PURPOSE OF THE STUDY This study aims to analyse a subpopulation of patients with severe haemorrhagic shock and a concurrent unstable pelvic ring fracture. MATERIAL AND METHODS This manuscript is a retrospective study of prospectively collected data on trauma patients over a period of 10 years, namely between 2010 and 2019. These patients, primarily (after injury) referred to the trauma centre of the University Hospital Hradec Králové, were diagnosed with an unstable pelvic ring fracture as a part of multiple injuries. RESULTS The total number of patients with a pelvic ring fracture and concurrent acute phase of decompensated haemorrhagic shock in the period from 2010 to 2019 was 112. After excluding 25 patients with AIS 4 and 5 (Abbreviated Injury Scale) severe head trauma and another two patients who died of late-stage SIRS (systemic infl ammatory response syndrome) complications, the group consisted of 85 patients. Subsequently, the subpopulation of patients "in extremis" evaluated by the study included a total of 22 patients with the baseline systolic pressure below 70 mm Hg and/or baseline haemoglobin level below 80 g/l. CONCLUSIONS Prior to the evaluation of this study population, our department had no single algorithm developed to treat such patients. Slow blood circulation stabilisation or death were usually associated with inadequate haemostatic algorithm. The patients leaving the operating room and being handed over to the ICU presented the signs of a decompensated shock. Oftentimes, the pelvis was merely stabilised, with no further intervention to stop the bleeding. The extraperitoneal pelvic packing was performed in very few cases only. The extravasation of contrast media during the initial CT scan does not necessarily have to be detected due to vasospasm or hypotension with reduced blood fl ow. In such cases, only the size of haematoma is a sign of arterial bleeding. It is also risky to rely solely on vasography when stopping the bleeding which will certainly fail to stop venous bleeding. However, venous bleeding always accompanies arterial bleeding. Stabilisation of both segments of the pelvis is essential to stop bleeding in haemodynamically unstable patients with a pelvic ring injury. It is followed by extraperitoneal pelvic packing and in the case of continuing haemodynamic instability also vasography, namely even if there is a negative fi nding of the initial CT scan or if no initial CT scan was performed. This procedure has become the core of our single haemostatic algorithm. Key words: pelvic ring injury, patients in extremis, haemostatic algorithm.
- MeSH
- fraktury kostí * komplikace chirurgie MeSH
- hemoragický šok * etiologie MeSH
- hemostatika * MeSH
- krvácení etiologie diagnóza terapie MeSH
- lidé MeSH
- pánevní kosti * zranění MeSH
- retrospektivní studie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- anglický abstrakt MeSH
- časopisecké články MeSH
- Názvy látek
- hemostatika * MeSH
PURPOSE: Pelvic ring fractures requiring surgical stabilization are severe injuries. Surgical site infections occurring after stabilization of the pelvis are serious complications, requiring complex and multidisciplinary treatment. METHODS: This is a retrospective observational study from a level I trauma centre. One hundred and ninety-two patients who underwent stabilization of closed pelvic ring injuries without signs of pathological fracture were selected for inclusion into the study. After excluding seven patients for having incomplete data, the final study group consisted of 185 patients (117 men and 68 women). Basic epidemiologic data and potential risk factors were recorded and analyzed by Cox regression, Kaplan-Meier curves, and risk ratios in 2 × 2 tables. Categorical variables were compared by Fisher exact tests and chi squared tests. Parametric variables were analyzed with Kruskal-Wallis tests with post hoc Wilcoxon tests. RESULTS: Surgical site infections occurred in 13% of the study group (24 from 185). Eighteen infections occurred in men (15.4%) and six in women (8.8%). There were two significant risk factors in women: age over 50 years (p = 0.0232) and concomitant urogenital trauma (p = 0.0104). The common risk ratio for both these factors was 212.59 (8.78-5148.68), p = 0.0010. No significant risk factors were identified in men despite younger men having a higher incidence of infection (p = 0.1428). CONCLUSION: Overall rate of infectious complications was higher than in the literature, but this might be caused by inclusion of all patients regardless of surgical strategy. Higher age in women and lower age in men were associated with higher infection rates. Concomitant urogenital trauma was a significant risk factor in women.
- Klíčová slova
- Fracture related infection, Infection, Pelvic ring, Risk factor analysis, Stabilization, Surgical site infection,
- MeSH
- fixace fraktur škodlivé účinky MeSH
- fraktury kostí * epidemiologie chirurgie komplikace MeSH
- infekce chirurgické rány epidemiologie etiologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- pánevní kosti * chirurgie zranění MeSH
- pozorovací studie jako téma MeSH
- retrospektivní studie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
- práce podpořená grantem MeSH
PURPOSE OF THE STUDY To compare the outcomes of parallel and convergent iliosacral screw insertion into the body of vertebra S1 in the treatment of posterior pelvic arch injuries. MATERIAL AND METHODS Radiographs of 120 patients (43 women, 77 men), aged between 14-79 years, treated with iliosacral screw fixation for posterior pelvic ring fractures between 1.1.2009 and 31.12.2019 were reviewed for inclusion in the study. In each case two screws were inserted into the body of vertebra S1. The screws were inserted in either parallel or convergent orientation. Convergent orientation allows the threads of both screws to be interconnected. In this technique, the first screw is inserted into the centre of the body of vertebra S1 as a compression screw. The second screw is inserted as a positioning screw and is placed so that the threads of both screws lock together. We believe that the interlocking of the threads of both screws and contact of the second screw with three cortices (two of the iliac bone and one of the sacrum) increase the stability of the fixation. Migration of loosened screws was measured on radiographs of the pelvis obtained at six weeks and at three, six and twelve months postoperatively. Migration of five millimetres or more within the first six weeks was considered to be clinically significant. Only patients after primary fracture treatment and with a complete one-year follow-up were included in the study. Cases of non-union and failure of osteosynthesis of the anterior pelvic arch and patients with incomplete follow-up were excluded. The incidence of significant screw migration between the two techniques was compared using Fisher's exact test with a 5% level of significance. RESULTS Sixty-three patients (23 women, 40 men) aged 17 to 79 years were included in the study. Parallel screws were used in 24 patients (8 women, 16 men) and convergent screws were used in 39 patients (15 women, 24 men). Clinically significant migration occurred in nine (38%) patients after parallel insertions. In two of these cases there was unstable fixation of the anterior pelvic arch. Migration of convergently placed iliosacral screws occurred in four (10%) cases. In three of these cases this was due to unstable fixation of the anterior pelvic arch. The difference in screw migration between the two groups was shown to be significant (p = 0.0219). DISCUSSION Iliosacral screws ensure sufficient stability of the posterior arch in type B and C pelvic fractures provided that the anterior pelvic arch is stable. Convergent insertion of iliosacral screws may increase the stability of fixation. Minimally invasive surgery with sufficient stability may be advantageous for early treatment of patients after multiple trauma and in elderly patients. The weaknesses of this study are its relatively small number of patients, which prevented reliable statistical analysis of screw migration according to the type of pelvic fractures. The second main limitation is the failure to perform densitometric examination of the skeleton in patients with X-ray proven screw migration for confirmation of osteoporosis as one of the possible causes of fixation failure. CONCLUSIONS The results of the study suggest that convergent insertion of iliosacral screws into S1 is associated with a lower risk of screw migration and subsequent failure of fixation of the posterior pelvic arch. Key words: pelvic fracture, pelvic injury, iliosacral screw, parallel screws, convergent screws, migration of iliosacral screws.
- MeSH
- dospělí MeSH
- fraktury kostí * chirurgie MeSH
- kostní šrouby škodlivé účinky MeSH
- křížová kost diagnostické zobrazování zranění chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- pánevní kosti * zranění MeSH
- senioři MeSH
- vnitřní fixace fraktury škodlivé účinky metody MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Open pelvic fractures are devastating injuries with high mortality and morbidity that require aggressive treatment and multidisciplinary approach to achieve the best results. We present three cases of open pelvic fracture with a Faringer I zone injury, which were treated at our level I trauma centre in 2020. The patients were treated with external fixation without the need for fecal diversion. None of the patients died. Early control of bleeding, appropriate treatment of soft tissues and prevention of fecal contamination are critical for the treatment of patients with open pelvic fractures. A multidisciplinary approach relying on an experienced and trained team is essential for successful treatment of these injuries. Key words: pelvis fracture, open fracture, trauma.
AIM OF THE STUDY: Epidemiologic evaluation of pelvic ring injuries in children. METHODS: Retrospective analysis over a period of 13 years, excluding pathological fractures. AO/OTA type, epidemiological data, type of treatment, and complications were recorded. Data were assessed using Fisher's exact test and Wilcoxon test. RESULTS: 243 boys, 115 girls, mean age (SD) 14.1 ± 3.0 years, AO/OTA types: 281 A, 52 B, 25 C. Multiple trauma: 62, combined trauma: 59, mono-trauma: 237. 281 patients were treated non-operatively, 97 surgically. ETIOLOGY: traffic accidents 88, falls from a great height 37, crushing injuries four, and sports injuries 192, simple falls 30, others seven. High-energy mechanisms prevailed in types B and C. Low-energy mechanism in type A (p < 0.0001). Similar differences were found between type A (p = 0.0009) and in case type C requiring surgery and cases treated non-operatively (p < 0.0001). Twenty-six patients (7.3%) had complications (pelvic asymmetry 5, neurological deficits 5, non-union 1, ectopic calcification 4, others 7). Higher complication rates were associated with types B and C (p = 0.0015), with surgically treated cases (p < 0.0001) and multiple trauma (p = 0.0305). DISCUSSION: Results of this trial were comparable with other studies. CONCLUSION: Sports injuries accounted for most type A injuries, while types B and C tended to be associated with high-energy trauma. Complications were associated with the severity of pelvic trauma, more common in surgically treated group of patients; this is primarily linked to the surgical cases being more serious as well as the associated injuries.
- Klíčová slova
- Epidemiology, Fracture, Multicentric study, Pediatric, Pelvic ring,
- MeSH
- dítě MeSH
- fraktury kostí * epidemiologie chirurgie MeSH
- lidé MeSH
- mladiství MeSH
- pánevní kosti * zranění chirurgie MeSH
- polytrauma * MeSH
- retrospektivní studie MeSH
- traumatologická centra MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- mladiství MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
PURPOSE OF THE STUDY Pelvic trauma causes severe threats especially to polytraumatized patients. Not only it is in itself a possible cause for significant bleeding, but it also indicates a high risk for intra-abdominal injuries. The initial treatment of patients with pelvic trauma follows the ATLS principles of priority-oriented treatment. To examine the value of this highly standardized concept and to evaluate the effect of different patient collectives on early outcome parameters, two large collectives from Germany and Qatar were analyzed regarding injury parameters and early outcomes. MATERIAL AND METHODS Patients were recruited in Hamad General Hospital, Doha, Qatar (HGH) and BG Trauma Center Ludwigshafen, Germany (BG). All patients that were treated with a pelvic fracture between 2013 and 2016 were included in this retrospective analysis. Demographic parameters were collected as well as type of injury and the frequency of complication parameters as pneumonia, acute kidney failure, ARDS, sepsis and amount of blood transfusion. 1436 patients with pelvic fracture (645 from BG and 791 from HGH) were recruited. The mean age was 57.4 years in the BG and 33.6 years in the HGH group (p<0.000). The mean ISS was 17.81 in the BG and 15.88 in the HGH group (p=0.009). The mean pelvic AIS was 2.65 in the BG and 2.25 in the HGH group (p<0.000). RESULTS The mean frequency of complications was 9.3% in the BG and 9.9% in the HGH group (p=0.128). The mean frequency of ARDS was significantly higher in the BG group than in the HGH group (5.6% vs. 1.8%, p<0.000). The mean frequency of blood transfusion was significantly lower in the BG group than in the HGH group (28.8% vs. 39.2%, p<0.000). CONCLUSIONS Despite significant differences in the two collectives, this analysis shows comparable results regarding early outcome parameters in patients with pelvic injuries. In total, pelvic injuries are accompanied by a relatively high complication risk and need to be evaluated and treated according to priority-based algorithms. Key words: ATLS®, pelvic injury, complications, polytrauma.
- MeSH
- fraktury kostí * epidemiologie terapie MeSH
- jednotky intenzivní péče MeSH
- lidé středního věku MeSH
- lidé MeSH
- pánevní kosti * zranění MeSH
- polytrauma * terapie MeSH
- retrospektivní studie MeSH
- skóre závažnosti úrazu MeSH
- traumatologická centra MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- Geografické názvy
- Katar epidemiologie MeSH
- Německo epidemiologie MeSH
PURPOSE OF THE STUDY The incidence of pelvic fractures in geriatric population has been increasing. The diagnostic method of first choice is plain pelvic anteroposterior X-ray which, however, mostly reveals merely the pubic rami fractures. The pain caused by undiagnosed lesion of the posterior pelvic segment may substantially reduce the patient s mobility, thus also their self-sufficiency which is crucial in elderly patients. The purpose of this prospective study was to evaluate the incidence of an occult injury to the posterior pelvic ring in patients with an X-ray finding of pubic rami fractures only. MATERIAL AND METHODS Throughout a three-year period (2017-2019), the incidence of an occult injury to the posterior pelvic ring was evaluated by means of a CT scan in 50 patients aged 65 years and over, in whom the plain anteroposterior pelvic radiograph initially revealed only the pubic rami fractures. The mean age of 35 women and 15 men was 76 years (the range of 65-94 years). RESULTS In 15 patients (30%) only, the CT scan confirmed the isolated pubic rami fracture. In the remaining 35 cases (70%), the CT scan revealed an injury to the posterior pelvic segment, namely in 32 cases ipsilaterally, in one case contralaterally and in two patients bilaterally. In 4 patients (8%) only, signs of the injury to the posterior pelvic segment were subsequently found on the plain X-ray of the pelvis. DISCUSSION Diagnosis of a pubic rami fracture in geriatric patients solely based on the performed X-ray can be misleading. It has been proven in our prospective study that majority of injuries to posterior pelvic ring is not detected on the plain X-ray, which is also the conclusion arrived at by foreign authors. The CT scan alone can safely determine the actual extent of the pelvic injury. While the isolated injuries to the anterior pelvic ring show biomechanical stability, and thus are less painful and can be successfully treated non-operatively, the associated injuries to the posterior pelvic ring can cause a certain degree of instability, which has to be reflected in treatment strategy. CONCLUSIONS Injuries to the posterior pelvic segment in geriatric population are much more frequent than expected. They are, however, rarely distinguishable on a plain radiograph. Often times, only the pubic rami fractures are clearly visible. The fractures of posterior segment tend to be accompanied by a higher number of complications and a worse prognosis. A reliable method to detect these injuries is the unenhanced CT scan of the pelvis that should be performed routinely in all the patients with pubic rami fractures identified on a radiograph. In cases when pain substantially limits the mobilisation of the patients, minimally invasive surgical treatment should be considered. Key words: pelvic ring injury, pubic rami, geriatric population.
- MeSH
- fraktury kostí * diagnostické zobrazování epidemiologie MeSH
- fraktury páteře * MeSH
- lidé MeSH
- pánev MeSH
- pánevní kosti * diagnostické zobrazování zranění MeSH
- prospektivní studie MeSH
- retrospektivní studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
PURPOSE OF THE STUDY The prevalence of nerve structure injuries accompanying pelvic and acetabular fractures is stated to be 5-25 %, with most frequent injuries to motor nerve structures associated with fractures of the posterior wall of the acetabulum. Prognostically worse outcomes of regeneration are documented mainly in iatrogenic, intraoperative injuries to nerve structures. This study aims to document the functional effect of muscle transfers restoring the movement of lower extremities with irreversible nerve lesion caused by the pelvic and acetabular fracture. MATERIAL AND METHODS A total of 18 patients with irreversible palsy of lower extremities in L4-S1 segments underwent a reconstruction surgery in the period 2006-2016, of whom 13 patients with the mean age of 42 (21-79) years arrived for a follow-up. The group included 10 patients with the loss of function of peroneal portion of the sciatic nerve, one patient sustained femoral nerve lesion and two patients suffered complete sciatic nerve lesion (both the peroneal and tibial portion). The patients were evaluated at the average follow-up of 77 (24-129) months after the reconstruction surgery. The average time interval from pelvic fracture to reconstruction by muscle transfer was 47 (18-151) months. Due to a wide spectrum of functional damage, the patients were evaluated in terms of the overall effect of the reconstruction surgery on the activities of daily living using the LEFS (The Lower Extremity Functional Scale). The surgical techniques used transposition of tensor fascie latae for femoral nerve lesion, transposition of tibialis posteriormuscle for palsy of the peroneal division of the sciatic nerve and tenodesis of tibialis anterior tendon and peroneus longustendon for the palsy of the peroneal and tibial portion of sciatic nerve. RESULTS The effect of movement restoration on daily living evaluated using the LEFS achieved 65 points (53-79) which is 85% of the average value of LEFS in healthy population. The transposition of active muscles tibialis posterior and tensor fasciae latae resulted in all the patients in active movement restoration. A loss of correction of foot position following the performed tenodesis of the paralysed tibialis anterior muscle was observed in one patient, with no significant impact on function. No infection complication was reported in the group. In 78% of patients the intervention was performed as day surgery. DISCUSSION There is a better prognosis for restoration in incomplete nerve lesion than in complete lesions and also in the loss of sensation than in the loss of motor function. The mini-invasive stabilisation of pelvic ring according to literature does not increase the risk of nerve lesions, while on the other hand a higher incidence of femoral nerve damage by INFIX fixator is documented. The type of muscle transfer is selected based on the availability of active muscles suitable for transposition and also with respect to functional requirements of the patient. CONCLUSIONS Irreversible palsy of lower extremity after the pelvic fracture is easily manageable as to the restoration of function. Surgical interventions using the preserved active muscles to restore the lost movement should be a component part of comprehensive surgical care for patients who sustained a pelvic fracture and should be performed centrally at a centre availing of comprehensive expertise. Key words: nerve lesion, tendon transfer, acetabulum, pelvis, fracture.
- MeSH
- acetabulum zranění MeSH
- činnosti denního života MeSH
- dospělí MeSH
- fraktury kostí komplikace MeSH
- kosterní svaly inervace transplantace MeSH
- lidé středního věku MeSH
- lidé MeSH
- mononeuropatie etiologie chirurgie MeSH
- pánevní kosti zranění MeSH
- paraplegie etiologie chirurgie MeSH
- plexus lumbosacralis zranění MeSH
- poranění dolní končetiny chirurgie MeSH
- poranění periferního nervu etiologie chirurgie MeSH
- přenos šlachy metody MeSH
- prognóza MeSH
- senioři MeSH
- zákroky plastické chirurgie metody MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- senioři MeSH
- Publikační typ
- časopisecké články MeSH
The author presents a case study of the use of resuscitative endovascular balloon occlusion (REBOA) as a suitable alternative to thoracotomy and clamping of the descending aorta to control retroperitoneal bleeding in a patient with a pelvic injury. The patient who suffered multiple trauma after car accident, type C pelvic injury and retroperitoneal bleeding among other things, was following the pre-hospital ambulance care transported to the department of emergency medicine, with catecholamine infusion to support the blood flow. After the primary survey following the ATLS principles, the patient was taken for a CT scan. The CT examination revealed also multiple sources of retroperitoneal bleeding. Subsequently, the patient was brought to the operating room, where endovascular balloon occlusion of the descending aorta was performed to temporarily control retroperitoneal bleeding, which provided more time to treat the patient in line with the damage control surgery principles. In bleeding patients who suffered blunt torso traumas and serious haemorrhagic shock, or patients "in extremis", the survival after emergency thoracotomy ranges only around 1%. The to date results of REBOA technique applied in same indications are very promising globally. The survival rate increases multiple times especially in hypotensive patients, without the necessity of their immediate cardiopulmonary resuscitation. Key words:resuscitative balloon occlusion of the aorta, REBOA, haemorrhagic shock, retroperitoneal bleeding.
- MeSH
- aorta chirurgie MeSH
- balónková okluze * MeSH
- dopravní nehody MeSH
- fraktury kostí komplikace MeSH
- hemoragický šok chirurgie MeSH
- lidé MeSH
- pánevní kosti zranění MeSH
- polytrauma etiologie terapie MeSH
- resuscitace metody MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
Blood vessels passing through pelvic region come into intimate contact with pelvic bone and can be injured by the sharp edges of the dislocated fracture fragments. The aim of the study was to evaluate the influence of localization, shape, and dislocation of individual pelvic ring bones' fractures on arterial injuries. The study group consisted of 474 patients enrolled in a 1-year prospective multicenter study. The pattern of pelvic fracture lines was characterized and recorded on a planar diagram of the subjected side of the pelvis. The diagram was subdivided into 11 designated areas. Frequency of injury at each 11 areas was recorded. The course of individual arteries in the 11 areas was also recorded in relation to each type of pelvic fractures. Out of the 474 investigated patients, the highest proportion of fractures occurred in the areas of the superior (62%) and inferior (59%) ramus of the pubis as well as in the lateral part of the sacrum (19%). These locations can be associated with injuries of the external iliac, obturator, internal iliac, and aberrant obturator arteries. The highest risk of arterial injuries was associated with vertically displaced fractures in the middle part of the superior and inferior pubic rami, along the ischial ramus, in the apex of the greater sciatic notch and in the vicinity of the ventral part of the sacroiliac joint, where the artery runs at a distance of less than 1 cm from the bone. Clin. Anat. 32:682-688, 2019. © 2019 Wiley Periodicals, Inc.
- Klíčová slova
- arterial bleeding, arteries, ilium, pelvic bones, pelvic bones fracture, pelvis, pubic bone, sacroiliac joint, sacroiliac joint dislocation, sacrum,
- MeSH
- arteria iliaca zranění MeSH
- fraktury kostí klasifikace komplikace patofyziologie MeSH
- kyčelní kloub anatomie a histologie krevní zásobení MeSH
- lidé MeSH
- pánevní kosti anatomie a histologie krevní zásobení zranění MeSH
- prospektivní studie MeSH
- sakroiliakální kloub krevní zásobení zranění MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
