This clinical trial was done on 47 patients with pelvic fracture who were unstable according to their hemodynamic evaluations. Among them 25 patients were managed by packing in pre-peritoneal portion, while 22 ones were treated by preperitoneal pack and external fixator. The patients were similar in demographic data including age and gender. This similarity can increase the internal validity of our study, because mortality and complications can rise in older patients. In both groups the main gender were males and this significant data also helped us to generalize our data because of most of the people who were evaluated due to pelvic fracture are males. In a new survey which was done to evaluate the unstable pelvic fractures in Taiwan the majority of patients were males and the most age specific group in this investigation was reported between 46–65 years old (14). Our data was similar to this and other appropriate studies in according to the mean age and gender of participants.
Mean of Injury Severity Score (ISS) was measured 23.12 ± 9.85 and 19.22 ± 8.09 in Pelvic Pack group and PPP plus external fixator group, respectively. This score was approximately similar to Schweigkofler et al. (15). Mean of hospital stay was not significant between two different types of operations. Malik et al reported the hospital stay more than 9 days for their cases. This study estimated the length of hospital stay less than our study (16). The patients in Malik study were managed by fixator and it may be the cause of difference between its hospital stay and ours. There was no significance between types of surgery and changing in values of BUN and creatinine. Some studies (17, 18) reported the acute kidney injury as an important complication in pelvic fracture who are unstable, but because of operation in all of patients in our study the prevalence of AKI was rare.
There was a significant difference between groups (P-Value = 0.017, LR = 6.42) in according to mortality rate. This result shows that using Pre-peritoneal packing with external fixator is more effective to decrease mortality rate in comparison with pre-peritoneal packing alone. In case group, the patients divided into two groups according to the time of external fixator replacement. In 6 patients the external fixator was placed within 2 days and in 16 ones the surgery was done after 2nd day of admission. One Mortality was reported in patients who were treated by external fixator within first 48 hours of admission, while it was not reported in cases who treated after 48 hours of admission.
Cothren and et al. declared that PPP is a fast manner for preventing hemorrhagic shock due to pelvic fracture and this treatment can be completed by angiography. Need of blood and its production transfusion and mortality rate was dramatically decreased after this type of surgery (4). Guthrie et al. mentioned that embolization via angiography was not a rapid way to control homeostasis in some medical centers and pelvic packing is able to decrease blood loss. Packing may be placed either retroperitoneal or pre-peritoneal. They believed that using external fixator can magnify the effects of packing in bleeding control (19).
Ertel et al. reported 20 patients with unstable situation due to pelvic fracture because of multiple trauma in a prospective investigation. They used hemoglobin, hematocrit and lactate to compare hemorrhagic shock in these patients. They found that pelvic packing with external fixator placement can be a more useful method to control bleeding (20). Roman Pavic and et al. concluded that the most effective therapeutic method for treatment of pelvic fracture is using external fixator or C-Clamps for immobilization. They declared that embolization can be used if these methods do not work (21). Artoni et al reported that Pelvic fractures due to multiple trauma which was managed by early surgical operation can be more effective and has less reduction in quality of life (22). This study was different about our study; they believed that early surgery as soon as possible can affect outcomes, while mortality was not reported in patients who were operated after 48 hours. This maybe because of using pack cell and hydration in our management which may better the outcome and decrease the mortality rate.
VTE was reported 12% and 4.5% in PPP group and PPP plus fixator ones, respectively. There was not significant in VTE reports, too. Many studies mentioned that VTE is a prevalent complication among individuals who had hemodynamic instability due to pelvic fracture (23, 24). In this study common morbidity and mortality rate of two different therapeutic approaches were investigated in patients with pelvic fracture and unstable hemodynamic state. AKI, infection and VTE were not significantly different between two types of treatment. Our study declared that pre-peritoneal pelvic pack with external fixator was more effective in decreasing mortality rate in comparison to pre-peritoneal pelvic pack without any fixator. The investigation did not mention the best time for place external fixator. According to data from our study and similar investigations which were discussed above, using external fixator along with pre-peritoneal packing can be more useful in controlling blood loss and decreasing mortality rate. One of our unique methodology was dividing placement of external fixator into two groups; within 48 hours and after 48 hours. Results did not show any relation between time of fixation and mortality rate.