Predictors of Acute Mortality After Open Pelvic Fracture: Experience From 37 Patients From A Level I Trauma Center.

BACKGROUND: Open pelvic fractures are caused by high-energy traumas and are accompanied by organ injuries. Despite improvements in pre-hospital care, the acute mortality rate following open pelvic fractures remains high. This study aimed to report experiences in managing open pelvic fractures, identify potential independent predictors that contribute to acute mortality in such patients, and generate a scoring formula to predict mortality rate. METHODS: Open pelvic fracture patients managed during a 42-month period were retrospectively studied. Logistic regression analysis was used to determine predictors of acute mortality. Using the Youden index, threshold values of predictors were selected. Significant predictors were weighted to create a scoring formula. The area under the curve (AUC) was tested in this specific group. RESULTS: The incidence of open pelvic fractures in all pelvic fractures was 4.9% (37/772), and the overall mortality rate was 21.6% (8/37). All the successfully resuscitated patients entered the reconstruction stage survived and underwent the complete treatment course. Univariate and multivariate logistic regression analyses revealed that the revised trauma score (RTS) was the single independent predictor of acute mortality. A scoring formula was generated following the statistical analysis. The probability of mortality was 0% and 100% when the score was above and below -2, respectively. This model predicted mortality with an AUC of 0.948 (95% confidence interval 0.881-1.000, P < 0.01). CONCLUSION: The RTS may be a potential predictor of acute mortality in open pelvic fracture patients. Further work would be required to validate the clinical efficacy of the generated scoring formula.

Clinical features and risk factors for mortality in patients with open pelvic fracture: A retrospective study of 46 cases.

BACKGROUND: This study aimed to investigate the clinical features, current management strategies, and outcomes of open pelvic fracture patients. METHODS: We performed a retrospective review of data on patients with blunt trauma and open pelvic fractures admitted to our trauma center over a 5-year period (January 2013 to December 2017). Demographic as well as clinical data including injury mechanism, injury severity score (ISS), fracture classifications, transfusion requirements, interventions, length of hospital and intensive care unit (ICU) stay, and prognosis were investigated. Univariate analysis and binary logistic regression were used to identify the risk variables of death. Finally, a brief literature review was performed to understand the current capacity of treatment and prognosis of this type of injury. RESULTS: Forty-six patients (36 male and 10 female) were included in this study, mean age 43.2 ± 14.2 years. The overall mortality rate was 17.4%; 43.5% of the patients were hypotensive (systolic blood pressure (SBP) <90 mmHg) on arrival. The average ISS was 31.7 ± 6.7, and the average packed red blood cell (PRBC) transfusion during the first 24 h was 9.6 ± 7.4 units. Five patients (10.9%) underwent transcatheter arterial embolization in the early stage of management. The average hospital and ICU length of stay were 53.0 ± 37.6 days and 14.3 ± 15.3 days, respectively. Statistically significant differences were found in ISS, PRBC units received with the first 24 h, SBP, lactate and base excess on admission, and mechanism of injury when comparing between the death and the survival groups (p < 0.05). ISS and lactate on admission were found to be the independent risk factors for mortality. CONCLUSION: The mortality rate of open pelvic fractures remains high. ISS and lactate on admission were the independent risk factors for mortality. Optimization of the trauma care algorithms for early identification and treatment of this injury could be the key to decreasing mortality.

Preperitoneal pelvic packing is effective for hemorrhage control in open pelvic fractures.

BACKGROUND: Open pelvic fractures are life-threatening injuries. Preperitoneal pelvic packing (PPP) has been suggested to be ineffective for hemorrhage control in open pelvic fractures. We hypothesize that PPP is effective at hemorrhage control in patients with open pelvic fractures and reduces mortality. METHODS: Patients undergoing PPP from 2005 to 2015 were analyzed. Patients with open pelvic fractures were defined as direct communication of the bony injury with overlying soft tissue, vagina, or rectum. RESULTS: During the 10-year study, 126 patients underwent PPP; 14 (11%) sustained an open pelvic fracture. After PPP, 1 patient (7%) underwent angioembolization with a documented arterial blush. PPP controlled pelvic hemorrhage in all patients. Overall mortality rate was 7% with one death due to traumatic brain injury. CONCLUSIONS: PPP is effective for hemorrhage control in patients with open pelvic fractures. PPP should be used in a standard protocol for hemodynamically unstable patients with pelvic fractures regardless of associated perineal injuries.

Combat-related acetabular fractures: Outcomes of open versus closed injuries.

INTRODUCTION: Since the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. METHODS: We performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. RESULTS: The mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. DISCUSSION: Open acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures.

Classification of soft-tissue injuries in open femur fractures: Relevant for systemic complications?

BACKGROUND: A broad range of systemic complications has been described to occur in patients with open major fractures. Various causes have been claimed to play a role. We therefore surveyed a nationwide trauma registry to assess risk factors associated with closed and various types of open femur fractures. METHODS: This was a cohort study in a nationwide population-based prospective database. Inclusion criteria for selection from database are as follows: individuals with femur fracture, age 16 years or older, and survival until primary admission. Main groups included closed and open femur fracture. Patient demographics, injury severity (New Injury Severity Score), surgical fracture management, length of stay, and systemic complications (e.g., multiple organ failure [MOF], sepsis, mortality) were collected and statistically analyzed using SPSS statistics. Multivariate regression analysis was performed to stratify subgroups for the degree of open soft-tissue injury according to Gustilo and Anderson. RESULTS: Among 32,582 documented trauma victims (January 1, 2002, to December 31, 2010), a total of 5,761 met the inclusion criteria. Main groups: 4,423 closed (76.8%) and 1,338 open femur fractures (23.2%). Open fractures subgroups were divided into I° (334, 28.1%), II° (526, 44.3%), and III° (328, 27.6%). Open fractures were associated with an increased risk of prehospital hemorrhagic shock (p = 0.01), higher resuscitation requirements (p < 0.001), MOF (p = 0.001), and longer in-hospital (p < 0.001) and intensive care stay (p = 0.001). While New Injury Severity Score values showed a minor increase per subgroup, the prevalence of MOF, sepsis, and mortality multiplied with the degree of open soft-tissue injury. Especially patients with Type III open femur fractures received mass transfusions (28.2%, p < 0.001), and mass transfusions were identified as independent predictor for sepsis (odds ratio [OR], 2.393; 95% confidence interval [CI], 1.821-3.143; p < 0.001) and MOF (OR, 2.966; 95% CI, 2.409-3.651; p < 0.001). Our data also indicate an increased mortality in patients with open femur managed outside Level I trauma centers (OR, 1.358; 95% CI, 1.018-1.812; p = 0.037). CONCLUSION: Open femur fractures are associated with higher in-hospital complications related to incidence of MOF, associated intensive care unit stay, and hospital days when compared with closed femur fractures. For prevention of in-hospital complications, prompt hemorrhage control, surgical fracture fixation, cautious blood management, and triage to a Level I trauma center must be considered. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level II.

Third degree open fractures and traumatic sub-/total amputations of the upper extremity: Outcome and relevance of the Mangled Extremity Severity Score.

INTRODUCTION: Third degree open fractures and traumatic sub-/total amputations of the upper extremity represent severe injuries and are associated with a high rate of functional impairment of the affected extremity. More than 20 years ago, the Mangled Extremity Severity Score (MESS) was introduced to predict amputation following severe lower extremity trauma. However, there have been few studies evaluating MESS in connection with the mangled upper limb. MATERIAL AND METHODS: A retrospective medical chart review was performed of all patients diagnosed with the aforementioned fractures of the upper extremity treated at the Department of trauma surgery (level I trauma center) and the Clinical division of plastic and reconstructive surgery at the general hospital of Vienna between 1994 and 2014. RESULTS: Fifty-four out of 606 patients (9%) suffered from a total of 61 third degree open fractures or traumatic sub-/total amputations of the upper extremity (Gustilo-Anderson, type IIIA, n=30; Gustilo-Anderson, type IIIB, n=15; Gustilo-Anderson, type IIIC, n=9; traumatic sub-/total amputations, n=7). Thirty-seven out of 54 patients (69%) suffered fractures of the forearm, 10/54 (19%) patients of the humerus and 7/54 (13%) patients of the forearm and the humerus. The median MESS and Injury Severity Score (ISS) for all patients was 5 (range: 3-10) and 9 (range: 4-50), respectively. Seventeen out of 54 patients (31%) were diagnosed with a MESS≥7. Twenty-one out of 54 patients (39%) suffered severe vascular injuries and 22/54 (41%) patients suffered injuries of neural structures. Throughout the therapy process, 6/54 (11%) patients died. Definite limb salvage was achieved in 45 (94%) of the 48 survivors, of whom 9/45 (20%) subjects had a MESS≥7. DISCUSSION: It became apparent that definite limb salvage could be achieved in the mangled upper extremity regardless of MESS. It should be noted that in the current study, limb functionality was not assessed. However, without a standardized scoring system, there might be significant risk of salving dysfunctional upper limbs. LEVEL OF EVIDENCE: IV: retrospective or historical series.

Global Forum: Fractures in the Elderly.

Fractures in the elderly are increasing in incidence and becoming a major health issue in many countries. With an increasing number of the elderly living to an older age, the problems associated with fractures will continue to increase. We describe the epidemiology of fractures in the elderly and identify six fracture patterns in the population of patients who are sixty-five years of age or older. We also analyzed multiple fractures and open fractures in the elderly and we show that both increase in incidence with older age. The incidence of open fractures in elderly women is equivalent to that in young men. Many factors, including patient socioeconomic deprivation, increase the incidence of fractures in the elderly. More than 90% of fractures follow low-energy falls and the mortality is considerable. Mortality increases with older age and medical comorbidities, but there is also evidence that it relates to premature discharge from the hospital.

Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure.

The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing, of which six were open injuries. The median time to exchange nailing from primary fixation was 8.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Multiple causes for non-union were found in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical procedures were required in nine (22.5%) cases, one of whom (2.5%) required the use of another fixation modality to achieve union. Union was ultimately achieved with exchange nailing in 34/37 (91.9%) patients. The median time to union after the exchange nailing was 9.4 months. Cigarette smoking and infection were risk factors for failure of exchange nailing. Multivariate analysis found infection to be the strongest predictor of exchange failure (p<0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. However, 50% of patients undergoing exchange nailing in the presence of infection required at least one further procedure. It is important to counsel patients of this so that they can plan for it and do not consider that the first exchange operation has failed.

Are low-energy open ankle fractures in the elderly the new geriatric hip fracture?

As the geriatric population in the United States continues to increase, ankle fractures in the elderly are predicted to exponentially increase in the future. As such, these injuries will become a common injury seen by physicians in various fields. Currently, no studies discussing low-energy open ankle fractures in the elderly and/or the mortality rate associated with these devastating injuries have been published. The purpose of the present study was to retrospectively review the morality rate associated with low-energy open ankle fractures in the elderly. We retrospectively identified 11 patients >60 years old who had sustained low-energy open ankle fractures and been treated at our institution. The patient demographics, mechanism of injury, wound size, medical comorbidities, treatment, follow-up data, and outcomes were recorded. Low-energy falls were defined as ground level falls from sitting or standing. The mean age of the patients was 70.72 years, with a mean body mass index of 35.93 ± 10.24. Of the 11 patients, 9 (81.81%) had ≥3 comorbidities (i.e., hypertension, diabetes, coronary artery disease, congestive heart failure, and/or chronic obstructive pulmonary disease). The mean size of the medially based ankle wound was 14.18 ± 4.12 cm; 10 (90.90%) were Gustilo and Anderson grade IIIA open ankle fractures. In our study, low-energy open ankle fractures in the elderly, very similar to hip fractures, were associated with a high mortality incidence (27.27%) at a mean of 2.67 ± 2.02 months, and 81.81% of our patients had ≥3 medical comorbidities.

The Jones-Powell Classification of open pelvic fractures: a multicenter study evaluating mortality rates.

BACKGROUND: Historically, open pelvic fractures have a high mortality rate. The Jones-Powell Classification system was developed to assist with morbidity and mortality prediction.The purposes of our study were twofold: 1. Apply the Jones-Powell Classification to mortality rates of open pelvic fractures; 2. Because the original article published on the Jones-Powell Classification was from 1997, there have been advances in the early treatment of pelvic fractures to include the use of the pelvic binder, early diverting colostomies, and emergent angiography. We wanted to examine if any of those acute interventions affected mortality rate. METHODS: This is a retrospective review of all patients presenting with open pelvic fractures at six Level I trauma centers between 2000 and 2006. RESULTS: There were 64 patients with an average age of 34 years (range, 17-57 years). Fourteen had stable pelvic fracture patterns, and 50 had unstable fracture patterns. The overall mortality rate in our study was 15 patients (23%). All patients who died had an unstable pelvic fracture and/or rectal laceration. Sixteen patients had diverting colostomies within 48 hours of injury. There were four patients with rectal lacerations and no patients with diverting colostomies who died. DISCUSSION: In our population group, there was an overall mortality rate of 23%. A Jones-Powell Class 3 injury had a 38% mortality rate. The presence of a rectal laceration may serve as a marker for the severity of the patient's injuries and increased risk of mortality. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

[Clinical treatment of open pelvic fractures associated with perineal injury].

OBJECTIVE: To investigate the method and the effectiveness of open pelvic fractures associated with perineal injury. METHODS: Between August 2000 and July 2010, 16 cases of open pelvic fractures associated with perineal injury were treated. There were 12 males and 4 females with an average age of 41 years (range, 17-69 years). Injury was caused by traffic accidents in 9 cases, by falling from height in 6 cases, and by crushing in 1 case. The mean time between injury and admission was 8 minutes (range, 5-20 minutes). According to Tile classification, 2 cases were rated as type A, 6 as type B, and 8 as type C. The wound size ranged from 5 cm x 3 cm to 15 cm x 12 cm. The perineal injured location included intraperitoneal rectal injury in 2 cases and extraperitoneal anorectal injury in 14 cases. The average injury severity score (ISS) was 29 (range, 25-48). The main treatments included emergency resuscitation, colostomy, external fixation of fractures, repeated debridement with pulsatile irrigation followed by intravenous antibiotics, and vacuum sealing drainage (VSD). RESULTS: In 5 deaths, 3 cases died of hemorrhagic shock and 2 cases died of multiple system organ failure within 4 days of admission. The other 11 cases were followed up 6-46 months (mean, 14 months). The X-ray films showed that bone union was achieved after 2-4 months of operation. Infection in varying degree occurred at perineal wounds; second stage healing of wounds was achieved in 10 cases after debridement and VSD treatment, and wound healed in 1 case after gracilis muscle flap repair. No anal incontinence occurred in the patients having anorectal injury during follow-up. CONCLUSION: For patients with perineal injury and open pelvic fractures, the following treatments should be carried out so as to obtain good effectiveness: early anti-shock, protection of important organ function, treatment of complications, late resistance to infection and stability restoration of the pelvic ring, functional repair and reconstruction of rectum and anal canal and urinary tract.

Elderly tibial shaft fractures: Open fractures are not associated with increased mortality rates.

OBJECTIVES: This study aims to assess whether elderly patients (>65 years) with open tibial shaft fractures (OFs) have increased mortality rates than those with closed fractures (CFs). PATIENTS AND METHODS: Patients admitted during 2003-2005 with open/closed diaphyseal (AO 42) fractures of the tibia were eligible to participate. EXCLUSION CRITERIA: Pathological and peri-prosthetic fractures. RESULTS: A total of 54 patients (38 females) met the inclusion criteria. Twenty-six patients had sustained CF and 28 OF (Gustilo grade I (11), grade II (five), grade IIIa (two) and grade IIIb (10)). The OF group was statistically significantly different with higher injury severity score, secondary procedures and length of hospital stay (p<0.05). A higher rate of admission/length of stay to intensive care unit and complication rate was noted in the OF group. Mortality rate between the two groups was comparable (CF=2/26, OF=3/28). CONCLUSIONS: Elderly patients with OFs of the tibial shaft have similar mortality rate to those with CFs.

[Arterial injuries combined with open fractures--management and therapy]. / Arterielle Gefässverletzungen im Rahmen offener Frakturen--Management und Versorgung.

Vascular injuries are an uncommon finding. In times of peace vascular injuries occur in approximately 1-4 % during traffic accidents. Especially challenging is the treatment of open fractures combined with arterial lesions. These fractures are usually accompanied with severe soft tissue damage and injuries to neurological structures. The overall prognosis of these trauma patients is dependent on fast and sufficient diagnostics and therapy. In particular, for unstable patients time-consuming diagnostics can be dispensed and a primarily operative therapy should be targeted. Vascular reconstruction by direct suture is sometimes only possible with interposition and should be the primary goal. Interposition should be performed with autologous vein material because of the high risk of infection. Here we demonstrate on the basis of our patients the interdisciplinary -management of such trauma patients in our hospital.

The outcome of open pelvic fractures in the modern era.

BACKGROUND: Recent series have reported that the mortality rate of open pelvic fractures has decreased to < 10%. These injuries are often associated with intra-abdominal visceral damage, although few series have documented the prognostic significance of this injury complex. METHODS: A retrospective review in an urban level I trauma center of all patients who sustained open pelvic fracture between 1995 and 2004. RESULTS: Forty-four patients were identified as having sustained open pelvic fracture. Average Injury Severity Score was 30, with 77% of patients having a score > or = 16. Overall mortality was 45% (n = 20): 11 early deaths and 9 late deaths at an average of 17 days. Vertical shear injuries, although rare, were universally fatal. Other risk factors for overall mortality included revised trauma score, Injury Severity Score, transfusion requirement, Faringer zones I or II injury, Gustilo grade III soft tissue injury, need for therapeutic angiography, and presence of intra-abdominal injury, the latter of which conferred 89% mortality. Risk factors for late deaths also included pelvic sepsis, which occurred in 5 patients and was fatal in 3 (60%). CONCLUSIONS: The morbidity of open pelvic fractures remains high. Associated intra-abdominal injury or active arterial bleeding requiring therapeutic angiography is associated with a grim prognosis. There is a continuing need for new therapeutic approaches to this injury complex.

Parameters of multiple organ dysfunction fail to predict secondary amputation following limb salvage in multiply traumatized patients.

OBJECTIVE: The purpose of this retrospective analysis was to evaluate whether systemic parameters that are used to characterize multiple organ dysfunction could also be used to predict the optimal time for amputation in patients failing limb salvage surgery following severe extremity injury. METHODS: The principal criterion for the study group was a lower limb amputation following a type IIIb or IIIc open tibial shaft fracture in multiply traumatized patients. This group was then divided into one group of primary amputation (group A) and one group of secondary amputation (group B). Beside these groups a third group of total traumatic lower limb amputation was recruited (group C). Data analysis included demographics, injury severity according to the ISS, evaluation of the limb injury by three different salvage scores (HFS, MESS and NISSSA) and organ function monitoring by the Denver MOD Score over a 14-day period posttrauma or up to 7 days after secondary amputation. RESULTS: Within the period 1987-1997 a total of 15 patients were recruited for group A (primary amputation), 10 patients for group B (secondary amputation) and nine patients for group C (traumatic amputation). The MOD score was only positive for pulmonary dysfunction, also reflected by the Horovitz quotient, in those patients that died later in either group. Mortality was higher in group A (three out of 15) compared with group B (one out of 10), which may be due to a higher ISS in group A (mean ISS 28.2 vs. 21.0 of group B). Although the MOD score of all recovered patients revealed no significant difference between group A and B, secondary amputation resulted in significantly longer demand of mechanical ventilation. According to our results secondary amputation may lead to transiently decreased pulmonary function but does not necessarily end in multiple organ dysfunction. The need for amputation in failed limb salvage was not indicated by systemic parameters. CONCLUSION: The right time for secondary amputation in order to prevent subsequent pulmonary dysfunction cannot be predicted by parameters otherwise indicating organ dysfunction. As the risk of secondary amputation for developing pulmonary dysfunction apparently cannot be estimated the decision for amputation or limb salvage should be made initially after trauma and should be the definite one.

Death from pelvic fracture: children are different.

This study compares outcome from pelvic fractures in children with that of adults. Data for 23,700 children registered in the National Pediatric Trauma Registry (NPTR) were compared with those of 10,720 adults recorded over 5 years in the registry of our level I trauma center. Patients were categorized by open versus closed fracture and by fracture type as defined by a modification of the Key and Conwell system. Outcome was evaluated by mortality rate and incidence of fracture-induced fatal exsanguination. The 722 pelvic fractures recorded in the NPTR represent 3% of the population and is half the frequency represented by the 532 adults evaluated (P < .001). The overall mortality rate was 5% for children and 17% for adults. Two children died of fracture-related exsanguination; there were 18 such deaths among the adults. Pelvic ring disruption was encountered more commonly among adults, and was associated with a significantly higher mortality rate. Patients with initial hemodynamic instability were more likely to die, although children less so than adults. The authors conclude that children do not die of pelvic fracture-associated hemorrhage as often as adults. Massive blood loss in the child occurs most commonly from solid visceral injury rather than from pelvic vascular disruption.

[Treatment concept and results of grade 3 open fractures with arterial injuries requiring reconstruction]. / Behandlungskonzept und Ergebnisse von drittgradig offenen Frakturen mit rekonstruktionspflichtigen Arterienverletzungen.

Ninety-one open fractures associated with arterial injury requiring vascular repair (type IIIC injuries) were treated at the University of Louisville between May 1983 and January 1994. Involved anatomical areas were the humerus (6x), the forearm (11x), the femur (16x), the tibia (36x), the ankle (11x) and the foot (11x). Fracture management consisted of meticulous radical debridement, copious wound irrigation, fasciotomy and fracture stabilization. Additionally, 49 wounds (53.8%) were treated with the supplemental local use of antibiotics (tobramycin-PMMA-beads). Thirty-four patients underwent primary amputation whereas 57 repairs of the injured vessels were performed. There were 7 secondary amputations due to infection or poor revascularization resulting in an overall amputation rate of 45.1%. The wound infection rate was 12.1% (11/91) and the rate for osteomyelitis was 3.3% (3/91). The local use of the antibiotic beads was of significant benefit to lower infectious complications. Primary coverage of the soft tissue defect with free tissue transfer was associated with a high infection rate (2/3) and is not recommended for this type of injury. Temporary wound coverage with the "antibiotic bead pouch" technique until wound closure can be obtained in a sterile and viable environment leads to more satisfying results.

A review of open tibia fractures in children.

Fifty-six open tibia fractures in 55 children were studied retrospectively. The overall case fatality rate was 7% (four patients). The most significant factor affecting death rate was injury to the chest and abdomen. Four amputations were performed in four patients with five injuries. Statistically, the presence of neurovascular compromise was significant, with four of eight compromised extremities (in seven patients) requiring amputation. Infection occurred in eight injuries, for an incidence of 14% overall (50% deep). The most important variables were presence of neurovascular injury and delay in getting the patient to surgery. A delay of > 6 h was correlated with a 25% infection rate compared with a 12% rate for those operated on within 6 h. The average time to union was approximately 5 +/- 4 months (range, 1.5-24.8 months). The most significant factor affecting union time was the age of the patient.

[Surgical management of complications of open pelvic injuries]. / Chirurgisches Management der Komplikationen offener Beckenverletzungen.

Open pelvic fractures are rare fractures usually resulting from a severe trauma. Only 4 of 121 patients treated operatively in 1994 for a pelvic trauma showed an open injury. The high lethality is caused by two complications: in the early phase the patient is threatened by bleeding to death and in the following course sepsis determines the lethal outcome. Only an aggressive surgical management prevents or treats such complications. The presented concept comprises in the end the hemipelvectomy and an intensive care management for prophylaxis of septic complications. So the lethality was diminished.

Upper and lower limb fractures with concomitant arterial injury.

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage.