Early fracture fixation may be "just fine" after head injury: no difference in central nervous system outcomes.

BACKGROUND: Recent reports suggest that early fracture fixation worsens central nervous system (CNS) outcomes. We compared discharge Glasgow Coma Scale (GCS) scores, CNS complications, and mortality of severely injured adults with head injuries and pelvic/lower extremity fractures treated with early versus delayed fixation. METHODS: Using trauma registry data, records meeting preselected inclusion criteria from the years 1991 to 1995 were examined. We identified 171 patients aged 14 to 65 years (mean age, 32.7 years) with head injuries and fractures who underwent early fixation (< or = 24 hours after admission) (n = 147) versus delayed fixation (> 24 hours after admission) (n = 24). RESULTS: Patients were severely injured, with a mean admission GCS score of 9.1, Revised Trauma Score of 6.2, Injury Severity Score of 38, median intensive care unit length of stay of 16.5 days, and hospital length of stay of 23 days. No differences between groups were found by age, admission GCS score, Injury Severity Score, Revised Trauma Score, intensive care unit length of stay, hospital length of stay, shock, vasopressors, major nonorthopedic operative procedures, total intravenous fluids or blood products, or mortality rates. In survivors, no differences in discharge GCS scores or CNS complications were found. CONCLUSION: We found no evidence to suggest that early fracture fixation negatively influences CNS outcomes or mortality.     

Associated injuries and not fracture instability predict mortality in pelvic fractures: a prospective study of 100 patients

BACKGROUND: Whether pelvic fracture instability is correlated to mortality in blunt multiply-injured trauma patients is debatable. This is the first prospective study on patients with pelvic fractures aiming at finding whether pelvic fracture type affects mortality. METHODS: There were 100 consecutive patients (77 males, mean age of 31 [3-73] years) studied between September 2003 and October 2004. Data were collected regarding mechanism of injury, associated injuries, Injury Severity Score (ISS), Revised Trauma Score, blood transfusions, and mortality. The fractures were classified according to instability, where type O is stable, type R is rotationally unstable, and type RV is both rotationally and vertically unstable. Because a pure acetabular fracture is a single break in the pelvic ring, we classified it as type O. Computer tomography was used for fracture classification in 73 patients and plain X-rays in 27 patients. RESULTS: There were 77 fractures caused by road traffic collisions. Type O fractures (n = 63) had lower median ISS (13 [4-48]) than type R (n = 19) (18 [9-75]) and type RV (n = 18) (18 [6-66]) (p = 0.019, Kruskall Wallis). There was no significant difference in ISS between type R and RV fractures. A logistic regression model has shown that ISS was the only significant factor that predicts mortality. CONCLUSIONS: ISS is the most important predictor in defining mortality in patients with pelvic fracture and not the type of pelvic instability.     

Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes

BACKGROUND: Pelvic fractures are often associated with major intraabdominal injuries or severe bleeding from the fracture site. OBJECTIVE: To study the epidemiology of pelvic fractures and identify important risk factors for associated abdominal injuries, bleeding, need for angiographic embolization, and death. METHODS: Trauma registry study on pelvic fractures from blunt trauma. Stepwise logistic regression was used to identify risk factors of severe pelvic fractures, associated abdominal injuries, need for major blood transfusion, therapeutic embolization, and death from pelvic fracture. Adjusted relative risks and 95% confidence intervals were derived. RESULTS: There were 16,630 trauma registry patients with blunt trauma, of whom 1,545 (9.3%) had a pelvic fracture. The incidence of abdominal injuries was 16.5%, and the most common injured organs were the liver (6.1%) and the bladder and urethra (5.8%). In severe pelvic fractures (Abbreviated Injury Scale [AIS] > or =4), the incidence of associated intraabdominal injuries was 30.7%, and the most commonly injured organs were the bladder and urethra (14.6%). Among the risk factors studied, motor vehicle crash is the only notable risk factor negatively associated with severe pelvic fracture. Major risk factors for associated liver injury were motor vehicle crash and pelvis AIS > or = 4. Risk factors of major blood loss were age > 16 years, pelvic AIS > or =4, angiographic embolization, and Injury Severity Score (ISS) > 25. Age> 55 years was the only predictor for associated aortic injury. Factors associated with therapeutic angiographic embolization were pelvic AIS > or =4 and ISS > 25. The overall mortality was 13.5%, but only 0.8% died as a direct result of pelvic fracture. The only pronounced risk factor associated with mortality was ISS>25. CONCLUSIONS: Some epidemiological variables are important risk factors of severity of pelvic fractures, presence of associated abdominal injuries, blood loss, and need of angiography. These risk factors can help in selecting the most appropriate diagnostic and therapeutic interventions.     

Treatment Outcomes of Open Pelvic Fractures Associated with Extensive Perineal Injuries

Background

The main causes of death in patients with open pelviperineal injuries are uncontrollable bleeding and pelvic sepsis. The aim of this study was to evaluate the management outcomes of open pelvic fractures associated with extensive perineal injuries.

Methods

We retrospectively studied 15 cases with open pelvic fractures associated with extensive perineal injuries (urethral and anal canal laceration) admitted between August 2006 and September 2010. Mechanism of injury, Injury Severity Score, associated injuries, hemodynamic status on arrival, resuscitation and transfusion requirements, operative techniques, intra- and postoperative complications, length of intensive care unit and hospital stay, and mortality were recorded in a computerised database for further evaluation and analysis.

Results

The male to female ratio was 12:3 with an average age of 38.6 years (ranged, 11 to 65 years). The average packed red blood cell units used were 8 units (ranged, 4 to 21 units). All patients were initially transferred to the operating room for colostomy, radical debridement and fixation of the pelvic fracture by an external fixator. One patient had acute renal failure, which improved with medical treatment and 2 patients (13.3%) died, one with type III anteroposterior compression fracture due to hemorrhagic shock and the other due to septicemia.

Conclusions

Open pelvic fractures with extensive perineal injuries are associated with high mortality rates. Early diagnosis and appropriate treatment, including reanimation, colostomy, cystostomy, vigorous and repeated irrigation and debridement, and fixation by an external fixator can improve the outcomes and reduce the mortality rate.     

Management and outcome of open pelvic fractures: a retrospective study of 41 cases

Background

Open pelvic fractures occur uncommonly. Despite serious sequelae, they have been infrequently reviewed.

Methods

We conducted a retrospective review of all patients with open pelvic fractures in our department from January 2001 to April 2010.

Results

Forty-one patients (32 men, 9 women) with these injuries were identified. The average Injury Severity Score (ISS) was 31.4, with 80% of patients having a score ≥16. The average blood transfusion in the first 24 h was 17.2 units, and the average hospital stay was 60 days. Overall mortality was 24%(n = 10): 3 early deaths and 7 late deaths. Factors associated with overall mortality by univariate analysis were ISS, RTS, GCS, age, pelvic sepsis, Gustilo classification of soft-tissue injury, and Young classification of bony fracture. Factors associated with late mortality by univariate analysis were: ISS, RTS, pelvic sepsis, Gustilo classification of soft-tissue injury, and blood transfusion in the first 24 h. Moreover, multivariate analysis showed that only RTS was independently associated with both overall and late mortality.

Conclusion

Despite treatment advances, mortality rates remain high in patients with open pelvic fractures. The urogenital and/or intra-abdominal injuries are not associated with mortality. RTS ≤ 8 might be a predictor of poor outcome in open pelvic fractures patients. Open reduction and internal fixation might be used in those unstable pelvic fractures without gross contamination in the fracture region after extensive cleansing and lavage. More emphasis needs to be placed on this injury complex.     

Auditing 655 fatalities with pelvic fractures by autopsy as a basis to evaluate trauma care

BACKGROUND: To determine the role of pelvic fractures in auditing mortality resulting from trauma. STUDY DESIGN: This retrospective case-control study based on autopsy-evaluated circumstances of the deaths of patients with pelvic fractures. RESULTS: Of 2,583 patients injured in motor-vehicle collisions, 655 (25.4%) constituted the pelvic fracture (PFx) group, and 1,928 (74.6%) constituted the control group. One-third of the PFx group's fatalities had an Injury Severity Score (ISS) of 75 and were not preventable. The PFx group had a substantially higher median ISS than the control group (50 versus 34; p < 0.0001). Four hundred fifty-four patients (69.3%) in the PFx group with ISS 16 to 74 had substantially higher rates of associated injuries. Nearly half of the PFx group patients with ISS 相似文献   

Pelvic fractures in pediatric and adult trauma patients: are they different injuries?

BACKGROUND: Many aspects of pediatric trauma are considerably different from adult trauma. Very few studies have performed comprehensive comparisons between pediatric and adult pelvic fractures. The purpose of this study was to compare the incidence of pelvic fracture, the epidemiologic characteristics, type of associated abdominal injuries, and outcomes between pediatric (age 16 years) patients. METHODS: This was a trauma registry study that included all blunt trauma admissions at a Level I trauma center during an 8-year period. The incidence and severity of pelvic fractures, associated abdominal injuries, need for blood transfusion, and mortality in the two age groups were compared with the two-sided Fisher's exact test. Stepwise logistic regression analysis was used to identify independent risk factors for associated abdominal injuries in pelvic fractures in the two age groups. RESULTS: The incidence of pelvic fractures was 10.0% (1,450 of 14,568) in the adult group and 4.6% (95 of 2,062) in the pediatric group (p < 0.0001). In motor vehicle and pedestrian injuries, adults were twice as likely and in falls from heights > 15 ft seven times as likely as children to suffer pelvic fractures. However, age group was not a significant predictor of the severity of pelvic fracture. Only 9.5% of pediatric fractures and 8.8% of adult fractures had a pelvis Abbreviated Injury Scale (AIS) score >/= 4. The incidence of associated abdominal injuries was high but similar in the two age groups (16.7% in adults and 13.7% in children, p = 0.48). Motor vehicle crash, pelvis AIS score >/= 4, and fall from height > 15 ft were significant predictors of associated abdominal injuries in the adult but not the pediatric group. The incidence of associated gastrointestinal injuries was similar in the two age groups (5.3% in children and 3.3% in adults, p = 0.37). The incidence of solid organ injuries was nearly identical in both groups (11.6% in children and 11.5% in adults). The need for blood transfusions and angiographic intervention was not significantly different between the two age groups. Exsanguination because of bleeding related to the pelvic fracture was responsible or possibly responsible in 42 deaths (2.9%) in the adult group and no deaths in the pediatric group. CONCLUSION: Pediatric trauma patients are significantly less likely than adults to suffer pelvic fractures, although the age group is not a significant risk factor for the severity of pelvic fracture. The incidence of associated abdominal injuries is high and similar in the two age groups. Motor vehicle crash, fall from a height, and pelvis AIS score >/= 4 were significant predictors of associated abdominal injuries in the adult but not the pediatric patients. The need for blood transfusion is similar in both groups irrespective of Injury Severity Score and pelvis AIS score. The mortality resulting from exsanguination related to pelvic fractures is very low, especially in pediatric patients.     

The outcome of open pelvic fractures in the modern era

BACKGROUND: Recent series have reported that the mortality rate of open pelvic fractures has decreased to < 10%. These injuries are often associated with intra-abdominal visceral damage, although few series have documented the prognostic significance of this injury complex. METHODS: A retrospective review in an urban level I trauma center of all patients who sustained open pelvic fracture between 1995 and 2004. RESULTS: Forty-four patients were identified as having sustained open pelvic fracture. Average Injury Severity Score was 30, with 77% of patients having a score > or = 16. Overall mortality was 45% (n = 20): 11 early deaths and 9 late deaths at an average of 17 days. Vertical shear injuries, although rare, were universally fatal. Other risk factors for overall mortality included revised trauma score, Injury Severity Score, transfusion requirement, Faringer zones I or II injury, Gustilo grade III soft tissue injury, need for therapeutic angiography, and presence of intra-abdominal injury, the latter of which conferred 89% mortality. Risk factors for late deaths also included pelvic sepsis, which occurred in 5 patients and was fatal in 3 (60%). CONCLUSIONS: The morbidity of open pelvic fractures remains high. Associated intra-abdominal injury or active arterial bleeding requiring therapeutic angiography is associated with a grim prognosis. There is a continuing need for new therapeutic approaches to this injury complex.     

Outcome from traumatic injury of the portal and superior mesenteric veins

Traumatic injuries to the portal vein (PV) and superior mesenteric vein (SMV) are rare and carry a high mortality rate, and the best approach and method of repair is still subject to debate. The objective of the present study was to analyze risk factors for mortality in portal and superior mesenteric venous injuries. A retrospective analysis of 18 patients during a 5-year period was performed. Mechanism of injury, shock upon admission, Revised Trauma Score (RTS), Injury Severity Score (ISS), intraoperative fluid requirements, classification of venous injury severity, and associated injuries were analyzed as potential predictors of outcome. All patients were male, 9 were victims of gunshot wounds, and 11 were in shock at the time of admission. Eight patients sustained PV, and 12 sustained SMV injuries. The great majority of patients had more than 1 associated injury and 61% had an associated vascular injury. Mortality rate correlated with injury severity. Overall mortality rate was 72%. Nonsurvivors had higher ISS than survivors (24 +/-0.4 and 20 +/-1.7, respectively; p = 0.006). Uncontrollable intraoperative hemorrhage was the cause of death in 5 of 13 patients (38.4%). Six patients died during the postoperative period from complications of prolonged shock and multiple organ failure, and 2 died of sepsis. The physiologic status upon admission, the number of associated injuries, and the severity of the vascular injury are the most important factors related to mortality in PV and SMV injuries.     

Risk factors associated with pelvic fractures sustained in motor vehicle collisions involving newer vehicles

BACKGROUND: Despite advances in automotive safety, pelvic fractures caused by motor vehicle collisions remain a significant cause of mortality, morbidity, and functional disability. This study was designed to evaluate epidemiologic and biomechanic risk factors associated with pelvic fractures resulting from motor vehicle collisions. We utilized the Crash Injury Research Engineering Network (CIREN) database to identify these risk factors in newer vehicles. METHODS: Data were prospectively collected at the ten CIREN centers from 1996 to 2005. Specific data were then abstracted on all patients, biomechanic crash characteristics, and injuries sustained. Patients involved in a frontal or near-side lateral impact with pelvic fractures were compared with those without. Univariate analysis was performed using a chi2 analysis. Logistic regression was used to identify significant risk factors in a multivariate analysis to control for confounding associations. RESULTS: Of the 1,851 patients studied, 511 (27.6%) had a pelvic fracture. The overall mortality was 17%. Injury specific factors associated with pelvic fracture were higher Injury Severity Score (ISS) and fatality of the patient. Biomechanic factors associated with the risk of pelvic fracture included; no airbag deployment (p < 0.001), smaller vehicle (p = 0.05), and lateral deformation location (p < 0.001). When stratified by vehicle deformation location, logistic regression models revealed statically significant variables in a frontal impact which included; higher body mass index, higher ISS, large patient vehicle, no seatbelt use, and higher deltaV. For near-side lateral impacts, multivariate analysis revealed statistically significant variables of lower body mass index, higher ISS, female sex, small vehicle size, and higher deltaV. CONCLUSIONS: Even in newer vehicles with federally mandated safety features, pelvic fractures remain a common injury. Pelvic fractures may serve as a marker of crash severity and specific crash characteristics are associated with pelvic fractures. Lateral crashes are significantly more likely to result in a pelvic fracture and, therefore, prevention of pelvic fractures should focus on improving occupant safety in near-side lateral impacts. Recognition of other associations should lead researchers to further investigate causative factors that will ultimately result in improved vehicle design.     

Acute diabetes insipidus in severe head injury: a prospective study

BACKGROUND: The incidence and risk factors for acute diabetes insipidus after severe head injury and the effect of this complication on outcomes have not been evaluated in any large prospective studies. STUDY DESIGN: We conducted a prospective study of all patients admitted to the surgical ICU of a Level I trauma center with severe head injury (head Abbreviated Injury Score [AIS] >or= 3). The following potential risk factors with p < 0.2 on bivariate analysis were included in a stepwise logistic regression to identify independent risk factors for diabetes insipidus and its association with mortality: age, mechanism of injury (blunt or penetrating), blood pressure, Glasgow Coma Scale, Injury Severity Score, head and other body area AIS, skull fracture, cerebral edema and shift, intracranial hemorrhage, and pneumocephaly. RESULTS: There were 436 patients (blunt injuries, 392; penetrating injuries, 44); 387 patients had isolated head injury. Diabetes insipidus occurred in 15.4% of all patients (blunt, 12.5%; penetrating, 40.9%; p < 0.0001) and in 14.7% of patients with isolated head injury (blunt, 11.8%; penetrating, 39.5%; p < 0.0001). The presence of major extracranial injuries did not influence the incidence of diabetes insipidus. Independent risk factors for diabetes insipidus in isolated head injury were Glasgow Coma Scale3. Diabetes insipidus was an independent risk factor for death (adjusted odds ratio, 3.96; 95% CI [1.65, 9.72]; adjusted p value = 0.002). CONCLUSIONS: The incidence of acute diabetes insipidus in severe head injury is high, especially in penetrating injuries. Independent risk factors for diabetes insipidus include a Glasgow Coma Scale3. Acute diabetes insipidus was associated with significantly increased mortality.     

Lower mortality in patients with scapular fractures

BACKGROUND: The purpose of this research was to compare associated injuries and mortality in multiply injured patients with scapular fractures with those without scapular fractures. METHODS: A prospectively collected database of multiply injured motor vehicle occupants with an Injury Severity Score >12 admitted to a level I regional trauma center during from January 1, 1996, to December 31, 2001, was reviewed to assess skeletal and organ injuries associated with a scapular fracture. RESULTS: Of 2,538 motor vehicle occupants, 94 occupants with concomitant scapular fractures and 2,444 occupants without scapular fractures revealed that 76.6% of motor vehicle occupants who sustained scapular fractures were males with a mean age of 44.3 years (SD=18.9). The presence of a scapular fracture reduced the risk of mortality by 44% (95%CI: 1-75%). Patients with scapular fractures had a greater proportion of flail chest injuries [relative risk (RR), 8.8; p < 0.001], clavicle fractures (RR, 4.5; p < 0.001), rib fractures (RR, 3.1; p < 0.01), spine fractures (RR, 2.7; p < 0.001), and tibia and fibular fractures (RR, 1.7; p < 0.025). The presence of a chest injury, either a pneumothorax (RR, 3.7; p < 0.001) or a pulmonary contusion (RR, 3.5; p < 0.001), was significantly more likely in patients with scapular fractures than control patients. Injuries to the spleen (RR, 2.4; p < 0.01) and liver (RR, 2.2; p < 0.025) were also significantly more common in patients with scapular fractures when compared with those without them. CONCLUSIONS: In an observational study of multiply injured trauma patients from motor vehicle crashes, we report the following: (1) scapular fractures occur 3.7% of the time; (2) the presence of a scapular fracture was associated with a lower mortality; and (3) scapular fractures should alert healthcare personnel to the presence of other injuries, such as chest injuries, clavicle fractures, rib fractures, spine fractures, tibial fractures, and spleen and liver injuries. Our findings should be interpreted cautiously, because the mechanism of the association between scapular fractures and mortality remains unclear.     

Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries.

Pelvic hemorrhage has been implicated as the cause of death in 50% of patients who die following pelvic fractures. To establish correlates of morbidity and mortality from pelvic fractures due to blunt trauma, we reviewed 236 patients treated during 4 years. The average age of the 144 men and 92 women was 31.5 years, the average Injury Severity Score was 21.3, the average blood requirement was 5 units, and the average hospital stay was 16.8 days. One hundred fifty-two patients (64.4%) were injured in motor vehicle accidents, 33 (14%) had motor vehicle-pedestrian accidents, 16 (6.8%) had crush injuries, 12 (5.1%) each had either motorcycle accidents or falls, and 11 (4.6%) had miscellaneous accidents. Eighteen patients (7.6%) died, with seven (38.9%) deaths due to hemorrhage. Only one death was caused by pelvic hemorrhage. Other deaths were due to hemorrhage from other sites (6), head injury (5), sepsis or multiple-organ failure (4), pulmonary injury (1), and pulmonary embolus (1). None of the septic deaths was related to a pelvic hematoma. Multivariate multiple regression analysis showed that the severity of injury was correlated with indices of severity of pelvic fractures such as fracture site (p less than 0.0001), fracture displacement (p less than 0.005), pelvic stability (p less than 0.0001), and vector of injury (p less than 0.01). However death could not be predicted on the basis of these indices of severity (p greater than 0.28). Of the nine patients who underwent pelvic arteriography, three required embolization of actively bleeding pelvic vessels, but seven had intra-abdominal hemorrhage that required laparotomy, and eight developed a coagulopathy. Massive bleeding from pelvic fractures was uncommon, and the major threat of hemorrhage was from nonpelvic sites. Furthermore, although injury severity was correlated with the severity of the pelvic fracture, hospital outcome was determined by associated injuries and not by the pelvic fracture.     

Paediatric pelvic ring fractures and associated injuries

Introduction

Paediatric pelvic fractures have been infrequently reviewed. The study was performed to highlight the unique features of pelvic fractures in children.

Patients and methods

A 14-year retrospective study was undertaken of all patients treated for a pelvic fracture at our institute.

Results

Thirty-nine children were included. The mean Injury Severity Score (ISS) was 17.1 (range 4–75). Simple ring fractures were the most common type (46%), dominated by pedestrian versus motor vehicle trauma (58.9%). A pelvic fracture was evident on the initial plain radiographs of all 39 children. Further radiographic investigations (12 CTs and 1 MRI) were undertaken in 13 (33%) of the children. Additional posterior ring fractures were identified in 9. A total of 32 children (82%) sustained one or more associated injuries. Head injuries accounted for 25% and orthopaedic/skeletal injuries for 33% of all associated injuries. Fourteen children required a total of 24 acute surgical procedures. Mean out-pateint clinical follow-up was for 27 months (range 3–85). There was one mortality in this series. Eight children (20%) suffered long term sequale.

Conclusion

Paediatric pelvic fractures differ from their adult counterpart in aetiology, fracture type, and associated injury pattern. They represent a reliable marker for severe trauma. Prospective studies are required to define optimal treatment guidelines, particularly in older children.     

Multiple trauma and scapula fractures: so what?

BACKGROUND Scapula fractures are rare and are presumed to indicate severe underlying trauma. We studied injury patterns and overall outcome in patients with multiple injuries with scapula fractures. METHODS: We carried out a retrospective review of patients with multiple injuries (Injury Severity Score [ISS] > or = 16) with chest and musculoskeletal injuries admitted to our institution between 1993 and 1999 to investigate whether the presence of a scapula fracture is a marker of increased morbidity and mortality. RESULTS: There were 1,164 patients admitted with multiple trauma. Seventy-nine (6.8%) of the 1,164 sustained a scapula fracture, forming the study group. The remainder of the patients (n = 1,085) formed the control group of the study. Both groups of patients were similar with regard to age and Glasgow Coma Scale score (age, 42 +/- 17.8 [+/- SD] vs. 40 +/- 22; GCS score, 11.2 +/- 5.1 vs. 11 +/- 5 in the study and control groups, respectively). The overall ISS was significantly higher in those with scapula fractures (27.12 +/- 15.13 vs. 22.8 +/- 14.4, p = 0.01). Patients with scapula fractures also had more severe chest injuries (Abbreviated Injury Scale score of 3.46 +/- 1.1 vs. 3.1 +/- 1.0, respectively), but not significantly so. However, the incidence of rib fractures was significantly higher in the patients with scapula fractures (p < 0.05). The incidence and severity of head and abdominal injuries were similar in the two groups. The severity of extremity injuries in patients with scapula fractures was significantly lower (2.4 +/- 0.6 vs. 2.7 +/- 0.7, p = 0.001). The rate of admission, the length of intensive care unit stay, and the overall length of hospital stay were similar in the two groups. The overall mortality rate was 11.4% in patients with scapula fractures and 20% in those without scapula fractures (p = 0.1). CONCLUSION: Patients with scapula fractures have more severe underlying chest injuries and overall ISS. However, this did not correlate with a higher rate of intensive therapy unit admission, length of hospital stay, or mortality.     

High-energy trauma patients with pelvic fractures: Management trends in Ontario,Canada

IntroductionAlthough fractures of the pelvic ring account for only 2–3% of all fractures, they are present in approximately 7–20% of patients with high-energy polytrauma. High-energy pelvic fractures are life-threatening injuries, with mortality estimates ranging from 6 to 35%. The purpose of this study was to examine trends in the incidence, diagnosis, treatment, and mortality rates of high-energy pelvic fractures in Ontario, Canada over a 10-year period.MethodsA cohort of 3915 patients who sustained a high-energy pelvic fracture in Ontario between 01 April 2005 and 31 March 2015 was identified using the Ontario Trauma Registry and administrative healthcare data linked by the Institute for Clinical Evaluative Science (ICES). Severely injured patients (defined as having an Injury Severity Score (ISS) of ≥16) with pelvic fractures following high-velocity mechanisms of injury were identified using applicable ICD-10 codes. Trends were assessed statistically using the Poisson and the Cochrane-Armitage tests for trend. Modified Poisson regression was used to model the adjusted risk ratio of mortality by pelvic fracture treatment.ResultsThe incidence of pelvic fracture remained constant at approximately 4.6 cases per 100,000 population annually between 2005 and 2011. From 2012, there was a decrease in patients with ISS ≥ 16 due to changes in the calculation of the ISS. The proportion of patients presenting with ISS > 50 increased from 8.2% to 14.1% (p = 0.008) over the study period. Automobile collisions or pedestrians struck by vehicles accounted for over half of injuries. Approximately 6% of patients underwent angioembolisation. Treatment with external fixation (15.5%–20.2%) or no surgical intervention (46.2%–61.3%) increased from 2005 to 2015. Mortality remained constant (11% at 30 days), and laparotomy was the only major intervention not associated with decreased risk of death.ConclusionsStable mortality despite increasing injury severity suggests that the quality of care provided to patients with high-energy pelvic fractures has improved over time. However, unchanged incidence suggests the need for ongoing efforts aimed towards injury prevention. ISS at presentation was the most significant predictor of mortality in this patient population.     

Scapular fractures and concomitant injuries

Objective: The association of scapular fractures with other life-threatening injuries including blunt thoracic aortic injury is widely recognized.Few studies have investigated this presumed association...     

Emergency Stabilization of Pelvic Instabilities with the Pelvic C-Clamp

Abstract Objective: Emergency stabilization of translationally unstable injuries/fractures of the pelvic ring (type C injuries). Temporary, rarely definitive, restoration of form and function of the posterior pelvis. Indications: Emergency stabilization of sacroiliac disruptions and fractures of the sacrum in type C pelvic injuries. Type B injuries with clinically apparent instability (rotational instability) and type C injuries (disruption of sacroiliac joint, fractured sacrum) with associated circulatory instability. Contraindications: Pelvic type A fractures. Pelvic fractures involving the iliac wing(s). Rotational instability of the pelvis without associated circulatory instability (type B). Surgical Technique: Closed reduction applying traction, pressure and rotation to the affected hemipelvis. Stab incisions and bilateral percutaneous introduction of the pins. Compression of the C-clamp under fluoroscopic monitoring stabilizes the posterior pelvic ring. Depending upon the patients general condition, open reduction and internal fixation (ORIF) will often be performed at a later time. Results: 39 patients with type C pelvic injuries underwent primary stabilization with the pelvic C-clamp. The patients average age was 36 years (11–89 years), 29 were men, ten woman. With the exception of two, all patients had sustained either multiple injuries, or polytrauma. The mean Hannover Polytrauma Score (HPS) was 39.9 points (11–79 points). Ten patients had a disrupted sacroiliac joint, 29 an unstable fracture of the sacrum. On admission, all patients with the exception of four were considered hemodynamically unstable. The initial hemoglobin count was 6.7 g/dl (3.1–12.3 g/dl) on average, the average base excess amounted to –8.7 mmol/l (+2 to –28.0 mmol/l), average systolic blood pressure on admission was 82 mmHg (0–130 mmHg), corresponding to marked findings of shock. At the time of C-clamp application, the indication for the C-clamp was a pelvic instability in 13 patients alone, and in 26 patients the pelvic instability was associated with a circulatory instability. In 15 patients the circulatory situation stabilized after application of the C-clamp. Complications occurred in seven patients (excessive compression of sacral fractures in three patients, one pin malpositioning, two bleeders from pin channels, one perforation of the ilium). This reflects a steep learning curve.The following is a reprint from Operat Orthop Traumatol 2004;16:192–204 and continues the new series of articles at providing continuing education on operative techniques to the European trauma community.Reprint from: Operat Orthop Traumatol 2004;16:192–204 DOI 10.1007/s00064-004-1101-3.     

Improved outcome after early fixation of acetabular fractures

This study was done in order to evaluate the effect of the timing of fixation for acetabular and pelvic ring fractures on patient outcome. Demographic, clinical and outcome data for 5821 trauma patients admitted from January 1993 through January 1996 were retrospectively reviewed. Pelvic fractures were classified according to Young and Burgess. Patients who had fixation within 24 h of admission were compared with those who had later operation. Main outcome measures were Multiple Organ Dysfunction Score according to Moore, hospital and intensive care unit length of stay and discharge disposition. Out of 416 patients with pelvic fractures, one hundred patients had fracture fixation [90 open reduction and internal fixation, 10 external fixation]. There were 59 acetabular fractures and 41 pelvic ring fractures. The overall mortality was 4%. Early fixation of acetabular fractures was associated with lower MODS (p < 0.006) and decreased total length of stay (p < 0.026). Length of hospital stay was also less with early fixation of pelvic ring fractures (p < 0.04). Functional outcome was improved in early fixation of acetabular fractures with a greater proportion of patients being discharged home rather than to rehabilitation or skilled care (p = 0.05). Patients who underwent early repair of acetabular and pelvic ring fractures had a shorter length of hospital stay compared to those with late fixation. Patients with early repair of acetabular fractures had significantly less organ dysfunction and exhibited improved functional outcome.     

Beta-blockers in isolated blunt head injury

BACKGROUND: The purpose of this study was to evaluate the effect of beta-blockers on patients sustaining acute traumatic brain injury. Our hypothesis was that beta-blocker exposure is associated with improved survival. STUDY DESIGN: The trauma registry and the surgical ICU databases of an academic Level I trauma center were used to identify all patients sustaining blunt head injury requiring ICU admission from July 1998 to December 2005. Patients sustaining major associated injuries (Abbreviated Injury Score > or = 4 in any body region other than the head) were excluded. Patient demographics, injury profile, Injury Severity Score, and beta-blocker exposure were abstracted. The primary outcomes measure evaluated was in-hospital mortality. RESULTS: During the 90-month study period, 1,156 patients with isolated head injury were admitted to the ICU. Of these, 203 (18%) received beta-blockers and 953 (82%) did not. Patients receiving beta-blockers were older (50 +/- 21 years versus 38 +/- 20 years, p < 0.001), had more frequent severe (Abbreviated Injury Score > or = 4) head injury (54% versus 43%, p < 0.01), Glasgow Coma Scale < or = 8 less often (37% versus 47%, p = 0.01), more skull fractures (20% versus 12%, p < 0.01), and underwent craniectomy more frequently (23% versus 4%, p < 0.001). Stepwise logistic regression identified beta-blocker use as an independent protective factor for mortality (adjusted odds ratio: 0.54; 95% CI, 0.33 to 0.91; p = 0.01). On subgroup analysis, elderly patients (55 years or older) with severe head injury (Abbreviated Injury Score > or = 4) had a mortality of 28% on beta-blockers as compared with 60% when they did not receive them (odds ratio: 0.3; 96% CI, 0.1 to 0.6; p = 0.001). CONCLUSIONS: Beta-blockade in patients with traumatic brain injury was independently associated with improved survival. Older patients with severe head injuries demonstrated the largest reduction in mortality with beta-blockade.