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Kolitsas A, Williams EC, Lewis MR, Benjamin ER, Demetriades D. Preperitoneal pelvic packing in isolated severe pelvic fractures is associated with higher mortality and venous thromboembolism: A matched-cohort study. Am J Surg 2024; 236:115828. [PMID: 39059112 DOI: 10.1016/j.amjsurg.2024.115828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/25/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION Preperitoneal pelvic packing (PPP) has been advocated as a damage control procedure for pelvic fracture bleeding, despite of weak evidence. METHODS Matched cohort study, TQIP database. Patients with isolated severe blunt pelvic fractures (pelvis abbreviated injury score [AIS] ≥ 3, AIS ≤2 in all other body regions) were included. Patients who underwent PPP were matched to patients with no PPP, 1:3 nearest propensity score. Matching was performed based on demographics, vital signs on admission, comorbidities, injury characteristics, type and timing of initiation of VTE prophylaxis, and additional procedures including laparotomy, REBOA, and angioembolization. RESULTS 64 patients with PPP were matched with 182 patients with No-PPP. PPP patients had higher in-hospital mortality (14.1 % vs 2.2 % p < 0.001) and higher rates of VTE and DVT (VTE: 14.1 % vs 4.4 % p = 0.018, DVT: 10.9 % vs 2.2 % p = 0.008). CONCLUSION PPP is associated with worse survival outcomes and increased rate of VTE and DVT complications.
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Affiliation(s)
- Apostolos Kolitsas
- LA General Medical Center and University of Southern California, United States
| | - Elliot C Williams
- LA General Medical Center and University of Southern California, United States
| | - Meghan R Lewis
- LA General Medical Center and University of Southern California, United States
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2
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Cao L, Shen G, Wu R, Shen X, Xu J, Sun H, Xiang X. Spring coil displacement after interventional embolization of severe pelvic fracture: a case report. J Int Med Res 2024; 52:3000605241266219. [PMID: 39075863 PMCID: PMC11289803 DOI: 10.1177/03000605241266219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/10/2024] [Indexed: 07/31/2024] Open
Abstract
Haemorrhagic shock, which arises as a complication of pelvic fracture subsequent to severe trauma, represents a perilous state. The utilization of interventional endovascular haemostasis assumes a pivotal role in the management of patients with vascular injury following pelvic fracture. This article reports the treatment of a patient with pelvic fracture caused by a serious work-related vehicle accident. Despite the implementation of timely blood and fluid transfusion to combat shock, the application of aortic balloon obstruction, and interventional iliac artery embolization for haemostasis, the patient's condition failed to display any discernible improvement. Repeat angiography further revealed a displacement of the interventional embolization material, and the patient subsequently died of multiple organ failure. The occurrence of spring coil displacement is infrequent, but the consequences thereof are considered grave, necessitating meticulous discernment in the selection of haemostatic materials for this type of patient. The diagnostic and therapeutic processes encompassing the particular case described here were analysed and are discussed with the objective of augmenting the efficacy and success rate of treatment modalities for patients in similar circumstances.
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Affiliation(s)
- Lijun Cao
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Guoping Shen
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Renyan Wu
- Department of Ultrasound, Wangdian People’s Hospital, Jiaxing, Zhejiang, China
| | - Xuning Shen
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Jun Xu
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Hui Sun
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Xianhua Xiang
- Outpatient Department, Sunto Women and Children’s Hospital, Jiaxing, Zhejiang, China
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3
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Whitesell RT, Burnett AM, Johnston SK, Sheafor DH. Pre-hospital emergency medicine: a spectrum of imaging findings. Emerg Radiol 2024; 31:405-415. [PMID: 38528277 DOI: 10.1007/s10140-024-02223-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 03/14/2024] [Indexed: 03/27/2024]
Abstract
The goal of emergency medical services (EMS) is to provide urgent medical care and stabilization prior to patient transport to a healthcare facility for definitive treatment. The number and variety of interventions performed in the field by EMS providers continues to grow as early management of severe injuries and critical illness in the pre-hospital setting has been shown to improve patient outcomes. The sequela of many field interventions, including those associated with airway management, emergent vascular access, cardiopulmonary resuscitation (CPR), patient immobilization, and hemorrhage control may be appreciated on emergency department admission imaging. Attention to these imaging findings is important for the emergency radiologist, who may be the first to identify a malpositioned device or an iatrogenic complication arising from pre-hospital treatment. Recognition of these findings may allow for earlier corrective action to be taken in the acute care setting. This review describes common EMS interventions and their imaging findings.
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Affiliation(s)
- Ryan T Whitesell
- Division of Emergency Radiology, Midwest Radiology, 2355 Highway 36 West, Roseville, MN, USA.
| | - Aaron M Burnett
- Department of Emergency Medicine, Regions Hospital, 640 Jackson St, St. Paul, MN, USA
| | - Sean K Johnston
- Division of Emergency Radiology, Midwest Radiology, 2355 Highway 36 West, Roseville, MN, USA
| | - Douglas H Sheafor
- Division of Emergency Radiology, Midwest Radiology, 2355 Highway 36 West, Roseville, MN, USA
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4
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Fokin AA, Wycech Knight J, Tharp ME, Brinton KC, Gallagher PK, Xie JF, Weisz RD, Puente I. Pelvic fractures in blunt trauma patients: A comparative study. World J Orthop 2024; 15:418-434. [PMID: 38835686 PMCID: PMC11145966 DOI: 10.5312/wjo.v15.i5.418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 05/15/2024] Open
Abstract
BACKGROUND Pelvic fractures (PF) with concomitant injuries are on the rise due to an increase of high-energy trauma. Increase of the elderly population with age related comorbidities further complicates the management. Abdominal organ injuries are kindred with PF due to the proximity to pelvic bones. Presence of contrast blush (CB) on computed tomography in patients with PF is considered a sign of active bleeding, however, its clinical significance and association with outcomes is debatable. AIM To analyze polytrauma patients with PF with a focus on the geriatric population, co-injuries and the value of contrast blush. METHODS This retrospective cohort study included 558 patients with PF admitted to level 1 trauma center (01/2017-01/2023). Analyzed variables included: Age, sex, mechanism of injury (MOI), injury severity score (ISS), Glasgow coma scale (GCS), abbreviated injury scale (AIS), co-injuries, transfusion requirements, pelvic angiography, embolization, laparotomy, orthopedic pelvic surgery, intensive care unit and hospital lengths of stay, discharge disposition and mortality. The study compared geriatric and non-geriatric patients, patients with and without CB and abdominal co-injuries. Propensity score matching was implemented in comparison groups. RESULTS PF comprised 4% of all trauma admissions. 89 patients had CB. 286 (52%) patients had concomitant injuries including 93 (17%) patients with abdominal co-injuries. Geriatric patients compared to non-geriatric had more falls as MOI, lower ISS and AIS pelvis, higher GCS, less abdominal co-injuries, similar CB and angio-embolization rates, less orthopedic pelvic surgeries, shorter lengths of stay and higher mortality. After propensity matching, orthopedic pelvic surgery rates remained lower (8% vs 19%, P < 0.001), hospital length of stay shorter, and mortality higher (13% vs 4%, P < 0.001) in geriatric patients. Out of 89 patients with CB, 45 (51%) were embolized. After propensity matching, patients with CB compared to without CB had more pelvic angiography (71% vs 12%, P < 0.001), higher embolization rates (64% vs 22%, P = 0.02) and comparable mortality. CONCLUSION Half of the patients with PF had concomitant co-injuries, including abdominal co-injuries in 17%. Similarly injured geriatric patients had higher mortality. Half of the patients with CB required an embolization.
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Affiliation(s)
- Alexander A Fokin
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Joanna Wycech Knight
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL 33316, United States
| | - Madison E Tharp
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Kyler C Brinton
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Phoebe K Gallagher
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Justin Fengyuan Xie
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Russell D Weisz
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
| | - Ivan Puente
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, FL 33431, United States
- Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL 33316, United States
- Herbert Wertheim College of Medicine, Department of Surgery, Florida International University, Miami, FL 33199, United States
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5
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Pandelani T, Carpanen D, Masouros SD. Evaluating Pelvis Response During Simulated Underbody Blast Loading. J Biomech Eng 2024; 146:024501. [PMID: 38071487 DOI: 10.1115/1.4064214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Indexed: 12/21/2023]
Abstract
In recent conflicts, blast injury from landmines and improvised explosive devices (IEDs) has been the main mechanism of wounding and death. When a landmine or IED detonates under a vehicle (an under-body blast), the seat acceleration rapidly transmits a high load to the pelvis of the occupants, resulting in torso and pelvic injury. Pelvic fractures have high mortality rates, yet their injury mechanism has been poorly researched. Three (3) fresh-frozen male pelvic specimens were tested under axial impact loading. The pelvis was impacted mounted upside down by dropping a 12 kg mass at target impact velocities ranging from 1 to 8.6 m/s with time to peak velocity ranging from 3.8 to 5.8 ms. Resulting fractures were broadly categorized as involving a bilateral pubis rami fracture, a bilateral ischium fracture, and sacroiliac joint disruption. The study provides insights into the type and severity of pelvic injury that may occur over a range of under-body blast (UBB)-relevant loading profiles.
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Affiliation(s)
- Thanyani Pandelani
- Unisa Biomechanics Research Lab, Department of Mechanical Engineering, School of Engineering, College of Science Engineering and Technology, University of South Africa, Pretoria 0184, South Africa; Department of Bioengineering, Imperial College London, London SW7 2BX, UK
| | | | - Spyros D Masouros
- Department of Bioengineering, Imperial College London, London SW7 2AZ, UK
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6
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Lawson MM, Peterson DF, Friess DM, Cook MR, Working ZM. Delay of fixation increases 30-day complications and mortality in traumatic pelvic ring injuries. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03589-9. [PMID: 37318555 DOI: 10.1007/s00590-023-03589-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/11/2023] [Indexed: 06/16/2023]
Abstract
PURPOSE While decreased time to fixation in femur fractures improves mortality, it remains unclear if the same relationship exists for pelvic fractures. The National Trauma Data Bank (NTDB) is a data repository for trauma hospitals in the United States (injury characteristics, perioperative data, procedures, 30-day complications), and we used this to investigate early, significant complications after pelvic-ring injuries. METHODS The NTDB (2015-2016) was queried to capture operative pelvic ring injuries in adult patients with injury severity score (ISS) ≥ 15. Complications included medical and surgical complications, as well as 30-day mortality. Multivariable logistic regression was used to investigate the association between days to procedure and complications after adjusting for demographic characteristics and comorbidities. RESULTS 2325 patients met inclusion criteria. 532 (23.0%) sustained complications, and 72 (3.2%) died within the first 30 days. The most common complications were deep vein thrombosis (DVT) (5.7%), acute kidney injury (AKI) (4.6%), and unplanned intensive care unit (ICU) admission (4.4%). In a multivariate analysis, days to procedure was independently significantly associated with complications, with an adjusted odds ratio (95% confidence interval) of 1.06 (1.03-1.09, P < 0.001), best interpreted as a 6% increase in the odds of complication or death for each additional day. CONCLUSION Time to pelvic fixation is a significant and modifiable risk factor for major complications and death. This suggests we should prioritize time to pelvic fixation on trauma patients to minimize mortality and major complications.
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Affiliation(s)
- Michelle M Lawson
- Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Danielle F Peterson
- Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Darin M Friess
- Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Mackenzie R Cook
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Zachary M Working
- Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, OR, USA.
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7
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Current Management of Hemodynamically Unstable Patients with Pelvic Fracture. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00348-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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8
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Devaney GL, Tarrant SM, Weaver N, King KL, Balogh ZJ. Major Pelvic Ring Injuries: Fewer Transfusions Without Deaths from Bleeding During the Last Decade. World J Surg 2023; 47:1136-1143. [PMID: 36648519 PMCID: PMC10070203 DOI: 10.1007/s00268-023-06897-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Pelvic fracture-associated bleeding can be difficult to control with historically high mortality rates. The impact of resuscitation advancements for trauma patients with unstable pelvic ring injuries is unknown. We hypothesized that the time elapsed since introduction of our protocol would be associated with decreased blood transfusion requirements. METHODS A level 1 trauma center's prospective pelvic fracture database was reviewed from 01/01/2009-31/12/2018. All patients with unstable pelvic ring injuries initially presenting to our institution were included. Adjusted regression analysis was performed on the overall cohort and separately for patients in traumatic shock (TS). The primary outcome was 24 h packed red blood cell (PRBC) requirements. Secondary outcomes were 24 h plasma, cryoprecipitate, platelet and intravenous fluid (IVF) requirements, length of stay and mortality. RESULTS Patients with mechanically unstable pelvic ring injuries (n = 144, median [Q1-Q3] age 44 [28-55] years, 74% male) received a median (Q1-Q3) of 0 (0-4) units PRBC within 24 h, with TS patients (n = 47, 42 [28-60] years, 74% male) receiving 6 (4-9) units PRBC. There was no decrease in 24 h PRBC requirements for the overall cohort (years; IRR = 0.91, 95% CI 0.83-1.01; p = 0.07). TS patients had decreases in 24 h PRBC (years; IRR = 0.90, 95%CI 0.84-0.96; p = 0.002), plasma (IRR = 0.92, 95%CI 0.85-0.99; p = 0.019), cryoprecipitate (IRR = 0.88, 95%CI 0.81-0.95; p = 0.001) and IVF (IRR = 0.94, 95%CI 0.90-0.98; p = 0.004). There were 5 deaths (5/144, 3.5%) with no deaths due to acute hemorrhage. CONCLUSIONS Over this 10-year period, there was no hemorrhage-related mortality among patients presenting with pelvic fractures. Crystalloid and transfusion requirements decreased for patients presenting with traumatic shock.
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Affiliation(s)
- Giles L Devaney
- Department of Traumatology, John Hunter Hospital, Lookout Rd, Newcastle, NSW, 2305, Australia
| | - Seth M Tarrant
- Department of Traumatology, John Hunter Hospital, Lookout Rd, Newcastle, NSW, 2305, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Natasha Weaver
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Kate L King
- Department of Traumatology, John Hunter Hospital, Lookout Rd, Newcastle, NSW, 2305, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital, Lookout Rd, Newcastle, NSW, 2305, Australia. .,School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia.
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Aoki R, Nakajima K, Kobayashi Y, Sakai Y, Kamide H, Yamamoto T, Furugori S, Sawamura S, Terauchi M, Kamiyama K, Ikeda S, Tsuji G, Koyama S, Yoshigi J, Sekikawa Z, Utsunomiya D. Common and uncommon vascular injuries and endovascular treatment associated with pelvic blunt trauma: a real-world experience. Jpn J Radiol 2023; 41:258-265. [PMID: 36350523 PMCID: PMC9974705 DOI: 10.1007/s11604-022-01355-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022]
Abstract
Pelvic fractures are common in cases of blunt trauma, which is strongly associated with mortality. Transcatheter arterial embolization is a fundamental treatment strategy for fatal arterial injuries caused by blunt pelvic trauma. However, vascular injuries due to blunt pelvic trauma can show various imaging findings other than arterial hemorrhage. We present a pictorial review of common and uncommon vascular injuries, including active arterial bleeding, pseudoaneurysm, arteriovenous fistula, arterial occlusion, vasospasm, and active venous bleeding. Knowledge of these vascular injuries can help clinicians select the appropriate therapeutic strategy and thus save lives.
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Affiliation(s)
- Ryo Aoki
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan. .,Department of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan.
| | - Kento Nakajima
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yusuke Kobayashi
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Yodo Sakai
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Hiroyuki Kamide
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Toh Yamamoto
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Shintaro Furugori
- grid.413045.70000 0004 0467 212XAdvanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Shungo Sawamura
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Miki Terauchi
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kazutoshi Kamiyama
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shin Ikeda
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Gengo Tsuji
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Shingo Koyama
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Jun Yoshigi
- grid.417369.e0000 0004 0641 0318Department of Diagnostic Radiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Zenjiro Sekikawa
- grid.413045.70000 0004 0467 212XDepartment of Diagnostic Radiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Daisuke Utsunomiya
- grid.268441.d0000 0001 1033 6139Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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10
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Anand T, El-Qawaqzeh K, Nelson A, Hosseinpour H, Ditillo M, Gries L, Castanon L, Joseph B. Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures. JAMA Surg 2023; 158:63-71. [PMID: 36449300 PMCID: PMC9713682 DOI: 10.1001/jamasurg.2022.5772] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/09/2022] [Indexed: 12/02/2022]
Abstract
Importance Management of hemodynamically unstable pelvic fractures remains a challenge. Hemostatic interventions are used alone or in combination. There is a paucity of data on the association between the pattern of hemorrhage control interventions and outcomes after a severe pelvic fracture. Objective To characterize clinical outcomes and study the patterns of hemorrhage control interventions in hemodynamically unstable pelvic fractures. Design, Setting, and Participants In this cohort study, a retrospective review was performed of data from the 2017 American College of Surgeons Trauma Quality Improvement Program database, a national multi-institutional database of trauma patients in the United States. Adult patients (aged ≥18 years) with pelvic fractures who received early transfusions (≥4 units of packed red blood cells in 4 hours) and underwent intervention for pelvic hemorrhage control were identified. Use and order of preperitoneal pelvic packing (PP), pelvic angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 were examined and compared against the primary outcome of mortality. The associations between intervention patterns and mortality, complications, and 24-hour transfusions were further examined by backward stepwise regression analyses. Data analyses were performed in September 2021. Main Outcomes and Measures Primary outcomes were rates of 24-hour, emergency department, and in-hospital mortality. Secondary outcomes were major in-hospital complications. Results A total of 1396 patients were identified. Mean (SD) age was 47 (19) years, 975 (70%) were male, and the mean (SD) lowest systolic blood pressure was 71 (25) mm Hg. The median (IQR) Injury Severity Score was 24 (14-34), with a 24-hour mortality of 217 patients (15.5%), ED mortality of 10 patients (0.7%), in-hospital mortality of 501 patients (36%), and complication rate of 574 patients (41%). Pelvic AE was the most used intervention (774 [55%]), followed by preperitoneal PP (659 [47%]) and REBOA zone 3 (126 [9%]). Among the cohort, 1236 patients (89%) had 1 intervention, 157 (11%) had 2 interventions, and 3 (0.2%) had 3 interventions. On regression analyses, only pelvic AE was associated with a mortality reduction (odds ratio [OR], 0.62; 95% CI, 0.47 to 0.82; P < .001). Preperitoneal PP was associated with increased odds of complications (OR, 1.39; 95% CI, 1.07 to 1.80; P = .01). Increasing number of interventions was associated with increased 24-hour transfusions (β = +5.4; 95% CI, +3.5 to +7.5; P < .001) and mortality (OR, 1.57; 95% CI, 1.05 to 2.37; P = .03), but not with complications. Conclusions and Relevance This study found that among patients with pelvic fracture who received early transfusions and at least 1 invasive pelvic hemorrhage control intervention, more than 1 in 3 died, despite the availability of advanced hemorrhage control interventions. Only pelvic AE was associated with a reduction in mortality.
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Affiliation(s)
- Tanya Anand
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Khaled El-Qawaqzeh
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Adam Nelson
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Hamidreza Hosseinpour
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Michael Ditillo
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Lynn Gries
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Lourdes Castanon
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Bellal Joseph
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
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11
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Maurer LR, Kaafarani HM. Nationwide Variation of Care for Patients With Bleeding Pelvic Fracture-An Opportunity to Rescue Better? JAMA Surg 2023; 158:71-72. [PMID: 36449322 DOI: 10.1001/jamasurg.2022.5778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- Lydia R Maurer
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Haytham M Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston
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12
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Raja AS, Rodriguez RM, Gupta M, Isaacs ED, Kornblith LZ, Prabhakar A, Saillant N, Schmit PJ, Wei SH, Mower WR. Developing a decision instrument to guide abdominal-pelvic imaging of blunt trauma patients: Methodology and protocol of the NEXUS abdominal-pelvic imaging study. PLoS One 2022; 17:e0271070. [PMID: 35877687 PMCID: PMC9312398 DOI: 10.1371/journal.pone.0271070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/22/2022] [Indexed: 11/19/2022] Open
Abstract
Although computed tomography (CT) of the abdomen and pelvis (A/P) can provide crucial information for managing blunt trauma patients, liberal and indiscriminant imaging is expensive, can delay critical interventions, and unnecessarily exposes patients to ionizing radiation. Currently no definitive recommendations exist detailing which adult blunt trauma patients should receive A/P CT imaging and which patients may safely forego CT. Considerable benefit could be realized by identifying clinical criteria that reliably classify the risk of abdominal and pelvic injuries in blunt trauma patients. Patients identified as “very low risk” by such criteria would be free of significant injury, receive no benefit from imaging and therefore could be safely spared the expense and radiation exposure associated with A/P CT. The goal of this two-phase nationwide multicenter observational study is to derive and validate the use of clinical criteria to stratify the risk of injuries to the abdomen and pelvis among adult blunt trauma patients. We estimate that nation-wide implementation of a rigorously developed decision instrument could safely reduce CT imaging of adult blunt trauma patients by more than 20%, and reduce annual radiographic charges by $180 million, while simultaneously expediting trauma care and decreasing radiation exposure with its attendant risk of radiation-induced malignancy. Prior to enrollment we convened an expert panel of trauma surgeons, radiologists and emergency medicine physicians to develop a consensus definition for clinically significant abdominal and pelvic injury. In the first derivation phase of the study, we will document the presence or absence of preselected candidate criteria, as well as the presence or absence of significant abdominal or pelvic injuries in a cohort of blunt trauma victims. Using recursive partitioning, we will examine combinations of these criteria to identify an optimal “very low risk” subset that identifies injuries with a sensitivity exceeding 98%, excludes injury with a negative predictive value (NPV) greater than 98%, and retains the highest possible specificity and potential to decrease imaging. In Phase 2 of the study we will validate the performance of a decision rule based on these criteria among a new cohort of patients to ensure that the criteria retain high sensitivity, NPV and optimal specificity. Validating the sensitivity of the decision instrument with high statistical precision requires evaluations on 317 blunt trauma patients who have significant abdominal-pelvic injuries, which will in turn require evaluations on approximately 6,340 blunt trauma patients. We will estimate potential reductions in CT imaging by counting the number of abdominal-pelvic CT scans performed on “very low risk” patients. Reductions in charges and radiation exposure will be determined by respectively summing radiographic charges and lifetime decreases in radiation morbidity and mortality for all “very low risk” cases.
Trial registration: Clinicaltrials.gov trial registration number: NCT04937868.
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Affiliation(s)
- Ali S. Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Robert M. Rodriguez
- Department of Emergency Medicine, San Francisco General Hospital, UCSF School of Medicine, San Francisco, California, United States of America
| | - Malkeet Gupta
- Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California, United States of America
- Antelope Valley Hospital Emergency Department, Lancaster, California, United States of America
| | - Eric D. Isaacs
- Department of Emergency Medicine, San Francisco General Hospital, UCSF School of Medicine, San Francisco, California, United States of America
| | - Lucy Z. Kornblith
- Department of Surgery, San Francisco General Hospital, UCSF School of Medicine, San Francisco, California, United States of America
| | - Anand Prabhakar
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Noelle Saillant
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Paul J. Schmit
- UCLA Department of Surgery, Ronald Reagan UCLA Medical Center, UCLA Geffen School of Medicine, Los Angeles, California, United States of America
| | - Sindy H. Wei
- UCLA Department of Radiological Sciences, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States of America
| | - William R. Mower
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States of America
- * E-mail:
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Different Lengths of Percutaneous Transverse Iliosacral Screw in Geometric Osseous Fixation Pathway: A Finite-Element Analysis. Indian J Orthop 2022; 56:1354-1362. [PMID: 35923306 PMCID: PMC9283617 DOI: 10.1007/s43465-022-00656-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 05/06/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate the biomechanical performances of the sacroiliac screw fixation of the first sacral vertebra with different lengths of screws using the Finite-Element Method. METHODS First, pelvic CT images were generated from a healthy volunteer, and multislice sagittal views were produced to determine the axis for the first sacral vertebra geometric osseous fixation pathway (GOFP). Subsequently, according to the geometric size and mechanical parameters of the iliosacral screw, the screw models with the same diameter of 7.3 mm and different lengths of 80 mm, 90 mm, 100 mm, 110 mm, 120 mm, 130 mm and 140 mm were built. Then the seven screws were assembled with the pelvic model. The maximum von Mises stress and the shape variables were evaluated for the pelvis and the screws. RESULTS Results are shown for the pelvic and GOFP screw, respectively. The simulation results show that the maximum von Mises stress in the cortex of the pelvic ring of the pelvis with the 130-mm length screw is the lowest among the pelvic models with different screws. Moreover, the peak displacement of the pelvis with the 130-mm length screw is the smallest. These results indicate that under the standing condition, a 130-mm length screw can decrease the stress concentration and result in a more effective transfer of stress within the reconstructed pelvis. In addition, the displacement of the screw with a 130-mm length is the smallest among all the considered screws. The peak von Mises stresses in the 130-mm length screw and the cortex are still within a low and elastic range below the yielding strengths of the materials. CONCLUSION Through the finite element analysis, the GOFP can be used as a safe and effective way for iliosacral screw fixation. The optimal length of the screw may be 130 mm length.
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McDonogh JM, Lewis DP, Tarrant SM, Balogh ZJ. Preperitoneal packing versus angioembolization for the initial management of hemodynamically unstable pelvic fracture: A systematic review and meta-analysis. J Trauma Acute Care Surg 2022; 92:931-939. [PMID: 34991126 PMCID: PMC9038232 DOI: 10.1097/ta.0000000000003528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/15/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemodynamically unstable pelvic fracture patients are challenging to manage. Preperitoneal packing (PPP) and angioembolization (AE) are two interventions commonly used to help gain hemorrhage control. Recently, there has been a tendency to support PPP in hemodynamically unstable pelvic fracture seemingly in direct comparison with AE. However, it seems that key differences between published cohorts exist that limits a comparison between these two modalities. METHODS A systematic literature search of the MEDLINE, CINAHL, and EMBASE databases was conducted. Prospective and retrospective studies were eligible. No limitation was placed on publication date, with only manuscripts printed in English eligible (PROSPERO CRD42021236219). Included studies were retrospective and prospective cohort studies and a quasirandomized control trial. Studies reported demographic and outcome data on hemodynamically unstable patients with pelvis fractures that had either PPP or AE as their initial hemorrhage control intervention. The primary outcome was in-hospital mortality rate. Eighteen studies were included totaling 579 patients, of which 402 were treated with PPP and 177 with AE. RESULTS Significant differences were found between AE and PPP in regard to age, presence of arterial hemorrhage, Injury Severity Score, and time to intervention. The crude mortality rate for PPP was 23%, and for AE, it was 32% (p = 0.001). Analysis of dual-arm studies showed no significant difference in mortality. Interestingly, 27% of patients treated with PPP did not get adequate hemorrhage control and required subsequent AE. CONCLUSION Because of bias, heterogeneity, and inadequate reporting of physiological data, a conclusive comparison between modalities is impossible. In addition, in more than a quarter of the cases treated with PPP, the patients did not achieve hemorrhage control until subsequent AE was performed. This systematic review highlights the need for standardized reporting in this high-risk group of trauma patients. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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15
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Marchand LS, Sepehri A, Hannan ZD, Zaidi R, DuBose JJ, Morrison JJ, O'Toole RV, Slobogean GM. Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamically Unstable Patients With Pelvic Ring Injuries. J Orthop Trauma 2022; 36:74. [PMID: 34050079 DOI: 10.1097/bot.0000000000002191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the outcomes of patients with pelvic ring injuries managed with resuscitative endovascular balloon occlusion of the aorta (REBOA). DESIGN Retrospective case series. SETTING Academic, Level 1 trauma center in North America. PATIENTS Twenty-five patients with disruption of the pelvic ring and hemodynamic instability. INTERVENTION Placement of a REBOA device as an adjuvant treatment to trauma resuscitation. MAIN OUTCOME MEASURE Death and ischemic-related complications. RESULTS The average age of patients was 43 years (range: 17-85). Patients presented with a median lactate of 6.3 mmol/L, systolic blood pressure of 116 mm Hg, heart rate of 121 beats/minute, and injury severity score of 34. The median unit of packed red blood cells received through transfusion in the first 24 hours of hospital admission was 13 (interquartile range: 8-28). Young-Burgess injury patterns included fractures of the following types: 5 lateral compression (LC)-1, 1 LC-2, 8 LC-3, 4 anteroposterior compression-2, and 7 anteroposterior compression-3. Angiography and embolization were performed in 24 (96%) patients. Selective embolization occurred in 18 (72%) patients, with nonselective angiography of the iliac system occurring in 7 (24%) patients. There were 12 (48%) deaths, 7 (28%) patients requiring lower extremity fasciotomy, and 5 (20%) patients requiring lower extremity amputations, and there was 1 (4%) patient requiring thrombectomy. CONCLUSIONS REBOA use in pelvic ring injuries is rare and most frequently used in critically ill patients with polytrauma. Successful pelvic embolization can occur in concert with REBOA use; however, the severity of injury is associated with a high complication profile. In this series of 25 patients, in-hospital mortality was 48%. For those patients who survived, 54% experienced a major complication (fasciotomy, amputation, and deep infection). Further investigation is required to evaluate the role REBOA may play in managing these patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S Marchand
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Aresh Sepehri
- University of British Columbia, Vancouver, BC, Canada
| | - Zachary D Hannan
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Raza Zaidi
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Joseph J DuBose
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Jonathan J Morrison
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
| | - Gerard M Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; and
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Marchand LS, Sepehri A, Hannan ZD, Zaidi SM, Bangura AT, Morrison JJ, Manson TT, Slobogean GP, O’Hara NN, O’Toole RV. Pelvic Ring Injury Mortality: Are We Getting Better? J Orthop Trauma 2022; 36:81-86. [PMID: 34128497 PMCID: PMC8669037 DOI: 10.1097/bot.0000000000002210] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS/PARTICIPANTS A total of 3314 patients with pelvic ring injuries who presented to a single referral center from 1999 to 2018 were included in the study. INTERVENTION Pelvic ring management, years 1999-2006 versus years 2007-2018. MAIN OUTCOME MEASUREMENTS In hospital mortality. Other examined variables included change in patient demographics, fracture characteristics, date of injury, associated injuries, length of hospital stay, Abbreviated Injury Severity Score. RESULTS The composite mortality rate was 6.5% (214/3314). The earliest cohort presented a mortality rate of 9.1% [111/1224; 95% confidence interval (CI), 7.6%-10.8%] compared with the more recent cohort mortality rate of 4.9% (103/2090; 95% CI, 4.1%-5.9%). Overall mortality was significantly lower in the more recent period, a risk difference of 4.1% (95% CI, 2.3%-6.1%; P < 0.01). After adjusting for age and Abbreviated Injury Severity Score of the brain, chest, and abdomen, the mortality reduction was more pronounced with an adjusted risk difference of 6.4% (95% CI, 4.7%-8.1%; P < 0.01). CONCLUSION Significant improvement in the mortality rate of pelvic ring injuries has been demonstrated in recent years (4.9% vs. 9.1%) and the difference is even large when accounting for known confounders. Improvement appears to coincide chronologically with changes in trauma resuscitation and implementation of adjuvant treatments for managing patients with severe hemorrhagic shock. Although the exact benefit of each treatment awaits further research, these data might indicate improved care over time for these difficult patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S. Marchand
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aresh Sepehri
- University of British Columbia, Department of Orthopaedic Surgery, Vancouver, BC, Canada
| | - Zachary D. Hannan
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Syed M.R. Zaidi
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abdulai T. Bangura
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan J. Morrison
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Theodore T. Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathan N. O’Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert V. O’Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
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17
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Taylor NA, Smith AA, Marr A, Stuke L, Greiffenstein P, Schoen J, Brown T, Chapman B, Hunt JP. Does Time to Pelvic Fixation Influence Outcomes in Trauma Patients? Am Surg 2021; 88:840-845. [PMID: 34797191 DOI: 10.1177/00031348211056266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pelvic fractures cause significant morbidity in the trauma population. Many factors influence time to fracture fixation. No previous study has determined the optimal time window for pelvic fixation. METHODS A retrospective review of trauma patients with pelvic fractures from 2016 to 2020 was performed. Patients were stratified into EARLY and LATE groups, by time to fixation within 3 days or greater than 3 days whether from admission or from completion of a life-saving procedure. Unpaired Student's t-test and Fisher's exact test were performed with multiple linear regression for variables with P < .2 on univariate analysis. RESULTS 287 patients were identified with a median fixation time of 3 days. There was no significant difference in demographics, incidence of preceding life-saving procedure, angioembolization, or mechanism of injury in the 2 groups (P > .05). Length of stay in the EARLY group was significantly reduced at 11.9 +/- .7 days compared to 18.0 +/-1.2 days in the LATE group (P < .001). There was no significant difference in rates of ventilator-associated pneumonia, deep vein thrombosis, pulmonary embolism (PE), acute kidney injury (AKI), pressure ulcer, or acute respiratory distress syndrome (ARDS) (P > .05). There were significantly more SSIs (surgical site infections) in the LATE group. After multiple linear regression adjusting for covariates of age and ISS, the difference in hospital LOS was 5.5 days (95% CI -8.0 to -3.1, P < .001). DISCUSSION Fixation of traumatic pelvic fractures within 3 days reduced LOS. Prospective multi-center studies will help identify additional factors to decrease time to surgery and improve patient outcomes.
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Affiliation(s)
- Nicholas A Taylor
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Alison A Smith
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Alan Marr
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Lance Stuke
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Patrick Greiffenstein
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Jonathan Schoen
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Tommy Brown
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Brett Chapman
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - John P Hunt
- Department of Surgery, 12258Louisiana State University Health Sciences Center, New Orleans, LA, USA
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Dreizin D, Rosales R, Li G, Syed H, Chen R. Volumetric Markers of Body Composition May Improve Personalized Prediction of Major Arterial Bleeding After Pelvic Fracture: A Secondary Analysis of the Baltimore CT Prediction Model Cohort. Can Assoc Radiol J 2021; 72:854-861. [PMID: 32910695 PMCID: PMC8011455 DOI: 10.1177/0846537120952508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
METHODS This work is a retrospective secondary analysis of a single institution cohort used in the development of the Baltimore CT prediction model. The cohort includes 115 consecutive patients that underwent admission contrast-enhanced CT of the abdomen and pelvis for blunt trauma with pelvic ring disruption followed by conventional angiography. Major arterial injury requiring angioembolization served as the outcome variable. Angioembolization was required in 73/115 patients (63% of the cohort). Average age was 46.9 years (±SD 20.4). Body composition measurements were determined as 2-dimensional (2D) or 3-dimensional (3D) parameters and included mid-L3 trabecular bone attenuation, abdominal visceral fat area or volume, and percent muscle fat fraction (as a marker of sarcopenia) measured using segmentation and histogram analysis. RESULTS Models incorporating 2D (Model B) or 3D markers (model C) of body composition showed improvement over the original Baltimore model (model A) in all parameters of performance, quality, and fit (area under the receiver-operating curve [AUC], Akaike information criterion, Brier score, Hosmer-Lemeshow test, and adjusted-R2). Area under the receiver-operating curve increased from 0.83 (A), to 0.86 (B), and 0.88 (C). The greatest improvement was seen with 3D parameters. CONCLUSION Once automated, quantitative visualization tools providing "free" 3D body composition information can be expected to improve personalized precision diagnostics, outcome prediction, and decision support in patients with bleeding pelvic fractures.
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Affiliation(s)
- David Dreizin
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Remberto Rosales
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hassan Syed
- Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rong Chen
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Mazzone A, Anderson R, Voelzke BB, Vanni AJ, Elliott SP, Breyer BN, Erickson BA, Buckley J, Myers J. Sexual function following pelvic fracture urethral injury and posterior urethroplasty. Transl Androl Urol 2021; 10:2043-2050. [PMID: 34159085 PMCID: PMC8185675 DOI: 10.21037/tau-20-1287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background To evaluate erectile and sexual function after pelvic fracture urethral injury (PFUI) by performing a retrospective review of a large multi-center database. We hypothesized that most men will have erectile dysfunction (ED) and poor sexual function following PFUI, which will remain after posterior urethroplasty. Methods Using the Trauma and Urologic Reconstructive Networks of Surgeons (TURNS) database, we identified PFUI patients undergoing posterior urethroplasty. We excluded patients with incomplete demographic, surgical and/or questionnaire data. Sexual Health Inventory of Men (SHIM), Male Sexual Health Questionnaire (MSHQ), and subjective changes in penile curvature were collected before urethroplasty surgery and at follow-up. We performed descriptive statistics for erectile and ejaculatory function using STATA v12. Results We identified 92 men meeting inclusion criteria; median age was 41.7 years and BMI was 26.5. The mechanism of injury was blunt in all patients, and average distraction defect length was 2.3 cm (SD 1.0 cm). In the 38 patients who completed both pre and post-operative SHIM questionnaires, the mean SHIM score was 10.5 (SD 7.0), with 63% having severe ED (SHIM <12). The median follow-up was 5.6 months and the mean post-operative SHIM was 9.3 (SD 6.5), with 68% having severe ED. The mean change in SHIM score was −1.18 (SD 6.29) with 6 (16%) patients reporting de novo ED (≥5 point decrease in score). Of the men with pre-operative MSHQ data, 46/74 (62.1%) had difficulty with ejaculation, 25/35 (71%) had change in penile length, and 6/33 (18%) reported penile curvature. In men with post-operative MSHQ, 19/44 (43%) expressed difficulty with ejaculation, 23/32 (72%) had change in penile length, and 9/33 (27%) reported penile curvature. Conclusions There is a high rate of severe ED, both following PFUI and remaining after posterior urethroplasty. Additionally, rates of ejaculatory difficulty and patient perceived changes in penile length and curvature underscore the complex nature of the impact of these injuries on sexual function beyond simple erectile function.
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Affiliation(s)
| | | | | | - Alex J Vanni
- Lahey Hospital and Medical Center Burlington, Burlington, MA, USA
| | | | | | | | - Jill Buckley
- University of California San Diego, San Diego, CA, USA
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El Khudari H, Abdel Aal AK. Endovascular Management of Pelvic Trauma. Semin Intervent Radiol 2021; 38:123-130. [PMID: 33883809 DOI: 10.1055/s-0041-1725112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Major pelvic fractures result from high-energy trauma including traffic accidents and falls, which usually leads to multiple injuries complicating the patient's management. Management of these patients requires a coordinated multidisciplinary approach. Transcatheter embolization is a minimally invasive and effective technique to control massive hemorrhage and can be performed using a variety of embolic agents. It has become an accepted first-line management option for retroperitoneal bleeds in many centers. In this article, the indications for endovascular management of hemorrhage from pelvic trauma, the various embolization techniques, and potential complications will be discussed.
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Affiliation(s)
- Husameddin El Khudari
- Division of Interventional Radiology, Department of Radiology, The University of Alabama at Birmingham (UAB), Birmingham, Alabama
| | - Ahmed Kamel Abdel Aal
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
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21
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Hundersmarck D, Hietbrink F, Leenen LPH, Heng M. Pelvic packing and angio-embolization after blunt pelvic trauma: a retrospective 18-year analysis. Injury 2021; 52:946-955. [PMID: 33223257 DOI: 10.1016/j.injury.2020.11.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/14/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Treatment of pelvic trauma related hemorrhage is challenging and remains controversial. In hemodynamically unstable patients suspected for massive bleeding, pre-peritoneal packing (PPP) with temporary external fixation (EF) and subsequent trans-arterial embolization (TAE) can be performed in order to control bleeding. In hemodynamically stable patients suspected for minor to moderate bleeding, primary TAE with EF may be performed. The goal of this study was to determine effectiveness and safety of both strategies. METHODS Retrospectively, patients that received treatment for pelvic trauma-related hemorrhage at two level 1 trauma centers located in the United States between January 2001 and January 2019 were evaluated. Both centers advocate subsequent TAE in addition to PPP and EF in hemodynamically unstable patients, and primary TAE in stable patients. Demographic and clinical data was collected and mortality, ischemic and infectious complications were determined. RESULTS In total, 135 patients met the inclusion criteria. Of these, 61 hemodynamically unstable patients suspected for massive pelvic bleeding underwent primary PPP (45%) and 74 stable patients suspected for minor/moderate bleeding underwent primary TAE (55%). In total, 37/61 primary PPP patients underwent EF (61%) and 48 underwent adjunct TAE (79%), performed bilaterally in 77% and unselective by use of gelfoam in 72% of cases. Primary TAE patients received embolization bilaterally in 49% and unselective in 35% of cases. Exsanguination-related deaths were found in 7/61 primary PPP patients (11%). There were none among the primary TAE patients. Potentially ischemic in-hospital complications, of which one could be considered severe (gluteal necrosis), occurred more in patients that received bilateral unselective TAE compared to all other TAE patients (p=0.02). CONCLUSION Primary TAE appears to be an effective and safe adjunct for (minor) pelvic hemorrhage in hemodynamically stable patients. Primary PPP followed by EF and adjunct bilateral unselective TAE with gelfoam appears effective for those suspected of massive pelvic bleeding. This unselective embolization approach using gelfoam might be related to (ischemic) complications. When considering the amount and severity of complications and the severity of pelvic trauma, these might not outweigh the benefit of fast hemorrhage control.
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Affiliation(s)
- Dennis Hundersmarck
- Harvard Medical School Orthopedic Trauma Initiative, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, USA.
| | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Marilyn Heng
- Harvard Medical School Orthopedic Trauma Initiative, Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, USA.
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22
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Surgical Wound Complications After Percutaneous Posterior Pelvic Ring Fixation in Patients Who Undergo Pelvic Arterial Embolization. J Orthop Trauma 2021; 35:167-170. [PMID: 32931686 DOI: 10.1097/bot.0000000000001956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To report on the incidence of surgical wound complications after percutaneous posterior pelvic ring fixation in patients who have also undergone pelvic arterial embolization (PAE) and determine whether the risks outweigh the benefits. DESIGN Retrospective cohort study. SETTING Academic level 1 trauma center. PATIENTS Two hundred one consecutive patients who underwent percutaneous posterior pelvic fixation at our institution were included in this study. Of these, 27 patients underwent pelvic arterial embolization. INTERVENTION Percutaneous posterior pelvic fixation and pelvic arterial embolization. MAIN OUTCOME MEASUREMENTS Charts were reviewed for posterior percutaneous surgical wound complications including infection, dehiscence, seroma, tissue necrosis, and return to OR for debridement in all patients. RESULTS Of the 27 patients who received PAE, none developed posterior surgical wound complications. Of those who did not receive PAE, there was one posterior surgical wound complication documented. There were no cases of wound infection in either group. CONCLUSION Pelvic arterial embolization can be a valuable intervention in treating hemodynamically unstable patients with pelvic ring injuries. Although even selective pelvic arterial embolization is not entirely benign, there seems to be minimal risk of wound complications when percutaneous posterior pelvic ring fixation is performed. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Zheng ZH, Xu F, Luo ZQ, Ren Y, Fu T, Xu HQ, Liu BB. A useful intraoperative technique for transiliac-transsacral screws: a point-to-point coaxial guide apparatus. J Orthop Surg Res 2021; 16:89. [PMID: 33509244 PMCID: PMC7845130 DOI: 10.1186/s13018-021-02239-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background The transiliac-transsacral screw placement is a clinical challenge for surgeons. This study explored a point-to-point coaxial guide apparatus assisting the transiliac-transsacral screw insertion and aimed to investigate the feasibility and accuracy of the guide apparatus in the treatment of posterior ring unstable pelvic fracture compared with a free-hand technique. Methods A retrospective study was performed to evaluate patients treated with transiliac-transsacral screws assisted by the point-to-point coaxial guide apparatus or free-hand technique. The intraoperative data of operative time and radiation exposure times were recorded. Postoperative radiographs and CT scans were performed to scrutinize the accuracy of screws position. The quality of the postoperative fracture reduction was assessed according to Matta radiology criteria. The pelvic function was assessed according to the Majeed scoring criteria at 6 months postoperatively. Results From July 2017 to December 2019, a total of 38 patients were included in this study, 20 from the point-to-point guide apparatus group and 18 from the free-hand group. There were no significant differences between the two groups in gender, age, injury causes, pelvic fracture type, screws level, and follow-up time (P > 0.05). The average operative time of the guide apparatus group for each screw was significantly less than that in the free-hand group (25.8 ± 4.7 min vs 40.5 ± 5.1, P < 0.001). The radiation exposure times were significantly lower in the guide apparatus group than that in the free-hand group (24.4 ± 6.0 vs 51.6 ± 8.4, P < 0.001). The intraosseous and juxtacortical rate of screw placement (100%) higher than in the free-hand group (94.4%). Conclusion The point-to-point coaxial guide apparatus is feasible for assisting the transiliac-transsacral screw in the treatment of posterior unstable pelvic fractures. It has the advantages of simple operation, reasonable design and no need for expensive equipment, and provides an additional surgical strategy for the insertion of the transiliac-transsacral screw.
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Affiliation(s)
- Ze-Hang Zheng
- Department of Orthopaedics Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Fei Xu
- Department of Orthopaedics Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zheng-Qiang Luo
- Department of Orthopaedics Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Ye Ren
- Department of Orthopaedics Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Tao Fu
- Department of Orthopaedics Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Han-Qing Xu
- Department of Orthopaedics Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Bin-Bin Liu
- Department of Orthopaedics Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
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Pierrie SN, Seymour RB, Wally MK, Studnek J, Infinger A, Hsu JR. Pilot randomized trial of pre-hospital advanced therapies for the control of hemorrhage (PATCH) using pelvic binders. Am J Emerg Med 2021; 42:43-48. [PMID: 33440330 DOI: 10.1016/j.ajem.2020.12.082] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Pelvic fractures represent a small percent of all skeletal injuries but are associated with significant morbidity and mortality secondary to hemodynamic instability from bleeding bone surfaces and disrupted pelvic vasculature. Stabilization of the pelvis prior to arrival at a treatment facility may mitigate the hemodynamic consequences of pelvic ring injuries and improve morbidity and mortality. Whether pelvic compression devices such as pelvic binders or sheets can be safely applied in the prehospital setting has not been well-studied. This study aims to evaluate the safety of applying a pelvic binder to at-risk patients in the field after scalable training and the feasibility of conducting a randomized trial evaluating this practice in the prehospital setting. METHODS A pilot study (prospective randomized trial design) was conducted in the pre-hospital environment in an urban area surrounding a level-one trauma center. Pre-hospital emergency medical (EMS) personnel were trained to identify patients at high-risk for pelvic fracture and properly apply a commercial pelvic binder. Adult patients with a high-energy mechanism, suspected pelvic fracture, and "Priority 1" criteria were prospectively identified by paramedics and randomized to pelvic binder placement or usual care. Medical records were reviewed for safety outcomes. Secondary outcomes were parameters of efficacy including interventions needed to control hemorrhage (such as angioembolization and surgical control of bleeding) and mortality. RESULTS Forty-three patients were randomized to treatment (binder: N=20; nonbinder: N=23). No complications of binder placement were identified. Eight patients (40%) had binders placed correctly at the level of the greater trochanter. Two binders (10%) were placed too proximally and 10 (50%) binders were not visualized on x-ray. Two binder group patients and three nonbinder group patients required angioembolization. None required surgical control of pelvic bleeding. Two nonbinder group patients and one binder group patient were readmitted within 30 days and one nonbinder group patient died within 30 days. CONCLUSION Identification of pelvic fractures in the field remains a challenge. However, a scalable training model for appropriate binder placement was successful without secondary injury to patients. The model for conducting prospective, randomized trials in the prehospital setting was successful.
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Affiliation(s)
- Sarah N Pierrie
- Department of Orthopaedics, San Antonio Military Medical Center, 3551Roger Brooke Dr, Fort Sam, Houston, TX 78234, United States
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC 28203, United States.
| | - Meghan K Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC 28203, United States
| | - Jon Studnek
- The Mecklenburg EMS Agency, 4425 Wilkinson Blvd, Charlotte, NC 28208, United States
| | - Allison Infinger
- The Mecklenburg EMS Agency, 4425 Wilkinson Blvd, Charlotte, NC 28208, United States
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, 1000 Blythe Boulevard, Charlotte, NC 28203, United States
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Abstract
BACKGROUND The timing of definitive surgical stabilization is a controversial topic of pelvic and acetabular fracture (PAF) management. Historically, staged care with delayed definitive fixation was recommended; however, more recently, some centers have shown early definitive fixation to be feasible in most patients. We hypothesized that time to definitive fixation of PAF decreased without adverse outcomes. METHODS A level 1 trauma center's prospective pelvic fracture database was retrospectively analyzed. A total of 341 of the 1,270 consecutive PAF patients had surgery between January 2009 and December 2018. Demographics, polytrauma status, hemodynamic stability, time to definitive operation, length of intensive care unit stay, hospital length of stay, mortality were recorded. Data is presented as mean ± SD, percentages. Statistical significance was determined at p < 0.05. RESULTS There were 34 ± 8 per year operatively treated PAF patients during the study period. The demographics (age, 44.1 ± 18 years; 74.5% males) and injury severity (Injury Severity Score, 20; interquartile range, 16-29) did not change. Time to definitive fixation on average was 85 ± 113 hours (range, 0.8-1286 hours). Linear regression analysis demonstrated a decrease in time to definitive fixation considering all patients (β = -0.186, p = 0.003). pelvic ring fractures with polytrauma (β = -1.404, p = 0.03). and hemodynamically unstable patients (β = -1.428, p = 0.037). There was no significant change in mortality, length of stay, or intensive care unit length of stay for the overall cohort or any subgroup. CONCLUSION Time to definitive fixation in PAF has decreased during the last decade, with the largest decrease in time to fixation occurring in the hemodynamically unstable and pelvic fracture with polytrauma cohorts. The timely definitive internal fixation is achievable without increased length of stay. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Chen X, Zheng F, Zhang G, Gao X, Wang Y, Huang W, Lin H. An experimental study on the safe placement of sacroiliac screws using a 3D printing navigation module. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1512. [PMID: 33313257 PMCID: PMC7729361 DOI: 10.21037/atm-20-7080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background In this experimental study, we evaluated the use of digital 3D navigation printing in minimizing complications arising from sacroiliac screw misplacement. Methods A total of 13 adult pelvic specimens were studied using 3D navigation printing. Mimics software was used for preoperative planning and for obtaining sacrum median sagittal resection and long axis resection of the S1 pedicle center by 3D segmentation. The ideal screw path had its origin at the post-median part of the auricular surface of the sacroiliac joint, the midpoint at the mid-position of the lateral recess and outlet of the anterior sacral foramina; and the endpoint at the S1 sagittal resection. A sacroiliac screw fixed the pelvic specimens with the assistance of the navigation module. The distance between the start point (ilium surface) and endpoint (sacral median sagittal resection) of the screw path was measured after the pre- and postoperative 3D pelvis module was 3D-registered according to the standard precision range. The origin/endpoint qualified rates of the postoperative (n/26) and preoperative (26/26) screw paths were analyzed by the chi-square test. Results No screw misplacement occurred in the screw paths of any of the 13 pelvic specimens. The mean distance between the preoperative and postoperative origin of the screw path was 1.5415±0.6806 mm, and the mean distance between the preoperative and postoperative endpoint was 2.2809±0.4855 mm. The qualified rate of origin was 23/26 when the precision grade was 2.4 mm (P>0.05, χ2=1.41), while the qualified rate of endpoint was 21/26 when the precision grade was 2.7 mm (P>0.05, χ2=3.54). Conclusions In this experimental study, using a 3D printing navigation module helped attain an accurate and safe sacroiliac screw implantation.
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Affiliation(s)
- Xuanhuang Chen
- Department of Orthopedics, the Affiliated Hospital of Putian University, Putian, China.,The Third School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Feng Zheng
- Department of Orthopedics, the Affiliated Hospital of Putian University, Putian, China
| | - Guodong Zhang
- Department of Orthopedics, the Affiliated Hospital of Putian University, Putian, China
| | - Xiaoqiang Gao
- Department of Orthopedics, the Affiliated Hospital of Putian University, Putian, China
| | - Ya Wang
- National Key Discipline of Human Anatomy, School of Basic Medical Science, Southern Medical University, Guangzhou, China
| | - Wenhua Huang
- National Key Discipline of Human Anatomy, School of Basic Medical Science, Southern Medical University, Guangzhou, China
| | - Haibin Lin
- Department of Orthopedics, the Affiliated Hospital of Putian University, Putian, China.,The Third School of Clinical Medicine, Southern Medical University, Guangzhou, China
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Firoozabadi R, Elhaddad M, Drever S, Soltani M, Githens M, Kleweno CP, Sharar SR, Patterson DR, Hoffman HG. Case Report: Virtual Reality Analgesia in an Opioid Sparing Orthopedic Outpatient Clinic Setting: A Case Study. FRONTIERS IN VIRTUAL REALITY 2020; 1:553492. [PMID: 33585832 PMCID: PMC7877803 DOI: 10.3389/frvir.2020.553492] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Immersive virtual reality is proving effective as a non-pharmacologic analgesic for a growing number of painful medical procedures. External fixator surgical pins provide adjunctive stability to a broken pelvic bone until the bones heal back together, then pins are removed. The purpose of the present case study was to measure for the first time, whether immersive virtual reality could be used to help reduce pain and anxiety during the orthopedic process of removing external fixator pins from a conscious patient in the orthopedic outpatient clinic, and whether it is feasible to use VR in this context. Using a within-subject within wound care design with treatment order randomized, the patient had his first ex-fix pin unscrewed and removed from his healing pelvic bone while he wore a VR helmet and explored an immersive snowy 3D computer generated world, adjunctive VR. He then had his second pin removed during no VR, standard of care pain medications. The patient reported having 43% less pain intensity, 67% less time spent thinking about pain, and 43% lower anxiety during VR vs. during No VR. In addition, the patient reported that his satisfaction with pain management was improved with the use of VR. Conducting simple orthopedic procedures using oral pain pills in an outpatient setting instead of anesthesia in the operating room greatly reduces the amount of opioids used, lowers medical costs and reduces rare but real risks of expensive complications from anesthesia including oversedation, death, and post-surgical dementia. These preliminary results suggest that immersive VR merits more attention as a potentially viable adjunctive non-pharmacologic form of treatment for acute pain and anxiety during medical procedures in the orthopedic outpatient clinic. Recent multi-billion dollar investments into R and D and mass production have made inexpensive immersive virtual reality products commercially available and cost effective for medical applications. We speculate that in the future, patients may be more willing to have minor surgery procedures in the outpatient clinic, with much lower opioid doses, while fully awake, if offered adjunctive virtual reality as a non-pharmacologic analgesic during the procedure. Additional research and development is recommended.
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Affiliation(s)
- Reza Firoozabadi
- Orthopedic Trauma Surgery Clinic, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Moamen Elhaddad
- Orthopedic Trauma Surgery Clinic, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Sydney Drever
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Maryam Soltani
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Michael Githens
- Orthopedic Trauma Surgery Clinic, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Conor P. Kleweno
- Orthopedic Trauma Surgery Clinic, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Sam R. Sharar
- Department of Anesthesiology & Pain Medicine, School of Medicine, University of Washington, Seattle, WA, United States
| | - David R. Patterson
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | - Hunter G. Hoffman
- Department of Radiology, University of Washington, Seattle, WA, United States
- Department of Mechanical Engineering, College of Engineering, University of Washington, Seattle, WA, United States
- Department of Psychology, University of Washington, Washington, ME, United States
- Correspondence: Hunter G. Hoffman,
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Ead MS, Palizi M, Jaremko JL, Westover L, Duke KK. Development and application of the average pelvic shape in virtual pelvic fracture reconstruction. Int J Med Robot 2020; 17:e2199. [PMID: 33200858 DOI: 10.1002/rcs.2199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND With unilateral pelvic fractures, the contralateral hemipelvis can be used as a template in virtual reconstruction; however, this cannot be applied for bilateral fractures. Therefore, statistical shape modelling was used to build average pelvic shapes that can serve as templates when reconstructing bilaterally fractured pelvises. METHODS Four average shape models were created for male and female, left and right hemipelves from 20 male and 20 female subjects. They were used as templates to reconstruct eight unilaterally fractured pelvises. RESULTS The average root-mean-square of deviations between the reconstructed and intact hemipelves was 1.46 ± 0.32 mm, which is less than the 2 mm threshold for causing hip joint complications. CONCLUSION This indicates that the reconstructions are reliable and the average shape models can be used to reconstruct bilaterally fractured pelvises. The proposed technique can potentially provide quick and accurate treatment plans for pelvic fracture patients, which is necessary for recovery.
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Affiliation(s)
- Maha S Ead
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Mehrdad Palizi
- Department of Civil and Environmental Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsey Westover
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Kajsa K Duke
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
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Abstract
BACKGROUND Pelvic trauma has emerged as one of the most severe injuries to be sustained by the victim of a blast insult. The incidence and mortality due to blast-related pelvic trauma is not known, and no data exist to assess the relative risk of clinical or radiological indicators of mortality. METHODS The UK Joint Theater Trauma Registry was interrogated to identify those sustaining blast-mediated pelvic fractures during the conflicts in Iraq and Afghanistan, from 2003 to 2014, with subsequent computed tomography image analysis. Casualties that sustained more severe injuries remote to the pelvis were excluded. RESULTS One hundred fifty-nine casualties with a 36% overall mortality rate were identified. Pelvic vascular injury, unstable pelvic fracture patterns, traumatic amputation, and perineal injury were higher in the dismounted fatality group (p < 0.05). All fatalities sustained a pelvic vascular injury. Pelvic vascular injury had the highest relative risk of death for any individual injury and an associated mortality of 56%. Dismounted casualties that sustained unstable pelvic fracture patterns, traumatic amputation, and perineal injury were at three times greater risk (relative risk, 3.00; 95% confidence interval, 1.27-7.09) to have sustained a pelvic vascular injury than those that did not sustain these associated injuries. Opening of the pubic symphysis and at least one sacroiliac joint was significantly associated with pelvic vascular injury (p < 0.001), and the lateral displacement of the sacroiliac joints was identified as a fair predictor of pelvic vascular injury (area under the receiver operating characteristic curve, 0.73). CONCLUSION Dismounted blast casualties with pelvic fracture are at significant risk of a noncompressible pelvic vascular injury. Initial management of these patients should focus upon controlling noncompressible pelvic bleeding. Clinical and radiological predictors of vascular injury and mortality suggest that mitigation strategies aiming to attenuate lateral displacement of the pelvis following blast are likely to result in fewer fatalities and a reduced injury burden. LEVEL OF EVIDENCE Prognostic, level III.
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Jang JY, Oh J, Shim H, Kim S, Jung PY, Kim S, Bae KS. The need for a rapid transfer to a hybrid operating theatre: Do we lose benefit with poor efficiency? Injury 2020; 51:1987-1993. [PMID: 32360089 DOI: 10.1016/j.injury.2020.04.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/29/2020] [Accepted: 04/17/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Recent studies on hybrid operating rooms (ORs) have mainly reported their applications in orthopaedic surgery and interventional radiology (IR); there are few studies assessing severely injured patients who underwent IR or surgery in hybrid ORs for haemostasis. Therefore, this study aimed to evaluate our early experience with the use of hybrid OR to control haemorrhage in severe trauma patients. METHODS Medical charts of patients who underwent an emergency surgery or IR for haemostasis were analysed retrospectively between January and December 2015. RESULTS Of the 95 patients directly transported to the general or hybrid OR, 69 (73%) were transported to the non-hybrid OR and underwent emergency surgeries, whereas 26 (27%) were transported to the hybrid OR and underwent emergency IR or surgery on-site. Patients transported to the hybrid OR had a higher median Injury Severity Score (median: 29, interquartile range[IQR]: 21-36.5 vs median: 21, IQR: 16-27) and lower median initial systolic blood pressure (median: 96, IQR: 82.75-128.75 vs median: 114, IQR: 95-151.5) than those transported to the non-hybrid OR. The median time from the emergency room (ER) arrival to the start of the emergency procedure in the hybrid OR group was similar with that in the non-hybrid OR group (median: 80, IQR: 62.75-91.5 vs median: 75, IQR: 56.5-99). Seven patients underwent IR and surgery concurrently in the hybrid OR because of a haemodynamically unstable pelvic fracture, severe liver injury, and severe brain haemorrhage. The median time from the ER arrival to the start of the haemostatic procedure or operation was 64(43-97) minutes. CONCLUSIONS Although the hybrid OR may be used for haemostasis in severely injured patients, the long median time from ER arrival to the start of a haemostatic procedure in hybrid OR indicates the need for a new workflow to reduce this time and to facilitate hybrid OR use.
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Affiliation(s)
- Ji Young Jang
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Republic of Korea.
| | - Jiwoong Oh
- Department of Neurosurgery, Yonsei University College of Medicine, Republic of Korea
| | - Hongjin Shim
- Department of Surgery, Yonsei University Wonju College of Medicine, Republic of Korea; Regional Trauma Centre, Wonju Severance Christian Hospital, Republic of Korea
| | - Seongyup Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Republic of Korea; Regional Trauma Centre, Wonju Severance Christian Hospital, Republic of Korea
| | - Pil Young Jung
- Department of Surgery, Yonsei University Wonju College of Medicine, Republic of Korea; Regional Trauma Centre, Wonju Severance Christian Hospital, Republic of Korea
| | - Sohyun Kim
- Department of Physiology, Yonsei University College of Medicine, Republic of Korea
| | - Keum Seok Bae
- Department of Surgery, Yonsei University Wonju College of Medicine, Republic of Korea; Regional Trauma Centre, Wonju Severance Christian Hospital, Republic of Korea
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Kim K, Shim H, Jung PY, Kim S, Choi YU, Bae KS, Lee JK, Jang JY. Effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing for patients with pelvic fractures and hemodynamic instability: A propensity score matching analysis. PLoS One 2020; 15:e0236645. [PMID: 32706824 PMCID: PMC7380609 DOI: 10.1371/journal.pone.0236645] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 07/10/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION We evaluated the effectiveness of kaolin-impregnated hemostatic gauze use in preperitoneal pelvic packing (PPP) for patients with hemodynamic instability due to severe pelvic fractures. MATERIALS AND METHODS Between May 2014 and October 2018, 53 of 75 patients who underwent PPP due to hemodynamic instability induced by pelvic fracture were enrolled. Their medical records were prospectively collected and retrospectively analyzed. QuikClot combat gauze (hydrophilic gauze impregnated with kaolin) and general surgical tape were used in 21 patients, while general surgical tape was used in the remaining 32 patients. RESULTS As there were differences in the characteristics of patients between the hemostatic gauze (HG) group and control group, propensity score matching (PSM) was performed to adjust for age, sex, and lactate levels. After PSM, the clinical characteristics between the two groups became similar. There were no differences in the rates of mortality and hemorrhage-induced mortality between the two groups. However, the packed red blood cell (RBC) requirement for an additional 12 hours in the HG group was significantly lower than that in the control group (4.1 ± 3.5 vs. 7.6 ± 6.1 units, p = 0.035). The lengths of intensive care unit and hospital stays tended to be shorter in the HG group than in the control group (11.6 vs. 18.5 days, p = 0.1582; 30.8 vs. 47.4 days, p = 0.1861, respectively). CONCLUSIONS The use of HG during PPP did not reduce hemorrhage-induced mortality, but did reduce the need for additional packed RBC transfusions in patients with hemodynamic instability due to severe pelvic fractures.
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Affiliation(s)
- Kwangmin Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Hongjin Shim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Pil Young Jung
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Seongyup Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Young Un Choi
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Keum Seok Bae
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Regional Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Jung Kuk Lee
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji Young Jang
- Department of Surgery, Trauma Center, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- * E-mail: ,
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Dreizin D, Zhou Y, Chen T, Li G, Yuille AL, McLenithan A, Morrison JJ. Deep learning-based quantitative visualization and measurement of extraperitoneal hematoma volumes in patients with pelvic fractures: Potential role in personalized forecasting and decision support. J Trauma Acute Care Surg 2020; 88:425-433. [PMID: 32107356 PMCID: PMC7830753 DOI: 10.1097/ta.0000000000002566] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Admission computed tomography (CT) is a widely used diagnostic tool for patients with pelvic fractures. In this pilot study, we hypothesized that pelvic hematoma volumes derived using a rapid automated deep learning-based quantitative visualization and measurement algorithm predict interventions and outcomes including (a) need for angioembolization (AE), pelvic packing (PP), or massive transfusion (MT), and (b) in-hospital mortality. METHODS We performed a single-institution retrospective analysis of 253 patients with bleeding pelvic fractures who underwent admission abdominopelvic trauma CT between 2008 and 2017. Included patients had hematoma volumes of 30 mL or greater, were 18 years and older, and underwent contrast-enhanced CT before surgical or angiographic intervention. Automated pelvic hematoma volume measurements were previously derived using a deep-learning quantitative visualization and measurement algorithm through cross-validation. A composite dependent variable of need for MT, AE, or PP was used as the primary endpoint. The added utility of hematoma volume was assessed by comparing the performance of multivariable models with and without hematoma volume as a predictor. Areas under the receiver operating characteristic curve (AUCs) and sensitivities, specificities, and predictive values were determined at clinically relevant thresholds. Adjusted odds ratios of automated pelvic hematoma volumes at 200 mL increments were derived. RESULTS Median age was 47 years (interquartile range, 29-61), and 70% of patients were male. Median Injury Severity Score was 22 (14-36). Ninety-four percent of patients had injuries in other body regions, and 73% had polytrauma (Injury Severity Score, ≥16). Thirty-three percent had Tile/Orthopedic Trauma Association type B, and 24% had type C pelvic fractures. A total of 109 patients underwent AE, 22 underwent PP, and 53 received MT. A total of 123 patients received all 3 interventions. Sixteen patients died during hospitalization from causes other than untreatable (abbreviated injury scale, 6) head injury. Variables incorporated into multivariable models included age, sex, Tile/Orthopedic Trauma Association grade, admission lactate, heart rate (HR), and systolic blood pressure (SBP). Addition of hematoma volume resulted in a significant improvement in model performance, with AUC for the composite outcome (AE, PP, or MT) increasing from 0.74 to 0.83 (p < 0.001). Adjusted unit odds more than doubled for every additional 200 mL of hematoma volume. Increase in model AUC for mortality with incorporation of hematoma volume was not statistically significant (0.85 vs. 0.90, p = 0.12). CONCLUSION Hematoma volumes measured using a rapid automated deep learning algorithm improved prediction of need for AE, PP, or MT. Simultaneous automated measurement of multiple sources of bleeding at CT could augment outcome prediction in trauma patients. LEVEL OF EVIDENCE Diagnostic, level IV.
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Affiliation(s)
- David Dreizin
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Yuyin Zhou
- Department of Computer Science, Center for Cognition Vision and Learning, Johns Hopkins University
| | - Tina Chen
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Guang Li
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Alan L. Yuille
- Department of Computer Science, Head, Center for Cognition Vision and Learning, Johns Hopkins University
| | - Ashley McLenithan
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Jonathan J. Morrison
- Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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Dreizin D, Zhou Y, Zhang Y, Tirada N, Yuille AL. Performance of a Deep Learning Algorithm for Automated Segmentation and Quantification of Traumatic Pelvic Hematomas on CT. J Digit Imaging 2020; 33:243-251. [PMID: 31172331 PMCID: PMC7064706 DOI: 10.1007/s10278-019-00207-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The volume of pelvic hematoma at CT has been shown to be the strongest independent predictor of major arterial injury requiring angioembolization in trauma victims with pelvic fractures, and also correlates with transfusion requirement and mortality. Measurement of pelvic hematomas (unopacified extraperitoneal blood accumulated from time of injury) using semi-automated seeded region growing is time-consuming and requires trained experts, precluding routine measurement at the point of care. Pelvic hematomas are markedly variable in shape and location, have irregular ill-defined margins, have low contrast with respect to viscera and muscle, and reside within anatomically distorted pelvises. Furthermore, pelvic hematomas occupy a small proportion of the entire volume of a chest, abdomen, and pelvis (C/A/P) trauma CT. The challenges are many, and no automated methods for segmentation and volumetric analysis have been described to date. Traditional approaches using fully convolutional networks result in coarse segmentations and class imbalance with suboptimal convergence. In this study, we implement a modified coarse-to-fine deep learning approach-the Recurrent Saliency Transformation Network (RSTN) for pelvic hematoma volume segmentation. RSTN previously yielded excellent results in pancreas segmentation, where low contrast with adjacent structures, small target volume, variable location, and fine contours are also problematic. We have curated a unique single-institution corpus of 253 C/A/P admission trauma CT studies in patients with bleeding pelvic fractures with manually labeled pelvic hematomas. We hypothesized that RSTN would result in sufficiently high Dice similarity coefficients to facilitate accurate and objective volumetric measurements for outcome prediction (arterial injury requiring angioembolization). Cases were separated into five combinations of training and test sets in an 80/20 split and fivefold cross-validation was performed. Dice scores in the test set were 0.71 (SD ± 0.10) using RSTN, compared to 0.49 (SD ± 0.16) using a baseline Deep Learning Tool Kit (DLTK) reference 3D U-Net architecture. Mean inference segmentation time for RSTN was 0.90 min (± 0.26). Pearson correlation between predicted and manual labels was 0.95 with p < 0.0001. Measurement bias was within 10 mL. AUC of hematoma volumes for predicting need for angioembolization was 0.81 (predicted) versus 0.80 (manual). Qualitatively, predicted labels closely followed hematoma contours and avoided muscle and displaced viscera. Further work will involve validation using a federated dataset and incorporation into a predictive model using multiple segmented features.
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Affiliation(s)
- David Dreizin
- Department of Diagnostic Radiology and Nuclear Medicine & R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD USA
| | - Yuyin Zhou
- Computational Cognition, Vision, and Learning (CCVL), Johns Hopkins University, Baltimore, MD USA
| | - Yixiao Zhang
- Computational Cognition, Vision, and Learning (CCVL), Johns Hopkins University, Baltimore, MD USA
| | - Nikki Tirada
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD USA
| | - Alan L. Yuille
- Computational Cognition, Vision, and Learning (CCVL), Johns Hopkins University, Baltimore, MD USA
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Hammer M, Gutbrod A, Sigrist NE, Jacot V, Del Chicca F, Evans R, Pozzi A. Predictors of comorbidities and mortality in cats with pelvic fractures. Vet Surg 2019; 49:281-290. [PMID: 31876001 DOI: 10.1111/vsu.13369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/14/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To characterize and evaluate risk factors for comorbidities and death of cats with pelvic fractures. STUDY DESIGN Retrospective case study. ANIMALS Cats (n = 280). METHODS Medical records were reviewed for cats in which pelvic fractures had been diagnosed (January 2003 to November 2016). Retrieved data included signalment, mechanism of injury, clinical findings, diagnostic imaging investigations, type and number of concurrent injuries based on anatomical location, type of therapy, and survival. Pelvic fractures were classified according to location and severity. Descriptive statistics were performed, and logistic regression models were constructed to examine associations between risk factors and outcome. RESULTS Cases consisted of 280 cats with no (9%), unilateral (43%), and bilateral (48%) involvement of the weight-bearing axis. Sacral fractures were found in 12% of cats. Surgical treatment and mortality rates increased progressively with the severity of the pelvic fractures (P < .001). Mean number of concurrent body regions injured was 2.4 ± 1.2 and was associated with mortality (P < .01). Twenty percent of cats did not survive to discharge. Cats with neurologic injuries were more likely not to survive (P = .02). CONCLUSION Concurrent injuries to at least one body region, especially the abdomen and thorax, were observed in cats sustaining pelvic fractures. Mortality was associated with increased severity of the fractures, neurologic injuries, and increased number of concurrent injuries. CLINICAL SIGNIFICANCE Concurrent injuries are common in cats with pelvic fractures, and comorbidities may be associated with mortality.
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Affiliation(s)
- Meike Hammer
- Clinic for Small Animal Surgery, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | | | - Nadja E Sigrist
- Division of Critical Care Medicine, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | | | - Francesca Del Chicca
- Clinic for Diagnostic Imaging, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | | | - Antonio Pozzi
- Clinic for Small Animal Surgery, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
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Technical Considerations and Fluoroscopy in Percutaneous Fixation of the Pelvis and Acetabulum. J Am Acad Orthop Surg 2019; 27:899-908. [PMID: 31192885 DOI: 10.5435/jaaos-d-18-00102] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Surgical treatment of the pelvic ring and acetabulum continues to evolve. Improved imaging technology and means for closed reduction have meant that percutaneous techniques have gained popularity in the treatment of the pelvic ring and, more recently, in the acetabulum. Potential benefits include decreased soft-tissue dissection, blood loss, and surgical time. However, these are technically demanding procedures that require substantial expertise from both the surgeon and the radiographer. This article details the necessary fluoroscopic views and general methods used in percutaneous techniques around the pelvis and acetabulum. Despite most studies reporting good-to-excellent clinical and radiographic results, further work is needed to facilitate standardization and optimization of these outcomes.
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Pelvic Fractures and Associated Genitourinary and Vascular Injuries: A Multisystem Review of Pelvic Trauma. AJR Am J Roentgenol 2019; 213:1297-1306. [DOI: 10.2214/ajr.18.21050] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Magnone S, Allievi N, Ceresoli M, Coccolini F, Pisano M, Ansaloni L. Prospective validation of a new protocol with preperitoneal pelvic packing as the mainstay for the treatment of hemodynamically unstable pelvic trauma: a 5-year experience. Eur J Trauma Emerg Surg 2019; 47:499-505. [PMID: 30955052 DOI: 10.1007/s00068-019-01115-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 03/26/2019] [Indexed: 10/27/2022]
Abstract
PURPOSES Hemodynamically unstable pelvic trauma has been a significant challenge even in most experienced Trauma Centres. In 2011 preperitoneal pelvic packing (PPP) was introduced in our Hospital as the first manoeuvre. This study aims to review overall mortality at 24 h from arrival in the emergency department. METHODS A retrospective review of our prospective database was performed considering patients with systolic blood pressure (SBP) < 90 mmHg or with the need for more than 2 Units of packed red blood cells (PRBC) on admission in the emergency department, (ED) and a pelvic fracture. Values were expressed as a median and interquartile range. Continuous variables were compared with the Mann-Whitney test. RESULTS Between September 2011 and December 2016, we treated 30 patients. Median age was 51 years (40-65) and Injury Severity Score 36 (34-42). SBP in the ED was 90 (67-99), heart rate was 115 (90-130), Base Excess - 8 (- 11.5/- 4.8), pH 7.23 (7.20-7.28). Median PRBC requirements during the first 24 h (from admission) were 13 Units (8-18.8). Time to emergency treatment was 63 min (51-113). 17 patients (56.6%) underwent angiography after PPP. Overall 24 h mortality was 30%. A comparison between survivors and non-survivors showed no statistically significant differences between groups. CONCLUSIONS In our experience, PPP resulted to be quick to perform and effective. No death occurred from direct pelvic bleeding.
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Affiliation(s)
- Stefano Magnone
- General Surgery I, Ospedale Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy.
| | - Niccolò Allievi
- General Surgery I, Ospedale Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Marco Ceresoli
- General Surgery I, Ospedale Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Federico Coccolini
- General Surgery I, Ospedale Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Michele Pisano
- General Surgery I, Ospedale Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - Luca Ansaloni
- General Surgery I, Ospedale Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy
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Pelvic Fractures and Indications for Pelvic Packing: An Update. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0228-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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American College of Surgeons Committee on Trauma verification level affects trauma center management of pelvic ring injuries and patient mortality. J Trauma Acute Care Surg 2019; 86:1-10. [DOI: 10.1097/ta.0000000000002062] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Multi-scale Attentional Network for Multi-focal Segmentation of Active Bleed After Pelvic Fractures. MACHINE LEARNING IN MEDICAL IMAGING 2019. [DOI: 10.1007/978-3-030-32692-0_53] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
OBJECTIVE Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject. DESIGN A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation; SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence; SFMU) in collaboration with the French Society of Radiology (Société Française de Radiologie; SFR), French Defence Health Service (Service de Santé des Armées; SSA), French Society of Urology (Association Française d'Urologie; AFU), the French Society of Orthopaedic and Trauma Surgery (Société Française de Chirurgie Orthopédique et Traumatologique; SOCFCOT), and the French Society of Digestive Surgery (Société Française de Chirurgie digestive; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE® methodology. RESULTS The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ± ), 11 have a low level of evidence (Grade 2 ± ). CONCLUSIONS Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture.
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Eisa A, Farouk O, Mahran DG, Badran M, Abdelnasser MK, Samir M, Kalampoki V, Hurtado-Chong A, Rometsch E, Mohamedean A, Adam F. Predictors of mortality after pelvic fractures: a retrospective cohort study from a level one trauma centre in Upper Egypt. INTERNATIONAL ORTHOPAEDICS 2018; 43:2405-2413. [PMID: 30515536 DOI: 10.1007/s00264-018-4230-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 11/04/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE The primary objective was to identify the predictors of in-hospital mortality after pelvic ring injuries. Secondary objectives were to analyze the differences between adults and children and to analyze the causes and timing of death. METHODS A retrospective cohort study from the pelvic registry of Assiut University Trauma Unit (AUTU), a level 1 trauma centre in Upper Egypt, was carried out. A total of 1188 consecutive patients with pelvic ring fractures treated from January 2010 to December 2013 were eligible for analysis. Potential predictors were identified using standard statistical tests: univariable and multivariable regression analysis. RESULTS Nine hundred fifty-one were adults (above 16 years) and 237 were children. According to Tile's classification, fractures type A, B, and C were 31.8%, 25.1%, and 43.1%, respectively. About a third of patients had fractures with soft tissue injury. Abdominopelvic collection as diagnosed by Focused Assessment with Sonography for Trauma (FAST) was positive in 11%. Associated injuries were present in 67.3% with abdominal-urogenital injuries being the most prevalent (66.3%). Median hospital stay was five days. Fifty-two patients (4.4%) were admitted to the ICU. One hundred three patients died (8.7%) within two peaks: first 24 hours and between 48 hours and one week. Multivariable logistic regression analysis identified increasing age, fractures with soft tissue injury, associated head injury, positive FAST examination, and admission to an ICU as significant predictors of in-hospital mortality. CONCLUSIONS The first 24 hours were confirmed to be critical for survival in pelvic fracture patients. Advancing age, associated soft tissue injury, associated head injury, admission to ICU, and positive FAST examination can serve as reliable predictors for an elevated mortality risk in such patients.
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Affiliation(s)
- Amr Eisa
- Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Hospitals, Assiut, 71526, Egypt.
| | - Osama Farouk
- Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Hospitals, Assiut, 71526, Egypt
| | - Dalia G Mahran
- Faculty of Medicine, Department of Public Health and Community Medicine, Assiut University, Assiut, Egypt
| | - Mahmoud Badran
- Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Hospitals, Assiut, 71526, Egypt
| | - Mohammad K Abdelnasser
- Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Hospitals, Assiut, 71526, Egypt
| | - Michael Samir
- Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Hospitals, Assiut, 71526, Egypt
| | - Vasiliki Kalampoki
- AO Clinical Investigation and Documentation (AOCID), AO Foundation, Dübendorf, Switzerland
| | - Anahi Hurtado-Chong
- AO Clinical Investigation and Documentation (AOCID), AO Foundation, Dübendorf, Switzerland
| | - Elke Rometsch
- AO Clinical Investigation and Documentation (AOCID), AO Foundation, Dübendorf, Switzerland
| | - Aly Mohamedean
- Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Hospitals, Assiut, 71526, Egypt
| | - Faisal Adam
- Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Assiut University Hospitals, Assiut, 71526, Egypt
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Kim MJ, Lee JG, Lee SH. Factors predicting the need for hemorrhage control intervention in patients with blunt pelvic trauma: a retrospective study. BMC Surg 2018; 18:101. [PMID: 30445931 PMCID: PMC6240179 DOI: 10.1186/s12893-018-0438-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/05/2018] [Indexed: 01/18/2023] Open
Abstract
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.
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Affiliation(s)
- Myoung Jun Kim
- Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Seung Hwan Lee
- Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Shim H, Jang JY, Kim JW, Ryu H, Jung PY, Kim S, Kwon HY, Kim KM, Chung H, Bae KS. Effectiveness and postoperative wound infection of preperitoneal pelvic packing in patients with hemodynamic instability caused by pelvic fracture. PLoS One 2018; 13:e0206991. [PMID: 30395596 PMCID: PMC6218082 DOI: 10.1371/journal.pone.0206991] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/23/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction Despite the use of a multidisciplinary treatment approach, the mortality rate of hemodynamic instability due to severe pelvic fracture remains 40–60%. Several recent studies have shown that preperitoneal pelvic packing (PPP) was useful for achieving hemostasis in these patients in the acute phase. However, few studies have examined postoperative complications. The purpose of the present study was to evaluate clinical outcomes and wound infections of PPP in these patients. Materials and methods We retrospectively reviewed the medical charts of 62 patients with hemorrhagic shock due to pelvic fracture between March 2011 and May 2017. Excluding four patients (two with other major hemorrhage sites and two who experienced cardiac arrest in the emergency room), the patients were divided into PPP (n = 30) and non-PPP (n = 28) groups according to PPP application. Clinical outcomes including early-stage mortality, transfusion amount, and surgical site infection (SSI) were compared between the two groups. Results The overall mortality rate was 48.3% and the mean Injury Severity Score (ISS) was 39 ± 9. The 30 patients in the PPP group had a significantly lower hemorrhage-induced mortality rate than the 28 patients in the non-PPP group (16.7% vs 50%, p = 0.019), although both groups had similar patient characteristics (age, ISS, and initial serum lactate level). Independent factors associated with hemorrhage-induced mortality were PPP and the requirement of packed red blood cells for 4 h. In the PPP group, SSI occurred in 5 of 25 (20%) patients. Conclusions PPP may be considered as a hemostatic modality for hemodynamic instability due to pelvic fracture because it reduces the hemorrhage-induced mortality rate. However, wound infections after the procedure should be considered.
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Affiliation(s)
- Hongjin Shim
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji Young Jang
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- * E-mail:
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center University of Ulsan, Seoul, Korea
| | - Hoon Ryu
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Pil Young Jung
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seongyup Kim
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hye Youn Kwon
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kwang Min Kim
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hoejeong Chung
- Department of Orthopedic Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Keum Seok Bae
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
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Abstract
INTRODUCTION Pelvic angiography with transcatheter arterial embolization (TAE) is an established intervention for management of pelvic arterial hemorrhage. This study analyzes complication rates after angiography among patients with pelvic trauma treated in the context of a multidisciplinary institutional pelvic fracture protocol. METHODS Retrospective analysis of prospectively collected data was conducted. Demographics, fracture type, embolization (ie, unilateral versus bilateral and selective versus nonselective), and complications (ie, pseudoaneurysm, renal failure, soft-tissue necrosis/infection, and anaphylactic reactions) were noted. RESULTS Eighty-one patients with pelvic ring injuries underwent angiography from 2009 to 2013. Complications among 41 patients who underwent angiography with TAE were compared with a control group of 40 patients who underwent angiography without TAE. Eight of 41 patients with TAE had complications (19.5%) compared with 3 of 40 (7.5%) in the control group (P = 0.19). The overall complication rate was 13.6%. CONCLUSION The use of angiography with TAE as part of an institutional pelvic fracture protocol involves an acceptable rate of complications. LEVEL OF EVIDENCE III.
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Borror W, Gaski GE, Steenburg S. Abdominopelvic bleed rate on admission CT correlates with mortality and transfusion needs in the setting of blunt pelvic fractures: a single institution pilot study. Emerg Radiol 2018; 26:37-44. [PMID: 30259226 DOI: 10.1007/s10140-018-1646-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/17/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE The objectives of this study were to calculate the total volumetric rate of abdominopelvic bleeding in patients with acute pelvic fractures and examine the relationships between the bleeding rate, patient outcomes, and required patient interventions. METHODS This was a retrospective cohort study which included 29 patients from a 4-year period (May 2013 to May 2017). Patients with acute pelvic fractures and active bleeding detected on CT with two phases of imaging were included. Software was used to measure the volume of active bleeding on arterial and parenchymal phases. The active bleeding rate was calculated by dividing the change in active bleeding volume by the time between the two phases. The total volumetric bleed rate from all sites was then computed. Clinical variables were compared between survivors and non-survivors. RESULTS Overall mortality in this cohort was 21% (n = 6). The mean abdominopelvic volumetric bleed rate in non-survivors was much greater than survivors (40.7 cc/min vs. 5.7 cc/min; p < 0.01). Ninety-six percent of survivors had an abdominopelvic bleed rate < 20 cc/min compared to 33% of non-survivors. An abdominopelvic bleed rate > 20 cc/min was associated with a mortality rate of 80% while a rate of < 20 cc/min was associated with a 92% survival rate. The mean pelvic hematoma volume was greater in non-survivors compared to survivors (1854 cc vs. 746 cc; p < 0.01). There was a positive association between hematoma volume and units of blood transfused (rs = 0.4, n = 29, p = 0.04). CONCLUSION An abdominopelvic bleeding rate > 20 cc/min was associated with a high risk of mortality.
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Affiliation(s)
- William Borror
- Department of Diagnostic and Interventional Imaging, University Of Texas, 6431 Fannin St, 2.130B, Houston, TX, 77030, USA.
| | - Greg E Gaski
- Indiana University Health Methodist Hospital, Department of Orthopedic Surgery, Indiana University School of Medicine, 1801 N. Senate Blvd, MPC 1, Ste. 53, Indianapolis, IN, 46202, USA
| | - Scott Steenburg
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd., Medical Sciences Building Room 0663, Indianapolis, IN, 46202, USA
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The pelvic fracture - Indicator of injury severity or lethal fracture? Injury 2018; 49:1568-1571. [PMID: 29909925 DOI: 10.1016/j.injury.2018.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/11/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Presence of pelvic fractures in trauma patients has previously been related to high mortality. However, there are controversies on whether pelvic fractures are the underlying cause of death or if it is rather an indicator of injury severity. We aimed to assess whether the presence of pelvic fracture increased mortality among a cohort of trauma patients or if it was simply an indicator of severe injury. MATERIAL AND METHODS Karolinska University Hospital is the largest trauma centre in Sweden. The hospital is linked to the Swedish National Trauma Registry, "SweTrau". Registry data was collected for the period January 2013 until December 2015 with a one year further follow-up regarding mortality. Patients in the pelvic fracture group were compared to the non-pelvic fracture group and regression analysis was performed adjusting for factors that could possibly affect mortality. RESULTS Univariable analysis showed that pelvic fracture was associated with an increased mortality, OR 2.4 (CI 1.3-3.4). Multivariable analysis showed that the presence of a pelvic fracture was not associated with an increased 30-day mortality (OR 0.5, CI 0.2-0.9), while factors as Shock (OR 7.1, CI 4.6-10.9), GCS < 9 (OR 6.2, CI 3.9-9.8), ISS > 15 (OR 12.4, CI 8.1-18.9), Age >60 (OR 3.2, CI 2.1-4,9) and ASA 3-4 (OR 4.7, CI 3.1-7.3) were associated with an increased 30-day mortality. Factors affecting 1-year mortality was analysed in the same way and the results were similar. CONCLUSION Presence of pelvic fractures in trauma patients is not correlated to increased mortality when adjusted for Age, ISS, ASA, GCS and Shock.
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Monchal T, Ndiaye A, Gadegbeku B, Javouhey E, Monneuse O. Abdominopelvic injuries due to road traffic accidents: Characteristics in a registry of 162,695 victims. TRAFFIC INJURY PREVENTION 2018; 19:529-534. [PMID: 29509045 DOI: 10.1080/15389588.2018.1447669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 02/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Road traffic accidents (RTAs) are the first cause of abdominopelvic injuries (APIs). The objective of this study was to describe the characteristics and severity of APIs due to traffic accidents in a large French trauma registry and to identify risk factors for API. METHODS All victims from the French Rhône registry of victims of RTAs were analyzed from 1996 to 2013. This registry contained data that were issued over a 20-year period from 245 medical departments, from prehospital care until re-adaptation, and forensic medicine departments. All APIs, defined as an injury between the diaphragm and the pelvic bone, were extracted and studied. RESULTS Among 162,695 victims, 10,165 had an API (6.7%). Accidents frequently involved young men and 2 cars. Mean Injury Severity Score (ISS) was 8.7. Mortality rate was 5.6%. Soft tissue injuries largely predominated (n = 6,388; 54.4% of patients). Overall, 2,322 victims had a pelvic bone injury. Internal abdominal organs were involved in 2,425 patients; the most frequent were the spleen, liver, and kidney. Wearing of the seat belt appeared to be a significant protective factor in API, including serious injuries. A partial analysis over the past 2 years among the most severe patients hospitalized in the intensive care unit indicated that nonoperative management was carried out in two thirds of the wounded. In uni- or multivariate analysis, sex, age, type of user, antagonist, time of occurrence, associated severe lesions, or wearing of the seat belt were statistically associated with the occurrence of API, highlighting a more dangerous user profile. CONCLUSIONS Abdominopelvic injuries concern a minority of road traffic injuries, but they are responsible for significant mortality. Large solid organs are the most frequently affected. Women drivers wearing a seat belt and driving in town during the day appear to be more protected against API.
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Affiliation(s)
- Tristan Monchal
- a Department of General Surgery , Sainte Anne Military Hospital , Toulon , France
| | - Amina Ndiaye
- b UMR Epidémiologique et de Surveillance Transport Travail Environnement, IFSTTAR (French Institute of Science and Technology for Transport, Spatial Planning, Development and Networks), Université Lyon1 , UMR , Bron , France
| | - Blandine Gadegbeku
- b UMR Epidémiologique et de Surveillance Transport Travail Environnement, IFSTTAR (French Institute of Science and Technology for Transport, Spatial Planning, Development and Networks), Université Lyon1 , UMR , Bron , France
| | - Etienne Javouhey
- b UMR Epidémiologique et de Surveillance Transport Travail Environnement, IFSTTAR (French Institute of Science and Technology for Transport, Spatial Planning, Development and Networks), Université Lyon1 , UMR , Bron , France
- c Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon , Bron , France
| | - Olivier Monneuse
- d Emergency and Trauma Surgery Department , Hôpital Édouard Herriot, Hospices Civils de Lyon , France
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49
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Analysis of isolated transverse process fractures sustained during blast-related events. J Trauma Acute Care Surg 2018; 85:S129-S133. [DOI: 10.1097/ta.0000000000001815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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50
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Ju YU, Cho JM, Kim NR, Lee KB, Kim JK, Oh JK. Analysis of the Importance of Sacroiliac Joint Fractures as a Prognostic Factor of the Patients with Pelvic Fractures. JOURNAL OF TRAUMA AND INJURY 2018. [DOI: 10.20408/jti.2018.31.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Yeon-Uk Ju
- Department of General Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Jun-Min Cho
- Department of General Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Nam-Ryeol Kim
- Department of General Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Kyung-Bum Lee
- Department of General Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Jin-Kak Kim
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Jong-Keon Oh
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea
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