Abstract
Purpose
In Bangladesh the incidence of pelvic fracture is increasing day by day due to suboptimal roads and heavy traffic. However, there is no epidemiological study of these injuries in Bangladesh. Our aim was to study the epidemiology of patients admitted with pelvic fractures at two tertiary care hospital in Dhaka, Bangladesh.
Methods
This was a prospective study carried out on trauma patients with pelvic fracture at two level 1 trauma care center of two tertiary care hospital in Dhaka, Bangladesh. The study period was from July 2015 to June 2019 (48 months). Patient’s data including demography of patients, mechanism of injuries, fracture types, associated injuries, method of treatment, post-operative complications, length of hospital stay were recorded according to a unified protocol.
Results
The study population was comprised of 696 patients, where 556 (79.88%) were male and 140 (20.12%) were female. Mean age was 37.75 years and road traffic accidents were the most common mode of injuries. Lateral compression fractures were the most common injuries and Urethral injuries were the most common associated injuries. Death was the outcome in 3.5% of the cases due to high energy trauma.
Conclusion
This study revealed that pelvic fractures were significantly more frequent in men. Most frequent cause was road traffic accident. The majority of these cases did not required surgery. Mortality was associated with high velocity trauma with severe injuries.
Keywords: Pelvic fractures, Epidemiology, Type of fractures, Treatment, Tertiary care center
1. Introduction
Pelvic fractures constitute about 1.5%–3% of all skeletal injuries as it is the most severe & life-threatening orthopedic injuries,1 The most common cause of pelvic fracture are high energy trauma with road traffic accidents (RTAs) and other causes are falls from height, and fall of heavy objects, etc.2 Patients with pelvic fracture frequently have associated multiple systemic injuries, adding to the overall morbidity & mortality. Incidence of pelvic injuries higher in male rather than female and occur in younger age groups.3, 4, 5, 6 Pelvis is the ring formed by the fused bones of the ischium, ilium and pubis attaches to the sacrum which contains vital structures, major blood vessels and nerves and digestive and reproductive organs. Major pelvic fractures can be fatal, mainly due to blood loss. Major pelvic fractures often associated with a number of complications that may require extensive rehabilitation. Pelvic trauma deaths frequently occur as a result of associated injuries and complications rather than the pelvic injury itself.7
In Bangladesh the incidence of pelvic fracture is increasing day by day due to increased number of accidents due to suboptimal roads and heavy traffic. But there is no epidemiological study regarding pelvic injuries in Bangladesh. Our aim was to study the epidemiology of patients admitted with pelvic fractures at two tertiary care hospital in Dhaka, Bangladesh.
2. Materials and methods
Type of Study: This was a prospective Study.
Duration of Study: Four years from July 2015 to June 2019.
Sample Size: 696 cases of pelvic fracture.
Study Methodology: This was a prospective study carried out on trauma patients with pelvic fractures from July 2015 to June 2019 at two level 1trauma care Centre in Dhaka, Bangladesh. One is Dhaka Medical College Hospital. It is a 5000 bed government hospital in Dhaka. Another one is Lab Aid Specialized Hospital in Dhaka. It is one of the largest private hospital in Dhaka.
2.1. Inclusion criteria
All trauma patients aged ≥18 years.
2.2. Exclusion criteria
1) Age below <18 years, 2) Pathological Fractures, 3) Patients absconding from hospital after admission, 4) Patients who lost follow –up, 5) Patients brought dead.
Patients data were recorded according to a unified protocol. Data collected regarding demography of patients, mechanism of injury, fracture types, associated injuries, method of treatment post-operative complications, length of hospital stay, mortality of patients. Patients were received by emergency department, evaluated and resuscitated according to ATLS protocol. After addressing life threatening injuries X-ray pelvis AP view, chest x-ray PA view and A FAST examination was done to find out the source of bleeding. Pelvis was rapidly stabilized with a sheet or commercial pelvic binder. Unstable pelvic fractures are managed by early application of external fixator. Hemodynamic status of the patients were corrected by following ATLS protocol. If open pelvic fracture was diagnosed or suspected broad spectrum antibiotics was given. Severely injured patients with unstable hemodynamic and unstable pelvic fracture were monitored closely in Pre-ICU and or ICU. After stabilization of hemodynamic secondary survey was done to rule out associated injuries proper history and physical examination was done to find out co-morbidity. X-ray of pelvis Inlet and outlet view, CT scan of pelvis with 3 D reconstruction was done.
Pelvic fractures were classified according to Young and Burgess classification8 Which were as follows;
Types of injuries: Lateral compression injury (LC), antero-posterior compression (APC), Vertical shear (VS), and combined mechanism (CM). LC injuries were further divided into LC 1, LC-2, LC-3,; APC injuries into APC 1, APC-2, APC-3. among these APC -1 and LC-1 were considered stable injuries and were treated conservatively. ents, for whom conservative management was contemplated, either due to stable fracture patterns or due to presence of severe associated injuries preventing surgical intervention, were advised to take rest for 6 weeks, with pelvic binder or skeletal traction according to the fracture pattern and morphology.
2.3. Statistical analysis
Statistical analysis was carried out using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, version 17.0 for Windows) and the Chi-square test done to compare qualitative variables. Values of P lower than 0.05 were taken to indicate significant differences. Our local ethics committee approved this prospective study.
3. Result
A total of 32,120 trauma cases were presented during study period, out of which 795 had sustained pelvic injuries comprising 2.47% of total cases. Out of these patients, 28 were died before operation due to severe injuries.16 patients were escaped from hospital, and 25 patients denied treatment in our hospital, 30 patients did not come to follow –up, so excluded from study. Total 696 patients were evaluated from July 2015 to June 2019. (48 months). Among these 556 (79.88%) were male and 140 (20.12%) were female. In men prevalence of pelvic fracture was significantly higher (p < 0.001). Mean age was 37.75 ± 13.4 years. (Range 18–85 years). The most common cause of injury was road traffic accident (n = 595,85.48%) (Table 1) which is significantly more in men (n = 523). In the mechanism fall from own height 90% 0f the individual were female. (Table 2) Occurrence of hospitalization due to pelvic fractures increased over the years (Fig. 1). There was no difference on prevalence between the months of the year. And we have noticed that maximum 250cases admitted in two tertiary care hospitals between the years of July 2018 to June 2019. Most of the fractures were LC type (n = 327, 47%), followed by APC type (n = 230, 33%), 66 patients (95%) had closed fracture and 35 patient (5%) had open fracture. (Fig. 2) Pelvic fractures were part of polytrauma in most of the cases, These patient had an average ISS score of 25 points. Associated injury were found in 313 (45%) cases. Associated orthopedic injury were in lower limb 90 cases. (12.93%). fracture shaft of tibia and fibula were most commonly involved. Urethral injury found in 112 cases (16.09%) cases which is the most common non orthopedic injury associated injury. Femoral vessel injury in 5 cases which needed amputation of the limb. Urethral injury was the most common in LC type injury, rectal injury in APC type injury. (see Table 2, Table 3)
Table 1.
Distribution of mechanism of injury of the study patients.
| N | Percentage | |
|---|---|---|
| Bus accident | 231 | (33.18%) |
| Motorcycle accident | 180 | (25.86% |
| Car accident | 148 | (21.26%) |
| Truck accident | 30 | (4.31%) |
| CNG driven 3 wheeler | 6 | (.86%) |
| Fall from own height | 66 | (9.48%) |
| Fall from height More than 12 feet | 20 | (2.87%) |
| Fall of heavy object | 15 | (2.15%) |
The following injury mechanism were observed.
Table 2.
Association of mode of injury with the gender of the study patients.
| Mode of injury | Male (n = 556) No. (%) |
Female (n = 100) No. (%) |
p-value |
|---|---|---|---|
| RTA | 523 (94.1%) | 72 (51.4%) | <0.001∗ |
| Other than RTA | 33 (5.94%) | 68 (48.6%) |
Chi-square test, ∗significant.
Fig. 1.
Occurrence of hospitalization due to pelvic fractures.
Fig. 2.
Distribution of pelvic fracture according to Young Burgess classification.
Table 3.
Associated injury.
| Number of cases | |
|---|---|
| No associated injury | 383 |
| With associated injury | 313 |
| a) Orthopedic injury | |
| Lower limb fracture | 90 |
| i) Fracture neck of femur | 4 |
| ii) Fracture of shaft of femur | 10 |
| iii) Tibial platue fracture | 20 |
| iv) Patella fracture | 5 |
| v) Open fracture tibia and fibula | 6 |
| vi) Closed fracture tibia and fibula | 30 |
| vii) Calcanian fracture | 15 |
| Upper limb fracture | 50 |
| I) Clavicle fracture | 15 |
| II) Humerus fracture | 8 |
| III) Radius ulna fracture | 15 |
| IV) Distal radius fracture | 12 |
| Acetabulum fracture | 60 |
| Sacral fracture below 1stscaral vertebra | 20 |
| Spine fracture | 10 |
| Mandibular fracture | 8 |
| b) Non orthopedic | |
| i) Urethral injury | 112 |
| ii) Ruptures bladder | 4 |
| iii) Chest injury | 50 |
| iv) Head injury | 25 |
| v) Blunt abdominal trauma | 45 |
| vi) Morel-Lavallee lesion | 40 |
| vii) Perineal injury/rectal | 15 |
| viii)Femoral vessel injury | 5 |
3.1. Observation
48% pelvic fracture cases didn’t require emergency intervention (Fig. 3). Remaining 52% cases were managed by emergency interventions which are as follows: anterior ex-fix – 105 cases (15%); laparotomy −25 cases (3%); chest decompression 40 cases (6%); external fixator for open fracture tibia −6 cases (1%); suprapubic catheter - 116 cases (17%); upper tibial skeletal traction-68 cases (10%). Regarding treatment 362 (52%) patient were treated conservatively. 334 (48%) surgically (Fig. 4). In LC group 2 25 patient had severe injury and co-morbidity, In APC group 2 and 3 12 cases had colostomy. So they were treated by Ex-fix. 20 patients were unfit for anesthesia. In vertical shear and combined mechanism group 12 patients were treated conservatively due to wound over incision site. The interval between presentation and surgery was observed to be 12 days on average (minimum 2 days maximum 40 days) (Fig. 5) Among 334 cases treated surgically 104 (31.13%) were operated on within 10 days. 197 (58.98%) within 11–20 days. rest 33 patient (9.88) due to presence of severe injury needed to be fit for anesthesia operated after 20 days. The surgery to standing time was 35 days on average (range 7–120 days) (Fig. 5). Per and Post-operative complications of operated patients (334):Various complications were noted. surgical site infection-14, Death-0., Intra articular screw-1,DVT-1, Hemorrhagic shock- 8, Bladder injury-10 Vascular injury-(corona mortes)-2, Brocken plate - 2 anterior ring plate Screw pull out- 5 cases, loss of both anterior ring and posterior ring fixation in 4 cases. The average hospital stay was 25 days (range 2–60 days). APC 3, VS, Combined mechanism injuries were required care at Pre –icu and or ICU. During study period, 795 had sustained pelvic injuries comprising 2.47% of total cases. Out of these 28 patients had died before operation due to severe injuries. Mortality rate was 3.5%. There were no per or post operative death.
Fig. 3.
Shows distribution of emergency intervention among the cases.
Fig. 4.
Distribution of treatment pattern of the cases.
Fig. 5.
Distribution of interval between fracture presentation and surgery.
4. Discussion
In our center total of 32,120 trauma cases were presented during study period, out of which 795 had sustained pelvic injuries comprising 2.47% of total cases. In a study Suvojit et al.,2 it has reported an incidence 2.8% less in and around authors tertiary care Centre. The mean age was 37.75 ± 13.4 years and range 18–85 years. Kobbe et al.9 reported a mean age of 47.3 years in their study. Jezek and Dzupa,10 in an epidemiological study on pelvic fracture had reported a slightly higher mean age (51 years); . Chueire et al.11 presented in their study Only the mean age of their cases (37 years) was similar to the present study.
In our study we have seen pelvic fractures were significantly higher in men (79.88%) in comparison to female (20.12%). Chueire et al.,11 in an epidemiological study, reported a larger number of males with ring injuries (67%); Alnaib et al.12 assessed only pelvic ring injuries due to low-energy trauma (osteoporotic bones) and found a higher incidence in females. In the present study we have noticed that in the point of mechanism of injury RTA (85.48%) significantly more in men in 523 cases than women (72 cases). Devarinos et al.13 indicated that the most frequent injury mechanism was RTA (74%). Chueire et al.11 reported a very similar percentage to that observed in the present study; in their study, pelvic ring injuries were caused by car accidents in 23% of cases (21.26% in the present study) and by motorcycle accidents in 19% (25.86% in the present study). But in present study bus accident is the commonest cause 231 cases (33.18%), This was because bus accident was very common in Bangladesh due to sub-optimal road, over speeding, over taking, reckless driving, unfit vehicle, violence of traffic rule/signs. In the mechanism fall from own height 90% of the individual are female in this present study. Jezek and Dzupa et al.,10 in their study mentioned that common fall from height was the most frequent cause of this type of injury in the elderly and, of those, females were the most affected. Simple falls and that high-energy trauma are infrequent causes in the patients with osteoporosis.14 We have noticed that maximum 250 cases were admitted in two tertiary care hospitals between the years of July 2018 to June 2019. Regarding the classification of pelvic fracture (Young and Burgess) following were observed in our study most of the fractures were LC type (n = 327, 47%), followed by APC type (n = 230, 33%), 661 patients (95%) had closed fracture and 35 patient (5%) had open fracture. We have used Young and Burges classification system.8 In present study these patients have an average ISS score of 25 points. In a study association of the severity of ring injuries with age was assessed and reported that the most serious injuries (including bone exposure) usually affect young adult males as a result of RTA.15 In the present study we have noticed that in the point of mechanism of injury RTA (85.48%) Pelvic fractures were part of poly trauma in most of the cases, associated injury were present in 313 (45%)cases. 383 (55%) cases were purely pelvic fracture cases. Maximum associated orthopedic injury were lower limb fracture cases (12.93%) and fracture shaft of tibia fibula. Among non-orthopedic injuries urethral injuries were in 112 cases (16.09%). We have observed that these associated injuries were in combination. Urethral injuries were most common in LC type injury, rectal injury in APC type injury. Higher percentage of cases of other injuries associated with pelvic ring fractures than of isolated fractures which is not similar to our results; 54% of their cases showed some type associated involvement.11 Sagi et al.16 in a study of serious injuries of the pelvic ring (vertical instability), observed concomitant injuries in 36.2% of patients and found bladder rupture as the most common injury associated with this type of ring injury which is not similar to our study. Most common associated injury was –lower limb fractures 17.6%, second most common injury was upper limb fractures 14.3% and Third Most common associated injury was –urethral injury 12.7%.17 In present study 48% pelvic fracture cases didn’t require emergency intervention. Remaining 52% cases were managed by emergency interventions which were as follows: anterior ex-fix 105 cases (15%), laparotomy – 25 cases (3%), chest decompression 40 cases (6%), external fixator for open fracture tibia −6 cases (1%), suprapubic catheter −116 cases (17%), upper tibial skeletal traction-68 cases (10%). According to Gilberto José et al.18 in the great majority (83.3%) of cases there was no need for urgent intervention. In cases where these interventions were made were orthopedic interventions like the use of C-clamp and anterior external fixator. An emergency intervention rate of 32% in their cases of pelvic ring fractures; orthopedic interventions and laparotomy were the most frequent.11 Balogh et al.19 in an epidemiological study of ring injuries, reported that 15% of the cases of high-energy trauma required emergency ring fixation. In turn, Pisanis et al.20 assessed in their study that only 3.4% of patients underwent emergency orthopedic procedures; of these, the C-clamp was most often used. Brum et al.21 in a study on serious injuries to the pelvic ring that included only polytrauma patients, reported that in 35% cases required emergency ring fixation, whether with C-clamp or another method. Regarding treatment 362 (52%) patient were treated conservatively. 334 (47.98%) surgically. In LC group 2, 25 patients had severe injury and co-morbidity, In APC group 2 and 3, 12 cases had Colostomy for which they were treated by Ex-fix. 20 patients were unfit for anesthesia. In vertical shear and combined mechanism group 12 patient were treated conservatively due to wound over incision site 63.6% cases underwent non-surgical treatment.18 Chueire et al.11 in their series of pelvic ring injuries, had presented a slightly smaller percentage of patients who underwent surgical treatment (29%) in comparison to our present study. The interval between presentation and surgery was observed to be 12 days on average (minimum 2days maximum 40 days) among 334 surgically treated cases 104 (31.13%) were operated within days. 197 (58.98%) within 11–20 days. rest 33 patients (9.88) due to presence of severe injury needed to be fit for anesthesia operated after 20 days. Interval between presentation and surgery was documented to be 9.67 days on average; minimum 1 day and maximum 37 days.2
In our present study 334 patients underwent surgery. Among them 287 had no complications. However, remaining 47 cases developed complications. These were surgical site infection-(14), Death-(0). Intra articular screw-(1), DVT-(1)Hemorrhagic shock-(8), Bladder injury-(10) Vascular injury-(corona mortes)-(2), Brocken plate –(2). Anterior ring plate Screw pull out- (5 cases), loss of both anterior ring and posterior ring fixation in (4 cases). According to M boudissa et al.22 in the ORIF group,D VT (9%, 14 patients), screw malposition within the joint cavity (7.6%, 12 patients), nerve injuries (5.7%, 9 patients), and hemorrhagic shock related to multiple injuries (5.7%, 9 patients).
In our present study the average hospital stay was 25days (range 2–60 days). APC 3, VS, Combined mechanism injury needed care at Pre –icu and or ICU. According to Subhajit et al.2 in his study the mean hospital stay was 14.4 days. In literature [0.6–8.] length of hospital stay was recorded same. The surgery to standing time was 35 days on average (range 7–120 days). A total of 32,120 trauma cases presented during study period, out of which 795 had sustained pelvic injuries comprising 2.47% of total cases. Out of these 28 patient died before operation due to severe injuries. Mortality rate is 3.5%. Gilberto José et al.18 the author emphasized the association of these rates with concomitant injuries and the severity of the ring injury and observed, the cases of death were ring injuries types B or C with severe associated injuries. Mortality observed in the Literature23,24 ranges from 2% to 46% which was dependent on severity of the ring injury, whether trauma was of high energy, and on the presence of associated injuries. Richard and Tornetta25 in a study on serious injuries of the pelvic ring, reported a mortality rate of 6.8%. which was very similar to literature by Chueire et al.11 Our treatment protocol was dependent on Pelvic fracture stability and hemodynamic status of the patient as well as with associated injury and co-morbidity. Today there has been an improvement in the overall care for polytrauma patients, skilled training and experience of the orthopedic staff, both in emergency procedures and in the definitive treatment of pelvic ring injuries playing important role to lower the mortality rate which was observed in the present work. We have very few pelvi-acetabular surgeon.
In Bangladesh we have no previous study on epidemiology on pelvic fractures. Though this study was done in two center in Dhaka, it does not represent whole Bangladesh. So we need further Multicenter study to find out the actual picture of pelvic fracture epidemiology and their management.
5. Conclusions
From the presented data, it could be concluded as the sample represented the Dhaka region and its surrounding, since this was not multicenter study. Predilection of these injuries to young male adults is high which has economic impact especially, on developing nation. In general, most common mechanism of injury is RTA. Most of the fractures were LC type. Most injuries do not need emergency intervention Mortality was associated with high velocity trauma with severe injuries. Among the associated injuries, Urethral injury was most common. Non-surgical treatment was the most common; Deaths occur in unstable fractures with severe associated injuries. Proper road safety training and driving regulations and extensive training to general Orthopedic surgeon are needed to decrease accident, morbidity and mortality of pelvic fractures.
Funding
Nill.
Ethical statement
This study has been approved by the local ethics committee and informed consent has been obtained from all the patients or their relatives.
Declaration of competing interest
The authors declare no conflicts of interest.
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