Search Results (5)

Background/Objectives: The aim was to investigate diagnostic, treatment and preventive options to establish an overview of the existing evidence on hemorrhage in pelvic fractures in older adults. Methods: A systematic review was conducted. Due to the rarity of this complication, only case reports and series with individuals older than 55 years with a pelvic ring fracture that is caused by a low-energy trauma or no apparent trauma, along with hemorrhage, were eligible. A search was performed on four databases. The CARE checklist was used to investigate the reporting integrity of the included studies. Analysis was performed narratively, and this study was registered on the Open Science Framework. Results: 21 patients from 19 studies were included (17 females and 4 males) with an average age of 82.1 years. The 21 patients suffered a total of 29 fractures. Pubic ramus fractures were present in 48.3% of all fractures. In 42.9%, an active hemorrhage was reported. Arterial vessels were injured in direct anatomical relationship to the fracture. Abdominal pain and hemorrhagic instability were the main red flag symptoms reported. Active arterial hemorrhage was diagnosed by CT with angiogram and treated by embolization with or without additional surgery. Conclusions: Clinically relevant hemorrhage in pelvic fractures due to low-energy trauma is rare. However, these fractures, combined with clinically relevant hemorrhage, account for an increased mortality and morbidity in elderly people. This systematic review was able to create a clinical decision tree for hemorrhage in ramus pubic fractures. Full article

Purpose: Pelvic fractures in older adults are a major public health problem and socioeconomic burden. The standard of care has changed over the past years, and there is limited consensus on which patients benefit from surgical fixation. There is currently no nationwide treatment protocol to guide the decision-making process. Therefore, the aim of this survey was to provide more insight into if, when, and why patients with a fragility fracture of the pelvis (FFPs) would be considered for additional imaging and surgical fixation by treating physicians. Methods: An online clinical vignette-based survey of hypothetical scenarios was sent out to all orthopedic and trauma surgeons in the Netherlands. The questionnaire comprised multiple-choice questions and radiographic images. Differences between subgroups were calculated using the X2 test or the Fisher exact test. Results: 169 surgeons responded to the survey, with varying levels of experience and working in different types of hospitals. In a patient with a simple pubic ramus fracture and ASA 2 or ASA 4, 32% and 18% of the respondents would always advise a CT scan for further analysis. In the same patients, 11% and 31% of the respondents would not advise a CT scan, respectively. When presented with three cases of increasing severity of co-morbidity (ASA) and/or increasing age and/or different clinical presentation of an FFP type 3c on a CT scan, an increasing number of respondents would not consider surgical fixation. There was significant variation in practice patterns between the respondents who do not work in a hospital performing pelvic and acetabular (P&A) fracture surgery and those who do work in a P&A referral hospital. Most respondents (77%) refer patients 1–5 times a year to an expert center for surgical fixation. Conclusion: There is currently a wide variety of clinical practices regarding the imaging and management of FFPs, which seems to be influenced by the type of hospital the patients are presented to. A regional or national evidence-based treatment protocol should be implemented to ensure a more uniform approach. Full article

Background and Objectives: Pubic ramus fractures are common in compound pelvic injuries known to have an increased rate of morbidity and mortality along with recurrent and chronic pain, impeding a patient’s quality of life. The current standard treatment of these fractures is percutaneous screw fixation due to its reduced risk of blood loss and shorter surgery times. However, this is an intricate surgical technique associated with high failure rates of up to 15%, related to implant failure and loss of reduction. Therefore, the aim of this biomechanical feasibility study was to develop and test a novel intramedullary splinting implant for fixation of superior pubic ramus fractures (SPRF), and to evaluate its biomechanical viability in comparison with established fixation methods using conventional partially or fully threaded cannulated screws. Materials and Methods: A type II superior pubic ramus fracture according to the Nakatani classification was created in 18 composite hemi-pelvises via a vertical osteotomy with an additional osteotomy in the inferior pubic ramus to isolate the testing of three SPRF fixation techniques performed in 6 semi-pelvises each using either (1) a novel ramus intramedullary splint, (2) a partially threaded ramus screw, or (3) a fully threaded ramus screw. Results: No significant differences were detected among the fixation techniques in terms of initial construct stiffness and number of cycles to failure, p ≥ 0.213. Conclusion: The novel ramus intramedullary splint can be used as an alternative option for treatment of pubic ramus fractures and has the potential to decrease the rate of implant failures due to its minimally invasive implantation procedure. Full article

Fractures of the superior pubic ramus can be treated with screw insertion into the osseous fixation pathway (OFP) of the anterior column (AC). The entry point determines whether the screw exits the OFP prematurely. This can be harmful when it enters the hip joint or damages soft tissues inside the lesser pelvis. The exact entry point varies between patients and can be difficult to ascertain on fluoroscopy during surgery. The aim of this study was to determine variation in the location of the entry point. A retrospective single center study was performed at a level 1 trauma center in the Netherlands. Nineteen adult patients were included with an undisplaced fracture of the superior pubic ramus on computer tomography (CT)-scan. Virtual three-dimensional (3D) models of the pelvises were created. Multiple screws were placed per AC and the models were superimposed. A total of 157 screws were placed, of which 109 did not exit the OFP prematurely. A universally reproducible entry point could not be identified. A typical crescent shaped region of entry points did exist and was located more laterally in females when compared to males. Three-dimensional virtual surgery planning can be helpful to identify the ideal entry points in each case. Full article

Background: Fractures of the pubic ramus without involvement of the posterior pelvic ring represent a minority of fragility fractures of the pelvis (FFP). The natural history of patients suffering this FFP Type I has not been described so far. Material and methods: All patients, who were admitted with isolated pubic ramus fractures between 2007 and mid-2018, have been reviewed. Epidemiologic data, comorbidities, in-hospital complications, and one-year mortality were recorded. Of all surviving patients, living condition before the fracture and at follow-up was noted. Mobility was scored with the Parker Mobility Score, quality of life with the European Quality of Life 5 Dimensions 3 Level (EQ-5D-3L), subjective sensation of pain with the Numeric Rating Scale (NRS). Results: A consecutive series of 138 patients was included in the study. There were 117 women (84.8%) and 21 men (15.2%). Mean age was 80.6 years (SD 8.6 years). 89.1% of patients presented with comorbidities, 81.2% of them had cardiovascular diseases. Five patients (4%) died during hospital-stay. Median in-hospital stay was eight days (2–45 days). There were in-hospital complications in 16.5%, urinary tract infections, and pneumonia being the most frequent. One-year mortality was 16.7%. Reference values for the normal population of the same age are 5.9% for men and 4.0% for women. One-year mortality rate was 22.2% in the patient group of 80 years or above and 8.8% in the patient group below the age of 80. The rate of surviving patients living at home with or without assistance dropped from 80.5% to 65.3%. The median EQ-5D-Index Value was 0.62 (0.04–1; IQR 0.5–0.78). Reference value for the normal population is 0.78. Average PMS was 4 and NRS 3. Within a two-year period, additional fragility fractures occurred in 21.2% and antiresorptive medication was taken by only 45.2% of patients. Conclusion. Pubic ramus fractures without involvement of the posterior pelvis (FFP Type I) are serious adverse events for elderly persons. During follow-up, there is an excess mortality, a loss of independence, a restricted mobility, and a decreased quality of life. Pubic ramus fractures are indicators for the need to optimize the patient’s general condition. Full article