Enhancing fracture diagnosis in pelvic X-rays by deep convolutional neural network with synthesized images from 3D-CT

Pelvic fractures pose significant challenges in medical diagnosis due to the complex structure of the pelvic bones. Timely diagnosis of pelvic fractures is critical to reduce complications and mortality rates. While computed tomography (CT) is highly accurate in detecting pelvic fractures, the initial diagnostic procedure usually involves pelvic X-rays (PXR). In recent years, many deep learning-based methods have been developed utilizing ImageNet-based transfer learning for diagnosing hip and pelvic fractures. However, the ImageNet dataset contains natural RGB images which are different than PXR. In this study, we proposed a two-step transfer learning approach that improved the diagnosis of pelvic fractures in PXR images. The first step involved training a deep convolutional neural network (DCNN) using synthesized PXR images derived from 3D-CT by digitally reconstructed radiographs (DRR). In the second step, the classification layers of the DCNN were fine-tuned using acquired PXR images. The performance of the proposed method was compared with the conventional ImageNet-based transfer learning method. Experimental results demonstrated that the proposed DRR-based method, using 20 synthesized PXR images for each CT, achieved superior performance with the area under the receiver operating characteristic curves (AUROCs) of 0.9327 and 0.8014 for visible and invisible fractures, respectively. The ImageNet-based method yields AUROCs of 0.8908 and 0.7308 for visible and invisible fractures, respectively.

Management of the Geriatric Trauma Patient

With a rapidly aging worldwide population, the care of geriatric trauma patients will be at the forefront of every career in Trauma and Acute Care Surgery. The unique intersection of advanced age, comorbidities, frailty, and physiologic changes presents a challenge in the care of elderly injured patients. It is well established that increasing age is associated with higher mortality and worse outcomes after injury, but it is also clear that there is room for improvement in the management of this special patient population.

Increased Neighborhood Deprivation Is Associated with Prolonged Hospital Stays After Surgical Fixation of Traumatic Pelvic Ring Injuries

BACKGROUND

The purpose of this study was to understand the role of social determinants of health assessed by the Area Deprivation Index (ADI) on hospital length of stay and discharge destination following surgical fixation of pelvic ring fractures.

METHODS

A retrospective chart analysis was performed for all patients who presented to our level-I trauma center with pelvic ring injuries that were treated with surgical fixation. Social determinants of health were determined via use of the ADI, a comprehensive metric of socioeconomic status, education, income, employment, and housing quality. ADI values range from 0 to 100 and are normalized to a U.S. mean of 50, with higher scores representing greater social deprivation. We stratified our cohort into 4 ADI quartiles. Statistical analysis was performed on the bottom (25th percentile and below, least deprived) and top (75th percentile and above, most deprived) ADI quartiles. Significance was set at p < 0.05.

RESULTS

There were 134 patients who met the inclusion criteria. Patients in the most deprived group were significantly more likely to have a history of smoking, to self-identify as Black, and to have a lower mean household income (p = 0.001). The most deprived ADI quartile had a significantly longer mean length of stay (and standard deviation) (19.2 ± 19 days) compared with the least deprived ADI quartile (14.7 ± 11 days) (p = 0.04). The least deprived quartile had a significantly higher percentage of patients who were discharged to a resource-intensive skilled nursing facility or inpatient rehabilitation facility compared with those in the most deprived quartile (p = 0.04). Race, insurance, and income were not significant predictors of discharge destination or hospital length of stay.

CONCLUSIONS

Patients facing greater social determinants of health had longer hospital stays and were less likely to be discharged to resource-intensive facilities when compared with patients of lesser social deprivation. This may be due to socioeconomic barriers that limit access to such facilities.

LEVEL OF EVIDENCE

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

Is the conservative treatment of sacral insufficiency fractures still up to date? Retrospective clinical observational study in 46 patients

BACKGROUND

According to current forecasts, our society will grow older and older, so that the proportion of 6% of the German population from 2017 who were 80 years or older will increase further. The frequency of falls in this patient population lead to a further increase of sacral insufficiency fractures.

HYPOTHESIS

The aim of this study is to evaluate the multimodal interdisciplinary conservative therapy regime for sacral insufficiency fractures in geriatric patients, especially on the basis of mobility and the need for assistance.

PATIENTS AND METHODS

A cohort of patients, who were treated as inpatients at the Waldkrankenhaus St. Marien in Erlangen with ICD-10 for sacral fractures S32.1 as the main diagnosis, was retrospectively examined. Only newly diagnosed sacral insufficiency fractures were taken into account. Patients were divided into groups based on the factors hospital stay, fracture location on the sacrum, and location of concomitant pelvic ring injury. The Barthel Index, the Tinetti's Mobility Test and the Timed Up&Go Test were recorded.

RESULTS

46 patients met the inclusion criteria. Using the conservative therapy, improvements were achieved in all patients in terms of need for care, mobility without aids and risk of falling, also patients with an anterior and posterior pelvic ring fracture. Regard a score improvement in the Barthel Index and Tinetti Mobility Test, patients with bilateral sacral insufficiency fracture (n=17, 37.0%) did not differ significantly from patients with unilateral sacral insufficiency fracture (n=22, 47.8%).

CONCLUSION

In geriatric patients, decisions about therapy should always be made on an individual and interdisciplinary basis. The conservative therapy regimen continues to play an important role in this. The collected tests-consisting of Barthel Index, Tinetti Mobility Test and Timed Up&Go Test-are well suited for further reproducible, objective studies with a larger patient collective.

LEVEL OF EVIDENCE

IV.

Current indications for acute total hip arthroplasty in older patients with acetabular fracture: Evidence in 601 patients from 2002 to 2021

Purpose

Older patient population with acetabular fractures is increasing rapidly, requiring enhanced recovery. Acute total hip arthroplasty (THA) is a good option for these patients, and it is becoming increasing popular. However, acute THA has different indications in different studies. Therefore, a systematic review is needed to assess and comprehend the indications for acute THA in older patients.

Methods

A systematic literature review was conducted to identify a retrospective series or prospective studies in older patients (>60 years) with acetabular fractures. The search timeline was from database construction till December 2021; PubMed, Embase, and Cochrane Library databases were searched. Two trained professional reviewers independently read the full text of documents that met the inclusion criteria and extracted information on the specific methods used and indication information based on the research design.

Results

In total, there were 601 patients with acetabular fractures aged >60 years from 33 studies were obtained. Twenty-eight studies reported that THA was a feasible treatment option for acetabular fractures in geriatric patients with good outcome. The primary indications were dome impaction, irreducible articular comminution, femoral head injury, and pre-existing osteoarthritis or avascular necrosis. The most common patterns were anterior column and posterior hemitransverse, posterior wall, both columns, and T-type.

Conclusion

Acute THA is an effective treatment strategy for older patients with acetabular fractures and should be considered when the abovementioned indications are observed on preoperative images. (PROSPERO: CRD42022329555).

Diagnostic accuracy of pelvic radiographs for the detection of traumatic pelvic fractures in the elderly

PURPOSE

Prompt identification of traumatic pelvic fractures in the elderly is critical to guide clinical management; however, the accuracy of pelvic radiographs is often compromised by multiple factors. The purpose of this study is to examine the diagnostic accuracy of radiographs for the detection of pelvic fractures, with CT as the standard of reference.

METHODS

A retrospective review was performed of patients ≥ 65 years with traumatic pelvic fractures evaluated with both pelvic radiography and computed tomography (CT) from May 2016 to October 2019. Pelvic fractures were classified into fractures of the pubis, ilium, ischium, sacrum, and acetabulum. All pelvic radiographs were independently reviewed by two emergency radiologists. Original CT reports were utilized for the reference standard.

RESULTS

177 patients were included, with a total of 555 fractures. The mean age was 81 years and 68% were female. The most common mechanism of injury was fall (62%), followed by motor vehicle accidents (18%). The most fractured bone was the pubis (314/555 fractures). Global pooled sensitivity for pelvic radiographs in detecting pelvic fractures compared to CT was 48%, with a specificity of 93%. Sensitivity for the detection of pelvic fractures is classified by the following types: pubis 61%, acetabulum 60%, ilium 41%, sacrum 20%, and ischium 17%. Eighteen patients (10%) required surgical fixation. Mortality was 8%.

CONCLUSION

Pelvic radiographs have low sensitivity in detecting traumatic pelvic fractures. These radiographically occult fractures may be clinically significant as a cause of long-term pain and may require orthopedic consultation and possible surgical management.

The impact of specific fracture characteristics of low-energy fractures of the pelvis on mortality

Background

Pelvic fractures in older patients are associated with relevant morbidity and mortality. Both might be determined by fracture morphology and/or patient characteristics. The aim of this project is to investigate the prognostic value of specific fracture characteristics with respect to overall survival and to compare it with an established classification system.

Methods

Retrospective analysis of patients ≥ 60 years, treated conservatively for a CT-scan verified, low-energy pelvic ring fracture between August 2006 and December 2018. Survival data was available from patients’ charts and cantonal or national registries.

The prognostic value of fracture characteristic describing the anterior and posterior involvement of the pelvic ring was investigated. This analysis was repeated after patients were stratified into a high-risk vs a low-risk group according to patient characteristic (age, gender, comorbidities, mobility, living situation). This allowed to assess the impact of the different fracture morphologies on mortality in fit vs. frail senior patients separately.

Results

Overall, 428 patients (83.4% female) with a mean age of 83.7 years were included. Two thirds of patients were still living in their home and mobile without walking aid at baseline. In-hospital mortality was 0.7%, overall, one-year mortality 16.9%. An independent and significant association of age, gender and comorbidities to overall survival was found. Further, the occurrence of a horizontal sacral fracture as well as a ventral comminution or dislocation was associated with an increased mortality. The effect of a horizontal sacral fracture was more accentuated in low-risk patients while the ventral fracture components showed a larger effect on survival in high-risk patients.

Conclusion

Specific fracture characteristics may indicate a higher risk of mortality in conservatively treated patients with a low-energy pelvic ring fracture. Hence, they should be taken into account in future treatment algorithms and decisions on patient management.

Focusing on individual morphological fracture characteristics of pelvic ring fractures in elderly patients can support clinical decision making

Introduction

Pelvic ring fractures in the elderly are often caused by minor trauma. Treatment of these patients is currently based on fracture classification, clinical course, and ability to mobilize. Our aim was to identify morphological fracture characteristics with potential prognostic relevance and evaluate their association with clinical decision making and outcome, as well as their interobserver reliability.

Methods

Five fracture characteristics were investigated as potential variables: 1. Extent of the dorsal pelvic ring fracture (absent, unilateral, bilateral); 2. Extent of the ventral pelvic ring fracture (absent, unilateral, bilateral); 3. Presence of a horizontal sacral fracture; 4. Ventral dislocation; 5. Ventral comminution.

These characteristics were assessed retrospectively in a series of 548 patients. The association of their presence with the decision to perform surgery, failure of conservative treatment and the length of hospital stay (LOS) was determined. Further, the inter-observer reliability for the specific characteristics was calculated and the relation with survival assessed.

Results

Four of the five evaluated characteristics showed an association with clinical decision making and patient management. In particular the extent of the dorsal fractures (absent vs. unilateral vs. bilateral) (OR = 7.0; p < 00.1) and the presence of ventral comminution/dislocation (OR = 2.4; p = 0.004) were independent factors for the decision to perform surgery. Both the extent of the dorsal fracture (OR = 1.8; p < 0.001) and the presence of ventral dislocation (OR = 1.7; p = 0.003) were independently associated with a prolonged overall LOS.

The inter-observer agreement for the fracture characteristics ranged from moderate to substantial.

A relevant association with increased mortality was shown for horizontal sacral and comminuted ventral fractures with hazard ratios (HR) of 1.7 (95% CI: 1.1, 2.5; p = 0.008) and HR = 1.5 (95% CI: 1.0, 2.2; p = 0.048).

Conclusion

In the elderly, the extent of the dorsal fractures and the presence of ventral comminution/dislocation were associated to the decision to undergo surgery, failure of conservative treatment and length of stay. Survival was related to horizontal sacral fractures and ventrally comminuted fractures. These characteristics thus represent a simplified but highly informative approach for the evaluation of pelvic ring fractures in the elderly. This approach can support clinical decision making, promote patient-centred treatment algorithms and thus improve the outcome of individualized care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03222-0.

Polytrauma in the Geriatric Population: Analysis of Outcomes for Surgically Treated Multiple Fractures with a Minimum 2 Years of Follow-Up

INTRODUCTION

This study analyzed the clinical and radiological outcomes of geriatric polytrauma patients who had multiple fractures surgically treated and a minimum of 2 years of follow-up.

METHODS

Eighty-six geriatric patients with polytrauma and multiple fractures which were surgically treated in orthopedics and who had a minimum of 2 years of follow-up were retrospectively analyzed. Patients' demographic characteristics, comorbidities, and follow-up time were recorded. The mechanism of injury, fracture type and location, Injury Severity Score (ISS), American Society of Anesthesiologists (ASA) score, duration of hospital stay, complications, and 1-year mortality were also recorded. Fracture union, implant failure, and refractures/misalignment were analyzed from radiographs.

RESULTS

There were 34 (39.5%) male and 52 (60.5%) female patients. Mean age was 73.5 years with an average follow-up time of 32.9 months. Patients had more low-energy traumas and more lower extremity, comminuted fractures. On the contrary, high-energy traumas and femur/pelvic fracture surgeries had higher associated mortality. The mean ISS score was 26.3. The most common ASA score was ASA 3 (75.8%). The most common clinical and radiological complications were prolonged wound drainage and implant failure. The total 1-year mortality rate was 22.1%. Patients with high ASA scores and patients with lower extremity fractures (femoral/pelvic fractures) also had significantly increased mortality rates. No significant relation was detected between mortality and ISS, fracture type, number of fractures, and duration of hospital stay.

CONCLUSION

Orthopedic surgeons must be alert about the possible complications of femoral fractures and comminuted fractures including pelvic girdle. Surgically treated, multifractured patients with high-energy trauma, advanced age, and high ASA scores are also at risk for mortality regardless of the ISS, comorbidities, and duration of hospital stay. Pulmonary thromboemboli must be kept in mind as a significant complication for mortality.

Inverse association between sarcopenia and displacement in the early phase of fragility fractures of the pelvis

Objectives

Fragility fractures of the pelvis (FFP) commonly occur in the frail elderly. Displacement in the posterior pelvic ring is recognized as the key sign of instability. This study aims to elucidate the relationship between computer tomography (CT)-based frailty markers and displacement of the posterior pelvic ring within 7 days after injury.

Methods

This retrospective study included 49 patients (42 females, 7 males) with FFP (type I 10, type II 24, type III 12, type IV 3). On a CT slice at the level of the third lumbar vertebra, skeletal muscle area, skeletal muscle radiation attenuation, and skeletal muscle index (SMI) were calculated as sarcopenia markers. Osteopenia was measured with trabecular region of interest attenuation technique on the same CT slice.

Results

There was no difference in the demographics between non-displaced and displaced FFP. CT-based data showed that patients with FFP had osteopenia. However, no difference was found between non-displaced and displaced FFP. SMI was higher in FFP types III/IV than non-displaced FFP when CT-based data on sarcopenia were compared among all patients. Female patients with FFP demonstrated similar results. Logistic regression analysis using the demographics and CT-based markers on sarcopenia and osteopenia revealed that SMI was a potential determinant of displacement of the posterior pelvic ring fractures.

Conclusions

There was inverse association between sarcopenia and displacement of the posterior pelvic ring in the early phase of FFP. Relatively preserved muscle may develop displacement in the elderly with osteopenia.

Does 3D Printing-Assisted Acetabular or Pelvic Fracture Surgery Shorten Hospitalization Durations among Older Adults?

Acetabular or anterior pelvic ring fractures are rare but extremely complicated and challenging injuries for orthopedic trauma surgeons. Three-dimensional (3D) printing technology is widely used in the management of these two fracture types for surgical benefits. Our study aimed to explore whether 3D printing-assisted acetabular or pelvic surgery is beneficial in terms of shortening the length of hospital stay (LHS) and intensive care unit (ICU) stay (ICU LS) for older patients. This retrospective study included two groups of 76 participants over 60 years old who underwent operations with (n = 41) or without (n = 35) guidance by 3D printing. The Mann–Whitney U test was used to analyze continuous variables. Chi-square analysis was applied for categorical variables. Univariable and multivariable linear regression models were used to analyze the factors associated with LHS. The median LHS in the group without 3D printing assistance was 16 (12–21) days, and the median ICU LS was 0 (0–2) days. The median LHS in the group with 3D printing assistance was 17 (12.5–22.5) days, and the median ICU LS was 0 (0–3) days. There was no significant difference in LHS associated with 3D printing assistance vs. that without 3D printing among patients who underwent open reduction and internal fixation for pelvic or acetabular fractures. The LHS positively correlated with the ICU LS whether the operation was 3D printing assisted or not. For fracture surgery in older patients, in addition to the advancement of surgical treatment and techniques, medical teams require more detailed preoperative evaluations, and more personalized medical plans regarding postoperative care to achieve the goals of shortening LHS, reducing healthcare costs, and reducing complication rates.

Beyond Hip Fractures: Other Fragility Fractures' Associated Mortality, Functional and Economic Importance: A 2-year-Follow-up

Background

Hip fractures are well researched in orthogeriatric literature. Equivalent investigations for fragility-associated periprosthetic and periosteosynthetic femoral, ankle joint, pelvic ring, and rib fractures are still rare.

The purpose of this study was to evaluate mortality, functional outcome, and socioeconomic parameters associated to the upper-mentioned fragility fractures prospectively in a 2-year follow-up.

Methods

Over the course of a year, all periprosthetic and periosteosynthetic femoral fractures (PPFF), ankle joint fractures (AJ), pelvic ring fractures (PR), and rib fractures (RF), that were treated on a co-managed orthogeriatric ward, were assessed. Parker Mobility Score (PMS), Barthel Index (BI), place of residence, and care level were recorded. After 2 years, patients and/or relatives were contacted by mailed questionnaires or phone calls in order to calculate mortality and reevaluate the mentioned parameters.

Results

Follow-up rate was 77.7%, assessing 87 patients overall. The relative mortality risk was significantly increased for PR (2.9 (95% CI: 1.5–5.4)) and PPFF (3.5 (95% CI: 1.2–5.8)) but not for RF (1.5 (95% CI: 0.4–2.6)) and AJ (2.0 (95% CI: 0.0–4.0)). Every fracture group except AJ showed significantly higher BI on average at follow-up. PMS was, respectively, reduced on average for PR and RF insignificantly, but significantly for PPFF and AJ in comparison to pre-hospital values. 10.0–27.3% (each group) of patients had to leave their homes permanently; care levels were raised in 30.0–61.5% of cases.

Discussion

This investigation provides a perspective for further larger examinations. PR and PPFF correlate with significant increased mortality risk. Patients suffering from PPFF, PR, and RF were able to significantly recover in their activities of daily living. AJ and PPFF conclude in significant reduction of PMS after 2 years.

Conclusion

Any fragility fracture has its impact on mortality, function, and socioeconomic aspects and shall not be underestimated. Despite some fractures not being the most common, they are still present in daily practice.

Low-energy lateral compression type 1 (LC1) pelvic ring fractures in the middle-aged and elderly affect hospital quality measures and functional outcomes

PURPOSE

The purpose of this study was to examine hospital quality measures and the long-term functional outcomes associated with lateral compression type 1 [LC1] pelvic ring injuries.

METHODS

A query was performed from December 2011 to September 2020 at two institutions within one hospital system for patients with a pelvic fracture diagnosis. Chart review was performed on admitted patients to determine demographic information, medical co-morbidities (to calculate Charlson Co-morbidity Index), in-hospital complications, length of stay [LOS], discharge disposition, and 30-day readmission rates. All patients included were treated nonoperatively. An attempt was made to contact all patients for long-term follow-up to assess current functional status with a Short Musculoskeletal Function Assessment [SMFA].

RESULTS

Two-hundred and eighty-six patients were included, with 172 (65.9%) patients admitted and analyzed with respect to hospital quality measures. Patients admitted were older (83 vs 80 years, p = 0.015) with more medical co-morbidities (p = 0.001) than those discharged from the emergency department. The average LOS was 5.7 ± 3.7 days and 31 (18%) experienced in-hospital complications. The inpatient mortality rate was 1.2%, and the 30-day readmission rate was 8.1%. When comparing admitted patients without concomitant injuries, admitted patients with concomitant injuries, and non-admitted patients, admitted patients with concomitant injuries were found to have more medical co-morbidities (p = 0.001). Forty-three patients were available for long-term follow-up (average 36.6 ± 7.3 months), with an average SMFA score of 29.0 ± 25.7.

CONCLUSIONS

Patients admitted for LC1 pelvic fractures are likely to be older with more medical co-morbidities, and up to 1/5th will experience inpatient complications. Although inpatient mortality remains low, this injury pattern can lead to significant functional disability that persists for several years after injury.

Pelvic fractures in severely injured elderly: a double-adjustment propensity score matched analysis from a level I trauma center

Purpose

Pelvic trauma has increased risk of mortality in the elderly. Our study aimed to analyze the impact of the additional burden of pelvic fractures in severely injured elderly.

Methods

This is a retrospective analysis of a prospectively maintained trauma registry from 2012 to 2018 at an American College of Surgeons (ACS) verified Level I Trauma Center. Trauma patients aged ≥ 65 years with ISS ≥ 16 and AIS severity score ≥ 3 in at least two body regions were divided in two groups: group I, consisted of elderly polytrauma patients without pelvic fractures, and group II elderly who had concomitant pelvic fractures. We used a double-adjustment method using propensity score matching (PSM) with subsequent covariate adjustment to minimize the effect of confounding factors, and give unbiased estimation of the impact of pelvic fractures. Balance assessment was conducted by computing absolute standardized mean differences (ASMDs) and ASMD < 0.10 reflects good balance between groups.

Results

Of 12,774 patients admitted during this time, 411 (3.2%) elderly with a mean age of 77.75 ± 8.32 years met the inclusion criteria. Of this cohort, only 92 patients (22.4%) had pelvic fractures. Females outnumbered males (55 vs. 45%). Comparing characteristics of group I and group II using ASMDs, pelvic trauma patients were more likely to have higher systolic blood pressure (SBP), head injuries, lower extremity injuries, anticoagulant therapy, and cirrhosis. Fewer variables differed significantly after matching. We observed few instances of worse outcomes associated with pelvic trauma using PSM with and without covariate adjustment. Crude PSM without covariate adjustment, showed a significantly higher rate of deep vein thrombosis (DVT) for pelvic trauma (p < 0.001). Crude PSM also showed a significantly higher rate of ventilator-associated pneumonia (VAP) in group II (p = 0.006). PSM with covariate adjustment did not confirm differences on these outcomes. PSM both without and with covariate adjustment found lower ventilator days and ICU length of stay among patients with pelvic trauma. No significant differences were seen on 12 outcomes: death, acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), cardiac arrest with cardiopulmonary resuscitation (CPR), myocardial infarction (MI), pulmonary embolism (PE), unplanned intubation, unplanned admission to intensive care unit (ICU), catheter-associated urinary tract infection (CAUTI), and hospital length of stay.

Conclusions

At a Level I Trauma Center the additional burden of pelvic fractures in seriously injured elderly did not translate into higher mortality. PSM without covariate adjustment suggests worse rates among pelvic trauma patients for DVT and VAP but covariate adjustment removed statistical significance for both outcomes. Pelvic trauma patients had shorter time on ventilator and in the ICU. Whether similar analytic methods applied to patients from larger data sources would produce similar findings remains to be seen.

Pelvic Fractures and Associated Injuries in Patients Admitted to and Treated at Emergency Department of Tibebe Ghion Specialized Hospital, Bahir Dar University, Ethiopia

Background

Pelvic fractures are high-risk injuries that require careful evaluation due to significant patient morbidity and mortality associated with damage to major blood vessels, nerves, and organs. Thus, the aim of this study was to assess pelvic fractures and associated injuries among patients presented at the emergency department of Tibebe Ghion Specialized Hospital, Bahir Dar, Ethiopia.

Methods

This is a cross-sectional study with a retrospective facility-based data collection technique. All patients who were managed for pelvic fracture from September 2018 to February 2021 were included. The patient’s chart number was collected from the orthopedics surgery morning register sheet and their case folders were retrieved from the medical record department. We used a structured and pretested checklist, and chart review for data collection. The collected data were cleaned, coded, and entered into Epi Info version 7 and exported to SPSS version 24 for analysis. Binary logistic regression analysis was used to identify factors associated with a pelvic fracture.

Results

We studied 64 cases of pelvic fracture during the study period. Pelvic was common among males with a ratio of 7:1 and young population (15–35 years). The most common associated injuries were lower extremity 23 (35.9%), abdominal injuries 16 (25.0%), and urethral injury in 13 (20.3%). Moreover, most patients with pelvic fracture have Tile A fracture 56.3%, Tile C in 20 (31.3%), and Tile B in 8 (12.5%) patients. The road traffic accident was the most common cause of pelvic fracture in 56.3%, followed by fall down accident (28.1%), and bullet injury (12.5%).

Conclusion

The incidence of pelvic fracture was high in the study area. It reflects the need for strong and multi-sectoral collaboration to prevent pelvic fracture. Additionally, it needs a careful, systematic management approach for survival, healing, and to address the associated complexities and the polytrauma nature.

Detecting pelvic fracture on 3D-CT using deep convolutional neural networks with multi-orientated slab images

Pelvic fracture is one of the leading causes of death in the elderly, carrying a high risk of death within 1 year of fracture. This study proposes an automated method to detect pelvic fractures on 3-dimensional computed tomography (3D-CT). Deep convolutional neural networks (DCNNs) have been used for lesion detection on 2D and 3D medical images. However, training a DCNN directly using 3D images is complicated, computationally costly, and requires large amounts of training data. We propose a method that evaluates multiple, 2D, real-time object detection systems (YOLOv3 models) in parallel, in which each YOLOv3 model is trained using differently orientated 2D slab images reconstructed from 3D-CT. We assume that an appropriate reconstruction orientation would exist to optimally characterize image features of bone fractures on 3D-CT. Multiple YOLOv3 models in parallel detect 2D fracture candidates in different orientations simultaneously. The 3D fracture region is then obtained by integrating the 2D fracture candidates. The proposed method was validated in 93 subjects with bone fractures. Area under the curve (AUC) was 0.824, with 0.805 recall and 0.907 precision. The AUC with a single orientation was 0.652. This method was then applied to 112 subjects without bone fractures to evaluate over-detection. The proposed method successfully detected no bone fractures in all except 4 non-fracture subjects (96.4%).

Optimizing Pelvic X-Ray indication in blunt trauma patients using clinical criteria

OBJECTIVE

to identify a subgroup of blunt trauma patients with very low chance of sustaining pelvic fractures based on clinical criteria.

METHODS

retrospective analysis of the trauma registry data, collected in a period of 24 months. We selected adult blunt trauma patients who had a PXR on admission. The frequency of pelvic fractures was calculated for the following groups: Normal neurological examination at admission (NNE), hemodynamical stability (HS), normal pelvic examination at admission (NPE), less than 60 years old (ID<60) and absence of distracting injuries (ADI). Logistic regression analysis was carried out in order to create a probability model of negative PXR.

RESULTS

an abnormal PXR was identified in 101 (3.3%) out of the 3,055 patients who had undergone a PXR at admission. Out of these, 1,863 sustained a NNE, with 38 positive CXRs (2.0%) in this group. Considering only the 1,535 patients with NNE and HS, we found 28 positive PXRs (1.8%). Out of these, 1,506 have NPE, with 21 abnormal PXRs (1.4%). Of these, 1,202 were younger than 60 y, with 11 positive PXRs (0.9%). By adding all these criteria to the ADI, we found 2 abnormal PXRs in 502 (0.4%) cases. The probability model including all these variables had a 0,89 area under the ROC curve.

CONCLUSIONS

by adding clinical criteria, it is possible to identify a group of trauma patients with very low chance of sustaining pelvic fractures. The necessity of PXR in these patients needs to be reassessed.

Mobility and mortality of 340 patients with fragility fracture of the pelvis

PURPOSE

To investigate prognosis of patients with fragility fracture of the pelvis (FFP) treated in a single trauma unit in Japan.

METHODS

We retrospectively investigated 340 consecutive patients with FFP (40 men, 300 women; average age, 82.5 years) treated in our facility from April 2012 to April 2019. Fractures were categorized according to the Rommens classification. Patients' mechanism of injury, existence of hip implant, standing and walking abilities (using the Majeed score), and 1-year mortality rate were evaluated.

RESULTS

According to the Rommens classification, there were 84 type Ia, 2 type Ib, 24 type IIa, 78 type IIb, 51 type IIc, 40 type IIIa, 1 type IIIb, 4 type IIIc, 1 type IVa, 51 type IVb, and 3 type IVc fractures. Sixteen patients (4.7%) received surgical treatments. Twenty-eight patients (8.2%) had no memory of a traumatic event, and 61 (18%) had implants from a previous hip surgery. A total of 176 patients (52%) were followed up for ≥ 1 year, and 70 (39.8%) and 67 (38.1%) patients had recovery of standing and walking abilities, similar to those before the injury. The operative group (7/9 = 77.8%) had a higher proportion of patients who regained their standing and walking abilities at the 1-year follow-up than the conservative group. The 1-year mortality rate of the patients who could be followed for ≥ 1 year was 6.7%.

CONCLUSION

According to our data, 4.7% of patients were indicated for surgery, and only < 40% of patients were able to regain their pre-injury standing and walking abilities at 1 year after the injury. FFP may greatly affect an elderly's activities of daily living and may lead to prognosis similar to patients with proximal hip fractures. To regain the walking ability of patients with FFP, more aggressive indication of surgical treatment may be considered depending on the patient's background. Further examinations are necessary to determine the surgical indications and treatment protocol for FFP.

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.

Morbidity and mortality following pelvic ramus fractures in an older Atlantic Canadian cohort

Background

Pelvic ramus fractures in older patients are associated with substantial morbidity and mortality. There is a paucity of literature on fractures of the pelvis in this age group. The purpose of this study was to report mortality rates following such injuries. In addition, we aimed to describe and quantify the important resultant morbidity in this vulnerable population.

Methods

We performed a retrospective chart review of all low-energy pelvic ramus fractures in patients more than age 60 years that occurred between January 2000 and December 2005. Data on survival, hospital length of stay, ambulatory status and place of residence were recorded. For comparison, we calculated the mortality rate for a surrogate age- and sex-matched group using Statistics Canada survival data for use as an uninjured control group.

Results

We identified 43 patients (32 women [74%]; mean age 79.4 yr) with isolated low-energy pelvic ramus fractures over the study period. The 1- and 5-year mortality rates were 16.3% (95% confidence interval [CI] 7.8%–30.3%) and 58.1% (95% CI 43.3%–71.6%), respectively, both significantly higher than the point estimates for the control group (6.6% and 31.3%, respectively). Following injury, 14/39 patients (36%) permanently required increased ambulatory aids, and 8 (20%) required a permanent increase in everyday level of care.

Conclusion

The results suggest that there may be increased mortality and morbidity following low-energy pattern pelvic ramus fractures in an older population compared to age- and sex-matched uninjured control subjects.

Loss of Ambulatory Independence Following Low-Energy Pelvic Ring Fractures

Introduction:

Lateral compression type 1 (LC1) pelvic ring fractures make up 63% of all pelvic ring injuries. This fracture pattern is typically seen in older patients. The purpose of this study is to assess the ambulatory status of individuals sustaining LC1 fractures at long-term follow-up and what specific characteristics, if any, effect this status or functional outcomes.

Methods:

Over a 2-year period, all pelvic ring injury at 2 hospitals within one academic institution was queried. One hundred sixty-one low-energy LC1 pelvic fractures were identified.

Results:

Fifty patients were available for long-term outcomes (mean: 36 months). Long-term functional outcomes (mean follow-up: 36 months) as measured by SMFA subgroup scores were demonstrated to be 3 times higher in patients currently using assistive devices for walking (P = .012). Increased age (P = .050) was associated with the continued use of assistive walking devices. Of the patients who did not use an ambulatory device prior to LC1 injury, 5 (11.6%) sustained a fall or medical complication within 30 days of the index pelvic fracture; this was associated with the current use of an assistive ambulatory device (P = .010). Forty-three (86%) patients didn’t use an assistive ambulatory device prior to sustaining the LC1 fracture. Seven (14%) patients utilized assistive devices both before and after the LC1 injury. Thirteen (26%) patients, who did not utilize assistive ambulatory devices prior to their injury, necessitated them at long-term follow-up.

Discussion:

Surgeons should be aware of these associations, as they can implement early interventions aimed at patients at risk, for assistive device use, following LC1 pelvic fractures.

Conclusion:

More than a quarter of the patients sustaining an LC1 pelvic fracture continue to use an aid for ambulation at long-term follow-up. Older age, complications, and falls within 30 days of this injury are associated with the utilization of an assistive ambulatory device.

Survival Benefit of Treatment at or Transfer to a Tertiary Trauma Center among Injured Older Adults

Objective: It is well established that seriously injured older adults are under-triaged to tertiary trauma centers. However, the survival benefit of tertiary trauma centers (TC) compared to a non-tertiary trauma centers (Non-TCs) remains unclear for this patient population. Using improved methodology and a larger sample, we hypothesized that there was a difference in hospital mortality between injured older adults treated at TCs and those treated at Non-TCs. Methods: This was a retrospective cohort study of injured older adults (> =55 years) reported to the Oklahoma statewide trauma registry between 2005 and 2014. The outcome of interest was 30-day in-hospital mortality and the exposure variable of interest was level of definitive trauma care (TC vs Non-TC). Overall survival benefit of treatment at a TC as well as the survival benefit of transferring injured older adults to a TC were evaluated using multivariable survival analyses as well as propensity score-adjusted analyses. Results: Of the 25,288 patients eligible for analysis, 43% (10,927) were treated at TCs. Multivariable Cox regression analyses revealed effect modification by age group and time. After adjusting for potential confounders within the age strata, overall, patients treated at TCs were significantly less likely to die within 7 days of admission and this effect was stronger for patients aged 55-64 years (HR 0.41, 95% CI 0.31-0.52) compared to those > =65 years (HR 0.62, 95% CI 0.55-0.70). Overall survival benefit of TCs beyond 7 days was also observed (HR 0.68, 95% CI 0.56-0.83). Similarly, for the survival benefit of transferring injured older adults, after adjusting for the propensity to be transferred and other confounders, transfer to a TC was associated with lower 30-day mortality both for patients less than 65 years old (HR 0.36, 95% CI: 0.27-0.49) and those 65 years and older (HR 0.55, 95% CI: 0.48-0.64). Conclusions: Our results suggest a survival benefit for injured older adults treated at TCs. This benefit was also observed for patients transferred from non-tertiary trauma centers. Further research should focus on identifying specific subgroups of patients who would especially benefit from this level of care to minimize trauma triage inefficiencies.

ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation) randomised controlled, feasibility in older people trial: a study protocol

INTRODUCTION

Pelvic fragility fractures (PFF) are common in older people and associated with a significant burden of mortality and morbidity. This is related to the challenges of appropriate pain control and early mobilisation. The current standard for treatment of PFF is non-surgical management. Minimally invasive surgical techniques for sacral fracture stabilisation have been shown to improve outcomes in terms of pain control and mobility, and they are safe. Randomised controlled trials are required before recommendations can be made for surgical management of PFF to become the new standard of care. This feasibility study will explore several uncertainties around conducting such a trial.

METHODS AND ANALYSIS

ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation) is a single-site randomised controlled, parallel-arm, feasibility trial of surgical stabilisation versus non-surgical management of acute sacral fragility fractures in people aged 70 years and over. Patients will be randomised to either surgical or non-surgical group on a 1:1 ratio. Follow-up of participants will occur at 2, 4 and 12 weeks with safety data collected at 52 weeks. Primary objectives are to determine feasibility and design of a future trial, including outcomes on recruitment, adherence to randomisation and safety. This will be supplemented with a qualitative interview study of participants and clinicians. Secondary objectives will inform study design procedures to determine clinical and economic outcomes between groups, including scored questionnaires, analgesia requirements, resource use and quality of life data. Data analysis will be largely descriptive to inform outcomes and future sample size.

ETHICS AND DISSEMINATION

Ethical approval was granted by the North East Newcastle and North Tyneside 2 Research Ethics Committee (reference 18/NE/0212). ASSERT was approved and sponsored by Nottingham University Hospitals NHS Trust (reference 18HC001) and the Health Research Authority (reference IRAS 232791). Recruitment is ongoing. Results will be presented at relevant conferences and submitted to appropriate journals on study completion.

TRIAL REGISTRATION NUMBER

ISRCTN16719542; Pre-results.

Pelvic ring injury in the elderly: Fragile patients with substantial mortality rates and long-term physical impairment

BACKGROUND

Pelvic ring injuries in the elderly often occur after low-energy accidents. They may result in prolonged immobilization, complications and an intense rehabilitation process. The aim of this study was to assess mortality, physical functioning and quality of life (QoL) in elderly patients with pelvic ring injuries.

METHODS

A cross-sectional study was performed including all elderly patients (≥ 65 years) admitted for a pelvic ring injury between 2007-2016. Mortality and survival were evaluated and patient reported outcome measures (PROMs) were used to assess physical functioning (SMFA) and QoL (EQ-5D). These were compared to age-matched normative data from the general Dutch population.

RESULTS

A total of 153 patients, with a mean age of 79 years (SD 8) at the time of injury, were included in this study. The mortality rate was 20% at 30 days, 27% at 1 year and 41% at 3 years of follow-up. All six patients with a type C fracture died within 30 days. Analyses of the 153 patients showed that increasing age, fracture type C and Injury Severity Score (ISS) were all independent risk factors for mortality. Eventually, after excluding patients that died (N = 78) or were unable to contact (N = 2), 73 patients were eligible for follow-up, of which 53 patients (73%) responded. Mean Short Musculoskeletal Function Assessment (SMFA) scores were respectively 67.4 (function index), 65.2 (bother index), 66.5 (lower extremity), 60.4 (activities of daily living) and 68.2 (emotion). Mean EuroQuol-5D (EQ-5D) score was 0.72. Overall, physical functioning and quality of life were significantly decreased in comparison with normative data from the general population.

CONCLUSION

Elderly people who sustain a pelvic ring injury should be considered as a fragile population with substantial mortality rates. The patients who survived demonstrated a substantially lower level of physical functioning and quality of life in comparison with their age-matched peers from the general population.

LEVEL OF EVIDENCE

IV, therapeutic study.

Geriatric Acetabular Surgery: Letournel's Contraindications Then and Now-Data From the German Pelvic Registry

OBJECTIVE

In his original series of 129 surgically treated acetabular fractures, Letournel did not operate on patients older than 60 years. Almost 30 years later, he still emphasized that no patients with reduced bone quality should be operated on. The aim of the study was to analyze epidemiologic characteristics and treatment modes for today's cohort of elderly patients with acetabular fractures.

DESIGN

Retrospective analysis.

SETTING

Multicenter registry/Level I trauma center.

PATIENTS

Three thousand seven hundred ninety-three patients who had sustained a fracture of the acetabulum.

INTERVENTION

Operative and nonoperative treatment of acetabular fractures.

MAIN OUTCOME MEASUREMENTS

Epidemiologic characteristics, treatment mode, in-hospital mortality, rate of secondary hip arthroplasty, and quality of life indicated by EQ-5D score.

RESULTS

For the multicenter registry, more than 50% of all patients with acetabular fractures had an age of 60 years or over. The age peak was found at 75-80 years. Fifty percent of the elderly patients were treated surgically. The in-hospital mortality was significantly higher in elderly patients than patients younger than 60 years. In our Level I trauma center, surgical treatment by open reduction and internal fixation did not influence in-hospital mortality or quality of life of elderly patients with acetabular fractures.

CONCLUSIONS

Today, elderly persons represent the dominant cohort among patients with fractures of the acetabulum. Fifty-five years after the publication of Letournel's original case series, data indicate that currently, surgical treatment is a common and necessary option in the therapy of acetabular fractures in elderly patients.

LEVEL OF EVIDENCE

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

Trauma in the elderly patient

Major Trauma Centres and Emergency Departments are treating an increasing number of elderly trauma patients in the UK. Elderly patients, defined as those over the age of 65 years, are more susceptible to injury from lesser mechanisms of trauma than younger adults. The number of elderly trauma cases is rising yearly, accounting for >25% of all major trauma nationally. The elderly have different physiological reserves and a different response to trauma due to premorbid frailty, co-existing conditions and prescribed medication. These factors need to be appreciated in trauma triaging, radiological assessment and clinical management. A lower threshold for trauma-call activation is recommended, including a lower threshold for advanced imaging. We will review general principles of trauma in the elderly, outline injury patterns in this age group and illustrate the radiological features per anatomical site, from head to pelvis and the extremities. We advocate using contrast-enhanced computed tomography as the primary diagnostic imaging modality as concern about intravenous contrast agent-induced nephropathy is relatively minor. Prompt investigation and diagnosis leads to timely appropriate treatment, therefore the radiologist can discerningly improve morbidity and mortality in this vulnerable group.

Out-of-hospital and Inter-hospital Under-triage to Designated Tertiary Trauma Centers among Injured Older Adults: A 10-year Statewide Geospatial-Adjusted Analysis

OBJECTIVE

While out-of-hospital under-triage of seriously injured older adults to tertiary trauma centers has long been acknowledged, no study has adjusted for place of injury or evaluated the extent of inter-facility under-triage. We sought to determine distance and confounder adjusted odds of treatment at a tertiary trauma center (TTC) for older adult trauma patients compared to younger trauma patients, for patients transported from the scene of injury and those transferred from a non-tertiary trauma (NTTC) center.

METHODS

This was a retrospective cohort study utilizing data from a statewide trauma registry reported over a 10-year period (2005-14). The outcome of interest was treatment at an American College of Surgeons or state-designated Level I/II trauma center (TTC). The predictor variable of interest was age group (> = 55 years vs. < 55 years). Covariates of interest included patient demographics, clinical characteristics and various distance measures calculated based on the patient's injury location.

RESULTS

84 930 patients met study criteria. Of these 42% (35659) were 55 years and older with an average age of 74 years (SD, 11.6). Older adult patients were on average, injured slightly farther away from a TTC (median distance, 34 vs. 29 miles, p < 0.001). Among patients initially presenting to NTTCs, older adults were significantly more likely to be transferred to another NTTC (53% vs. 34%). After adjusting for confounders and distance measures, older adults were less likely to be treated at TTCs overall (OR = 0.54, 95% CI: 0.52-0.56), whether transported by EMS from the scene of injury (OR = 0.47, 95% CI: 0.44-0.50) or via inter-facility transfer (OR = 0.63, 95%CI: 0.59-0.68).

CONCLUSIONS

Injured older adults face significant under-triage to TTCs whether by EMS from the scene of injury or via transfer from NTTCs. Adjusting for proximity of injury to a TTC does not alter these findings.

Pelvic fractures in the Netherlands: epidemiology, characteristics and risk factors for in-hospital mortality in the older and younger population

PURPOSE

To examine nationwide epidemiology of pelvic fractures in the Netherlands and to compare characteristics and outcome of older versus younger patients as well as predictors for in-hospital mortality.

METHODS

Retrospective review of pelvic fracture patients admitted to all Dutch hospitals (2008-2012) utilizing National Trauma Registry. Average annual incidence of (minor and major) pelvic fractures was calculated for the population. Older (≥ 65 years) and younger (< 65 years) patients were compared. Multivariate regression analysis was performed to identify independent predictors for in-hospital mortality.

RESULTS

Of 11,879 pelvic fracture patients (61.8%, ≥ 65 years), annual incidence of pelvic fractures in older versus younger population was 57.9 versus 6.4 per 100,000 persons. Older patients had lower ISS (7.1 (SD 6.9) vs 15.4 (SD 13.4)) and less frequently had severe associated injuries (15.6 vs 43.5%), an admission systolic blood pressure (SBP) ≤ 90 mmHg (1.6 vs 4.1%) or Glasgow Coma Score (GCS) ≤ 12 (2.0 vs 13.3%) (all, p < 0.01). In-hospital mortality was equal in older and younger patients (5.3 vs 4.8%: p = 0.28). In both subgroups, greatest independent predictors for in-hospital mortality were GCS ≤ 12, ISS ≥ 16, and SBP ≤ 90 mmHg and in all patients age ≥ 65 (OR 6.59 (5.12-8.48): p < 0.01).

CONCLUSION

The annual incidence of (both minor and major) pelvic fractures in the older population was substantially higher than in the younger population. Elderly patients had a disproportionately high in-hospital mortality rate considering they were less severely injured. Among other factors, age was the greatest independent predictor for in-hospital mortality in all pelvic fracture patients.

Outcome and 2-Year Survival Rate in Elderly Patients With Lateral Compression Fractures of the Pelvis

Introduction:

Osteoporotic pelvic ring fractures are a rising problem for surgeons in industrialized countries. There is no evidence-based treatment strategy especially for lateral compression (LC) fractures involving the sacrum. The aim of this study was to evaluate and compare outcome and survival rate of nonoperative and operative treatment strategies for lateral compression fractures.

Patients and Methods:

In a retrospective study, 128 patients (aged ≥65 years) with an Orthopedic Trauma Association (OTA) types B2.1 and B3.3 fracture were included and analyzed regarding demographic and treatment data and adverse events. After a follow-up period of at least 2-year survival rate, quality of life and pain were evaluated using the EuroQol-5D and Short Form–12 questionnaires and the visual analog scale.

Results:

Fifty patients (78.3 ± 7.6 years) obtained operative treatment and 77 patients (82.7 ± 7.9 years) obtained nonoperative treatment. One died within 24 hours after admission. High rates of complications occurred in both groups (operative group: 18% and nonoperative group: 8%). Eighteen percent (14 of the 77) of conservatively treated patients needed operative treatment after discharge due to worsening pain and mobilization. The 2-year follow-up showed a high overall mortality (30%), with a significant higher survival rate for operatively treated patients (2-year survival: operatively treated 82% vs conservative 61%). No difference was found in pain and quality of life.

Discussion:

Elderly patients display a high rate and variety of complications and mortality in the aftermath of lateral compression fractures of the pelvis. Although a significantly higher 2-year survival rate for operatively treated patients was found, this study cannot give proof of superior position for operative treatment. Due to lacking data for alternative treatment algorithms especially for fracture-related immobilized patients, we recommended operative treatment with the aim to reduce complications related to prolonged bed rest and ensure early mobilization.

Predictors of mortality among initially stable adult pelvic trauma patients in the US: Data analysis from the National Trauma Data Bank

OBJECTIVES

Pelvic fractures are associated with increased risk of death among trauma patients. Studies show independent risks predicting mortality among patients with pelvic fractures vary across different geographic regions. This study analyses national data to determine predictors of mortality in initially stable adult pelvic trauma patients in the US.

METHODS

This study is a retrospective analysis of the US National Trauma Data Bank from January 2003 to December 2010 among trauma patients ≥18 years of age with pelvic fractures (including acetabulum). Over 150 variables were reviewed and analysed. The primary outcome was all-cause in-hospital mortality. Logistic regression analysis was used to determine independent risk factors predictive of in-hospital mortality in stable pelvic fracture patients.

RESULTS

30,800 patients were included in the final analysis. Overall in-hospital mortality rate was 2.7%. Mortality increased twofold in middle aged patients (age 55-70), and increased nearly fourfold in patients with advanced age ≥70. We found patients with advanced age, higher severity of injury, Glasgow Coma Scale (GCS) <8, GCS between 9 and 12, prolonged mechanical ventilation, and/or in-hospital blood product administration experienced higher mortality. Patients transported to level 1 or level 2 trauma centres experienced lower mortality while concomitantly experiencing higher associated internal injuries.

CONCLUSIONS

Geriatric and middle aged pelvic fracture patients experience higher mortality. Predictors of mortality in initially stable pelvic fracture patients are advanced age, injury severity, mental status, prolonged mechanical ventilation, and/or in-hospital blood product administration. These patients might benefit from transport to local level 1 or level 2 trauma centres.

Predictors of mortality for complex fractures of the pelvic ring in the elderly: a twelve-year review from a German level I trauma center

STUDY OBJECTIVE

To document mortality rate and predictors of mortality in elderly patients with complex pelvic fractures.

METHODS

We reviewed a total of 84 subjects whose ages were above 70 years with complex pelvic fractures, admitted to our hospital from January 2001 to December 2012. A multivariate linear regression model was used to determine the predictors of mortality in the study population. The median age of the patients was 80.4 years (range 70-94 years). 65 of 84 (77%) patients were females. There were 72 Tile Type B fractures (86%) and 12 Type C fractures (14%). The most common associated injuries were thoracic, extremity and head injuries, with incidence of 13 (15%), 11 (13%), and 9 (11%), respectively.

RESULTS

The mortality rate was 10% in our study population. The initial haemoglobin on admission (p<0.01), the presence of blood vessel injuries (p<0.01) and the number of PRBCs transfused within the first six hours after admission (p<0.01) independently predicted mortality in elderly patients with complex pelvic fractures.

CONCLUSION

Although there is a downward trend in mortality in elderly patients with complex pelvic fractures, haemodynamic instability still has a significant impact on survival of those patients.

Effect of anaesthesia on the perioperative outcomes of pelvi-acetabular fracture surgeries in the apex trauma centre of a developing country-a retrospective analysis

BACKGROUND

Regional anaesthesia has been proposed to reduce intraoperative blood loss, duration of hospital stay and in-hospital complications with improved postoperative pain control. General anaesthesia is advantageous for prolonged surgeries. We hypothesized that combined regional and general anaesthesia would offer advantages of both in pelvi-acetabular fracture surgeries.

METHODS

We identified 71 patients who underwent open reduction and internal fixation of pelvi-acetabular fractures from May 2012 to 2013 in our trauma centre. We excluded patients with incomplete records (n = 4) and other injuries operated along (n = 8). Hence, 59 patients were divided into three groups: G group (general anaesthesia), R group (regional anaesthesia) and GR group (combined regional and general anaesthesia). Main outcome measurements studied were intraoperative blood loss, duration of hospital stay, duration of surgery and intraoperative and postoperative complications.

RESULTS

No differences were obtained in between the groups in terms of age, gender, Injury Severity Score, number of comorbidities, or duration from injury to surgery. No significant differences were found between the three groups for intraoperative blood loss, days of hospital stay and duration of surgery. Intraoperative and postoperative complications were also comparable between the groups (p > 0.05).

CONCLUSIONS

There is no specific significant advantage of the technique of anaesthesia on the observed perioperative complications in pelvi-acetabular fracture surgeries.

Profile, outcome and predictors of mortality of abdomino-pelvic trauma patients in a tertiary intensive care unit in Saudi Arabia

INTRODUCTION

The Kingdom of Saudi Arabia (KSA) is one of countries with the world's highest number of deaths per 100,000 populations from road traffic accidents (RTAs). Numerous trauma victims sustain abdomino-pelvic injuries, which are associated with considerable morbidity and mortality. The purpose of this study was to describe profile, outcomes and predictors of mortality of patients with abdomino-pelvic trauma admitted to the intensive care unit (ICU) in a tertiary care trauma centre in Riyadh, KSA.

METHODS

This was a retrospective analysis of prospectively collected ICU database. All consecutive patients older than 14 years with abdomino-pelvic trauma from March 1999 to June 2013 were included. The followings were extracted: demographics, injury severity, mechanism and type of injury, associated injuries, use of vasopressors and mechanical ventilation, and worst laboratory results in the first 24h. The primary outcome was hospital mortality. We compared profile and outcomes between survivors and non-survivors and reported predictors of mortality.

RESULTS

Of the 11,374 trauma patients who were admitted to the hospital during the study period, 2120 (18.6%) patients had abdomino-pelvic injuries, out of which 702 (33.1%) patients were admitted to the ICU. The mean age was 30.7 (SD 14.4) years and the majority was male (89.5%). RTA was the most common cause of abdomino-pelvic trauma (70.4%). Pelvis (46.2%), liver (25.8%), and spleen (23.1%) were the most frequently injured organs; and chest (55.6%), head (41.9%), and lower extremities (27.5%) were the most commonly associated injuries. Mechanical ventilation was required in 89.6% with a mean duration of 9.1 (SD 9.2) days and emergency surgery was performed in 45.0% of the patients with prolonged ICU and hospital length of stay (10.8 [SD 10.8], 56.9 [SD 96.7] days; respectively). Of the 702 patients with abdomino-pelvic trauma, 115 (16.4%) patients did not survive. Associated head trauma and retroperitoneal haematoma, higher level of lactic acid on admission and ISS, and advanced age were potential risk factors for hospital mortality.

CONCLUSIONS

Abdomino-pelvic injuries are common in trauma patients, affecting mainly young male victims, and are associated with significant morbidity and mortality, and resource utilisation.

Increasing rates of pelvic fractures among older adults: The Netherlands, 1986-2011

BACKGROUND

age-related issues are expected to rise in the coming decades. Osteoporosis, falls and fractures are major public health issues among elderly. Pelvic fractures are associated with a serious morbidity and hospitalisation rate. We therefore performed a study to determine trends in incidence and age-specific rates of pelvic fracture-related hospitalisations among elderly (≥65 years).

METHODS

a secular trend analysis of all hospitalisations due to a pelvic fracture among older adults, using the National Medical Registration, 1986-2011, The Netherlands.

RESULTS

the total number of hospitalisations due to a pelvic fracture increased from 887 in 1986 to 2,013 admissions in 2011 (127% increase). The overall age-adjusted incidence rate increased from 5.19 in 1986 to 7.14 per 10,000 population in 2011 (37.5% increase). The incidence rate increased with age and was higher for females. The Percentual Annual Change was 1.2% (95% CI: 0.9;1.5) for older males, and 1.0% (95% CI: 0.9;1.2) for females, respectively. The mean length of hospital stay decreased between 1991 and 2011 to 12.0 days (53.4% decrease). The total number of hospital-bed-days decreased from 29,002 days in 1991 to 17,283 days in 2011 (40.4% decrease), despite an increase in absolute number of admissions.

CONCLUSION

absolute numbers and incidence rates of pelvic fractures are increasing among the older Dutch population. Considering the fact the general population is growing older, an increasing number of elderly suffer from pelvic fractures. Attention on osteoporosis screening and prevention of falls in elderly remains important, in order to limit-related healthcare costs in the future.

One-year mortality after isolated pelvic fractures with posterior ring involvement in elderly patients

Previous 1-year mortality studies of pelvic fractures in elderly patients have focused on pubic rami fractures, in elderly patients with multiple injuries, or both. Baseline information on the 1-year mortality of isolated pelvic fractures in elderly patients is unavailable. The purpose of this study was to evaluate the 1-year mortality of elderly patients (aged 60 years or older) after isolated pelvic fractures with posterior ring involvement (Orthopaedic Trauma Association type 61-B and C). All patients aged 60 years or older treated for pelvic injuries at a single Level I trauma center over a 12-year period were retrospectively reviewed (N=1223). Exclusion criteria were associated injuries to other body systems (Abbreviated Injury Scale greater than 2), ballistic injuries, long bone fractures, concurrent acetabular fractures, and type 61-A fractures or isolated pubic rami fractures without posterior involvement. Mortality data were obtained from the Social Security Death Index. Seventy patients met the inclusion criteria. Patients treated nonoperatively were significantly older compared with those treated operatively. However, the Charlson Comorbidity Index did not significantly differ between treatment groups. A significantly higher percentage of type-B fractures (83.0%) were treated nonoperatively compared with type-C fractures, which were treated operatively 88.2% of the time. Mortality rates at 3 and 6 months and 1 year postoperatively were 7.1%, 11.4%, and 12.9%, respectively. These results suggest that the 1-year mortality rates of isolated pelvic fractures in elderly patients are lower than those reported previously for hip fractures and pelvic fractures with concurrent injuries. Although age was identified as a significant variable differing between patients treated operatively vs nonoperatively, comorbidities were not.

High-energy skeletal trauma in the elderly

Despite the increasing prevalence of high-energy skeletal trauma in the elderly (i.e., sixty years or older), there is a lack of prospective data regarding best care for these injuries.Elderly patients with multiple injuries are often undertriaged to trauma centers and underresuscitated.Aggressive early resuscitation can improve outcomes in elderly patients who have sustained skeletal trauma.Comanagement by orthopaedic surgeons and geriatricians of elderly patients with skeletal trauma can lead to a lower length of hospital stay, lower readmission rates, shorter time to operation, lower complication rates, and lower mortality.

Direct transport of geriatric trauma patients with pelvic fractures to a Level I trauma center within an organized trauma system: impact on two-week incidence of in-hospital complications

BACKGROUND

Undertriage of elderly trauma patients to tertiary trauma centers is well documented. This study evaluated the impact of directness of transport to a Level I trauma center on morbidity in geriatric trauma patients sustaining severe pelvic fractures.

METHODS

This was a retrospective cohort study of 87 geriatric trauma patients diagnosed with potentially unstable pelvic fractures, treated at a Level I trauma center between 2008 and 2010.

RESULTS

Of the 87 patients, 39% (34 of 87) initially were transported to a nontertiary trauma center. After adjusting for presence of comorbidity and injury severity, the 2-week incidence of complications was 54% higher in transferred patients compared with those directly transported (rate ratio, 1.54; 95% confidence interval, .95-2.54). In particular, transferred patients had increased odds of developing pneumonia/systemic inflammatory response syndrome.

CONCLUSIONS

Despite lacking precision, results of this study suggest an increased risk of complications in transferred geriatric trauma patients with severe pelvic fractures compared with their directly transported counterparts.

Persistent impairment after surgically treated lateral compression pelvic injury

BACKGROUND

Recently, fixation of lateral compression (LC) pelvic fractures has been advocated to improve patient comfort and to allow earlier mobilization without loss of reduction, thus minimizing adverse systemic effects. However, the degree of acceptable deformity and persistence of disability are unclear.

QUESTIONS/PURPOSES

We determined if (1) injury pattern; (2) demographics; (3) final posterior displacement; (4) L5/S1 involvement; (5) associated injuries; and (6) time influence outcome measurements, sexual dysfunction, and pain.

METHODS

We retrospectively reviewed 119 patients with unstable LC injuries treated surgically between 2000 and 2010. There were 52 males and 67 females; mean age was 39 years with a mean body mass index of 27 kg/m(2). All patients underwent clinical examination and radiographic imaging for instability and accompanying injuries. We obtained Short Musculoskeletal Function Assessment (SMFA). The minimum followup was 12 months (mean, 33 months; range, 12-100 months).

RESULTS

SMFA subscores were not affected by injury pattern and demographics. Posterior reduction was less than 5 mm with persistent displacement in 99 of 119 (83%). Displacement of 5 to 10 mm did not affect any SMFA subscore at any time interval. Patients with additional lower extremity injuries had worse SMFA scores. Function improved with time. A visual analog scale pain score of 4 or more at 6 months predicted pain and overall SMFA score at last followup.

CONCLUSIONS

Unstable LC pelvic ring injuries result in persistent disability based on validated outcome measurements. Near anatomical reduction can be achieved and maintained. While our findings need to be confirmed in studies with high rates of followup, patients with unstable LC pelvic injuries should be counseled concerning the possibility of some degree of persistent disability.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Functional outcomes in women after high-energy pelvic ring injury

OBJECTIVES

Residual dysfunction after pelvic trauma has been previously described, but limited functional outcome data are available in the female population after high-energy pelvic ring injury. The purposes of this study were to determine functional outcomes and to characterize factors predictive of outcome.

DESIGN

Prospective collection of functional outcomes data.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Eighty-seven women with mean age of 33.5 years and mean Injury Severity Score of 23.1 were included. The Orthopaedic Trauma Association classification included 32 B-type and 55 C-type fractures. Four were open fractures and six had bladder ruptures.

INTERVENTION

Forty-nine patients were treated operatively and 38 nonoperatively.

MAIN OUTCOME MEASUREMENTS

Musculoskeletal Functional Assessment (MFA) questionnaires were completed after a minimum of 16 months and a mean of 41 months of follow-up.

RESULTS

The mean MFA score was 33. Only 15 women (17.2%) had MFA scores comparable with an uninjured reference value (9.3), and 34 (39.1%) had better than the reference value for prior hip injury (25.5). Anteroposterior compression injuries had worse scores versus other patterns (48.3 vs 31.0, P = 0.01), and trends toward worse outcomes were noted after symphyseal disruption (P = 0.11) and transsymphyseal plating (P = 0.09). Sacral fracture or sacroiliac injury, amount of initial or final displacement, and type of posterior ring treatment were not associated with MFA scores. Mean scores were 32.3 after surgery and 34.0 after nonoperative management (P = 0.67). Functional outcomes were not related to age or Injury Severity Score, but isolated pelvis fractures had better MFA scores (21.1 vs 35.5, P = 0.008) and worse MFA scores (41.7 vs 29.1, P = 0.004) were seen with other lower extremity fractures. Those with bladder ruptures (n = 6) also had poor outcomes, mean MFA 50.0 (P = 0.078).

CONCLUSIONS

Wide variation is seen in functional outcome of women after high-energy pelvic ring fracture as measured by the MFA with mean scores demonstrating substantial residual dysfunction. Better outcomes were noted after isolated fractures and in women who had not sustained other fractures in their lower extremities. History of bladder rupture or anteroposterior compression injury was associated with poor MFA scores.

LEVEL OF EVIDENCE

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

Combined pubic rami and sacral osteoporotic fractures: a prospective study

Background

Pelvic osteoporotic fractures (POFs) are often associated with considerable morbidity and mortality mainly as a result of infections and cardiovascular events. Patients usually need prolonged institutionalization, rehabilitation, and follow-up, with a high rate of dependency and cost. The most common sites of POFs include the pubic rami, sacrum, ilium, and acetabulum. Combined pubic rami (PROFs) and sacral osteoporotic fractures (SOFs) have been reported, mostly in retrospective studies, describing the mechanism of injury and incidence. The aim of this study was to evaluate the association between PROFs and SOFs and to assess the effect of combined PROFs and SOFs on patients’ mobility, discharge destination, and length of stay.

Materials and methods

We prospectively studied 67 patients with low-impact PROFs and/or SOFs. There were 54 (80.4%) female and 13 (19.6%) male patients, and the average age was 87.5 (range 65–96) years. All patients were assessed by the fracture liaison service. Patients had magnetic resonance imaging or bone scan when there was history of low back pain following the injury or lumbosacral tenderness on clinical examination.

Results

The mean length of stay for all patients was 45 (±35) days. Mortality rate was 10.4%. A significant relationship was found between low back pain and a positive finding of sacral fracture. Patients with combined PROFs and SOFs showed significantly longer length of stay than those with isolated PROFs.

Conclusions

The presence of low back pain and tenderness in patients who had low-impact pelvic injuries was highly suggestive of the presence of an associated SOF. There was a high association between sacral and PROFs. The length of stay of patients with PROFs associated with sacral osteoporotic fractures was significantly longer than that of patients with PROFs only. Therefore, we recommend considering the high association between SOFs and PROFs in planning the management and rehabilitation of patients with POFs.

Survivorship and severe complications are worse for octogenarians and elderly patients with pelvis fractures as compared to adults: data from the national trauma data bank

Purpose. This study examined whether octogenarians and elderly patients with pelvic fractures have a different risk of complication and mortality as compared to adults. Methods. Data was gathered from the National Trauma Data Bank from 2002 to 2006. There were 32,660 patients 18-65, 6,408 patients 65-79, and 5,647 patients ≥ 80 years old with pelvic fractures. Descriptive statistics and bivariate and multivariate analyses were performed with the adult population as a referent. Results. Multivariate analysis showed 4.7-fold higher odds of death and 4.57 odds of complications in the octogenarian group after a pelvic fracture compared to adults. The elderly had 1.81-fold higher odds of death and 2.18-fold higher odds of severe complications after sustaining a severe pelvic fracture relative to adults. An ISS ≥ 16 yielded 15.1-fold increased odds of mortality and 18.3-fold higher odds of severe complications. Hypovolemic shock had 7.65-fold increased odds of death and 6.31-fold higher odds of severe complications. Between the ages of 18 and 89 years, there is approximately a 1% decrease in survivorship every 10 years. Conclusions. This study illustrates that patients older than 80 years old with pelvis fractures have a higher mortality and complications rate than elderly or adult patients.

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.