DOI: https://doi.org/10.21203/rs.3.rs-1604358/v1
Background: Pelvic fractures are often associated with other injuries, and in our study, pelvic fractures associated with humeral fractures were the most common. We pooled patient data to analyze the independent risk factors for pelvic fractures associated with humeral fractures.
Methods: A retrospective study was conducted on the clinical data of 254 patients with pelvic fractures admitted to the Department of Orthopedics of Chengdu Fifth People’s Hospital, from August 2017 to August 2021. Independent sample T test found that pelvic fractures combined with humeral fractures were statistically significant. The main outcome indicators of pelvic fracture combined with humeral fracture were as follows: Tile classification of pelvic fractures, number of humeral fractures and Injury Severity Scale (ISS); Secondary outcome indicators: gender, age, body mass index (BMI), cause of injury, underlying diseases, etc. Single factor analysis was performed to screen risk factors for each indicator, and logistic analysis was used to determine independent risk factors for indicators with P < 0.05.
Results: Of the 254 patients with pelvic fractures, 24 (9.45%) were associated with humeral fractures, much higher than other single injuries, and only pelvic fractures associated with humeral fractures were statistically significant (P=0.014). Pelvic fractures without concomitant humeral fractures (n=230) and pelvic fractures with concomitant humeral fractures (n=24) were associated with age (P=0.006; 95% CI = 0.087-0.665; OR=10.258), ISS score (P=0.002; 95% CI = 1.839-4.445; OR=8.721), Tile scores (P=0.01; 95% CI = 22.554-87.419; OR=22.736), but there was no statistical significance in gender (P=1.03), BMI (P=0.437) and injury cause (P=3.04).
Conclusion: The combination of pelvic fracture and humerus fracture was statistically significant, and age > 60 years old, pelvic fracture Tile B2 classification above and high ISS were the independent risk factors for humerus fracture in pelvic fracture. Therefore, in clinical work, when clinicians treat patients with pelvic fractures aged > 60 years old, Tile B2 type above classification of pelvic fractures and high ISS, they should be highly vigilant about whether the humerus fractures are accompanied.
Pelvic fractures are mostly caused by high energy injuries, such as falling from a height or car collision caused by fractures, pelvic fractures accounted for 2.8%. In addition, 20% of multiple trauma patients with blunt trauma also had pelvic injury[1]. Of all musculoskeletal injuries, pelvic fractures are considered to be the leading cause of death and morbidity. According to statistics, the incidence of pelvic fracture accounted for 1%~3% of the total number of systemic fractures, its disability rate was 50%~60%, and its fatality rate was as high as 10%~25%[2, 3]. The mortality associated with open unstable pelvic fractures is approximately 20%, while the mortality associated with open fractures alone is approximately 50%. The incidence of pelvic fractures is reported to be 17–37/100,000 persons/year, and the incidence of high-energy pelvic fractures is reported to be 10/100,000 persons/year. High energy pelvic fractures have traditionally been considered serious injuries, leading to a mortality rate of 47% in patients with multiple trauma[4]. In Rothenberg et al. 's study of 31 open pelvic injuries, the reported mortality was 42%[5].
Because the patient of pelvic fracture is often traumatized by great violence, often the serious trauma of other organization and organ is combined, the incidence rate of shock is as high as 30% above. However, once hemodynamic instability occurs after injury, it can significantly increase the mortality of patients. Death rates in patients reporting shock, such as Starr, can be as high as 57%[6]. However, for non-severe pelvic fractures, clinicians tend to pay attention to the complications related to pelvic fractures in addition to the fracture itself, which is easy to cause serious consequences and affect the subsequent diagnosis and treatment [7].Therefore, considering the high energy forces of pelvic injury, it is crucial to anticipate other related injuries in different body parts and systems. In addition, the assessment of patients with traumatic pelvic injury should not be taken lightly and the injury should not always be treated as an isolated case. Up to 60% of patients with pelvic injuries have long bone fractures, spinal fractures, head injuries, abdominal organ injuries or nervous system injuries[1, 5, 8, 9]. Proximal humeral fractures are common, accounting for 4.6% of all fractures. They are mostly related to osteoporosis, with 78% of fractures occurring in older patients over the age of 65[10, 11].
When a pelvic fracture is associated with a humerus fracture, the pain of the humerus fracture may not be obvious because the patient is bedridden and has little movement of the upper limb. Therefore, when pelvic fracture combined with humeral fracture, orthopedic surgeons and patients tend to pay more attention to the pelvis and easily ignore the humerus, resulting in missed diagnosis and delayed treatment, resulting in serious consequences. To clarify the clinical characteristics and risk factors of patients with pelvic fracture combined with humeral fracture is of great clinical significance for early detection and timely treatment of humeral fracture. Therefore, this study aims to retrospectively study the patients with pelvic fracture admitted to our department in recent 3 years, analyze the risk factors of pelvic fracture combined with humerus fracture, and provide evidence-based medical evidence for clinicians to be vigilant of combined humerus fracture when treating patients with pelvic fracture.
In this retrospective study, we collected 254 patients with pelvic fractures who were treated at Department of Orthopedic Surgery, Chengdu Fifth People’s Hospital from August 2017 to August 2021. This study has been approved by the Medical Ethics Committee of Chengdu Fifth People’s Hospital, and all patients were informed of the risks and benefits of the trial, gave their consent and signed an informed consent. The outcome indicators were measured on the Neusoft PACS. Inclusion criteria: ① Pelvic fractures with a clear history of trauma; ② Complete clinical and imaging materials (X - ray and 3D-CT). Exclusion criteria: ① Pathological fracture; ② Old pelvic fracture or old humeral fracture; ③ Pelvic fracture and humeral fracture are not the same injury; ④ The accuracy of the results is affected by factors such as inability to judge or incomplete data.
Data were collected by two independent investigators, including general baseline information (gender, age, body mass index (BMI), cause of injury, and underlying disease), imaging data (pelvic X-ray and 3D-CT, humeral X-ray and 3D-CT), and injury severity score (ISS). The pelvic fractures were Tile typed and recorded by two independent, senior physicians based on the patient's radiographic data and counted by a third independent investigator (Fig. 1). In the event of inconsistent results, the decision will be made jointly by the three independent investigators. Main outcome measures: Tile classification of pelvic fractures, number of humeral fractures, and ISS.
Secondary outcome measures: gender, age, BMI, cause of injury, underlying diseases, etc.
Gender, age, BMI, ISS, cause of injury and Tile classification of pelvic fracture were used as independent variables, and pelvic fracture combined with humeral fracture was used as dependent variables (Fig. 1). See Table 1 for the assignment of variables. The independent T test was first used for univariate analysis (Table 3), and then the screened variables with P < 0.05 were analyzed by logistic analysis to determine risk factors. P < 0.05 was considered to be statistically significant. SPSS 23.0 (IBM Corp., USA) software was used for statistical analysis.
A total of 254 patients were included in this study, including 133 males, accounting for 52.36%; 121 cases were female (47.64%). The age range was 10–91 years, with an average of 50.6 years. Among the injury causes, 115 cases were car accident injury, 79 cases were fall injury, 48 cases were high fall injury, 12 cases were crush injury. There were 143 cases with BMI > 25Kg/m2 and 111 cases with BMI < 25Kg/m2. Tile classification of pelvic fractures: 116 cases of type A, 85 cases of type B and 53 cases of type C (Table. 3).
There were 24 patients with pelvic fracture combined with humeral fracture, accounting for 9.45% of all combined injuries, far higher than other patients with single combined injuries, and only pelvic fracture combined with humeral fracture had statistical significance (P = 0.014) (Table. 2), indicating the correlation between pelvic fracture combined with humeral fracture. Age (P = 0.01), fracture Tile classification (P = 0.02), ISS score (P < 0.01), but there was no statistical significance in gender (P = 1.03), BMI (P = 0.437) and injury cause (P = 3.04) (Table 3). It is suggested that age, fracture Tile classification and ISS are the risk factors of pelvic fracture combined with humerus fracture, while gender, BMI and injury cause have little influence on the incidence of pelvic fracture combined with humerus fracture.
In logistic analysis of pelvic fracture combined with humerus fracture, age, ISS and fracture Tile classification score were taken as independent variables, and pelvic fracture combined with humerus fracture was taken as dependent variables to analyze the independent risk factors of pelvic fracture combined with humerus fracture. The results showed that age (P = 0.006; 95%CI = 0.087–0.665; OR = 10.258), ISS (P = 0.002; 95%CI = 1.839–4.445; OR = 8.721), fracture Tile classification scores (P = 0.01; 95%CI = 22.554–87.419; OR = 22.736) is a risk factor for pelvic fracture combined with humeral fracture. BMI (P = 0.627; 95%CI = 0.524–2.88; OR = 1.381) was not a risk factor for pelvic fracture combined with humeral fracture. Logistic analysis showed that age > 60 years old, Tile B2 type or above and high ISS were independent risk factors for pelvic fracture complicated with humeral fracture. Therefore, clinicians should be highly alert to whether humeral fractures occur at the same time in patients with pelvic fractures > 60 years old, Tile B2 type or above and high ISS (Table. 4).
A retrospective study was conducted on the clinical data of 254 cases of pelvic fracture hospitalized in the department of Orthopedics of our hospital from August 2017 to August 2021. Univariate and Logistic analysis of risk factors showed that: Age > 60 years, Tile type B2 or higher, and high ISS were independent risk factors for pelvic fracture complicated with humerus fracture, while BMI, injury cause, and gender were not independent risk factors for pelvic fracture combined with humerus fracture. In this study, we retrospectively collected nearly three years of 254 patients with pelvic fractures were admitted in our hospital orthopedics, among them, 24 cases of pelvic fractures combination with humerus fracture, for most of all a single combined injury, and after the single factor analysis respectively, statistically significant only the pelvic fractures combination of humerus fracture. This discovery has not been mentioned in previous literature reports[1, 2, 4–10, 12–23]. The results of counting the causes of injuries show that there are 115 cases of car accidents, 79 cases of falls, 48 cases of high falls and 12 cases of crush injuries. The injury mechanism was analyzed, and it was found that when patients suffered from pelvic fracture, most patients would fall to the ground on the side, resulting in shoulder or elbow joint landing, resulting in humeral fracture. Shoulder joint landing is common, so the probability of proximal humeral fracture is high[19]. On the basis of screening out that pelvic fracture combined with humeral fracture accounts for the highest proportion in all single pelvic fracture combined injuries, and has statistical significance, we also made logistic analysis on the related risk factors of pelvic fracture combined with humeral fracture. In logistic analysis, we tested the likelihood ratio test (LR), odds ratio (OR), confidence interval (95%CI), probability (P) and other indicators, thus avoiding the error caused by single indicator analysis.
Why age, ISS score and Tile score of pelvic fracture would be independent risk factors was analyzed by referring to a large number of literatures, and the results are as follows:
1. Age factor
In the data analysis of Table. 2, we found that the probability of humeral fracture combined with injury in patients with pelvic fracture over 60 years old (P = 0.006; 95%CI = 0.087–0.665; OR = 10.258) was significantly larger than that of patients with pelvic fracture aged < 60 years. This may be related to patients' old age, poor bone condition and brittle fracture after osteoporosis. Court-Brown et al.[13] reported the findings of a 5-year prospective epidemiological study of 1,027 proximal humeral fractures in Edinburgh, UK. Humeral fractures in patients aged 65 years account for 73% of all humeral fractures, with the highest incidence occurring in women aged 80–89 years and less than 20% of fractures occurring in patients younger than 50 years. Breuil et al.[23] found through a large number of epidemiological studies that the incidence of senile osteoporotic pelvic fractures is related to age and gender: there are more women than men, and the incidence increases with age. After the elderly patients with pelvic fracture and humeral fracture, because the elderly are not sensitive to pain, the patients stay in bed for a long time after the fracture, and there are not many opportunities for upper limb exertion. When the proximal humeral fracture (Neer type I or II) occurs, the humeral shaft is intact, and the upper limb movement is only slightly limited, clinicians tend to ignore the existence of pelvic fracture and injuries, and miss the diagnosis of humeral fracture[16]. In order to avoid missed diagnosis, it is particularly important to ask the patient's medical history and physical examination at the time of admission. Elderly patients should also take into account the sensitivity and responsiveness to pain and the mental state after injury, and have a careful physical examination[3].
2. Injury severity score (ISS)
ISS fully reflected the intensity of violence at the time of injury, and the statistical results of this group (P = 0.002; 95%CI = 1.839 4.445; OR = 8.721) showed that the greater the degree of trauma, the higher the incidence of humeral fractures in patients with pelvic fractures (Table. 4). When the body is subjected to violence, on the one hand, individuals instinctively extend their upper limbs for support, and the violence reaches the upper arm through conduction, which may lead to a humeral fracture. On the other hand, as the protruding part of the body, the bilateral shoulders are more vulnerable to the impact of the violence that causes the humeral fracture at the moment when the trauma force causes the body to fly out and touch the ground. When the shoulder joint is dislocated, proximal humerus fractures are likely due to rotator cuff pull [10]. Bao-guo Jiang et al.[11] believed that there are two age peaks in patients with humeral fracture, which are around 30 years old and over 60 years old respectively, and humeral fracture around 30 years old is mostly caused by high-energy injury.
3. Tile classification score of pelvic fracture
In this group, the pelvic fractures were classified by Tile B2 or above (P = 0.01; 95%CI = 22.554–87.419; OR = 22.736) is significantly higher than that of patients with Tile B2 or below (Table. 4). After analyzing the injury mechanism of patients corresponding to the Tile scores of each pelvic fracture, it was found that the injury mechanism was firstly directly related to the great violence suffered by the body during the trauma[9]; Secondly, in patients with high Tile classification of pelvic fractures, the violence suffered by trauma is often not unidirectional, and multi-directional violence is more likely to cause multiple fractures, while humeral fractures have the highest incidence among pelvic fractures combined with injuries[24]. In clinical work, patients with severe pelvic fractures are often combined with hemodynamic instability and damage to the thoracic and abdominal internal organs, which is life-threatening. at this time, saving life is the first element[4]. Patients often enter the intensive care unit for treatment after thoracic, abdominal or craniocerebral operations, while orthopedic treatment is often the last treatment to exclude other combined injuries. At this time, it is more likely to miss the diagnosis of fractures in other parts with unclear malformations[17]. Therefore, for severe pelvic fractures, when we pay attention to the pelvic fractures and life-threatening combined injuries, we should also pay attention to the timely detection of non-fatal combined injuries, such as humerus fractures, and early treatment, so as to strive to achieve the best curative effect for patients[12].
In this study, the clinical data of 254 cases of pelvic fractures in the past three years were collected and analyzed by univariate and logistic analysis, but there are still many shortcomings. First, this study is a single center, which can only represent the situation of patients with pelvic fractures in this area, but can't cover all the risk factors. Secondly, the sample size is relatively small, which has the disadvantage of insufficient sample size, and the collected data may have selective deviation; Third, the accuracy of the definition of the assignment of some variables needs further evaluation; Fourthly, this study is a retrospective study and does not further track the treatment and prognosis of patients, which has an impact on the authenticity of the results. Therefore, a multi-center, long-term prospective study combined with multiple hospitals is needed in order to provide more convincing evidence. Also, is there a statistical significance of pelvic fractures with other single injuries as the sample size increases? And are there other independent risk factors for pelvic fractures combined with humerus fractures? These all need to be further studied before they can be confirmed.
The combination of pelvic fracture and humerus fracture was statistically significant, and age > 60 years old, pelvic fracture Tile B2 classification above and high ISS were the independent risk factors for humerus fracture in pelvic fracture. Therefore, in clinical work, when clinicians treat patients with pelvic fractures aged > 60 years old, Tile B2 type above classification of pelvic fractures and high ISS, they should be highly vigilant about whether the humerus fractures are accompanied.
Table. 5 List of abbreviations
|
The full name |
abbreviations |
|
injury severity score |
ISS |
|
body mass index |
BMI |
Ethics approval and consent to participate
This study has been approved by the Medical Ethics Committee of Chengdu Fifth People’s Hospital. All patients were informed of the risks and benefits of the trial, gave their consent and signed an informed consent.
Consent for publication
All participants in the study agreed to the publication of the paper.
Availability of data and materials
All the data were from the Department of Orthopedic surgery of Chengdu Fifth People's Hospital. Therefore, all data and materials in this article are available.
Competing Interests
The authors declare that they have no competing interest.
Funding
This work was supported by Scientific research project of Sichuan Provincial Health and Family Planning Commission（grant No. 18PJ480）.
Authors' contributions
Xing Chen, Zhengjiang Li and Yan Zhang were responsible for the design of the study, Zhengjiang Li, Shuxing Xing, Yongkui Li and Shunqiang Li are responsible for data collection, sorting and analysis. Zhengjiang Li, Xing Chen and Haibo Ji were responsible for the writing and revision of the paper.
Acknowledgements
Thanks to all the medical staff of orthopedics department of Chengdu Fifth People's Hospital for their contribution to the data collection of the study.
Tables 1 to 4 are available in the Supplementary Files section.