2019 Trauma/Critical Care Presentations

William J Parker, MD, Robert Despain, MD, Jeffrey Bailey, MD, Eric Elster, MD, Carlos Rodriguez, MD, MBA, Matthew Bradley, MD; Walter Reed National Military Medical Center

Introduction: Pelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts has yet to be described, especially in the context of dismounted complex blast injury. Our goal was to identify incidence, patterns of injury, and management of pelvic fractures.

Methods: We conducted a retrospective review on all combat injured patients who arrived at our military treatment hospital between November 2010 and November 2012. Basic demographics, Young-Burgess fracture pattern classification, and treatment strategies were examined.

Results: Of 562 patients identified within the study time period, 14% (81/562) were found to have a pelvic fracture. The vast majority (85%) were secondary to an improvised explosive device.  The average injury severity score for patients with pelvic fracture was 31 +/-12 and 70% were classified as open.  Of the 228 patients with any traumatic lower extremity amputation, 22% had pelvic fractures; while 31% of patients with bilateral above-knee amputations also sustained a pelvic fracture. The most common Young-Burgess injury pattern was anterior-posterior compression (APC) (57%), followed by lateral compression (LC) (36%) and vertical sheer (VS) (7%).  Only 2% of all patients (9/562) were recorded as having pelvic binders placed in the pre-hospital setting.  49% of patients with pelvic fracture required procedural therapy, the most common of which was placement of a pelvic external fixator (34/40; 85%), followed by pre-peritoneal packing (16/40; 40%), and angio-embolization (3/40; 0.75%). 17 patients (42.5%) required combinations of these three treatment modalities, the majority of which were a combination of external fixator and pre-peritoneal packing.  Likelihood to need procedural therapy was impacted by injury pattern as 72% of patients with an APC injury, 100% of patients with a VS injury, and 25% of patients with a LC injury required procedural therapy. 

Conclusions: Pelvic fractures were common concomitant injuries following blast-induced traumatic lower extremity amputations.  APC was the most common pelvic fracture pattern identified. While procedural therapy was frequent, the majority of patients underwent conservative therapy. However, placement of an external fixator was the most frequently used modality.  Considering angioembolization was used in less than 1% of cases, in the forward deployed military environment, management should focus on pelvic external fixation +/- pre-peritoneal packing.  Finally, pre-hospital pelvic binder application may be an area for further process improvement.