Pelvic injury prognosis is more closely related to vascular injury severity than anatomical fracture complexity: the WSES classification for pelvic trauma makes sense

Abstract

Background: The most common cause of death in cases of pelvic trauma is exsanguination caused by associated injuries, not the pelvic injury itself. For patients with relatively isolated pelvic trauma, the impact of vascular injury severity on outcome remains unclear. We hypothesized that the severity of the pelvic vascular injury plays a more decisive role in outcome than fracture pattern complexity. Methods: Medical records of patients with pelvic fracture at a single center between January 2016 and December 2017 were retrospectively reviewed. Those with an abbreviated injury scale (AIS) score ≥ 3 in areas other than the pelvis were excluded. Lateral compression (LC) type 1 fractures and anteroposterior compression (APC) type 1 fractures according to the Young-Burgess classification and ischial fractures were defined as simple pelvic fractures, while other fracture types were considered complicated pelvic fractures. Based on CT, vascular injury severity was defined as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling/extravasation). Patient demographics, clinical parameters, and outcome measures were compared between the groups. Results: Severe vascular injuries occurred in 26 of the 155 patients and were associated with poorer hemodynamics, a higher injury severity score (ISS), more blood transfusions, and a longer ICU stay (3.81 vs. 0.86 days, p = 0.000) and total hospital stay (20.7 vs. 10.1 days, p = 0.002) compared with minor vascular injuries. By contrast, those with complicated pelvic fractures (LC II/III, APC II/III, vertical shear, and combined type fracture) required a similar number of transfusions and had a similar length of ICU stay as those with simple pelvic fractures (LC I, APC I, and ischium fracture) but had a longer total hospital stay (13.6 vs. 10.3 days, p = 0.034). These findings were similar even if only patients with ISS ≥ 16 were considered. Conclusions: Our results indicate that even in patients with relatively isolated pelvic injuries, vascular injury severity is more closely correlated to the outcome than the type of anatomical fracture. Therefore, a more balanced classification of pelvic injury that takes both the fracture pattern and hemodynamic status into consideration, such as the WSES classification, seems to have better utility for clinical practice.

The application of the WSES classification system for open pelvic fractures—validation and supplement from a nationwide data bank

“…In addition to stopping concomitant external and internal hemorrhage, the difficulty of open pelvic fracture treatment includes the management of severe wound infection and further sepsis and multiple organ failure [ 11 , 24 ]. The WSES guidelines suggest that the management of pelvic trauma must consider physiological and mechanical derangement [ 17 , 19 ]. An international validation using the National Trauma Data Bank proved that the WSES guidelines were an accurate and reproducible classification system for pelvic injuries [ 18 ].…”

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

“…However, vascular injury was also found in 7–10% of stable pelvic fractures, which have often been considered minor injuries and are normally treated conservatively [ 14 , 15 ]. Some of these fractures even require angioembolization to achieve hemostasis [ 9 , 14 , 16 ]. Not only mechanical stability but also associated vascular injury should be evaluated in the management of pelvic fracture.…”

“…Not only mechanical stability but also associated vascular injury should be evaluated in the management of pelvic fracture. Wu et al reported that vascular injury severity is more closely correlated with the outcome than the type of anatomical fracture of the pelvis [ 9 ]. Our previous study, which was based on a single institution experience, also showed that the role of pelvic stability is not significant when evaluating associated hemorrhage in the management of patients with pelvic fracture [ 17 ].…”

“…Although pelvic ring stability was evaluated by the WSES classification, associated vascular injury was not. It has been reported that the severity of vascular injury is a more significant factor in determining patient outcomes than the fracture pattern in patients with pelvic fracture [ 9 ]. Therefore, the role of vascular injury in this system was also analyzed.…”

Management of Hemodynamically Unstable Pelvic Ring Fractures

“…However, the anatomical description of the Young and Burgess classification does not aid in determining the prognosis of a pelvic fracture patient. To this extent the World Society of Emergency Surgery (WSES) classification has been proposed and validated (7). This classification stratifies patients according to vascular injury severity in combination with the mechanical instability of the pelvic ring.…”