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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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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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Yu YH, Hsu YH, Chou YC, Liu CH, Tseng IC, Chen IJ. Three-year functional outcome after open pelvic fracture treatment: a retrospective case series from a level I trauma center. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:937-945. [PMID: 35224667 PMCID: PMC10126096 DOI: 10.1007/s00590-022-03234-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Open pelvic fractures have high mortality rates, and survivors may have ongoing functional deficits from severe trauma and invasive life-saving procedures. However, there are limited reports regarding the functional status evaluation following open pelvic fractures. We aimed to report the treatment experiences and short-term functional outcomes of patients with open pelvic fractures. METHODS We retrospectively reviewed the data of 19 consecutive patients with pelvic fractures who underwent treatment at a single institute between January 2014 and June 2018. The resuscitation protocol, osteosynthesis strategy, reduction quality of the pelvic ring, and functional outcomes were analyzed. RESULTS The incidence and mortality rates in patients with open pelvic fractures were 4.9 and 21.6%, respectively. Ten, one, and seven of the open wounds related to the pelvic fractures were located in Faringer zones I, II, and III, respectively. Fractures of four patients were categorized as classes 1 and 2, and those of 11 patients as class 3, according to the Jones-Powell classification. Eleven of 19 (57.9%) and 9 of 19 (47.5%) revealed excellent reduction quality by Matta/Torenetta and Lefaivre criteria, respectively. The Merle d'Aubigné score improved at each evaluation but stagnated after 24 months. The Majeed hip score also improved at the 12-month evaluation but the improvement stopped thereafter. At a 3-year follow-up, the patients with excellent reduction of the pelvic ring showed the highest functional performances. CONCLUSION Improvements in functional status of patients with open pelvic fractures can be anticipated based on the reduction quality of the pelvis ring.
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Affiliation(s)
- Yi-Hsun Yu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5 Fu-Hsin Street, Kweishan, Tao-Yuan, 33302, Taiwan.
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5 Fu-Hsin Street, Kweishan, Tao-Yuan, 33302, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5 Fu-Hsin Street, Kweishan, Tao-Yuan, 33302, Taiwan
| | - Chang-Heng Liu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5 Fu-Hsin Street, Kweishan, Tao-Yuan, 33302, Taiwan
| | - I-Chuan Tseng
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5 Fu-Hsin Street, Kweishan, Tao-Yuan, 33302, Taiwan
| | - I-Jung Chen
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5 Fu-Hsin Street, Kweishan, Tao-Yuan, 33302, Taiwan
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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: 23] [Impact Index Per Article: 7.7] [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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Tiziani S, Halvachizadeh S, Knöpfel A, Pfeifer R, Sprengel K, Tarkin I, Pape HC. Early fixation strategies for high energy pelvic ring injuries - the Zurich algorithm. Injury 2021; 52:2712-2718. [PMID: 32736823 DOI: 10.1016/j.injury.2020.07.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 06/04/2020] [Accepted: 07/18/2020] [Indexed: 02/02/2023]
Abstract
In isolated high energy pelvic ring injuries, early surgical and nonsurgical fixation belongs to the rescue tools required for rapid recovery. With the increasing use of pelvic binders on scene, these patients frequently arrive in a better condition at the level I trauma centre than without any measures of immobilisation. We describe our surgical tools to achieve rapid fixation within the first hours after arrival, taking into account if additional injuries or special stations are relevant.
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Affiliation(s)
- Simon Tiziani
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Adrian Knöpfel
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Ivan Tarkin
- Dept. of Orthopaedic Trauma, University of Pittsburgh, 15213 Pittsburgh, USA
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
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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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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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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
OBJECTIVES To evaluate the incidence of unplanned reoperations after pelvic ring injuries and to develop a risk prediction model. DESIGN Retrospective review. SETTING Level I Trauma Center. PATIENTS The medical records of 913 patients (644 male and 269 female patients; mean age, 39 years; age range, 16-89 years) with unstable pelvic ring fractures operatively treated at our center from 2003 to 2015 were reviewed. INTERVENTION Multiple logistic regression analysis was conducted to evaluate the relative contribution of associated clinical parameters to unplanned reoperations. A risk prediction model was developed to assess the effects of multiple covariates. MAIN OUTCOME MEASUREMENTS Unplanned reoperation for infection, fixation failure, heterotopic ossification, or bleeding complication. RESULTS Unplanned reoperations totaled 137 fractures, with an overall rate of 15% (8% infection, 6% fixation failure, <1% heterotopic ossification, and <1% bleeding complication). Reoperations for infection and fixation failure typically occurred within the first month after the index procedure. Four independent predictors of reoperation were open fractures, combined pelvic ring and acetabular injuries, abdominal visceral injuries, and increasing pelvic fracture grade. No independent association was shown between reoperation and patient, treatment, or other injury factors. CONCLUSIONS Unplanned reoperations were relatively common. Infection and fixation failure were the most common indications for unplanned reoperations. Factors associated with reoperation are related to severity of pelvic and abdominal visceral injuries. Our findings suggest that these complications might be inherent and in many cases unavoidable despite appropriate current treatment strategies. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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10
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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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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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Rodrigues-Pinto R, Kurd MF, Schroeder GD, Kepler CK, Krieg JC, Holstein JH, Bellabarba C, Firoozabadi R, Oner FC, Kandziora F, Dvorak MF, Kleweno CP, Vialle LR, Rajasekaran S, Schnake KJ, Vaccaro AR. Sacral Fractures and Associated Injuries. Global Spine J 2017; 7:609-616. [PMID: 28989838 PMCID: PMC5624377 DOI: 10.1177/2192568217701097] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [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
STUDY DESIGN Literature review. OBJECTIVE The aim of this review is to describe the injuries associated with sacral fractures and to analyze their impact on patient outcome. METHODS A comprehensive narrative review of the literature was performed to identify the injuries associated with sacral fractures. RESULTS Sacral fractures are uncommon injuries that result from high-energy trauma, and that, due to their rarity, are frequently underdiagnosed and mistreated. Only 5% of sacral fractures occur in isolation. Injuries most often associated with sacral fractures include neurologic injuries (present in up to 50% of sacral fractures), pelvic ring disruptions, hip and lumbar spine fractures, active pelvic/ abdominal bleeding and the presence of an open fracture or significant soft tissue injury. Diagnosis of pelvic ring fractures and fractures extending to the lumbar spine are key factors for the appropriate management of sacral fractures. Importantly, associated systemic (cranial, thoracic, and abdominopelvic) or musculoskeletal injuries should be promptly assessed and addressed. These associated injuries often dictate the management and eventual outcome of sacral fractures and, therefore, any treatment algorithm should take them into consideration. CONCLUSIONS Sacral fractures are complex in nature and often associated with other often-missed injuries. This review summarizes the most relevant associated injuries in sacral fractures and discusses on their appropriate management.
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Affiliation(s)
- Ricardo Rodrigues-Pinto
- Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
,Ricardo Rodrigues-Pinto, Department of Orthopaedics, Centro Hospitalar do Porto, Hospital de Santo António, Largo Prof. Abel Salazar, Porto 4099-001, Portugal.
| | - Mark F. Kurd
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - James C. Krieg
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jörg H. Holstein
- Institute for Clinical & Experimental Surgery, University of Saarland, Homburg/Saar, Germany
| | - Carlo Bellabarba
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Reza Firoozabadi
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Frank Kandziora
- Berufsgenossenschaftliche Unfallklinik Frankfurt, Center for Spinal Surgery and Neurotraumatology, Frankfurt am Main, Germany
| | - Marcel F. Dvorak
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Conor P. Kleweno
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Luiz R. Vialle
- Cajuru University Hospital, Catholic University of Parana, Curitiba, Brazil
| | | | - Klause J. Schnake
- Schön Klinik Nürnberg Fürth, Center for Spinal Surgery, Fürth, Germany
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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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15
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Purcell RL, McQuade MG, Kluk MW, Gordon WT, Lewandowski LR. Combat-related pelvic ring fractures in survivors. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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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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18
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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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19
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Abstract
Rectal trauma is associated with high rates of morbidity and mortality and generally affects young males due to its aetiology of violent crime and vehicular collision. Historically, management has followed principles derived from military practice, with faecal diversion, pre-sacral drainage and distal washout being mandatory. Civilian trauma studies examining management of colon and rectum injuries from the early 1950s identified major differences in the level of energy transfer between civilian and military wounds, given that the vast majority are penetrating in nature. This led to a re-evaluation of the necessity for these interventions for all rectal injuries. Current management depends on whether the injury is intra- or extraperitoneal, with those above the peritoneal reflection being readily accessible and amenable to treatment as for colon injury. Extraperitoneal injuries remain difficult to access and direct repair is usually impossible; the mainstay of treatment in most instances remains faecal diversion. The role of pre-sacral drainage and distal washout remains contentious in the realms of civilian rectal injury but retains a place in battlefield or other high-energy transfer rectal injuries where aggressive early management reduces septic complications. This article reviews the historical and current evidence for the management of both civilian and military extraperitoneal rectal injuries.
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Affiliation(s)
- Sarah Barkley
- Department of Colorectal Surgery, Northern General Hospital, Sheffield, UK
| | - Mansoor Khan
- Department of General Surgery, Doncaster Royal Infirmary, Doncaster, UK
| | - Jeff Garner
- Rotherham NHS Foundation Trust and Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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20
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Goswami D, Kochhar PK, Suri T, Zutshi V, Batra S. Obstetric and gynecological outcome in a patient with traumatic pelvic fracture and perineal injuries. J Obstet Gynaecol Res 2012; 38:1118-23. [PMID: 22540310 DOI: 10.1111/j.1447-0756.2011.01838.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Deepti Goswami
- Department of Obstetrics and Gynecology Orthopedics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India.
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21
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Fracture Detection in Traumatic Pelvic CT Images. Int J Biomed Imaging 2012; 2012:327198. [PMID: 22287952 PMCID: PMC3263603 DOI: 10.1155/2012/327198] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Revised: 09/30/2011] [Accepted: 09/30/2011] [Indexed: 12/04/2022] Open
Abstract
Fracture detection in pelvic bones is vital for patient diagnostic decisions and treatment planning in traumatic pelvic injuries. Manual detection of bone fracture from computed tomography (CT) images is very challenging due to low resolution of the images and the complex pelvic structures. Automated fracture detection from segmented bones can significantly help physicians analyze pelvic CT images and detect the severity of injuries in a very short period. This paper presents an automated hierarchical algorithm for bone fracture detection in pelvic CT scans using adaptive windowing, boundary tracing, and wavelet transform while incorporating anatomical information. Fracture detection is performed on the basis of the results of prior pelvic bone segmentation via our registered active shape model (RASM). The results are promising and show that the method is capable of detecting fractures accurately.
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22
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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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23
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Abstract
High energy fractures of the pelvis are a challenging problem both in the immediate post-injury phase and later when definitive fixation is undertaken. No single management algorithm can be applied because of associated injuries and the wide variety of trauma systems that have evolved around the world. Initial management is aimed at saving life and this is most likely to be achieved with an approach that seeks to identify and treat life-threatening injuries in order of priority. Early mortality after a pelvic fracture is most commonly due to major haemorrhage or catastrophic brain injury. In this article we review the role of pelvic binders, angiographic embolisation, pelvic packing, early internal fixation and blood transfusion with regard to controlling haemorrhage. Definitive fixation seeks to prevent deformity and reduce complications. We believe this should be undertaken by specialist surgeons in a hospital resourced, equipped and staffed to manage the whole spectrum of major trauma. We describe the most common modes of internal fixation by injury type and review the factors that influence delayed mortality, adverse functional outcome, sexual dysfunction and venous thromboembolism.
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Affiliation(s)
- H. C. Guthrie
- Trauma and Orthopaedic Department, St George’s Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - R. W. Owens
- Trauma and Orthopaedic Department, St George’s Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - M. D. Bircher
- Trauma and Orthopaedic Department, St George’s Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
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Sharma OP, Oswanski MF, Rabbi J, Georgiadis GM, Lauer SK, Stombaugh HA. Pelvic Fracture Risk Assessment on Admission. Am Surg 2008. [DOI: 10.1177/000313480807400819] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Patients with pelvic fractures (PF) have high incidences of associated injuries and mortality. To identify patients with PF at the highest risk for mortality on admission to a Level I trauma center, investigators analyzed 566 PF in 12,128 patients (1996 to 2005). PF were categorized on arrival as high risk (HR) or low risk (LR) by initial blood pressure, examination, radiographs, and CT. HR PF included open fractures, open-book injuries, PF 4 or greater abbreviated injury score, and hypotension (89 mmHg or less systolic blood pressure); all other cases were categorized as LR PF. Patients with PF had 6 per cent (35 of 566) mortality compared with 3 per cent (300 of 11,529) without PF. Mortality was 24 per cent (25 of 103) in HR PF, including 11 per cent (one of nine) of open fractures, 25 per cent (12 of 49) of open-book injuries, 23 per cent (14 of 62) of 4 or greater abbreviated injury score, and 33 per cent (20 of 60) of hypotensive patients compared with 3 per cent (13 of 454) of LR PF. Compared with LR PF, patients with HR PF were younger (43.5 vs 53.8 years) with higher injury severity scores (28.7 vs 11.9) and longer hospital stays (10.6 vs 7.4 days). PF mortality remains high despite treatment in a Level I trauma center. Trauma mechanism, initial blood pressure, pelvic radiography, and CT can be used to predict a patient's mortality risk.
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Affiliation(s)
- Om P. Sharma
- Trauma Services, The Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
| | - Michael F. Oswanski
- Trauma Services, The Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
| | - Jamal Rabbi
- Department of Surgery, Fairview Hospital, Cleveland, Ohio
| | - Gregory M. Georgiadis
- Orthopaedics Trauma Services, The Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
| | - Sherry K. Lauer
- Trauma Services, The Toledo Hospital & Toledo Children's Hospital, Toledo, Ohio
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Lu K, Shoemaker WC, Wo CCJ, Lee J, Demetriades D. A mathematical program to predict survival and to support initial therapeutic decisions for trauma patients with long-bone and pelvic fractures. Injury 2007; 38:318-28. [PMID: 17049525 DOI: 10.1016/j.injury.2006.06.117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2006] [Revised: 06/06/2006] [Accepted: 06/20/2006] [Indexed: 02/02/2023]
Abstract
AIM To test a mathematical program to monitor early haemodynamic patterns of patients with fractures, predict survival and support initial therapeutic decisions. METHODS A mathematical search and display program based on non-invasive haemodynamic monitoring was used to study 430 consecutively monitored patients with fractures during the first 48 h after admission to the emergency department of an inner city public hospital. We studied four types of fractures: simple extremity fractures, long-bone fractures, pelvic fractures and fractures incidental to severe trauma. The program continuously displayed haemodynamic patterns and predicted survival probability (SP), which was evaluated by the actual outcome at hospital discharge. The program also assessed the effectiveness of therapies according to haemodynamic responses. RESULTS The cardiac index, heart rate, mean arterial pressure, arterial saturation and transcutaneous oxygen tensions at the initial resuscitation were significantly higher in survivors than in non-survivors. After the first 48 h, the haemodynamic patterns were more influenced by fever, sepsis, complications and organ failures. The calculated survival probability averaged 81%+/-18% in the first 48 h for survivors and 72%+/-20% for non-survivors. CONCLUSION Early continuous non-invasive haemodynamic monitoring using the proposed information system is helpful in predicting outcome and guiding therapy for patients with fractures.
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Affiliation(s)
- Kevin Lu
- Department of Surgery, LAC+USC Medical Center, Keck School of Medicine, University of Southern California, 1200 N State Street, Los Angeles, CA 90033, USA
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Katsoulis E, Giannoudis PV. Impact of timing of pelvic fixation on functional outcome. Injury 2006; 37:1133-42. [PMID: 17092504 DOI: 10.1016/j.injury.2006.07.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2006] [Accepted: 07/12/2006] [Indexed: 02/02/2023]
Abstract
Pelvic fractures are the third most common cause of death in motor vehicle accidents. Recent improvements in mortality can be attributed to the progress made in modern critical care medicine, multidetector CT, ATLS principles, multidisciplinary protocols and early fracture stabilisation. Currently, the timing of pelvic fixation is often based on the haemodynamic status and response of the patient to resuscitation, the fracture pattern, the presence of associated injuries and the immuno-inflammatory status of the patient. The purpose of this review is to focus on the impact of timing of reconstruction of pelvic fractures on the functional outcome of the patients. Thirty seven scientific studies on the outcome of pelvic and acetabular injuries were reviewed. Four on pelvic ring fractures, and one study on pelvic and acetabular fractures met our second inclusion criterion of prospective or retrospective studies investigating the outcome after early or late pelvic and acetabular fixation. These five studies suggested early pelvic and acetabular fixation for optimal outcome but their main difference was the definition of the length in time of that early period. In polytrauma patients, the "damage control orthopaedics" principle should be applied for haemodynamic and skeletal stabilisation (and faecal diversion, if indicated in cases of open fractures of the pelvis). The definitive fixation should be performed after the fourth post-injury day, when the physiological state of the patient is conducive to surgery.
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Affiliation(s)
- Efstathios Katsoulis
- Department of Trauma & Orthopaedics, St James' University Hospital, Beckett Street, Leeds LS9 7TF, UK.
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27
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Lunsjo K, Abu-Zidan FM. Does Colostomy Prevent Infection in Open Blunt Pelvic Fractures? A Systematic Review. ACTA ACUST UNITED AC 2006; 60:1145-8. [PMID: 16688089 DOI: 10.1097/01.ta.0000197615.31553.1e] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Open pelvic fracture is a rare injury. Our aim in this study is to systematically review the literature to define when diverting colostomy is indicated to protect the patient from infection in open blunt pelvic fractures. METHODS Papers studying open pelvic fractures and the use of colostomy were retrieved through MEDLINE and PUBMED. The papers were critically appraised regarding their methodology and conclusions. Relevant information was combined. RESULTS The level of evidence for the use of colostomy in open pelvic fractures is very low. All reports are retrospective and no statistical methods have been used to support conclusions drawn. We found no difference in the overall infectious complication rate between the colostomy and noncolostomy groups. There is an assumption that patients with perineal wounds would benefit from colostomy; however, rectal involvement in these injuries was not detailed. CONCLUSION The role of colostomy in open blunt pelvic fractures is unresolved and randomized multicenter trials are needed.
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Affiliation(s)
- Karl Lunsjo
- Department of Surgery, UAE University, Al Ain, United Arabic Emirates
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Boufous S, Finch C, Lord S, Close J. The increasing burden of pelvic fractures in older people, New South Wales, Australia. Injury 2005; 36:1323-9. [PMID: 15979626 DOI: 10.1016/j.injury.2005.02.008] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Revised: 02/08/2005] [Accepted: 02/08/2005] [Indexed: 02/02/2023]
Abstract
Despite their significant health burden, epidemiological information regarding pelvic fractures is scarce. In this study, we examine trends in admission for pelvic fractures to acute hospitals in New South Wales, Australia, between July 1988 and June 2000, using routinely collected hospital separations statistics. Over this period, the number of admissions for pelvic fractures among those aged 50 years and over increased by 58.4% in men and 110.8% in women. Age-specific rates of admissions per 100,000 population for pelvic fracture also rose significantly, particularly for those aged at least 75 years. The number and proportion of transport related pelvic fractures fell significantly for both men (chi(2)=23.82, d.f.=1, p<0.001) and women (chi(2)=49.26, d.f.=1, p<0.001) while those resulting from falls increased significantly over the 12-year-period. Falls are increasingly becoming the single most important cause of pelvic injuries in older people, suggesting that preventive measures aimed at reducing the risk of falls need to be pursued. Factors contributing to the rise of fall-related pelvic fractures need to be investigated to inform strategies aimed at reversing the observed increase in the number and age-specific rates of pelvic fractures in older people.
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Affiliation(s)
- Soufiane Boufous
- University of New South Wales, NSW Injury Risk Management Research Centre, Sydney, NSW 2052, Australia.
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29
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Petrisor B, Bhandari M. (i) Injuries to the pelvic ring: Incidence, classification, associated injuries and mortality rates. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.cuor.2005.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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31
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Grotz MRW, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis PV. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 2005; 36:1-13. [PMID: 15589906 DOI: 10.1016/j.injury.2004.05.029] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2004] [Indexed: 02/02/2023]
Abstract
Open pelvic fractures constitute one of the most devastating injuries in musculo-skeletal trauma and must be treated aggressively, incorporating a multidisciplinary approach. Early treatment, focusing on prevention of haemorrhage and sepsis, is essential. The management of associated soft tissue injuries must also be aggressive, including early administration of broad-spectrum antibiotics and repeated, meticulous wound debridement and irrigation. Selective faecal diversion, based on wound location, is compulsory and safe, minimising the risk of sepsis and reducing mortality rates.
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Affiliation(s)
- M R W Grotz
- Department of Trauma and Orthopaedics, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK
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32
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Abstract
Significant soft tissue injuries often occur as part of high-energy injuries to the pelvis. These soft tissue injuries must be recognized and considered when implementing a treatment plan if complications are to be minimized. Vigilance in diagnosing open fractures must be maintained. Patients with these injuries must be managed aggressively, because they are at high risk for complications and death. Closed pelvic and acetabular fractures also may include soft tissue injury that requires special consideration. Careful evaluation and management of the soft tissues aids in determining appropriate techniques for reduction and fixation of the associated fractures.
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Affiliation(s)
- Cory Collinge
- Orthopaedic Specialty Associates, 1325 Pennsylvania Avenue, Suite 890, Fort Worth, TX 76104, USA
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33
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Westhoff J, Höll S, Kälicke T, Muhr G, Kutscha-Lissberg F. [Open pelvic fracture. Treatment strategy and results for 12 patients]. Unfallchirurg 2004; 107:189-96. [PMID: 15042300 DOI: 10.1007/s00113-003-0724-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This article presents treatment priorities for open pelvic fracture and the results of 12 patients. In a retrospective study we analyzed 12 patients treated at a level 1 trauma center between 1994 and 1998 of whom eight were male and four female with an average age of 29.6 years. Six type C (6 x III degrees open) and six type B (4 x II degrees and 2 x III degrees open) were identified. On average, 15 EKs were necessary within the first 12 h of treatment (type C=17, type B=13). All type C fractures underwent emergency stabilization with the pelvic C-clamp. Early laparotomy was performed in 60%. Perineal laceration was identified in 58%, followed by nerve and plexus lesions in 42%, injuries of the genitourinary tract in 33%, and lesions of the fecal stream in 25%. Altogether, there were more peripelvic injuries associated with type C fracture than with type B (12 vs 8). On average, there were 27 second-look operations necessary with 3-.2 operations per patient. The average stay in the ICU was 82 days (80-360); 25% died. Control of hemorrhage is fundamental; therefore, emergency stabilization of the pelvis is essential followed by surgical procedures. Early surgical definitive stabilization of the fracture decreases septic complications. Such complex injuries should be treated at specialized trauma centers.
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Affiliation(s)
- J Westhoff
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, 30625 Hannover, Germany.
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