Treatment Study for unstable pelvic ring fractures by external fixation = Nghiên cứu điều trị gãy khung chậu không vững bằng khung cố định ngoài (tóm tắt + toàn văn)

  MINISTRY OF EDUCATION AND TRAINING MINISTRY OF NATIONAL DEFENSE VIETNAM MILITARY MEDICAL UNIVERSITY NGUYEN NGOC TOAN STUDY ON TREATMENT UNSTABLE PELVIC RING FRACTURE BY EXTERNAL FIXATION Speciality: Orthopaedic Trauma and Reconstructive Surgery Code: 62 72 01 29 SUMMARY OF DOCTORAL MEDICAL DISSERTATION Hanoi - 2014 THE WORK HAS BEEN COMPLETED AT VIETNAM MILITARY MEDICAL UNIVERSITY Scientific instructors: Prof, PhD Nguyễn Tiến Bình Assoc Prof., PhD Phạm Đăng Ninh Opponent 1: Assoc Prof, PhD Đao Xuan Tich Opponent 2: Assoc Prof, PhD Lưu Hong Hai Opponent 3: Assoc Prof, PhD Nguyen Xuan Thuy The dissertation will be defended in presence of the University Level Dissertation Assessment Council At………… on……… References at: National Library of Vietnam Library of Vietnam Military Medical University Library of Cho Ray Hospital LIST OF SCIENTIFIC WORKS ANNOUNCING RESULTS OF THE DISSERTATION THEME Nguyen Ngoc Toan (2013); “Lesions characteristic of anatomy of unstable pelvic ring fractures”, Vietnam Medicine, Volume 408 (2), page 43 – 48 Nguyen Ngọc Toan, Pham Dang Ninh, Nguyen Tien Binh (2013); “Outcomes of treatment unstable pelvic ring fracture by external fixation”, Vietnam Medicine, Volume 409 (1), page 101 – 105 1   ABSTRACT Pelvic fractures are common injuries with a rate of 23-37/100.000 in one year According Failinger (1992), pelvic fractures account for - 3% of all fractures and approximately 2% of hospital admissions caused by trauma Demetriades (2002) and another study showed that pelvic fracture rates from to 9.3% of all fracture types including traumatic shock rate accounts for above 40% According to the statistics of Larry (1994), Ganssen (1996), Chueire (2004) and Barzilay (2005), Zsolt (2007), the pelvic fracture had percentage from 40 to 55.2% of the type of pelvic trauma This is seriously injured, complex, with high mortality rate, and especiallly, the number of pelvic trauma was as much as traumatic brain injuries, ranging from 10-20% of the pelvic fracture In particular, the group with open pelvic fractures have ratio from 20% to 50% In Vietnam, Ngo Bao Khang (1995) and Nguyen Duc Phuc (2004) reported rate of pelvic fractures account for 3-5% of all fracture types, but it had no statistics about mortality Using external frame to fix the pelvic fracture is very simple and safe, and this technique can be applied at where hospital have an orthopaedic specialist Many authors suggest that, as early pelvic fractures was fixed, pain relief will achieve effectively It’s helpful to control of bleeding and preventing traumatic shock injuries When fractures was fixed, patients have early mobilization and comfortable conditions that the wound was faster recovery In recent years, at the Department of Orthopaedic Trauma Cho Ray Hospital, orthopadics have treated patients with unstable pelvic fractures by frame outside the quadrilateral shape With this approach, pelvic has corrected for anatomy recovery relatively With this method, a treatment comes from clinical practice that we thought to anatomy characteristic injury of unstable pelvic fractures in order to improve efficiency and better treatment That is why we carried out the study: "Study on the treatment unstable pelvic ring fractures by external fixation" for two goals: Survey lesions characteristic of anatomy of unstable pelvic ring fractures Evaluation outcomes treatment of unsntable pelvic ring fractures by external fixation and commented some factors affecting treatment outcomes 2   Chapter I OVERVIEW 1.2 Pelvis Fracture Injury Pelvic fractures are usually divided into categories : - Open and closed fractures of the pelvis - Stable and unstable pelvic fractures - Partial fracture of the pelvis is small lesions such as iliac crest, pubic bone, ischium, sacrum or coccyx - Acetabular fracture is a particular fracture of the pelvis relating to the hip So the classification and treatment differ from pelvic fractures significantly Currently, the authors agree acetabular fractures classified as a separate type 1.2.3 Morphology pelvic fracture injury * Pelvic Injuries - Tile (1984, 2003) [147, 150], from the previous 70 years of the twentieth century, assessed anatomy of pelvic fractures were less intent in study because the majority of patients with pelvic fractures were used conservation treatments It is very little cases of surgical treatment and the studying on cadaver pelvic fracture basically - Malgaigne (1859) describes pelvic fractures in which anterior lessions (disruption of the symphysis, inferior and superior pubic) and posterior lession (vertical ileum disruption, SI joint dislocation), 1/2 pelvic displaced upwards by muscles contracting [96] Since 1980, people has started research on lesions of the pelvic fracture Along with the development of the internal fixation to treat pelvic fracture, and the type of fracture was made clearly - Buchholz (1981) [36] describe 47 cadaver dissections had pelvic fractures He shown anatomical lesions of the pelvic fracture which comprises posterior lession about 19 cases SI dislocation, cases sacral wing fractures, case iliac wing fracture, case trauma combined injury Anterior lession included 12 cases of bilateral pubic rami fractures, cases pubic rami fractures, symphysis pubis dislocation with cases and case with combined injury 3   The author argues that the exact location of the pelvic lesion assessment is not important as much as the level of the pelvis stable - In 1990, Young and Burgess have studied 210 cases of pelvic fracture (162 fractures of the pelvis and 48 case of acetabular fractures), anatomical lesions of the pelvic fracture was assessed by posture XQ (straight, Inlet, Outlet) The author’s classification based on mechanism of injury and kind of pelvic fracture stable, including types ( LC: 106 patients - 65.4 %; APC: 25 patients - 15.4 %; VS: patients - 5.6 %, CM : 11 patients - 11 6.8 % and 11 patients with iliac wing fractures - 6.8 %) Thereby, It is very important to predict complications and identify therapeutic strategies with different fractures Classification of Young and Burgess (1990) Based on the mechanism of injury, anatomical lesions and stable of the pelvis, the authors divide into pelvis fractures type: Figure 1.9 Classification of Pelvis Fracture according to Young & Burgess (1990 ) * Source : Tile M (2003 ) [150]   + Lateral Compression (LC): anterior injury rami fractures + Antero - Posterior Compression (APC): anterior injury = symphyseal diastasis/rami fractures + Vertical Shear (VS): vertical displacement of hemipelvis with symphyseal diastasis or rami fractures anteriorly; iliac wing or sacral fracture or SI dislocation posteriorly + Combined Mechanism (CM) any combination of above injuries * Status of pelvic instability Pelvic fractures were divided into two groups: stable and unstable pelvic ring fractures Evaluating this condition helps physicians predict the severity of the injury and provide appropriate therapeutic strategies Unstable pelvic fracture must have lost completely continuous ring at least location, losing pelvis stiffness [43], [150] Young and Burgess (1990) [35], Tile (1996, 1999, 2003) [148, 149, 150] and the other authors are unified perspective: unstable pelvic fracture is a bone fracture or pelvic joints dislocation (pubic rami fractures, symphysis pubis dislocation) in both posterior and anterior lessions, as a result one side or two sides of the pelvis deformation, displacement or rotation in both vertical and longitudinal - Unstable pelvic ring fracture incompletely (unstable in longitudinal, stable in vertical): external rotation fracture type (APC) and the internal rotation fracture (LC) - Unstable pelvic ring fractures completely (unstable both longitudinal and vertical rotation): one side of pelvic fracture (VS, Malgaigne or Voillermier), or fractures on both sides (CM) 1.3.5 Treatment of pelvic ring fractures by external fixation Indications of the external fixation for usntable pelvic ring fracture: Mear (1980, 1986) , Tile (1984 , 2003), Majeed (1990), Pennig (1989) , agree on to the indication external fixation for pelvis as follows: - Temporary purpose, hemostatic, anti- shock pain in the emergency treatment; - Open fractures of the pelvis ; - Treat unstable fracture incompletely types (APC , LC);   - Implement to posterior arcs fixation (internal fixation or traction) for unstable pelvic ring fractures completely (VS, CM) - Unstable pelvic fracture is severe injury, a common emergency trauma, indicated for the treatment of surgical intervention But the understanding of type of fracture is to improve the effectiveness of treatment , both in the world and in certain countries There have no study has been carried out to understand more clearly the anatomical lesions of unstable pelvic ring fractures, especially, characteristic lesions of this complex fracture types in Vietnam and assessment treatment experience is the reason why we conducted this topic Chapter PATIENTS AND METHODS 2.1 Patients 94 patients with unstable pelvic ring fractures due to different causes, aged 1663 (mean 30.6 ± 6.3), 55 males and 39 females, male/female is 1.41 ISS scores ranged from 16 to 45 points, (mean 26.4 ± 7.2) All these cases were diagnosed and treated at the Department of Orthopaedic Trauma, Cho Ray Hospital, for period of time from 03/ 2007 to 11/2011 * Patient selection criteria - The patient was diagnosed with unstable pelvic ring fractures classified by Young and Burgess (1990) - All of the patients were treated by external fixation - Age ≥ 16 * Exclude criteria - Fractures of the pelvis together with acetabular fractures; - Treatment used orther medthod 2.2 Methods Observation series cases clinical trials, longitudinal monitoring, no control group including prospective and retrospective 6   - A prospective study: 79 patients in the hospital from 8/2008 to 11/2011, was conducted after research proposal and complete data collection sheet - Retrospective study: 15 patients in the hospital from 03/ 2007 to 7/2008, the last time before the research proposal should have a more complete additional indicators and data to be collected 2.2.2 Study on anatomical lesions * Pelvic Injuries - Closed fractures - open pelvic according to Jones (2002) - Classification of pelvic ring injuries according to Young and Burgess (1990 ) + APC fracture, anterior and posterior pressure ; + LC fractures, side pressure ; + VS fracture, tear force vertical; + CM fracture, combines the two sides of the pelvic fractures (VS + VS or VS + APC or VS + LC) - Assessment posterior pelvic injury: + SI joints injury; + Sacral wing fracture; + Iliac wing fracture; + Combine ( fractures, SI dislocation ) - Assessment anterior pelvic injury: + Symphyseal diastasis; + Anterior ring fracture (one side or both sides); + Combine (Symphysis + anterior pelvic ring) * Whole body condition and combined trauma - Shock + Traumatic shock, standards of Nguyen Thu (2002) + Level of shock: Halvorsen (1990) - Combined trauma: pelvic organs and others - Severity of the patients 7   2.2.3 Treatment of pelvic fractures by external fixation * Prepare patients - Examination and subclinical need to confirm the diagnosis - Consultation on management - Do ideological work to patients and their family * Materials The frame of Cho Ray hospital designed front quadrangle (Figure 2.2) The frame structure includes : - horizontal bars and steel cross bracing  = mm in diameter - vertical bars curved steel link  = mm - The configuration connecting rods linked together - SCHANZ screws  = mm, length 15 cm Figure 2.2 Frame pelvic external fixation of Cho Ray hospital * Treatment Strategy - Patients not in shock or had stable treatment: external fixation set delayed - If patients with shock, shock treatment must be immediately + If the shock is stable, proceed setting fixation emergency delayed + If shock is treated aggressively but still not stable, after excluding bleeding from the outside pelvic organs (abdomen, chest ), only to put external fixation pelvic to anti-shock 8   Figure 2.4 The patient after operation (75) 2.2.4 Method of assessment results * Evaluate early results - Results of the anatomical correction Table 2.1 Criteria for anatomical recovery results Anatomical recovery Excellent Good Fair Poor 3,5 < 0,5 0,5 - < 1 - 1,5 > 1,5 Symphyseal diastasis or anterior pelvic displacement (cm) Displacement of remaining posterior pelvic arc (cm) - Evaluate changes and bone healing time - The complications of the technique * Evaluate longterm outcomes Time evaluation longterm results: after reduction and removed frame at least 03 months (minimum 06 months after injury) - Evaluation of the pain [4], [48] - Functional outcome for standards of Majeed (1989) (Table 2.2) - The overall result: to assess the overall treatment outcome of pelvic fractures according to the following criteria: results of anatomical outcome, functional outcome and healing of pelvic bone Through the actual process conducting research, we build treatment assessment scores overall results for pelvic fractures (table 2.3)   Chapter RESULTS 3.1 General Characteristics Of Patients 3.1.1 Age and sex 94 patients included 55 men (58.5 %), 39 women (41.5 %) The male/ female = 1.41; youngest 16 ages, oldest 63 ages; mean 30.6 ± 6.3 3.1.2 Causes of injury Table 3.2 Causes of injury (n = 94) Patient Ratio (%) 83 77 88,3 3,2 81,9 3,2 Labor accident 11 11,7 Total 94 100 Causes Traffic Accident auto Patient moto walking Result: traffic accidents accounted for 88.3%, private accidents involving motorcycles 77/94 patients (81.9%); labor accidents only 11.7% 3.2 Characteristics of Anatomical Lesions 3.2.1 Characteristics of the pelvic ring fracture * Classification of unstable pelvic fractures according to the open – close fracture Table 3.4 Distribution of patients according to the nature of open-close fracture (n = 94) Patients Ratio (%) Close fracture 71 75,5 Open fracture 23 - 19 24,5 00 20,3 4,2 Characteristics type I type II type III Result: closed fracture pelvis majority (75.5%) There are 23 cases of open pelvic fractures 10   * Classification according to Young and Burgess Table 3.5 Pelvic fracture classification according to Young and Burgess (n = 94) Patients Ratio(%) APC 43 45,7 LC 25 26,6 VS 10 10,7 CM 16 17,0 94 100,0 Classification Total Result: the most common type of fracture APC (45.7%), 26.6% LC * Lesion position of the anterior pelvic arc Table 3.7 Distribution by anterior pelvic arc lesions (n = 94) Patients Ratio (%) Symphyseal diastasis 34 36,2 Anterior pelvic fracture One side 25 26,6 Two side 21 22,3 14 14,9 94 100,0 Position Combine* Total (*) Sympyseal diastasis combined with anterior pelvic fractures Result: lesion fractures (ischium and ramus) of anterior pelvic account for a high proportion (63.8%) * Lessions position of the posterior pelvic arc Table 3.8 Distribution of lessions position of the posterior pelvic arc (n = 94) One side Total (n=94) Two side Patients % Patients % Patients % Side of lesions (nb=178) SI joint 43 45,8 38 40,4 81 86,2 119 Fracture of sacral wing 16 17,1 2,1 18 19,2 20 Fracture of iliac wing 17 18,1 0,0 17 18,1 17 Combine (*) 20 21,2 1,1 21 22,3 22 Position (*) SI joints injury combined with pelvic wing or sacral wing fractures 11   Result: 188 posterior pelvic sides of 94 patients with 178 lesions sides (10 cases of VS one side only) SI joint damage 81/94 (86.2%), in which the two types of lesions inside the pelvic joints of 38 cases (40.4%) accounted for the highest percentage in the type of posterior arcs injury 3.2.2 Combined injuries The wound is the most common injury in different positions and levels (90.4%), followed by fractures and other dislocation joints accounted for 53.1% There are 11 cases of traumatic brain injury may include: cases of concussion; brain trauma and intracranial hematoma cases 3.2.3 Traumatic shock Number of patients with traumatic shock: 64/94 (68.1%) - 30 patients hospitalized in a state of shock; - 34 cases of shock, were treated before hospitalized 3.4 Pelvic fracture treatment outcomes 3.4.1 The early outcomes * Anatomical recovery Table 3.19 Anatomical recovery results (n = 94) Type Anatomical recovery Total Excellent Good Fair Poor APC (37,5%) 21 (50,0%) 15 (51,7%) (1/7) 43 (45,7%) LC (56,2%) 14 (33,3%) (6,9%) 25 (26,6%) VS (6,3%) (16,7%) (6,9%) 10 (10,6%) CM 0 10 (34,5%) (6/7) 16 (17,0%) 16 (17,0%) 42 (44,7%) 29 (30,9%) (7,4%) 94 (100%) Total Result: the two types of fractures with APC, LC that anatomical recovery rate is excellent and good about 50/68 patients (73.5%) The type incompletely unstable fractures (APC, LC) results recovery higher than the unstable fracture completely (VS, CM) 12   * Early complications Table 3.22 General complications (n = 94) Patients Ratio (%) Lesion of external femoral nerve 07 7,4 Lesion of hip joints 02 2,1 Errors are perforation of the iliac bone 02 2,1 Pin-site infection 64 68,1 Aseptic loosing pin 08 8,5 Complications - Missing in diagnosing lesions: no cases among 94 patients - External femoral nerve damage due to pin: cases (7.4%) had signs of numbness on the front thigh and groin area, but all they recovered after 02 weeks - Screw into hip jont: 02 cases (25, 38) - Screw out of the pelvic outer : 02 cases (46, 82) - Pin site infections: 64 patients with the different levels (68.1%) Table 3.23 General pin-site infections (nđ = 376) Level Pin-sites infection Pin-sites Pin-site infection 83 67 43 12 205 376 Ratio (%) 22,07 17,81 11,44 3,2 54,52 100,0 Result: The pin-site infection rate at different levels relatively high 68.1 % and 54.52 % of the total number of pin-sites * Time to reduction and frame removed 94/94 patients ( 100 %) have good reduction The time to keep frame from 6.5 weeks to 10.5 weeks ; average of 8.9 ± 1.3 weeks 3.4.2 The longterm outcomes There ere 81/94 case was assessed longterm outcome, reaching 86.2 % Time tracking results as months and 62 months, mean 25.6 months 13   * The posttraumatic sequel - Pain: we recorded 65/81 patients (80.2 %) had pain at different levels at the posterior pelvic, mostly in SI joints There are 11/65 cases of pelvic pain accounting for 16.9 % Table 3.29 VAS score and displacement of remaining posterior pelvic arc (n = 65) VAS score Displacement of remaining posterior pelvic arc < 10 mm ≥ 10 mm Total p; χ2 23 0,008; 7,03 Patients Ratio(%) Patients Ratio(%) 22 33,8 1,5 23 35,4 4,5 7,7 10 15,6 - 1,5 (1,5%) Total 50 76,9 15 23,1% 65 (100%) (35,4%) 26 0,07; 3,25 (40,0%) 15