Definitive control of mortality from severe pelvic fracture

Assessment of fetal radiation exposure in pregnant women undergoing computed tomography and rotational angiography examinations for pelvic trauma

This study aimed to assess fetal radiation exposure in pregnant women undergoing computed tomography (CT) and rotational angiography (RA) examinations for the diagnosis of pelvic trauma. In addition, this study aimed to compare the dose distributions between the two examinations. Surface and average fetal doses were estimated during CT and RA examinations using a pregnant phantom model and real-time dosemeters. The pregnant model phantom was constructed using an anthropomorphic phantom, and a custom-made abdominal phantom was used to simulate pregnancy. The total average fetal dose received by pregnant women from both CT scans (plain, arterial and equilibrium phases) and a single RA examination was ~60 mGy. Because unnecessary repetition of radiographic examinations, such as CT or conventional 2D angiography can increase the radiation risk, the irradiation range should be limited, if necessary, to reduce overall radiation exposure.

Outcomes of supra-acetabular pin placement with and without fluoroscopic assisted: a prospective randomized controlled trial

PURPOSE

To compare outcomes of fluoroscopic-assisted supra-acetabular pin placement percutaneous technique versus the open technique in traumatic pelvic fractures.

METHODS

Prospective randomized controlled trial was performed at Maharat Nakhon ratchasima hospital from January 2020 to March 2021. Time, size of wound, and position of supra-acetabular pin were recorded intraoperatively. Pin positions were confirmed and measured by postoperative CT scan. Complications such as cortex penetration, infection, hip joint violation, and lateral thigh numbness were recorded at 2 weeks postoperatively.

RESULTS

Twenty patients (40 hemipelvis) were randomized to fluoroscopic-assisted and non-fluoroscopic groups. Time taken for supra-acetabular pin placement for fluoroscopic-assisted and non-fluoroscopic-assisted groups was 211 and 522 s, respectively (P value < 0.001). Average wound size was 2.81 cm in the fluoroscopic-assisted group and 6.01 cm in the non-fluoroscopic-assisted group (P value < 0.001). Overall complications were similar in both groups with higher infection rates in the fluoroscopic-assisted group (5 and 0%, respectively).

DISCUSSION

Pelvic fracture is a life-threatening condition, which requires emergency pelvic stabilization. This study examined operative times for supra-acetabular placement and complication rates. The results show shorter operative times for the non-fluoroscopic-assisted technique without significant differences in complication rates.

CONCLUSION

Non-fluoroscopic technique greatly reduced operative times for supra-acetabular pin placement with comparable safety to the fluoroscopic-assisted technique.

Comparison of mortality among hemorrhage-control methods performed for hemodynamically unstable patients with traumatic pelvic fractures: A multi-center study

BACKGROUND

/Objective: We aimed to analyze the effects of hemorrhage control methods on the mortality of patients with hemodynamic instability due to pelvic fracture and investigate independent mortality risk factors in these patients.

METHODS

Ninety-seven pelvic bone fracture patients with hemodynamic instability who visited the emergency departments of two university hospitals over 5 years were enrolled. These patients were categorized based on 28-day mortality (survival group) and acute hemorrhage mortality (non-survival group). Forty-seven patients (48.5%) underwent pelvic angiography; 45 (46.4%), pre-peritoneal pelvic packing; and 19 (19.6%), external fixation.

RESULTS

Differences in hemorrhage control methods did not significantly affect mortality. However, there was a significant difference in mortality between the groups with and without hemorrhage control methods. Multivariate logistic regression analysis revealed that patient age, trauma and injury severity score (probability of survival), and blood transfusion amount within 24 h were independent risk factors for 28-day mortality. Meanwhile, patient age, Glasgow coma scale (GCS) score, systolic blood pressure (SBP), and blood transfusion amount within 24 h were independent risk factors for mortality due to acute hemorrhage.

CONCLUSION

Rapid and appropriate application of hemorrhage control methods can reduce acute hemorrhage-related mortality in hemodynamically unstable patients with pelvic fractures. Moreover, none of the hemorrhage control methods were superior for the decreasing mortality rate in these patients.

Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures

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.

An Alternative Site for Pin Placement in External Fixation of Pelvic Fractures: Lateral Posterior Pelvic External Fixator Surgical Technique

Introduction: The application of an external fixator for unstable pelvic fractures is an important component of many resuscitation protocols. Moreover, certain pelvic fractures may be treated with an external fixator without requiring further internal fixation. We report our initial clinical results with an alternate pelvic external fixator site, the lateral posterior external fixator (LPEF), and describe the surgical technique.

Methods and Materials: From 2010 to 2013, we identified 27 consecutive patients (mean age 44.6 years, range 18–80 years) treated by the same surgeon (MKR) with an LPEF in a level 1 trauma center. Retrospective data collection included mechanism of injury, surgical interventions, and complications.

Results: The LPEF was used in 16 patients as acute pelvic stabilization and converted at a median of 2 days (interquartile range 1–3.5) to internal fixation, whereas in 10 patients, it was used as definitive treatment and removed at a median of 48 days (interquartile range 37–64). One patient died on day 14, secondary to his severe closed head injury. The only surgical complications were two wound infections (20%, 2/10 in the group of definitive LPEFs), which resolved without sequelae after the removal of the LPEF (at 36 and 50 days) and antibiotics, one case of loss of fixation leading to the removal of the LPEF at 71 days, and one patient who had hypergranulating external fixator sites and eventually healed without any cutaneous sequelae. All fractures consolidated in a good position.

Discussion: The described techniques of pelvic external fixation include the anterosuperior (iliac wing), supra-acetabular (anteroinferior), and subcristal (anterior superior iliac spine) insertion sites. The reported infection rates in definitive pelvic fracture treatment range from 20 to 40%. Due to the localization of the insertion sites, the lateral femoral cutaneous nerve is potentially at risk with the last two techniques. On the other hand, the LPEF insertion site is quite safe, as it is anatomically far from any nerves and the inguinal region, and allows easy access for laparotomy. The results in this series suggest that the lateral posterior pelvic external fixator technique is an alternative to previous techniques with a low risk of complications.

Impact of Chemoprophylaxis on Thromboembolism Following Operative Fixation of Pelvic Fractures

BACKGROUND

Venous thromboembolism (VTE) is a common cause of serious morbidity and mortality. While chemoprophylaxis decreases VTE, there is the theoretical risk of increased hemorrhagic complications. The purpose of this study was to evaluate the impact of preoperative anticoagulation on VTE and bleeding complications in patients with blunt pelvic fractures requiring operative fixation.

METHODS

Patients with blunt pelvic fractures requiring operative fixation over 10.5 years were identified. Patients were stratified by age, severity of shock, operative management, and timing and duration of anticoagulation. Outcomes were evaluated to determine risk factors for bleeding complications and VTE.

RESULTS

310 patients were identified: 212 patients received at least one dose of preoperative anticoagulation and 98 received no preoperative anticoagulation. 68% were male with a mean injury severity score and Glasgow Coma Scale of 26 and 13, respectively. Bleeding complications occurred in 24 patients and 21 patients suffered VTE. Patients with VTE had a greater initial severity of shock (resuscitation transfusions, 4 vs. 2 units, P = .02). Despite longer time to mobilization (4 vs. 3 days, P = .001), patients who received their scheduled preoperative doses within 48 hours of arrival had no significant differences in the number of deep vein thrombosis events (5.2% vs. 5.7%, P = .99), but fewer episodes of pulmonary embolism (PE) (1.5% vs. 6.8%, P = .03) with no difference in bleeding complications (7.5% vs. 8%, P = .87) compared to either patients who had their doses held until after 48 hours of arrival or received no preoperative anticoagulation.

DISCUSSION

Preoperative anticoagulation prior to pelvic fixation reduced the risk of PE without increasing bleeding complications. Preoperative anticoagulation is safe and beneficial in this group of patients.

Transarterial embolisation is associated with improved survival in patients with pelvic fracture: propensity score matching analyses

INTRODUCTION

Transarterial embolisation (TAE) is an effective intervention for management of arterial haemorrhage associated with pelvic fracture. However, its effects on survival and clinical outcomes are unclear.

METHODS

Trauma patients with survival data between November 2015 and December 2019 were identified using a trauma database. Patients were divided between TAE and non-TAE groups, and a propensity score was developed using multivariate logistic regression. Survival at 28 days was compared between the groups after propensity score matching.

RESULTS

Among 881 patients included in this study, 308 (35.0%) were treated with TAE. After propensity score matching, 130 pairs were selected. Survival at 28 days was significantly higher among patients treated with TAE than among those treated without TAE [122 (93.9%) vs. 112 (86.2%); odds ratio = 2.45; 95% CI 1.02-5.86; p = 0.039].

CONCLUSIONS

TAE use was associated with improved survival at 28 days in patients with pelvic fracture and should therefore be considered in the management of severely injured patients with pelvic fracture.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Prognostic, level III.

The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study

BACKGROUND

Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects.

METHODS

This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05.

RESULTS

A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%).

CONCLUSION

Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Treatment Discrepancy for Pelvic Fracture Patients With Urethral Injuries: A Survey of Orthopaedic and Urologic Surgeons

OBJECTIVES

In patients with traumatic pelvic fracture urethral injuries (PFUI), the interaction between urethral management and orthopaedic decision making remains unknown. We aimed to survey orthopaedic and urologic surgeons to assess interdisciplinary interactions in the management of PFUI.

METHODS

An anonymous cross-sectional survey of members of the Orthopaedic Trauma Association (OTA) and the Society of Genitourinary Reconstructive Surgeons (GURS) was conducted between September 2017 and August 2018. Participants were queried regarding the impact of urethral injuries and their management on orthopaedic operative decision making.

RESULTS

Fifty-three GURS and 64 OTA members responded (17% response rate). For urethral injury management, 73% of OTA respondents preferred that suprapubic tubes (SPTs) were not placed for urethral injury management, whereas 43% of GURS respondents preferred SPTs (P = 0.08). Ninety-two percent of OTA respondents stated that SPTs increase hardware infection risks in patients undergoing pelvic open reduction with internal fixation (ORIF), whereas only 8% of GURS respondents agreed (P < 0.01). Although 66% of GURS respondents reported not considering the operative plans of orthopaedics when determining urethral management, 75% of OTA respondents reported that they were less inclined to proceed with ORIF, and 70% would perform external fixation in the setting of an SPT, despite 78% believing that this resulted in an inferior outcome for the patient.

CONCLUSIONS

There is discordance between urologists and orthopaedists as to the optimal management of PFUI patients, with significant disagreement regarding the infectious risks of SPT in the setting of ORIF. Improved data and interdisciplinary dialogue are required to maximize patient outcomes.

LEVEL OF EVIDENCE

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

Levels of evidence in pelvic trauma: a bibliometric analysis of the top 50 cited papers

BACKGROUND

Scientific research is an essential aspect in the ongoing development of medical education and improved patient care. Dissemination of findings is a pivotal goal of any health research study. The number of citations that a published article receives is reflective of the importance that paper has on clinical practice. To date, it is unknown which journals are most frequently cited as influencing the management of pelvic trauma.

METHODS

The aim of this study was to identify the top 50 publications relating to the management of pelvic trauma. The database of the Science Citation Index of the Institute for Scientific Information (1945 to 2016) was reviewed to identify the 50 papers most commonly cited.

RESULTS

A total of 1535 papers were included. Of these, 31 papers were cited over 100 times with the top 50 cited 69 times or more. The top 50 were subjected to further analysis to identify the authors and institutions involved. The majority of these publications originated in the USA, followed by Canada. The most cited paper is "pelvic ring fractures-should they be fixed", published by Tile in 1988.

CONCLUSION

We have identified and analysed the publications that have contributed most to the assessment and management of pelvic trauma over the past 50 years. We have also identified the researchers and institutions which have most influenced the evidence-based approach currently employed in the management of pelvic trauma.

Angiography and Embolization in the Management of Bleeding Pelvic Fractures

The use, timing, and priority of angioembolization in the management of bleeding pelvic fractures remain ambiguous. The most common vessels for angioembolization are, in decreasing order, the internal iliac artery and its branches, the superior gluteal artery, the obturator artery, and the internal pudendal artery. Technical success rates for this treatment option range from 74% to 100%. The fracture patterns most commonly requiring angioembolization are the Young and Burgess lateral compression and anterior-posterior compression types and Tile type C. Mortality rates after angioembolization of 16% to 50% have been reported, but deaths are usually related to concomitant injuries. The sensitivity and specificity of contrast-enhanced CT in detecting the need for angioembolization range from 60% to 90% and 92% to 100%, respectively. Angioembolization can be effective in the management of bleeding pelvic fractures, but as with any treatment, the risks of complications must be considered. Availability of angioembolization and institutional expertise/preference for the alternative strategy of pelvic packing influence its use.

Predictability of successful trans-arterial embolization in pelvic fracture bleeding based on patient initial presentation

BACKGROUND

Pelvic fracture bleeding generally leads to hemorrhagic shock. Trans-arterial embolization (TAE) is regarded as the most useful treatment; however, the initial presentation of the patient can impact the effectiveness of TAE for pelvic fracture bleeding. The aim of this retrospective study is to explore whether the patient data at the initial presentation can predict the success of TAE for pelvic fracture bleeding.

METHODS

Twenty-seven charts were retrospectively reviewed. TAE failure was defined as any patient who eventually received an exigent laparotomy or who died due to uncontrolled bleeding after TAE. For patients who received TAE, we analyzed factors recorded at the initial presentation, including age, gender, systolic blood pressure, heart rate, respiratory rate, body temperature, Glasgow coma scale (GCS) score, injury severity score (ISS) and associated injuries, using Pearson's correlation and independent t-tests. The odds ratio was used to determine the cut-off values for the patient presentation findings related to successful TAE and thus was used to assess congruity.

RESULTS

Successful TAE was not correlated with age or gender. The hierarchical order of statistically significant associations between successful TAE and initial presentation data was as follows: the patient's body temperature, associated injury, respiratory rate, systolic blood pressure, GCS score, and ISS. The odds ratios for all statistically significant initial presentation factors were within a 95% confidence interval.

CONCLUSION

The findings upon initial presentation of a patient with pelvic fracture bleeding that were related to the predictability of successful TAE include the following: hypothermia prevention with maintenance of the body temperature above 36°C, associated injuries limited to two organ systems, maintenance of the respiratory rate at approximately twenty-two breaths per minute, a sustained systolic blood pressure of approximately 90mmHg, maintenance of a heart rate of approximately one hundred beats per minute, a minor head injury with a GCS score greater than thirteen and a moderate ISS of less than twenty.

[Influence of external pelvic stabilization on hemodynamically unstable pelvic fractures]

BACKGROUND

In the treatment of complex pelvic fractures hemorrhage control is of primary importance; however, studies regarding the localization of bleeding are contradictory so that various treatment approaches are recommended. The primary aim of external pelvic compression applied in the trauma room is to reduce the pelvic volume and counteract blood loss through self-induced tamponade. This study examined the influence of external pelvic compression on mortality and outcome in cases of hemodynamically unstable pelvic fractures in a larger number of cases.

MATERIAL AND METHODS

The current study used the TraumaRegister DGU® (TR-DGU) to retrospectively evaluate the records of 104 patients treated between 2002 and 2011. All patients suffered severe injury with an injury severity score (ISS) of at least 16 points. In addition, the patients were hemodynamically unstable with confirmed relevant isolated pelvic injuries. To evaluate the effectiveness of external pelvic compression, patients with and without external pelvic stabilization were compared.

RESULTS

Of the investigated patients 26.9 % died of their injuries and of these the mortality was 78.6 % within the first 6 h of admission to the trauma room. External pelvic stabilization was performed in 45.2 % of patients. The mortality was 19.1 % in patients with external pelvic stabilization and in contrast, the mortality in the group of patients without external pelvic stabilization was 33.3 %. During the course of hospitalization, surviving patients with external pelvic stabilization were significantly more likely to develop sepsis or multiple organ failure and required longer periods of intensive care.

CONCLUSION

External pelvic stabilization seems to be an important instrument for the initial treatment of hemodynamically unstable pelvic fractures and showed a positive effect on patient mortality.

Pelvic fracture pattern predicts the need for hemorrhage control intervention-Results of an AAST multi-institutional study

BACKGROUND

Early identification of patients with pelvic fractures at risk of severe bleeding requiring intervention is critical. We performed a multi-institutional study to test our hypothesis that pelvic fracture patterns predict the need for a pelvic hemorrhage control intervention.

METHODS

This prospective, observational, multicenter study enrolled patients with pelvic fracture due to blunt trauma. Inclusion criteria included shock on admission (systolic blood pressure <90 mm Hg or heart rate >120 beats/min and base deficit >5, and the ability to review pelvic imaging). Demographic data, open pelvic fracture, blood transfusion, pelvic hemorrhage control intervention (angioembolization, external fixator, pelvic packing, and/or REBOA [resuscitative balloon occlusion of the aorta]), and mortality were recorded. Pelvic fracture pattern was classified according to Young-Burgess in a blinded fashion. Predictors of pelvic hemorrhage control intervention and mortality were analyzed by univariate and multivariate regression analyses.

RESULTS

A total of 163 patients presenting in shock were enrolled from 11 Level I trauma centers. The most common pelvic fracture pattern was lateral compression I, followed by lateral compression I, and vertical shear. Of the 12 patients with an anterior-posterior compression III fracture, 10 (83%) required a pelvic hemorrhage control intervention. Factors associated with the need for pelvic fracture hemorrhage control intervention on univariate analysis included vertical shear pelvic fracture pattern, increasing age, and transfusion of blood products. Anterior-posterior compression III fracture patterns and open pelvic fracture predicted the need for pelvic hemorrhage control intervention on multivariate analysis. Overall in-hospital mortality for patients admitted in shock with pelvic fracture was 30% and did not differ based on pelvic fracture pattern on multivariate analysis.

CONCLUSION

Blunt trauma patients admitted in shock with anterior-posterior compression III fracture patterns or patients with open pelvic fracture are at greatest risk of bleeding requiring pelvic hemorrhage control intervention.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Pelvic trauma mortality reduced by integrated trauma care

OBJECTIVES

A multidisciplinary approach that emphasised improved triage, early pelvic binder application, early administration of blood and blood products, adherence to algorithmic pathways, screening with focused sonography (FAST), early computed tomography scanning with contrast angiography, angio-embolisation and early operative intervention by specialist pelvic surgeons was implemented in the last decade to improve outcomes after pelvic trauma. The manuscript evaluated the effect of this multi-faceted change over a 12-year period.

METHODS

A retrospective cohort study was conducted comparing patients presenting with serious pelvic injury in 2002 to those presenting in 2013. The primary exposure and comparator variables were the year of presentation and the primary outcome variable was mortality at hospital discharge. Potential confounders were evaluated using multivariable logistic regression analysis.

RESULTS

There were 1213 patients with a serious pelvic injury (Abbreviated Injury Scale ≥3), increasing from 51 in 2002 to 156 in 2013. Demographics, injury severity and presenting clinical characteristics were similar between the two time periods. There was a statistically significant difference in mortality from 20% in 2002 to 7.7% in 2013 (P = 0.02). The association between the primary exposure variable of being injured in 2013 and mortality remained statistically significant (adjusted odds ratio 0.10; 95% confidence interval: 0.02-0.60) when adjusted for potential clinically important confounders.

CONCLUSIONS

Multi-faceted interventions directed at the spectrum of trauma resuscitation from pre-hospital care to definitive surgical management were associated with significant reduction in mortality of patients with severe pelvic injury from 2002 to 2013. This demonstrates the effectiveness of an integrated, inclusive trauma system in achieving improved outcomes.

Strategies for the management of haemorrhage following pelvic fractures and associated trauma-induced coagulopathy

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy. This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.

Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery)

Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients.

Hemodynamically Unstable Pelvic Trauma is a frequent death cause among people who sustain blunt trauma. We present the results of the First Italian Consensus Conference.

Outcome of angiographic embolisation for unstable pelvic ring injuries: Factors predicting success

INTRODUCTION

Angiographic embolisation (AE) is a successful treatment for haemodynamically unstable pelvic ring injuries. However, recent evidence has shown a significant complication rate following AE together with a lower success rate than previously reported. The aim of the current study was to review and indentify the factors predicting success or failure of AE.

PATIENTS AND METHODS

651 patients with high energy (ISS>16) pelvic ring injuries were treated in our institution between the years 1997 and 2009. Mean patient age was 37 (range 5-89) years, and the average ISS 33.4 (range 16-66). Patients' information was collected from the institution's trauma registry as well as from the patient's medical chart and radiographs. Data included age, ISS, length of stay, ICU stay, initial blood pressure and pulse, blood products consumption, blood creatinine levels, fracture type and treatment, embolisation details, complications and mortality. 61 patients (9.3%) underwent urgent angiography due to haemodynamic instability. Angiography was positive (PA) in 38 patients (62.3%) and was negative for haemorrhage (NA) in the remaining 23 (37.7%).

RESULTS

Ten patients required a branch vessel embolisation while 17 patients required major vessel embolisation, 11 required bilateral internal iliac embolisation and three patients underwent multiple vessel embolisation. Overall mortality rate was 26%. 32 patients required surgical intervention for pelvic ring stabilisation. Significant reduction in blood transfusion was seen in patients with an APC fracture type following AE. No significant correlation was found between fracture type and mortality. Multiple vessel embolisations were associated with increased surgical complications and mortality.

DISCUSSION

Angiographic embolisation provides a reasonable option for haemodynamically unstable pelvic ring injured patients with an acceptable outcome, supporting previously reported literature. Patients with unstable APC type pelvic fracture may benefit the most from early angiographic embolisation. Patients requiring multiple vessel embolisation have a guarded outcome.

Management of bleeding and coagulopathy following major trauma: an updated European guideline

INTRODUCTION

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

RESULTS

Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

CONCLUSIONS

A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.

Does the size of the hemoperitoneum help to discriminate the bleeding source and guide therapeutic decisions in blunt trauma patients with pelvic ring fracture?

BACKGROUND

In blunt trauma patients with a hemoperitoneum and a pelvic injury, multiple sources of active bleeding may exist. The purpose of this study was to determine whether the size of the hemoperitoneum helps to establish the bleeding source and guide therapeutic decisions in patients with pelvic fractures.

METHODS

The charts of patients with pelvic fractures admitted to a trauma intensive care unit from January 2005 to December 2009 were reviewed retrospectively. The hemoperitoneum size was defined by semiquantitative analysis (minimal/none, moderate, and large) using the Federle score on computed tomographic scan or during laparotomy. Active peritoneal hemorrhages requiring immediate laparotomy were compared according to hemoperitoneum size.

RESULTS

Of 185 patients, hemoperitoneum did not occur in 116 patients, moderate in 43, and large in 26. Among 102 patients (55%) who were hypotensive (systolic blood pressure <90 mm Hg) on admission, 27 needed therapeutic laparotomy and 15 needed pelvic embolization. Laparotomy (39% vs. 2%) and pelvic embolization (22% vs. 4%) were required significantly more often in patients with hemoperitoneum (moderate or large) than those without hemoperitoneum. The positive predictive value for an active peritoneal hemorrhage derived from qualitative analysis of the hemoperitoneum (moderate or large) was 39% (4% in hypotensive patients and 40% in those requiring pelvic embolization). The corresponding values for large hemoperitoneum only (semiquantitative analysis) were 62%, 70%, and 67%, respectively.

CONCLUSION

In patients with pelvic fractures, hemoperitoneum does not mean peritoneal injury requiring hemostatic procedure. Semiquantitative analysis of the hemoperitoneum improves predictability of peritoneal hemorrhage than qualitative analysis of hemoperitoneum. However, there remains numerous false-positives even in presence of large hemoperitoneum associated with hypotension.

Use of Computed Tomography Findings and Contrast Extravasation in Predicting the Need for Embolization with Pelvic Fractures

Transarterial embolization (AE) can be a lifesaving procedure for severe hemorrhage associated with pelvic fractures. The purpose of this study was to identify demographic and radiographic findings that predict the need for embolization. We performed a retrospective review of all patients with at least one pelvic fracture and admission to the intensive care unit over a 35-month period. Computed tomography (CT) and pelvic radiographs were reviewed. Patient demographics, outcomes, time to angiography, and whether or not embolization was performed were determined. Statistical analysis was used to determine factors associated with the need for AE. Of the 327 total patients with pelvic fractures, 317 underwent CT scanning. Forty-four patients (13.5%) underwent angiography and 25 (7.6%) required therapeutic embolization. There were 39 total deaths (11.6%) with five deaths related to pelvic hemorrhage (1.5%). Multivariate analysis revealed that age older than 55 years (odds ratio [OR], 1.06; P < 0.001), systolic blood pressure less than 90 mmHg in the emergency department (OR, 11.64; P = 0.0008), and CT extravasation (OR, 147.152; P < 0.0001) were significantly associated with the need for embolization. Contrast extravasation was not present in 25 per cent of patients requiring therapeutic AE. The presence of contrast extravasation is highly associated with the need for pelvic embolization in patients with pelvic fractures, but its absence does not exclude the need for pelvic angiography.

Effects of pelvic volume changes on retroperitoneal and intra-abdominal pressure in the injured pelvic ring: a cadaveric model

BACKGROUND

Pelvic ring injuries can be associated with severe blood loss and hemodynamic instability. The increase in pelvic volume in disrupted pelvic ring injuries is thought to cause accumulation of large volumes of blood in the retroperitoneal cavity. Extra abdominal compression for reduction of the pelvic ring may affect intrapelvic pressure. We examined the effects of pelvic volume changes on retroperitoneal pressures (RPP) and intra-abdominal pressures (IAPs) in the intact and unstable pelvic ring.

METHODS

In a cadaver study, unembalmed human torsos were used. Infusion lines were placed adjacent to the sacroiliac joint in the retroperitoneum and in the abdominal cavity. IAP and RPP measurements were performed with sequential infusion of crystalloid solution in 1,000 mL increments. Measurements were performed in the intact pelvic ring and after induction of unilateral and bilateral instability by disruption of the pubic symphysis, the sacroiliac joints, the sacrotuberous ligaments, and sacrospinous ligaments.

RESULTS

After infusion of 4,000 mL of saline, we observed a pressure increase in the retroperitoneal cavity (RPP) of 19.64 mm Hg ± 6.43 mm Hg in the intact pelvis, 5.22 mm Hg ± 1.74 mm Hg in unilateral instability, and 2.78 mm Hg ± 0.57 mm Hg in bilateral instability. The RPP response in the case of instability decreased significantly (p = 0.019). The IAP showed a change of 4.63 mm Hg ± 2.64 mm Hg in the intact pelvis, 3.88 mm Hg ± 1.84 mm Hg in unilateral instability, and 2.30 mm Hg ± 0.36 mm Hg in bilateral instability. Further infusion revealed a close association between RAPs and IAPs.

CONCLUSIONS

In the intact pelvis, RPP rises rapidly with increasing volume. The results seem to support the idea that disrupted pelvic ring fractures may lead to a significant volume uptake that is reversed during reduction.

Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review

BACKGROUND

Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice.

METHODS

Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence.

RESULTS

Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing?

CONCLUSIONS

Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

The diagnostic accuracy of 64-slice computed tomography in detecting clinically significant arterial bleeding after pelvic fractures

The purpose of this study was to determine the diagnostic accuracy of the 64-slice multidetector computed tomography (MDCT) in detecting active pelvic arterial bleeding associated with blunt pelvic fractures. We hypothesized that this modality yields high accuracy. We conducted a retrospective review of all MDCT detected pelvic fractures over an 18-month period admitted to LAC+ USC Medical Center, a Level 1 trauma center. The main outcome was the presence of contrast extravasation (CE) on admission MDCT, consistent with clinically significant arterial bleeding requiring a subsequent embolization or intraoperative ligation of pelvic arteries. Overall, 127 patients met study criteria and 12 per cent (n = 15) had CE on admission MDCT of which four were managed conservatively. Eighty-two per cent (n = 9) of the remaining 11 patients who went on to have invasive procedure had active arterial bleeding that required embolization or surgical ligation. Two of the 112 (1.8%) patients without CE on their admission MDCT were subjected to embolization after further investigation with angiography as a result of the severity of their pelvic fracture and continuous transfusion requirements. The calculated sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the 64-slice MDCT to identify clinically relevant arterial bleeding were 82, 95, 60, 98, and 94 per cent, respectively. The modern 64-slice MDCT provides relatively high diagnostic accuracy in detecting a clinically relevant arterial hemorrhage after blunt pelvic fracture. Nevertheless, in patients with clinical signs of ongoing hemorrhage, timely angiography or operative intervention is warranted, even in the absence of MDCT contrast extravasation.

SPONTANEOUS RESOLUTION OF PSEUDOANEURYSM OF AN ILIAC ARTERY BRANCH IN A MULTIPLE TRAUMA PATIENT WITH PELVIC FRACTURE: CLINICAL CASE

In patients who have been the victims of high-energy trauma, severe pelvic injury should always be suspected. Most of these fractures are stable and respond well to conservative treatment. Pelvic fractures constitute 3% of all skeletal fractures and are associated with high-energy trauma. They are potentially serious injuries with significant mortality and large numbers of associated lesions. There are fundamentally three sources of bleeding in pelvic fractures: arterial, venous and through the bone ends of the fracture. Arterial bleeding is more associated with hemodynamic instability. In such cases, both early external fixation of the pelvic fracture and angiography with selective embolization of the bleeding vessels are effective methods for achieving hemostasis. Aneurysms of iliac artery branches are rare and are mostly pseudoaneurysm relating to the traumatic event. The natural history of pseudoaneurysms is unknown because of their rarity, but if they rupture, the mortality rate is high. We report a case of spontaneous thrombosis of a pseudoaneurysm of a branch of the right iliac artery.

Biomechanical aspects of pelvic ring reconstruction techniques: Evidence today

Despite the remarkable advances achieved within the boundaries of the new discipline of Pelvic surgery, pelvic ring disruptions remain challenging and complex problems in orthopaedics. The long-term complications related to reconstruction techniques of these injuries have motivated researchers and surgeons to explore various alternative treatment modalities. Several biomechanical studies have addressed these issues. We performed a medline search including studies published during the last 30 years. Our search yielded 114 studies, 39 of which met the pre-specified inclusion criteria and were further critically analysed and discussed regarding the biomechanical aspects of pelvic ring reconstruction techniques. Based on observational approach and evaluation of the studies specific keypoints are highlighted comprising the clinical translation of the biomechanical supported findings.

External fixation in pelvic fractures

Pelvic fractures account for 4-5% of all fracturated patients, and they occur in 4-5% of polytraumatized patients. In the most of the cases, they are consequent to high-energy trauma with a high percentage of lesions of other organs (cerebral, thoracic, and abdominal lesions. The most of the patients (80%) who die are dying within the first hours after trauma for a massive hemorrhagic shock. When the pelvic fracture and the patient's hemodynamic conditions are both unstable, osteosynthesis of the fracture is mandatory. Fracture stabilization should be performed within the first hour after trauma (as soon as possible), and it should be considered as part of the resuscitation procedure. We usually make an urgent stabilization of pelvic fracture with an anterior external fixator technique. We have revised all unstable pelvic fractures treated in our department (Orthopaedic Clinic Pisa University) from 2000 up to the 2005 to determine a correct treatment protocol for these lesions. Pelvic stabilization, reducing the pelvic volume and bleeding from the stumps of fracture, determines the arrest of the hemorrhage, as evidenced by the sharp decline in the number of transfusions in postoperative period. In these cases, there is an absolute indication for an urgent pelvic stabilization. Pelvic stabilization, whether temporary or permanent, allows to control the bleeding because it (1) leads to a reduction in the volume pelvis with a containment on the retro-peritoneal hematoma (2) reduces bleeding from the fracture fragments (3) reduces motility fracture promoting the blood clotting. The stabilization of the pelvis also makes it easier to manage the patient and his mobilization for the implementation of subsequent investigations. In our experience, external fixator accounts for its characteristics the gold standard approach for the urgent stabilization of these lesions, and, for most of them, it can be used as the definitive treatment. External fixation is a quick and easy procedure for pelvic fractures stabilization for surgeons with experience with this technique.

Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity

BACKGROUND

Although the benefits of acute stabilization of long bone fractures are recognized, the role of early fixation of unstable pelvis and acetabular fractures is not well-defined. The purpose of this study was to review complications and hospital course of patients treated surgically for pelvis and acetabulum fractures. We hypothesized that early definitive fixation would reduce morbidity and decrease length of stay.

METHODS

Six hundred forty-five patients were treated surgically at a level I trauma center for unstable fractures of the pelvic ring (n = 251), acetabulum (n = 359), or both (n = 40). Mean age was 40.5 years, and mean Injury Severity Score (ISS) was 25.6 (range 9-66). They were retrospectively reviewed to determine complications including acute respiratory distress syndrome (ARDS), pneumonia, deep vein thrombosis, pulmonary embolism, multiple organ failure (MOF), infections, and reperations.

RESULTS

Definitive fixation was within 24 hours of injury in 233 patients (early, mean 13.4 hours) and >24 hours in 412 (late, mean 99.2 hours). Twenty-nine patients (12.4%) had complications after early fixation versus 81 (19.7%) after late, p = 0.006. Length of stay and intensive care unit days were 10.7 days versus 11.6 days (p = 0.26) and 8.1 days versus 9.9 days (p = 0.03) for early and late groups, respectively. With ISS >18 (n = 165 early [ISS 32.7]; n = 253 late [ISS 33.1]), early fixation resulted in fewer pulmonary complications (12.7% versus 25%, p = 0.0002), less ARDS (4.8% versus 12.6%, p = 0.019), and less MOF (1.8% versus 4.3%, p = 0.40). Rates of complications, pulmonary complications, deep vein thrombosis, and MOF were no different for patients with pelvis versus acetabulum fractures. In patients receiving ≥ 10U packed red blood cells (n = 41 early, n = 56 late) early fixation led to fewer pulmonary complications (24% versus 55%, p = 0.002), less ARDS (12% versus 25%, p = 0.09), and MOF (7.3% versus 14%, p = 0.23). Two hundred ten patients had some chest injury (32.6%). Chest injury with Abbreviated Injury Scores ≥ 3 was present in 46 (19.7%) of early and 78 (18.9%) of late patients (p = 0.44) and was associated with pulmonary complications in 26.1% versus 35.9%; ARDS in 15.2% versus 23.1%; and MOF in 6.5% versus 6.4%, respectively (all p > 0.20). However, chest injury with Abbreviated Injury Scores ≥ 3 was independently associated with more complications including ARDS (20.2% versus 3.3%, p < 0.0001), other pulmonary complications (32.3% versus 10.4%, p < 0.0001), and MOF (6.5% versus 1.2%, p = 0.0016), regardless of timing of fixation.

CONCLUSIONS

Early fixation of unstable pelvis and acetabular fractures in multiply injured patients reduces morbidity and length of intensive care unit stay, which may decrease treatment costs. Further study to ascertain the effects of associated systemic injuries and the utility of physiologic and laboratory parameters during resuscitation may delineate recommendations for optimal surgical timing in specific patient groups.

Management of bleeding following major trauma: an updated European guideline

INTRODUCTION

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

RESULTS

Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

CONCLUSIONS

This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

Pelvic Fracture and Risk Factors for Mortality: A Population-Based Study in Taiwan

OBJECTIVE

To study the incidence, demographics, distribution of fracture sites, associated injuries, and risk factors for the outcomes of pelvic fracture on a population basis.

METHODS

An annual claim dataset from 2001 to 2003 was retrieved from the Bureau of National Health Insurance (BNHI) trauma database with any International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) coded as pelvic fracture. Statistical analyses were conducted to discover the association between variables such as age, gender, month of injury, injury mechanisms, associated injuries, and outcome.

RESULTS

Pelvic fracture was diagnosed in 10,109 patients (4,693 males, 46.4%) and 384 patients (3.8%) died. The incidence was 14.97/100,000 person-years. The mean length of stay was 9.3 days (females, 8.8 days; males, 9.9 days; p < 0.01) and the average cost per patient was US$1,475. Both were affected by age, gender, and hospital accreditation level and ownership. There were more female cases in the age groups over 44 years old. Head injury (excluding concussion), associated chest and abdominal injuries, open pelvic fracture, and the transfusion of more than four units of blood significantly increased the risk of mortality.

CONCLUSIONS

The incidence rate of pelvic fracture was higher in females over 44 years of age, but the average medical resource use was higher in males. Associated injuries were stronger positive factors for the risk of mortality than gender, fracture sites, injury mechanisms, and the characteristics of the treating hospitals.

Acute management of hemodynamically unstable pelvic trauma patients: time for a change? Multicenter review of recent practice

BACKGROUND

Hemorrhage-related mortality (HRM) associated with pelvic fractures continues to challenge trauma care. This study describes the management and outcome of hemodynamically unstable patients with a pelvic fracture, with emphasis on primary intervention for hemorrhage control and HRM.

METHODS

Blunt trauma patients [Injury Severity Score (ISS) >or=16] with a major pelvic fracture (Abbreviated Injury Score, pelvis >or=3) and hemodynamic instability [admission systolic blood pressure (SBP) <or=90 mmHg or receiving >or=6 units of packed red blood cells (PRBCs)/24 hours) were included into a 48-month (ending in December 2003) multicenter retrospective study of 11 major trauma centers. Data are presented as the mean +/- SD.

RESULTS

A total of 217 patients (mean age 41 +/- 19 years, 71% male, ISS 42 +/- 16) were studied. The admission SBP was 96 +/- 37 mmHg and the Glascow Coma Scale (GCS) 11 +/- 5. Patients received 4 +/- 2 liters of fluids including 4 +/- 4 units of PRBCs in the emergency room (ER). In total, 69 (32%) patients died, among whom the HRM was 19%; 29% of the deaths were due to pelvic bleeding. Altogether, 120 of the 217 (55%) patients underwent focused abdominal sonography for trauma (FAST) or diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL); 60 of the 217 (28%) patients were found to have pelvic binding in the ER. In all, 53 of 109 (49%) patients had no bleeding noted at laparotomy, 26 of 106 (25%) had no abdominal findings, and 15 of 53 (28%) had had no prior abdominal investigation (FAST/DPL/computed tomography). Angiography was positive in 48 of 58 (83%) patients. The HRM was highest in patients with laparotomy as the primary intervention (29%) followed by the angiography group (18%), the combined laparotomy/pelvic fixation group (16%), and the pelvic fixation-only group (10%).

CONCLUSION

HRM associated with major pelvic trauma is unacceptably high especially in the laparotomy group. Hence, nontherapeutic laparotomy must be avoided, concentrating instead on arresting pelvic hemorrhage. Standards of care must be implemented and abided by.

Predictors of positive angiography in pelvic fractures: a prospective study

BACKGROUND

Severe pelvic fractures continue to be a major problem for trauma surgeons. Early identification of patients who would benefit from therapeutic angiographic embolization (AE) of pelvic bleeding would be beneficial. We hope to identify simple risk factors that would pinpoint patients who would benefit from therapeutic AE.

STUDY DESIGN

This is a prospective observational study at an academic Level I trauma center. All blunt trauma patients with a pelvic fracture admitted from December 2003 to February 2007 were included. AE was performed for hemodynamic instability (systolic blood pressure < 100 mmHg), fracture pattern (sacroiliac joint [SIJ] disruption, butterfly, open book), or CT demonstrating a large pelvic hematoma. AE was considered therapeutic if contrast extravasation was noted and addressed with embolization. Main outcomes measures were positive angiography and mortality. Stepwise logistic regression was performed to identify predictors of therapeutic AE. A predictive model was built based on these independent risk factors to estimate the probability of a therapeutic AE.

RESULTS

One hundred thirty-seven (23%) of 603 patients with pelvic fractures had angiography. Therapeutic AE was performed in 85 patients (62%). Indications for angiography included hemodynamic instability (58%), fracture pattern (26%), and CT findings (9%). Nineteen patients (22%) with therapeutic AE had no hypotension or tachycardia. Independent predictors for therapeutic AE were SIJ disruption (odds ratio [OR]: 4.5; 95% CI, 1.6 to 12.6; p = 0.005), female gender (OR: 3.9; 95% CI, 1.5 to 10.0; p = 0.005), and duration (in minutes) of systolic blood pressure < 100 mmHg (OR: 1.4; 95% CI, 1.1 to 1.9; p = 0.007).

CONCLUSIONS

Presence of SIJ disruption, female gender, and duration of hypotension can reliably predict patients who would benefit from AE. This predictive model can help early identification of patients who would benefit from pelvic angiography.

Multidisciplinary approach for patients with pelvic fractures and hemodynamic instability

The hemodynamically unstable patient with a pelvic fracture presents a diagnostic and therapeutic challenge. The care of these patients requires a unique multidisciplinary approach with input and expertise from many different specialists. An understanding of pelvic anatomy and fracture patterns can help guide the diagnostic evaluation and treatment plan. The initial management of these patients must focus on rapid airway and hemorrhage control while preparing for ongoing blood loss. Rapid temporary fracture stabilization with simple bedside modalities is crucial in limiting additional blood loss. An exhaustive search must also be performed to evaluate for concomitant injuries that commonly accompany major pelvic fractures and the treatment of these other injuries must be appropriately prioritized. For patients who are unresponsive to standard resuscitation and bedside attempts at limiting hemorrhage, angiographic embolization is often utilized as the next step to attain hemodynamic stability. The key to successful management of these patients lies in the careful coordination of different specialists and the expertise that each brings to the clinical care of the patient.

Prise en charge radiologique des lésions vasculaires secondaires aux traumatismes du bassin

Pelvic injuries are serious, with mortality higher than 40% if the patient is in shock upon arrival at the hospital. These injuries are generally secondary to traffic accidents with violent kinetics, which explains the frequency of the associated extrapelvic lesions. With the vital prognosis at stake, management of these patients is a true challenge from both the radiographic and emergency care points of view. The objectives of this review are to present the epidemiological and physiological issues involved in pelvic injuries and the place of imaging today, necessarily integrated within a multidisciplinary team associating emergency physicians, surgeons, radiologists, and biologists.

Emergent pelvic fixation in patients with exsanguinating pelvic fractures

BACKGROUND

An alternative to embolization or external pelvic fixation (EPF) in patients with multiple pelvic fractures and hemorrhage is a pelvic orthotic device (POD), which may easily be placed in the resuscitation area. Little published information is available about its effectiveness. This study evaluated the efficacy of the POD compared with EPF in patients with life-threatening pelvic fractures.

STUDY DESIGN

We evaluated patients with blunt pelvic fractures over a 10-year period. Inclusion required multiple pelvic fractures with vascular disruption and severe retroperitoneal hematoma, open book fracture with symphysis diastasis, or sacroiliac disruption with vertical shear. Patients with EPF were compared with those in whom a POD was used. Outcomes included transfusions, hospital stay, and mortality.

RESULTS

There were 3,359 patients with pelvic fractures who were admitted: 186 (6%) met entry criteria; 93 had EPF and 93 had POD. There were no differences in age or shock severity. Both 24-hour (4.9 versus 17.1 U, p < 0.0001) and 48-hour transfusions (6.0 versus 18.6 U, p < 0.0001) were reduced with POD. Twenty-three percent of each group underwent pelvic angiography, and 24-hour transfusion amounts for those patients were also reduced with POD (9.9 versus 21.5 U, p < 0.007). Hospital length of stay (16.5 versus 24.4 days, p < 0.03) was less with POD. Although there was decreased mortality with POD (26%) versus EPF (37%), it was not statistically significant (p=0.11).

CONCLUSIONS

The therapeutic shift to POD has substantially reduced transfusion requirements and length of hospital stay, and has reduced mortality in patients with unstable pelvic fractures. POD has made a major contribution to the care of critically injured patients with the most severe pelvic fractures.