A Multidisciplinary Approach to Treating Traumatic Pelvic Fractures: 1.1 www.aornjournal.org/content/cme

Management of pelvic ring fractures in limited resources country: a retrospective study

PURPOSE

Pelvic ring fractures (PRFs) management needs adequate facilities and human resources. However, the prehospital ambulance management role in Indonesia is insufficient. Many hospitals have limited resources that necessitate patients to be referred to higher trauma centers. This study aims to describe the state of PRFs management at a level 1 trauma center in limited-resource country.

METHODS

We conducted retrospective studies of PRFs management from 2011 to 2021 at Cipto Mangunkusumo Hospital. We analyzed patient's management flow from injury, referral process, initial to definitive treatment, mortality, and Majeed functional score.

RESULTS

From 109 patients, 30.3% were non-referrals that came without ambulance, while 69.7% were referrals using an ambulance. All non-referral patients came without pelvic binder with 54.5% unstable hemodynamic, while 35.5% of the referrals came with unstable hemodynamic and 72.4% had pelvic binder. Median time for non-referrals reaching our hospital is 12.5 h. Unlike local referrals, 75% of regional and 85.7% of national referrals general improvement had to be improved before being referred. Polytrauma cases were 33.9% with 12 days mean interval to definitive treatment. Mortality rate in this study was 13.8%. During post-operative follow-up with a mean of 4 years, 83% of patients could be followed up and reported 93 median Majeed score.

CONCLUSION

The management of PRFs at level 1 trauma center in limited-resource country shows a mortality rate of 13.8% through various limitations such as unimplemented ambulance prehospital management, number of patients who were referred without pelvic binder applied, and the long waiting interval for definitive treatment.

Proposal of standardization of every step of angiographic procedure in bleeding patients from pelvic trauma

Trauma accounts for a third of the deaths in Western countries, exceeded only by cardiovascular disease and cancer. The high risk of massive bleeding, which depends not only on the type of fractures, but also on the severity of any associated parenchymal injuries, makes pelvic fractures one of the most life-threatening skeletal injuries, with a high mortality rate. Therefore, pelvic trauma represents an important condition to correctly and early recognize, manage, and treat. For this reason, a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, emergency room physicians and interventional radiologists is needed to promptly manage the resuscitation of pelvic trauma patients and ensure the best outcomes, both in terms of time and costs. Over the years, the role of interventional radiology in the management of patient bleeding due to pelvic trauma has been increasing. However, the current guidelines on the management of these patients do not adequately reflect or address the varied nature of injuries faced by the interventional radiologist. In fact, in the therapeutic algorithm of these patients, after the word “ANGIO”, there are no reports on the different possibilities that an interventional radiologist has to face during the procedure. Furthermore, variations exist in the techniques and materials for performing angioembolization in bleeding patients with pelvic trauma. Due to these differences, the outcomes differ among different published series. This article has the aim to review the recent literature on optimal imaging assessment and management of pelvic trauma, defining the role of the interventional radiologist within the multidisciplinary team, suggesting the introduction of common and unequivocal terminology in every step of the angiographic procedure. Moreover, according to these suggestions, the present paper tries to expand the previously drafted algorithm exploring the role of the interventional radiologist in pelvic trauma, especially given the multidisciplinary setting.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Improving the improvisational pelvic circumferential compression technique for open-book pelvic fractures using a simulation model and a sphygmomanometer

BACKGROUND

Open-book pelvic fractures are associated with significant mortality. Emergency management may require a commercial pelvic circumferential compression device to reduce the fracture and compress haemorrhaging pelvic vasculature. Standard, commercial, twin-sized bedsheets are acceptable should commercial devices be unavailable. However, obese victims or personnel with insufficient body strength may impede successful reduction.

OBJECTIVE

To demonstrate the value of an improvisational windlass (intravenous pole) in improving the ability to reduce an open-book pelvic fracture.

METHODS

The Institutional Review Board-approved study involved 28 diverse healthcare students and emergency medicine residents. Each participant's demographic information and physical characteristics were recorded. A METIman was prepared with knee and ankle binding and a sphygmomanometer set at 40 mm Hg placed over the symphysis pubis. Two-person teams were randomly selected to place a bedsheet at greater trochanter level and atop the sphygmomanometer. The bedsheet was secured with maximum effort by the pairs and the pressure recorded. Following this, the pairs inserted an intravenous pole in the knot and torqued the pole to maximum effort and a repeat pressure recorded.

RESULTS

The mean increase in pressure using only the bedsheet was 106.43 mm Hg per team. With bedsheet and intravenous pole, the mean pressure increase was 351.79 mm Hg per team. The difference was statistically significant (independent samples t-test: t = 17.177, p < 0.001, 95% CI (216.65 to 274.07 mm Hg). There was no correlation between pressure increases and the individual physical characteristics of the subjects (r = - 0.183, p = 0.352).

CONCLUSIONS

Regardless of personnel's physical attributes, the addition of an improvisational windlass to a pelvic circumferential compression bedsheet can improve the ability to reduce an open-book fracture, especially in obese victims.