Regional Clinical Hospital of Emergency Medical Aid, 

Barnaul, Russia

 

Pelvic injuries include bone fractures, disruptions of pelvic ring joints (61^st segment according to AO/ASIF classification) [1] and acetabular fractures (62^nd segment ‒ AO/ASIF). Pelvic injuries are predominant in polytrauma (PT) [2-6]. 8,599 patients with PT were treated in Regional Clinical Hospital of Emergency Medical Aid during 2000-2013. Pelvic injuries were in 1,956 (22.7 %) patients. Isolated injuries were treated in 641 patients ‒ 24.7 % of total number of the patients with pelvic injuries (2,597). It follows herefrom that in case of high energy trauma it is necessary to exclude pelvic injury on a first-priority basis, and for patients with pelvic injuries to perform active searching other injuries to organs and systems. It stresses the importance of the problem of pelvic injuries in PT.

Pelvic ring injuries are chiefly dangerous because of severe complications. Massive blood loss and traumatic shock are most common at resuscitation stage. At profile clinical stage the most common disorders are pneumonia, bed sores, phlebothrombosis et al., which are consequences of common conservative techniques. Acetabular fractures are not life dangerous as a rule, but are associated with severe disorders of pelvic joint function.

Pelvic ring injuries and acetabular fractures require stabile fixation and precise anatomic apposition of bone fragments and pelvic junctions. Such operations are quite difficult and crucial and are not performed in early PT period because of severe state of patients. Because of some causes it is impossible to achieve satisfactory apposition of fragments in late period (retraction of soft tissues, periosteal proliferation, osteolysis of avascular fragments etc.). All it gives necessity for close attention of physicians to the problem of treatment of pelvic ring injury in PT.

Objective ‒ to identify features of pelvic ring and acetabular injuries, characteristics of complications and possibilities for treatment in patients with polytrauma.

 

MATERIALS AND METHODS

The patients were included into the study after their written consent according to Helsinki Declaration – Ethic Principles for Medical Research Involving Human Subjects 2000 and the Rules for Clinical Practice in Russian Federation confirmed by Ministry of Health Of Russia from 19.06.2003, #266. The study protocol was approved by the local ethical committee of Altay State Medical University, the protocol #14 from 21.05.2014. There were 1.956 patients with pelvic injuries and PT: 1,095 (56 %) men, 861 women (44 %). The men/women ratio was 1:0.8. The age of the patients varied from 1 to 92 (Median (Me) ‒ 39 years, interquartile range ‒ 25-54). There were different values for mean age of the injured men and women. For the men Me was 38 years, interquartile range ‒ 26-51, for the women Me ‒ 42, interquartile range ‒ 24-59 years. The increase in the mean age of the women is associated with greater amount of pedestrian accidents among them.

There were 625 (32 %) non-working persons of employable age, 618 (31.6 %) students and retired persons, 372 (19 %) persons of blue-collar occupation, 325 (16.6 %) officials and 16 (0.8 %) preschoolers.

The most common causes of road traffic accidents were road traffic accidents (RTA) ‒ 1,328 (67.9 %), falling from height ‒ 405 (20.7 %), pelvic compression with heavy objects ‒ 144 (7.4 %) and others ‒ 79 (4 %).

Concomitant injury was identified in 1,717 (87.8 %) patients, multiple injuries to the locomotor ‒ in 227 (11.6 %), combined injuries ‒ in 12 (0.6 %).

According to ISS [6], mild PT (< 17 points) was identified in 324 (16.6 %) patients, severe PT without life threat (17-25) ‒ in 666 (34 %), severe life threatening PT (26-40) ‒ in 469 (24 %), critical (≥ 41) ‒ in 497 (25.4 %). Therefore, severe PT prevailed in most cases ‒ 1,632 (83.4 %).

Traumatic brain injuries (TBI) were noted in 1,418 (72.5 %) patients, injuries to internal organs ‒ in 709 (36.2 %), locomotorium injuries in other locations ‒ in 1,160 (59.3 %).

TBI was in view of brain concussion in 674 (34.5 %), brain contusion ‒ in 744 (38 %). Closed TBI was identified in 1,261 (64.5 %) patients, open TBI ‒ in 157 (8 %). Skull vault and base fractures were in 172 (8.8 %) patients, intracranial hemorrhage ‒ in 68 (3.5 %), subarachnoid hemorrhage ‒ in 52 (2.7 %).

Rib fractures were identified in 546 (27.9 %) including bilateral fractures in 87 (4.4 %). 351 (17.9 %) cases were complicated. The complications included pneumothorax in 183, hemothorax in 48, hemo- and pneumothorax in 120. Lung and heart contusion was noted in 172 cases, sternum fractures ‒ in 15.

Renal contusion was identified in 331 cases. Internal organ disruptions were in 127 cases, spleen ‒ in 112, intestine ‒ in 54, mesentery ‒ in 66, urethra and renal ducts ‒ in 26, kidneys ‒ in 10, urinary bladder ‒ in 96, pancreas ‒ in 3, ovary ‒ in 9, diaphragm ‒ in 22, gall bladder ‒ in 5, inferior vena cava ‒ in 2, renal vein ‒ in 1.

There were 1,700 fractures in other locations (1,418 closed fractures, 282 open fractures). There were 33 fractures of scapula, clavicle ‒ 123, humerus ‒ 191, forearm ‒ 222, hand ‒ 33, femur ‒ 360, patella ‒ 22, leg ‒ 392, ankle ‒ 72, foot ‒ 111, spine ‒ 141 (22 complicated fractures). 179 dislocations were identified including femur ‒ 130 (6 bilateral dislocations), clavicle ‒ 7, humerus ‒ 22, forearm ‒ 10, hand and fingers ‒ 10. The extensive wounds of corpus and extremities were in 609 patients.

AO/ASIF classification was used for estimation of pelvic injuries [1]. Pelvic ring injuries (segment 61) were identified in 1,598 (81.7 %) patients. There were 761 stabile fractures (61-A, 38.9 %), 535 partially stabile (61-B) (27.4 %), 302 non-stabile (61-C) (15.4 %). There were 358 acetabular fractures (segment 62, 18.3 %). Among them the fractures of one column (62-A) were in 202 (10.3 %) cases, both columns with transverse fracture line (62-B) ‒ in 125 (6.4 %), full intraarticular fractures (62-C) ‒ in 31 (1.6 %). There were 77 (3.9 %) pelvic ring injuries which were associated with acetabular fractures (segments 61 and 62). Closed pelvic injuries were identified in 1,823 (93.2 %) patients, open fractures ‒ in 133 (6.8 %).

In case of suspicion of pelvic ring injury, apart from standard anterior-posterior pelvic X-ray, the X-ray examination for inlet and outlet of small pelvis was carried out. Multispiral computer tomography (MSCT) was performed for diagnosing non-complete disruptions of posterior ring. In acetabular fractures the primary diagnostics was performed with oblique ileac and obturative views for an injured joint, MSCT was used for detalization of injuries.

Most patients (1,541, 78.8 %) were admitted during the first 24 hours, 225 (11.5 %) ‒ during 1-7 days, 120 (6.1 %) ‒ 8-14 days, 43 (2.2 %) ‒ 15-21 days, 27 (1.4 %) ‒ after 22 days.

At resuscitation stage of treatment of severe non-stabile pelvic ring injuries the temporary fixation with pelvic loop was used in most cases. Pelvic forceps and external fixation devices were used in 59 cases (Fig. 1). Skeletal traction was used for acetabular fractures. Femoral dislocation was an indication for emergent reduction.

Figure 1

Fixation of unstable pelvic ring injuries (61-B) at resuscitation stage: a – presurgical X-ray image; b – postsurgical X-ray image; c – the patient’s appearance.

a         a

b         b

c         c

Conservative techniques (Volkovich position, skeletal traction) and osteosynthesis (transosseous external fixation, internal fixation with plates and screws, combined fixation) were used for treatment at profile clinical stage. The parts from the packages of Ilizarov device were used for osteosynthesis (the pilot plant by Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics, the constructions from Osteomed, Moscow, and SYNTHES, Switzerland).

Non-stable injuries to pelvic ring and acetabular fractures with displaced fragments were indications for osteosynthesis. Osteosynthesis was performed for 580 (29.7 %) patients. The distribution was performed depending on severity of pelvic ring injuries and used osteosynthesis techniques (table 1).

Table 1
Distribution of patients depending on severity of pelvic ring injuries and osteosynthesis techniques

Fracture type and group	Used osteosynthesis technique			Total
	Transosseous	Internal	Combined
61-B	101	102	16	219
61-C	63	103	29	195
62	33	82	21	136
61B,C + 62A,B,C	2	16	12	30
Total	199	303	78	580

As one can see in the table 1, external fixation was most common one. External and combined techniques were less frequent. External fixation device was used for partially stable injuries to pelvic ring, type of “open book” (61-B1), less frequent ‒ for non-stable injuries without significant displacement (61-C1) and in complete intraarticular fractures of both acetabular columns (62-C) without significant displacement of fragments and dislocations of femoral head (Fig. 2). Wider usage of this technique is limited by weak reposition possibilities of external fixation device, especially in vertical displacements, and need for fixation with achievement of full consolidation of fractures.

Figure 2

To the left – ANF osteosynthesis of incomplete intraarticular fracture with transverse line of fracture of the right acetabulum, X-ray images and the patient’s appearance (a, b). To the right – computer 3D reconstruction of unstable pelvic ring injury (61-C) after trauma (a, b). Computer 3D reconstruction (c, d) and X-ray (e) image after ANF osteosynthesis.     

a       a

b     b

 cd e

Osteosynthesis with internal constructions was used for all types of pelvic ring injuries. Anterior stabilization was usually realized with plates, posterior stabilization ‒ with cannulated screws (Fig. 3). The patients with Morel-Lavelle injuries (4 cases) and with injuries to iliac bones received transcutaneous osteosynthesis with cannulated screws (Fig. 4). Acetabular fractures were treated with plates, standard and cannulated spongious screws in different combinations.

Figure 3

To the left – computer 3D reconstruction of pelvic ring injury (61-B) with disruptions of pubic symphysis and of the right sacroiliac joint, and sacral fracture to the left.  

      

Figure 4

To the left – computer 3D reconstruction of unstable pelvic ring injury (61-C) complicated with Morel-Lavelle syndrome; b – X-ray image of the pelvis by the same patient after internal osteosynthesis with 7.3 mm screws. To the right: a – computer 3D reconstruction of unstable pelvic ring injury (61-C) with comminuted fracture of the right iliac wing; b – computer 3D reconstruction of the same patient after osteosynthesis with 7.3 mm screws.    

a        a

b        b

Figure 5

Incomplete intraarticular T-shaped fracture of the left acetabulum (62-B) associated with posterior wall fracture: a – X-ray image after admission; b – after open reposition and posterior column reconstruction with LCP reconstruction plate, of posterior wall with screws; c – X-ray image one year after osteosynthesis; d – functional outcome 3 years after trauma. 

 a  c

 b  d 

In case of pelvic ring injuries the combination of external and internal fixation was used in open injuries to the urinary tracts (Fig. 6). External fixation was used in acetabular fractures for unloading an injured joint in excessive weight of a patient (Fig. 7).

Figure 6

Open unstable injury to the pelvic ring (61-C) with disrupted urinary bladder, posterior osteosynthesis with 7.3 mm cannulated screws, anterior ANF complex: a – pelvic X-ray image on admission; b – pelvic X-ray image after osteosynthesis and epicystostomy;  c – the patient’s appearance after surgery.     

 a       b

  c

Figure 7

X-ray image of the heavy weight patient with pelvic ring injury (61-C) associated with acetabular transverse fracture (62-B): a – pelvic X-ray image on admission; b – pelvic X-ray image after hammock positioning; c – pelvic X-ray image after posterior and acetabular osteosynthesis with 7.3 mm screws, anterior osteosynthesis with reconstruction plate and anterior ANF frame; d – pelvic X-ray image 3 years after trauma; e – functional outcomes of treatment 3 years after trauma. 

  a    b

  c    d

  e

Hospital mortality, the number and characteristics of complications, and short term outcomes were considered.

The analysis of the data was initiated with frequency diagram construction. The median and interquartile range (25th and 75th percentiles) were defined. For estimation of statistical significance χ2 test with Yates' correction and Bonferroni technique for multiple comparisons were used. For null hypothesis the critical level of significance was lower than 0.05 [8].                                                                                   

RESULTS AND DISCUSSION

336 (17.2 %) patients died, mostly during the first 24 hours ‒ 215 (11 %), 1-3 days ‒ 36 (1.8 %), 3 days-3 weeks ‒ 56 (2.7 %), more than 3 weeks ‒ 29 (1.5 %). The latest lethal outcome was on 105^th day of the hospital stay.

According to ISS, mild PT (< 17) was cause of death in 2 patients, the hospital mortality (HM) was 0.6 %, in severe non-life threatening PT (ISS of 17-25) ‒ 21 (HM 3.2 %), in severe life threatening PT (ISS of 26-40) ‒ 69 (HM 12.6 %), in critical one (ISS ≥ 41) ‒ 254 (HM 51.1 %).

303 patients (90.2 %) died at resuscitation stage, 33 (9.8 %) ‒ at profile clinical stage. The causes of lethal outcomes were acute blood loss and shock ‒ 200 (59.7 %), TBI ‒ 62 (18.5 %), sepsis ‒ 32 (9.6 %), cardiovascular insufficiency ‒ 28 (8.4 %), pulmonary embolism (PE) ‒ 9 (2.7 %), multiple organ insufficiency ‒ 3 (0.9 %), acute cerebrovascular accident ‒ 1 (0.3 %).

72 (HM 9.5 %) patients died in the hospital as result of stable pelvic ring injuries (61-A), 92 (HM 17.2 %) ‒ in partially stable, 146 (HM 48.3 %) ‒ in non-stable (61-C) injuries, 26 (HM 7.2 %) ‒ in acetabular fractures (62).

The greatest amount of the patients (318, 94.6 %) received conservative treatment, for 18 (5.4 %) osteosynthesis was performed. External fixation of pelvic ring was performed for 14 patients (external fixation device ‒ 9, pelvic forceps ‒ 5). Among them 9 patients died during the first 24 hours after admission because of acute blood loss and shock, 3 patients ‒ on days 31, 38 and 61 because of sepsis, 2 patients ‒ on day 15 and 105 because of PE. 2 patients died after internal osteosynthesis with plates and screws, one patient ‒ on day 37 after PE, one patient ‒ on day 67 after sepsis. Two patients died after combined screw osteosynthesis and external fixation, one patient died after gastric bleeding on day 17 (bleeding developed after administration of anticoagulants), one patient died after PE on day 10. There were statistically significant differences in the rate of lethal outcomes in the patients who received conservative and surgical treatment (p < 0.001).

According to the mortality analysis, most patients died at resuscitation stage during 3 days after injury. Acute massive blood loss and traumatic (hemorrhagic) shock were most common causes of lethal outcomes. In the patients with pelvic fractures the highest HM was noted in polytrauma with ISS > 40 and, correspondingly, in unstable injuries (61-C) to the pelvic ring.

Surgical intervention or its complications were not direct causes of death.

The table 2 shows the number of the admitted, died and operated patients who were treated with different techniques of pelvic osteosynthesis in our clinic from 2000 till 2013. The figure 8 shows dynamics of HM rates (%) and relation between the number of operated patients and admitted patients (%). The table 2 and the figure 8 demonstrate the inverse relationship between the number of pelvic osteosynthesis procedures and HM level.

Table 2

The number of admitted, died and operated patients with different pelvic ostheosynthesis techniques during 2000-2013

	2000	2001	2002	2003	2004	2005	2006	2007	2008	2009	2010	2011	2012	2013	Total
Admitted	112	125	141	183	153	123	130	168	147	131	125	143	129	146	1956
Died	35	23	38	44	27	20	25	30	20	18	19	16	14	7	336
ANF	-	6	13	63	54	37	7	11	3	-	1	1	1	2	199
Combined	-	-	-	-	-	7	25	25	6	7	2	3	2	1	78
Internal	-	1	1	3	2	4	11	24	35	36	41	45	60	40	289
Total operations	-	7	14	66	56	48	43	60	44	43	44	49	63	43	580

1,099 complications were registered. 972 complications were registered in the patients with conservative treatment, 127 ‒ with surgical treatment (p < 0.05).

Some difficulties appeared during the analysis:

‒ firstly, there was no clear classification of complications until the present time;

‒ secondly, for patients with PT the traditional separation into general (somatic) and local complications is not possible. So, it is unclear whether deep venous thrombosis on the side of pelvic ring injury is a local complication because of direct vascular injury, or result of general disorders in blood clotting system. This also holds true for peritonitis after open pelvic fracture with urinary tract injury;

‒ thirdly, significant proportion of registered complications is not associated with pelvic injury (for example, meningoencephalitis after traumatic brain injury or development of intestinal fistula in enterorrhexis);

‒ fourthly, many complications (bed sores, hypostatic pneumonia, phlebothrombosis etc.) are associated with forced physical inactivity of patients on bed rest, which is conditioned by pelvic injury or injuries to other organs and systems.

Considering all above mentioned facts in the analysis of complications the decision was made to be restricted only with the general characteristics according to the classification by V.A. Sokolov (2002) [9].

1. The most common life dangerous non-infectious complications were thrombosis in magistral veins and arteries (224 patients), fat embolia and DIC (16 patients), acute renal, liver and multiple organ failure (65 patients), acute cerebrovascular accident (1 patient), myocardial infarction (1 patient).

2. The most common life dangerous infectious complications were associated with respiratory system (332 patients): mainly, nosocomial pneumonia, tracheobronchitis, pleuritis. Bed sores and phlegmon were in 130 patients including 42 patients with sepsis. Pelvic hematoma purulence in closed injuries was in 50 patients. Cystitis and ascendant pyelonephritis were in 17 patients.

3. Life dangerous postsurgical abdominal complications (peritonitis, abdominal abscess, pancreatic necrosis etc.) were noted in 33 patients after TBI surgery (meningoencephalitis, hygroma, cerebrospinal-fluid fistula et al.) (83 patients), postsurgical purulent wounds after internal pelvic fixation with plates (10 patients), purulent soft tissue after osteosynthesis of other segments (28 patients).                                     

4. Other complications were psychiatric disorders as delirium alcoholicum or mixed delirium (48 patients).

5. Non-life dangerous complications were posttraumatic deforming coxarthrosis in acetabular fractures with development during up to 3 years after trauma (51 patients), migrated or fractured metal constructs (9 patients), radicular syndrome at the level of sacrolumbar spine (1 patient).

Most registered complications are related to general (somatic) ones, which are caused by forced physical inactivity because of injuries to other organs and systems. There was a relatively small amount of local complications after surgical treatment of pelvic injuries (3.3 %). Here we indicated postsurgical purulent wounds after internal pelvic fixation, migration and fractures of metal constructs. There is an unsolved question: whether coxarthrosis after acetabular fractures is a postsurgical complication or a consequence of trauma?

Figure 8

The relation between hospital mortality (HM) level in the patients with pelvic injury and the number of operated patients with osteosynthesis.

 

 

CONCLUSION

1. Injuries to other organs and systems are noted in 75.3 % of patients with pelvic injuries. As for PT, pelvic injuries occur in 22.7 % of cases. Considering this fact, in case of high energy trauma it is necessary to exclude pelvic fracture, but in case of identification of pelvic fracture one should perform active searching other injuries.

2. Non-stable pelvic ring injuries are most common in PT.

3. Hospital mortality achieves 17.2 % in patients with pelvic injuries with PT. Most patients died on the first day after injury. Acute massive blood loss and traumatic (hemorrhagic) shock were the most common causes of lethal outcomes. The highest mortality (51.1 %) was noted in patients with ISS > 40 and in unstable injuries to the pelvic ring of C type (48.3 %).

4. The greatest proportion of the diseased patients received conservative treatment. Pelvic osteosynthesis or its complications were not causes of death. Conversely, the decrease in HM level was noted with increasing amount of operations.

5. Forced physical inactivity because of severity of primary injury and use of conservative techniques were the causes of the greatest proportion of complications.