Use of inherent anteversion of an intramedullary nail to avoid malrotation in femur fractures.

Rotational malalignment after intramedullary (IM) nailing of femoral fractures remains a significant problem. A technique using intraoperative fluoroscopy and the anteversion inherent to the IM nail for obtaining appropriate femoral rotational alignment is presented. The technique is advocated as a simple alternative to more complex methods for estimation of femoral anteversion during placement of femoral IM nails. This method is simple and requires intraoperative fluoroscopy on the injured extremity alone. It reliably sets the femoral anteversion within a normal physiologic range with minimal additional intraoperative steps and without preoperative measurements.

Functional outcomes in elderly patients with acetabular fractures treated with minimally invasive reduction and percutaneous fixation.

OBJECTIVES: To present the functional outcomes of elderly patients treated with percutaneous acetabular surgery and compare them with those treated with traditional open reduction and internal fixation in previously published series. DESIGN: Retrospective. SETTING: University level I trauma center. PATIENTS: All patients aged 60 and older treated with percutaneous screw fixation for acetabular fractures from 1994 to 2007 were included. Seventy-nine consecutive patients were identified. Thirty-six patients died before functional outcomes were obtained, leaving 43 patients and fractures in our study group. Functional outcomes were obtained in 35 of 43 (81.3%) patients at an average of 6.8 years after the index surgery. INTERVENTION: Minimally invasive reduction and percutaneous fixation of acetabular fractures. MAIN OUTCOME MEASUREMENT: Short musculoskeletal functional assessment and Harris Hip Score. RESULTS: One-year mortality was 13.9% (11 of 79). Average short musculoskeletal functional assessment dysfunction and bother indices were 23.3 and 21.3, respectively, in 24 patients who maintained their native hip. When compared with Short Musculoskeletal Functional Assessment data from 2 other series of patients treated with formal open reduction and internal fixation, no differences existed in the dysfunction (P = 0.49) or bother (P = 0.55) indices. Conversion to total hip arthroplasty occurred in 11 of 36 patients (30.6%). Average Harris Hip Scores in patients with their native hip was 77 (range, 33-100). In the 11 patients converted to total hip arthroplasty, average Short Musculoskeletal Functional Assessment dysfunction and bother indices were 24.3 and 23.9, respectively. No differences were found in the dysfunction (P = 0.93) or bother (P = 0.16) indices when compared with patients converted from open reduction and internal fixation to total hip arthroplasty. Average Harris Hip Score in patients converted to total hip arthroplasty was 83 (range, 68-92), and this was not significantly different from the best scores reported with acute total hip arthroplasty. CONCLUSIONS: Functional outcomes and rates of conversion to total hip arthroplasty of acetabular fractures in elderly patients treated with percutaneous reduction and fixation show no significant differences when compared with published series of patients treated with formal open reduction and internal fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A prospective study of thrombophilia in trauma patients with pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) is a rare, but often fatal, complication of trauma. To date, there has been no study of the prevalence of thrombophilic abnormalities among trauma patients who sustain a PE. Our purpose was to determine whether heritable thrombophilia is associated with the development of PE in trauma patients. METHODS: All patients admitted to the trauma service over a five-month period had residual blood from standard laboratory samples stored. Patients were then prospectively followed through their hospital. Greets' formula was used to estimate risk of thromboembolic disease. For every patient who developed a PE (n = 20), four controls with similar risk were randomly selected. DNA samples were genotyped. The genes screened included MTHFR, Factor II, Factor V, and Protein C. RESULTS: DNA genotyping for Factor V and Protein C revealed only wild-type alleles in the cases. Genotyping of Factor II revealed mutations in 25% (10 of 40) of alleles in the cases and 17% (27 of 160) of alleles in the controls (p = 0.24). Mutation in alleles of the MTHFR1 gene occurred in 28% (11 of 40) of the cases and in 28% (40 of 150) of the controls (p = 0.92); genotyping in five of the controls (10 alleles) was indeterminate at the MTHFR1 alleles after testing. CONCLUSIONS: No statistically significant differences were found in genetic abnormalities among trauma patients who developed PE and who did not; however, the sample size was small. Routine screening for thrombophilia in trauma patients is not recommended.

Ipsilateral femoral shaft and neck fractures: are cephalomedullary nails appropriate?

A retrospective review was conducted to examine rates of malreduction and nonunion in ipsilateral femoral neck and shaft fractures using different fixation strategies. Twenty-two consecutive patients with 23 fractures were identified. Participants were treated with various fixation strategies for ipsilateral femoral neck and shaft fractures. Cephalomedullary devices were used in 13 cases, while cannulated screws and a retrograde femoral nail were used in nine cases. One patient was treated with cannulated screws and external fixation of the femoral shaft. Radiographic assessment of the quality of reduction and union of both fractures was evaluated. Clinical and radiographic follow-up was available in 20 fractures (87%) with a mean of 12 months (range 3-50). Two femoral neck nonunions occurred; both had fair reductions of the fractures obtained by closed maneuvers, and two-device fixation was used in each. One femoral shaft nonunion occurred in a fracture treated with a cephalomedullary nail. All three united after revision surgery. No cases of osteonecrosis or conversion to hip arthroplasty were noted. A combination of retrograde femoral nailing and screw fixation of the femoral neck or placement of a cephalomedullary nail can provide excellent reduction and rate of union in the treatment of this injury pattern. Excellent reduction of the femoral neck fracture is key to preventing femoral neck nonunion.

Survivorship of the native hip joint after percutaneous repair of acetabular fractures in the elderly.

Our purpose was to examine survivorship of the native hip joint in patients ages 60 and over who underwent percutaneous reduction and fixation of acetabular fractures. A retrospective review at a University Level I Trauma Center was performed. Our institutional trauma database was reviewed. Patients aged 60 or older treated with percutaneous reduction and fixation of acetabular fractures between 1994 and 2007 were selected. 79 consecutive patients with 80 fractures were identified. Rate of conversion to total hip arthroplasty were used to construct a Kaplan-Meier curve showing survivorship of the native hip joint after treatment. 75 fractures had adequate clinical follow-up with a mean of 3.9 years (range 0.5-11.9 years). Average blood loss was 69 cc and there were no postoperative infections. 19/75 (25%) were converted to total hip arthroplasty at a mean time of 1.4 years after the index procedure. Survivorship analysis demonstrated a cumulative survival of 65% at 11.9 years of follow-up. There were no conversions to arthroplasty beyond 4.7 years postoperatively. There were no statistically significant associations between conversion to arthroplasty and age, sex, closed vs. limited open reduction, and simple vs. complex fracture pattern. Percutaneous fixation is a viable treatment option for patients age 60 or greater with acetabular fractures. Rates of conversion to total hip arthroplasty are comparable to open treatment methods and if conversion is required, soft tissues are preserved for future surgery.

The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients.

BACKGROUND: The understanding of the mortality risk posed by pelvic fracture is incomplete. The purposes of this study were (1) to compare the mortality risk associated with a pelvic fracture with the risk conferred by other injuries and (2) to determine if the association of a pelvic fracture with mortality varies when combined with other known risk factors. METHODS: Trauma registry records from two level-I trauma centers were examined. Regression analysis was done on 63,033 patients to assess the odds ratio for mortality associated with pelvic fracture compared with other variables such as age, shock, head injury, abdominal or chest injury, and extremity injury. A second analysis was carried out to determine if the impact of a pelvic fracture on mortality varied when combined with other known risk factors for mortality. RESULTS: Logistic regression analysis demonstrated that pelvic fracture was significantly associated with mortality (p < 0.001). The odds ratio for mortality associated with a pelvic fracture (approximately 2) was similar to that posed by an abdominal injury. Hemodynamic shock, severe head injury, and an age of sixty years or more all had an odds ratio for mortality greater than that associated with pelvic fracture. CONCLUSIONS: For the majority of trauma patients, pelvic fracture is significantly associated with a greater risk of mortality. However, pelvic fracture is one variable among many that contribute to mortality risk, and it must be considered in relation to these other variables.

A modified anterior exposure to the acetabulum for treatment of difficult anterior acetabular fractures.

Many approaches to the acetabulum have been described for the treatment of displaced acetabular fractures. However, the treatment of complex anterior column fractures remains difficult. Commonly used approaches allow access to the internal cortical surface of the anterior column or a limited view of the outer cortical surface of the anterior column. We present a modification of a traditional Smith-Peterson approach with osteotomies for extensile exposure to the anterior column of the acetabulum.

Case report: locked pubic symphysis: an open reduction technique.

A locked pubic symphysis occasionally occurs after a lateral compression injury of the pelvic ring. One pubic bone becomes entrapped behind the contralateral pubis. Lateral compression pelvic injuries are well recognized, but a lateral compression pelvic injury resulting in a locked pubic symphysis is rare. We describe a locked pubic symphysis with greater than 4 cm overlap that was reduced with simple maneuvers and readily available instruments.

Reduction of displaced pelvic ring disruptions using a pelvic reduction frame.

The need for reduction in displaced pelvic ring disruptions is well established, but actual techniques to perform this difficult task are evolving. Reduction is often difficult, especially if minimally invasive techniques are used. This pelvic reduction frame (Starr Frame LLC, Richardson, TX) provides stabilization of the intact hemipelvis to the operating table and facilitates multiplanar reduction of the injured hemipelvis with the use and manipulation of external fixator pins. With the pelvis reduced and locked on the frame, the surgeon is free to place, or teach, fixation in a controlled manner. This lessens the usual assistance, training, and hardware placement difficulties associated with the surgical treatment of these injuries. The basic surgical technique and 2 cases of acute fracture treatment are presented.

Use of a midline anterior incision for isolated medial tibial plateau fractures.

A technique using an anterior midline incision with a medial parapatellar arthrotomy and a medial full-thickness skin flap for the open reduction and internal fixation of isolated medial tibial plateau fractures is presented. The approach is advocated as an alternative to a posteromedial approach when medial tibial plateau fractures are present alone. The anterior approach is simple and familiar for orthopaedic surgeons. It offers good visualization, simplifies reduction, and provides a functional scar if future procedures are necessary.

Management of an unstable pelvic ring disruption in a 20-month-old patient.

A 20-month-old patient with a markedly displaced pelvic ring disruption was successfully managed with fluid resuscitation, immobilization using bolsters, and percutaneous screw fixation of the posterior ring coupled with hip spica casting.

Superior pubic ramus fractures fixed with percutaneous screws: what predicts fixation failure?

OBJECTIVE: The purpose of this study is to present the early complications of percutaneous screw fixation of superior pubic ramus fractures and to present a new classification scheme for superior pubic ramus fractures. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS: One hundred and twelve patients with pelvic fracture between the ages of 14 to 89 years underwent percutaneous screw fixation of 145 pubic ramus fractures. Eighty-one patients with 107 surgically repaired fractures were followed to fracture union. Follow-up averaged 9 months (range 2-52 months). One additional patient who sustained fixation failure 4 days after surgery was included to yield a study group of 82 patients with 108 surgically repaired ramus fractures. INTERVENTION: Patients underwent percutaneous screw fixation of a superior pubic ramus fracture. MAIN OUTCOME MEASUREMENTS: Superior pubic ramus fractures were classified according to a new scheme, the Nakatani system, which categorizes superior ramus fractures according to location with respect to the obturator foramen. Patient radiographs were examined for evidence of loss of reduction, defined as any motion at the ramus fracture site or hardware motion, after fracture surgery. RESULTS: Of the 82 patients followed to union or fixation failure, 12 (15%) had loss of reduction on follow-up radiographs. The average age of patients who lost reduction was 55 years. The most common mechanism of reduction loss was a collapse of the pubic ramus over the screw, with recurrence of an internal rotation deformity of the injured hemipelvis. Ten patients who lost reduction were women, and 11 had undergone ramus screw placement in retrograde fashion. No loss of reduction was seen in Zone III ramus fractures (those that involve the bone lateral to the obturator foramen). No patient sustained recognized neurologic, vascular, or urologic injury as a result of percutaneous screw fixation of a superior pubic ramus fracture. CONCLUSIONS: The prevalence of loss of reduction after percutaneous screw fixation of pubic ramus fractures is 15%. Loss of reduction is more common in elderly and female patients and in patients whose ramus screws are placed in a retrograde fashion. Also, loss of reduction appears to be more common in fractures medial to the lateral border of the obturator foramen.

Cephalomedullary nails in the treatment of high-energy proximal femur fractures in young patients: a prospective, randomized comparison of trochanteric versus piriformis fossa entry portal.

OBJECTIVE: The purpose of this study is to compare a cephalomedullary nail that uses a piriformis fossa starting point to one that uses a trochanteric starting point, in the treatment of high-energy proximal femur fractures in young patients. Our hypothesis was that a nail that uses a trochanteric starting point would result in less blood loss than a nail that uses a piriformis fossa starting point. DESIGN: Prospective, randomized. SETTING: Level 1 trauma center. PATIENTS: Thirty-four consecutive patients aged between 18 and 50 years who sustained a subtrochanteric, intertrochanteric, or ipsilateral femoral neck/shaft fracture due to a high-energy injury were enrolled. INTERVENTION: Patients were randomized to have their fractures repaired with a Russell-Taylor Recon Nail or Howmedica Long Gamma Nail. Surgery was performed on a fracture table, in supine or lateral position according to the surgeon's preference. Direct fracture exposure was avoided. Reduction was obtained through traction, patient positioning, and manual pressure. If necessary, stab-wound incisions were made to introduce instruments to improve reduction. Intramedullary reamers were used, and all nails were statically locked. Bone grafting was not used. MAIN OUTCOME MEASURES: Blood loss, incision length, duration of surgery, and body mass index were recorded for each patient. Surgeon's assessment of ease of use of the device and quality of reduction were noted. Patients were to be followed up to assess fracture union. Hip and knee ranges of motion at latest follow-up were measured. Radiographs obtained at the time of union were assessed for varus malalignment. Return to work status was recorded, and the Harris Hip Score was used to assess hip function. RESULTS: There were 17 patients in each group. The 2 groups did not differ with regard to blood loss, incision length, and duration of surgery or intraoperative complications. Body mass index was significantly linked to duration of surgery (P<0.001) and incision length (P<0.001). Surgeon's assessment of ease of use and reduction quality for the two devices did not differ. The rate of varus malunion did not differ between the 2 groups. Two patients were lost to follow-up before fracture union. All other fractures healed with no need for bone grafting or other procedures to obtain union. One obese patient developed a wound infection that resolved after debridement and a course of antibiotics. A total of 6 patients were lost prior to their 1-year follow-up visit. Among the remaining 28 patients, at an average follow-up of 14 months, no difference was noted between the 2 groups with regard to return to work status, Harris Hip Score, or hip and knee ranges of motion. CONCLUSIONS: Both devices yield predictably good results in these difficult fractures. We found no difference between the two devices with regard to incision length, duration of surgery, blood loss, reduction, ease of use, union rate, complication rate, or outcome.

Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure?

OBJECTIVE: To measure the failure rate of percutaneous iliosacral screw fixation of vertically unstable pelvic fractures and particularly to test the hypothesis that fixations in which the posterior injury is a vertical fracture of the sacrum are more likely to fail than fixations with dislocations or fracture-dislocations of the sacroiliac joint. DESIGN: Retrospective review. SETTING: Level 1 trauma center. METHODS: All patients with pelvic fractures admitted between January 1, 1993, and December 31, 1998, were identified from the trauma registry. Hospital records were used to identify patients treated with iliosacral screws. Radiologic studies were examined to identify patients who had unequivocally vertically unstable pelvic fractures. Immediate postoperative and follow- up anteroposterior, inlet, and outlet radiographs from a minimum of 12 months postinjury were examined. Position, length, and numbers of iliosacral screws and any evidence of screw failure (eg, bending or breakage) were recorded. Residual postoperative displacement and late displacement of the posterior pelvis were measured. The main outcome measure was failure, defined as at least 1cm of combined vertical displacement of the posterior pelvis compared with immediate postoperative position. The main analysis was for association between fracture pattern and failure. Patient demographic data, iliosacral screw position, and anterior pelvic fixation method also were studied. RESULTS: The study group comprised 62 patients with unequivocally vertically unstable pelvic fractures in whom the posterior injury was treated with closed reduction and percutaneous iliosacral screw fixation. Of patients, 32 had dislocations or fracture-dislocations of the sacroiliac joint, and 30 had vertical fractures of the sacrum. Fixation failed in four patients, all with vertical sacral fractures and all within the first 3 weeks after surgery. These four patients required revision fixation. In two further cases with vertical sacral fractures, there was evidence that the fracture had only barely been held by the fixation, but these fractures healed, and followup radiographs did not meet the displacement criteria for failure. A vertical sacral fracture pattern was associated significantly with failure (Fisher exact test, P = 0.04); the excess risk of failure compared with sacroiliac joint injury was 13% (95% confidence interval 1% to 25%). There was no significant association between failure and anterior fixation method, iliosacral screw arrangement or length, or any demographic or injury variable. CONCLUSIONS: Percutaneous iliosacral screw fixation is a useful technique in the management of vertically unstable pelvic fractures, but a vertical sacral fracture should make the surgeon more wary of fixation failure and loss of reduction.

The effect of screening for deep vein thrombosis on the prevalence of pulmonary embolism in patients with fractures of the pelvis or acetabulum: a review of 973 patients.

OBJECTIVES: In patients with pelvic or acetabular fractures, to compare the prevalence of pulmonary embolism in a time period without screening for deep vein thrombosis to that seen when a screening protocol was in place. DESIGN: Retrospective. SETTING: County hospital. PATIENTS: All patients with closed fractures of the pelvis or acetabulum treated during the study periods. INTERVENTION: Prophylaxis for deep vein thrombosis was the same for both groups. From November 1, 1997 though November 31, 1999, a screening protocol for deep vein thrombosis was employed using ultrasound and magnetic resonance venography. From January 1, 2000 through December 1, 2001, no screening was used. MAIN OUTCOME MEASUREMENT: Pulmonary emboli were recorded. RESULTS: The 1997 to 1999 time period included 486 patients with fractures of the pelvis or acetabulum; the 2000 to 2001 time period included 487. In the period when a screening protocol was in place, 10 patients (2%) were diagnosed with pulmonary embolism by pulmonary arteriogram, autopsy, or ventilation perfusion scan. All but 2 who were diagnosed with pulmonary embolism had undergone screening for deep vein thrombosis, and none of the screening tests were positive. In the 2000 to 2001 time period, when no screening for deep vein thrombosis was done, 7 patients (1.4%) were diagnosed with pulmonary embolism, by pulmonary arteriogram, autopsy, spiral computed tomography scan, or high clinical suspicion. There was no significant difference between the prevalence of pulmonary embolism seen in 1997 to 1999 and that seen in 2000 to 2001 (P = 0.48). CONCLUSION: Discontinuation of screening for the diagnosis of deep vein thrombosis did not change the rate of pulmonary embolism.

Symptoms of posttraumatic stress disorder after orthopaedic trauma.

BACKGROUND: The purpose of this study was to determine the prevalence of posttraumatic stress disorder among patients seen following an orthopaedic traumatic injury and to identify whether injury-related or demographic variables are associated with the disorder. METHODS: Five hundred and eighty patients who had sustained orthopaedic trauma completed a Revised Civilian Mississippi Scale for Posttraumatic Stress Disorder questionnaire. Demographic and injury data were collected to analyze potential variables associated with posttraumatic stress disorder. RESULTS: Two hundred and ninety-five respondents (51%) met the criteria for the diagnosis of posttraumatic stress disorder. Patients with posttraumatic stress disorder had significantly higher Injury Severity Scores (p = 0.04), a higher sum of Extremity Abbreviated Injury Scores (p = 0.05), and a longer duration since the injury than those without posttraumatic stress disorder (p < 0.01). However, none of these three variables demonstrated a good or excellent ability to discriminate between patients who had posttraumatic stress disorder and those who did not. The response to the item, "The emotional problems caused by the injury have been more difficult than the physical problems," was significantly associated with the presence of posttraumatic stress disorder (p < 0.0001) and showed a fair ability to identify patients with the disorder. CONCLUSIONS: Posttraumatic stress disorder is common after orthopaedic trauma. Patients who respond positively to the item, "The emotional problems caused by the injury have been more difficult than the physical problems," may meet diagnostic criteria for this disorder and should be evaluated further.

Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure?

OBJECTIVE: To measure the failure rate of percutaneous iliosacral screw fixation of vertically unstable pelvic fractures and particularly to test the hypothesis that fixations in which the posterior injury is a vertical fracture of the sacrum are more likely to fail than fixations with dislocations or fracture-dislocations of the sacroiliac joint. DESIGN: Retrospective review. SETTING: Level 1 trauma center. METHODS: All patients with pelvic fractures admitted between January 1, 1993, and December 31, 1998, were identified from the trauma registry. Hospital records were used to identify patients treated with iliosacral screws. Radiologic studies were examined to identify patients who had unequivocally vertically unstable pelvic fractures. Immediate postoperative and follow-up anteroposterior, inlet, and outlet radiographs from a minimum of 12 months postinjury were examined. Position, length, and numbers of iliosacral screws and any evidence of screw failure (eg, bending or breakage) were recorded. Residual postoperative displacement and late displacement of the posterior pelvis were measured. The main outcome measure was failure, defined as at least 1cm of combined vertical displacement of the posterior pelvis compared with immediate postoperative position. The main analysis was for association between fracture pattern and failure. Patient demographic data, iliosacral screw position, and anterior pelvic fixation method also were studied. RESULTS: The study group comprised 62 patients with unequivocally vertically unstable pelvic fractures in whom the posterior injury was treated with closed reduction and percutaneous iliosacral screw fixation. Of patients, 32 had dislocations or fracture-dislocations of the sacroiliac joint, and 30 had vertical fractures of the sacrum. Fixation failed in four patients, all with vertical sacral fractures and all within the first 3 weeks after surgery. These four patients required revision fixation. In two further cases with vertical sacral fractures, there was evidence that the fracture had only barely been held by the fixation, but these fractures healed, and follow-up radiographs did not meet the displacement criteria for failure. A vertical sacral fracture pattern was associated significantly with failure (Fisher exact test, P = 0.04); the excess risk of failure compared with sacroiliac joint injury was 13% (95% confidence interval 1% to 25%). There was no significant association between failure and anterior fixation method, iliosacral screw arrangement or length, or any demographic or injury variable. CONCLUSIONS: Percutaneous iliosacral screw fixation is a useful technique in the management of vertically unstable pelvic fractures, but a vertical sacral fracture should make the surgeon more wary of fixation failure and loss of reduction.

Complications following the "T extensile" approach: a modified extensile approach for acetabular fracture surgery-report of forty-three patients.

OBJECTIVE: Analyze the prevalence and severity of surgical complications encountered with a modified extended iliofemoral approach, the "T extensile" approach, in the treatment of complex acetabular fractures. STUDY DESIGN: Prospective. METHODS: During a sixteen-month study period, forty-three patients with complex acetabular fractures were treated via the T extensile approach. Perioperative antibiotics were used to prevent infection, and prophylaxis for heterotopic ossification was done with postoperative irradiation. Complications and clinical results were recorded. The patients were followed for an average of thirty months. RESULTS: Acceptable reductions were obtained in forty patients. Poor reductions were obtained in three patients. There were no infections or iatrogenic nerve injuries. Brooker Grade 1 heterotopic ossification was seen in nineteen patients, eight had Grade 2, two had Grade 3, and no heterotopic ossification was seen in the other fourteen patients. No patient who received radiation developed heterotopic ossification beyond Brooker Grade 2. Seven patients went on to require total hip arthroplasty. The remaining thirty-six patients had an average Harris Hip Score of 86. CONCLUSIONS: Extensile exposures to the acetabulum can be safely carried out with limited morbidity, as long as appropriate steps are taken to limit predictable complications.

Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality.

OBJECTIVE: To determine if age, fracture pattern, systolic blood pressure on arrival, base deficit, or the Revised Trauma Score is predictive of mortality, transfusion requirements, use of pelvic arteriography, later complications, or injuries associated with the pelvic ring disruption. STUDY DESIGN: Retrospective review of a prospectively collected database. METHODS: All closed pelvic ring disruptions seen between November 1, 1997 and November 30, 1999 were included. Predictive variables and outcome variables were recorded for each patient. Statistical analysis was used to determine if the above variables were predictive. RESULTS: Shock on arrival and the Revised Trauma Score were significantly associated with mortality, transfusion requirement, Injury Severity Score, and all the Abbreviated Injury Scores except the one for skin. In addition, the Revised Trauma Score was significantly associated with the use of pelvic arteriography and predicted more complications than did shock on arrival. Age was significantly associated with transfusion requirement, Injury Severity Score, the chest and skin Abbreviated Injury Scores, use of arteriography, and death. The mortality rate among patients who presented in shock was 57 percent. A Revised Trauma Score of less than 11 predicted mortality with a sensitivity and specificity of 58 percent and 92 percent, respectively. Shock on arrival predicted mortality with a sensitivity and specificity of 27 percent and 96 percent, respectively. Age greater than sixty years predicted mortality with a sensitivity and specificity of 26 percent and 91 percent, respectively. In our analysis of the fracture patterns, we were unable to demonstrate consistent, meaningful links between specific fracture classes and the outcome variables. CONCLUSIONS: Shock on arrival and the Revised Trauma Score are useful predictors of mortality and transfusion requirements, Injury Severity Score, and Abbreviated Injury Scores for the head and neck, face, chest, abdomen, and extremities. In addition, the Revised Trauma Score predicts the use of pelvic arteriography and later complications. Age predicted transfusion requirement, Injury Severity Score, the chest and skin Abbreviated Injury Scores, use of arteriography, and death.

Percutaneous screw fixation of fractures of the iliac wing and fracture-dislocations of the sacro-iliac joint (OTA Types 61-B2.2 and 61-B2.3, or Young-Burgess "lateral compression type II" pelvic fractures).

A technique for closed reduction and percutaneous screw fixation of fractures of the iliac wing and fracture-dislocations of the sacro-iliac joint is presented. Twenty-seven pelvic fractures were treated with attempted closed reduction followed by percutaneous screw fixation. Closed reduction failed in two patients. In the other twenty-five, closed reduction to within one centimeter of residual displacement was obtained, and was followed by stabilization with percutaneously placed cannulated screws. Complications included dislodgment of a screw from the superior pubic ramus in one patient, and partial cut-out of a screw along the inner cortex of the iliac wing in another. Two patients were lost to follow-up before fracture union occurred. The remaining twenty-three patients were followed-up for an average of twenty-seven months (range, 18-48 months). All of the fractures healed in the twenty-three patients who were not lost to follow-up. All but two of the patients who were working before injury returned to work. All but one of the patients was satisfied with the outcome of their pelvic fracture treatment. Closed reduction and percutaneous screw fixation of fractures of the posterior portion of the iliac wing yields acceptable reductions, with minimal blood loss and limited damage to the surrounding soft tissues.