Concomitant external and internal hemorrhage: Challenges to managing patients with open pelvic fracture

Fu, Chih-Yuan; Huang, Ruo-Yi; Wang, Shang‐Yu; Liao, Chien‐Hung; Huang, Jen‐Seng; Hsu, Yung‐Heng; Lin, Chia-Yun; Kang, Shih‐Ching

doi:10.1016/j.ajem.2018.02.014

Cited by 14 publications

(14 citation statements)

References 33 publications

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“…Application of minimally invasive preperitoneal packing balloon and abdominal aortic junction tourniquet has been proposed as an alternative to open preperitoneal packing (OP) for the treatment of bleeding associated with open pelvic fractures. At the same time, most patients also need early transcatheter arterial embolization (TAE) to control definite bleeding. In extreme cases, a half hip or half pelvic amputation is performed.…”

Section: Discussionmentioning

confidence: 99%

Regional Injury Classification and Treatment of Open Pelvic Fractures

Wang

2019

Orthopaedic Surgery

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ObjectivesTo propose the regional injury classification of open pelvic fracture and summarize the characteristics of its treatment.MethodsClinical data for 67 open pelvic fractures treated from January 2001 to December 2017 were retrospectively analyzed. There were 48 male and 19 female patients. The patients were aged from 12 to 68 years old, and their pelvic fractures were categorized according to Tile classification (type A: 23 cases; type B: 19 cases; type C: 25 cases). Main injury distribution: pubic perineum, 29 cases; ilioinguinal, 20 cases; and sacroiliac, 7 cases. There were 5 cases of ilioinguinal‐perineum and 6 cases of sacroiliac‐perineum injury. Based on the region of the injury, the mortality and combined injury of each group were observed. The relationship between regional injury groups and death was examined.ResultsFollowing active treatment, 28 patients died. The mortality rate was 41.8% (28/67), with 39 patients surviving. The average follow‐up time was 6 months (3 months to 1 year after discharge). Majeed pelvic fracture score: the score was excellent in 12 cases, good in 14 cases, fair in 9 cases, and poor in 4 cases; there was an excellent and good rate of 66.7%. Open pelvic fracture regional injury classification includes: the perineal type (type I); the ilioinguinal type (type II); the sacroiliac type (type III); and the composite type (type IV). All types were independent of each other, and the mortality of open pelvic fractures was positively correlated with this classification, with a correlation coefficient of 0.620 (P = 0.001 < 0.05; the difference was statistically significant). In this study, cystourethral injury, anorectal injury, and infection were the main combined injuries of type I. The type II and III injuries were mainly iliac vascular injuries. The main combined injuries of type IV were infection, injury of ilium vessels and its branches. There was a statistical difference among the combined injuries of each subtype (P = 0.001 < 0.05).ConclusionsThe criteria for regional classification were clear, the mortality of the four subtypes increased gradually, and the incidence of combined injury of each subtype varied. Each subtype had different therapeutic characteristics.

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Section: Discussionmentioning

confidence: 99%

Regional Injury Classification and Treatment of Open Pelvic Fractures

Wang

2019

Orthopaedic Surgery

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“…Table 4 summarizes 21 prominent studies of open pelvic fracture from 2000 to 2019 with a total of 782 patients with an overall mortality rate of 24.4%. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][26][27][28][29][30][31] In this study, the overall mortality rate was 17.4%, which is considerably lower than the average of other series. This finding may be attributed to the consistency of multidisciplinary teamwork in dealing with multisystem injuries which may be the most prominent challenge in the treatment of open pelvic fractures.…”

Section: Discussionmentioning

confidence: 80%

“…1 In the 21st century, the mortality of open pelvic fracture was reported to range from 4% to 45%. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] The development of a definitive treatment algorithm is limited by the low incidence of this complex injury. Because of the rarity of this severe injury and its poor prognosis, we conducted a retrospective study to evaluate all consecutive open pelvic fractures in patients treated in our trauma center during a 5-year period and explore the risk factors associated with mortality.…”

Section: Introductionmentioning

confidence: 99%

Clinical features and risk factors for mortality in patients with open pelvic fracture: A retrospective study of 46 cases

Qing-shan

Zhang

Zhou

et al. 2020

J Orthop Surg (Hong Kong)

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Background: This study aimed to investigate the clinical features, current management strategies, and outcomes of open pelvic fracture patients. Methods: We performed a retrospective review of data on patients with blunt trauma and open pelvic fractures admitted to our trauma center over a 5-year period (January 2013 to December 2017). Demographic as well as clinical data including injury mechanism, injury severity score (ISS), fracture classifications, transfusion requirements, interventions, length of hospital and intensive care unit (ICU) stay, and prognosis were investigated. Univariate analysis and binary logistic regression were used to identify the risk variables of death. Finally, a brief literature review was performed to understand the current capacity of treatment and prognosis of this type of injury. Results: Forty-six patients (36 male and 10 female) were included in this study, mean age 43.2 ± 14.2 years. The overall mortality rate was 17.4%; 43.5% of the patients were hypotensive (systolic blood pressure (SBP) <90 mmHg) on arrival. The average ISS was 31.7 ± 6.7, and the average packed red blood cell (PRBC) transfusion during the first 24 h was 9.6 ± 7.4 units. Five patients (10.9%) underwent transcatheter arterial embolization in the early stage of management. The average hospital and ICU length of stay were 53.0 ± 37.6 days and 14.3 ± 15.3 days, respectively. Statistically significant differences were found in ISS, PRBC units received with the first 24 h, SBP, lactate and base excess on admission, and mechanism of injury when comparing between the death and the survival groups ( p < 0.05). ISS and lactate on admission were found to be the independent risk factors for mortality. Conclusion: The mortality rate of open pelvic fractures remains high. ISS and lactate on admission were the independent risk factors for mortality. Optimization of the trauma care algorithms for early identification and treatment of this injury could be the key to decreasing mortality.

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“…In contrast to closed fractures, open pelvic fractures can lead to concomitant external hemorrhage, internal hemorrhage, associated anorectal or urogenital injuries and contaminated wound-related infection [ 3 , 20 , 21 ]. Several complications, such as septicemia, AKI and multiple organ dysfunction, may occur because of an uncontrolled infection [ 22 ].…”

Section: Discussionmentioning

confidence: 99%

Accuracy of the WSES classification system for pelvic ring disruptions: an international validation study

Wang

Bajani

et al. 2021

World J Emerg Surg

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Background In 2017, a novel classification for pelvic injuries was established by the World Society of Emergency Surgery (WSES). We validated its effectiveness using nationwide real-world data. The roles of associated vascular injury and open fracture in this system were also evaluated. Methods Patients with pelvic fractures in the National Trauma Data Bank 2015 dataset were retrospectively studied. First, the mortality rates were compared by WSES classification. Second, independent predictors of mortality were evaluated using a multivariate logistic regression model. Patients with and without associated vascular injuries and the same hemodynamic and pelvic ring stability statuses were compared. Patients with associated vascular injuries were compared to the proportion of nonsurvivors and survivors with unstable pelvic ring injuries. Third, the outcomes were compared between patients with open pelvic fracture and closed pelvic fracture in the mild, moderate and severe WSES classes. Results During the 12-month study period, 44,163 blunt pelvic fracture patients were included. The mortality rates were 1.8%, 3.8% and 10.6% for the mild, moderate and severe WSES classes, respectively (p < 0.001). MLR analysis showed that unstable pelvic ring injury did not significantly affect mortality (p = 0.549), whereas open pelvic fracture and associated vascular injury were independent predictors of mortality (odds of mortality: open pelvic fracture 1.630, p < 0.001; associated vascular injury 1.602, p < 0.001). Patients with associated vascular injuries showed that there was no significant difference in the proportion of patients with unstable pelvic ring injuries between survivors and nonsurvivors (37.2% vs. 32.7%, p = 0.323). In all three classes, patients with open pelvic fractures had significantly higher mortality rates and infection rates than patients with closed fractures (mortality rates: minor 3.5% vs. 1.8%, p = 0.009, moderate 11.2% vs. 3.3%, p < 0.001, severe 23.8% vs. 9.8%, p < 0.001; infection rates: minor 3.3% vs. 0.7%, p < 0.001, moderate 6.7% vs. 2.1%, p < 0.001, severe 7.9% vs. 2.8%, p < 0.001). Conclusions Based on this nationwide study, the WSES guideline provides an accurate and reproducible classification of pelvic fractures. It is recommended that open/closed fractures and associated vascular injuries be evaluated as supplements of the WSES classification.

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Concomitant external and internal hemorrhage: Challenges to managing patients with open pelvic fracture

Cited by 14 publications

References 33 publications

Regional Injury Classification and Treatment of Open Pelvic Fractures

Regional Injury Classification and Treatment of Open Pelvic Fractures

Clinical features and risk factors for mortality in patients with open pelvic fracture: A retrospective study of 46 cases

Accuracy of the WSES classification system for pelvic ring disruptions: an international validation study

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