Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures

Objective

To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation.

Methods

A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n = 20) or early pelvic angiography (ANGIO group, n = 20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded.

Results

The PACK group underwent operative packing at a median of 45 min from admission; the median time to angiography in the ANGIO group was 130 min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24 h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage.

Conclusions

Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.     

Time to pelvic embolization for hemodynamically unstable pelvic fractures may affect the survival for delays up to 60 min

Introduction

We evaluated the relationship between survival and time from arrival to angiography for hemodynamically unstable patients with pelvic trauma.

Methods

A retrospective review of patients admitted to Fukui Prefectural Hospital with pelvic fractures during a 7.5-year period. Charts were reviewed for age, injury characteristics, injury severity score, systolic blood pressure and heart rate on arrival, base deficit, and the lactate concentration on arrival, transfusion requirement, fracture pattern, the time from hospital arrival to angiography, and the time spent in the angiography suite.

Results

Of a total of 140 patients, 68 patients underwent pelvic angiography and embolization. Of the patients, 24 patients were hemodynamically unstable. The average injury severity score was 41.7. Of the patients, 17 had major ligamentous disruption. The average time from hospital arrival to angiography suite was 76 min. Of the hemodynamically unstable 24 patients, there were 12 deaths (50%). Patients who were embolized within 60 min of arrival had a significantly lower mortality rate (16 vs. 64%; p = 0.04). There was no embolization-related complication and repeat angiography was not required in all patients.

Conclusion

Earlier pelvic embolization within 60 min may affect the survival of hemodynamically unstable patients with pelvic fracture.     

Outcome of angiographic embolisation for unstable pelvic ring injuries: Factors predicting success

Introduction

Angiographic embolisation (AE) is a successful treatment for haemodynamically unstable pelvic ring injuries. However, recent evidence has shown a significant complication rate following AE together with a lower success rate than previously reported. The aim of the current study was to review and indentify the factors predicting success or failure of AE.

Patients and methods

651 patients with high energy (ISS > 16) pelvic ring injuries were treated in our institution between the years 1997 and 2009. Mean patient age was 37 (range 5–89) years, and the average ISS 33.4 (range 16–66). Patients’ information was collected from the institution's trauma registry as well as from the patient's medical chart and radiographs. Data included age, ISS, length of stay, ICU stay, initial blood pressure and pulse, blood products consumption, blood creatinine levels, fracture type and treatment, embolisation details, complications and mortality. 61 patients (9.3%) underwent urgent angiography due to haemodynamic instability. Angiography was positive (PA) in 38 patients (62.3%) and was negative for haemorrhage (NA) in the remaining 23 (37.7%).

Results

Ten patients required a branch vessel embolisation while 17 patients required major vessel embolisation, 11 required bilateral internal iliac embolisation and three patients underwent multiple vessel embolisation. Overall mortality rate was 26%. 32 patients required surgical intervention for pelvic ring stabilisation. Significant reduction in blood transfusion was seen in patients with an APC fracture type following AE. No significant correlation was found between fracture type and mortality. Multiple vessel embolisations were associated with increased surgical complications and mortality.

Discussion

Angiographic embolisation provides a reasonable option for haemodynamically unstable pelvic ring injured patients with an acceptable outcome, supporting previously reported literature. Patients with unstable APC type pelvic fracture may benefit the most from early angiographic embolisation. Patients requiring multiple vessel embolisation have a guarded outcome.     

Detecting active pelvic arterial haemorrhage on admission following serious pelvic fracture in multiple trauma patients

Background

The early diagnosis of pelvic arterial haemorrhage is challenging for initiating treatment by transcatheter arterial embolization (TAE) in multiple trauma patients. We use an institutional algorithm focusing on haemodynamic status on admission and on a whole-body CT scan in stabilized patients to screen patients requiring TAE. This study aimed to assess the effectiveness of this approach.

Methods

This retrospective cohort study included 106 multiple trauma patients admitted to the emergency room with serious pelvic fracture [pelvic abbreviated injury scale (AIS) score of 3 or more].

Results

Of the 106 patients, 27 (25%) underwent pelvic angiography leading to TAE for active arterial haemorrhage in 24. The TAE procedure was successful within 3 h of arrival in 18 patients. In accordance with the algorithm, 10 patients were directly admitted to the angiography unit (n = 8) and/or operating room (n = 2) for uncontrolled haemorrhagic shock on admission. Of the remaining 96 stabilized patients, 20 had contrast media extravasation on pelvic CT scan that prompted pelvic angiography in 16 patients leading to TAE in 14. One patient underwent a pelvic angiography despite showing no contrast media extravasation on pelvic CT scan. All 17 stabilized patients who underwent pelvic angiography presented a more severely compromised haemodynamic status on admission, and they required more blood products during their initial management than the 79 patients who did not undergo pelvic angiography. The incidence of unstable pelvic fractures was however comparable between the two groups. Overall, haemodynamic instability and contrast media extravasation on the CT-scan identified 26 out of the 27 patients who required subsequent pelvic angiography leading to TAE in 24.

Conclusions

An algorithm focusing on haemodynamic status on arrival and on the whole-body CT scan in stabilized patients may be effective at triaging multiple trauma patients with serious pelvic fractures.     

Comparing the predictive value of the pelvic ring injury classification systems by Tile and by Young and Burgess

Introduction

Radiology-based classifications of pelvic ring injuries and their relevance for the prognosis of morbidity and mortality are disputed in the literature. The purpose of this study was to evaluate potential differences between the pelvic ring injury classification systems by Tile and by Young and Burgess with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries.

Patients and methods

Two-hundred-and-eighty-five consecutive patients with pelvic ring fractures were analyzed for mortality within 30 days after admission, number of blood units and total volume of fluid infused during the first 24 h after trauma, the Abbreviated Injury Severity (AIS) scores for head, chest, spine, abdomen and extremities as a function of the Tile and the Young–Burgess classifications.

Results

There was no significant relationship between occurrence of death and fracture pattern but a significant relationship between fracture pattern and need for blood units/total fluid volume for Tile (p < .001/p < .001) and Young–Burgess (p < .001/p < .001). In both classifications, open book fractures were associated with more fluid requirement and more severe injuries of the abdomen, spine and extremities (p < .05). When divided into the larger subgroups “partially stable” and “unstable”, unstable fractures were associated with a higher mortality rate in the Young–Burgess system (p = .036). In both classifications, patients with unstable fractures required significantly more blood transfusions (p < .001) and total fluid infusion (p < .001) and higher AIS scores.

Conclusions

In this first direct comparison of both classifications, we found no clinical relevant differences with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries.     

Comparison of circumferential pelvic sheeting versus the T-POD on unstable pelvic injuries: A cadaveric study of stability

Objectives

Commercially available binder devices are commonly used in the acute treatment of pelvic fractures, while many advocate simply placing a circumferential sheet for initial stabilization of such injuries. We sought to determine whether or not the T-POD would provide more stability to an unstable pelvic injury as compared to circumferential pelvic sheeting.

Methods

Unstable pelvic injuries (OTA type 61-C-1) were surgically created in five fresh, lightly embalmed whole human cadavers. Electromagnetic sensors were placed on each hemi-pelvis. The amount of angular motion during testing was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). Either a T-POD or circumferential sheet was applied in random order for testing. The measurements recorded in this investigation included maximum displacements for sagittal, coronal, and axial rotation during application of the device, bed transfer, log-rolling, and head of bed elevation.

Results

There were no differences in motion of the injured hemi-pelvis during application of either the T-POD or circumferential sheet. During the bed transfer, log-rolling, and head of bed elevation, there were no significant differences in displacements observed when the pelvis was immobilized with either a sheet or pelvic binder (T-POD).

Conclusions

A circumferential pelvic sheet is more readily available, costs less, is more versatile, and is equally as efficacious at immobilizing the unstable pelvis as compared to the T-POD. We advocate the use of circumferential sheeting for temporary stabilization of unstable pelvic injuries.     

选择性动脉造影与栓塞在血流动力学不稳定骨盆骨折诊治中的应用

目的 探讨选择性动脉造影与栓塞在诊治骨盆骨折伴血流动力学不稳定患者中的应用.方法 回顾性分析2002年1月至2008年12月收治的62例骨盆骨折伴动脉损伤患者资料,骨折采用AO分型:A2型2例;B1型6例,B2型9例,B3型8例;C1型16例,C2型13例,C3型8例.其中开放性损伤6例(Gustilo分型:Ⅱ型1例,Ⅲ型5例).多发伤患者46例,12例发生休克.62例患者在积极补液及应用血管活性药物的同时进行动脉造影检查,其中59例患者行栓塞治疗. 结果 62例患者行动脉造影79次,其中行2次以上动脉造影患者12例.损伤动脉由多至少依次为臀上动脉、髂腰动脉、骶外侧动脉、闭孔动脉、臀下动脉、阴部内动脉以及髂内动脉和髂外动脉的主干.32例患者伴有两条以上动脉(分支)损伤.59例行骨盆内动脉损伤栓塞治疗的患者中,56例有效.7例患者因腹腔脏器严重损伤抢救无效而死亡,10例失访,45例患者术后获6～52个月(平均14个月)随访.11例患者患侧臀部肌肉力量较健侧弱,未见其他明显并发症.12例多次行选择性动脉造影与(或)栓塞治疗的患者均获随访,其中2例发生患侧臀部肌肉力量减弱. 结论 选择性动脉造影与栓塞是诊治骨盆骨折患者动脉损伤的有效措施.对于多发动脉损伤或延迟动脉损伤的患者,重复性动脉造影和栓塞治疗是必要且安全有效的.     

Time to intervention in patients with splenic injury in a Dutch level 1 trauma centre

Background

Timely intervention in patients with splenic injury is essential, since delay to treatment is associated with an increased risk of mortality. Transcatheter Arterial Embolisation (TAE) is increasingly used as an adjunct to non-operative management. The aim of this study was to report time intervals between admission to the trauma room and start of intervention (TAE or splenic surgery) in patients with splenic injury.

Methods

Consecutive patients with splenic injury aged ≥16 years admitted between January 2006 and January 2012 were included. Data were reported according to haemodynamic status (stable versus unstable). In haemodynamically (HD) unstable patients, transfusion requirement, intervention-related complications and the need for a re-intervention were compared between the TAE and splenic surgery group.

Results

The cohort consisted of 96 adults of whom 16 were HD unstable on admission. In HD stable patients, median time to intervention was 105 (IQR 77–188) min: 117 (IQR 78–233) min for TAE compared to 95 (IQR 69–188) for splenic surgery (p = 0.58). In HD unstable patients, median time to intervention was 58 (IQR 41–99) min: 46 (IQR 27–107) min for TAE compared to 64 (IQR 45–80) min for splenic surgery (p = 0.76). The median number of transfused packed red blood cells was 8 (3–22) in HD unstable patients treated with TAE versus 24 (9–55) in the surgery group (p = 0.09). No intervention-related complications occurred in the TAE group and one in the splenic surgery group (p = 0.88). Two spleen related re-interventions were performed in the TAE group versus 3 in the splenic surgery group (p = 0.73).

Conclusions

Time to intervention did not differ significantly between HD unstable patients treated with TAE and patients treated with splenic surgery. Although no difference was observed with regard to intervention-related complications and the need for a re-intervention, a trend towards lower transfusion requirement was observed in patients treated with TAE compared to patients treated with splenic surgery. We conclude that if 24/7 interventional radiology facilities are available, TAE is not associated with time loss compared to splenic surgery, even in HD unstable patients.     

Intra- and postoperative complications of navigated and conventional techniques in percutaneous iliosacral screw fixation after pelvic fractures: Results from the German Pelvic Trauma Registry

Background

Percutaneous iliosacral screw placement following pelvic trauma is a very demanding technique involving a high rate of screw malpositions possibly associated with the risk of neurological damage or inadequate stability. In the conventional technique, the screw's correct entry point and the small target corridor for the iliosacral screw may be difficult to visualise using an image intensifier. 2D and 3D navigation techniques may therefore be helpful tools.The aim of this multicentre study was to evaluate the intra- and postoperative complications after percutaneous screw implantation by classifying the fractures using data from a prospective pelvic trauma registry. The a priori hypothesis was that the navigation techniques have lower rates of intraoperative and postoperative complications.

Methods

This study is based on data from the prospective pelvic trauma registry introduced by the German Society of Traumatology and the German Section of the AO/ASIF International in 1991. The registry provides data on all patients with pelvic fractures treated between July 2008 and June 2011 at any one of the 23 Level I trauma centres contributing to the registry.

Results

A total of 2615 patients were identified. Out of these a further analysis was performed in 597 patients suffering injuries of the SI joint (187 × with surgical interventions) and 597 patients with sacral fractures (334 × with surgical interventions).The rate of intraoperative complications was not significantly different, with 10/114 patients undergoing navigated techniques (8.8%) and 14/239 patients in the conventional group (5.9%) for percutaneous screw implantation (p = 0.4242).Postoperative complications were analysed in 30/114 patients in the navigated group (26.3%) and in 70/239 patients (29.3%) in the conventional group (p = 0.6542). Patients who underwent no surgery had with 66/197 cases (33.5%) a relatively high rate of complications during their hospital stay. The rate of surgically-treated fractures was higher in the group with more unstable Type-C fractures, but the fracture classification had no significant influence on the rate of complications.

Discussion

In this prospective multicentre study, the 2D/3D navigation techniques revealed similar results for the rate of intraoperative and postoperative complications compared to the conventional technique. The rate of neurological complications was significantly higher in the navigated group.     

Results of operative treatment of avulsion fractures of the iliac crest apophysis in adolescents

Background

Avulsion fracture of the iliac crest apophysis is a rare condition that commonly occurs in adolescent athletes. Conservative treatment for this injury can produce excellent functional outcomes. However, the rehabilitation process requires a rather long immobilisation period. This study aimed to evaluate the use of cannulated screws for fixation of avulsion fractures of iliac crest apophysis.

Methods

Ten patients with avulsion fractures of iliac crest apophysis were treated by open reduction and internal fixation using cannulated screws.

Results

The mean age of patients was 14.6 years (range, 13–15 years). The mean intraoperative blood loss was 14.9 ml (range, 10–25 ml). The mean operative time was 40.3 min (range, 33–52 min). The mean follow-up period was 11.2 months (range, 6–20 months). At the 4-week follow-up, all patients returned to previously normal activity without pain and had no evidence of lower extremity muscle weakness. At the final follow-up, all patients resumed their athletic activity without any complications.

Conclusion

Open reduction and internal fixation for the treatment of avulsion fracture of iliac crest apophysis can be recommended for patients requiring rapid rehabilitation.     

Preperitoneal pelvic packing is effective for hemorrhage control in open pelvic fractures

Background

Open pelvic fractures are life-threatening injuries. Preperitoneal pelvic packing (PPP) has been suggested to be ineffective for hemorrhage control in open pelvic fractures. We hypothesize that PPP is effective at hemorrhage control in patients with open pelvic fractures and reduces mortality.

Open supracondylar femur fractures with bone loss in the polytraumatized patient – Timing is everything!

Introduction

Open supracondylar femur fractures are rare, complex injuries which occur in polytrauma patients and are complicated by bone loss, contamination, compromised soft tissues, and poor host condition. The purpose of this study is to demonstrate a successful treatment protocol for these challenging injuries.

Methods

A consecutive series of 15 open supracondylar femur fractures in 14 polytrauma patients (ages 16–75, mean 41) were treated at one Level I trauma centre by a single surgeon. Fracture patterns included seven AO/OTA Type C2 and eight Type C3 fractures. All fractures were open and classified by Gustillo/Anderson as type IIIA (10 fractures) and type IIIB (five fractures). Stage I was performed within 24 h and included thorough open fracture care and early definitive fixation with a laterally based locking device and antibiotic bead placement. Stage II was performed several months later (average 3.6 months) when the soft tissue envelope had revascularized and the polytrauma patient had recovered from their other injuries. Stage II consisted of either an anterior incision or subvastus approach to the distal femur, bone grafting, BMP application, and addition of medial column support to create rigid fixation.

Results

All fractures (15/15) healed uneventfully. Union was determined by absence of pain and radiographic union in 3/4 cortices. Mean time to union was 4 months. There were no deep infections and alignment was maintained (average tibiofemoral angel of 5° of valgus) although several limbs were complicated by knee stiffness.

Conclusions

Healing of open supracondylar femur fractures with critical sized bone defects requires diligent surgical timing in order to optimise the host and wound bed. Thorough initial debridement and early definitive fixation halt ongoing soft tissue injury, restores length and alignment, and allow for sterilisation of the wound. After patients have recovered from their other injuries and the soft tissue sleeve has revascularized, bone grafting with BMP supplementation and medial column plating allows for rigid fixation of the femur and offers the biology these fracture patterns require for successful union without infection.     

Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: A randomised controlled trial

Background

Falls and related injuries are a major public health concern in elderly people. Multifactorial interventions may result in significant reduction in falls but their effectiveness in prevention of fall-induced injuries at centre-based falls clinics is unclear. This study assessed the effectiveness of the multifactorial Chaos Clinic Falls Prevention Programme on rate of falls and related injuries of home-dwelling older adults.

Methods

This study was a pragmatic, randomised controlled trial concentrating on high risk individuals and their individual risk factors of falling. Home-dwelling elderly people aged 70 years or more were recruited to the Chaos falls clinics in the cities of Lappeenranta and Tampere in Finland between January 2005 and June 2009. 1314 participants with high-risk for falling and fall-induced injuries and fractures were randomised into intervention group (n = 661) and control group (n = 653). A multifactorial, individualized 12-month falls prevention programme concentrating on strength and balance training, medical review and referrals, medication review, proper nutrition (calcium, vitamin D), and home hazard assessment and modification was carried out in the intervention group. The main outcome measures were rates of falls, fallers, and fall-induced injuries.

Results

During the one-year follow-up, 608 falls occurred in the intervention group and 825 falls in the control group. The rate of falls was significantly lower in the intervention group (95 falls per 100 person-years) than in the controls (131 falls per 100 person-years), the incidence rate ratio (IRR) being 0.72 (95% confidence interval (CI) 0.61–0.86, p < 0.001, NNT 3). In the intervention group 296 participants fell at least once. In the controls the corresponding number was 349. The hazard ratio (HR) of fallers in the intervention group compared with the control group was 0.78 (95% CI 0.67–0.91, p = 0.001, NNT 6). The number of fall-induced injuries in the intervention group was 351 with the corresponding rate (per 100 person-years) of 55. In the control group, these figures were higher, 468 and 75. The IRR of fall-induced injuries in the intervention group compared with the control group was 0.74 (95% CI 0.61–0.89, p = 0.002, NNT 5).

Conclusions

The multifactorial Chaos Clinic Falls Prevention Programme is effective in preventing falls of older adults. The programme reduces the rate of falls and related injuries by almost 30%.     

Critical review of pelvic fractures associated with external iliac artery lesion: A series of six cases

Introduction

Bleeding associated with pelvic fracture mostly comes from the pre-sacral and lumbar venous plexus, or directly from the fracture site. Bleeding as a consequence of arterial lesion is less common (15–20%), and that resulting from lesion of the external iliac artery (EIA) is extremely rare. The mortality rate associated with iliac artery injury ranges from 38% to 72%. Total body CT-scan with contrast medium, angiography or packing can be performed when there is arterial injury. In some cases, embolisation can stop bleeding; however, when there is involvement of the aorta, common iliac artery or EIA, immediate surgery is mandatory. The aim of this study was to report our experience of pelvic fractures associated with EIA lesion.

Materials and methods

Six patients with pelvic fracture and associated rupture of the EIA have been observed at our unit from 2004 to 2009. According to Tile classification there were three cases of type C and two cases of type B fracture. One case was a two-column acetabular fracture. Angiography was performed in all cases.

Results

Three patients died on the day of trauma: two after angiography, and one after surgery of vascular repair. Three patients survived: two underwent a hemipelvectomy, and one underwent hip disarticulation.

Discussion

Haemodynamic instability in patients with pelvic ring fracture is usually because of venous bleeding from the pre-sacral and lumbar plexus, or from the fracture site. Arterial injury is present in around 20% of cases. EIA lesions require immediate surgical treatment to restore blood flow. Depending on the type of injury, vascular surgery can be associated with pelvic fracture stabilisation.

Conclusions

Pelvic ring fracture associated with an EIA lesion is extremely rare, with few cases reported in the literature. Angiography is used for diagnosis, and immediate surgical treatment is required to restore blood flow. Associated injuries and open fracture can lead to fatal complications or amputation. Rates of mortality and severe disability are extremely high.     

Locked versus standard unlocked plating of the symphysis pubis in a Type-C pelvic injury: A cadaver biomechanical study

Introduction

The benefits of locked plating for pubic symphyseal disruption have not been established. The purpose of this biomechanical study was to determine whether locked plating offers any advantage over conventional unlocked plating of the pubic symphysis in the vertically unstable, Type-C pelvic injury.

Methods

In each of eight embalmed cadaver pelvis specimens, sectioning of the pubic symphysis in conjunction with a unilateral release of the sacroiliac, sacrospinous, and sacrotuberous ligaments and pelvic floor was performed to simulate a vertically unstable Type-C (Orthopaedic Trauma Association 61-C1.2) pelvic injury. The disrupted SI joint was then reduced and fixed using two 6.5 mm cannulated screws inserted into the S1 body. Using a six-hole 3.5 mm plate specifically designed for the symphysis pubis having both locked and unlocked capability, four pelvises were fixed with locked screws and four pelvises were fixed with standard unlocked bicortical screws. Both groups were similar based on a dual-emission X-ray absorptiometry evaluation (P = 0.69). Each pelvis was then mounted on a servohydraulic materials-testing apparatus using a bilateral stance model to mainly stress the symphyseal fixation and was cycled up to 1 million cycles or failure, whichever occurred first.

Results

Five specimens experienced failure at the jig mounting/S1 vertebral body interface, occurring between 360,000 and 715,000 cycles. Frank failure of the anterior or posterior instrumentation did not occur. However, end-trialing diastasis of the initial pubic symphysis reduction was found in all pelvises. There were no differences between the groups with respect to this loss of symphyseal reduction (P = 0.69) or average cycles to failure (P = 1.0).

Conclusion

Pubic symphyseal locked plating does not appear to offer any advantage over standard unlocked plating for a Type-C (OTA 61-C1.2) pelvic ring injury.     

Prospective observational study with an abbreviated protocol in the management of blunt renal injury in children

Background

There are no published management schemes for blunt renal injuries. We are conducting a 2-center prospective observational study with a fixed management scheme.

Methods

Children with CT proven renal injuries were enrolled with permission. Ambulation is allowed when able regardless of grade. Discharge occurs when tolerating a diet and pain is controlled regardless of hematuria. Urinalysis occurs at follow up in 2–4 weeks and repeated as indicated.

Results

Between 9/2008 and 9/2012, 70 patients were enrolled. Mean age was 11.8 years (3–17), and 70% were male. The mean grade of injury was 2.8 ± 1.1 , , ,  and . One nephrectomy (1.4%) was performed for a grade 5 injury. Other renal interventions included an embolization for the hilar bleed and one cystotomy for a clot. Mean LOS was 2.9 days ± 2.4 days. In patients without other major injury, LOS was 1.9 ± 1.7 days (0.4–8 days). There were 5 (7%) readmissions: 3 for pain, 1 for hematuria, and 1 for a bladder clot. 58 patients (83%) gave urinalysis samples at initial follow up (med 18 days), where 31 (53%) were positive for blood.

Conclusions

Children with blunt renal injury may benefit from management without strict bedrest guidelines. Hematuria appears to have little influence on recovery.     

Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques

Background

Emergency devices for pelvic ring stabilization include circumferential sheets, pelvic binders, and c-clamps. Our knowledge of the outcome of these techniques is currently based on limited information.

Methods

Using the dataset of the German Pelvic Trauma Registry, demographic and injury-associated characteristics as well as the outcome of pelvic fracture patients after sheet, binder, and c-clamp treatment was compared. Outcome parameters included transfusion requirement of packed red blood cells, length of hospital stay, mortality, and incidence of lethal pelvic bleeding.

Results

Two hundred seven of 6137 (3.4%) patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets, binders, or c-clamps. In most cases, c-clamps (69%) were used, followed by sheets (16%), and binders (15%). The median age was significantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs. 47 vs. 42 years, p = 0.01). Sheet wrapping was associated with a significantly higher incidence of lethal pelvic bleeding compared to binder or c-clamp stabilization (23% vs. 4% vs. 8%). No significant differences between the study groups were found in sex, fracture type, blood haemoglobin concentration, arterial blood pressure, Injury Severity Score, the incidence of additional pelvic packing and arterial embolization, need of red blood cell transfusion, length of hospitalisation, and mortality.

Conclusions

The data suggest that emergency stabilization of the pelvic ring by binders and c-clamps is associated with a lower incidence of lethal pelvic bleeding compared to sheet wrapping.

Level of evidence

Level III.     

Cranial injuries secondary to assault with a machete

Background

Assaults with a machete cause compound skull fractures which present as a neurosurgical emergency. We aimed to profile cranial injuries caused by a machete over a 10 year period in a single neurosurgical unit.

Materials and methods

Retrospective data analysis of cranial injuries following assault with a machete, admitted to the neurosurgery ward, from January 2003 to December 2012 was performed. Medical records were analyzed for demographics, clinical presentation, CT scan findings, surgical treatment and Glasgow Outcome Scale (GOS) at discharge. Management involved wound debridement with antibiotic cover.

Results

Of 185 patients treated 172 (93%) were male. Mean age was 31 ± 11.4 years. Mean GCS on admission was 13 ± 2. Presenting features were focal neurological deficit (48%), brain matter oozing from wounds (20%), and post traumatic seizures (12%). Depressed skull fractures were found in 162 (88%) patients. Findings on CT brain scan were intra-cranial haematoma (88%), pneumocephalus (39%) and features of raised intra-cranial pressure (37%). Thirty-one patients (17%) presented with septic head wounds. One hundred and fifty seven patients (85%) were treated surgically. The median hospital stay was 8 days (range 1–145). The median GOS at discharge was 5 (range 1–5). Twelve patients died within the same admission (6.5%).

Conclusion

Machetes cause complex cranial injuries with associated neurological deficit and should be treated as neurosurgical emergency. Timeous intervention and good surgical principles are advocated to prevent secondary infection and further neurological deterioration.     

Combined Ultrasmall Superparamagnetic Particles of Iron Oxide–Enhanced and Diffusion-Weighted Magnetic Resonance Imaging Reliably Detect Pelvic Lymph Node Metastases in Normal-Sized Nodes of Bladder and Prostate Cancer Patients

Background

Lymph node staging of bladder or prostate cancer using conventional imaging is limited. Newer approaches such as ultrasmall superparamagnetic particles of iron oxide (USPIO) and diffusion-weighted magnetic resonance imaging (DW-MRI) have inconsistent diagnostic accuracy and are difficult to interpret.

Objective

To assess whether combined USPIO and DW-MRI (USPIO–DW-MRI) improves staging of normal-sized lymph nodes in bladder and/or prostate cancer patients.

Design, setting, and participants

Twenty-one consecutive patients with bladder and/or prostate cancer were enrolled between May and October 2008. One patient was excluded secondary to bone metastases detected on DW-MRI with subsequent abstention from surgery.

Intervention

Patients preoperatively underwent 3-T MRI before and after administration of lymphotropic USPIO using conventional MRI sequences combined with DW-MRI. Surgery consisted of extended pelvic lymphadenectomy and resection of primary tumors.

Measurements

Diagnostic accuracies of the new combined USPIO–DW-MRI approach compared with the “classic” reading method evaluating USPIO images without and with DW-MRI versus histopathology were evaluated. Duration of the two reading methods was noted for each patient.

Results and limitations

Diagnostic accuracy (90% per patient or per pelvic side) was comparable for the classic and the USPIO–DW-MRI reading method, while time of analysis with 80 min (range 45–180 min) for the classic and 13 min (range 5–90 min) for the USPIO–DW-MRI method was significantly shorter (p < 0.0001). Interobserver agreement (three blinded readers) was high with a kappa value of 0.75 and 0.84, respectively. Histopathological analysis showed metastases in 26 of 802 analyzed lymph nodes (3.2%). Of these, 24 nodes (92%) were correctly diagnosed as positive on USPIO–DW-MRI. In two patients, one micrometastasis each (1.0 × 0.2 mm; 0.7 × 0.4 mm) was missed in all imaging studies.

Conclusions

USPIO–DW-MRI is a fast and accurate method for detecting pelvic lymph node metastases, even in normal-sized nodes of bladder or prostate cancer patients.     

Nonoperative Management of Grade 5 Renal Injury in Children: Does It Have a Place?

Background

Nonoperative treatment of blunt renal trauma in children is progressively gaining acceptance; grade 5 renal trauma is associated with a significant rate of complications.

Objective

To assess the feasibility and outcome of initial nonoperative management of grade 5 blunt renal trauma in children.

Design, setting, and participants

This retrospective study included 18 children (12 boys and 6 girls; mean age: 8.4 ± 3.4 yr) who presented to the authors’ institutes with grade 5 blunt renal trauma between 1990 and 2007.

Measurements

An intravenous contrast-enhanced computed tomography (CT) scan demonstrated grade 5 renal trauma in all patients. Associated major vascular injuries were suspected in four patients. All were initially managed conservatively. Indications for intervention included hemodynamic instability, progressive urinoma, or persistent bleeding. Dimercaptosuccinic acid (DMSA) scans were performed at a mean time of 3.1 yr (range: 1–17) following the injury in nine patients.

Results and limitations

Four patients (22%) with suspected major vascular injuries required nephrectomy 1–21 d following the trauma. Two patients with continuing hemorrhage required selective lower-pole arterial embolization (11%). Three patients (17%) had their progressive urinoma drained percutaneously, and two of them required delayed reparative surgery for ureteropelvic junction (UPJ) avulsion. Nine patients (50%) were successfully managed nonoperatively. Kidneys were salvaged in 78% of patients. DMSA scanning showed a split function >40% in 44% of evaluated kidneys. Two patients (22%) had split function <30%. At last follow-up, none of the children were hypertensive or had any abnormality on urine analysis.

Conclusions

Nonoperative management of grade 5 renal trauma is feasible. Prompt surgical intervention is required for those with major vascular injuries. Superselective arterial embolization can be an excellent option in patients with continuing hemorrhage and who have pseudoaneurysms. Patients with UPJ disruption can be salvaged by initial drainage of the urinoma followed by deferred correction.