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Laparotomy and unstable pelvic fractures
Injury, Int. J. Care Injured (2008) 39, 853—857
www.elsevier.com/locate/injury
Laparotomy and unstable pelvic fractures J.K. Bryceland, J.F. Keating * Royal Infirmary of Edinburgh, Scotland, United Kingdom Accepted 3 December 2007
KEYWORDS Pelvic fracture; Laparotomy; Blunt abdominal trauma
Summary The requirement for laparotomy was analysed in 91 patients with unstable pelvic fractures. Laparotomies were classified as positive or negative. Injuries found at laparotomy were compared with the pelvic fracture pattern. Laparotomy was carried out in 28 patients but was unnecessary in 8. Eleven of the 28 patients died, a mortality of 39%. Vertical shear and combined mechanical injury pelvic fracture patterns had the highest incidence of abdominal injuries (28%) but the fracture pattern was not a reliable guide to the presence or nature of intra-abdominal injury. Inadequate preoperative investigations contributed to the eight negative laparotomies and three of these patients died. Laparotomy was only necessary in 22% of our patients. Major pelvic fractures with concomitant intra-abdominal injuries have a high mortality rate. Preoperative CT scanning was 98% accurate in the identification of intra-abdominal injury and was the most useful investigation for determining the need for laparotomy and minimising the risk of negative laparotomy. # 2007 Elsevier Ltd. All rights reserved.
Introduction The large forces required to cause major unstable pelvic fractures mean that while they are relatively uncommon injuries, there is a high incidence of severe concomitant injuries. Patients are often hypotensive on presentation, making the initial clinical evaluation very difficult.9,10,5 There is particular difficulty in abdominal evaluation in this situation. * Corresponding author at: Department of Orthopaedic Trauma, Royal Infirmary, Little France, Old Dalkeith Road, Edinburgh EH16 4SU, Scotland, United Kingdom. Tel.: +44 131 242 3436; fax: +44 131 242 3467. E-mail address: [email protected] (J.F. Keating).
Diagnostic tools such as diagnostic peritoneal lavage (DPL)11,1 and ultrasonography (US)7,5 are sensitive but non-specific for the presence of intra-abdominal injury. Computerised tomography (CT)4,8 is the most accurate investigation but may be impractical in a haemodynamically unstable patient. The decision regarding the indication to perform laparotomy is therefore often difficult. There are limited data in the published literature in relation to the need for laparotomy in pelvic fractures. Clearly laparotomy to deal with abdominal visceral injury is necessary, but the procedure in patients with pelvic fractures is not without risk. Experimental studies have shown laparotomy in pelvic fracture can contribute to an increase in pelvic volume, contributing
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.12.001
854 to haemodynamic instability.2 Other studies record a high mortality in patients undergoing laparotomy in conjunction with unstable pelvic fractures.12 The aim of the present study was to define the need for laparotomy to deal with intra-abdominal injury in patients with unstable pelvic fractures.
Patients and methods We evaluated 91 consecutive patients with unstable pelvic fractures admitted to our unit during the period 1995—2005. The royal infirmary of Edinburgh is the sole trauma unit for treatment of all fractures in the Lothian region. Tertiary referral cases are referred regularly from other centres in south-east Scotland and elsewhere. The accident and emergency department operates a dedicated emergency ambulance for rapid retrieval of patients involved in high-energy trauma that covers the south-east of Scotland region. Following admission patients are assessed and managed in accordance with the ATLS system of emergency care. Relevant expertise from general surgery, cardiothoracic surgery and interventional radiology is available on site. All data were collected prospectively. Information including age, sex, mechanism of injury, investigations and surgical interventions were recorded on a database specifically for this purpose. The database was then used to identify which of these patients had received a laparotomy, and in how many of these patients laparotomy had been deemed necessary. Details, which were omitted from the database initially, were retrieved from patient records. In particular we wanted to define the spectrum of intraabdominal injuries and whether these had any relationship to the most commonly used classification of fracture pattern. In addition we wanted to determine in what proportion of these patients the procedure was deemed to be necessary. Finally we intended to identify any factors, which may help determine whether a patient requires a laparotomy following a major unstable pelvic fracture. The patients’ fractures were categorised by the pelvic fracture classification proposed by Young et al.,13 where pelvic fractures fit into one of four groups, which relate injury mechanism to the pattern of disruption and probable associated injuries:
Anteroposterior compression (APC). Lateral compression (LC). Vertical shear (VS). Combined mechanical injury (CMI).
The case notes for the patients in the study group were analysed with emphasis on evaluation on
J.K. Bryceland, J.F. Keating investigations leading to the decision to proceed with laparotomy. The laparotomies were classified as either negative or positive, depending on the surgeon’s findings at the time of operating. A positive laparotomy was defined as one which was deemed necessary given the nature of the patient’s abdominal injuries. The term negative laparotomy described those operations where no significant abdominal injuries were found, or if the disruptions found would not in themselves have required a laparotomy, for example, a self-limiting retroperitoneal haematoma or minor mesenteric bleeding. The subgroup of patients, whose laparotomies were categorised as positive, was studied in greater detail, recording the abdominal injuries found in each at laparotomy and comparing these with the pattern of pelvic fracture according to the Young et al. classification. The case records of patients who underwent what were later deemed to have been unnecessary laparotomies were studied with emphasis on the preoperative investigations, as well as indicators of their overall condition including Glasgow coma scale and whether or not they were hypotensive (systolic blood pressure below 100 mm/Hg). This information was then compared with that of the group with positive laparotomies and analysed to derive the best predictors for the requirement of laparotomy following an unstable pelvic fracture.
Results Over the 11-year period (1995—2005), there were 77 males and 14 females, with a mean age of 39 years (range, 14—84 years). The origin of patients was variable with 57 coming from the Edinburgh area, 21 coming from elsewhere in Scotland, 11 from elsewhere in the United Kingdom and 1 from foreign patient. The most common mechanism of injury was a road traffic accident (Table 1). The median injury severity score of the 91 patients was 30 (range 9— 75) and 40 patients (43%) were hypotensive at the time of presentation. There was a significant head injury in 19 patients and a significant intrathoracic injury in 31 patients, which contributed to the injury severity score. Of the 91 patients, 16 died, an overall mortality rate of 18%. Using the Young et al. classification,13 the incidence of each fracture type and the requirement for laparotomy is given in Fig. 1. Of the 91 patients, 28 underwent laparotomy and 20 of these laparotomies were positive. This gives an overall laparotomy rate of 31%, of which 71% were positive and 29% were negative. The mortality rate of the patients undergoing laparotomy was 36%. Of
Laparotomy and unstable pelvic fractures
855
Table 1 Mechanisms of injury Mechanism of injury
No. of patients
Incidence rate (%)
Mortality rate (%)
RTA Motor vehicle Motorbike Cyclist Pedestrian
29 13 2 12
31.9 14.3 2.2 13.2
13.8 7.7 0 25.0
Fall from a height Crush injury
26 9
28.6 9.9
19.2 33.3
20 patients with positive laparotomies, 9 died. However 3 of 8 patients whose laparotomies were negative also died. If the negative laparotomies are excluded, the positive, and therefore required laparotomy rate was significantly lower in lateral compression type fractures ( p < 0.05) than in the other fracture patterns. There was no significant difference between the positive laparotomy rates for APC, VS or CMI patterns of fracture. The injury severity score of patients undergoing positive laparotomy (median 36, range 16—75) was significantly ( p < 0.01) higher than those in whom laparotomy was not performed (median 20, range 9—75). The difference in ISS for patients having a negative laparotomy (median 32, range 16—68) was also higher than those in whom laparotomy was not performed although the difference was not quite significant ( p < 0.07). There was no significant difference in the ISS of patients with negative laparotomies (median 32, range 16—68) compared with positive laparotomies (median 36, range 16—75; p = 0.4).
lavage, one had a positive ultrasound scan and one had persistent haematuria. Six positive laparotomies were carried out in APC injuries. One of these patients died. Abdominal injuries were confined mainly to the bladder and urethra, though one patient sustained a bowel injury (Table 2). Three positive laparotomies were carried out in lateral compression fractures. There were two diaphragmatic ruptures and one urethral injury. The requirement of laparotomy in these fractures was low–—only 3 patients of 30 lateral compression injuries had a laparotomy (Table 2). None of these patients died. Vertical sheer and combined mechanical injuries accounted for a large proportion (11/20) of patients with abdominal injuries found on laparotomy, and were grouped together since all of the CMI fractures had a vertical shear component on one side. The abdominal injuries found at laparotomy were more variable than for the other fracture types, with injuries to the spleen, kidneys and a high proportion of bladder and urethral injuries (Table 2). Six of the 11 patients in this group died, a mortality of 55%.
Positive laparotomies Negative laparotomies Twenty positive laparotomies were performed. In these patients preoperative CT scans were performed in 15 (75%), all of which were positive for intra-abdominal injury requiring intervention. In the five patients who did not have a preoperative CT scan, three had a positive diagnostic peritoneal
Figure 1
Incidence and laparotomy rate of fractures.
Eight patients underwent a negative laparotomy and three of these died. There were two APC, three LC and three VS/CMI fracture patterns. Of these 8 patients, 5 (63%) did have a preoperative CT scan compared with 42 (51%) of the other 83 patients in the study. Three patients who underwent negative laparotomy had a CT scan. In two of these patients, the CT scan was negative for intra-abdominal injury, but one had a laparotomy because of hypotension and the other had a laparotomy because of persistent haematuria. In the third patient, the CT scan was thought to suggest a bowel injury although this was not definite and the laparotomy was performed on that basis. No bowel injury was discovered. In the remaining five patients, three had at least one positive abdominal investigation, which was considered to be an indication for laparotomy (Table 3). Of the eight patients with negative lapar-
856
J.K. Bryceland, J.F. Keating
Table 2 Abdominal injuries associated with pattern of pelvic fracture Fracture type APC
LC
VS
CMI
Age
Sex
43 22 52 45 14 53
M M M M F M
33 21 25
F M M
39 53 25 34 25 29 27 30 43
M M M M M M M M M
34 17
M M
Abdominal injury Urethra
Bladder
+ +
+ + +
Bowel
Spleen
Diaphragm
Kidney
Arterial
+ + + + + + + + +
+ +
+ + +
+
+ +
+ indicates presence of urethral, visceral or arterial injury and
otomy, five were hypotensive and this was the main clinical indication for performing the procedure. The five patients who did not receive a CT scan were all treated prior to 1998. There were 39 patients treated between 1995 and 1998, 13 of whom underwent laparotomy, and 5 (38%) of these were negative. Of 52 patients treated between 1999 and 2005, 15 underwent laparotomy, though only 3 (20%) of these were negative. The rate of negative laparotomy has therefore decreased during the study period. In the entire series there were a total of 47 CT scans carried out. There were no false negative scans. One scan as indicated suggested a possible bowel injury, which was not confirmed at laparotomy. This gives a false positive rate of 2%.
+ +
indicates absence of visceral or arterial injury.
The sensitivity of CT scanning was therefore 100% and the specificity 97% with an overall accuracy of 98%.
Discussion The overall laparotomy rate in unstable pelvic fractures in this study was 31%. However, almost a third of these were negative and only 22% of patients actually required a laparotomy. The laparotomy rate varied with the fracture type. Anterior posterior compression fractures, vertical shear and combined mechanical injury patterns had laparotomy rates of 28—29%. In contrast the laparotomy rate in
Table 3 Abdominal investigations in patients with negative laparotomies Fracture type
Age
Sex
Abdominal investigations CT
DPL
Ultrsound
Haematuria
APC
84 38
F M
0 +
0 0
0 0
LC
18 42 25
M M M
0 0
0 + 0
65 29 40
M M M
0 0
0 + 0
VS
GCS
Hypotensive
0 0
3 15
+
0 0 0
0
6 15 4
+
0 0 0
+ +
5 6 15
+ + +
0 indicates investigation not performed, + indicates a positive result and
+
indicates a negative result.
Laparotomy and unstable pelvic fractures lateral compression fractures was much lower at only 10%. The classification we used was developed to predict the pattern of pelvic disruption associated with a particular injury mechanism and also the likely associated soft tissue injuries. However, in our series, there was considerable variation in the type of intraabdominal injury encountered. The pelvic fracture type was not helpful in predicting either the need for laparotomy or nature of the intra-abdominal injuries sustained. However more severe abdominal injuries were observed in vertical shear fractures and combined mechanical injuries, which contributed to a higher mortality in patients with these injury patterns. Overall, the most commonly injured internal structures were the urethra and the bladder, due to their close relationship to disrupted bony anatomy. There were a number of decision-making errors contributing to the decision to carry out a negative laparotomy. CT scanning was used less frequently in these patients and two scans negative for intraabdominal pathology were disregarded incorrectly because of persistent hypotension. Earlier on in the study period there was a greater reliance on DPL and ultrasound, which were are less accurate investigations. Although CT scanning is considered a timeconsuming investigation, a modern CT scanner is capable of very rapid imaging of head, chest, abdomen and pelvis and is the investigation of choice unless the patient has profound life-threatening hypotension. Major pelvic fractures are uncommon,6 and although this study looked at a relatively large cohort of 91 patients, the 28 patients who underwent laparotomy is a relatively small subgroup. With larger numbers of patients it is possible that the patterns of associated injuries noted by Young et al.13 might have been more obvious. However the findings in our study indicate that the relationship between pelvic fracture pattern and intraabdominal injury proposed by the Young et al. classification lacks specificity.
Conclusions Laparotomy was required in approximately one fifth of patients with unstable pelvic fractures. The pattern of pelvic fracture does not reliably predict the need for laparotomy or intra-abdominal findings, but VS/CMI patterns are more likely to result in intra-abdominal injuries requiring laparotomy.
857 Preoperative CT scanning is the most accurate investigation for evaluation of abdominal injury and more widespread use of this in the preoperative phase of assessment should reduce the number of negative laparotomies performed in these patients. Other abdominal investigations are not as reliable, and hypotension alone was not an indication for laparotomy.
Conflict of interest The authors have no conflict of interest to declare.
References 1. Fischer RP, Beverlin BC, Engrav LH, et al. Diagnostic peritoneal lavage: fourteen years and 2586 patients later. Am J Surg 1978;136(December (6)):701—4. 2. Ghanayem AJ, Wilber JH, Lieberman JM, Motta AO. The effect of laparotomy and external fixator stabilisation on pelvic volume in an unstable pelvic injury. J Trauma 1995;38(March (3)):396—400. 4. Low R, Duber C, Schweden F, et al. Whole body spiral CT in primary diagnosis of patients with multiple trauma in emergency situations. Rofo Fortsher Geb Rontgenstr Neuen Bildgeb Verfahr 1997;166(May (5)):382—8. 5. Mackersie RC, Tiwary AD, Shackford SR, Hoyt DB. Intraabdominal injury following blunt trauma. Arch Surg 1989;124(July (7)):809—13. 6. Pehle B, Nast-Kolb D, Oberbeck R, et al. Significance of physical examination and radiography of the pelvis during treatment in the shock emergency room. Unfallchirurg 2003;106(August (8)):642—8. 7. Porter RS, Nester BA, Dalsey WC, et al. Use of ultrasound to determine need for laparotomy in trauma patients. Ann Emerg Med 1997;29(March (3)):323—30. 8. Roberts JL. CT of abdominal and pelvic trauma. Semin Ultrasound CT MRI 1996;17(April (2)):142—69. 9. Rothenberger D, Fisher R, Strate R, et al. The mortality associated with pelvic fractures. Surgery 1978;84(September (3)):356—61. 10. Schurink GW, Bode PJ, Van Luijt PA, Van Vugt AB. The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study. Injury 1997;28(May (4)):261—5. 11. Souzuer EM, Akyurek N, Kafali ME, Yildirim C. Diagnostic peritoneal lavage in blunt abdominal trauma victims. Eur J Emerg Med 1998;5(June (2)):231—4. 12. Varney M, Fischer I, Becker H, et al. Additional intra-abdominal injuries in multiple-traumatized patients with pelvic fractures. Difficulties in diagnosis and therapy. Aktuelle Traumatol 1990;20(October (5)): 226—30. 13. Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology 1986;160(August (2)):445—51.
www.elsevier.com/locate/injury
Laparotomy and unstable pelvic fractures J.K. Bryceland, J.F. Keating * Royal Infirmary of Edinburgh, Scotland, United Kingdom Accepted 3 December 2007
KEYWORDS Pelvic fracture; Laparotomy; Blunt abdominal trauma
Summary The requirement for laparotomy was analysed in 91 patients with unstable pelvic fractures. Laparotomies were classified as positive or negative. Injuries found at laparotomy were compared with the pelvic fracture pattern. Laparotomy was carried out in 28 patients but was unnecessary in 8. Eleven of the 28 patients died, a mortality of 39%. Vertical shear and combined mechanical injury pelvic fracture patterns had the highest incidence of abdominal injuries (28%) but the fracture pattern was not a reliable guide to the presence or nature of intra-abdominal injury. Inadequate preoperative investigations contributed to the eight negative laparotomies and three of these patients died. Laparotomy was only necessary in 22% of our patients. Major pelvic fractures with concomitant intra-abdominal injuries have a high mortality rate. Preoperative CT scanning was 98% accurate in the identification of intra-abdominal injury and was the most useful investigation for determining the need for laparotomy and minimising the risk of negative laparotomy. # 2007 Elsevier Ltd. All rights reserved.
Introduction The large forces required to cause major unstable pelvic fractures mean that while they are relatively uncommon injuries, there is a high incidence of severe concomitant injuries. Patients are often hypotensive on presentation, making the initial clinical evaluation very difficult.9,10,5 There is particular difficulty in abdominal evaluation in this situation. * Corresponding author at: Department of Orthopaedic Trauma, Royal Infirmary, Little France, Old Dalkeith Road, Edinburgh EH16 4SU, Scotland, United Kingdom. Tel.: +44 131 242 3436; fax: +44 131 242 3467. E-mail address: [email protected] (J.F. Keating).
Diagnostic tools such as diagnostic peritoneal lavage (DPL)11,1 and ultrasonography (US)7,5 are sensitive but non-specific for the presence of intra-abdominal injury. Computerised tomography (CT)4,8 is the most accurate investigation but may be impractical in a haemodynamically unstable patient. The decision regarding the indication to perform laparotomy is therefore often difficult. There are limited data in the published literature in relation to the need for laparotomy in pelvic fractures. Clearly laparotomy to deal with abdominal visceral injury is necessary, but the procedure in patients with pelvic fractures is not without risk. Experimental studies have shown laparotomy in pelvic fracture can contribute to an increase in pelvic volume, contributing
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.12.001
854 to haemodynamic instability.2 Other studies record a high mortality in patients undergoing laparotomy in conjunction with unstable pelvic fractures.12 The aim of the present study was to define the need for laparotomy to deal with intra-abdominal injury in patients with unstable pelvic fractures.
Patients and methods We evaluated 91 consecutive patients with unstable pelvic fractures admitted to our unit during the period 1995—2005. The royal infirmary of Edinburgh is the sole trauma unit for treatment of all fractures in the Lothian region. Tertiary referral cases are referred regularly from other centres in south-east Scotland and elsewhere. The accident and emergency department operates a dedicated emergency ambulance for rapid retrieval of patients involved in high-energy trauma that covers the south-east of Scotland region. Following admission patients are assessed and managed in accordance with the ATLS system of emergency care. Relevant expertise from general surgery, cardiothoracic surgery and interventional radiology is available on site. All data were collected prospectively. Information including age, sex, mechanism of injury, investigations and surgical interventions were recorded on a database specifically for this purpose. The database was then used to identify which of these patients had received a laparotomy, and in how many of these patients laparotomy had been deemed necessary. Details, which were omitted from the database initially, were retrieved from patient records. In particular we wanted to define the spectrum of intraabdominal injuries and whether these had any relationship to the most commonly used classification of fracture pattern. In addition we wanted to determine in what proportion of these patients the procedure was deemed to be necessary. Finally we intended to identify any factors, which may help determine whether a patient requires a laparotomy following a major unstable pelvic fracture. The patients’ fractures were categorised by the pelvic fracture classification proposed by Young et al.,13 where pelvic fractures fit into one of four groups, which relate injury mechanism to the pattern of disruption and probable associated injuries:
Anteroposterior compression (APC). Lateral compression (LC). Vertical shear (VS). Combined mechanical injury (CMI).
The case notes for the patients in the study group were analysed with emphasis on evaluation on
J.K. Bryceland, J.F. Keating investigations leading to the decision to proceed with laparotomy. The laparotomies were classified as either negative or positive, depending on the surgeon’s findings at the time of operating. A positive laparotomy was defined as one which was deemed necessary given the nature of the patient’s abdominal injuries. The term negative laparotomy described those operations where no significant abdominal injuries were found, or if the disruptions found would not in themselves have required a laparotomy, for example, a self-limiting retroperitoneal haematoma or minor mesenteric bleeding. The subgroup of patients, whose laparotomies were categorised as positive, was studied in greater detail, recording the abdominal injuries found in each at laparotomy and comparing these with the pattern of pelvic fracture according to the Young et al. classification. The case records of patients who underwent what were later deemed to have been unnecessary laparotomies were studied with emphasis on the preoperative investigations, as well as indicators of their overall condition including Glasgow coma scale and whether or not they were hypotensive (systolic blood pressure below 100 mm/Hg). This information was then compared with that of the group with positive laparotomies and analysed to derive the best predictors for the requirement of laparotomy following an unstable pelvic fracture.
Results Over the 11-year period (1995—2005), there were 77 males and 14 females, with a mean age of 39 years (range, 14—84 years). The origin of patients was variable with 57 coming from the Edinburgh area, 21 coming from elsewhere in Scotland, 11 from elsewhere in the United Kingdom and 1 from foreign patient. The most common mechanism of injury was a road traffic accident (Table 1). The median injury severity score of the 91 patients was 30 (range 9— 75) and 40 patients (43%) were hypotensive at the time of presentation. There was a significant head injury in 19 patients and a significant intrathoracic injury in 31 patients, which contributed to the injury severity score. Of the 91 patients, 16 died, an overall mortality rate of 18%. Using the Young et al. classification,13 the incidence of each fracture type and the requirement for laparotomy is given in Fig. 1. Of the 91 patients, 28 underwent laparotomy and 20 of these laparotomies were positive. This gives an overall laparotomy rate of 31%, of which 71% were positive and 29% were negative. The mortality rate of the patients undergoing laparotomy was 36%. Of
Laparotomy and unstable pelvic fractures
855
Table 1 Mechanisms of injury Mechanism of injury
No. of patients
Incidence rate (%)
Mortality rate (%)
RTA Motor vehicle Motorbike Cyclist Pedestrian
29 13 2 12
31.9 14.3 2.2 13.2
13.8 7.7 0 25.0
Fall from a height Crush injury
26 9
28.6 9.9
19.2 33.3
20 patients with positive laparotomies, 9 died. However 3 of 8 patients whose laparotomies were negative also died. If the negative laparotomies are excluded, the positive, and therefore required laparotomy rate was significantly lower in lateral compression type fractures ( p < 0.05) than in the other fracture patterns. There was no significant difference between the positive laparotomy rates for APC, VS or CMI patterns of fracture. The injury severity score of patients undergoing positive laparotomy (median 36, range 16—75) was significantly ( p < 0.01) higher than those in whom laparotomy was not performed (median 20, range 9—75). The difference in ISS for patients having a negative laparotomy (median 32, range 16—68) was also higher than those in whom laparotomy was not performed although the difference was not quite significant ( p < 0.07). There was no significant difference in the ISS of patients with negative laparotomies (median 32, range 16—68) compared with positive laparotomies (median 36, range 16—75; p = 0.4).
lavage, one had a positive ultrasound scan and one had persistent haematuria. Six positive laparotomies were carried out in APC injuries. One of these patients died. Abdominal injuries were confined mainly to the bladder and urethra, though one patient sustained a bowel injury (Table 2). Three positive laparotomies were carried out in lateral compression fractures. There were two diaphragmatic ruptures and one urethral injury. The requirement of laparotomy in these fractures was low–—only 3 patients of 30 lateral compression injuries had a laparotomy (Table 2). None of these patients died. Vertical sheer and combined mechanical injuries accounted for a large proportion (11/20) of patients with abdominal injuries found on laparotomy, and were grouped together since all of the CMI fractures had a vertical shear component on one side. The abdominal injuries found at laparotomy were more variable than for the other fracture types, with injuries to the spleen, kidneys and a high proportion of bladder and urethral injuries (Table 2). Six of the 11 patients in this group died, a mortality of 55%.
Positive laparotomies Negative laparotomies Twenty positive laparotomies were performed. In these patients preoperative CT scans were performed in 15 (75%), all of which were positive for intra-abdominal injury requiring intervention. In the five patients who did not have a preoperative CT scan, three had a positive diagnostic peritoneal
Figure 1
Incidence and laparotomy rate of fractures.
Eight patients underwent a negative laparotomy and three of these died. There were two APC, three LC and three VS/CMI fracture patterns. Of these 8 patients, 5 (63%) did have a preoperative CT scan compared with 42 (51%) of the other 83 patients in the study. Three patients who underwent negative laparotomy had a CT scan. In two of these patients, the CT scan was negative for intra-abdominal injury, but one had a laparotomy because of hypotension and the other had a laparotomy because of persistent haematuria. In the third patient, the CT scan was thought to suggest a bowel injury although this was not definite and the laparotomy was performed on that basis. No bowel injury was discovered. In the remaining five patients, three had at least one positive abdominal investigation, which was considered to be an indication for laparotomy (Table 3). Of the eight patients with negative lapar-
856
J.K. Bryceland, J.F. Keating
Table 2 Abdominal injuries associated with pattern of pelvic fracture Fracture type APC
LC
VS
CMI
Age
Sex
43 22 52 45 14 53
M M M M F M
33 21 25
F M M
39 53 25 34 25 29 27 30 43
M M M M M M M M M
34 17
M M
Abdominal injury Urethra
Bladder
+ +
+ + +
Bowel
Spleen
Diaphragm
Kidney
Arterial
+ + + + + + + + +
+ +
+ + +
+
+ +
+ indicates presence of urethral, visceral or arterial injury and
otomy, five were hypotensive and this was the main clinical indication for performing the procedure. The five patients who did not receive a CT scan were all treated prior to 1998. There were 39 patients treated between 1995 and 1998, 13 of whom underwent laparotomy, and 5 (38%) of these were negative. Of 52 patients treated between 1999 and 2005, 15 underwent laparotomy, though only 3 (20%) of these were negative. The rate of negative laparotomy has therefore decreased during the study period. In the entire series there were a total of 47 CT scans carried out. There were no false negative scans. One scan as indicated suggested a possible bowel injury, which was not confirmed at laparotomy. This gives a false positive rate of 2%.
+ +
indicates absence of visceral or arterial injury.
The sensitivity of CT scanning was therefore 100% and the specificity 97% with an overall accuracy of 98%.
Discussion The overall laparotomy rate in unstable pelvic fractures in this study was 31%. However, almost a third of these were negative and only 22% of patients actually required a laparotomy. The laparotomy rate varied with the fracture type. Anterior posterior compression fractures, vertical shear and combined mechanical injury patterns had laparotomy rates of 28—29%. In contrast the laparotomy rate in
Table 3 Abdominal investigations in patients with negative laparotomies Fracture type
Age
Sex
Abdominal investigations CT
DPL
Ultrsound
Haematuria
APC
84 38
F M
0 +
0 0
0 0
LC
18 42 25
M M M
0 0
0 + 0
65 29 40
M M M
0 0
0 + 0
VS
GCS
Hypotensive
0 0
3 15
+
0 0 0
0
6 15 4
+
0 0 0
+ +
5 6 15
+ + +
0 indicates investigation not performed, + indicates a positive result and
+
indicates a negative result.
Laparotomy and unstable pelvic fractures lateral compression fractures was much lower at only 10%. The classification we used was developed to predict the pattern of pelvic disruption associated with a particular injury mechanism and also the likely associated soft tissue injuries. However, in our series, there was considerable variation in the type of intraabdominal injury encountered. The pelvic fracture type was not helpful in predicting either the need for laparotomy or nature of the intra-abdominal injuries sustained. However more severe abdominal injuries were observed in vertical shear fractures and combined mechanical injuries, which contributed to a higher mortality in patients with these injury patterns. Overall, the most commonly injured internal structures were the urethra and the bladder, due to their close relationship to disrupted bony anatomy. There were a number of decision-making errors contributing to the decision to carry out a negative laparotomy. CT scanning was used less frequently in these patients and two scans negative for intraabdominal pathology were disregarded incorrectly because of persistent hypotension. Earlier on in the study period there was a greater reliance on DPL and ultrasound, which were are less accurate investigations. Although CT scanning is considered a timeconsuming investigation, a modern CT scanner is capable of very rapid imaging of head, chest, abdomen and pelvis and is the investigation of choice unless the patient has profound life-threatening hypotension. Major pelvic fractures are uncommon,6 and although this study looked at a relatively large cohort of 91 patients, the 28 patients who underwent laparotomy is a relatively small subgroup. With larger numbers of patients it is possible that the patterns of associated injuries noted by Young et al.13 might have been more obvious. However the findings in our study indicate that the relationship between pelvic fracture pattern and intraabdominal injury proposed by the Young et al. classification lacks specificity.
Conclusions Laparotomy was required in approximately one fifth of patients with unstable pelvic fractures. The pattern of pelvic fracture does not reliably predict the need for laparotomy or intra-abdominal findings, but VS/CMI patterns are more likely to result in intra-abdominal injuries requiring laparotomy.
857 Preoperative CT scanning is the most accurate investigation for evaluation of abdominal injury and more widespread use of this in the preoperative phase of assessment should reduce the number of negative laparotomies performed in these patients. Other abdominal investigations are not as reliable, and hypotension alone was not an indication for laparotomy.
Conflict of interest The authors have no conflict of interest to declare.
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