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Background: Patients with pelvic and/or acetabular fractures are at high risk of developing thromboembolic (TE) complications. In our study we investigate TE complications and the potential negative effects of concomitant pelvic or acetabular injuries in multiple injured patients according to pelvic/acetabular injury severity and fracture classification. Methods: The TraumaRegister DGU® was analyzed between 2010 and 2019. Multiple injured patients with pelvic and/or acetabular fractures with ISS ≥ 16 suffering from TE complications were identified. We conducted a univariate and multivariate analysis with TE events as independent variable to examine potential risk factors and contributing factors. Results: 10.634 patients met our inclusion criteria. The overall TE incidence was 4.9%. Independent risk factors for the development of TE complications were sepsis, ≥ 10 operative interventions, mass transfusion (≥ 10 PRBCs), age ≥ 65 years and AISAbdomen ≥ 3 (all p < 0.001). No correlation was found for overall injury severity (ISS), moderate traumatic brain injury, additional injury to lower extremities, type B and C pelvic fracture according to Tile/AO/OTA and closed or open acetabular fracture. Conclusions: Multiple injured patients suffering from pelvic and/or acetabular fractures are at high risk of developing thromboembolic complications. Independent risk factors for the development of thromboembolic events in our study cohort were age ≥ 65 years, mass transfusion, AISAbdomen ≥ 3, sepsis and ≥ 10 surgery procedures. Among multiple injured patients with acetabular or pelvic injuries the severity of these injuries seems to have no further impact on thromboembolic risk. Our study, however, highlights the major impact of early hemorrhage and septic complications on thromboembolic risk in severely injured trauma patients. This may lead to individualized screening examinations and a patient-tailored thromboprophylaxis in high-risk patients for TE. Furthermore, the number of surgical interventions should be minimized in these patients to reduce thromboembolic risk.

Background Pelvic fractures are severe injuries with frequently associated multi-system trauma and a high mortality rate. The value of the pelvic fracture pattern for predicting transfusion requirements and mortality is not entirely clear. To address hemorrhage from pelvic injuries, the early application of pelvic binders is now recommended and arterial angio-embolization is widely used for controlling arterial bleeding. Our aim was to assess the association of the pelvic fracture pattern according to the Tile classification system with transfusion requirements and mortality rates, and to evaluate the correlation between the use of pelvic binders and arterial angio-embolization and the mortality of patients with pelvic fractures. Methods Single-center retrospective cohort study including all consecutive patients with a pelvic fracture from January 2008 to June 2015. All radiological fracture patterns were independently reviewed and grouped according to the Tile classification system. Data on patient demographics, use of pelvic binders and arterial angio-embolization, transfusion requirements and mortality were extracted from the institutional trauma registry and analyzed. Results The present study included 228 patients. Median patient age was 43.5 years and 68.9% were male. The two independent observers identified 105 Tile C (46.1%), 71 Tile B (31.1%) and 52 Tile A (22.8%) fractures, with substantial to almost perfect interobserver agreement (Kappa 0.70-0.83). Tile C fractures were associated with a higher mortality rate (p = 0.001) and higher transfusion requirements (p

Aims The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization. Patients and Methods The study used data from the German Pelvic Trauma Registry and compared patients undergoing conservative management (n = 2394), surgical treatment (n = 1345) and transpubic surgery, including posterior stabilization (n = 730) with isolated posterior osteosynthesis (n = 405) in non-complex Type B and C fractures that only involved the obturator ring anteriorly. Calculated odds ratios were adjusted for potential confounders. Outcome criteria were intraoperative and general short-term complications, the incidence of nerve injuries, and mortality. Results Operative stabilization reduced mortality by 36% (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.42 to 0.98) but the incidence of complications was twice as high (OR 2.04, 95% CI 1.57 to 2.64). Mortality and the incidence of neurological deficits at discharge were no different after isolated posterior or combined anteroposterior fixation. However, the odds of both surgical (98%, OR 1.98, 95%CI 1.22 to 3.22) and general complications (43%, OR 1.43, 95% CI 1.02 to 2.00) were higher in the group with the more extensive surgery. Conclusion Operative stabilization is recommended for non-complex unstable pelvic fractures. The need for anterior fixation of obturator ring fractures should, however, be considered critically. Cite this article: Bone Joint J 2018;100-B:973-83.

Switzerland, the country with the highest health expenditure per capita, is lacking data on trauma care and system planning. Recently, 12 trauma centres were designated to be reassessed through a future national trauma registry by 2015. Lausanne University Hospital launched the first Swiss trauma registry in 2008, which contains the largest database on trauma activity nationwide. Prospective analysis of data from consecutively admitted shock room patients from 1 January 2008 to 31 December 2012. Shock room admission is based on physiology and mechanism of injury, assessed by prehospital physicians. Management follows a surgeon-led multidisciplinary approach. Injuries are coded by Association for the Advancement of Automotive Medicine (AAAM) certified coders. Over the 5 years, 1,599 trauma patients were admitted, predominantly males with a median age of 41.4 years and median injury severity score (ISS) of 13. Rate of ISS >15 was 42%. Principal mechanisms of injury were road traffic (40.4%) and falls (34.4%), with 91.5% blunt trauma. Principal patterns were brain (64.4%), chest (59.8%) and extremity/pelvic girdle (52.9%) injuries. Severe (abbreviated injury scale [AIS] score ≥ 3) orthopaedic injuries, defined as extremity and spine injuries together, accounted for 67.1%. Overall, 29.1% underwent immediate intervention, mainly by orthopaedics (27.3%), neurosurgeons (26.3 %) and visceral surgeons (13.9%); 43.8% underwent a surgical intervention within the first 24 hours and 59.1% during their hospitalisation. In-hospital mortality for patients with ISS >15 was 26.2%. This is the first 5-year report on trauma in Switzerland. Trauma workload was similar to other European countries. Despite high levels of healthcare, mortality exceeds published rates by >50%. Regardless of the importance of a multidisciplinary approach, trauma remains a surgical disease and needs dedicated surgical resources.

1985年1月～1995年6月に, 奈良医大泌尿器科ならびに関連施設で入院治療した下部尿路損傷61例について臨床的検討を行った. 1)膀胱挫傷は保存的治療を行い, 膀胱破裂は早期の外科的治療を必要とした. 2)尿道損傷については出血, 著明な尿の溢流等がない場合, 膀胱瘻の設置にとどめ, 積極的な治療は骨盤骨析等の合併損傷の安定をみてから尿道形成を行う方が, 尿道狭窄等の合併症の発生頻度が低くなると考えられた, A total of 61 patients with lower urinary tract injuries were treated at Nara Medical University and its affiliated hospitals, between January 1985 and June 1995. There were 9 patients with bladder injuries and 52 patients with urethral injuries. The main cause of bladder injury was a traffic accident sustained in 4 patients (44.5%) and that of urethral injury was an occupational accident sustained in 27 cases (51.9%). The major associated injuries were a bone fracture seen in 45 patients (73.8%) and an intrascrotal hematoma seen in 28 patients (45.9%). Posterior urethral injuries associated with pelvic bone fractures were classified into 3 types according to the classification reported by Colapinto et al.; 8 patients (32.0%) into Type I, 8 (32.0%) into Type II and 9 (36.0%) into Type III. Of the 25 patients with posterior urethral injuries, 8 (32.0%) underwent immediate surgical treatment, 12 (48.0%) underwent initial cystostomies and delayed surgical treatment and 5 (20.0%) received indwelling of urethral catheters. Postoperative complications of urethral injury included urethral stricture in 30 patients (57.7%), incontinence in 3 (5.8%) and impotence in 3 (5.8%). A significant relationship between the duration of cystostomy and the incidence of postoperative urethral stricture was observed in our patients. Therefore at least three weeks of cystostomy will be necessary in the management of patients with complicated urethral injuries.

Introduction: Hemorrhage is the leading cause of death in patients with a pelvic fracture. The majority of blood loss derives from injured retroperitoneal veins and broad cancellous bone surfaces. The emergency management of multiply injured patients with pelvic ring disruption and severe hemorrhage remains controversial. Although it is well accepted that the displaced pelvic ring injury must be rapidly reduced and stabilized, the methods by which control of hemorrhagic shock is achieved remain under discussion. It has been proposed to exclusively use external pelvic ring stabilization for control of hemorrhage by producing a ‘tamponade effect' of the pelvis. However, the frequency of clinically important arterial bleeding after external fixation of the pelvic ring remains unclear. We therefore undertook this retrospective review to attempt to answer this one important question: How frequently is arterial embolization necessary to control hemorrhage and restore hemodynamic stability after external pelvic ring fixation? Materials and methods: We performed a retrospective review of 55 consecutive patients who presented with unstable types B and C pelvic ring fractures. Those patients designated as being in hemorrhagic shock (defined as a systolic blood pressure less than 90mmHg after receiving 2L of intravenous crystalloid) were treated by application of the pelvic C-clamp. Patients who remained in hemorrhagic shock, or were determined to be in severe shock (defined as mandatory catecholamines or more than 12 blood transfusions over 2h), underwent therapeutic angiography within 24h in order to control bleeding. Results: Fourteen patients were identified as being hemodynamically unstable (ISS 30.1±11.3 points) and were treated with a C-clamp. In those patients with persistent hemodynamic instability, arterial embolization was performed. After C-clamp application, 5 of 14 patients required therapeutic angiography to control bleeding. Two patients died, one from multiple sources of bleeding and the other from an open pelvic fracture (total mortality 2/14, 14%). Conclusions: Although the C-clamp is effective in controlling hemorrhage, one must be aware of the need for arterial embolization to restore hemodynamic stability in a select subgroup of patients

High energy pelvic fractures or dislocations are associated with a high rate of early complications, due to the associated intrapelvic organs. The high rate of early mortality is mostly due to the intrapelvic, retroperitoneal bleeding caused by the laceration of vascular structures located in the presacral area. External compression of the pelvic ring, using such devices as PASG or external fixators may prevent the intrapelvic collection of large hematomas by providing indirect tamponade. Unfortunately, these devices are either unavailable on the accident site, or the complexity of their handling is discouraging for the primary care-taker. A simple system of external pelvic compression which could be applied on the scene of trauma consisting of a pelvic strap-belt was therefore developed. The application of the device is easy, quick (30 seconds) and straightforward. Its use does not induce any known complications and requires minimal training. The cost and transportability of the system are further advantages. The system has already been used in 19 patients equipped on accident scene. Our first experiences using this device are reviewed.

Three lethal cases of urinary infiltration were reported. Case 1. 42-year-old male. Extravasation of urine from the urethra occurred after traffic accident resulting in widespread urinary infiltration so far up to the chest. He died 2 days after the accident despite wide incision. Case 2. 67-year-old male with bladder tumor. Blood clot in the bladder had to be repeatedly removed. This instrumentation caused urinary infiltration, which disappeared 41 days after operation. Case 3. 68-year-old male with cystitis. His complaint of pain on urination did not disappear in spite of chemotherapy and indwelling catheterization. Urological instrumentation (catheterization) was made frequently for urinary urgency. Urinary extravazation suddenly occurred at the scrotal and penile regions. Scarification was immediately performed in portions of the extravasation of urine. But 2 days after surgical treatment he died of myocardial infarction. An extensive literature survey on extravasation of urine was made, and our cases were also discussed. The conclusion obtained were as follows; 1) Scarification of wide areas and drainage of all areas into which urine has extravasated should be caried out immediately. 2) Appropriate chemotherapy of large dose had to be made after operation. 3) Though the prognosis is almost pessimistic, prompt scarification and adequate chemotherapy are the most advisable treatments.

Objectives The objectives of this study were to compare arterial and venous contrast medium extravasation in severe pelvic injury detected by ante- and post-mortem multi-detector CT (MDCT) and determine whether vascular injury is associated with certain types of pelvic fracture. Methods We retrospectively included two different cohorts of blunt pelvic trauma with contrast medium extravasation shown by MDCT. The first group comprised 49 polytrauma patients; the second included 45 dead bodies undergoing multi-phase post-mortem CT-angiography (MPMCTA). Two radiologists jointly reviewed each examination concerning type, site of bleeding and pattern of underlying pelvic ring fracture. Results All 49 polytrauma patients demonstrated arterial bleeding, immediately undergoing subsequent angiography; 42 (85%) had pelvic fractures, but no venous bleeding was disclosed. MPMCTA of 45 bodies revealed arterial (n = 33, 73%) and venous (n = 35, 78%) bleeding and pelvic fractures (n = 41, 91%). Pelvic fracture locations were significantly correlated with ten arterial and six venous bleeding sites in dead bodies, with five arterial bleeding sites in polytrauma patients. In dead bodies, arterial haemorrhage was significantly correlated with the severity of pelvic fracture according to Tile classification (p = 0.01), unlike venous bleeding (p = 0.34). Conclusions In severe pelvic injury, certain acute bleeding sites were significantly correlated with underlying pelvic fracture locations. MPMCTA revealed more venous lesions than MDCT in polytrauma patients. Future investigations should evaluate the proportional contribution of venous bleeding to overall pelvic haemorrhage as well as its clinical significance.