During the study period, a total of 2112 patients sustained traumatic pelvic injuries of which 1814 (85.9%) had traumatic pelvic fractures (11.1%) of total trauma admissions in Qatar and 13% of Germany total trauma admissions. Table 1 shows the demographic characteristics, mechanisms of injury, associated injuries, injury severity scores, clinical presentation, ED dispositions and clinical outcomes of pelvic fracture patients in the study cohort. The male to female ratio was 3:1 and the majority (76.5%) were males (88.2% in Qatar and 55.4% in Germany) and the mean age was 41.2±21.1 years (32.1±14.3 in Qatar and 57.4±21.6 in Germany). The most common mechanisms of pelvic fracture were traffic-related 59% [motor vehicle crashes (27.9%), pedestrian injury (28.0%), ATV (1.5%), 1.5% for motorcycles and bicycles), followed fall from height (32.8%), while fall of heavy objects was involved only in 6.6% cases. Figure 1 shows the overall study design.
The associated injury by region frequently involved chest (37.3%) followed by the spine (31.6%), abdomen (27.4%) and extremities (lower 26%, upper 27%); while the head injury was associated in 18.2% cases.
Figure 2 demonstrates the distribution of associated injuries with pelvic fracture. The chest injuries such as rib fractures (27%), lung contusion (22%), pneumothorax (13%), hemothorax (7%) and hemopneumothorax (5%) were most commonly associated followed by SOI (22%), bowel/mesenteric injuries (4.3%), and hematomas (8.7%).
The mean ISS was 16.5±13.3 (15.8±10.6 in Qatar and 17.7±16.9 in Germany), RTS was 7.23±1.38; the Head AIS was 3.3± 1.3. The majority were presented with blood pressure and oxygen saturation within the normal range but with a high mean heart rate (96 b/min) and respiratory rate of 20 breath per minute. Positive FAST was seen in 11%, blood transfusion was needed in 34.5% (38.1% in Qatar and 27.8% in Germany) and in 10.6% it reached the massive transfusion limit of 10 units over 24 hours. The majority of the fractures (65%) were treated conservatively while 35% underwent surgical treatment (reduction and fixation open or closed external fixation).
With regard to ED disposition; more than half of patients were admitted to regular trauma ward and a quarter needed trauma ICU admission; the majority were treated initially conservatively while 19% needed immediate transfer to Operation Theater for life-saving interventions. The common in-hospital complications were pneumonia (6.5%), sepsis (3.2%), ARDS (3.0%), and AKI (2.4%). The frequency of other complications such as DVT (0.8%), PE (0.5%) and multi-organ failure (0.7%) was very low. The median length of mechanical ventilation and ICU stay was 5 days and the median hospital stay was 15 days. Eighty-six patients died with an overall in-hospital mortality of 4.7% (5.0% in Qatar and 4.3% in Germany).
Table 2 shows the clinical characteristics and outcomes by types of pelvic fractures. The pelvic fracture pattern based on Tiles classification was available in 1228 (67.7%). Tile A (60%) was most frequently observed followed by Tile B (30%) and Tile C (10%). There were 284 patients having acetabular fractures; of which 273 were isolated acetabular fractures and hip dislocation in 8 patients. Falls was the most common mechanism in all pelvic ring fracture types followed by pedestrian mostly had type A and MVC in type B while fall of heavy objects was more common in tiles C (P=0.001 for all). The associated injuries mainly chest, spine and abdomen showed significant association with type C (P=0.001). Also, patients with Tile C were more likely to have higher ISS, pelvis AIS, chest AIS, abdomen AIS and lower GCS ED (p<0.001 for all); in comparison to Tile A and B.
Elevated shock index (≥ 0.8) was found in 61.5% of tile C compared to 47% in tile B and 38.5% in Tile A (p=0.001). The need for blood transfusion (P=0.001), MTP (P=0.001), intubation (P=0.001) and surgical intervention (P=0.001) were also greater in patients with Tile C.
With respect to in-hospital complications, patients with Tile B showed a higher association with pneumonia (P=0.01) whereas, the rate of sepsis, ARDS, AKI and DVT (P=0.001 for all) were significantly higher in Tile C group. Also, patients with Tile C had prolonged hospital stay (P=0.001) with the highest in-hospital mortality (13%) as compared to Tile A (3.2%) and Tile B (4.7%; p=0.001).
Table 3 compares the clinical characteristics and outcomes of pelvic fracture patients by hemodynamic status. Hemodynamically unstable patients tended to be younger in age, sustain more associated injuries, severely injured (higher ISS, higher AIS, lower GCS, and lower RTS (P=0.001 for all) as compared to stable patients. Also, unstable patients were more likely to have unstable pelvic fractures i.e. Tile B and C and had a higher rate of intubation, positive FAST, in-hospital complications, greater need for blood transfusion, and MTP (p=0.001) and had prolonged mechanical ventilation, ICU and hospital stay (p=0.001) than the stable group. On the other hand, stable patients were more likely to be male, frequently had Tile A (p=0.001) and acetabular fracture (p=0.004) as compared to the unstable group. The rate of mortality was significantly higher in the hemodynamically unstable group (9.1% vs. 1.4%; p=0.001) (82.4% males and 17.6% females) as compared to the stable group (90% males and 10% females).
In Qatar, during the study period, the angiography and subsequent angioembolization were performed in 65 patients. The most commonly involved vessel was the internal iliac artery (50 cases), while the other embolized vessels were the pudendal, sacral and other unnamed arteries with immediate satisfactory results and a smooth course. Data on arterial embolization is not available at the German institution. If needed, it can be transferred to a cooperating hospital and sent back after intervention but this is not the daily routine.