High-energy pelvic ring disruptions

Delayed Presentation of Bowel Injury Associated with Pelvic Fragility Fracture in Patient with Bladder Sling: A Case Report

CASE

An 85-year-old woman with a history of bladder mesh sling placement sustained a pelvic fracture and extraperitoneal bladder rupture after a ground-level fall. The patient underwent cystorrhaphy and percutaneous anterior column screw placement. Free air was identified on abdominal computed tomography scan on postoperative day 5. Exploratory laparotomy revealed a sigmoid colon perforation and extensive bowel adhesions to the anterior pelvis.

CONCLUSION

This is the first report describing bowel injury and associated bladder rupture in a pelvic fragility fracture related to a prior bladder mesh sling. This case highlights the importance of obtaining a thorough surgical history when treating pelvic injuries.

Fracture Types Influence the Likelihood of Lower Urinary Tract Injuries in Patients with Pelvic Fractures

BACKGROUND

The combination of pelvic fractures with lower urinary tract injuries (LUTIs) is a severe traumatic injury. This study was performed to determine the relationship between LUTIs and pelvic fracture types.

METHODS

Patients who sustained pelvic fractures combined with LUTIs between 1 January 2018 and 1 January 2022 in our institution were retrospectively analyzed. The patients' demographics, mechanism of injury, presence of open pelvic fractures, types of pelvic fractures, patterns of LUTIs, and early complications were analyzed. The association between pelvic fracture types and the identified LUTIs was statistically analyzed.

RESULTS

This study involved 54 patients diagnosed with pelvic fractures combined with LUTIs. The overall incidence of pelvic fractures combined with LUTIs was 7.7% (n = 54/698). All patients had unstable pelvic fractures. The male:female ratio was approximately 2.4:1.0. The incidence of LUTIs was higher in men than women with pelvic fractures (9.1% vs. 4.4%). Bladder injuries occurred at roughly equal rates in men and women (4.5% vs. 4.4%, p = 0.966), but urethral injuries were more frequent in men (6.1% vs. 0.5%, p = 0.001). The most common pelvic injury pattern was a type C fracture according to the Tile classification and a vertical-shear-type fracture according to the Young-Burgess classification. The Young-Burgess fracture classification was related to the severity of bladder injury in men (p = 0.037). There was no significant difference in bladder injury according to the two classifications among women (p = 0.524 vs. p = 1.000) or among the entire cohort (p = 0.454 vs. p = 0.342).

CONCLUSIONS

Men and women are equally likely to sustain a bladder injury, but a urethral injury with pelvic fracture is more frequent in men. LUTIs tend to be accompanied by unstable pelvic fractures. It is imperative to be vigilant for potential bladder injury when men sustain vertical-shear-type pelvic fractures.

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.

A Morphologic Analysis of the Pubic Symphysis Using CT and MRI

INTRODUCTION

The goal of this study was to investigate prevalence and morphometric parameters of pubic ligaments and the interpubic disk and its cavity using imaging methods for use in clinical medicine.

METHODS

Pubic symphysis morphology was investigated in 652 patients (348 women and 304 men), from which 449 CT scans and 203 MR scans were available. The average age of men was 48 years and women 39 years. Investigated parameters included dimensions of the interpubic disk, visibility and width of the reinforcing ligaments, and visibility, dimensions, and location of the symphysial cavity. The results were compared with MR scans of 20 healthy volunteers and 21 dissected anatomic specimens.

RESULTS

The craniocaudal, ventrodorsal, and mediolateral diameters of the pubic disk were 36 to 37.7, 14.8 to 15.2, and 2.2 to 4.2 mm in women and 42 to 42.3, 18.6 to 19, and 2.4 to 4.5 mm in men, respectively. Higher age correlated with shorter mediolateral diameter and larger craniocaudal and ventrodorsal diameters. The superior pubic ligament was visible in 93.1% of men (1.44 mm thick) and in 100% of women (1.7 mm); the inferior pubic ligament in 89.7% of men (1.74 mm) and 88% of women (1.95 mm), the anterior pubic ligament in 96.6% of men (1.5 mm) and 82% of women (1.34 mm); and the posterior pubic ligament in 65.5% of men (1.18 mm) and 63.7% of women (0.83 mm). A symphysial cavity was found in 24% of men and 22.9% of women, with craniocaudal, ventrodorsal, and mediolateral dimensions of 13, 10.7, and 3.2 mm in men and 9.5, 10.7, and 3 mm in women, respectively.

CONCLUSION

The presented morphologic parameters provide an anatomic reference for diagnostics of pathologic conditions of the pubic symphysis. The following anatomic structures should be added to the official anatomic terminology: symphysial cavity (cavitas symphysialis), retropubic eminence (eminentia retropubica), anterior pubic ligament (ligamentum pubicum anterius), and posterior pubic ligament (ligamentum pubicum posterius).

LEVEL OF EVIDENCE

II-III.

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.

Pelvic fractures in severely injured children: Results from the TraumaRegister DGU

Injuries in the pelvic region in children and adolescents are very rare and often associated with a high energy trauma. Aim of this prospective multicenter study was, by analyzing the data from the TraumaRegister Deutsche Gesellschaft für Unfallchirurgie (TR-DGU), to evaluate any correlation between the severity of pelvic fractures and resulting mortality in different age groups.These study findings are based on a large pool of data retrieved from the prospectively-setup pelvic trauma registry established by the German Trauma Society (DGU) and the German Section of the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) International in 1991. The registry provides data on all patients suffering pelvic fractures within a 14-year time frame at any 1 of the 23 level 1 trauma centers contributing to the registry. The analysis covers 4 age groups ranging from 0 to 17 years, covering different factors regarding pelvic fractures and their treatment.We identified a total of 9684 patients including 1433 pelvic fractures in children aged ≤17 years. Those patients were divided into 4 subgroups according to the patients' age (groups A-D) and according to the fracture severity (group 1 =  Abbreviated Injury Scale (AIS) score pelvis ≤2, and group 2 = AIS pelvis ≥3). The mortality in group 1 was 8.8% with a RISC (Revised Injury Severity Score) II of 8.6%, standard mortality rate (SMR) of 1.02 and 7.2% in group 2 with an RISC II of 9.9% (SMR 0.73). In pelvic factures of Type A (Tile classification of pelvic fractures), an SMR of 0.76 was recorded, in Type B fractures the SMR was 0.65, and in Type C fractures 0.79. Severe pelvic injuries (AIS pelvis ≥2) were associated with a higher rate of whole body computer tomograph (CT) scans (1-5 years: 80%, 6-10 years 81.8%, 11-14 years 84.7%, and 15-17 years 85.6%). The rate of pelvic surgery rose with the pelvic injury's severity (AIS 2: 7.6%, AIS 3: 35%, AIS 4: 65.6%, AIS 5 61.5%). We observed higher rates of preclinical and initial clinical hypotension defined as Riva-Rocci (RR) <90 mmHG) as well as of preclinical fluid application in all age groups. The presence of a pelvic injury was associated with a higher rate of severe abdominal injuries with an AIS of ≥3 (25.1% vs. 14.6%) and of severe thorax injuries with an AIS≥3 (43.6% vs. 28.6%).We have been able to analyze an enormous number of pelvic fractures in children and adolescents including different age groups by relying on data from the TR-DGU. Mortality seems to be associated with the severity of the pelvic injury, but is lower than the RISC II score's prognosis.

APC Injuries With Symphyseal Fixation: What Affects Outcome?

OBJECTIVE

To evaluate the influence of the symphyseal position at union, implant failure, and the type of posterior ring injury on validated outcome measures.

DESIGN

Retrospective review with prospectively collected validated outcome data.

SETTING

Two academic level 1 trauma centers.

PATIENTS/PARTICIPANTS

We evaluated 54 patients with operatively treated anterior-posterior compression (APC) type 2 and 3 injuries.

INTERVENTION

Thirty-five APC type 2 and 19 APC type 3 injuries were reviewed at a minimum of 2 years after surgery. Average follow-up was 7 years.

MAIN OUTCOME MEASURES

Patients were evaluated with validated EuroQol five dimensions (EQ5D), EuroQol health index, Visual Analog Score (VAS) pain, Majeed pelvic scores, and change in work status. The final anterior-posterior (AP) radiograph available was reviewed for implant failure and displacement. Revision surgery was documented based on implant status and displacement at final follow-up.

RESULTS

There were trends toward better outcomes for APC type 2 for EQ5D and VAS pain. Patients with injury severity score (ISS) >16 had worse reported health, Majeed scores, and VAS pain. Nineteen patients had failure of fixation. There were no differences in any outcome measure; trends toward better Majeed score were found for patients with intact fixation. Displacements >15 mm anteriorly at final follow-up negatively affect outcomes with significantly worse EQ5D, reported health, and Majeed score. Two patients required revision surgery. There were no differences in final outcomes.

CONCLUSIONS

No significant differences were found for APC type 2 versus type 3 injuries. Higher injury severity score resulted in worse outcomes and more pain. Outcomes were not effected by implant failure; however, major loss of reduction (>15 mm) anteriorly did negatively impact outcomes. Patients with failure who were revised to union did not have worse outcomes.

LEVEL OF EVIDENCE

Prognostic level IV. See Instructions for Authors for a complete description of levels of evidence.

INFIX/EXFIX: Massive Open Pelvic Injuries and Review of the Literature

Introduction. Open pelvic fractures make up 2–5% of all pelvic ring injuries. Their mortality has been reported to be as high as 50%. During Operation Enduring Freedom protocols for massive open pelvic injuries lead to the survival of injuries once thought to be fatal. The INFIX is a subcutaneous anterior fixator for pelvic stabilization which is stronger than external fixation. The purpose of this paper is to describe the use of INFIX and modern algorithms for massive open pelvic injuries. Methods. An IRB approved retrospective review describes 4 cases in civilian practice with massive open pelvic injuries. We also review the modern literature on open pelvic injures. Discussion. Key components in the care of massive open pelvic injuries include hemorrhage control by clamping of the aorta or REBOA when necessary and fecal/urinary diversion. The INFIX can be used internally, as a partial INFIX partial EXFIX, or as an EXFIX. Its low profile allows for easy application of wound vacs and wound care and when subcutaneous avoids pin tract infections. Conclusion. Massive open pelvic injuries are a difficult problem. Following modern protocols can help prevent mortality.

Immediate percutaneous sacroiliac screw insertion for unstable pelvic fractures: is it safe enough?

OBJECTIVES

The purpose of this study was to compare the results of immediate and delayed percutaneous sacroiliac screws surgery for unstable pelvic fractures, regarding technical results and complication rate.

DESIGN

Retrospective study.

SETTING

The study was conducted at the Soroka University Medical center, Beer Sheva, Israel, which is a level 1 trauma Center.

PATIENTS

108 patients with unstable pelvic injuries were operated by the orthopedic department at the Soroka University Medical Center between the years 1999-2010. A retrospective analysis found 50 patients with immediate surgery and 58 patients with delayed surgery. Preoperative and postoperative imaging were analyzed and data was collected regarding complications.

INTERVENTION

All patients were operated on by using the same technique-percutaneous fixation of sacroiliac joint with cannulated screws.

MAIN OUTCOME MEASUREMENTS

The study's primary outcome measure was the safety and quality of the early operation in comparison with the late operation.

RESULTS

A total of 156 sacroiliac screws were inserted. No differences were found between the immediate and delayed treatment groups regarding technical outcome measures (P value = 0.44) and complication rate (P value = 0.42).

CONCLUSIONS

The current study demonstrated that immediate percutaneous sacroiliac screw insertion for unstable pelvic fractures produced equally good technical results, in comparison with the conventional delayed operation, without additional complications.

Pelvic Fractures in Children Results from the German Pelvic Trauma Registry: A Cohort Study

As pelvic fractures in children and adolescents are very rare, the surgical management is not well delineated nor are the postoperative complications. The aim of this study using the prospective data from German Pelvic Trauma Registry study was to evaluate the various treatment approaches compared to adults and delineated the differences in postoperative complications after pelvic injuries.Using the prospective pelvic trauma registry established by the German Society of Traumatology and the German Section of the Arbeitsgemeinschaft für Osteosynthesefragen (AO), International in 1991, patients with pelvic fractures over a 12-year time frame submitted by any 1 of the 23 member level I trauma centers were reviewed.We identified a total of 13,525 patients including pelvic fractures in 13,317 adults and 208 children aged ≤14 years and compared these 2 groups. The 2 groups' Injury Severitiy Score (ISS) did not differ statistically. Lethality in the pediatric group was 6.3%, not statistically different from the adults' 4.6%. In all, 18.3% of the pediatric pelvic fractures were treated surgically as compared to 22.7% in the adult group. No child suffered any thrombosis/embolism, acute respiratory distress syndrome (ARDS), multiorgan failure (MOF), or neurologic deficit, nor was any septic MOF detected. The differences between adults and children were statistically significant in that the children suffered less frequently from thrombosis/embolism (P = 0.041) and ARDS and MOF (P = 0.006).This prospective multicenter study addressing patients with pelvic fractures reveals that the risk for a thrombosis/embolism, ARDS, and MOF is significant lower in pediatric patients than in adults. No statistical differences could be found in the ratios of operative therapy of the pelvic fractures in children compared to adults.

Does Removal of the Symphyseal Cartilage in Symphyseal Dislocations Have Any Effect on Final Alignment and Implant Failure?

OBJECTIVES

To compare final symphyseal alignment, incidence of implant failure, and revision surgery with and without symphyseal cartilage excision in patients with symphyseal dislocations treated operatively.

DESIGN

Retrospective review.

SETTING

Two academic level 1 trauma centers.

PATIENTS/PARTICIPANTS

We reviewed the records of 96 patients (89 men, 7 women) who had anterior posterior compression (APC) type 2 and 3 injuries requiring anterior plating. The average age was 46 years, and the average Injury Severity Score was 15.6.

INTERVENTION

Fifty patients were treated with symphyseal cartilage removal, whereas a second cohort of 46 patients was treated without removal of the symphyseal cartilage at the time of symphyseal open reduction and internal fixation during the same time period in a different center. Operative indications were the same for both centers, with iliosacral screws used only for type 3 injuries. Both centers used 6-hole plates through a rectus sparing approach.

MAIN OUTCOME MEASUREMENTS

Symphyseal separation was measured radiographically on preoperative and postoperative anteroposterior (AP) and outlet projections. The incidence of implant failure was recorded from the final postoperative radiograph available. Revision surgery was documented.

RESULTS

The symphyseal space after cartilage excision was less than if retained, which was maintained through union. The incidence of implant failure was statistically lower when symphyseal cartilage was excised. There were 2 revisions of symphyseal fixation in the symphyseal retention group for implant failure versus none when excised.

CONCLUSIONS

Symphyseal cartilage excision led to closer apposition of the symphyseal bodies, which correlated with substantially lower rates of implant failure, and revision surgery.

LEVEL OF EVIDENCE

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

A rare case of paediatric pelvic ring injury with lower urinary tract obstruction secondary to a combat blast mechanism

Paediatric pelvic ring fractures are rare, and typically the result of high-energy mechanisms that yield other potentially fatal visceral and solid organ injuries. Specific pelvic fracture patterns have been associated with injury to the lower urinary tract, with the most severe involving laceration of the bladder or transection of the urethra. We report a unique case of paediatric pelvic ring disruption causing an isolated obstruction of the lower urinary tract without laceration or discontinuity. Although most paediatric pelvic fractures are managed non-operatively, we postulate that significant ring deformity contributing to urinary retention be considered an indication for open surgical treatment.

Fractures of the pelvis in children: a review of the literature

Trauma is the leading cause of death in children. Pelvic ring injuries account for 0.3-4% of all paediatric injuries. The pattern of fractures differs to that seen in adults as it is more ductile. Pelvic ring injuries tend to be more stable as the relatively thick periosteum restricts bony displacement. Intrapelvic viscera are not well protected and can sustain injury in the absence of pelvic fractures. These injuries have traditionally been treated non-operatively. In this paper, we comprehensively review the literature and propose a protocol for treatment taking into consideration associated organ injuries, hemodynamic status of the patient, patient's age, type of fracture and the stability of the pelvic ring.

An overview of pelvic ring disruption

Pelvic ring disruption after trauma is uncommon, occurring in 20–37/100,000 people in the general population. However, in high velocity poly trauma up to 20% of cases have this injury contributing significantly to morbidity and mortality. The management of pelvic and acetabular trauma has become a subspecialty within the orthopaedic trauma care. The injury patterns are now better understood, there is agreement on a classification system and operative stabilisation has become a viable treatment option.

A minimally invasive stabilizing system for dorsal pelvic ring injuries

BACKGROUND

Open reduction and stabilization of dorsal pelvic ring injuries is accompanied by a high rate of soft tissue complications. Minimally invasive techniques have the potential to decrease soft tissue trauma, but the risk of iatrogenic nerve and vessel damage through the reduced surgical exposure should be considered. We treated these injuries using a transiliac internal fixator (TIFI) in a minimally invasive technique characterized by implantation of a pedicle screw and rod system, bridging the sacroiliac joints and the sacral area.

QUESTIONS/PURPOSES

We asked whether (1) we could achieve anatomic restoration with the device, (2) specific complications were associated with this minimally invasive approach (particularly enhanced intraoperative blood loss, soft tissue complications, and iatrogenic neurovascular damage), and (3) function 3 years after trauma was comparable to that of established methods.

METHODS

We retrospectively reviewed 67 patients with dorsal pelvic injuries during a 7-year period. We evaluated the (1) reduction by grading the maximal displacement measured with three radiographic views, (2) the complications during the observation period, and (3) the function with a validated questionnaire (Pelvic Outcome Score) in all but five patients at least 3 years after trauma (mean, 37 months; range, 36-42 months).

RESULTS

At last followup we observed a secondary fracture displacement greater than 5 mm in one patient. The intraoperative blood loss was less than 50 mL in all patients. No neurovascular lesions occurred owing to implantation. Four patients had wound infections, one had loosening of a single pedicle screw, and one had an iatrogenic screw malpositioning. Thirty-five of the 62 patients achieved Pelvic Outcome Scores of either a maximum score or 6 of 7 points.

CONCLUSION

Our observations suggest TIFI is a reasonable alternative to other established fixation devices for injuries of the dorsal pelvic ring with minor risks of major blood loss or iatrogenic neurovascular damage.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Early experience with reduction of displaced disruption of the pelvic ring using a pelvic reduction frame

We describe our early operative experience with a new pelvic reduction frame and the standard of reduction of fractures of the pelvic ring which we achieved in the first 35 consecutive patients, with 34 acute fractures and one nonunion. The pre-operative and immediate post-operative radiographs were measured, using two methods, to find the maximum radiological displacement of the fracture and the quality of the reduction according to the criteria of Tornetta and Matta. There were 19 vertical shear fractures and 16 compression injuries. The mean age of the patients was 33.5 years (10 to 59) and mean delay to surgery was 4.6 days (0 to 16) in the 34 acute injuries. The mean operative time in isolated procedures was 103.4 minutes (SD 6.5). All but one patient had iliosacral screws implanted, 18 had screws in the anterior column, six had plates at the symphysis pubis and 12 had anterior external fixators. The mean maximum horizontal or vertical displacement was improved from 30.8 mm (SD 2.7) to a mean of 7.1 mm (SD 0.7). The reduction was assessed as excellent in ten patients, good in 18, and fair in the remainder. There was no significant influence on the quality of the reduction caused by obesity (p = 0.34), the type of fracture (p = 0.41) or delay to surgery (p = 0.83). The frame was shown to be effective, allowing the surgeon to obtain a satisfactory reduction and fixation of acute displaced disruptions of the pelvic ring.

Reduction of displaced pelvic ring disruptions using a pelvic reduction frame

The need for reduction in displaced pelvic ring disruptions is well established, but actual techniques to perform this difficult task are evolving. Reduction is often difficult, especially if minimally invasive techniques are used. This pelvic reduction frame (Starr Frame LLC, Richardson, TX) provides stabilization of the intact hemipelvis to the operating table and facilitates multiplanar reduction of the injured hemipelvis with the use and manipulation of external fixator pins. With the pelvis reduced and locked on the frame, the surgeon is free to place, or teach, fixation in a controlled manner. This lessens the usual assistance, training, and hardware placement difficulties associated with the surgical treatment of these injuries. The basic surgical technique and 2 cases of acute fracture treatment are presented.

Do initial radiographs agree with crash site mechanism of injury in pelvic ring disruptions? A pilot study

OBJECTIVE

Direction of injury force inferred from pelvic radiographs may be used in trauma care to predict associated injuries and guide intervention. Our objective was to compare injury direction determined from anteroposterior (AP) pelvic radiographs with injury forces determined from crash site investigation.

MATERIALS AND METHODS

We studied all 28 subjects from the Crash Injury Research Engineering Network (CIREN) database who met inclusion criteria of pelvic ring disruption, single-event crash, restrained front-seat occupant, diagnostic-quality pelvic radiography, and complete crash investigation data. Assessment of diagnostic quality of pelvic radiography was made by 2 radiologists who were blinded to all other subject information. Crash site investigation data included principal direction of force (PDOF), crash magnitude, and passenger compartment intrusion. An orthopedic trauma surgeon and a fellowship-trained emergency radiologist independently assessed the pelvic radiographs to determine the injury PDOF and the Young-Burgess and Tile fracture classifications, with disputes resolved by an additional emergency radiologist. Agreement between injury forces and pelvic radiographs was assessed using the kappa statistic.

RESULTS

The PDOF was anterior in 9 (32%) and lateral in 19 (68%) subjects. The readers agreed with the crash primary direction of force in 21 (75%) subjects (kappa=0.42). In subjects with lateral PDOF, agreement was 89% (17/19) compared to 44% for anterior PDOF (4/9). Interobserver agreement for the Young and Tile classification schemes was moderate (weighted kappa 0.44 and 0.54, respectively).

CONCLUSION

Crash site investigation and pelvic radiography may provide conflicting information about primary direction of injuring forces. Presumed anterior impact based on PDOF is not in consistent agreement with the pattern of injury evident on the AP pelvic radiograph.

Contemporary management of pelvic fractures

BACKGROUND

Pelvic fractures occur when there is high kinetic energy transfer to the patient such as would be expected in motor vehicle crashes, auto-pedestrian collisions, motorcycle crashes, falls, and crush injuries. High-force impact implies an increased risk for associated injuries to accompany the pelvic fracture, as well as significant mortality and morbidity risks. Choosing the optimum course of diagnosis and treatment for these patients can be challenging. The purpose of this review is to supply a contemporary view of the diagnosis and therapy of patients with this important group of injuries.

METHODS

A comprehensive review of the medical literature, focusing on publications produced in the last 10 years, was undertaken. The principal sources were found in surgical, orthopedic, and radiographic journals.

CONCLUSIONS

The central challenge for the clinician evaluating and managing a patient with a pelvic fracture is to determine the most immediate threat to life and control this threat. Treatment approaches will vary depending on whether the main threat arises from pelvic fracture hemorrhage, associated injuries, or both simultaneously. Functional outcomes in the long-term depend on the quality of the rigid fixation of the fracture, as well as associated pelvic neural and visceral injuries.

Staged management and outcome of combined pelvic and liver trauma. An international experience of the deadly duo

Pelvic fracture associated with liver trauma is not an uncommon injury combination in multiple trauma and is associated with high morbidity and mortality. The aim of this study was to examine the characteristics of this specific patient group, to describe the diagnostic and treatment protocols and finally to analyse risk factors associated with mortality. Data were collected over a 6-year period, ending in 2001. The pelvic injury was graded according to the Tile classification system and the hepatic injury was scored using the organ injury scale (OIS). Treatment protocol, associated injuries, complications, length of ICU/Hospital stay and mortality were recorded and analysed. A total of 140 patients (40% female) with a mean age of 35.1+/-15.9 years and a median ISS of 41 were included in this study. The overall mortality rate was 40.7%. Binomial logistic regression analysis revealed age, initial blood pressure, transfusion requirement as well as the severity of head, chest, spleen and liver injury as independent parameters predicting reduced survival rates. This deadly duo of injuries presents a challenge to the trauma surgeon. Rapid assessment and treatment is required to prevent death by haemorrhage. The presence of concomitant injuries renders the patient very sensitive to ongoing or additional physiological disturbance. The principles of 'damage control surgery' must be applied to avoid complications such as acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS).

Complications of temporary and definitive external fixation of pelvic ring injuries

OBJECTIVES

To determine the incidence of complications of external fixation in pelvic ring injuries, comparing fixator use for temporary and definitive treatment.

DESIGN

Retrospective case-note review.

SETTING

A regional centre for pelvic trauma in the UK.

PATIENTS

100 consecutive patients.

INTERVENTION

All patients were treated with pelvic external fixation for a pelvic ring injury.

RESULTS

In 52 patients, external fixation was intended for use as the definitive treatment of the pelvic ring injury and was maintained for a mean duration of 60 days (17-113). In 48 patients, it was used temporarily for a mean duration of 8 days (1-20) before internal fixation of the pelvic ring. The complication rate for definitive and temporary fixators was 62 and 21%, respectively. Pin-site infection occurred in 50% of definitive fixators and 13% of temporary fixators but rarely led to more serious complications. In five patients, the definitive management was changed as a result of a complication of the external fixator. The commonest cause for revision of either fixator was aseptic pin loosening. Revision for loose pins in eight patients was associated with the use of two pins in each iliac crest rather than three.

CONCLUSIONS

The temporary use of external fixation is safe and effective, but use for definitive treatment is associated with a high rate of infection and aseptic pin loosening.

Open pelvic fractures: epidemiology, current concepts of management and outcome

Open pelvic fractures constitute one of the most devastating injuries in musculo-skeletal trauma and must be treated aggressively, incorporating a multidisciplinary approach. Early treatment, focusing on prevention of haemorrhage and sepsis, is essential. The management of associated soft tissue injuries must also be aggressive, including early administration of broad-spectrum antibiotics and repeated, meticulous wound debridement and irrigation. Selective faecal diversion, based on wound location, is compulsory and safe, minimising the risk of sepsis and reducing mortality rates.

Damage control orthopaedics in unstable pelvic ring injuries

Pelvic ring injuries are often associated with other system injuries and require a multidisciplinary approach for their treatment. Early mortality is usually secondary to uncontrolled haemorrhage whereas late mortality is due to associated injuries and sepsis-induced multiple organ failure. The management of the pelvic fracture should be conceived as part of the resuscitative effort as errors in early management may lead to significant increases in mortality. In severely multiple injured patients who are in an 'unstable' or 'in extremis' clinical condition damage control orthopedics is the current treatment of choice. By performing limited surgical interventions the subsequent reduction in blood loss and transfusion requirements can only be beneficial in these critically ill patients, reducing the risk of developing systemic complications and early mortality.

Hemorrhage in pelvic fracture: who needs angiography?

Pelvic fractures are rare but potentially devastating injuries. An understanding of the bony and peripelvic anatomy along with common patterns and the classification of the injury are of critical importance in their management. These form the basis for a general treatment algorithm for pelvic fracture patients. Angiographic embolization is time-consuming and often delayed. Hemodynamic instability with unstable pelvic fracture is therefore best approached with a combination of pelvic emergency stabilization (C-clamp) and surgical hemostasis by pelvic tamponade. This is especially true for critically injured patients in extremis.