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Pfalzgraf F, Ecker M, Goßlau Y, Mayr E. [Traumatic hemipelvectomy : An uncommon case in trauma surgery]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:607-612. [PMID: 38990311 PMCID: PMC11286686 DOI: 10.1007/s00113-024-01455-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 07/12/2024]
Abstract
The challenge in treating traumatic hemipelvectomy is the dynamics of the complex and life-threatening consequences of the injury. These include skin and soft tissue defects, osseous, neural and vascular injuries as well as the subsequent hemostatic derangement and organ dysfunction as part of the shock process. The treatment requires rapid and targeted decisions to save the patient's life. In this particular case a 34-year-old farmer was trapped between a wheeled loader and a stationary trailer. Upon arrival at the hospital the patient was in a state of hemorrhagic shock with accompanying acute traumatic coagulopathy and a grade III open pelvic trauma with complete ischemia of the left leg and a bladder injury. After performing emergency surgery and a two-stage approach for pelvic stabilization the patient's condition deteriorated up to multiorgan failure, necessitating left-sided hemipelvectomy as an immediate life-saving salvage procedure. In the further course multiple revision surgeries and plastic reconstructions due to wound infections and the presence of skin and soft tissue damage were required. Due to the rare confrontation with this type of injury in everyday practice and the absence of a universal treatment algorithm, the following case report is intended to contribute to a better understanding of the treatment and to illustrate the coherent interactions of the individual organ systems affected.
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Affiliation(s)
- F Pfalzgraf
- Klinik für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland.
| | - M Ecker
- Klinik für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
| | - Y Goßlau
- Klinik für Gefäßchirurgie und endovaskuläre Chirurgie, Universitätsklinikum Augsburg, Augsburg, Deutschland
| | - E Mayr
- Klinik für Unfallchirurgie, Orthopädie, Plastische und Handchirurgie, Universitätsklinikum Augsburg, Stenglinstraße 2, 86156, Augsburg, Deutschland
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Baker JE, Ladhani HA, McCall C, Horwood CR, Werner NL, Platnick B, Cothren Burlew C. Factors Associated With Pelvic Infection After Pre-Peritoneal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures. Surg Infect (Larchmt) 2024; 25:399-406. [PMID: 38752886 DOI: 10.1089/sur.2023.360] [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] [Indexed: 06/21/2024] Open
Abstract
Background: Preperitoneal pelvic packing (PPP) and external fixation has led to improved mortality after devastating pelvic trauma. However, there is limited literature on infection after this intervention. We aim to study the risk factors associated with pelvic infection after PPP. Patients and Methods: A retrospective review of patients who underwent PPP at a single level 1 trauma center was performed. Results: Over the 18-year study period, 222 patients were identified. Twenty-three percent of patients had an open fracture. Pelvic angiography was performed in 24% of patients with 16% requiring angioembolization (AE). The average time to packing removal was two (one to two days) days, although 10% of patients had their pelvis re-packed. Overall infection rate was 14% (n = 31); if pelvic re-packing was performed, the infection rate increased to 45%. Twenty-two of the patients with an infection required additional procedures for their infection, and ultimately hardware removal occurred in eight patients. On univariable analysis, patients with pelvic infections had more open fractures (55% vs. 17%; p < 0.01), underwent AE more frequently (29% vs. 14%; p = 0.04), were more likely to undergo repacking (32% vs. 6%; p < 0.01), and had packing in place for longer (2 [1,2] vs. 2 [2,3]; p = 0.01). On logistic multivariable regression analysis, open fracture (odds ratio [OR], 5.8; 95% confidence interval [CI], 2.4-14.1) and pelvic re-packing (OR, 4.7; 95% CI, 1.2-18.5) were independent risk factors for pelvic infection. Conclusions: Pelvic infection after PPP is a serious complication independently associated with open fracture and re-packing of the pelvis. Re-intervention was required in most patients with infection.
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Affiliation(s)
- Jennifer E Baker
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
- Division of Gastrointestinal, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Husayn A Ladhani
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
- Division of Gastrointestinal, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Caitlyn McCall
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
- Division of Gastrointestinal, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Chelsea R Horwood
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
- Division of Gastrointestinal, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Nicole L Werner
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Barry Platnick
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Clay Cothren Burlew
- Division of Gastrointestinal, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
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Matsunaga Y, Haba T, Kobayashi M, Suzuki S, Asada Y, Chida K. Assessment of fetal radiation exposure in pregnant women undergoing computed tomography and rotational angiography examinations for pelvic trauma. RADIATION PROTECTION DOSIMETRY 2024; 200:580-587. [PMID: 38486458 DOI: 10.1093/rpd/ncae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/18/2024] [Accepted: 02/26/2024] [Indexed: 04/23/2024]
Abstract
This study aimed to assess fetal radiation exposure in pregnant women undergoing computed tomography (CT) and rotational angiography (RA) examinations for the diagnosis of pelvic trauma. In addition, this study aimed to compare the dose distributions between the two examinations. Surface and average fetal doses were estimated during CT and RA examinations using a pregnant phantom model and real-time dosemeters. The pregnant model phantom was constructed using an anthropomorphic phantom, and a custom-made abdominal phantom was used to simulate pregnancy. The total average fetal dose received by pregnant women from both CT scans (plain, arterial and equilibrium phases) and a single RA examination was ~60 mGy. Because unnecessary repetition of radiographic examinations, such as CT or conventional 2D angiography can increase the radiation risk, the irradiation range should be limited, if necessary, to reduce overall radiation exposure.
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Affiliation(s)
- Yuta Matsunaga
- Department of Imaging, Nagoya Kyoritsu Hospital, 1-172, Hokke, Nakagawa-ku, Nagoya, Aichi, Japan
- Department of Radiological Technology, Faculty of Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
| | - Tomonobu Haba
- Faculty of Radiological Technology, School of Medical Science, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho,Toyoake, Aichi, Japan
| | - Masanao Kobayashi
- Faculty of Radiological Technology, School of Medical Science, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho,Toyoake, Aichi, Japan
| | - Shoichi Suzuki
- Faculty of Radiological Technology, School of Medical Science, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho,Toyoake, Aichi, Japan
| | - Yasuki Asada
- Faculty of Radiological Technology, School of Medical Science, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho,Toyoake, Aichi, Japan
| | - Koichi Chida
- Department of Radiological Technology, Faculty of Health Sciences, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan
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Choi D, Cho WT, Song HK, Kwon J, Kang BH, Jung H, Jung K. Management strategy for open pelvic fractures: A 11-year single-centre, retrospective observational study. Injury 2023; 54:1156-1162. [PMID: 36849305 DOI: 10.1016/j.injury.2023.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/06/2022] [Accepted: 02/19/2023] [Indexed: 03/01/2023]
Abstract
INTRODUCTION Open pelvic fractures are commonly associated with life-threatening, uncontrollable haemorrhages. Although management methods for pelvic injury-associated haemorrhage have been established, the early mortality rate associated with open pelvic fractures remains high. This study aimed to identify predictors of mortality and effective treatment methods for open pelvic fractures. METHODS We defined open pelvic fractures as pelvic fractures with an open wound directly connected to the adjacent soft tissue, genitals, perineum, or anorectal structures, resulting in soft tissue injuries. This study was performed on trauma patients (age ≥15 years) injured by a blunt mechanism between 2011 and 2021 at a single trauma centre. We collected and analysed the data on the Injury Severity Score (ISS), the Revised Trauma Score (RTS), the Trauma and Injury Severity Score (TRISS), length of hospital stay, length of intensive care unit stay, transfusion, preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta (REBOA), therapeutic angio-embolisation, laparotomy, faecal diversion, and mortality. RESULTS Forty-seven patients with blunt open pelvic fractures were included. The median age was 45 years (interquartile range, 27-57 years) and median ISS was 34 (24-43). The most frequently performed treatment methods were laparotomy (53%) and pelvic binder (53%), followed by faecal diversion (40%) and PPP (38%). PPP was the only method performed at a higher rate in the survival group for haemorrhagic control (41% vs. 30%). Haemorrhagic mortality was present in one case that received PPP. The overall mortality was 21%. In the univariate logistic regression analysis, initial systolic blood pressure (SBP), TRISS, RTS, packed red blood cell transfusion for the first 24 h, and base excess showed statistical significance (p<0.05). In the multivariate logistic regression model, initial SBP was identified as an independent risk factor for mortality (odds ratio, 0.943; 95% confidence interval, 0.907-0.980; p = 0.003). CONCLUSION A low initial SPB may be an independent predictor of mortality in patients with open pelvic fractures. Our findings suggest that PPP might be a feasible method to decrease haemorrhagic mortality from open pelvic fractures, especially for haemodynamically unstable patients with low initial SBP. Further studies are required to validate these clinical findings.
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Affiliation(s)
- Donghwan Choi
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Republic of Korea
| | - Won Tae Cho
- Department of Orthopedic Surgery, Ajou University School of Medicine, Republic of Korea
| | - Hyung Keun Song
- Department of Orthopedic Surgery, Ajou University School of Medicine, Republic of Korea
| | - Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Republic of Korea
| | - Byung Hee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Republic of Korea
| | - Hohyung Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Republic of Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Republic of Korea.
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Roszman AD, John DQ, Patch DA, Spitler CA, Johnson JP. Management of open pelvic ring injuries. Injury 2023; 54:1041-1046. [PMID: 36792402 DOI: 10.1016/j.injury.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/18/2023] [Accepted: 02/02/2023] [Indexed: 02/17/2023]
Abstract
Open pelvic ring injuries are rare clinical entities that require multidisciplinary care. Due to the scarcity of this injury, there is no well-defined treatment algorithm. As a result, conflicting evidence surrounding various aspects of care including wound management and fecal diversion remain. Previous studies have shown mortality reaching 50% in open pelvic ring injuries, nearly five times higher than closed pelvic ring injuries. Early mortality is due to exsanguinating hemorrhage, while late mortality is due to wound sepsis and multiorgan system failure. With advancements in trauma care and ATLS protocols, there has been an improved survival rate reported in published case series. Major considerations when treating these injuries include aggressive resuscitation with hemorrhage control, diagnosis of associated injuries, prevention of wound sepsis with early surgical management, and definitive skeletal fixation. Classification systems for categorization and management of bony and soft tissue injury related to pelvic ring injuries have been established. Fecal diversion has been proposed to decrease rates of sepsis and late mortality. While clear indications are lacking due to limited studies, previous studies have reported benefits. Further large-scale studies are necessary for adequate evaluation of treatment protocols of open pelvic ring injuries. Understanding the role of fecal diversion, avoidance of primary closure in open pelvic ring injuries, and importance of well-coordinated care amongst surgical teams can optimize patient outcomes.
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Affiliation(s)
- Alexander D Roszman
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Devin Q John
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - David A Patch
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Joey P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States.
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Garay M, McKinney R, Wheatley B, Altman DT, Altman GT, Westrick ER. Complications of surgically treated pelvic ring injuries with associated genitourinary injuries. Injury 2023; 54:960-963. [PMID: 36725489 DOI: 10.1016/j.injury.2023.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Pelvic ring injuries are often associated with vascular and intrapelvic organ injuries including damage to the genitourinary system. The purpose of this study was to examine the relationship between surgically treated pelvic ring injuries and genitourinary injuries. The primary outcome was to determine the rate of post-operative complications including infection, urinary dysfunction, and sexual dysfunction. The secondary outcome was to determine if the time to surgery was associated with post-operative complications. METHODS Retrospective chart review from September 1, 2015 to December 31, 2019 of patients who sustained a pelvic ring injury which required surgical intervention. All patients with closed triradiate cartilage were included. RESULTS A total of 115 patients met the inclusion criteria, 12 patients with an associated genitourinary (GU) injury were included in the GU group and 103 without GU injury were placed in the non-GU group. The median (range) age of patients in the GU group was 49.5 years (20, 64) and 48 years (15, 92) in the control group (p = 0.92). Demographic characteristics including age, Injury Severity Score and Elixhauser comorbidity score were similar between groups. Within the GU group, five patients had an injury to their bladder, four to their urethra and three had an injury to their kidney. In the GU group, one patient developed a wound dehiscence and one developed a urinary tract infection with subsequent sepsis (17%), while in the non-GU group, one patient (1%) developed erectile dysfunction (p = 0.028). Regression analysis demonstrated that having concomitant pelvic ring and GU injuries, as well as the number of surgeries were variables associated with post-operative complications, while time to surgery was not. DISCUSSION AND CONCLUSIONS Pelvic ring injuries with concomitant genitourinary injuries were associated with increased odds of post-operative complications. No differences were noted in complication rates due to the time to surgery between groups.
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Affiliation(s)
- Mariano Garay
- Allegheny General Hospital Department of Orthopaedic Surgery, Pittsburgh, PA 320 E North Ave, Pittsburgh, PA 15212, United States.
| | - Richard McKinney
- Allegheny General Hospital Department of Orthopaedic Surgery, Pittsburgh, PA 320 E North Ave, Pittsburgh, PA 15212, United States.
| | - Benjamin Wheatley
- Allegheny General Hospital Department of Orthopaedic Surgery, Pittsburgh, PA 320 E North Ave, Pittsburgh, PA 15212, United States
| | - Daniel T Altman
- Allegheny General Hospital Department of Orthopaedic Surgery, Pittsburgh, PA 320 E North Ave, Pittsburgh, PA 15212, United States.
| | - Gregory T Altman
- Allegheny General Hospital Department of Orthopaedic Surgery, Pittsburgh, PA 320 E North Ave, Pittsburgh, PA 15212, United States.
| | - Edward R Westrick
- Allegheny General Hospital Department of Orthopaedic Surgery, Pittsburgh, PA 320 E North Ave, Pittsburgh, PA 15212, United States.
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Tischler EH, Wolfert AJ, Lyon T, Suneja N. A review of open pelvic fractures with concurrent genitourinary injuries. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03388-8. [PMID: 36209481 DOI: 10.1007/s00590-022-03388-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/02/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Open pelvic fractures (OPFs) are uncommon but potentially lethal traumatic injuries. Often caused by high energy blunt trauma, they can cause severe injury to abdominal and pelvic structures. We sought to conduct a review of the literature in order to ascertain the rates of genitourinary injury and vaginal laceration after OPF and the rates of resulting infection and mortality. METHODS A review of PubMed was conducted to identify studies reporting the rates of genitourinary injury from OPF. Study characteristics, patient characteristics, and outcomes were collected. The data were pooled, and descriptive statistics were obtained. RESULTS Eight studies encompassing 343 patients were included. Average age was 35.1 years (10-85.9), 28% were female, and the average Injury Severity Score was 26.5 (4-75). 95.5% of patients had a blunt mechanism of injury. Motor vehicle collision (23.9%), motorcycle accident (19.7%), and pedestrian struck (19.3%) were the most common etiologies. Overall mortality and infection rates were 31.2% and 18.7%, respectively. 19.7% of patients suffered an injury to the genitourinary system, and 32.4% of females sustained a vaginal laceration. DISCUSSION OPFs have the potential for extremely high morbidity and mortality. While much research has been done to prevent early mortality from hemorrhage, there is comparatively little research into late mortality stemming from infection and sepsis. Intravenous antibiotics are the mainstay of treatment, and local antibiotics usage has been encouraged. In patients with a vaginal laceration, it is important to provide antibiotic coverage for vaginal flora.
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Affiliation(s)
- Eric H Tischler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, MSC 30, Brooklyn, NY, 11203, USA.
| | - Adam J Wolfert
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, MSC 30, Brooklyn, NY, 11203, USA
| | - Thomas Lyon
- Department of Orthopedic Surgery, New York University Langone Hospital, 150 55th Street, Brooklyn, NY, 11220, USA
| | - Nishant Suneja
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, MSC 30, Brooklyn, NY, 11203, USA
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Lu S, Liu F, Xu W, Zhou X, Li L, Zhou D, Li Q, Dong J. Management of Open Tile C Pelvic Fractures and Their Outcomes: A Retrospective Study of 30 Cases. Ther Clin Risk Manag 2022; 18:929-937. [PMID: 36119388 PMCID: PMC9473294 DOI: 10.2147/tcrm.s378740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Open Tile C pelvic fractures are particularly severe. However, reports on their management and outcomes are relatively rare. This study analyzed the demographic and clinical characteristics of patients with open Tile C pelvic fractures and describes our management and outcomes of these injuries. Methods This retrospective review included all patients with open Tile C pelvic fractures treated in our department between January 2014 and June 2021. Data on patient demographics, characteristics of the injuries, surgical management, and outcomes were analyzed. Results Thirty patients with a mean age of 34.0 years met the diagnostic criteria. The average Injury Severity Score was 40.3. According to the Tile fracture classification, 6 patients sustained type C1.1, 12 sustained type C1.2, 3 sustained type C1.3, 5 sustained C2 and 4 sustained type C3. Most patients had soft tissue injuries in multiple zones. All patients sustained associated injuries. Management consisted of bed rest in 8 cases, external fixation as the final strategy in 14, conversion from external fixation to internal fixation in 3, open reduction with internal fixation in 5, and amputation in 6. The average amount of packed red blood cells transfused was 33.3 units, the average intensive care unit stay was 11.3 days, the mean number of operations required was 6.2, and the mean length of hospital stay was 81.8 days. The main complications were early soft tissue infections and venous thrombosis. One patient died of sepsis and multi-organ failure. Soft tissue injuries in multiple zones increased utilization of hospital resources whereas anorectal injuries did not. Vascular damage accompanying truck crush injuries had a high amputation rate. Conclusion Open Tile C pelvic fractures require multidisciplinary diagnosis and management and consume considerable hospital resources. More emphasis needs to be placed on this complex injury.
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Affiliation(s)
- Shun Lu
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan City, Shandong Providence, People's Republic of China
| | - Fanxiao Liu
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan City, Shandong Providence, People's Republic of China
| | - Weicheng Xu
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan City, Shandong Providence, People's Republic of China
| | - Xiaofeng Zhou
- Department of Orthopaedics Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan City, Shandong Providence, People's Republic of China
| | - Lianxin Li
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan City, Shandong Providence, People's Republic of China
| | - Dongsheng Zhou
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan City, Shandong Providence, People's Republic of China
| | - Qinghu Li
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan City, Shandong Providence, People's Republic of China
| | - Jinlei Dong
- Department of Orthopaedics Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan City, Shandong Providence, People's Republic of China
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Li PH, Hsu TA, Kuo YC, Fu CY, Bajani F, Bokhari M, Mis J, Poulakidas S, Bokhari F. The application of the WSES classification system for open pelvic fractures-validation and supplement from a nationwide data bank. World J Emerg Surg 2022; 17:29. [PMID: 35624457 PMCID: PMC9145531 DOI: 10.1186/s13017-022-00434-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Open pelvic fractures are rare but complex injuries. Concomitant external and internal hemorrhage and wound infection-related sepsis result in a high mortality rate and treatment challenges. Here, we validated the World Society Emergency Society (WSES) classification system for pelvic injuries in open pelvic fractures, which are quite different from closed fractures, using the National Trauma Data Bank (NTDB). Methods Open pelvic fracture patients in the NTDB 2015 dataset were retrospectively queried. The mortality rates associated with WSES minor, moderate and severe injuries were compared. A multivariate logistic regression model (MLR) was used to evaluate independent factors of mortality. Patients with and without sepsis were compared. The performance of the WSES classification in the prediction of mortality was evaluated by determining the discrimination and calibration. Results A total of 830 open pelvic fracture patients were studied. The mortality rates of the mild, moderate and severe WSES classes were 3.5%, 11.2% and 23.8%, respectively (p < 0.001). The MLR analysis showed that the presence of sepsis was an independent factor of mortality (odds of mortality 9.740, p < 0.001). Compared with patients without sepsis, those with sepsis had significantly higher mortality rates in all WSES classes (minor: 40.0% vs. 3.1%, p < 0.001; moderate: 50.0% vs. 9.1%, p < 0.001; severe: 66.7% vs. 22.2%, p < 0.001). The receiver operating characteristic (ROC) curve showed an acceptable discrimination of the WSES classification alone for evaluating the mortality of open pelvic fracture patients [area under curve (AUC) = 0.717]. Improved discrimination with an increased AUC was observed using the WSES classification plus sepsis (AUC = 0.767). Conclusions The WSES guidelines can be applied to evaluate patients with open pelvic fracture with accurate evaluation of outcomes. The presence of sepsis is recommended as a supplement to the WSES classification for open pelvic fractures.
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Affiliation(s)
- Pei-Hua Li
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Ting-An Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Yu-Chi Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan. .,Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA.
| | - Francesco Bajani
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Marissa Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Justin Mis
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Stathis Poulakidas
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
| | - Faran Bokhari
- Department of Trauma and Burn Surgery, Stroger Hospital of Cook County, Rush University, 8th floor, 1950 West Polk Street, Chicago, IL, 60612, USA
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Lai CY, Lai PJ, Tseng IC, Su CY, Hsu YH, Chou YC, Yu YH. Postoperative Reduction Quality May Be the Most Important Factor That Causes Worse Functional Outcomes in Open and Closed Pelvic Fractures. World J Surg 2022; 46:568-576. [PMID: 34973073 PMCID: PMC8803804 DOI: 10.1007/s00268-021-06386-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 11/26/2022]
Abstract
Background Data on the functional outcomes of patients with open pelvic fractures after osteosynthesis are limited, and whether open fracture is a risk factor for worse outcomes, as compared with closed fracture, remains unclear. This study aimed to compare the functional outcomes of patients with open and closed pelvic fractures and evaluate potential factors that might affect outcomes. Methods Overall, 19 consecutive patients with open pelvic fractures and 78 patients with closed pelvic fractures between January 2014 and June 2018 were retrospectively reviewed. All fractures were surgically treated, with a minimal follow-up period of three years. Patients’ demographic profile, associated injuries, management protocol, quality of reduction, and outcomes were recorded and analyzed. Results Patients with open pelvic fractures had higher new injury severity score, higher incidence of diverting colostomy, and longer length of stay. Both radiological and functional evaluations revealed no significant differences between the two groups at 1-year and 3-year evaluations. Multiple logistic regression analysis identified poor radiological outcomes (using Lefaivre criteria) and longer length of stay as risk factors for worse short-term functional outcomes. At 3-year evaluation, fair-to-poor radiological outcomes (using Matta/Tornetta and Lefaivre criteria) and the presence of diverting colostomy were potential risk factors. Conclusions Compared with closed pelvic fracture, open pelvic fracture was not an indicator of worse functional outcomes. Functional outcomes may be comparable between patients with open and closed pelvic fractures at different time points within three years postoperatively. Achieving anatomical reduction in a fracture is crucial, because it might affect patient satisfaction.
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Affiliation(s)
- Chih-Yang Lai
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - Po-Ju Lai
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - I-Chuan Tseng
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan Branch, Tao-Yuan City, Taiwan
| | - Chun-Yi Su
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, Kee-Lung City, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - Yi-Hsun Yu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Tao-Yuan, Taiwan. 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan.
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11
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Management and outcomes of open pelvic fractures: An update. Injury 2021; 52:2738-2745. [PMID: 32139131 DOI: 10.1016/j.injury.2020.02.096] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/07/2020] [Accepted: 02/19/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Open pelvic fractures remain challenging in terms of their management. The purpose of this narrative review was to evaluate the latest advances made in the management of these injuries and report on their clinical outcome. PATIENTS AND METHODS A literature review was undertaken focusing on studies that have been published on the management of open pelvic fractures between January 2005 and November 2019. Information extracted from each article include demographics, mechanism of injury, injury severity score (ISS), classification of pelvic ring fracture, classification of open soft tissue, specific injury zone classification, number of cases with hemodynamic instability, number of cases that received blood transfusions, amount of packed red blood cells transfused during the first 24 h, number of cases with anorectal trauma, urogenital injury, number of fecal diversional colostomies and laparotomies, angiographies and embolization, preperitoneal pelvic packings, length of stay in intensive care unit (ICU) and in hospital, and mortality. RESULTS Fifteen articles with 646 cases formed the basis of this review. The majority of patients were male adults (74.9%). The mean age was 35.1 years. The main mechanism of injury was road traffic accidents, accounting for 67.1% of the injuries. The mean ISS was 26.8. A mean of 13.5 units of PRBCs were administered the first 24 h. During the whole hospital stay, 79.3% of the patients required blood transfusions. Angiography and pelvic packing were performed in a range of 3%-44% and 13.3%-100% respectively. Unstable types of pelvic injuries were the majority (72%), whilst 32.7% of the cases were associated with anorectal trauma, and 32.6% presented with urogenital injuries. Bladder ruptures were the most reported urogenital injury. Fecal diversional colostomy was performed in 37.4% of the cases. The mean length of ICU stay was 12.5 days and the mean length of hospital stay was 53.0 days. The mean mortality rate was 23.7%. CONCLUSION Mortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. Sufficient blood transfusion, bleeding control, treatments of associated injuries, fracture fixation and soft tissue management remain essential for the reduction of mortality and improved outcomes.
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Vaginal Laceration in an Open Pelvic Fracture Case Report: A Novel, Prophylactic Antibiotic Delivery Mechanism. Case Rep Orthop 2021; 2021:5594270. [PMID: 34055438 PMCID: PMC8112908 DOI: 10.1155/2021/5594270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/24/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Rotational displaced pelvic ring injuries are associated with internal injuries to both the gastrointestinal and genitourinary viscera and anatomic structures. Vaginal lacerations and open genitourinary-associated injuries are at increased risk of mortality due to sepsis. Case Presentation. This case presents a 65-year-old female status post-pedestrian-vehicle struck diagnosed with an open pelvic fracture with extension into the outer one-third of the vaginal wall. The patient was successfully treated with emergent surgical debridement, pelvic stabilization, and internal placement of a novel combination of metronidazole antibiotic gel and vancomycin/tobramycin Polymethyl methacrylate beads. Conclusion No evidence of infection was observed with the use of topical metronidazole-coated vancomycin/tobramycin Polymethyl methacrylate beads for contaminated open pelvic fracture injury involving the vaginal wall. Further research on antibiotic gels for use in high-risk open fractures is required.
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13
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Guo Q, Zhang L, Zhou S, Zhang Z, Liu H, Zhang L, Talmy T, Li Y. Clinical features and risk factors for mortality in patients with open pelvic fracture: A retrospective study of 46 cases. J Orthop Surg (Hong Kong) 2021; 28:2309499020939830. [PMID: 32696709 DOI: 10.1177/2309499020939830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND This study aimed to investigate the clinical features, current management strategies, and outcomes of open pelvic fracture patients. METHODS We performed a retrospective review of data on patients with blunt trauma and open pelvic fractures admitted to our trauma center over a 5-year period (January 2013 to December 2017). Demographic as well as clinical data including injury mechanism, injury severity score (ISS), fracture classifications, transfusion requirements, interventions, length of hospital and intensive care unit (ICU) stay, and prognosis were investigated. Univariate analysis and binary logistic regression were used to identify the risk variables of death. Finally, a brief literature review was performed to understand the current capacity of treatment and prognosis of this type of injury. RESULTS Forty-six patients (36 male and 10 female) were included in this study, mean age 43.2 ± 14.2 years. The overall mortality rate was 17.4%; 43.5% of the patients were hypotensive (systolic blood pressure (SBP) <90 mmHg) on arrival. The average ISS was 31.7 ± 6.7, and the average packed red blood cell (PRBC) transfusion during the first 24 h was 9.6 ± 7.4 units. Five patients (10.9%) underwent transcatheter arterial embolization in the early stage of management. The average hospital and ICU length of stay were 53.0 ± 37.6 days and 14.3 ± 15.3 days, respectively. Statistically significant differences were found in ISS, PRBC units received with the first 24 h, SBP, lactate and base excess on admission, and mechanism of injury when comparing between the death and the survival groups (p < 0.05). ISS and lactate on admission were found to be the independent risk factors for mortality. CONCLUSION The mortality rate of open pelvic fractures remains high. ISS and lactate on admission were the independent risk factors for mortality. Optimization of the trauma care algorithms for early identification and treatment of this injury could be the key to decreasing mortality.
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Affiliation(s)
- Qingshan Guo
- State Key Laboratory of Trauma, Burns and Combined Injury, Medical Center of Trauma and War injury, Daping Hospital, Army Medical University, Chongqing, China.,* Qingshan Guo and Letian Zhang Contributed equally to this work
| | - Letian Zhang
- Department of Radiology, Daping Hospital, Army Medical University, Chongqing, China.,* Qingshan Guo and Letian Zhang Contributed equally to this work
| | - Siru Zhou
- State Key Laboratory of Trauma, Burns and Combined Injury, Medical Center of Trauma and War injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Zhiyang Zhang
- State Key Laboratory of Trauma, Burns and Combined Injury, Medical Center of Trauma and War injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Huayu Liu
- State Key Laboratory of Trauma, Burns and Combined Injury, Medical Center of Trauma and War injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Lianyang Zhang
- State Key Laboratory of Trauma, Burns and Combined Injury, Medical Center of Trauma and War injury, Daping Hospital, Army Medical University, Chongqing, China
| | - Tomer Talmy
- The Institute of Research in Military Medicine, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yang Li
- State Key Laboratory of Trauma, Burns and Combined Injury, Medical Center of Trauma and War injury, Daping Hospital, Army Medical University, Chongqing, China
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Truszczyńska-Baszak A, Guszkowska M, Dadura E, Tarnowski A. Prognostic factors of post-traumatic stress disorder risk in patients with surgical treatment of hip acetabular fracture. Original study. CURRENT PSYCHOLOGY 2021. [DOI: 10.1007/s12144-021-01488-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AbstractThe aim of the study was to assess the risk of developing post-traumatic stress disorder in patients after hip acetabular fracture surgery. The study involved 42 patients fulfilling inclusion criteria. Physical ability levels of the patients were determined with the Harris Hip Score, and modified Merle d’Aubigné scale. High risk of post-traumatic stress disorder was assessed with the PTSD-C questionnaire. Patients had in PTSD-C questionnaire 42.86 ± 28,10 points. In Harris Hip Score 63.64 ± 16.06, in Merle scale 11.10 ± 2.82, that was poor results in both scales. Positive correlation with age reached the level of tendency (ρ = 0.294; p = 0.059). Patients at risk of PTSD were in worse functional state measured by HHS (U = 136.0; p = 0.034) and Merle scale (U = 132.0; p = 0.026) and they were older (U = 147.5; p = 0.068). The groups differed significantly in gender ratio (χ2 = 4.01; p = 0.045). Women (8/10) were more often than men (14/32) at risk of PTSD. Patients after surgical fixation of the acetabulum experience significant functional disability. Increased level of disability after fracture and surgery, older age and female sex make patients vulnerable to PTSD. It is advisable to make medical staff who treat accident victims aware towards aspects which may be related to disorders of the patients’ psychological health.
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15
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Yu B, Lee G, Lee MA, Choi K, Gwak J, Park Y, Yoon YC, Lee J. The Management of Open Pelvic Fractures: A Report of 2 Cases. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.008] [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
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16
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Watkins RJ, Hsu JM. The Road to Survival for Haemodynamically Unstable Patients With Open Pelvic Fractures. Front Surg 2020; 7:58. [PMID: 32984402 PMCID: PMC7493634 DOI: 10.3389/fsurg.2020.00058] [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] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/21/2020] [Indexed: 11/13/2022] Open
Abstract
Management of haemodynamically unstable pelvic ring injuries has been simplified into treatment algorithms to streamline care and emergent decision making in order to improve patient outcomes whilst decreasing mortality and morbidity. Pelvic ring injuries are most commonly a result of high-velocity and energy forces that exert trauma to the pelvic bones causing not only damage to the bone but the surrounding soft-tissue, organs, and other structures and are usually accompanied by injuries to other parts of the body resulting in a polytraumatised patient. Open pelvic fractures are a rare subset of pelvic ring fractures that are on the more severe end of the pelvic fracture continuum and usually produce uncontrolled haemorrhage from fractured bone, retroperitoneal haematomas, intraabdominal bleeding from bowel injury, soft tissue injuries to the anus, perineum, and genitals, fractures of the pelvic bones, causing bleeding from cancellous bone, venous, and arterial injuries combined with bleeding from concomitant injuries. This is a very complex and challenging clinical situation and timely and appropriate decisions and action are paramount for a positive outcome. Consequently, open pelvic fractures have an extremely high rate of mortality and morbidity and outcomes remain poor, despite evidence-based improvements in treatment, knowledge, and identification of haemorrhage; in the pre-hospital, critical care, and operative settings. In the future utilisation of haemostatic drugs, dressings, devices, and procedures may aid in the time to haemorrhage control.
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Affiliation(s)
| | - Jeremy M Hsu
- Trauma Service, Westmead Hospital, Westmead, NSW, Australia.,Discipline of Surgery, University of Sydney, Sydney, NSW, Australia
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17
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Gabbe BJ, Stewart I, Veitch W, Beck B, Cameron P, Russ M, Bucknill A, Steiger RD, Esser M. Long-term outcomes of major trauma with unstable open pelvic fractures: A population-based cohort study. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620933203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims The aims of this study were to describe the profile and longer-term outcomes of major trauma patients with unstable open pelvic fractures. Patients and methods An observational study was performed using data from the population-based Victorian State Trauma Registry. Adult (≥16 years) major trauma patients who had sustained an unstable open pelvic fracture between 1 July 2010 and 30 June 2017 in Victoria (Australia) were included. Patient demographics, injury event, severity and management data were extracted. Patients were followed up at 6, 12 and 24 months post-injury to collect information about health status, function and return to work. Results There were 67 patients. The mean (SD) age was 41.4 (18.3) years, and 66% were male. Seventy-six per cent were road traffic injuries, 96% were managed at Level 1 trauma centres and all were multi-trauma patients. A third were Tile C fractures and 80% underwent surgical stabilisation of the pelvic injury. Eighty per cent were admitted to intensive care. The in-hospital mortality rate was 9%. Most (89%) survivors were discharged to an inpatient rehabilitation facility. The proportion classified as ‘severe disability’ on the Glasgow Outcome-Scale Extended declined from 38% at 6 months to 19% at 24 months. The overall three-level EuroQoL five-dimensional instrument score increased with time indicating better health status, and 50% of patients returned to work by 24 months. Conclusions Major trauma with unstable, open pelvic fracture is rare. Low in-hospital mortality was observed. Most survived to hospital discharge and outcomes improved with time post-injury, but 75% of patients experienced persistent pain and ongoing mobility and activity restrictions.
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Affiliation(s)
- Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Swansea, UK
| | - Ian Stewart
- Department of Orthopaedic Surgery, The Alfred, Prahran, Australia
| | - William Veitch
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Faculty of Medicine, Laval University, Quebec City, Canada
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Emergency and Trauma Centre, The Alfred, Melbourne, Australia
| | - Matthias Russ
- Department of Orthopaedic Surgery, The Alfred, Prahran, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Andrew Bucknill
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Australia
- Department of Surgery, University of Melbourne, Parkville, Australia
| | - Richard de Steiger
- Department of Surgery, University of Melbourne, Parkville, Australia
- Department of Surgery, Epworth Healthcare, Richmond, Australia
| | - Max Esser
- Department of Orthopaedic Surgery, The Alfred, Prahran, Australia
- Department of Surgery, Monash University, Melbourne, Australia
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18
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Frane N, Iturriaga C, Bub C, Regala P, Katsigiorgis G, Linn M. Risk factors for complications and in-hospital mortality: An analysis of 19,834 open pelvic ring fractures. J Clin Orthop Trauma 2020; 11:1110-1116. [PMID: 33192016 PMCID: PMC7656482 DOI: 10.1016/j.jcot.2020.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 08/18/2020] [Accepted: 08/22/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Open pelvic fractures are rare injuries, associated with high patient morbidity and mortality. Few studies have investigated the impact of patient demographics, comorbidities, and injury related factors on complication and mortality rates. The purpose of this study was to: (1) identify the overall incidence of complications and mortality after open pelvic fractures, (2) compare patient factors between those who did and did not develop complications, (3) identify perioperative independent risk factors for complications and mortality. METHODS A query was performed for patients with open pelvic fractures between 2007 and 2017 using the American College of Surgeons National Trauma Data Bank. Patient and injury specific variables were collected and complications were identified using International Classification of Disease Ninth and Tenth edition Codes. Patient demographic and perioperative data was compared using Fisher's exact test and chi-square test for categorical variables, and Welch's t-test for continuous variables. Using pooled data from multiple imputations, logistic regressions were used to calculate odds ratios and confidence intervals of independent risk factors for complications. RESULTS A total of 19,834 open pelvic fracture cases were identified, with 9622 patients (48.5%) developing at least one complication. Patients who developed complications were older (35.0 vs 38.1 years), and had higher Injury Severity Scores (17.7 vs 26.5), lower Glasgow Coma Scores (14.2 vs 11.7), and a larger proportion presenting with hypotension (21% vs 6.9%). After pooled regression involving 19 factors, these were the strongest independent predictors of inpatient complication and mortality. CONCLUSION We report a mortality rate of 14%, with an inclusive complication rate of 48.5%. Evaluating risk factors for morbidity and mortality for this devastating orthopaedic injury provides knowledge of an inherently sparse population. LEVEL OF EVIDENCE Level II, Retrospective study.
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Key Words
- ACS, American College of Surgeons
- ACS-NTDB, American College of Surgeons National Trauma Data Bank
- AIS, Abbreviated Injury Scale
- BP, blood pressure
- E-Code, external cause of injury
- ED, Emergency Department
- Epidemiology
- GCS, Glasgow Coma Scale
- ICD-10, International Classification of Disease Tenth
- ICD-9, International Classification of Disease Ninth
- ISS, Injury Severity Score
- MCAR, missing completely at random
- NTDB
- National trauma data bank
- Open pelvic fractures
- Orthopaedic surgery
- Orthopaedic trauma
- PE, pulmonary embolism
- Pelvic fractures
- RTS, Revised Trauma Score
- SBP, systolic blood pressure
- UTI, urinary tract infection
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Affiliation(s)
- Nicholas Frane
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, 888 Old Country Road, Plainview, New York, 11803, USA,Corresponding author. Department of Orthopaedic Surgery, 888 Old Country Road, Plainview, New York, 11803, USA.
| | - Cesar Iturriaga
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, Long Island Jewish Hospital, Northwell Health, Great Neck, NY, 11021, USA
| | - Christine Bub
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, Long Island Jewish Hospital, Northwell Health, Great Neck, NY, 11021, USA
| | - Peter Regala
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, 888 Old Country Road, Plainview, New York, 11803, USA
| | - Gus Katsigiorgis
- Zucker School of Medicine at Hofstra/Northwell, Department of Orthopaedic Surgery, 888 Old Country Road, Plainview, New York, 11803, USA
| | - Michael Linn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Southside Hospital, Northwell Health, 217 East Main Street, Bayshore, NY, 11706, USA
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Abstract
We describe the case of an 8-year old female patient with an open pelvic fracture after being run over by a bus. Open pelvic injuries in pediatric patients are very rare and are associated with high mortality rates and long-term morbidity. In this case, a multidisciplinary surgical approach is described. The injuries include a complex pelvic ring fracture, which was treated with an internal external fixator, together with severe urogenital and soft-tissue injury. The internal external fixator, a surgical technique involving a temporary internal fixation device, is well described in adults, but has not been described in pediatric patients before. This case presentation shows the severity and complexity of the treatment of open pelvic fractures with severe associated injures. Albeit the treatment of her orthopaedic injuries has been successful so far, our patient unfortunately still suffers notable morbidity from her other injuries.
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20
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Huang GB, Hu P, Gao JM, Lin X. Analysis of early treatment of multiple injuries combined with severe pelvic fracture. Chin J Traumatol 2019; 22:129-133. [PMID: 31076162 PMCID: PMC6543179 DOI: 10.1016/j.cjtee.2019.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 03/19/2019] [Accepted: 03/27/2019] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To summarize and analyze the early treatment of multiple injuries combined with severe pelvic fractures, especially focus on the hemostasis methods for severe pelvic fractures, so as to improve the successful rate of rescue for the fatal hemorrhagic shock caused by pelvic fractures. METHODS A retrospective analysis was conducted in 68 cases of multiple trauma combined with severe pelvic fractures in recent 10 years (from Jan. 2006 to Dec. 2015). There were 57 males and 11 females. Their age ranged from 19 to 75 years, averaging 42 years. Causes of injury included traffic accidents in 34 cases (2 cases of truck rolling), high falling injuries in 17 cases, crashing injuries in 15 cases, steel cable wound in 1 case, and seat belt traction injury in 1 case. There were 31 cases of head injury, 11 cases of chest injury, 56 cases of abdominal and pelvic injuries, and 37 cases of spinal and limb injuries. Therapeutic methods included early anti-shock measures, surgical hemostasis based on internal iliac artery devasculization for pelvic hemorrhage, and early treatment for combined organ damage and complications included embolization and repair of the liver, spleen and kidney, splenectomy, nephrectomy, intestinal resection, colostomy, bladder ostomy, and urethral repair, etc. Patients in this series received blood transfusion volume of 1200-10,000 mL, with an average volume of 2850 mL. Postoperative follow-up ranged from 6 months to 1.5 years. RESULTS The average score of ISS in this series was 38.6 points. 49 cases were successfully treated and the total survival rate was 72.1%. Totally 19 patients died (average ISS score 42.4), including 6 cases of hemorrhagic shock, 8 cases of brain injury, 1 case of cardiac injury, 2 cases of pulmonary infection, 1 case of pulmonary embolism, and 1 case of multiple organ failure. Postoperative complications included 1 case of urethral stricture (after secondary repair), 1 case of sexual dysfunction (combined with urethral rupture), 1 case of lower limb amputation (femoral artery thrombosis), and 18 cases of consumptive coagulopathy. CONCLUSION The early treatment of multiple injuries combined with severe pelvic fractures should focus on pelvic hemostasis. Massive bleeding-induced hemorrhagic shock is one of the main causes of poor prognosis. The technique of internal iliac artery devasculization including ligation and embolization can be used as an effective measure to stop or reduce bleeding. Consumptive coagulopathy is difficult to deal with, which should be detected and treated as soon as possible after surgical measures have been performed. The effect of using recombinant factor VII in treating consumptive coagulopathy is satisfactory.
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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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Petrone P, Rodríguez-Perdomo M, Pérez-Jiménez A, Ali F, Brathwaite CEM, Joseph DK. Pre-peritoneal pelvic packing for the management of life-threatening pelvic fractures. Eur J Trauma Emerg Surg 2018; 45:417-421. [DOI: 10.1007/s00068-018-1018-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/20/2018] [Indexed: 11/28/2022]
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Hermans E, Edwards MJR, Goslings JC, Biert J. Open pelvic fracture: the killing fracture? J Orthop Surg Res 2018; 13:83. [PMID: 29653551 PMCID: PMC5899387 DOI: 10.1186/s13018-018-0793-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 03/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Open pelvic fractures are rare but represent a serious clinical problem with high mortality rates. The purpose of this study was to evaluate the outcomes of open pelvic fractures in our clinic and to compare the results from our patient group with those of closed fractures and with the literature from the past decade. METHODS Data of patients older than 16 years of age who were admitted to our hospital with a pelvic fracture between January 1, 2004, and December 31, 2014, were analyzed. The collected data were patient demographics, mechanism of injury, RTS, ISS, transfusion requirement during the first 24 h, Gustilo-Anderson and Faringer classification, number and type of interventions complications, mortality, and length of stay. RESULTS Twenty-four of 492 patients (5% of all pelvic fracture patients) had an open fracture. Their mean age was 36 years, the mean ISS was 31, and the mean number of transfused packed red blood cells was 5.5. These numbers were all significantly higher than in the patients with a closed fracture, although they were comparable to other studies with open fractures. The mortality was 4% in the open group versus 14% in the closed group (p = 0.23). The reported mortality in the literature ranges between 4 and 45%. CONCLUSION Open pelvic fractures are relatively rare but are a cause of significant morbidity. In this series, we treated patients with open pelvic fractures successfully, with a survival rate of 96%. There was no significant difference in survival rate between open and closed pelvic fractures. Compared with other studies, the mortality in our study was relatively low.
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Affiliation(s)
- E Hermans
- Department of Surgery, Radboud University Medical Center, Nijmegen, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - M J R Edwards
- Department of Surgery, Radboud University Medical Center, Nijmegen, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - J C Goslings
- Department of Surgery, Onze Lieve Vrouwe Gasthuis Amsterdam, PO-BOX 95500, 1090 HM, Amsterdam, The Netherlands
| | - J Biert
- Department of Surgery, Radboud University Medical Center, Nijmegen, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Preperitoneal pelvic packing is effective for hemorrhage control in open pelvic fractures. Am J Surg 2018; 215:675-677. [DOI: 10.1016/j.amjsurg.2017.11.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 11/20/2017] [Indexed: 11/19/2022]
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Fu CY, Huang RY, Wang SY, Liao CH, Huang JF, Hsu YP, Lin CY, Kang SC. Concomitant external and internal hemorrhage: Challenges to managing patients with open pelvic fracture. Am J Emerg Med 2018; 36:1937-1942. [PMID: 29486990 DOI: 10.1016/j.ajem.2018.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 02/01/2018] [Accepted: 02/16/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Managing patients with open pelvic fractures continues to be challenging and requires a multidisciplinary approach. In this study, we examined the characteristics of patients with open pelvic fractures and strategies for managing such patients. MATERIALS AND METHODS The records of patients with open pelvic fractures from January 2010 to August 2016 were retrospectively reviewed. Emergency surgery was performed to control hemorrhaging in patients with an active external hemorrhage. Transcatheter arterial embolization (TAE) was used for definitive hemostasis. The relation between cause of death and timing of death was examined. We also compared the characteristics of surviving and non-surviving patients. Furthermore, patients who received both surgery and post-operative TAE were analyzed in detail. RESULTS In total, 42 patients with open pelvic fractures were enrolled in the study. The overall mortality rate among patients with open pelvic fractures was 26.2%. Patients whose deaths were related to hemorrhaging and associated injuries died significantly earlier than patients whose deaths were related to sepsis and multiple organ failure (1.3days vs. 12.3days, p<0.001). Sixteen patients (38.1%) received TAE for hemostasis, and their systolic blood pressure (SBP) improved significantly following TAE (from 88.4mmHg to 111.6mmHg, p<0.05). In the patients who received both surgery and post-operative TAE (n=8), the SBP increased significantly after surgery (from 58.8mmHg to 81.1mmHg, p<0.05). Similarly, the patients' SBP after TAE was significantly higher than their post-operative SBP (110.5mmHg vs. 81.1mmHg, p<0.05). CONCLUSION Active external hemorrhaging was initially controlled when managing patients with open pelvic fractures; however, most patients also required TAE for definitive hemorrhage control. Early TAE should be considered due to the high probability of concomitant internal and external hemorrhage. Close observation and further infection control are important following the hemostatic procedure.
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Affiliation(s)
- Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan
| | - Ruo-Yi Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan
| | - Shang-Yu Wang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan.
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan.
| | - Yu-Pao Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan.
| | - Chia-Yun Lin
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, Taiwan
| | - Shih-Ching Kang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taiwan.
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Siada SS, Davis JW, Kaups KL, Dirks RC, Grannis KA. Current outcomes of blunt open pelvic fractures: how modern advances in trauma care may decrease mortality. Trauma Surg Acute Care Open 2017; 2:e000136. [PMID: 29766121 PMCID: PMC5887774 DOI: 10.1136/tsaco-2017-000136] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 11/22/2017] [Accepted: 11/27/2017] [Indexed: 12/02/2022] Open
Abstract
Background Open pelvic fracture, caused by a blunt mechanism, is an uncommon injury with a high mortality rate. In 2008, evidence-based algorithm for managing pelvic fractures in unstable patients was published by the Western Trauma Association (WTA). The use of massive transfusion protocols has become widespread as has the availability and use of pelvic angiography. The purpose of this study was to evaluate the outcome of open pelvic fractures in association with related advances in trauma care. Methods A retrospective review was performed, at an American College of Surgeon verified level I trauma center, of patients with blunt open pelvic fractures from January 2010 to April 2016. The WTA algorithm, including massive transfusion protocol, and pelvic angiography were uniformly used. Data collected included injury severity score, demographic data, transfusion requirements, use of pelvic angiography, length of stay, and disposition. Data were compared with a similar study from 2005. Results During the study period, 1505 patients with pelvic fractures were analyzed; 87 (6%) patients had open pelvic fractures. Of these, 25 were from blunt mechanisms and made up the study population. Patients in both studies had similar injury severity scores, ages, Glasgow Coma Scale, and gender distributions. Use of angiography was higher (44% vs. 16%; P=0.011) and mortality was lower (16% vs. 45%; P=0.014) than in the 2005 study. Conclusions Changes in trauma care for patients with open blunt pelvic fracture include the use of an evidence-based algorithm, massive transfusion protocols and increased use of angioembolization. Mortality for open pelvic fractures has decreased with these advances. Level of evidence Level IV.
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Affiliation(s)
- Sammy S Siada
- Department of Surgery, Community Regional Medical Center, University of California, San Francisco-Fresno, Fresno, California, USA
| | - James W Davis
- Department of Surgery, Community Regional Medical Center, University of California, San Francisco-Fresno, Fresno, California, USA
| | - Krista L Kaups
- Department of Surgery, Community Regional Medical Center, University of California, San Francisco-Fresno, Fresno, California, USA
| | - Rachel C Dirks
- Department of Surgery, Community Regional Medical Center, University of California, San Francisco-Fresno, Fresno, California, USA
| | - Kimberly A Grannis
- Department of Surgery, Community Regional Medical Center, University of California, San Francisco-Fresno, Fresno, California, USA
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Rehwald R, Schönherr E, Petersen J, Jeske HC, Fialkovska A, Luger AK, Grams AE, Loizides A, Jaschke W, Glodny B. Prognostic factors in endovascular treated pelvic haemorrhage after blunt trauma. BMC Surg 2017; 17:89. [PMID: 28793885 PMCID: PMC5551004 DOI: 10.1186/s12893-017-0283-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 07/25/2017] [Indexed: 12/20/2022] Open
Abstract
Background Angioembolization is the method of choice for treating haemorrhage after blunt pelvic trauma. The aim of this study was to determine technical factors related to endovascular procedures which might be related to patient outcome. Methods This retrospective study included 112 consecutive patients (40 women and 72 men; mean age 57.2 ± 20.0). Results There were age peaks at 43 and at 77 years. Patients over 65 years had mainly “low-energy” trauma; younger patients were more likely to have polytraumas. Younger patients were more severely injured and had more surgical interventions, larger haematoma volumes, lower Hb levels and required more transfusions than older patients. Women were older than men, had fewer surgeries and waited longer for an angiography (p < 0.05 each). Logistic regression analyses identified the injury severity score (ISS) as relevant for survival before age, haematoma volume and Hb. Propensity score analyses showed that in addition to the need for transfusions, haemoglobin, and haematoma volume, the length of the coils and the number of microcoils used were relevant (p < 0.05 each). The location of haemorrhage in peripheral parietal arteries (superior and inferior gluteal artery) was an influencing factor for re-angiographies, which were associated with considerably longer hospital stays of more than 40 days. Fewer particles had generally been used in these patients. Conclusions The use of too few coils and not using microparticles in angioembolization for pelvic haemorrhage are major influencing factors for the mortality or re-angiography rate. Special attention should be given to thorough peripheral embolization with microcoils, in particular for haemorrhage from the parietal branches of the internal iliac artery.
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Affiliation(s)
- Rafael Rehwald
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.,Institute of Neurology, University College London, Queen Square, London, United Kingdom
| | - Elisabeth Schönherr
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Johannes Petersen
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Hans-Christian Jeske
- Department of Trauma Surgery, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Anna Fialkovska
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Anna Katharina Luger
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Astrid Ellen Grams
- Department of Neuroradiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Alexander Loizides
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Werner Jaschke
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
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Fitzgerald CA, Moore TJ, Morse BC, Subramanian A, Dente CJ, Patel DC, Reisman WM, Schenker ML, Gelbard RB. The Role of Diverting Colostomy in Traumatic Blunt Open Pelvic Fractures. Am Surg 2017. [DOI: 10.1177/000313481708300805] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Thomas J. Moore
- Department of Orthopedic Surgery Emory University Atlanta, Georgia
| | | | | | | | | | | | - Mara L. Schenker
- Department of Orthopedic Surgery Emory University Atlanta, Georgia
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Song W, Zhou D, Xu W, Zhang G, Wang C, Qiu D, Dong J. Factors of Pelvic Infection and Death in Patients with Open Pelvic Fractures and Rectal Injuries. Surg Infect (Larchmt) 2017; 18:711-715. [PMID: 28759327 DOI: 10.1089/sur.2017.083] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Open pelvic fractures associated with rectal injuries are uncommon. They often cause serious pelvic infection, even death. This combination of injuries has been reviewed infrequently. Herein, we report factors associated with pelvic infection and death in a group of patients with open pelvic fractures and concurrent rectal injuries. METHODS We retrospectively reviewed the records of patients with open pelvic fractures and rectal injuries who were treated at our institution from January 2010-April 2014. From the medical records, age, gender, Injury Severity Score (ISS), cause of fracture, associated injuries, classification of the fracture, degree of soft-tissue injury, Glasgow Coma Score (GCS), Revised Trauma Score (RTS), packed red blood cells (PRBCs) needed, presence/absence of shock, early colostomy (yes or no), drainage (yes or no), and rectal washout (yes or no) were extracted. Univariable and multivariable analysis were performed to determine the association between risk factors and pelvic infection or death. RESULTS Twenty patients were identified. Pelvic infection occurred in 50% (n = 10) of the patients. Four patients suffered septicemia, and three patients died of multiple organ dysfunction. The mortality rate thus was 15%. According to the univariable analysis, the patients in whom pelvic infection developed had shock, RTS ≤8, GCS ≤8, blood transfusion ≥10 units in the first 24 h, no colostomy, or Gustilo grade III soft-tissue injury. According to the multivariable analysis, shock and absence of colostomy were independently associated with pelvic infection. By univariable analysis, the only factor associated with death was RTS ≤8. CONCLUSION The incidence of pelvic infection was lower in patients having early colostomy (p < 0.05). Patients with shock had a higher risk of pelvic infection, and we recommend aggressive measures to treat these patients. According to our results, RTS ≤8 could be a predictor of poor outcomes in patients with open pelvic fracture and concurrent rectal injury. Open reduction and internal fixation after extensive debridement is recommended in patients with unstable pelvic fractures.
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Affiliation(s)
- Wenhao Song
- Department of Orthopedic Surgery, Shandong Provincial Hospital affiliated to Shandong University , Shandong, People's Republic of China
| | - Dongsheng Zhou
- Department of Orthopedic Surgery, Shandong Provincial Hospital affiliated to Shandong University , Shandong, People's Republic of China
| | - Weicheng Xu
- Department of Orthopedic Surgery, Shandong Provincial Hospital affiliated to Shandong University , Shandong, People's Republic of China
| | - Guoming Zhang
- Department of Orthopedic Surgery, Shandong Provincial Hospital affiliated to Shandong University , Shandong, People's Republic of China
| | - Chunhui Wang
- Department of Orthopedic Surgery, Shandong Provincial Hospital affiliated to Shandong University , Shandong, People's Republic of China
| | - Daodi Qiu
- Department of Orthopedic Surgery, Shandong Provincial Hospital affiliated to Shandong University , Shandong, People's Republic of China
| | - Jinlei Dong
- Department of Orthopedic Surgery, Shandong Provincial Hospital affiliated to Shandong University , Shandong, People's Republic of China
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Giordano V, Koch HA, Gasparini S, Serrão de Souza F, Labronici PJ, do Amaral NP. Open Pelvic Fractures: Review of 30 Cases. Open Orthop J 2016; 10:772-778. [PMID: 28217202 PMCID: PMC5301299 DOI: 10.2174/1874325001610010772] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/09/2016] [Accepted: 12/13/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Open pelvic fractures are rare but usually associated with a high incidence of complications and increased mortality rates. The aim of this study was to retrospectively evaluate all consecutive open pelvic fractures in patients treated at a single Level-1 Trauma Center during a 10-year interval. PATIENTS AND METHODS In a 10-year interval, 30 patients with a diagnosis of open pelvic fracture were admitted at a Level-1 Trauma Center. A retrospective analysis was conducted on data obtained from the medical records, which included patient's age, sex, mechanism of injury, classification of the pelvic lesion, Injury Severity Score (ISS), emergency interventions, surgical interventions, length of hospital and Intensive Care Unit stay, and complications, including perioperative complications and death. The Jones classification was used to characterize the energy of the pelvic trauma and the Faringer classification to define the location of the open wound. Among the survivors, the results were assessed in the last outpatient visit using the EuroQol EQ-5D and the Blake questionnaires. It was established the relationship between the mortality and morbidity and these classification systems by using the Mann-Whitney non-parametric test, with a level of significance of 5%. RESULTS Twelve (40%) patients died either from the pelvic lesion or related injuries. All of them had an ISS superior to 35. The Jones classification showed a direct relationship to the mortality rate in those patients (p = 0.012). In the 18 (60%) other patients evaluated, the mean follow-up was 16.3 months, ranging from 24 to 112 months. Eleven (61%) patients had a satisfactory outcome. The Jones classification showed a statistically significant relationship both to the objective and subjective outcomes (p < 5%). The Faringer classification showed a statistically significant relationship to the subjective, but not to the objective outcome. In addition, among the 18 patients evaluated at the last outpatient visit, the Faringer classification showed statistical significance on the need of colostomy (p = 0.001) in the acute phase of treatment. CONCLUSION We suggest the routine use of the Jones classification for the emergency room assessment and management of all open fractures of the pelvic ring. We believe the Faringer classification seems to be useful for the abdominal surgeons for the indication of gut transit derivation but not for the acute management of the bony component of an open pelvic fracture.
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Affiliation(s)
- Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brazil
| | - Hilton Augusto Koch
- Departamento de Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Savino Gasparini
- Serviço de Cirurgia Geral, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brazil
| | - Felipe Serrão de Souza
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brazil
| | - Pedro José Labronici
- Universidade Federal Fluminense (UFF), Rio de Janeiro, RJ, Brazil and Hospital Santa Teresa, Petrópolis, RJ, Brazil
| | - Ney Pecegueiro do Amaral
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brazil
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INFIX/EXFIX: Massive Open Pelvic Injuries and Review of the Literature. Case Rep Orthop 2016; 2016:9468285. [PMID: 27493818 PMCID: PMC4963555 DOI: 10.1155/2016/9468285] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/16/2016] [Indexed: 11/28/2022] Open
Abstract
Introduction. Open pelvic fractures make up 2–5% of all pelvic ring injuries. Their mortality has been reported to be as high as 50%. During Operation Enduring Freedom protocols for massive open pelvic injuries lead to the survival of injuries once thought to be fatal. The INFIX is a subcutaneous anterior fixator for pelvic stabilization which is stronger than external fixation. The purpose of this paper is to describe the use of INFIX and modern algorithms for massive open pelvic injuries. Methods. An IRB approved retrospective review describes 4 cases in civilian practice with massive open pelvic injuries. We also review the modern literature on open pelvic injures. Discussion. Key components in the care of massive open pelvic injuries include hemorrhage control by clamping of the aorta or REBOA when necessary and fecal/urinary diversion. The INFIX can be used internally, as a partial INFIX partial EXFIX, or as an EXFIX. Its low profile allows for easy application of wound vacs and wound care and when subcutaneous avoids pin tract infections. Conclusion. Massive open pelvic injuries are a difficult problem. Following modern protocols can help prevent mortality.
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Wang H, Robinson RD, Moore B, Kirk AJ, Phillips JL, Umejiego J, Chukwuma J, Miller T, Hassani D, Zenarosa NR. Predictors of early versus late mortality in pelvic trauma patients. Scand J Trauma Resusc Emerg Med 2016; 24:27. [PMID: 26964737 PMCID: PMC4785731 DOI: 10.1186/s13049-016-0220-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 03/04/2016] [Indexed: 11/22/2022] Open
Abstract
Background Risks of predicting time-related in-hospital mortality varies in pelvic trauma patients. We aim to identify potential independent risks predictive of time-related (early versus late) mortality among pelvic trauma patients. Methods Local trauma registry data from 2004 through 2013 were reviewed. Mortality causes and timing of death were investigated. Multivariate logistic regression identified independent risks predictive of early versus late mortality in pelvic trauma patients while adjusting for patient demographics (age, sex, race), clinical variables (initial vital signs, mental status, injury severity, associated injuries, comorbidities), and hospital outcomes (surgical interventions, crystalloid resuscitations, blood transfusions). Results We retrospectively collected data on 1566 pelvic trauma patients with a mortality rate of 9.96 % (156/1566). Approximately 74 % of patients died from massive hemorrhage within the first 24 h of hospitalization (early mortality). Revised trauma score (RTS), injury severity score (ISS), initial hemoglobin, direct transfer to operating room, and blood transfusion administration in the Emergency Department were considered independent risk factors predictive of early mortality. Age, ISS, and Glasgow Coma Scale (GCS) were deemed risk factors predictive of death after 24 h (late mortality). Discussion Given the fact of a substantial number of patients died within the first 24 h of hospital arrival, it is reasonable to consider the first 24 h of hospitalization as the appropriate window within which early mortality may be expected to occur in pelvic trauma patients. The risk factors associated with massive hemorrhage were strong predictors of early mortality, whereas late mortality predictors were more closely linked with comorbidities or in-hospital complications. Conclusions While risk factors predictive of early versus late mortality vary, ISS seems to predict both early and late mortality accurately in pelvic trauma patients.
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Affiliation(s)
- Hao Wang
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA.
| | - Richard D Robinson
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA
| | - Billy Moore
- Research Institute, JPS Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
| | - Alexander J Kirk
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA
| | | | - Johnbosco Umejiego
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA
| | - Joseph Chukwuma
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA
| | - Tyler Miller
- Emergency Department, JPS Health Network, 1575 S. Main St, Fort Worth, TX, 76104, USA
| | - Donna Hassani
- University of South Florida, Morsani College of Medicine, 12901 Bruce B. Downs Blvd., MDC061, Tampa, FL, 33612-4799, USA
| | - Nestor R Zenarosa
- Research Institute, JPS Health Network, 1500 S. Main St, Fort Worth, TX, 76104, USA
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Buller LT, Best MJ, Quinnan SM. A Nationwide Analysis of Pelvic Ring Fractures: Incidence and Trends in Treatment, Length of Stay, and Mortality. Geriatr Orthop Surg Rehabil 2016; 7:9-17. [PMID: 26929851 PMCID: PMC4748159 DOI: 10.1177/2151458515616250] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Previous studies evaluating the epidemiology of pelvic ring fractures and predictors of mortality are largely based upon non-US populations, potentially limiting their generalizability. This study sought to analyze trends of pelvic ring fractures and associated complications in the United States using the largest and most recent national data set available. The specific aims of this study were to determine whether the incidence of pelvic ring fractures changed over time, whether in-hospital mortality following pelvic ring fracture changed over time, whether hospital length of stay following pelvic ring fracture changed over time, and whether there are independent predictors of in-hospital mortality, adverse events, or nonroutine discharge following pelvic fracture. METHODS The National Hospital Discharge Survey was queried to identify all patients admitted to US hospitals with pelvic ring fractures between 1990 and 2007. A cohort representative of 1 464 458 patients was identified, and multivariable logistic regression was used to find independent predictors of mortality, adverse events, and nonroutine discharge to another inpatient facility. RESULTS Between 1990 and 2007, the population-adjusted incidence of pelvic ring fractures increased from 27.24 to 34.30 per 100 000 capita (P < .001). Mortality declined from 4.2% to 2.8% (P < .001) paralleling an increase in the proportion of patients treated with surgical fixation (7.22%-10.36%). All forms of internal fixation were associated with decreased odds of mortality, while external fixation was associated with increased odds of mortality. Internal fixation was also associated with lower odds of adverse events and nonroutine discharge to inpatient facilities. The average in-hospital length of stay decreased from 11.2 days to 6.5 days (P < .001). CONCLUSION This study provides the largest and most comprehensive epidemiologic analysis of pelvic ring fractures in the United States. Knowledge of the increasing incidence of pelvic fractures and prognostic factors associated with poor outcomes may improve outcomes.
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Affiliation(s)
- Leonard T Buller
- Department of Orthopaedic Surgery and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stephen M Quinnan
- Department of Orthopaedic Surgery and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL, USA
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Scolaro JA, Wilson DJ, Routt MLC, Firoozabadi R. Use of the initial trauma CT scan to aid in diagnosis of open pelvic fractures. Injury 2015. [PMID: 26199029 DOI: 10.1016/j.injury.2015.06.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Open pelvic disruptions represent high-energy injuries. The prompt identification and management of these injuries decreases their associated morbidity and mortality. Computed tomography (CT) scans are routinely obtained in the initial evaluation of patients with pelvic injuries. The purpose of this study is to identify the incidence and source of air densities noted on computed tomography (CT) scans of the abdominal and pelvic region in patients with pelvic fractures and evaluate the use of initial CT imaging as an adjunctive diagnostic tool to identify open injuries. A retrospective review of a prospectively collected database was performed at a single institution. Seven hundred and twenty-two consecutive patients with a pelvic disruption over a two-year period were included. Review of initial injury CT scans was performed using bone and lung viewing algorithms to identify the presence of extra-luminal air. The primary outcome was the presence, location and source of air identified on pre-operative CT scans. Secondary measurements were identification of air by plain radiograph and correlation between identified air densities on CT and clinically diagnosed open pelvic fractures. Ninety-eight patients were identified as having extra-luminal air densities on CT scans. Eighty-one patients were included in the final analysis following application of inclusion and exclusion criteria. Air was noted by the radiologist in forty-five (55.6%) instances. Six patients (7.4%) were clinically diagnosed with an open pelvic ring disruption; in two patients (2.4%) this diagnosis was delayed. In all patients, the CT was able to track air from its origin. In patients with pelvic disruptions, the injury CT should also be evaluated for the presence and source of extra-luminal air. In some patients, this finding may represent an open pelvic ring disruption. A complete physical exam and CT evaluation should be used to decrease the missed or delayed diagnosis of an open pelvic ring injury.
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Affiliation(s)
| | | | | | - Reza Firoozabadi
- Harborview Medical Center, University of Washington, Seattle, WA, USA.
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Lustenberger T, Wutzler S, Störmann P, Laurer H, Marzi I. The role of angio-embolization in the acute treatment concept of severe pelvic ring injuries. Injury 2015; 46 Suppl 4:S33-8. [PMID: 26542864 DOI: 10.1016/s0020-1383(15)30016-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND In recent years a wide variety of strategies to treat the haemodynamically unstable patient with pelvic ring fractures have been proposed. This study evaluates our institutional management of patients with severe pelvic fractures and analyses their outcomes. METHODS Retrospective review of all severely injured trauma patients with pelvic ring injuries admitted to a level I trauma centre from 2007 to 2012. Patient records were documented prospectively in a trauma database and evaluation was performed by SPSS. RESULTS During the study period, a total of 173 patients with pelvic ring fractures were admitted and formed the basis of this study. Overall, 46% of the patients had suffered a type A fracture, 25% a type B fracture and the remaining 29% a type C pelvic ring fracture. Surgical treatment was required in 21% of the patients (pelvic C-clamp, n = 6; supra-acetabular external fixator, n = 32; pelvic packing, n = 12; definitive plate osteosynthesis of the pubis symphysis, n = 6). Angio-embolization was performed in 16 patients (9%); in 8 patients it was the only specific treatment for the pelvic injury on day 0 and in 8 patients it was performed immediately post-operatively. The overall mortality rate was 12.7% (n = 22), with the type C pelvic fractures having the highest mortality (30.0%). Four patients died immediately after admission in the shock room. CONCLUSIONS Angiographic embolization as a first-line treatment was only performed in haemodynamically stable patients or in patients responding to fluid resuscitation with the finding of an arterial blush in the CT scan. In haemodynamically unstable patients, pre-peritoneal pelvic packing in combination with mechanical pelvic stabilization was immediately carried out, followed by angio-embolization post-operatively if signs of persistent bleeding remained present.
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Affiliation(s)
- Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany.
| | - Sebastian Wutzler
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Philip Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Helmut Laurer
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany
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Modeling of unstable pelvic fractures for 20 ° sagittally rotated pelvic displacement. Med Eng Phys 2015; 37:1076-81. [PMID: 26388402 DOI: 10.1016/j.medengphy.2015.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 06/09/2015] [Accepted: 08/19/2015] [Indexed: 11/20/2022]
Abstract
Early and accurate assessment of unstable pelvic fractures decreases mortality and morbidity by improving the outcomes of closed reduction surgery. In some circumstances (such as in developing countries or in acute trauma), accurate computed tomography (CT) 3D reconstructions are difficult to obtain and plain radiography must be relied upon for surgical planning. Therefore, a simulation model of pelvic displacement was evaluated as a basis for improving the assessment of pelvic fracture displacement from plain radiography images. The simulated model was based on a modified anteroposterior (AP) view of the pelvis constructed using anatomical data. Plain radiography imaging data of sagittal 20 ° hemipelvic rotation, similar to that observed in trauma, was obtained from the simulated model and were compared with normal pelvic rings from 10 cadaveric specimens (actual model). For each data set, the anterior superior iliac spine and ipsilateral pubic symphysis were measured on both sides. There was no significant difference between pelvic sides in the simulated and actual models (P = 0.870). Furthermore, no significant difference was found between the rotational degree of each pelvis based on calculated or simulated degrees and the 20 ° rotational angle (P = 0.322). A simulation model based on plain radiography of pelvic displacement could contribute to the optimal surgical management of unstable pelvic fractures without relying on CT.
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Kostić I, Golubović I, Kocić B, Stojanović M. THE ASSOCIATION BETWEEN PELVIC FRACTURES (RING AND ACETABULUM FRACTURES) AND OTHER ORGAN SYSTEM INJURIES. ACTA MEDICA MEDIANAE 2015. [DOI: 10.5633/amm.2015.0304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Haddad SH, Yousef ZM, Al-Azzam SS, AlDawood AS, Al-Zahrani AA, AlZamel HA, Tamim HM, Deeb AM, Arabi YM. Profile, outcome and predictors of mortality of abdomino-pelvic trauma patients in a tertiary intensive care unit in Saudi Arabia. Injury 2015; 46:94-9. [PMID: 25152429 DOI: 10.1016/j.injury.2014.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 07/08/2014] [Accepted: 07/26/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Kingdom of Saudi Arabia (KSA) is one of countries with the world's highest number of deaths per 100,000 populations from road traffic accidents (RTAs). Numerous trauma victims sustain abdomino-pelvic injuries, which are associated with considerable morbidity and mortality. The purpose of this study was to describe profile, outcomes and predictors of mortality of patients with abdomino-pelvic trauma admitted to the intensive care unit (ICU) in a tertiary care trauma centre in Riyadh, KSA. METHODS This was a retrospective analysis of prospectively collected ICU database. All consecutive patients older than 14 years with abdomino-pelvic trauma from March 1999 to June 2013 were included. The followings were extracted: demographics, injury severity, mechanism and type of injury, associated injuries, use of vasopressors and mechanical ventilation, and worst laboratory results in the first 24h. The primary outcome was hospital mortality. We compared profile and outcomes between survivors and non-survivors and reported predictors of mortality. RESULTS Of the 11,374 trauma patients who were admitted to the hospital during the study period, 2120 (18.6%) patients had abdomino-pelvic injuries, out of which 702 (33.1%) patients were admitted to the ICU. The mean age was 30.7 (SD 14.4) years and the majority was male (89.5%). RTA was the most common cause of abdomino-pelvic trauma (70.4%). Pelvis (46.2%), liver (25.8%), and spleen (23.1%) were the most frequently injured organs; and chest (55.6%), head (41.9%), and lower extremities (27.5%) were the most commonly associated injuries. Mechanical ventilation was required in 89.6% with a mean duration of 9.1 (SD 9.2) days and emergency surgery was performed in 45.0% of the patients with prolonged ICU and hospital length of stay (10.8 [SD 10.8], 56.9 [SD 96.7] days; respectively). Of the 702 patients with abdomino-pelvic trauma, 115 (16.4%) patients did not survive. Associated head trauma and retroperitoneal haematoma, higher level of lactic acid on admission and ISS, and advanced age were potential risk factors for hospital mortality. CONCLUSIONS Abdomino-pelvic injuries are common in trauma patients, affecting mainly young male victims, and are associated with significant morbidity and mortality, and resource utilisation.
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Affiliation(s)
- Samir H Haddad
- Surgical Intensive Care Unit, Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Zeyad M Yousef
- Department of Surgery, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Saleh S Al-Azzam
- Department of Surgery, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Abdulaziz S AlDawood
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Ali A Al-Zahrani
- Department of Surgery, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Heythem A AlZamel
- Department of Surgery, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Hani M Tamim
- King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Riyadh, Saudi Arabia; Department of Internal Medicine, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Ahmad M Deeb
- King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
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Shepherd Q, Schrickel TT. Open pelvic fracture due to crush injury. J Osteopath Med 2014; 114:936. [PMID: 25429084 DOI: 10.7556/jaoa.2014.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Quin Shepherd
- From the Des Moines University College of Osteopathic Medicine in Iowa and the Department of Medical Education at St Joseph's Health Center in Warren, Ohio (Student Doctor Shepherd), and the Department of Orthopaedic Trauma at St Elizabeth's Health Center in Youngstown, Ohio (Dr Schrickel)
| | - Tyson T Schrickel
- From the Des Moines University College of Osteopathic Medicine in Iowa and the Department of Medical Education at St Joseph's Health Center in Warren, Ohio (Student Doctor Shepherd), and the Department of Orthopaedic Trauma at St Elizabeth's Health Center in Youngstown, Ohio (Dr Schrickel)
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Pelvic ring fractures: has mortality improved following the implementation of damage control resuscitation? Am J Surg 2014; 208:1083-90; discussion 1089-90. [PMID: 25440492 DOI: 10.1016/j.amjsurg.2014.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 09/12/2014] [Accepted: 09/15/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Over the last 10 years, the paradigm of damage control resuscitation (DCR) has been associated with improved patient outcomes. This study investigates the outcomes of both closed and open pelvic ring fractures at a single institution before and after the formal implementation of DCR principles. METHODS A retrospective chart review was performed in an urban level I trauma center of all patients who sustained open or closed pelvic ring fractures between 2002 and 2012. RESULTS Two thousand two hundred forty-seven patients presented with pelvic fractures between 2002 and 2012. Overall mortality was 10% (n = 212). Only 8% of all patients with closed fractures required DCR compared with 28% of patients with open fractures. There was no difference in mortality when comparing DCR and pre-DCR cohorts for either open or closed pelvic fractures. CONCLUSIONS Interestingly, although DCR seems to lead to more efficient initial resuscitations, further improvements in patient mortality were not realized with formal implementation of DCR principles.
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Arregui-Dalmases C, Kerrigan JR, Sanchez-Molina D, Velazquez-Ameijide J, Crandall JR. A review of pelvic fractures in adult pedestrians: experimental studies involving PMHS used to determine injury criteria for pedestrian dummies and component test procedures. TRAFFIC INJURY PREVENTION 2014; 16:62-69. [PMID: 25261186 DOI: 10.1080/15389588.2014.898841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Perform a systematic review for the most relevant pelvic injury research involving PMHS. The review begins with an explanation of the pelvic anatomy and a general description of pelvic fracture patterns followed by the particular case of pelvic fractures sustained in pedestrian-vehicle collisions. Field data documenting the vehicle, crash, and human risk factors for pedestrian pelvic injuries are assessed. METHOD A summary of full-scale PMHS tests and subsystem lateral pelvic tests is provided with an interpretation of the most significant findings for the most relevant studies. CONCLUSIONS Based on the mechanisms of pedestrian pelvic injury, force, acceleration, and velocity and compression have been assessed as predictive variables by researchers although no consensus criterion exists.
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Taylor AM, Gundara JS, Wines M, Ruff S, Samra JS. Perineal small bowel evisceration following blunt abdominal trauma. ANZ J Surg 2013; 83:992-3. [PMID: 24289053 DOI: 10.1111/ans.12225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alaina M Taylor
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, University of Sydney, St Leonards, New South Wales, Australia
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El-Haj M, Bloom A, Mosheiff R, Liebergall M, Weil YA. Outcome of angiographic embolisation for unstable pelvic ring injuries: Factors predicting success. Injury 2013; 44:1750-5. [PMID: 23796438 DOI: 10.1016/j.injury.2013.05.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 05/28/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Angiographic embolisation (AE) is a successful treatment for haemodynamically unstable pelvic ring injuries. However, recent evidence has shown a significant complication rate following AE together with a lower success rate than previously reported. The aim of the current study was to review and indentify the factors predicting success or failure of AE. PATIENTS AND METHODS 651 patients with high energy (ISS>16) pelvic ring injuries were treated in our institution between the years 1997 and 2009. Mean patient age was 37 (range 5-89) years, and the average ISS 33.4 (range 16-66). Patients' information was collected from the institution's trauma registry as well as from the patient's medical chart and radiographs. Data included age, ISS, length of stay, ICU stay, initial blood pressure and pulse, blood products consumption, blood creatinine levels, fracture type and treatment, embolisation details, complications and mortality. 61 patients (9.3%) underwent urgent angiography due to haemodynamic instability. Angiography was positive (PA) in 38 patients (62.3%) and was negative for haemorrhage (NA) in the remaining 23 (37.7%). RESULTS Ten patients required a branch vessel embolisation while 17 patients required major vessel embolisation, 11 required bilateral internal iliac embolisation and three patients underwent multiple vessel embolisation. Overall mortality rate was 26%. 32 patients required surgical intervention for pelvic ring stabilisation. Significant reduction in blood transfusion was seen in patients with an APC fracture type following AE. No significant correlation was found between fracture type and mortality. Multiple vessel embolisations were associated with increased surgical complications and mortality. DISCUSSION Angiographic embolisation provides a reasonable option for haemodynamically unstable pelvic ring injured patients with an acceptable outcome, supporting previously reported literature. Patients with unstable APC type pelvic fracture may benefit the most from early angiographic embolisation. Patients requiring multiple vessel embolisation have a guarded outcome.
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Affiliation(s)
- Madi El-Haj
- Department of Orthopaedics, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
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The Jones-Powell Classification of open pelvic fractures: a multicenter study evaluating mortality rates. J Trauma Acute Care Surg 2013; 74:901-6. [PMID: 23425755 DOI: 10.1097/ta.0b013e3182827496] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Historically, open pelvic fractures have a high mortality rate. The Jones-Powell Classification system was developed to assist with morbidity and mortality prediction.The purposes of our study were twofold: 1. Apply the Jones-Powell Classification to mortality rates of open pelvic fractures; 2. Because the original article published on the Jones-Powell Classification was from 1997, there have been advances in the early treatment of pelvic fractures to include the use of the pelvic binder, early diverting colostomies, and emergent angiography. We wanted to examine if any of those acute interventions affected mortality rate. METHODS This is a retrospective review of all patients presenting with open pelvic fractures at six Level I trauma centers between 2000 and 2006. RESULTS There were 64 patients with an average age of 34 years (range, 17-57 years). Fourteen had stable pelvic fracture patterns, and 50 had unstable fracture patterns. The overall mortality rate in our study was 15 patients (23%). All patients who died had an unstable pelvic fracture and/or rectal laceration. Sixteen patients had diverting colostomies within 48 hours of injury. There were four patients with rectal lacerations and no patients with diverting colostomies who died. DISCUSSION In our population group, there was an overall mortality rate of 23%. A Jones-Powell Class 3 injury had a 38% mortality rate. The presence of a rectal laceration may serve as a marker for the severity of the patient's injuries and increased risk of mortality. LEVEL OF EVIDENCE Epidemiologic study, level IV.
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Amorosa LF, Amorosa JH, Wellman DS, Lorich DG, Helfet DL. Management of pelvic injuries in pregnancy. Orthop Clin North Am 2013; 44:301-15, viii. [PMID: 23827834 DOI: 10.1016/j.ocl.2013.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pelvic fractures in pregnant women are usually high-energy injuries associated with risk of mortality to both mother and fetus. The mother's life always takes priority in the acute setting as it offers the best chance of survival to both the mother and the fetus. Indications for operative intervention of acute pubic symphysis rupture depend on presence of an open disruption, amount of displacement, and degree of disability. Chronic symphyseal instability related to pregnancy is a challenging problem and the first line of treatment is nonoperative care. A previous pelvic fracture is not a contraindication by itself to vaginal delivery.
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Affiliation(s)
- Louis F Amorosa
- Department of Orthopaedic Surgery, New York Medical College, 19 Bradhurst Ave, Suite 1300, Hawthorne, NY 10532, USA.
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Abstract
Mortality associated with pelvic and perineal trauma (PPT) has fallen from 25% to 10% in the last decade thanks to progress accomplished in medical, surgical and interventional radiology domains (Dyer and Vrahas, 2006) [1]. The management strategy depends on the hemodynamic status of the patient (stable, unstable or extremely unstable). Open trauma requires specific treatment in addition to control of bleeding. All surgical centers can be confronted some day with patients with hemorrhagic PPT and for this reason, all surgeons should be familiar with the initial management. In expert centers, management of patients with severe PPT is complex, multidisciplinary and often requires several re-interventions. Obstetrical and sexual trauma, also requiring specific management, will not be dealt with herein.
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Selective faecal diversion in open pelvic fractures: reassessment based on recent experience. Injury 2012; 43:522-5. [PMID: 21975556 DOI: 10.1016/j.injury.2011.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 08/10/2011] [Accepted: 09/07/2011] [Indexed: 02/02/2023]
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Hou Z, Smith WR, Strohecker KA, Bowen TR, Irgit K, Baro SM, Morgan SJ. Hemodynamically unstable pelvic fracture management by advanced trauma life support guidelines results in high mortality. Orthopedics 2012; 35:e319-24. [PMID: 22385440 DOI: 10.3928/01477447-20120222-29] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to examine the acute outcomes and mortality rates of an Advanced Trauma Life Support guideline approach for managing hemodynamically unstable pelvic ring injuries. We retrospectively reviewed the acute outcomes of 48 consecutive patients with hemodynamically unstable pelvic fractures. Patients underwent treatment via the advanced trauma life support protocol, with primary angiography based on trauma surgeon preference. Mean patient age was 51.2 years, with a mean injury severity score of 43.2±14.3. Mean systolic blood pressure was 74.8±16.1 mm Hg at presentation. Patients received an average of 7.0±6.6 units of red blood cells and 4.2±2.3 units of fresh frozen plasma in the first 6 hours. Fourteen patients underwent emergent angiography, and 12 patients were treated with embolization. Mean time to angiography was 3 hours and 55 minutes (range, 2-19 hours). Twenty patients died during hospitalization, with an overall mortality rate of 41.7%; 13 (27.1%) of them died within 24 hours. Advanced Trauma Life Support guidelines with angiography are not adequate for the management of hemodynamically unstable pelvic ring injuries and result in unacceptably high mortality rates compared with more specific approaches using transfusion protocols and interventions, such as pelvic packing.
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Affiliation(s)
- Zhiyong Hou
- Department of Orthopaedics, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.
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Dong JL, Zhou DS. Management and outcome of open pelvic fractures: a retrospective study of 41 cases. Injury 2011; 42:1003-7. [PMID: 21349516 DOI: 10.1016/j.injury.2011.01.032] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 01/31/2011] [Accepted: 01/31/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Open pelvic fractures occur uncommonly. Despite serious sequelae, they have been infrequently reviewed. METHODS We conducted a retrospective review of all patients with open pelvic fractures in our department from January 2001 to April 2010. RESULTS Forty-one patients (32 men, 9 women) with these injuries were identified. The average Injury Severity Score (ISS) was 31.4, with 80% of patients having a score ≥16. The average blood transfusion in the first 24h was 17.2 units, and the average hospital stay was 60 days. Overall mortality was 24% (n=10): 3 early deaths and 7 late deaths. Factors associated with overall mortality by univariate analysis were ISS, RTS, GCS, age, pelvic sepsis, Gustilo classification of soft-tissue injury, and Young classification of bony fracture. Factors associated with late mortality by univariate analysis were: ISS, RTS, pelvic sepsis, Gustilo classification of soft-tissue injury, and blood transfusion in the first 24 h. Moreover, multivariate analysis showed that only RTS was independently associated with both overall and late mortality. CONCLUSION Despite treatment advances, mortality rates remain high in patients with open pelvic fractures. The urogenital and/or intra-abdominal injuries are not associated with mortality. RTS≤8 might be a predictor of poor outcome in open pelvic fractures patients. Open reduction and internal fixation might be used in those unstable pelvic fractures without gross contamination in the fracture region after extensive cleansing and lavage. More emphasis needs to be placed on this injury complex.
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Affiliation(s)
- Jin-lei Dong
- Department of Orthopaedics, Provincial Hospital Affiliated to Shandong University, 324 Jing Wu Road, 250021 Jinan, China
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