Clinical characteristics, injury pattern and management of pediatric pelvic fracture: An observational retrospective study from a level I trauma center.

BACKGROUND: Pediatric pelvic fractures (PPF) are uncommon among children requiring hospitalization after blunt trauma. The present study explored our experience for the prevalence, patients demographics, clinical characteristics, injury pattern and management of pediatric pelvic fractures in a level I trauma center. METHODS: This is a retrospective review of prospectively collected data obtained from trauma registry database for all pediatrics trauma patients of age ≤18 years. Data were analyzed according to different aspects relevant to the clinical applications such as Torode classification for pelvic ring fracture (Type I-IV), open versus closed triradiate cartilage, and surgical versus non-surgical management. RESULTS: During the study period (3 and half years), a total of 119 PPF cases were admitted at the trauma center (11% of total pediatric admissions); the majority had pelvic ring fractures (91.6%) and 8.4% had an acetabular fracture. The mean age of patients was 11.5 ± 5.7, and the majority were males (78.2%). One hundred and four fractures were classified as type I (5.8%), type II (13.5%), type III (68.3%) and type IV (12.5%). Patients in the surgical group were more likely to have higher pelvis AIS (p = 0.001), type IV fractures, acetabular fractures and closed triradiate cartilage as compared to the conservative group. Type III fractures and open triradiate cartilage were significantly higher in the conservative group (p < 0.05). Patients with closed triradiate cartilage frequently sustained spine, head injuries, acetabular fracture and had higher mean ISS and pelvis AIS (p < 0.01) than the open group. However, the rate of in-hospital complications and mortality were comparable among different groups. The overall mortality rate was 2.5%. CONCLUSION: PPF are uncommon and mainly caused by high-impact trauma associated with multisystem injuries. The majority of PPF are stable, despite the underlying high-energy mechanism. Management of PPF depends on the severity of fracture as patients with higher grade fractures require surgical intervention. Furthermore, larger prospective study is needed to understand the age-related pattern and management of PPF.

The role of patient positioning on the outcome of acetabular fractures fixation through the Kocher-Langenbeck approach.

BACKGROUND: Open reduction and internal fixation through the Kocher-Langenbeck approach is the treatment of choice for selected acetabular fracture patterns. Patient positioning (lateral vs prone) can affect the outcome and post-operative complications. METHODS: A retrospective cohort of seventy-three adult patients' with acetabular fractures treated with open reduction and internal fixation through the Kocher-Langenbeck approach in either prone or lateral position. Primary outcome was the quality of radiographic fracture reduction; secondary outcomes included operative time, intra-operative estimated blood loss and pre-operative complications. RESULTS: The demographics and fracture type were similar between the two groups. There was no difference in the quality of reduction using the Matta radiographic grading. Laterally positioned group demonstrated significant shorter surgical time and lower incidence of iatrogenic sciatic nerve injury. There was no difference in estimated blood loss, heterotopic ossification or infection. CONCLUSION: This study showed no difference in the quality of fracture reduction, intraoperative blood loss, post-operative infection and heterotopic ossification between both groups. Hence, patients' condition, surgeon experience and preference are important factors for deciding patient positioning in the Kocher-Langenbeck approach for acetabulum fracture fixation.

Prognostic Role of Shock Index in Traumatic Pelvic Fracture: A Retrospective Analysis.

BACKGROUND: We aimed to validate the utility of shock index (SI) in predicting the need of blood transfusion and outcomes in patients with traumatic pelvic fracture (TPF). MATERIALS AND METHODS: We conducted a retrospective analysis for patients who sustained TPF between 2012 and 2016 in a level 1 trauma center. Patients were categorized into patients with low versus high SI based on the cutoff obtained from the receiver operating characteristic curves to predict mortality. RESULTS: A total of 966 patients sustained TPF (28.5% had SI ≥ 0.9 based on receiver operating characteristic curves) with a median age of 33 (IQR 25-47) y. Type B and C pelvic fractures significantly had higher SI. The frequency of blood transfusion use was greater in patients with high SI (P = 0.001). SI correlated significantly with Injury Severity Score (r = 0.32), Revised Trauma Score (r = -0.40), and transfused blood units (r = 0.35). Patients with high SI had prolonged hospital length of stay and higher mortality (P = 0.001). SI ≥ 0.9 showed high sensitivity and negative predictive value to identify the need of massive blood transfusion (77% and 86%, respectively) and mortality (73.5% and 98.1%, respectively). For hospital mortality, high SI had a sensitivity of 73.5%, specificity 74%, negative predictive value 98%, and negative likelihood ratio of 0.36. After adjustment for age, sex, Injury Severity Score, Glasgow Coma Scale, pelvis Abbreviated Injury Scale, blood transfusion, and Tile classification, the multivariate analysis models showed that high SI was an independent predictor of blood transfusion (odd ratio 5.6) and mortality (odd ratio 3.63). CONCLUSIONS: SI is a potentially useful instant tool for the prediction of massive transfusion and mortality in patients with TPF. Further prospective studies are warranted to support our findings.

Efficiency of fragment specific fixation plates in the treatment of comminuted distal radial fractures.

PURPOSE: The purpose of this study was to assess the clinical, radiologic and functional outcome of treating comminuted intra-articular distal radius fractures with fragment specific fixation. METHODS: This was a retrospective chart review of 25 unstable intra-articular distal radius fractures (type C2 AO) that had fragment specific fixation done in the orthopaedic department of the Hamad General Hospital (level 1 trauma center) over three years (2010-2013), with a follow up of one year post-operatively. Pre-operative X-rays (wrist parameters) were compared to post-operative X-rays at different time points (i.e. 6 weeks, 3 months, 6 months, etc.). Range of motion and grip strength were recorded at different time points until the final follow up evaluation. All the data has been obtained from patients' charts (including outpatient and occupational therapy rehabilitation range of motion data) after final approval from the Hamad Corporation medical research center/Ethics committee. RESULTS: There were 25 patients ranging in age from 24 to 58 years with 13 patients above 35 years (52%) and 12 patients below 35 years (48%). There were 22 males (88%) and 3 females (12%) with different mechanisms of injury such as falling from height (average 2 metres), which was the most common with 13 patients (52%), and most were work related. Left wrist was more common than right wrist injuries and mostly in the non-dominant hand with 14 patients (56%). There was an obvious improvement between pre and post-operative wrist parameters at different time points, but P-values were not significant; supination and pronation at six weeks of follow up showed significant values (p = 0.04 & 0.03, respectively). Grip strength improved about 76% compared to the normal side. CONCLUSIONS: Fragment specific fixation is a reasonable alternative for treating intra-articular distal radius fractures. At final follow up evaluations, results showed a better clinical, radiological and functional outcome. Stable fixation allowed starting active and passive motion of the wrist without compromising post-operative alignment.

Management of Traumatic Femur Fractures: A Focus on the Time to Intramedullary Nailing and Clinical Outcomes.

BACKGROUND: Femur shaft factures (FSF) are common injuries following high-energy mechanisms mainly involving motor vehicle crashes (MVC). We evaluated the timings of nailing management and analyzed the pattern of fracture union and outcome in a level 1 trauma center. METHODS: This was a retrospective observational study of all the admitted trauma patients who sustained femoral fractures between January 2016 and September 2020. Data were analyzed and compared based on time to Intramedullary Nailing (IMN) (<12 h, 12-24 h and >24 h) and outcomes of FSF (union, delayed union and nonunion). RESULTS: A total of 668 eligible patients were included in the study, of which the majority were males (90.9%) with a mean age of 34.5 ± 15.8, and 54% of the injuries were due to MVCs. The chest (35.8%) was the most commonly associated injured body region, followed by the pelvis (25.9%) and spine (25.4%). Most of femur fractures (93.3%) were unilateral, and 84.4% were closed fractures. The complete union of fractures was observed in 76.8% of cases, whereas only 4.2% and 3.3% cases had delayed union and nonunion, respectively, on the clinical follow-up. Patients in the delayed IMN (>24 h) were severely injured, had bilateral femur fracture (p = 0.001) and had higher rate of external fixation, blood transfusion, pulmonary complications and prolonged hospitalization. Non-union proportion was greater in those who had IMN <24 h, whereas a delayed union was greater in IMN done after 24 h (p = 0.5). Those with a nonunion femur fracture were more likely to have bilateral fracture (p = 0.003), frequently had retrograde nailing (p = 0.01), and high-grade femur fracture (AO type C; p = 0.04). CONCLUSION: This study showed that femur fracture is not uncommon (8.9%), which is manifested with the variety of clinical characteristics, depending on the mechanism, management and outcome in our center. Bilateral fracture, retrograde nailing and AO classification type C were the significant risk factors of non-union in patients with diaphyseal fractures. The timing of IMN has an impact on the fracture union; however, it is not a statistically significant difference. Therefore, the treating physicians should consider the potential risk factors for a better outcome by careful selection of treatment in sub-groups of patients.

Bilateral pelvic crescent fracture combined with left acetabular fracture: A case report.

INTRODUCTION: Crescent fracture-dislocations are subtype of lateral compression fractures of the pelvic ring, which usually occur following high-velocity impacts. Bilateral crescent fractures are rare entities, with a limited number of cases reported in the literature. Of those reported, none were combined with an acetabulum fracture. PRESENTATION OF CASE: The case involves a 49-year-old male, who presented to the trauma unit after a motor vehicle collision and sustained a bilateral crescent pelvic fracture combined with a left acetabulum fracture. The patient was resuscitated and managed initially according to the advanced trauma life support (ATLS) protocol then staged fixation of his pelvic and acetabulum fractures was carried out. CONCLUSION: Bilateral crescent fractures of the pelvis combined with acetabulum fractures constitute a rare injury. Given their rarity, a standard of care is lacking and has not been described yet. Staged surgical stabilization of such combined injuries is recommended, and may contribute to a better outcome.

Bilateral femoral neck fracture following a convulsion in the presence of chronic kidney disease. A case report.

INTRODUCTION AND IMPORTANCE: Bilateral femoral neck fractures in young adults are a rare entity. It is usually associated with pre-existing metabolic diseases, such as osteoporosis, renal osteodystrophy, or hypocalcemic seizures. Hence, it is essential in such cases to look for other associated injuries following a traumatic event. Missing associated injuries may lead to significant morbidities and poor functional outcomes. CASE PRESENTATION: A 37 years old male, who had chronic renal failure secondary to hypertension, and presented to the emergency room following a seizure episode, in which he developed a generalized tonic-clonic convulsion secondary to electrolyte imbalances with metabolic acidosis. As a result, he developed bilateral neck of femur fracture. INTERVENTION AND OUTCOME: The medical team optimized electrolytes imbalance and then the patient underwent surgical stabilization of both femur neck fracture, 1 year following the surgical fixation the patient had full range of motion of both hips with radiological evidence of complete healing of the fracture. CONCLUSION: In cases of fractures secondary to metabolic conditions, bilateral femoral neck fractures should be suspected and investigated; especially in young patients who develop a generalized tonic-clonic seizure. The etiology is multifactorial, and the treating surgeon should be aware of predisposing factors which may affect bone quality, thereby raising the risk of fractures even with low-energy atraumatic events. Hip preservation should always be the primary target when treating these patients.

Total knee arthroplasty for Ochronosis induced knee arthropathy. Case report.

INTRODUCTION: Alkaptunurea is a rare metabolic disorder with autosomal recessive genetic pattern in transmission, it is characterized by accumulation of hemogenistic acid in the tissues due to deficiency of homogentisate 1,2 dioxygenase activity. Characteristically, affected patient will have dark urine and blackish discoloration of connective tissue, especially cartilage and bone and hence it is known as black bone disease. PRESENTATION OF THE CASE: The reported case is for 49 years old gentleman, known to have hypertension, hypothyroidism and Alkaptunurea. He presented to our facility with long standing bilateral knee pain (more in the left) with difficulty in doing daily activities. He presented to our tertiary facility after failure of previous treatment measures. The patient underwent uncomplicated Robotic assisted total knee arthroplasty that resulted in significant improvement of his pain and function. CONCLUSION: Knee arthroplasty is a reliable and reproducible modality in treating Ochronotic knee arthropathy and it would result in pain reduction and better function of patients with such condition.

Patterns, management, and outcomes of traumatic pelvic fracture: insights from a multicenter study.

BACKGROUND: Traumatic pelvic fracture (TPF) is a significant injury that results from high energy impact and has a high morbidity and mortality. PURPOSE: We aimed to describe the epidemiology, incidence, patterns, management, and outcomes of TPF in multinational level 1 trauma centers. METHODS: We conducted a retrospective analysis of all patients with TPF between 2010 and 2016 at two trauma centers in Qatar and Germany. RESULTS: A total of 2112 patients presented with traumatic pelvic injuries, of which 1814 (85.9%) sustained TPF, males dominated (76.5%) with a mean age of 41 ± 21 years. In unstable pelvic fracture, the frequent mechanism of injury was motor vehicle crash (41%) followed by falls (35%) and pedestrian hit by vehicle (24%). Apart from both extremities, the chest (37.3%) was the most commonly associated injured region. The mean injury severity score (ISS) of 16.5 ± 13.3. Hemodynamic instability was observed in 44%. Blood transfusion was needed in one third while massive transfusion and intensive care admission were required in a tenth and a quarter of cases, respectively. Tile classification was possible in 1228 patients (type A in 60%, B in 30%, and C in 10%). Patients with type C fractures had higher rates of associated injuries, higher ISS, greater pelvis abbreviated injury score (AIS), massive transfusion protocol activation, prolonged hospital stay, complications, and mortality (p value < 0.001). Two-thirds of patients were managed conservatively while a third needed surgical fixation. The median length of hospital and intensive care stays were 15 and 5 days, respectively. The overall mortality rate was 4.7% (86 patients). CONCLUSION: TPF is a common injury among polytrauma patients. It needs a careful, systematic management approach to address the associated complexities and the polytrauma nature.