Management of hemodynamic instability important in lowering mortality risk of pelvic ring fracture

Gabbe BJ. Injury. 2011. doi:10.1016/j.injury.2011.06.003.

Issue: November 2011

Risk of mortality following severe trauma of the pelvic ring can be most effectively reduced through control of hemodynamic instability, according to researchers in Australia.

The researchers searched the Victorian State Trauma Registry for relevant cases in patients 15 years of age or older from July 1, 2001 to June 30, 2008. Predictors of mortality were identified through logistic regression, with potential predictors being patient demographics, pre-hospitalization characteristics and admission characteristics.

The authors identified 348 cases over the 8-year scope of the study, finding a mortality rate of 19%. Patients 65 years of age or older were found to be at higher risk for mortality than those patients aged 15 years to 34 years. Patients were more likely to die if they were hypotensive at the scene and on arrival at their definitive hospital of care, the authors noted.

A concurrent severe chest injury and injury occurring in an intentional event were both associated with a higher risk of mortality.

Lastly, though the authors did note differences in management protocol among the major trauma services investigated, they were unable to find any association between the hospital of definitive management and overall mortality.

“As most patients survive these injuries, further research should focus on long-term morbidity and the impact of different treatment approaches,” the authors wrote.

This paper describes a well-conducted population-based study examining the outcome of 348 pelvic fractures over a 7-year period. The study aims were to profile pelvic ring injuries and establish predictors of mortality. Data from an established state wide trauma registry was used (contributory hospitals, n=138). The authors carefully outline the pelvic trauma protocols of the receiving major trauma centres and highlight subtle differences. Demographics, study criteria, data capture and statistical analysis are fully outlined.

This study emphasises that though major pelvic fractures are rare, the mortality is high at 19%. The majority of fractures are in men that have been involved in road traffic trauma. Major contributors to mortality include age over 65 years, an 8-fold increase and concomitant injuries. Hypotension defined as less than 100 systolic, pre-hospital or hospital, is recognised as a significant risk factor.

Though much of the information in this paper is already available elsewhere, the authors highlight the basic fundamental principles of treating haemodynamic instability well. Both major centres in the study had established “massive transfusion protocols” for administration of blood products. Despite differences in the use of interventional radiology, the emergent management of unstable patients in each protocol was laparotomy and packing against temporary pelvic stabilisation. Overall, the study is a well executed audit of the author’s regional service.

— Graeme S. Carlile, MBChB, MRCS
Trauma & Orthopaedics Department
Plymouth Hospitals NHS Trust
Devon, UK

Disclosure: Carlile has no relevant financial disclosures.

Severe pelvic fractures represent problem physicians of many disciplines are looking for optimum protocols, not only for treatment guidance, but also to provide data regarding expected outcomes. In this population based review by Gabbe et al, we were provided data regarding outcome.

Most of the information regarding factors associated with in hospital mortality were expected as other articles found similar results. Age, being hypotensive-where at the scene or hospital and severe chest injury all were related to in hospital mortality. Interestingly, those patient injured from an intentional trauma were also found to have a higher mortality rate.

The authors did not include specific information on fracture pattern. It would be interesting to determine if certain fracture pattern remained a factor in mortality. I also found the result of 32% (112 cases, of which 38% died) not receiving external fixation or ORIF to be interesting if these were severe pelvic fractures. Specificity of fracture pattern and their definition of severe pelvic fracture would be desired information in interpreting these results.

More than half of the deaths occurred in the short term (within 5 hours of arrival)Because there was no difference in mortality between the two hospitals with differing protocols regarding initial treatment, perhaps the aggressiveness of resuscitation and early management, no matter what type are important in minimizing mortality.

— Lisa K. Cannada, MD
Associate Professor
Department of Orthopaedic Surgery
Saint Louis University
St. Louis, MO

Disclosure: Cannada has no relevant financial disclosures.