Max Esser

Predictors of mortality following severe pelvic ring fracture: Results of a population-based study

INTRODUCTION Traumatic disruption of the pelvic ring is uncommon but is associated with a high risk of mortality. These injuries are predominantly due to high energy blunt trauma such as a fall from height, road or workplace trauma, and severe associated injuries are prevalent, increasing the complexity of managing this patient group. The aim of this population-based study was to investigate predictors of mortality following severe pelvic ring fractures managed in an inclusive, regionalised trauma system. METHODS Cases aged≥15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based statewide Victorian State Trauma Registry for analysis. Patient demographic, prehospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated. RESULTS There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged≥65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15-34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), whilst patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres). CONCLUSIONS The findings highlight the importance of effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.

The imaging and classification of severe pelvic ring fractures: Experiences from two level 1 trauma centres

We describe the routine imaging practices of Level 1 trauma centres for patients with severe pelvic ring fractures, and the interobserver reliability of the classification systems of these fractures using plain radiographs and three-dimensional (3D) CT reconstructions. Clinical and imaging data for 187 adult patients (139 men and 48 women, mean age 43 years (15 to 101)) with a severe pelvic ring fracture managed at two Level 1 trauma centres between July 2007 and June 2010 were extracted. Three experienced orthopaedic surgeons classified the plain radiographs and 3D CT reconstruction images of 100 patients using the Tile/AO and Young-Burgess systems. Reliability was compared using kappa statistics. A total of 115 patients (62%) had plain radiographs as well as two-dimensional (2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and eight patients (4.3%) had no available images. The plain radiograph was limited to an anteroposterior pelvic view. Patients without imaging, or only plain films, were more severely injured. A total of 72 patients (39%) were imaged with a pelvic binder in situ. Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17) and Young-Burgess (Kappa 0.09 to 0.21) was low, and insufficient for clinical and research purposes. Severe pelvic ring fractures are difficult to classify due to their complexity, the increasing use of early treatment such as with pelvic binders, and the absence of imaging altogether in important patient sub-groups, such as those who die early of their injuries.

Functional and return to work outcomes following major trauma involving severe pelvic ring fracture

There is limited evidence describing the long‐term outcomes of severe pelvic ring fractures. The aim of this study was to describe the longer term independent living and return to work outcomes following severe pelvic ring fracture.

Closed Küntscher nailing: a clinical review after 20 years.

A long-term study of patients treated by primary closed Küntscher nailing of fractures of the femoral shaft was carried out. Minimal reaming allowed nails of only 9.5-11 mm diameter to be used. One hundred and sixteen patients with 120 fractures treated in this way from 1959 to 1978 attended for clinical examination. Primary bony union was achieved in 98 per cent and the infection rate was less than 1 per cent. Full, unsupported weight bearing was possible at an average of 15.6 weeks. Symptoms and residual deformity were minimal. These results support the use of this technique in adults with most types of fracture of the femoral shaft.

Use of the HemiCAP partial hip resurfacing technique for traumatic femoral head osteochondral defects following obturator hip dislocations

Fracture of the femoral head (OTA 31-C1.3) following anterior obturator dislocations are a challenging problem as the fractures are often communited, impacted and with loose osteochondral fragments, making surgical fixation difficult. This can result in residual articular defects if the fragments cannot be internally fixed and need be excised, predisposing to secondary osteoarthritis. Treatment options for these defects are limited, have variable results and with limited literature to guide us on outcomes due to the rarity of these injuries. Here, we describe the first use of the technique of partial femoral head resurfacing in two patients with such fractures and report on their long term outcomes.

Lower risk of pelvic metalware infection with operative repair of concurrent bladder rupture: Bladder rupture and pelvic metalware infection

Patients with traumatic bladder rupture frequently have associated pelvic fracture. With increasing numbers of pelvic fractures fixed internally, there are concerns that conservative management of bladder rupture may increase the risk of pelvic metalware infection. This study aims to determine if operative repair of bladder rupture in comparison to conservative management with catheter drainage alone is associated with a lower rate of infection of internal fixation device for concurrent pelvic fracture.

Pelvic trauma mortality reduced by integrated trauma care

A multidisciplinary approach that emphasised improved triage, early pelvic binder application, early administration of blood and blood products, adherence to algorithmic pathways, screening with focused sonography (FAST), early computed tomography scanning with contrast angiography, angio‐embolisation and early operative intervention by specialist pelvic surgeons was implemented in the last decade to improve outcomes after pelvic trauma. The manuscript evaluated the effect of this multi‐faceted change over a 12‐year period.