Complex Pelvic Injuries Research Articles

Clinical Workflow Algorithm for Preoperative Planning, Reduction and Stabilization of Complex Acetabular Fractures with the Support of Three-Dimensional Technologies.

Background: Treatment of pelvic injuries poses serious problems for surgeons due to the difficulties of the associated injuries. The objective of this research is to create a clinical workflow that integrates three-dimensional technologies in preoperative planning and performing surgery for the reduction and stabilization of associated acetabular fractures. Methods: The research methodology consisted of integrating the stages of virtual preoperative planning, physical preoperative planning, and performing the surgical intervention in a newly developed clinical workflow. The proposed model was validated in practice in a pilot surgical intervention. Results: On a complex pelvic injury case of a patient with an associated both-column acetabular fracture (AO/OTA-62C1g), we presented the results obtained in the six stages of the clinical workflow: acquisition of three-dimensional (3D) images, creation of the virtual model of the pelvis, creation of the physical model of the pelvis, preoperative physical simulation, orthopedic surgery, and imaging validation of the intervention. The life-size 3D model was fabricated based on computed tomography imagistics. To create the virtual model, the images were imported into Invesalius (version 3.1.1, CTI, Brazil), after which they were processed with MeshLab (version 2023.12, ISTI-CNR, Italy) and FreeCAD (version 0.21.2, LGPL, FSF, Boston, MA, USA). The physical model was printed in 21 h and 37 min using Ultimaker Cura software (version 5.7.2), on an Ultimaker 2+ printing machine through a Fused Deposition Modeling process. Using the physical model, osteosynthesis plate dimensions and fixation screw trajectories were tested to reduce the risk of neurovascular injury, after which they were adjusted and resterilized, which enhanced preoperative decision-making. Conclusions: The life-size physical model improved anatomical appreciation and preoperative planning, enabling accurate surgical simulation. The tools created demonstrated remarkable accuracy and cost-effectiveness that support the advancement and efficiency of clinical practice.

Computed tomography in the assessment of pelvic bone fractures in patients with combined injuries

To date, mortality from a complex pelvic injury remains high. It is noted that the total mortality from pelvic injury is 4.7 %. It is recognized that diagnostic imaging plays a leading role in the treatment of pelvic fractures, and image quality helps to reduce the morbidity and mortality of patients with injuries. The aim of the study was to evaluate the role of CT with three-dimensional reconstruction in the diagnosis of pelvic bone fractures. Material and methods. During the 36-month period, 76 patients of both sexes (54 (71.0 %) men and 22 (29.0 %) women) were examined. The Young-Burgess classification system was used to assess the nature of pelvic fractures. A spiral computed tomograph Aquilion 16 Model TSX-101A (Toshiba, Japan) was used. All patients are scanned in a supine position with no movement during the examination. The scan was started from the top of the iliac crest and continued through the level of the sciatic tubercles. The thickness of the cut and the step of the tomography is 10 mm, the table feed is 15 mm per tube revolution, the pitch is 1.5:1, the scanning time is 20–30 seconds. Results. The average age of the patients was 35.2 ± 1.77 years. The largest share was road injuries – 86.9 %: road accidents – 30.3 %, collisions with a pedestrian – 32.9 %, motorcycle and bicycle accidents – 23.7 %, falling from a height – 13.1 % of patients. Pelvic organ radiography diagnosed a sacral fracture in 33 (43.4 %) patients. Anteroposterior compression (AS) was recorded in 9.2 % of cases, of which AS-I in 7.89 %, AS-II – 1.31 %. Lateral compression was observed in 73.68 % of cases: LC-I – 57.89 %, LC-II – 10.53 %, LC-III – 5.26 %. Vertical shift and mixed mechanical injury were detected in 7.89 and in 7.89 % of cases, respectively. The unclassified fracture was detected in 1.31 % of cases. Pelvic ring fractures were associated with sacral fractures (69 (90.8 %) patients) and with acetabular fractures (63 (82.9 %) cases), in 6 (7.9 %) patients – not associated. Conclusions. In combined injuries, lateral compression injuries of the pelvis were more common, which, in comparison with traditional radiographs, were statistically significantly recognized on CT images (p < 0.001), which confirmed the fact that pelvic fractures are more common in lateral compression injuries than in anteroposterior injuries. For a complete assessment of the pelvic ring, in addition to the pelvic view, a CT scan of the lateral part of the sacrum is required.

Complex pelvic injury in a morbidly obese patient – A case report

Unstable pelvic ring injuries continue to be challenging to manage. Obese patients have a higher risk of complications and such management entails additional difficulties for emergency services and the medical-surgical team. A 41-year-old male with a body mass index of 44 fell from a water slide and suffered an anteroposterior pelvic compression impact injury. He presented with a Tile C1.3 pelvic fracture, Denis III sacral fracture, and Roy-Camille Type 4 spinopelvic dissociation. We performed a posterior triangular fixation and anterior double plating, and the patient gained full recovery and was able to return to work. This case report focuses on some key tools and techniques to consider when managing complex pelvic fractures in obese patients, requiring specialized equipment or adjustments to conventional treatments to obtain a good outcome. We used accessory portals through the fat pad to adequately place the plate screws. In addition, we used polypropylene mesh for post-operative incisional hernia prophylaxis, longer instruments for iliosacral screw placement, and a multidisciplinary approach with rehabilitation and nutrition control.

Effect of angioembolization for isolated complex pelvic injury: A post-hoc analysis of a nationwide multicenter trauma database in Japan

Background and importanceComplex pelvic injuries are among the types of trauma with the highest mortality. Treatment strategies should be based on the hemodynamic status, the anatomical type of fracture, and the associated injuries. Combination therapies, including preperitoneal pelvic packing, temporary mechanical stabilization, resuscitative endovascular balloon occlusion of the aorta, and angioembolization, are recommended for pelvic injuries. ObjectiveTo investigate the effect of urgent angioembolization alone on severe pelvic injury-associated mortality. Design, settings, and participantsWe used the Japan Trauma Data Bank database, a multicenter observational study, to retrospectively identify adult patients with isolated blunt pelvic injuries (Abbreviated Injury Scale [AIS] score: 3–5) from 2004 to 2018. Outcome measures and analysisThe primary outcome measure was in-hospital mortality. We subdivided patients into two groups, those who underwent urgent angioembolization and non-urgent angioembolization, and compared their mortality rates. We performed multiple imputation and multivariable analyzes to compare the mortality rates between groups after adjusting for known potential confounding factors (age, sex, Glasgow Coma Scale score, systolic blood pressure on hospital arrival, Injury Severity Score, pelvic AIS score, laparotomy, resuscitative endovascular balloon occlusion of the aorta, and external fixation) and for within-hospital clustering using the generalized estimating equation. Main resultsWe analyzed 4207 of 345,932 trauma patients, of whom 799 underwent urgent angioembolization. The in-hospital mortality rate was significantly higher in the urgent embolization group than in the non-urgent embolization group (7.4 vs. 4.0%; p < 0.01). However, logistic regression analysis revealed that the mortality rates of patients with urgent angioembolization significantly decreased after adjusting for factors independently associated with mortality (odds ratio: 0.60; 95% confidence interval: 0.37–0.96; p = 0.03). ConclusionUrgent angioembolization may be an effective treatment for severe pelvic injury regardless of the pelvic AIS score and the systolic blood pressure on hospital arrival.

Specialized trauma care in the acute period of trauma for a victim with unstable pelvic ring injury and acute acetabulum fracture

The final reconstructive treatment of complex pelvic injury in a patient with combined trauma in the acute period of traumatic disease is presented. Indirect reposition, limited access, stable functional osteosynthesis were performed, which allowed to obtain a good anatomical and functional outcome.

Holding versus seeing pathology. Three-dimensional printing of the bony pelvis for preoperative planning of a complex pelvis fracture: A case report.

Pelvic injuries are not uncommon. The complex anatomy of the pelvic bones, the complex pattern of injuries, associated important structures such as neurovascular bundles, and difficult access make the reduction and fixation of these fractures difficult. Often the surgical outcomes are not satisfactory. Three-dimensional (3D) imaging using computed tomography (CT) scan (3DCT) has been the mainstay of preoperative evaluation since the 1980s, however, even with these images it may be difficult to understand complex injury patterns. Preoperative printing of a 3D model using the same CT scan data allows surgeons to hold the pelvis in their hands and then plan appropriate treatment. We report one such case of complex pelvic injury and its management using the novel method of preoperative 3D model printing.

Pelvic Trauma.

The leading cause of death in the pediatric population is trauma, of which pelvic injuries make up a very small percentage. Trauma to the pelvis can result in multiple injuries to the bony pelvis, rectum, bladder, and or the urethra. Although mortality in the pediatric population is typically secondary to associated injuries, pelvic hemorrhage can be a life-threatening event. The management of patients with complex pelvic injuries requires a multidisciplinary approach in order to achieve the best possible outcomes.

Successful Percutaneous Embolization of a Persistent Extraperitoneal Bladder Leak

In contradistinction to intraperitoneal bladder injuries, isolated extraperitoneal bladder rupture (EPR) is traditionally managed nonoperatively via continuous decompression by transurethral or suprapubic catheterization [1, 2]. Once placed, such catheters are maintained anywhere from 10 to 21 days, thereby allowing evacuation of blood and healing by secondary intention of the bladder wall [3]. Although this treatment strategy is the accepted standard for EPR, only retrospective data exist to support its use [2]. Correire and Sandler’s [4] 1986 single-center study found 39 patients with EPR and a success rate of 87 % for catheterization alone. Kotkin and Koch’s [5] 1995 article included similar data from a single-center study with 85 % success of their 70 patients, identifying complex pelvic injuries as a major predictor of failure of nonoperative management. To our knowledge, there have been no reported cases of a percutaneous technique for the repair. A 53-year-old male presented to our trauma bay after falling 20 feet from a rooftop. The patient had a grossly deformed right hip and pelvic x-ray revealed an open-book pelvic fracture. In addition to retroperitoneal bleeding, CT cystography displayed an extraperitoneal bladder rupture (EPR, Fig. 1). Hemorrhage was controlled via embolotherapy and pelvic stabilization. The patient’s EPR was initially managed by transurethral catheter placement. Six weeks after the initial injury, repeat cystogram found persistent urinary extravasation from the bladder. The patient underwent attempt at operative repair of the bladder, but a third cystogram 2 weeks later again found persistent urinary extravasation into a contained cavity. The patient also had unremitting pain in this region. Further attempts at operative repair were felt to be futile. An ethylene vinyl chloride copolymer (Onyx 34, Covidien, Mansfield, MA) therefore was placed percutaneously into the pseudodiverticulum cavity via the following technique. Dilute contrast was infused through the existing Foley catheter to opacify the bladder. A cone beam CT was then performed to identify the precise location of the bladder pseudodiverticulum. Using the XperGuide CT system (Philips, Andover, MA), a 21-gauge micropuncture needle was advanced from the low anterior abdominal/pubic level into the pseudodiverticulum. There was free flow of contrast across the neck and into the bladder. A 0.014-in. SV-5 guidewire (Cordis, Bridgewater, NJ) was advanced through the access needle into the pseudodiverticulum, through its neck, and into the bladder. The Foley catheter was then backed out over a 0.035-in. hydrophilic guidewire and a 10-Fr sheath was advanced into the bladder through the penile urethra. Through the sheath, a 15-mm diameter gooseneck snare was advanced and used to capture the tip of the guidewire. The wire was then pulled out through the sheath and thus ‘‘through and through’’ access was M. Radomski (&) J. Messing B. Sarani Division of Trauma & General Surgery, George Washington University, 2150 Pennsylvania Ave. NW, Washington, DC 20037, USA e-mail: michal.radomski.1@gmail.com

Trauma registry record linkage: methodological approach to benefit from complementary data using the example of the German Pelvic Injury Register and the TraumaRegister DGU®

BackgroundIn Germany, hospitals can deliver data from patients with pelvic fractures selectively or twofold to two different trauma registries, i.e. the German Pelvic Injury Register (PIR) and the TraumaRegister DGU® (TR). Both registers are anonymous and differ in composition and content. We describe the methodological approach of linking these registries and reidentifying twofold documented patients. The aim of the approach is to create an intersection set that benefit from complementary data of each registry, respectively. Furthermore, the concordance of data entry of some clinical variables entered in both registries was evaluated.MethodsPIR (4,323 patients) and TR (34,134 patients) data from 2004-2009 were linked together by using a specific match code including code of the trauma department, dates of admission and discharge, patient’s age, and sex. Data entry concordance was evaluated using haemoglobin and blood pressure levels at emergency department arrival, Injury Severity Score (ISS), and mortality.ResultsAltogether, 420 patients were identified as documented in both data sets. Linkage rates for the intersection set were 15.7% for PIR and 44.4% for TR. Initial fluid management for different Tile/OTA types of pelvic ring fractures and the patient’s posttraumatic course, including intensive care unit data, were now available for the PIR population. TR is benefiting from clinical use of the Tile/OTA classification and from correlation with the distinct entity “complex pelvic injury.” Data entry verification showed high concordance for the ISS and mortality, whereas initial haemoglobin and blood pressure data showed significant differences, reflecting inconsistency at the data entry level.ConclusionsIndividually, the PIR and the TR reflect a valid source for documenting injured patients, although the data reflect the emphasis of the particular registry. Linking the two registries enabled new insights into care of multiple-trauma patients with pelvic fractures even when linkage rates were poor. Future considerations and development of the registries should be done in close bilateral consultation with the aim of benefiting from complementary data and improving data concordance. It is also conceivable to integrate individual modules, e.g. a pelvic fracture module, into the TR likewise a modular system in the future.

Small bowel obstruction in percutaneous fixation of traumatic pelvic fractures

The use of external fixation for the initial treatment of unstable, complex pelvic injuries with hemodynamic instability remains an effective treatment for multiply injured patients. Bowel entrapment within a pelvic fracture is a rarely reported, potentially fatal complication. Here, we report a polytrauma patient with pelvic fractures who developed an intestinal obstruction after an external fixation. At an explorative laparotomy, we found an ileum segment trapped in the sacral fracture. Reported cases of bowel entrapment in pelvic fractures, especially in sacral fractures, are exceedingly rare. The diagnosis is often delayed due to difficulty distinguishing entrapment from the more common adynamic ileus. In conclusion, clinicians and radiologists should be aware of this potentially lethal complication of pelvic fractures treatment. To exclude bowel entrapment, patients with persistent ileus or sepsis should undergo early investigations.

What are Predictors of Mortality in Patients with Pelvic Fractures?

Our knowledge of factors influencing mortality of patients with pelvic ring injuries and the impact of associated injuries is currently based on limited information. We identified the (1) causes and time of death, (2) demography, and (3) pattern and severity of injuries in patients with pelvic ring fractures who did not survive. We prospectively collected data on 5340 patients listed in the German Pelvic Trauma Registry between April 30, 2004 and July 29, 2011; 3034 of 5340 (57%) patients were female. Demographic data and parameters indicating the type and severity of injury were recorded for patients who died in hospital (nonsurvivors) and compared with data of patients who survived (survivors). The median followup was 13 days (range, 0-1117 days). A total of 238 (4%) patients died a median of 2 days after trauma. The main cause of death was massive bleeding (34%), predominantly from the pelvic region (62% of all patients who died because of massive bleeding). Fifty-six percent of nonsurvivors and 43% of survivors were male. Nonsurvivors were characterized by a higher incidence of complex pelvic injuries (32% versus 8%), less isolated pelvic ring fractures (13% versus 49%), lower initial blood hemoglobin concentration (6.7 ± 2.9 versus 9.8 ± 3.0 g/dL) and systolic arterial blood pressure (77 ± 27 versus 106 ± 24 mmHg), and higher injury severity score (ISS) (35 ± 16 versus 15 ± 12). Patients with pelvic fractures who did not survive were characterized by male gender, severe multiple trauma, and major hemorrhage. Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Today’s Role of External Fixation in Unstable and Complex Pelvic Fractures

The treatment of pelvic fractures has undergone a change over the past few years. As there seems to be a trend away from external towards internal fixation, the goal of this study was to investigate whether the use of an external fixator is still a standard procedure for the initial as well as - if necessary - for the definitive treatment of complex and unstable pelvic injuries. During a period of five years at the Level I Trauma Center, an external fixator was applied in 28 (11%) out of 236 pelvic ring fracture cases. The common indications were open fractures, complex fractures and multiple injuries with hemodynamic instability. Hemorrhage control, fracture stabilization and infection prophylaxis in cases of open fracture were achieved by variable placement and fixation of Schanz screws. In some cases, the assembly of a hybrid combined with internal osteosynthesis was used to increase stability. Of the 28 patients, 20 survived, while eight (28.6%) died in the course of treatment due to fatal hemorrhage, craniocerebral trauma, multi-organ failure and sepsis. A satisfactory result (anatomical and functional outcome) was achieved in 16 of the 20 cases (80%). The remaining four (20%) suffered from serious complications, the majority of them caused by the initial type of injury. The use of the external fixator for the initial and in some cases for the definitive fixation of unstable and complex pelvic injuries with hemodynamic instability is still a successful treatment of multiply injured patients.

Die komplexe Beckenverletzung im Kindesalter

Pelvic disruptions are rare in children caused by the flexible anchoring of bony parts associated with a high elasticity of the skeleton. Portion of pelvic fractures in infants is lower than 5% even when reviewing cases of specialized centers. The part of complex pelvic injuries and multiple injured patients in infants is higher when compared to adults, a fact caused by the more intense forces that are necessary to lead to pelvic disruption in children. Combination of a rare injury and the capability of children to compensate blood loss for a long time may implicate a wrong security and prolong diagnostic and therapeutic procedures--a problem that definitely should be avoided. Three cases were analyzed and established algorithms for treatment of patients matching these special injury-features demonstrated. A good outcome may only be achieved when all components of injury pattern get recognized and treatment is organized following the hierarchy of necessity. Therefore in the time table first life-saving steps have to be taken and then accompanying injuries can be treated that often decisively influence life quality. As seen in our cases unstable and dislocated fractures require open reduction and internal fixation ensuring nerval decompression, stop of hemorrhage and realizing the prerequisite for effective treatment of soft tissue damage. The acute hemorrhagic shock is one of the leading causes of death following severe pelvic injuries. After stabilization of fracture, surgical treatment of soft tissue injuries and intraabdominal bleeding sources the immediate diagnostic angiography possibly in combination with a therapeutic selective embolization is a well established part of the treatment. The aim of complete restitution can only be accomplished by cooperation of several different specialists and consultants in a trauma center.

Epidemiology of pelvic ring injuries

3260 patients with pelvic and acetabular fractures were assessed using a standardized documentation form by collating the data on 1905 patients treated at the Department of Traumatology of the Hannover Medical School together with those patients treated between 1991 and 1993 in the German Multicentre Study Group (Pelvis) of the German Trauma Society and the German Section of the AO International. 2551 patients had pelvic ring injuries. 61.7% of the patients were multiply injured. 12.2% were suffering a complex pelvic trauma defined as a pelvic injury with concomitant soft tissue injury. The pelvic ring fracture was classified as stable in 54.8% (type A injury), as rotationally unstable in 24.7% (type B injury), and as unstable in translation in 20.5% (type C injury). There were concomitant acetabular fractures in 15.7%. The most frequent single lesions affecting the pelvic girdle were fractures of the ischiopubic bones (transpubic instability), injuries involving the sacroiliac joint (transiliosacral instability), and sacral fractures (transsacral instability). The overall rate of operative stabilizations was 21.6%. Type B injuries were stabilized in 28.9% and type C injuries in 46.7%. The overall mortality rate was 13.4%, depending significantly on the associated extrapelvic trauma. In complex pelvic injuries, the mortality rate was 31.1% whereas for pelvic fractures without concomitant soft tissue injury the rate was only 10.8%.