Guidelines for the management of haemodynamically unstable pelvic fracture patients

Enhancing pelvic fracture care: The impact of extraperitoneal pelvic packing on definitive Orthopaedic treatment

This study investigates the impact of extraperitoneal pelvic packing (EPP) on the definitive surgical treatment of pelvic fractures (PF) in trauma patients. While EPP is recognized as an effective life-saving technique for controlling non-compressible retroperitoneal bleeding, concerns persist about its potential to complicate subsequent surgical interventions. A total of 220 trauma patients treated in a single First Level Trauma Centre from October 2016 to December 2021 were analysed. Demographic data, trauma mechanisms, hemodynamic stability, Injury Severity Scores (ISS), New ISS, PF classification (Tile), surgical timelines, and postoperative complications according to the Clavien-Dindo classification were collected. The study population was divided into two groups: those who underwent EPP (n = 42) and those who did not (n = 178). Statistical analyses included propensity score matching to balance baseline characteristics and reduce selection bias. Key findings show that EPP effectively improved survival rates in hemodynamically unstable patients, achieving a survival rate of 71.43 %. However, EPP was associated with delays in definitive surgical treatment and a higher incidence of major postoperative complications (41.67 % vs. 17.65 %, p = 0.014). Despite these delays, EPP did not significantly limit the possibility of achieving definitive surgery or the choice of fixation technique. Patients who underwent both EPP and open reduction internal fixation did not show a higher rate of severe complications compared to those managed without EPP. The study concludes that while EPP should be considered a practical emergency intervention for critically unstable PF patients, and even though it may affect the timing of definitive PF treatment, it does not prevent further surgical management.

Comparison of the MIPPO technique and the modified Stoppa approach in the treatment of unstable anterior pelvic ring injuries: a retrospective cohort study

BACKGROUND

Anterior pelvic ring injuries have gradually become common. Using a minimally invasive technique to treat this injury may be feasible if the reduction and stability can be effectively achieved. We describe a percutaneous technique, minimally invasive percutaneous plate osteosynthesis (MIPPO), to fixate the anterior pelvis via establishing a subperiosteal tunnel between two limited incisions over the iliac crest(s) and pubic ramus in this research.

METHODS

A retrospective cohort study comparing the MIPPO technique (n = 60) versus the modified Stoppa approach (n = 53) for anterior pelvic ring injuries with posterior ring instability was performed from September 2016 to January 2023. The relative surgery variables, follow-up function evaluation, and complications were compared in two groups. The reduction quality of fracture was assessed according to the Matta criterion, and the functional score was evaluated using the Majeed score.

RESULTS

All patients completed follow-up, with an average interval of 39.90 ± 17.53 months (range 12-78). In the MIPPO technique group, the surgery interval and blood losses were lower compared to the modified Stoppa approach group (P<0.05). The mean procedure times and intraoperative blood losses were 69.56 ± 14.04 min/side (range 50-110) and 156.23 ± 49.75 mL/side (range 90-250) for unilateral anterior ring MIPPO fixation separately. All patients got a satisfactory reduction of the fracture. In the follow-up, earlier ambulation, shorter postoperative hospital stays, and lower complication rates were observed for patients using the MIPPO technique compared to the modified Stoppa approach (P<0.05). However, there is no statistical difference in these indicators including fracture union interval, full load time, the Majeed score, patient satisfaction level, and return to pre-injured work rate between the two groups.

CONCLUSION

This clinical experience gives support for the use of the MIPPO technique to stabilize the anterior pelvis. This minimally invasive technique was an effective and safe surgery method and could obtain satisfactory function results, particularly fitting to part of patients with resistance using the modified Stoppa approach.

Outcomes of Preperitoneal Packing and Angioembolization for Hemorrhage Control in Hemodynamically Unstable Pelvic Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Hemodynamically unstable pelvic fractures are often life-threatening injuries; however, the optimal management remains uncertain. This systematic review and meta-analysis aim to evaluate the most appropriate primary management of hemorrhage in adult patients with hemodynamically unstable pelvic fractures by comparing outcomes following the initial use of preperitoneal packing (PPP) vs angioembolization (AE).

METHODS

A systematic search of PubMed, Embase, Google Scholar, and ProQuest databases was conducted following PRISMA guidelines. Studies assessing hemorrhage management in trauma patients with hemodynamically unstable pelvic fractures were included. The data extracted from selected articles included patient demographics, study design, and outcomes such as 24-hour PRBC transfusions, in-hospital mortality, and DVT rate.

RESULTS

Eight articles were included in the systematic review. Among the included studies, 2040 patients with hemodynamically unstable pelvic fractures were analyzed. Meta-analyses revealed that treatment with PPP was associated with fewer 24-hour PRBC transfusions (mean difference = -1.0, 95% CI: -1.8 to -.2) than AE. However, no significant differences were noted in in-hospital mortality (RR: .91, 95% CI: .80-1.05) and the rate of deep vein thrombosis (RR: .89, 95% CI: .62-1.28) between groups.

CONCLUSION

The findings of this study suggest that primary management with PPP was associated with fewer 24-hour PRBC transfusions compared to AE. The choice of primary management with PPP or AE did not significantly impact in-hospital mortality. Future studies should address clinical outcomes and the factors that affect them to better understand the impact of different management strategies and direct the creation of practice management guidelines.

Management of Open Tile C Pelvic Fractures and Their Outcomes: A Retrospective Study of 30 Cases

BACKGROUND

Open Tile C pelvic fractures are particularly severe. However, reports on their management and outcomes are relatively rare. This study analyzed the demographic and clinical characteristics of patients with open Tile C pelvic fractures and describes our management and outcomes of these injuries.

METHODS

This retrospective review included all patients with open Tile C pelvic fractures treated in our department between January 2014 and June 2021. Data on patient demographics, characteristics of the injuries, surgical management, and outcomes were analyzed.

RESULTS

Thirty patients with a mean age of 34.0 years met the diagnostic criteria. The average Injury Severity Score was 40.3. According to the Tile fracture classification, 6 patients sustained type C1.1, 12 sustained type C1.2, 3 sustained type C1.3, 5 sustained C2 and 4 sustained type C3. Most patients had soft tissue injuries in multiple zones. All patients sustained associated injuries. Management consisted of bed rest in 8 cases, external fixation as the final strategy in 14, conversion from external fixation to internal fixation in 3, open reduction with internal fixation in 5, and amputation in 6. The average amount of packed red blood cells transfused was 33.3 units, the average intensive care unit stay was 11.3 days, the mean number of operations required was 6.2, and the mean length of hospital stay was 81.8 days. The main complications were early soft tissue infections and venous thrombosis. One patient died of sepsis and multi-organ failure. Soft tissue injuries in multiple zones increased utilization of hospital resources whereas anorectal injuries did not. Vascular damage accompanying truck crush injuries had a high amputation rate.

CONCLUSION

Open Tile C pelvic fractures require multidisciplinary diagnosis and management and consume considerable hospital resources. More emphasis needs to be placed on this complex injury.

What's old is best again Is anterior plating best for fixation of type-C pelvic fractures? A systematic review and meta-analysis

BACKGROUND

Type-C pelvic fractures are a rare but potentially fatal injury that often leads to poor outcomes, despite surgical fixation. Many fixation methods are used but the optimal method remains contentious, with failure and complications common. This study compared outcomes for each fixation method.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A search of studies which reported on outcomes after surgically treated type-C pelvic fractures was undertaken. Data retrieved included fixation method, length of follow up, surgical revision, and complications rates (hardware breakage, post-operative outcomes, screw mal-positioning, screw loosening, loss of reduction and infection). Study quality was assessed using the Methodological Index for Non-Randomised Studies (MINORS). Pooled revision, outcome and complication rates were calculated using a quality-adjusted model in MetaXL 5.3.

RESULTS

Fifty-two studies met the inclusion criteria representing 1567 patients and 7 fixation methods. The meta-analyses demonstrated high rates of 'less-than-good' outcomes for most fixation methods, with a higher rate for bilateral injuries (overall 23%; unilateral 21% v bilateral 41%). The mean pooled rate for surgical revision rate was 4%, hardware breakage 3%, screw mal-positioning 2%, screw loosening 3%, loss of reduction 5% and infection 4%. Each fixation method had different performance profiles; however, anterior plating outperformed all other fixation methods for patient outcomes, with a 'less-than-good' rate of just 7% vs the pooled mean of 23% and demonstrated at or below pooled mean rates for all complications except revision which was 5%.

CONCLUSIONS

Post-operative outcomes for surgically treated type-C pelvic fractures revealed a 'less-than-good' pooled outcome rate of 23% and a revision rate of 4%. Anterior plates outperformed most other systems particularly for patient reported outcomes. Pooled revision, patient-reported outcome and complication rates for type-C pelvic fractures have not previously been reported and these data provide a benchmark for practice and future research.

Contemporary utility of diagnostic peritoneal aspiration in trauma

BACKGROUND

Focused Assessment with Sonography for Trauma (FAST) has supplanted diagnostic peritoneal lavage (DPL) as the preferred bedside evaluation for traumatic hemoperitoneum. Diagnostic peritoneal aspiration (DPA) is a simpler, faster modification of DPL with an unclear role in contemporary practice. This study delineated modern roles for DPA and defined its diagnostic yield.

METHODS

All trauma patients presenting to our Level I center who underwent DPA were included (May 2015 to May 2020). Demographics, comorbidities, clinical/injury data, and outcomes were collected. The diagnostic yield and accuracy of DPA were calculated against the criterion standard of hemoperitoneum at exploratory laparotomy or computed tomography scan.

RESULTS

In total, 41 patients underwent DPA, typically after blunt trauma (n = 37, 90%). Patients were almost exclusively hypotensive (n = 20, 49%) or in arrest (n = 18, 44%). Most patients had an equivocal or negative FAST and hypotension or return of spontaneous circulation after resuscitative thoracotomy (n = 32, 78%); or had a positive FAST and known cirrhosis (n = 4, 10%). In two (5%) patients, one obese, the catheter failed to access the peritoneal cavity. Diagnostic peritoneal aspiration sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 100%, 100%, and 90%, with an accuracy of 93%. One (2%) complication, a small bowel injury, occurred.

CONCLUSION

Despite near ubiquitous FAST availability, DPA remains important in diagnosing or excluding hemoperitoneum with exceedingly low rates of failure and complications. Diagnostic peritoneal aspiration is most conclusive when positive, without false positives in this study. Diagnostic peritoneal aspiration was most used among blunt hypotensive or postarrest patients who had an equivocal or negative FAST, in whom the preliminary diagnosis of hemoperitoneum is a critically important decision making branch point.

LEVEL OF EVIDENCE

Diagnostic, level III.

Management and outcomes of open pelvic fractures: An update

BACKGROUND

Open pelvic fractures remain challenging in terms of their management. The purpose of this narrative review was to evaluate the latest advances made in the management of these injuries and report on their clinical outcome.

PATIENTS AND METHODS

A literature review was undertaken focusing on studies that have been published on the management of open pelvic fractures between January 2005 and November 2019. Information extracted from each article include demographics, mechanism of injury, injury severity score (ISS), classification of pelvic ring fracture, classification of open soft tissue, specific injury zone classification, number of cases with hemodynamic instability, number of cases that received blood transfusions, amount of packed red blood cells transfused during the first 24 h, number of cases with anorectal trauma, urogenital injury, number of fecal diversional colostomies and laparotomies, angiographies and embolization, preperitoneal pelvic packings, length of stay in intensive care unit (ICU) and in hospital, and mortality.

RESULTS

Fifteen articles with 646 cases formed the basis of this review. The majority of patients were male adults (74.9%). The mean age was 35.1 years. The main mechanism of injury was road traffic accidents, accounting for 67.1% of the injuries. The mean ISS was 26.8. A mean of 13.5 units of PRBCs were administered the first 24 h. During the whole hospital stay, 79.3% of the patients required blood transfusions. Angiography and pelvic packing were performed in a range of 3%-44% and 13.3%-100% respectively. Unstable types of pelvic injuries were the majority (72%), whilst 32.7% of the cases were associated with anorectal trauma, and 32.6% presented with urogenital injuries. Bladder ruptures were the most reported urogenital injury. Fecal diversional colostomy was performed in 37.4% of the cases. The mean length of ICU stay was 12.5 days and the mean length of hospital stay was 53.0 days. The mean mortality rate was 23.7%.

CONCLUSION

Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. Sufficient blood transfusion, bleeding control, treatments of associated injuries, fracture fixation and soft tissue management remain essential for the reduction of mortality and improved outcomes.

Epidemiologic, Postmortem Computed Tomography-Morphologic and Biomechanical Analysis of the Effects of Non-Invasive External Pelvic Stabilizers in Genuine Unstable Pelvic Injuries

Unstable pelvic injuries are rare (3–8% of all fractures) but are associated with a mortality of up to 30%. An effective way to treat venous and cancellous sources of bleeding prehospital is to reduce intrapelvic volume with external noninvasive pelvic stabilizers. Scientifically reliable data regarding pelvic volume reduction and applicable pressure are lacking. Epidemiologic data were collected, and multiple post-mortem CT scans and biomechanical measurements were performed on real, unstable pelvic injuries. Unstable pelvic injury was shown to be the leading source of bleeding in only 19%. All external non-invasive pelvic stabilizers achieved intrapelvic volume reduction; the T-POD^® succeeded best on average (333 ± 234 cm³), but with higher average peak traction (110 N). The reduction results of the VBM^® pneumatic pelvic sling consistently showed significantly better results at a pressure of 200 mmHg than at 100 mmHg at similar peak traction forces. All pelvic stabilizers exhibited the highest peak tensile force shortly after application. Unstable pelvic injuries must be considered as an indicator of serious concomitant injuries. Stabilization should be performed prehospital with specific pelvic stabilizers, such as the T-POD^® or the VBM^® pneumatic pelvic sling. We recommend adjusting the pressure recommendation of the VBM^® pneumatic pelvic sling to 200 mmHg.

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.

Management of pelvic injuries in hemodynamically unstable polytrauma patients - Challenges and current updates

Pelvic injuries are notorious for causing rapid exsanguination, and also due to concomitant injuries and complications, they have a relatively higher mortality rate. Management of pelvic fractures in hemodynamically unstable patients is a challenging task and has been variably approached. Over the years, various concepts have evolved, and different guidelines and protocols were established in regional trauma care centers based mainly on their previous experience, outcomes, and availability of resources. More recently, damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation are being employed in the management of these unstable injuries, without clear consensus or guidelines. In this background, we have performed a computerized search using the Cochrane Database of Systematic Reviews, Scopus, Embase, Web of Science, and PubMed databases on studies published over the past 30 years. This comprehensive review aims to consolidate available literature on the current epidemiology, diagnostics, resuscitation, and management options of pelvic fractures in polytraumatized patients with hemodynamic instability with particular focus on damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation.

Extension of the thoracic spine sign as a diagnostic marker for thoracic trauma

INTRODUCTION

The initial evaluation of patients with thoracic trauma remains a diagnostic challenge for surgery and emergency physicians. Chest sonography plays a key role in the approach for this group of patients, through extended and focused evaluation with trauma sonography (E-FAST).

OBJECTIVES

To establish the diagnostic performance of the extension of the thoracic spine sign using chest sonography in trauma to diagnose hemothorax and compare it with the gold standard test chest computed tomography (CT).

METHODS

This prospective observational study was conducted over 1 year. Patients who attended the emergency room with closed or penetrating thoracic or thoraco-abdominal trauma, an indication for a chest CT as part of a diagnostic evaluation according to institutional protocols, and who previously underwent a chest sonogram to determine the extent of the thoracic spine sign to diagnose hemothorax. Sonographic results were compared to a radiologist's interpretation of the chest CT. The radiologists were blinded to the initial sonogram interpretation.

RESULTS

Seventy-six patients were enrolled with an average age of 32 years. They mainly had closed trauma, which accounted for 77.6% of samples, and 222 chest images were taken. The sensitivity and specificity for this study were 78.7% and 92.6%, respectively, with a positive predictive value and negative predictive value of 65% and 97.8%, respectively.

CONCLUSIONS

Extension of the thoracic spine sign allows rapid identification of the presence, and more precisely, the absence of pleural effusion. This, therefore, allows an appropriate diagnosis and approach in the emergency room in patients with chest trauma.

Novel transcatheter arterial embolization method for hemodynamically unstable pelvic fractures to prevent complications of gluteal necrosis

Purpose

To validate our previously designed transcatheter arterial embolization (TAE) technique for bilateral iliac arteries in unstable pelvic fractures, which is designed to also prevent gluteal necrosis and avoid vasopressors.

Methods

We retrospectively analyzed the data of patients with pelvic fractures who underwent our new TAE procedure to determine the incidence of subsequent gluteal necrosis. We also compared certain variables between patients who underwent TAE before 2005 using a different technique and developed gluteal necrosis and patients who underwent TAE in 2005 and onward using our technique. Gluteal necrosis was confirmed by a radiologist based on imaging findings.

Results

Seventy patients with pelvic fractures who underwent our TAE technique met the inclusion criteria (bilateral iliac arterial embolization and no embolic agent other than a gelatin sponge). Patients’ median age was 47.5 years, 33 were male, and 92.9% (65/70) had unstable fractures. Sixty-eight patients had severe multiple trauma. No patients developed gluteal necrosis following our TAE procedure and the overall survival rate was 82.9% (58/70). We found no statistically significant difference in procedure time between the previous and new technique, although the new procedure tended to be shorter. Furthermore, overall survival did not significantly differ between the groups. Multiple regression analysis revealed that TAE procedure time and external pelvic fracture fixation were independently related to gluteal necrosis.

Conclusions

Our non-selective bilateral iliac arterial embolization procedure involves arresting shock quickly, resulting in no post-procedure gluteal necrosis. The procedure involves cutting the gelatin sponge rather than “pumping” and avoids the use of vasopressors.

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.

Concomitant external and internal hemorrhage: Challenges to managing patients with open pelvic fracture

INTRODUCTION

Managing patients with open pelvic fractures continues to be challenging and requires a multidisciplinary approach. In this study, we examined the characteristics of patients with open pelvic fractures and strategies for managing such patients.

MATERIALS AND METHODS

The records of patients with open pelvic fractures from January 2010 to August 2016 were retrospectively reviewed. Emergency surgery was performed to control hemorrhaging in patients with an active external hemorrhage. Transcatheter arterial embolization (TAE) was used for definitive hemostasis. The relation between cause of death and timing of death was examined. We also compared the characteristics of surviving and non-surviving patients. Furthermore, patients who received both surgery and post-operative TAE were analyzed in detail.

RESULTS

In total, 42 patients with open pelvic fractures were enrolled in the study. The overall mortality rate among patients with open pelvic fractures was 26.2%. Patients whose deaths were related to hemorrhaging and associated injuries died significantly earlier than patients whose deaths were related to sepsis and multiple organ failure (1.3days vs. 12.3days, p<0.001). Sixteen patients (38.1%) received TAE for hemostasis, and their systolic blood pressure (SBP) improved significantly following TAE (from 88.4mmHg to 111.6mmHg, p<0.05). In the patients who received both surgery and post-operative TAE (n=8), the SBP increased significantly after surgery (from 58.8mmHg to 81.1mmHg, p<0.05). Similarly, the patients' SBP after TAE was significantly higher than their post-operative SBP (110.5mmHg vs. 81.1mmHg, p<0.05).

CONCLUSION

Active external hemorrhaging was initially controlled when managing patients with open pelvic fractures; however, most patients also required TAE for definitive hemorrhage control. Early TAE should be considered due to the high probability of concomitant internal and external hemorrhage. Close observation and further infection control are important following the hemostatic procedure.

Effect of angioembolisation versus surgical packing on mortality in traumatic pelvic haemorrhage: A systematic review and meta-analysis

BACKGROUND

The management of complex pattern of bleeding associated with pelvic trauma remains a big challenge for trauma surgeons. We aimed to conduct a comprehensive meta-analysis to compare the outcomes of angioembolisation and pelvic packing in patients with pelvic trauma.

METHODS

We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the CENTRAL; the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists. The primary outcome was defined as mortality. Combined overall effect sizes were calculated using random-effects models. Results are reported as the odds ratio (OR) and 95% confidence interval (CI).

RESULTS

We identified 3 observational studies reporting a total of 120 patients undergoing angioembolisation (n=60) or pelvic packing (n=60) for pelvic trauma. Reporting of the Injury Severity Score (ISS) was variable, with higher ISS in the pelvic packing group. The risk of bias was low in two studies, and moderate in one. The pooled analysis demonstrated that angioembolisation did not significantly reduce mortality in patients with pelvic trauma compared to surgery (OR=1.99; 95% CI= 0.83-4.78, P=0.12). There was mild between-study heterogeneity (I²=0%, P=0.65).

CONCLUSION

Our analysis found no significant difference in mortality between angioembolisation and pelvic packing in patients with traumatic pelvic haemorrhage. The current level of evidence in this context is very limited and insufficient to support the superiority of a treatment modality. Future research is required.

Effect of Early Pelvic Binder Use in the Emergency Management of Suspected Pelvic Trauma: A Retrospective Cohort Study

BACKGROUND

We aimed to evaluate the effect of early pelvic binder use in the emergency management of suspected pelvic trauma, compared with the conventional stepwise approach.

METHODS

We enrolled trauma patients with initial stabilization using a pelvic binder when suspecting pelvic injury. The inclusion criteria were traumatic injury requiring a trauma team and at least one of the following: a loss of consciousness or a Glasgow coma score (GCS) of <13; systolic blood pressure of <90 mmHg; falling from ≥6 m; injury to multiple vital organs; and suspected pelvic injury. Various parameters, including gender, age, mechanism of injury, GCS, mortality, hospital stay, initial vital signs, revised trauma score, injury severity score, and outcome, were assessed and compared with historical controls.

RESULTS

A total of 204 patients with high-energy multiple-trauma from a single level I trauma center in North Taiwan were enrolled in the study from August 2013 to July 2014. The two group baseline patient characteristics were all collected and compared. The trauma patients with suspected pelvic fractures initially stabilized with a pelvic binder had shorter hospital and intensive care unit (ICU) stays. The study group achieved statistically significantly improved survival and lower mean blood transfusion volume and mortality rate, although they were more severe in the trauma score.

CONCLUSIONS

We recommend prompt pelvic binder use for suspected pelvic injury before definitive imaging is available, as a cervical spine collar is used to protect the cervical spine from further injury prior to definitive identification and characterization of an injury.

A case series of pelvic fracture patients who developed lower urinary tract symptoms after transarterial embolization of bilateral internal iliac arteries

Cases

Transarterial embolization of bilateral internal iliac arteries (TAE) is a useful hemostatic method for the management of pelvic fracture patients, but its effects on urinary functions remain unclear. In this study, we evaluated the impact of TAE on lower urinary tract symptoms (LUTS) in 10 pelvic fracture patients.

Outcomes

Lower urinary tract symptoms before and after hospitalization were evaluated by International Prostate Symptoms Score, Overactive Bladder Symptoms Score, and Quality Of Life score. All scores showed significant worsening. The changes did not correlate with sex, age, injury severity score, or durations of unstable hemodynamics or urethral catheterization. Changes of International Prostate Symptoms Score and Quality Of Life score showed significant positive correlations with intervals between the evaluations.

Conclusion

Pelvic fracture patients treated with TAE showed significant worsening of LUTS. Risk for exacerbation of LUTS should be taken into consideration when deciding to use TAE.

Intra-pelvic pressure changes after pelvic fracture: A cadaveric study quantifying the effect of a pelvic binder and limb bandaging over a bolster

INTRODUCTION

Unstable pelvic fractures can be life-threatening due to catastrophic haemorrhage. Non-invasive methods of reducing and stabilising these injuries include pelvic binder application and also lower limb bandaging over a knee-flexion bolster. Both of these methods help close the pelvic ring and should tamponade bleeding. This study aimed to quantify the intra-pelvic pressure changes that occurred with 3 different manoeuvres: lower limb bandaging over a bolster; a Trauma Pelvic Orthotic Device (T-POD) pelvic binder, and a combination of both.

METHODS

Following a pilot study with 2 soft embalmed cadavers, a formal study with 6 unembalmed cadavers was performed. For each specimen an unstable pelvic injury was created (OA/OTA 61-C1) by dividing the pelvic ring anteriorly and posteriorly. A 3-4cm manometric water-filled balloon was placed in the retropubic space and connected to a 50ml syringe and water manometer via a 3-way tap. A baseline pressure of 8cmH₂O (equating to the average central venous pressure) was used for each cadaver. Steady intra-pelvic pressures (more reliably reflecting the pressures achieved following an intervention) were used in the subsequent statistical analysis, using R statistical language and Rstudio. Paired t-test or Wilcoxon's rank sum test were used (depending on the normality of the dataset) to determine the impact of each intervention on the intra-pelvic pressure.

RESULTS

The mean steady intra-pelvic pressures were significantly greater than the baseline pressure for each intervention. The binder and limb bandaging over a bolster alone increased the mean steady pelvic pressures significantly to 24 (SE=5) (p<0.036) and 15.5 (SE=2) (p<0.02)cmH₂O respectively. Combining these interventions further increased the mean steady pressure to 31 (SE=7)cmH₂O. However, this was not significantly greater than pressures for each of the individual interventions.

DISCUSSION

Both lower limb bandaging over a bolster and pelvic binder application significantly increased intra-pelvic pressure above the baseline pressure. This was further increased through combining these interventions, which could be useful clinically to augment haemorrhage control in these fractures.

CONCLUSION

Lower-limb bandaging over a bolster, and pelvic binder application, both significantly increased intra-pelvic pressures, and were greatest in combination. These findings support the use of these techniques to facilitate non-surgical haemorrhage control.

Fractures of the pelvic ring

Traumatic disruptions of the pelvic ring are high energy life threatening injuries. Management represents a significant challenge, particularly in the acute setting in the presence of severe haemorrhage. Initial management is focused on preserving life by controlling haemorrhage and associated injuries. Advances in prehospital care, surgery, interventional radiology and the introduction of treatment algorithms to streamline decision making have improved patient survival. As more patients with unstable pelvic injuries survive, the poor results associated with nonoperative management and increasing patient expectations of outcome are making surgical management of these fractures increasingly common. The aim of operative fracture fixation is to correct deformity and restore function. The advent of percutaneous fixation techniques has reduced the morbidity previously associated with large operative exposures and internal fixation.

Pelvic trauma: WSES classification and guidelines

Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.

The Role of Transcatheter Arterial Embolization in Traumatic Pelvic Hemorrhage: Not Only Pelvic Fracture

Purpose: The most common life-threatening complication of pelvic trauma is bleeding. Arterial bleedings frequently require active management, preferably with transcatheter arterial embolization (TAE). Hemodynamic instability and/or contrast extravasation at computer tomography (CT) examination are reliable indicators of arterial injury. Unstable pelvic fractures are much more hemorrhagic than stable fractures. Nevertheless, an absent or isolated pelvic fracture does not exclude pelvic hemorrhage.

Materials and Methods: A retrospective study was conducted on our institutional database by collecting data of patients who underwent pelvic angiography and/or embolization due to pelvic blunt trauma in the period between August 2010 and August 2015.

Results: In a period of five years, 39 patients with traumatic pelvic bleeding underwent angiography at our institution. Thirty-six of the 39 (92%) patients did show CT signs of active pelvic bleeding. Nineteen of 39 (49%) patients were hemodynamically unstable at presentation. Three of the 39 patients did not require embolization. Technical success was 35/36 (97%), and overall mortality was 3/39 (8%). Notably, 5/39 (13%) patients did not have any pelvic fracture at presentation, and 18/39 (46%) had only isolated or stable pelvic ring fracture.

Conclusions: TAE is an effective technique to treat arterial pelvic bleeding after trauma. The absence of a major pelvic fracture does not exclude the risk of active bleeding requiring prompt treatment.

Effects of internal iliac artery embolization on systemic inflammatory response syndrome in dogs with simulated-pelvic-fracture combined with massive bleeding

BACKGROUND

Pelvic fracture combined with massive bleeding (PFCMB) is a complex issue in clinical practice. Currently, the use of angiography and embolization for the treatment of PFCMB obtains good results. The aim of this study is to observe the effects of early internal iliac artery embolization on the SIRS in dogs with simulated-pelvic-fracture combined with massive bleeding.

METHODS

Twenty adult dogs were randomly divided into an embolization group (EG) and a control group (CG). For the two groups, heart rate, respiratory rate and body temperature and other physiological variables were measured, and IL-6, TNF-α and arterial blood gas levels were monitored. These variables were assayed every 30 min until death in the CG, while dogs in the EG underwent arterial angiography after 60 min of modeling. The internal iliac artery was embolized on the injured side.

RESULTS

The average time to SIRS in the CG was 3.56 h, occurring at a rate of 90 % (9/10) within 24 h, with a mortality rate of 50 % (5/10); the average time to SIRS for the EG was 5.33 h, occurring at a rate of 30 % (3/10) within 24 h, with a mortality rate of 10 % (1/10). When SIRS occurred in the EG, the mean plasma IL-6 level was 52.66 ± 7.38 pg/ml and the TNF-α level was 11.45 ± 2.72 ng/ml, showing a significant difference with those of the CG (P < 0.05). In the two groups, the respiratory rate and leukocyte levels were higher at each monitored time after modeling than those before modeling; the mean arterial pressure, levels of hemoglobin and oxygen partial pressure were significantly lower at each time point after modeling than those before modeling except for the mean arterial pressure at 0 h in EG; the platelet levels at 4 and 8 h were higher than those before modeling; and the differences were statistically significant (P < 0.05). In the EG, the mean arterial pressure, heart rate, respiratory rate and hemoglobin levels at 2 , 4 and 8 h were lower than those at 0 h; the levels of leukocytes, platelets and carbon dioxide partial pressure at 4 and 8 h after modeling were higher than those at 0 h, and the differences were statistically significant (P < 0.05, P < 0.01); in the CG after modeling, the mean arterial pressure, levels of hemoglobin and carbon dioxide partial pressure at 2, 4 and 8 h were lower than those at 0 h; the levels of heart rate and leukocytes were higher than those before modeling; the respiratory rate and platelet levels at 4 and 8 h were higher than those at 0 h; and the differences were statistically significant (P < 0.05). The levels of the mean arterial pressure and hemoglobin at 4 and 8 h and the pH values at 8 h after modeling in the EG were significantly higher than those in the CG, while the heart rate and respiratory rate at 4 and 8 h were significantly lower than those in the CG. The pH values at 8 h after modeling were significantly lower than those of the other monitored times in the CG (P < 0.05, P < 0.01). The two groups had elevated levels of alkaline phosphatase after injury induction.

CONCLUSION

Through the use of an on-spot interventional treatment cabin, early internal iliac artery embolization can control bleeding associated with pelvic fractures, delay the occurrence of SIRS, and improve the success rate of the treatment of pelvic fracture combined with bleeding.

From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment

Ultrasound is a ubiquitous and versatile diagnostic tool. In the setting of acute injury, ultrasound enhances the basic trauma evaluation, influences bedside decision-making, and helps determine whether or not an unstable patient requires emergent procedural intervention. Consequently, continued education of surgeons and other acute care practitioners in performing focused emergency ultrasound is of great importance. This article provides a synopsis of focused assessment with sonography for trauma (FAST) and the extended FAST (E-FAST) that incorporates basic thoracic injury assessment. The authors also review key pitfalls, limitations, controversies, and advances related to FAST, E-FAST, and ultrasound education.

The role of endovascular treatment of pelvic fracture bleeding in emergency settings

PURPOSE

To evaluate the role of endovascular treatment for controlling haemorrhage in haemodynamically unstable patients with pelvic bone fractures and to relate clinical efficacy to pre-procedural variables.

MATERIALS AND METHODS

From March 2009 through April 2013, 168 patients with major pelvic trauma associated with high-flow haemorrhage were referred to our emergency department and were retrospectively reviewed. Pelvic arteries involved were one or more per patient. Embolisation was performed using various materials (micro-coils, Spongostan, plug, glue, covered stent), and technical success, complications, treatment success, clinical efficacy, rebleeding, and mortality rates were assessed. Factors influencing clinical efficacy were also evaluated.

RESULTS

The technical success rate was 100%; no complications occurred during the procedures. Treatment was successful in 94.6% cases, and clinical efficacy was 85.7%. Three patients had to undergo a second arteriography due to recurrent haemorrhage. Fifteen patients died. Pre-embolisation transfusion demand was significantly associated with clinical efficacy.

CONCLUSIONS

Percutaneous embolisation of pelvic bleeding may be considered a safe, effective, and minimally invasive therapeutic option. As haemodynamic stability is the first objective with traumatic haemorrhagic patient, arterial embolisation can assume a primary role. On the basis of our results, pre-procedural transfusion status may be considered a prognostic factor.

KEY POINTS

• The series presented is one of the largest in a single centre. • Arterial embolisation is a life-saving procedure in patients with pelvic haemorrhage. • In pelvic traumas associated with haemorrhage, prognosis is dependent upon prompt treatment. • Transfusion status is significantly related to clinical efficacy.

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

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

Factors associated with pelvic fracture-related arterial bleeding during trauma resuscitation: a prospective clinical study

OBJECTIVES

To determine predictors of pelvic fracture-related arterial bleeding (PFRAB) from the information available in the Emergency Department (ED).

DESIGN

Prospective cohort study.

SETTING

Single level-1 Trauma Center.

PATIENTS

In a 3-year period ending in December 2008, consecutive high-energy pelvic fracture patients older than 18 years were included. Patients who arrived >4 hours after injury or dead on arrival were excluded. Patient management followed advanced trauma life support and institutional guidelines. Collected data included patient demographics, mechanism of injury, vital signs, acid-base status, fluid resuscitation, trauma scores, fracture patterns, procedures, and outcomes. Potential predictors were identified using standard statistical tests: Univariate analysis, Pearson correlation (r), receiver operator characteristic, and decision tree analysis.

INTERVENTION

Observational study.

OUTCOME MEASURES

PFRAB was determined based on angiography or computed tomography angiogram or laparotomy findings.

RESULTS

Of the 143 study patients, 15 (10%) had PFRAB. They were significantly older, more severely injured, more hypotensive, more acidotic, more likely to require transfusions in the ED, and had higher mortality rate than non-PFRAB patients. No single variable proved to be a strong predictor but some had a significant correlation with PFRAB. Useful predictors identified were worst base deficit (BD), receiver operator characteristic (0.77, cutoff: 6 mmol/L, r = 0.37), difference between any 2 measures of BD within 4 hours (ΔBD) >2 mmol/L, transfusion in ED (yes/no), and worst systolic blood pressure <104 mm Hg. Demographics, injury mechanism, fracture pattern, temperature, and pH had poor predictive value.

CONCLUSIONS

BD <6 mmol/L, ΔBD >2 mmol/L, systolic blood pressure <104 mm Hg, and the need for transfusion in ED are independent predictors of PFRAB in the ED. These predictors can be valuable to triage blunt trauma victims for pelvic hemorrhage control with angiography.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Pelvic circumferential compression devices benefit patients with pelvic fractures who need transfers

INTRODUCTION

Patients with pelvic fracture usually require transfers to trauma centers for additional advanced treatment. Patient safety during the transfer should always be a priority. The noninvasive pelvic circumferential compression device (PCCD) can reportedly provide a tamponade effect, which reduces hemorrhage. In the present study, we evaluated the feasibility and efficiency of PCCD in patients with pelvic fracture who required transfer to trauma centers.

MATERIALS AND METHODS

In the present study, we aimed to evaluate patients with pelvic fractures who were transferred from other hospitals. We investigated and compared the characteristics of these types of patients with and without pretransfer PCCD. We compared 2 groups (with and without pretransfer PCCD) of patients under different situations (unstable pelvic fracture, stable pelvic fracture, or indicated for transcatheter arterial embolization). We also analyzed the characteristics of patients with unstable pelvic fracture who were initially evaluated as having stable pelvic fracture primarily before being transferred.

RESULTS

During the 53-month period, we enrolled 585 patients in the study. The patients with unstable pelvic fractures who received pretransfer PCCDs required significantly fewer blood transfusions (398.4 ± 417.6 mL vs 1954.5 ± 249.0 mL, P < .001), shorter intensive care unit length of stay (LOS; 6.6 ± 5.2 days vs 11.8 ± 7.7 days, P = .024), and shorter hospital LOS (9.4 ± 7.0 days vs 19.5 ± 13.7 days, P = .006) compared with patients who did not receive the pretransfer PCCD. The stable patients who received pretransfer PCCDs required significantly fewer blood transfusions (120.2 ± 178.5 mL vs 231.8 ± 206.2 mL, P = .018) and had shorter intensive care unit LOS (1.7 ± 3.3 days vs 3.4 ± 2.9 days, P = .029) and shorter hospital LOS (6.8 ± 5.1 days vs 10.4 ± 7.6 days, P = .018) compared with patients who did not receive the pretransfer PCCD.

CONCLUSION

Pelvic circumferential compression devices benefit patients with pelvic fracture who need to be transferred to trauma centers. Pretransfer PCCDs appeared to be a feasible and safe procedure during the transfer. In discussions between the referring physicians and the receiving physicians, we recommend using pretransfer PCCDs.

Nonsurgical techniques to control massive bleeding

Significant advancements in nonsurgical and surgical approaches to control bleeding in severely injured patients have also improved the treatment of critical trauma-related coagulopathy. Nonsurgical procedures such as angiographic embolization are progressively considered to terminate arterial bleeding from pelvic fractures. The disturbance of coagulation may aggravate bleeding and hamper surgical procedures. The administration of coagulation factors and factor concentrates may be useful for correcting systemic coagulopathy and reducing the need for fresh frozen plasma, platelet, and red blood cell transfusions, which are associated with various adverse outcomes. In this review, nonsurgical management of critical trauma bleeding is discussed.

Retroperitoneal pelvic packing for haemodynamically unstable pelvic fractures in children and adolescents: a level-one trauma-centre experience

PURPOSE

This study aims to review the outcomes of haemodynamically unstable paediatric patients with pelvic fractures undergoing protocol intervention of retroperitoneal pelvic packing (RPP) with external fixation and angiography.

METHODS

From 2004 to 2011, consecutive patients younger than 19 years treated in our centre for haemodynamically unstable pelvic fractures were retrospectively reviewed. From 2008, protocol intervention triad of external fixation, RPP, and angiography with embolization was implemented.

RESULTS

Before 2008, only 2 boys with fall injuries received intervention. One received initial angiography showing extravasation near iliac bifurcation. Laparotomy proceeded without embolization for multiple visceral injuries, but he succumbed postoperatively. The other had persistent bleeding after external fixation but became stabilized after embolization. After 2008 protocol implementation, 5 youngsters received the triad of interventions for unstable pelvic fractures. Mean age was 15.4 yrs. The mean injury severity score was 42 (18-66) with 62.5% mean probability of survival (6.8-98.8%). The mean operating time for RPP was 23 mins (20-35 mins). One boy died of rapid exanguination intraoperatively. The other 4 youngsters recovered for rehabilitation.

CONCLUSION

Fall from heights is a major cause for severe pelvic injuries in our locality. RPP is a simple effective procedure to include in protocol intervention for pelvic fractures. This case series suggests it helps improve haemostasis and survival in unstable young patients, although larger cohorts will be necessary to validate this.

Anterior-posterior compression pelvic fracture increases the probability of requirement of bilateral embolization

INTRODUCTION

Transarterial embolization has become an effective method in the management of pelvic fracture-related retroperitoneal hemorrhage. However, the selection of bilateral embolization or selective unilateral embolization remains controversial. The anterior-posterior compression (APC) pelvic fracture creates a complete diastasis of the anterior pelvis, which might be associated with bilateral sacroiliac joint injuries and further bilateral arterial injuries. In the current study, we evaluated the correlation between APC pelvic fracture and the need for bilateral internal iliac artery (IIA) embolization.

METHODS

During the 78-month investigational period, patients who received either unilateral or bilateral IIA embolization over the injured site, as determined by angiographic findings, were enrolled. The patients with bilateral contrast extravasation (CE) revealed by angiography were compared with the patients with unilateral CE revealed by angiography. Among the patients with only unilateral positive findings (CE or hematoma formation) on computed tomographic scanning, the characteristics and risk factors of patients who required bilateral IIA embolization were analyzed. The patients with postembolization hemorrhage who had received repeat transarterial embolization were also identified and discussed.

RESULTS

Seventy patients were enrolled in the current study. The rate of APC pelvic fracture among patients who received bilateral IIA embolization was 66.7% (18/27), which was significantly higher than the rate among patients who received unilateral IIA embolization (30.2%; 3/43) (P = .006). Of the patients with only unilateral positive findings on computed tomographic scanning, 21.6% (11/51) underwent bilateral IIA embolization because of bilateral CE revealed by angiography. There were also more patients with APC pelvic fracture in this group.

CONCLUSION

In the management of APC pelvic fracture, more attention should be paid to the higher probability of bilateral hemorrhage. Bilateral IIA embolization should be considered in patients with APC pelvic fracture.

Efficacy and safety of emergency non-invasive pelvic ring stabilisation

BACKGROUND

Urgent non-invasive pelvic ring stabilisation (pelvic binding, PB) in shocked patients is recommended by state and institutional guidelines regardless of the fracture pattern. The purpose of this study was to determine the adherence to the guidelines, efficacy of the technique and identification of potential adverse effects associated with PB.

PATIENTS AND METHODS

A 41-month retrospective analysis of the prospective pelvic fracture database was undertaken at a level 1 trauma centre. High-energy pelvic fractures were included in the analysis with exclusion of the A type injuries (AO/OTA classification) and patients who were dead on arrival. Collected data included patient demographics, injury severity score, fracture classification, application and timing of PB, associated injuries, physiological parameters, resuscitation fluids and outcomes. Pre and post-PB radiographs were reviewed. The potential effects of the PB on soft tissue (femoral vessel, bladder and rectal injury) complications were assessed by independent experts.

RESULTS

115 patients with high-energy B and C type pelvic ring injuries were included. Thirty-six (31%) patients presented in haemorrhagic shock on arrival. A total of 43 pelvic bindings were performed, 18 of them on shocked patients. The adherence to the guidelines was 50% (18/36) overall. Analysing fracture types of shocked patients the adherence was: B1 80%, B2 20%, B3 20%, C1 66%, C2 86%, C3 33%. The alignment of the pelvis was improved or perfect on post-PB radiographs in 68% and had not changed in 21%. In some cases of B2 and B3 type injuries the PB increased the deformity after application (11%). There were 10 deaths (8.7%) in the study group, with 4 deaths attributed to acute pelvic bleeding. Two of these had PB applied and two were identified as potential for improvement. One femoral artery injury, four bladder injuries and three rectum injuries were identified in patients who had PB applied. Association between the PB and these injuries is unlikely.

CONCLUSION

The adherence to the guidelines should be improved with further education and system development. The good effect of the technique was evident on radiographs. Although in some lateral compression fracture patterns the deformity increased, no hazards were associated with the use of PB.

Retroperitoneal pelvic packing in the management of hemodynamically unstable pelvic fractures: a level I trauma center experience

BACKGROUND

Our objective is to evaluate the mortality and outcomes of hemodynamically unstable patients with pelvic fractures treated with a protocol that directs the patient to either early pelvic angiography or early retroperitoneal pelvic packing.

METHOD

This is a retrospective review of prospectively collected database at a local trauma center. Hemodynamically unstable pelvic fracture patients received treatment according to our hospital protocol during two different time periods. Before June 2008, these patients underwent early angiography (ANGIO group, n=13), and from June 2008 onward, these patients underwent early pelvic packing and subsequent angiography if there was continued hemorrhage from the pelvis (PACKING group, n=11). The mechanism of injury, physiologic parameters, blood transfusion requirements, time to intervention, trauma scores, and mortality were recorded.

RESULTS

Mean time to intervention in the ANGIO group was longer than that in the PACKING group, although this was not statistically significant (139.5 minutes vs. 78.8 minutes, respectively, p=0.248). Mortality in the ANGIO group was higher than that in the PACKING group; however, this was also not significant (69.2% vs. 36.3%, p=0.107). After univariate analysis, factors associated with mortality included systolic blood pressure, Glasgow Coma Score, Injury Severity Score, Revised Trauma Score, Trauma and Injury Severity Score, pH, and base excess. In the PACKING group, one patient died of uncontrolled hemorrhage from a liver laceration. In the ANGIO group, three patients died of uncontrolled hemorrhage from the pelvic fracture.

CONCLUSION

Early experience in our institution suggests that early pelvic packing with subsequent angiography if needed is as good as angiography with embolization in treating patients with hemodynamically unstable pelvic fractures.

Angioembolization provides benefits in patients with concomitant unstable pelvic fracture and unstable hemodynamics

INTRODUCTION

Pelvic fractures result in hemodynamic instability in 5% to 20% of patients, and the reported mortality rate is 18% to 40%. Previous studies have reported the application of angioembolization in pelvic fracture patients with a systolic blood pressure (SBP) less than 90 mm Hg, a fluid resuscitation requirement of more than 2000 mL, or a blood transfusion of more than 4 to 6 units within 24 hours. In the current study, we attempted to delineate the efficacy and outcome of angioembolization in unstable pelvic fracture patients with concomitant unstable hypotension status.

METHODS

We retrospectively reviewed the charts of patients with pelvic fractures between January 2005 and May 2010. We focused on unstable pelvic fracture patients with an SBP less than 90 mm Hg after fluid resuscitation who did not receive computed tomography scans. The demographics, injury severity score, abbreviated injury scale, and hemodynamic status after angioembolization were analyzed.

RESULTS

In total, 26 patients were enrolled. There were 16 patients receiving angioembolization directly without computed tomography scans and 12 patients receiving emergency laparotomy due to a finding of hemoperitoneum on sonography, followed by angioembolization. In both groups, the SBP improved significantly after angioembolization. The overall survival rate was 85.7%.

CONCLUSIONS

In patients with concomitant unstable hemodynamics and unstable pelvic fracture, angioembolization serves as an effective adjunct to hemostasis. Aggressive embolization should be performed even in patients without contrast extravasation in angiography.

Effect of a new pelvic stabilizer (T-POD®) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures

BACKGROUND

Pelvic fractures, often the result of high energy blunt trauma, are associated with severe morbidity and mortality. A new pelvic stabilizer (T-POD®) provides secure and effective simultaneous circumferential compression of the pelvis.

METHODS

In this study we describe 15 patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the T-POD®. Before and 2 min after applying the T-POD®, heart rate and blood pressure were measured. An X-ray before and directly after applying the T-POD® was made to measure the effect on reduction in symphyseal diastasis.

RESULTS

Application of the T-POD® reduced the symphyseal diastasis with 60% (p = 0.01). The mean arterial pressure (MAP) increased significant from 65.3 to 81.2 mm Hg (p = 0.03) and the heart rate declined from 107 beats per minute to 94 (p = 0.02). Out of ten patients in whom the circulatory response before and after the T-POD® was recorded, seven were good responders, one had a transient response and two responded poor.

CONCLUSION

In the acute setting, the T-POD® device has a clear compressive effect on the pelvic volume in unstable pelvic fractures. The T-POD® is therefore an effective and easy to use device in (temporarily) stabilizing the pelvic ring in haemodynamically unstable patients.

External fixation in pelvic fractures

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

Low-energy osteoporotic pelvic fractures

The vast majority of pelvic fractures in geriatric patients are classified as stable injuries. The current treatment strategies of these fractures involve pain management and mobilization. Pain-related immobility may pose a serious hazard to patients with severe preexisting comorbidities. There is paucity of literature on the outcome and mortality after osteoporotic pelvic fractures in the elderly. This review aims to provide an overview of epidemiology, injury mechanism, fracture patterns, management and outcome after osteoporotic pelvic fractures.

Management of bleeding following major trauma: an updated European guideline

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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