Unstable pelvic fractures in women: implications on obstetric outcome

Purpose Obstetric outcomes in women following pelvic injuries requiring surgical fixation is not thoroughly known. We aimed to evaluate if radiographic measurements (RMs) can be used to provide information on delivery methods outcome after these injuries, and to evaluate if metal work removal is required prior to delivery. Method A retrospective study in a level 1 trauma centre of female patients with pelvic fractures treated operatively, aged 16–45 at the time of injury. Participants completed a questionnaire regarding their obstetric history. RM evaluating pelvic symmetry, displacement, and pelvimetry were conducted on postoperative radiographs and CT scans. Patients who gave birth after the injury were divided to two groups according to the delivery method: vaginal delivery (VD) and caesarean section (CS). These two groups RM were compared. Results Forty-four patients were included, comparison of the RM of patients who delivered by CS (9) and patients who had only VD (11) showed no significant difference between the groups. Two patients underwent a trial of VD who subsequently underwent urgent CS due to prolonged labour, their RM were below the average and their pelvimetry measurements were above the cut-off for CS recommendation. Eleven patients had uncomplicated VD, all had retained sacroiliac screws at the time of delivery and one patient had an anterior pubic plate. Conclusion Postoperative RM did not show an effect on delivery method of women after pelvic fracture fixation. A relatively high number of patients who underwent normal vaginal delivery had retained sacroiliac screws. These findings can form the foundation for larger cohort studies

Incidence, risk factors and potential timing of occurrence of pulmonary embolism in fatal trauma: An autopsy based case–control study on 2705 victims

Background: Pulmonary embolism (PE) following trauma is a potentially preventable but highly lethal complication. We sought to investigate the incidence, risk factors and potential timing of occurrence of post-traumatic PE in a large cohort of trauma fatalities. Methods: A case–control study on 9266 consecutive trauma fatalities (between 1996 and 2005) from a regional autopsy-based trauma registry. Injuries were classified according to the Abbreviated Injury Scale-1990 edition (AIS-90) and the Injury Severity Score (ISS) was calculated. Hospitalized victims were categorized according to the presence or absence of PE on autopsy. Univariate comparisons and multivariate logistic regression analysis for probabilities of association (odds ratios-OR) were performed. Results: Out of 2705 subjects who met the inclusion criteria, 116 had autopsy findings of PE and constituted the PE group (incidence of 4,3%), while the remaining victims formed the control group. The survival time of the PE group ranged from 0.66 to 104.73 days. Victims in the PE group were older (median age 69.5 vs 59), had lower ISS values (median 16 vs 26) and longer post-injury survival times (median 13.6 vs 5.7 days). Positively associated risk factors were AIS2-5 pelvic ring injuries (OR:2.23) and secondary deaths following an uneventful hospital discharge (OR:3.97), while AIS2-5 head (OR:0.33) and abdominal injuries (OR:0.23) showed a reverse association. Conclusions: Trauma fatalities with autopsy findings of PE were associated with less severe trauma indicating that PE was likely detrimental to the fatal outcome. Both the early and delayed occurrence of PE was reaffirmed. Prophylactic measures should be initiated promptly and extended post discharge for high risk patients to prevent secondary deaths. © 2022 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Irelan

Severe trauma with associated pelvic fractures: the impact of regional trauma networks on clinical outcome

Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs. Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were excluded. All patients with known outcomes were included and were divided into 2 distinct periods (pre-RTN era: between January 2002 and March 2008 (control group); and RTN era April 2013 to June 2017 (study group)). Data from the transition period from April 2008 to March 2013 were excluded to minimize the effect of variations between the developing networks and MTCs during that era. Overall, the study group included 10,641 patients, whereas the control group was 3152 patients, with a median age of 52.4 and 35.1 years and an ISS of 24 and 27 respectively. A systolic blood pressure below 90mmHg was observed in 7.2% of patients in the study group and 10.4% in the control group. A significant increase of the median time to death (from 8hrs to 188hrs) was observed between the two eras. The cumulative mortality of severely injured patients with pelvic fractures decreased significantly from 17.8% to 12.4% (p<0.0001). The recorded improvement of survivorship in the subgroup of severely injured patients with a pelvic fracture (32% lower in the post-RTN than in the pre-RTN period: OR 1.32 (95% CI 1.21 – 1.44), following the first 5 years of established regional trauma networks in NHS England, is encouraging, and should be attributed to a wide range of factors that translate to all levels of trauma care

The influence of osteoporosis in femoral fracture healing time

Aim: In order to assess the effect of osteoporosis on healing time, the files of 165 patients with femoral shaft fractures that were treated in our institution with locked-reamed intramedullary nailing were retrospectively reviewed. Patients and methods: Patients with open fractures, pathological fractures, revision surgery, severe brain injuries and prolonged ITU stay were excluded. In all patients the Singh-index score for osteoporosis and the canal bone ratio (CBR) were assigned. Sixty-six patients fulfilled the inclusion criteria. Patients were divided into two groups; group A (29 patients) consisted of patients over 65 years old with radiological evidence of osteoporosis and group B (37 patients) of patients between 18 and 40 years old with no signs of osteoporosis. Results: In all group A patients Singh score ≤4 and CBR &gt; 0.50 were assigned, suggesting the presence of osteoporosis, whereas all group B patients were assigned with Singh score ≥5 and CBR &lt; 0.48. Fractures of group A healed in 19.38 ± 5.9 weeks (12-30) and in group B 16.19 ± 5.07 weeks (10-28), P = 0.02. Conclusions: Fracture healing of nailed femoral diaphyseal fractures is significantly delayed in older osteoporotic patients. Further studies are required to clarify the exact impact of osteoporosis in the whole healing process. © 2008 Elsevier Ltd. All rights reserved

Minimally invasive plate osteosynthesis - an update

The advent of locking plates for the management of metaphyseal fractures, and subsequent experience of biological fracture fixation, has led to the development of minimally invasive percutaneous osteosynthesis (MIPO), which is now proven to have multiple advantages. Soft tissue stripping is minimized, with preservation of vascular pedicles, and the fracture haematoma around the site of injury remains undisturbed promoting fracture healing. While early published results are encouraging, MIPO technique is not applicable to every fracture. To avoid complications, defining the correct indications is of paramount importance. © 2008 Elsevier Ltd. All rights reserved

Motor vehicle collision fatalities involving alcohol and illicit drugs in Greece: The need for management protocols and a reassessment of surveillance

Aims: The frequency and the effect of alcohol and illicit drugs on injury type, severity and location of death in motor vehicle collision (MVC) fatalities were investigated. Design: Retrospective case-control study based on autopsy and toxicology. Settings: Single faculty accepting referrals from Greater Athens and prefectures. Participants: Consecutive pre-hospital and in hospital fatalities. Measurements Demographics, toxicology, abbreviated injury scale (AIS), injury severity score (ISS), and location of death. Findings: Of the 1860 screened subjects, 612 (32.9%) constituted the positive toxicology group (PTG) for alcohol or illicit drugs or both and the 1248 (67.1%) the negative toxicology group (NTG). The median age was 34 (4-90) years for the PTG and 45 (3-97) years for the NTG. The PTG included significantly higher proportions of males and motorcyclists. The PTG had a 50% increased risk for a severe (AIS≥3) cervical spine and 85% for a severe upper extremity injury, compared to the NTG. A total of 29.2% of the PTG and 22.4% of the NTG deaths were non-preventable (ISS = 75). The frequency of severe trauma (ISS≥16) was comparable between PTG and NTG (P = 0.87). The PTG presented with a median ISS of 43 (6-75) versus 41 (2-75) of the NTG, hence without significant difference (P = 0.11). The pre-hospital death rate was 77.8% for the PTG versus 58% of the NTG (P &lt; 0.001). The analysis confirmed that the odds of positive toxicology were considerably higher in the subjects who arrived dead at the hospital (OR 2.62, P &lt; 0.001). Conclusions: In the greater Athens region, almost a third of motor vehicle collision-related fatalities involved alcohol, illicit drugs or both. Individuals screened positive for alcohol or drugs were 2.6 times more likely to die before hospital admission than those with a negative toxicology screen, despite comparable injury severity. Specific evidence-based management protocols and reassessment of surveillance are required. © 2010 The Authors, Addiction © 2010 Society for the Study of Addiction