Treatment options in the hemodynamically unstable patient with a pelvic fracture

Pre-hospital and emergency department management of pelvic fractures and major trauma centre status: Has practice changed?

Introduction

Pelvic fractures are indicative of high-energy injuries and carry a significant morbidity and mortality and pelvic binders are used to stabilise them in both the pre-hospital and emergency department setting. Our unit gained major trauma centre status in April 2012 as part of a national programme to centralise trauma care and improve outcomes. This study investigated whether major trauma centre status led to a change in workload and clinical practice at our centre.

Methods

A retrospective analysis of all patients admitted with a pelvic fracture for the six-month periods before, after and at one-year following major trauma centre status designation. Data were retrospectively collected from electronic patient records and binder placement assessed using an accepted method. Patients with isolated pubic rami fractures were excluded.

Results

Overall, 6/16 (37.5%) pelvic fracture admissions had a binder placed pre-major trauma centre status, rising to 14/34 (41.2%) immediately post-major trauma centre status and 22/32 (68.8%) ( p = 0.025) one year later. Binders were positioned accurately in 4 patients (80%, one exclusion) pre-major trauma centre status, 12 (92.4%) post-major trauma centre status and 22 (100%) at one year. CT imaging was the initial imaging used in 9 (56.3%) patients pre-major trauma centre status, 29 (85.3%) ( p = 0.04) post-major trauma centre status and 27 (84.4%) at one year.

Discussion

Pelvic fracture admissions doubled following major trauma centre status. Computed tomography, as the initial imaging modality, increased significantly with major trauma centre status, likely a reflection of the increased resources made available with this change. Although binder application rates did not change immediately, a significant improvement was seen after one year, with binder accuracy increasing to 100%. This suggests that although changes in clinical practice often do not occur immediately, with the increased infrastructure and clinical exposure afforded through centralisation of trauma services, they will occur, ultimately leading to improvements in trauma patient care.

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

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