Automated Association for Osteosynthesis Foundation and Orthopedic Trauma Association classification of pelvic fractures on pelvic radiographs using deep learning.

High-energy impacts, like vehicle crashes or falls, can lead to pelvic ring injuries. Rapid diagnosis and treatment are crucial due to the risks of severe bleeding and organ damage. Pelvic radiography promptly assesses fracture extent and location, but struggles to diagnose bleeding. The AO/OTA classification system grades pelvic instability, but its complexity limits its use in emergency settings. This study develops and evaluates a deep learning algorithm to classify pelvic fractures on radiographs per the AO/OTA system. Pelvic radiographs of 773 patients with pelvic fractures and 167 patients without pelvic fractures were retrospectively analyzed at a single center. Pelvic fractures were classified into types A, B, and C using medical records categorized by an orthopedic surgeon according to the AO/OTA classification system. Accuracy, Dice Similarity Coefficient (DSC), and F1 score were measured to evaluate the diagnostic performance of the deep learning algorithms. The segmentation model showed high performance with 0.98 accuracy and 0.96-0.97 DSC. The AO/OTA classification model demonstrated effective performance with a 0.47-0.80 F1 score and 0.69-0.88 accuracy. Additionally, the classification model had a macro average of 0.77-0.94. Performance evaluation of the models showed relatively favorable results, which can aid in early classification of pelvic fractures.

Executive Summary: State-of-the-Art Review: Evaluation and Management of Pelvic Osteomyelitis in Stage IV Pressure Injuries: A Multidisciplinary Collaborative Approach.

Managing pelvic osteomyelitis (POM) in the setting of stage IV pressure injuries requires multidisciplinary evaluation as well as patient and caregiver engagement and is complicated by the lack of high-evidence data to guide best practices. In this review, we describe our approach to pressure injury and POM evaluation and management through multidisciplinary collaboration and highlight areas of future research that are necessary to enhance patient outcomes, reduce healthcare costs, and improve the quality of life of those affected by POM.

Evaluation and Management of Pelvic Osteomyelitis in Stage IV Pressure Injuries: A Multidisciplinary Collaborative Approach.

Managing pelvic osteomyelitis (POM) in the setting of stage IV pressure injuries requires multidisciplinary evaluation as well as patient and caregiver engagement and is complicated by the lack of high-evidence data to guide best practices. In this review, we describe our approach to pressure injury and POM evaluation and management through multidisciplinary collaboration and highlight areas of future research that are necessary to enhance patient outcomes, reduce healthcare costs, and improve the quality of life of those affected by POM.

Evaluation of the Impact of a Less-Invasive Trunk and Pelvic Trauma Protocol on Mortality in Patients with Severe Injury by Interrupted Time-Series Analysis.

Background and Objectives: Minimally invasive trauma management, including interventional radiology and non-operative approaches, has proven effective. Consequently, our hospital established a trauma IVR protocol called "Ohta Nishinouchi Hospital trauma protocol (ONH trauma protocol) in 2013, mainly for trunk trauma. However, the efficacy of the ONH trauma protocol has remained unverified. We aimed to assess the protocol's impact using interrupted time-series analysis (ITSA). Materials and Methods: This retrospective cohort study was conducted at Ohta Nishinouchi hospital, a tertiary emergency hospital, from January 2004 to December 2019. We included patients aged ≥ 18 years who presented to our institution due to severe trauma characterized by an Abbreviated Injury Scale of ≥3 in any region. The primary outcome was the incidence of in-hospital deaths per 100 transported patients with trauma. Multivariable logistic regression analysis was conducted with in-hospital mortality as the outcome, with no exposure before protocol implementation and with exposure after protocol implementation. Results: Overall, 4558 patients were included in the analysis. The ITSA showed no significant change in in-hospital deaths after protocol induction (level change -1.49, 95% confidence interval (CI) -4.82 to 1.84, p = 0.39; trend change -0.044, 95% CI -0.22 to 0.14, p = 0.63). However, the logistic regression analysis revealed a reduced mortality effect following protocol induction (odds ratio: 0.50, 95% CI: 0.37 to 0.66, p < 0.01, average marginal effects: -3.2%, 95% CI: -4.5 to -2.0, p < 0.01). Conclusions: The ITSA showed no association between the protocol and mortality. However, before-and-after testing revealed a positive impact on mortality. A comprehensive analysis, including ITSA, is recommended over before-and-after comparisons to assess the impact of the protocol.

Prevalence and clinical significance of incidental findings in chest and abdominopelvic CT scans of trauma patients; A cross-sectional study.

BACKGROUND: Imaging may inadvertently reveal pathologies unrelated to their performing purpose, known as incidental findings (IF). This study aimed to assess the prevalence, clinical significance, and documentation of IFs in chest and abdominopelvic computed tomography (CT) scans of trauma patients. METHODS: This observational study was conducted at two urban level-1 trauma centers from March 2019 through April 2022. Official radiology reports of trauma patients who underwent chest and/or abdominopelvic CT scans at the emergency department (ED) were explored, and IF were extracted. Predictive factors of the presence of IFs and their documenting were investigated. RESULTS: Out of 656 chest and 658 abdominopelvic CT scans, 167 (25.37%) and 212 (32.31%) scans harbored at least one IF, respectively. Patients with IFs tended to be of higher age and female in both chest (age: 48 [IQR: 35-62] vs. 34 [IQR: 25-42.5]; female: 31.14% vs 14.66%, p < 0.001 for both) and abdominopelvic CT scans (age: 41 [IQR: 30-57.5] vs 33 [IQR: 25-43], female: 26.42% vs. 13.96%, p < 0.001 for both). As for documentation of significant IFs, only 49 of 112 chest IFs (43.8%) and 55 of 176 abdominopelvic IFs (31.3%) were documented. Investigating factors associated with documentation of clinically significant IFs, shorter length of hospital stay (1.5 (IQR: 0-4) vs. 3 (IQR: 2-8), p = 0.003), and discharging by ED physicians (documentation rate: 13.2% vs 42.6%, p < 0.001) were associated with poorer documentation of IFs only in abdominopelvic scans. CONCLUSION: CT imaging in ED trauma patients often reveals incidental findings, especially in older patients. Over 50% of these findings are clinically significant, yet they are frequently ignored and not documented. Physicians need to be more vigilant in recognizing and documenting these incidental findings and informing patients of the need for further evaluation.

Comparison of Adult Female and Male PMHS Pelvis and Lumbar Response to Underbody Blast.

The goal of this study was to gather and compare kinematic response and injury data on both female and male whole-body Post-mortem Human Surrogates (PMHS) responses to Underbody Blast (UBB) loading. Midsized males (50th percentile, MM) have historically been most used in biomechanical testing and were the focus of the Warrior Injury Assessment Manikin (WIAMan) program, thus this population subgroup was selected to be the baseline for female comparison. Both small female (5th percentile, SF) and large female (75th percentile, LF) PMHS were included in the test series to attempt to discern whether differences between male and female responses were predominantly driven by sex or size. Eleven tests, using 20 whole-body PMHS, were conducted by the research team. Preparation of the rig and execution of the tests took place at the Aberdeen Proving Grounds (APG) in Aberdeen, MD. Two PMHS were used in each test. The Accelerative Loading Fixture (ALF) version 2, located at APG's Bear Point range was used for all male and female whole-body tests in this series. The ALF was an outdoor test rig that was driven by a buried explosive charge, to accelerate a platform holding two symmetrically mounted seats. The platform was designed as a large, rigid frame with a deformable center section that could be tuned to simulate the floor deformation of a vehicle during a UBB event. PMHS were restrained with a 5-point harness, common in military vehicle seats. Six-degree-of-freedom motion blocks were fixed to L3, the sacrum, and the left and right iliac wings. A three-degree-of freedom block was fixed to T12. Strain gages were placed on L4 and multiple locations on the pelvis. Accelerometers on the floor and seat of the ALF provided input data for each PMHS' feet and pelvis. Time histories and mean peak responses in z-axis acceleration were similar among the three PMHS groups in this body region. Injury outcomes were different and seemed to be influenced by both sex and size contributions. Small females incurred pelvis injuries in absence of lumbar injures. Midsized males had lumbar vertebral body fractures without pelvis injuries. And large females with injuries had both pelvis and lumbar VB fractures. This study provides evidence supporting the need for female biomechanical testing to generate female response and injury thresholds. Without the inclusion of female PMHS, the differences in the injury patterns between the small female and midsized male groups would not have been recognized. Standard scaling methods assume equivalent injury patterns between the experimental and scaled data. In this study, small female damage occurred in a different anatomical structure than for the midsized males. This is an important discovery for the development of anthropomorphic test devices, injury criteria, and injury mitigating technologies. The clear separation of small female damage results, in combination with seat speeds, suggest that the small female pelvis injury threshold in UBB events lies between 4 - 5 m/s seat speed. No inference can be made about the small female lumbar threshold, other than it is likely at higher speeds and/or over longer duration. Male lumbar spine damage occurred in both the higher- and lower lower-rate tests, indicating the injury threshold would be below the seat pulses tested in these experiments. Large females exhibited injury patterns that reflected both the small female and midsized male groups - with damaged PMHS having fractures in both pelvis and lumbar, and in both higher- and lower- rate tests. The difference in damage patterns between the sex and size groups should be considered in the development of injury mitigation strategies to protect across the full population.

Frontal-Crash Occupant Protection in the Rear Seat: Submarining and Abdomen/Pelvis Response in Midsized Male Surrogates.

Frontal-crash sled tests were conducted to assess submarining protection and abdominal injury risk for midsized male occupants in the rear seat of modern vehicles. Twelve sled tests were conducted in four rear-seat vehicle-bucks with twelve post-mortem human surrogates (PMHS). Select kinematic responses and submarining incidence were compared to previously observed performance of the Hybrid III 50th-percentile male and THOR-50M ATDs (Anthropomorphic Test Devices) in matched sled tests conducted as part of a previous study. Abdominal pressure was measured in the PMHS near each ASIS (Anterior Superior Iliac Spine), in the inferior vena cava, and in the abdominal aorta. Damage to the abdomen, pelvis, and lumbar spine of the PMHS was also identified. In total, five PMHS underwent submarining. Four PMHS, none of which submarined, sustained pelvis fractures and represented the heaviest of the PMHS tested. Submarining of the PMHS occurred in two out of four vehicles. In the matched tests, the Hybrid III never underwent submarining while the THOR-50M submarined in three out of four vehicles. Submarining occurred in vehicles having both conventional and advanced (pretensioner and load limiter) restraints. The dominant factors associated with submarining were related to seat pan geometry. While the THOR-50M was not always an accurate tool for predicting submarining in the PMHS, the Hybrid III could not predict submarining at all. The results of this study identify substantive gaps in frontal-crash occupant protection in the rear seat for midsized males and elucidates the need for additional research for rear-seat occupant protection for all occupants.

Comparison and Utility of Intravenous Iodinated Contrast in Chest, Abdomen, Pelvis Computerized Tomography for Trauma Patients With Blunt Mechanism of Injury Before and After the May 9, 2022 Global Contrast Shortage at a Level II Trauma Center.

Background: Intravenous (IV) contrast improves the sensitivity and specificity of injury detection in computerized tomography (CT). Its use is recommended in the workup of trauma patients by the American College of Surgeons and American College of Radiology. On May 9, 2022, the Food and Drug Administration declared a shortage of iodinated contrast due to the COVID-19 pandemic. Although the shortage has ended, the temporary lack of IV contrast forced physicians to be prudent in ordering CT scans with IV contrast. We sought to determine if there was a change in the percentage of CT contrast studies performed during the contrast shortage and if this change affected patient outcomes.Methods: Retrospective chart review was performed on all adult tier 2 trauma patients at a 619-bed community-based level II trauma center who received CT chest, abdomen, and pelvis imaging as initial workup for blunt trauma from 5/9/2021-6/30/2021 (pre-shortage) and 5/9/2022-6/30/2022 (during shortage).Results: Patients were predominantly male with median age of 31-52 and of White or Hispanic ethnicity. Before the contrast shortage, all 110 trauma patients were scanned with contrast. During the shortage, 29 of 114 patients were scanned with contrast (P < 0.001). Injuries were identified in 59% of patients scanned with contrast (P < 0.001). There were no significant differences in blood transfusion needs, repeat CT, disposition, or mortality when comparing pre-shortage to during shortage or when comparing between non-contrast and contrast studies during the shortage.Discussion: There was a decrease in the percentage of CT contrast studies performed during the shortage. A higher percentage of injuries were identified in the patients scanned with contrast. However, there were no significant differences in patient outcomes. Certain trauma patients may be safely scanned without contrast.

Management of Pelvic Trauma.

Pelvic fractures are common after blunt trauma with patients' presentation ranging from stable with insignificant fractures to life-threatening exsanguination from unstable fractures. Often, hemorrhagic shock from a pelvic fracture may go unrecognized and high clinical suspicion for a pelvic source lies with the clinician. A multidisciplinary coordinated effort is required for management of these complex patients. In the exsanguinating patient, hemorrhage control remains the top priority and may be achieved with external stabilization, resuscitative endovascular balloon occlusion of the aorta, preperitoneal pelvic packing, angiographic intervention, or a combination of therapies. These modalities have been shown to reduce mortality in this challenging population.

Penile traumatic testicular dislocation: a case report.

Traumatic testicular dislocation is rare and usually occurs in patients after a traumatic motor accident. Manual reduction or surgical exploration is the main treatment for this condition. We report a rare case of unilateral traumatic testicular dislocation in a man with an ectopic testis in the middle of the penis after a motorcycle crash injury. On the sixth day of hospitalization, the patient found a lump in the middle of his penis. Doppler ultrasound showed an ectopic testicle in the middle of the penis with good blood flow. After consultation, a manual reduction was successfully performed. A careful physical examination should be performed in patients with multiple injuries from the first medical exam. Early detection and timely reduction are critical to protect testicular function.

[Diagnostics and treatment of insufficiency fractures of the pelvis]. / Diagnostik und Therapie von Beckeninsuffizienzfrakturen.

Insufficiency fractures of the pelvis have increased in recent years, primarily due to the demographic change and the incidence will continue to rise. In addition to conventional X­rays, the diagnostics always require slice imaging. Unlike high-energy trauma magnetic resonance imaging (MRI) plays an important role in insufficiency fractures. Once the fracture has been diagnosed, in addition to the extent of instability in the anterior and posterior pelvic rings, the pain symptoms are crucial for the decision on surgical treatment. The basic principle is to stabilize as little as possible but as much as necessary. There are currently a variety of procedures that can be applied as a minimally invasive procedure, especially for the often slightly or displaced insufficiency fractures. The decisive factor for treatment is that it enables early mobilization of the patients. All of these measures must be accompanied by thorough diagnostics of osteoporosis and the appropriate treatment.

A retrospective observational study assessing mortality after pelvic trauma embolisation.

INTRODUCTION: Trauma to the pelvic ring and associated haemorrhage represent a management challenge for the multidisciplinary trauma team. In up to 10% of patients, bleeding can be the result of an arterial injury and mortality is reported as high as 89% in this cohort. We aimed to assess the mortality rate after pelvic trauma embolisation and whether earlier embolisation improved mortality. METHODS: Retrospective study at single tertiary trauma and referral centre, between 1 January 2009 and 30 June 2022. All adult patients who received embolisation following pelvic trauma were included. Patients were excluded if angiography was performed but no embolisation performed. RESULTS: During the 13.5-year time period, 175 patients underwent angiography and 28 were excluded, leaving 147 patients in the study. The all-cause mortality rate at 30-days was 11.6% (17 patients). The median time from injury to embolisation was 6.3 h (range 2.8-418.4). On regression analysis, time from injury to embolisation was not associated with mortality (OR 1.01, 95% CI 0.952-1.061). Increasing age (OR 1.20, 95% CI 1.084-1.333) and increasing injury severity score (OR 1.14, 95% CI 1.049-1.247) were positively associated with all-cause 30-day mortality, while non-selective embolisation (OR 0.11, 95% CI 0.013-0.893) was negatively associated. CONCLUSION: The all-cause mortality rate at 30-days in or cohort was very low. In addition, earlier time from injury to embolisation was not positively associated with all-cause 30-day mortality. Nevertheless, minimising this remains a fundamental principle of the management of bleeding in pelvic trauma.

Do we fix front and back of every APC pelvic injury?

HISTORY-A 47-year-old male was on a cliff when he jumped into the water below. He jumped about 50 feet. Upon landing in the water, he felt his legs separate and abduct violently. He was taken to the Emergency unit of the nearest trauma center and was found to have no injuries except to his pelvis. He could not weight bear because of pelvic pain but had normal distal sensory and motor exam and rectal exam. His-pelvis was painful to examination anteriorly with minor left-sided posterior SI pain, and he had no blood at his meatus. X-rays and CT were done, (Figures 1-5).

Traumatic injuries of the immature hip and pelvis.

PURPOSE OF REVIEW: The pelvis and hip account for 0.3--4% of fractures of the immature skeleton, and generally result from high energy trauma. These fractures range in severity from apophyseal avulsions to complete disruptions of the pelvic ring. The purpose of this article is to review the presentation, diagnosis, treatment and complications of these injuries in order to inform clinicians involved in their management. There is a lack of evidence-based management protocols for fractures of the immature pelvis largely due to their rarity and lack of robust scientific literature on the topic. RECENT FINDINGS: Computed tomography/MRI is essential as up to 30% of pelvis and 70% of acetabular fractures are not identified on initial radiographs. A sub-optimal outcome is common in unstable fractures treated conservatively and adequate reduction and surgical stabilization is often required to avoid long-term morbidity. SUMMARY: A coordinated approach involves resuscitation and temporary stabilization with planned definitive fixation. It is generally accepted that these injures should be managed in paediatric trauma centres. Whilst injuries vary in pattern and severity, we present an overview that considers the evaluation and treatment of the paediatric patient with pelvic and hip fractures to ensure that these injuries are identified promptly and treated by surgeons familiar with contemporary management algorithms.

Pelvis-Sacrum-Lumbar Spine Injury Characteristics From Underbody Blast Loading.

INTRODUCTION: Combat-related injuries from improvised explosive devices occur commonly to the lower extremity and spine. As the underbody blast impact loading traverses from the seat to pelvis to spine, energy transfer occurs through deformations of the combined pelvis-sacrum-lumbar spine complex, and the time factor plays a role in injury to any of these components. Previous studies have largely ignored the role of the time variable in injuries, injury mechanisms, and warfighter tolerance. The objective of this study is to relate the time or temporal factor using a multi-component, pelvis-sacrum-lumbar spinal column complex model. MATERIALS AND METHODS: Intact pelvis-sacrum-spine specimens from pre-screened unembalmed human cadavers were prepared by fixing at the superior end of the lumbar spine, pelvis and abdominal contents were simulated, and a weight was added to the cranial end of the fixation to account for torso effective mass. Prepared specimens were placed on the platform of a custom vertical accelerator device and aligned in a seated soldier posture. An accelerometer was attached to the seat platen of the device to record the time duration to peak velocity. Radiographs and computed tomography images were used to document and associate injuries with time duration. RESULTS: The mean age, stature, weight, body mass index, and bone density of 12 male specimens were as follows: 65 ± 11 years, 1.8 ± 0.01 m, 83 ± 13 kg, 27 ± 5.0 kg/m2, and 114 ± 21 mg/cc. They were equally divided into short, medium, and long time durations: 4.8 ± 0.5, 16.3 ± 7.3, and 34.5 ± 7.5 ms. Most severe injuries associated with the short time duration were to pelvis, although they were to spine for the long time duration. CONCLUSIONS: With adequate time for the underbody blast loading to traverse the pelvis-sacrum-spine complex, distal structures are spared while proximal/spine structures sustain severe/unstable injuries. The time factor may have implications in seat and/or seat structure design in future military vehicles to advance warfighter safety.

Does time to angiography affect the survival of trauma patients with embolization to the pelvis? A retrospective study across trauma centers in the United States.

INTRODUCTION: Traumatic pelvic injuries can result in rapid exsanguination. Bleeding control interventions include stabilization, angiography, and possible embolization. Previous studies yielded conflicting results regarding the benefit of a shorter time to embolization. OBJECTIVES: The aim of this study is to examine the impact of the time to angioembolization on the survival of patients presenting with pelvic injuries using a national database. MATERIALS AND METHODS: This was an observational retrospective study that used the National Trauma Data Bank 2017 dataset. Adult patients with pelvic injuries and who received angiography with embolization to the pelvis were included. Univariate and bivariate analyses (survival to hospital discharge yes/no) were done. This was followed by a multivariable logistic regression analysis to assess the impact of time to angiography on survival to hospital discharge after adjusting for potential confounders. RESULTS: A total of 1,057 patients were included. They were predominantly of male gender (69.3 %) with a median age of 50 years (IQR = [31-64]). The mean time to pelvic angiography was 264.0 ± 204.4 min. The overall survival rate at hospital discharge was 72.0 %. Time to angiography was not significantly associated with survival to hospital discharge before and after adjusting for clinically and statistically significant confounders (aOR = 1.000; 95 %CI=[0.999 - 1.001]; p = 0.866). CONCLUSION: Time to angiography was not associated with survival to hospital discharge of patients with pelvic injuries who required embolization. Further research examining specific patterns of injuries and assessing the impact of early angioembolization is needed.

Early versus late surgical treatment of pelvic and acetabular fractures a five-year follow-up of 419 patients.

BACKGROUND: Surgical treatment of pelvic and acetabular fractures is an advanced intervention with a high risk of subsequent complications. These patients are often polytrauma patients with multiple injuries in several organ systems. The optimal timing for the definitive surgery of these fractures has been debated. The primary aim of this study was to investigate the influence of timing of definitive surgery on the rate of unplanned reoperations. Secondary aims included its influence on the occurrence of adverse events and mortality. METHODS: All patients from 18 years with a surgically treated pelvic or acetabular fracture operated at the Karolinska University Hospital in Sweden during 2010 to 2019 were identified and included. Data was collected through review of medical records and radiographs. Logistic regression analysis was performed to evaluate factors associated with unplanned reoperations and other adverse events. RESULTS: A total of 419 patients with definitive surgical treatment within 1 month of a pelvic (n = 191, 46%) or an acetabular (n = 228, 54%) fracture were included. The majority of the patients were males (n = 298, 71%) and the mean (SD, range) age was 53.3 (19, 18-94) years. A total of 194 (46%) patients had their surgery within 72 h (early surgery group), and 225 (54%) later than 72 h (late surgery group) after the injury. 95 patients (23%) had an unplanned reoperation. There was no difference in the reoperation rate between early (n = 44, 23%) and late (n = 51, 23%) surgery group (p = 1.0). A total of 148 patients (35%) had any kind of adverse event not requiring reoperation. The rate was 32% (n = 62) in the early, and 38% (n = 86) in the late surgery group (p = 0.2). When adjusting for relevant factors in regression analyses, no associations were found that increased the risk for reoperation or other adverse events. The 30-day mortality was 2.1% (n = 4) for the early and 2.2% (n = 5) for the late surgery group (p = 1.0). The 1-year mortality was 4.1% (n = 8) for the early and 7.6% (n = 17) for the late surgery group (p = 0.2). CONCLUSIONS: Early (within 72 h) definitive surgery of patients with pelvic or acetabular fractures seems safe with regard to risk for reoperation, other adverse events and mortality.

Frontal plane pelvic kinematics during high velocity running: Association with hamstring injury history.

INTRODUCTION: Hamstring injuries are the most prevalent non-contact soft tissue injury in sports, with a larger portion of injuries being recurrent. The sagittal plane running kinematics correlated to hamstring injury history has been well documented. However, analysis of frontal plane kinematics allows for observation of stability and symmetry. This study aimed to examine the frontal plane running kinematics of elite collegiate level sprinters, with and without previous hamstring injury, compared to healthy counterparts. METHODS: Thirty-nine participants performed three 50-m sprints, with three inertial measurement unit sensors placed on the pelvis: one on each iliac crest and one on the sacrum. Participants were classified based on sex, competitive status, and injury history. To investigate differences based on group classification, the data were used to analyze mediolateral motion (relative magnitude of mediolateral acceleration) and asymmetry (difference in acceleration between right and left iliac crests) during each stance phase throughout the run. RESULTS: Injured sprinters displayed significantly greater mediolateral motion and asymmetry during stances than healthy counterparts. CONCLUSIONS: This study demonstrates that frontal plane running stance dynamics are different in athletes with previous hamstring injury than healthy athletes. These athletes may benefit from rehabilitation strategies targeting postural control and stability during dynamic tasks.