The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta.

There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication.

The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation.

This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study.

The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection.

Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003).

This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection.

In the polytrauma patient, intraoperative patient positioning is one factor thought to influence pulmonary complications associated with intramedullary (IM) nailing of the femur. With regards to lateral femoral nailing, it is currently unknown as to whether the position of the injured lung contributes to changes in pulmonary function. It has been proposed that, similar to prone positioning in the ICU for acute respiratory distress syndrome management, having the injured lung in a dependent position during lateral femoral nailing would prevent barotrauma from hyperinflation and promote gas exchange in the non-dependent healthy lung. This study aims to assess the association between the position of the injured lung during lateral femoral nailing and pulmonary complications as determined by ICU LOS.

This retrospective cohort study was conducted at a single level 1 trauma centre. All patients treated with IM nailing for femur fracture between 2006 and 2014 were screened for inclusion. Only patients who 1) underwent lateral femoral nailing and 2) had a significant chest injury, defined by chest Abbreviated Injury Scale (AIS) of three or greater, were included. Patients with bilateral femur fractures or symmetric bilateral thoracic injuries were excluded. Intraoperative position of the lung injury was described depending on whether the injured lung was down, or in the dependent position, during lateral femoral nailing, versus the healthy lung down. The primary outcome was ICU LOS in all study patients. Secondary analysis was performed on the subgroup of patients who were admitted to ICU prior to femoral nailing. Data analysis assessing for differences in ICU LOS between groups was performed through Wilcoxan testing.

One hundred and thirteen femur fractures were included in the study. During lateral femoral nailing, 53 patients had the injured lung down and 60 patients had the healthy lung down. No differences between age, ICU admission rate, injury severity score, chest AIS or head AIS were detected between the groups. There were no detectable differences in the rate of ICU admission between patients with the injured lung down (47.2%) and patients with the healthy lung down (46.7%) (P=0.96).

We were unable to detect a difference in average ICU LOS between patients who had the injured lung down (4.9 days, 95% CI 2.8 – 7) compared to patients with the healthy lung down (6 days, 95% CI 3.7 – 8.4) during lateral femoral nailing (P=0.73). When looking only at patients who were admitted to ICU prior to femoral nailing, the LOS was 10.3 days (95% CI 7 – 13.7) in injured lung down patients compared to 12.9 days (9.2 – 16.6) in healthy lung down patients (P= 0.25).

In patients with chest AIS greater than three, the position of the injured lung during lateral femoral IM nailing does not appear to affect ICU LOS.