Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature

Comparison of ESIN and other minimally invasive techniques for anterior pelvic ring injury: a finite element analysis and case-control study

OBJECT

A novel technique, percutaneous elastic stable intramedullary nail fixation (ESIN), proposed by our team for the treatment of anterior pelvic ring injury. Finite element analysis and retrospective case-control study were used to compare biomechanical properties and clinical outcomes between ESIN and other techniques.

METHODS

Four groups of finite element models of pelvic anterior ring injury were simulated, including ESIN (model A), retrograde transpubic screw fixation (RTSF, model B), subcutaneous internal fixator (model C), and external fixator (model D), and a vertical downward load of 500 N was applied to the S1 vertebral endplate. Stress and displacement distributions of intact pelvis, displacement distributions of pubic fracture fragments, and stress distributions of fixation devices were analysed. Then 31 patients with anterior pelvic ring injury (15 in the ESIN group and 16 in the RTSF group) were reviewed. Clinical outcomes were evaluated at the final follow-up. Postoperative complications were also recorded.

RESULTS

Under 500N loading, the intact stability of the pelvis was compared as follows: model B (20.58 mm, 121.82 MPa), model A (20.80 mm, 129.97 MPa), model C (22.02 mm, 141.70 MPa), and model D (22.57 mm, 147.06 MPa). The regional stability of superior pubic ramus was compared as follows: model B (9.48 mm), model A (10.16 mm), model C (10.52 mm), and model D (10.76 mm). All 31 patients received follow-up at least 12 months postsurgery (range 12-20 months). Age, sex, injury mechanism, fracture type, time between the injury and operation, American Society of Anesthesiologists score, intraoperative blood loss, hospital stay, follow-up period, time to union, and Majeed scores did not differ significantly between the two groups ( P >0.05). However, the differences in the duration of unilateral surgery, unilateral intraoperative fluoroscopy and one-time success rate were significant ( P <0.05).

CONCLUSIONS

With sufficient biomechanical stability and minimally invasive advantage, the percutaneous technique using ESIN can be used to successfully treat anterior pelvic ring injuries. In addition, advantages over RTSF include a shorter duration of surgery, reduced requirement for intraoperative fluoroscopy, and a higher one-time success rate. ESIN therefore constitutes a good alternative to RTSF.

Standard practice in the treatment of unstable pelvic ring injuries: an international survey

PURPOSE

Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe.

METHODS

A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents).

RESULTS

The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization).

CONCLUSION

The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences' impact on outcomes needs to be further explored.

Outcomes in Blunt vs Penetrating Pelvic Vascular Injuries

OBJECTIVES

The purpose of this study is to determine if there is a difference in outcomes for patients with blunt and penetrating vascular injuries of the pelvis.

METHODS

Data were abstracted from the Trauma Quality Improvement Program database from 2011 to 2015. Patients >18 years with hypogastric, iliac, uterine, or ovarian arterial or venous injuries were included. Individuals with an AIS head or chest score >3 were excluded.

RESULTS

Of the 2559 patients included, the mean age was 43 years (±19), 75.25% were male, and 32.6% had a comorbidity. 64.9% presented with blunt injury (mean ISS of 23 (±12)). 74.9% experienced a complication. The median hospital length of stay (LOS) and ICU LOS were 10 days and 4 days, respectively. 6.7% had an adverse discharge. Mortality occurred in 8.3%. On bivariate analysis, patients who sustained blunt trauma were older (51 vs 31 years), female (32.7% vs 10.1%), had a higher ISS (25.71 vs 17.65), and had a longer hospital LOS (16.65 vs 13.88). Patients with penetrating trauma had an increased chance of complications (78.4% vs 73.0%) and mortality (10.7% vs 7.0%). Multivariate analysis revealed in patients with blunt injuries have more complications (OR: 1.950 CI: 0.886-4.291 P = .097), a lower ISS (OR: 0.919, CI: 0.908-0.930, P < .001, were more likely to have an adverse discharge (OR: 2.05, CI: 1.62-2.60, P = .000), and had a higher risk of mortality (OR: 4.08 CI: 2.78-6.41 P < .000).

CONCLUSION

Patients with blunt pelvic vessel injuries are at risk for an increased number of complications and have a higher risk of mortality. Those who survive are more likely to have an adverse discharge.

The combination of intraoperative CT navigation and C-arm fluoroscopy for INFIX and percutaneous TITS screw placement in the treatment of pelvic ring injury: technical note

Background

The subcutaneous screw rod system, commonly known as the internal pelvic fixator (INFIX), is useful in managing unstable pelvic ring fractures. Conventional INFIX and transiliac–transsacral (TITS) screw techniques are performed using C-arm fluoroscopy. There have been problems with medical exposure and screw insertion accuracy with these techniques. This work describes new INFIX and TITS techniques using intraoperative computed tomography (CT) navigation and C-arm fluoroscopy for pelvic ring fracture.

Methods

A typical case is presented in this study. An 86-year-old woman suffered from an unstable pelvic ring fracture due to a fall from a height. INFIX and TITS screw fixation with intraoperative CT navigation were selected to optimize surgical invasiveness and proper implant placement.

Results

The patient was placed in a supine position on a Jackson table. An intraoperative CT navigation was imaged, and screws were inserted under the navigation. Postoperative X-rays and CT confirmed that the screw was inserted correctly. This technique was less invasive to the patient and had little radiation exposure to the surgeon. Rehabilitation of walking practice was started early after the surgery, and she was able to walk with the assistance of a walker by the time of transfer.

Conclusions

The technique employed in our case study has the cumulative advantages of safety, accuracy, and reduced radiation exposure, together with the inherent advantages of functional outcomes of previously reported INFIX and TITS screw techniques. Further experience with this approach will refine this technique to overcome its limitations and facilitate its wider use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-02920-0.

The role of angioembolization and C-clamp fixation: Damaged control orthopaedic in haemodynamically unstable pelvic fracture

INTRODUCTION

Unstable pelvic fracture may emerge to major bleeding complication. Angioembolization is one of method to stop the bleeding effectively. This case series aims to analyze whether the bleeding of unstable pelvic fracture is managed by angioembolization to achieve the better functional outcome.

PRESENTATION OF CASE

Three cases of haemodynamically unstable pelvic fracture were studied retrospectively and prospectively. A staged approach using damage control orthopaedic surgery was performed. Initial resuscitation began from fluid resuscitation, pelvic wrapping using binder. All patients followed with pelvic external fixation, while 2 patients immediately replaced binder to C-Clamp, and 1 patient with anterior frame. Angioembolization was done to all patients. All patients required definitive internal fixation, while only 2 patients reach the definitive surgery. Finally, we measured the functional outcome of all patients using Hannover Pelvic score, Majeed pelvic score, and Iowa Pelvic score.

DISCUSSION

We review some literatures regarding pelvic angioembolization. The previous study suggested to resuscitate patients when the hemodynamic is unstable, the angioembolization procedure is still preferred. The indication and successful definition of this procedure is still unclear, yet it shows decrease of mortality rate of pelvic injury if this procedure starts ahead a schedule.

CONCLUSION

Angioembolization as a part of damaged control orthopaedic has been shown a favorable result in managing unstable pelvic injury.

[Interventional radiology as emergency therapy]

CLINICAL ISSUE

Both the progress of surgical techniques and the demographic development with increasing numbers of multimorbid patients demand and also encourage radiology in the setting of trauma and acute emergencies. In addition to a fast and precise diagnostics, this also includes image-guided, minimally invasive therapy to control and treat several acute pathologies.

STANDARD RADIOLOGICAL PROCEDURES

Computed tomography (CT) is not only important for the diagnosis of abscesses, active bleeding or other acute pathologies, but also allows minimally invasive therapy. While digital subtraction angiography (DSA) guides catheter-based procedures, e.g., to control bleedings or to place percutaneous transhepatic cholangiodrain (PTCD), fluoroscopy allows the 3D-visualization to drain abdominal and thoracic abscesses.

METHODOLOGICAL INNOVATION AND EVALUATION

Radiology has established itself in the treatment of acute emergencies or acute complications through gentle and usually fast minimally invasive procedures. Presumably, MRI interventions will become increasingly important in the near future and, thus, complement the portfolio.

PRACTICAL RECOMMENDATIONS

Every clinical radiologist who works on night shifts should be able to safely carry out some basic interventional techniques in order to stabilize the patient and at least ensure medically safe bridging to the next routine workday. Due to the diversity of materials and the rarity and difficulty of some procedures, the full portfolio requires years of expertise and will therefore remain restricted to specialized interventional radiologists.

Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons

OBJECTIVES

To assess the interobserver reliability (IOR) of the Tile classification system, and its potential influence on outcomes, for the interpretation of CT images of pelvic fractures by radiologists and surgeons.

METHODS

Retrospective data (1/2008-12/2016) from 238 patients with pelvic fractures were analyzed. Mean patient age was 44 years (SD 20); 66% were male. There were 54 Tile A, 82 Tile B, and 102 Tile C type injuries. The 30-day mortality rate was 15% (36/238). Six observers, three radiologists, and three surgeons with different levels of experience (attending/resident/intern) classified each fracture into one of the 26 second-order subcategories of the Tile classification. Weighted kappa coefficients were used to assess the IORs for the three main categories and nine first-order subcategories.

RESULTS

The overall IORs of the Tile system for the main categories and first-order subcategories were moderate (kappa = 0.44) and fair (kappa = 0.31), respectively. IOR was fair to moderate among radiologists, but only fair among surgeons. By level of training, IOR was moderate between attendings and between residents, whereas it was only fair between interns. IOR was moderate to substantial (kappa = 0.56-0.70) between the radiology attending and resident. Association of the Tile fracture type with 30-day mortality was present based on two out of six observer ratings.

CONCLUSIONS

The overall IOR of the Tile classification system is only fair to moderate, increases with the level of rater experience and is better among radiologists than surgeons. In the light of these findings, results from studies using this classification system must be interpreted cautiously.

KEY POINTS

• The overall interobserver reliability of the Tile pelvic fracture classification is only fair to moderate. • Interobserver reliability increases with observer experience and radiologists have higher kappa coefficients than surgeons. • Interobserver reliability has an impact on the association of the Tile classification system with mortality in two out of six cases.

Prehospital use of pelvic circumferential compression devices in a physician-based emergency medical service: A 6-year retrospective cohort study

Fractures of the pelvic ring are a potential source of significant bleeding. Pelvic circumferential compression devices (PCCDs) can reduce and immobilize unstable fractures, but their hemostatic effect is unproven. Our aim was to assess the current practice of prehospital PCCD application and to identify factors available in the field predictive of significant pelvic ring injuries. All interventions (n = 13,435) in the Lausanne University Hospital Emergency Medical Service (EMS) were screened for PCCD placements from January 2008 to November 2014. Significant pelvic ring injuries (Tile types B or C) were considered as potentially benefitting from a PCCD. Data were extracted from the local prehospital registry. During the study period, 2366 trauma missions were performed. A PCCD was applied to 552/2366 (23%) patients. Significant pelvic ring injuries were present in 105/2366 (4.4%). Factors associated with the presence of significant pelvic ring injury were increased respiratory rate (OR 1.04), prolonged capillary refill time (OR 2.11), increased shock index (OR 3.91), pedestrians hit by a vehicle (OR 2.19), and presenting with falls from more than 2 m (OR 1.91). Among patients with a significant pelvic ring injury, a PCCD was placed in 79 (75%) and omitted in 26 (25%). One sixth of patients with a PCCD had a final diagnosis of significant pelvic ring injury. Further studies are needed to better understand which patient-, or accident-related factors are associated with prehospital PCCD omission among patients with significant pelvic ring injury.

Association between Young-Burgess pelvic ring injury classification and concomitant injuries requiring urgent intervention

BACKGROUND

Young-Burgess classification (YB) is a mechanistic system which classifies pelvic ring injuries into anterior-posterior compression (APC), lateral compression (LC), vertical shear (VS) injuries, and combined mechanism (CM). The objective of this study was to identify associated injuries which require urgent operative intervention by YB classification. We hypothesize that YB classification is associated with 1) need for urgent intervention for pelvic fracture-related hemorrhage and 2) patterns of injury complexes requiring surgery.

METHODS

This is a retrospective study of severely injured trauma patients with pelvic ring injuries who presented to an urban Level-1 trauma center from 2007 to 2017. Associated injuries and procedures were determined by Abbreviated Injury Scale (AIS) and ICD-9/10 codes. YB classes were compared, followed by a cluster analysis to identify injury patterns and association with YB classifications.

RESULTS

Overall, 135 patients were included. 98 (72%) of patients presented with LC, 16 (12%) with APC, 8 (6%) with VS, and 13 (10%) with CM. VS and APC groups had higher rates of REBOA use compared to LC and CM groups (38% and 31% versus 11% and 0%, respectively, p = 0.01). The CM group, compared to LC, APC, and VS, had higher rates of urgent operative intervention for bleeding control (69% versus 32%, 50% and 43%, respectively, p = 0.01). 39 (29%) patients had a concomitant injury which was identified by CT scan in initial trauma work up and altered management, 46% which merited urgent intervention. On cluster analysis, there were no distinct injury complexes which required urgent operative intervention by YB class.

CONCLUSIONS

These data failed to identify unique injury complexes which merit urgent operative intervention by YB class. Nearly one in four patients had injuries identified by initial CT imaging which altered initial management, demonstrating the importance of early, full body CT imaging in severely injured patients with pelvic ring injuries.

Contrast blush on CT is a poor predictor of active bleeding on pelvic angiography

Objective:

Determine if contrast extravasation (CE) on computed tomography (CT), also called CT blush, is a reliable predictor of clinically relevant arterial bleeding from pelvic ring injury.

Design:

Retrospective cohort.

Setting:

Single level I trauma center.

Patients/participants:

A total of 189 patients who underwent pelvic angiography between 1999 and 2015.

Intervention:

Demographic and injury data, including Young–Burgess fracture classification, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and clinical data including hypotension and heart rate upon presentation were recorded. Charts, radiographs, and interventional radiology reports and studies were reviewed.

Main outcome measurements:

CE on CT scan was noted from reports. Angiography studies were reviewed for active arterial bleeding.

Results:

Mean age was 49 years, with 64% male. CE was noted in 111 patients (66%), with increasing frequency over the study period. Patients under age 55 were less likely to have CE (P < .001). GCS was higher and ISS lower in patients with CE (both P < .05). For CE as predictor of active bleeding, sensitivity was 67%, specificity 34%, and positive predictive value (PPV) was 58% (P = .95). For CE as predictor of overall mortality, the sensitivity, specificity, and PPV were 67%, 33%, and 16%, respectively (P = 1.0). However, hypotension had sensitivity of 83% for active bleeding and 97% for mortality, both P < .001.

Conclusions:

While CT blush was neither a sensitive nor specific predictor of active bleeding on pelvic angiography, hypotension was a sensitive indicator of both bleeding and mortality. These findings suggest that CE is not an independently sufficient indication for pelvic angiography.

Level of Evidence: Level III

Trans-arterial embolisation (TAE) in haemorrhagic pelvic injury: review of management and mid-term outcome of a major trauma centre

BACKGROUND

Management of pelvic fracture associated haemorrhage is often complex with high morbidity and mortality rates. Different treatment options are used to control bleeding with an on-going discussion in the trauma community regarding the best management algorithm.

MAIN BODY

Recent studies have shown trans-arterial embolisation (TAE) to be a safe and effective technique to control pelvic fracture associated haemorrhage. Computed tomography (CT) evidence of active bleeding, haemodynamic instability, and pelvic fracture patterns are amongst important indicators for TAE.

CONCLUSION

Herein, we aim to provide a comprehensive literature review of the effectiveness of TAE in controlling haemorrhage secondary to pelvic fracture according to the indications, technique and embolic agents, and outcomes, whilst incorporating our Level 1 major trauma centre's (MTC) results between 2014-2017.

Imaging and endovascular management of traumatic pelvic fractures with vascular injuries

This paper will give an overview of the relevant anatomy, management and imaging, aspects as well as therapeutic aspects of traumatic pelvic fractures with vascular injuries.

Update on critical care for acute spinal cord injury in the setting of polytrauma

Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of > 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.

Vertical shear pelvic injury: evaluation, management, and fixation strategies

Vertical shear pelvic ring fractures are rare and account for less than 1% of all fractures. Unlike severely displaced antero-posterior compression and lateral compression pelvic fractures, patients' mortality is lower. Nevertheless, patients must be managed acutely using well-defined ATLS protocols and institution-specific protocols for haemodynamically unstable pelvic ring fractures. The definitive treatment of vertical shear pelvic fractures is however more controversial with a paucity of literature to recommend the ideal reduction and fixation strategy. While the majority of injuries can be reduced and fixed in a closed manner, orthopaedic traumatologists should be familiar with the contraindications to those techniques as well as options such as tension band plating and lumbo pelvic fixation. Our paper reviews the acute management, associated injuries and definitive reduction and fixation strategies of vertical shear pelvic fractures. In addition, we propose a treatment algorithm for the selection of the most appropriate fixation technique.

Association of pelvic fracture patterns, pelvic binder use and arterial angio-embolization with transfusion requirements and mortality rates; a 7-year retrospective cohort study

Background

Pelvic fractures are severe injuries with frequently associated multi-system trauma and a high mortality rate. The value of the pelvic fracture pattern for predicting transfusion requirements and mortality is not entirely clear. To address hemorrhage from pelvic injuries, the early application of pelvic binders is now recommended and arterial angio-embolization is widely used for controlling arterial bleeding. Our aim was to assess the association of the pelvic fracture pattern according to the Tile classification system with transfusion requirements and mortality rates, and to evaluate the correlation between the use of pelvic binders and arterial angio-embolization and the mortality of patients with pelvic fractures.

Methods

Single-center retrospective cohort study including all consecutive patients with a pelvic fracture from January 2008 to June 2015. All radiological fracture patterns were independently reviewed and grouped according to the Tile classification system. Data on patient demographics, use of pelvic binders and arterial angio-embolization, transfusion requirements and mortality were extracted from the institutional trauma registry and analyzed.

Results

The present study included 228 patients. Median patient age was 43.5 years and 68.9% were male. The two independent observers identified 105 Tile C (46.1%), 71 Tile B (31.1%) and 52 Tile A (22.8%) fractures, with substantial to almost perfect interobserver agreement (Kappa 0.70-0.83). Tile C fractures were associated with a higher mortality rate (p = 0.001) and higher transfusion requirements (p < 0.0001) than Tile A or B fractures. Arterial angio-embolization for pelvic bleeding (p = 0.05) and prehospital pelvic binder placement (p = 0.5) were not associated with differences in mortality rates.

Conclusions

Tile C pelvic fractures are associated with higher transfusion requirements and a higher mortality rate than Tile A or B fractures. No association between the use of pelvic binders or arterial angio-embolization and survival was observed in this cohort of patients with pelvic fractures.

Less invasive lumbopelvic fixation technique using a percutaneous pedicle screw system for unstable pelvic ring fracture in a patient with severe multiple traumas

Pelvic ring fractures are defined as life-threatening injuries that can be treated surgically with external or internal fixation. The authors report on an 81-year-old woman with an unstable pelvic fracture accompanying multiple traumas that was successfully treated with a less invasive procedure. The patient was injured in a traffic accident and sustained a total of 20 fractures, including pelvic ring, bilateral rib, and lumbar transverse processes fractures, and multiple fractures of both upper and lower extremities. The pelvic ring fracture was unstable with fractures of the bilateral sacrum with right sacroiliac disruption, right superior and inferior pubic rami, left superior pubic ramus, and ischium. During emergency surgery, bilateral external fixation was applied to the iliac crest to stabilize the pelvic ring. Second and third surgeries were performed 11 and 18 days after the first emergency surgery, respectively, to treat the multiple fractures. At the third surgery, the pelvic ring fracture was stabilized surgically using a less invasive posterior fixation technique. In this technique, 2 iliac screws were inserted on each side following an 8-cm midline posterior incision from the S-1 to S-3 spinous process, with the subcutaneous tissue detached from the fascia of the paraspinal muscles. The S-2 spinous process was removed and 2 rods were connected to bilateral iliac screws to stabilize the bilateral ilium in a switchback fashion. A crosslink device was applied to connect the 2 rods at the base of the S-2 spinous process. Following pelvic fixation, percutaneous pedicle screws were inserted into L-4 and L-5 vertebral bodies on both sides, and connected to the cranial rod connecting the bilateral iliac screws, thus completing the lumbopelvic fixation. The postoperative course was favorable with no postoperative complications. At the 10-month follow-up, bone union had been achieved at the superior ramus of the pubis, the patient did not complain of pain, and her activities of daily life returned to preinjury status. Unstable pelvic ring fractures need to be sufficiently stabilized for good surgical outcome. However, to avoid postoperative complications, a less invasive treatment is preferred, particularly in cases with poor general condition. This procedure is less invasive and provides sufficient stabilization to the unstable pelvic ring fracture, and thus is the ideal surgical procedure for such cases.

Lumbar artery perforator (LAP) flap: a salvage tool for extended lumbo-sacral necrosis after bilateral internal iliac arteries embolization

We report the case of a 52-year-old man presenting an extensive lumbosacral necrosis after bilateral internal iliac arteries embolization following unstable pelvic fracture. Coverage of the defect was performed using two extended lumbar artery perforator flaps in a propeller fashion. Good functional and esthetic result was achieved at one-year follow-up.

Pelvic ring injuries: Emergency assessment and management

Pelvic ring injuries are associated with significant morbidity and mortality. Understanding the anatomy of the pelvic ring is essential for accurate diagnosis and treatment. A systematic approach taking into account the mechanism of injury, physical examination, and radiographic assessment is important to quickly identify unstable pelvic disruptions and associated injuries. Because the pelvis is a ring structure, isolated pubic rami fractures on plain radiographs are unusual and should warrant careful evaluation for posterior pelvic disruption with computed tomography. Hemorrhagic shock can occur in about 10% of pelvic ring injuries. Immediate recognition and treatment of this life-threatening condition is critical in emergency management. In addition to fluid resuscitation and blood transfusion, circumferential wrapping, angiographic embolization, laparotomy with pelvic packing, and external fixation can be important life-saving adjuncts in the setting of hemodynamic instability.

Resuscitation of Polytrauma Patients: The Management of Massive Skeletal Bleeding

The term ‘severely injured patient’ is often synonymous of polytrauma patient, multiply-injured patient or, in some settings, polyfractured patient. Together with brain trauma, copious bleeding is the most severe complication of polytrauma. Consequently hypotension develop. Then, the perfusion of organs may be compromised, with the risk of organ failure. Treatment of chest bleeding after trauma is essential and is mainly addressed via surgical manoeuvres. As in the case of lesions to the pelvis, abdomen or extremities, this approach demonstrates the application of damage control (DC). The introduction of sonography has dramatically changed the diagnosis and prognosis of abdominal bleeding. In stable patients, a contrast CT-scan should be performed before any x-ray projection, because, in an emergency situation, spinal or pelvic fractures be missed by conventional radiological studies. Fractures or dislocation of the pelvis causing enlargement of the pelvic cavity, provoked by an anteroposterior trauma, and in particular cases presenting vertical instability, are the most severe types and require fast stabilisation by closing the pelvic ring diameter to normal dimensions and by stabilising the vertical shear. Controversy still exists about whether angiography or packing should be used as the first choice to address active bleeding after pelvic ring closure. Pelvic angiography plays a significant complementary role to pelvic packing for final haemorrhage control. Apart from pelvic trauma, fracture of the femur is the only fracture provoking acute life-threatening bleeding. If possible, femur fractures should be immobilised immediately, either by external fixation or by a sheet wrap around both extremities.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY POINTS

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

Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery)

Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients.

Hemodynamically Unstable Pelvic Trauma is a frequent death cause among people who sustain blunt trauma. We present the results of the First Italian Consensus Conference.

Frequency of external iliac artery branch injury in blunt trauma: improved detection with selective external iliac angiography

PURPOSE

To assess the utility of selective external iliac artery (EIA) angiography and the frequency of injury to branches of the EIA in cases of blunt pelvic trauma.

MATERIALS AND METHODS

A retrospective review of pelvic angiograms in 66 patients with blunt pelvic trauma was conducted over a 12-month period. Pelvic and femur fracture patterns were correlated to the presence of EIA injury. Pelvic arteriography was compared versus selective EIA angiography for the detection of arterial injury.

RESULTS

Fifty-four of 66 patients (82%) exhibited pelvic arterial injury or elicited enough suspicion for injury to warrant embolization. Internal iliac artery embolization was performed in 50 of 66 (76%). EIA branch injury was identified in 11 of 66 patients (17%), and 10 were successfully embolized. EIA branch vessel injury was identified more frequently when there was ipsilateral intertrochanteric fracture (P = .07) or ipsilateral ilium fracture (P = .07). The sensitivity of nonselective pelvic angiography in the detection of EIA branch vessel injury was 45%.

CONCLUSIONS

EIA branch injury occurs in a substantial fraction of patients with blunt pelvic trauma who undergo pelvic angiography. Selective EIA angiography should be considered in all patients undergoing pelvic angiography in this situation.

Minimally invasive treatment for pubic ramus fractures combined with a sacroiliac joint complex injury

PURPOSE

Fractures of the pubic rami due to low energy trauma are common in the elderly, with an incidence of 26 per 100,000 people per year in those aged more than 60 years. The purpose of this study was to evaluate the clinical application of this minimally invasive technique in patients with pubic ramus fractures combined with a sacroiliac joint complex injury, including its feasibility, merits, and limitations.

METHODS

Fifteen patients with pubic ramus fractures combined with sacroiliac joint injury were treated with the minimally invasive technique from June 2008 until April 2012. The quality of fracture reduction was evaluated according to the Matta standard.

RESULTS

Fourteen cases were excellent (93.3 %), and one case was good (6.7 %). The fracture lines were healed 12 weeks after the surgery. The 15 patients had follow-up visits between four to 50 months (mean, 22.47 months). All patients returned to their pre-injury jobs and lifestyles. One patient suffered a deep vein thrombosis during the peri-operative period. A filter was placed in the patient before the surgery and was removed six weeks later. There was no thrombus found at the follow-up visits of this patient.

CONCLUSION

The minimally invasive technique in patients with pubic ramus fractures combined with a sacroiliac joint complex injury provided satisfactory efficacy.

Early Total Care versus Damage Control: Current Concepts in the Orthopedic Care of Polytrauma Patients

The management of the polytraumatized orthopedic patient remains a challenging issue. In recent years many efforts have been made to develop rescue techniques and to promote guidelines for the management of these patients. Currently controversies persist between two orthopedic approaches: the Early Total Care and the Damage Control Orthopedics. An overview of the current literature on the orthopedic management of polytrauma patient is provided. Subsequently, femoral shaft fractures, representing extremely common lesions, and pelvic ring injuries, that are associated with a high mortality rate, are analyzed in detail.

Orthopaedic management in the polytrauma patient

The past century has seen many changes in the management of the polytraumatized orthopaedic patient. Early recommendations for non-operative treatment have evolved into early total care (ETC) and damage control orthopaedic (DCO) treatment principles. These principles force the treating orthopaedist to take into account multiple patient parameters including hypothermia, coagulopathy and volume status before deciding upon the operative plan. This requires a multidisciplinary approach involving critical care physicians, anesthesiologists and others.