Pelvic ring fractures: epidemiological study

Abstracts

De fevereiro de 2000 a setembro de 2001, 84 pacientes apresentando fratura do anel pélvico foram avaliados, segundo determinado protocolo aplicado. Houve predomínio do sexo masculino (67%), a maioria dos pacientes eram brancos (86%) e a idade média foi de 37 anos. Quanto ao tipo de acidente, os mais freqüentes foram os relacionados ao trânsito (58%) - carro, moto e atropelamento - pacientes vítimas de traumas de alta energia. As fraturas foram classificadas de acordo com Tile(13) em estáveis, em 55% (fraturas do tipo A); rotacionalmente instáveis, em 30% (fraturas do tipo B) e rotacional e verticalmente instáveis, em 15% (fraturas do tipo C). A fratura mais freqüentemente encontrada foi a dos ramos isquiopúbicos. O tratamento cirúrgico foi realizado em 29% dos pacientes. Houve necessidade de transfusão sangüínea em 20% dos pacientes, utilizando-se uma média de cinco unidades de sangue total; exceto dois pacientes (2,4%) com lesão arterial intra pélvica que necessitaram mais de 10 unidades de sangue nas primeiras 48 horas. A mortalidade foi de sete por cento tendo relação significativa com traumas extra pélvicos.

Fraturas; Anel pélvico; Epidemiologia

ORIGINAL ARTICLE

Pelvic ring fractures: Epidemiological study

Alceu Gomes Chueire^I; Guaracy Carvalho Filho^II; Antonio Fernando dos Santos^III; Karen Panzarini Pockel^IV

^IPhD Professor in Medicine, Head of the Orthopedics and Traumatology Department of Funfarme-Famerp

^IIPhD Professor, Head, Orthopedics and Traumatology Discipline, Famerp-Funfarme

^IIIAssistant Professor of Orthopedics and Traumatology Department of Famerp-Funfarme

^IVEx-resident of the Orthopedics and Traumatology Department of Famerp-Funfarme

^{Correspondence}

SUMMARY

From February 2000 to September 2001, 84 patients with pelvic fractures were assessed, using a determined protocol.

There were more men (67%) than women. Most of the patients were white (86%) and the average was 37 years of age. The most frequent accident was reported to have been traffic accidents (58%) such as motor vehicle, motorcycle and running over - victims of high-energy injuries.

The pelvic ring fractures were classified according to Tile ⁽¹³⁾ as stable in 55% (type A injury), as rotationally unstable in 30% (type B injury) and as unstable in translation in 15% (type C injury). The most frequent lesion affecting the pelvic girdle was the isquiopubic bones fracture (transpubic instability).

The overall rate of operative stabilization was 29%. An average of five units of total blood transfusion was required in 20% of the patients; exception to two (2,4%) patients with intrapelvic arterial injury that required more than 10 units of blood in the first 48 hours.

The overall mortality rate was 7%, depending significantly on the associated extrapelvic traumas.

Key words: Fracture; Epidemiology; Pelvic ring.

INTRODUCTION

Severe lesions of pelvic ring have occurred more frequently due to high-energy traumas so common in modern society. In the last decades, there has been a great deal of improvement in initial evaluation of polytraumatic as well as in orthopedic treatment of these lesions.

Presently, it is possible to decrease unstable pelvic fractures rapidly and effectively with external fixations that allow early mobilization and immediate stabilization of the patient.

Associated with that, the Advanced Trauma Life Support (ATLS), applied in First Aid Units and the improvement in polytraumatic rescues have promoted a decrease in morbi-mortality of pelvic lesions.

The pelvic ring fractures are little frequent but since they are associated with large retroperitoneal bleedings they are the only ones which can lead to death soon after the trauma.

Therefore, in high-energy traumas, a pelvic lesion should always be suspected in severe polytraumas.

The aim of this paper was to evaluate a sample of patients with pelvic fractures under the epidemiological approach in a given portion. The medium and long-term results were not discussed.

MATERIALS AND METHODS

It was performed a prospective study for 19 months (from February 2000 to September 2001) with patients showing pelvic ring fractures in the Traumato-Orthopedics Service.

The Trauma Surgery Group provided the first aids and so the patients were led to the Traumato-Orthopedics Group. 84 patients were evaluated, 55 (67%) were men and 27 (33%) were women (Graphic 1).

The average age was 37 years old, ranging from 3 to 88 years old. There were only three children (Graphic 2). 71 (86%) patients were white and 11 (14%) were from other races*.

Besides the "inlet" and "outlet" occurrences, an anteroposterior panoramic radiograph of the pelvic cavity was performed in all patients. After being admitted to the hospital, some patients underwent a computerized tomograph.

It was used a protocol presenting the date of the accident, color, age, gender, occupation, type of accident (traffic, fall, squash or other), type of fracture (using Tile⁽¹³⁾ classification – Table 1) associated lesions, applied procedures and dates, immediate complications and blood transfusion. During hospitalization, all the processes were evaluated from the simplest complications to death, including the methodology of treatment (opening and closed reduction, or conventional treatment).

The procedures for the treatment were: 1) Conventional treatment, 2) opening reduction and internal fixation with plate and screws and 3) closed reduction and external fixation made up of three schanz pins placed percutaneously in each ilium, the first through the anterior superior iliac spine, the second through tuberculum iliaco (angle of 45º between them) and the third schanz between them.

RESULTS

In most patients, the pelvic lesion occurred due to traffic accidents (58%); from these 23% were car accidents, 19% were motorcycle accidents and 16% were running over patients. The second largest group included falls (32%); of these, 14% were own height falls and 18% fell down from very high points (most of the patients were construction workers who fell down from scaffolds). The remaining 10% were crushed (six (6% were crushed by tractors in rural areas) three (3% were crushed by trucks) and one (1% was buried by a wall) (Graphic 3).

Evaluating the fractures radiographs by using Tile classification (see Table 1) the following figures were obtained: 46 (55%) type A fractures, 25 (30%) type B and 13 (15%) type C.

Among type A fractures, four were classified as A1; two of them were anterior superior iliac spine avulsions, one was of the ramus pubicus in abdominal muscle insertion and the other was an ischial tuberosity. There were ten sub-type A2.1 fractures and only one of them was an open fracture. 28 were sub-types A2.2 and two were sub-type A2.3. In sub-type A 3 fractures, there was one coccygeal fracture and one coccygeal dislocation and the sacral fractures were classified as type C.

Of 25 type B fractures, there were: 12 type B1, three type B2.1, two type B2.2 and three type B3. Among type C fractures, there were six sub-type C1, four sub-type C2 and three sub-type C3 (Graphic 4).

A large amount of patients (54%) had other associated lesions; 13 (15%) patients underwent exploratory laparotomy.

Two of them (2%) had large pelvic vessels lesions and 11 (13%) other varied abdominal traumas. Six patients (7%) with thoracic trauma, 10 (12%) with cranioencephalic traumas (CET) and 42 (50%) presented other associated fractures including 17 (18%) acetabulum fractures.

19 patients (23%) needed blood transfusion during the first 48 hours. An average of five units of blood (U) were applied per patient, varying from two to ten units.

Two patients with large vessels lesions (iliac artery), received more than 10 U during the first hours, besides other blood derivatives and they were excluded from this average.

The treatment of stable fractures was the bed rest during a variable time, from three to eight weeks (Figure 1 – A and ^B); one wing of ilium open fracture was fixed in emergency by using open reduction and internal fixation (ORIF) with Kirschner wires.

From the 12 type B1 (Figures 2 A and ^B) open book fractures, four were treated with an external fixation during admission and two were fixed by ORIF with autocompression plates. These ones presented pubic symphisis opening superior or equal to 2,5 cm⁽¹³⁾.

From 10 subtype B2 fractures, only two were surgically treated (one by external fixation and the other by ORIF). From 3 subtype B3 fractures, two were treated by external fixation.

All subtype C1 fractures needed surgery (four in admission by external fixation and two during hospitalization by ORIF).

All subtype C2 and C3 fractures were fixed in emergency by external fixation since it is one of the safest and fastest set among the described by other authors⁽⁶⁾. (Figure 3-A, ^B, ^C).

One compartmental syndrome of the thigh that resulted in amputation, three deep venous thromboses (DVT that were clinically treated, one pulmonary embolism and one sciatic nerve neuropraxia that received a conservative treatment were the immediate complications.

There were six deaths (7%) and all of them presented one or more associated lesions of the thorax, abdomen or cranium.

Table 2 shows a comparative evaluation of fracture subtypes and their percentage related to the number of transfused patients, occurrence of associated lesions, surgical treatment and mortality.

DISCUSSION

Most of the pelvic fractures occurred with men, white, mean age of 37 years old and victims of car accidents.

The rarity of the pelvic fractures in children (three patients or 3,5%) is explained by the presence of cartilage components (pubic symphisis, triradiated cartilage and articular sacroiliac cartilage) that provide certain flexibility and elasticity⁽¹¹⁾.

Stable type A fractures prevailed in 46 patients (54%). Of these, the most frequent ones were isquiopubic bones fractures, presenting a significant importance in elder individuals. The second most frequent type of fracture was the pubic symphisis disjunction, found in 12 patients (14%). The unstable fractures (type C) were the least frequent, occurring in 13 patients (15%); however, all of them needed surgical treatment and 12 of these patients (92%) presented associated lesions.

Other authors⁽¹³⁾ found approximated numbers showing that type A fractures were the most frequent ranging from 50 to 60%.

Of all patients, 45 (54%) presented associated lesions. 11 (13%) underwent exploratory laparotomy, six (7%) presented thoracic trauma, ten (12%) CET and 17 patients (18%) showed associated acetabulum fractures. Other authors ⁽⁵⁾ report approximated percentages.

The mortality rates found in literature range from 4,4 to 30%. In our study, they reached 7% and the complexity of the pelvic trauma had a direct influence in this rate. Gänsslen et al.⁽³⁾ report that the mortality rate was 10,8% for patients without soft tissues lesions and increased to 31,5% for complex traumas.

Of the patients who died, three (50%) presented a CET in some degree. Muir et al.⁽⁸⁾ showed in their study a significantly higher mortality rate among those patients who presented pelvic fractures, CET or cervical lesion.

Bleedings were considered leaders in death cases⁽⁷⁾ and the bleeding source was usually regarded to the pelvic fracture (arterial or venous lesions, spongy bone and adjacent tissues lesions) or a combination of intraperitoneal, thoracic or long bones traumas⁽³⁾. Besides being a direct reason for deaths, the hemodynamic instability is constant in complex pelvic cavity fractures. Of the evaluated patients, 23% underwent to blood transfusion using an average of 5 units of blood (U).

Cryer et al.⁽²⁾ report that 36 to 55% of types B and C fractures will present an intra-abdominal lesion and 6 to 18% will have pelvic arterial lesions with the loss of large amounts of blood.

Panetta et al.⁽⁹⁾ suggest the early use of angiography in all patients that need more than four U during the first 24 hours or more than six U in 48 hours.

In our study, two patients (2%) presented iliac arterial lesions, surgically fixed by a vascular surgeon.

A patient evolved to a compartmental syndrome of the thigh and another to DVT in the lower limb, next to the lesion site. Both underwent amputation of 1/3 proximal of the thigh. One of the patients died.

Among the immediate complications, the DVT deserves note since it occurred in three patients (3,5%) added to one case of pulmonary embolism (1,2%). It is known that patients with complex pelvic lesions have the highest risk of developing DVT and that the risk of embolism in these patients may reach 2% comparing to the risk of 0,2% of polytraumatic patients⁽¹⁾.

Regarding surgical treatment, it was found in literature that over 60% of all the pelvic lesions are stable and don't require stabilization, even if the patients are in large trauma centers. Of the lesions that need stabilization around 60% will undergo external fixation and 40% will undergo internal fixation⁽¹⁵⁾. In our study, 29% of surgical treatment was obtained, divided into 75% of external fixation and 25% of internal fixation.

According to Tile⁽¹³⁾, when the pelvic cavity is vertically unstable, the stabilization by external fixation is imperfect and may lead to a migration of the hemipelve. It is emphasized that the treatment of these lesions should not be closed or open; however, if the closed treatment fails, the author suggests the opening. The severe chronicle incapacity originates from the posterior sacroiliac complex or from the sustaining arcus of the pelvic cavity weight, pseudoarthrosis and vicious consolidations leading to chronic pain, generally in the inferior lumbar or sacroiliac region⁽¹³⁾.

Other authors^(4,14) also agree that in the last few years, the external fixation has been the preferable one. On the other hand, it was obtained a high percentage of external fixation (75%), which can be explained by the short period of evaluation of patients after hospitalization since the ORFI is only performed when the patient is clinically stable

CONCLUSION

Pelvic fractures by high-energy traumas are severe lesions, with significant mortality rate and a great number of associated lesions.

In high-energy traumas, pelvic fractures should always be suspected and conducted together with other lesions.

The early attendance and the use of protocols such as the ATLS provide agility and guide the beginning of good prognosis.

Arteriograph in hemodynamically unstable patients is essential and when it is performed early can decrease the morbi-mortality rate in patients with arterial lesions.

An external fixation is very useful in emergency to stabilization of initial hemodynamics.

REFERÊNCIAS BIBLIOGRÁFICAS

Work performed at Hospital de Base de São José do Rio Preto

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Publication Dates

• Publication in this collection
  24 June 2004
• Date of issue
  Mar 2004

History

• Received
  09 Apr 2003
• Accepted
  10 Feb 2004