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.

Contemporary management of pelvic fractures

BACKGROUND: Pelvic fractures occur when there is high kinetic energy transfer to the patient such as would be expected in motor vehicle crashes, auto-pedestrian collisions, motorcycle crashes, falls, and crush injuries. High-force impact implies an increased risk for associated injuries to accompany the pelvic fracture, as well as significant mortality and morbidity risks. Choosing the optimum course of diagnosis and treatment for these patients can be challenging. The purpose of this review is to supply a contemporary view of the diagnosis and therapy of patients with this important group of injuries. METHODS: A comprehensive review of the medical literature, focusing on publications produced in the last 10 years, was undertaken. The principal sources were found in surgical, orthopedic, and radiographic journals. CONCLUSIONS: The central challenge for the clinician evaluating and managing a patient with a pelvic fracture is to determine the most immediate threat to life and control this threat. Treatment approaches will vary depending on whether the main threat arises from pelvic fracture hemorrhage, associated injuries, or both simultaneously. Functional outcomes in the long-term depend on the quality of the rigid fixation of the fracture, as well as associated pelvic neural and visceral injuries.     

骨盆骨折引起后尿道损伤的早期处理

目的：探讨骨盆骨折引起后尿道损伤早期合理的处理方法。方法：回顾性分析36例男性骨盆骨折并发后尿道损伤患者的临床资料,其中8例尿道黏膜裂伤或尿道部分断裂患者行留置导尿,另28例尿道完全断裂患者均在伤后24h内行手术治疗,其中18例行尿道会师加牵引,其余10例单纯膀胱造瘘。结果：随访6个月～5年,8例留置尿管患者,拔管后排尿通畅6例,尿线变细2例,经定期尿道扩张,排尿正常。18例尿道会师加牵引患者,拔管后适时扩张尿道,排尿通畅15例,尿线较细3例,经定期尿道扩张后,1例排尿通畅,2例失败。10例单纯膀胱造瘘患者,术后均不能排尿,分别于伤后6～12个月行开放手术及尿道内切开治疗。结论：尿道会师加牵引术是治疗骨盆骨折所致后尿道断裂的有效方法。     

不稳定型骨盆骨折的疗效探讨

目的 探讨不稳定型骨盆骨折(Tile B和Tilec型)的治疗和疗效。方法 比较78例骨盆骨折患者使用和非使用骨盆外固定支架手术疗效。结果 在38例骨盆骨折患者未使用骨盆外固定支架治疗中，失血性休克的纠正率为76％，死亡率10．6％，平均ISS评分11．6。而在使用骨盆外固定支架治疗的40例患者中，失血性休克的纠正率为90％，死亡率为2．5％，平均ISS评分9．87结论 骨盆外固定支架治疗不稳定型骨盆骨折合并失血性休克，手术简单，疗效可靠，大大降低了患者的死亡率。     

Instability of the pelvic ring and injury severity can be predictors of death in patients with pelvic ring fractures: a retrospective study

Background  The correlation between fracture type and mortality in patients with pelvic fracture has been previously investigated. The purpose of this study was to determine whether instability of the pelvic ring as assessed by Tile’s classification is a predictor of death in patients with pelvic fractures. Materials and methods  The clinical course of consecutive patients with pelvic fractures was retrospectively reviewed. Eighty-seven patients with pelvic ring fractures were included in the study. As potential predictive factors, fracture type according to Tile’s classification, and generally used traumatic parameters (injury severity score, revised trauma score, and probability of survival) were analyzed. Results  The mortality was significantly higher in patients with unstable fracture patterns (P < 0.05). In non-survivors, index values of traumatic parameters were more severe than those in survivors (P < 0.05). Conclusion  The present study suggests that patients with unstable pelvic fractures have an increased risk of death associated with exacerbated injury severity.     

伴会阴部损伤的开放性骨盆骨折治疗

目的探讨伴会阴部损伤的开放性骨盆骨折治疗方法及疗效。方法 2000年8月-2010年7月,收治16例伴会阴部损伤的开放性骨盆骨折患者。男12例,女4例;年龄17～69岁,平均41岁。致伤原因:交通事故伤9例,高处坠落伤6例,重物砸伤1例。受伤至入院时间为5～20 min,平均8 min。骨盆骨折按照Tile分型标准:A型2例,B型6例,C型8例。创面范围5 cm×3 cm～15 cm×12 cm。会阴部损伤部位:腹膜内直肠损伤2例,腹膜外直肠肛管损伤14例。按创伤严重度评分标准(injury severity score,ISS)评分为25～48分,平均29分。入院后按创伤骨折流程急救处理,主要包括急救复苏、结肠造瘘、外固定架固定、创面多次清创、冲洗、持续封闭式负压引流技术(vacuum sealingdrainage,VSD)。结果入院4 d内死亡5例,其中3例死于失血性休克,2例死于多器官功能衰竭。余11例存活患者均获随访,随访时间6～46个月,平均14个月。X线片检查示骨盆骨折于术后2～4个月达骨性愈合。术后会阴部损伤创面均有不同程度感染,经扩创、VSD治疗后,其中10例创面直接拉拢缝合后Ⅱ期愈合,1例行股薄肌皮瓣移位修复后愈合。直肠肛管损伤患者随访期间无失禁表现。结论对于伴会阴部损伤的开放性骨盆骨折,应早期积极抗休克、保护重要脏器功能、处理合并症,后期抗感染、恢复骨盆环稳定性、修复重建直肠肛管及尿道功能,以获得较好疗效。     

Predictors of mortality following severe pelvic ring fracture: results of a population-based study

Introduction

Traumatic disruption of the pelvic ring is uncommon but is associated with a high risk of mortality. These injuries are predominantly due to high energy blunt trauma such as a fall from height, road or workplace trauma, and severe associated injuries are prevalent, increasing the complexity of managing this patient group. The aim of this population-based study was to investigate predictors of mortality following severe pelvic ring fractures managed in an inclusive, regionalised trauma system.

Methods

Cases aged ≥ 15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based statewide Victorian State Trauma Registry for analysis. Patient demographic, prehospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated.

Results

There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged ≥ 65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15–34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), whilst patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres).

Conclusions

The findings highlight the importance of effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.     

Effectiveness and complications of pelvic circumferential compression devices in patients with unstable pelvic fractures: A systematic review of literature

Background

Pelvic fractures can cause massive haemorrhage. Early stabilisation and compression of unstable fractures is thought to limit blood loss. Reposition of fracture parts and reduction of pelvic volume may provide haemorrhage control. Several non-invasive techniques for early stabilisation have been proposed, like the specifically designed pelvic circumferential compression devices (PCCD). The purpose of this systematic review was to investigate current evidence for the effectiveness and safety of non-invasive PCCDs.

Methods

To investigate current literature the search string: “pelvi* AND fract* AND (bind* OR t-pod OR tpod OR wrap OR circumferential compression OR sling OR sheet)” was entered into EMBASE, PubMed (Medline), PiCarta, WebofScience, Cochrane Online, UptoDate, CINAHL, and Scopus. All scientific publications published in indexed journals were included.

Results

The search resulted in 17 included articles, none of which were level I or II studies. One clinical cohort study (level III) and 1 case-control study (level IV) were found. These showed a significant reduction of pelvic volume after applying a PCCD, without an effect on outcome. Other included literature consisted of 4 case series (level V). Two biomechanical analysis studies of fractures in human cadavers showed pelvic stabilisation and effective volume reduction by PCCD, especially when applied around the greater trochanters. Finally, 7 case reports (level VI) and 3 expert opinions (level VII) were identified. These case reports suggested complications such as pressure sores and nerve palsy.

Conclusion

PCCDs seem to be effective in early stabilisation of unstable pelvic fractures. However, prospective data concerning mortality and complications is lacking. Some complications, like pressure sores have been described.     

Time to Initial Debridement and wound Excision (TIDE) in severe open tibial fractures and related clinical outcome: A multi-centre study

BackgroundRecent national (NICE) guidelines in England recommend that initial debridement and wound excision of open tibial fractures take place within 12 h of the time of injury, a change from the previous target of 24 h. This study aims to assess the effect of timing of the initial debridement and wound excision on major infective complications, the impact of the new guidance, and the feasibility of adhering to the 12 h target within the infrastructure currently existing in four major trauma centres in England.MethodsA retrospective review was performed of Gustilo-Anderson grade 3B open tibial fractures presenting acutely to four Major Trauma Centres (MTCs) in England with co-located plastic surgery services over a ten-month period. The incidence of deep infective complications was compared between patients who underwent initial surgery according to the new NICE guidance and those who did not. Patients warranting emergency surgery for severely contaminated injury, concomitant life-threatening injury and neurovascular compromise were excluded. Multi-variable logistic regression analysis was performed to assess the effect of timing of surgical debridement on development of deep infective complications.Results112 patients with 116 fractures were included. Six fractures (5.2%) developed deep infective complications. 38% (n = 44) underwent primary debridement within 12 h and 90% within 24 h. There was no significant difference in the incidence of major infective complications if debrided in less than or greater than 12 h (4.5% vs 5.6%, p = 1.00). Logistic regression found no significant relationship between timing of wound excision and development of deep infection. There was no significant decrease in mean time to debridement following introduction of new national guidance (13.6 vs 16.1 h) in these four MTCs.ConclusionOverall, the rate of deep infection in high energy open tibial fractures managed within the four major trauma centes is low. Achieving surgical debridement within 12 h is challenging within the current infrastructure, and it is unclear whether adhering to this target will significantly affect the incidence of severe infective complications. Debridement within 24 h appears achievable. If a 12-h target is to be met, it is vital to ensure dedicated orthoplastic capacity is adequately resourced.     

Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures

The management of open tibial fractures is a challenge to all orthopaedic trauma surgeons. The major goals are fracture union, uncomplicated soft tissue healing and return to pre-injury level of function. The geographical isolation and vastness of the Northern Territory of Australia complicates the management of these injuries by adding a significant delay to treatment. Forty-five patients sustained 48 open tibial fractures over the 30-month period of the study. Twelve received primary surgical treatment within 6h of injury but 33 were treated more than 6h after injury. The mean time to treatment in this latter group was 12h 15min (median 9h 45min, range 6-37h). The majority of injuries were high energy, with 23 patients having multiple injuries and 29 fractures (60%) being classified as AO C3 with 35 (73%) having Gustilo III soft tissue injuries. There was a mean time to union of 7.5 months and an overall complication rate of 42.2%. Thirteen patients (29%) required additional (late) surgical procedures subsequent to definitive fracture and soft tissue management. The zone of injury infection rate was 12.5%. The high incidence of open tibial fractures places a large financial burden on the state. However, despite the absence of a plastic surgical service and delays in presentation, satisfactory outcomes can be obtained by the application of the established surgical principles of thorough debridement, soft tissue management and fracture stabilisation.     

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.     

髋臼骨折与开放骨折

随着交通事业的发展,由高能量损伤所致的髋臼骨折与开放性骨折日益增多。X线片结合CT检查及螺旋CT三维成像有助于髋臼骨折的诊断。骨折分型广泛采用Lelournel分型及AO分型。保守治疗的应用范围趋于局限,更多地采用手术治疗,强调髋臼骨折的理想复位、坚强内固定和早期功能活动。须注意正确选择手术入路,防止坐骨神经损伤、异位骨化和静脉血栓等手术并发症。而对于开放性骨折,目前强调早期充分清创和固定骨折,及早闭合伤口,注意使用抗生素,早期进行功能锻炼,以促进骨折的愈合和功能的恢复。     

真空负压封闭技术加外固定器治疗肢体开放性骨折

目的 探讨真空负压封闭技术(VS)加外固定器治疗四肢严重开放性骨折的效果。方法 近4年来收治63例四肢严重开放性骨折患者，采用VS加外固定器治疗，清创后骨折用Orthofix单边外固定器固定，创面或创腔内用Vacuseal材料覆盖，接负压封闭吸引，6～10d后二期缝合、植皮或皮瓣转移。结果 63例患者创面均愈合，浅表感染3例(4．8％)和针道感染13例19针(7．5％)；骨折愈合53例(84．1％)，延迟愈合或不愈合10例(15．9％)。平均愈合时间6．5个月。结论 VS技术结合外固定架固定治疗四肢严重开放性骨折，在迅速有效地稳定骨折的同时，能安全有效地封闭创面，缩短二期创面修复时间，促进骨折愈合，减少并发症；其方法简单有效，值得临床推广应用。     

Open treatment of pelvic and acetabular fractures

The open operative management of pelvic and acetabular fractures in the obese is technically demanding, with a significantly higher rate of complications compared with patients who are nonobese. The decision to perform surgery should involve a thorough understanding of risks, and patients should be counseled. Careful attention should be paid to patient factors; coexisting systemic conditions and patient positioning to reduce complications. Wound complications are most commonly seen, and techniques to reduce risk should be incorporated. When complications occur, aggressive management can result in successful salvage. Future areas of study should include methods to reduce risk of surgical site infections and improving our understanding of the physiologic alterations that occur with obesity. This article summarizes the current literature on open treatment of pelvic and acetabular fractures in the obese patient, reviews the physiologic adaptations of obesity as they relate to pelvic surgery, highlights risk factors for complications, and provides recommendations to reduce the incidence of complications.     

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.     

严重骨盆骨折的救治及手术治疗

目的报道严重骨盆骨折的治疗经验,以期进一步提高其早期诊断和救治水平。方法回顾性分析总结了1994年4月～2002年3月106例严重骨盆骨折的临床资料。结果骨盆骨折主要的致伤原因为交通事故伤(69例,占65.1%)及坠落伤(31例,占29.3%)。106例中,87例生存,19例死亡,死亡率为17.9%,其中10例死于出血性休克,4例死于严重脑外伤,3例死于多器官功能衰竭,2例死于急性呼吸窘迫综合征。其中骨盆骨折手术治疗32例,优良率达91.7%。结论严重骨盆骨折救治中院前急救十分重要,要及时处理严重合并伤,积极行骨盆骨折内固定手术。     

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.     

Laparotomy and unstable pelvic fractures

The requirement for laparotomy was analysed in 91 patients with unstable pelvic fractures. Laparotomies were classified as positive or negative. Injuries found at laparotomy were compared with the pelvic fracture pattern. Laparotomy was carried out in 28 patients but was unnecessary in 8. Eleven of the 28 patients died, a mortality of 39%. Vertical shear and combined mechanical injury pelvic fracture patterns had the highest incidence of abdominal injuries (28%) but the fracture pattern was not a reliable guide to the presence or nature of intra-abdominal injury. Inadequate preoperative investigations contributed to the eight negative laparotomies and three of these patients died. Laparotomy was only necessary in 22% of our patients. Major pelvic fractures with concomitant intra-abdominal injuries have a high mortality rate. Preoperative CT scanning was 98% accurate in the identification of intra-abdominal injury and was the most useful investigation for determining the need for laparotomy and minimising the risk of negative laparotomy.     

Haemodynamically unstable pelvic fractures

Bleeding pelvic fractures that result in haemodynamic instability have a reported mortality rate as high as 40%. Because of the extreme force needed to disrupt the pelvic ring, associated injuries are common and mortality is usually from uncontrolled haemorrhage from extra-pelvic sources. Identifying and controlling all sources of bleeding is a complex challenge and is best managed by a multi-disciplinary team, which include trauma surgeons, orthopaedic surgeons and interventional radiologists. Once the pelvis is identified as the major source of haemorrhage, component therapy reconstituting whole blood should be used and the pelvic region wrapped circumferentially with a sheet or pelvic binder. Patients at risk for arterial bleeding who continue to show haemodynamic instability despite resuscitative efforts should undergo immediate arteriography and embolisation of bleeding pelvic vessels. If this is unavailable or delayed, or the patient has other injuries (i.e., head, chest, intra-abdominal, long bone), external fixation and pelvic packing, performed concomitantly with other life-saving procedures, may be used to further reduce pelvic venous bleeding. If however, the patient remains haemodynamically labile without apparent source of blood loss, transcatheter angiographic embolisation should be attempted to locate and stop pelvic arterial bleeding. Institutional practice guidelines have been shown to reduce mortality and should be developed by all centres treating pelvic fractures.