Pelvic trauma in rapidly fatal motor vehicle accidents

Prevalence of Psychiatric Morbidity and Stress Burden among Patients with Limb Fracture

Background

To assess the prevalence of psychiatric morbidity and stress burden among the patients with limb fractures and compare them with age and gender matched control group.

Materials and Methods

The cross-sectional study was conducted on 25 patients each of lower and upper limb fractures, presenting 2 weeks or more after the fracture to orthopedics OPD of Dayanand Medical College and Hospital. Psychiatric manifestations and stress burden were assessed using Mini International Neuropsychiatric Interview (M.I.N.I.), perceived stress scale (PSS), and impact of event scale-revised (IES-R) on the patients. It was compared to an equal number of age and gender matched normal control group.

Results

Majority of the patients with limb fractures were male (70%). The upper limb fracture was in age group of 18-30 years (52%), and those with lower limb fracture were >50 years of age (48%). Most common psychiatric morbidity seen in patients was major depressive disorder (52%) which was statistically significant in comparison with control group. The impact of trauma on patients resulted in avoidance and hyperarousal symptoms significantly in lower limb fracture patients than upper limb ones (P < 0.05).

Conclusions

The long bone injuries in patient cause significant psychiatric morbidity which increases the stress burden in such patients due to immobility and pain.

Bladder deformity accompanied by pelvic fracture indirectly indicates clinical severity

BACKGROUND

That the bladder can be compressed by extraperitoneal hematoma induced by obstetrics and gynecologic diseases, is well known. However, there have been no reports on the clinical significance of compressed bladder induced by pelvic fracture (PF). We therefore retrospectively investigated the clinical features of compressed bladder induced by the PF.

METHODS

From January 2018 to December 2021, we performed a retrospective review of the hospital medical charts of all emergency outpatients who were treated by emergency physicians at the department of acute critical care medicine in our hospital, and who were diagnosed with PF based on computed tomography (CT) on arrival. The subjects were divided into two groups: the Deformity group, in which the bladder was compressed by extraperitoneal hematoma, and the Normal group. Variables were compared between the two groups.

RESULTS

During the investigation period, 147 patients with PF were enrolled as subjects. There were 44 patients in the Deformity group and 103 in the Normal group. There were no significant differences between the two groups with regard to sex, age, GCS, heart rate or final outcome. However, the average systolic blood pressure in the Deformity group was significantly lower, and the average respiratory rate, injury severity score, rate of unstable circulation, rate of transfusion and duration of hospitalization in the Deformity group were significantly greater in comparison to the Normal group.

CONCLUSIONS

The present study showed that bladder deformity induced by PF tended to be a poor physiological sign that was associated with severe anatomical abnormality, unstable circulation requiring transfusion, and long hospitalization. Accordingly, physicians should evaluate shape of bladder when treating PF.

Fuel tank injury in a fatal motorcycle accident

Vehicular trauma is the most common cause of pelvic fractures. In motorcycle collisions, the driver strikes or is struck by a fixed object, and is subjected to blunt trauma and deceleration forces. Injuries around the scrotum and perineum of victims in motorcycle accidents are known as a fuel tank injuries (FTI). We report the case of a 26-year-old male motorcyclist involved in a fatal high-speed head-on collision with a car. At autopsy, purple bruising distributed symmetrically over both hips with scrotal lacerations were found. Partial bowel evisceration through an abdominal lacerated wound, extensive abdominal organ injuries and multiple fractures were also found. Considering the dynamics of the accident and the type of motorcycle he had been riding, the pelvic bruising and the scrotal injury were related to violent deceleration following the impact, leading the driver to slide forward against the fuel tank of the motorcycle.FTI is comparatively rare in motorcycle accidents because it only occurs in cases involving a head-on collision, and most drivers try to swerve or correct their direction just prior to the collision. Nevertheless, the most frequent cause of pelvic injuries in motorcyclists is caused by contact with the vehicles fuel tank during the crash. Forensic pathologists should have a better knowledge of FTIs as they are helpful in understand the dynamics of the accident and in distinguishing the driver from the passenger in two-rider motorcycle crashes.

Association between 3D Printing-Assisted Pelvic or Acetabular Fracture Surgery and the Length of Hospital Stay in Nongeriatric Male Adults

Pelvic and acetabular fractures are challenging for orthopedic surgeons, but 3D printing has many benefits in treating these fractures and has been applied worldwide. This study aimed to determine whether 3D printing can shorten the length of hospital stay (LHS) in nongeriatric male adult patients with these fractures. This is a single-center retrospective study of 167 nongeriatric male adult participants from August 2009 to December 2021. Participants were divided into two groups based on whether they received 3D printing assistance. Subgroup analyses were performed. Pearson’s correlation and multivariable linear regression models were used to analyze the LHS and the parameters. Results showed that 3D printing-assisted surgery did not affect LHS in the analyzed patients. The LHS was positively correlated with the Injury Severity Score (ISS). Initial hemoglobin levels were negatively associated with LHS in patients aged 18−40 and non-major trauma (ISS < 16) patients. In 40−60-year-old and non-major trauma patients, the duration from fracture to admission was significantly associated with LHS. This study indicates that 3D-assisted technology for pelvic or acetabular fracture surgery for nongeriatric male adults does not influence the LHS. More importantly, the initial evaluation of patients in the hospital was the main predictor of the LHS.

Fatal Motor Vehicle-Pedestrian Collision Injury Patterns-A Systematic Literature Review

INTRODUCTION

Injury patterns in pedestrians struck by motor vehicles were described in medical literature first published almost a half century ago. "Classical" triads of injury distribution were described for adults (skull-pelvis-extremity) and subsequently applied to children (head-hip or pelvis-distal femur/knee joint). Notably, these classical triads were derived from two publications reporting clinical observations of only 11 patients, all of whom were adults.

METHODS

A systematic literature review was conducted using Medline, CINAHL, EMBASE, and Cochrane to determine the evidence-base for motor vehicle collision (MVC)-pedestrian injury "triads" and other trauma patterns described for pedestrians in the adult and pediatric age groups.

RESULTS

Of the 1540 full-text articles identified in the review, 56 articles published in English met the inclusion criteria, that is, motor vehicle-pedestrian collision resulting in specific, fatal injuries determined by postmortem examinations. There were variations in injury patterns that differed from the "classical" triads. These differences likely stem from advances in vehicle design and safety features which have affected the nature and distribution of injuries.

DISCUSSION

Further research on the correlation of specific injuries sustained by pedestrians of different ages with various types of vehicles and impacts are needed to assess the validity of previously observed injury patterns in relation to the current motor vehicle fleet. Delineation of injury patterns can assist health care teams in trauma management. Vehicle manufacturers and government regulators can better assess whether the introduction of advanced driver assistance features designed to protect pedestrians when struck will be effective in reducing severe injuries. In forensic pathology practice, knowledge of pedestrian injury patterns based on data representative of impacts involving modern vehicles can provide MVC death investigators the means to determine MVC dynamics and pedestrian kinematics.

Patterns, management, and outcomes of traumatic pelvic fracture: insights from a multicenter study

Background

Traumatic pelvic fracture (TPF) is a significant injury that results from high energy impact and has a high morbidity and mortality.

Purpose

We aimed to describe the epidemiology, incidence, patterns, management, and outcomes of TPF in multinational level 1 trauma centers.

Methods

We conducted a retrospective analysis of all patients with TPF between 2010 and 2016 at two trauma centers in Qatar and Germany.

Results

A total of 2112 patients presented with traumatic pelvic injuries, of which 1814 (85.9%) sustained TPF, males dominated (76.5%) with a mean age of 41 ± 21 years. In unstable pelvic fracture, the frequent mechanism of injury was motor vehicle crash (41%) followed by falls (35%) and pedestrian hit by vehicle (24%). Apart from both extremities, the chest (37.3%) was the most commonly associated injured region. The mean injury severity score (ISS) of 16.5 ± 13.3. Hemodynamic instability was observed in 44%. Blood transfusion was needed in one third while massive transfusion and intensive care admission were required in a tenth and a quarter of cases, respectively. Tile classification was possible in 1228 patients (type A in 60%, B in 30%, and C in 10%). Patients with type C fractures had higher rates of associated injuries, higher ISS, greater pelvis abbreviated injury score (AIS), massive transfusion protocol activation, prolonged hospital stay, complications, and mortality (p value < 0.001). Two-thirds of patients were managed conservatively while a third needed surgical fixation. The median length of hospital and intensive care stays were 15 and 5 days, respectively. The overall mortality rate was 4.7% (86 patients).

Conclusion

TPF is a common injury among polytrauma patients. It needs a careful, systematic management approach to address the associated complexities and the polytrauma nature.

[Imaging techniques in modern trauma diagnostics]

Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.

[Imaging techniques in modern trauma diagnostics]

Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.

Comparative study of anxiety and depression following maxillofacial and orthopedic injuries. Study from a Nigerian University Teaching Hospital

This study hopes to compare levels of anxiety and depression in the maxillofacial and orthopedic injured patients over a period of 12 weeks. This was a prospective, repeated measure design. A total of 160 participants (80 with maxillofacial and 80 with long bone fractures) had repeated review follow-ups within 1 week of arrival in the hospital (Time 1), 4-8 weeks after initial contact (Time 2) and 10-12 weeks thereafter (Time 3), using hospital anxiety and depression scale questionnaire. Road traffic accident remained the main cause of injury in both groups of subjects. The Hospital anxiety and Depression scale detected 42 (52.5%) cases of depression at baseline, 36 (47.4%) cases at Time 2, and 14 (18.4%) cases at Time 3 in the maxillofacial injured group. In the long bone fracture subjects, 47 (58.8%) cases were depressed at baseline, 23(33.3%) cases at Time 2, and only 5 (7.2%) cases at Time 3. Both groups showed reduction in depression levels with time. Fifty-six (70.0%) had anxiety at baseline, 32 (42.1%) at Time 2, and only 9 (11.8%) had anxiety at Time 3 in the maxillofacial fracture group, whereas in the long bone fracture group, 69 (86.3%) subjects were anxious at baseline, 32 (46.4%) at Time 2, and 22 (31.9%) at Time 3. There were significant differences in depression and anxiety level in both the maxillofacial and the long bone fracture subjects at baseline (Time 1), Time 2(4-8 weeks) and Time 3(10-12 weeks).

Fractures of the pelvic ring

Traumatic disruptions of the pelvic ring are high energy life threatening injuries. Management represents a significant challenge, particularly in the acute setting in the presence of severe haemorrhage. Initial management is focused on preserving life by controlling haemorrhage and associated injuries. Advances in prehospital care, surgery, interventional radiology and the introduction of treatment algorithms to streamline decision making have improved patient survival. As more patients with unstable pelvic injuries survive, the poor results associated with nonoperative management and increasing patient expectations of outcome are making surgical management of these fractures increasingly common. The aim of operative fracture fixation is to correct deformity and restore function. The advent of percutaneous fixation techniques has reduced the morbidity previously associated with large operative exposures and internal fixation.

Kendrick's extrication device and unstable pelvic fractures: Should a trochanteric belt be added? A cadaveric study

INTRODUCTION

Pre-hospital pelvic stabilisation is advised to prevent exsanguination in patients with unstable pelvic fractures (UPFs). Kendrick's extrication device (KED) is commonly used to extricate patients from cars or crevasses. However the KED has not been tested for potential adverse effects in patients with pelvic fractures. The aim of this study was to examine the effect of the KED on pubic symphysis diastasis (SyD) with and without the use of a trochanteric belt (TB) during the extraction process following a MVC.

MATERIALS AND METHODS

Left-sided "open-book" UPFs were created in 18 human cadavers that were placed in seven different positions simulating pre-extraction and extraction positions using the KED with and without a TB in two different positions (through and over the thigh straps). The SyD was measured using anteroposterior radiographs. The effects of the KED with and without TB, on the SyD, were evaluated.

RESULTS

The KED alone resulted in a non-significant increase of the SyD compared to baseline, whereas the addition of a TB to the KED resulted in a significant reduction of the SyD (p<0.001). The TB through the straps provided a significantly better reduction than the TB over the straps in the extracted position (p<0.05).

CONCLUSION

Our study demonstrated that a TB in combination with the KED on UPFs is an effective way to achieve early reduction. The addition of the TB in combination with the KED could be considered for Pre-Hospital Trauma Life Support (PHTLS) training protocols.

What is the best internal fixation in pelvic fracture models with open-book injury and anterior sacroiliac joint disruption?

Background: The best operative management for open-book pelvic injury with anterior sacroiliac disruption (OTA/AO B1.1 classification) is still debated. This biomechanical study aimed to find the best internal fixation technique for such injury. Methods: Open-book injury with anterior sacroiliac joint disruption was simulated on 25 artificial pelvic bones. Twenty five artificial pelvic bones were divided into 5 groups (n=5 /group) and fixated with five different fixation techniques: 1). 1SP+1IS; 2). 2SP; 3). 2SP+2SIP; 4). 1SP+2IS S1, and 5). 1SP+1IS S1+S2. Biomechanical properties of each fixation technique were assessed using Tensilon® RTF-1310 to measure the resistance to translation and load to failure. Data were statistically analyzed using one-way ANOVA followed by post-hoc Bonferroni test.Results: The highest mean load to failure of axial forces (1490.36 N) was achieved by the fixation technique using one symphyseal plate and two iliosacral screws located at S1 dan S2. The addition of one iliosacral screw significantly increased the mean load to failure for axial compression (p<0.05).Conclusion: The addition of sacroiliac joint posterior fixation, either with plate or screw, will increase the fixation biomechanical strength. Single symphyseal plate and two iliosacral screws on S1 and S2 provided the best mechanical resistance to axial loading. Thus, it can be concluded that such fixation technique is best for open-book pelvic injury with anterior sacroiliac disruption.

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.

Classification of pelvic ring fractures in skeletonized human remains

Pelvic ring fractures are associated with high rates of mortality and thus can provide key information about circumstances surrounding death. These injuries can be particularly informative in skeletonized remains, yet difficult to diagnose and interpret. This study adapted a clinical system of classifying pelvic ring fractures according to their resultant degree of pelvic stability for application to gross human skeletal remains. The modified Tile criteria were applied to the skeletal remains of 22 individuals from the Cleveland Museum of Natural History and Universidad Nacional Autónoma de México that displayed evidence of pelvic injury. Because these categories are tied directly to clinical assessments concerning the severity and treatment of injuries, this approach can aid in the identification of manner and cause of death, as well as interpretations of possible mechanisms of injury, such as those typical in car-to-pedestrian and motor vehicle accidents.

Flight vibrations and bleeding in helicoptered patients with pelvic fracture

Depending on their amplitude and frequency, vibrations may facilitate bleeding and worsen the prognosis of patients with pelvic fractures transported by helicopter emergency medical services (HEMS). We measured the range of frequencies and amplitudes of forced vibrations produced by the helicopter used by the HEMS of the Italian Friuli Venezia Giulia region on the pelvis of transported persons. We performed 3 flight tests with 3 different volunteers (mass 70, 80, and 90 kg, respectively) loaded on the helicopter's stretcher and recorded the amplitudes and frequencies of vibrations through a triaxis sensor placed on the HEMS stretcher in the pelvis area. The flight profile planned was identical for each of the 3 iterations. Over the whole flight, the frequencies of vibration were between 26.4 and 53.5 Hz, and the greastest amplitude was 0.035 mm. The vibrations recorded in the helicopter may facilitate bleeding in unstable fractures. In the management of patients with pelvic fractures, HEMS crews should provide prehospital care that includes the use of specific splinting devices in addition to the spinal board, which allows an early immobilization of fractures and the limitation of pelvic motion.

Role of routine pelvic radiography in initial evaluation of stable, high-energy, blunt trauma patients

BACKGROUND

Pelvic fractures are among the most devastating traumatic injuries accompanied by high morbidity and mortality rate leading to catastrophic outcomes and haemodynamic consequences. Although Advanced Trauma Life Support (ATLS) recommends performing pelvic radiography in all major blunt trauma patients, several lines of evidence recommend that it can be limited to those blunt trauma patients who are haemodynamically unstable or have positive pelvic physical examination. Thus, we performed this study in order to evaluate the efficacy of routine pelvic radiography in haemodynamically stable, high-energy, blunt trauma patients.

METHODS

This was a prospective cross-sectional study including all the haemodynamically stable, high-energy, blunt trauma patients with negative pelvic physical examination referring to our trauma centre during a 5-month period (May-September 2010). Pelvic radiographies were performed and reviewed for abnormalities. In those who had negative pelvic physical examination and the radiography was not revealing enough, CT imaging was requested and reviewed.

RESULTS

During the study period, 1679 high-energy blunt trauma patients referred to our centre out of which 389 were haemodynamically stable and had negative pelvic physical examination. Pelvic radiography was found to be normal in all the patients except one (0.25%) who had pelvic fracture. Only three patients required CT imaging out of which two (0.5%) were found to be normal.

CONCLUSIONS

Pelvic radiography could be eliminated from the primary survey protocol of the patients with high-energy blunt trauma who are haemodynamically stable and have negative pelvic physical examination.

Development and validation of an instrument to predict functional recovery in tibial fracture patients: the Somatic Pre-Occupation and Coping (SPOC) questionnaire

OBJECTIVE

To explore the role of patients' beliefs in their likelihood of recovery from severe physical trauma.

METHODS

We developed and validated an instrument designed to capture the impact of patients' beliefs on functional recovery from injury: the Somatic Pre-Occupation and Coping (SPOC) questionnaire. At 6-weeks postsurgical fixation, we administered the SPOC questionnaire to 359 consecutive patients with operatively managed tibial shaft fractures. We constructed multivariable regression models to explore the association between SPOC scores and functional outcome at 1 year as measured by return to work and Short Form-36 (SF-36) physical component summary and mental component summary scores.

RESULTS

In our adjusted multivariable regression models that included preinjury SF-36 scores, SPOC scores at 6 weeks postsurgery accounted for 18% of the variation in SF-36 physical component summary scores and 18% of SF-36 mental component summary scores at 1 year. In both models, 6-week SPOC scores were a far more powerful predictor of functional recovery than age, gender, fracture type, smoking status, or the presence of multitrauma. Our adjusted analysis found that for each 14-point increment in SPOC score at 6 weeks (14 chosen on the basis of half a standard deviation of the mean SPOC score), the odds of returning to work at 1 year decreased by 40% (odds ratio, 0.60; 95% confidence interval, 0.50-0.73).

CONCLUSION

The SPOC questionnaire is a valid measurement of illness beliefs in patients with tibial fracture and is highly predictive of their long-term functional recovery. Future research should explore if these results extend to other trauma populations and if modification of unhelpful illness beliefs is feasible and would result in improved functional outcomes.

Effects of pelvic volume changes on retroperitoneal and intra-abdominal pressure in the injured pelvic ring: a cadaveric model

BACKGROUND

Pelvic ring injuries can be associated with severe blood loss and hemodynamic instability. The increase in pelvic volume in disrupted pelvic ring injuries is thought to cause accumulation of large volumes of blood in the retroperitoneal cavity. Extra abdominal compression for reduction of the pelvic ring may affect intrapelvic pressure. We examined the effects of pelvic volume changes on retroperitoneal pressures (RPP) and intra-abdominal pressures (IAPs) in the intact and unstable pelvic ring.

METHODS

In a cadaver study, unembalmed human torsos were used. Infusion lines were placed adjacent to the sacroiliac joint in the retroperitoneum and in the abdominal cavity. IAP and RPP measurements were performed with sequential infusion of crystalloid solution in 1,000 mL increments. Measurements were performed in the intact pelvic ring and after induction of unilateral and bilateral instability by disruption of the pubic symphysis, the sacroiliac joints, the sacrotuberous ligaments, and sacrospinous ligaments.

RESULTS

After infusion of 4,000 mL of saline, we observed a pressure increase in the retroperitoneal cavity (RPP) of 19.64 mm Hg ± 6.43 mm Hg in the intact pelvis, 5.22 mm Hg ± 1.74 mm Hg in unilateral instability, and 2.78 mm Hg ± 0.57 mm Hg in bilateral instability. The RPP response in the case of instability decreased significantly (p = 0.019). The IAP showed a change of 4.63 mm Hg ± 2.64 mm Hg in the intact pelvis, 3.88 mm Hg ± 1.84 mm Hg in unilateral instability, and 2.30 mm Hg ± 0.36 mm Hg in bilateral instability. Further infusion revealed a close association between RAPs and IAPs.

CONCLUSIONS

In the intact pelvis, RPP rises rapidly with increasing volume. The results seem to support the idea that disrupted pelvic ring fractures may lead to a significant volume uptake that is reversed during reduction.

Factors associated with mortality in combat-related pelvic fractures

Pelvic fractures were sustained by ≥26% of service members who died during Operation Enduring Freedom and Operation Iraqi Freedom in 2008. To determine factors associated with patient mortality following combat-related pelvic fracture (CRPF), the Joint Theater Trauma Registry database was searched to identify service members who survived CRPF sustained in the year 2008 (group 1), and the Armed Forces Medical Examiner System was searched to identify nonsurvivors of such trauma in the same year (group 2). Stable pelvic ring injuries were associated with a lower mortality rate than were unstable injuries when controlling for large-vessel and anatomic brain injuries (43% and 85%, respectively; P < 0.05). Associated injuries that were significant predictors of mortality included large-vessel, anatomic brain, cardiopulmonary, and solid organ abdominal (P < 0.05). Compared with a similar cohort of nonsurvivors, persons who survive CRPF have less severe pelvic fractures and associated injuries. In addition, pelvic fractures secondary to direct combat (ie, blast-related blunt injury, penetrating injury) were significantly more lethal than were those caused by mechanisms analogous to civilian trauma.

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.

The relationship between benzodiazepine use and traffic accidents: A systematic literature review

In many countries, benzodiazepines are the most commonly used and misused psychoactive medicinal drugs. Results of epidemiological studies investigating the association between benzodiazepine use and traffic accidents seem to be inconclusive or inconsistent at first sight. However, the outcome of epidemiological studies may be influenced by several methodological factors like study design, study population, exposure measurement, outcome definitions and possible confounders. Our objective was to conduct a systematic literature review of epidemiological studies that investigated the association between benzodiazepine use and traffic accidents, including related outcomes like culpability and injury or accident severity. We searched EMBASE, PubMed and Forensic Science Abstracts 3/0 (FORS) for references included in these databases at 1 June 2009 using the term 'benzodiazepines' in combination with 'driving performance' or 'accident risk' or 'traffic accident'. For inclusion in this review, the study design had to be comparative, include road users involved in accidents and provide specific data about benzodiazepines. Sixty-six studies were included in the review. The study populations varied from the general (driving) population, accident-involved road users with or without injury and persons admitted to a hospital to fatally injured accident-involved drivers. Exposure assessment was performed by using toxicological results, prescription data or questionnaires. The divergent study populations and comparison groups and the variety of methods used to express the outcome of interest hampered comparison between results. Evidence is growing that exposure to benzodiazepines is related to increased accident risk. The literature indicates that the greatest accident risk is associated with the use of long half-life benzodiazepines, increasing dosage and the first few weeks of use of benzodiazepines. Clear evidence of increased culpability associated with benzodiazepine use is scarce. More research has to be done to elucidate the relationship between benzodiazepine use and injury severity.

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.

The epidemiology of pelvic ring fractures: a population-based study

BACKGROUND

The severity of pelvic ring fractures (PRFs) can range from minor injury with low-energy mechanism to high-energy injury causing prehospital death. The purpose of this study was to prospectively describe the comprehensive pelvic fracture occurrence in an inclusive trauma system.

METHODS

A 12-month prospective, population-based epidemiologic study was performed in the Hunter Region, New South Wales, Australia (population of 600,000, served by one Level I trauma center and 7 referring hospitals). Patient demographics, mechanism, injury severity, shock parameters, and outcomes were recorded prospectively. The database included all pelvic fractures from the region: high-energy pelvic fractures (HE-PRFs), low-energy pelvic fractures (LE-PRFs), and prehospital deaths (PD-PRFs).

RESULTS

The incidence of PRF in the trauma system was 23 per 100,000 persons (138 fractures). The incidences of HE-PRF and LE-PRF were each 10 per 100,000 persons, whereas there were 3 PD-PRFs per 100,000. HE-PRF compared with LE-PRF occurred predominantly in men (64% vs. 20%, p < 0.05), younger persons (41 +/- 3 vs. 83 +/- 1 years, p < 0.05), those who had a higher Injury Severity Score (23 +/- 3 vs. 6 +/- 1, p < 0.05), and those with lower blood pressure (111 +/- 1 mm Hg vs. 153 +/- 1 mm Hg, p < 0.05), but the inhospital mortality rate was not statistically different (15% vs. 8%, p = NS). The overall mortality of the cohort was 23% (60% of those were from the PD-PRF group). The PRF-related mortality was 7% (HE-PRF: 7%; LE-PRF: 2%; PD-PRF: 33%), which was always attributable to bleeding. The incidence of demonstrated pelvic fracture-related arterial bleeding was 1.3 per 100,000 persons per year.

CONCLUSIONS

LE-PRF and HE-PRF are equally frequent among hospital admissions. They represent two distinct demographic groups with similar mortality rate. Most PRF-related deaths occur prehospitally. Bleeding remains the primary cause of PRF-related mortality in all groups.

A degloving foot injury in a traffic accident

An unusual human remain found on a road became one key to reconstruct the traffic accident. A woman was found dead on a snow-covered road. Her left foot showed a large deficit of skin and underlying fat tissue. The detached skin and tissue were found into her left sock and shoe lying at a distance of 23 m from the body. There were multiple fractures on her back and occipital cranial bone. Severe injuries revealed in heart, liver, and brain. The neck remained intact. These findings suggested that her back has been strongly hit by the object with the flat surface, for example, the front side of a cab-over or truck, from behind at a high speed. Furthermore, the degloving injury in her left foot suggested that a vehicle ran over the foot which faced the vehicle. We reconstructed the accident as follows. Firstly the wheel of the vehicle ran over the victim's foot, and then, the victim turned away from the vehicle. Finally, the front side hit her twisted body from behind, resulting in a traumatic degloving injury.

Is routine portable pelvic X-ray in stable multiple trauma patients always justified in a high technology era?

INTRODUCTION

According to the Advanced Trauma Life Support, portable pelvis radiography (PXR) is mandatory in multiple trauma patients, and is performed following initial clinical evaluation. The purpose of an early PXR is to identify pelvic fractures that may have haemodynamic consequences. Today, ultrafast multi-detector CT scanners (MDCT) are readily available and widely used in the evaluation of stable trauma patients. The objective of this study was to determine the impact of PXR in stable blunt multiple trauma patients, who required CT scan for full evaluation of the abdomen and pelvis.

METHODS

A retrospective review of all stable blunt trauma patients, suffering from pelvic fractures was performed from January 2001 until December 2004 at two high volume Trauma Centres. Patients' demographics and Injury Severity Scores (ISS) were abstracted from our trauma registry. Two certified radiologists and two certified orthopaedic surgeons retrospectively evaluated and compared PXR films and CT angiographies (CTA) of the abdomen and pelvis. We recorded each case when the management policy was altered due to the results of imaging and compared the clinical impact of both modalities.

RESULTS

One hundred and twenty-nine stable blunt multiple trauma patients with pelvic fractures underwent CTA of the abdomen and pelvis during their initial evaluation. Mean ISS was 16.5. Average Glasgow Coma Scale on arrival was 13.2 (range 3-15). Compared to CTA, sensitivity and specificity of the PXR was 64.4 and 90.0%, respectively. CTA diagnosed 35.6% more pelvic fractures than PXR (p<0.05). No changes in the therapeutic policy were observed following PXR results. In 19 (14.7%) patients, CTA findings led to pelvic angiography.

CONCLUSIONS

PXR in stable blunt multiple trauma patients did not change the therapeutic policy in our patients. CTA of the abdomen and pelvis is the imaging modality of choice in blunt multiple trauma, regardless of the findings of PXR. Benefit of routine PXR is questionable in hospitals where MDCT is available. Based on our results, we suggest re-evaluating the current practice of routine mandatory portable pelvis radiography.

Anwendung der Beckenzwinge beim polytraumatisierten Patienten mit instabilem Becken

BACKGROUND

Unstable fractures of the posterior pelvic ring are frequently combined with severe hemorrhage. In 80% of cases the bleeding originates in the ruptured presacral venous plexus or the fracture itself. Arterial bleeding is less common. The pelvic clamp introduced by Ganz can make it possible to stabilise the pelvis, with subsequent compression of the fracture planes and reduction of the intrapelvic volume in such cases, so improving the prognosis. Use of the pelvic clamp can be integrated into the management in the emergency room with no problem.

METHODS

This paper presents the authors' own modification of the technique for using the pelvic clamp in the emergency situation when only a clinical examination of the patient has been possible and also analyses specific problems that arise in this situation. To this end, the data relating to 29 polytraumatised patients with unstable posterior pelvic ring fractures were analysed in a retrospective study.

RESULTS

In all, 8 complications were seen in 6 patients. There were 2 cases of pin malposition and 2 of over-compression of the ossa coxae and local wound problems. Secondary pin dislocation was observed in 1 case. In all these cases it was possible to correct the pelvic clamp, so that emergency stabilisation was practicable without further surgical intervention. Minor complications were found in 2 patients. These took the form of bleeding at the pin-insertion site. In 1 case an unstable transiliacal fracture was found, and in this case it was not possible to stabilise the posterior pelvic ring with the pelvic clamp. No iatrogenic lesions were detected following application of the pelvic clamp.

CONCLUSION

In the hands of an experienced and practised user application of the pelvic clamp is a safe method for emergency stabilisation of the posterior pelvic ring in polytraumatised patients, even without blood volume control. Problems can be solved and do not generally mean the pelvic clamp cannot be used. The immediate radiological check (e.g. during the emergency CT -scan performed for primary diagnosis) is a must, however.

Contemporary management of pelvic fractures

BACKGROUND

Pelvic fractures occur when there is high kinetic energy transfer to the patient such as would be expected in motor vehicle crashes, auto-pedestrian collisions, motorcycle crashes, falls, and crush injuries. High-force impact implies an increased risk for associated injuries to accompany the pelvic fracture, as well as significant mortality and morbidity risks. Choosing the optimum course of diagnosis and treatment for these patients can be challenging. The purpose of this review is to supply a contemporary view of the diagnosis and therapy of patients with this important group of injuries.

METHODS

A comprehensive review of the medical literature, focusing on publications produced in the last 10 years, was undertaken. The principal sources were found in surgical, orthopedic, and radiographic journals.

CONCLUSIONS

The central challenge for the clinician evaluating and managing a patient with a pelvic fracture is to determine the most immediate threat to life and control this threat. Treatment approaches will vary depending on whether the main threat arises from pelvic fracture hemorrhage, associated injuries, or both simultaneously. Functional outcomes in the long-term depend on the quality of the rigid fixation of the fracture, as well as associated pelvic neural and visceral injuries.

Auditing 655 Fatalities with Pelvic Fractures by Autopsy as a Basis to Evaluate Trauma Care

BACKGROUND

To determine the role of pelvic fractures in auditing mortality resulting from trauma.

STUDY DESIGN

This retrospective case-control study based on autopsy-evaluated circumstances of the deaths of patients with pelvic fractures.

RESULTS

Of 2,583 patients injured in motor-vehicle collisions, 655 (25.4%) constituted the pelvic fracture (PFx) group, and 1,928 (74.6%) constituted the control group. One-third of the PFx group's fatalities had an Injury Severity Score (ISS) of 75 and were not preventable. The PFx group had a substantially higher median ISS than the control group (50 versus 34; p < 0.0001). Four hundred fifty-four patients (69.3%) in the PFx group with ISS 16 to 74 had substantially higher rates of associated injuries. Nearly half of the PFx group patients with ISS <or= 74 had a potential cause of major hemorrhage other than pelvic fracture. Twenty-three (3.5%) deaths were directly attributable to pelvic fractures. Postinjury median survival time was 55 minutes for the PFx group and 100 minutes for the control group (p < 0.0001). The time limit for management of the patients with pelvic fractures was short, as 527 (81.5%) died in the first 6 hours. It was evident that the more severe the injuries were, the sooner the deaths occurred. Of 151 subjects who left the emergency department alive, 61.6% were subjected to operation and 48.3% to abdominal operation.

CONCLUSIONS

Pelvic fracture is an indicator of severe multiple trauma, but a small proportion of deaths are directly attributable to pelvic fracture. A method based on autopsy audited patients with pelvic fractures as a paradigm of injury revealed that pelvic fracture is an important injury to consider in auditing trauma care and indicated several issues that should be considered to reduce mortality.

Die Beckenringzerreißung beim polytraumatisierten Patienten

Pelvic injuries represent a thorny and stubborn therapeutic challenge. Because major forces are required to fracture the pelvis, pelvic ring disruption, more than any other fracture, can lead to life-threatening associated injuries such as massive bleeding, organ injuries, and open fractures including hemipelvectomy. The rapid diagnosis and effective treatment ("damage control") of those injuries play the key role in the patient's survival, inasmuch as the mortality of multiply injured patients with pelvic ring disruption remains high with 20-35%. Exsanguinating hemorrhage represents the most dreaded acute complication of pelvic injuries. Therefore, diagnostic and therapeutic procedures have to be primarily adapted to the hemodynamics of the patient, secondarily to injuries of the brain and the torso. The time point and the techniques of definitive pelvic ring stabilization may be different in the patient with multiple injuries compared to isolated pelvic ring injuries.

[Shock trauma room management of pelvic injuries. A systematic review of the literature]

OBJECTIVE

Injuries to the pelvis may occur as a life threatening situation which then requires immediate surgical treatment. A review of the literature represents the range of current recommendations.

METHODS

Clinical trials were systematically collected (Medline, Cochrane and hand searches) reviewed and classified into evidence levels (1 to 5 according to the Oxford system).

RESULTS

According to the literature there is a consent that immediate resuscitation and surgical intervention is essential in complex pelvic fractures. In contrast the way of emergency stabilization of the pelvis (fixateur externe or c-clamp) is still under discussion as well as the radiological diagnostic (x-ray or CT) and the way of bleeding control (tamponade or embolization).

CONCLUSION

Emergency management of pelvic fractures means treatment of a life threatening injury in first place. Although there are different methods that can be used, they all follow the same principle of resuscitation and mechanical stabilization of the pelvis in parallel.