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.     

伴直肠肛管损伤的开放性骨盆骨折的早期急救处理策略及死亡危险因素分析

目的 探讨伴有直肠、肛管损伤的开放性骨盆骨折的早期急救处理策略及死亡危险因素.方法 回顾性分析2001年4月至2010年4月两家医院救治的25例伴有直肠、肛管损伤的开放性骨盆骨折患者,男23例,女2例;年龄16～56岁,平均(30.1±10.9)岁.采用Fisher精确概率法及多因素Logistic回归分析法对可能的死亡危险因素进行统计学分析.结果 19例存活,6例死亡,死亡率为24%.经Fisher精确概率法分析显示:骨盆骨折Tile分型、创伤严重程度评分(injury severity score,ISS)、格拉斯哥昏迷评分(glasgow coma score,GCS)及改良创伤评分(revised trauma score,RTS)是此类损伤的死亡危险因素.当Tile分型为C型、ISS≥25分、GCS≤8分或RTS≤8分时,患者的死亡概率较大.对此4个危险因素进行多因素Logistic回归分析后发现,RTS≤8分是此类损伤的独立危险因素.结论 积极稳定血流动力学,创口彻底清创引流,早期结肠造瘘以及骨盆固定是此类损伤早期急救处理的关键.RTS是否≤8分可作为判断患者死亡概率的可靠指标.     

The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures

In order to identify the prognostic factors and to evaluate the impact of associated injuries in the outcome of patients with pelvic fractures, a retrospective review of the medical records of patients admitted with a pelvic fracture during a 42-month period was carried out. Demographic data, the mechanism of injury, the physiologic status on admission, associated injuries, pelvic fracture classification, complications and mortality were analysed. One hundred and three patients were included in the study. Fifty-nine were male, and the mean age was 34. The mean Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.1 and 20, respectively. Pedestrian vs vehicle (59%), was the most frequent mechanism of injury. Twenty patients died (19%) most frequently due to "shock". Complications developed in 37 patients (36%), pneumonia being the most frequent. Age greater than 40 years (p=0.02), "shock" upon admission (p=0.002), a Glasgow Coma Scale (GCS)<9, Head AIS>2 (p<0. 001), Chest AIS>2 (p=0.007), and abdominal AIS>2 (p=0.03) all correlated with increased mortality. No correlation between pelvic fracture classification or fracture stability with mortality was observed. The outcome of patients with pelvic fractures due to blunt trauma correlates with the severity of associated injuries and physiological derangement on admission rather than with characteristics of or the type of fracture.     

Efficacy and safety of emergency non-invasive pelvic ring stabilisation

BackgroundUrgent non-invasive pelvic ring stabilisation (pelvic binding, PB) in shocked patients is recommended by state and institutional guidelines regardless of the fracture pattern. The purpose of this study was to determine the adherence to the guidelines, efficacy of the technique and identification of potential adverse effects associated with PB.Patients and methodsA 41-month retrospective analysis of the prospective pelvic fracture database was undertaken at a level 1 trauma centre. High-energy pelvic fractures were included in the analysis with exclusion of the A type injuries (AO/OTA classification) and patients who were dead on arrival. Collected data included patient demographics, injury severity score, fracture classification, application and timing of PB, associated injuries, physiological parameters, resuscitation fluids and outcomes. Pre and post-PB radiographs were reviewed. The potential effects of the PB on soft tissue (femoral vessel, bladder and rectal injury) complications were assessed by independent experts.Results115 patients with high-energy B and C type pelvic ring injuries were included. Thirty-six (31%) patients presented in haemorrhagic shock on arrival. A total of 43 pelvic bindings were performed, 18 of them on shocked patients. The adherence to the guidelines was 50% (18/36) overall. Analysing fracture types of shocked patients the adherence was: B1 80%, B2 20%, B3 20%, C1 66%, C2 86%, C3 33%. The alignment of the pelvis was improved or perfect on post-PB radiographs in 68% and had not changed in 21%. In some cases of B2 and B3 type injuries the PB increased the deformity after application (11%). There were 10 deaths (8.7%) in the study group, with 4 deaths attributed to acute pelvic bleeding. Two of these had PB applied and two were identified as potential for improvement. One femoral artery injury, four bladder injuries and three rectum injuries were identified in patients who had PB applied. Association between the PB and these injuries is unlikely.ConclusionThe adherence to the guidelines should be improved with further education and system development. The good effect of the technique was evident on radiographs. Although in some lateral compression fracture patterns the deformity increased, no hazards were associated with the use of PB.     

Penetrating trauma to the abdominal vessels

Between January 1975 and December 1989, 1860 patients were admitted to the American University of Beirut Medical Centre with abdominal injuries. Their mean age was 23 years. Of these patients 107 had vascular injuries (an incidence of 6%). Bullets were the most common injurious agents (72%), followed by shrapnel (22%). There were 28 arterial and 113 venous injuries. All patients presented to the emergency unit within 5 h of injury (mean 45 min) and were surgically explored. The overall mortality rate was 36.5%. Patients who were haemodynamically stable had a better outcome than those who presented in shock (P < 0.005). The major cause of death was haemorrhage from uncontrolled bleeding. Two subgroups with a higher mortality were identified: patients with inferior vena caval injury associated with a liver injury had a mortality rate of 78.5%, and those with vascular injury associated with pelvic fracture had a mortality rate of 57% (P < 0.05). Abdominal vascular injuries have a high mortality rate, especially if the inferior vena cava is involved or associated pelvic fractures are present. Prompt resuscitation and control of bleeding are the key to an improved salvage rate.     

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.     

Risk factors for cervical spine injury

IntroductionThe early recognition of cervical spine injury remains a top priority of acute trauma care. Missed diagnoses can lead to exacerbation of an existing injury and potentially devastating consequences. We sought to identify predictors of cervical spine injury.MethodsTrauma registry records for blunt trauma patients cared for at a Level I Trauma Centre from 1997 to 2002 were examined. Cervical spine injury included all cervical dislocations, fractures, fractures with spinal cord injury, and isolated spinal cord injuries. Univariate and adjusted odds ratios (ORs) were calculated to identify potential risk factors. Variables and two-way interaction terms were subjected to multivariate analysis using backward conditional stepwise logistic regression.ResultsData from 18,644 patients, with 55,609 injuries, were examined. A total of 1255 individuals (6.7%) had cervical spine injuries. Motor Vehicle Collision (MVC) (odds ratio (OR) of 1.61 (1.26, 2.06)), fall (OR of 2.14 (1.63, 2.79)), age <40 (OR of 1.75 (1.38–2.17)), pelvic fracture (OR of 9.18 (6.96, 12.11)), Injury Severity Score (ISS) >15 (OR of 7.55 (6.16–9.25)), were all significant individual predictors of cervical spine injury. Neither facial fracture nor head injury alone were associated with an increased risk of cervical spine injury. Significant interactions between pelvic fracture and fall and pelvic fracture and head injury were associated with a markedly increased risk of cervical spine (OR 19.6 (13.1, 28.8)) and (OR 27.2 (10.0–51.3)).ConclusionsMVC and falls were independently associated with cervical spine injury. Pelvic fracture and fall and pelvic fracture and head injury, had a greater than multiplicative interaction and high risk for cervical spine injury, warranting increased vigilance in the evaluation of patients with this combination of injuries.     

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 strategy of vascular injuries associated with pelvic fractures.

To establish the frequency of major vascular trauma, facilitate recognition of potential injury based on fracture pattern, and formulate a systematic approach to evaluation and management, we studied 429 consecutive patients with acute blunt pelvic fracture. Fracture patterns were grouped as non-ring brakes (n = 43), anterior pelvic ring (n = 197), posterior pelvic ring (n = 104), or acetabular (n = 85) involvement. Mean age was 31 (range 2 to 90); 55% were male. Injuries resulted primarily from motor vehicle accidents (31%), pedestrian injuries (26%), and motorcycle accidents (19%). The fracture pattern was correlated with the occurrence of documented vascular injury, modality of management, transfusion greater than or equal to 10 units in the first day, associated injuries, and outcome. Laparotomy was performed in 22 patients (5%), but helpful only if associated visceral injuries were encountered. There were no instances of iliac or femoral vascular injuries. Hemodynamically unstable patients (BP less than 90) with major pelvic fractures and no other documented source of bleeding underwent pelvic angiography. Posterior ring disruption was associated with vascular injury requiring intervention (p less than 0.001). The occurrence of associated injuries (p less than 0.001), need of greater than 10 units of blood transfusion in the first 24 hours (p less than 0.005), and death (p less than 0.01) were consequences of posterior ring disruption. Based on this experience we conclude that: (1) aortoiliac and femoral arterial as well as iliofemoral venous injuries are a very rare consequence of pelvic fracture; (2) pelvic fracture with posterior ring disruption has a higher incidence of vascular injury necessitating intervention, associated injury, major transfusion requirement, and death; (3) early interventional radiology is efficacious in the control of arterial disruption caused by pelvic fracture; and (4) a tailored management strategy using the expertise of the vascular and orthopedic surgeon as well as the radiologist is required for recalcitrant hemorrhage.     

Pelvic fracture among polytrauma decedents

Pelvic fractures (PF) sustained from accidents are commonly believed to be a major cause of mortality in polytraumatized patients. The purpose of this paper is to determine whether PF are usually the primary cause or a contributing cause of mortality in these patients. A 10-year retrospective review was performed of all polytrauma patients with PF who were admitted to, and died, at a large, level-I trauma center. The pelvic injury was graded according to Schatzker and Tile into stable (type A), partially stable (type B), and unstable (type C). The injury severity score (ISS), which incorporates associated injuries and their potential impact on mortality, was calculated for all patients. For each patient, a separate subjective designation of the probable cause of death was determined. We identified 74 decedents with PF following deceleration trauma. The pelvic fractures were classified as 12 type A (16%), 36 type B (49%), and 26 type C (35%). The mean ISS was extremely high, 40.6 +/- 1.4 (range 18-75), more than four times the score for simply a severe PF. The ISS was also not significantly different among the three pelvic fracture groups (P = 0.613). The records subjectively identified PF as the precipitating cause of death in only 13% of the patients. In this study, patients who died with PF had an ISS that implicated at least one or two additional major visceral injuries. These data do not support the hypothesis that PF, regardless of its complexity, is the usual primary cause or the major precipitating event of death in the polytraumatized patient. In these patients, mortality appears to be a function of the associated injuries based on the ISS calculation.     

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   

Posterior pelvic ring injury of straddle fractures: Incidence,fixation methods,and clinical outcomes

Straddle fracture, a superior and inferior ramus fracture of both sides, is generally treated conservatively. However, posterior pelvic ring injury is often associated with straddle fracture, leading to unstable pelvic bone fracture that requires surgical treatment. The present study reports the clinical and radiological outcomes of straddle fracture with posterior pelvic ring injury.This study included 73 patients (41 men, 32 women) with a straddle fracture injury. The injury mechanism, injury severity score (ISS), accompanying injuries, presence of posterior pelvic ring injury, and fixation methods for the pelvic fracture were analyzed, and outcomes were evaluated functionally and radiologically.Of the 73 patients, 56 (77%) had a posterior pelvic ring injury and 7 died. In 43 patients, the posterior pelvic ring injuries constituted unstable pelvic injury and were treated surgically. The fixation method was determined based on the severity of the posterior pelvic injury. The patients’ mean ISS was 24.7 points. Radiological evaluation of surgical outcomes in 43 patients revealed the outcomes as anatomic in 20, nearly anatomic in 14, moderate in 5, and poor in 4, whereas functional evaluation revealed the outcomes as excellent in 21, good in 9, fair in 7, and poor in 6.Posterior pelvic ring fracture can accompany straddle fractures, which may lead to pelvic injury instability. Thus, special attention is required for patients with a straddle fracture.     

复合性骨盆伤的早期失血及救治相关因素

目的 研究复合性骨盆伤的早期失血及损伤特点，及其与救治关系、对预后结局的影响，探讨其分类救治的方法。方法 对233例具有严重骨盆伤伴有血液动力学不稳定患者按暴力方式、骨盆骨折类型及合并伤情分组，采用生理状态、解剖损伤及输血容量等方面的量化指标进行伤情评定分级，并计算生存概率(Ps)，以此进行比较和统计学分析。结果 骨盆骨折多伴有合并损伤，常为高能量交通伤所致；其出血源、出血量及血流动力学改变为非对称相关；其中不稳定型骨盆骨折合并脏器破裂出血者伤后血压改变和早期输血量均较为显著，骨盆AIS和ISS分值较高，生存概率(Ps)较低。结论 高能量所致骨盆伤多为高危性创伤，易合并多发伤，常有多源性出血，加强整体伤势和出血来源的认识，区别不同伤情，有利于对其进行分类救治。     

Management and outcomes of open pelvic fractures: An update

BackgroundOpen pelvic fractures remain challenging in terms of their management. The purpose of this narrative review was to evaluate the latest advances made in the management of these injuries and report on their clinical outcome.Patients and methodsA literature review was undertaken focusing on studies that have been published on the management of open pelvic fractures between January 2005 and November 2019. Information extracted from each article include demographics, mechanism of injury, injury severity score (ISS), classification of pelvic ring fracture, classification of open soft tissue, specific injury zone classification, number of cases with hemodynamic instability, number of cases that received blood transfusions, amount of packed red blood cells transfused during the first 24 h, number of cases with anorectal trauma, urogenital injury, number of fecal diversional colostomies and laparotomies, angiographies and embolization, preperitoneal pelvic packings, length of stay in intensive care unit (ICU) and in hospital, and mortality.ResultsFifteen articles with 646 cases formed the basis of this review. The majority of patients were male adults (74.9%). The mean age was 35.1 years. The main mechanism of injury was road traffic accidents, accounting for 67.1% of the injuries. The mean ISS was 26.8. A mean of 13.5 units of PRBCs were administered the first 24 h. During the whole hospital stay, 79.3% of the patients required blood transfusions. Angiography and pelvic packing were performed in a range of 3%-44% and 13.3%-100% respectively. Unstable types of pelvic injuries were the majority (72%), whilst 32.7% of the cases were associated with anorectal trauma, and 32.6% presented with urogenital injuries. Bladder ruptures were the most reported urogenital injury. Fecal diversional colostomy was performed in 37.4% of the cases. The mean length of ICU stay was 12.5 days and the mean length of hospital stay was 53.0 days. The mean mortality rate was 23.7%.ConclusionMortality following open pelvic fracture remains high despite the evolution of trauma management the last 2 decades. Sufficient blood transfusion, bleeding control, treatments of associated injuries, fracture fixation and soft tissue management remain essential for the reduction of mortality and improved outcomes.     

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.     

Interventionelle Notfallembolisation bei schweren Beckenfrakturen mit arterieller Blutung

Objective

Presentation of our own experiences and results of an early clinical algorithm for treatment integrating emergency embolization (TAE) in cases of unstable pelvic ring fractures with arterial bleeding.

Method

Consecutive patient series from April 2002 to December 2006 at a level 1 trauma center. The data of the online shock room documentation (Traumawatch®) of patients with a pelvic fracture and arterial bleeding detected on multislice computed tomography (MSCT) were examined for the following parameters: demographic data, injury mechanism, fracture classification according to Tile/AO and severity of the pelvic injury assessed with the Abbreviated Injury Score (AIS), accompanying injuries with elevation of the cumulative injury severity according to the Injury Severity Score (ISS), physiological admission parameters (circulatory parameters and initial Hb value) as well as transfusion requirement during treatment in the shock room, time until embolization, duration of embolization, and source of bleeding.

Results

Of a total of 162 patients, arterial bleeding was detected in 21 patients by contrast medium extravasation on MSCT, 12 of whom were men and 9 women with an average age of 45 (14–80) years. The mechanism of injury was high energy trauma in all cases. In 33% it involved type B pelvic fractures and in 67% type C fractures with an average AIS pelvis of 4.4 points (3–5) and a total severity of injury with the ISS of 37 points (21–66). Upon admission 47.6% presented hemodynamic instability with an average Hb value of 7.8 g/dl (3.2–12.4) and an average transfusion requirement of 6 red blood cell units (4–13). The time until the TAE was started was on average 62 min (25–115) with a duration period of the TAE of 25 min (15–67). Branches of the internal iliac artery were identified as the sole source of bleeding. The success rate of TAE amounted to over 90%.

Conclusion

Interventional TAE represents an effective as well as a fast procedure for hemostasis of arterial bleeding detected on MSCT in patients with pelvic fractures. If an experienced radiologist on 24-h stand-by is assured and the infrastructure is efficient, this can be performed shortly after hospital admission and therefore should be integrated into the early clinical treatment protocol.     

Spinal injury in major trauma: Epidemiology of 1104 cases from an Italian first level trauma center

IntroductionTraumatic spinal injuries are frequent and their management is debated, especially in major trauma patients. This study aims to describe a large population of major trauma patients with vertebral fractures to improve prevention measures and fracture management.Patients and methodsRetrospective analysis of 6274 trauma patients prospectively collected between October 2010 and October 2020. Collected data include demographics, mechanism of trauma, type of imaging, fracture morphology, associated injuries, injury severity score (ISS), survival, and death timing. The statistical analysis focused on mechanism of trauma and the search of predictive factors for critical fractures.ResultsPatients showed a mean age of 47 years and 72.5% were males. Trauma included 59.9% of road accidents and 35.1% of falls. 30.7% patients had at least a severe fracture, while 17.2% had fractures in multiple spinal regions. 13.7% fractures were complicated by spinal cord injury (SCI). The mean ISS of the total population was 26.4 (SD 16.3), with 70.7% patients having an ISS≥16. There is a higher rate of severe fractures in fall cases (40.1%) compared to RA (21.9% to 26.3%). The probability of a severe fracture increased by 164% in the case of fall and by 77% in presence of AIS≥3 associated injury of head/neck while reduced by 34% in presence of extremities associated injuries. Multiple level injuries increased with ISS rise and in the case of extremities associated injuries. The probability of a severe upper cervical fracture increased by 5.95 times in the presence of facial associated injuries. The mean length of stay was 24.7 days and 9.6% of patients died.ConclusionsIn Italy, road accidents are still the most frequent trauma mechanism and cause more cervico-thoracic fractures, while falls cause more lumbar fractures. Spinal cord injuries represent an indicator of more severe trauma. In motorcyclists or fallers/jumpers, there is a higher risk of severe fractures. When a spinal injury is diagnosed, the probability of a second vertebral fracture is consistent. These data could help the decisional workflow in the management of major trauma patients with vertebral injury.     

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.     

Epidemiology and outcome of complex pelvic injury

Soft tissue injuries associated with pelvic fractures are often responsible for compromised haemodynamics. The objective of this study was to clarify what parameters determine patient outcome. In a cohort study, all patients with a pelvic fracture treated between 1991 and 2001 at a Level I trauma center were analysed for associated intrapelvic injuries, classification, severity of trauma, type of intervention and outcome. Of 552 patients with a pelvic fracture who entered the study, 15.5% presented with associated intrapelvic injuries secondary to the fracture (group I). A subgroup of patients with lacerations of branches of the iliac artery was identified as being at high risk for lethal outcome; they represented 4.3% of all patients with pelvic fracture (group II). The overall mortality reached 4.4%; it increased in group I to 15.5%, and in group II to 33.3%. In the subgroup with pelvic arterial haemorrhage (group II), the severity of injury, the proportion of multiple injured patients, the prevalence of unstable fractures and the incidence of sepsis were significantly increased. The only predictive factor for outcome was the amount of blood transfused, suggesting that fast elimination of the bleeding source decides about patient survival.     

Paediatric pelvic fractures: A review of 2 cohorts over 22 years

AimsThe aim of this retrospective review was to identify all children that presented to our institution with a pelvic or acetabular fracture and to compare these children to a previous cohort of paediatric pelvic fractures that we have reported.Patients53 children under the age of 16 were identified over a ten year period.MethodsWe reviewed our trauma database, hospital records and radiological imaging to determine the age, gender, fracture pattern, associated injuries and management of the pelvic fracture.ResultsThere were 32 boys and 21 girls. Mean age of the boys was 8.8 years and the girls 10.7 years. In seven children the pelvic fracture was an isolated injury and in the remaining 46 children, there were 113 additional injuries. 56% of the additional injuries was either a fracture/dislocation (37%) or a head injury (19%). Compared to our first cohort, we had a larger number of children in the second cohort. Age, sex distribution, mechanism of injury was similar in the two groups. In this current cohort, use of CT scan imaging was more frequent, there were more unstable pelvic fracture patterns identified, ISS scores were higher and mortality was lower.ConclusionWe have seen more children with more severe injuries, higher ISS scores but a lower mortality rate.