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Fokin AA, Wycech Knight J, Tharp ME, Brinton KC, Gallagher PK, Xie JF, Weisz RD, Puente I. Pelvic fractures in blunt trauma patients: A comparative study. World J Orthop 2024; 15:418-434. [DOI: 10.5312/wjo.v15.i5.418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 05/15/2024] Open
Abstract
BACKGROUND Pelvic fractures (PF) with concomitant injuries are on the rise due to an increase of high-energy trauma. Increase of the elderly population with age related comorbidities further complicates the management. Abdominal organ injuries are kindred with PF due to the proximity to pelvic bones. Presence of contrast blush (CB) on computed tomography in patients with PF is considered a sign of active bleeding, however, its clinical significance and association with outcomes is debatable.
AIM To analyze polytrauma patients with PF with a focus on the geriatric population, co-injuries and the value of contrast blush.
METHODS This retrospective cohort study included 558 patients with PF admitted to level 1 trauma center (01/2017-01/2023). Analyzed variables included: Age, sex, mechanism of injury (MOI), injury severity score (ISS), Glasgow coma scale (GCS), abbreviated injury scale (AIS), co-injuries, transfusion requirements, pelvic angiography, embolization, laparotomy, orthopedic pelvic surgery, intensive care unit and hospital lengths of stay, discharge disposition and mortality. The study compared geriatric and non-geriatric patients, patients with and without CB and abdominal co-injuries. Propensity score matching was implemented in comparison groups.
RESULTS PF comprised 4% of all trauma admissions. 89 patients had CB. 286 (52%) patients had concomitant injuries including 93 (17%) patients with abdominal co-injuries. Geriatric patients compared to non-geriatric had more falls as MOI, lower ISS and AIS pelvis, higher GCS, less abdominal co-injuries, similar CB and angio-embolization rates, less orthopedic pelvic surgeries, shorter lengths of stay and higher mortality. After propensity matching, orthopedic pelvic surgery rates remained lower (8% vs 19%, P < 0.001), hospital length of stay shorter, and mortality higher (13% vs 4%, P < 0.001) in geriatric patients. Out of 89 patients with CB, 45 (51%) were embolized. After propensity matching, patients with CB compared to without CB had more pelvic angiography (71% vs 12%, P < 0.001), higher embolization rates (64% vs 22%, P = 0.02) and comparable mortality.
CONCLUSION Half of the patients with PF had concomitant co-injuries, including abdominal co-injuries in 17%. Similarly injured geriatric patients had higher mortality. Half of the patients with CB required an embolization.
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Affiliation(s)
- Alexander A Fokin
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Joanna Wycech Knight
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL 33316, United States
| | - Madison E Tharp
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Kyler C Brinton
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Phoebe K Gallagher
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Justin Fengyuan Xie
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Russell D Weisz
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
| | - Ivan Puente
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, FL 33431, United States
- Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL 33316, United States
- Herbert Wertheim College of Medicine, Department of Surgery, Florida International University, Miami, FL 33199, United States
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King DR, Hwabejire JO, Pham QP, Elsharkawy AE, Eid AI, Duggan MJ, Gelsinger S, Fornaciari M, Sharma U. Self-expanding foam versus preperitoneal packing for exsanguinating pelvic hemorrhage. J Trauma Acute Care Surg 2024; 96:727-734. [PMID: 37700445 PMCID: PMC10932884 DOI: 10.1097/ta.0000000000004138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Mortality for pelvic fracture patients presenting with hemorrhagic shock ranges from 21% to 57%. The objective of this study was to develop a lethal and clinically relevant pelvic hemorrhage animal model with and without bony fracture for evaluating therapeutic interventions. ResQFoam is a self-expanding foam that has previously been described to significantly decrease mortality in large-animal models of abdominal exsanguination. We hypothesized that administration of ResQFoam into the preperitoneal space could decrease mortality in exsanguinating pelvic hemorrhage. METHODS Two pelvic hemorrhage models were developed using noncoagulopathic swine. Pelvic hemorrhage model 1: bilateral, closed-cavity, major vascular retroperitoneal hemorrhage without bony pelvic fracture. After injury, animals received no treatment (control, n = 10), underwent preperitoneal packing using laparotomy pads (n = 11), or received ResQFoam (n = 10) injected into the preperitoneal space. Pelvic hemorrhage model 2: unilateral, closed-cavity, retroperitoneal hemorrhage injury (with intraperitoneal communication) combined with complex pelvic fracture. After injury, animals received resuscitation (control, n = 12), resuscitation with preperitoneal packing (n = 10) or with ResQFoam injection (n = 10) into the preperitoneal space. RESULTS For model 1, only ResQFoam provided a significant survival benefit. The median survival times were 50 minutes and 67 minutes for preperitoneal packing and ResQFoam, compared with 6 minutes with controls ( p = 0.002 and 0.057, respectively). Foam treatment facilitated hemodynamic stabilization and resulted in significantly less hemorrhage (21.5 ± 5.3 g/kg) relative to controls (31.6 ± 5.0 g/kg, p < 0.001) and preperitoneal packing (32.7 ± 5.4 g/kg, p < 0.001). For model 2, both ResQFoam and preperitoneal packing resulted in significant survival benefit compared with controls. The median survival times were 119 minutes and 124 minutes for the preperitoneal packing and ResQFoam groups, compared with 4 minutes with controls ( p = 0.004 and 0.013, respectively). CONCLUSION Percutaneous injection of ResQFoam into the preperitoneal space improved survival relative to controls, and similar survival benefit was achieved compared with standard preperitoneal pelvic packing. The technology has potential to augment the armamentarium of tools to treat pelvic hemorrhage.
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Affiliation(s)
- David Richard King
- From the Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA (D.R.K., J.O.H., A.E.E., M.J.D.); Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA & Emergency and Traumatology Department (Q.P.P., S.G., M.F., U.S.), Tanta University, Egypt (A.I.E.); and Arsenal Medical, Inc., Waltham, MA
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3
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Garlaschelli G, Ignativ A, Meyer F. [Interdisciplinary surgical spectrum in cooperation of abdominal surgery and gynecology : What must the (general/abdominal) surgeon know?]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:382-394. [PMID: 38294496 PMCID: PMC11031494 DOI: 10.1007/s00104-024-02033-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/01/2024]
Abstract
AIM This short overview aims to concisely outline the most important gynecological issues from a predominantly operative point of view, which could also be relevant for general and abdominal surgeons as well as important gynecological aspects of primarily visceral surgical pathologies. METHOD Narrative review on the topic of interdisciplinary cooperation in gynecological/general and abdominal surgery through the use of PubMed® as well as the Cochrane Library with search terms, such as "operative profile of abdominal surgery and gynecology", "interdisciplinary surgery aspects of gynecology/abdominal surgery" as well as "interdisciplinary surgical approach-surgical complication". RESULTS (MAIN POINTS) As the close anatomical relationship suggests, numerous primarily gynecological pathologies can also occur in abdominal organs. Likewise, predominantly surgical pathologies can result in involvement of gynecological organs. This can make an intraoperative collaboration necessary. In addition, as a result of diagnostic uncertainty or within the context of complications, interdisciplinary collaboration can also be required preoperatively and postoperatively. Multidisciplinary knowledge as well as close cooperation of the involved specialties can improve the outcome of affected patients. CONCLUSION Many pathologies extend not only to the boundaries of an individual discipline but can also affect physiological systems exceeding those limits. Therefore, for an optimal treatment it is necessary to be aware of such aspects of the diseases and to establish structured procedures for interdisciplinary cooperation.
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Affiliation(s)
- Gabriele Garlaschelli
- Klinik für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A. ö. R., Magdeburg, Deutschland.
| | - Atanas Ignativ
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Magdeburg A. ö. R., Magdeburg, Deutschland
| | - Frank Meyer
- Klinik für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A. ö. R., Magdeburg, Deutschland
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Singh A, Kotzur T, Koslosky E, Gonuguntla R, Canseco L, Momtaz D, Seifi A, Martin C. Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures. J Orthop Trauma 2024; 38:254-258. [PMID: 38378177 DOI: 10.1097/bot.0000000000002789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 02/22/2024]
Abstract
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 . 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.
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Affiliation(s)
| | | | | | | | | | | | - Ali Seifi
- Department of Neurosurgery, UT Health San Antonio, San Antonio, TX
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Wu Z, Dai Y, Zeng Y. Intelligent robot-assisted fracture reduction system for the treatment of unstable pelvic fractures. J Orthop Surg Res 2024; 19:271. [PMID: 38689343 PMCID: PMC11059586 DOI: 10.1186/s13018-024-04761-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/21/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Precise and minimally invasive closed reduction is the premise of minimally invasive internal fixation. This paper aims to explore the safety and efficacy of a robot-assisted fracture reduction system (RAFR) in the treatment of pelvic fractures and to analyze its clinical advantages and existing problems. METHODS The RAFR system intelligently designed the optimal reduction path and target position based on a preoperative three-dimensional(3D) CT scan of the patient. The reduction robotic arm automatically reduced the affected hemipelvis according to the pre-planned reduction path. RESULTS The average residual displacement was the 6.65 ± 3.59 mm. According to Matta's criteria, there were 7 excellent, 10 good, and 3 fair, and the excellent and good rate was 85%. No postoperative complications occurred. CONCLUSION In our study, the RAFR system could complete accurate and minimally invasive closed reduction for most patients with unstable pelvic fractures, which could achieve good fracture reduction quality and short-term efficacy.
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Affiliation(s)
- Zhengjie Wu
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China.
| | - Yonghong Dai
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
| | - Yanhui Zeng
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, Foshan, Guangdong, China
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Elamin MH, Elkaramany I, Salman LA, Albasha A, Parambathkandi A, Elramadi A, Ahmed G. The epidemiology of pelvic ring fractures in Qatar. INTERNATIONAL ORTHOPAEDICS 2024; 48:1097-1103. [PMID: 38296877 PMCID: PMC10933172 DOI: 10.1007/s00264-024-06103-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 01/21/2024] [Indexed: 02/02/2024]
Abstract
PURPOSE This study aimed to determine the incidence of pelvic ring fractures and their associated epidemiological profile in Qatar. METHODS A retrospective cross-sectional study was performed at the only level I trauma centre in Qatar for patients diagnosed with pelvic ring fractures between January 2016 and December 2018. Age, sex, mechanism of injury, fracture classification and associated characteristics, mode of treatment, associated nerve injuries, and other complications were analyzed. RESULTS A total of 327 consecutive patients were included, with an average age of 32.6 years. Most of the included patients were males, 85% (279), with a male: female ratio of 6:1. The incidence of pelvic fractures was 3.887/100,000 across the three years. High-speed motor vehicle collisions (MVC) were the most common mechanism of injury (108, 33%), followed by falling from height (105, 32%). Young-Burgess lateral compression (LC) fracture type was the most frequent (224, 68.5%) and was associated with 25% of the entire mortalities. Nine (2.8%) cases were open fractures, and 12% (39) were deemed unstable. Around 29% of cases had associated injuries, with an overall mortality rate of 4.9% (16) observed. Most fractures were treated nonoperatively(n = 283,86.5%). CONCLUSION This study demonstrated the epidemiology of pelvic fractures in Qatar. MVC and work-related injuries were predominant in a younger cohort compared to the literature. Also, the mortality rate was lower than those reported in the literature. Therefore, well-trained surgeons and specialized trauma centres for treating these injuries are recommended.
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Affiliation(s)
- Mohamed H Elamin
- Orthopedics Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Islam Elkaramany
- Orthopedics Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Loay A Salman
- Orthopedics Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar.
- Department of Orthopaedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar.
| | - Anas Albasha
- Orthopedics Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Ashik Parambathkandi
- Orthopedics Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Ahmed Elramadi
- Orthopedics Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Ghalib Ahmed
- Orthopedics Department, Hamad General Hospital, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
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7
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Jensen LR, Possfelt-Møller E, Nielsen AE, Singh UM, Svendsen LB, Penninga L. Accuracy of FAST in detecting intraabdominal bleeding in major trauma with pelvic and/or acetabular fractures: a retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1479-1486. [PMID: 38253932 PMCID: PMC10980602 DOI: 10.1007/s00590-023-03813-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024]
Abstract
PURPOSE The Focused Assessment with Sonography for Trauma (FAST) is a tool to rapidly detect intraabdominal and intrapericardial fluid with point-of-care ultrasound. Previous studies have questioned the role of FAST in patients with pelvic fractures. The aim of the present study was to assess the accuracy of FAST to detect clinically significant intraabdominal hemorrhage in patients with pelvic fractures. METHODS We included all consecutive patients with pelvic and/or acetabular fractures treated our Level 1 trauma center from 2009-2020. We registered patient and fracture characteristics, FAST investigations and CT descriptions, explorative laparotomy findings, and transfusion needs. We compared FAST to CT and laparotomy findings, and calculated true positive and negative findings, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS We included 389 patients. FAST had a sensitivity of 75%, a specificity of 98%, a PPV of 84%, and a NPV of 96% for clinically significant intraabdominal bleeding. Patients with retroperitoneal hematomas were at increased risk for laparotomy both because of True-negative FAST and False-positive FAST. CONCLUSION FAST is accurate to identify clinically significant intraabdominal blood in patients with severe pelvic fractures and should be a standard asset in these patients. Retroperitoneal hematomas challenge the FAST interpretation and thus the decision making when applying FAST in patients with pelvic fractures.
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Affiliation(s)
- Lasse Rehné Jensen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emma Possfelt-Møller
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Allan Evald Nielsen
- Department of Orthopaedic Surgery, Trauma Section, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Upender Martin Singh
- Department of Orthopaedic Surgery, Trauma Section, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Bo Svendsen
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Luit Penninga
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Collins AP, Abdelfattah W, Dasari SP, Unno F, Firoozabadi R, Kleweno CP, Psutka SP, Lack WD. Stable Lateral Compression Pelvic Ring Injury Requiring Operative Treatment due to Bladder Impingement: A Case Report. JBJS Case Connect 2024; 14:01709767-202406000-00037. [PMID: 38788049 DOI: 10.2106/jbjs.cc.24.00090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
CASE A 25-year-old man sustained a stable lateral compression Type I (LC I) pelvic ring injury upon missing the landing of a downhill ski jump. He presented with painful voiding from a displaced bony fragment, partially impaling the bladder wall. With operative fixation of the fracture and urologic co-management, the patient had excellent outcomes at 1-year follow-up. CONCLUSION We describe a rare urologic injury in the setting of an LC I pelvic ring injury. In the setting of an otherwise stable pelvic ring injury, careful review of imaging, detailed clinical history, and physical examination remain critical to optimizing patient outcomes.
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Affiliation(s)
- Andrew P Collins
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | | | - Suhas P Dasari
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Florence Unno
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Reza Firoozabadi
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Conor P Kleweno
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, Washington
| | - William D Lack
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
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Gottfried A, Gendler S, Chayen D, Radomislensky I, Mitchnik IY, Epshtein E, Tsur AM, Almog O, Talmy T. Hemorrhagic Shock in Isolated and Non-Isolated Pelvic Fractures: A Registries-Based Study. PREHOSP EMERG CARE 2024; 28:589-597. [PMID: 38416869 DOI: 10.1080/10903127.2024.2322014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/15/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Pelvic fractures resulting from high-energy trauma can frequently present with life-threatening hemodynamic instability that is associated with high mortality rates. The role of pelvic exsanguination in causing hemorrhagic shock is unclear, as associated injuries frequently accompany pelvic fractures. This study aims to compare the incidence of hemorrhagic shock and in-hospital outcomes in patients with isolated and non-isolated pelvic fractures. METHODS Registries-based study of trauma patients hospitalized following pelvic fractures. Data from 1997 to 2021 were cross-referenced between the Israel Defense Forces Trauma Registry (IDF-TR), documenting prehospital care, and Israel National Trauma Registry (INTR) recording hospitalization data. Patients with isolated pelvic fractures were defined as having an Abbreviated Injury Scale (AIS) <3 in other anatomical regions, and compared with patients sustaining pelvic fracture and at least one associated injury (AIS ≥ 3). Signs of profound shock upon emergency department (ED) arrival were defined as either a systolic blood pressure <90 mmHg and/or a heart rate >130 beats per min. RESULTS Overall, 244 hospitalized trauma patients with pelvic fractures were included, most of whom were males (84.4%) with a median age of 21 years. The most common injury mechanisms were motor vehicle collisions (64.8%), falls from height (13.1%) and gunshot wounds (11.5%). Of these, 68 (27.9%) patients sustained isolated pelvic fractures. In patients with non-isolated fractures, the most common regions with a severe associated injury were the thorax and abdomen. Signs of shock were recorded for 50 (20.5%) patients upon ED arrival, but only four of these had isolated pelvic fractures. In-hospital mortality occurred among 18 (7.4%) patients, all with non-isolated fractures. CONCLUSION In young patients with pelvic fractures, severe associated injuries were common, but isolated pelvic fractures rarely presented with profound shock upon arrival. Prehospital management protocols for pelvic fractures should prioritize prompt evacuation and resuscitative measures aimed at addressing associated injuries.
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Affiliation(s)
- Amir Gottfried
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
| | - Sami Gendler
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
| | - David Chayen
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Irina Radomislensky
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- The National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel-HaShomer, Israel
| | - Ilan Y Mitchnik
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Orthopedic Surgery, Shamir Medical Center, Zrifin, Israel
| | - Elad Epshtein
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
| | - Avishai M Tsur
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Medicine, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Almog
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Tomer Talmy
- Israel Defense Forces Medical Corps, Surgeon's General Headquarters, Ramat Gan, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Division of Anesthesia, Intensive Care, and Pain, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
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10
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Saiz AM, O'Donnell E, Kellam P, Cleary C, Moore X, Schultz BJ, Mayer R, Amin A, Gary J, Warner SJ, Routt ML, Eastman JG. Bladder Repair With Irrigation and Debridement and Open Reduction Internal Fixation of the Anterior Pelvic Ring Is Safe and Decreases Risk of Infection in Pelvic Ring Injuries With Extraperitoneal Bladder Ruptures. J Orthop Trauma 2024; 38:72-77. [PMID: 37941118 DOI: 10.1097/bot.0000000000002720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES To determine the incidence of infection in nonoperative versus operative management of extraperitoneal bladder ruptures in patients with pelvic ring injuries. METHODS DESIGN A retrospective cohort study of 2 prospectively collected trauma registries. SETTING Two Level 1 trauma centers. PATIENT SELECTION CRITERIA Patients with operative pelvic ring injuries, 68 (6%) had extraperitoneal bladder ruptures. OUTCOME MEASURES AND COMPARISONS The primary outcome was the incidence and associated risk factors of deep pelvic infection requiring return to OR for surgical debridement. Secondary outcomes included quality of reduction, other complications, and radiographic union. Comparisons were made based on the status of any associated bladder injury. RESULTS Of 1127 patients with operative pelvic ring injuries, 68 patients had extraperitoneal bladder ruptures, 55 had bladder repair and 13 did not. Of those 13 without repair, none had ORIF of the anterior pelvic ring. Patients without bladder repair had an increased odds of infection 17-fold compared to patients who did have a repair performed (OR 16.9, 95% CI 1.75 - 164, P = 0.01). Other associated factors for deep pelvic infection included use of suprapubic catheter ( p < 0.02) and a closed reduction of the anterior ring ( p < 0.01). Patients undergoing anterior ring ORIF and bladder repair had improved reductions and no increased infection risk. CONCLUSIONS Operative repair of extraperitoneal bladder ruptures decreases risk of infection in patients with pelvic ring injuries. Additionally, ORIF of the anterior pelvic ring does not increase the risk of infection and results in better reductions compared to closed reduction. Treatment algorithms for these combined injuries should consider recommending early bladder repair and anterior pelvic ORIF. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Augustine M Saiz
- University of Texas Health Science Center at Houston, Houston, TX
- University of California, Davis, Sacramento, CA; and
| | | | - Patrick Kellam
- University of Texas Health Science Center at Houston, Houston, TX
| | - Courtney Cleary
- University of Texas Health Science Center at Houston, Houston, TX
| | - Ximia Moore
- University of Texas Health Science Center at Houston, Houston, TX
| | - Blake J Schultz
- University of Texas Health Science Center at Houston, Houston, TX
| | - Ryan Mayer
- University of Texas Health Science Center at Houston, Houston, TX
| | - Adeet Amin
- University of Texas Health Science Center at Houston, Houston, TX
| | - Joshua Gary
- Keck School of Medicine of USC, Los Angeles, CA
| | - Stephen J Warner
- University of Texas Health Science Center at Houston, Houston, TX
| | - Milton L Routt
- University of Texas Health Science Center at Houston, Houston, TX
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Naccache R, Scemama U, El Ahmadi AA, Habert P, Zieleskiewicz L, Chaumoitre K, Michelet P, Varoquaux A, Di Bisceglie M. Can the use of whole-body CT be reduced in cases of kinetic-based polytrauma patients without a clinical severity criterion? A bi-center retrospective study. Eur J Radiol 2024; 171:111278. [PMID: 38157779 DOI: 10.1016/j.ejrad.2023.111278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/03/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To identify clinical and biological criteria predictive of significant traumatic injury in only kinetic-based polytrauma patients without clinical severity criteria. To propose a decisional algorithm to assist the emergency doctor in deciding whether or not to perform a WBCT in the above population. METHODS Retrospective bi-center study. 1270 patients with high velocity trauma without clinical severity criteria, for whom a WBCT was performed in 2017, were included. Patients with hemodynamic, respiratory or neurological severity criterion or those requiring pre-hospital resuscitation measures were excluded. Our primary endpoint was the identification of a significant lesion, i.e. any lesion that led to hospitalization > 24 h for monitoring or medico-surgical treatment. Data collected were age, sex, mechanism of injury, Glasgow Coma Scale score, number of symptomatic body regions, blood alcohol level, and neutrophil count. RESULTS Multivariate analysis found independent predictors of significant injury: fall > 5 m (OR: 14.36; CI: 2.3-283.4; p = 0.017), Glasgow score = 13 or 14 (OR: 4.40; CI:1.30-18.52; p = 0.027), presence of 2 symptomatic body regions (OR: 10.21; CI: 4.66-23.72; p = 0.05), positive blood alcohol level (OR: 2.81; CI: 1.13-7.33; p = 0.029) and neutrophilic leukocytosis (OR: 8.76; CI: 3.94-21.27; p = 0.01). A composite clinico-biological endpoint predictive of the absence of significant lesion was identified using a Classification and Regression Tree: number of symptomatic regions < 2, absence of Neutrophilic leukocytosis and negative blood alcohol concentration. CONCLUSION A simple triage algorithm was created with the objective of identifying, in high velocity trauma without clinical severity criteria, those without significant traumatic injury.
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Affiliation(s)
- Robin Naccache
- Department of Radiology, North Hospital, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Ugo Scemama
- Department of Radiology, Saint Joseph Hospital, Marseille, France
| | - Ahmed-Ali El Ahmadi
- Department of Radiology, North Hospital, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Paul Habert
- Department of Radiology, North Hospital, Assistance Publique Hôpitaux de Marseille, Marseille, France; CERIMED, Aix Marseille University, Marseille, France; LiiE, Aix Marseille University, Marseille France
| | - Laurent Zieleskiewicz
- Department of Anesthesiology and Critical Care, North Hospital, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, C2VN Marseille, France
| | - Kathia Chaumoitre
- Department of Radiology, North Hospital, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Pierre Michelet
- Department of Emergency, Timone Hospital, Assistance Publique Hôpitaux de Marseille, France
| | - Arthur Varoquaux
- Department of Radiology, Hôpital de la Conception, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Mathieu Di Bisceglie
- Department of Radiology, North Hospital, Assistance Publique Hôpitaux de Marseille, Marseille, France; CERIMED, Aix Marseille University, Marseille, France; LiiE, Aix Marseille University, Marseille France.
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12
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Almansouri DH, Elsherbini AI, Alharthi M, ALotaibi S, Alshehri L. The Role of MRI and CT Scan in Classification and Management of Pelvic Fractures: A Systematic Review. Cureus 2024; 16:e52215. [PMID: 38347986 PMCID: PMC10861139 DOI: 10.7759/cureus.52215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2024] [Indexed: 02/15/2024] Open
Abstract
The mortality risk for individuals with pelvic fractures ranges from 10% to 50%, depending on the severity of the bleeding and the presence of concurrent brain, thorax, and abdomen injuries. This systematic review aims to comprehensively investigate the role of MRI and CT in diagnosing and managing pelvic fractures. PubMed, SCOPUS, Web of Science, and Science Direct were systematically searched for relevant literature. The keywords "Pelvic fractures," "Diagnosis," "Computed tomography," "CT," "Magnetic resonance imaging," and "MRI" were converted into PubMed Mesh terms and used to find the relevant studies. Rayyan Qatar Computing Research Institute (QCRI) was employed throughout this comprehensive process. The systematic review included publications with full English text, available free articles, and human trials among adults. This review included 12 studies with 1,798 patients, and 935 (52%) of them were females. Two articles were prospective, and 10 articles were retrospective. In conclusion, the diagnosis and management of pelvic fractures require a tailored approach based on patient characteristics, injury mechanisms, and hemodynamic status. Because MRI detects a high number of concealed sacral fractures, it provides greater sensitivity and diagnostic validity in identifying acute pelvic fractures. Moreover, MRI is effective in diagnosing occult pelvic fractures and detecting soft tissue anomalies. However, MRI is unlikely to replace CT as the gold standard in the initial diagnosis of pelvic fractures; CT may also be preferable to MRI due to shorter emergency department (ED) time and the significant proportion of elderly patients who are contraindicated to MRI. Additionally, CT scanning aids in determining the need for emergent angiographic embolization and facilitates surgical planning.
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Affiliation(s)
| | | | - Manal Alharthi
- Radiology Technology, Alwadi Primary Health Care, Riyadh, SAU
| | - Shatha ALotaibi
- Radiological Technology, King Abdulaziz Specialist Hospital, Taif , SAU
| | - Lamyaa Alshehri
- Radiologic Technology, Primary Health Care, King Abdulaziz Medical City for National Gurad, Jeddah, SAU
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13
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Kuo LY, Silverman J, Morgan S, Steer R. Unrecognised entrapment of a herniated bladder at the pubic symphysis following reduction and external fixation of an unstable pelvic fracture. BMJ Case Rep 2023; 16:e258147. [PMID: 38056932 PMCID: PMC10711860 DOI: 10.1136/bcr-2023-258147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Abstract
Bladder injury is frequently associated with complex pelvic fractures with men being the predominant population to sustain such injuries. Entrapment of the bladder through the site of pelvic fracture is a rare clinical entity. We report a case of an entrapped bladder post closed reduction and external fixation of an unstable anteroposterior compression type 3 (APC-3) fracture. This report highlights the diagnostic difficulty with identifying an entrapped bladder and the patient's functional outcome after 1 year of follow-up.
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Affiliation(s)
- Lu Yu Kuo
- Gold Coast University Hospital, Department of Surgery/Urology, Queensland Health, Southport, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, City of Brisbane, Queensland, Australia
| | - Joshua Silverman
- Gold Coast University Hospital, Department of Surgery/Urology, Queensland Health, Southport, Queensland, Australia
| | - Samuel Morgan
- Gold Coast University Hospital, Department of Orthopaedics, Queensland Health, Southport, Queensland, Australia
| | - Richard Steer
- Faculty of Medicine, The University of Queensland, Herston, City of Brisbane, Queensland, Australia
- Gold Coast University Hospital, Department of Orthopaedics, Queensland Health, Southport, Queensland, Australia
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14
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Nourian Kafshgari H, Farhadi D, Kohandel Gargari M, Pourasghary S, Tahmasbi F, Soleimanzadeh F. Effects of continuous use of Tadalafil on male sexual function after posterior urethroplasty: A clinical trial. Urologia 2023; 90:735-740. [PMID: 37306088 DOI: 10.1177/03915603231179533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Posterior urethral injuries in men commonly occur following pelvic and perineal trauma. Erectile dysfunction (ED), whether brought on by the severity of the initial trauma or the surgery itself, is one of the complications in these patients. MATERIALS AND METHODS In this study, we divided candidates of posterior urethroplasty due to traumatic urethral injury into intervention and placebo groups; the former received continuous treatment with tadalafil (10 mg daily), and the latter received a placebo. Other services were provided equally to both groups. Before and after the intervention, both groups completed the International Index of Erectile Function version 5 (IIEF-5) questionnaire, and the findings were analyzed. RESULTS Forty patients were studied in groups of 20 with a mean age of 43.87 ± 15.70 years. The patient's most common cause of urethral injury was a pelvic fracture. Before the intervention, the mean scores of IIEF for patients in the intervention group and placebo group were 14.85 ± 7.39 and 14.77 ± 6.48, respectively with no statistical significance (p = 0.962) and patients of the groups were similar in terms of the severity of ED. The mean IIEF score in the intervention group was 20.12 ± 4.94 and in the placebo group, it was 18.05 ± 4.88 at the three-month follow-up, with no statistically significant difference (p = 0.063). In both the intervention and placebo groups, the IIEF score was significantly increased by 5.27 ± 4.04 (p < 0.001) and 3.27 ± 2.97 (p < 0.001), respectively. The rate of IIEF increase in the intervention group was higher than in the placebo group during the follow-up at 3-month follow-up with statistical significance. (p = 0.022). CONCLUSION The findings of this study suggest that tadalafil, in a 3-month treatment course, may improve erectile function in individuals with mild-to-moderate ED, significantly more than placebo. However, more studies, specifically with longer duration of follow-up and larger populations, are necessary for generalizing the current findings.
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Affiliation(s)
| | - Danial Farhadi
- Urology Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morad Kohandel Gargari
- Imam Reza Hospital, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sajjad Pourasghary
- Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran
| | - Fateme Tahmasbi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Research Center for Evidence-based Medicine, Iranian EBM Centre: A Joanna Briggs Institute (JBI) of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farzin Soleimanzadeh
- Research Center for Evidence-based Medicine, Iranian EBM Centre: A Joanna Briggs Institute (JBI) of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
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15
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Moeng MS, Viljoen F, Makhadi S. The Role for Preperitoneal Pelvic Packing in Low-to-Middle-Income Countries: A 16-Year Experience at a Johannesburg Trauma Unit. World J Surg 2023; 47:2651-2658. [PMID: 37716931 PMCID: PMC10545629 DOI: 10.1007/s00268-023-07173-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/18/2023]
Abstract
INTRODUCTION Preperitoneal pelvic packing for early pelvic haemorrhage control reduces mortality. Bleeding noted with pelvis fractures is predominantly due to associated venous complex injuries. More studies are advocating for angiography as first-line therapy for haemodynamic instability in pelvic fractures; however, these facilities are not in abundance in middle- and low-income countries. We hypothesized that PPP improves outcomes under these circumstances. METHODS Retrospective analysis of data from the patients charts over a period of 16 years from 01 January, 2005 to 31 December, 2020. All patients over the age of 18 years who presented with haemodynamic instability from a pelvic fracture and required PPP were included. The demographics, physiological parameter in emergency department, blood products transfused, morbidity and mortality were analysed. RESULTS There were 110 patients identified in the study period who underwent pelvic preperitoneal packing for refractory shock or ongoing bleeding. The majority (75.5%) of patients were men (n = 83). The median age was 38 years. The most common mechanism of injury was pedestrian vehicle collision (51%), followed by motor vehicle collisions (27.3%). The median ISS and NISS were 35 and 40, respectively. The median RTS in ED was 4.8(3-6.8). None of our patients rebleed after pack removal and no one needed repacking or adjunct angioembolization in our study group. The in-hospital mortality rate was 43.6% (n = 48) in patients who underwent preperitoneal pelvic packing. The operating room table mortality was 20% (n = 22/110), and the mortality rate of those who survived to ICU transfer was 29.5% (n = 26/88). CONCLUSIONS Pelvic preperitoneal packing has a role in the acute management of haemodynamically abnormal patients with pelvic fractures in our environment. In the absence of immediate angioembolization, preperitoneal packing can be lifesaving.
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Affiliation(s)
- Maeyane Stephens Moeng
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Francois Viljoen
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa
| | - Shumani Makhadi
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2193, South Africa.
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16
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Minici R, Mercurio M, Guzzardi G, Venturini M, Fontana F, Brunese L, Guerriero P, Serra R, Piacentino F, Spinetta M, Zappia L, Costa D, Coppola A, Galasso O, Laganà D. Transcatheter Arterial Embolization for Bleeding Related to Pelvic Trauma: Comparison of Technical and Clinical Results between Hemodynamically Stable and Unstable Patients. Tomography 2023; 9:1660-1682. [PMID: 37736986 PMCID: PMC10514840 DOI: 10.3390/tomography9050133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/23/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Endovascular intervention is now the primary line of therapy for arterial injury brought on by pelvic trauma since it can significantly reduce considerable morbidity associated with surgery and can swiftly access and control bleeding sites. Despite international guidelines and widespread awareness of the role of angioembolization in clinical practice, robust evidence comparing the outcomes of angioembolization in hemodynamically stable and unstable patients is still lacking. This study aims to directly compare the outcomes of angioembolization for the treatment of pelvic traumatic arterial injury in patients with hemodynamic stability vs. hemodynamic instability. METHODS In our multicenter retrospective investigation, we analyzed data from consecutive patients who underwent, from January 2020 to May 2023, angioembolization for traumatic pelvic arterial injury. RESULTS In total, 116 angioembolizations were performed. Gelatin sponges (56.9%) and coils (25.9%) were the most widely used embolic agents. The technical and clinical success rates were 100% and 91.4%, respectively. No statistically significant differences were observed between the two groups in terms of technical success, clinical success, procedure-related complication rate, or 30-day bleeding-related mortality. CONCLUSIONS Angioembolization is an effective and safe option for the management of traumatic pelvic arterial lesions even in hemodynamically unstable patients, despite technical variations such as greater use of prophylactic angioembolization.
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Affiliation(s)
- Roberto Minici
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
| | - Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, Magna Græcia University, Dulbecco University Hospital, 88100 Catanzaro, Italy; (M.M.); (O.G.)
| | - Giuseppe Guzzardi
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy; (G.G.); (M.S.)
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Federico Fontana
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Luca Brunese
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy; (L.B.); (P.G.)
| | - Pasquale Guerriero
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy; (L.B.); (P.G.)
| | - Raffaele Serra
- Vascular Surgery Unit, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Dulbecco University Hospital, 88100 Catanzaro, Italy;
| | - Filippo Piacentino
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - Marco Spinetta
- Radiology Unit, Maggiore della Carità University Hospital, 28100 Novara, Italy; (G.G.); (M.S.)
| | - Lorenzo Zappia
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
| | - Davide Costa
- Department of Law, Economics and Sociology, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy;
| | - Andrea Coppola
- Diagnostic and Interventional Radiology Unit, ASST Settelaghi, Insubria University, 21100 Varese, Italy; (M.V.); (F.F.); (F.P.); (A.C.)
| | - MGJR Research Team
- Magna Graecia Junior Radiologists Research Team, 88100 Catanzaro, Italy;
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, Magna Græcia University, Dulbecco University Hospital, 88100 Catanzaro, Italy; (M.M.); (O.G.)
| | - Domenico Laganà
- Radiology Unit, Dulbecco University Hospital, 88100 Catanzaro, Italy; (L.Z.); (D.L.)
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
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17
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Farid AR, Stearns SA, Atarere JO, Suneja N, Weaver MJ, Von Keudell AG. Trends in non-operative management of low-energy pelvic fracture: An analysis of the Nationwide Inpatient Sample. J Orthop 2023; 43:101-108. [PMID: 37564706 PMCID: PMC10410464 DOI: 10.1016/j.jor.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023] Open
Abstract
Introduction Non-operative management is common for low-impact pelvic fractures. In this study, we characterize the epidemiology of those treated nonoperatively following low-energy pelvic fracture, while identifying recent management trends. Methodology Data from the Nationwide Inpatient Sample (NIS) database from 2011 to 2018 were analyzed. We identified adult patients diagnosed with pelvic fracture based on International Classification of Diseases (ICD) codes, excluding fractures of the acetabulum, femur, polytrauma, and open fractures to isolate cases caused by low-impact mechanisms. Codes indicating operative management were excluded. Demographic information and outcomes (length of stay, in-hospital mortality, hospital discharge status) were collected. Sub-analyses were performed to identify trends. Findings 123,936 eligible patients were identified. The average age was 68.7 years. 70% were female, showing a decline from 75% to 66% over the study period. Pubic bone involvement was observed in 59% of fractures. The mean Charlson Comorbidity Index (CCI) was 3.83, corresponding to a 10-year survival rate of 58.5%, which remained relatively stable throughout the study period. 62.4% of patients received treatment at urban teaching hospitals. Average length of hospital stay was 6.3 days. Discharge to a skilled nursing facility (SNF) was the most common outcome, ranging from 62.1% to 65.0% during the study period, while 20.0% of patients were discharged home (18.4%-21.1%). Mean in-hospital mortality was 3.28%, showing no significant change, with higher rates among male patients (5.1%) and patients of Asian descent (3.8%). Conclusion The majority of patients receiving nonoperative treatment for low-energy pelvic fractures were females in their mid-60s with moderate comorbidity. The study reveals a relatively high in-hospital mortality rate of 3.28%, particularly among male patients and those of Asian descent, indicating the need for increased surveillance for further injury in these groups. Most patients were discharged to a SNF, highlighting the necessity for extended rehabilitation in this population. This persistent trend is noteworthy considering the growing emphasis on the cost of inpatient admissions and advancements in outpatient management of orthopedic injuries.
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Affiliation(s)
- Alexander R. Farid
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen A. Stearns
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph Okiemute Atarere
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J. Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arvind Gabriel Von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Trauma, Bispebjerg hospitalet, University of Copenhagen, 2400, Copenhagen, Denmark
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Morales-García D, Pérez-Nuñez MI, Portilla Mediavilla L, Ovejero-Gómez VJ, Marini CP, Petrone P. Retrospective observational study correlating traumatic pelvic fractures and their associated injuries according to the Tile classification. Cir Esp 2023; 101:548-554. [PMID: 36265775 DOI: 10.1016/j.cireng.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/06/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Pelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification. METHODS Retrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016. RESULTS A total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P = .032), and Tile B with sacral fractures (P = .033) and visceral injuries (P = .049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock. CONCLUSIONS Tile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.
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Affiliation(s)
- Dieter Morales-García
- Servicio de Cirugía General, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - María Isabel Pérez-Nuñez
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | | | | | - Corrado P Marini
- Department of Surgery, Jacobi Medical Center, Bronx, New York, USA
| | - Patrizio Petrone
- Department of Surgery, NYU Langone Hospital-Long Island, Mineola, New York, USA.
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19
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Dai J, He J, Ying Y, Huang D, Feng L. Clinical and epidemiological characteristics of 369 patients with pelvic fractures in Eastern Zhejiang Province of China: a retrospective study. BMC Musculoskelet Disord 2023; 24:495. [PMID: 37328894 DOI: 10.1186/s12891-023-06632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Data on the epidemiological characteristics and prognostic factors of patients with pelvic fractures are lacking, particularly in China. This study aimed to summarise the clinical and epidemiological characteristics of patients with pelvic fractures in eastern Zhejiang Province, China, and to identify risk factors for poor prognosis. METHODS The clinical data of 369 patients with pelvic fractures admitted to the Ningbo No. 6 Hospital between September 2020 and September 2021 were retrospectively analysed. Data on the demographic characteristics; fracture classification; injury time, cause, and site; treatment plan; and prognosis were collected using the Picture Archiving and Communication System and the Hospital Information System. Differences in constituent proportions were analysed using the chi-square test. Logistic regression analysis was used to identify factors affecting patient prognosis. Statistical significance was set at p ≤ 0.05. RESULTS Among the 369 patients, there were 206 men and 163 women, at a ratio of 1.26:1, and the average age was 53.64 ± 0.78 years. More than 50% of patients were aged 41-65 years. The average length of hospital stay was 18.88 ± 1.78 days. The three most common causes of pelvic fractures were traffic accidents (51.2%), falls from height (31.44%), and flat-ground falls (14.09%). There were significant differences in the distribution of the three causes of injury depending on age (p < 0.001), sex (p < 0.001), and occupation (p < 0.0001). Most patients were manual workers (48.8%). Furthermore, most patients (n = 262, 71.0%) underwent surgical treatment for pelvic fractures. Postoperative complications occurred in 26 patients (7.05%), and infection was the main complication (73.08%). Age (p = 0.013), occupation (p = 0.034), cause of injury (p = 0.022), treatment options (p = 0.001), and complications (p < 0.0001) were independent factors affecting the prognosis of patients with pelvic fractures. One death (0.027%) occurred, which was due to severe blood loss. CONCLUSIONS Age, occupation, cause of injury, treatment options and complications were factors affecting patient prognosis. In addition, changes in blood flow and prevention of infection warrant attention.
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Affiliation(s)
- Jiao Dai
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Junhong He
- Department of Pharmacy, Ningbo No. 6 Hospital, Ningbo, China
| | - Ying Ying
- Department of Nursing, Ningbo No. 6 Hospital, Ningbo, China
| | - Dichao Huang
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Leling Feng
- Department of Nursing, Ningbo No. 6 Hospital, Ningbo, China.
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20
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Nguyen P, Pokrzywa C, Figueroa J, Jocoy KA, Brandolino A, Karam BS, Schramm AT, Deshpande D, Lawton J, Milia D, Lenz T. Predictive Factors for the Application of Pelvic Binders in the Prehospital Setting. PREHOSP EMERG CARE 2023; 28:425-430. [PMID: 37171847 DOI: 10.1080/10903127.2023.2213316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVES Early pelvic binder placement in the field stabilizes pelvic fractures and tamponades potential hemorrhage within the pelvis. Despite known risk factors for pelvic fracture, it remains challenging to quickly triage and correctly apply a pelvic binder. We aim to develop a prediction model that exclusively uses prehospital criteria to inform the decision to place a pelvic binder. METHODS The trauma registry was used to identify all trauma patients admitted to an urban Level I trauma center between January 2013 and December 2017. Variables collected included patient demographics, mechanism of injury, prehospital vital signs, and the presence of a pelvic fracture. Participants were randomly assigned to a training group (70%) or a validation group (30%). Univariate analyses were used to identify significant predictors for use in multivariate predictive models. RESULTS A total of 8,480 (65% male; median age 49; median ISS 9) and 3,676 (65% male; median age 48; median ISS 9) trauma patients were randomly assigned to the training and validation groups, respectively. Univariate analysis showed significant likelihood of pelvic fracture associated with female sex, hemodynamic instability (initial systolic blood pressure < 90 mmHg), blunt injury type, specific mechanisms of injury (motor vehicle collision, motorcycle collision, pedestrian struck by motor vehicle, crushing injury, and riding an animal), impact location, and position in vehicle. Multivariate models adjusting for blunt type injury, hemodynamic instability, impact location, and position in vehicle showed that presence of two or more of these risk factors is significantly associated with presence of pelvic fracture. CONCLUSION Establishing select prehospital criteria for the empiric application of pelvic binders for patients in the field with blunt injuries, hemodynamic instability, frontal or side motor vehicle collision impact, and non-front seat passenger may improve outcomes among patients with pelvic fractures.
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Affiliation(s)
- Peter Nguyen
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Courtney Pokrzywa
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Juan Figueroa
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathleen A Jocoy
- Department of Psychology, Frostburg State University, Frostburg, Maryland
| | - Amber Brandolino
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Basil S Karam
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrew T Schramm
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Deshpande
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joseph Lawton
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Milia
- Department of Surgery, Division of Trauma & Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Timothy Lenz
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Lai CY, Lai PJ, Tseng IC, Su CY, Hsu YH, Chou YC, Yu YH. Morel-Lavallee lesions and number of surgeries for associated injuries predict surgical site infection risk following pelvic ring injury osteosynthesis. Sci Rep 2023; 13:8208. [PMID: 37217581 DOI: 10.1038/s41598-023-35488-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/18/2023] [Indexed: 05/24/2023] Open
Abstract
We examined the incidence and causative factors of surgical site infection (SSI) following osteosynthesis for pelvic ring injury by reviewing the data of 97 consecutive patients with pelvic ring injuries treated between 2014 and 2019. Osteosyntheses, including internal or external skeletal fixation with plates or screws, were performed based on fracture type and patient's condition. Fractures were treated surgically, with a 36 months minimum follow-up period. Eight (8.2%) patients experienced SSI. The most common causative pathogen was Staphylococcus aureus. Patients with SSI had significantly worse functional outcomes at 3, 6, 12, 24, and 36 months than those without. For patients with SSI, the average Merle d'Aubigné and Majeed scores at 3, 6, 12, 24, and 36 months after injury were 2.4, 4.1, 8.0, 11.0, and 11.3, and 25.5, 32.1, 47.9, 61.9, and 63.3, respectively. Patients with SSI had a higher likelihood of undergoing staged operations (50.0 vs. 13.5%, p = 0.02), more surgeries for associated injuries (6.3% vs. 2.5%, p = 0.04), higher likelihood of Morel-Lavallee lesions (50.0% vs. 5.6%, p = 0.002), higher incidence of diversional colostomy (37.5% vs. 9.0%, p = 0.05), and longer intensive care unit stay (11.1 vs. 3.9 days, p = 0.001) than those without. The contributing factors for SSI were Morel-Lavallee lesions (odds ratio [OR] 4.55, 95% confidence interval [95% CI] 3.34-50.0) and other surgeries for associated injuries (OR 2.37, 95% CI 1.07-5.28). Patients with SSI after osteosynthesis for pelvic ring injuries may have worse short-term functional outcomes.
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Affiliation(s)
- Chih-Yang Lai
- Department of Orthopedic Surgery, Linkou Branch, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Po-Ju Lai
- Department of Orthopedic Surgery, Linkou Branch, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - I-Chuan Tseng
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan Branch, Taoyuan City, Taiwan
| | - Chun-Yi Su
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung City, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Linkou Branch, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Linkou Branch, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan
| | - Yi-Hsun Yu
- Department of Orthopedic Surgery, Linkou Branch, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Taiwan.
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Zhao X, Lu S, Wang B, Zhou X, Liu F, Xu W, Zhou D, Li L, Dong J. Fracture Types Influence the Likelihood of Lower Urinary Tract Injuries in Patients with Pelvic Fractures. J Clin Med 2023; 12:jcm12082967. [PMID: 37109301 PMCID: PMC10145837 DOI: 10.3390/jcm12082967] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 04/29/2023] Open
Abstract
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.
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Affiliation(s)
- Xuehui Zhao
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Shun Lu
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Bingzhi Wang
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Xiaofeng Zhou
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Fanxiao Liu
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Weicheng Xu
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Dongsheng Zhou
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Lianxin Li
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
| | - Jinlei Dong
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China
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Ansorge A, de Foy M, Gayet-Ageron A, Andereggen E, Gamulin A. Epidemiology of high-energy blunt pelvic ring injuries: A three-year retrospective case series in a level-I trauma center. Orthop Traumatol Surg Res 2023; 109:103446. [PMID: 36270442 DOI: 10.1016/j.otsr.2022.103446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 01/26/2022] [Accepted: 03/09/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Alexandre Ansorge
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, University Hospitals of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland; Department of Spine Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne, Switzerland.
| | - Michaël de Foy
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, University Hospitals of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Angèle Gayet-Ageron
- Clinical Research Center, Faculty of Medicine, University of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland; Division of Clinical Epidemiology, Department of Health and Community Medicine, University Hospitals of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Elisabeth Andereggen
- Division of Emergency Medicine, Department of Acute Medicine, University Hospitals of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Axel Gamulin
- Division of Orthopaedic and Trauma Surgery, Department of Surgery, University Hospitals of Geneva, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland
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Chen K, Bhattacharjee S, Seidel H, Dillman DB, Strelzow JA. Association of Pelvic Trauma With Rates of Cesarean Section, Sexual Dysfunction, and Genitourinary Dysfunction in a National Database. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202304000-00006. [PMID: 37036931 PMCID: PMC10090791 DOI: 10.5435/jaaosglobal-d-22-00166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 01/31/2023] [Indexed: 04/12/2023]
Abstract
INTRODUCTION Pelvic fractures are severe injuries that can drastically affect a woman's quality of life through sexual dysfunction (SD), genitourinary dysfunction (GD), and increasing the potential need for future cesarean section (C-section). Limited research has captured long-term outcomes after pelvic fractures in women of childbearing age. This study aimed to determine the association between pelvic fractures and rates of C-section, SD, and GD. METHODS All women of childbearing age who sustained a pelvic fracture were identified in a national insurance database. A comparison group of patients with lower extremity long-bone fractures was selected. Patients who gave birth after injury were additionally identified. A minimum of 5 years of follow-up was required for inclusion. Rates of C-section, SD, and GD were compared between cohorts. Multivariate logistic regression analysis was conducted with the inclusion of diabetes, tobacco, hypertension, obesity, and advanced maternal age. RESULTS A total of 6,174 patients with pelvic fracture and 27,154 control fracture patients were identified. 434 patients with pelvic fracture (7.0%) and 1,258 control fracture patients (4.6%) gave birth after fracture. Patients with pelvic fracture had a significantly higher rate of C-section (50.0% versus 38.8%, P < 0.001), SD diagnosis (10.9% versus 8.8%, P < 0.001), and urinary retention diagnosis (3.5% versus 2.8%, P < 0.001). No significant difference in global GD diagnosis was identified. Multivariate analyses showed that pelvic fracture was associated with C-section (odds ratio [OR]: 1.78; 95% confidence interval [95% CI]: 1.42 to 2.23, P < 0.001), SD diagnosis (OR: 1.23; 95% CI: 1.12 to 1.35, P < 0.001), and urinary retention diagnosis (OR: 1.35; 95% CI: 1.15 to 1.57, P < 0.001). DISCUSSION Pelvic fractures confer an intrinsic level of risk of C-section, SD, and urinary retention that is elevated beyond what would be expected from a traumatic lower extremity injury alone. Treating orthopaedic surgeons should actively counsel women regarding increased risks, openly discuss postinjury sequelae, and coordinate interspecialty care beyond initial treatment of acute trauma.
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Affiliation(s)
- Kevin Chen
- From the Pritzker School of Medicine at the University of Chicago, Chicago, IL (Mr. Chen, Dr. Bhattacharjee, and Mr. Seidel); and the Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, IL (Dr. Dillman and Dr. Strelzow)
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25
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Roszman AD, John DQ, Patch DA, Spitler CA, Johnson JP. Management of open pelvic ring injuries. Injury 2023; 54:1041-1046. [PMID: 36792402 DOI: 10.1016/j.injury.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/18/2023] [Accepted: 02/02/2023] [Indexed: 02/17/2023]
Abstract
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.
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Affiliation(s)
- Alexander D Roszman
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Devin Q John
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - David A Patch
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Joey P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
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Parker W, Despain RW, Bailey J, Elster E, Rodriguez CJ, Bradley M. Military experience in the management of pelvic fractures from OIF/OEF. BMJ Mil Health 2023; 169:108-111. [PMID: 32938710 DOI: 10.1136/bmjmilitary-2020-001469] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Pelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), have yet to be described, especially in the context of dismounted complex blast injury. Our goal was to identify the incidence, patterns of injury and management of pelvic fractures. METHODS We conducted a retrospective review on all combat-injured patients who arrived at our military treatment hospital between November 2010 and November 2012. Basic demographics, Young-Burgess fracture pattern classification and treatment strategies were examined. RESULTS Of 562 patients identified within the study time period, 14% (81 of 562) were found to have a pelvic fracture. The vast majority (85%) were secondary to an improvised explosive device. The average Injury Severity Score for patients with pelvic fracture was 31±12 and 70% were classified as open. Of the 228 patients with any traumatic lower extremity amputation, 23% had pelvic fractures, while 30% of patients with bilateral above-knee amputations also sustained a pelvic fracture. The most common Young-Burgess injury pattern was anteroposterior compression (APC) (57%), followed by lateral compression (LC) (36%) and vertical shear (VS) (7%). Only 2% (nine of 562) of all patients were recorded as having pelvic binders placed in the prehospital setting. 49% of patients with pelvic fracture required procedural therapy, the most common of which was placement of a pelvic external fixator (34 of 40; 85%), followed by preperitoneal packing (16 of 40; 40%) and angioembolisation (three of 40; 0.75%). 17 (42.5%) patients required combinations of these three treatment modalities, the majority of which were a combination of external fixator and preperitoneal packing. The likelihood to need procedural therapy was impacted by injury pattern, as 72% of patients with an APC injury, 100% of patients with a VS injury and 25% of patients with an LC injury required procedural therapy. CONCLUSIONS Pelvic fractures were common concomitant injuries following blast-induced traumatic lower extremity amputations. APC was the most common pelvic fracture pattern identified. While procedural therapy was frequent, the majority of patients underwent conservative therapy. However, placement of an external fixator was the most frequently used modality. Considering angioembolisation was used in less than 1% of cases, in the forward deployed military environment, management should focus on pelvic external fixation±preperitoneal packing. Finally, prehospital pelvic binder application may be an area for further process improvement.
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Affiliation(s)
- William Parker
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - R W Despain
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - J Bailey
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - E Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - C J Rodriguez
- Division of Trauma, John Peter Smith Hospital, Fort Worth, Texas, USA
| | - M Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Current Management of Hemodynamically Unstable Patients with Pelvic Fracture. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00348-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury. J Trauma Acute Care Surg 2023; 94:344-349. [PMID: 36121280 DOI: 10.1097/ta.0000000000003774] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI. METHODS Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction. RESULTS There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784). CONCLUSION In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Anand T, El-Qawaqzeh K, Nelson A, Hosseinpour H, Ditillo M, Gries L, Castanon L, Joseph B. Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures. JAMA Surg 2023; 158:63-71. [PMID: 36449300 PMCID: PMC9713682 DOI: 10.1001/jamasurg.2022.5772] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/09/2022] [Indexed: 12/02/2022]
Abstract
Importance Management of hemodynamically unstable pelvic fractures remains a challenge. Hemostatic interventions are used alone or in combination. There is a paucity of data on the association between the pattern of hemorrhage control interventions and outcomes after a severe pelvic fracture. Objective To characterize clinical outcomes and study the patterns of hemorrhage control interventions in hemodynamically unstable pelvic fractures. Design, Setting, and Participants In this cohort study, a retrospective review was performed of data from the 2017 American College of Surgeons Trauma Quality Improvement Program database, a national multi-institutional database of trauma patients in the United States. Adult patients (aged ≥18 years) with pelvic fractures who received early transfusions (≥4 units of packed red blood cells in 4 hours) and underwent intervention for pelvic hemorrhage control were identified. Use and order of preperitoneal pelvic packing (PP), pelvic angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 were examined and compared against the primary outcome of mortality. The associations between intervention patterns and mortality, complications, and 24-hour transfusions were further examined by backward stepwise regression analyses. Data analyses were performed in September 2021. Main Outcomes and Measures Primary outcomes were rates of 24-hour, emergency department, and in-hospital mortality. Secondary outcomes were major in-hospital complications. Results A total of 1396 patients were identified. Mean (SD) age was 47 (19) years, 975 (70%) were male, and the mean (SD) lowest systolic blood pressure was 71 (25) mm Hg. The median (IQR) Injury Severity Score was 24 (14-34), with a 24-hour mortality of 217 patients (15.5%), ED mortality of 10 patients (0.7%), in-hospital mortality of 501 patients (36%), and complication rate of 574 patients (41%). Pelvic AE was the most used intervention (774 [55%]), followed by preperitoneal PP (659 [47%]) and REBOA zone 3 (126 [9%]). Among the cohort, 1236 patients (89%) had 1 intervention, 157 (11%) had 2 interventions, and 3 (0.2%) had 3 interventions. On regression analyses, only pelvic AE was associated with a mortality reduction (odds ratio [OR], 0.62; 95% CI, 0.47 to 0.82; P < .001). Preperitoneal PP was associated with increased odds of complications (OR, 1.39; 95% CI, 1.07 to 1.80; P = .01). Increasing number of interventions was associated with increased 24-hour transfusions (β = +5.4; 95% CI, +3.5 to +7.5; P < .001) and mortality (OR, 1.57; 95% CI, 1.05 to 2.37; P = .03), but not with complications. Conclusions and Relevance This study found that among patients with pelvic fracture who received early transfusions and at least 1 invasive pelvic hemorrhage control intervention, more than 1 in 3 died, despite the availability of advanced hemorrhage control interventions. Only pelvic AE was associated with a reduction in mortality.
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Affiliation(s)
- Tanya Anand
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Khaled El-Qawaqzeh
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Adam Nelson
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Hamidreza Hosseinpour
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Michael Ditillo
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Lynn Gries
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Lourdes Castanon
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Bellal Joseph
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
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Mair OA, Himmler M, Brunnemer S, Faymonville C, Honeck P, Horn T, Biberthaler P, Hanschen M. Positive Predictive Factors for Urogenital Injuries in Severely Injured Patients with Pelvic and Spinal Fractures: Introducing the UPPS Scoring System. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58111583. [PMID: 36363539 PMCID: PMC9695250 DOI: 10.3390/medicina58111583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
Abstract
Background and Objectives: Although urogenital injuries are common in severely injured patients, their diagnosis is often delayed. Predicting genitourinary injuries (GUI), especially in the immediate stages post injury, remains a challenge. This study aims to evaluate and determine positive predictive factors for the presence of GUI in polytrauma patients. Subsequently, these factors shall be used to develop an easy-to-use scoring system, deployable directly in the emergency setting. Materials and Methods: This study evaluates all severely injured patients with an Injury Severity Score (ISS) ≥ 16 admitted to the emergency departments of two German university hospitals between 2016 and 2020. These patients were retrospectively scanned for injuries of the thoracic and/or lumbar spine and/or the pelvic girdle. Demographic data was analyzed alongside trauma mechanism, type of injuries, mortality, length of hospital stays, surgeries, laboratory results, and urological treatment. Subgroup analysis was performed to compare patients with and without GUIs using t-tests. Conducting a binary logistic regression model, the significant factors were combined to create a scoring system, which was further analyzed for accuracy. Results: In total, 413 patients with an average ISS of 33.8 ± 15.0 were identified, and 47 patients (11.4%) sustained urogenital injuries with an average Abbreviated Injury Scale (AIS) score of 2.3 ± 1.1 (range: 1−5). The severity of the pelvic girdle injury correlated with the presence of urogenital injuries (p = 0.002), while there was no correlation with spinal injuries. Moreover, most GUIs resulted from motorcycle accidents (p < 0.001) and 87.2% of these patients were male. Patients with GUI were significantly more likely to show macrohematuria (p < 0.001) on admission and were more severely injured overall (ISS > 34). There was no significant difference in the length of intensive care unit (ICU) stay, the days until discharge, or death rates. Conclusions: Factors or circumstances which reliably predict the presence of GUI were found to include the male sex, a motorcycle accident, high severity of pelvic girdle fractures, macrohematuria on admission to the emergency department, and an ISS > 34. With these findings, we introduce the ‘Urotrauma in Polytrauma patients with Pelvic and/or Spinal injuries’ (UPPS) score for easier prediction of GUI in the emergency setting.
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Affiliation(s)
- Olivia Anna Mair
- Department of Trauma Surgery, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675 Munich, Germany
- Correspondence: ; Tel.: +49-89-4140-9382
| | - Maren Himmler
- Department of Urology and Urological Surgery, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Suna Brunnemer
- Department of Trauma Surgery, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Christoph Faymonville
- Department of Trauma Surgery, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Patrick Honeck
- Department of Urology and Urological Surgery, University Medical Center Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Thomas Horn
- Department of Urology, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Marc Hanschen
- Department of Trauma Surgery, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675 Munich, Germany
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Ma Y, Mandell JC, Rocha T, Mendicuti MAD, Weaver MJ, Khurana B. Diagnostic accuracy of pelvic radiographs for the detection of traumatic pelvic fractures in the elderly. Emerg Radiol 2022; 29:1009-1018. [PMID: 36190583 DOI: 10.1007/s10140-022-02090-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 09/22/2022] [Indexed: 10/10/2022]
Abstract
PURPOSE Prompt identification of traumatic pelvic fractures in the elderly is critical to guide clinical management; however, the accuracy of pelvic radiographs is often compromised by multiple factors. The purpose of this study is to examine the diagnostic accuracy of radiographs for the detection of pelvic fractures, with CT as the standard of reference. METHODS A retrospective review was performed of patients ≥ 65 years with traumatic pelvic fractures evaluated with both pelvic radiography and computed tomography (CT) from May 2016 to October 2019. Pelvic fractures were classified into fractures of the pubis, ilium, ischium, sacrum, and acetabulum. All pelvic radiographs were independently reviewed by two emergency radiologists. Original CT reports were utilized for the reference standard. RESULTS 177 patients were included, with a total of 555 fractures. The mean age was 81 years and 68% were female. The most common mechanism of injury was fall (62%), followed by motor vehicle accidents (18%). The most fractured bone was the pubis (314/555 fractures). Global pooled sensitivity for pelvic radiographs in detecting pelvic fractures compared to CT was 48%, with a specificity of 93%. Sensitivity for the detection of pelvic fractures is classified by the following types: pubis 61%, acetabulum 60%, ilium 41%, sacrum 20%, and ischium 17%. Eighteen patients (10%) required surgical fixation. Mortality was 8%. CONCLUSION Pelvic radiographs have low sensitivity in detecting traumatic pelvic fractures. These radiographically occult fractures may be clinically significant as a cause of long-term pain and may require orthopedic consultation and possible surgical management.
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Affiliation(s)
- Yuntong Ma
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Jacob C Mandell
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Tatiana Rocha
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Maria ADuran Mendicuti
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Michael J Weaver
- Department of Orthopedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Bharti Khurana
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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Morales-García D, Pérez-Nuñez MI, Portilla Mediavilla L, Ovejero-Gómez VJ, Marini CP, Petrone P. Estudio observacional retrospectivo correlacionando las fracturas traumáticas de pelvis y sus lesiones asociadas según la clasificación de Tile. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Shingaki K, Abe T, Ameda T, Nakamura T. Intraperitoneal Rupture of the Urinary Bladder Mimics an Intra-Abdominal Hemorrhage: A Case Report. Cureus 2022; 14:e28275. [PMID: 36158448 PMCID: PMC9492443 DOI: 10.7759/cureus.28275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2022] [Indexed: 11/29/2022] Open
Abstract
Hemorrhagic shock due to polytrauma is a life-threatening condition, requiring immediate diagnosis of the bleeding site and determination of an appropriate hemostatic procedure. Intra-abdominal injuries and pelvic fractures are major causes of massive hemorrhage, although the appropriate hemostatic procedures are different for each injury. We present a case of intraperitoneal rupture of the urinary bladder associated with pelvic fracture, in which urine extravasation into peritoneal spaces mimics intra-abdominal hemorrhage.
A 33-year-old man with a known case of schizophrenia attempted suicide by jumping down from the 4th floor of his apartment (approximately 10 meters in height). He was in a state of shock on arrival. Focused assessment with sonography for trauma (FAST) showed fluid collection around his spleen only but not the perivesical space. Pelvic X-ray showed multiple pelvic fractures. We suspected the patient was in a state of hemorrhagic shock due to intra-abdominal hemorrhage and pelvic fracture. The patient's hemodynamic status did not respond to massive fluid infusion and blood transfusion, including eight units of packed RBCs transfusion. Resuscitative endovascular balloon occlusion of the aorta was performed; however, the patient's hemodynamic status did not recover. We performed an emergency laparotomy to control the suspected intra-abdominal hemorrhage. In peritoneal space, we found a large amount of non-bloody fluid. The liver, spleen, and bowels were not injured, whereas the urinary bladder was ruptured, indicating the correct diagnosis was intraperitoneal rupture of the urinary bladder associated with pelvic fracture. The ruptured urinary bladder wall was sutured, and temporary abdominal closure was performed. A contrast-enhanced CT performed after the laparotomy showed massive hemorrhage around the pelvic fracture. After arrival at the angiography room, the patient became bradycardia, and the pulsation at the carotid artery was not palpable. We performed cardiopulmonary resuscitation; however, the patient died eventually.
Intraperitoneal rupture of the urinary bladder would mimic an intra-abdominal hemorrhage. Therefore, a comprehensive diagnostic-treatment approach such as a hybrid ER system would be beneficial for early and accurate diagnosis.
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Kunii M, Nakao S, Nakagawa Y, Shimazaki J, Ogura H. Impact of Pelvic Fracture Sites on Fibrinogen Depletion in Patients with Blunt Trauma: A Single-Center Cohort Study. J Clin Med 2022; 11:jcm11164689. [PMID: 36012927 PMCID: PMC9409758 DOI: 10.3390/jcm11164689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background: We aimed to examine the association of pelvic fracture sites with the minimum fibrinogen level within 24 h after hospital arrival. Methods: We conducted a single-center cohort study using health records review. We included patients with pelvic fractures transported by ambulance to a tertiary-care hospital from January 2012 to December 2018 and excluded those transported from other hospitals or aged younger than 16 years. The pelvic fracture was diagnosed and confirmed by trauma surgeons and/or radiologists. We classified the fracture sites of the pelvis as ilium, pubis, ischium, acetabulum, sacrum, sacroiliac joint diastasis, and pubic symphysis diastasis, and each side was counted separately except for pubic symphysis diastasis. We performed linear regression analysis to evaluate the association between pelvic fracture sites and the minimum fibrinogen level within 24 h of arrival. Results: We analyzed 120 pelvic fracture patients. Their mean age was 47.3 years, and 69 (57.5%) patients were men. The median Injury Severity Score was 24, and in-hospital mortality was 10.8%. The mean minimum fibrinogen level within 24 h of arrival was 171.4 mg/dL. Among pelvic fracture sites, only sacrum fracture was statistically significantly associated with the minimum fibrinogen level within 24 h of arrival (estimate, −34.5; 95% CI, −58.6 to −10.4; p = 0.005). Conclusions: Fracture of the sacrum in patients with pelvic fracture was associated with lower minimum fibrinogen levels within 24 h of hospital arrival and the requirement of blood transfusion.
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Yang Q, Feng S, Song J, Cheng C, Liang C, Wang Y. Computer-aided automatic planning and biomechanical analysis of a novel arc screw for pelvic fracture internal fixation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 220:106810. [PMID: 35462347 DOI: 10.1016/j.cmpb.2022.106810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/28/2022] [Accepted: 04/10/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVE The sacroiliac joint screw is a common fixation method for pelvic posterior ring fractures. The complex anatomical structure around the pelvis makes it impossible to find a suitable fixed path, which increases the difficulty of surgical operation. In this paper, we propose an automatic planning algorithm based on a computer-aided internal arc fixation channel for pelvic fractures for the first time. METHODS A channel generation algorithm based on seed derived points was designed, and the optimal channel was selected by scoring rules based on 3D erode algorithm for the generated channel. The biomechanical properties of the internal arc fixation screw and traditional internal straight fixation screw in three postures were compared using biomechanical finite element analysis. RESULTS The proposed algorithm verified the existence of a more adaptable internal arc fixation channel and can quantitatively plan a relatively optimal constant-curvature internal arc fixation channel in pelvises of ten adults. Significantly high stresses concentrated around the interaction region between the screws and bone may increase the risk of bone fractures and screw loosening in the long term. The experimental results show that the internal arc fixation screw has better strain and deformation performance than the internal straight fixation screw. CONCLUSIONS A novel arc internal fixation method for pelvic fractures was proposed to improve the safety and stability of screw fixation of pelvic fracture. The nonparametric test proved that the sacroiliac dislocation model repaired by internal arc fixation screw was significantly different from that repaired by internal straight fixation screw. The computer-aided automatic planning algorithm provides the possibility of robot-assisted pelvic fracture fixation.
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Affiliation(s)
- Qing Yang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China; Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China
| | - Siru Feng
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China; Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China
| | - Jian Song
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China; Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China
| | - Chang Cheng
- Department of Mathematics and Computer Science Colorado College, Colorado, USA
| | - Chendi Liang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China; Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China
| | - Yu Wang
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China; Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China.
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An Extra Set of Intelligent Eyes: Application of Artificial Intelligence in Imaging of Abdominopelvic Pathologies in Emergency Radiology. Diagnostics (Basel) 2022; 12:diagnostics12061351. [PMID: 35741161 PMCID: PMC9221728 DOI: 10.3390/diagnostics12061351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/19/2022] [Accepted: 05/26/2022] [Indexed: 11/25/2022] Open
Abstract
Imaging in the emergent setting carries high stakes. With increased demand for dedicated on-site service, emergency radiologists face increasingly large image volumes that require rapid turnaround times. However, novel artificial intelligence (AI) algorithms may assist trauma and emergency radiologists with efficient and accurate medical image analysis, providing an opportunity to augment human decision making, including outcome prediction and treatment planning. While traditional radiology practice involves visual assessment of medical images for detection and characterization of pathologies, AI algorithms can automatically identify subtle disease states and provide quantitative characterization of disease severity based on morphologic image details, such as geometry and fluid flow. Taken together, the benefits provided by implementing AI in radiology have the potential to improve workflow efficiency, engender faster turnaround results for complex cases, and reduce heavy workloads. Although analysis of AI applications within abdominopelvic imaging has primarily focused on oncologic detection, localization, and treatment response, several promising algorithms have been developed for use in the emergency setting. This article aims to establish a general understanding of the AI algorithms used in emergent image-based tasks and to discuss the challenges associated with the implementation of AI into the clinical workflow.
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Li PH, Hsu TA, Kuo YC, Fu CY, Bajani F, Bokhari M, Mis J, Poulakidas S, Bokhari F. The application of the WSES classification system for open pelvic fractures-validation and supplement from a nationwide data bank. World J Emerg Surg 2022; 17:29. [PMID: 35624457 PMCID: PMC9145531 DOI: 10.1186/s13017-022-00434-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Open pelvic fractures are rare but complex injuries. Concomitant external and internal hemorrhage and wound infection-related sepsis result in a high mortality rate and treatment challenges. Here, we validated the World Society Emergency Society (WSES) classification system for pelvic injuries in open pelvic fractures, which are quite different from closed fractures, using the National Trauma Data Bank (NTDB). Methods Open pelvic fracture patients in the NTDB 2015 dataset were retrospectively queried. The mortality rates associated with WSES minor, moderate and severe injuries were compared. A multivariate logistic regression model (MLR) was used to evaluate independent factors of mortality. Patients with and without sepsis were compared. The performance of the WSES classification in the prediction of mortality was evaluated by determining the discrimination and calibration. Results A total of 830 open pelvic fracture patients were studied. The mortality rates of the mild, moderate and severe WSES classes were 3.5%, 11.2% and 23.8%, respectively (p < 0.001). The MLR analysis showed that the presence of sepsis was an independent factor of mortality (odds of mortality 9.740, p < 0.001). Compared with patients without sepsis, those with sepsis had significantly higher mortality rates in all WSES classes (minor: 40.0% vs. 3.1%, p < 0.001; moderate: 50.0% vs. 9.1%, p < 0.001; severe: 66.7% vs. 22.2%, p < 0.001). The receiver operating characteristic (ROC) curve showed an acceptable discrimination of the WSES classification alone for evaluating the mortality of open pelvic fracture patients [area under curve (AUC) = 0.717]. Improved discrimination with an increased AUC was observed using the WSES classification plus sepsis (AUC = 0.767). Conclusions The WSES guidelines can be applied to evaluate patients with open pelvic fracture with accurate evaluation of outcomes. The presence of sepsis is recommended as a supplement to the WSES classification for open pelvic fractures.
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Affiliation(s)
- Pei-Hua Li
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Ting-An Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Yu-Chi Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan. .,Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA.
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Marissa Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Justin Mis
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Stathis Poulakidas
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Faran Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
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Does the accuracy of prehospital pelvic binder placement affect cardiovascular physiological parameters during rescue? A clinical study in patients with pelvic ring injuries. OTA Int 2022; 5:e186. [PMID: 35949268 PMCID: PMC9359013 DOI: 10.1097/oi9.0000000000000186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/18/2021] [Indexed: 11/25/2022]
Abstract
Introduction: Methods: Results: Conclusion: Level of Evidence:
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Administration of Venous Thromboembolism Chemoprophylaxis Within 12 Hours of Pelvic and Acetabular Surgery Has No Effect on Estimated Blood Loss, Perioperative Change in Hemoglobin, or Need for Transfusion. J Orthop Trauma 2022; 36:167-171. [PMID: 34483319 DOI: 10.1097/bot.0000000000002255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine if preoperative administration of venous thromboembolism (VTE) chemoprophylaxis (PPx) before pelvic and acetabular fracture surgery affects estimated blood loss (EBL), perioperative change in hemoglobin (ΔHgb), or transfusion rates. DESIGN Retrospective cohort study. SETTING Level 1 trauma center, southeastern United States. PATIENTS/PARTICIPANTS All pelvic and acetabular surgeries performed between April 2014 and February 2020. MAIN OUTCOME MEASUREMENTS EBL, immediate and 24-hour postoperative ΔHgb, and intraoperative/postoperative transfusion. RESULTS In all, 267 surgeries were included: 97 prechange and 170 postchange. Median injury severity score was 17 before versus 14 after the change. One surgeon retired and two started during the study, producing differences in acetabular approaches. Median surgical duration was longer postchange. Cohorts were otherwise similar. No differences were observed in EBL, ΔHgb, or transfusion rates. Rates of VTE and surgical site complications were unchanged. No VTE-related deaths occurred. In the as-treated analysis (63 patients given low-molecular-weight heparin <12 hours preoperatively vs. 190 patients not given PPx), no differences were observed. CONCLUSIONS Administration of VTE PPx within 12 hours of pelvic and acetabular surgery had no effect on perioperative blood loss. This study is limited by changes in faculty, but it suggests that traumatologists need not advocate for holding VTE PPx before pelvic and acetabular trauma surgery. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Kaneko T, Yanagida K, Matsui K, Kimura M, Kawai T, Yamada Y, Ishii K, Kurozumi T, Suzuki T, Watanabe Y, Kawano H, Sakamoto T, Nakagawa T. Incidence of genitourinary injuries in pelvic fractures: A 12-year single-center retrospective study. Neurourol Urodyn 2022; 41:1025-1030. [PMID: 35325489 DOI: 10.1002/nau.24919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This study aimed to determine the epidemiology of genitourinary injuries in pelvic fractures and elucidate the clinical outcomes of patients with pelvic fractures with and without genitourinary injuries at a tertiary trauma center in Japan. METHODS Patients with pelvic fractures in our tertiary trauma center between May 2009 and April 2021 were retrospectively assessed. The patients' demographics, mechanism of injury, and hospital course details were collected. The outcomes of patients with pelvic fractures with and without genitourinary injuries were compared. RESULTS Of 402 patients with pelvic fractures, 18 (4.5%) had genitourinary injuries. Falls were the most common mechanisms of injury for all pelvic fractures The incidence of bladder, kidney, urethral, and testis injuries were 2.0%, 1.2%, 1.2%, and 0.5%, respectively. Patients with genitourinary injuries were significantly younger (median age, 26 vs. 51 years; p < 0.001), had a higher rate of intensive care unit admission (94% vs. 58%; p = 0.002), remained hospitalized longer (median duration, 82 vs. 45 days; p < 0.001), and had a longer intensive care unit stay (median duration, 6 vs. 2 days; p < 0.001) when compared to patients without genitourinary injuries. Genitourinary injuries were not associated with in-hospital mortality. CONCLUSIONS The incidence of genitourinary injuries with pelvic fractures was 4.5%. The presence of genitourinary injuries was associated with a higher rate of intensive care unit admission, longer hospital stay, and longer intensive care unit stay, but it was not associated with in-hospital mortality.
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Affiliation(s)
- Tomoyuki Kaneko
- Department of Urology, Teikyo University School of Medicine, Tokyo, Japan
| | - Kazuki Yanagida
- Department of Urology, Teikyo University School of Medicine, Tokyo, Japan
| | - Kentaro Matsui
- Department of Orthopedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Masaki Kimura
- Department of Urology, Teikyo University School of Medicine, Tokyo, Japan
| | - Taketo Kawai
- Department of Urology, Teikyo University School of Medicine, Tokyo, Japan
| | - Yukio Yamada
- Department of Urology, Teikyo University School of Medicine, Tokyo, Japan
| | - Keisuke Ishii
- Department of Orthopedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Taketo Kurozumi
- Department of Orthopedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takashi Suzuki
- Department of Orthopedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshinobu Watanabe
- Department of Orthopedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Hirotaka Kawano
- Department of Orthopedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Tohru Nakagawa
- Department of Urology, Teikyo University School of Medicine, Tokyo, Japan
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Complications after surgical treatment of pelvic fractures: a five-year follow-up of 194 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:877-882. [PMID: 35142922 PMCID: PMC10125928 DOI: 10.1007/s00590-022-03215-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Surgical treatment of pelvic fractures is an advanced intervention associated with multiple complications. The primary aim of this study was to investigate the rate of unplanned reoperations after pelvic fracture surgery. Secondary aims included occurrence of other adverse events and mortality. METHODS All adult patients ≥ 18 years with surgically treated pelvic fracture operated at the Karolinska University Hospital in Sweden between 2010 and 2019 were identified and retrospectively included. Data were collected through review of medical records and radiographs. Logistic regression analysis was performed to evaluate factors associated with unplanned reoperations and other adverse events. RESULTS A total of 194 patients were included with mean age (± SD, range) 45.4 (16, 18-83) years. 62% were males (n = 121) and the median (IQR) follow-up time was 1890 (1791) days (4.9 years). Forty-eight patients (25%) had an unplanned reoperation, with infection being the most common cause of reoperation (n = 18, 9.3%). Seventy-eight (40%) patients had an adverse event not requiring reoperation and the most common event was nerve injury (n = 34, 18%). Concomitant abdominal injury was identified as a risk factor for an adverse event (OR 2.5, 95% CI 1.3-4.9, p < 0.01). 30-day mortality was 1.5% and 1-year mortality 6.2%. CONCLUSION The rate of unplanned reoperation after pelvic fracture surgery was high, as was the rate of other adverse events not requiring surgery. No identified risk factor was found to predict further surgery, but concomitant abdominal injury was a risk factor for other adverse events. Mortality was low at both 30 days and 1 year.
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Marchand LS, Sepehri A, Hannan ZD, Zaidi R, DuBose JJ, Morrison JJ, O'Toole RV, Slobogean GM. Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamically Unstable Patients With Pelvic Ring Injuries. J Orthop Trauma 2022; 36:74. [PMID: 34050079 DOI: 10.1097/bot.0000000000002191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the outcomes of patients with pelvic ring injuries managed with resuscitative endovascular balloon occlusion of the aorta (REBOA). DESIGN Retrospective case series. SETTING Academic, Level 1 trauma center in North America. PATIENTS Twenty-five patients with disruption of the pelvic ring and hemodynamic instability. INTERVENTION Placement of a REBOA device as an adjuvant treatment to trauma resuscitation. MAIN OUTCOME MEASURE Death and ischemic-related complications. RESULTS The average age of patients was 43 years (range: 17-85). Patients presented with a median lactate of 6.3 mmol/L, systolic blood pressure of 116 mm Hg, heart rate of 121 beats/minute, and injury severity score of 34. The median unit of packed red blood cells received through transfusion in the first 24 hours of hospital admission was 13 (interquartile range: 8-28). Young-Burgess injury patterns included fractures of the following types: 5 lateral compression (LC)-1, 1 LC-2, 8 LC-3, 4 anteroposterior compression-2, and 7 anteroposterior compression-3. Angiography and embolization were performed in 24 (96%) patients. Selective embolization occurred in 18 (72%) patients, with nonselective angiography of the iliac system occurring in 7 (24%) patients. There were 12 (48%) deaths, 7 (28%) patients requiring lower extremity fasciotomy, and 5 (20%) patients requiring lower extremity amputations, and there was 1 (4%) patient requiring thrombectomy. CONCLUSIONS REBOA use in pelvic ring injuries is rare and most frequently used in critically ill patients with polytrauma. Successful pelvic embolization can occur in concert with REBOA use; however, the severity of injury is associated with a high complication profile. In this series of 25 patients, in-hospital mortality was 48%. For those patients who survived, 54% experienced a major complication (fasciotomy, amputation, and deep infection). Further investigation is required to evaluate the role REBOA may play in managing these patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S Marchand
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Aresh Sepehri
- University of British Columbia, Vancouver, BC, Canada
| | - Zachary D Hannan
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Raza Zaidi
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Joseph J DuBose
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Jonathan J Morrison
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Gerard M Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
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Marchand LS, Sepehri A, Hannan ZD, Zaidi SM, Bangura AT, Morrison JJ, Manson TT, Slobogean GP, O’Hara NN, O’Toole RV. Pelvic Ring Injury Mortality: Are We Getting Better? J Orthop Trauma 2022; 36:81-86. [PMID: 34128497 PMCID: PMC8669037 DOI: 10.1097/bot.0000000000002210] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS/PARTICIPANTS A total of 3314 patients with pelvic ring injuries who presented to a single referral center from 1999 to 2018 were included in the study. INTERVENTION Pelvic ring management, years 1999-2006 versus years 2007-2018. MAIN OUTCOME MEASUREMENTS In hospital mortality. Other examined variables included change in patient demographics, fracture characteristics, date of injury, associated injuries, length of hospital stay, Abbreviated Injury Severity Score. RESULTS The composite mortality rate was 6.5% (214/3314). The earliest cohort presented a mortality rate of 9.1% [111/1224; 95% confidence interval (CI), 7.6%-10.8%] compared with the more recent cohort mortality rate of 4.9% (103/2090; 95% CI, 4.1%-5.9%). Overall mortality was significantly lower in the more recent period, a risk difference of 4.1% (95% CI, 2.3%-6.1%; P < 0.01). After adjusting for age and Abbreviated Injury Severity Score of the brain, chest, and abdomen, the mortality reduction was more pronounced with an adjusted risk difference of 6.4% (95% CI, 4.7%-8.1%; P < 0.01). CONCLUSION Significant improvement in the mortality rate of pelvic ring injuries has been demonstrated in recent years (4.9% vs. 9.1%) and the difference is even large when accounting for known confounders. Improvement appears to coincide chronologically with changes in trauma resuscitation and implementation of adjuvant treatments for managing patients with severe hemorrhagic shock. Although the exact benefit of each treatment awaits further research, these data might indicate improved care over time for these difficult patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S. Marchand
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aresh Sepehri
- University of British Columbia, Department of Orthopaedic Surgery, Vancouver, BC, Canada
| | - Zachary D. Hannan
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Syed M.R. Zaidi
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abdulai T. Bangura
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan J. Morrison
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Theodore T. Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathan N. O’Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert V. O’Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
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Thromboelastography is predictive of mortality, blood transfusions, and blood loss in patients with traumatic pelvic fractures: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:345-350. [PMID: 33175987 PMCID: PMC8371986 DOI: 10.1007/s00068-020-01533-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/17/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE In patients with traumatic pelvic fractures, thromboelastography (TEG) is a useful tool to rapidly evaluate and identify coagulation disturbances. The purpose of this study was to examine the coagulation kinetics of patients with traumatic pelvic fractures (pelvic ring and/or acetabulum) by analyzing the TEG results at initial presentation and its relationship with mortality and blood loss. METHODS A retrospective review at our Level-1 trauma center was conducted to identify Full Trauma Team activations (FTTa) with traumatic pelvic and/or acetabular fractures who were evaluated with a TEG on initial presentation between 2012 and 2016. In-hospital mortality, product transfusion, and hemoglobin changes were analyzed. Subgroup analysis was performed based on pelvic fracture type. RESULTS 141 patients with a mean age of 49.0 ± 20.8 years and mean Injury Severity Score (ISS) of 25.18 ± 12.8 met inclusion criteria. PRBC transfusion occurred in 78.0% of patients; a total of 1486 blood products were transfused. A total of 65 patients (46.1%) underwent operative treatment for the pelvic injuries, and 18 patients (12.7%) required embolization. The overall in-hospital mortality rate was 14.9%. The degree of clot lysis at 30 min (LY30) was significantly associated with blood loss (p < 0.0001), units of packed red blood cells (PRBCs) transfused (p < 0.0001), and mortality rate (p = 0.0002). CONCLUSION Increased fibrinolysis evidenced by an elevated LY30 on initial TEG in patients with traumatic pelvic fractures is associated with increased blood loss, blood product transfusions, and mortality. Future studies should evaluate the clinical utility of reversing hyperfibrinolysis on initial TEG. LEVEL OF EVIDENCE Prognostic level III.
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Revisiting Role of Bilateral Ligation of Internal Iliac Arteries and Preperitoneal Pelvic Packing for Hemorrhage Control in Patients with Pelvic Injuries in Resource Constraint Settings. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03210-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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46
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Effects of Loading Conditions on the Pelvic Fracture Biomechanism and Discrimination of Forensic Injury Manners of Impact and Run-Over Using the Finite Element Pelvic Model. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12020604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to systematically simulate the responses of pelvic fracture under impact and run-over to clarify the effects of boundary and loading conditions on the pelvic fracture mechanism and provide complementary quantitative evidence for forensic practice. Based on the THUMS finite element model, we have validated the simulation performance of the model by a real postmortem human pelvis side impact experiment. A total of 54 simulations with two injury manners (impact and run-over), seven loading directions (0°, 30°, 60°, 90°, 270°, 300°, 330°), and six loading velocities (10, 20, 30, 40, 50, and 60 km/h) were conducted. Criteria of effective strain, Von-Mises stress, contact force, and self-designed normalized eccentricity were used to evaluate the biomechanism of pelvic fracture. Based on our simulation results, it’s challenging to distinguish impact from run-over only rely on certain characteristic fractures. Loads on the front and back were less likely to cause pelvic fractures. In the 30°, 60°, 300° load directions, the overall deformation caused a “diagonal” pelvic fracture. The higher is the velocity (kinetic energy), the more severe is the pelvic fracture. The contact force will predict the risk of fracture. In addition, our self-designed eccentricity will distinguish the injury manner of impact and run-over under the 90° loads. The “biomechanical fingerprints” based on logistic regression of all biomechanical variables have an AUC of 0.941 in discriminating the injury manners. Our study may provide simulation evidence and new methods for the forensic community to improve the forensic identification ability of injury manners.
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47
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O'Donovan S, van den Heuvel C, Baldock M, Byard RW. Causes of fatalities in motor vehicle occupants: an overview. Forensic Sci Med Pathol 2022; 18:511-515. [PMID: 35881221 PMCID: PMC9636288 DOI: 10.1007/s12024-022-00503-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 12/14/2022]
Abstract
Injuries from motor vehicle collisions are frequently encountered in routine forensic practice. While the most common lethal events involve blunt force trauma with injuries to the head and neck, chest, abdomen, pelvis and limbs, review of the literature and case files shows that a wide variety of other fatal situations can occur that may involve sharp force and penetrating trauma, incineration, drowning, asphyxia, organic diseases and combinations of these. The following overview details potential factors that may contribute to death following vehicle crashes.
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Affiliation(s)
- Siobhan O'Donovan
- School of Biomedicine, The University of Adelaide, Level 2 Helen Mayo North Building, Frome Road, Adelaide, SA, 5005, Australia
- Forensic Science SA, Adelaide, Australia
| | - Corinna van den Heuvel
- School of Biomedicine, The University of Adelaide, Level 2 Helen Mayo North Building, Frome Road, Adelaide, SA, 5005, Australia
- The University of Adelaide, Adelaide, South Australia, Australia
| | | | - Roger W Byard
- School of Biomedicine, The University of Adelaide, Level 2 Helen Mayo North Building, Frome Road, Adelaide, SA, 5005, Australia.
- Forensic Science SA, Adelaide, Australia.
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48
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Taylor NA, Smith AA, Marr A, Stuke L, Greiffenstein P, Schoen J, Brown T, Chapman B, Hunt JP. Does Time to Pelvic Fixation Influence Outcomes in Trauma Patients? Am Surg 2021; 88:840-845. [PMID: 34797191 DOI: 10.1177/00031348211056266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pelvic fractures cause significant morbidity in the trauma population. Many factors influence time to fracture fixation. No previous study has determined the optimal time window for pelvic fixation. METHODS A retrospective review of trauma patients with pelvic fractures from 2016 to 2020 was performed. Patients were stratified into EARLY and LATE groups, by time to fixation within 3 days or greater than 3 days whether from admission or from completion of a life-saving procedure. Unpaired Student's t-test and Fisher's exact test were performed with multiple linear regression for variables with P < .2 on univariate analysis. RESULTS 287 patients were identified with a median fixation time of 3 days. There was no significant difference in demographics, incidence of preceding life-saving procedure, angioembolization, or mechanism of injury in the 2 groups (P > .05). Length of stay in the EARLY group was significantly reduced at 11.9 +/- .7 days compared to 18.0 +/-1.2 days in the LATE group (P < .001). There was no significant difference in rates of ventilator-associated pneumonia, deep vein thrombosis, pulmonary embolism (PE), acute kidney injury (AKI), pressure ulcer, or acute respiratory distress syndrome (ARDS) (P > .05). There were significantly more SSIs (surgical site infections) in the LATE group. After multiple linear regression adjusting for covariates of age and ISS, the difference in hospital LOS was 5.5 days (95% CI -8.0 to -3.1, P < .001). DISCUSSION Fixation of traumatic pelvic fractures within 3 days reduced LOS. Prospective multi-center studies will help identify additional factors to decrease time to surgery and improve patient outcomes.
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Affiliation(s)
- Nicholas A Taylor
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Alison A Smith
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Alan Marr
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Lance Stuke
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Patrick Greiffenstein
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Jonathan Schoen
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Tommy Brown
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Brett Chapman
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - John P Hunt
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
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49
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Dreizin D, Rosales R, Li G, Syed H, Chen R. Volumetric Markers of Body Composition May Improve Personalized Prediction of Major Arterial Bleeding After Pelvic Fracture: A Secondary Analysis of the Baltimore CT Prediction Model Cohort. Can Assoc Radiol J 2021; 72:854-861. [PMID: 32910695 PMCID: PMC8011455 DOI: 10.1177/0846537120952508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
METHODS This work is a retrospective secondary analysis of a single institution cohort used in the development of the Baltimore CT prediction model. The cohort includes 115 consecutive patients that underwent admission contrast-enhanced CT of the abdomen and pelvis for blunt trauma with pelvic ring disruption followed by conventional angiography. Major arterial injury requiring angioembolization served as the outcome variable. Angioembolization was required in 73/115 patients (63% of the cohort). Average age was 46.9 years (±SD 20.4). Body composition measurements were determined as 2-dimensional (2D) or 3-dimensional (3D) parameters and included mid-L3 trabecular bone attenuation, abdominal visceral fat area or volume, and percent muscle fat fraction (as a marker of sarcopenia) measured using segmentation and histogram analysis. RESULTS Models incorporating 2D (Model B) or 3D markers (model C) of body composition showed improvement over the original Baltimore model (model A) in all parameters of performance, quality, and fit (area under the receiver-operating curve [AUC], Akaike information criterion, Brier score, Hosmer-Lemeshow test, and adjusted-R2). Area under the receiver-operating curve increased from 0.83 (A), to 0.86 (B), and 0.88 (C). The greatest improvement was seen with 3D parameters. CONCLUSION Once automated, quantitative visualization tools providing "free" 3D body composition information can be expected to improve personalized precision diagnostics, outcome prediction, and decision support in patients with bleeding pelvic fractures.
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Affiliation(s)
- David Dreizin
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Remberto Rosales
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hassan Syed
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rong Chen
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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DuBose JJ, Burlew CC, Joseph B, Keville M, Harfouche M, Morrison J, Fox CJ, Mooney J, O'Toole R, Slobogean G, Marchand LS, Demetriades D, Werner NL, Benjamin E, Costantini T. Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control. J Trauma Acute Care Surg 2021; 91:e93-e103. [PMID: 34238857 DOI: 10.1097/ta.0000000000003331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Major pelvic hemorrhage remains a considerable challenge of modern trauma care associated with mortality in over a third of patients. Efforts to improve outcomes demand continued research into the optimal employment of both traditional and newer hemostatic adjuncts across the full spectrum of emergent care environments. The purpose of this review is to provide a concise description of the rationale for and effective use of currently available adjuncts for the control of pelvic hemorrhage. In addition, the challenges of defining the optimal order and algorithm for employment of these adjuncts will be outlined. LEVEL OF EVIDENCE Review, level IV.
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Affiliation(s)
- Joseph J DuBose
- From the R Adams Cowley Shock Trauma Center (J.J.D., M.K., M.H., J.M., C.J.F., R.O., G.S.), University of Maryland Medical System, Baltimore, Maryland; Department of Surgery (C.C.B., N.L.W.), Denver Health Medical Center, Denver, Colorado; Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery (B.J.), College of Medicine, University of Arizona, Tucson, Arizona; Baylor University Medical Center (J.M.), Dallas, Texas; Department of Orthopedic Surgery (L.S.M.), University of Utah, Salt Lake City, Utah; Division of Trauma and Surgical Critical Care (D.D., E.B.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; Trauma/Surgical Critical Care (T.C.), Grady Memorial Hospital/Emory University School of Medicine, Atlanta, Georgia; and Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (T.C.), University of California San Diego School of Medicine, San Diego, California
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