Pelvic Fracture Patients Research Articles

Pelvic angiography is effective for emergency pediatric patients with pelvic fractures: a propensity-score-matching study with a nationwide trauma registry in Japan

PurposeThe aim of this study was to evaluate the association between the implementation of pelvic angiography (PA) and outcome in emergency pediatric patients with pelvic fracture.MethodsWe extracted data on pelvic fracture patients aged ≤ 19 years between 2004 and 2015 from a nationwide trauma registry in Japan. The main outcome was hospital mortality. We assessed the relationship between implementation of PA and hospital mortality using one-to-one propensity-score-matching analysis to reduce potential confounding effects in comparing the PA group with the non-PA group.ResultsIn total, 1351 patients were eligible for our analysis, with 221 patients (16.4%) included in the PA group and 1130 patients (83.6%) included in the non-PA group. For all patients, the proportion of hospital mortality was higher in the PA group than in the non-PA group [13.6% (30/221) vs 7.1% (80/1130), crude odds ratio (OR) 2.062 (95% confidence interval (CI), 1.318–3.224); p = 0.002]. In the propensity-score-matched patients, the proportion of hospital mortality was lower in the PA group than in the non-PA group [10.5% (22/200) vs 18.2% (38/200), p = 0.027]. This finding was confirmed in both the multivariable logistic regression model [adjusted OR 0.392 (95% CI, 0.171–0.896); p = 0.026] and the conditional logistic regression model [conditional OR 0.484 (95% CI, 0.261–0.896); p = 0.021].ConclusionThe implementation of PA was significantly associated with lower hospital mortality among emergency pediatric patients with pelvic fractures compared with the non-implementation of PA.

Multifactorial intervention for hip and pelvic fracture patients with mild to moderate cognitive impairment: study protocol of a dual-centre randomised controlled trial (OF-CARE)

BackgroundA hip or pelvic fracture is a major fall-related injury which often causes a decline in mobility performance and physical activity. Over 40% of patients with hip fracture have cognitive impairment or dementia and poorer rehabilitation outcomes than those without cognitive impairment. In this subgroup, there is a lack of evidence on the best practices supporting recovery. The main aim of this study is to investigate the effects of a transitional care intervention after inpatient rehabilitation on physical activity and functional performance in this group of cognitively impaired patients.Methods/designThis dual-centre, randomised controlled trial compares a multifactorial intervention with usual care as control condition. Two hundred and forty community-dwellers (≥ 65 years) with a hip or pelvic fracture and mild to moderate cognitive impairment (MMSE 17–26) are recruited at the end of inpatient rehabilitation.The four-month intervention consists of (a) an individually tailored, progressive home exercise program and physical activity promotion delivered by professional instructors and lay instructors (two home visits per week) and (b) a long-term care counselling approach addressing unmet care needs, pleasurable activities, and caregiver issues if needed. Primary outcome parameters are physical activity, measured as daily walking duration with an accelerometer-based activity monitor (activPAL™) over 72 h, and functional performance, assessed with Short Physical Performance Battery sum scores. Secondary outcome parameters are fear of falling, fall related self-efficacy, falls, quality of life, depression and activity of daily living. Data are collected at the end of rehabilitation, before the intervention at the patient’s home (baseline), after four months (post-intervention), and seven months (follow-up). In addition to completer and intent-to-treat analyses of outcomes, economic data and incremental cost-effectiveness are analysed.DiscussionExisting service models of volunteer services and legal counselling provided by care counsellors were considered when developing the intervention protocol. Therefore, it should be feasible to translate and deliver the intervention into real-world practice if it has been demonstrated to be effective.Trial registrationGerman Clinical Trials Register, DRKS00008863 (Accessed 17 Apr 2019), ISRCTN registry, ISRCTN69957256 (Accessed 17 Apr 2019).

The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study.

Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. Therapeutic study, level IV.

Intraabdominal hypertension/abdominal compartment syndrome after pelvic fractures: How they occur and what can be done?

BackgroundLimited data exist regarding intraabdominal hypertension/abdominal compartment syndrome (IAH/ACS) after pelvic fractures. We aimed to explore risk factors for IAH/ACS in pelvic fracture patients, assess the physiological effects of decompressive laparotomy (DL) on IAH/ACS, and generate an algorithm to manage IAH/ACS after pelvic fracture. Materials and methodsPelvic fracture patients were included based on the presence of IAH/ACS. Intraabdominal pressure (IAP) was measured through a Foley catheter. DL was performed in patients with refractory IAH or ACS. Multivariable linear regression was applied to assess associations between IAP levels (≥12 mmHg) and age, sex, injury severity score (ISS), pelvic fracture, volume of resuscitation fluids over 24 h and hemoglobin values. The Wilcoxon signed-rank test for paired samples was used to compare variables before and after DL. ResultsAmong 455 pelvic fracture patients, 44 (9.7%) and 5 (1.1%) were diagnosed with IAH and ACS, respectively. The volume of resuscitation fluids over 24 h exhibited a significant positive correlation with IAP levels (≥12 mmHg) (p = 0.002). The main findings during DL were edematous bowel (11/20) and retroperitoneal hematoma (7/20). DL caused a significant decrease in the mean IAP from 24.4 ± 8.5 mmHg to 13.4 ± 4.0 mmHg (p < 0.0001). Physiological parameters (APP, PaO2/FIO2 ratio, PIP, arterial lactate and UOP) were significantly improved after DL. The mortality rate was 15% in patients who underwent DL and 40% in ACS patients. ConclusionsIAH/ACS is common in pelvic fracture patients. The most effective method to decrease IAP in pelvic fracture patients is DL. Prophylactic DL is important for decreasing mortality as it prevents IAH from progressing to ACS. Massive fluid resuscitation is a significant risk factor for IAH/ACS. A pathway incorporating prophylactic/therapeutic DL and optimized fluid resuscitation to prevent and manage IAH/ACS after pelvic fractures may reduce morbidity and mortality.

Prediction of arterial extravasation in pelvic fracture patients with stable hemodynamics using coagulation biomarkers

BackgroundDetermining the presence of an active arterial hemorrhage in the acute phase is important as a treatment strategy in patients with pelvic fracture. The purpose of this study was to evaluate whether coagulation biomarkers could predict arterial extravasation, especially in pelvic fracture patients with stable hemodynamics.MethodsWe studied patients with a pelvic fracture who had a systolic blood pressure above 90 mmHg and lactate level less than 5.0 mmol/L on hospital arrival. Patients were divided into two groups: those with arterial extravasation on enhanced computed tomography (CT) or angiography (extravasation [+] group) and those without arterial extravasation (extravasation [−] group). Coagulation biomarkers measured on arrival were statistically compared between the two groups. Predictive ability of arterial extravasation using coagulation biomarkers was evaluated by receiver-operating characteristic analyses provided area under the receiver-operating characteristic curves (AUROC) and diagnostic indicators with optimal cutoff point including sensitivity, specificity, positive and negative predictive values, and diagnostic odds ratio (DOR).ResultsSixty patients were analyzed. Fibrin degradation products (FDP), D-dimer, prothrombin time–international normalized ratio (PT–INR), and the ratio of FDP to fibrinogen were significantly higher in the extravasation (+) group than in the extravasation (−) group (FDP, 242 μg/mL [145–355] vs. 96 μg/mL [58–153]; D-dimer, 81 μg/mL [41–140] vs. 39 μg/mL [21–75]; PT–INR, 1.09 [1.05–1.24] vs. 1.02 [0.98–1.08]; and ratio of FDP to fibrinogen, 1.06 [0.85–2.01] vs. 0.46 [0.25–0.74]). The highest AUROC was with a ratio of FDP to fibrinogen of 0.777 (95% confidence interval, 0.656–0.898), and the highest predictive ability in terms of DOR was with a ratio of FDP to fibrinogen (sensitivity, 0.76; specificity, 0.76; DOR 9.90).ConclusionCoagulation biomarker could predict of arterial extravasation in pelvic fracture patients with stable hemodynamics.

Prompt Procedures to Hemodynamically Unstable Patients with Pelvic Fractures

Background: Angioembolization is a widely accepted method for an effective and useful hemostasis procedure in pelvic fracture (PF) patients. We evaluated and introduced the time course of the initial management and angiogra-phy in hemodynamically unstable pelvic fracture patients. Methods: We retrospectively reviewed 56 PF patients who underwent interventional radiology (IR) from May 2010 to Dec 2016. We defined arrival to angiography time (ATAT), and this was recorded in all enrolled patients in which the first angiography image represented the initiation of angiography. We also evaluated total embolization time (TET) and single artery embolization time (SAET; time for artery selection, injection, embolization, and confirmation). Results: The median ATAT and TET were respectively 73 and 33 minutes. They were much faster than the previous reports. Conclusions: Our trauma IR strategy with a specialized team might contribute to a shortening of the management time

Re: The Risk of Erectile Dysfunction following Pelvic Angiographic Embolization in Pelvic Fracture Patients: .

Re: The Risk of Erectile Dysfunction following Pelvic Angiographic Embolization in Pelvic Fracture Patients: .

Venous thromboembolism after hospital discharge in pelvic and acetabular fracture patients treated operatively.

The purposes of this study were to determine the rate of venous thromboembolism (VTE) after discharge from the hospital in patients treated operatively with a pelvic ring or acetabular fracture and to define the main time frame in which VTE occurs within the 90-day period after hospital discharge. California and Florida State Inpatient Databases from 2005 to 2009 were used to identify patients with clinically significant VTEs within 90 days of hospital discharge. ICD-9 diagnosis codes identified patients with a pelvic ring or acetabular fracture and a VTE. Procedure codes distinguished patients having surgical fracture treatment. Deep vein thrombosis (DVT) and pulmonary embolus (PE) were included. Overall, 13,589 patients had a pelvic ring or acetabular fracture and operative treatment. One hundred thirteen patients (0.83%) had a VTE within 90 days after hospital discharge: 69 (0.51%) had a DVT, 28 (0.21%) had a PE, and 16 (0.12%) had both. Twenty-four (28%) of DVTs and 10 (23%) of PEs occurred >35 days after discharge, being evenly distributed out to 90 days. There were five fatal PEs, occurring 2, 3, 7, 31, and 51 days after discharge. Therefore, overall, <0.2% of patients developed a DVT and <0.1% were diagnosed with a PE (only 1 fatal; <0.01%) >35 days after the index hospitalization. A substantial proportion of VTE events occur over 35 days after discharge; however, the overall risk is low with fatal PE being extremely low (<0.01%). Given the diminished VTE risk after 35 days, the decision to further extend antithrombotic drug therapy may be guided by patient-specific factors, such as prolonged immobility.

Predictors of mortality after pelvic fractures: a retrospective cohort study from a level one trauma centre in Upper Egypt.

The primary objective was to identify the predictors of in-hospital mortality after pelvic ring injuries. Secondary objectives were to analyze the differences between adults and children and to analyze the causes and timing of death. A retrospective cohort study from the pelvic registry of Assiut University Trauma Unit (AUTU), a level 1 trauma centre in Upper Egypt, was carried out. A total of 1188 consecutive patients with pelvic ring fractures treated from January 2010 to December 2013 were eligible for analysis. Potential predictors were identified using standard statistical tests: univariable and multivariable regression analysis. Nine hundred fifty-one were adults (above 16years) and 237 were children. According to Tile's classification, fractures type A, B, and C were 31.8%, 25.1%, and 43.1%, respectively. About a third of patients had fractures with soft tissue injury. Abdominopelvic collection as diagnosed by Focused Assessment with Sonography for Trauma (FAST) was positive in 11%. Associated injuries were present in 67.3% with abdominal-urogenital injuries being the most prevalent (66.3%). Median hospital stay was fivedays. Fifty-two patients (4.4%) were admitted to the ICU. One hundred three patients died (8.7%) within two peaks: first 24hours and between 48hours and oneweek. Multivariable logistic regression analysis identified increasing age, fractures with soft tissue injury, associated head injury, positive FAST examination, and admission to an ICU as significant predictors of in-hospital mortality. The first 24hours were confirmed to be critical for survival in pelvic fracture patients. Advancing age, associated soft tissue injury, associated head injury, admission to ICU, and positive FAST examination can serve as reliable predictors for an elevated mortality risk in such patients.

The Risk of Erectile Dysfunction Following Pelvic Angiographic Embolization in Pelvic Fracture Patients: A Nationwide Population-Based Cohort Study in Taiwan.

Pelvic fracture with hypovolemic shock is a known crucial injury in trauma patients. Pelvic fracture with vessel injury often leads to hemodynamic complications; in a trauma scenario, evidence of other systems being affected is often absent. Bleeding cessation and resuscitation are important for these types of trauma patients. For this purpose, pelvic angiographic embolization is frequently used. Multiple studies have reported that angiographic embolization may cause erectile dysfunction (ED) in hemodynamically stable patients with pelvic fracture. However, no study has evaluated a large patient cohort with a long-term follow-up. We hypothesized that angiographic embolization to control bleeding may compromise blood supply to the genitourinary organs or cause secondary neurogenic injury that increases the risk of ED. Our goal was to evaluate the risk of ED following pelvic fractures in male patients treated with pelvic angiographic embolization. We used data from the National Health Insurance Research Database (NHIRD) from 1997 to 2010 provided by the Bureau of National Health Insurance of the Department of Health in Taiwan. We collected disease histories from inpatient files. The disease diagnoses were based on the International Classification of Diseases (ICD), Ninth Revision, Clinical Modification. These data were all deidentified, and we did not contact the patients. As such, informed consent was not needed. Eighty-five and 82,802 patients were included in the case and control cohorts, respectively. All patients were aged 15-45, and the proportion of pelvic fracture locations was equal between the groups. After investigating the causes of ED among male patients aged 15-45 with pelvic fractures using logistic regression analysis in a generalized estimating equations model and after adjusting for the influence of confounders, we found that these patients had high risks (odds ratio (OR): 32.637; 95% confidence interval: 14.137-75.346; P < 0.001) of developing ED post-angiographic embolization. Male patients in Taiwan with pelvic fractures who undergo angiographic embolization to control bleeding have a higher risk of ED than those who do not undergo the procedure. Physicians should practice caution and inform patients of this connection before the procedure.

A biomechanical study comparing minimally invasive anterior pelvic ring fixation techniques to external fixation

IntroductionINFIX and Pelvic Bridge are two new minimally invasive surgical techniques for unstable pelvic ring injuries, and they have demonstrated early clinical success in small, single-center case-series. The primary objective of this study is to gather evidence speaking to the biomechanical stability of internal bridging methods relative to external fixation, with the expectation of biomechanical equivalence. MethodsTen human cadaveric pelvic specimens were dissected free of all skin, fat, organs, and musculature and were prepared with a partially unstable pelvic ring injury (OTA/AO 61-B). The specimens were randomized to two groups and were repaired and tested with anterior pelvic external fixation (APEF) and INFIX sequentially, or APEF and Pelvic Bridge sequentially. Testing was performed with each specimen mounted onto a servo-hydraulic testing frame with axial compression applied to the superior base of the sacrum under five axial loading/unloading sinusoidal cycles between 10 N and 1000 N at 0.1 Hz. Relative translational motion and rotation across the osteotomy site was reported as our primary outcome measures. Outcome measures were further analyzed using a Wilcoxon signed-rank test to determine differences between non-parametric data sets with significance defined as a p value < 0.05. ResultsWe found no statistical difference in translation (p = 0.237, 0.228) or rotation (p = 0.278, 0.873) at the fracture site when comparing both new constructs to external fixation. Under the imposed loading protocol, no episodes of implant failure or failure at the bone-implant interface occurred. DiscussionOur study provides the biomechanical foundation necessary to support future clinical trial implementation for pelvic fracture patients. While biomechanical stability of these newer, subcutaneous techniques is equivalent to APEF, the surgeon must take into account their technical abilities and knowledge of pelvic anatomy, patient-specific factors including body habitus, and the potential complications associated with each implant and the ability to avoid them.

The application of multifunctional inflatable pelvis and hip-joint fixator (MIPHF) in damage control in patients with pelvic fracture

Objective To discuss the safety and the application of the self-designed multifunctional inflatable pelvis and hip-joint fixator (MIPHF) in damage control in pelvic fracture patients. Methods The MIPHF was subjected to pressure test and quality inspection. From September 2016 to June 2017, 61 pelvic-fracture patients were treated with our self-designed MIPHF as pre-hospital first-aid care according to the concept of damage control orthopedics (DCO) (MIPHF group). The control group consisted of 69 pelvic-fracture patients who had not received pre-hospital first-aid care with the self-designed MIPHF from December 2015 to August 2016. There were no statistically significant differences between the two groups in gender, age, types of pelvic fracture, and preoperative injure severity score (ISS). The study compared the two groups for the case fatality rate, volume of blood transfused during surgeries, early complication rates, fracture reduction (Matta standards), and long-term efficacy (Cole scores). Results The pressure test showed that the MIPHF had a good fixation effect on the pelvis. And the quality inspection showed that the material used for the MIPHF was in line with national standards and the safety was guaranteed. The MIPHF group had 1 death (1.6%) and the control group had 8 deaths (11.6%), which was a significant difference (χ2=4.979, P=0.026). All survival patients in both groups were followed up. The MIPHF group (61 cases) received 3.0 to 18.0 months follow-up, with an average of 9.0 months. And the control group (69 cases) had 18.0 to 30.0 months follow-up, with an average of 21.9 months. In the MIPHF group, 23 cases were treated conservatively, and 37 cases were treated with surgery. Among them, 3 cases were fixed with external fixator, 20 cases with anterior open reduction and internal fixation, 9 cases with posterior open reduction and internal fixation, and 5 cases with combined anterior and posterior fixation. The timing of surgery was 1 to 20 days after injury, with an average of 4.1 days. The volume of blood transfused in the MIPHF group during surgery was 200 to 1500 ml, with an average of 628.6 ml. In the control group, 27 patients were treated conservatively, and 42 patients were treated with surgery. Among them, 2 cases were fixed with external fixator, 24 cases with anterior open reduction and internal fixation, 10 cases with posterior open reduction and internal fixation, and 6 cases with combined anterior and posterior fixation. The timing of surgery was 1 to 15 days after injury, with an average of 3.1 days. The volume of blood transfused in the control group during surgery was 200 to 4000 ml, with an average of 1 707.1 ml. There was a significant difference between the two groups in intraoperative blood transfusion(Z=-2.330, P=0.020). The MIPHF group had 10 (16.4%) cases of early serious complications and the control group had 22 (31.9%) cases, which had a significant difference (χ2=4.187, P=0.041). According to the criteria proposed by Matta et al., the good rate of results for treating fractures was 82.0% in the MIPHF group and 60.9% in the control group, which got a significant difference (χ2=6.967, P=0.008). The MIPHF group and the control group also differed significantly in their mean long-term Cole scores (27.2±4.0 versus 25.1±5.6, t=2.457, P=0.015). Conclusion MIPHF, which reflects the DCO concept, may be recommended as pre-hospital first-aid care for patients with pelvic fracture because it can lessen bleeding and prevent secondary pelvic injury, thus reduce case fatality rate and the incidence of complications. It can also improve the success rate of treating pelvic fracture, which will positively affect long-term outcomes. Key words: Pelvis; Fractures, bone; External fixators; First aid

Optimal sequence of surgical procedures for hemodynamically unstable patients with pelvic fracture: A network meta-analysis

BackgroundThe mortality rate of patients with hemodynamic instability due to severe pelvic fracture remains substantial and massive transfusion happens frequently. Angio-embolization, external fixation and preperitoneal pelvic packing of the pelvis are the main managements used to control bleeding in these patients. In this paper, we aimed at characterizing the rationale of these surgical managements, and placed them in optimal management algorithm to compose a new guideline. MethodsWe selected controlled trials, assessing safety of management for the intervention of hemorrhagic shock from mortality data, and assessing efficacy from volume of first 24 h blood transfusion following hospitalization. Six single and combined managements were extracted as comparison. A pairwise meta-analysis was conducted using a random effect model, and then the analysis was extended to a network meta-analysis. Pooled effect sizes were ranked and demonstrated the probability of being the best treatments for safety and efficacy. Results13 clinical trials and 24,396 participants were identified for this analysis. The assessment of rank probability indicated that pelvic packing presented the greatest likelihood of improving safety, while external fixation was indicated most efficient among the interventions for controlling hemorrhage. ConclusionsClinical protocols for guidelines of hemodynamically unstable pelvic fracture patients have been multidirectionally developed. We strongly support the initial application of an external fixator. Provided that patients remain hemodynamically unstable after application of an external fixation, pelvic packing is the next procedure to consider. Angio-embolization is the complementary but not alternative method of choice subsequently.

The effect of angioembolization for life-threatening retroperitoneal hemorrhage in patients with pelvic fracture

BackgroundConventionally, pelvic fracture-related acute retroperitoneal hemorrhage (ARH) is life threatening and difficult to control. However, the use of angioembolization to treat fracture-associated ARH improves the hemodynamic stability of patients with pelvic fractures. The role of angioembolization in the management of patients with pelvic fracture-related ARH was examined. Materials and methodsWe retrospectively reviewed a large case series of patients with pelvic fractures between January 2010 and December 2014. Comparisons were made between patients with and without ARH. In addition, the characteristics of mortality were delineated, whereas the causes of death in patients with pelvic fracture were discussed and analyzed. ResultsA total of 1070 patient records were reviewed during the 60-month study period, and the overall mortality rate of pelvic fracture was 7.7% (82/1070). However, there were only seven patients who died due to uncontrolled ARH (0.7%). The patients with ARH had more injuries to other organs than did the patients without ARH (head: 79.7% vs. 31.7%, p < 0.001; chest: 50.3% vs. 10.9%, p < 0.001; abdomen: 72.0% vs. 22.7%, p < 0.001; spine: 12.6% vs. 4.4%, p < 0.001; extremities: 69.2% vs. 44.3%, p < 0.001). ConclusionThe treatment for pelvic fracture patients declared dead upon arrival remains limited. However, pelvic fracture-related ARH could be controlled effectively with angioembolization. In addition to ARH, injuries to other organs may play a key role in the mortality of patients with pelvic fractures.

The focused abdominal sonography for trauma examination can reliably identify patients with significant intra-abdominal hemorrhage in life-threatening pelvic fractures.

The focused abdominal sonography for trauma (FAST) examination has been reported to be unreliable in pelvic fracture patients. Additionally, given the advent of new therapeutic interventions, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), rapid identification of intra-abdominal hemorrhage compared with Zone III hemorrhage may guide different therapeutic strategies. We hypothesized that FAST is reliable for detecting clinically significant intra-abdominal hemorrhage in the face of complex pelvic fractures. Our pelvic fracture database of all hemodynamically unstable patients requiring intervention from January 1, 2005, to July 1, 2015, was reviewed. The FAST examination was compared with operative and computed tomography (CT) scan findings. Confirmatory evaluation for FAST(-) patients was considered positive if therapeutic intervention was required. During the study period, 81 patients in refractory shock with FAST imaging in our emergency department (ED) underwent pelvic packing. Mean age was 45 ± 2 years and Injury Severity Score was 50 ± 1.5. The FAST examination was negative in 53 patients; 52 patients did not require operative intervention for abdominal bleeding while one patient required splenectomy. The FAST examination was positive in 28 patients; 26 had findings confirmed by CT or laparotomy while two patients did not have intra-abdominal hemorrhage on further evaluation. The sensitivity and specificity for FAST in this population was 96% and 96%, respectively, positive predictive value was 93%, and negative predictive value was 98%. The false-negative and -positive rates for FAST were 2% and 7%. Focused abdominal sonography for trauma examination reliably identifies clinically significant hemoperitoneum in life-threatening, pelvic fracture related hemorrhage. The incidence of a false-negative FAST in this unstable pelvic fracture population was 2%. FAST results may be used when determining the role of REBOA in these multisystem trauma patients and requires further study. REBOA placement should be considered in hemodynamically unstable pelvic fracture patients who are FAST(-), while laparotomy should be used in FAST(+) patients. Therapeutic, level IV.

Outcome of Haemodynamically Unstable Open Pelvic Fracture Patients Managed With “3-in-1” Pelvic Damage Control Protocol in a Major Trauma Centre

IntroductionOpen pelvic fractures are one of the most challenging and severe injuries of orthopaedics. These patients usually are associated with high mortality and morbidity. Therefore, multiple studies have suggested different methods to deal with this challenging problem. Our hospital is one of the few trauma centers in Hong Kong that deals with these patients. We have developed a “3-in-1” pelvic damage control protocol that strategically treats patients with pelvic injuries with open fractures. This article aims to review the outcomes of patients suffering from open pelvic fractures, admitted from January 2011 to 2016. Patients & MethodsAll patients diagnosed with hemodynamically unstable open fracture admitted from January 2011 to 2016 were retrospectively reviewed. All these patients were treated with our hospital’s “3-in-1” pelvic damage control protocol. We analyzed their demographics, associated injuries, Injury Severity and final outcomes. ResultsTwelve consecutive patients were included in this study. Seventy-five percent (n = 9) of them were successfully resuscitated and discharged from hospital as their final outcome. ConclusionOur hospital’s “3-in-1” pelvic damage control protocol improves the survival rate of patients suffering from haemodynamically unstable open fracture, including open fracture. External fixation of pelvis, retroperitoneal packing and emergency angiography with embolization play important and inseparable roles in management of these critical patients. Adequate wound lavage, timely urinary and faecal diversion will improve the overall morbidity and survival further.

Open pelvic fracture: the killing fracture?

BackgroundOpen pelvic fractures are rare but represent a serious clinical problem with high mortality rates. The purpose of this study was to evaluate the outcomes of open pelvic fractures in our clinic and to compare the results from our patient group with those of closed fractures and with the literature from the past decade.MethodsData of patients older than 16 years of age who were admitted to our hospital with a pelvic fracture between January 1, 2004, and December 31, 2014, were analyzed. The collected data were patient demographics, mechanism of injury, RTS, ISS, transfusion requirement during the first 24 h, Gustilo-Anderson and Faringer classification, number and type of interventions complications, mortality, and length of stay.ResultsTwenty-four of 492 patients (5% of all pelvic fracture patients) had an open fracture. Their mean age was 36 years, the mean ISS was 31, and the mean number of transfused packed red blood cells was 5.5. These numbers were all significantly higher than in the patients with a closed fracture, although they were comparable to other studies with open fractures.The mortality was 4% in the open group versus 14% in the closed group (p = 0.23). The reported mortality in the literature ranges between 4 and 45%.ConclusionOpen pelvic fractures are relatively rare but are a cause of significant morbidity. In this series, we treated patients with open pelvic fractures successfully, with a survival rate of 96%. There was no significant difference in survival rate between open and closed pelvic fractures. Compared with other studies, the mortality in our study was relatively low.

Three-in-one protocol reduces mortality of patients with haemodynamically unstable pelvic fractures—a five year multi-centred review in Hong Kong

The mortality rate in patients with haemodynamically unstable pelvic fractures is as high as 40-60%. Despite the new advances in trauma care which are in phase in trauma centres in Hong Kong, the management of haemodynamically unstable pelvic fracture is still heterogeneous. The aim of this study is to review the results of management of haemodynamically unstable pelvic fracture patients in Hong Kong over a fiveyear period. This is a retrospective multi-centred cohort study of patients with haemodynamic and mechanically unstable pelvic fractures from 1 January 2010 to 31 December 2014. The primary outcome investigated is mortality of patients (including overall, 30-day, 7-day and 24-hour mortalities). Implementation of three-in-one pelvic damage control protocol was identified to be a significant independent predictive factor for overall, 30-day, seven-day and 24-hour mortalities. The overall in-hospital and 30-day mortality rates for patients managed with three-in-one protocol was 12.5%, while it was 11% for sevenday mortality and 6% for 24 hour mortality. There were no significant differences in demographic characteristics, physiological measurements, types of pelvic fracture, severity and mechanism of injury between patients managed with or without three-in-one protocol. Implementation of the multidisciplinary three-in-one pelvic damage control protocol reduces mortality and therefore should be highly recommended. The results are convincing as it has eliminated the limitations of our previous single-centred trial.

Risk Stratification for Erectile Dysfunction After Pelvic Fracture Urethral Injuries

To compare the frequency and severity of erectile dysfunction (ED) among pelvic fracture patients with and without urethral injuries and to identify potential risk factors for ED in the setting of pelvic fracture injury. A retrospective review was conducted of male patients treated for pelvic fractures with and without urethral injuries at a Level 1 trauma center between 2005 and 2016. The International Index of Erectile Function (IIEF-5) questionnaire was administered to patients by telephone to assess post-injury ED. Additional questions about pre-injury ED, post-injury symptoms, and past medical history were reviewed. Fifty patients (42%, n = 118) responded to the IIEF-5 questionnaire: 29 with pelvic fractures alone and 21 with PFUIs. We observed a numerical increase in frequency of new onset ED in patients with pelvic fracture urethral injuries (PFUIs) (n = 12, 57%) compared with patients with pelvic fractures alone (n = 11, 38%) (P = .3). Patients with PFUIs reported lower IIEF-5 scores (ie worse ED) than patients with pelvic fractures alone (13 versus 18, P = .05). There were no significant differences in potential risk factors between the 2 groups on univariate analyses. ED was more severe following PFUI than pelvic fracture alone. We suspect that urethral injury is not the direct cause of ED, but rather a surrogate for extensive pelvic injury and risk for neurovascular injury. A larger prospective analysis is warranted to clarify this hypothesis and to further stratify risk factors for developing ED in pelvic fracture patients with and without urethral injuries.

Severe Bleeding in Pelvic Fractures: Considerations in Planning Damage Control

Severe bleeding due to pelvic fractures may require damage control procedures, such as preperitoneal packing. In many cases, preperitoneal packing is performed without full abdominal exploration. There are concerns that such an approach may miss major iliac vascular injuries or other intraabdominal injuries. This analysis assessed the incidence of iliac vascular and intraabdominal injuries in patients with pelvic fractures. The National Trauma Data Bank was queried for blunt trauma patients. Patients with severe pelvic fractures were observed. Common or external iliac vascular lacerations (CEIVL) and associated intraabdominal injuries were recorded. The study comprised 42,122 patients with pelvic fractures, of which 3,221 (7.6%) were severe pelvic fractures. The incidence of CEIVL in patients with severe pelvic fractures was 10.7 per cent. Patient age greater than or equal to 65 years was an independent predictor of CEIVL. A total of 34.3 per cent of severe pelvic fracture patients had severe associated intraabdominal injuries, including injuries to the bladder (26.5%) and bowel (16.7%). Severe pelvic fractures are associated with a high incidence of iliac vascular and intraabdominal injuries. Preperitoneal pelvic packing without abdominal exploration may miss these injuries.