Current management of severe pelvic and perineal trauma

Managing severe (and open) pelvic disruption

Open pelvic fractures are a rare yet catastrophic injury pattern, often resulting from high-energy trauma such as motor vehicle collisions, motorcycle accidents, and pedestrian impacts. They account for only 2%-4% of all pelvic fractures, but their severity lies in the complex anatomy of the pelvis and its associated structures, including the vasculature, bowel, bladder, and genital organs. Mortality rates range from 15% to 50%, with some studies reporting rates as high as 70% in cases involving severe perineal or rectal injuries. These injuries pose two main risks to survival: hemorrhagic shock in the acute phase and pelvic sepsis during the later phases of recovery. Acute hemorrhage can occur from arterial injury (eg, internal iliac arteries), venous plexuses, or bony sources. Delayed deaths are often caused by sepsis due to fecal contamination of wounds or infected hematomas. Additionally, these fractures are often associated with other life-threatening injuries, including intra-abdominal trauma, genitourinary disruptions, and neurovascular compromise, further complicating their management. Management of these injuries has evolved significantly with advancements in hemorrhage control techniques such as preperitoneal pelvic packing and resuscitative endovascular balloon occlusion of the aorta. A multidisciplinary approach is essential to address the multifaceted challenges posed by these injuries.

CT angiography of the lower abdomen should be considered with vaginal trauma and excessive bleeding, even though there are no pelvic fractures present

A healthy woman in her 20s presented to the emergency department (ED) after she endured a high-energy trauma during a dirt bike race. Physical examination showed no signs of thoracic or abdominal injury. Her pubic bone was painful at palpation, with a large amount of vaginal bleeding and a rupture of the vaginal back wall. Additional imaging with X-rays and extended focused assessment with sonography in trauma showed no fractures or free fluid in the abdomen, and the patient was then taken to the operating room for closure of the rupture. This patient became haemodynamically unstable during the operative procedure because of a transection of a side branch of the left internal iliac artery. Angiography with selective embolisation was performed, after which the bleeding stopped. We present a rare case of a high-pressure arterial bleed in the pelvis due to blunt trauma without osseous injuries. The learning point of this case is that prior to the operative procedure, a CT angiography of the abdomen should have been performed in the ED. Even though traumatic isolated injury to the internal iliac artery is a rare occurrence and the patient was initially haemodynamically stable, the intensity of the trauma and a large amount of vaginal bleeding warranted additional imaging.

Safety or speed? Assessing alternative vascular access for angiography after resuscitative endovascular balloon occlusion of the aorta (REBOA) in severe pelvic trauma patients

Introduction

Pelvic fractures often result in life-threatening bleeding and hemodynamic instability. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a promising strategy for patients with severe pelvic fractures, facilitating subsequent hemostatic interventions. Transcatheter arterial embolization (TAE) is a well-established procedure for managing pelvic fractures accompanied by hemorrhage.Ideally, an angiographic access point distinct from the initial REBOA placement is sought to maintain REBOA deflation without complete removal, thereby preventing hemodynamic instability during the procedure. However, in cases of extreme and severe pelvic trauma, gaining access for REBOA is already challenging, not to mention the additional difficulty posed by subsequent angiographic access.This study aims to assess the challenges associated with gaining access in cases where successful TAE was ultimately performed, particularly in the context of severe pelvic trauma. We investigate the complexities surrounding access management and its implications for patient outcomes.

Methods

We conducted a retrospective analysis of patients who presented with pelvic fractures and underwent sequential REBOA and TAE procedures at our institution between 2017 and 2023. We excluded patients with Abbreviated Injury Scores (AIS) ≥3 in systems other than the pelvis, those who underwent TAE prior to REBOA, and cases of suboptimal REBOA insertion.We collected demographic data, injury characteristics, details of the REBOA and TAE procedures, information on complications, and data on patient survival. The primary endpoints of our analysis included overall survival and the success of TAE (defined as post TAE mean arterial pressure (MAP) ≥65 mm Hg). Secondary endpoints encompassed the duration details of two interventions.

Results

Between 2017 and 2023, a total of 17 patients were included in this study. Among this cohort, 12 (70.6%) were male, with a median age of 51 years. Overall survival was 23.5%. Patients were grouped into angiography after REBOA deflation (AAD) or angiography after REBOA removal (AAR). AAR group was younger (39.0 vs 63.0, p=0.030) and had higher Shock Index at triage (2.30 vs 1.10, p=0.015). More patient whose post TAE MAP >=65 mm Hg was found in the AAR group, although no significant difference on overall survival (25.0% vs 22.2%, p=1.000). Angiographic cannulation times, pre-angiographic MAP, and amount of pre-angiographic transfusion of packed red blood cell were similar across groups.

Conclusion

Our findings provide empirical insights into vascular access selection and suggest that AAR in the management of severe pelvic fractures can be beneficial, particularly when pre-angiographic resuscitation is sufficient. Larger studies are required to validate these observations and assess long-term outcomes.

Level of evidence

III.

Age-period-cohort analysis of epidemiological trends in pelvic fracture in China from 1992 to 2021 and forecasts for 2046

Background

This study explored the epidemiological trends in pelvic fracture (PF) in China from 1992 to 2021, analyze their relationships with age-period-cohort (APC) factors, and predict the trends of PF from 2022 to 2046.

Methods

Incidence and years lived with disabilities (YLDs) of PF among sexes in China from 1992 to 2021 were obtained through the 2021 Global Burden of Disease (GBD) database. Trends in the incidence and YLDs were described, and a joinpoint regression model was used. The APC model was used to explore the effects of age, period, and cohort on the incidence and YLDs. Nordpred forecasted the incidence and YLDs in China from 2022 to 2046.

Results

In 2021, there were an estimated 0.63 million incidence cases and 0.33 million of YLDs, respectively. The number and age-standardized rate (ASR) of incidence and YLDs were both gradually increased. The average annual percent change (AAPC) in incidence and YLDs for men were 0.26% and -0.17%, respectively. For women, the AAPC values for incidence and YLDs were -0.03% and -0.57% (p < 0. 001), respectively. The relative risk (RR) of PF increases with age, with the lowest risk in those aged 10-14 years for incidence and aged 1-4 for YLDs and the highest risk in those aged >95 years for incidence and aged 90-94 years for YLDs. The period effect showed a totally increase in the risk across the general, male, and female populations. Cohort effects indicated a totally significant decline for both incidence and YLDs. The predicted incidence and YLDs of PF in China from 2022 to 2046 showed an initial rise, followed by a decline, with 2029 and 2034 being the turning point for incidence and YLDs, respectively.

Conclusion

The characteristics of pelvic fracture incidence and YLDs in China are complex. Thus, primary prevention measures must be strengthened. Raising awareness about osteoporosis prevention, enhancing public health education, and promoting good dietary and hygiene habits are appropriate preventive measures for PF in China.

Spring coil displacement after interventional embolization of severe pelvic fracture: a case report

Haemorrhagic shock, which arises as a complication of pelvic fracture subsequent to severe trauma, represents a perilous state. The utilization of interventional endovascular haemostasis assumes a pivotal role in the management of patients with vascular injury following pelvic fracture. This article reports the treatment of a patient with pelvic fracture caused by a serious work-related vehicle accident. Despite the implementation of timely blood and fluid transfusion to combat shock, the application of aortic balloon obstruction, and interventional iliac artery embolization for haemostasis, the patient's condition failed to display any discernible improvement. Repeat angiography further revealed a displacement of the interventional embolization material, and the patient subsequently died of multiple organ failure. The occurrence of spring coil displacement is infrequent, but the consequences thereof are considered grave, necessitating meticulous discernment in the selection of haemostatic materials for this type of patient. The diagnostic and therapeutic processes encompassing the particular case described here were analysed and are discussed with the objective of augmenting the efficacy and success rate of treatment modalities for patients in similar circumstances.

Total hip arthroplasty in patients with colostomy: impact on inpatient complications, hospital costs, and length of stay

INTRODUCTION

The presence of permanent end-colostomy is traditionally thought of as a risk factor for complications following orthopedic joint replacement; however, literature supporting this association is scarce. This study aims to discern how length of stay, cost of stay, and inpatient complications following total hip arthroplasty (THA) are impacted by presence of colostomy.

METHODS

Data from the National Inpatient Sample was analyzed by International Classification of Diseases, 10th Revision, Clinical Modification regarding THA in patients with and without end-colostomy. Unmatched and matched analyses comparing length of stay, cost of stay, and post-operative adverse outcomes between the two groups were conducted. In the unmatched analysis, 445 THA patients with colostomy were compared to 367,449 THA patients without colostomy. The colostomy patients were then matched for age, sex, race, diabetes, obesity, and the matched groups consisted of 445 patients with and 425 patients without colostomy, respectively.

RESULTS

Compared to the THA without colostomy group, the colostomy group was significantly older, had longer hospital stays, and greater cost of stay. When matched for age and comorbidities, length of hospital stay (p < 0.001) and cost of stay (p = 0.002) remained significantly higher. The colostomy group was at significantly increased risk for periprosthetic fracture, dislocation, and infection compared to all THA patients. When matched for age and common comorbidities, the colostomy group had significantly higher risk in only periprosthetic dislocation [p = 0.003, OR 11.8 (1.6-4.6, 95% CI)] and periprosthetic infection [p < 0.05, OR 2.7 (0.97-7.7 95% CI)].

CONCLUSION

Patients with colostomy are at risk of longer hospital courses and greater incurred costs following THA compared to patients without colostomy. They are additionally at significantly increased risk of periprosthetic dislocation and periprosthetic infection, warranting treatment as high-risk patients.

STUDY DESIGN

Retrospective cohort study.

Speeding pelvic fracture fixation: CT scan with simultaneous 3-D pelvic reconstruction in the emergency department

INTRODUCTION

Contrast-enhanced computed tomography (CT) scans are usually needed in the emergency department (ED) to evaluate intra-abdominal injuries associated with pelvic fractures. Three-dimensional (3-D) images for pelvis reconstruction are also needed for planning surgical fixation after admission. This study investigates the advantages integrating a one-stage computed tomography (CT) scan with these two diagnostic modalities simultaneously to reduce the time to surgery and improve the outcomes of pelvic fracture fixation.

METHODS

A retrospective cohort study (2018-2021) of patients with pelvic fractures was performed. Patients were categorized into the one-stage CT group or the two-stage CT group, and propensity score matching was used to address biases. The outcome measures included time to surgical fixation, time to CT scan for 3-D pelvis reconstruction, and overall length of hospital stay.

RESULTS

Four hundred forty-four pelvic fracture patients who underwent definite surgical fixation were identified. Of those, 320 underwent a one-stage CT scan, while the remaining 124 underwent a two-stage CT scan. After well-balanced matching, those in the one-stage CT group had a significantly shorter time to surgical fixation than those in the two-stage CT group (4.6 vs. 6.8 days, p < 0.001). Even among critically ill patients necessitating intensive care unit (ICU) admission, the one-stage CT scan group had a shorter time to definitive surgical fixation (5.5 vs. 7.2 days, p = 0.002) and a shorter hospital stay (19.0 vs. 32.7 days, p = 0.006).

CONCLUSION

A one-stage contrast-enhanced CT scan combined with simultaneous 3-D pelvis reconstruction is promising for expediting surgical fixation in pelvic fracture patients. This innovative strategy may improve patient outcomes by facilitating timely surgical interventions and minimizing delays associated with additional CT scans.

Higher pelvic incidence values are a risk factor for trans-iliac trans-sacral screw malposition in sacroiliac complex fracture treatment

BACKGROUND

Percutaneous iliosacral (IS) screw fixation and trans-iliac trans-sacral (TITS) screw fixation are clinically effective treatments of posterior pelvic sacroiliac fractures. In order to accurately assess the sacrum position relative to the pelvis, pelvic incidence (PI) is a commonly utilized radiographic parameter in sagittal view. This study aimed to investigate and compare the surgical outcomes and radiographic parameters of IS or TITS screw fixations for the treatment of posterior sacroiliac complex fractures with different PI values.

MATERIALS AND METHODS

The data on patients with posterior pelvic sacroiliac fractures who underwent percutaneous IS or TITS screw fixations, or both, at a single level I trauma center between January 2017 and June 2020 were reviewed. We documented the patient characteristics and fracture types, reviewed surgical records, and measured the radiographic parameters via plain films and multi-planar computed tomography (mpCT) images. Radiographic variations in PI, sacral slope, pelvic tilt, sacral dysmorphism, pelvic ring reduction quality, screw deviation angles, screw malposition grading, and iatrogenic complications were documented and analyzed.

RESULTS

A total of 85 patients were included, and 65 IS and 70 TITS screws were accounted for. Patients were divided into two groups according to screw fixation method and further divided into four sub-groups based on baseline PI values. The PI cutoff values were 49.85° and 48.05° in the IS and TITS screw groups, respectively, according to receiver operating characteristic analysis and Youden's J statistic. Smaller PI values were significantly correlated with sacral dysmorphism (p = 0.027 and 0.003 in the IS and TITS screw groups, respectively). Patients with larger PI values were at a significantly increased risk of screw malposition in the TITS screw group (p = 0.049), with no association in the IS screw group. Logistic regression confirmed that a larger PI value was a significant risk factor for screw malposition in the TITS screw group (p = 0.010). The post-operative outcomes improved from poor/fair (at 6 months) to good/average (at 12 months) based on the Postel Merle d'Aubigné and Majeed scores, with no significant differences between subgroups.

CONCLUSIONS

Both percutaneous IS and TITS screw fixations are safe and effective treatments for posterior pelvic sacroiliac fractures. Due to the higher risk of screw malposition in patients with larger PI values, it is crucial to identify potential patients at risk when performing TITS screw fixation surgery.

LEVEL OF EVIDENCE

Level III.

Management of open pelvic ring injuries

Open pelvic ring injuries are rare clinical entities that require multidisciplinary care. Due to the scarcity of this injury, there is no well-defined treatment algorithm. As a result, conflicting evidence surrounding various aspects of care including wound management and fecal diversion remain. Previous studies have shown mortality reaching 50% in open pelvic ring injuries, nearly five times higher than closed pelvic ring injuries. Early mortality is due to exsanguinating hemorrhage, while late mortality is due to wound sepsis and multiorgan system failure. With advancements in trauma care and ATLS protocols, there has been an improved survival rate reported in published case series. Major considerations when treating these injuries include aggressive resuscitation with hemorrhage control, diagnosis of associated injuries, prevention of wound sepsis with early surgical management, and definitive skeletal fixation. Classification systems for categorization and management of bony and soft tissue injury related to pelvic ring injuries have been established. Fecal diversion has been proposed to decrease rates of sepsis and late mortality. While clear indications are lacking due to limited studies, previous studies have reported benefits. Further large-scale studies are necessary for adequate evaluation of treatment protocols of open pelvic ring injuries. Understanding the role of fecal diversion, avoidance of primary closure in open pelvic ring injuries, and importance of well-coordinated care amongst surgical teams can optimize patient outcomes.

Infection from an Iliosacral Screw 16 Years Postoperatively in Demolition Derby Umpire Crushed Between 2 Cars: A Case Report

CASE

A 47-year-old man crushed between 2 cars during a demolition derby, a nonracing North American motorsport, underwent open reduction and internal fixation, iliosacral screw fixation, arterial embolization, and multiple urologic procedures after massive pelvic ring injury, remarkably recovering nearly full function. Sixteen years after injury, he developed an abscess emanating from an iliosacral screw requiring irrigation, debridement, and hardware removal.

CONCLUSION

Deep surgical infections from iliosacral screws may present late, even more than 15 years after the original surgery. Obesity, preoperative embolization, diabetes, and urethral injuries are relevant risk factors. Similar patients should have a low threshold for infection workup when presenting with symptoms, even years after surgery.

Substantation of the method of lumbo-pelvic fixation in verically unstable fractures of the sacrum

Background. According to the literature and our own observations, there is an increase in the number of victims of young, able-bodied age with severe injuries to the pelvic structures. Despite numerous developments and studies in this area, high mortality and a high percentage of unsatisfactory treatment results remain. The publication reflects the advantages of using bilateral lumbopelvic fixation in the treatment of injuries to the cross. Load calculation, biomechanical modeling of damages and displacing factors are presented. Bilateral lumbopelvic fixation has proven to be a reliable method capable of providing reliable fixation of the fracture at all stages of treatment. Aim. To substantiate and test modified lumbopelvic stabilization of the pelvic ring in patients with vertically unstable (C1-2-3 according to Tile M.) sacral fractures. Material and methods. Based on the treatment of 20 patients with severe sacral fractures, it was proved that the best result was achieved with bilateral lumbopelvic stabilization. The use of the author's version (RF Patent No. 2684870 "Method of fixation in unilateral unstable sacral fractures") of osteosynthesis is presented on the example of the treatment of multiple pelvic trauma, a good clinical result was obtained, and neurological symptoms were stopped. Results. Lumbar-iliac osteosynthesis for vertically unstable sacral fractures is the optimal method of fixation. The distribution vector of the levers of the latch corresponds to the biasing force, which ensures maximum reliability of the synthesis. The method, if necessary, creates conditions for decompression of the roots, prevents the early development of arthrosis of the sacroiliac joints. Using it allows you to maintain or correct the sagittal and frontal balance of the spine. The use of bilateral 8-screw lumboiliac fixation with the installation of a transverse tie is recommended, since unilateral fixation or a decrease in the number of fixing elements can lead to loosening of the fixator. Conclusion. Based on biomechanical modeling and the results of treatment of patients with severe injuries of the posterior pelvic ring, the effectiveness of the proposed method of lumbopelvic fixation was proven.

Proposal of an algorithm for the management of rectally inserted foreign bodies: a surgical single-center experience with review of the literature

BACKGROUND

Retained rectal foreign bodies (RFBs) are uncommon clinical findings. Although the management of RFBs is rarely reported in the literature, clinicians regularly face this issue. To date, there is no standardized management of RFBs. The aim of the present study was to evaluate our own data and subsequently develop a treatment algorithm.

METHODS

All consecutive patients who presented between January 2006 and December 2019 with rectally inserted RFBs at the emergency department of the Klinikum Stuttgart, Germany, were retrospectively identified. Clinicopathologic features, management, complications, and outcomes were assessed. Based on this experience, a treatment algorithm was developed.

RESULTS

A total of 69 presentations with rectally inserted RFBs were documented in 57 patients. In 23/69 cases (33.3%), the RFB was removed transanally by the emergency physician either digitally (n = 14) or with the help of a rigid rectoscope (n = 8) or a colonoscope (n = 1). In 46/69 cases (66.7%), the RFB was removed in the operation theater under general anesthesia with muscle relaxation. Among these, 11/46 patients (23.9%) underwent abdominal surgery, either for manual extraction of the RFB (n = 9) or to exclude a bowel perforation (n = 2). Surgical complications occurred in 3/11 patients. One patient with rectal perforation developed pelvic sepsis and underwent abdominoperineal extirpation in the further clinical course.

CONCLUSION

The management of RFBs can be challenging and includes a wide range of options from removal without further intervention to abdominoperineal extirpation in cases of pelvic sepsis. Whenever possible, RFBs should obligatorily be managed in specialized colorectal centers following a clear treatment algorithm.

Management and outcomes of open pelvic fractures: An update

BACKGROUND

Open pelvic fractures remain challenging in terms of their management. The purpose of this narrative review was to evaluate the latest advances made in the management of these injuries and report on their clinical outcome.

PATIENTS AND METHODS

A literature review was undertaken focusing on studies that have been published on the management of open pelvic fractures between January 2005 and November 2019. Information extracted from each article include demographics, mechanism of injury, injury severity score (ISS), classification of pelvic ring fracture, classification of open soft tissue, specific injury zone classification, number of cases with hemodynamic instability, number of cases that received blood transfusions, amount of packed red blood cells transfused during the first 24 h, number of cases with anorectal trauma, urogenital injury, number of fecal diversional colostomies and laparotomies, angiographies and embolization, preperitoneal pelvic packings, length of stay in intensive care unit (ICU) and in hospital, and mortality.

RESULTS

Fifteen articles with 646 cases formed the basis of this review. The majority of patients were male adults (74.9%). The mean age was 35.1 years. The main mechanism of injury was road traffic accidents, accounting for 67.1% of the injuries. The mean ISS was 26.8. A mean of 13.5 units of PRBCs were administered the first 24 h. During the whole hospital stay, 79.3% of the patients required blood transfusions. Angiography and pelvic packing were performed in a range of 3%-44% and 13.3%-100% respectively. Unstable types of pelvic injuries were the majority (72%), whilst 32.7% of the cases were associated with anorectal trauma, and 32.6% presented with urogenital injuries. Bladder ruptures were the most reported urogenital injury. Fecal diversional colostomy was performed in 37.4% of the cases. The mean length of ICU stay was 12.5 days and the mean length of hospital stay was 53.0 days. The mean mortality rate was 23.7%.

CONCLUSION

Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. Sufficient blood transfusion, bleeding control, treatments of associated injuries, fracture fixation and soft tissue management remain essential for the reduction of mortality and improved outcomes.

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.

Pelvic Fractures and Associated Injuries in Patients Admitted to and Treated at Emergency Department of Tibebe Ghion Specialized Hospital, Bahir Dar University, Ethiopia

Background

Pelvic fractures are high-risk injuries that require careful evaluation due to significant patient morbidity and mortality associated with damage to major blood vessels, nerves, and organs. Thus, the aim of this study was to assess pelvic fractures and associated injuries among patients presented at the emergency department of Tibebe Ghion Specialized Hospital, Bahir Dar, Ethiopia.

Methods

This is a cross-sectional study with a retrospective facility-based data collection technique. All patients who were managed for pelvic fracture from September 2018 to February 2021 were included. The patient’s chart number was collected from the orthopedics surgery morning register sheet and their case folders were retrieved from the medical record department. We used a structured and pretested checklist, and chart review for data collection. The collected data were cleaned, coded, and entered into Epi Info version 7 and exported to SPSS version 24 for analysis. Binary logistic regression analysis was used to identify factors associated with a pelvic fracture.

Results

We studied 64 cases of pelvic fracture during the study period. Pelvic was common among males with a ratio of 7:1 and young population (15–35 years). The most common associated injuries were lower extremity 23 (35.9%), abdominal injuries 16 (25.0%), and urethral injury in 13 (20.3%). Moreover, most patients with pelvic fracture have Tile A fracture 56.3%, Tile C in 20 (31.3%), and Tile B in 8 (12.5%) patients. The road traffic accident was the most common cause of pelvic fracture in 56.3%, followed by fall down accident (28.1%), and bullet injury (12.5%).

Conclusion

The incidence of pelvic fracture was high in the study area. It reflects the need for strong and multi-sectoral collaboration to prevent pelvic fracture. Additionally, it needs a careful, systematic management approach for survival, healing, and to address the associated complexities and the polytrauma nature.

Angiography in patients with pelvic fractures and contrast extravasation on CT following high-energy trauma

INTRODUCTION

Pelvic fracture may be accompanied by severe bleeding. Computed tomography (CT) is a gold standard diagnostic tool in stable trauma patients. Contrast extravasation detected on CT of pelvis is a sign of hemorrhage, but its significance is not clear. We aimed to evaluate the need for angiography in patients with pelvic fracture and CT revealed contrast extravasation. We tried to identify parameters that might help to choose patients who will benefit from therapeutic angiography.

METHODS

Electronic medical records of patients with pelvic fracture admitted to Level II Trauma Center during 10 years were retrospectively reviewed. Patients who had contrast extravasation on CT were included. Data base consisted of demographics, injury severity, initial physiologic parameters, laboratory data, results of CT and angiography.

RESULTS

Forty out of 396 patients had contrast extravasation detected by CT. Twelve patients underwent angiography and 4 of them benefited from embolization. The sensitivity of contrast extravasation in evaluating the need for embolization was 1.0 (95% CI 0.398, 1.0), positive predictive value was 0.1 (95% CI 0.028, 0.237), and the negative predictive value was 1.0 (95% CI 0.990, 1.0).

CONCLUSION

The role of angiography in stable patients with pelvic fracture and CT identified contrast extravasation remains questionable. Most of these patients are not in need of angioembolization.

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.

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.

Patterns, management, and outcomes of traumatic pelvic fracture: insights from a multicenter study

Background

Traumatic pelvic fracture (TPF) is a significant injury that results from high energy impact and has a high morbidity and mortality.

Purpose

We aimed to describe the epidemiology, incidence, patterns, management, and outcomes of TPF in multinational level 1 trauma centers.

Methods

We conducted a retrospective analysis of all patients with TPF between 2010 and 2016 at two trauma centers in Qatar and Germany.

Results

A total of 2112 patients presented with traumatic pelvic injuries, of which 1814 (85.9%) sustained TPF, males dominated (76.5%) with a mean age of 41 ± 21 years. In unstable pelvic fracture, the frequent mechanism of injury was motor vehicle crash (41%) followed by falls (35%) and pedestrian hit by vehicle (24%). Apart from both extremities, the chest (37.3%) was the most commonly associated injured region. The mean injury severity score (ISS) of 16.5 ± 13.3. Hemodynamic instability was observed in 44%. Blood transfusion was needed in one third while massive transfusion and intensive care admission were required in a tenth and a quarter of cases, respectively. Tile classification was possible in 1228 patients (type A in 60%, B in 30%, and C in 10%). Patients with type C fractures had higher rates of associated injuries, higher ISS, greater pelvis abbreviated injury score (AIS), massive transfusion protocol activation, prolonged hospital stay, complications, and mortality (p value < 0.001). Two-thirds of patients were managed conservatively while a third needed surgical fixation. The median length of hospital and intensive care stays were 15 and 5 days, respectively. The overall mortality rate was 4.7% (86 patients).

Conclusion

TPF is a common injury among polytrauma patients. It needs a careful, systematic management approach to address the associated complexities and the polytrauma nature.

Associated abdominal injuries do not influence quality of care in pelvic fractures-a multicenter cohort study from the German Pelvic Registry

Background

Pelvic fractures are rare but serious injuries. The influence of a concomitant abdominal trauma on the time point of surgery and the quality of care regarding quality of reduction or the clinical course in pelvic injuries has not been investigated yet.

Methods

We retrospectively analyzed the prospective consecutive cohort from the multicenter German Pelvic Registry of the German Trauma Society in the years 2003–2017. Demographic, clinical, and operative parameters were recorded and compared for two groups (isolated pelvic fracture vs. combined abdominal/pelvic trauma).

Results

16.359 patients with pelvic injuries were treated during this period. 21.6% had a concomitant abdominal trauma. The mean age was 61.4 ± 23.5 years. Comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger (47.3 ± 22.0 vs. 70.5 ± 20.4 years; p < 0.001). Both, complication (21.9% vs. 9.9%; p < 0.001) and mortality (8.0% vs. 1.9%; p < 0.001) rates, were significantly higher.

In the subgroup of acetabular fractures, the operation time was significantly longer in the group with the combined injury (198 ± 104 vs. 176 ± 81 min, p = 0.001). The grade of successful anatomic reduction of the acetabular fracture did not differ between the two groups.

Conclusion

Patients with a pelvic injury have a concomitant abdominal trauma in about 20% of the cases. The clinical course is significantly prolonged in patients with a combined injury, with increased rates of morbidity and mortality. However, the quality of the reduction in the subgroup of acetabular fractures is not influenced by a concomitant abdominal injury.

Trial registration

ClinicalTrials.gov, NCT03952026, Registered 16 May 2019, retrospectively registered

[Quality of operative treatment of pelvic fractures is not influenced by an additional abdominal injury : A monocentric registry study]

BACKGROUND

Pelvic fractures are rare but severe injuries. The influence of a concomitant abdominal trauma on the quality of care regarding operative parameters, such as reduction quality and the clinical course in pelvic injuries has not yet been sufficiently investigated.

METHODS

This study retrospectively analyzed the prospective consecutive data of patients with pelvic injuries treated at the BG Trauma Center in Tübingen in the years 2003-2017. Demographic, clinical and operative parameters were recorded and compared between two groups (isolated pelvic fracture vs. combined abdominal/pelvic trauma).

RESULTS

A total of 1848 patients with pelvic injuries were treated during this period and 18.6% had a concomitant abdominal trauma. The mean age was 62.3 ± 23.1 years. Comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger (46.3 ± 20.3 years vs. 70.6 ± 20.8 years; p < 0.001). Both the overall complication rate (31.2% vs. 9.4%; p < 0.001) and mortality (5.0% vs. 1.7%; p = 0.001) were significantly higher in the group with a combination of injuries. The time until definitive surgery of the pelvis was significantly longer in the group with combined injuries (6.0 ± 6.4 days vs. 4.5 ± 4.4 days; p = 0.002). The results of postoperative reduction did not differ between the two groups.

CONCLUSION

Patients with a pelvic injuries have a concomitant abdominal trauma in approximately 20% of the cases. The clinical course is significantly prolonged in patients with a combined injury and morbidity and mortality rates are increased; however, the quality of the postoperative results is not influenced by a concomitant abdominal injury.

Effects of tranexamic acid on reducing blood loss in pelvic trauma: A randomised double-blind placebo controlled study

BACKGROUND

Management of pelvic trauma is complicated with patients' instability and remains high in skeletal injuries. The patients usually are young and in middle age and the management of bleeding is more important. The aim of this study is to assess the effects of Tranexamic Acid in Reducing Blood Loss in pelvic trauma: A Randomised Double-Blind Placebo Controlled Study.

METHOD AND MATERIALS

In this randomized clinical trial study 106 patients with Pelvic Trauma (PT) were randomly divided into two groups. The case group received 1 g Intravenous TXA for loading dose and 3 dose per 8 h for the maintenance and control group received only serum 0.9% N.S (Normal Saline) or placebo. The Hemoglobin (Hb), Hematocrit (HCT), Pulse Rate (PR) and Blood Pressure (BP) was checked at admission, 24 h, 48 h and 72 h after admission.

RESULTS

From 106 patients 61(%57.54) male and 45 (%42.46) female patients enrolled to the study. The mean age was 48.14 ± 13.54 and the range was 18-60 years old. There was no difference between two groups based on Blood Pressure at admission, 24 h, 48 h and 72 h after admission. There was a significant difference between two groups in 24 h, 48 h and 72 h after admission based on Hb and HCT amount.

CONCLUSION

based on our findings it appears that TXA can reduce bleeding amount in the first, second and third 24 h after surgery based on Hb and HCT without any effect on systolic and diastolic BP and PR. In other hand no side effect reported by any patients.

Analyses of clinical outcomes after severe pelvic fractures: an international study

Background

This study aimed to compare treatment outcomes between patients with severe pelvic fractures treated at a representative trauma center that was established in Korea since 2015 and matched cases treated in the USA.

Methods

Two cohorts were selected from a single institution trauma database in South Korea (Ajou Trauma Data Bank (ATDB)) and the National Trauma Data Bank (NTDB) in the USA. Adult blunt trauma patients with a pelvic Abbreviated Injury Scale >3 were included. Patients were matched based on covariates that affect mortality rate using a 1:1 propensity score matching (PSM) approach. We compared differences in outcomes between the two groups, performed survival analysis for the cohort after PSM and identified factors associated with mortality. Lastly, we analyzed factors related to outcomes in the ATDB dataset comparing a period prior to the implementation of the trauma center according to US standards, an interim period and a postimplementation period.

Results

After PSM, a total of 320 patients (160 in each cohort) were identified for comparison. Inhospital mortality was significantly higher in the ATDB cohort using χ² test, but it was not statistically significant when using Kaplan-Meier survival curves and Cox regression analysis. Moreover, the mortality rate was similar comparing the NTDB cohort to ATDB data reflecting the post-trauma center establishment period. Older age, lower systolic blood pressure (SBP) and Glasgow Coma Scale (GCS) at admission were factors associated with mortality.

Discussion

Mortality rate after severe pelvic fractures was significantly associated with older age, lower SBP and GCS scores at admission. Efforts to establish a trauma center in South Korea led to improvement in outcomes, which are comparable to those in US centers.

Level of evidence

Level IV.

Preperitoneal pelvic packing

Severe pelvic traumatisms are associated with elevated mortality because of the high risk of exsanguination from multiple sources of bleeding. Treatment should encompass resuscitation, bone stabilization and hemorrhage control by arterio-embolization or surgery. Pre-peritoneal packing has been described in hemodynamically unstable patients who need damage control. The surgical technique of this simple and effective procedure is fully described by the authors with some complementary useful technical advices.

Pelvic trauma: WSES classification and guidelines

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

Mortality in trauma patients with active arterial bleeding managed by embolization or surgical packing: An observational cohort study of 66 patients

Objective:

Exsanguination due to coagulopathy and vascular injury is a common cause of death among trauma patients. Arterial injury can be treated either by angiography and embolization or by explorative laparotomy and surgical packing. The purpose of this study was to compare 30-day mortality and blood product consumption in trauma patients with active arterial haemorrhage in the abdominal and/or pelvic region treated with either angiography and embolization or explorative laparotomy and surgical packing.

Material and Methods:

From January 1^st 2006 to December 31^st 2011 2,173 patients with an ISS of >9 were admitted to the Trauma Centre of Copenhagen University Hospital, Rigshospitalet, Denmark. Of these, 66 patients met the inclusion criteria: age above 15 years and active arterial haemorrhage from the abdominal and/or pelvic region verified by a CT scan at admission. Gender, age, initial oxygen saturation, pulse rate and respiratory rate, mechanism of injury, ISS, Probability of Survival, treatment modality, 30-day mortality and number and type of blood products applied were retrieved from the TARN database, patient records and the Danish Civil Registration System.

Results:

Thirty-one patients received angiography and embolization, and 35 patients underwent exploratory laparotomy and surgical packing. Gender, age, initial oxygen saturation, pulse rate and respiratory rate, ISS and Probability of Survival were comparable in the two groups.

Conclusion:

A significant increased risk of 30-day mortality (P = 0.04) was found in patients with active bleeding treated with explorative laparotomy and surgical packing compared to angiography and embolization when data was adjusted for age and ISS. No statistical significant difference (P > 0.05) was found in number of transfused blood products applied in the two groups of patients.

Indications for embolization in a French level 1 trauma center

Abdominal trauma accounts for nearly 20% of all traumatic injuries. It often involves young patients sustaining multiple injuries, with a high associated mortality rate. Management should begin at the scene of injury and relies on a structured chain of care in order to transport the trauma patient to the appropriate hospital center. Management is multi-disciplinary, involving intensive care specialists, surgeons and radiologists. Imaging to precisely define injury is best performed with whole body dual phase computed tomography, which can also identify the source of bleeding. Non-operative management has developed considerably over the years: this includes selective embolization in case of active bleeding or vascular anomalies in stable or stabilized patients after resuscitation. Embolization has become one of the corner stones of abdominal trauma management and interventional radiologists must play an active role on the trauma team. This overview details the different embolization procedures according to the involved organ and embolic agent used.

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.

Utilization of angiography and embolization for abdominopelvic trauma: 14 years' experience at a level I trauma center

OBJECTIVE

The objective of our study was to evaluate the long-term trends in the use of angiography and embolization for abdominopelvic injuries.

MATERIALS AND METHODS

Utilization rates for pelvic and abdominal angiography, arterial embolization, and CT were analyzed for trauma patients with pelvic fractures and liver and kidney injuries admitted to a level 1 trauma center from 1996 to 2010. Multivariable linear regression was used to evaluate trends in the use of angioembolization.

RESULTS

A total of 9145 patients were admitted for abdominopelvic injuries during the study period. Pelvic angiography decreased annually by 5.0% (95% CI, -6.4% to -3.7%) from 1996 to 2002 and by 1.8% (-2.4% to -1.2%) from 2003 to 2010. Embolization rates for these patients varied from 49% in 1997 to 100% in 2010. Utilization of pelvic CT on the day of admission increased significantly during this period. Abdominal angiography for liver and kidney injuries decreased annually by 3.3% (95% CI, -4.8% to -1.8%) and 2.0% (-4.3% to 0.3%) between 1996 and 2002 and by 0.8% (95% CI, -1.4% to -0.1%) and 0.9% (-2.0% to 0.1%) from 2003 to 2010, respectively. Embolization rates ranged from 25% in 1999 to 100% in 2010 for liver injuries and from 0% in 1997 to 80% in 2002 for kidney injuries. Abdominal CT for liver and kidney injuries on the day of admission also increased.

CONCLUSION

A significant decrease in angiography use for trauma patients with pelvic fractures, liver injuries, and kidney injuries from 1996 to 2010 and a trend toward increasing embolization rates among patients who underwent angiography were found. These findings reflect a declining role of angiography for diagnostic purposes and emphasize the importance of angiography as a means to embolization for management.

Treatment outcomes of open pelvic fractures associated with extensive perineal injuries

Background

The main causes of death in patients with open pelviperineal injuries are uncontrollable bleeding and pelvic sepsis. The aim of this study was to evaluate the management outcomes of open pelvic fractures associated with extensive perineal injuries.

Methods

We retrospectively studied 15 cases with open pelvic fractures associated with extensive perineal injuries (urethral and anal canal laceration) admitted between August 2006 and September 2010. Mechanism of injury, Injury Severity Score, associated injuries, hemodynamic status on arrival, resuscitation and transfusion requirements, operative techniques, intra- and postoperative complications, length of intensive care unit and hospital stay, and mortality were recorded in a computerised database for further evaluation and analysis.

Results

The male to female ratio was 12:3 with an average age of 38.6 years (ranged, 11 to 65 years). The average packed red blood cell units used were 8 units (ranged, 4 to 21 units). All patients were initially transferred to the operating room for colostomy, radical debridement and fixation of the pelvic fracture by an external fixator. One patient had acute renal failure, which improved with medical treatment and 2 patients (13.3%) died, one with type III anteroposterior compression fracture due to hemorrhagic shock and the other due to septicemia.

Conclusions

Open pelvic fractures with extensive perineal injuries are associated with high mortality rates. Early diagnosis and appropriate treatment, including reanimation, colostomy, cystostomy, vigorous and repeated irrigation and debridement, and fixation by an external fixator can improve the outcomes and reduce the mortality rate.