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Jammal M, Nasrallah K, Kanaann M, Mosheiff R, Liebergall M, Weil Y. Pelvic ring fracture in the older adults after minor pelvic trauma - is it an innocent injury? Injury 2024; 55:111773. [PMID: 39106535 DOI: 10.1016/j.injury.2024.111773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 07/31/2024] [Indexed: 08/09/2024]
Abstract
OBJECTIVE This study aimed to evaluate the prevalence of severe hemorrhage as a potentially life-threatening complication in elderly patients with isolated, low-energy pelvic ring fractures, which may be more common than previously described. PATIENTS AND METHODS A retrospective cohort study was conducted at an academic level 1 trauma center, including 579 patients aged over 65 who suffered from isolated low-energy pelvic fractures between 2006 and 2020. Pelvic computer tomography (CT) scans, with or without contrast, were performed and reviewed for patients with suspected posterior ring injury or bleeding. Patients without CT scans were excluded from the study. RESULTS Among the 123 patients with isolated pubic rami fractures, 30 (24.4 %) had bleeding with a significant hemoglobin drop (>2 g%). 21(70 %) patients of these had posterior pelvic ring involvement as compared to 45 who did not bleed (51 %, p = 0.07). There was a significantly larger proportion of patient who received anticoagulant therapy (ACT) with posterior ring injury among the bleeding group (20 % vs 3.2 % p < 0.01). Treatment included blood transfusion (19/123, 15.5 %), and arterial angiographic embolization (5/123, 4 %). No complications related to angio-embolization were observed, and all patients survived the initial 90-day period. No other source of bleeding was identified in any of these patients. CONCLUSION Severe pelvic hemorrhage in the older adults due to a minor pelvic injury after a low-energy trauma is not an uncommon complication, especially with combination of ACT and posterior pelvic ring fracture. This indicates that these injuries more challenging than previously believed. Geriatric pelvic ring injuries should be monitored carefully with serial blood counts, and low threshold for imaging including contrast enhanced CT scans and angiography.
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Affiliation(s)
- Mahmoud Jammal
- Orthopedic Department, Hadassah Hebrew University Hospital, Kiryat Hadassah, P.O.B: 12000, Jerusalem 91120, Israel.
| | - Khalil Nasrallah
- Western Galilee Medical Center, Nahariya-Cabri 9, Nahariya 22100, Israel
| | - Mahdi Kanaann
- Orthopedic Department, Hadassah Hebrew University Hospital, Kiryat Hadassah, P.O.B: 12000, Jerusalem 91120, Israel
| | - Rami Mosheiff
- Orthopedic Department, Hadassah Hebrew University Hospital, Kiryat Hadassah, P.O.B: 12000, Jerusalem 91120, Israel
| | - Meir Liebergall
- Orthopedic Department, Hadassah Hebrew University Hospital, Kiryat Hadassah, P.O.B: 12000, Jerusalem 91120, Israel
| | - Yoram Weil
- Orthopedic Department, Hadassah Hebrew University Hospital, Kiryat Hadassah, P.O.B: 12000, Jerusalem 91120, Israel
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Al-Rawi Z, Nached Y, Abdelwahab A, Samy BM. Life-Threatening Bleeding Following a Stable Fracture of the Superior Pubic Ramus: A Case Report. Cureus 2024; 16:e61520. [PMID: 38957245 PMCID: PMC11218421 DOI: 10.7759/cureus.61520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2024] [Indexed: 07/04/2024] Open
Abstract
Corona mortis, an anatomical variant documented in the literature, presents a noteworthy concern due to its proximity to the superior pubic ramus. Consequently, it remains susceptible to injury, even in stable, benign fractures of the pelvis, typically addressed through conservative management. Stable pelvic fractures are infrequently associated with complications; therefore, diligent monitoring is often overlooked in clinical practice. However, it becomes crucial, particularly in the elderly population given their suboptimal hemostatic capabilities. The standard approach for managing bleeding associated with pelvic fractures involves superselective embolization, a minimally invasive procedure with favorable outcomes. We present a case involving a 61-year-old female who experienced a stable pelvic fracture following low-energy trauma. Despite the ostensibly benign nature of the fracture, the patient exhibited hemodynamic instability attributable to bleeding from the corona mortis, necessitating embolization. The pelvic fracture itself was managed conservatively, leading to the patient's subsequent discharge in a stable condition. Therefore, we advocate for a comprehensive physical examination, serial hemoglobin monitoring, and additional imaging modalities based on the patient's clinical condition.
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Affiliation(s)
- Zeinab Al-Rawi
- Department of Orthopaedics and Trauma, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, ARE
| | - Yasmin Nached
- Department of Orthopaedics and Trauma, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, ARE
| | - Abdulla Abdelwahab
- Department of Orthopaedics and Trauma, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, ARE
| | - Baher M Samy
- Department of Orthopaedics and Trauma, Dubai Health, Rashid Hospital, Dubai, ARE
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Fokin AA, Wycech Knight J, Tharp ME, Brinton KC, Gallagher PK, Xie JF, Weisz RD, Puente I. Pelvic fractures in blunt trauma patients: A comparative study. World J Orthop 2024; 15:418-434. [PMID: 38835686 PMCID: PMC11145966 DOI: 10.5312/wjo.v15.i5.418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 05/15/2024] Open
Abstract
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.
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Affiliation(s)
- Alexander A Fokin
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Joanna Wycech Knight
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL 33316, United States
| | - Madison E Tharp
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Kyler C Brinton
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Phoebe K Gallagher
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Justin Fengyuan Xie
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, United States
| | - Russell D Weisz
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
| | - Ivan Puente
- Trauma and Critical Care Services, Delray Medical Center, Delray Beach, FL 33484, United States
- Charles E Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, FL 33431, United States
- Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, FL 33316, United States
- Herbert Wertheim College of Medicine, Department of Surgery, Florida International University, Miami, FL 33199, United States
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Singh A, Kotzur T, Koslosky E, Gonuguntla R, Canseco L, Momtaz D, Seifi A, Martin C. Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures. J Orthop Trauma 2024; 38:254-258. [PMID: 38378177 DOI: 10.1097/bot.0000000000002789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVES To compare cost, hospital-related outcomes, and mortality between angioembolization (AE) and preperitoneal pelvic packing (PPP) in the setting of pelvic ring or acetabulum fractures. METHODS . DESIGN Retrospective database review. SETTING National Inpatient Sample, years 2016-2020. PATIENT SELECTION CRITERIA Hospitalized adult patients who underwent AE or PPP in the setting of a pelvic ring or acetabulum fracture. OUTCOME MEASURES AND COMPARISONS Mortality and hospital-associated outcomes, including total charges, following AE versus PPP in the setting of pelvic ring or acetabulum fractures. RESULTS A total of 3780 patients, 3620 undergoing AE and 160 undergoing PPP, were included. No significant differences in mortality, length of stay, time to procedure, or discharge disposition were found ( P > 0.05); however, PPP was associated with significantly greater charges than AE ( P = 0.04). Patients who underwent AE had a mean total charge of $250,062.88 while those undergoing PPP had a mean total charge of $369,137.16. CONCLUSIONS Despite equivalent clinical efficacy in terms of mortality and hospital-related outcomes, PPP was associated with significantly greater charges than AE in the setting of pelvic ring or acetabulum fractures. This data information can inform clinical management of these patients and assist trauma centers in resource allocation. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | | | | | | | | | - Ali Seifi
- Department of Neurosurgery, UT Health San Antonio, San Antonio, TX
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Lundy ME, Zhang B, Ditillo M. Management of the Geriatric Trauma Patient. Surg Clin North Am 2024; 104:423-436. [PMID: 38453311 DOI: 10.1016/j.suc.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
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.
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Affiliation(s)
- Megan Elizabeth Lundy
- University of Arizona Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, 1501 North Campbell Avenue, Tucson, AZ 85724, USA. https://twitter.com/MLundyMD
| | - Bo Zhang
- University of Arizona Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, 1501 North Campbell Avenue, Tucson, AZ 85724, USA. https://twitter.com/bo_zhang1
| | - Michael Ditillo
- University of Arizona Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, 1501 North Campbell Avenue, Tucson, AZ 85724, USA.
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Kastanis G, Pantouvaki A, Siligardou MR, Chaniotakis C, Kroustalakis E, Stavrakakis I, Kapsetakis P. Can Nondisplacement Osteoporotic Pubic Rami Fracture Be Life-Threatening Injuries? A Case Report, Overview, and Algorithm Protocol for Management. J Investig Med High Impact Case Rep 2024; 12:23247096241231648. [PMID: 38491774 PMCID: PMC10943755 DOI: 10.1177/23247096241231648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/13/2024] [Accepted: 01/23/2024] [Indexed: 03/18/2024] Open
Abstract
Pubic rami fractures in the geriatric population are usually osteoporotic fractures resulting from low energy trauma and are characterized as stable injuries. Established treatment of these injuries is conservative, including rest, analgesic medication, and progressive active mobilization. These injuries are life-threatened when pubic rami fractures are accompanied by acute bleeding, either from an injury to a vessel (corona mortis) or from medication (anticoagulant or antiplatelet) for comorbidities, then. In this case study, we present the unusual case of an 82-year-old woman admitted to the emergency department 24 hours after a simple fall, causing nondisplacement osteoporotic pubic rami fracture, who, after 48 hours, developed a hematoma on the contralateral side of the pelvis, with progressive anemia and acute abdominal pain. This study has 2 objectives: to increase awareness of this life-threatening injury in the emergency department and to describe diagnosis and treatment modalities.
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Affiliation(s)
| | - Anna Pantouvaki
- General Hospital of Heraklion “Venizeleio-Pananeio,” Greece
- Hellenic Mediterranean University, Heraklion, Greece
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Farid AR, Stearns SA, Atarere JO, Suneja N, Weaver MJ, Von Keudell AG. Trends in non-operative management of low-energy pelvic fracture: An analysis of the Nationwide Inpatient Sample. J Orthop 2023; 43:101-108. [PMID: 37564706 PMCID: PMC10410464 DOI: 10.1016/j.jor.2023.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023] Open
Abstract
Introduction Non-operative management is common for low-impact pelvic fractures. In this study, we characterize the epidemiology of those treated nonoperatively following low-energy pelvic fracture, while identifying recent management trends. Methodology Data from the Nationwide Inpatient Sample (NIS) database from 2011 to 2018 were analyzed. We identified adult patients diagnosed with pelvic fracture based on International Classification of Diseases (ICD) codes, excluding fractures of the acetabulum, femur, polytrauma, and open fractures to isolate cases caused by low-impact mechanisms. Codes indicating operative management were excluded. Demographic information and outcomes (length of stay, in-hospital mortality, hospital discharge status) were collected. Sub-analyses were performed to identify trends. Findings 123,936 eligible patients were identified. The average age was 68.7 years. 70% were female, showing a decline from 75% to 66% over the study period. Pubic bone involvement was observed in 59% of fractures. The mean Charlson Comorbidity Index (CCI) was 3.83, corresponding to a 10-year survival rate of 58.5%, which remained relatively stable throughout the study period. 62.4% of patients received treatment at urban teaching hospitals. Average length of hospital stay was 6.3 days. Discharge to a skilled nursing facility (SNF) was the most common outcome, ranging from 62.1% to 65.0% during the study period, while 20.0% of patients were discharged home (18.4%-21.1%). Mean in-hospital mortality was 3.28%, showing no significant change, with higher rates among male patients (5.1%) and patients of Asian descent (3.8%). Conclusion The majority of patients receiving nonoperative treatment for low-energy pelvic fractures were females in their mid-60s with moderate comorbidity. The study reveals a relatively high in-hospital mortality rate of 3.28%, particularly among male patients and those of Asian descent, indicating the need for increased surveillance for further injury in these groups. Most patients were discharged to a SNF, highlighting the necessity for extended rehabilitation in this population. This persistent trend is noteworthy considering the growing emphasis on the cost of inpatient admissions and advancements in outpatient management of orthopedic injuries.
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Affiliation(s)
- Alexander R. Farid
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen A. Stearns
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph Okiemute Atarere
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael J. Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arvind Gabriel Von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Trauma, Bispebjerg hospitalet, University of Copenhagen, 2400, Copenhagen, Denmark
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Polytrauma in the Geriatric Population: Analysis of Outcomes for Surgically Treated Multiple Fractures with a Minimum 2 Years of Follow-Up. Adv Ther 2022; 39:2139-2150. [PMID: 35294739 DOI: 10.1007/s12325-022-02109-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/01/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION This study analyzed the clinical and radiological outcomes of geriatric polytrauma patients who had multiple fractures surgically treated and a minimum of 2 years of follow-up. METHODS Eighty-six geriatric patients with polytrauma and multiple fractures which were surgically treated in orthopedics and who had a minimum of 2 years of follow-up were retrospectively analyzed. Patients' demographic characteristics, comorbidities, and follow-up time were recorded. The mechanism of injury, fracture type and location, Injury Severity Score (ISS), American Society of Anesthesiologists (ASA) score, duration of hospital stay, complications, and 1-year mortality were also recorded. Fracture union, implant failure, and refractures/misalignment were analyzed from radiographs. RESULTS There were 34 (39.5%) male and 52 (60.5%) female patients. Mean age was 73.5 years with an average follow-up time of 32.9 months. Patients had more low-energy traumas and more lower extremity, comminuted fractures. On the contrary, high-energy traumas and femur/pelvic fracture surgeries had higher associated mortality. The mean ISS score was 26.3. The most common ASA score was ASA 3 (75.8%). The most common clinical and radiological complications were prolonged wound drainage and implant failure. The total 1-year mortality rate was 22.1%. Patients with high ASA scores and patients with lower extremity fractures (femoral/pelvic fractures) also had significantly increased mortality rates. No significant relation was detected between mortality and ISS, fracture type, number of fractures, and duration of hospital stay. CONCLUSION Orthopedic surgeons must be alert about the possible complications of femoral fractures and comminuted fractures including pelvic girdle. Surgically treated, multifractured patients with high-energy trauma, advanced age, and high ASA scores are also at risk for mortality regardless of the ISS, comorbidities, and duration of hospital stay. Pulmonary thromboemboli must be kept in mind as a significant complication for mortality.
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9
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Sivapathasuntharam D, Smith G, Master MA, Bates P. Fragility fractures of the pelvis in the older population. Age Ageing 2022; 51:6550829. [PMID: 35305085 DOI: 10.1093/ageing/afac063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Indexed: 11/12/2022] Open
Abstract
Pelvic fractures are an increasingly common injury seen in the older population and represent a significant burden of morbidity and mortality in this age group, as well as a large financial burden on the health service. It is well established that early fixation of femoral neck and acetabular fractures improves outcomes and increases the chances of patients returning close to their premorbid functional baseline. However, fixation of fragility fractures of the pelvis is less well established in current practice. There has been recent development of novel stabilisation techniques for unstable pelvic fractures, designed to tackle the difficulties associated with fixation in poor bone quality, along with medical trials of parathyroid hormone analogue treatment. However, it is still current practice to manage nearly all fragility fractures of the pelvis conservatively. In this article, we consider whether the development of surgical stabilisation techniques for pelvic fragility fractures may have the potential to improve the well-described morbidity and mortality associated with them.
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Affiliation(s)
| | - Gillian Smith
- Trauma Service, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | | | - Peter Bates
- Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
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Fleischhacker E, Gleich J, Hesse E, Bücking B, Liener UC, Neuerburg C. [Individual aspects in eldery patients with fragility fractures]. Radiologe 2021; 61:1107-1114. [PMID: 34767032 DOI: 10.1007/s00117-021-00928-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Due to our ageing population, the number of elderly patients who are treated in the emergency department due to low-energy trauma (e.g., tripping) continues to rise. These minor accidents often result in fragility fractures classically located in the proximal humerus, distal radius, spine, pelvis, and near the hip joint. Pre-existing conditions, polypharmacy, and general frailty increase the risk of fragility fractures in this patient population. METHODS Geriatric trauma fractures and especially insufficiency fractures of the posterior pelvic ring are often difficult to diagnose by plain X‑ray. Therefore, in geriatric trauma patients, cross-sectional imaging, e.g., computed tomography (CT), dual-energy CT (DECT), or magnetic resonance imaging (MRI), should be considered early for reliable evaluation of a suspected fracture. This also allows for the identification of older fractures. Particularly in cognitively impaired elderly patients, difficult examination conditions or an unclear fall event, cross-sectional imaging is often indicated. However, this may also involve risks, e.g., use of contrast medium in patients with impaired renal function, so that each case must be considered individually. Furthermore, the diagnosis and treatment of osteoporosis, which is an underlying disease that leads to fragility fractures, is of particular importance. In the diagnostic workup, measurement of bone density using dual energy X‑ray absorptiometry (DXA) is the standard method according to guidelines. In specific situations, high-resolution peripheral quantitative CT (HR-pQCT) may also be used. CONCLUSION Due to the special challenges of correctly detecting fragility fractures and being able to quickly initiate adequate therapy, good cooperation between radiologists and trauma surgeons is necessary.
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Affiliation(s)
- E Fleischhacker
- Klinik für Orthopädie und Unfallchirurgie, Muskuloskelettales Universitätszentrum München (MUM), Klinikum der Universität München, Ludwig-Maximilians-Universität München, Campus Großhadern, München, Deutschland
| | - J Gleich
- Klinik für Orthopädie und Unfallchirurgie, Muskuloskelettales Universitätszentrum München (MUM), Klinikum der Universität München, Ludwig-Maximilians-Universität München, Campus Großhadern, München, Deutschland
| | - E Hesse
- Institut für Molekulare Muskuloskelettale Forschung, Klinikum der Ludwig-Maximilians-Universität München, München, Deutschland
| | - B Bücking
- Klinik für Unfallchirurgie, Klinikum Hochsauerland GmbH, Arnsberg, Deutschland
| | - U C Liener
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Vinzenz von Paul Kliniken gGmbH Marienhospital Stuttgart, Stuttgart, Deutschland
| | - Carl Neuerburg
- Klinik für Orthopädie und Unfallchirurgie, Muskuloskelettales Universitätszentrum München (MUM), Klinikum der Universität München, Ludwig-Maximilians-Universität München, Campus Großhadern, München, Deutschland.
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Gogna S, Latifi R, Samson DJ, Butler J. Pelvic fractures in severely injured elderly: a double-adjustment propensity score matched analysis from a level I trauma center. Eur J Trauma Emerg Surg 2021; 48:2219-2228. [PMID: 34432083 PMCID: PMC8385478 DOI: 10.1007/s00068-021-01772-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 08/12/2021] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Shekhar Gogna
- Department of Surgery, Westchester Medical Center, New York Medical College, 100 Woods Road, Taylor Pavilion, E-348, Valhalla, NY, 10595, USA
| | - Rifat Latifi
- Westchester Medical Center, New York Medical College, School of Medicine, Valhalla, NY, 10595, USA.
| | - David J Samson
- Department of Surgery, Clinical Research Unit, Westchester Medical Center, 100 Woods Road, Taylor Pavilion, Office E-348, Valhalla, NY, 10595, USA
| | - Jonathan Butler
- Clinical Research Unit, Westchester Medical Center, 100 Woods Road, Taylor Pavilion, Office E-348, Valhalla, NY, 10595, USA
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Kuršumović K, Hadeed M, Bassett J, Parry JA, Bates P, Acharya MR. Lateral compression type 1 (LC1) pelvic ring injuries: a spectrum of fracture types and treatment algorithms. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:841-854. [PMID: 33860399 DOI: 10.1007/s00590-021-02935-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
Lateral compression type 1 (LC1) fractures are the commonest pelvic ring injury. However, they represent a heterogenous spectrum of injury mechanisms and fracture patterns, resulting in a lack of strong evidence for a universally agreed treatment algorithm. Although consensus exists that LC1 fractures have a preserved posterior ligamentous complex and are vertically stable, controversy persists around defining internal rotational instability. As such, treatment strategies extend from routine non-operative management through to dynamic imaging such as examination under anaesthetic (EUA) or stress radiographs to guide fixation algorithm. Multiple protocols sit between these two, all with slightly different thresholds for advocating surgery or otherwise, exemplifying a broad lack of consensus that is not seen for other, more severe, grades of pelvic ring injury. In the following review we discuss the evolving concepts of pelvic ring instability and management, starting from a historical perspective, through to current trends and controversies in LC1 fracture treatment. Emerging directions for research and emerging pharmacological and surgical treatments/technologies are also considered and expert commentary from 3 leading centres provided. The distinction is made between LC1 fracture arising from high-energy trauma and those following low-energy falls from standing height (so-called fragility fractures of the pelvis-FFP), since these two patient groups have different functional requirements and medical vulnerabilities. Issues pertaining to FFP are considered separately.
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Affiliation(s)
- Kenan Kuršumović
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Michael Hadeed
- Department of Orthopaedic Surgery, Denver Health Medical Centre, University of Colorado School of Medicine, Denver, CO, USA
| | - James Bassett
- Department of Trauma and Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Joshua A Parry
- Department of Orthopaedic Surgery, Denver Health Medical Centre, University of Colorado School of Medicine, Denver, CO, USA
| | - Peter Bates
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, The Royal London Hospital, London, UK.
| | - Mehool R Acharya
- Department of Trauma and Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
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Marmor M, El Naga AN, Barker J, Matz J, Stergiadou S, Miclau T. Management of Pelvic Ring Injury Patients With Hemodynamic Instability. Front Surg 2020; 7:588845. [PMID: 33282907 PMCID: PMC7688898 DOI: 10.3389/fsurg.2020.588845] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/12/2020] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Meir Marmor
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Ashraf N El Naga
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jordan Barker
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jacob Matz
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | | | - Theodore Miclau
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
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14
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Garcia M, Firek M, Zakhary B, Brenner M, Hildebrand F, Coimbra R. Severe Pelvic Fracture in the Elderly: High Morbidity, Mortality, and Resource Utilization. Am Surg 2020; 86:1401-1406. [PMID: 33103461 DOI: 10.1177/0003134820964493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Monika Garcia
- Riverside University Health System & CECORC-Comparative Effectiveness and Clinical Outcomes Research Center, Riverside, CA, USA.,Department of Surgery, University of California Riverside, CA, USA
| | - Matthew Firek
- Riverside University Health System & CECORC-Comparative Effectiveness and Clinical Outcomes Research Center, Riverside, CA, USA
| | - Bishoy Zakhary
- Riverside University Health System & CECORC-Comparative Effectiveness and Clinical Outcomes Research Center, Riverside, CA, USA
| | - Megan Brenner
- Riverside University Health System & CECORC-Comparative Effectiveness and Clinical Outcomes Research Center, Riverside, CA, USA.,Department of Surgery, University of California Riverside, CA, USA
| | | | - Raul Coimbra
- Riverside University Health System & CECORC-Comparative Effectiveness and Clinical Outcomes Research Center, Riverside, CA, USA.,Loma Linda University School of Medicine, CA, USA
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Surgical Site Infection After Open Upper Extremity Fracture and the Effect of Urgent Operative Intervention. J Orthop Trauma 2020; 34:258-262. [PMID: 31738238 DOI: 10.1097/bot.0000000000001700] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To identify which factors are predictive of surgical site infection in upper extremity fractures, and to assess whether the timing of operative debridement influences infection risk. DESIGN Retrospective database review. SETTING Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. PATIENTS Patients in the NSQIP database with fractures involving the upper extremity. INTERVENTION Surgical management of upper extremity fracture, including operative debridement for open injuries. MAIN OUTCOME MEASUREMENTS Surgical site infection, including both superficial and deep infections. RESULTS A total of 22,578 patients were identified, including 1298 patients with open injuries (5.7% of total). The overall wound infection rate was 0.79%. Patients with open injuries were found to have a higher incidence of infection compared with those with closed injuries (1.7% vs. 0.7%, P < 0.001). Independent risk factors for 30-day infection included open fracture diagnosis, obesity, smoking, and American Society of Anesthesiolgists class >2 (all P < 0.05). Of patients with open fractures, 79.7% were taken expediently to the operating room. The rate of infection did not differ based on whether surgery was performed expediently or not (1.8% vs. 1.1%, P = 0.431). CONCLUSIONS Based on an analysis of the NSQIP database, the overall risk of surgical site infection following intervention for open or closed upper extremity fractures remains low. Risk factors for infection include open injury, obesity, and cigarette smoking. There was no difference in the infection rate based on the urgency of operative debridement. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Dhara S, Moore EE, Yaffe MB, Moore HB, Barrett CD. Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays? CURRENT TRAUMA REPORTS 2020; 6:69-81. [PMID: 32864298 DOI: 10.1007/s40719-020-00183-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose of Review The purpose of this review is to briefly outline the current state of hemorrhage control and resuscitation in trauma patients with a specific focus on the role viscoelastic assays have in this complex management, to include indications for use across all phases of care in the injured patient. Recent Findings Viscoelastic assay use to guide blood-product resuscitation in bleeding trauma patients can reduce mortality by up to 50%. Viscoelastic assays also reduce total blood products transfused, reduce ICU length of stay, and reduce costs. There are a large number of observational and retrospective studies evaluating viscoelastic assay use in the initial trauma resuscitation, but only one randomized control trial. There is a paucity of data evaluating use of viscoelastic assays in the operating room, post-operatively, and during ICU management in trauma patients, rendering their use in these settings extrapolative/speculative based on theory and data from other surgical disciplines and settings. Summary Both hypocoagulable and hypercoagulable states exist in trauma patients, and better indicate what therapy may be most appropriate. Further study is needed, particularly in the operating room and post-operative/ICU settings in trauma patients.
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Affiliation(s)
- Sanjeev Dhara
- University of Chicago School of Medicine, Chicago, IL
| | - Ernest E Moore
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Michael B Yaffe
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Christopher D Barrett
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA
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Wilke J, Pennig D. [Percutaneous stabilization of the anterior pelvic ring in osteoporotic fractures]. Unfallchirurg 2019; 122:612-617. [PMID: 31076807 DOI: 10.1007/s00113-019-0659-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The number of low energy traumas in older people with subsequent pelvic ring fractures is increasing in contrast to high energy traumas with pelvic injury in younger people. Geriatric pelvic fractures can be treated conservatively with analgesics and physiotherapy-assisted mobilization, depending on the symptoms. If physical complaints do not allow adequate mobilization, surgical stabilization is indicated. It is often possible to stabilize the dorsal pelvic ring with transiliosacral screws. If additional instability associated with anterior pelvic ring complaints is prevalent, stabilization of the anterior ring can be achieved by invasive osteosynthesis using a plate or percutaneously by implanting an intramedullary plastic polymer.
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Affiliation(s)
- J Wilke
- Klinik für Unfall- und Wiederherstellungschirurgie, Handchirurgie und Orthopädie, St.-Vinzenz Hospital Köln, Merheimer Straße 221-223, 50733, Köln, Deutschland.
| | - D Pennig
- Klinik für Unfall- und Wiederherstellungschirurgie, Handchirurgie und Orthopädie, St.-Vinzenz Hospital Köln, Merheimer Straße 221-223, 50733, Köln, Deutschland
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19
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Kwong WY, Yang MLC, Wong OF, Lui CT, Tsui KL. Epidemiological study of major pelvic fracture in Hong Kong and analysis of predictors for mortality. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919856218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Wing Yan Kwong
- Department of Accident and Emergency, Queen Elizabeth Hospital, Jordan, Hong Kong
| | - Marc LC Yang
- Department of Accident and Emergency, Queen Elizabeth Hospital, Jordan, Hong Kong
| | - Oi Fung Wong
- Department of Accident and Emergency, North Lantau Hospital, Tung Chung, Hong Kong
| | - Chun Tat Lui
- Department of Accident and Emergency, Tuen Mun Hospital, Tuen Mun, Hong Kong
| | - Kwok Leung Tsui
- Department of Accident and Emergency, Tuen Mun Hospital, Tuen Mun, Hong Kong
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20
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Age and "general health"-beside fracture classification-affect the therapeutic decision for geriatric pelvic ring fractures: a German pelvic injury register study. INTERNATIONAL ORTHOPAEDICS 2019; 43:2629-2636. [PMID: 30949757 DOI: 10.1007/s00264-019-04326-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 03/19/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Pelvic ring fractures in the elderly gain increasing importance. Nonetheless, data on factors influencing treatment decision in relation to fracture classification, age, and the resulting treatment are still rare. METHODS Prospectively collected data of the German Pelvic Injury Registry from patients aged over 65 years with a pelvic ring fracture were evaluated retrospectively. Acetabular fractures, as well as type A1 and A3 fractures, were excluded. The variables age, injury pattern, type of treatment, the reason for conservative treatment, and Orthopaedic Trauma Association (OTA)/Tile classification were analyzed. Furthermore, the fracture distribution was examined after dividing patients into six age groups. RESULTS A total of 1814 patients with a mean age of 80.7 ± 7.6 years, predominantly female (79.0%), were available for evaluation. The majority of patients suffered from isolated pelvic ring fractures (70.1%) and 8.2% were severely injured (ISS > 16). The most common fracture types were type A2 (35.4%), type B2 (38.0%), and type C1 (7.3%). Especially pelvic ring fractures of type A2 (96.9%) and type B2 (83.0%) were treated conservatively (overall 76.9%). Fracture instability according to the OTA/Tile classification increased the probability for an operative treatment (generalized odds ratio [OR] 6.90 [5.62; 8.52]). In contrary, increasing age independent of the fracture pattern decreased this probability (OR 0.47 [0.41-0.53]). With increasing fracture instability, general health conditions were up to 50% of the reasons for conservative treatment. CONCLUSION The results of the present study underline the importance of the factors age and general health besides fracture classification for therapeutic decision-making in the treatment of pelvic ring fractures in the elderly.
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21
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Atinga A, Shekkeris A, Fertleman M, Batrick N, Kashef E, Dick E. Trauma in the elderly patient. Br J Radiol 2018; 91:20170739. [PMID: 29509505 DOI: 10.1259/bjr.20170739] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Major Trauma Centres and Emergency Departments are treating an increasing number of elderly trauma patients in the UK. Elderly patients, defined as those over the age of 65 years, are more susceptible to injury from lesser mechanisms of trauma than younger adults. The number of elderly trauma cases is rising yearly, accounting for >25% of all major trauma nationally. The elderly have different physiological reserves and a different response to trauma due to premorbid frailty, co-existing conditions and prescribed medication. These factors need to be appreciated in trauma triaging, radiological assessment and clinical management. A lower threshold for trauma-call activation is recommended, including a lower threshold for advanced imaging. We will review general principles of trauma in the elderly, outline injury patterns in this age group and illustrate the radiological features per anatomical site, from head to pelvis and the extremities. We advocate using contrast-enhanced computed tomography as the primary diagnostic imaging modality as concern about intravenous contrast agent-induced nephropathy is relatively minor. Prompt investigation and diagnosis leads to timely appropriate treatment, therefore the radiologist can discerningly improve morbidity and mortality in this vulnerable group.
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Affiliation(s)
- Angela Atinga
- 1 Department of Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust , London , UK
| | - Andreas Shekkeris
- 1 Department of Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust , London , UK
| | - Michael Fertleman
- 2 Department of Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust , London , UK
| | - Nicola Batrick
- 3 Department of Emergency Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust , London , UK
| | - Elika Kashef
- 1 Department of Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust , London , UK
| | - Elizabeth Dick
- 1 Department of Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust , London , UK
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Abstract
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.
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23
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Rowbotham SK, Blau S, Hislop-Jambrich J, Francis V. Skeletal Trauma Resulting From Fatal Low (≤3 m) Free Falls: An Analysis of Fracture Patterns and Morphologies. J Forensic Sci 2017; 63:1010-1020. [DOI: 10.1111/1556-4029.13701] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/10/2017] [Accepted: 10/31/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Samantha K. Rowbotham
- Department of Forensic Medicine; Monash University; 65 Kavanagh Street Southbank Vic 3006 Australia
| | - Soren Blau
- Department of Forensic Medicine; Monash University; 65 Kavanagh Street Southbank Vic 3006 Australia
- Victorian Institute of Forensic Medicine; 65 Kavanagh Street Southbank Vic 3006 Australia
| | | | - Victoria Francis
- Victorian Institute of Forensic Medicine; 65 Kavanagh Street Southbank Vic 3006 Australia
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Pelvic fractures in the Netherlands: epidemiology, characteristics and risk factors for in-hospital mortality in the older and younger population. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:197-205. [PMID: 28993913 DOI: 10.1007/s00590-017-2044-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/24/2017] [Indexed: 01/24/2023]
Abstract
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.
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Rehwald R, Schönherr E, Petersen J, Jeske HC, Fialkovska A, Luger AK, Grams AE, Loizides A, Jaschke W, Glodny B. Prognostic factors in endovascular treated pelvic haemorrhage after blunt trauma. BMC Surg 2017; 17:89. [PMID: 28793885 PMCID: PMC5551004 DOI: 10.1186/s12893-017-0283-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 07/25/2017] [Indexed: 12/20/2022] Open
Abstract
Background Angioembolization is the method of choice for treating haemorrhage after blunt pelvic trauma. The aim of this study was to determine technical factors related to endovascular procedures which might be related to patient outcome. Methods This retrospective study included 112 consecutive patients (40 women and 72 men; mean age 57.2 ± 20.0). Results There were age peaks at 43 and at 77 years. Patients over 65 years had mainly “low-energy” trauma; younger patients were more likely to have polytraumas. Younger patients were more severely injured and had more surgical interventions, larger haematoma volumes, lower Hb levels and required more transfusions than older patients. Women were older than men, had fewer surgeries and waited longer for an angiography (p < 0.05 each). Logistic regression analyses identified the injury severity score (ISS) as relevant for survival before age, haematoma volume and Hb. Propensity score analyses showed that in addition to the need for transfusions, haemoglobin, and haematoma volume, the length of the coils and the number of microcoils used were relevant (p < 0.05 each). The location of haemorrhage in peripheral parietal arteries (superior and inferior gluteal artery) was an influencing factor for re-angiographies, which were associated with considerably longer hospital stays of more than 40 days. Fewer particles had generally been used in these patients. Conclusions The use of too few coils and not using microparticles in angioembolization for pelvic haemorrhage are major influencing factors for the mortality or re-angiography rate. Special attention should be given to thorough peripheral embolization with microcoils, in particular for haemorrhage from the parietal branches of the internal iliac artery.
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Affiliation(s)
- Rafael Rehwald
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.,Institute of Neurology, University College London, Queen Square, London, United Kingdom
| | - Elisabeth Schönherr
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Johannes Petersen
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Hans-Christian Jeske
- Department of Trauma Surgery, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Anna Fialkovska
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Anna Katharina Luger
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Astrid Ellen Grams
- Department of Neuroradiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Alexander Loizides
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Werner Jaschke
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
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Carpenter CR, Arendts G, Hullick C, Nagaraj G, Cooper Z, Burkett E. Major trauma in the older patient: Evolving trauma care beyond management of bumps and bruises. Emerg Med Australas 2017; 29:450-455. [DOI: 10.1111/1742-6723.12785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 03/19/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine; Washington University School of Medicine in St. Louis; St. Louis Missouri USA
| | - Glenn Arendts
- Department of Emergency Medicine; The University of Western Australia; Perth Western Australia Australia
- Harry Perkins Institute for Medical Research, Centre for Clinical Research in Emergency Medicine; Perth Western Australia Australia
| | - Carolyn Hullick
- Emergency Department, John Hunter Hospital; Newcastle New South Wales Australia
- Department of Emergency Medicine; Faculty of Health and Medicine, The University of Newcastle; Newcastle New South Wales Australia
| | - Guruprasad Nagaraj
- Department of Emergency Medicine; Liverpool Hospital; Liverpool New South Wales Australia
- Department of Emergency Medicine, School of Medicine; The University of Sydney; Sydney New South Wales Australia
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital; Harvard University School of Medicine; Boston Massachusetts USA
| | - Ellen Burkett
- Princess Alexandra Hospital; Brisbane Queensland Australia
- Department of Emergency Medicine; School of Medicine, The University of Queensland; Brisbane Queensland Australia
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27
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Advanced Imaging Lacks Clinical Utility in Treating Geriatric Pelvic Ring Injuries Caused by Low-Energy Trauma. J Orthop Trauma 2017; 31:194-199. [PMID: 27984444 DOI: 10.1097/bot.0000000000000761] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Abstract
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.
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Aoki M, Hagiwara S, Tokue H, Shibuya K, Kaneko M, Murata M, Nakajima J, Sawada Y, Isshiki Y, Ichikawa Y, Oshima K. Prediction of extravasation in pelvic fracture using coagulation biomarkers. Injury 2016; 47:1702-6. [PMID: 27267962 DOI: 10.1016/j.injury.2016.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 05/02/2016] [Accepted: 05/09/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the usefulness of coagulation biomarkers, which are easy and quick to analyze in emergency settings, for prediction of arterial extravasation due to pelvic fracture. PATIENTS AND METHODS The medical records of pelvic fracture patients transferred to the emergency department of Gunma University Hospital between December 2009 and May 2015 were reviewed. Patients were divided into two groups, those with (Extra(+)) and without (Extra(-)) arterial extravasation on enhanced CT or angiography. Levels of fibrin degradation products (FDP), D-dimer, fibrinogen, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, systolic blood pressure, heart rate, the Glasgow Coma Scale, pH, base excess, hemoglobin and lactate levels, the pattern of pelvic injury, and injury severity score were measured at hospital admission, and compared between the two groups. Parameters with a significant difference between the two groups were used to construct receiver operating characteristic (ROC) curves. RESULTS The study included 29 patients with pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most useful parameters for predicting arterial extravasation due to pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, and hemoglobin and lactate levels were significantly higher in the Extra(+) group than in the Extra(-) group (FDP, 354.8μg/mL [median] versus 96.6μg/mL; D-dimer, 122.3μg/mL versus 42.1μg/mL; the ratio of FDP to fibrinogen, 3.39 versus 0.42; the ratio of D-dimer to fibrinogen, 1.14 versus 0.18; hemoglobin, 10.5g/dL versus 13.5g/dL; lactate, 3.5mmol/L versus 1.7mmol/L). The area under the ROC curves for FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, hemoglobin and lactate levels were 0.900, 0.882, 0.918, 0.900, 0.815 and 0.765, respectively. CONCLUSION Coagulation biomarkers, and hemoglobin and lactate levels could be useful to predict the existence of arterial extravasation due to pelvic fracture. The ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most accurate markers. Coagulation biomarkers may enable more rapid and specific treatment for pelvic fracture.
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Affiliation(s)
- Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan; Emergency and General Medical Center, Gunma University Hospital, Maebashi, Japan.
| | - Shuichi Hagiwara
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan; Emergency and General Medical Center, Gunma University Hospital, Maebashi, Japan
| | - Hiroyuki Tokue
- Department of Diagnostic and Interventional Radiology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Kei Shibuya
- Department of Diagnostic and Interventional Radiology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Minoru Kaneko
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan; Emergency and General Medical Center, Gunma University Hospital, Maebashi, Japan
| | - Masato Murata
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan; Emergency and General Medical Center, Gunma University Hospital, Maebashi, Japan
| | - Jun Nakajima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan; Emergency and General Medical Center, Gunma University Hospital, Maebashi, Japan
| | - Yusuke Sawada
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan; Emergency and General Medical Center, Gunma University Hospital, Maebashi, Japan
| | - Yuta Isshiki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan; Emergency and General Medical Center, Gunma University Hospital, Maebashi, Japan
| | - Yumi Ichikawa
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan; Emergency and General Medical Center, Gunma University Hospital, Maebashi, Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan; Emergency and General Medical Center, Gunma University Hospital, Maebashi, Japan
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Bhattacharya B, Davis KA. Nuances in the Care of Emergent Splenic Injury in the Elderly Patient. CURRENT GERIATRICS REPORTS 2016. [DOI: 10.1007/s13670-016-0153-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Improved Survival After Pelvic Fracture: 13-Year Experience at a Single Trauma Center Using a Multidisciplinary Institutional Protocol. J Orthop Trauma 2016; 30:22-8. [PMID: 26360539 DOI: 10.1097/bot.0000000000000443] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyze pelvic fracture mortality rates before and after initiation of a multidisciplinary pelvic fracture protocol. DESIGN Retrospective database analysis. SETTING Prospective data from our Level-I National Trauma Registry of The American College of Surgeons (NTRACS) database. PATIENTS/PARTICIPANTS A total of 1682 trauma patients with pelvic fractures from 2000 to 2013 were compared with a control group of 42,629 without pelvic fractures. INTERVENTION Initiation of a multidisciplinary institutional protocol to guide the initial management of trauma patients with pelvic fractures. MAIN OUTCOME MEASUREMENTS Patients were grouped into 3 periods (group 1: 2000-2003, group 2: 2004-2007, group 3: 2008-2013). Multivariate logistic regression analysis was conducted to assess associations between mortality and age, shock (systolic blood pressure less than or equal to 90 mm Hg), head injury (Glasgow Coma Scale less than or equal to 8), Injury Severity Score (ISS), and time period. RESULTS Unadjusted mortality rates decreased [12.5%-11.0% (P = 0.72)]; however, ISS increased [19.1-22.7 (P < 0.01)]. Age, shock, head injury, increasing ISS, and earlier period were significantly associated with mortality. Adjusted mortality decreased over time [odds ratio for 2000-2003 vs. 2008-2013: 2.05, 95% confidence interval = (1.26, 3.33) and odds ratio for 2004-2007 vs. 2008-2013: 1.71, 95% confidence interval = (1.09, 2.67)]. From 2000 to 2003, an unstable fracture pattern in the healthiest cohort significantly increased mortality compared with the stable fracture pattern cohort (8.6% and 0.0%, P < 0.01). In subsequent intervals, there was no statistically significant association between stable versus unstable fracture patterns and mortality. CONCLUSIONS Adjusted pelvic fracture mortality rates have significantly decreased over time. In the healthiest patients with unstable pelvic fractures, the mortality rate is now similar to that of patients with stable fracture patterns. With sustained institutional effort to address pelvic fractures, mortality rates can be diminished. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Wang H, Phillips JL, Robinson RD, Duane TM, Buca S, Campbell-Furtick MB, Jennings A, Miller T, Zenarosa NR, Delaney KA. Predictors of mortality among initially stable adult pelvic trauma patients in the US: Data analysis from the National Trauma Data Bank. Injury 2015; 46:2113-7. [PMID: 26377773 DOI: 10.1016/j.injury.2015.08.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/29/2015] [Accepted: 08/29/2015] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States.
| | - J Laureano Phillips
- Department of Surgery, Research Institute, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States
| | - Richard D Robinson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States
| | - Therese M Duane
- Department of Surgery, Research Institute, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States
| | - Stefan Buca
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States
| | - Mackenzie B Campbell-Furtick
- Department of Surgery, Research Institute, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States
| | - Adam Jennings
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States
| | - Tyler Miller
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States
| | - Nestor R Zenarosa
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States
| | - Kathleen A Delaney
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, United States
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Ojodu I, Pohlemann T, Hopp S, Rollmann MFR, Holstein JH, Herath SC. Predictors of mortality for complex fractures of the pelvic ring in the elderly: a twelve-year review from a German level I trauma center. Injury 2015; 46:1996-8. [PMID: 26275513 DOI: 10.1016/j.injury.2015.07.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 07/03/2015] [Accepted: 07/26/2015] [Indexed: 02/02/2023]
Abstract
STUDY OBJECTIVE To document mortality rate and predictors of mortality in elderly patients with complex pelvic fractures. METHODS We reviewed a total of 84 subjects whose ages were above 70 years with complex pelvic fractures, admitted to our hospital from January 2001 to December 2012. A multivariate linear regression model was used to determine the predictors of mortality in the study population. The median age of the patients was 80.4 years (range 70-94 years). 65 of 84 (77%) patients were females. There were 72 Tile Type B fractures (86%) and 12 Type C fractures (14%). The most common associated injuries were thoracic, extremity and head injuries, with incidence of 13 (15%), 11 (13%), and 9 (11%), respectively. RESULTS The mortality rate was 10% in our study population. The initial haemoglobin on admission (p<0.01), the presence of blood vessel injuries (p<0.01) and the number of PRBCs transfused within the first six hours after admission (p<0.01) independently predicted mortality in elderly patients with complex pelvic fractures. CONCLUSION Although there is a downward trend in mortality in elderly patients with complex pelvic fractures, haemodynamic instability still has a significant impact on survival of those patients.
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Affiliation(s)
- Ishaq Ojodu
- Department of Trauma, Hand, and Reconstructive Surgery, University of Saarland, Kirrberger Strasse 1, 66421 Homburg/Saar, Germany; Department of Orthopedic and Trauma Surgery, Cedarcrest Hospital, 37 Oladipo Bateye Street, 23401 Lagos, Nigeria
| | - Tim Pohlemann
- Department of Trauma, Hand, and Reconstructive Surgery, University of Saarland, Kirrberger Strasse 1, 66421 Homburg/Saar, Germany
| | - Sascha Hopp
- Department of Trauma, Hand, and Reconstructive Surgery, University of Saarland, Kirrberger Strasse 1, 66421 Homburg/Saar, Germany
| | - Mika F R Rollmann
- Department of Trauma, Hand, and Reconstructive Surgery, University of Saarland, Kirrberger Strasse 1, 66421 Homburg/Saar, Germany
| | - Joerg H Holstein
- Department of Trauma, Hand, and Reconstructive Surgery, University of Saarland, Kirrberger Strasse 1, 66421 Homburg/Saar, Germany
| | - Steven C Herath
- Department of Trauma, Hand, and Reconstructive Surgery, University of Saarland, Kirrberger Strasse 1, 66421 Homburg/Saar, Germany.
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Mears SC, Kates SL. A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2. Geriatr Orthop Surg Rehabil 2015; 6:58-120. [PMID: 26246957 DOI: 10.1177/2151458515572697] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.
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The Immediate Intramedullary Nailing Surgery Increased the Mitochondrial DNA Release That Aggravated Systemic Inflammatory Response and Lung Injury Induced by Elderly Hip Fracture. Mediators Inflamm 2015; 2015:587378. [PMID: 26273137 PMCID: PMC4530272 DOI: 10.1155/2015/587378] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/08/2015] [Accepted: 02/20/2015] [Indexed: 02/04/2023] Open
Abstract
Conventional concept suggests that immediate surgery is the optimal choice for elderly hip fracture patients; however, few studies focus on the adverse effect of immediate surgery. This study aims to examine the adverse effect of immediate surgery, as well as to explore the meaning of mtDNA release after trauma. In the experiment, elderly rats, respectively, received hip fracture operations or hip fracture plus intramedullary nail surgery. After fracture operations, the serum mtDNA levels as well as the related indicators of systemic inflammatory response and lung injury significantly increased in the rats. After immediate surgery, the above variables were further increased. The serum mtDNA levels were significantly related with the serum cytokine (TNF-α and IL-10) levels and pulmonary histological score. In order to identify the meaning of mtDNA release following hip fracture, the elderly rats received injections with mtDNA. After treatment, the related indicators of systemic inflammatory response and lung injury significantly increased in the rats. These results demonstrated that the immediate surgery increased the mtDNA release that could aggravate systemic inflammatory response and lung injury induced by elderly hip fracture; serum mtDNA might serve as a potential biomarker of systemic inflammatory response and lung injury following elderly hip fracture.
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Sadro CT, Sandstrom CK, Verma N, Gunn ML. Geriatric Trauma: A Radiologist’s Guide to Imaging Trauma Patients Aged 65 Years and Older. Radiographics 2015; 35:1263-85. [DOI: 10.1148/rg.2015140130] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
ABSTRACT
Objective:
We examined the records of patients presenting to the emergency department (ED) with low-impact pelvic fractures. We describe frequency, demographics, management and patient outcomes in terms of ambulatory ability, living independence and mortality.
Methods:
Patients treated for a pelvic fracture over a 2-year period in Kingston, Ont., were identified. We performed a retrospective hospital record review to distinguish high- versus low-impact injury mechanisms, and to characterize the injury event, ED management and outcomes for patients with low-impact fractures.
Results:
Of 132 pelvic fractures identified, 77 were low-impact fractures. Patients were predominantly women (82%) with a mean age of 81 years; 96% had some pre-existing medical comorbidity. The pubic rami were most commonly involved (86%). The median length of stay in the ED was 9.4 hours. Twenty-five patients (32%) were admitted to hospital. Ten patients had surgical stabilization, mostly of the acetabulum. Five patients died in hospital, 4 from pneumonia and 1 from myocardial infarction. Eight additional patients died within 1 year of injury. At discharge, only 18% lived independently and 16% walked without aids versus 42% and 38%, respectively, before injury.
Conclusion:
Low-impact pelvic fractures affect predominantly elderly women with pre-existing comorbidities. A substantial amount of time and resources in the ED are used during the workup of these patients and while awaiting their disposition from the ED. These injuries are important because they affect independence and seem associated with an increased risk of death.
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Kodadek LM, Selvarajah S, Velopulos CG, Haut ER, Haider AH. Undertriage of older trauma patients: is this a national phenomenon? J Surg Res 2015; 199:220-9. [PMID: 26070496 DOI: 10.1016/j.jss.2015.05.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/01/2015] [Accepted: 05/12/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Older age is associated with high rates of morbidity and mortality after injury. Statewide studies suggest significantly injured patients aged ≥55 y are commonly undertriaged to lower level trauma centers (TCs) or nontrauma centers (NTCs). This study determines whether undertriage is a national phenomenon. MATERIALS AND METHODS Using the 2011 Nationwide Emergency Department Sample, significantly injured patients aged ≥55 y were identified by diagnosis and new injury severity score (NISS) ≥9. Undertriage was defined as definitive care anywhere other than level I or II TCs. Weighted descriptive analysis compared characteristics of patients by triage status. Multivariable logistic regression determined predictors of undertriage, controlling for hospital characteristics, injury severity, and comorbidities. RESULTS Of 4,152,541 emergency department (ED) visits meeting inclusion criteria, 74.0% were treated at lower level TCs or NTCs. Patients at level I and II TCs more commonly had NISS ≥9 (22.2% versus 12.3%, P < 0.001), but among all patients with NISS ≥9, 61.3% were undertriaged to a lower level TC or a NTC. On multivariable logistic regression, factors independently associated with higher odds of being undertriaged were increasing age, female gender, and fall-related injuries. A subgroup analysis examined urban and suburban areas only where access to a TC is more likely and found that 55.8% of patients' age were undertriaged. CONCLUSIONS There is substantial undertriage of patients aged ≥55 y nationwide. Over half of significantly injured older patients are not treated at level I or II TCs. The impact of undertriage should be determined to ensure older patients receive trauma care at the optimal site.
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Affiliation(s)
- Lisa M Kodadek
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Shalini Selvarajah
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Catherine G Velopulos
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Division of Trauma and Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adil H Haider
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
OBJECTIVES To determine predictors of pelvic fracture-related arterial bleeding (PFRAB) from the information available in the Emergency Department (ED). DESIGN Prospective cohort study. SETTING Single level-1 Trauma Center. PATIENTS In a 3-year period ending in December 2008, consecutive high-energy pelvic fracture patients older than 18 years were included. Patients who arrived >4 hours after injury or dead on arrival were excluded. Patient management followed advanced trauma life support and institutional guidelines. Collected data included patient demographics, mechanism of injury, vital signs, acid-base status, fluid resuscitation, trauma scores, fracture patterns, procedures, and outcomes. Potential predictors were identified using standard statistical tests: Univariate analysis, Pearson correlation (r), receiver operator characteristic, and decision tree analysis. INTERVENTION Observational study. OUTCOME MEASURES PFRAB was determined based on angiography or computed tomography angiogram or laparotomy findings. RESULTS Of the 143 study patients, 15 (10%) had PFRAB. They were significantly older, more severely injured, more hypotensive, more acidotic, more likely to require transfusions in the ED, and had higher mortality rate than non-PFRAB patients. No single variable proved to be a strong predictor but some had a significant correlation with PFRAB. Useful predictors identified were worst base deficit (BD), receiver operator characteristic (0.77, cutoff: 6 mmol/L, r = 0.37), difference between any 2 measures of BD within 4 hours (ΔBD) >2 mmol/L, transfusion in ED (yes/no), and worst systolic blood pressure <104 mm Hg. Demographics, injury mechanism, fracture pattern, temperature, and pH had poor predictive value. CONCLUSIONS BD <6 mmol/L, ΔBD >2 mmol/L, systolic blood pressure <104 mm Hg, and the need for transfusion in ED are independent predictors of PFRAB in the ED. These predictors can be valuable to triage blunt trauma victims for pelvic hemorrhage control with angiography. LEVEL OF EVIDENCE Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Delayed bleeding and pelvic haematoma after low-energy osteoporotic pubic rami fracture in a warfarin patient: an unusual cause of abdominal pain. Case Rep Emerg Med 2014; 2014:783268. [PMID: 25143839 PMCID: PMC4124805 DOI: 10.1155/2014/783268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 07/05/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction. Acute abdominal pain may be the presenting symptom in a wide range of diseases in the elderly. Acute abdominal pain related to a delayed bleeding and pelvic haematoma after a low-energy pubic rami fracture is rare and can have important consequences; to the best of our knowledge, only one case has been previously described. Case Report. We present an unusual case of an 83-year-old woman taking warfarin for atrial fibrillation, admitted to the Emergency Department (ED) with acute abdominal pain and progressive anemia related to a delayed bleeding and pelvic haematoma 72 hours after a low-energy osteoporotic pubic rami fracture. Warfarin was withheld, anticoagulation was reversed by using fresh frozen plasma and vitamin K, and concentrated red blood cells were given. Haemoglobin level gradually returned to normal with a progressive resorption of the haematoma. Conclusion. Delayed bleeding and pelvic haematoma after osteoporotic pubic rami fracture should be considered in the differential diagnosis of acute abdominal pain in the elderly. This case indicates the need for hospital admission, careful haemodynamic monitoring, and early identification of bleeding in patients with "benign" osteoporotic pubic rami fracture, especially those receiving anticoagulants, to provide an adequate management and prevent severe complications.
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Alton TB, Firoozabadi R. Management of Pelvic Ring Fractures in the Geriatric Patient. CURRENT GERIATRICS REPORTS 2014. [DOI: 10.1007/s13670-014-0082-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Preinjury ambulatory status is associated with 1-year mortality following lateral compression Type I fractures in the geriatric population older than 80 years. J Trauma Acute Care Surg 2014; 76:1306-9. [DOI: 10.1097/ta.0000000000000212] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Linn M, Schwartz A. Bilateral Iliac Fracture: An Unusual Sequela of Osteoporosis and Spinal Fusion: A Case Report. JBJS Case Connect 2014; 4:e8. [PMID: 29252554 DOI: 10.2106/jbjs.cc.m.00118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Michael Linn
- Department of Orthopaedic Surgery, Washington University, Campus Box 8233, 660 South Euclid, St. Louis, MO 63110
| | - Alexandra Schwartz
- Department of Orthopaedic Surgery, University of California, San Diego, 350 Dickinson Street, San Diego, CA 92103
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Evaluation of geriatric patients with trauma scores after motor vehicle trauma. Am J Emerg Med 2013; 31:1453-6. [DOI: 10.1016/j.ajem.2013.07.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 07/20/2013] [Accepted: 07/24/2013] [Indexed: 11/19/2022] Open
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Abstract
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.
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Abstract
Despite the increasing prevalence of high-energy skeletal trauma in the elderly (i.e., sixty years or older), there is a lack of prospective data regarding best care for these injuries.Elderly patients with multiple injuries are often undertriaged to trauma centers and underresuscitated.Aggressive early resuscitation can improve outcomes in elderly patients who have sustained skeletal trauma.Comanagement by orthopaedic surgeons and geriatricians of elderly patients with skeletal trauma can lead to a lower length of hospital stay, lower readmission rates, shorter time to operation, lower complication rates, and lower mortality.
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Affiliation(s)
- Julie A Switzer
- Division of Orthopaedic Trauma, University of Minnesota-Regions Hospital, 640 Jackson Street, St. Paul, MN 55101, USA.
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50
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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. Am J Surg 2012; 204:921-5; discussion 925-6. [PMID: 23063096 DOI: 10.1016/j.amjsurg.2012.05.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 05/09/2012] [Accepted: 05/22/2012] [Indexed: 11/20/2022]
Abstract
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.
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