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. 2020 Aug 25;11(6):1099–1103. doi: 10.1016/j.jcot.2020.08.009

Association between Young-Burgess pelvic ring injury classification and concomitant injuries requiring urgent intervention

Julia R Coleman a, Ernest E Moore a,b, David Rojas Vintimilla b, Joshua Parry b,∗, Jesse T Nelson c, Jason M Samuels a, Angela Sauaia a,b, Mitchell J Cohen a,b, Clay Cothren Burlew a,b, Cyril Mauffrey b
PMCID: PMC7656475  PMID: 33192014

Abstract

Background

Young-Burgess classification (YB) is a mechanistic system which classifies pelvic ring injuries into anterior-posterior compression (APC), lateral compression (LC), vertical shear (VS) injuries, and combined mechanism (CM). The objective of this study was to identify associated injuries which require urgent operative intervention by YB classification. We hypothesize that YB classification is associated with 1) need for urgent intervention for pelvic fracture-related hemorrhage and 2) patterns of injury complexes requiring surgery.

Methods

This is a retrospective study of severely injured trauma patients with pelvic ring injuries who presented to an urban Level-1 trauma center from 2007 to 2017. Associated injuries and procedures were determined by Abbreviated Injury Scale (AIS) and ICD-9/10 codes. YB classes were compared, followed by a cluster analysis to identify injury patterns and association with YB classifications.

Results

Overall, 135 patients were included. 98 (72%) of patients presented with LC, 16 (12%) with APC, 8 (6%) with VS, and 13 (10%) with CM. VS and APC groups had higher rates of REBOA use compared to LC and CM groups (38% and 31% versus 11% and 0%, respectively, p = 0.01). The CM group, compared to LC, APC, and VS, had higher rates of urgent operative intervention for bleeding control (69% versus 32%, 50% and 43%, respectively, p = 0.01). 39 (29%) patients had a concomitant injury which was identified by CT scan in initial trauma work up and altered management, 46% which merited urgent intervention. On cluster analysis, there were no distinct injury complexes which required urgent operative intervention by YB class.

Conclusions

These data failed to identify unique injury complexes which merit urgent operative intervention by YB class. Nearly one in four patients had injuries identified by initial CT imaging which altered initial management, demonstrating the importance of early, full body CT imaging in severely injured patients with pelvic ring injuries.

Keywords: Young-Burgess, Pelvic ring injury, Pelvic fracture, Operative injuries, Injury complexes, Hemodynamically unstable, Hemorrhage

1. Introduction

Pelvic fractures represent a significant cause of morbidity and mortality following trauma, with a population-adjusted incidence of 34 per 100,000 capita and mortality ranging from 3% to 45%.1, 2, 3, 4 The location, magnitude, vector of injury, and stability are all important characteristics of pelvic ring injuries. Several classification systems exist to standardize descriptions of pelvic fractures.5 In 1980, Pennal et al.6 first suggested a systematic radiologic assessment, classifying pelvic ring injuries into anterior-posterior compression (APC), lateral compression (LC), and vertical shear (VS) injuries. Later, this classification system was modified under the Young-Burgess (YB) classification, placing an emphasis on the stability of the pelvic ring injury.7

Several studies have demonstrated a high correlation between the YB classification and clinical outcomes including transfusion, need for embolization, and mortality.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 However, the association with YB classification and concomitant injuries that require urgent operative intervention for bleeding is poorly defined. Defining associated injury complexes requiring surgical intervention is particularly relevant in the advent of resuscitative endovascular balloon occlusion of the aorta (REBOA), which permits temporary pelvic vascular control as described and recommended by Tactical Combat Casualty Care (TCCC) and World Society of Emergency Surgery (WSES) guidelines23, 24, 25, 26, 27; temporary stabilizations, such as REBOA, can ultimately permit computed tomography (CT) scanning for delineation of injuries which may merit concomitant operative intervention before definitive operative pelvic bleeding control.

The primary objective of this study was to identify associated injuries by YB classification, with particular attention to those that require urgent operative intervention. We hypothesize that vector of injury, as described by YB classification, is associated with (1) need for urgent intervention for pelvic fracture-related hemorrhage and (2) specific patterns of concomitant injuries requiring urgent operative intervention, thereby potentially altering initial trauma evaluation and management. After addressing this primary objective and hypotheses, a secondary objective was to explore the role of a whole-body CT scan and the use of REBOA, with the hypothesis that REBOA may allow for temporization of patients for CT imaging which may provide results crucial to initial management.

2. Methods

This is a retrospective study of severely injured (injury severity score [ISS] >15) adult trauma patients with pelvic ring injuries who presented to a single, urban, American College of Surgeons verified- and state certified-academic Level-1 trauma center, from 2007 to 2017. Data was solicited from an internal trauma registry. The inclusion criteria were severely injured adult patients (injury severity score [ISS] > 15) who presented with a pelvic ring injury after blunt trauma. The Institutional Review Board approved this study.

Associated injuries were determined by Abbreviated Injury Scale (AIS) and ICD-9/10 codes. Recognizing that AIS alone as a proxy for associated injuries may be problematic given its equal consideration to injuries of the head, thorax, abdomen, face, extremities, and external injuries, associated injuries were also determined by ICD-9/10 codes. Concomitant injury categories included rib fracture, upper extremity fracture, femur fracture, lower extremity fractures (distal to femur), splenic laceration, renal laceration, liver laceration, bladder injury, traumatic brain injury (TBI; presence of intraparenchymal hemorrhage, subarachnoid hemorrhage, subdural hemorrhage or epidural hemorrhage), spine fractures, and major vascular injuries. All concomitant injury classifications were determined a priori based on categories from our trauma registry and individually confirmed with an internal orthopedic trauma database.

Surgical procedure performed were ascertained from ICD-9/10 codes and included external pelvic fixation, open reduction and internal fixation (ORIF), or percutaneous fixation, fixation of lower or upper extremity fractures, exploratory laparotomy, resuscitative thoracotomy, bladder repair, splenectomy, small or large bowel resection, spinal surgery, major vascular repair, and neurosurgical procedure (including craniectomy, craniotomy, or bolt placement).

In order to examine specific urgent operative interventions and our secondary objective of exploring the use of REBOA and CT in this patient population, individual chart review was performed to ascertain if a patient underwent initial trauma CT scan, if REBOA was inserted and/or if urgent surgical operation for hemorrhage control (including exploratory laparotomy for hemoperitoneum and/or preperitoneal pelvic packing) was performed. In trauma patients with polytrauma, CT scanning is pursued if a patient is hemodynamically stable. According to our institutional practice, in trauma patients who present to the emergency department in shock, a 7 French sheath is inserted into the common femoral artery. This is then used for arterial blood pressure monitoring and can be used for rapid REBOA insertion. In patients with suspected pelvic fracture-related hemorrhage and persistent SBP <80 mm Hg in the emergency department, zone III REBOA is inflated to temporize patients to the operating room. In patients with pelvic ring injuries who undergo external fixation of the pelvis but have ongoing hemodynamic instability or transfusion requirement, preperitoneal pelvic packing is performed to address ongoing pelvic hemorrhage.

Descriptive analysis was performed using Chi-square tests for proportional comparisons and Mann-Whitney U test for comparison of non-normally distributed continuous variables. Unique injury complexes and those which required urgent operative intervention were compared by YB classification to look for significant associations with univariate and then cluster analysis. Additionally, a descriptive analysis was performed to ascertain of those who underwent CT scanning, what was the rate of discovery of associated injuries that were followed in temporality by an urgent operative intervention (altering initial trauma management prior to scanning). All statistical analyses were performed in R Core Team: R 3.5.1 (R Foundation for Statistical Computing, Vienna, Austria). Statistical significance was considered to be a p-value < 0.05.

3. Results

3.1. Overall patient population

Overall, 135 patients were included in this analysis. The majority (61%) were male, and the median age was 39.7 years (interquartile range [IQR] 28.0–54.5). The most common mechanisms were motor vehicle collision or motorcycle crash (75 patients, 56%), fall (31 patients, 23%), and auto-pedestrian (13 patients, 10%). The median ISS was 26 (IQR 17–34), median mean arterial pressure (MAP) was 81 mm Hg (IQR 60–98), and 23% of patients presented in shock (MAP < 60 mm Hg).

Overall, 98 (72%) of patients presented with a lateral compression fracture classification (38% LC1, 24% LC2, 10% LC3), 16 (12%) with APC (all but one were APC3), 8 (6%) with VS, and 13 (10%) with CM patterns. The ISS was similar between YB classification groups (27 [22–41 IQR] in LC, 31 [25–51 IQR] in VS, 31 [19–43 IQR] in APC, 32 [27–46 IQR] in CM, p = 0.47). Nearly half (55%) of patients required pelvic fixation, including damage control external fixation (30%), open reduction and internal fixation (23%), and percutaneous fixation (2%). The most common injuries requiring operation were extremity fractures (60%) and abdominal visceral injuries (32%).

3.2. Hemodynamic instability requiring intervention for pelvic fracture-related bleeding

Urgent interventions for hemorrhage control were required in 56 (40%) patients, including zone 3 REBOA placement in 19 (14%) patients in the trauma bay and preperitoneal pelvic packing for pelvic hemorrhage in 37 (26%) patients. VS and APC groups had higher rates of REBOA insertion compared to LC and CM groups (38% [3] and 31% [5] versus 11% [11] and 0% [0], respectively, p = 0.01). The CM group, compared to LC, APC, and VS groups, had higher rates of urgent operative intervention for abdominal and pelvic bleeding control (69% versus 32%, 50% and 43%, respectively, p = 0.01), including preperitoneal pelvic packing for pelvic hemorrhage (61% versus 19%, 44%, and 37%, respectively, p = 0.001).

3.3. Concomitant injury complexes and operative injuries identified on imaging

Overall, 93 (69%) of patients had concomitant injuries which merited surgical intervention at some point during their hospitalization. Among these, 32 (24%) had a concomitant injury which was identified by CT scan in the initial trauma work up which required urgent intervention and changed initial operative planning. These urgent interventions included craniectomy/craniotomy or bolt placement by neurosurgery due to CT findings concerning for severe traumatic brain injury (n = 8), ureteral, bladder, or renal surgery for active urinary or arterial extravasation identified on initial CT (n = 6), exploratory laparotomy for high-grade splenic or hepatic injuries with concern for active extravasation (n = 7), exploratory laparotomy for CT findings concerning for bowel injury (hematoma, air, etc) (n = 4), open repair for active extravasation seen in a proximal extremity or main visceral blood vessel identified on initial CT (n = 5), and thoracic endovascular aortic repair (TEVAR) for aortic injury identified on initial CT (n = 2).

Across YB classifications and abbreviated injury score (AIS), upon cluster analysis, while we identified associations of injuries by YB class, there were no distinct injury complexes which required urgent operative intervention (Table 1). LC and VS groups had a higher median AIS for chest injuries than APC and CM injuries (3 and 2 versus 0 and 0, p = 0.01), while APC and CM groups had a median AIS for extremity injuries (4 and 4 versus 3 and 3, p = 0.01). Further, CM group had a higher rate of pancreatic injuries compared to the LC, APC, and VS groups (15% versus 2%, 0%, and 0%, p = 0.04), and the VS group had a higher rate of lumbar spine and sacral injuries then the LC, APC, and CM groups (88% vs 31% in all others, p = 0.01). But despite these injury associations by YB class, concomitant injuries requiring urgent operative intervention were not specific to YB class.

Table 1.

Concomitant injuries associated with pelvic ring injuries by Young-Burgess classification. Presented as incidence (n, %) or median (interquartile range).

LC (n = 98) VS (n = 8) APC (n = 16) CM (n = 13) p value
Head/neck AIS 0 (0–3) 0 (0–2) 0 (0–4) 0 (0–0) 0.37
Subarachnoid hemorrhage 24 (24%) 1 (12%) 5 (31%) 0 (0%) 0.15
Subdural hemorrhage 12 (12%) 0 (0%) 3 (19%) 1 (8%) 0.56
Intraparenchymal hemorrhage 6 (6%) 1 (12%) 1 (6%) 0 (0%) 0.69
Epidural hemorrhage 3 (3%) 0 (0%) 0 (0%) 0 (0%) 0.76
Cervical spine fractures 8 (8%) 1 (12%) 2 (12%) 0 (0%) 0.31
Skull fracture 18 (18%) 1 (12%) 2 (12%) 1 (8%) 0.74
Major cervical vascular injury 9 (9%) 1 (12%) 0 (0%) 0 (0%) 0.38



Face AIS 0 (0–0) 0 (0–1) 0 (0–0) 0 (0–1) 0.98
Facial fractures 18 (18%) 1 (12%) 2 (12%) 2 (15%) 0.92



Chest AIS 3 (0–3) 2 (0–3) 0 (0–2) 0 (0–3) 0.01∗
Pneumothorax 48 (49%) 4 (50%) 4 (29%) 5 (38%) 0.49
Rib fractures 60 (61%) 4 (50%) 4 (29%) 5 (38%) 0.07
Thoracic spine fractures 14 (14%) 1 (12%) 2 (12%) 0 (0%) 0.54
Major thoracic vascular injury 5 (5%) 0 (0%) 0 (0%) 1 (8%) 0.70
Sternal fracture 8 (8%) 1 (12%) 1 (6%) 0 (0%) 0.70
Pulmonary contusion 28 (28%) 2 (25%) 3 (19%) 2 (15%) 0.74
Shoulder girdle injury 14 (14%) 1 (12%) 0 (0%) 1 (8%) 0.45



Abdomen/pelvis AIS 2 (0–3) 2 (2–3) 2 (0–2) 2 (1–3) 0.45
Liver laceration 20 (20%) 2 (25%) 2 (12%) 2 (15%) 0.90
Splenic laceration 17 (17%) 2 (25%) 1 (6%) 1 (8%) 0.55
Renal laceration 13 (13%) 1 (12%) 2 (12%) 2 (15%) 0.99
Bowel injury 12 (12%) 3 (38%) 3 (19%) 2 (15%) 0.26
Pancreatic injury 2 (2%) 0 (0%) 0 (0%) 2 (15%) 0.04∗
Genitourinary injury 13 (13%) 3 (38%) 2 (12%) 3 (21%) 0.28
Major pelvic or abdominal vascular injury 8 (8%) 2 (25%) 2 (12%) 1 (8%) 0.45
Lumbar spine fractures 30 (31%) 7 (88%) 5 (31%) 4 (31%) 0.01∗
Adrenal contusion 5 (5%) 1 (12%) 0 (0%) 0 (0%) 0.44



Extremity AIS 3 (2–4) 3 (2–5) 4 (2–5) 4 (3–4) 0.01∗
Sacral fracture 34 (35%) 3 (38%) 1 (6%) 4 (31%) 0.15
Femur fractures 19 (19%) 1 (12%) 4 (25%) 4 (31%) 0.70
Lower extremity fracture 33 (34%) 5 (62%) 6 (38%) 6 (46%) 0.37
Upper extremity fracture 24 (24%) 3 (38%) 1 (6%) 3 (23%) 0.31
Major vascular injury in extremity 5 (5%) 0 (0%) 2 (12%) 0 (0%) 0.41



External AIS 1 (0–1) 1 (0–1) 1 (0–1) 1 (0–1) 0.74
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LC = lateral compression, VS = vertical shear, APC = anterior-posterior compression, CM = combined mechanisms, AIS = abbreviated injury score.

∗Statistical significance was considered to be a p-value < 0.05.

4. Discussion

In this review of severely injured trauma patients with pelvic ring injuries presenting to an urban Level-1 trauma center, the primary objective of this study was to identify associated injuries by YB classification, with particular attention to those that require urgent operative intervention. Our results and cluster analysis reveal that ultimately, YB classifications are not associated with specific injuries requiring urgent operative intervention, but rather among patients who underwent CT scanning, we identified a high percentage of patients with injuries that required urgent operative intervention (regardless of YB class). Nearly one fourth of patients had a concomitant injury identified on initial trauma work up that merited urgent intervention, altering the initial acute operative plan. In line with our second objective of the study to explore the role of a whole body CT scan and the use of REBOA, our findings suggest that when possible, temporizing patients with REBOA for whole body CT scanning should be considered, given the lack of urgent operative injury patterns differentiated by YB class alone. This is a particularly attractive option, given the low rate of complications related to REBOA, as described in most recent reviews of its use,28,29 and the high rate of concomitant injuries altering initial management identified on CT as described in our data.

Previous work has explored the association of YB class with clinical outcomes including embolization, massive transfusion, and overall resuscitation requirement, multiorgan failure, and mortality.10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 However, there is a paucity of data focusing on YB-associated injury complexes associated with the need for urgent procedural or operative intervention. Our analysis indicated a higher rate of REBOA placement in patients with VS vector of injury and higher rates of urgent operative intervention for pelvis or abdominal hemorrhage control in patients with CM vectors of injury. These data support previous work by the American Association for the Surgery of Trauma, which found that among pelvic fracture patients with shock on admission, VS pattern was associated with higher need for pelvic fracture hemorrhage control.14 However, notably, these interventions for hemorrhage control were common across all groups.

While the results of this study’s cluster analysis did not identify unique injury complexes which merit urgent surgical intervention by YB class, the univariate analysis on overall injuries associated with YB class supports previous orthopedic and trauma literature focused on the association of pelvic ring injury classifications and concomitant injuries. Lateral compression was the most common vector of injury in our study, as has been described in other literature,14,18,30 and was associated with chest injuries and rib fractures. This supports previous work linking LC to thoracic injuries.15,21 Dalal et al.15 reviewed 343 polytrauma patients with major pelvic ring disruption and found a higher rate of pulmonary injury with LC fractures as compared to other YB classifications. Similarly, in a review of 1248 patients with pelvic fractures at a single level-1 trauma center, Manson et al.12 found higher chest AIS was associated with LC fractures. Our study also found an association between VS injuries and lumbar spine fractures, supporting previous work, which describes a higher rate of sacral and lumbosacral plexus injuries with VS pelvic fractures.31, 32, 33 Understanding the higher probability of lumbar spine injuries and quickly diagnosing them is essential, as the presence of lower lumbar fractures may be the only indication of anterior ring injury and independently predict instability.34,35 Additionally, sacral fractures, which often present neurologically intact and can be missed on plain imaging radiologic evaluation, pose significant morbidity if left untreated.36,37 Similar to the difficulty in diagnosing sacral fractures, pancreatic injuries can be difficult to detect early in polytrauma patients. Our study links a higher rate of pancreatic injuries with CM pelvic ring injury vectors, with 15% of CM patients presented with pancreatic injury; therefore, in severely injured patients with pelvic ring injuries, providers should have a lower threshold to consider an occult pancreatic injury, in particular if a patient worsens clinically after initial resuscitation in the ICU.

There are several limitations to this work. First, while this is an in-depth description of all severely injured pelvic ring injury patients over several years, we are limited to a relatively small sample size; therefore, there is a possibility of both type I and type II error. Based on the observed differences in interventions for hemodynamic instability in the CM group (38%), to determine a 10% difference between YB groups, it would require a sample size of 692 patients to reach a power of 0.8 and an alpha level of 0.05. Secondly, while we had an experienced group of orthopedic surgeons review each patient’s individual radiographs, we did not have multiple reviewers for each image, allowing for potential bias from inconsistency of pelvic ring injury classification. However, previous literature suggests high rate of interrater reliability of the YB classification system.8,9 Lastly, our results must be interpreted within historical context of our institution since REBOA was not extensively used until 2014, and as such, this may skew our perception of the relationship between YB classes and REBOA association.

In conclusion, while there are common concomitant injuries associated with YB class, this study did not identify unique injury complexes which merit urgent or inpatient operative intervention. Nearly one in four patients had injuries identified on initial trauma whole body scan which merited urgent operative intervention and changed initial management. These results demonstrate the importance of early, full body CT imaging in severely injured patients with pelvic ring injuries prior to fixation of pelvic fractures or interventions for definitive bleeding control. Based on these results, we recommend zone 3 REBOA placement for patients with major pelvic ring injuries who remain hemodynamically unstable after pelvic binding to allow completion of full body CT scanning before definitive control of pelvic bleeding to identify and address concomitant urgent injuries.

Author contribution

Coleman, Moore, Rojas Vintimilla, Parry, and Mauffrey were involved in study conception and design. Coleman, Rojas Vintimilla, Mauffrey, and Nelson were involved in data collection. Coleman, Moore, Rojas Vintimilla, Parry, Sauaia, Cohen, and Mauffrey were responsible for data analysis and interpretation. Coleman, Rojas Vintimilla, Nelson, Moore, and Mauffrey were involved in the literature review and manuscript drafting. Coleman, Moore, Rojas Vintimilla, Nelson, Samuels, Parry, Sauaia, Cohen, Mauffrey, and Burlew were involved in critical manuscript revisions.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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