Young-Burgess classification of pelvic ring fractures: does it predict mortality, transfusion requirements, and non-orthopaedic injuries?

Sacroiliac Joint Ankylosis in Pelvic Ring Injuries with Posterior Ilium Fractures

Purpose

Sacroiliac joint (SIJ) changes due to ankylosis may influence the fracture pattern of the posterior ilium, an essential component of the posterior ring. This study aimed to assess the association between SIJ ankylosis and posterior ilium fractures (PL) in pelvic ring injuries.

Materials and Methods

A retrospective analysis was conducted on 272 patients diagnosed with pelvic ring injuries between January 2004 and October 2023. Patients were categorized into non-ankylosed (n=185) and ankylosed (n=87) SIJ cohorts. The prevalence of SIJ ankylosis in our study sample was 32.0% (87/272). Patient demographics, SIJ ankylosis, PL, and fracture classification using computed tomography were compared between the two groups. PL was defined as any type of posterior ring injury with fracture lines extending to the region posterior to the iliac pillar, with or without SIJ subluxation or dislocation. To determine the association between SIJ ankylosis and PL, a logistic regression analysis adjusted for age, body mass index, sex, and energy of injury mechanism was performed.

Results

Our results found that the ankylosed group had a higher PL ratio (47.1% vs. 31.4%, P=0.012), was older (64.9 years vs. 53.5 years, P<0.001), and included more males (58.6% vs. 37.8%, P=0.001) than the non-ankylosed group. Multivariate analysis revealed a significant association between SIJ ankylosis and PL (odds ratio 2.15, P=0.022).

Conclusion

This study determined that SIJ ankylosis is significantly associated with PL in pelvic ring injuries; transformed SIJ may contribute to changes in posterior ring fracture patterns.

Introducing AEM-RADS: A novel reporting and data system for abdominal emergencies

PURPOSE

The Reporting and Data System (RADS) has proven successful in various medical settings, but a standardized reporting system for abdominal emergencies is lacking. In this study, the Abdominal Emergency Reporting and Data System (AEM-RADS) for urgent findings on abdominal CT scans is introduced to address the need for consistency in emergency radiology.

METHODS

In this prospective observational study, conducted over a six-month period, the urgency of abdominal CT scans was assessed using the proposed AEM-RADS scoring system. The committee developed a scale ranging from AEM-RADS 1 (normal) to AEM-RADS 5 (urgent disease). Interobserver agreement between two observers with different experience was evaluated, and robust AEM-RADS reference values were established by radiologists who were not observers. Statistical analysis used mean, standard deviations and Kendall's tau analysis for interobserver agreement.

RESULTS

Among 2656 patients who underwent CT for abdominal emergencies, the AEM-RADS distribution was 17.50% AEM-RADS 1, 28.57% AEM-RADS 2, 7.22% AEM-RADS 3, 35.61% AEM-RADS 4, and 11.06% AEM-RADS 5. Interobserver agreement was high, especially for urgent and emergent cases (p < 0.0001). Notable discrepancies were observed in AEM-RADS categories 2C-D and 3B-C, emphasizing the influence of radiologists' experience on interpretation. However, the interobserver agreement for both AEM-RADS 2C-D and 3B-C were statistically significant (p < 0.001).

CONCLUSIONS

AEM-RADS showed promising reliability, particularly in identifying urgent and emergent cases. Despite some inter-observer discrepancies, the system showed potential for standardized emergency workups. AEM-RADS could significantly enhance diagnostic accuracy in abdominal emergencies and provide a structured framework for shared decision-making between clinicians and radiologists.0.

Prevalence of pelvic CT angiography (CTA) and angiographic embolization in geriatric patients with pelvic ring fractures presenting to two level I trauma centers

OBJECTIVES

Hemorrhage in osteoporotic pelvic ring fractures is a rare, but serious complication. Most bleeding comes from the bone or venous plexuses, but arterial injury does occur. The purpose of this study was to characterize a large geriatric pelvic fracture cohort and determine the prevalence of pelvic CT angiography (CTA) and subsequent need for arterial embolization.

METHODS

A cohort of geriatric pelvic fracture patients at two level 1 trauma centers was reviewed. Many epidemiologic and patient factors were collected for cohort characterization. The primary outcome was if patients underwent a CTA of the pelvis and subsequently underwent arterial embolization.

RESULTS

There were 457 patients included and mean age was 83.1 years (range 65-100). Most patients had a low energy mechanism (91.4 %). In-hospital mortality was recorded for 30 cases (6.6 %). Of these deaths, two received a pelvic CTA and two had an embolization procedure. Pelvic CTA was performed on 33 patients (7.2 %). Fourteen patients (3.0 %) had an arterial embolization procedure. A high energy mechanism of injury was associated with receiving a pelvic CTA (p = 0.0067). Mechanism of injury was not associated with undergoing an embolization procedure (p = 0.685).

DISCUSSION

In the geriatric population, even patients with stable pelvic fractures can present with life-threatening arterial bleeding. A non-insignificant percentage of patients will require CTA for suspected bleeding (7.2 %) and embolization to treat confirmed arterial bleeding (3.0 %).

CONCLUSIONS

Bleeding events in geriatric pelvic ring injuries is a previously under researched area of orthopedic trauma. Further research is needed to elucidate the exact pathomechanisms of arterial injury and what patients or injury patterns are most significantly associated. Specifically, larger cohort sizes and evaluating our existing cohort with different injury classification systems may yield useful results.

Comparison of the AO/OTA 1996/2007 and 2018 pelvic ring fracture classifications

Pelvic ring fractures may present with relevant mechanical and haemodynamic instability. Classifications of the bony or ligamentous injuries of the pelvic ring are well established. The most common classifications used analyse the injury mechanisms and the resulting instability of the pelvic ring structure. Fracture classifications should be simple and easy to use, comprehensive, and radiographically and anatomically based, resulting in a hierarchical alphanumeric order of types and subtypes and thereby allow adequate treatment decisions based on a high degree of inter- and intraobserver reliability. In 2018 a new AO/OTA pelvic ring fracture and dislocation classification was published that combined the most commonly used "historical" classification schemes, e.g. the Tile/AO classification and the classification according to Young and Burgess. Compared with these older classifications, several relevant changes were integrated in the 2018 edition. The changes between the AO/OTA 1996/2007 and 2018 classifications were analysed in detail. Overall, several problems were identified regarding the type-B pelvic ring injury classification. These changes may result in difficulties in classifying pelvic ring injuries and thereby prevent relevant comparisons between former and future clinical studies on pelvic injuries.Level of Evidence: V.

Nonoperative management of minimally displaced lateral compression type 1 (LC1) injuries with comminuted rami fractures is associated with late displacement

PURPOSE

Rami comminution has been found to be predictive of lateral compression type 1 (LC1) injury instability on examination under anesthesia (EUA) and lateral stress radiographs (LSR). The purpose of this study was to evaluate how rami comminution and subsequent operative vs. nonoperative management impact the late displacement of these injuries.

METHODS

Retrospective review of a prospectively collected LC1 database was performed to identify all patients with minimally displaced LC1 injuries (< 1 cm) and follow-up radiographs over a four-year period (n = 125). Groups were separated based on the presence of rami comminution and subsequent management, including rami comminution/operative (n = 49), rami comminution/nonoperative (n = 54), and no comminution/nonoperative (control group, n = 22). The primary outcome was late fracture displacement, analyzed as both a continuous variable and as late displacement ≥ 5 mm.

RESULTS

As a continuous variable, late fracture displacement was lower in the comminuted rami/operative group as compared to the comminuted rami/nonoperative group (PD: -3.0 mm, CI: -4.8 to -1.6 mm, p = 0.0002) and statistically non-different from control. Late displacement ≥ 5 mm was significantly more prevalent in the comminuted rami/nonoperative group than in the comminuted rami/operative and no comminution/nonoperative groups (control)(PD: -33.9%, CI: -49.0% to -16.1%, p = 0.0002 and PD: -30.0%, CI: -48.2% to -6.5%, p = 0.02, respectively).

CONCLUSION

Late fracture displacement was greatest in the group with rami comminution/nonoperative management. Rami comminution, which has been previously associated with dynamic displacement on EUA and LSR, is also associated with a higher incidence of late displacement when managed nonoperatively.

LEVEL OF EVIDENCE

Level III, prognostic retrospective cohort study.

Identification and Management of Pelvic Fractures in Prehospital and Emergency Department Settings

INTRODUCTION

This study aims to describe the characteristics of patients with a pelvic fracture treated at a level 1 trauma center, the proportion of prehospital undertriage and the use of pelvic circumferential compression device (PCCD).

METHODS

This is a retrospective cohort study. Prehospital and inhospital medical records of adults (≥16 y old) with a pelvic fracture who were treated at Hopital de l'Enfant-Jesus-CHU de Québec (Quebec City, Canada), a university-affiliated level 1 trauma center, between September 01, 2017 and September 01, 2021 were reviewed. Isolated hip or pubic ramus fracture were excluded. Data are presented using proportions and means with standard deviations.

RESULTS

A total of 228 patients were included (males: 62.3%; mean age: 54.6 [standard deviation 21.1]). Motor vehicle collision (47.4%) was the main mechanism of injury followed by high-level fall (21.5%). Approximately a third (34.2%) needed at least one blood transfusion. Compared to those admitted directly, transferred patients were more likely to be male (73.0% versus 51.3%, P < 0.001) and to have a surgical procedure performed at the trauma center (71.3% versus 46.9%, P < 0.001). The proportion of prehospital undertriage was 22.6%. Overall, 17.1% had an open-book fracture and would have potentially benefited from a prehospital PCCD. Forty-six transferred patients had a PCCD applied at the referral hospital of which 26.1% needed adjustment.

CONCLUSIONS

Pelvic fractures are challenging to identify in the prehospital environment and are associated with a high undertriage of 22.6%. Reducing undertriage and optimizing the use of PCCD are key opportunities to improve care of patients with a pelvic fracture.

What interventions add value in lateral compression type 1 fragility pelvis fractures? A retrospective cohort study

Introduction

Fragility fractures are a large source of morbidity and mortality in the elderly. Orthopaedic surgeons are regularly the main point of contact in patients with lateral compression type 1 pelvis fractures, despite many of these being treated non-operatively. This study aims to identify risk factors for mortality and elucidate which follow-up visits have the potential to improve care for these patients.

Methods and materials

In all, 211 patients have been identified with fragility lateral compression type 1 fractures at a level 1 trauma centre over a 5-year period. For all patients, we recorded patient demographics, imaging data, hospital readmissions, medical complications and death dates if applicable.

Results

Of the 211 patients identified, 56.4% had at least one orthopaedic follow-up, of which no patient had a clinically meaningful medical intervention initiated. 30-day readmission rate was 19%, and 1-year mortality was 24%. Male sex, need for an assist device, higher Charlson Comorbidity Index and increased age were found to be statistically associated with increased risk of mortality. Patients who followed up with their primary care physician were found to have a statistically lower risk of mortality. Computed tomography scans were obtained in 70% of patients and never limited patient weight-bearing status or found any additional injury not already identified on the radiograph.

Discussion/Conclusions

For patients with lateral compression type 1 type fragility fractures, orthopaedic surgeons did not offer additional clinically meaningful intervention after the time of initial diagnosis in this patient cohort. The rate of clinical follow-up with a primary care physician is relatively low despite high rates of medical comorbidity. Computed tomography scans were utilised frequently but did not change recommendations. The high rate of medical complications and lack of orthopaedic intervention suggest that we should re-evaluate the role of the orthopaedic surgeon versus the primary care physician as the primary point of medical contact for patients with these injuries.

Work Productivity Loss After Minimally Displaced Complete Lateral Compression Pelvis Fractures

OBJECTIVE

To quantify work impairment and economic losses due to lost employment, lost work time (absenteeism), and lost productivity while working (presenteeism) after a lateral compression pelvic ring fracture. Secondarily, productivity loss of patients treated with surgical fixation versus nonoperative management was compared.

METHODS

DESIGN

Secondary analysis of a prospective, multicenter trial.

SETTING

Two level I academic trauma centers.

PATIENT SELECTION CRITERIA

Adult patients with a lateral compression pelvic fracture (OTA/AO 61-B1/B2) with a complete posterior pelvic ring fracture and less than 10 mm of initial displacement. Excluded were patients who were not working or non-ambulatory before their pelvis fracture or who had a concomitant spinal cord injury.

OUTCOME MEASURES AND COMPARISONS

Work impairment, including hours lost to unemployment, absenteeism, and presenteeism, measured by Work Productivity and Activity Impairment assessments in the year after injury. Results after non-operative and operative treatment were compared.

RESULTS

Of the 64 included patients, forty-seven percent (30/64) were treated with surgical fixation, and 53% (30/64) with nonoperative management. 63% returned to work within 1 year of injury. Workers lost an average of 67% of a 2080-hour average work year, corresponding with $56,276 in lost economic productivity. Of the 1395 total hours lost, 87% was due to unemployment, 3% to absenteeism, and 10% to presenteeism. Surgical fixation was associated with 27% fewer lost hours (1155 vs. 1583, P = 0.005) and prevented $17,266 in average lost economic productivity per patient compared with nonoperative management.

CONCLUSIONS

Lateral compression pelvic fractures are associated with a substantial economic impact on patients and society. Surgical fixation reduces work impairment and the corresponding economic burden.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous screw fixation and external stabilization as definitive surgical intervention for a pelvic ring injury combined with an acetabular fracture in the acute phase of polytrauma in Korea: a case report

Unstable pelvic ring injuries are potentially life-threatening and associated with high mortality and complication rates in polytrauma patients. The most common cause of death in patients with pelvic ring injuries is massive bleeding. With resuscitation, external fixation can be performed as a temporary stabilization procedure for hemostasis in unstable pelvic fractures. Internal fixation following temporary external fixation of the pelvic ring yields superior and more reliable stabilization. However, a time-consuming extended approach to open reduction and internal fixation of the pelvic ring is frequently precluded by an unacceptable physiologic condition and/or concomitant injuries in patients with multiple injuries. Conservative treatment may lead to pelvic ring deformity, which is associated with various functional disabilities such as limb length discrepancy, gait disturbance, and sitting intolerance. Therefore, if the patient is not expected to be suitable for additional surgery due to a poor expected physiologic condition, definitive external fixation in combination with various percutaneous screw fixations to restore the pelvic ring should be considered in the acute phase. Herein, we report a case of unstable pelvic ring injury successfully treated with definitive external fixation and percutaneous screw fixation in the acute phase in a severely injured polytrauma patient.

Combined Anterior-Posterior versus Posterior-Only Fixation of Stress-Positive Minimally Displaced Lateral Compression Type 1 (LC1) Pelvic Ring Injuries

OBJECTIVES

To compare hospital outcomes and late displacement between stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries treated with combined anterior-posterior versus posterior-only fixation.

DESIGN

Retrospective comparative cohort.

SETTING

Urban level-one trauma center.

PATIENTS/PARTICIPANTS

LC1 injuries managed operatively.

INTERVENTION

Anterior-posterior versus posterior-only fixation.

MAIN OUTCOME MEASUREMENTS

Physical therapy (PT) clearance, discharge location, hospital length of stay (LOS), inpatient morphine equivalent doses (MED), and fracture displacement at follow-up.

RESULTS

Groups were similar in demographic and injury characteristics (age, high energy mechanism, ASA score, stress displacement, and rami/sacral fracture classifications). Anterior-posterior fixation resulted in longer operative times (median difference (MD): 27.0 minutes, 95% confidence interval (CI): 17.0 to 40.0, P < 0.0001) and had a trend of increased estimated blood loss (MD: 10 mL, CI: 0 to 30, P = 0.07). Patients with anterior-posterior fixation required less inpatient MEDs (MD: -180.0, CI: -341.2 to -15.0, P = 0.02), were more likely to clear PT by discharge (100% vs. 70%, proportional difference (PD): 30%, CI: 2.0%-57.2%, P = 0.02), were less likely to discharge to rehabilitation facilities (0% vs. 30%, PD: 30%, CI: 2.0%-57.2%, P = 0.02), and had a trend of less days to clear PT after surgery (MD: -1, CI: -2 to 0, P = 0.09) and decreased LOS (MD: -1, CI: -4 to 1, P = 0.17). Late fracture displacement did not differ between groups.

CONCLUSION

Anterior-posterior fixation of LC1 injuries was associated with an improved early hospital course-specifically, reduced inpatient opioid use and an increased number of patients who could clear PT and discharge home.

LEVEL OF EVIDENCE

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

Prediction of massive transfusion with the Revised Assessment of Bleeding and Transfusion (RABT) score at Canadian level I trauma centers

BACKGROUND

Early damage control resuscitation and massive transfusion (MT) protocol activations improve outcomes in trauma patients with hemorrhagic shock, where scores to guide MT prediction are used including: the Assessment of Blood Consumption (ABC), Shock Index (SI), and Revised Assessment of Bleeding and Transfusion (RABT) scores. Our aim was to validate the RABT score in patients from two level I trauma centers in Canada.

METHODS

A retrospective review of adult patients meeting trauma team activation criteria receiving >1 unit of red blood cells (RBCs) within 24 h of admission, from 2015 to 2020, was conducted. A RABT score ≥ 2, ABC score ≥ 2, and Shock Index (SI) ≥ 1 was used to predict MT using both research (≥10 RBCs in 24 h) and clinical (≥3 RBCs in 3 h) definitions. Scores were assessed and compared using sensitivity, specificity, and the area under the receiver operating characteristic (AUROC).

RESULTS

We analyzed 514 patients with a mean age of 44.4 (19.2) years and a median injury severity score of 29 [18-38]. For both MT definitions, the RABT score trended towards higher sensitivity and lower specificity compared to ABC score and SI. For both research and clinical definitions of MT, the AUROC for the RABT score was not significantly higher (Research - RABT: 0.673 [0.610-0.735], ABC: 0.642 [0.551-0.734], SI 0.691 [0.625-0.757]; Clinical - RABT: 0.653 [0.608-0.698], ABC: 0.646 [0.600-0.691], SI 0.610 [0.559-0.660]).

CONCLUSION

The RABT score is a valid tool for predicting the need for MTPs, performing similarly with a trend towards higher sensitivity when compared to the ABC score and SI.

Revisiting Non-operative Treatment of Lateral Compression Pelvic Fractures, Analysis of Rehabilitation, and Radiologic Outcomes in a Historical Cohort Using Today's Association of Osteosynthesis (AO) Stability Criteria

BACKGROUND

Type I lateral compression pelvic fractures (LC-I) have historically been treated conservatively. Inferior outcomes in a distinctive subset of these injuries have been reported, therefore their management has shifted towards surgery. Revisiting the historical series of LC-I allows us to determine whether non-operative management of these unstable patterns results in poorer outcomes. The objective was to evaluate the differences in the rehabilitation progress, fracture consolidation, and displacement in non-operatively treated LC-I fractures that would be considered unstable using today's Association of Osteosynthesis (AO) criteria.

METHODS

We conducted a retrospective review of conservatively treated LC-I injuries in a single-level I trauma center between June 2010 and June 2014. Patients were distributed in stable (group A) and unstable (group B) groups according to the 2018 AO classification. Time to walk independently (TWI), time to return to work (TRW), fracture consolidation, and displacement were analyzed.

RESULTS

34 patients, mean age of 45.5 ±14.5 years, were included. Mean TWI in groups A and B were 71.2 ±31.9 and 105.9 ±50.9 days (p=0.027). Mean TRW was 106 ±51.3 and 157 ±84 days in groups A and B, respectively (p=0.038). A difference in mean TWI and TRW of 34.7 and 51.3 days between groups was observed. No significant differences in fracture consolidation or displacement were observed.

CONCLUSION

Unstable fractures presented significantly longer TWI and TRW. The revised AO classification contributes to the identification of fracture patterns that correlate with prolonged rehabilitation in which additional treatment strategies might be considered.

Management of high-energy blunt pelvic ring injuries: A retrospective cohort study evaluating an institutional protocol

INTRODUCTION

High-energy blunt pelvic ring injuries with hemodynamic instability are complicated by a high mortality rate (up to 32%). There is no consensus on the best management strategy for these injuries. The aim of this study was to evaluate the high-energy blunt pelvic ring injury management protocol implemented in the authors' institution.

PATIENTS AND METHODS

This retrospective cohort study was performed in an academic level I trauma center. The institutional protocol incorporates urgent pelvic mechanical stabilization of hemodynamically unstable patients not responding to a pelvic belt, fluids, and transfusions. If hemodynamic instability persists, angiography ± embolization is performed. Adult patients sustaining a high-energy blunt pelvic ring injury between 2014.01.01 and 2019.12.31 were included in the study. The primary outcome was mortality at 1, 2, 30 and 60 days. The secondary outcomes were the number of packed red blood cell units transfused during the first 24 h, intensive care unit stay, and total hospitalization length of stay.

RESULTS

192 high-energy blunt pelvic ring injury patients were analyzed. Of these, 71 (37%) were hemodynamically unstable, and 121 (63%) were stable. The overall in-hospital mortality of the hemodynamically unstable and stable groups was 20/71 (28.2%) and 4/121 (3.3%) respectively (p<0.001). Cumulative mortality rates for hemodynamically unstable patients were 15.5% at day 1, 16.9% at day 2, 26.8% at day 30 and 28.2% at day 60, and for hemodynamically stable patients, rates were 0% at day 1 and 2, 2.5% at day 30 and 3.3% at day 60. Unstable patients required a higher number of packed red blood cell units than stable patients during the first 24 h (5.1 vs. 0.1; p<0.001). Intensive care unit length of stay and total hospitalization duration was 11.25 and 37.4 days for unstable patients and 1.9 and 20.9 days for stable patients (p<0.001).

CONCLUSIONS

For both hemodynamically unstable and stable patients, the institutional protocol showed favorable mortality rates when compared to available literature. Comparative studies are needed to determine the management strategies with the best clinical outcome and survival.

CT of Sacral Fractures: Classification Systems and Management

CT is often performed as part of a whole-body protocol in the setting of polytrauma and is the standard of care for diagnosing and characterizing sacral fractures. These fractures are not uncommon, occurring in conjunction with pelvic ring disruption in approximately 40%-50% of patients. Knowledge of basic functional anatomy and fracture biomechanics is important in understanding sacral fracture patterns, which only rarely result from direct impact. More often, sacral fractures result from an indirect mechanism with fracture lines that propagate along relative lines of weakness, leading to predictable fracture patterns. Each fracture pattern has implications with respect to neurologic injury, spinopelvic stability, management, and potential complications. The authors explore the Denis, Roy-Camille, Isler, Robles, Sabiston-Wing, and shape-based classification systems for sacral fractures. These form the basis of the subsequently discussed unified AOSpine sacral fracture classification, a consensus system developed by spine and orthopedic surgeons as a means of improving and standardizing communication. The AOSpine sacral fracture classification also includes clinical designations for neurologic status and patient-specific modifiers. When a patient is unexaminable owing to obtundation or sedation, CT is an invaluable indirect marker of nerve compression or traction injury. It also plays an important role in visualizing and characterizing the type and extent of any associated soft-tissue injuries that may warrant a delay in surgery or an alternative operative approach. ©RSNA, 2022.

Mortality and functional outcomes of fragility fractures of the pelvis by fracture type with conservative treatment: a retrospective, multicenter TRON study

PURPOSE

Fragility fractures of the pelvis (FFP) are becoming a commonly encountered disease in aging societies. We aimed to (1) clarify the overall survival rate of FFP, (2) compare survival rates by Rommens and Hofmann classification FFP type, (3) investigate the complications during hospitalization, and (4) investigate walking ability before and after injury depending on the type of fracture in patients with FFP treated conservatively.

METHODS

This retrospective, multicenter study included 867 patients with FFP treated conservatively between 2014 and 2018 and excluded patients with insufficient follow-up for two years, lost data, and operative cases. This is a retrospective multicenter study. We established the database, which is named as TRON. We evaluated survival rate by fracture type using the log-rank test. We compared walking ability as defined by a new mobility score and the modified Majeed Pelvic Score among fracture types.

RESULTS

We reviewed 552 cases (98 males and 454 females) with conservative treatment. The overall survival rates of patients with FFP treated conservatively were 0.90 at 1 year and 0.83 at 2 years. Although the survival rate was the lowest in FFP Type III, there was no significant difference in survival rates between fracture types (P = 0.143). The rates of complications during hospitalization were high for both Type III and Type IV fractures. Walking ability post-injury was worse in the patients with Type III fracture.

CONCLUSIONS

The survival rate of patients treated by conservative treatment was relatively good. Type III in the Rommens and Hofmann classification was related to lower life expectancy and loss of walking ability.

Dual-Energy CT and Cinematic Rendering to Improve Assessment of Pelvic Fracture Instability

Background Grading of pelvic fracture instability is challenging in patients with pelvic binders. Dual-energy CT (DECT) and cinematic rendering can provide ancillary information regarding osteoligamentous integrity, but the utility of these tools remains unknown. Purpose To assess the added diagnostic value of DECT and cinematic rendering, with respect to single-energy CT (SECT), for discriminating any instability and translational instability in patients with pelvic binders. Materials and Methods In this retrospective analysis, consecutive adult patients (age ≥18 years) were stabilized with pelvic binders and scanned in dual-energy mode using a 128-section CT scanner at one level I trauma center between August 2016 and January 2019. Young-Burgess grading by orthopedists served as the reference standard. Two radiologists performed blinded consensus grading with the Young-Burgess system in three reading sessions (session 1, SECT; session 2, SECT plus DECT; session 3, SECT plus DECT and cinematic rendering). Lateral compression (LC) type 1 (LC-1) and anteroposterior compression (APC) type 1 (APC-1) injuries were considered stable; LC type 2 and APC type 2, rotationally unstable; and LC type 3, APC type 3, and vertical shear, translationally unstable. Diagnostic performance for any instability and translational instability was compared between reading sessions using the McNemar and DeLong tests. Radiologist agreement with the orthopedic reference standard was calculated with the weighted κ statistic. Results Fifty-four patients (mean age, 41 years ± 16 [SD]; 41 men) were analyzed. Diagnostic performance was greater with SECT plus DECT and cinematic rendering compared with SECT alone for any instability, with an area under the receiver operating characteristic curve (AUC) of 0.67 for SECT alone and 0.82 for SECT plus DECT and cinematic rendering (P = .04); for translational instability, the AUCs were 0.80 for SECT alone and 0.95 for SECT plus DECT and cinematic rendering (P = .01). For any instability, corresponding sensitivities were 61% (22 of 36 patients) for SECT alone and 86% (31 of 36 patients) for SECT plus DECT and cinematic rendering (P < .001). The corresponding specificities were 72% (13 of 18 patients) and 78% (14 of 18 patients), respectively (P > .99). Agreement (κ value) between radiologists and orthopedist reference standard improved from 0.44 to 0.76 for SECT versus the combination of SECT, DECT, and cinematic rendering. Conclusion Combined use of single-energy CT, dual-energy CT, and cinematic rendering improved instability assessment over that with single-energy CT alone. © RSNA, 2022 Online supplemental material is available for this article.

Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamically Unstable Patients With Pelvic Ring Injuries

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.

Pelvic ring and acetabular fracture: Concepts of traumatological forensic interest

Fractures of the pelvic ring and acetabulum generally result after high energy trauma. Pelvic fractures, especially, are considered complex injuries from a therapeutic point of view, in relation to the frequent coexistence of skeletal and / or parenchymal lesions affecting other areas, and the abundant bleeding invariably associated with the latter. The systematic study of these injuries, starting from the 1950s, has led to a significant prognostic improvement, while generally remaining a non-negligible degree of disability. The knowledge of the characteristics of the lesions and of the classification systems, as well as an accurate assessment of the anatomo-functional repercussions, represent therefore the fundamental prerequisites for the correct assessment of physical damage. Herein, we aim to examine whether the medico-legal assessment parameters of physical damage being used in Italy and Europe are appropriate and consistent with the complexity of similar injuries.

Pelvic Ring Injury Mortality: Are We Getting Better?

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.

Total endoscopic anterior pelvic approach (TAPA) - A new approach to the internal fixation of the symphysis

This study presents a detailed documentation of a total endoscopic anterior pelvic approach (TAPA) for plate fixation of a symphyseal disruption. The purpose of this work is to describe a minimally invasive technique as a possible method for reducing complications and hospitalization. Other goals included giving technical recommendations and assessing potential pitfalls and problems of this new surgical approach. Surgery was performed in an interdisciplinary setting by an experienced orthopaedic and general surgeon. The first endoscopic approach used to visualize the injury was the same as is used for endoscopic hernia surgery. The repositioning of the symphysial rupture was achieved either through external fixation or indirectly with traction and a pelvic binder. Plate positioning and fixation were achieved through two additional, minimally invasive incisions. The endoscopic approach shows multiple advantages, such as no detachment of the rectus abdominis muscle and smaller skin incisions. Furthermore, this approach could lessen the incidence of hernia and postoperative pain. We see the presented technique as a simple and innovative surgical method for treating symphyseal disruption.

Unstable minimally displaced lateral compression type 1 (LC1) pelvic ring injuries have a similar hospital course as intertrochanteric femur fractures

INTRODUCTION

The purpose of this study was to evaluate how the hospital course of minimally displaced LC1 fractures, with and without occult instability, compares with that of intertrochanteric femur fractures.

PATIENTS AND METHODS

Retrospective comparative cohort analysis at an urban level one trauma center of 40 consecutive patients with an isolated LC1 pelvic ring injury and 40 age/sex matched patients with an isolated intertrochanteric femur fracture was performed. Medical records and radiographs were reviewed for patient and injury characteristics, including demographics, displacement, time to surgery, ambulation, physical therapy (PT) clearance, hospital length of stay (LOS), and inpatient morphine milligram equivalents (MME).

RESULTS

The LC1 pelvic ring injury group included 26 (65%) patients with ≥ 10 mm of displacement on lateral stress radiographs. The unstable LC1 group, compared to the stable LC1 group, had a greater LOS (median difference (MD): 2 days, 95% confidence interval (CI): 1 to 4, p = 0.0004), longer time to ambulate 15 feet (MD: 1 day, CI: 1 to 2, p = 0.0002), longer time to clear PT (MD: 2 days, CI: 1 to 3, p = 0.0003), and more inpatient MMEs (MD: 386 MME, CI: 225.8 to 546.7, p = 0.0002). The unstable LC1 and intertrochanteric fracture groups had no detectable differences in LOS (p = 0.24), days to ambulate 15 feet (p = 0.46), days to clear PT (p = 0.95), and inpatient MMEs (p = 0.06).

CONCLUSION

Patients with minimally displaced unstable LC1 injuries had worse hospital courses than stable LC1 injuries and similar hospital courses as intertrochanteric femur fractures. These findings emphasize the associated morbidity of unstable LC1 injuries.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Management of LC Type I (LC-1) Pelvic Injuries with Complete Sacral Fracture: Comparison of Solitary Anterior Fixation with Combined Anterior-Posterior Fixation

BACKGROUND

Management of LC-1 type pelvic injuries, particularly in patients with complete sacral fracture (LC-1 PICSF, OTA type 61-B2.1), remains controversial. Specific indications for solitary fixation remain unclear, and there is a paucity of outcomes data in comparison to combined fixation. We undertook a retrospective study in patients with LC-1 PICSFs to compare outcomes between solitary anterior fixation and combined anterior-posterior fixation.

METHODS

A retrospective cohort study was conducted with enrollment from 2016 to 2018 at a single tertiary-referral center in China. Adults with operatively managed LC-1 PICSFs were enrolled. Patients with sacral displacement < 1 cm as assessed by axial CT received solitary anterior ring fixation (group A); patients with displacement ≥ 1 cm received combined fixation of both the anterior and posterior rings (group B). Reduction was confirmed by manipulation under anesthesia. Patients followed up for at least 24 months postoperatively. Primary outcome was function (Majeed score). Secondary outcomes included intraoperative characteristics, pain (VAS score), quality of fracture reduction (Tornetta and Matta radiographic grading), rate of nonunion, early weight-bearing status, and complication rate.

RESULTS

68 (89%) of 76 enrolled patients completed follow-up. Patients in group A exhibited improved operative times, less time under fluoroscopy, and less blood loss as compared to group B. There were no significant differences between groups A and B regarding quality of fracture reduction, rate of union, functional outcomes, or rate of complications. Notably, group B patients were more likely to achieve full early weight-bearing.

CONCLUSION

LC-1 PFCSFs can get benefits from ORIF; the treatment algorithm should be differently made following the degree of the sacral fractures displacement. Less than 1 cm sacral fracture displacement may get good functional outcomes from solitary anterior fixation. However, for the sacral fractures displacement greater or equal to 1 cm, both the anterior and posterior pelvic rings should be surgical stabilization.

The morphological mapping of lateral compression type 1 pelvic fracture and pelvic ring stability classification: a finite element analysis

Purpose

This finite element analysis assessed lateral compression (LC-1) fracture stability using machine learning for morphological mapping and classification of pelvic ring stability.

Methods

Computed tomography (CT) files of LC-1 pelvic fractures were collected. After morphological mapping and producing matrix data, we used K-means clustering in unsupervised machine learning to classify the fractures. Based on these subtypes, we manually added fracture lines in ANSYS software. Finally, we performed a finite element analysis of a normal pelvis and eight fracture subtypes based on von Mises stress and total deformation changes.

Results

A total of 218 consecutive cases were analyzed. According to the three main factors—zone of sacral injury and completion, pubic ramus injury side, and the sagittal rotation of the injured hemipelvis—the LC-1 injuries were classified into eight subtypes (I–VIII). No significant differences in stress or deformation were observed between unilateral and bilateral public ramus fractures. Subtypes VI and VIII showed the maximum stress while subtypes V–VIII showed the maximum deformation in the total pelvis and sacrum. The subtypes did not differ in superior public ramus deformation.

Conclusions

Complete fracture of sacrum zones 2/3 may be a feature of unstable LC-1 fractures. Surgeons should give surgical strategies for subtypes V–VIII.

Operative management of fragility fractures of the pelvis - a systematic review

Background

The incidence of osteoporotic pelvic fractures in elderly patient is rising. This brings an increasing burden on health and social care systems as these injuries often lead to prolonged hospital admissions, loss of independence, morbidity and mortality. Some centres now advocate stabilisation of these injuries to reduce pain, facilitate early mobilisation, decrease hospital stay and restore independence. A systematic review of the literature was planned to establish the evidence for this intervention.

Methods

A systematic review was performed according to PRISMA guidelines. A clinical librarian performed a search of the following databases: NHS Evidence, TRIP, the Cochrane Database of Systematic Reviews, MEDLINE and EMBASE. Seventeen eligible studies were identified with 766 patients.

Results

The quality of evidence was poor with no good quality randomised trials. The majority of injuries were minimally displaced. Posterior ring injuries were most often stabilised with percutaneous screws which were sometimes augmented with void filler. A number of techniques were described for stabilisation of the anterior ring although fixation of the anterior ring was frequently not performed.

There was consistent evidence from the included studies that operative intervention significantly improved pain. Complications were minimal but there were increased failure rates when a single unaugmented sacroiliac joint screw was used. The limited availability of non-operative comparators made it difficult to draw firm conclusions about the efficacy of surgical over non-surgical management in these patients.

Conclusions

Operative management of fragility fractures of the pelvis should be considered for patients failing a brief period of non-operative management, however prospective randomised trials need to be performed to provide improved evidence for this intervention. Surgeons should consider which fixation techniques for fragility fractures of the pelvis are robust enough to allow immediate weightbearing, whilst minimising operative morbidity and post-operative complications.

PROSPERO Systematic Review ID: CRD42020171237.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04579-w.

The morphology of ligamentous sacroiliac lesions - challenge to the antero-posterior compression mechanism

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.

Comparison of One-Year Functional Outcomes and Quality of Life between Posterior Pelvic Ring Fixation and Combined Anterior-Posterior Pelvic Ring Fixation after Lateral Compression (B2 Type) Pelvic Fracture

Background and Objectives: The treatment algorithm of lateral compression B2 type pelvic fractures are still under debate. Some authors advocate conservative treatment, while others recommend surgical approach. The clear indications for isolated anterior or posterior ring fixation or combined anterior-posterior pelvic ring fixation of B2 type fractures remain unclear. The aim of this study was to compare the functional outcomes and quality of life after isolated posterior pelvic ring fixation and combined anterior-posterior pelvic ring fixation for the treatment of B2 pelvic fractures. Materials and Methods: Patients aged 18 to 65 years with B2 type pelvic fracture hospitalized in a single trauma centre over a period of 3 years were included in the research. Based on the attending surgeon’s preference, patients were treated with isolated posterior or combined anterior-posterior pelvic fixation. The quality of life and pelvic function were assessed using SF-36 and Majeed questionnaires, respectively. Patients filled in the questionnaires twice: during the first hospitalization (concerning their pre-trauma state—timepoint I) and one-year after the injury (timepoint II). Results: A cohort of 32 patients with B2 type pelvic fracture was enrolled in the analysis: 23 (72%) were female and 9 (28%) were male. The mean age was 35.3 ± 11.9 years. In this cohort 13 (41%) patients underwent isolated posterior pelvic ring fixation (group I) and 19 (59%) patients underwent combined anterior-posterior pelvic ring fixation (group II). No statistically significant differences were observed between the groups in both timepoints concerning Majeed, SF-36 PCS and MCS scores. However, in both groups Majeed and SF-36 PCS scores were statistically significantly lower one year after pelvic fracture compared with pre-trauma state, while SF-36 MCS scores did not differ. Conclusions: No differences were found in quality of life and functional outcomes between isolated posterior pelvic ring fixation and combined anterior-posterior fixation for the treatment of B2 type pelvic fractures.

A nomogram to predict arterial bleeding in patients with pelvic fractures after blunt trauma: a retrospective cohort study

Background

Pelvic bone fractures are one of the biggest challenges faced by trauma surgeons. Especially, the presence of bleeding and hemodynamic instability features is associated with high morbidity and mortality in patients with pelvic fractures. However, prediction of the occurrence of arterial bleeding causing massive hemorrhage in patients with pelvic fractures is difficult. Therefore, the aim of this study was to develop a nomogram to predict arterial bleeding in patients with pelvic bone fractures after blunt trauma.

Methods

The medical records of 1404 trauma patients treated between January 2013 and August 2017 were retrospectively reviewed. Patients older than 15 years with a pelvic fracture due to blunt trauma were enrolled (n = 148). The pelvic fracture pattern on anteroposterior radiography was classified according to the Orthopedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO) system. Multivariable logistic regression modeling was used to determine the independent risk factors for arterial bleeding. A nomogram was constructed based on the identified risk factors.

Results

The most common pelvic fracture pattern was type A (58.8%), followed by types B (34.5%) and C (6.7%). Of the 148 patients, 28 (18.9%) showed pelvic arterial bleeding on contrast-enhanced computed tomography or angiography, or in the operative findings. The independent risk factors for arterial bleeding were a type B or C pelvic fracture pattern, body temperature < 36 °C, and serum lactate level > 3.4 mmol/L. A nomogram was developed using these three parameters, along with a systolic blood pressure < 90 mmHg. The area under the receiver operating characteristic curve of the predictive model for discrimination was 0.8579. The maximal Youden index was 0.1527, corresponding to a cutoff value of 68.65 points, which was considered the optimal cutoff value for predicting the occurrence of arterial bleeding in patients with pelvic bone fractures.

Conclusions

The developed nomogram, which was based on the initial clinical findings identifying risk factors for arterial bleeding, is expected to be helpful in rapidly establishing a treatment plan and improving the prognosis for patients with pelvic bone fractures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02247-2.

Multicenter Validation of the Revised Assessment of Bleeding and Transfusion (RABT) Score for Predicting Massive Transfusion

BACKGROUND

Massive transfusion (MT) is a lifesaving treatment for hemorrhaging patients. Predicting the need for MT is crucial to improve survival. The aim of our study was to validate the Revised Assessment of Bleeding and Transfusion (RABT) score to predict MT in a multicenter cohort of trauma patients.

METHODS

We performed a (2015-2017) analysis of adult (age ≥ 18 year) trauma patients who had a high-level trauma team activation at three Level I trauma centers. The RABT was calculated using the 4-point score [blunt (0)/penetrating trauma (1), shock index ≥ 1 (1), pelvic fracture (1), and FAST positive (1)]. A RABT score of ≥ 2 was used to predict MT (≥ 10 units of packed red blood cells within 24 h). The area under the receiver operating characteristic curve (AUROC) was calculated to assess the score's predictive power compared to the Assessment of Blood Consumption (ABC) score.

RESULTS

We analyzed 1018 patients: 216 (facility I), 363 (facility II), and 439 (facility III). The mean age was 41 ± 19 year, and the injury severity score (ISS) was 29 [22-36]. The overall MT rate was 19%. The overall AUROC of RABT ≥ 2 was 0.89. The sensitivity of the RABT ≥ 2 was 78%, and the specificity was 91%. The RABT score had a higher sensitivity (78% vs. 69%) and specificity (91% vs. 82%) than the ABC score.

CONCLUSION

The RABT score is a valid tool to predict MT in severely injured trauma patients. It is an objective score that aids clinicians in predicting the need for MT to mobilize blood products and minimize the waste of resources.

Management of Pelvic Ring Injury Patients With Hemodynamic Instability

Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.

An overview of the key principles and guidelines in the management of pelvic fractures

Pelvic fractures are complex injuries with a range of different presentations depending on the mechanism of trauma. Due to the morbidity and mortality of pelvic fractures, patients require thorough investigation and timely management with multidisciplinary input. Various surgical and non-surgical techniques can be used to treat pelvic fractures, as well as any associated visceral injuries. Following repair, it is important to remain vigilant for postoperative complications such as infection, sexual and urinary dysfunction, chronic pain and adverse psychological health. This article summarises the relevant UK guidance and literature and presents them in a format that follows the patient’s journey. In doing so, it highlights the key perioperative factors that need to be considered in cases of pelvic fracture.

Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons

OBJECTIVES

To assess the interobserver reliability (IOR) of the Tile classification system, and its potential influence on outcomes, for the interpretation of CT images of pelvic fractures by radiologists and surgeons.

METHODS

Retrospective data (1/2008-12/2016) from 238 patients with pelvic fractures were analyzed. Mean patient age was 44 years (SD 20); 66% were male. There were 54 Tile A, 82 Tile B, and 102 Tile C type injuries. The 30-day mortality rate was 15% (36/238). Six observers, three radiologists, and three surgeons with different levels of experience (attending/resident/intern) classified each fracture into one of the 26 second-order subcategories of the Tile classification. Weighted kappa coefficients were used to assess the IORs for the three main categories and nine first-order subcategories.

RESULTS

The overall IORs of the Tile system for the main categories and first-order subcategories were moderate (kappa = 0.44) and fair (kappa = 0.31), respectively. IOR was fair to moderate among radiologists, but only fair among surgeons. By level of training, IOR was moderate between attendings and between residents, whereas it was only fair between interns. IOR was moderate to substantial (kappa = 0.56-0.70) between the radiology attending and resident. Association of the Tile fracture type with 30-day mortality was present based on two out of six observer ratings.

CONCLUSIONS

The overall IOR of the Tile classification system is only fair to moderate, increases with the level of rater experience and is better among radiologists than surgeons. In the light of these findings, results from studies using this classification system must be interpreted cautiously.

KEY POINTS

• The overall interobserver reliability of the Tile pelvic fracture classification is only fair to moderate. • Interobserver reliability increases with observer experience and radiologists have higher kappa coefficients than surgeons. • Interobserver reliability has an impact on the association of the Tile classification system with mortality in two out of six cases.

Vertical shear pelvic ring injuries: do transsacral screws prevent fixation failure?

OBJECTIVES

To determine the frequency of fixation failure after transsacral-transiliac (TS) screw fixation of vertical shear (VS) pelvic ring injuries (OTA/AO 61C1) and to describe the mechanism of failure of TS screws.

DESIGN

Retrospective cohort study.

SETTING

Level 1 academic trauma center.

PATIENTS/PARTICIPANTS

Twenty skeletally mature patients with unilateral, displaced, unequivocal VS injuries were identified between May 1, 2009 and April 31, 2016. Mean age was 31 years and mean follow-up was 14 months. Twelve had sacroiliac dislocations (61C1.2) and eight had vertical sacral fractures (61C1.3).

INTERVENTION

Operative treatment with at least one TS screw.

MAIN OUTCOME MEASUREMENTS

Radiographic failure, defined as a change of >1 cm of combined displacement of the posterior pelvis compared with the intraoperative position on inlet and outlet radiographs.

RESULTS

Radiographic failure occurred in 4 of 8 (50%) vertical sacral fractures. Posterior fixation was comprised of a single TS screw in 3 of these 4 failures. The dominant mechanism of screw failure was bending. All of these failures occurred early in the postoperative period. No fixation failures occurred among the sacroiliac dislocations. There were no deep infections or nonunions.

CONCLUSIONS

This is the first study to describe the mechanism of failure of TS screws in a clinical setting after VS pelvic injuries. We caution surgeons from relying on single TS screw fixation for vertically unstable sacral fractures. Close radiographic monitoring in the first few weeks after surgery is advised.

LEVEL OF EVIDENCE

Level IV.

Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense

Background

The most common cause of death in cases of pelvic trauma is exsanguination caused by associated injuries, not the pelvic injury itself. For patients with relatively isolated pelvic trauma, the impact of vascular injury severity on outcome remains unclear. We hypothesized that the severity of the pelvic vascular injury plays a more decisive role in outcome than fracture pattern complexity.

Methods

Medical records of patients with pelvic fracture at a single center between January 2016 and December 2017 were retrospectively reviewed. Those with an abbreviated injury scale (AIS) score ≥ 3 in areas other than the pelvis were excluded. Lateral compression (LC) type 1 fractures and anteroposterior compression (APC) type 1 fractures according to the Young-Burgess classification and ischial fractures were defined as simple pelvic fractures, while other fracture types were considered complicated pelvic fractures. Based on CT, vascular injury severity was defined as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling/extravasation). Patient demographics, clinical parameters, and outcome measures were compared between the groups.

Results

Severe vascular injuries occurred in 26 of the 155 patients and were associated with poorer hemodynamics, a higher injury severity score (ISS), more blood transfusions, and a longer ICU stay (3.81 vs. 0.86 days, p = 0.000) and total hospital stay (20.7 vs. 10.1 days, p = 0.002) compared with minor vascular injuries. By contrast, those with complicated pelvic fractures (LC II/III, APC II/III, vertical shear, and combined type fracture) required a similar number of transfusions and had a similar length of ICU stay as those with simple pelvic fractures (LC I, APC I, and ischium fracture) but had a longer total hospital stay (13.6 vs. 10.3 days, p = 0.034). These findings were similar even if only patients with ISS ≥ 16 were considered.

Conclusions

Our results indicate that even in patients with relatively isolated pelvic injuries, vascular injury severity is more closely correlated to the outcome than the type of anatomical fracture. Therefore, a more balanced classification of pelvic injury that takes both the fracture pattern and hemodynamic status into consideration, such as the WSES classification, seems to have better utility for clinical practice.

Patterns, management, and outcomes of traumatic pelvic fracture: insights from a multicenter study

Background

Traumatic pelvic fracture (TPF) is a significant injury that results from high energy impact and has a high morbidity and mortality.

Purpose

We aimed to describe the epidemiology, incidence, patterns, management, and outcomes of TPF in multinational level 1 trauma centers.

Methods

We conducted a retrospective analysis of all patients with TPF between 2010 and 2016 at two trauma centers in Qatar and Germany.

Results

A total of 2112 patients presented with traumatic pelvic injuries, of which 1814 (85.9%) sustained TPF, males dominated (76.5%) with a mean age of 41 ± 21 years. In unstable pelvic fracture, the frequent mechanism of injury was motor vehicle crash (41%) followed by falls (35%) and pedestrian hit by vehicle (24%). Apart from both extremities, the chest (37.3%) was the most commonly associated injured region. The mean injury severity score (ISS) of 16.5 ± 13.3. Hemodynamic instability was observed in 44%. Blood transfusion was needed in one third while massive transfusion and intensive care admission were required in a tenth and a quarter of cases, respectively. Tile classification was possible in 1228 patients (type A in 60%, B in 30%, and C in 10%). Patients with type C fractures had higher rates of associated injuries, higher ISS, greater pelvis abbreviated injury score (AIS), massive transfusion protocol activation, prolonged hospital stay, complications, and mortality (p value < 0.001). Two-thirds of patients were managed conservatively while a third needed surgical fixation. The median length of hospital and intensive care stays were 15 and 5 days, respectively. The overall mortality rate was 4.7% (86 patients).

Conclusion

TPF is a common injury among polytrauma patients. It needs a careful, systematic management approach to address the associated complexities and the polytrauma nature.

How effective are different models of pelvic binders: results of a study using a Pelvic Emergency Simulator

BACKGROUND

The application of pelvic binders in the preclinical and early clinical phase is advisable to avoid or treat C-problems in unstable and potential bleeding pelvic ring fractures, even if the clinical effectivity is not completely proved. The use for pathologies in the posterior pelvic ring is still debatable.

QUESTIONS/PURPOSES

We determined if there is a difference in achievable compression in the dorsal pelvic ring depending on position and pelvic binder model. Can this effect be tested with a simplified artificial model?

METHODS

We simulated a Tile type C fracture within the established pelvic emergency trainer and measured in a test series the effectivity of reduction with a non-invasive stabilization technique using 3 different pelvic binders.

RESULTS

Any therapeutic effect of a pelvic binder with compression to the posterior pelvic ring requires at first a reduction maneuver. While the compression effect in the symphysis depends only on positioning of the binder, in the posterior pelvic ring, the result varies with the used model. The achievable pressure in the SI joint with a pelvic binder is only 20-25% (33.5-47 N) compared to the C-Clamp values (156 N).

CONCLUSIONS

The use of pelvic binders for non-invasive pelvic ring stabilization, even with a posterior pathology, could be proven in a simplified fracture model. A proper fracture reduction and an adequate device positioning influence the effectiveness.

CLINICAL RELEVANCE

The use of an emergency pelvic trainer even for a non-invasive maneuver is advisable.

TULIP: a randomised controlled trial of surgical versus non-surgical treatment of lateral compression injuries of the pelvis with complete sacral fractures (LC1) in the non-fragility fracture patient-a feasibility study protocol

INTRODUCTION

Lateral compression type 1 (LC1) pelvic fractures are the most common type of pelvic fracture. The majority of LC1 fractures are considered stable. Fractures where a complete sacral fracture is present increases the degree of potential instability and have the potential to displace over time. Non-operative management of these unstable fractures may involve restricted weight bearing and significant rehabilitation. Frequent monitoring with X-rays is also necessary for displacement of the fracture. Operative stabilisation of these fractures may be appropriate to prevent displacement of the fracture. This may allow patients to mobilise pain-free, quicker.

METHODS AND ANALYSIS

The study is a feasibility study to inform the design of a full definitive randomised controlled trial to guide the most appropriate management of these injuries. Participants will be recruited from major trauma centres and randomly allocated to either operative or non-operative management of their injuries. A variety of outcome instruments, measuring health-related quality of life, functional outcome and pain, will be completed at several time points up to 12 months post injury. Qualitative interviews will be undertaken with participants to explore their views of the treatments under investigation and trial processes.Eligibility and recruitment to the study will be analysed to inform the feasibility of a definitive trial. Completion rates of the measurement instruments will be assessed, as well as their sensitivity to change and the presence of floor or ceiling effects in this population, to inform the choice of the primary outcome for a definitive trial.

ETHICS AND DISSEMINATION

Ethical approval for the study was given by the South West-Central Bristol NHS Research Ethics Committee on 2nd July 2018 (Ref; 18/SW/0135). The study will be reported in relevant specialist journals and through presentation at specialist conferences.

TRIAL REGISTRATION NUMBER

ISRCTN10649958.

Association between Young-Burgess pelvic ring injury classification and concomitant injuries requiring urgent intervention

BACKGROUND

Young-Burgess classification (YB) is a mechanistic system which classifies pelvic ring injuries into anterior-posterior compression (APC), lateral compression (LC), vertical shear (VS) injuries, and combined mechanism (CM). The objective of this study was to identify associated injuries which require urgent operative intervention by YB classification. We hypothesize that YB classification is associated with 1) need for urgent intervention for pelvic fracture-related hemorrhage and 2) patterns of injury complexes requiring surgery.

METHODS

This is a retrospective study of severely injured trauma patients with pelvic ring injuries who presented to an urban Level-1 trauma center from 2007 to 2017. Associated injuries and procedures were determined by Abbreviated Injury Scale (AIS) and ICD-9/10 codes. YB classes were compared, followed by a cluster analysis to identify injury patterns and association with YB classifications.

RESULTS

Overall, 135 patients were included. 98 (72%) of patients presented with LC, 16 (12%) with APC, 8 (6%) with VS, and 13 (10%) with CM. VS and APC groups had higher rates of REBOA use compared to LC and CM groups (38% and 31% versus 11% and 0%, respectively, p = 0.01). The CM group, compared to LC, APC, and VS, had higher rates of urgent operative intervention for bleeding control (69% versus 32%, 50% and 43%, respectively, p = 0.01). 39 (29%) patients had a concomitant injury which was identified by CT scan in initial trauma work up and altered management, 46% which merited urgent intervention. On cluster analysis, there were no distinct injury complexes which required urgent operative intervention by YB class.

CONCLUSIONS

These data failed to identify unique injury complexes which merit urgent operative intervention by YB class. Nearly one in four patients had injuries identified by initial CT imaging which altered initial management, demonstrating the importance of early, full body CT imaging in severely injured patients with pelvic ring injuries.

Trends and predictors of mortality in unstable pelvic ring fracture: a 10-year experience with a multidisciplinary institutional protocol

Background

Pelvic ring fracture is often combined with other injuries and such patients are considered at high risk of mortality and complications. There is controversy regarding the gold standard protocol for the initial treatment of pelvic fracture. The aim of this study was to assess which risk factors could affect the outcome and to analyze survival using our multidisciplinary institutional protocol for traumatic pelvic ring fracture.

Material and methods

This retrospective study reviewed patients who sustained an unstable pelvic ring fracture with Injury Severity Score (ISS) ≥ 5. All patients were admitted to the emergency department and registered in the Trauma Registry System of a level I trauma center from January 1, 2008, to December 31, 2017. The annular mortality rate after the application of our institutional protocol was analyzed. Patients with different systems of injury and treatments were compared, and regression analysis was performed to adjust for factors that could affect the rate of mortality and complications.

Results

During the 10-year study period, there were 825 unstable pelvic ring injuries, with a mean ISS higher than that of other non-pelvic trauma cases. The annual mortality rate declined from 7.8 to 2.4% and the mean length of stay was 18.1 days. A multivariable analysis showed that unstable initial vital signs, such as systolic blood pressure < 90 mmHg (odds ratio [OR] 2.53; confidence interval [CI] 1.11–5.73), Glasgow Coma Scale < 9 (OR 3.87; CI 1.57–9.58), 24 > ISS > 15 (OR 4.84; CI 0.85–27.65), pulse rate < 50 (OR 11.54; CI 1.21–109.6), and diabetes mellitus (OR 3.18; CI 1.10–9.21) were associated with higher mortality. No other specific system in the high Abbreviated Injury Scale increased the rates of mortality or complications.

Conclusion

Poor initial vital signs and Glasgow Coma Scale score, higher ISS score, and comorbidity of diabetes mellitus affect the mortality rate of patients with unstable pelvic ring fractures. No single system of injury was found to increase mortality in these patients. The mortality rate was reduced through institutional efforts toward the application of guidelines for the initial management of pelvic fracture.

Traumatic Injuries of the Pelvis

Traumatic injuries of the hip and pelvis are commonly encountered in the emergency department. This article equips all emergency medicine practitioners with the knowledge to expertly diagnose, treat, and disposition these patients. Pelvic fractures occurring in young patients tend to be associated with high-energy mechanisms and polytrauma. Pelvic and hip fractures in the elderly are often a result of benign trauma but are associated with significant morbidity and mortality.

Young–Burgess classification: Inter-observer and inter-method agreement between pelvic radiograph and computed tomography in emergency polytrauma management

Background:

While there are intrinsic differences in the pros and cons between plain radiographs and computer tomography, the role of pelvic radiographs in polytrauma management is diminishing as computer tomography scans are becoming more accessible. Previous studies found varying results in the inter-observer agreement in pelvic radiograph interpretations.

Objectives:

To evaluate inter-observer agreement of classifying pelvic fractures in major trauma patients by emergency physicians, and the inter-method agreement between plain radiographs and computer tomography scans.

Methods:

Three hundred sixty-nine patients with pelvic trauma were recruited from the trauma registries of four designated trauma centres in Hong Kong, each having one set of anteroposterior pelvic radiographs and pelvic computer tomography scans. Pelvic radiographs were classified by two emergency physicians using Young–Burgess classification, and pelvic computer tomography scans classified by an experienced radiologist. Disagreed pelvic radiographs were evaluated by a senior emergency physician to make a final decision before comparing with computer tomography scans. Cohen’s kappa was used to measure the inter-observer and the inter-method agreements, in the groups ‘mechanism of injury’, ‘stable versus unstable fractures’ and ‘complete classification’.

Results:

Inter-observer agreements of plain radiograph classification for ‘mechanism of injury’, ‘stable versus unstable fractures’ and ‘complete classification’ were moderate to substantial (κ = 0.72, 0.60 and 0.55, respectively). Inter-method agreement for the three groups between plain radiographs and computer tomography were fair to moderate (κ = 0.42, 0.59 and 0.38, respectively).

Conclusion:

The inter-method agreement between plain pelvic radiographs and computer tomography scans was fair in classifying pelvic fractures, and moderate in detection of unstable pelvic fractures. If the patient is haemodynamically unstable or when computer tomography is unavailable, it is reasonable to obtain plain radiographs to screen for unstable pelvic fractures to expedite early intervention. A review in the education approach and material of Young–Burgess classification may improve inter-observer agreement.

Retrospective evaluation of factors influencing transfusion requirements and outcome in cats with pelvic injury (2009-2014): 122 cases

OBJECTIVE

To characterize a population of cats with pelvic trauma and evaluate factors influencing transfusion requirement and outcome.

DESIGN

Retrospective case series (2009-2014).

SETTING

University teaching hospital.

ANIMALS

One hundred twelve client-owned cats with pelvic trauma.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty-one (18.8%) cats received a transfusion. Most cats required only 1 fresh whole blood transfusion (85.8%). Packed cell volume at admission was significantly lower in cats that required transfusion but was not associated with hospitalization time or survival to discharge. Increasing Animal Trauma Triage (ATT) score at admission was significantly associated with transfusion requirement (P = 0.0001) and nonsurvival to discharge (P = 0.03). Number of pelvic fractures was not associated with transfusion requirement but cats with sacroiliac luxations and pubic fractures were more likely to require a transfusion (P = 0.0015 and P = 0.0026, respectively). However, fracture type was not associated with survival to discharge. Most cats (86%) required a surgical procedure and half of transfusions were administered preoperatively. No surgical comorbidities were associated with transfusion requirement or survival. Transfusion requirement was associated with longer length of hospitalization but not survival to discharge.

CONCLUSIONS

Transfusion requirement in this population of cats with pelvic fractures was fairly high. Transfusion requirement was associated with lower packed cell volume, higher ATT score at admission, longer length of hospitalization, and certain types of pelvic fractures. Transfusion requirement was not associated with surgical comorbidities, surgical intervention, or survival to discharge. Lower ATT score at admission was associated with survival to discharge.

Urethral injury in major trauma

Urethral injury in major trauma is infrequent, with complex problems of diagnosis and treatment. The aims of this study are to determine the incidence and epidemiological factors relating to urethral injury in major trauma, as well as determine if any additional prognostic factors are evident within this cohort of patients. A retrospective review of patients sustaining urethral injury following major trauma was made over a 6-year period, from 2010 to 2015. Quantitative analysis was made using the national trauma registry for England and Wales, the Trauma Audit and Research Network (TARN) database, identifying all patients with injury codes for urethral injury. 165 patients with urethral injuries were identified, over 90% were male, most commonly injured during road traffic accidents and with an associated overall mortality of 12%. Urethral injury in association with pelvic fracture occurred in 136 patients (82%), representing 0.6% of all pelvic fractures, and was associated with double the rate of mortality. Urethral injury was associated with unstable pelvic fractures (LC2, LC3, APC3, VS, CM) but not with a specific pelvic fracture type. This study confirms the rare incidence of this injury in major trauma at 1 per 2 million population per year.

Early management of severe pelvic injury (first 24 hours)

OBJECTIVE

Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject.

DESIGN

A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation; SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence; SFMU) in collaboration with the French Society of Radiology (Société Française de Radiologie; SFR), French Defence Health Service (Service de Santé des Armées; SSA), French Society of Urology (Association Française d'Urologie; AFU), the French Society of Orthopaedic and Trauma Surgery (Société Française de Chirurgie Orthopédique et Traumatologique; SOCFCOT), and the French Society of Digestive Surgery (Société Française de Chirurgie digestive; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE^® methodology.

RESULTS

The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ± ), 11 have a low level of evidence (Grade 2 ± ).

CONCLUSIONS

Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture.

Trans-arterial embolisation (TAE) in haemorrhagic pelvic injury: review of management and mid-term outcome of a major trauma centre

BACKGROUND

Management of pelvic fracture associated haemorrhage is often complex with high morbidity and mortality rates. Different treatment options are used to control bleeding with an on-going discussion in the trauma community regarding the best management algorithm.

MAIN BODY

Recent studies have shown trans-arterial embolisation (TAE) to be a safe and effective technique to control pelvic fracture associated haemorrhage. Computed tomography (CT) evidence of active bleeding, haemodynamic instability, and pelvic fracture patterns are amongst important indicators for TAE.

CONCLUSION

Herein, we aim to provide a comprehensive literature review of the effectiveness of TAE in controlling haemorrhage secondary to pelvic fracture according to the indications, technique and embolic agents, and outcomes, whilst incorporating our Level 1 major trauma centre's (MTC) results between 2014-2017.

Factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma: a retrospective study

Background

Blunt pelvic injuries are often associated with pelvic fractures and injuries to the rectum and genitourinary tract. Pelvic fractures can lead to life-threatening hemorrhage, which is a common cause of morbidity and mortality in trauma. Thus, early identification of patients with pelvic fractures at risk severe bleeding requiring urgent hemorrhage control is crucial. This study aimed to investigate early factors predicting the need for hemorrhage control in blunt pelvic trauma.

Methods

The medical records of 1760 trauma patients were reviewed retrospectively between January 2013 and June 2018. We enrolled 187 patients with pelvic fracture due to blunt trauma who were older than 15 years. The pelvic fracture pattern was classified according to the Orthopedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen (OTA/AO) classification. A multivariate logistic regression model was used to determine independent predictors of the need for pelvic hemorrhage control intervention.

Results

The most common pelvic fracture pattern was type A (54.5%), followed by types B (36.9%) and C (8.6%). Of 187 patients, 48 (25.7%) required pelvic hemorrhage control intervention. Hemorrhage control interventions were most frequently performed in patients with type B fractures (54.2%). Multivariate logistic regression analysis revealed that type B (odds ratio [OR] = 4.024, 95% confidence interval [CI] = 1.666–9.720, p = 0.002) and C (OR = 7.077, 95% CI = 1.781–28.129, p = 0.005) fracture patterns, decreased body temperature (OR = 2.275, 95% CI = 0.134–0.567, p < 0.001), and elevated serum lactate level (OR = 1.234, 95% CI = 1.061–1.435, p = 0.006) were factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma.

Conclusion

Patients with type B and C fracture patterns on the OTA/AO classification, hypothermia, or an elevated serum lactate level are at risk for bleeding and require pelvic hemorrhage control intervention.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0438-8) contains supplementary material, which is available to authorized users.

Pediatric Pelvic Ring Injuries

The purpose of this study was to determine whether pelvic fracture pattern is associated with transfusion requirements or concomitant injuries in pediatric patients. This was a single-institution, retrospective review from 1970 to 2000. Pelvic ring injuries were classified using the Orthopaedic Trauma Association system. Injury Severity Scores were assigned. Ninety patients were included in this study. There were 27 A-type (30.0%), 51 B-type (56.7%), and 12 C-type (13.3%) injuries. Mean Injury Severity Scores were 8.1 for 61 A-type, 12.7 for 61 B-type, and 23.6 for 61 C-type fractures (P<.0001). Transfusion was required for 14.8% of A-type, 18.4% of B-type, and 66.7% of C-type injuries (P=.0009). There was no significant association with the number of units transfused (P=.9614). Decreased pelvic ring fracture stability was associated with an increased need for blood transfusion, although not with the number of units. Pelvic ring fracture stability may be a marker of associated injuries. [Orthopedics. 2018; 41(5):e701-e704.].