We describe the routine imaging practices of Level 1 trauma centres for patients with severe pelvic ring fractures, and the interobserver reliability of the classification systems of these fractures using plain radiographs and three-dimensional (3D) CT reconstructions. Clinical and imaging data for 187 adult patients (139 men and 48 women, mean age 43 years (15 to 101)) with a severe pelvic ring fracture managed at two Level 1 trauma centres between July 2007 and June 2010 were extracted. Three experienced orthopaedic surgeons classified the plain radiographs and 3D CT reconstruction images of 100 patients using the Tile/AO and Young–Burgess systems. Reliability was compared using kappa statistics. A total of 115 patients (62%) had plain radiographs as well as two-dimensional (2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and eight patients (4.3%) had no available images. The plain radiograph was limited to an anteroposterior pelvic view. Patients without imaging, or only plain films, were more severely injured. A total of 72 patients (39%) were imaged with a pelvic binder in situ.

Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17) and Young–Burgess (Kappa 0.09 to 0.21) was low, and insufficient for clinical and research purposes.

Severe pelvic ring fractures are difficult to classify due to their complexity, the increasing use of early treatment such as with pelvic binders, and the absence of imaging altogether in important patient sub-groups, such as those who die early of their injuries.

Cite this article: Bone Joint J 2013;95-B:1396–1401.

Traumatic disruption of the pelvic ring has a high risk of mortality. These injuries are predominantly due to high-energy, blunt trauma and severe associated injuries are prevalent, increasing management complexity. This population-based study investigated predictors of mortality following severe pelvic ring fractures managed in an organised trauma system.

Cases aged greater than 15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based state-wide Victorian State Trauma Registry for analysis. Patient demographic, pre-hospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated.

There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged greater than 65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15–34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), while patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres).

The findings highlight the importance of the need for effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.

Osteochondral fracture of the femoral head is an uncommon injury with a high potential for a poor functional outcome. Management is often challenging with limited options. We present two cases in which osteochondral fractures of the femoral head were treated with partial resurfacing using the HemiCAP System (Arthrosuface, Franklin MA, USA).

Background: There are various sites for pin placement in the pelvis. Recent studies have suggested that the supra acetabular pin placement is mechanically stronger and has been recommended as an alternative. The aim of this study is to analyse the morbidity of the most commonly used pin placement sites namely, conventional pin placement into the anterior iliac crest versus the low pin placement into the supra acetabular region.

Methods: Sixty one patients who required pelvic external fixation as part of their management between April 1998 and December 2001 were identified. Three patients died and were excluded from the study. Of the remaining 58 patients, 33 were treated with a supra-acetabular external fixator and 25 had an iliac crest external fixator. The majority of patients sustained the pelvic fracture as a result of road traffic accident. There were no statistically significant differences in the number of patients, mean age, length of stay, ISS or type of fractures for the two patient groups.

Results: Fewer complications were noted in the supra-acetabular group versus the iliac crest group (21.2% vs. 56.0%, p< 0.05). In particular, infection rates were significantly lower in the supra-acetabular group (15.1% vs. 36%, p< 0.05). There were no significant differences between the two groups in the number of pin cut-outs or misplacements, injury to the lateral femoral cutaneous nerve or loss of reduction.

Conclusion: The supra-acetabular technique of pin insertion for pelvic external fixation has fewer complications and should be utilised if an image intensifier is available. The lower rate of pin tract infection is a favourable outcome when secondary pelvic reconstructive procedures are necessary.

Introduction: Unilateral posterior Pelvic Ring injuries but especially bilateral sacral fractures or bilateral sacroiliac joint (SI) ruptures as well as lumbosacral dislocations and fracture dislocations remains a significant surgical challenge.^1,2,3 despite advances in surgical techniques. Although the true incidence of these fractures are unknown, 30% are identified late.⁴

The treatment of those fractures varies from conservative treatment, posterior plate fixation, anterior plating as well as percutaneous and open Sacroiliac (SI) joint screws.

However, screw pull-outs and loss of fixation in those methods are well described In the Alfred Hospital, Melbourne (Australia) a Level 1 Trauma Center a series of 14 patients were treated from 10/2006 to date with a multiaxial spinal system.

Methods: Patients with posterior pelvic injuries separation were identified prospectively since October 2006. Data was extracted from the trauma registry database and medical record and diagnostic imaging. Since Ocober 2006, 10 patients with bilateral posterior pelvic ring injuries and 4 with unilateral injuries were identified for fixation.

Technique: The patients were put supine and a incision medial/distalto the posterior iliac spine was made. The placement for the incision gives the surgeon the opportunity to estend the approach to an open reduction of the sacral fracture or SI Joint disruption if a closed reduction cannot be achieved.

A pedicel screw from a multiaxial spinal system (Xia, Stryker or Pangea, Synthes) is placed percutaneously in the posterior iliac crest on both sides and the reduction is performed with the screws attached to the screw handles and with Image Intensifier.

After the reduction the multiaxial screwheads are bent and transfixed with a bar which is tunneled epifacial.

All patients underwent a multislice pelvic and lumbar spine CT and these patients were assessed clinically for neurovascular symptoms and stability. The follow-up included clinical assessment and CT imaging.

Results: Since October 2006 14 patients (10 male, 4 female) with an average age of 32.4 years (range: 20–44 years, median 33 years) and an average ISS (Injury Severity Score) of 37 (range: 14–66, median 34). The mechanism of injury for these patients included: pedestrians versus car; motorcylce; paragliding and motor car collision. All patients had associated anterior pelvic ring injuries which were internally fixed in all but one case.

The follow up time was one to 18 month. The patients were assessed clinically and with CT imaging. No complications or loss of fixation have been observed in this patient group in this short follow up time.

Discussion: The fixation system is highly versaitle and the whole posterior iliac crest can be used for fixation. The posterior instrumentation provides also a good control of the reduction of anterior pelvic ring fractures which should be fixed when associated. In all cases but 3 the nature of the comminuted sacral fractures did not allow the use of SI-Joint screws or anterior SI-Joint plating.

The construct provides initial stability and allows mobilization of the patient. It can be used in cases with sacral comminution and may offer advantages over posterior plate fixation, by reducing complications with prominent metalware.

Pelvic fractures in multi-trauma patients are an indicator of severe trauma and often require advanced wound management of pelvic, abdominal or extremity injuries. Poor wound management may result infected pelvic hardware, necessitating revision surgery. We propose that TNP is a safe method of wound management and report our experience.

In 2006 91 multi-trauma patients required pelvic/ace-tabular fixation at The Alfred, either internal or external. Of those, 23 needed TNP for wound care of pelvic, abdominal or extremity injuries. Indications for TNP included Morel-Lavelle lesions, concomitant bladder disruption with anterior wounds, severe edema preventing any wound closure, extremity open fractures/degloving/fasciotomies and post-op infections.

The average age of the group was 33, the average injury severity score was 36, 5 were female, 18 were male. There was one pelvic wound infection that resolved with TNP and local wound care. Two unsalvageable limbs (one transhumeral, one transfemoral) required amputation after TNP, all others were either closed primarily or with a flap and skin graft. There was one death in the group from unrelated causes. Pelvic scores, SF-12, visual analog pain scores and sexual dysfunction rates are being gathered and will be reported.

Topical negative pressure is a safe and effective method of managing complex wounds in multi-trauma patients with pelvic injuries.

Introduction The purpose of this paper is to illustrate the role of MDCT (multislice or multi-detector row computerised tomography) in the acquisition of information in musculoskeletal pathology and the subsequent manipulation of this data in obtaining 3D reconstruction to aid surgical planning.

Methods Numerous CT studies were performed on patients who had sustained significant and often complex injuries, including pelvic, acetabular, femoral head, proximal tibial and pilon fractures. The images were acquired on GE lightspeed scanners and post processed using advantage window workstations. The 3D imaging was then used in the planning of surgery. This allowed the accurate assessment of site and extent of fracture displacement as well as a 3D appreciation of any deformity present.

Results The images obtained were displayed using multiple formats: axially acquired source images, multiplanar isotropic reformatted images and 3D surface or volume-rendered images. The facility of being able to remove a particular bare to view adjacent bony structures increases the ability to assess the anatomical nature of a clinical problem.

Conclusions Multislice CT with 3D reconstructions is an extremely useful diagnostic tool in aiding surgical planning for trauma cases. In addition, the ability to rotate images on the workstation and obtain multiple perspectives, as well as being able to remove osseous structures to view adjacent bones with greater clarity provides useful additional information.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.

Introduction Pelvic ring disruptions have well established biomechanical forces that correlate with fracture pattern. These patterns have considerable soft tissue and ligamentous disruptions associated with high velocity vectors which result in unstable injuries. This study critically evaluates the functional outcome of anatomically and or haemodynamically unstable pelvic ring disruptions treated with operative management and presents a retrospective analysis of injury pattern, surgical therapy and complications in surgically treated Tile B and Tile C disruptions.

Methods This study is a retrospective review of results of the operative management of pelvic fractures at the Alfred Hospital, Melbourne over the period of May 1997 to May 2001 (one to four years) using the Iowa Pelvic Score (Martin-American Academy Meeting 1999) to assess functional outcome. Initial screening resulted in 204 patients with pelvic disruptions via DRG coding. Of this 65 patients were managed operatively and only 34 patients were subquently included in the study. Exclusion criteria were; residual cognitive defect, hip or ace-tabular injury, spinal injury with neurological deficit, repeat trauma or ongoing litigation. The inital data gathered included; age, sex, type of accident, Tile classification, neurological injury, urogential injury, type of treatment, adequacy of treatment, post-operative complications, length of hospital and stay in rehabilitation. A follow-up survey was performed for each of these patients by telephone to obtain a post-operative functional outcome score. Thirty two of the 34 patient were able to complete the survey.

Results Thirty-four patients were included in the study with 29 (85%) males and five (14%) females. The modes of injury were as follows: five motor car occupants, 13 motorbike riders, three pedestrians struck by motorcar, three falls, three occupational and seven other. Twenty-seven were classified as Tile B and seven Tile C. These fractures were treated with the following; external fixation alone was used in four patients, external fixation followed by anterior plating was used for 18 patients, anterior plating and posterior ilio-sacral screws were used for nine patients, three patients received both anterior and posteior plate fixation. The mean number of operations to stabilize the disruptions was two. The major complication incurred by most of the patients was pin site infection. The mean length of hospital stay was 25 days and the mean length of rehabilitation stay was 35 days. Of the 32 patients interviewed all had function outcome scores greater than 70 (good). Most (n=13) of them returned to full time work. All reported cosmetic changes in their pelvis.

Conclusions We feel that this study provided good quality retrospective data for the demographics and surgical therapy used to stabilize pelvic ring disruptions that are unstable. These results were consistent with current belief that internal fixation of pelvic fractures produced good functional outcome.

A retrospective review of 1542 Charnley low-friction arthroplasties was carried out to compare the incidence of deep infection arising after plain and gentamicin-containing acrylic cement. There was no significant difference between the two series in primary operations, the infection rate being 1.72% and 1.65% respectively. However, in secondary operations (conversions and revisions) the gentamicin-containing cement gave significantly better results--a 0.81% infection rate as compared with 3.46%. All operations were performed in a clean air enclosure using total-body exhaust suits. Radiological diagnosis of deep infection was possible within one year of operation in all cases. Late haematogenous infection occurred in one case and was related to a skin lesion.

Total hip replacement has been very successful in patients with painful, stiff hips associated with protrusio acetabuli, but the heat of polymerisation of methylmethacrylate cement may cause necrosis of the thin medial wall with consequent danger of migration of the cup. Since 1968 at Wrightington, thin slices of the head of the femur have been used as bone grafts to reinforce the acetabulum. We have reviewed 61 hips in 51 patients at an average of 4 years 3 months after operation. Grading for severity is discussed and the degree of physiological remodelling of the medial wall of the acetabulum after grafting assessed. There was an average of about 4 mm of remodelling, but this varied considerably; most took place within the first year. In no case was there relapse of the protrusio.

In a randomised prospective trial 98 elderly women with trochanteric fractures of the femur were treated with either a 135 degrees Jewett nail-plate or a 135 degrees Dynamic hip screw. The results at six weeks, three months and six months were statistically analysed. There were no significant differences in the two groups with regard to pain, length of hospital stay, morbidity or mortality. Although operative difficulties and open reduction were more common with the Dynamic hip screw, at the end of six months more patients in this group were mobile and there was significant radiological evidence of better compression without loss of fixation.