Comparison of skin pressure measurements with the use of pelvic circumferential compression devices on pelvic ring injuries

ObjectivesPelvic circumferential compression devices are commonly used in the acute treatment of pelvic fractures for reduction of pelvic volume and initial stabilisation of the pelvic ring. There have been reports of catastrophic soft-tissue breakdown with their use. The aim of the current investigation was to determine whether various pelvic circumferential compression devices exert different amounts of pressure on the skin when applied with the force necessary to reduce the injury. The study hypothesis was that the device with the greatest surface area would have the lowest pressures on the soft-tissue.MethodsRotationally unstable pelvic injuries (OTA type 61-B) were surgically created in five fresh, whole human cadavers. The amount of displacement at the pubic symphysis was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). The T-POD, Pelvic Binder, Sam Sling, and circumferential sheet were applied in random order for testing. The devices were applied with enough force to obtain a reduction of less than 10 mm of diastasis at the pubic symphysis. Pressure measurements, force required, and contact surface area were recorded with a Tekscan pressure mapping system.ResultsThe mean skin pressures observed ranged from 23 to 31 kPa (173 to 233 mm of Hg). The highest pressures were observed with the Sam Sling, but no statistically significant skin pressure differences were observed with any of the four devices (p > 0.05). The Sam Sling also had the least mean contact area (590 cm²). In greater than 70% of the trials, including all four devices tested, skin pressures exceeded what has been shown to be pressure high enough to cause skin breakdown (9.3 kPa or 70 mm of Hg).ConclusionsApplication of commercially available pelvic binders as well as circumferential sheeting commonly results in mean skin pressures that are considered to be above the threshold for skin breakdown. We therefore recommend that these devices only be used acutely, and definitive fixation or external fixation should be performed early as patient physiology allows. There may be some advantage of use of a simple sheet given its low cost, versatility, and ability to alter contact surface area.     

Randomised clinical trial comparing pressure characteristics of pelvic circumferential compression devices in healthy volunteers

Introduction

The role of pelvic circumferential compression devices (PCCDs) is to temporarily stabilise a pelvic fracture, reduce the volume and tamponade the bleeding. Tissue damage may occur when PCCDs are left in place longer than a few hours. The aim of this randomised clinical trial was to quantify the pressure at the region of the greater trochanters (GTs) and the sacrum, induced by PCCDs in healthy volunteers.

Materials and methods

In a crossover study, the Pelvic Binder^®, SAM-Sling^® and T-POD^® were applied successively onto 80 healthy participants in random order. The pressure was measured using a pressure mapping system, with the volunteers in supine position on a spine board and on a hospital bed. Data were analysed using Mixed Linear Modelling.

Results

On a spine board, the pressure exceeded the tissue damaging threshold at the GTs and the sacrum. Pressure at the GTs was highest with the Pelvic Binder^®, and lowest with the SAM-Sling^®. Pressure at the sacrum was highest with the Pelvic Binder^®. The pressure at the GTs and sacrum was reduced significantly for all three PCCDs upon transfer to a hospital bed.

Conclusion

The results of this randomised clinical trial in healthy volunteers showed that patients with pelvic fractures, temporarily stabilised with a PCCD, are at risk for developing pressure sores. The pressure on the skin exceeded the tissue damaging threshold and is, besides PCCD type, influenced by BMI, waist size and age. Regardless with which PCCD trauma patients are stabilised, early transfer from the spine board is of key importance to reduce the pressure to a level below the tissue damaging threshold. Clinicians should be aware of the potential deleterious effects associated with the application of a PCCD, and every effort must be made to remove the PCCD once haemodynamic resuscitation has been established.     

Midline sagittal sacral fractures in anterior-posterior compression pelvic ring injuries

OBJECTIVE: To evaluate the outcome of an uncommon variant of the anterior-posterior compression pelvic injury, in which the posterior ring injury is a midline sagittal sacral fracture extending into the spinal canal. DESIGN: Prospective, consecutive series.SETTING Two regional trauma centers. PATIENTS: A consecutive series of 10 patients with rotationally displaced, vertically stable anterior-posterior compression pelvic ring fractures (OTA type 61-B1) in which the posterior ring injury is a midline sagittally oriented sacral fracture involving the spinal canal (Denis zone III). This injury pattern comprised 0.6% of pelvic fractures and 1.4% of sacral fractures treated at these two institutions during a 10-year period. INTERVENTION: Patients were treated according to the same principles used in more commonly seen types of anterior-posterior compression pelvic ring injuries. Nine patients were treated with reduction and anterior pelvic stabilization at an average of 5 days after injury, 8 of whom were treated with open reduction and internal fixation and 1 with external fixation. No posterior pelvic fixation was used. One patient with nondisplaced bilateral pubic ramus fractures was treated nonoperatively. Immediate weight bearing was allowed as tolerated. MAIN OUTCOME MEASUREMENTS: Prospectively collected clinical follow-up data emphasized a detailed neurologic examination, whereas radiographic evaluation involved anteroposterior, inlet, and outlet plain radiographic views of the pelvis. RESULTS: An anatomical or near-anatomical reduction of the pelvis was achieved and maintained in all patients. Fractures healed at an average of 10 weeks. At an average follow-up of 31 months (range 20-46 months), there were no objective neurologic deficits that could be attributed to sacral root injury and no significant residual pain or gait disturbance related to the pelvic fracture. Loss of bowel or bladder function, loss of perianal sensation or sphincter tone, and lumbosacral radicular pain or sensorimotor deficit were specifically absent in all patients. Three patients, however, complained of sexual dysfunction at final follow-up. None of these patients had clinical evidence of sacral root/plexus injury secondary to the fracture. One additional patient, who sustained a urethral tear, required a chronic suprapubic catheter because of stricture. Six patients, one of whom had needed repair of a retroperitoneal bladder tear, had no urogenital sequelae. DISCUSSION AND CONCLUSION: Patients who sustain sagittally oriented midline fractures of the sacrum that extend into the spinal canal (Denis zone III) as part of displaced, vertically stable anterior-posterior compression pelvic injuries, have a low incidence of neurologic deficit attributable to sacral root or plexus injury. This is in contrast to the high rate of neurologic deficit (>50%) otherwise reported in zone III sacral fractures, particularly in those associated with a displaced transverse component. In the midline sagittal fracture variant, simultaneous lateral displacement of both bony and neural elements through the midline may protect the sacral roots and plexi from significant traction or shear injury by maintaining the spatial orientation between the sacral foramina and sciatic notch. Long-term sequelae were related to urogenital complaints rather than to musculoskeletal problems, as 4 of the 10 patients in this series had either sexual or urologic dysfunction.     

Noninvasive reduction of open-book pelvic fractures by circumferential compression

OBJECTIVES: To determine the efficacy and optimal application parameters of circumferential compression to reduce external rotation-type pelvic fractures. DESIGN: Biomechanical investigation on human cadaveric specimens. SETTING: Biomechanics laboratory. INTERVENTION: Partially stable and unstable external rotation injuries of the pelvic ring (OTA classification 61-B1 and 61-C1) were created in seven human cadaveric specimens. A prototype pelvic strap was applied subsequently at three distinct transverse levels around the pelvis. Circumferential pelvic compression was induced by gradual tensioning of the strap to attempt complete reduction of the symphysis diastasis. MAIN OUTCOME MEASUREMENTS: Pelvic reduction was evaluated with respect to strap tension and the strap application site. The effect of circumferential compression on intraperitoneal pressure and skin-strap interface pressure was measured. RESULTS: A successive increase in circumferential compression consistently induced a gradual decrease in symphysis diastasis. An optimal strap application site was determined, at which circumferential compression most effectively yielded pelvic reduction. The minimum strap tension required to achieve complete reduction of symphysis diastasis was determined to be 177 +/- 44 Newtons and 180 +/- 50 Newtons in the partially stable and unstable pelvis, respectively. CONCLUSIONS: Application of circumferential compression to the pelvic soft tissue envelope with a pelvic strap was an efficient means to achieve controlled reduction of external rotation-type pelvic fractures. This study derived application parameters with direct clinical implication for noninvasive emergent management of traumatic pelvic ring disruptions.     

Outcomes of pelvic ring injuries

Routine internal fixation of selected pelvic ring injuries has been performed for more than 10 years. A literaturereview of long-term outcome studies is presented. Since 1948, investigators have presented the results of their protocols for treatment of pelvic ring injuries. Indications for conservative versus operative treatment have not been standardized, and different tools for measuring outcomes have been used. Historical differences comparing nonoperative treatment, open reduction internal fixation, and the intermittent use of external fixators are not sufficient to show the efficacy of any treatment. All classes of pelvic fractures, including undisplaced low-energy injuries have the potential for long-term disability. Treatment of the pelvic ring injury might also be overwhelmed by the disability caused by associated injuries. In the absence of significant historical differences, a randomized prospective study comparing nonoperative treatment, open reduction and internal fixation, and the intermittent use of internal fixation needs to be organized.     

Moving forward with the management of minimally displaced lateral compression pelvic ring injuries

European Journal of Orthopaedic Surgery & Traumatology -     

Combined anterior and posterior ring fixation versus posterior ring fixation alone in the management of unstable Tile B and C pelvic ring injuries: A randomized controlled trial

PurposeCombined anterior and posterior ring (APR) fixation is classically performed in Tile B2 and C1 injuries to achieve superior biomechanical stability. However, the posterior ring (PR) is the main weight bearing portion that is responsible for weight transmission from the upper parts of the body to the lower limbs through the sacrum and the linea terminalis. It is hypothesized that isolated PR fixation can achieve comparable radiological and clinical outcomes to APR fixation. Therefore, we conducted this study to compare the two fixation principles in managing Tile B2 and C1 injuries.MethodsOur study included 20 patients with Tile B2 injuries and 20 patients with Tile C1 injuries. This study was a randomized control single-blinded study via computerized random numbers with a 1:1 allocation by using random block method. The study was performed at a level one trauma center. A total of 40 patients with Tile B2 and C1 injuries underwent combined APR or isolated PR fixation (Group A and B, respectively). Matta & Tornetta radiological principles and Majeed pelvic scoring system were used for the assessment of primary outcomes and postoperative complications. Secondary outcomes included operative time, amount of blood loss, intraoperative assessment of reduction, need of another operation, length of hospital stay, ability to weight bear postoperatively and pain control metrics. We used student t-test to compare the difference in means between two groups, and Chi-square test to compare proportions between two qualitative parameters. We set the confidence interval to 95% and the margin of error accepted to 5%. So, p ≤ 0.05 was considered statistically significant.ResultsThe mean follow-up duration was 18 months. The operative time (mean difference 0.575 h) and the intraoperative blood loss (mean difference 97.5 mL) were lower in Group B. Also, despite the higher frequency of rami displacement before union in the same group, there were no significant differences in terms of radiological outcome (excellent outcome with OR = 2.357), clinical outcome (excellent outcome with OR = 2.852) and postoperative complications assessment (OR = 1.556) at last follow-up.ConclusionThe authors concluded that isolated PR fixation could favorably manage Tile B2 and C1 pelvic ring injuries with Nakatani zone II pubic rami fractures and intact inguinal ligament. Its final radiological and clinical outcomes and postoperative complications were comparable to combined APR fixation, but with less morbidity (shorter operation time, lower amount of blood, and no records of postoperative wound infection).     

不稳定型骨盆骨折髋臼上方加压外固定技术

外固定支架技术是不稳定型骨盆骨折患者早期治疗的重要组成部分.传统的髂骨翼置钉方式操作简便,但长期稳定性欠佳,对骨盆后方移位的控制较差.髋臼上方置钉外固定技术的固定钉位于髂前下棘至髂后上棘间髋臼上方厚实的骨质内,可获得更长的4钉-骨界面并增加稳定性;股骨牵引下对水平和垂直方向的骨盆骨折进行畸形矫正及加压条件下进行固定,可加强骨盆后方稳定性的维持.充分了解骨盆解剖,熟练掌握置钉技术和特殊的透视位置,可防止固定钉穿出骨质或进入髋臼;钝性分离和导向器保护可减少股外侧皮神经损伤的风险;良好的护理可减少钉道感染并延长支架的固定时间.髋臼上方加压外固定的生物力学稳定性好,便于腹部手术操作,是特定情况下不稳定型骨盆骨折临时和确定性治疗的良好选择.     

Reduction and temporary stabilization of Tile C pelvic ring injuries using a posteriorly based external fixation system

Tile C pelvic ring injuries are challenging to manage even in the most experienced hands. The majority of such injuries can be managed using percutaneous reduction techniques, and the posterior ring can be stabilized using percutaneous transiliac–transsacral screw fixation. However, a subgroup of patients present with inadequate bony corridors, significant sacral zone 2 comminution or significant lateral/vertical displacement of the hemipelvis through a complete sacral fracture. Percutaneous strategies in such circumstances can be dangerous. Those patients may benefit from prone positioning and open reduction of the sacral fracture with fixation through tension band plating or lumbo-pelvic fixation. Soft tissue handling is critical, and direct reduction techniques around the sacrum can be difficult due to the complex anatomy and the fragile nature of the sacrum making clamp placement and tightening a challenge. In this paper, we propose a mini-invasive technique of indirect reduction and temporary stabilization, which is soft tissue friendly and permits maintenance of reduction during definitive fixation surgical.     

Management of open pelvic ring injuries

Open pelvic ring injuries are rare clinical entities that require multidisciplinary care. Due to the scarcity of this injury, there is no well-defined treatment algorithm. As a result, conflicting evidence surrounding various aspects of care including wound management and fecal diversion remain. Previous studies have shown mortality reaching 50% in open pelvic ring injuries, nearly five times higher than closed pelvic ring injuries. Early mortality is due to exsanguinating hemorrhage, while late mortality is due to wound sepsis and multiorgan system failure. With advancements in trauma care and ATLS protocols, there has been an improved survival rate reported in published case series. Major considerations when treating these injuries include aggressive resuscitation with hemorrhage control, diagnosis of associated injuries, prevention of wound sepsis with early surgical management, and definitive skeletal fixation. Classification systems for categorization and management of bony and soft tissue injury related to pelvic ring injuries have been established. Fecal diversion has been proposed to decrease rates of sepsis and late mortality. While clear indications are lacking due to limited studies, previous studies have reported benefits. Further large-scale studies are necessary for adequate evaluation of treatment protocols of open pelvic ring injuries. Understanding the role of fecal diversion, avoidance of primary closure in open pelvic ring injuries, and importance of well-coordinated care amongst surgical teams can optimize patient outcomes.     

Occult injuries of the pelvic ring

With major trauma to the pelvis, injuries at more than one site within the pelvic ring are common. However, minor injuries seem to result in isolated fractures most frequently of the pubic rami. By means of the bone scan we have demonstrated in 6 consecutive cases that these apparent isolated injuries are associated with disruptions elsewhere within the ring, usually the acetabulum or sacroiliac joints. This finding may explain the complaints of pain in the sacral region or about the hip in some patients following isolated fractures of the pubic rami.     

A clinical and experimental investigation of occult injuries of the pelvic ring

Apparently isolated fractures of the pubic rami must be associated with damage elsewhere in the pelvic ring. In a clinical review of 20 patients it was demonstrated that radiographic evidence of isolated fractures of the pubic rami was associated with the increased uptake of technetium polyphosphate on bone scans in either the sacroiliac joints or the acetabulum.The nature of the injury causing increased uptake was evaluated by means of an experimental study creating pelvic injuries in rabbits. Radiographs, bone scans, autoradiographs and histological sections of the pelves of these animals all showed evidence of microavulsion fractures of the subchondral bone mediated through the sacroiliac ligaments and Sharpey's fibres. The associated injuries account for the clinical picture in patients who complain of pain in the hip and sacroiliac region following fractures of the pubic rami.The clinical and radiographic evidence presented clearly demonstrates that an injury at one site in the pelvic ring must be associated with another on the other side of the ring. Furthermore, the technique developed for autoradiography of the animal pelves provides a new and useful tool for further study of injury to bones and ligaments.     

骨盆后环损伤的内固定治疗

目的 探讨手术内固定治疗骨盆后环损伤的临床疗效.方法 对22例骨盆后环损伤患者分别采用微创技术椎弓根螺钉固定、骶髂关节空心螺钉固定及骨盆重建带后方髂髂固定3种方式治疗.结果 22例均随访,时间4~22个月.无切口感染、血管神经损伤及内固定松动或断裂,无骨折不愈合.结论 微创椎弓根螺钉固定、骶髂关节空心螺钉固定及骨盆重建带后方髂髂固定3种方式均为治疗骨盆后环损伤的有效方法,根据骨折类型及患者的情况选择不同的内固定方式,可获满意疗效.     

A prospective, randomised controlled trial of femoral ring allograft versus a titanium cage in circumferential lumbar spinal fusion with minimum 2-year clinical results

The literature reports on the safety and efficacy of titanium cages (TCs) with additional posterior fixation for anterior lumbar interbody fusion. However, these papers are limited to prospective cohort studies. The introduction of TCs for spinal fusion has resulted in increased costs, without evidence of superiority over the established practice. There are currently no prospective controlled trials comparing TCs to femoral ring allografts (FRAs) for circumferential fusion in the literature. In this prospective, randomised controlled trial, our objective was to compare the clinical outcome following the use of FRA (current practice) to the use of TC in circumferential lumbar spinal fusion. Full ethical committee approval and institutional research and development departmental approval were obtained. Power calculations estimated a total of 80 patients (40 in each arm) would be required to detect clinically relevant differences in functional outcome. Eighty-three patients were recruited for the study fulfilling strict entry requirements (>6 months chronic discogenic low back pain, failure of conservative treatment, one- or two-level discographically proven discogenic low back pain). The patients completed the Oswestry Disability Index (ODI), Visual Analogue Score (VAS) for back and leg pain and the Short-Form 36 (SF-36) preoperatively and also postoperatively at 6, 12 and 24 months, respectively. The results were available for all the 83 patients with a mean follow-up of 28 months (range 24–75 months). Five patients were excluded on the basis of technical infringements (unable to insert TC in four patients and FRA in one patient due to the narrowing of the disc space). From the remaining 78 patients randomised, 37 received the FRA and 41 received the TC. Posterior stabilisation was achieved with translaminar or pedicle screws. Baseline demographic data (age, sex, smoking history, number of operated levels and preoperative outcome measures) showed no statistical difference between groups (p<0.05) other than for the vitality domain of the SF-36. For patients who received the FRA, mean VAS (back pain) improved by 2.0 points (p<0.01), mean ODI improved by 15 points (p=<0.01) and mean SF-36 scores improved by >11 points in all domains (p<0.03) except that of general health and emotional role. For patients who received the TC, mean VAS improved by 1.1 points (p=0.004), mean ODI improved by 6 points (p=0.01) and SF-36 improved significantly in only two of the eight domains (bodily pain and physical function). Revision procedures and complications were similar in both groups. In conclusion, this prospective, randomised controlled clinical trial shows the use of FRA in circumferential lumbar fusion to be associated with superior clinical outcomes when compared to those observed following the use of TCs. The use of TCs for circumferential lumbar spinal fusion is not justified on the basis of inferior clinical outcome and the tenfold increase in cost.     

骨盆环损伤的分类及治疗

长期以来 ,骨盆环损伤不论其稳定性如何 ,均被推荐行保守治疗 ,并认为损伤后活下来的患者不会残留后遗症 ,直到最近才认识到一些不稳定性骨盆环骨折用保守治疗的远期疗效远不如手术治疗满意〔1～ 3〕。现就有关骨盆环损伤的分类及治疗进展作一介绍。1　骨盆环损伤的分型早在 1938年 ,Ｗａｔｓｏｎ Ｊｏｎｅｓ就根据骨盆环损伤的解剖部位进行了分型。 195 0年Ｐｅｎｎａｌ创造性地将骨盆环损伤分为前后压缩 (ａｎｔｅｒｉｏｒｐｏｓｔｅｒｉｏｒｃｏｍｐｒｅｓｓｉｏｎ ,ＡＰＣ)、外侧压缩 (ｌａｔｅｒａｌｃｏｍｐｒｅｓｓｉｏｎ ,ＬＣ)和垂…