Vascular injuries associated with pelvic fractures

Pelvic fractures, which are most often caused by blunt abdominal trauma in our motor vehicle-oriented society, continue to be associated with significant mortality and morbidity. Hemorrhage is the cause of death in nearly 60 per cent of those patients who die of pelvic fractures. With increasing awareness of the problem and improved methods of management, the mortality rate of acute hemorrhage secondary to pelvic fracture should decrease. Four cases of vascular injuries associated with severe pelvic fractures are discussed. One patient presented with bleeding from a false aneurysm of the superior gluteal artery 3 months after his pelvic fracture. This complication was successfully managed by selective arteriographic embolization. The other three patients required early angiography with embolization of hypogastric vessels to control acute hemorrhage after pelvic fracture. Pelvic arteriography with selective embolization of injured vessels is recommended in the management of hemorrhage secondary to severe pelvic fractures. Application of the Military Antishock Trousers (MAST) suit may also be a useful maneuver. These principles of management and a pertinent review of the literature are presented.     

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.     

Posterior urethral injuries associated with pelvic fractures

The types of fracture of the bony pelvis are categorized, and a system for diagnosis and treatment is recommended which should prevent many strictures and make those which do develop, easier to repair secondarily. This system of treatment should reduce trauma to the nerves and blood vessels.     

Soft tissue injuries associated with pelvic fractures

Significant soft tissue injuries often occur as part of high-energy injuries to the pelvis. These soft tissue injuries must be recognized and considered when implementing a treatment plan if complications are to be minimized. Vigilance in diagnosing open fractures must be maintained. Patients with these injuries must be managed aggressively, because they are at high risk for complications and death. Closed pelvic and acetabular fractures also may include soft tissue injury that requires special consideration. Careful evaluation and management of the soft tissues aids in determining appropriate techniques for reduction and fixation of the associated fractures.     

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.     

Critical review of the classification and treatment of pediatric pelvic fractures

BackgroundHistorically most pediatric pelvic fractures were treated non-operatively because of the presumed potential of the pediatric pelvis to remodel and the subsequent increased fracture stability. Currently a wide variety of classifications in pediatric pelvic fractures is used to assess fracture stability and guide treatment, yet none have proven to be ideal since the structural behavior of the pediatric pelvis differs greatly from the adult pelvis. The aim of this review is to critically appraise the use of these different classification systems, fracture (in)stability, the treatment of pediatric pelvic fractures and how it reflects on long-term complications such as pelvic asymmetry and functional outcome.MethodsA literature search was performed in Medline, Embase, Cochrane, PubMed, Google Scholar and references of the selected articles. Studies that reported on pain, leg length discrepancy (LLD), abnormal gait (GA), pelvic asymmetry, and functional outcomes of pediatric pelvic fractures were included.ResultsA total of six different classification systems were used, the most common were Tile (n= 9, 45%) and Torode and Zieg (n= 8, 40%). There was great disparity in treatment choice for the same type of fracture pattern, resulting in several pelvic ring fractures that were defined as unstable being treated non-operatively. Pelvic asymmetry is seen in rates up to 48% in non-operatively treated patients. In contrast, pelvic asymmetry in surgically fixated unstable pelvic fractures was rare, and these patients often showed excellent functional outcomes during follow-up.ConclusionThere is a substantial heterogeneity in which fracture patterns are considered to be unstable or in need of surgical fixation. Functional outcomes seem to be correlated with the frequency of pelvic asymmetry and are likely due to an underestimation of the stability of the pelvic fracture. Taking into consideration the force that is necessary to cause a facture in the pediatric pelvis, a fracture of the pelvic ring alone could be suggestive for instability. The results of this review imply that the field of pediatric pelvic surgery is currently not grasping the full scope of the complexity of these fractures, and that there is a need for a pediatric pelvic classification system and evidence-based treatment guideline.     

Common and external iliac artery injuries associated with pelvic fractures.

BACKGROUND: Common and external iliac artery injuries associated with pelvic fractures are uncommon. The diagnosis of such injuries is based on clinical findings and confirmed by arteriography. DESIGN: Retrospective chart review. SETTING: University Level I trauma center. PATIENTS: Five men and three women, aged seventeen to seventy-six years, with injuries to the common and external iliac arteries associated with pelvic fractures. RESULTS: All patients sustained complex pelvic fractures associated with multiple blunt injuries. Five injuries occurred on the right side. Two patients had an associated right vertical shear pelvic fracture. In five patients, vascular injury was diagnosed in the first six hours after admission. One patient presented with an aneurysm of the right common iliac artery two months after his initial injury. All patients underwent surgical repair with an interposition graft, which failed in two patients, who underwent vascular reconstruction ten hours after the injury. One patient died of associated injuries. CONCLUSIONS: Arterial hyperextension with intimal damage seems to be the most likely cause of this injury. Ideally, an extraperitoneal approach should be attempted to minimize blood losses and, due to the size of the iliac vessels, an interposition graft should be used for reconstruction.     

Traumatic injuries of the lower ureter associated with pelvic fractures

Ureteral injuries following blunt pelvic trauma are extremely rare. Experiences with two cases of lacerations of the lower ureter due to pelvic fractures are presented. In patients with acetabular fractures the likelihood of lower ureteral injuries should be suspected and excluded by an intravenous urogram.     

Role of computed tomography in the classification and management of pediatric pelvic fractures

In adults, pelvic computed tomography (CT) scanning plays an important role in the treatment of pelvic fractures; however, the role of CT scanning in the management of pediatric pelvic fractures is unclear. The purpose of this study was to investigate the efficacy of CT scanning in the management of pelvic fractures in children. One hundred three consecutive patients were identified. All patients underwent anteroposterior plain radiographic evaluation; CT scans were performed in 62. Three orthopaedic surgeons independently reviewed the plain radiographs and determined fracture classification and management. Subsequently, each observer was shown corresponding CT scans and again determined classification and management. Interobserver agreement was calculated using Kappa statistics. After the addition of CT scans, the mean changes in classification were nine (15%) and in management two (3%). Plain radiographs alone reliably predicted the need and type of operative intervention. Kappa statistics demonstrated "excellent" agreement for classification and management without and with CT scans. We reliably determined fracture classification and management based on plain radiographs alone.     

转流性结肠造瘘在骨盆骨折合并会阴部损伤中的应用

 目的 总结转流性结肠造瘘在骨盆骨折合并会阴部损伤中的应用效果。方法 2005年 4 月至 2011年 4月, 治疗 27例骨盆骨折合并会阴部损伤患者, 男 23例, 女 4例;年龄 16~62岁, 平均 32.9岁;交通伤 19例, 高处坠落伤 4例, 挤压伤 2例, 重物砸伤 2例。骨盆骨折按 Tile分型: A型 4例, B 型 10例, C型 13例。采用骨盆外固定支架固定, 稳定血流动力学, 选择性应用转流性结肠造瘘及骨折复 位固定术进行治疗。应用 Fisher精确概率法对早期(伤后48h内)和非早期(损伤超过 48h或未造瘘) 行转流性结肠造瘘术患者的感染率进行比较。结果 24例患者存活, 3例死亡, 死亡率为 11%。存活的 24例患者均获得随访, 随访时间 4~42个月, 平均 10.9个月。 13例早期行结肠造瘘患者均未发生感染。 11例非早期行结肠造瘘患者中, 4例发生感染。早期行转流性结肠造瘘术患者的感染率显著低于非早 期患者, 两者比较差异有统计学意义。结论 骨盆骨折合并会阴部损伤早期急救重点为稳定血流动力学、选择性应用转流性结肠造瘘及早期骨盆固定。对于累及直肠、肛管的会阴部损伤或虽不累及直肠、 肛管但软组织损伤广泛的会阴部损伤均应行转流性结肠造瘘术。伤后 48h内行转流性结肠造瘘, 不但可有效降低感染率, 而且对保持患者良好营养状态、节省医疗开支及降低医护人员工作量有重要意义。     

Changing patterns of pediatric pelvic fractures with skeletal maturation: implications for classification and management.

Orthopaedic traumatologists have recognized the unique fracture patterns and injury constellations of pediatric pelvic fractures. However, an understanding of the effect of advancing skeletal maturation is needed to avoid applying adult classifications and management. The authors determined how pelvic fracture patterns and management change with advancing skeletal maturity. At their pediatric trauma center, they identified 166 consecutive pelvic fractures. Eighty percent of patients had plain radiographs adequate to evaluate the triradiate cartilage. Physes were scored as open, narrowed, or closed. The Risser sign, fracture pattern, survival after injury, and need for open reduction and internal fixation were recorded. Ninety-seven patients (mean age 5.7 years) had an open triradiate or an "immature pelvis." Thirty-two patients (mean age 14 years) had a closed triradiate cartilage or a "mature pelvis." The immature group had a higher propensity for isolated pubic rami and iliac wing fractures. The mature group had a higher predilection for acetabular fractures and pubic or sacroiliac diastasis. All patients requiring open reduction and internal fixation had a mature pelvis. The incidences of specific pelvic fracture patterns between the two groups were statistically different. Management of fractures to the immature pelvis should focus on associated injuries. Once the triradiate cartilage has closed, adult pelvic fracture classifications and management principles should be used.     

Abdominal aortic injuries associated with chance fractures in pediatric patients

Injury to the abdominal aortic artery from blunt trauma is an infrequent event with few cases reported in either the adult or the pediatric literature. Injury to the thoracic aorta after blunt abdominal trauma is more common. It has been estimated that 95% to 99% of all aortic disruptions are in the thoracic region. Injury to the abdominal aorta is rarely seen in association with fractures of the lumbar spine secondary to seat belt use in motor vehicle accidents; there are few cases in the literature of these injuries in pediatric patients. Nevertheless, the overall mortality rate of this injury has been reported to be between 18% and 37%. It is therefore important to be aware of the possible association to allow prompt diagnosis and management of multitraumatized patients because extensive injuries to the abdominal viscera may mask aortic dissection and prognosis is significantly improved with early intervention.     

Urethral injuries in female subjects following pelvic fractures.

Pelvic fractures resulting from high speed motor vehicle and/or pedestrian-motor vehicle accidents commonly coexist with urethral injuries in the male patient. A review of 130 female patients with pelvic fractures managed at our institution revealed coexisting urethral injuries in 6 (4.6%). Partial urethral disruptions accounted for the majority of morbidity with early removal of the Foley catheter resulting in urinary extravasation, voiding difficulties and vulvar edema. In 3 patients the injury was misdiagnosed, 2 of whom had life-threatening sepsis with necrotizing fascitis as a consequence. Blood at the vaginal introitus was noted in more than 80% of our patients. However, only half of them had a careful vaginal inspection. If this pertinent portion of the physical examination had been performed more than two-thirds of our patients could have been correctly diagnosed. The need for meticulous vaginal examination when blood is located at the vaginal introitus, and the need for careful cystoscopic and/or radiographic evaluations in the female patient with voiding difficulties and/or vulvar edema in the acute post-traumatic phase are stressed.     

Management of genitourinary injuries in patients with pelvic fractures.

Associated injuries frequently occur in patients who sustain fractures of the pelvis. Hemorrhage from intrapelvic vessels, rupture of the urinary bladder and avulsion of the membranous urethra in males are among the integral risks in this trauma. Non-operative methods of managing hemorrhage have gained favor in recent experience. The case records of 282 male patients with pelvic fractures were reviewed to evaluate experience with lower genitourinary injuries. Early recognition is important in bladder injuries, and surgical repair is advised, except in selected patients who may be managed by catheter drainage alone. Delayed complications of bladder injury are rare. Membranous urethral injuries entail a high risk of chronic stricture disease and sexual impotence. The rationale of early repair versus delayed repair of these injuries is discussed. The results in this series show advantage for delayed repair.     

髋臼上方置钉外固定支架治疗伴腹部脏器损伤的骨盆骨折

 目的 探讨髋臼上方置钉外固定支架治疗伴腹部脏器损伤骨盆骨折的疗效、特点及手术 方法。方法 2009年 3月至 2010年 12月, 治疗 17例伴腹部脏器损伤的骨盆骨折患者, 男 9例, 女 8 例;年龄 21~75岁, 平均 42岁。根据 Tile分型, B1型 7例, B2型 3例, B3型 2例, C1型 4例, C2型 1例。 其中合并失血性休克 15例, 合并会阴部损伤 2例, 合并四肢骨折 12例。应用经髋臼上方置钉外固定支 架复位和固定治疗。采用 Cole等及 Matta和 Tornetta标准对术后疗效进行评价。结果 17例患者全部 获得随访, 随访时间 2~18个月, 平均 6.5个月, 所有骨折均愈合, 愈合时间 8~12周, 平均 9.2周。术后 3 例患者出现一过性股外侧皮神经麻痹, 口服营养神经药物弥可保 1个月后缓解;5例发生软组织内钉道 感染, 经换药、清创、抗感染等综合治疗后 4例愈合, 1例在骨折愈合拆除外固定支架后愈合。根据 Cole 等提出的骨盆骨折效果评分表进行功能评价, 优 15例、良 1例、可 1例, 优良率为 94.12%。按照 Matta 和 Tornetta标准对骨折复位进行评估, 优 12例、良 3例、可 2例, 优良率为 88.24%。结论 经髋臼上方 置钉外固定支架治疗伴腹部脏器损伤的骨盆骨折具有创伤小, 操作简单, 固定可靠的特点。     

Cardiovascular injuries associated with sternal fractures.

OBJECTIVE: To find out if the presence of a sternal fracture indicates cardiac and aortic injuries and to clarify the difference between a retrosternal haematoma and widened mediastinum. DESIGN: Retrospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 418 patients with blunt chest trauma of whom 29 had a fractured sternum (11 with retrosternal haematoma and 18 without) and 389 did not (7 with widened mediastinum and 382 without). MAIN OUTCOME MEASURES: Definitions, risk factors, morbidity, and mortality. RESULTS: Retrosternal haematomas were found adjacent to many fractures and ranged in size from a few mm to 2 cm. They were more common in fractures of the body of sternum. There was no significant difference in the number of associated lesions between patients with sternal fractures with or without a retrosternal haematoma. Conversely, patients with a widened mediastinum had a higher injury severity score, longer hospital stay (p < 0.0001), and more associated lesions (p < 0.05) than those with retrosternal haematomas. Six patients still had pain 1 month after injury of whom two had injury-related long-term disability because of pain. No serious cardiac or aortic injuries were detected in this series. The early mortality in our study was 2/29 in patients with sternal fractures and 1/7 in patients with widened mediastinum. CONCLUSIONS: Sternal fractures are more common than previously reported. An aggressive approach including early operative reduction is recommended even for a stable fracture to reduce the overhelming pain. Sternal fracture with or without retrosternal heamatoma is not a reliable indicator of cardiac and aortic injuries, while mediastinal widening is still a fairly reliable clue that should indicate further investigation.