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Stahel PF, Ziran N. The pathophysiology of pelvic ring injuries: a review. Patient Saf Surg 2024; 18:16. [PMID: 38741186 DOI: 10.1186/s13037-024-00396-x] [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: 02/16/2024] [Accepted: 04/04/2024] [Indexed: 05/16/2024] Open
Abstract
Traumatic pelvic ring injuries continue to represent a major challenge due to the high rates of post-injury mortality of around 30-40% in the peer-reviewed literature. The main root cause of potentially preventable mortality relates to the delayed recognition of the extent of retroperitoneal hemorrhage and post-injury coagulopathy. The understanding of the underlying pathophysiology of pelvic trauma is predicated by classification systems for grading of injury mechanism and risk stratification for developing post-injury coagulopathy with subsequent uncontrolled exsanguinating hemorrhage. This review article elaborates on the current understanding of the pathophysiology of severe pelvic trauma with a focus on the underlying mechanisms of retroperitoneal bleeding and associated adverse outcomes.
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Affiliation(s)
- Philip F Stahel
- Department of Surgery, East Carolina University, Brody School of Medicine, 27834, Greenville, NC, USA.
- Rocky Vista University, College of Osteopathic Medicine, 80134, Parker, CO, USA.
- Mission Health, HCA Healthcare, North Carolina Division, 28803, Asheville, NC, USA.
| | - Navid Ziran
- St. Joseph's Hospital and Medical Center, 85020, Phoenix, AZ, USA
- North Bay Medical Center, 94534, Fairfield, CA, USA
- Satori Orthopaedics, Inc, 85020, Phoenix, AZ, USA
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Caterson AD, Olthof DC, Abel C, Balogh ZJ. The morphology of ligamentous sacroiliac lesions - challenge to the antero-posterior compression mechanism. Injury 2021; 52:941-945. [PMID: 33250185 DOI: 10.1016/j.injury.2020.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 10/25/2020] [Accepted: 11/12/2020] [Indexed: 02/02/2023]
Abstract
AIM This paper evaluates computer tomographic morphology of partial ligamentous lesions of the sacroiliac joint. We hypothesised that in antero-posterior compression (APC) injuries the anterior superior portion of the sacroiliac joint (SIJ) should open up the most as suggested by the vector forces outlined in the Young and Burgess classification. METHODS All patients who underwent operative fixation of a ligamentous APC pelvic injury between July 2009 and December 2015 in a single Level-1 trauma centre were included. Patients were case matched (1:1) to controls without pelvic injury. SIJ width was measured by two independent reviewers at the anterior superior and anterior inferior part of the SIJ. Wilcoxon ranged test was applied for analysis. RESULTS 70 patients (35 cases, 35 controls) were evaluated. Median inferior and superior SI joint widths were 5.27 (IQR 3.68-7.80) and 4.05 (IQR 3.13-5.31) mm in cases versus 2.24 (IQR 1.83-2.50) and 2.44 (IQR 2.14-2.65) mm in controls, respectively. The difference between the inferior and superior SI width in cases was larger than in controls (p-value < 0.01, median of -0.22 mm in the control group versus 1.51 mm in the cases). CONCLUSION Our data suggests that the inferior part of the SIJ opens up after injury more, relative to its superior portion. The vector of the force involved in rotationally unstable pelvic injuries is unlikely to be antero-posterior if the force causes the SI joint to widen up inferiorly first. This should be considered in SIJ fixation and challenges the APC mechanism in pure ligamentous rotationally unstable pelvic ring injuries.
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Affiliation(s)
- A D Caterson
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Lookout Rd, New Lambton Heights NSW, 2305, Australia
| | - D C Olthof
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Lookout Rd, New Lambton Heights NSW, 2305, Australia
| | - C Abel
- Department of Radiology, John Hunter Hospital, Lookout Rd, New Lambton Heights NSW, 2305, Australia
| | - Z J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Lookout Rd, New Lambton Heights NSW, 2305, Australia.
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Fadl SA, Sandstrom CK. Pattern Recognition: A Mechanism-based Approach to Injury Detection after Motor Vehicle Collisions. Radiographics 2019; 39:857-876. [PMID: 31059399 DOI: 10.1148/rg.2019180063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Motor vehicle collisions cause substantial mortality, morbidity, and expense worldwide. Certain types of injuries are more likely to result from frontal versus side-impact collisions, and knowledge of these specific patterns and why they occur aids in accurate and efficient diagnosis of traumatic injuries. Although the proper use of seat belts decreases crash-related mortality during frontal impact, certain injury patterns to the torso are directly attributed to restraint use. The spectrum of seat belt-related injuries ranges from mild skin and soft-tissue contusions to traumatic bowel injuries and unstable spine injuries that require surgery. Impact with the steering wheel or windshield during a frontal crash can cause characteristic injuries to the head, neck, torso, and distal upper extremity. Steering wheel deformity is an independent predictor of serious thoracic and abdominal injury among front-seat passengers. Impact of a flexed knee with the dashboard during a frontal collision can cause knee, thigh, and hip injuries. Distal lower extremity injuries are encountered frequently when the floorboard is driven into the foot. Lateral impact crashes often result in traumatic brain, thoracic, abdominal, and pelvic injuries, which are more often fatal to occupants on the side of the impact. The specific mechanism-based injury patterns are reviewed to establish a structured systematic search pattern that enables the radiologist to identify traumatic injuries with greater accuracy and speed, thereby improving the care of patients who experience acute trauma. ©RSNA, 2019 See discussion on this article by Ballard and Mellnick .
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Affiliation(s)
- Shaimaa A Fadl
- From the Department of Radiology, University of Washington Medical Center, Box 359728, 325 Ninth Ave, Harborview Medical Center, Seattle, WA 98104-2499
| | - Claire K Sandstrom
- From the Department of Radiology, University of Washington Medical Center, Box 359728, 325 Ninth Ave, Harborview Medical Center, Seattle, WA 98104-2499
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Ballard DH, Mellnick VM. Invited Commentary on “Pattern Recognition: A Mechanism-based Approach to Injury Detection after Motor Vehicle Collisions”. Radiographics 2019; 39:876-878. [DOI: 10.1148/rg.2019180212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- David H. Ballard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine St Louis, Missouri
| | - Vincent M. Mellnick
- Mallinckrodt Institute of Radiology, Washington University School of Medicine St Louis, Missouri
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Shi C, Cai L, Hu W, Sun J. Study of the X-Ray Diagnosis of Unstable Pelvic Fracture Displacements in Three-Dimensional Space and its Application in Closed Reduction. J INVEST SURG 2017; 32:18-26. [PMID: 28925750 DOI: 10.1080/08941939.2017.1370518] [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: 10/18/2022]
Abstract
ABSTRACTS Objective: To study the method of X-ray diagnosis of unstable pelvic fractures displaced in three-dimensional (3D) space and its clinical application in closed reduction. METHODS Five models of hemipelvic displacement were made in an adult pelvic specimen. Anteroposterior radiographs of the pelvis were analyzed in PACS. The method of X-ray diagnosis was applied in closed reductions. From February 2012 to June 2016, 23 patients (15 men, 8 women; mean age, 43.4 years) with unstable pelvic fractures were included. All patients were treated by closed reduction and percutaneous cannulate screw fixation of the pelvic ring. According to Tile's classification, the patients were classified into type B1 in 7 cases, B2 in 3, B3 in 3, C1 in 5, C2 in 3, and C3 in 2. The operation time and intraoperative blood loss were recorded. Postoperative images were evaluated by Matta radiographic standards. RESULTS Five models of displacement were made successfully. The X-ray features of the models were analyzed. For clinical patients, the average operation time was 44.8 min (range, 20-90 min) and the average intraoperative blood loss was 35.7 (range, 20-100) mL. According to the Matta standards, 7 cases were excellent, 12 cases were good, and 4 were fair. CONCLUSIONS The displacements in 3D space of unstable pelvic fractures can be diagnosed rapidly by X-ray analysis to guide closed reduction, with a satisfactory clinical outcome.
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Affiliation(s)
- Chengdi Shi
- a Orthopaedic Department , The First Affiliated Hospital of Soochow University , Suzhou , Jiangsu , P.R. China
| | - Leyi Cai
- b Department of Orthopaedics Surgery , The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University , Luheng District, Wenzhou , Zhejiang Province , P.R. China
| | - Wei Hu
- b Department of Orthopaedics Surgery , The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University , Luheng District, Wenzhou , Zhejiang Province , P.R. China
| | - Junying Sun
- a Orthopaedic Department , The First Affiliated Hospital of Soochow University , Suzhou , Jiangsu , P.R. China
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Sandstrom CK, Gross JA, Linnau KF. Imaging of Pelvic Ring and Acetabular Trauma. Semin Roentgenol 2016; 51:256-67. [DOI: 10.1053/j.ro.2016.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
INTRODUCTION This survey was conducted during the 38(th) Brazilian Congress of Orthopaedics and Traumatology to identify the opinion of Brazilian orthopaedic surgeons on the standard treatment of pelvic fractures. MATERIALS AND METHODS Participants were randomly selected and invited to voluntarily answer a questionnaire of 10 multiple choice questions addressing the main aspects of the treatment of pelvic fractures: classification, fixation methods in unstable patients, optimal surgical timing in stable patients, and fixation methods in different types of anterior and posterior pelvic injuries. RESULTS/CONCLUSION Three hundred and fifty-two questionnaires were completed, and the following main observations were made: most orthopaedists prefer to use an external fixator in the iliac crest for the emergency stabilisation of pelvic injuries in haemodynamically unstable patients (79.5%); they consider a period of up to one week as optimal for fixation in stable patients (55.1%); they use a plate for the fixation of fractures of the iliopubic rami through a Pfannenstiel or ilio-inguinal approach (53.9%); and they use reconstruction plates for the fixation of fractures of the iliac wing (63.1%). Regarding other studied aspects, there was no predominance of more than 50% of the choices among respondents.
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Osterhoff G, Scheyerer MJ, Fritz Y, Bouaicha S, Wanner GA, Simmen HP, Werner CML. Comparing the predictive value of the pelvic ring injury classification systems by Tile and by Young and Burgess. Injury 2014; 45:742-7. [PMID: 24360744 DOI: 10.1016/j.injury.2013.12.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 10/21/2013] [Accepted: 12/02/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Radiology-based classifications of pelvic ring injuries and their relevance for the prognosis of morbidity and mortality are disputed in the literature. The purpose of this study was to evaluate potential differences between the pelvic ring injury classification systems by Tile and by Young and Burgess with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries. PATIENTS AND METHODS Two-hundred-and-eighty-five consecutive patients with pelvic ring fractures were analyzed for mortality within 30 days after admission, number of blood units and total volume of fluid infused during the first 24h after trauma, the Abbreviated Injury Severity (AIS) scores for head, chest, spine, abdomen and extremities as a function of the Tile and the Young-Burgess classifications. RESULTS There was no significant relationship between occurrence of death and fracture pattern but a significant relationship between fracture pattern and need for blood units/total fluid volume for Tile (p<.001/p<.001) and Young-Burgess (p<.001/p<.001). In both classifications, open book fractures were associated with more fluid requirement and more severe injuries of the abdomen, spine and extremities (p<.05). When divided into the larger subgroups "partially stable" and "unstable", unstable fractures were associated with a higher mortality rate in the Young-Burgess system (p=.036). In both classifications, patients with unstable fractures required significantly more blood transfusions (p<.001) and total fluid infusion (p<.001) and higher AIS scores. CONCLUSIONS In this first direct comparison of both classifications, we found no clinical relevant differences with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries.
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Affiliation(s)
- Georg Osterhoff
- Division of Trauma Surgery, University Hospital Zurich, Switzerland.
| | - Max J Scheyerer
- Division of Trauma Surgery, University Hospital Zurich, Switzerland
| | - Yannick Fritz
- Division of Trauma Surgery, University Hospital Zurich, Switzerland
| | - Samy Bouaicha
- Division of Trauma Surgery, University Hospital Zurich, Switzerland
| | - Guido A Wanner
- Division of Trauma Surgery, University Hospital Zurich, Switzerland
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Steinke H, Hammer N, Lingslebe U, HÖCh A, Klink T, BÖhme JÖ. Ligament-induced sacral fractures of the pelvis are possible. Clin Anat 2014; 27:770-7. [DOI: 10.1002/ca.22312] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 07/24/2013] [Accepted: 07/30/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Hanno Steinke
- Universität Leipzig, Institut für Anatomie (Institute of Anatomy); Leipzig F.R. of Germany
| | - Niels Hammer
- Universität Leipzig, Institut für Anatomie (Institute of Anatomy); Leipzig F.R. of Germany
| | - Uwe Lingslebe
- Hochschule für Technik, Wissenschaft und Kunst (HTWK), (Leipzig University of Applied Sciences, HTWK); Leipzig F.R. of Germany
| | - Andreas HÖCh
- Universität Leipzig, Klinik für Unfall- und Wiederherstellungschirurgie, (Department of Trauma and Reconstructive Surgery); Leipzig F.R. of Germany
| | - Thomas Klink
- Hochschule für Technik, Wissenschaft und Kunst (HTWK), (Leipzig University of Applied Sciences, HTWK); Leipzig F.R. of Germany
| | - JÖrg BÖhme
- Universität Leipzig, Klinik für Unfall- und Wiederherstellungschirurgie, (Department of Trauma and Reconstructive Surgery); Leipzig F.R. of Germany
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Cordts Filho RDM, Parreira JG, Perlingeiro JAG, Soldá SC, Campos TD, Assef JC. Pelvic fractures as a marker of injury severity in trauma patients. Rev Col Bras Cir 2012. [PMID: 22124641 DOI: 10.1590/s0100-69912011000500005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To assess whether the presence of a pelvic fracture is associated with greater severity and worse prognosis in victims of blunt trauma. METHODS A retrospective analysis of protocols and records of victims of blunt trauma admitted from June 2008 to March 2009 was separated into two groups: those with pelvic fracture (Group I) and those without it (Group II). Data were collected from pre-hospital admission rates of trauma, laboratory tests, diagnosed lesions, treatment and outcome. We used the Student t test, Fisher's exact test and chi-square test for statistical analysis, considering p <0.05 as significant. RESULTS During the study period, 2019 individuals had multiple trauma protocols completed, of which 43 (2.1%) had pelvic fractures. Patients in Group I had significantly lower average blood pressure, higher mean heart rate, lower mean Glasgow Coma Scale, the highest average AIS in the segments head, chest, abdomen and extremities, as well as higher mean ISS and lower mean TRISS and RTS on admission. Group I more frequently presented with traumatic subarachnoid hemorrhage (7% vs. 1.6%), spinal cord injury (9% vs. 1%), thoracic and abdominal injuries, as well as need for laparotomy (21% vs. 1 %), chest drainage (32% vs. 2%) and damage control (9% vs. 0%). Complications were more frequent in group I: ARDS (9% vs. 0%), persistent shock (30% vs. 1%), coagulopathy (23% vs. 1%), acute renal failure (21% vs. 0%) and death (28% vs. 2%). CONCLUSION The presence of a pelvic fracture is a marker of greater severity and worse prognosis in victims of blunt trauma.
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Affiliation(s)
- Roberto de Moraes Cordts Filho
- Department of Surgery, Faculdade de Ciência Médicas da Santa Casa de São Paulo, Emergency Service, Santa Casa de Misericordia de Sao Paulo
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