Can MDCT Unmask Instability in Binder-Stabilized Pelvic Ring Disruptions?

Dreizin, David; Nascone, Jason W.; Davis, Derik L.; Mascarenhas, Daniel; Tirada, Nikki; Chen, Haoxing; Bodanapally, Uttam K.

doi:10.2214/ajr.16.16630

Cited by 16 publications

(20 citation statements)

References 34 publications

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“…Predictor variable selection.-Candidate predictor variables were selected on the basis of clinical practicality and scientific evidence (2,(12)(13)(14)(15)(16)(18)(19)(20)(21)(22)(23)(24) in consultation with two orthopedic trauma surgeons with nationally recognized expertise in pelvic trauma (J.W.N., R.V.O.). CT predictors shown to be associated with major vascular injury include ICE and segmented pelvic hematoma volumes (2,(13)(14)(15)(16).…”

Section: Discussionmentioning

confidence: 99%

“…is more likely with wide fracture gaps (approximately 5 mm or greater); with comminution; and with pubic symphysis diastasis, which is indicative of mechanical instability (9,12,(18)(19)(20). The Tile classification provides an overall impression of mechanical instability on the basis of qualitative CT findings (21)(22)(23)25).…”

Section: Scanning Parametersmentioning

confidence: 99%

“…Pelvic circumferential compression devices ("pelvic binders") are visible at CT and can influence hematoma volume through splinting and tamponade, can affect the degree of pubic symphysis diastasis, and can hinder discrimination of Tile instability grade (22,23).…”

Section: Scanning Parametersmentioning

confidence: 99%

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CT Prediction Model for Major Arterial Injury after Blunt Pelvic Ring Disruption

et al. 2018

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Purpose To develop and test a computed tomography (CT)-based predictive model for major arterial injury after blunt pelvic ring disruptions that incorporates semiautomated pelvic hematoma volume quantification. Materials and Methods A multivariable logistic regression model was developed in patients with blunt pelvic ring disruptions who underwent arterial phase abdominopelvic CT before angiography from 2008 to 2013. Arterial injury at angiography requiring transarterial embolization (TAE) served as the outcome. Areas under the receiver operating characteristic (ROC) curve (AUCs) for the model and for two trauma radiologists were compared in a validation cohort of 36 patients from 2013 to 2015 by using the Hanley-McNeil method. Hematoma volume cutoffs for predicting the need for TAE and probability cutoffs for the secondary outcome of mortality not resulting from closed head injuries were determined by using ROC analysis. Correlation between hematoma volume and transfusion was assessed by using the Pearson coefficient. Results Independent predictor variables included hematoma volume, intravenous contrast material extravasation, atherosclerosis, rotational instability, and obturator ring fracture. In the validation cohort, the model (AUC, 0.78) had similar performance to reviewers (AUC, 0.69-0.72; P = .40-.80). A hematoma volume cutoff of 433 mL had a positive predictive value of 87%-100% for predicting major arterial injury requiring TAE. Hematoma volumes correlated with units of packed red blood cells transfused (r = 0.34-0.57; P = .0002-.0003). Predicted probabilities of 0.64 or less had a negative predictive value of 100% for excluding mortality not resulting from closed head injuries. Conclusion A logistic regression model incorporating semiautomated hematoma volume segmentation produced objective probability estimates of major arterial injury. Hematoma volumes correlated with 48-hour transfusion requirement, and low predicted probabilities excluded mortality from causes other than closed head injury. RSNA, 2018 Online supplemental material is available for this article.

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Section: Discussionmentioning

confidence: 99%

Section: Scanning Parametersmentioning

confidence: 99%

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CT Prediction Model for Major Arterial Injury after Blunt Pelvic Ring Disruption

et al. 2018

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“…Firstly, patients with PCCDs in place while undergoing CT (63%) were included in the present study. It has been shown previously that the presence of PCCDs may lead to misinterpretation of the fracture pattern and thus have an influence on fracture classification [46][47][48] and assessment of pelvic ring stability [49]. However, given the widespread use of PCCDs in the prehospital setting [50], this situation is now frequently encountered and represents clinical conditions under which fracture classifications have to occur.…”

Section: Limitations and Strengthsmentioning

confidence: 99%

Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons

et al. 2020

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Objectives To assess the interobserver reliability (IOR) of the Tile classification system, and its potential influence on outcomes, for the interpretation of CT images of pelvic fractures by radiologists and surgeons. Methods Retrospective data (1/2008–12/2016) from 238 patients with pelvic fractures were analyzed. Mean patient age was 44 years (SD 20); 66% were male. There were 54 Tile A, 82 Tile B, and 102 Tile C type injuries. The 30-day mortality rate was 15% (36/238). Six observers, three radiologists, and three surgeons with different levels of experience (attending/resident/intern) classified each fracture into one of the 26 second-order subcategories of the Tile classification. Weighted kappa coefficients were used to assess the IORs for the three main categories and nine first-order subcategories. Results The overall IORs of the Tile system for the main categories and first-order subcategories were moderate (kappa = 0.44) and fair (kappa = 0.31), respectively. IOR was fair to moderate among radiologists, but only fair among surgeons. By level of training, IOR was moderate between attendings and between residents, whereas it was only fair between interns. IOR was moderate to substantial (kappa = 0.56–0.70) between the radiology attending and resident. Association of the Tile fracture type with 30-day mortality was present based on two out of six observer ratings. Conclusions The overall IOR of the Tile classification system is only fair to moderate, increases with the level of rater experience and is better among radiologists than surgeons. In the light of these findings, results from studies using this classification system must be interpreted cautiously. Key Points • The overall interobserver reliability of the Tile pelvic fracture classification is only fair to moderate. • Interobserver reliability increases with observer experience and radiologists have higher kappa coefficients than surgeons. • Interobserver reliability has an impact on the association of the Tile classification system with mortality in two out of six cases.

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“…A retrospective review of the CT imaging while the binder was still in place showed some signs that may have indicated a more serious injury than initially suspected, such as the pelvic hematoma, a small avulsion fracture at the pubic symphysis (Figure 1B) and a subtle widening of the left sacroiliac joint on the initial CT imaging (Figure 1C). 1 Local pre-hospital guidelines state that a binder should be applied if there is suspicion of a pelvic injury after blunt high-energy trauma with hemodynamic instability (or systolic blood pressure < 110 mm Hg). 2 Serious pelvic injuries may be missed in the presence of a well-applied pelvic binder, 3 which is particularly true for purely ligamentous anteroposterior compression injuries.…”

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Binder use obscures traumatic pelvic injury in a 29-year-old man

Seah

Mackay

2021

CMAJ

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Can MDCT Unmask Instability in Binder-Stabilized Pelvic Ring Disruptions?

Abstract: Evaluation for avulsive signs improves MDCT sensitivity for the detection of rotational instability but not vertical instability in patients with binders.

Cited by 16 publications

References 34 publications

CT Prediction Model for Major Arterial Injury after Blunt Pelvic Ring Disruption

CT Prediction Model for Major Arterial Injury after Blunt Pelvic Ring Disruption

Interobserver reliability of the Tile classification system for pelvic fractures among radiologists and surgeons

Binder use obscures traumatic pelvic injury in a 29-year-old man

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