Management of Pelvic Ring Injuries in Unstable Patients

Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures

OBJECTIVES

To compare cost, hospital-related outcomes, and mortality between angioembolization (AE) and preperitoneal pelvic packing (PPP) in the setting of pelvic ring or acetabulum fractures.

METHODS

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DESIGN

Retrospective database review.

SETTING

National Inpatient Sample, years 2016-2020.

PATIENT SELECTION CRITERIA

Hospitalized adult patients who underwent AE or PPP in the setting of a pelvic ring or acetabulum fracture.

OUTCOME MEASURES AND COMPARISONS

Mortality and hospital-associated outcomes, including total charges, following AE versus PPP in the setting of pelvic ring or acetabulum fractures.

RESULTS

A total of 3780 patients, 3620 undergoing AE and 160 undergoing PPP, were included. No significant differences in mortality, length of stay, time to procedure, or discharge disposition were found ( P > 0.05); however, PPP was associated with significantly greater charges than AE ( P = 0.04). Patients who underwent AE had a mean total charge of $250,062.88 while those undergoing PPP had a mean total charge of $369,137.16.

CONCLUSIONS

Despite equivalent clinical efficacy in terms of mortality and hospital-related outcomes, PPP was associated with significantly greater charges than AE in the setting of pelvic ring or acetabulum fractures. This data information can inform clinical management of these patients and assist trauma centers in resource allocation.

LEVEL OF EVIDENCE

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

Minimally Invasive Treatment of Pelvic Fractures with Titanium Elastic Nailing: An Innovative Technology

BACKGROUND

Minimally invasive treatment has become the most popular and effective treatment for pelvic fractures. This study aimed to evaluate the safety and efficacy of a new technique, titanium elastic nailing (TEN), for the minimally invasive treatment of pelvic fractures.

METHOD

Twenty-four patients with pelvic fractures were referred to us between January 2020 to January 2022, including sixteen males and 8 females. Pelvic fractures were temporarily fixed by pelvic fixation belt accompanied by traction from the lower limb bone. Anterior pelvic ring injuries (superior ramus of pubis) and ilium fractures were treated with closed reduction and intramedullary fixation with minimally invasive TEN. Intraoperative C-arm, including pelvic anteroposterior, pelvic outlet, inlet and ilium oblique views, and O-arm fluoroscopy (intraoperative CT) were employed to assess fractures reduction and determine the location of the elastic titanium nail within the bone channel.

RESULTS

By adopting closed reduction and minimally invasive incision techniques, pelvic fractures could be safely fixed by placing an elastic titanium nail in the osseous medullary cavity channels of the pelvis. Postoperative investigation indicated that the wounds of all patients were healed in the first stage without any occurrence of complications, such as injuries to the nerves, blood vessels, and important tissue structures. Patients are essential quickly after the operation and could perform the functional exercise in the early stages of the recovery.

CONCLUSION

TEN can be used for minimally invasive treatment of pelvic fractures. This novel technique has no obvious complications and is worthwhile in clinical practice.

Specifying the Starting Point for S1 Iliosacral Screw Placement in the Dysmorphic Sacrum

BACKGROUND

Sacral dysmorphism is not uncommon and complicates S1 iliosacral screw placement partially because of the difficulty of determining the starting point accurately on the sacral lateral view. We propose a method of specifying the starting point.

METHODS

The starting point for the S1 iliosacral screw into the dysmorphic sacrum was specifically set at a point where the ossification of the S1/S2 intervertebral disc (OSID) intersected the posterior vertebral cortical line (PVCL) on the sacral lateral view, followed by guidewire manipulation and screw placement on the pelvic outlet and inlet views. Computer-simulated virtual surgical procedures based on pelvic computed tomography (CT) data on 95 dysmorphic sacra were performed to determine whether the starting point was below the iliac cortical density (ICD) and in the S1 oblique osseous corridor and to evaluate the accuracy of screw placement (with 1 screw being used, in the left hemipelvis). Surgical procedures on 17 patients were performed to verify the visibility of the OSID and PVCL, to check the location of the starting point relative to the ICD, and to validate the screw placement safety as demonstrated with postoperative CT scans.

RESULTS

In the virtual surgical procedures, the starting point was consistently below the ICD and in the oblique osseous corridor in all patients and all screws were Grade 1. In the clinical surgical procedures, the OSID and PVCL were consistently visible and the starting point was always below the ICD in all patients; overall, 21 S1 iliosacral screws were placed in these 17 patients without malpositioning or iatrogenic injury.

CONCLUSIONS

On the lateral view of the dysmorphic sacrum, the OSID and PVCL are visible and intersect at a point that is consistently below the ICD and in the oblique osseous corridor, and thus they can be used to identify the starting point.

LEVEL OF EVIDENCE

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

Epidemiology of high-energy blunt pelvic ring injuries: A three-year retrospective case series in a level-I trauma center

BACKGROUND

High-energy pelvic ring injuries (PRI) represent a heavy burden for institutions treating severely injured patients. Epidemiological data knowledge may help to provide them appropriate management. Only two epidemiologic studies about high-energy PRI were published during last decade. This study aimed to determine the gender-specific and global incidences of high-energy blunt AO/OTA type B or C PRI and their frequency among high-energy blunt trauma. It further reports the spectrum of these injuries and compares their characteristics and outcomes to high-energy blunt trauma without type B or C PRI.

HYPOTHESIS

Type B or C PRI incidence isn't gender specific and approximates 5/100,000/year.

PATIENTS AND METHODS

A prospective database of a level-I trauma center serving approximately 500,000 inhabitants was retrospectively queried for all high-energy trauma patients injured between 01.01.2014 and 12.31.2016. Inclusion criteria were: alive emergency department delivery; entire acute treatment at the authors' institution; age >16. Exclusion criteria were: penetrating, blast, burn and electrical injuries; drownings; low-energy trauma; patients living outside the institution's catchment area. Three authors performed PRI classifications. Clinical data were extracted from the database.

RESULTS

We analyzed 434 patients. High-energy blunt type B or C PRI incidence was 3.8/100,000/year without gender disparity (p=0.6697). High-energy blunt trauma incidence was lower in women than in men (20.5 vs. 51.6/100,000/year, p<0.001). Type B or C PRI frequency during high-energy blunt trauma was higher in women than in men (17.6% vs. 7.9%, p=0.003). Type B or C PRI patients were more severely injured and needed more treatment resources than other high-energy blunt trauma patients but didn't present higher complication or death rates.

DISCUSSION

The incidence of high-energy blunt type B or C PRI was comparable to previously published data. Women were less likely to sustain a high-energy blunt trauma, but when they sustained one, they were more likely to have a type B or C PRI. Despite higher injury severity score and resource requirements, complication and death rates weren't different between type B or C PRI patients and other high-energy blunt trauma patients.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Bladder deformity accompanied by pelvic fracture indirectly indicates clinical severity

BACKGROUND

That the bladder can be compressed by extraperitoneal hematoma induced by obstetrics and gynecologic diseases, is well known. However, there have been no reports on the clinical significance of compressed bladder induced by pelvic fracture (PF). We therefore retrospectively investigated the clinical features of compressed bladder induced by the PF.

METHODS

From January 2018 to December 2021, we performed a retrospective review of the hospital medical charts of all emergency outpatients who were treated by emergency physicians at the department of acute critical care medicine in our hospital, and who were diagnosed with PF based on computed tomography (CT) on arrival. The subjects were divided into two groups: the Deformity group, in which the bladder was compressed by extraperitoneal hematoma, and the Normal group. Variables were compared between the two groups.

RESULTS

During the investigation period, 147 patients with PF were enrolled as subjects. There were 44 patients in the Deformity group and 103 in the Normal group. There were no significant differences between the two groups with regard to sex, age, GCS, heart rate or final outcome. However, the average systolic blood pressure in the Deformity group was significantly lower, and the average respiratory rate, injury severity score, rate of unstable circulation, rate of transfusion and duration of hospitalization in the Deformity group were significantly greater in comparison to the Normal group.

CONCLUSIONS

The present study showed that bladder deformity induced by PF tended to be a poor physiological sign that was associated with severe anatomical abnormality, unstable circulation requiring transfusion, and long hospitalization. Accordingly, physicians should evaluate shape of bladder when treating PF.

Incidence rate and topography of intra-pelvic arterial lesions associated with high-energy blunt pelvic ring injuries: a retrospective cohort study

Background

The aim of this study was to determine the rate and topography of intra-pelvic arterial lesions associated with high-energy blunt pelvic ring injuries (PRI).

Methods

This retrospective cohort study was conducted in a level I trauma center serving 500,000 inhabitants. A total of 127 consecutive patients with high-energy blunt PRI were included between January 1st, 2014 and December 31st, 2017. Every patient had a total body or thoraco-abdominal computed tomography scan including contrast enhanced arterial sequences. A board-certified radiologist reviewed all the vascular images and precisely described every intra-pelvic arterial lesion in terms of localization. Complete pelvic series (standard radiographs and fine cut computed tomography images) were reviewed by three board-certified orthopedic surgeons experienced in PRI management, and Young and Burgess and AO/OTA classifications were determined. Demographic, clinical, therapeutic and outcome data were extracted from the institutional severely injured patients’ registry.

Results

Patients’ mean age was 45.3 years and 58.3% were males. Fifteen (11.8%) had a total of 21 intra-pelvic arterial lesions: seven lesions of the obturator artery, four of the superior gluteal artery, three of the inferior gluteal artery, two of the vesical artery, and one of each of the following arteries: internal iliac, internal pudendal, fifth lumbar, lateral sacral, ilio-lumbar. These lesions occurred in 8.6% of lateral compression injuries, 33.3% of anteroposterior compression injuries and 23.5% of vertical shear and combined mechanism injuries (Young and Burgess classification, p = 0.003); and in 0% of type A injuries, 9.9% of type B injuries and 35% of type C injuries (AO/OTA classification, p = 0.001). Patients with an intra-pelvic arterial lesion were more likely to present with pre-hospital hemodynamic instability (p = 0.046) and to need packed red blood cells transfusion within the first 24 h (p = 0.023; they needed a mean of 7.53 units vs. 1.88, p = 0.0016); however, they did not have a worst outcome in terms of complications or mortality.

Conclusions

This systematic study found an 11.8% rate of intra-pelvic arterial lesion related to high-energy blunt PRI. The obturator, superior gluteal and inferior gluteal arteries were most often injured. These findings are important for the aggressive management of high-energy blunt PRI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00470-y.

Optimizing Pelvic X-Ray indication in blunt trauma patients using clinical criteria

OBJECTIVE

to identify a subgroup of blunt trauma patients with very low chance of sustaining pelvic fractures based on clinical criteria.

METHODS

retrospective analysis of the trauma registry data, collected in a period of 24 months. We selected adult blunt trauma patients who had a PXR on admission. The frequency of pelvic fractures was calculated for the following groups: Normal neurological examination at admission (NNE), hemodynamical stability (HS), normal pelvic examination at admission (NPE), less than 60 years old (ID<60) and absence of distracting injuries (ADI). Logistic regression analysis was carried out in order to create a probability model of negative PXR.

RESULTS

an abnormal PXR was identified in 101 (3.3%) out of the 3,055 patients who had undergone a PXR at admission. Out of these, 1,863 sustained a NNE, with 38 positive CXRs (2.0%) in this group. Considering only the 1,535 patients with NNE and HS, we found 28 positive PXRs (1.8%). Out of these, 1,506 have NPE, with 21 abnormal PXRs (1.4%). Of these, 1,202 were younger than 60 y, with 11 positive PXRs (0.9%). By adding all these criteria to the ADI, we found 2 abnormal PXRs in 502 (0.4%) cases. The probability model including all these variables had a 0,89 area under the ROC curve.

CONCLUSIONS

by adding clinical criteria, it is possible to identify a group of trauma patients with very low chance of sustaining pelvic fractures. The necessity of PXR in these patients needs to be reassessed.

Impact of a simplified management algorithm on outcome following exsanguinating pelvic fractures: A 10-year experience

BACKGROUND

Optimal management of exsanguinating pelvic fractures remains controversial. Our previous experience suggested that management decisions based on a defined algorithm were associated with a significant reduction in transfusion requirements and mortality. Based on these outcomes, a clinical pathway (PW) for the management of exsanguinating pelvic fractures was developed. The purpose of this study was to evaluate the impact of this PW on outcomes.

METHODS

Consecutive patients over 10 years with blunt pelvic fractures subsequent to the implementation of the clinical PW were identified. Patients with hemodynamically unstable pelvic fractures are managed initially with a pelvic orthotic device. For those with continued hemodynamic instability and no extrapelvic source of hemorrhage, pelvic angiography was performed followed by elective pelvic fixation. Patients managed according to the PW were compared with those patients whose management deviated (DEV) from the PW.

RESULTS

There were 3,467 patients identified. Three hundred twelve (9%) met entry criteria: 246 (79%) comprised the PW group and 66 (21%) the DEV group. Injury severity, as measured by Injury Severity Score (35 vs. 36; p = 0.55), admission Glasgow Coma Scale (10 vs. 10; p = 0.58), admission BE (-7.4 vs. -6.4, p = 0.38), admission SBP (107 vs. 104, p = 0.53), and PRBC requirements during initial resuscitation (6.1 units vs. 6.6 units, p = 0.22) were similar between the groups. Pelvic orthotic device use was 48% in the DEV group (p < 0.001). Twenty-four percent of the PW group required angiography compared with 74% of the DEV group (p < 0.001). Forty-eight-hour transfusions (11 vs. 16, p = 0.01) and mortality (35% vs. 48%, p = 0.04) were reduced in the PW group compared with the DEV group. Pathway adherence was identified as an independent predictor of both decreased transfusions (β = -5.8, p = 0.002) via multiple linear regression and decreased mortality (hazard ratio, 0.74; 95% confidence interval, 0.42-0.98) via multivariable cox proportional hazards analysis.

CONCLUSION

Adherence to a defined clinical PW simplified the management of exsanguinating pelvic fractures and contributed to a reduction in both transfusion requirements and mortality.

LEVEL OF EVIDENCE

Prognostic, level III.

The new method of pelvic packing against continuing intrapelvic bleeding resulting from the unstable pelvic ring fractures

Unstable pelvic ring fractures are one of the common causes of death of patients with concomitant injuries. The existing methods applied to treat such conditions can cause a number of complications and have contraindications. We have described a successful clinical case of intrapelvic hemorrhage arrest in a patient with multiple injuries. in this case, we applied the new method combining minimally invasive angioembolization and easily applicable and effective balloon tamponade.

Where and what arteries are most likely injured with pelvic fractures?: The Influence of Localization, Shape, and Fracture Dislocation on the Arterial Injury During Pelvic Fractures

Blood vessels passing through pelvic region come into intimate contact with pelvic bone and can be injured by the sharp edges of the dislocated fracture fragments. The aim of the study was to evaluate the influence of localization, shape, and dislocation of individual pelvic ring bones' fractures on arterial injuries. The study group consisted of 474 patients enrolled in a 1-year prospective multicenter study. The pattern of pelvic fracture lines was characterized and recorded on a planar diagram of the subjected side of the pelvis. The diagram was subdivided into 11 designated areas. Frequency of injury at each 11 areas was recorded. The course of individual arteries in the 11 areas was also recorded in relation to each type of pelvic fractures. Out of the 474 investigated patients, the highest proportion of fractures occurred in the areas of the superior (62%) and inferior (59%) ramus of the pubis as well as in the lateral part of the sacrum (19%). These locations can be associated with injuries of the external iliac, obturator, internal iliac, and aberrant obturator arteries. The highest risk of arterial injuries was associated with vertically displaced fractures in the middle part of the superior and inferior pubic rami, along the ischial ramus, in the apex of the greater sciatic notch and in the vicinity of the ventral part of the sacroiliac joint, where the artery runs at a distance of less than 1 cm from the bone. Clin. Anat. 32:682-688, 2019. © 2019 Wiley Periodicals, Inc.

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.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.

Strategies for the management of hemodynamically unstable pelvic fractures: From preperitoneal pelvic packing to definitive internal fixation

BACKGROUND/OBJECTIVE

Preperitoneal pelvic packing is useful, and favorable treatment outcomes have been reported. However, the timing of subsequent internal fixation of the pelvis is still debatable. We report the outcomes of a study on patients that underwent internal fixation after preperitoneal packing.

METHODS

A retrospective review was performed for patients with hemodynamically unstable pelvic fracture who underwent preperitoneal pelvic packing and internal fixation. Patients who underwent internal fixation with simultaneous packing removal were placed in Group 1. Patients who underwent definitive internal fixation later were placed in Group 2.

RESULTS

Of the 56 patients (mean age 44.7 years), 36 were male. The mean time from injury to internal fixation was 1.3 (1-2) days and 5.6 (3-10) days in Group 1 and 2, respectively. There was a significant difference in the mean duration of stay in the intensive care unit: 10.9 (3-54) days in Group 1 vs. 14.4 (5-43) days in Group 2 (p = 0.019). Thirty-one cases of complications occurred among 14 patients (25%), including six cases of surgical site infection. Among the six cases of infection, four were superficial and two were deep; five of these cases occurred in Group 2, including both cases of deep infection (p = 0.013).

CONCLUSION

Performing internal fixation with packing removal should aid the return of the patient to a stable state, as it is possible to utilize the same incision line used for the original packing procedure, while providing stability to the pelvis.

Factors that influence the survival of unstable pelvic fracture in the acute phase

Background: The fatality rate of unstable pelvic fracture is still high (20–50%) due to acute phase hemorrhage or late multiple organ failure. The assurance for 100% survival in acute phase had been reported if the emergency room team have the right technique, right timing, and right protocol. The aim of this study was to evaluate and to date factors that influence the non-survival unstable pelvic fracture within 2x24 hours.Methods: This retrospective study was conducted in emergency unit of Dr. Soetomo General Hospital Surabaya during 2012–2016 for unstable pelvic fracture with unstable hemodynamic, without concomitant head or thoracic injury and admitted within 4 hours after the incident. All patients were handled according to the protocol for resuscitation and C-clamp insertion immediately. X-ray was taken after the insertion to check the C-clamp position and to confirm the diagnosis. The 2x24-hour data were taken whether the patient survive or not survive, including mean arterial pressure (MAP) pre-and post, heart rate (HR) pre-and post, and initial hemoglobin and platelet count. Data were analyzed with independent t-test and multiple regression analysis.Results: Twenty two patients were recorded as the inclusive criteria, separated into 17 survivors and 5 non-survivors. They were comprised of 14 males and 8 female patients, with an average of 31.9±15.3 years old. The MAP post, HR pre-and post, and platelet count were significantly different. The factor that influenced the survival within 2x24 hours was the MAP post C-clamp (>70 mmHg) (p<0.05).Conclusion: The acute phase 2x24-hour outcome after C-clamp insertion and resuscitation was significantly influenced by MAP post C-clamp and resuscitation.