady intra-pelvic pressures were significantly greater than the baseline pressure for each intervention. The binder and limb bandaging over a bolster alone increased the mean steady pelvic pressures significantly to 24 (SE=5) (p<0.036) and 15.5 (SE=2) (p<0.02)cmH₂O respectively. Combining these interventions further increased the mean steady pressure to 31 (SE=7)cmH₂O. However, this was not significantly greater than pressures for each of the individual interventions.

DISCUSSION

Both lower limb bandaging over a bolster and pelvic binder application significantly increased intra-pelvic pressure above the baseline pressure. This was further increased through combining these interventions, which could be useful clinically to augment haemorrhage control in these fractures.

CONCLUSION

Lower-limb bandaging over a bolster, and pelvic binder application, both significantly increased intra-pelvic pressures, and were greatest in combination. These findings support the use of these techniques to facilitate non-surgical haemorrhage control.

Bone fracture nonunion rate decreases with increasing age: A prospective inception cohort study

BACKGROUND

Fracture nonunion risk is related to severity of injury and type of treatment, yet fracture healing is not fully explained by these factors alone. We hypothesize that patient demographic factors assessable by the clinician at fracture presentation can predict nonunion.

METHODS

A prospective cohort study design was used to examine ~2.5 million Medicare patients nationwide. Patients making fracture claims in the 5% Medicare Standard Analytic Files in 2011 were analyzed; continuous enrollment for 12months after fracture was required to capture the ICD-9-CM nonunion diagnosis code (733.82) or any procedure codes for nonunion repair. A stepwise regression analysis was used which dropped variables from analysis if they did not contribute sufficient explanatory power. In-sample predictive accuracy was assessed using a receiver operating characteristic (ROC) curve approach, and an out-of-sample comparison was drawn from the 2012 Medicare 5% SAF files.

RESULTS

Overall, 47,437 Medicare patients had 56,492 fractures and 2.5% of fractures were nonunion. Patients with healed fracture (age 75.0±12.7SD) were older (p<0.0001) than patients with nonunion (age 69.2±13.4SD). The death rate among all Medicare beneficiaries was 4.8% per year, but fracture patients had an age- and sex-adjusted death rate of 11.0% (p<0.0001). Patients with fracture in 14 of 18 bones were significantly more likely to die within one year of fracture (p<0.0001). Stepwise regression yielded a predictive nonunion model with 26 significant explanatory variables (all, p≤0.003). Strength of this model was assessed using an area under the curve (AUC) calculation, and out-of-sample AUC=0.710.

CONCLUSIONS

A logistic model predicted nonunion with reasonable accuracy (AUC=0.725). Within the Medicare population, nonunion patients were younger than patients who healed normally. Fracture was associated with increased risk of death within 1year of fracture (p<0.0001) in 14 different bones, confirming that geriatric fracture is a major public health issue. Comorbidities associated with increased risk of nonunion include past or current smoking, alcoholism, obesity or morbid obesity, osteoarthritis, rheumatoid arthritis, type II diabetes, and/or open fracture (all, multivariate p<0.001). Nonunion prediction requires knowledge of 26 patient variables but predictive accuracy is currently comparable to the Framingham cardiovascular risk prediction.

Pelvic fracture in multiple trauma: A 67-case series

INTRODUCTION

Severe pelvic trauma remains associated with elevated mortality, largely due to hemorrhagic shock.

OBJECTIVE

The main study objective was to test for correlation between fracture type and mortality. The secondary objective was to assess the efficacy in terms of mortality of multidisciplinary management following a decision-tree in multiple trauma victims admitted to a level 1 trauma center.

MATERIAL AND METHODS

Between July 2011 and July 2013, 534 severe trauma patients were included in a single-center continuous prospective observational study. All patients with hemorrhagic shock received early treatment by pelvic binder. Patients with active bleeding on full-body CT or persisting hemorrhagic shock underwent arteriography with or without embolization. Pelvic trauma was graded on the Tile classification. The principle end-point was mortality.

RESULTS

Median age was 40 years (range, 26-48 years), with a 79% male/female sex ratio. Thirty-two of the 67 patients with pelvic trauma (48%) were in hemorrhagic shock at admission. Median injury severity score (ISS) was 36 (range, 24-43). On the Tile classification, 22 patients (33%) were grade A, 33 (49%) grade B and 12 (18%) grade C. Overall mortality was 19%, and 42% in case of hemorrhagic shock. Mortality was significantly higher with Tile C than A or B (58% vs. 9.1% and 12.1%, respectively; P=0.001).

CONCLUSION

Vertical shear fracture (Tile C) was associated with greater mortality from hemorrhagic shock.

LEVEL OF EVIDENCE

IV, case series.

Scoring system to predict hemorrhage in pelvic ring fracture

BACKGROUND

Risk factors for hemorrhage in patients with pelvic ring fracture have been widely reported. Because there are many risk factors, it is thought that prediction accuracy of hemorrhage in cases of pelvic ring fracture could be improved by using a scoring system.

HYPOTHESIS

We investigated the risk factors for massive hemorrhage (MH) and created a novel predictive score of MH in pelvic ring fractures.

MATERIAL AND METHODS

We retrospectively reviewed patients with pelvic ring fractures (Abbreviated Injury Score≥3 and age≥16 years) from January 2007 to June 2015. We excluded the cases that might have hemorrhage from other sites sufficient to require a blood transfusion. Massive hemorrhage was defined as hemorrhage requiring transfusion of≥6 red cell concentrate units within 24h of admission.

RESULTS

The MH group included 27 patients and the non-MH group included 71 patients. Lactate level, AO/OTA classification and extravasation of computed tomography (CT) contrast fluid had a significantly higher risk as a result of multivariable analysis. The combined score using these risk factors according to their odds-adjusted ratios was created to predict for MH: lactate level>2.5-5.0 (mmol/L)=1 point,>5.0 (mmol/L)=2 points, partially stable (OA/OTA classification B1/B2/B3)=1 point, unstable (C1/C2/C3)=2 points, pelvic extravasation of contrast on CT=4 points. The AUC of the calculated score was 0.93 (95% CI: 0.89-0.98).

CONCLUSION

The combined score using these risk factors according to their odds-adjusted ratios was created to predict MH and was an effective prediction score.

LEVEL OF EVIDENCE

IV, retrospective study.

Blood loss in pelvic ring fractures: CT-based estimation

BACKGROUND

The main cause of mortality after pelvic ring fractures is the acute haemorrhagic shock. The aim of the study was to estimate blood loss using CT and to correlate estimated blood loss to the mortality.

METHODS

A retrospective analysis of 42 patients with AO/OTA C-type pelvic ring fractures was performed. In total 29 AO/OTA C1-type, 4 C2-type and 9 C3-type fractures were analysed. A CT-volumetric analysis was developed to estimate the early blood loss in the different compartments. The results were correlated to the mortality of the patients.

RESULTS

Significant increases in interstitial free blood volume (392±502.8 vs. 888±663; P<0.05) and total blood loss (476±535 vs. 1,005±649; P<0.05) were seen when comparing C1 to C3-type fractures. Early blood loss significantly correlated to mortality. No significant difference was seen between all groups with respect to systolic blood pressure, haemoglobin concentration and the Injury Severity Score (ISS).

CONCLUSIONS

In pelvic ring fractures the CT-estimated blood loss correlates to mortality.

Prediction of extravasation in pelvic fracture using coagulation biomarkers

PURPOSE

To evaluate the usefulness of coagulation biomarkers, which are easy and quick to analyze in emergency settings, for prediction of arterial extravasation due to pelvic fracture.

PATIENTS AND METHODS

The medical records of pelvic fracture patients transferred to the emergency department of Gunma University Hospital between December 2009 and May 2015 were reviewed. Patients were divided into two groups, those with (Extra(+)) and without (Extra(-)) arterial extravasation on enhanced CT or angiography. Levels of fibrin degradation products (FDP), D-dimer, fibrinogen, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, systolic blood pressure, heart rate, the Glasgow Coma Scale, pH, base excess, hemoglobin and lactate levels, the pattern of pelvic injury, and injury severity score were measured at hospital admission, and compared between the two groups. Parameters with a significant difference between the two groups were used to construct receiver operating characteristic (ROC) curves.

RESULTS

The study included 29 patients with pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most useful parameters for predicting arterial extravasation due to pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, and hemoglobin and lactate levels were significantly higher in the Extra(+) group than in the Extra(-) group (FDP, 354.8μg/mL [median] versus 96.6μg/mL; D-dimer, 122.3μg/mL versus 42.1μg/mL; the ratio of FDP to fibrinogen, 3.39 versus 0.42; the ratio of D-dimer to fibrinogen, 1.14 versus 0.18; hemoglobin, 10.5g/dL versus 13.5g/dL; lactate, 3.5mmol/L versus 1.7mmol/L). The area under the ROC curves for FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, hemoglobin and lactate levels were 0.900, 0.882, 0.918, 0.900, 0.815 and 0.765, respectively.

CONCLUSION

Coagulation biomarkers, and hemoglobin and lactate levels could be useful to predict the existence of arterial extravasation due to pelvic fracture. The ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most accurate markers. Coagulation biomarkers may enable more rapid and specific treatment for pelvic fracture.

Management of Pelvic Ring Injuries in Unstable Patients

High-energy pelvic ring injuries can represent life-threatening injuries in the polytraumatized patient, particularly when presenting with hemodynamic instability. These injuries mandate a systematic multidisciplinary approach to evaluation, and timely intervention to address hemorrhage while concomitantly addressing mechanical instability. These pelvic injuries are associated with potentially lethal hemorrhage originating from venous, arterial, and osseous sources. A thorough understanding of anatomy, radiographic findings, and initial physical examination can alert one to the presence of pelvic instability necessitating emergent treatment. The focus is on hemorrhage control, using techniques for skeletal stabilization, angiography, and open procedures to decrease mortality in this high-risk patient population.

Pelvic angioembolization in trauma - Indications and outcomes

INTRODUCTION

Pelvic stabilization with angioembolization (AE) is steadily supplanting operative management for the treatment of pelvic hemorrhage in trauma. We aimed to provide a brief review of the indications, effectiveness and complications associated with AE for pelvic injuries.

METHODS

We conducted a literature search using the terms "trauma," "angioembolization," and "pelvis" limited to studies published in the English language. Abstracts and full text were manually reviewed to identify suitable articles.

RESULTS

The current brief review is based on content from articles published in the last 10 years related to pelvic AE for retroperitoneal hemorrhage after trauma.

DISCUSSION

Pelvic injuries often require complex management because the high energy transfer causes concomitant injuries. Outcomes for hemodynamically unstable patients may be better with AE than with operative management.

CONCLUSION

Pelvic AE is the most effective intervention for management of hemorrhage associated with pelvic fracture in both hemodynamically stable and unstable patients. It can be used as the primary definitive intervention or in conjunction with operative management in the setting of concomitant intra-abdominal injury.

Open pelvic fracture associated with lumbosacral dislocation and extensive perineal injury

Open pelvic fractures are caused by high-energy trauma. Injuries to other organs are common and the mortality rate can be as high as 50%. Perineal injury is reported in 5% of open pelvic fractures. We report a case of a 31-year-old man that had an open pelvic injury with Denis zone III fracture of the sacrum, lumbosacral dislocation, symphysis dislocation, bilateral pubic rami fractures and an extensile perineal wound. He underwent an early diverting colostomy in order to prevent pelvic sepsis and subsequent stage reconstruction of the pelvic ring. At a 4-year follow-up a full recovery was present. The aim of this paper is to underline the importance of a safe, approach to manage open pelvic fractures.

The role of angio-embolization in the acute treatment concept of severe pelvic ring injuries

BACKGROUND

In recent years a wide variety of strategies to treat the haemodynamically unstable patient with pelvic ring fractures have been proposed. This study evaluates our institutional management of patients with severe pelvic fractures and analyses their outcomes.

METHODS

Retrospective review of all severely injured trauma patients with pelvic ring injuries admitted to a level I trauma centre from 2007 to 2012. Patient records were documented prospectively in a trauma database and evaluation was performed by SPSS.

RESULTS

During the study period, a total of 173 patients with pelvic ring fractures were admitted and formed the basis of this study. Overall, 46% of the patients had suffered a type A fracture, 25% a type B fracture and the remaining 29% a type C pelvic ring fracture. Surgical treatment was required in 21% of the patients (pelvic C-clamp, n = 6; supra-acetabular external fixator, n = 32; pelvic packing, n = 12; definitive plate osteosynthesis of the pubis symphysis, n = 6). Angio-embolization was performed in 16 patients (9%); in 8 patients it was the only specific treatment for the pelvic injury on day 0 and in 8 patients it was performed immediately post-operatively. The overall mortality rate was 12.7% (n = 22), with the type C pelvic fractures having the highest mortality (30.0%). Four patients died immediately after admission in the shock room.

CONCLUSIONS

Angiographic embolization as a first-line treatment was only performed in haemodynamically stable patients or in patients responding to fluid resuscitation with the finding of an arterial blush in the CT scan. In haemodynamically unstable patients, pre-peritoneal pelvic packing in combination with mechanical pelvic stabilization was immediately carried out, followed by angio-embolization post-operatively if signs of persistent bleeding remained present.