Protocolo de embolizacion arterial como parte del control de la hemorragia por fractura pélvica: serie de casos en un centro de referencia de trauma / Arterial embolization protocol as control of pelvic fracture hemorrhage: case series in a trauma reference center

Introducción Las fracturas pélvicas se asocian a sangrado arterial y/o venoso, ocasionando mortalidad elevada. El objetivo del estudio es diseñar, implementar y evaluar un protocolo para el tratamiento de fracturas pélvicas Materiales y métodos estudio prospectivo observacional, de pacientes con fractura pélvica que ingresaron a la clínica Medical. Variables: edad, sexo, arteria comprometida, lesión unilateral o bilateral, tipo de fractura pélvica (clasificación de Tile), indicación de la arteriografía, acceso uni o bilateral, éxito angiográfico, complicaciones del procedimiento, lesiones asociadas, mortalidad a 30 días, mecanismo de trauma, días de estancia en cuidado intensivo. Resultados 56 pacientes con fractura pélvica, 17 pacientes se llevaron a arteriografía pélvica por sospecha de sangrado, 14 pacientes tenían sangrado arterial, promedio de 36 años, las arterias más comúnmente lesionadas fueron la arteria hipogástrica, arteria sacra lateral y la arteria obturatriz. la mayoría de sangrados se asociaron a fracturas tipo C, las lesiones asociadas se encontraron en un 34% de casos, la indicación de la arteriografía fue inestabilidad hemodinámica al momento del ingreso, el control del sangrado se logró en el 86% de casos, la punción fue única en el 100% de casos, se requirió empaquetamiento pélvico 12% de casos. Discusión El trauma pélvico asociado a accidentes de motocicleta es común, el manejo multidisciplinario y la oportuna intervención del cirujano vascular es decisiva para el diagnóstico y tratamiento temprano de las lesiones vasculares pélvicas; la realización de un protocolo de manejo con un algoritmo de embolización mostró ser efectivo y seguro para el control del sangrado pélvico. Nivel de Evidencia: III

Background Pelvic fractures are frequently associated with arterial and / or venous bleeding, leading to high mortality (10 and 50%). Aim of study is to show our experience, based on an institutional protocol developed for the management of the patient with major pelvic trauma. Methods We conducted a prospective observational study for a 3 years period of time. The variables analyzed were: age, sex, artery involved, unilateral or bilateral lesion, type of pelvic fracture (Tile classification), indication of arteriography, unilateral or bilateral access, angiographic success, complications of the procedure, associated injuries, mortality at 30 days, trauma mechanism, days of stay in ICU and floor. Results We found 56 patients with pelvic fracture, 17 patients were taken to pelvic arteriography due to suspected bleeding, 14 patients had arterial bleeding, with an average age of 36 years, the arteries most commonly injured were the hypogastric artery, lateral sacral artery and the obturator artery, 50% of cases the bleeding was bilateral, the majority of bleeds were associated with type C fractures, associated lesions were found in 34% of cases, the indication of arteriography was hemodynamic instability at the time of admission, control of bleeding was achieved in 86% of cases (n: 15), the puncture was unique in 100% of cases (n: N: 14), pelvic packing was required in 2 patients (12%) Discussion Pelvic embolization for pelvic fracture is a safe and feasible procedure. A multidisciplinary approach and a high suspicion of pelvic arterial injury must be always in mind. Mortality in our trial was very low comparative with previous reports. Evidence Level: III

Fractura abierta de pelvis en un accidente: a propósito de un caso y revisión bibliográfica / Open pelvic fracture in an accident: Case report

Las fracturas abiertas de pelvis son un desafío clínico y quirúrgico como consecuencia de la gravedad de las lesiones óseas, de órganos internos, de partes blandas, hemorragia y cobertura cutánea. Su frecuencia es baja con una incidencia del 2-4%. La mortalidad llega a ser del 15-25% en fracturas cerradas y alcanza hasta el 50% en fracturas abiertas. La primera causa de mortalidad suele ser por shock hemorrágico. Presentamos un caso clínico tratado en el Servicio de Cirugía Ortopédica y Traumatología (COT) del Complejo Hospitalario Universitario de Santiago de Compostela (CHUS). Tras el análisis de los datos obtenidos de la revisión de este caso y la bibliografía correspondiente, podríamos afirmar que, ante una fractura de pelvis abierta, en primer lugar hay que asegurar la supervivencia en el momento inicial y proceder al control inicial de la hemorragia y la estabilidad pélvica. Posteriormente, debe llevarse a cabo el tratamiento quirúrgico inicial urgente multidisciplinario. Por último, debe pasarse a un tratamiento definitivo mediante reducción abierta y fijación interna. Hay que considerar también, por su importancia, el gran número de secuelas que produce este tipo de lesiones, algo que debemos prever y minimizar en la medida de lo posible. Nivel de evidencia clínica. Nivel IV.

Open pelvic fractures are a clinical and surgical challenge because of the severity of bone lesions, internal organs, soft tissue, skin coverage and hemorrhage. Its frequency is low with an incidence of 2-4%. The mortality is as high as 15-25% in closed fractures and to 50% in open fractures. The leading cause of death is usually by hypovolemic shock. We report a case treated in the Department of Orthopedic Surgery and Trauma (COT) of the University Hospital of Santiago de Compostela (CHUS). After analyzing the data obtained from the review of this case and the relevant literature, we could say that, in an open fractured pelvis first thing to do is to ensure survival at the initial time and the initial control of bleeding and pelvic stability, subsequently an urgent multidisciplinary initial surgical treatment should be performed. And finally, a definitive treatment by open reduction and internal fixation has to be accomplished. Sequels that this type of injury produce have also been considered since the initial patient evaluation in order to anticipate and minimize them as much as possible. Evidence level. IV.

Clinical Features and Outcomes of Pelvic Insufficiency Fractures

PURPOSE: The purpose of this study was to investigate the radiological and epidemiological characteristics, as well as the clinical course of pelvic insufficiency fractures in the elderly population. MATERIALS AND METHODS: At a Haeundae Paik Hospital, we retrospectively reviewed patients with pelvic insufficiency fractures between March 2010 and May 2017. The demographic data of patients were analyzed, and bone mineral density and bone turnover markers were evaluated to estimate the metabolic status of the bone. The radiological characteristics were evaluated by comparing the simple x-ray images with the computed tomography images, and the types of fractures were classified via computed tomography images. For clinical course evaluation, we investigated comorbid complications, and compared the walking ability scale before and 6 months after the fracture. RESULTS: A total of 42 patients were included, with an average age of 76.5 years. All were female except one case. In 5 cases where the initial medical examination was from another institution, the fracture was not found in 3 cases. All cases received conservative treatment. After the diagnosis of pelvic bone fracture using a simple x-ray imaging, additional fractures were found in 81.0% of the study population using a computed tomography. Initiation of gait occurred at an average of 2.8 weeks, and every case except 1 (97.6%) fully recovered their gait ability. CONCLUSION: We concluded that there was a limitation with diagnosing pelvic insufficiency fracture using only a simple x-ray imaging technique. In general, cases in this study showed conservative treatment yielded favorable clinical outcome with relatively less critical complications.

Dyspareunia Caused by Pelvis Malunion / 대한고관절학회지

In unstable pelvic ring injury, if there is damage to both the anterior and posterior, both anterior and posterior fixation will be needed in order to stabilze the pelvic ring. A female patient complained of dyspareunia due to malunion and additional bone bridge at the inferior ramus of the pelvis. She should have undergone both anterior and posterior fixation, but had undergone anterior fixation only. We report on a patient who was treated successfully with resection of additional bone bridge, scar tissue and adhesive band around the vagina.

The Incidence of Venous Thromboembolism in Trauma Patients with Pelvic or Acetabular Fracture

PURPOSE: To evaluate the incidence of venous thromboembolism (VTE) in trauma patients with pelvic or acetabular fracture and determine high risk factors. MATERIALS AND METHODS: Twenty-three patients who had a pelvic or acetabular fracture were enrolled between March 2011 and February 2012. All patients had mechanical and chemical prophylaxis and underwent deep vein thrombosis (DVT) computed tomography around 2 weeks after injury for evaluation of VTE. The relationships between VTE and each of sex, age, body mass index, injury severity score, intensive care unit stay, transfusion, operation time, coagulopathy, and associated injury were analyzed. RESULTS: A total of 8 patients developed VTE (34.8%), of which 5 had DVT, 2 had pulmonary embolism (PE), and one had both DVT and PE. The group with a VTE risk score of 14 or more had a significantly higher incidence of VTE. CONCLUSION: Careful attention is needed in management of patients with pelvic or acetabular fracture.

Comparison with Number and Position of Percutaneous Iliosacral Screws as Treatment of Unstable Pelvic Fracture / 대한정형외과학회잡지

PURPOSE: A closed reduction of the posterior arch and percutaneous fixation with S1 and S2 iliosacral (IS) screw was performed on an unstable pelvis fracture with a disruption of the sacroiliac complex. The radiological and clinical results were analyzed according the number of screws and their position. MATERIALS AND METHODS: Of 31 cases with an unstable pelvis fracture involving the sacral complex, classified as Tile type C (AO/OTA), 16 and 15 cases were treated with one S1 screw fixation and two screws fixation into S1 and S2, respectively, using a percutaneous fixation technique. The patients were followed up for a minimum of 12 months and the radiological and clinical outcomes were analyzed statistically using the Majeed score and SF-36. RESULTS: Five cases of screw displacement occurred in the one screw fixation group. On the other hand, there was no screw displacement in the two screws fixation group after a mean follow-up of 40.2 months. In the case of a narrow safe zone (iliac cortical density, ICD), it is impossible to fix with two S1 screws. However, in these patients, good clinical results were achieved with S1 and S2 were achieved with S1 and S2 screw without complications. CONCLUSION: The technique of two screws fixation is an efficient and reliable method for reducing and fixing the unstable pelvic ring disruptions. Additional S2 screw fixation is recommended for patients with a narrow ICD.

The effect of interventional vas embolism operation at bedside in patients with severe pelvis fracture / 中华急诊医学杂志

Objective To evaluate the effect of interventional vas embolism operation at ICU bedside in severe pelvis fracture patients complicated with hemorrhagic shock. Method Forty-eight severe pelvis fracture patients with hemorrhagic shock were treated by interventional vas embolism operation at bedside as well as intensive monitoring. The clinical results were compared with those of the traditional conservative therapy group. Results In the interventional therapy group, 46 patients with hemorrhage had been controlled within an hour after the operation and the success ratio reached 95.8%. The blood transfusion volume, the complication incidence and mortality rate were all significantly lower than those of the conservative therapy group. Conclusion Interventional vas embolism operation at ICU bedside is a safe, practical and effective treatment on pelvis fracture with iliac vas trauma.

Anterior Fixation Techniques on Unstable Pelvic Ring Injury / 대한정형외과학회잡지

PURPOSE: We reviewed the clinical result of two techniques of anterior fixation method for unstable pelvic ring injuries, which are external and internal fixation. MATERIALS AND METHODS: A retrospective clinical analysis was performed on 33 cases which had been operated from September 1998 to February 2003.Mean follow-up period is 29 months (range, 12-54 months).Previous to anterior fixation percutaneous iliosacral screw fixation was applied on iliosacral joint in Type C injury. After then plate and screw fixation were done in 17 cases and external fixation in 16 cases as an anterior fixation method. The patient' functional outcome was evaluated by Postel score and comparison between two groups was performed. RESULTS: In external fixator group the complaints are long duration of application of external fixator, excessive scar formation due to pin tract infection, pain and discomfort (Postel score 9.9;range, 8-11) due to malunion. In internal fixation group all of them showed more than good result and satisfactory to the postoperative condition and clinically (Postel score 11.6;range, 10-12). CONCLUSION: An open reduction and internal fixation technique is better than external fixation for the treatment of injured anterior pelvic ring in unstable pelvis fracture.