Orthopaedic trauma in the pregnant patient

An interplay between orthopaedic trauma and pregnancy-A case series of 42 patients

BACKGROUND

Pregnancy and trauma are complex situations with significant implications for maternal and fetal health. Physical and psychological trauma during pregnancy can lead to pre-term labor, abruptio-placenta, and fetal injury or death. Management of trauma is challenging due to physiological and anatomical changes, which can affect fracture management and the risk of radiation exposure. A multidisciplinary approach is beneficial for patient care. This study aimed to determine the impact of orthopaedic trauma on pregnancy and its outcome, and influence of pregnancy on fracture management.

METHODS AND MATERIAL

A retrospective-study was conducted at a Level-1 trauma-care-center, focusing on 54 pregnant women who sustained trauma between January 2015 and December 2022. The study included patients with closed or open fractures, but excluded those without fractures. Forty-two patients were available with minimum 1 year follow-up. Data was collected from hospital records and PACS, including demographic details, emergency care, and laboratory parameters. Changes made in protocol in fracture management due to pregnancy (primary definitive fixation vs staged management), and impact of trauma on pregnancy outcome; mode-of-delivery, maternal and fetal loss were evaluated.

RESULTS

The mean age was 30-years (range: 21-43years). Road-traffic-collision was most-common mode-of-injury (66.7 %). 38.1 % were in the first-trimester, 35.7 % in second, and 26.2 % in third-trimester. Eight patients had polytrauma, seven had multiple-injuries, and 27 had isolated-injuries. The maternal-mortality-rate was 0.45 %. Three polytraumatized patients ended up with intrauterine death, two polytrauma patients underwent elective abortion, one patient presented with spontaneous-abortion, and fetal loss was 14.3 % (6-of-42). Out of 42 patients, 10 had open-injuries and 32 had closed-injuries. Nine patients underwent LSCS(lower-segment-caesarean-section), six of them were planned for elective-LSCS due to injury and associated fractures (two patients with pelvic injuries, two neck femur fracture patients, one open distal femur fracture, and one ankle fracture dislocation).

CONCLUSION

Orthopaedic trauma during pregnancy can significantly affect pregnancy outcomes and is associated with a notably higher risk of fetal loss. An elective-caesarean-section is recommended for patients with polytrauma, pelvic-injuries, and those who are immobilized for longer-duration. During the third-trimester and in polytraumatized patients, external-fixator-application for lower-limb-injuries is a safe strategy, and definitive fixation could be performed post-delivery.

Nonoperative Management of Both Column Acetabular Fracture and Protrusio Acetabuli in a Pregnant Patient: A Case Report

CASE

We present a case of a 39-year-old woman at 23 weeks gestation who sustained traumatic both-column acetabular fracture and protrusio acetabuli, managed with initial traction and delayed total hip arthroplasty (THA) until after cesarean section delivery.

CONCLUSION

Initial skeletal traction with subsequent delayed THA may be a viable treatment option in select pregnant female patients who sustain both-column acetabular fractures. Interdisciplinary collaboration is necessary to optimize maternal-fetal health and provide patient education of procedural risk to enable informed decision making.

Incidence of fracture hospitalization and surgery during pregnancy in Finland-1998-2017: a retrospective register-based cohort study

INTRODUCTION

The aim of this study was to assess the incidence of all major fractures and surgery during pregnancy and the outcomes of pregnancy in Finland between 1998 and 2017.

MATERIALS AND METHODS

A retrospective cohort study using nationwide data from the Finnish Care Register for Health Care and the Finnish Medical Birth Register. As participants we included all women aged between 15 and 49 years from January 1, 1998 to December 31, 2017 and their ≥ 22-week pregnancies.

RESULTS

Of a total 629,911 pregnancies, 1813 pregnant women were hospitalized with a fracture diagnosis, yielding an incidence of 247 fractures/100,000 pregnancy-years. Of these, 24% (n = 513/2098) were treated operatively. The most common fractures were fractures of the tibia, ankle, and the forearm, which made up half of all fractures. The incidence of pelvic fractures was 6.8/100,000 pregnancy-years, with an operation rate of 14%. The stillbirth rate of all fracture patients was low at 0.6% (n = 10/1813), although this was 1.5-fold the overall stillbirth rate in Finland. Lumbosacral and comminuted spinopelvic fractures resulted in preterm delivery in 25% (n = 5/20) of parturients, with a stillbirth rate of 10% (n = 2/20).

CONCLUSION

The incidence of fracture hospitalization during pregnancy is lower than in the general population, and fractures in this population are more often treated conservatively. A higher proportion of preterm deliveries and stillbirths occurred in women with lumbosacral and comminuted spinopelvic fractures. Maternal mortality and stillbirth rates remain low among women with fractures leading to hospitalization or surgery during pregnancy.

Combined Acetabulum Fracture and Hip Dislocation in an 18-Year-Old Female at 35-Week Gestation: A Case Report and Review of the Literature

Caring for an injured, pregnant patient can be a management challenge. We report the case of an 18-year-old female who sustained a left acetabulum fracture with a concurrent hip dislocation at 35 weeks' gestation following a motor vehicle accident. Through an interdisciplinary, team-based approach, the patient was guided through obstetric delivery and orthopedic surgical fracture fixation without complication. By being familiar with the unique challenges in management posed by pregnant patients, orthopedic surgeons can be better equipped to minimize morbidity and mortality in this patient population while maximizing clinical outcomes.

Lateral Compression-I Pelvic Ring Injury: Not Benign to the Developing Fetus

OBJECTIVE

To determine whether certain patterns of pelvic ring injury are associated with more frequent intrauterine fetal demise (IUFD).

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Of 44 pregnant patients with pelvic and/or acetabular fractures, 40 had complete records that allowed determination of fetal viability. χ2 tests were used for categorical variables (Fisher exact tests when expected cell counts were fewer than 5), and t tests were used for continuous variables.

MAIN OUTCOME MEASUREMENTS

Fetal or maternal death.

RESULTS

Sixteen patients had isolated acetabular fractures, 25 had isolated pelvic ring injuries, and 3 had acetabular fractures with concomitant pelvic ring injuries. Maternal and fetal mortality were 2% and 40%, respectively. No patients with isolated acetabular fractures experienced IUFD, compared with 68% (15/22) of those with isolated pelvic ring injuries (P < 0.0001). Eight (53%) of 15 IUFDs were associated with lateral compression (LC)-I pelvic ring injuries (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 61-B2). Of the 13 LC-I pelvic ring injuries, 8 (62%) resulted in IUFD. Pelvic ring stability, Young-Burgess classification, and operative treatment were not associated with IUFD. Maternal Glasgow Coma Scale (average 13.2) and Injury Severity Score (average 18.2) at admission were predictive of IUFD.

CONCLUSIONS

The most frequent pelvic fractures in gravid trauma patients are LC-I. Although the rate of maternal mortality was low, the risk of IUFD was quite high (40%). LC-I pelvic ring injuries often had catastrophic outcomes, with IUFD in 62% of cases.

LEVEL OF EVIDENCE

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

Treatment of Pregnant Patients With Orthopaedic Trauma

Fracture management in pregnant patients is challenging. Anatomic and physiologic changes in pregnancy increase the complexity of treatment. Maternal trauma increases the risk of fetal loss, preterm birth, placental abruption, cesarean delivery, and maternal death. Initial resuscitation and treatment in a facility equipped to handle the orthopaedic injury and preterm births are paramount. Pelvic and acetabular injuries are potentially life threatening. The benefits and risks of surgical treatment must be carefully considered. The risks posed by anesthetic agents, antibiotic agents, anticoagulant agents, and radiation exposure must be understood. Positioning of the patient can affect the viability of the fetus. If surgery is necessary, the left lateral decubitus position decreases fetal hypotension. A specialized team including an obstetrician, perinatologist, orthopaedic surgeon, general trauma surgeon, critical care specialist, emergency medicine specialist, anesthesiologist, radiologist, and nurse must collaborate to improve maternal and fetal outcomes.

Challenges in interventional radiology: the pregnant patient

A pregnant patient presenting to interventional radiology (IR) has a different set of needs from any other patient requiring a procedure. Often, the patient's care can be in direct conflict with the growth and development of the fetus, whether it be optimal fluoroscopic imaging, adequate sedation of the mother, or the timing of the needed procedure. Despite the additional risks and complexities associated with pregnancy, IR procedures can be performed safely for the pregnant patient with knowledge of the special and general needs of the pregnant patient, use of acceptable medications and procedures likely to be encountered during pregnancy, in addition to strategies to protect the patient and her fetus from the hazards of radiation.

Management of pelvic injuries in pregnancy

Pelvic fractures in pregnant women are usually high-energy injuries associated with risk of mortality to both mother and fetus. The mother's life always takes priority in the acute setting as it offers the best chance of survival to both the mother and the fetus. Indications for operative intervention of acute pubic symphysis rupture depend on presence of an open disruption, amount of displacement, and degree of disability. Chronic symphyseal instability related to pregnancy is a challenging problem and the first line of treatment is nonoperative care. A previous pelvic fracture is not a contraindication by itself to vaginal delivery.

Ankle fracture surgery on a pregnant patient complicated by intraoperative emergency caesarian section

We report the case of a woman in the third trimester of pregnancy who sustained an ankle fracture dislocation that could not be adequately closed reduced. After discussions with the patient, her obstetrician, and the anesthesiologists, she was indicated for surgical fixation. A heart tone monitor was used to assess fetal health during the procedure. During surgical incision, the fetus went into distress, and an emergency caesarian section was performed. After delivery of the infant and abdominal closer, surgery was completed. Due to a cohesive team effort, both the patient and her infant had excellent outcomes. There are many important considerations in the surgical management of the pregnant patient with traumatic orthopaedic injuries. Of especial importance to the orthopaedic surgeon is the impact of patient positioning on uteroplacental blood flow. This report discusses factors that should be taken into account by any orthopaedist who plans to operate on a pregnant patient.

Prenatal diagnosis and management of intrauterine fracture

Intrauterine fracture is an extremely rare finding, but can occur as the result of maternal trauma, osteogenesis imperfecta (OI), or theoretically other metabolic/structural abnormalities. Increased clinical awareness of the diagnosis and optimal management of these cases can lead to more positive outcomes for the patient and her child. Blunt abdominal trauma late in gestation increases the risk of fetal skull fracture, while a known diagnosis of OI or other abnormalities leading to decreased fetal bone density creates concern for long bone fracture. Biochemical and genetic tests can aid in the prenatal diagnosis of OI, while ultrasound is the best overall imaging modality for identifying fetal fracture of any etiology. When fetal fracture is diagnosed radiologically, specific management is recommended to promote optimal outcomes for mother and fetus, with special consideration given to the mother with OI. With the exception of fetal fractures due to lethal conditions, cesarean delivery is recommended in most cases, especially when fetal or maternal well-being cannot be assured. When a patient presents with risk factors for intrauterine fracture, careful evaluation via thorough history-taking, ultrasonography of the entire fetal skeleton, and laboratory tests should be performed. Heightened awareness of intrauterine fracture allows better postpartum management, whether for simple fracture care or for long-term care of patients with OI or genetic/metabolic abnormalities.

TARGET AUDIENCE

Obstetricians & Gynecologist, Family Physicians.

LEARNING OBJECTIVES

After completion of this educational activity, the reader will be able to compare x-ray, ultrasound modalities and MRI and their utility in diagnosing fetal fracture. Formulate a differential diagnosis for fetal fracture. Propose a delivery plan for a patient whose fetus has a prenatally diagnosed fetal fracture.

Awareness and attitudes amongst basic surgical trainees regarding radiation in orthopaedic trauma surgery

This study investigated the awareness and attitudes of basic surgical trainees. Trainees were asked to answer questions from a pre-set questionnaire. Fifty basic surgical trainees from England and Wales were involved in the study. The areas covered were basic knowledge of radiation hazards, use of protective wear, pregnancy test in female trauma victims of reproductive age, and principles of safe radiation. All the questions were asked in the context of orthopaedic trauma surgery. All questions were evidence based.It was unfortunate to notice that basic surgical trainees are lacking in the essential knowledge of ionising radiation. Most of the trainees are not adhering to radiation safety principle, and are not practising safely. The authors strongly recommend that surgical trainees should have more robust training and information available in this context. And they suggest that it should be provided on local, regional and national basis. © 2010 Biomedical Imaging and Intervention Journal. All rights reserved.

Complications associated with distraction osteogenesis for infected nonunion of the femoral shaft in the presence of a bone defect: a retrospective series

We undertook a retrospective study of 50 consecutive patients (41 male, 9 female) with an infected nonunion and bone defect of the femoral shaft who had been treated by radical debridement and distraction osteogenesis. Their mean age was 29.9 years (9 to 58) and they had a mean of 3.8 (2 to 19) previous operations. They were followed for a mean of 5.9 years (2.0 to 19.0). The mean duration of the distraction osteogenesis was 24.5 months (2 to 39). Pin-track infection was observed in all patients. The range of knee movement was reduced and there was a mean residual leg-length discrepancy of 1.9 cm (0 to 8) after treatment. One patient required hip disarticulation to manage intractable sepsis. In all, 13 patients had persistent pain. Bony union was achieved in 49 patients at a mean of 20.7 months (12 to 35). Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with a high rate of complications.

Operative fixation of acetabular fractures in the pregnant patient

OBJECTIVE

To describe in utero radiation exposures in pregnant patients undergoing acetabular fracture repair.

DESIGN

Retrospective case series.

SETTING

University-affiliated regional trauma center.

PATIENT/PARTICIPANTS

Eight pregnant patients with acetabular fractures treated over a 6-year period. There were an additional 518 acetabular fractures in nonpregnant patients treated during the same time period.

INTERVENTION

Open reduction and internal fixation of the acetabulum fracture.

OUTCOME MEASUREMENTS

None. This is a descriptive series reporting fetal radiation doses, fetal fluoroscopy exposure times, and fetal viability after treatment.

RESULTS

The gestational age of the fetuses at presentation ranged from 5 to 26 weeks. Infant delivery averaged 27 weeks from the time of surgery and all pregnancies reached 36 weeks. Apgar scores were normal each child including 1 twin delivery. There were 4 posterior wall fractures, 3 transverse or posterior wall fractures, and 1 posterior column fracture. Intraoperative pelvic fluoroscopy averaged 39 seconds. There were no operative complications and fracture reductions were anatomic in 7 patients. Computed tomography scan of the pelvis conferred the greatest exposure risk to the fetus and fluoroscopy conferred the least. In each case that required a computed tomography scan of the pelvis, the calculated radiation exposure dose to the fetus was greater than 5 cGy.

CONCLUSIONS

The results of this study demonstrate that with a team approach and the judicious use of radiographic imaging during the surgical care of a displaced acetabular fracture in the pregnant patient, minimal risk to the baby can be achieved in pursuit of acceptable articular reductions.