External Fixation for Temporary Stabilization and Wound Management of an Open Pelvic Ring Injury With Extensive Soft Tissue Damage: Case Report and Review of the Literature

Effect of Early Pelvic Binder Use in the Emergency Management of Suspected Pelvic Trauma: A Retrospective Cohort Study

BACKGROUND

We aimed to evaluate the effect of early pelvic binder use in the emergency management of suspected pelvic trauma, compared with the conventional stepwise approach.

METHODS

We enrolled trauma patients with initial stabilization using a pelvic binder when suspecting pelvic injury. The inclusion criteria were traumatic injury requiring a trauma team and at least one of the following: a loss of consciousness or a Glasgow coma score (GCS) of <13; systolic blood pressure of <90 mmHg; falling from ≥6 m; injury to multiple vital organs; and suspected pelvic injury. Various parameters, including gender, age, mechanism of injury, GCS, mortality, hospital stay, initial vital signs, revised trauma score, injury severity score, and outcome, were assessed and compared with historical controls.

RESULTS

A total of 204 patients with high-energy multiple-trauma from a single level I trauma center in North Taiwan were enrolled in the study from August 2013 to July 2014. The two group baseline patient characteristics were all collected and compared. The trauma patients with suspected pelvic fractures initially stabilized with a pelvic binder had shorter hospital and intensive care unit (ICU) stays. The study group achieved statistically significantly improved survival and lower mean blood transfusion volume and mortality rate, although they were more severe in the trauma score.

CONCLUSIONS

We recommend prompt pelvic binder use for suspected pelvic injury before definitive imaging is available, as a cervical spine collar is used to protect the cervical spine from further injury prior to definitive identification and characterization of an injury.

Midterm radiologic and functional outcomes of minimally-invasive fixation of unstable pelvic fractures using anterior internal fixator(INFIX) and percutaneous iliosacral screws

BACKGROUND

Anterior pelvic external fixation is associated with pin site infections, aseptic loosening with loss of reduction, frame bulkiness hindering patient mobilization and consequent difficulties in inpatient nursing. We performed a single-center prospective series to evaluate the feasibility, safety, limitations and midterm radiologic and functional outcomes of an alternative minimally invasive pelvic internal fixation technique using an anterior subcutaneous pelvic internal fixator (INFIX) and percutaneous iliosacral screws in unstable pelvic ring fractures.

METHODS

Fifteen consecutive patients with vertically and/or rotationally unstable pelvic fractures, presenting to a Level-1 trauma center were treated with closed reduction, appropriate posterior stabilization with percutaneous iliosacral screws and anterior INFIX application. Outcomes were analyzed with respect to the quality of fracture reduction (Matta's radiologic criteria), ease of inpatient nursing, patient mobility and comfort, functional outcomes at final follow-up (Majeed score, SF-12 score), social reintegration and complications.

RESULTS

Most common injury pattern was AO/OTA type 61-C pelvic fracture in thirteen patients. Mean procedure time and intra-operative blood loss were, 57.1+/-4.9 min (range,51-68 min) and 115.3+/-26.7 ml (range,80-170 ml) respectively. Mean follow-up was 34.9+/-4.1 months (range,31-42 months). Fracture reduction was excellent in twelve and good in three patients (Matta's criteria). Functional outcomes were excellent in eight and good in seven patients (Majeed score). Mean SF-12 scores for physical and mental health were 48.58+/-5.61 and 50.89+/-3.97 respectively. Thirteen patients returned to their pre-injury jobs. All fifteen patients reintegrated into society without any restrictions. INFIX was removed at a mean post-operative period of 7.3+/-1.5 months (range,5.5-11 months). Complications included, lateral femoral cutaneous nerve irritation(n = 1), superficial wound infection(n = 1) and loss of reduction(n = 2).

CONCLUSION

Minimally invasive pelvic stabilization using INFIX and percutaneous iliosacral screws is easy to learn and apply, achieves good fracture reduction and definitive stabilization with minimum complications and offers excellent functional outcomes at a minimum follow-up of 31 months.

LEVEL OF EVIDENCE

Level IV.

Anterior pre-tensioned external fixator for pelvic fractures and dislocations. Initial clinical series

In the treatment of unstable pelvic ring fractures, external fixators have the limitation of not adequately stabilizing the injured posterior elements. This article presents a novel and simple technique of temporary external fixation of the pelvic ring, able to produce compression of both the anterior and posterior pelvic elements. A curved flexible carbon-fiber rod is used, pre-tensioned before attachment to supra-acetabular Schanz screws. Although more extensive clinical experience is required, favorable preliminary results in a series of 13 patients with unstable pelvic fracture were encouraging: the aim of closing the posterior and anterior elements of the pelvic ring was achieved in all cases treated with this technique, and 12 patients survived. Radiological results were excellent in 3 cases and good in 9 cases. No major complications, such as secondary displacement, vertical re-displacement or deep infection, were observed. Mean operative time was 25min, compatible with emergency management.

Is application of an internal anterior pelvic fixator anatomically feasible?

BACKGROUND

Spinal hardware has been adapted for fixation in the setting of anterior pelvic injury. This anterior subcutaneous pelvic fixator consists of pedicle screws placed in the supraacetabular region connected by a contoured connecting rod placed subcutaneously and above the abdominal muscle fascia.

QUESTIONS/PURPOSES

We examined the placement of the components for anterior subcutaneous pelvic fixator relative to key vascular, urologic, bony, and surface structures.

METHODS

We measured the CT scans of 13 patients after placement of the pelvic fixator to determine the shortest distances between the fixator components and important anatomic structures: the femoral vascular bundle, the urinary bladder, the cranial margin of the hip, the screw insertion point on the bony pelvis, the relationship between the pedicle screw and the corridor of bone in which it resided, and the position relative to the skin.

RESULTS

The average distance from the vascular bundle to the pedicle screw was 4.1 cm and 2.2 cm to the connecting rod. The average distance from the connecting rod to the anterior edge of the bladder was 2.6 cm. The average distance from the screw insertion point to the hip was 2.4 cm; none penetrated the hip. The average screw was in bone for 5.9 cm. The pedicle screws were on average 2.1 cm under the skin. The average distance from the anterior skin to the connecting rod was 2.7 cm.

CONCLUSIONS

Components of this anterior pelvic fixator are close to important anatomic structures. Careful adherence to the surgical technique should minimize potential risk.

LEVEL OF EVIDENCE

Level IV, retrospective study. See Guidelines for Authors for a complete description of levels of evidence.

Pelvic fractures as a marker of injury severity in trauma patients

OBJECTIVE

To assess whether the presence of a pelvic fracture is associated with greater severity and worse prognosis in victims of blunt trauma.

METHODS

A retrospective analysis of protocols and records of victims of blunt trauma admitted from June 2008 to March 2009 was separated into two groups: those with pelvic fracture (Group I) and those without it (Group II). Data were collected from pre-hospital admission rates of trauma, laboratory tests, diagnosed lesions, treatment and outcome. We used the Student t test, Fisher's exact test and chi-square test for statistical analysis, considering p <0.05 as significant.

RESULTS

During the study period, 2019 individuals had multiple trauma protocols completed, of which 43 (2.1%) had pelvic fractures. Patients in Group I had significantly lower average blood pressure, higher mean heart rate, lower mean Glasgow Coma Scale, the highest average AIS in the segments head, chest, abdomen and extremities, as well as higher mean ISS and lower mean TRISS and RTS on admission. Group I more frequently presented with traumatic subarachnoid hemorrhage (7% vs. 1.6%), spinal cord injury (9% vs. 1%), thoracic and abdominal injuries, as well as need for laparotomy (21% vs. 1 %), chest drainage (32% vs. 2%) and damage control (9% vs. 0%). Complications were more frequent in group I: ARDS (9% vs. 0%), persistent shock (30% vs. 1%), coagulopathy (23% vs. 1%), acute renal failure (21% vs. 0%) and death (28% vs. 2%).

CONCLUSION

The presence of a pelvic fracture is a marker of greater severity and worse prognosis in victims of blunt trauma.

Percutaneous limited internal fixation combined with external fixation to treat open pelvic fractures concomitant with perineal lacerations

External fixation combined with colostomy is a traditional management of the pelvic fractures associated with perineal lacerations. However, malunion and dysfunction caused by malreduction and loss of reduction are common. One-stage definitive fixation without soft tissue harassment is requisite for the treatment. The purpose of this study was to assess the outcome of 1-stage definitive fixation by combining percutaneous limited internal fixation and external fixation in the treatment of pelvic fractures with perineal lacerations. Eighteen adults with high-energy unstable pelvic ring fractures associated with perineal lacerations were admitted between June 2003 and December 2010. Mean follow-up was 28 months. After wound closure and colostomy, 10 patients received external fixation and percutaneous screw fixation, and 8 patients underwent external fixation. Demographics, wound and fracture classification, and Injury Severity Score were comparable between the groups (P>.05). Initial reduction quality was comparable between the groups (P=.14), but the loss of reduction during follow-up was more significant in the external fixation group (P=.004). Combined fixation achieved better functional results than external fixation (P=.02). There were 2 cases of superficial wound infection in each group (P=1.0). By combining debridement, wound closure, colostomy, percutaneous limited internal fixation, and external fixation, we improved pelvic fracture recovery while reducing the risk of infection. One-stage definitive fixation is a better choice than external fixation in the treatment of open pelvic fracture concomitant with perineal wound.

Supra-acetabular external fixation for pelvic fractures: a digital anatomical study

Supra-acetabular external fixation is an important tool for pelvic fractures. Understanding the anatomical characteristics of anterior inferior iliac spine (AIIS) is crucial for the operation. Here, we analyzed the morphology of AIIS and adjacent structures via a digital measurement mode. One hundred and twenty normal pelvic computed tomography (CT) scans were converted into three-dimensional digital models and their parameters were measured by Geomagics software. We obtained the values of 13 important AIIS anatomical characteristics, which were the perpendicular distance of the anterior superior iliac spine(ASIS) and AIIS (PDASIS-AIIS), the perpendicular distance between the AIIS and superior pubic tubercle (PDAIIS-PT), the distance between the AIIS and anterior median line (HDAIIS-ML), the angle of the pin tract line and the horizontal plane (AHOR), the transverse diameter of AIIS (TD), and the minimum diameter of the pin tract plane (DMIN), etc. Among them, six parameters showed significant difference between male and female (PDASIS-AIIS: P =0.040, PDAIIS-PT: P = 0.001, HDAIIS-ML: P = 0.019, AHOR: P = 0.021, TD: P < 0.001, and DMIN: P = 0.003, respectively). These results provided references in locating pinning site for a safer and more accurate supra-acetabular external fixation and also suggested that gender difference should be considered during the surgery.

Randomised clinical trial comparing pressure characteristics of pelvic circumferential compression devices in healthy volunteers

INTRODUCTION

The role of pelvic circumferential compression devices (PCCDs) is to temporarily stabilise a pelvic fracture, reduce the volume and tamponade the bleeding. Tissue damage may occur when PCCDs are left in place longer than a few hours. The aim of this randomised clinical trial was to quantify the pressure at the region of the greater trochanters (GTs) and the sacrum, induced by PCCDs in healthy volunteers.

MATERIALS AND METHODS

In a crossover study, the Pelvic Binder(®), SAM-Sling(®) and T-POD(®) were applied successively onto 80 healthy participants in random order. The pressure was measured using a pressure mapping system, with the volunteers in supine position on a spine board and on a hospital bed. Data were analysed using Mixed Linear Modelling.

RESULTS

On a spine board, the pressure exceeded the tissue damaging threshold at the GTs and the sacrum. Pressure at the GTs was highest with the Pelvic Binder(®), and lowest with the SAM-Sling(®). Pressure at the sacrum was highest with the Pelvic Binder(®). The pressure at the GTs and sacrum was reduced significantly for all three PCCDs upon transfer to a hospital bed.

CONCLUSION

The results of this randomised clinical trial in healthy volunteers showed that patients with pelvic fractures, temporarily stabilised with a PCCD, are at risk for developing pressure sores. The pressure on the skin exceeded the tissue damaging threshold and is, besides PCCD type, influenced by BMI, waist size and age. Regardless with which PCCD trauma patients are stabilised, early transfer from the spine board is of key importance to reduce the pressure to a level below the tissue damaging threshold. Clinicians should be aware of the potential deleterious effects associated with the application of a PCCD, and every effort must be made to remove the PCCD once haemodynamic resuscitation has been established.

Comparison of three different pelvic circumferential compression devices: a biomechanical cadaver study

BACKGROUND

Pelvic circumferential compression devices are designed to stabilize the pelvic ring and reduce the volume of the pelvis following trauma. It is uncertain whether pelvic circumferential compression devices can be safely applied for all types of pelvic fractures because the effects of the devices on the reduction of fracture fragments are unknown. The aim of this study was to compare the effects of circumferential compression devices on the dynamic realignment and final reduction of the pelvic fractures as a measure of the quality of reduction.

METHODS

Three circumferential compression devices were evaluated: the Pelvic Binder, the SAM Sling, and the T-POD. In sixteen cadavers, four fracture types were generated according to the Tile classification system. Infrared retroreflective markers were fixed in the different fracture fragments of each pelvis. The circumferential compression device was applied sequentially in a randomized order with gradually increasing forces applied. Fracture fragment movement was studied with use of a three-dimensional infrared video system. Dynamic realignment and final reduction of the fracture fragments during closure of the circumferential compression devices were determined. A factorial repeated-measures analysis of variance with pairwise post hoc comparisons was performed to analyze the differences in pulling force between the circumferential compression devices.

RESULTS

In the partially stable and unstable (Tile type-B and C) pelvic fractures, all circumferential compression devices accomplished closure of the pelvic ring and consequently reduced the pelvic volume. No adverse fracture displacement (>5 mm) was observed in these fracture types. The required pulling force to attain complete reduction at the symphysis pubis varied substantially among the three different circumferential compression devices, with a mean (and standard error of the mean) of 43 ± 7 N for the T-POD, 60 ± 9 N for the Pelvic Binder, and 112 ± 10 N for the SAM Sling.

CONCLUSIONS

The Pelvic Binder, SAM Sling, and T-POD provided sufficient reduction in partially stable and unstable (Tile type-B1 and C) pelvic fractures. No undesirable overreduction was noted. The pulling force that was needed to attain complete reduction of the fracture parts varied significantly among the three devices, with the T-POD requiring the lowest pulling force for fracture reduction.