骨盆骨折-读书报告.ppt

Reading Report Pelvic Ring Fracture2024/5/27 周一1.Article 12024/5/27 周一2.Isolated Injury of the Acetabulum and Pelvic RinglHistorically,pelvic ring disruptions were classified based on anatomic location(Judet),mechanism of injury(Young-Burgess),or stability(Tile).2024/5/27 周一3.Judet Classfication2024/5/27 周一4.Combined Acetabular andPelvic Ring InjurieslThe incidence of combined injury patterns is difficult to assess,but in case series the rate has been reported to be 5%to 15.7%。lIn patients with isolated acetabular fractures,fracture of the posterior wall is common;however,this fracture type is rare in combined injuries.lCompared with isolated fracture types,combined injuries have a higher incidence of transverse and associated both-column fractures.2024/5/27 周一5.2024/5/27 周一6.Initial Management2024/5/27 周一周一7.Definitive ManagementlDefinitive surgical timing and management of combined injuries should be performed commensurate with the patients physiology,resuscitation status,and associated injuries.2024/5/27 周一8.lSurgical indications for combined pelvic ring injury and acetabular fractures are similar to those of isolated injuries;only the surgical tactics and logistics may differ.lIndications for surgical management of acetabular injury include an incongruent joint with displacement measuring5 mm,although some recommend fixation when displacement measures2 mm;a hip joint that is either subluxated or unstable;posterior wall fracture with demonstrated hip instability;the presence of intra-articular fragments;a roofarc measurement of45 on any AP or Judet view plain radiographs;open injury;progressive neurologic deficit;or an irreducible hip dislocation.Definitive Management2024/5/27 周一9.Definitive Management2024/5/27 周一10.Definitive Management2024/5/27 周一11.2024/5/27 周一12.SummarylAn orthopaedic surgeon should be intimately involved early to help guide treatment strategies.lOnce the patient is stabilized,attention can be turned to definitive management of the combined injury,which requires meticulous identification and thorough understanding of both the pelvic ring and acetabular fractures.lThese injuries should be assessed separately,and the overall treatment strategy should integrate the independent assessments of the pelvic ring and acetabular fractureslThe surgeon should strive to achieve anatomic reduction of both the acetabulum and the pelvic ring.2024/5/27 周一13.Article 22024/5/27 周一14.METHODSlWe identified 109 patients treated at a Level I trauma centre between 1973 and 1990 with multiple blunt orthopaedic injuries including an injury to the pelvic ring,with an Injury Severity Score(ISS)of 16.lThese patients were invited for clinical review at a minimum of ten years after the initial injury,at which point functional results,general health scores and socioeconomic factors were assessed.2024/5/27 周一15.METHODSlIn all 33 isolated anterior(group A),33 isolated posterior(group P)and 43 combined anterior/posterior pelvic ring injuries(group A/P)were included.The mean age of the patients at injury was 28.8 years(5 to 55)and the mean ISS was 22.7(16 to 44)lThe Short Form(SF)-12 survey was used to assess the quality of life.lThe Hannover Score for Polytrauma Outcome(HASPOC)was used to classify the rehabilitation of severely injured patients.2024/5/27 周一16.METHODS2024/5/27 周一17.Results2024/5/27 周一18.Results2024/5/27 周一19.Results2024/5/27 周一20.Results2024/5/27 周一21.ResultslAt review the mean Short-Form 12 physical component score for the A/P group was 38.71(22.12 to 56.56)and the mean Hannover Score for Polytrauma Outcome subjective score was 67.27(12.48 to 147.42),being significantly worse compared with the other two groups(p=0.004 and p=0.024,respectively).lA total of 42 patients(39%)had a limp and 12(11%)required crutches.lCar or public transport usage was restricted in 16 patients(15%).lOverall patients in groups P and A/P had a worse outcome.2024/5/27 周一22.DiscussionlPosterior and combined anterior/posterior injuries had a worse outcome than isolated anterior injuries.lA higher proportion of patients in group A required analgesia.2024/5/27 周一23.Article 32024/5/27 周一24.lEmergency devices for pelvic ring stabilization include circumferential sheets,pelvic binders,and c-clamps.lOur knowledge of the outcome of these techniques is currently based on limited information.Background2024/5/27 周一25.lTwo hundred seven of 6137 (3.4%)patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets,binders,or c-clamps.lMost of the participating institutions (listed in the Acknowledgements)fulfilled the requirements of a Level I trauma centre according to the classification of the American College of Surgery and the German Trauma SocietylImages included pelvic X-rays and,depending on the fracture type and medical condition of the patient,additional CT scans，and in a substantial number of cases additional autopsyMETHODS2024/5/27 周一26.lAfter checking normality of distributions and equal variance,the differences in age group proportions,sex,fracture type,mortality,as well as incidence of complex fractures,pelvic packing,arterial embolization,and lethal pelvic bleeding between patients treated by sheets,binders,and c-clamps were analysed using chi-square test.lDifferences in numerical age,time between admission and procedure,systolic arterial blood pressure,Injury Severity Score (ISS),number of packed red blood cells transfused during the first 6h after admission,and time of hospitalisation were evaluated using the KruskalWallis test.lDifferences in blood haemoglobin concentration were analysed by one-way ANOVA.METHODS2024/5/27 周一27.lAs the main outcome measure,the overall mortality was considered.For the analysis of predictors for patient mortality a multivariate logistic regression model was built.lFollowing demographic and clinical characteristics were documented in the registry and considered as relevant adjustment factors for the present analysis.METHODS2024/5/27 周一28.ResultslMost patients were treated by c-clamps (133 of 192 patients;69%),followed by sheets (31 of 192 patients;16%),and binders(28 of 192 patients;15%).lThe fraction of females was 16%(5 of 31 patients)in the sheet,36%(10 of 28 patients)in the binder,and 35%(46 of 133 patients)in the c-clamp group(p=0.12).2024/5/27 周一29.ResultslThe median age was significantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs.47 vs.42 years,p=0.01).Accordingly,the fraction of individuals under 40 years of age was significantly higher in the binder group than in the sheet and c-clamp groups.2024/5/27 周一30.Results2024/5/27 周一31.Results2024/5/27 周一32.Results2024/5/27 周一33.ResultslSheet wrapping was associated with a significantly higher incidence of lethal bleeding from the pelvic region compared to binder and c-clamp stabilization.2024/5/27 周一34.Results2024/5/27 周一35.lMultivariate logistic regression model showed 4 significant predictors for patient mortality.lPatients with higher age (Odds Ratio (OR)for each additional age year 1.05;CI 95%1.031.08;p 0.001),with additional packing (OR yes vs.no 3.24;CI 95%1.407.46;p =0.01),with higher ISS (OR for each additional ISS point 1.04;CI 95%1.011.07;p =0.01)and emergency stabilization measure (OR sheet wrapping vs.c-clamp 3.26;CI 95%1.159.26;p =0.03)had a higher likelihood for passing away in the sample.Results2024/5/27 周一36.lMeasurement of blood haemoglobin and arterial blood pressure at admission as well as fracture patterns and ISS were comparable between patients treated by sheets,binders,and c-clamps.This suggests that the outcome of these measures was not affected by the pattern and severity of injuries.lThis finding might indicate that sheets and binders were mostly used in the emergency room,while c-clamps were applied more often in the safer environment of the operation theatre.l Sheet wrapping and pelvic binders can also be applied in the pre-hospital courseConclusions2024/5/27 周一37.ConclusionslWe assume that the influence of additional packing was not causal for the lethal outcome,but rather reflected the severity of injury,whereas sheet wrapping might have been indeed in several cases not effective to control pelvic haemorrhage.lOur data suggest that emergency stabilization of the pelvic ring by c-clamps in younger patients with lower ISS is associated with less mortality.lUnadjusted analyses showed a lower rate of lethal pelvic bleeding for binders and c-clamps in comparison with sheet wrapping.lCircumferential sheets and binders seem to be,however,faster applicable than the c-clamp.2024/5/27 周一38.Article 42024/5/27 周一39.IntroductionlThe potential associated chronic complications in this special group include chronic pain,gait impairment,and sexual and urinary dysfunction.lThe urogenital system(bladder,urethra,vagina,uterus,and prostate)and lumbar and sacral plexuses because of their proximity to the bony pelvis are often concomitantly damaged at the time of pelvic fracture.lAlthough these injuries have been identified as one of the basic factors of late morbidity and complications,their late sequel,especially regarding sexual function,has not been investigated in adequate detail.2024/5/27 周一40.ObjectiveslTo provide evidence on the midterm sexual-function and health-related quality-of-life outcome of patients with a traumatic pelvic fracture,as recorded at least 12 months after their surgery.2024/5/27 周一41.PATIENTS AND METHODSlPatients aged 18 65 years at the time of their accident and at least 1 year after treatment for a pelvic fracture were considered eligible to participate in this study.lSubjects were excluded if they had urogenital associated pathology before the accident or other clinical conditions that would preclude participation in the trial or potentially interfere with ambulation or rehabilitation.2024/5/27 周一42.lA proforma was used to collect the following data:demographics,injury mechanism,fracture pattern classified using the Young et al pelvic fracture classification system,ISS associated injuries and treatment method.lThe international index of erectile function(IIEF)and the female sexual function index(FSFI)were used to assess sexual function in men and women,respectively,and the European EuroQol(EQ5D)was used to assess their health-related quality of life.PATIENTS AND METHODS2024/5/27 周一43.Results2024/5/27 周一44.Results2024/5/27 周一45.Results2024/5/27 周一46.Results2024/5/27 周一47.Results2024/5/27 周一48.ResultslSexual dysfunction was identified in 43.8%of the female and 52.1%of the male patients2024/5/27 周一49.Results2024/5/27 周一50.Results2024/5/27 周一51.ResultslUrinary tract injury and open reduction internal fixation of the pelvic fractures were show n to be significant risk factors for sexual dysfunction as de fined by the FSFI and IIEF(P,0.049 and P,0.016,respectively).The ISS showed a n ear significant relations hip with sexual dysfunction(P,0.05).2024/5/27 周一52.DiscussionlAll domains of female and male sexual function were significantly decreased at a minimum of a year after pelvic fracture.lQuality of life was also significantly decreased in this group with sexual dysfunction shown to be an independent risk factor for decreased quality of life after injury.lHigh clinical suspicion and prompt engagement of appropriate multidisciplinary pathways,including urological,gynecological,and psychiatric consultations,is recommended.2024/5/27 周一53.2024/5/27 周一54.2024/5/27 周一55.5/27/202456.