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Oda T, Kitada S, Hirase H, Takada Y, Iwasa K, Niikura T. Evaluation of a treatment protocol based on conservative therapy for fragility fractures of the pelvis. Eur J Trauma Emerg Surg 2024; 50:1173-1181. [PMID: 38393362 DOI: 10.1007/s00068-024-02469-z] [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: 06/21/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE In an aging society, fragility fractures of the pelvis (FFP) have increased significantly. However, there is no clear consensus on the timing and criteria for transitioning from conservative treatment to surgery for these fractures. Thus, we aimed to investigate the effects of our treatment protocol for FFP based on conservative treatment. METHODS We conducted a retrospective study including 74 patients with FFP at our institution between 2015 and 2021. All patients were treated conservatively for the first two weeks. During this period, only wheelchair transfer was allowed. If the patient could not walk after this period, surgery was performed. Fracture type (Rommens classification), walking ability, presence of complications after admission, presence of fracture union, and surgical treatment was investigated. Patients were divided into two groups: a stable group (type I/II) and an unstable group (type III/IV). RESULTS Fracture union was achieved in all patients. Thirteen patients developed complications after being admitted to our hospital; seven showed decreased walking ability, and six required surgeries. The stable and unstable groups comprised 47 and 27 patients, respectively. There were no statistically significant differences between the groups regarding the percentage of patients who developed complications or experienced decrease in walking ability. The percentage of patients who required surgery was significantly higher in the unstable group (p < 0.05). CONCLUSION Our FFP management protocol was effective regardless of fracture type. It is important to provide a period for careful assessment of instability, and to try to prevent fracture progression.
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Affiliation(s)
- Takahiro Oda
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Shimpei Kitada
- Orthopaedic Reconstruction Center, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan.
| | - Hitoshi Hirase
- Orthopaedic Reconstruction Center, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Yuma Takada
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Kenjiro Iwasa
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
- Orthopaedic Reconstruction Center, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
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Al-Rawi Z, Nached Y, Abdelwahab A, Samy BM. Life-Threatening Bleeding Following a Stable Fracture of the Superior Pubic Ramus: A Case Report. Cureus 2024; 16:e61520. [PMID: 38957245 PMCID: PMC11218421 DOI: 10.7759/cureus.61520] [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] [Accepted: 06/02/2024] [Indexed: 07/04/2024] Open
Abstract
Corona mortis, an anatomical variant documented in the literature, presents a noteworthy concern due to its proximity to the superior pubic ramus. Consequently, it remains susceptible to injury, even in stable, benign fractures of the pelvis, typically addressed through conservative management. Stable pelvic fractures are infrequently associated with complications; therefore, diligent monitoring is often overlooked in clinical practice. However, it becomes crucial, particularly in the elderly population given their suboptimal hemostatic capabilities. The standard approach for managing bleeding associated with pelvic fractures involves superselective embolization, a minimally invasive procedure with favorable outcomes. We present a case involving a 61-year-old female who experienced a stable pelvic fracture following low-energy trauma. Despite the ostensibly benign nature of the fracture, the patient exhibited hemodynamic instability attributable to bleeding from the corona mortis, necessitating embolization. The pelvic fracture itself was managed conservatively, leading to the patient's subsequent discharge in a stable condition. Therefore, we advocate for a comprehensive physical examination, serial hemoglobin monitoring, and additional imaging modalities based on the patient's clinical condition.
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Affiliation(s)
- Zeinab Al-Rawi
- Department of Orthopaedics and Trauma, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, ARE
| | - Yasmin Nached
- Department of Orthopaedics and Trauma, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, ARE
| | - Abdulla Abdelwahab
- Department of Orthopaedics and Trauma, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, ARE
| | - Baher M Samy
- Department of Orthopaedics and Trauma, Dubai Health, Rashid Hospital, Dubai, ARE
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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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Lustenberger T, Störmann P, Eichler K, Nau C, Janko M, Marzi I. Secondary Angio-Embolization After Emergent Pelvic Stabilization and Pelvic Packing Is a Safe Option for Patients With Persistent Hemorrhage From Unstable Pelvic Ring Injuries. Front Surg 2020; 7:601140. [PMID: 33392246 PMCID: PMC7773821 DOI: 10.3389/fsurg.2020.601140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/30/2020] [Indexed: 12/30/2022] Open
Abstract
Introduction: In patients with severe pelvic ring injuries, exsanguination still is the leading cause of death in the early post-injury phase. While mechanical pelvic ring stabilization and pre-peritoneal pelvic packing are mainly addressing venous bleeding, angio-embolization aims to control arterial bleeding. The goal of the present study was to evaluate the rate of postoperative angio-embolization after mechanical pelvic ring injury stabilization and pre-peritoneal pelvic packing. Bleeding sources detected in the angiography and the patient's outcome were investigated. Patients and Methods: Retrospective observational cohort study at a single academic level I trauma center, reviewing all patients with pelvic ring injuries admitted from 01/2010 to 12/2019. Patients with emergent mechanical pelvic ring stabilization (supraacetabular external fixator and/or pelvic C-clamp) and direct pre-peritoneal pelvic packing were further analyzed. Patients that underwent postoperative angio-embolization were compared with those that did not. All postoperative angio-embolizations were evaluated with regards to bleeding sources and type of embolization. Results: During the study period, a total of 39 patients required immediate mechanical pelvic stabilization and direct pre-peritoneal pelvic packing. Of these, 12 patients (30.8%) underwent a postoperative angio-embolization. The following vessels were identified as bleeding sources: superior gluteal artery (n = 6), obturator artery (n = 2), internal pudendal artery (n = 2), unnamed branches of the internal iliac artery (n = 3). A selective embolization was successful in 11 patients; in 1 patient, an unilateral complete occlusion of the internal iliac artery was performed to control the bleeding. Mean time from hospital admission to the surgical procedure was 52.8 ± 14.7 min and the mean time from admission to angio-embolization was 189.1 ± 55.5 min. The in-hospital mortality rate of patients with angio-embolization was 25.0% (n = 3). Of these, 2 patients died due to multiple organ failure and 1 patient due to severe head injury. Conclusion: Secondary angio-embolization after external pelvic fixation and pre-peritoneal pelvic packing was effective in controlling ongoing bleeding. The most frequently detected bleeding vessel was the superior gluteal artery, which is difficult to surgically address, further highlighting the importance of angio-embolization in the management algorithm.
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Affiliation(s)
- Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Philipp Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Kathrin Eichler
- Institute for Diagnostic and Interventional Radiology, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Christoph Nau
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Maren Janko
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt am Main, Frankfurt, Germany
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Frequency and Clinical Review of the Aberrant Obturator Artery: A Cadaveric Study. Diagnostics (Basel) 2020; 10:diagnostics10080546. [PMID: 32751771 PMCID: PMC7459979 DOI: 10.3390/diagnostics10080546] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/12/2020] [Accepted: 07/29/2020] [Indexed: 11/20/2022] Open
Abstract
The occurrence of an aberrant obturator artery is common in human anatomy. Detailed knowledge of this anatomical variation is important for the outcome of pelvic and groin surgeries requiring appropriate ligation. Familiarity with the occurrence of an aberrant obturator artery is equally important for instructors teaching pelvic anatomy to students. Case studies highlighting this vascular variation provide anatomical instructors and surgeons with accurate information on how to identify such variants and their prevalence. Seven out of eighteen individuals studied (38.9%) exhibited an aberrant obturator artery, with two of those individuals presenting with bilateral aberrant obturator arteries (11.1%). Six of these individuals had an aberrant obturator artery that originated from the deep inferior epigastric artery (33.3%). One individual had an aberrant obturator artery that originated directly from the external iliac artery (5.6%).
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Sng M, Gentle J, Asadollahi S. Bleeding Risk Associated With Hemodynamically Stable Low-Energy Pelvic Fracture. Geriatr Orthop Surg Rehabil 2020; 11:2151459320911868. [PMID: 32284903 PMCID: PMC7133069 DOI: 10.1177/2151459320911868] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 11/23/2019] [Accepted: 12/08/2019] [Indexed: 12/23/2022] Open
Abstract
Introduction: Life-threatening hemorrhage associated with low-energy pelvic fracture has been described in single cases in the literature. However, there is limited evidence available on the bleeding risk associated with hemodynamically stable osteoporotic pelvic fractures. The objective of this study was to estimate the bleeding risk associated with low-energy osteoporotic pelvic fractures in the elderly population. Materials and Methods: A retrospective review of patients aged > 65 years old with pelvic fractures admitted between 2015 and 2018 was performed. Eighty-two patients were identified: 12 males and 70 females with a median age of 86 years. The median Charlson comorbidity index was 6 (interquartile range = 5-7). Eighty-one fractures were classified as lateral compression I or Tile A2, and 1 fracture was classified as lateral compression II or Tile B2. Forty patients were on concurrent anticoagulation treatment. In 4 patients on warfarin, this treatment was reversed on admission. Results: The mean hemoglobin (Hb) level on arrival was 12.36 g/dL (±1.67 g/dL). There were significant drops in Hb levels on day 1 (Hb = 11.22 ± 1.86 g/dL, P < .001) and day 4 (Hb = 10.97 ± 1.6 g/dL, P < .001). Nine percent of patients required a blood transfusion. The mean baseline Hb level pre-transfusion was 8.33 g/dL (±1.15). Preexisting anticoagulation treatment did not predispose patients to greater decreases in Hb levels on day 1 (mean difference = 0.16 g/dL, P = .62) or day 4 (mean difference = 0.29 g/dL, P = .48) post-admission. Discussion: An observed mean decrease in Hb level of up to 1.4 g/dL can occur in hemodynamically stable elderly patients with osteoporotic pelvic fractures, reflecting an approximate loss of 1.4 units of packed red blood cells. Conclusion: This degree of decrease in Hb may be clinically significant in geriatric patients with chronic anemia and a history of cardiovascular disease.
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Affiliation(s)
- Marcus Sng
- Department of Orthopaedic Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Juliette Gentle
- Department of Orthopaedic Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Saeed Asadollahi
- Department of Orthopaedic Surgery, Northern Health, Melbourne, Victoria, Australia
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Importance of Both Internal and External Iliac Artery Interrogation in Pelvic Trauma as Evidenced by Hemorrhage from Bilateral Corona Mortis with Unilateral Aberrant Origin off the External Iliac Artery. Case Rep Radiol 2019; 2019:6734816. [PMID: 31360574 PMCID: PMC6644275 DOI: 10.1155/2019/6734816] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 06/27/2019] [Indexed: 11/17/2022] Open
Abstract
Transcatheter angiography and embolization has long been recognized as the gold standard for patients with hemodynamic instability secondary to blunt pelvic trauma. While often the bleeding source can be readily localized based on the distribution of extravasation on preprocedural Computed Tomographic Angiography, one should be cautious in assessment for aberrant anatomy. A variant obturator artery originating from the inferior epigastric branch of the external iliac artery is commonly referred to as the corona mortis. We present a case of blunt pelvic trauma in which a patient demonstrated extravasation in the anterior distributions of both internal iliac arteries. Following embolization of bilateral internal iliac arteries, identification and embolization of bilateral corona mortis branches was crucial to achieving hemodynamic stability in this patient.
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Trends and efficacy of external emergency stabilization of pelvic ring fractures: results from the German Pelvic Trauma Registry. Eur J Trauma Emerg Surg 2019; 47:523-531. [PMID: 31119322 DOI: 10.1007/s00068-019-01155-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE External emergency stabilization (EES) of unstable pelvic fractures reduces haemorrhage and mortality. Available are non-invasive procedures (sheet sling and pelvic binder) and invasive procedures (external fixator and pelvic C-clamp). Nevertheless, there is no recommended standard as to which procedure for EES should be used. METHODS Prospectively collected data between 2007 and 2016 from the German Pelvic Trauma Registry were used to evaluate 989 patients with in-hospital EES. Besides age, gender and injury severity score (ISS), the fracture classification was evaluated. Furthermore, the frequency of used EES, time to application, their reported efficacy and the frequencies of change to another EES were investigated. RESULTS The use of pelvic binders increased up to 40% while all other procedures decreased in frequency over the 10-year period. The ISS was highest in patients treated with a pelvic C-clamp or combination of pelvic C-clamp and external fixator (p < 0.05). Non-invasive stabilization was applied significantly faster than invasive procedures (p < 0.0001). Overall, the reported efficacy was good (at least 70%) for all procedures but with poorest results for the pelvic binder and best for the external fixator (p < 0.00001). Most change to another EES was found for the sheet sling and pelvic binder. CONCLUSION In case of suspected unstable pelvic fracture, an EES should be performed, in case of doubt with a non-invasive EES until imaging and final diagnosis. Which method should be used depends on the individual situation and the available information about the overall injury pattern. Invasive EES are preferable for treatment according to Damage Control Orthopaedics.
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The Influence of Pelvic Ramus Fracture on the Stability of Fixed Pelvic Complex Fracture. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2015; 2015:790575. [PMID: 26495033 PMCID: PMC4606186 DOI: 10.1155/2015/790575] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 03/30/2015] [Accepted: 04/05/2015] [Indexed: 01/05/2023]
Abstract
This study aims to evaluate the biomechanical mechanism of pelvic ring injury for the stability of pelvis using the finite element (FE) method. Complex pelvic fracture (i.e., anterior column with posterior hemitransverse lesion) combined with pelvic ramus fracture was used to evaluate the biomechanics stability of the pelvis. Three FE fracture models (i.e., Dynamic Anterior Plate-Screw System for Quadrilateral Area (DAPSQ) for complex pelvic fracture with intact pubic ramus, DAPSQ for complex pelvic fracture with pubic ramus fracture, and DAPSQ for complex pelvic fracture with fixed pubic ramus fracture) were established to explore the biomechanics stability of the pelvis. The pubic ramus fracture leads to an unsymmetrical situation and an unstable situation of the pelvis. The fixed pubic ramus fracture did well in reducing the stress levels of the pelvic bone and fixation system, as well as displacement difference in the pubic symphysis, and it could change the unstable situation back to a certain extent. The pelvic ring integrity was the prerequisite of the pelvic stability and should be in a stable condition when the complex fracture is treated.
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Wagner D, Ossendorf C, Gruszka D, Hofmann A, Rommens PM. Fragility fractures of the sacrum: how to identify and when to treat surgically? Eur J Trauma Emerg Surg 2015; 41:349-62. [PMID: 26038048 PMCID: PMC4523697 DOI: 10.1007/s00068-015-0530-z] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/07/2015] [Indexed: 12/29/2022]
Abstract
The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.
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Affiliation(s)
- D Wagner
- Department of Orthopaedics and Traumatology, University Medical Centre, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany,
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