Pelvic fracture in the elderly is associated with increased mortality

Pelvic fractures in blunt trauma patients: A comparative study

BACKGROUND

Pelvic fractures (PF) with concomitant injuries are on the rise due to an increase of high-energy trauma. Increase of the elderly population with age related comorbidities further complicates the management. Abdominal organ injuries are kindred with PF due to the proximity to pelvic bones. Presence of contrast blush (CB) on computed tomography in patients with PF is considered a sign of active bleeding, however, its clinical significance and association with outcomes is debatable.

AIM

To analyze polytrauma patients with PF with a focus on the geriatric population, co-injuries and the value of contrast blush.

METHODS

This retrospective cohort study included 558 patients with PF admitted to level 1 trauma center (01/2017-01/2023). Analyzed variables included: Age, sex, mechanism of injury (MOI), injury severity score (ISS), Glasgow coma scale (GCS), abbreviated injury scale (AIS), co-injuries, transfusion requirements, pelvic angiography, embolization, laparotomy, orthopedic pelvic surgery, intensive care unit and hospital lengths of stay, discharge disposition and mortality. The study compared geriatric and non-geriatric patients, patients with and without CB and abdominal co-injuries. Propensity score matching was implemented in comparison groups.

RESULTS

PF comprised 4% of all trauma admissions. 89 patients had CB. 286 (52%) patients had concomitant injuries including 93 (17%) patients with abdominal co-injuries. Geriatric patients compared to non-geriatric had more falls as MOI, lower ISS and AIS pelvis, higher GCS, less abdominal co-injuries, similar CB and angio-embolization rates, less orthopedic pelvic surgeries, shorter lengths of stay and higher mortality. After propensity matching, orthopedic pelvic surgery rates remained lower (8% vs 19%, P < 0.001), hospital length of stay shorter, and mortality higher (13% vs 4%, P < 0.001) in geriatric patients. Out of 89 patients with CB, 45 (51%) were embolized. After propensity matching, patients with CB compared to without CB had more pelvic angiography (71% vs 12%, P < 0.001), higher embolization rates (64% vs 22%, P = 0.02) and comparable mortality.

CONCLUSION

Half of the patients with PF had concomitant co-injuries, including abdominal co-injuries in 17%. Similarly injured geriatric patients had higher mortality. Half of the patients with CB required an embolization.

Enhancing fracture diagnosis in pelvic X-rays by deep convolutional neural network with synthesized images from 3D-CT

Pelvic fractures pose significant challenges in medical diagnosis due to the complex structure of the pelvic bones. Timely diagnosis of pelvic fractures is critical to reduce complications and mortality rates. While computed tomography (CT) is highly accurate in detecting pelvic fractures, the initial diagnostic procedure usually involves pelvic X-rays (PXR). In recent years, many deep learning-based methods have been developed utilizing ImageNet-based transfer learning for diagnosing hip and pelvic fractures. However, the ImageNet dataset contains natural RGB images which are different than PXR. In this study, we proposed a two-step transfer learning approach that improved the diagnosis of pelvic fractures in PXR images. The first step involved training a deep convolutional neural network (DCNN) using synthesized PXR images derived from 3D-CT by digitally reconstructed radiographs (DRR). In the second step, the classification layers of the DCNN were fine-tuned using acquired PXR images. The performance of the proposed method was compared with the conventional ImageNet-based transfer learning method. Experimental results demonstrated that the proposed DRR-based method, using 20 synthesized PXR images for each CT, achieved superior performance with the area under the receiver operating characteristic curves (AUROCs) of 0.9327 and 0.8014 for visible and invisible fractures, respectively. The ImageNet-based method yields AUROCs of 0.8908 and 0.7308 for visible and invisible fractures, respectively.

Management of the Geriatric Trauma Patient

With a rapidly aging worldwide population, the care of geriatric trauma patients will be at the forefront of every career in Trauma and Acute Care Surgery. The unique intersection of advanced age, comorbidities, frailty, and physiologic changes presents a challenge in the care of elderly injured patients. It is well established that increasing age is associated with higher mortality and worse outcomes after injury, but it is also clear that there is room for improvement in the management of this special patient population.

Pelvic fractures in severely injured elderly: a double-adjustment propensity score matched analysis from a level I trauma center

Purpose

Pelvic trauma has increased risk of mortality in the elderly. Our study aimed to analyze the impact of the additional burden of pelvic fractures in severely injured elderly.

Methods

This is a retrospective analysis of a prospectively maintained trauma registry from 2012 to 2018 at an American College of Surgeons (ACS) verified Level I Trauma Center. Trauma patients aged ≥ 65 years with ISS ≥ 16 and AIS severity score ≥ 3 in at least two body regions were divided in two groups: group I, consisted of elderly polytrauma patients without pelvic fractures, and group II elderly who had concomitant pelvic fractures. We used a double-adjustment method using propensity score matching (PSM) with subsequent covariate adjustment to minimize the effect of confounding factors, and give unbiased estimation of the impact of pelvic fractures. Balance assessment was conducted by computing absolute standardized mean differences (ASMDs) and ASMD < 0.10 reflects good balance between groups.

Results

Of 12,774 patients admitted during this time, 411 (3.2%) elderly with a mean age of 77.75 ± 8.32 years met the inclusion criteria. Of this cohort, only 92 patients (22.4%) had pelvic fractures. Females outnumbered males (55 vs. 45%). Comparing characteristics of group I and group II using ASMDs, pelvic trauma patients were more likely to have higher systolic blood pressure (SBP), head injuries, lower extremity injuries, anticoagulant therapy, and cirrhosis. Fewer variables differed significantly after matching. We observed few instances of worse outcomes associated with pelvic trauma using PSM with and without covariate adjustment. Crude PSM without covariate adjustment, showed a significantly higher rate of deep vein thrombosis (DVT) for pelvic trauma (p < 0.001). Crude PSM also showed a significantly higher rate of ventilator-associated pneumonia (VAP) in group II (p = 0.006). PSM with covariate adjustment did not confirm differences on these outcomes. PSM both without and with covariate adjustment found lower ventilator days and ICU length of stay among patients with pelvic trauma. No significant differences were seen on 12 outcomes: death, acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), cardiac arrest with cardiopulmonary resuscitation (CPR), myocardial infarction (MI), pulmonary embolism (PE), unplanned intubation, unplanned admission to intensive care unit (ICU), catheter-associated urinary tract infection (CAUTI), and hospital length of stay.

Conclusions

At a Level I Trauma Center the additional burden of pelvic fractures in seriously injured elderly did not translate into higher mortality. PSM without covariate adjustment suggests worse rates among pelvic trauma patients for DVT and VAP but covariate adjustment removed statistical significance for both outcomes. Pelvic trauma patients had shorter time on ventilator and in the ICU. Whether similar analytic methods applied to patients from larger data sources would produce similar findings remains to be seen.

Detecting pelvic fracture on 3D-CT using deep convolutional neural networks with multi-orientated slab images

Pelvic fracture is one of the leading causes of death in the elderly, carrying a high risk of death within 1 year of fracture. This study proposes an automated method to detect pelvic fractures on 3-dimensional computed tomography (3D-CT). Deep convolutional neural networks (DCNNs) have been used for lesion detection on 2D and 3D medical images. However, training a DCNN directly using 3D images is complicated, computationally costly, and requires large amounts of training data. We propose a method that evaluates multiple, 2D, real-time object detection systems (YOLOv3 models) in parallel, in which each YOLOv3 model is trained using differently orientated 2D slab images reconstructed from 3D-CT. We assume that an appropriate reconstruction orientation would exist to optimally characterize image features of bone fractures on 3D-CT. Multiple YOLOv3 models in parallel detect 2D fracture candidates in different orientations simultaneously. The 3D fracture region is then obtained by integrating the 2D fracture candidates. The proposed method was validated in 93 subjects with bone fractures. Area under the curve (AUC) was 0.824, with 0.805 recall and 0.907 precision. The AUC with a single orientation was 0.652. This method was then applied to 112 subjects without bone fractures to evaluate over-detection. The proposed method successfully detected no bone fractures in all except 4 non-fracture subjects (96.4%).

An alphanumeric classification of osteoporotic pelvic ring injuries

INTRODUCTION

Classification and management of osteoporotic pelvic ring injuries (OPRI) continue to pose a considerable challenge to orthopaedic traumatologists. The currently used fragility fractures of the pelvis (FFP) classification of OPRI has recently been shown to have significant weaknesses. The aim of this study therefore was to propose a new, simple, yet comprehensive alphanumeric classification (ANC) of OPRI and to assess its intra- and interobserver reliability. Furthermore, its potential advantages over the FFP classification are discussed.

MATERIALS AND METHODS

One hundred consecutive CT scans from patients with OPRI were evaluated by three orthopaedic traumatologists with varying levels of experience and one musculoskeletal radiologist. Intra- and interobserver reliability of the proposed classification system was assessed using weighted kappa (κ) statistics and percentage agreement. In addition, the Fleiss' kappa statistic was computed to assess interobserver agreement among all four raters.

RESULTS

Overall intraobserver reliability of the proposed ANC was substantial [κ ranging from 0.71 to 0.80; percentage agreement: 70% (range, 67-76%)]. Overall interobserver reliability between pairs of raters was substantial as well [κ ranging from 0.61 to 0.68; percentage agreement: 58% (range, 53-61%)]. For ANC types, groups and subgroups, intra- and interobserver reliability were substantial to almost perfect. Interobserver agreement among all four raters was moderate to substantial, with Fleiss' kappa values of 0.48, 0.69, 0.71 and 0.52 for ANC overall, types, groups and subgroups, respectively.

CONCLUSION

The proposed ANC of OPRI demonstrated overall reliability comparable to that of the FFP classification. The ANC, however, is simple, more comprehensive, and consistently relates to injury severity.

Management of Pelvic Ring Injury Patients With Hemodynamic Instability

Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.

Severe Pelvic Fracture in the Elderly: High Morbidity, Mortality, and Resource Utilization

Severe pelvic fractures (PF) in the elderly are common and analysis of outcomes and resource utilization are lacking. Using the National Trauma Databank (2007-2016), 13 267 patients aged ≥65 years with severe PF (Abbreviated Injury Scale [AIS] pelvis ≥3; AIS 3 = 10 388; AIS 4 = 2124; AIS 5 = 805) were studied. Demographic data, management, resource utilization, complications, and mortality were analyzed for each group. Data are represented as % or median interquartile range (IQR). Multivariate logistic regression analyzed risk factors for mortality, Intensive Care Unit (ICU) admission, and ventilator use. Median age was 77, and most of them were females (59%). Falls occurred in 52%, motor vechicle crash in 21.5%, and pedestrian struck in 11.6%. Median injury severity score was 16 (IQR: 9,27). Shock on admission (9.4%) increased with injury severity. Glasgow Coma Scale < 8 occurred in 8%. Blood transfusion increased with injury severity (17%, 29%, and 51%). Angiography occurred in 9%, external fixation in 4%, internal fixation in 16%, and pelvic packing in 1%, the majority in the AIS 5 group. Overall, 46% required ICU admission and 30% underwent mechanical ventilation; median Hospital Length of Stay was 6 (IQR 4,11), ICU length of stay was 5 (IQR 2,10), and median ventilator days were 4 (IQR 1-11). Mortality rate was 13.3% (AIS 3 = 10%, AIS 4 = 19%, and AIS 5 = 44%).Severe PF in the elderly is associated with high resource utilization, complications, and mortality.

Morbidity and mortality following pelvic ramus fractures in an older Atlantic Canadian cohort

Background

Pelvic ramus fractures in older patients are associated with substantial morbidity and mortality. There is a paucity of literature on fractures of the pelvis in this age group. The purpose of this study was to report mortality rates following such injuries. In addition, we aimed to describe and quantify the important resultant morbidity in this vulnerable population.

Methods

We performed a retrospective chart review of all low-energy pelvic ramus fractures in patients more than age 60 years that occurred between January 2000 and December 2005. Data on survival, hospital length of stay, ambulatory status and place of residence were recorded. For comparison, we calculated the mortality rate for a surrogate age- and sex-matched group using Statistics Canada survival data for use as an uninjured control group.

Results

We identified 43 patients (32 women [74%]; mean age 79.4 yr) with isolated low-energy pelvic ramus fractures over the study period. The 1- and 5-year mortality rates were 16.3% (95% confidence interval [CI] 7.8%–30.3%) and 58.1% (95% CI 43.3%–71.6%), respectively, both significantly higher than the point estimates for the control group (6.6% and 31.3%, respectively). Following injury, 14/39 patients (36%) permanently required increased ambulatory aids, and 8 (20%) required a permanent increase in everyday level of care.

Conclusion

The results suggest that there may be increased mortality and morbidity following low-energy pattern pelvic ramus fractures in an older population compared to age- and sex-matched uninjured control subjects.

Emergency Orthogeriatrics: Concepts and Therapeutic Considerations for the Geriatric Patient

Appropriate recognition of the physiologic, psychological, and clinical differences among geriatric patients, with respect to orthopedic injury and disease, is paramount for all emergency medicine providers to ensure they are providing high-value care for this vulnerable population.

Loss of Ambulatory Independence Following Low-Energy Pelvic Ring Fractures

Introduction:

Lateral compression type 1 (LC1) pelvic ring fractures make up 63% of all pelvic ring injuries. This fracture pattern is typically seen in older patients. The purpose of this study is to assess the ambulatory status of individuals sustaining LC1 fractures at long-term follow-up and what specific characteristics, if any, effect this status or functional outcomes.

Methods:

Over a 2-year period, all pelvic ring injury at 2 hospitals within one academic institution was queried. One hundred sixty-one low-energy LC1 pelvic fractures were identified.

Results:

Fifty patients were available for long-term outcomes (mean: 36 months). Long-term functional outcomes (mean follow-up: 36 months) as measured by SMFA subgroup scores were demonstrated to be 3 times higher in patients currently using assistive devices for walking (P = .012). Increased age (P = .050) was associated with the continued use of assistive walking devices. Of the patients who did not use an ambulatory device prior to LC1 injury, 5 (11.6%) sustained a fall or medical complication within 30 days of the index pelvic fracture; this was associated with the current use of an assistive ambulatory device (P = .010). Forty-three (86%) patients didn’t use an assistive ambulatory device prior to sustaining the LC1 fracture. Seven (14%) patients utilized assistive devices both before and after the LC1 injury. Thirteen (26%) patients, who did not utilize assistive ambulatory devices prior to their injury, necessitated them at long-term follow-up.

Discussion:

Surgeons should be aware of these associations, as they can implement early interventions aimed at patients at risk, for assistive device use, following LC1 pelvic fractures.

Conclusion:

More than a quarter of the patients sustaining an LC1 pelvic fracture continue to use an aid for ambulation at long-term follow-up. Older age, complications, and falls within 30 days of this injury are associated with the utilization of an assistive ambulatory device.

Epidemiological study of major pelvic fracture in Hong Kong and analysis of predictors for mortality

Objectives and Background

Pelvic fracture causes significant mortality and morbidities. The purpose of this study is to identify the characteristics of patients with pelvic fracture in Hong Kong and to determine the factors predicting mortality. The result could help to identify high-risk patients who might benefit from more intensive evaluation and intervention.

Method:

Five hundred and eight patients (age > 12 years old) with pelvic fractures were identified from the trauma registries of four designated trauma centres in Hong Kong from 1 January 2005 to 31 December 2012. Patient baseline characteristics and outcomes were analysed. Stepwise logistic regression was performed to identify independent clinical predictors for mortality.

Result:

Mean age was 45.4 ± 19.2 years, 43.3% were female, mean length of hospital stay was 27.9 ± 42.4 days and mean length of intensive care unit stay was 4.8 ± 6.8 days. Injury severity score was 28.9 ± 18.7, revised trauma score was 7.2 ± 2 and 30-day mortality was 20.9%. Stepwise logistic regression identified patient’s age, presenting systolic blood pressure, initial Glasgow Coma Scale, injuries to the thoracic and abdominal regions, first base excess and the volume of red blood cell transfusion required within the first 6 h to be independent risk factors predicting mortality.

Conclusion:

Pelvic fracture is associated with significant risk of mortality in major trauma patients. Clinical characteristics obtained during emergency department resuscitation can help in selecting patients for timely aggressive interventions.

Autologous Transplantation of Press-fit Bone Cylinders in the Treatment of Pelvic Nonunion

The present study describes method for autologous bone transplantation to an area of nonunion at the pelvic ring in a way that ensures the best possible bone‐to‐bone interface (“press‐fit”) and provides optimal preconditions for the ingrowth of the bone graft. We modified a technique that has been used to transplant press‐fit bone‐baseplate‐cartilage cylinders for the repair of joint cartilage defects. The technique allows for precise harvesting of bone cylinders with a diamond‐coated and fluid‐cooled instrument. At the site where the graft shall be inserted, a cylindrical hole is created with a corresponding hollow diamond‐coated trephine. This ensures an optimal press‐fit implantation of the graft. The new surgical technique has been applied in four patients with nonunion of the pelvic ring. No intraoperative or postoperative complications occurred. In three patients, the procedure led to a reduction of pain and a higher level of mobility as well as a timely radiographic union (imaging not available for another patient). Our technique offers a valuable new treatment option for pelvic nonunion. The current article serves as a proof of concept. Future comparative studies will have to determine its value in detail.

Inter- and intraobserver reliability and critical analysis of the FFP classification of osteoporotic pelvic ring injuries

INTRODUCTION

The classification and management of osteoporotic pelvic ring injuries (OPRI) remain challenging. The fragility fractures of the pelvis (FFP) classification system proposed by Rommens and Hofmann constitutes the first comprehensive classification system of OPRI and may contribute to a more thorough assessment and grading of these injuries. The reliability of the FFP classification system, however, has not been evaluated yet. The purpose of this study therefore was to determine the inter- and intraobserver reliability of the FFP classification system and to critically analyse its strengths and weaknesses.

MATERIALS AND METHODS

One-hundred pelvic CT scans obtained from a consecutive series of patients aged 70 years and older who sustained a low-energy pelvic ring injury were included in this study. Three orthopaedic traumatologists of varying levels of experience (one experienced pelvic surgeon, one consultant, one resident) and one musculoskeletal radiologist independently classified each OPRI according to the FFP classification in two different sessions. Intra- and interobserver reliability were determined using percentage agreement and Cohen's Kappa coefficients.

RESULTS

The observed relative distribution of FFP fracture types was comparable to that reported in the original study by Rommens and Hofmann. Overall interobserver reliability for all 100 cases was moderate with Kappa values from 0.42 to 0.59 (mean percentage agreement: 61% (54%-68%)), while intraobserver reliability was substantial with Kappa values from 0.68 to 0.72 (mean percentage agreement: 77% (76%-78%)). Subgroup analysis revealed lowest reliability for the classification of Type IIc, IIIc and IVb injuries (32 cases). Within this subgroup of combined anterior and posterior OPRI involving a complete nondisplaced or displaced (uni- or bilateral) sacral fracture, Kappa values for interobserver reliability ranged from 0.10 to 0.52, while those for intraobserver reliability ranged from 0.29 to 0.66.

CONCLUSION

Overall interobserver reliability of the FFP classification system was moderate, while intraobserver reliability was substantial. Despite the acceptable overall reliability, classification of FFP subtypes involving a complete nondisplaced or displaced sacral fracture showed relatively poor reliability. The latter limits the usefulness of the FFP classification for both clinical and research purposes and needs to be addressed in future studies.

Dynamic Simulation of Biomechanical Behaviour of the Pelvis in the Lateral Impact Loads

The objective of this study was to develop and validate a novel 3D dynamic model of a pelvic side-impactor system. The biomechanical responses of a pelvic flexible model (having .mnf file suffix) under the lateral impact load for predicting the bone fracture mechanism are investigated as well. The 3D solid model of the side-impactor system was imported into MSC/ADAMS software for analyzing the dynamic model, and the pelvic flexible model was extracted from the CT images of a Chinese female volunteer. The flexible model of the pelvis system was developed considering a wide range of mechanical properties in the bone complex and soft tissue to achieve a realistic biomechanical response during a lateral impact. Good agreements were achieved between the dynamic simulations and the experimental results of pelvic side impacts, in terms of the biomechanical criteria. The dynamic model of impactor system could be employed to investigate the hip protector effectiveness, improving the vehicle safety, and biomechanical response of the other human organs.

Mortality After High-Energy Pelvic Fractures in Patients of Age 65 Years or Older

OBJECTIVES

To document in-hospital and 1-year mortality rates after high-energy pelvic fracture in patients 65 years of age or older as compared to a younger cohort.

DESIGN

Retrospective review.

SETTING

Urban Level 1 academic trauma center.

PATIENTS

Seventy consecutive patients 65 years of age and older treated for pelvic fracture resulting from high-energy mechanism from 2008 to 2011. A total of 140 patients 18-64 years of age were matched to the study population based on mechanism of injury and OTA Code 61 subtype for comparison.

INTERVENTION

Review of demographics, injury characteristics, hospital management, and mortality.

MAIN OUTCOME MEASUREMENTS

Mortality.

RESULTS

The overall inpatient mortality rate was 10%. The older cohort exhibited an inpatient mortality rate 3 times higher than the younger cohort (18.6% vs. 5.7%, P = 0.003). There was no difference in mortality 1 year post discharge (5.3% vs. 3.8%, P = 0.699). No significant differences in initial Glasgow Coma Scale or Injury Severity Score were identified (GCS 12.9 vs. 12.4, P = 0.363; ISS 24.7 vs. 23.4, P = 0.479). Multivariate analysis identified the Charlson Comorbidity Index (CCI) (P = 0.012) and Abbreviated Injury Scale (AIS)-chest (P = 0.005) as independent predictors of in-hospital mortality, and CCI (0.005) and AIS-abdomen (0.012) for 1-year mortality.

CONCLUSIONS

After controlling for mechanism of injury and pelvic fracture classification, we found that adults ≥65 and those with multiple comorbidities were more likely to die in the hospital than younger adults. However, mortality within 1-year postdischarge was low and did not differ between groups. This is in sharp contrast to the high rates of postdischarge mortality observed in elderly patients with a hip fracture.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcome Determinants of Patients with Traumatic Pelvic Fractures: A Cohort Study in a Level I Trauma Center in Southern Iran

Pelvic fracture is a result of devastating injuries and is usually encountered in conjunction with other life-threatening injuries. The aim of the current study was to determine the outcome determinants of patients with pelvic fractures referred to a large trauma center in southern Iran. This retrospective cross-sectional study was conducted in a level I trauma center over a period of three years from 2012 to 2015. We included all patients with pelvic fractures whose medical records had sufficient data. Data were compared between good condition and poor conditions. A total of 327 patients with mean age of 40.1 ± 19.7 years were included. Poor condition was defined as being associated with higher heart rate (p=0.002), lower systolic blood pressure (p<0.001), lower diastolic blood pressure (p=0.002) lower Glasgow Coma Scale (GCS) on admission (p<0.001) and higher Injury Severity Score (ISS) (p<0.001). Those with poor conditions had significantly higher admission to ICU (p<0.001), higher rate of surgical interventions (p<0.001) and higher mortality (p<0.001). The hospital length of stay (p<0.001) and ICU length of stay (p=0.025) were also longer in those with poor condition. Lower hemoglobin, lower pH, higher heart rate, lower systolic blood pressure, lower GCS on admission and higher ISS were important outcome determinants of traumatic pelvic fractures.

Pelvic fractures in the Netherlands: epidemiology, characteristics and risk factors for in-hospital mortality in the older and younger population

PURPOSE

To examine nationwide epidemiology of pelvic fractures in the Netherlands and to compare characteristics and outcome of older versus younger patients as well as predictors for in-hospital mortality.

METHODS

Retrospective review of pelvic fracture patients admitted to all Dutch hospitals (2008-2012) utilizing National Trauma Registry. Average annual incidence of (minor and major) pelvic fractures was calculated for the population. Older (≥ 65 years) and younger (< 65 years) patients were compared. Multivariate regression analysis was performed to identify independent predictors for in-hospital mortality.

RESULTS

Of 11,879 pelvic fracture patients (61.8%, ≥ 65 years), annual incidence of pelvic fractures in older versus younger population was 57.9 versus 6.4 per 100,000 persons. Older patients had lower ISS (7.1 (SD 6.9) vs 15.4 (SD 13.4)) and less frequently had severe associated injuries (15.6 vs 43.5%), an admission systolic blood pressure (SBP) ≤ 90 mmHg (1.6 vs 4.1%) or Glasgow Coma Score (GCS) ≤ 12 (2.0 vs 13.3%) (all, p < 0.01). In-hospital mortality was equal in older and younger patients (5.3 vs 4.8%: p = 0.28). In both subgroups, greatest independent predictors for in-hospital mortality were GCS ≤ 12, ISS ≥ 16, and SBP ≤ 90 mmHg and in all patients age ≥ 65 (OR 6.59 (5.12-8.48): p < 0.01).

CONCLUSION

The annual incidence of (both minor and major) pelvic fractures in the older population was substantially higher than in the younger population. Elderly patients had a disproportionately high in-hospital mortality rate considering they were less severely injured. Among other factors, age was the greatest independent predictor for in-hospital mortality in all pelvic fracture patients.

Advanced Imaging Lacks Clinical Utility in Treating Geriatric Pelvic Ring Injuries Caused by Low-Energy Trauma

OBJECTIVES

Is advanced imaging necessary in the evaluation of pelvic fractures caused by low-energy trauma in elderly patients?

DESIGN

Retrospective review.

SETTING

Single institution, Level 1 Trauma Center.

PATIENTS

Age ≥60 years old treated for low-energy traumatic pelvic ring injuries.

INTERVENTION

None.

MAIN OUTCOMES

Posterior pelvic ring injuries diagnosed on advanced imaging, radiographic displacement, admission status, hospital length of stay, change in weight-bearing status recommendations, and whether operative treatment was pursued.

RESULTS

Eighty-seven patients met the inclusion criteria, of which 42 had advanced imaging to evaluate the posterior pelvic ring (10 magnetic resonance imaging, 32 computed tomography). More posterior pelvic ring injuries were identified with advanced imaging compared with radiographs alone (P < 0.001). There was no statistically significant difference in rate of admission (P = 0.5) or hospital length of stay (P = 0.31) between patients with radiographs alone compared with patients evaluated with radiographs plus advanced imaging. The rate of displacement >1 cm at presentation and 6-week follow-up was unaffected by the presence of a posterior injury diagnosed on advanced imaging. Treatment for all 87 patients remained weight-bearing as tolerated with assist device irrespective of advanced imaging findings, and no patient underwent surgical intervention by 12-week follow-up.

CONCLUSIONS

Despite frequent identification of posterior pelvic ring injuries in patients evaluated with advanced imaging, admission status, length of hospital stay, radiographic displacement, and treatment recommendations were unaffected by these findings. The use of advanced imaging in elderly patients with low-energy traumatic pelvic ring fractures may not be necessary.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Geriatric Trauma

Within the next 15 years, 1 in 5 Americans will be over age 65. $34 billion will be spent yearly on trauma care of this age group. This section covers situations in trauma unique to the geriatric population, who are often under-triaged and have significant injuries underestimated. Topics covered include age-related pathophysiological changes, underlying existing medical conditions and certain daily medications that increase the risk of serious injury in elderly trauma patients. Diagnostic evaluation of this group requires liberal testing, imaging, and a multidisciplinary team approach. Topics germane to geriatric trauma including hypothermia, elder abuse, and depression and suicide are also covered.

Genitourinary trauma in geriatric patients

PURPOSE OF REVIEW

The geriatric population is the fastest growing segment of the population, and geriatric trauma patients are increasingly common. Caring for this population has unique challenges. The goal of the review is to identify factors that may help in the care of geriatric patients suffering from genitourinary trauma.

RECENT FINDINGS

Multiple factors lead to inferior outcomes in patients with geriatric trauma including failure to rescue, treatment in lower volume trauma centers, and undertriage of geriatric patients. Improvement in geriatric trauma outcomes occurs with the use of dedicated geriatric consult teams. The surgical management of genitourinary injuries in the geriatric population remains unchanged.

SUMMARY

Interventions for geriatric patients differ from younger populations. Direct changes in overall management of the geriatric population lead to improved outcomes. The treatment of geriatric trauma patients with genitourinary injuries is similar to a younger cohort. The lack of recent studies in clinical outcomes in this population has been identified as a gap in knowledge that will require future research to answer.

Clinical presentation of geriatric polytrauma patients with severe pelvic fractures: comparison with younger adult patients

BACKGROUND

Elderly polytrauma patients with pelvic fractures are at higher risk than young adults for severe medical outcomes and/or death in the early post-trauma phase. The aim of our study was to identify predictive factors of medical severity among geriatric polytrauma patients.

METHODS

We conducted a retrospective cross-sectional study of polytrauma patients treated at our center, who had a pelvic fracture and at least two other injuries with an abbreviated injury score ≥3. Our study group included 15 geriatric (mean age, 65 years) and 13 young (mean age, 39 years) adults. Factors related to medical status on admission were compared between the groups to identify those predictive of a severe medical outcome, defined by massive transfusion (>10 units of red blood cells) within the first 24 h of admission and/or death.

RESULTS

Groups were comparable in terms of injury severity score (mean, 29), systolic blood pressure, heart rate, shock index, hemoglobin level, the prothrombin time-to-international normalized ratio (PT-INR) and base deficit. Over two-third of geriatric patients required a massive transfusion, with two patients dying, compared with the death of one young patient. Among geriatric patients, predictors of a severe medical outcome were extravasation of contrast medium on computed tomography, a hemoglobin level <11 g/dl, a PT-INR >1.1 and a base deficit >2 mmol/l.

CONCLUSIONS

Even with our aggressive treatment algorism of pelvic fractures, particularly for the elderly, most of the geriatric polytrauma patients with severe pelvic fractures were at a high risk of massive transfusion. Extravasation on enhanced computed tomography and abnormal levels of select blood serum markers could assist in the early identification of geriatric polytrauma patients at risk for a severe medical outcome.

INFIX/EXFIX: Massive Open Pelvic Injuries and Review of the Literature

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.

A Nationwide Analysis of Pelvic Ring Fractures: Incidence and Trends in Treatment, Length of Stay, and Mortality

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.

Patients with pelvic fractures from blunt trauma. What is the cause of mortality and when?

BACKGROUND

Mortality in patients sustaining pelvic fractures has been reported to be 4% to 15%. We sought to investigate the cause of death based on timing and evaluate if type of fracture and Injury Severity Score have an influence on the survival time.

METHODS

Sixty-nine patients of eight hundred sixty seven with a pelvic fracture who died during their hospital admission were included. Fractures were classified using the Arbeitsgemeinschaft Osteosynthesefragen/Orthopaedic Trauma Association system. Cause determined by autopsy in 48/69.

RESULTS

The leading cause of death within 6 hours was abdominal and pelvic hemorrhage; 6 to 24 hours head injury, and greater than 24 hours multiple organ dysfunction syndrome. Survival time did not correlate between fracture type (P < .12) or Injury Severity Score. Only 2 patients died of isolated pelvic hemorrhage.

CONCLUSIONS

Despite the advances made in acute management of the traumatized patient in the emergency department, mortality is unavoidable in a small group of patients with hemorrhage being the commonest cause of early death but isolated pelvic hemorrhage rare.

Predictors of mortality among initially stable adult pelvic trauma patients in the US: Data analysis from the National Trauma Data Bank

OBJECTIVES

Pelvic fractures are associated with increased risk of death among trauma patients. Studies show independent risks predicting mortality among patients with pelvic fractures vary across different geographic regions. This study analyses national data to determine predictors of mortality in initially stable adult pelvic trauma patients in the US.

METHODS

This study is a retrospective analysis of the US National Trauma Data Bank from January 2003 to December 2010 among trauma patients ≥18 years of age with pelvic fractures (including acetabulum). Over 150 variables were reviewed and analysed. The primary outcome was all-cause in-hospital mortality. Logistic regression analysis was used to determine independent risk factors predictive of in-hospital mortality in stable pelvic fracture patients.

RESULTS

30,800 patients were included in the final analysis. Overall in-hospital mortality rate was 2.7%. Mortality increased twofold in middle aged patients (age 55-70), and increased nearly fourfold in patients with advanced age ≥70. We found patients with advanced age, higher severity of injury, Glasgow Coma Scale (GCS) <8, GCS between 9 and 12, prolonged mechanical ventilation, and/or in-hospital blood product administration experienced higher mortality. Patients transported to level 1 or level 2 trauma centres experienced lower mortality while concomitantly experiencing higher associated internal injuries.

CONCLUSIONS

Geriatric and middle aged pelvic fracture patients experience higher mortality. Predictors of mortality in initially stable pelvic fracture patients are advanced age, injury severity, mental status, prolonged mechanical ventilation, and/or in-hospital blood product administration. These patients might benefit from transport to local level 1 or level 2 trauma centres.

Clinical conundrums and challenges during geriatric orthopedic emergency surgeries

Despite so many advancements and innovations in anesthetic techniques, expectations and challenges have also grown in plenty. Cardiac, pediatric, obstetric and neuro-anesthesia have perfectly developed to fulfill the desired needs of respective patient population. However, geriatric anesthesia has been shown a lesser interest in teaching and clinical practices over the years as compared with other anesthetic sub-specialties. The large growing geriatric population globally is also associated with an increase number of elderly patients presenting for orthopedic emergency surgeries. Orthopedic emergency surgery in geriatric population is not only a daunting clinical challenge but also has numerous socio-behavioral and economic ramifications. Decision making in anesthesia is largely influenced by the presence of co-morbidities, neuro-cognitive functions and the current socio-behavioral status. Pre-anesthetic evaluation and optimization are extremely important for a better surgical outcome but is limited by time constraints during emergency surgery. The current review aims to highlight comprehensively the various clinical, social, behavioral and psychological aspects during pre-anesthetic evaluation associated with emergency orthopedic surgery in geriatric population.

Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques

BACKGROUND

Emergency devices for pelvic ring stabilization include circumferential sheets, pelvic binders, and c-clamps. Our knowledge of the outcome of these techniques is currently based on limited information.

METHODS

Using the dataset of the German Pelvic Trauma Registry, demographic and injury-associated characteristics as well as the outcome of pelvic fracture patients after sheet, binder, and c-clamp treatment was compared. Outcome parameters included transfusion requirement of packed red blood cells, length of hospital stay, mortality, and incidence of lethal pelvic bleeding.

RESULTS

Two hundred seven of 6137 (3.4%) patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets, binders, or c-clamps. In most cases, c-clamps (69%) were used, followed by sheets (16%), and binders (15%). The median age was significantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs. 47 vs. 42 years, p=0.01). Sheet wrapping was associated with a significantly higher incidence of lethal pelvic bleeding compared to binder or c-clamp stabilization (23% vs. 4% vs. 8%). No significant differences between the study groups were found in sex, fracture type, blood haemoglobin concentration, arterial blood pressure, Injury Severity Score, the incidence of additional pelvic packing and arterial embolization, need of red blood cell transfusion, length of hospitalisation, and mortality.

CONCLUSIONS

The data suggest that emergency stabilization of the pelvic ring by binders and c-clamps is associated with a lower incidence of lethal pelvic bleeding compared to sheet wrapping.

LEVEL OF EVIDENCE

Level III.

Pelvic trauma: What are the predictors of mortality and cardiac, venous thrombo-embolic and infectious complications following injury?

INTRODUCTION

This study sought to determine risk factors that influence mortality, cardiac events, venous thrombo-embolic disease (VTED), and infection following fractures of the pelvis and/or acetabulum.

METHODS

The 2008 National Sample Program (NSP) of the National Trauma Databank was queried to identify all patients who sustained pelvic and acetabular fractures. Demographic data, injury-specific and surgical characteristics, and medical co-morbidities were abstracted. The occurrence of in-hospital mortality, cardiac events, VTED and infections were documented. Univariate testing, weighted logistic regression, and sensitivity analyses were performed to identify significant independent predictors of mortality and the complications under study.

RESULTS

The NSP contained 41,297 cases of pelvic trauma. In-hospital mortality was documented in 3055 (7%) and one or more complications occurred in 6932 (17%). Cardiac events transpired in 2% of patients, VTED in 4% and infections in 3%. Increasing age, shock, time to procedure, ISS, and GCS were predictive of mortality. Cardiac events were found to be influenced by obesity, diabetes, ISS, GCS, age, and trauma mechanism. VTED was impacted by obesity, history of respiratory disease, male sex, ISS, GCS, medical co-morbidities, and time to procedure. Injuries caused by mechanisms other than blunt trauma, shock, age, ISS, GCS, medical co-morbidities, and time to procedure were associated with infection.

CONCLUSIONS

Several important predictors were identified for specific complications and mortality following pelvic trauma. The design of this study may render it more generalisable to American patients with pelvic injuries.

LEVEL OF EVIDENCE

II - Prognostic retrospective study of a prospective dataset.

What are predictors for patients' quality of life after pelvic ring fractures?

BACKGROUND

Data from literature on predictors for patients' quality of life after pelvic ring fractures are conflicting and based on small study populations.

QUESTIONS/PURPOSES

We therefore evaluated predictors for health-related quality of life in patients with pelvic ring injuries at a minimum of 1 year postfracture.

METHODS

We surveyed 172 patients of the German Pelvic Trauma Registry admitted to four medical centers between February 3, 2004, and May 11, 2011. The median age of the followup cohort was 47 years (range, 8-88 years); 69 of 172 (40%) patients were female. Patients were characterized by a median Injury Severity Score of 17. There were 31 Tile Type A fractures (18%), 77 Type B fractures (45%), and 64 Type C fractures (37%). The incidence of complex fractures and multiple traumas was 34 of 172 (20%) and 116 of 172 (67%), respectively. One hundred twenty-five (73%) patients were treated operatively. We obtained the EQ-5D™ score to assess patients' health-related quality of life. For the analysis of predictors for quality of life, a multivariate linear regression model was built. The median followup was 3 years (range, 1-6 years).

RESULTS

The median EQ-5D™ score was 0.78 (interquartile limits, 0.63 and 1.00). Age, complex trauma, and surgery independently predicted the EQ-5D™ score.

CONCLUSIONS

We conclude patients with higher age, complex trauma, and surgery had a higher likelihood for a reduced quality of life after pelvic ring injuries.

Trauma in the older adult: epidemiology and evolving geriatric trauma principles

The older adult patient with trauma is becoming a growing part of the overall trauma population. With the world population increasing in age, the rate of the traumatically injured older adult will continue to increase. Recognizing this problem and the fact that the elderly are at higher risk for injury and its complications will be necessary if the increasing volume of patients is to be dealt with. This review discusses these issues, as well as appropriate triage and treatment of injuries and associated comorbidities. Early recognition of injury, even minor, and expedited care using specialized teams will help to improve outcomes for these patients.

Direct transport of geriatric trauma patients with pelvic fractures to a Level I trauma center within an organized trauma system: impact on two-week incidence of in-hospital complications

BACKGROUND

Undertriage of elderly trauma patients to tertiary trauma centers is well documented. This study evaluated the impact of directness of transport to a Level I trauma center on morbidity in geriatric trauma patients sustaining severe pelvic fractures.

METHODS

This was a retrospective cohort study of 87 geriatric trauma patients diagnosed with potentially unstable pelvic fractures, treated at a Level I trauma center between 2008 and 2010.

RESULTS

Of the 87 patients, 39% (34 of 87) initially were transported to a nontertiary trauma center. After adjusting for presence of comorbidity and injury severity, the 2-week incidence of complications was 54% higher in transferred patients compared with those directly transported (rate ratio, 1.54; 95% confidence interval, .95-2.54). In particular, transferred patients had increased odds of developing pneumonia/systemic inflammatory response syndrome.

CONCLUSIONS

Despite lacking precision, results of this study suggest an increased risk of complications in transferred geriatric trauma patients with severe pelvic fractures compared with their directly transported counterparts.

What are predictors of mortality in patients with pelvic fractures?

BACKGROUND

Our knowledge of factors influencing mortality of patients with pelvic ring injuries and the impact of associated injuries is currently based on limited information.

QUESTIONS/PURPOSES

We identified the (1) causes and time of death, (2) demography, and (3) pattern and severity of injuries in patients with pelvic ring fractures who did not survive.

METHODS

We prospectively collected data on 5340 patients listed in the German Pelvic Trauma Registry between April 30, 2004 and July 29, 2011; 3034 of 5340 (57%) patients were female. Demographic data and parameters indicating the type and severity of injury were recorded for patients who died in hospital (nonsurvivors) and compared with data of patients who survived (survivors). The median followup was 13 days (range, 0-1117 days).

RESULTS

A total of 238 (4%) patients died a median of 2 days after trauma. The main cause of death was massive bleeding (34%), predominantly from the pelvic region (62% of all patients who died because of massive bleeding). Fifty-six percent of nonsurvivors and 43% of survivors were male. Nonsurvivors were characterized by a higher incidence of complex pelvic injuries (32% versus 8%), less isolated pelvic ring fractures (13% versus 49%), lower initial blood hemoglobin concentration (6.7 ± 2.9 versus 9.8 ± 3.0 g/dL) and systolic arterial blood pressure (77 ± 27 versus 106 ± 24 mmHg), and higher injury severity score (ISS) (35 ± 16 versus 15 ± 12).

CONCLUSION

Patients with pelvic fractures who did not survive were characterized by male gender, severe multiple trauma, and major hemorrhage.

LEVEL OF EVIDENCE

Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Survivorship and severe complications are worse for octogenarians and elderly patients with pelvis fractures as compared to adults: data from the national trauma data bank

Purpose. This study examined whether octogenarians and elderly patients with pelvic fractures have a different risk of complication and mortality as compared to adults. Methods. Data was gathered from the National Trauma Data Bank from 2002 to 2006. There were 32,660 patients 18-65, 6,408 patients 65-79, and 5,647 patients ≥ 80 years old with pelvic fractures. Descriptive statistics and bivariate and multivariate analyses were performed with the adult population as a referent. Results. Multivariate analysis showed 4.7-fold higher odds of death and 4.57 odds of complications in the octogenarian group after a pelvic fracture compared to adults. The elderly had 1.81-fold higher odds of death and 2.18-fold higher odds of severe complications after sustaining a severe pelvic fracture relative to adults. An ISS ≥ 16 yielded 15.1-fold increased odds of mortality and 18.3-fold higher odds of severe complications. Hypovolemic shock had 7.65-fold increased odds of death and 6.31-fold higher odds of severe complications. Between the ages of 18 and 89 years, there is approximately a 1% decrease in survivorship every 10 years. Conclusions. This study illustrates that patients older than 80 years old with pelvis fractures have a higher mortality and complications rate than elderly or adult patients.

Work-Related Injuries: Injury Characteristics, Survival, and Age Effect

Work-related injuries impose a significant burden on society. The goal of this study was to delineate the epidemiology and the effect of age on type and mortality after occupational injuries. Patients 16 years of age or older sustaining work-related injuries were identified from the National Trauma Databank 12.0. The study population was stratified into four age groups: 16 to 35, 36 to 55, 56 to 65, and older than 65 years old. The demographic characteristics, type of injury, mechanism of injury, setting of injury, use of alcohol or other illicit drugs, and mortality were analyzed and related to age strata. Overall 67,658 patients were identified. There were 27,125 (40.1%) patients in the age group 16 to 35 years, 30,090 (44.5%) in the group 36 to 55 years, 6,618 (9.8%) in the group 56 to 65 years, and 3,825 (5.7%) older than 65 years. The injury severity increased significantly with age. Elderly patients were significantly more likely to sustain intracranial hemorrhages, spinal, and other skeletal injuries. The overall mortality was 2.9 per cent (1938) with the latter increasing significantly in a stepwise fashion with progressing age, becoming sixfold higher in patients older than 65 years (OR, 6.18; 95% CI, 4.78 to 7.80; P < 0.001). Our examination illustrates the associations between occupational injury and significant mortality that warrant intervention for mortality reduction. There is a stepwise-adjusted increase in mortality with progressing age.

Low-energy osteoporotic pelvic fractures

The vast majority of pelvic fractures in geriatric patients are classified as stable injuries. The current treatment strategies of these fractures involve pain management and mobilization. Pain-related immobility may pose a serious hazard to patients with severe preexisting comorbidities. There is paucity of literature on the outcome and mortality after osteoporotic pelvic fractures in the elderly. This review aims to provide an overview of epidemiology, injury mechanism, fracture patterns, management and outcome after osteoporotic pelvic fractures.

Patients with pelvic fracture: what factors are associated with mortality?

BACKGROUND

Pelvic fracture is one of the major injuries that lead to death in patients who sustain high-impact injuries such as road traffic accidents and falls from height.

AIMS

This study aims to look at the epidemiology and the significant predictors of mortality in victims with pelvic fracture presenting to the emergency department (ED) of an urban Asian city.

METHODS

This was a retrospective data analysis of all trauma patients with pelvic fracture who were treated at the ED of an urban adult hospital in Singapore from April 2001 to December 2004. Student's t-test and χ(2) test were used in statistical analysis where appropriate.

RESULTS

The study included 179 consecutive patients. Sixty-four percent of patients were males, and 71% of patients were in the 20-49-year-old age group. Road traffic accidents and falls from height were the two most common mechanisms of injury. Mortality rate was 37%. Pelvic fracture severity, shock and coma at presentation, and the presence of concurrent head and chest injuries were associated with increased mortality. Gender, other mechanisms of injury and other concomitant injuries were not associated with increased mortality.

CONCLUSIONS

The mortality rate of trauma patients with pelvic fracture continues to be high. In such patients, predictors of mortality are the severity of the pelvic fracture, the presence of coma, shock, and head and chest injuries.

Fractures of the pubic rami: a retrospective review of 534 cases

INTRODUCTION

Fractures of the pubic rami are typically classified as stable injuries. The current treatment strategies involve pain management and mobilization. However, pain-dependent immobilization may pose a serious hazard to patients with severe preexisting co-morbidities. There is paucity of literature on the outcome and mortality of these patients.

METHODS

We retrospectively analysed 534 patients with these injuries. The following parameters were examined: gender, age, mechanism of injury, fracture pattern, length of hospital stay, care after discharge, number of outpatient follow-ups, and 1-year mortality. Multiple logistic regression analysis was performed for the assessment of factors influencing 1-year mortality.

RESULTS

The observed 1-year mortality in the patients group was further compared to a virtual control group with the same age and gender distribution. Women were older and more frequently injured as a result of a simple fall. Age was the only factor to be predictive of 1-year mortality. Mortality increased with higher age in both the patient and the control group, but mortality was higher in the patients group in all age groups. This difference was significant for patients > or =90 years of age. Pubic rami fractures are a heterogeneous cohort of injuries and might not be as benign as thought in patients with severe preexisting co-morbidities.

CONCLUSION

Prospective studies are needed to better gauge the outcome after pubic rami fractures.

The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients

BACKGROUND

The understanding of the mortality risk posed by pelvic fracture is incomplete. The purposes of this study were (1) to compare the mortality risk associated with a pelvic fracture with the risk conferred by other injuries and (2) to determine if the association of a pelvic fracture with mortality varies when combined with other known risk factors.

METHODS

Trauma registry records from two level-I trauma centers were examined. Regression analysis was done on 63,033 patients to assess the odds ratio for mortality associated with pelvic fracture compared with other variables such as age, shock, head injury, abdominal or chest injury, and extremity injury. A second analysis was carried out to determine if the impact of a pelvic fracture on mortality varied when combined with other known risk factors for mortality.

RESULTS

Logistic regression analysis demonstrated that pelvic fracture was significantly associated with mortality (p < 0.001). The odds ratio for mortality associated with a pelvic fracture (approximately 2) was similar to that posed by an abdominal injury. Hemodynamic shock, severe head injury, and an age of sixty years or more all had an odds ratio for mortality greater than that associated with pelvic fracture.

CONCLUSIONS

For the majority of trauma patients, pelvic fracture is significantly associated with a greater risk of mortality. However, pelvic fracture is one variable among many that contribute to mortality risk, and it must be considered in relation to these other variables.

Elderly Patients with Pelvic Fracture: Interventions and Outcomes

We examined the outcome of elderly trauma patients with pelvic fractures. Patients 65 years of age and older (elderly) with pelvic fractures were retrospectively compared with patients younger than 65 years with pelvic fractures and also with elderly patients without fracture. Over the study period, 1223 patients sustained a pelvic fracture (younger than 65 years, n = 1066, 87.2%; elderly, n = 157,12.8%). These patients were also compared with 1770 elderly patients with blunt trauma without fracture. Although the pelvic fracture patients were equally matched for Injury Severity Score (21.2 ± 13.4 nonelderly vs 20.5 ± 13.6 elderly), hospital length of stay was increased in the elderly (12.5 ± 13.1 days vs 11.5 ± 14.1 days) and they had a higher mortality rate (20.4% [32 of 157] vs 8.3% 88 of 1066]). The elderly without fracture also had a higher mortality rate when compared with the younger patients (10.9% [191 of 1760]; P < 0.03). The elderly were more likely to die from multisystem organ failure (25.0% [eight of 32] vs 10.2% [nine of 88]), whereas the nonelderly group was more likely to die from exsanguination (45.5% [40 of 88] younger than 65 years vs 21.9% [seven of 32] 65 years or older; P < 0.05). Elderly patients with pelvic fracture have worse outcomes than their younger counterparts despite aggressive management at a Level I trauma center.

Pelvic Fracture Risk Assessment on Admission

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.

Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective

BACKGROUND

We wished to determine the characteristics of patients with pelvic ring fractures (PGs) in England and Wales, make comparisons to major trauma patients without pelvic injury (NPGs), and determine factors predicting mortality, including the impact of presence of pelvic reconstruction facilities in the receiving hospitals on outcome.

METHODS

Prospective data from 106 trauma receiving hospitals forming the Trauma Audit and Research Network were studied. Between January 1989 and December 2001 data of 159,746 trauma patients were collected in the Trauma Audit and Research Network database. Because of incomplete data, 1,610 pelvic fracture patients and 13,499 patients without pelvic fracture were excluded from detailed analysis. In total, 11,149 patients in the PG and the remaining 133,486 patients in the NPG (control) group were included in the final analysis.

RESULTS

There were statistically significantly more patients with an Injury Severity Score >15 in the PG group (n = 3,576; 32.1%) than in NPG group (n = 19,238; 14.4%) (p < 0.001), indicating that pelvic injuries were more often associated with other injuries. The majority of patients sustained Abbreviated Injury Score (AIS) 2 pelvic injuries (65.0%), whereas AIS 4 and 5 injuries were found in less than 10% of patients. Pelvic ring injuries were most commonly associated with chest trauma with >AIS 2 severity in 21.2% of the patients, head injuries (>AIS 2) in 16.9%, liver or spleen injuries in 8.0%, and two or more long bone fractures in 7.8%. The 3-month cumulative mortality rate of the patients with pelvic injuries was 14.2% (1,586 patients) versus 5.6% (7,465 patients) of the NPG group.

CONCLUSION

Age, early physiologic derangement, and presence of other injuries (head or trunk) were associated with reduced survival rates. When the expertise to deal with such a group of patients is not available, early transfer under safe conditions should be considered to improve survival rates.

[Severe pelvic fractures, associated injuries and hemodynamic instability: incidence, management and outcome in our center]

INTRODUCTION

The aim of this study was to review the incidence, treatment and outcome of severe pelvic fractures, as well as associated injuries, in our center.

PATIENTS AND METHOD

We performed a retrospective study of patients included in our trauma registry between June 1993 and January 2005. Pelvic fractures were classified according to the system proposed by Tile. Clinical and demographic data such as age, gender, mechanism of injury, transfer time, hemodynamic status, and trauma scores were compared and analyzed statistically. Shock was defined as a systolic blood pressure of < or = 90 mmHg during the primary assessment. Mortality and associated risk factors were analyzed, with emphasis on patients in shock on admission.

RESULTS

Of 1274 patients with severe trauma admitted during the study period, 192 (15%) had pelvic fracture. Only 6.7% were isolated fractures and 6% were open fractures. Twenty percent of the patients were in shock on admission. The mean Injury Severity Score of the series was 28.5 +/- 14 and that of patients in shock was 38 +/- 16. The most frequently associated injuries were thoracic (70%), abdominal (55%), long bone fractures (52%), and head injuries (40%). Twenty-three percent of the patients had retroperitoneal hematoma. Arteriograms were performed in 16 patients, with four embolizations. Eight patients underwent external orthopedic fixation, and none posterior orthopedic fixation. Five patients underwent pelvic packing and two patients underwent ligation of hypogastric arteries. Overall mortality was 30% and mortality in patients in shock was 61%. Predictors of mortality were shock on admission, a Glasgow Coma Scale score of < or = 8, ISS > 25 and age > 55 years.

CONCLUSIONS

Patients in shock with pelvic fractures have a poor prognosis in our center, frequently related to the severity of associated injuries, the relative rarity of these fractures, and the lack of a clearly defined management protocol. The main cause of death was massive hemorrhage.