Background: Pelvic fractures are frecuently associated with massive intrapelvic bleeding from venous or arterial sources. Different treatment algorithms has been proposed in order to stablish early control of haemorragic sites, mostly based on external fixation/angiography. The aim of present study was to evaluate the clinical evolution of 70 pelvic fractures with uncontrolled hypotension treated with combined ex fix/angio based on fracture pattern.

Materials and methods: Case serie . We analyzed a serie of patients admitted at our center between 1994 and 2004 with pelvic fracture and haemodinamic instability , treated by the same algorithm. Decision-making for the first treatment(angio vs external fixation) were based on the type of pelvic fracture. Patients was considered unstable if PAS was less than 90mmHg or the patients needs more than two blood products replacement in first 24 hours.

Results: External fixation was used in 45 patients(64%) and 37 patients were treated by angio. We found active arterial bleeding in 31 cases (44%). The combination of both treatment was used in 20 patients. Laparotomy was performed in 21 patients. Incidence of sistemic complications were high . Mortality was 26% . Mortality were higher in two groups: patients with TBI and those treated by laparotomy.

Conclusions: Arterial lesions demostrated by angio were high in our study(44%). In our experience a combined algorithm using both external fixation or angio based on type fracture control intrapelvic bleeding in most cases , although mortality in patients with pelvic fractre and haemodinamic instabilty remains high.

Introduction and Objectives: High-energy fractures of the pelvis carry a high mortality and pose a diagnostic and therapeutic challenge in modern orthopaedic trauma. A multidisciplinary approach has reduced mortality in the past two decades. In cooperation with the polytrauma ICU, we have developed a diagnostic-therapeutic algorithm to determine indications for laparotomy, external fixation, and angiography, in terms of clinical evolution and fracture type. Materials and Methods: This is a retrospective study of 67 patients with pelvic fractures and persistent hae-modynamic instability who were treated in our centre between 1994 and 2002. The following parameters were analyzed: personal data, AIS, ISS, RTS, type of fracture (Young and Burgess classification), associated injuries, haematologic requirements, and degree of adherence to the algorithm in terms of diagnostic and therapeutic measures. The following results variables were examined: mortality, incidence of systemic complications associated with traumatic illness (MOF, ARDS, DIC), and length of hospital stay. Results: The study involved a total of 67 patients, all with pelvic fractures and persistent haemodynamic instability. Average age was 37.7 years, and average time in the ICU was 13.8 days. In 53.7% of cases, patients were transported to the centre by ambulance, 41.8% by helicopter, and the remaining 4.5% by other means. Adjusted mortality was 25%. External fixation was used on 42 patients (62%) and angiography in 36 (53%). Both techniques were used in combination in 17 patients. Of the 36 patients who underwent angiography, 33 showed positive findings (91.7%). Exploratory laparotomy was required in 23 patients due to positive findings on abdominal ultrasound, which yielded positive results in 20 cases. Mortality in these patients was 45%. Average ISS was 29. Discussion and Conclusions: Rapid evaluation and a multidisciplinary approach are necessary in handling patients with pelvic fracture and haemodynamic instability. External fixation is a rapid procedure that is safe and simple, permitting the control of haemody-namic instability, which should be considered more as an emergency stabilisation technique than a reconstructive procedure. Abdominal ultrasound is a very sensitive method when deciding whether or not to perform an exploratory laparotomy. In cases with rotational instability of the pelvis, laparatomy should be done only after pelvic fixation. A diagnostic-therapeutic algorithm has been designed for the management of pelvic instability, with particular emphasis on indicators of a poor prognosis

Reviewing our experience of scoliosis in children with a Cavopulmonary Shunt or Fontan circulation and the cardiovascular challenges that this presents. A notes and x ray review was performed. Special attention was paid to the changes in cardiovascular status whilst prone. The review was from first presentation to latest follow up. There were 6 patients who underwent 7 major procedures between 2001 and 2009. All had cardiac procedures in early life. Both definitive fusion and growing instrumentation was used. All procedures were successful. Growing instrumentation allowed earlier primary surgery before completion of the Fontan circulation. All have been subsequently lengthened in a lateral position. The mean follow up is 56 months. There was one death 40 months following last surgery, cause unrelated to spinal surgery. In the older patients with a completed Fontan significant blood loss was seen, due to the raised venous pressure required to run the Fontan, and occult hypotension seen as a climbing difference between Pulmonary Artery Wedge Pressure and Central Venous Pressure were common when prone. We recommend early intervention, using instrumentation without fusion to correct the deformity over time and allow intervention prior to completing the Fontan circulation. As haemodynamic instability increases with increasing time in the prone position, surgery should be expedited rapidly

Purpose: To ascertain whether the methods of prone positioning we use have any influence on the incidence of perioperative critical incidents and development of postoperative liver dysfunction in our scoliosis patients. Methods: A retrospective review of 72 patients undergoing posterior correction and fusion for scoliosis from August 2006 to November 2007. Details were recorded from anaesthetic charts, operation notes, blood results and cell salvage data. Results: Patients ranged in age from 2 to 24 years. The methods of prone positioning were Transverse Bolsters (23), Allen Frame 4-point support (25), Lateral Bolsters (11) and the Knight Table (13). Perioperative haemodynamic instability was noted in 8% of patients on the Allen Frame, 43% on transverse bolsters, 15% on the Knight Table and 55% on lateral bolsters. Two cardiac arrests, one fatal and one with good recovery, both occurred on transverse bolsters. Of 22 other complications attributable to mechanical effects of prone positioning, 16 occurred on transverse bolsters, 4 on the Allen Frame, 1 on lateral bolsters and 1 on the Knight Table. 34% of patients had liver dysfunction postoperatively. None had been positioned on the Knight Table or lateral bolsters. There was no significant difference between the incidence of liver dysfunction associated with the Allen Frame or transverse bolsters. Conclusion: Transverse bolsters are associated with a high number of critical incidents and should be avoided if possible. Ethics approval – not required. Interest Statement - none

Traumatic disruption of the pelvic ring has a high risk of mortality. These injuries are predominantly due to high-energy, blunt trauma and severe associated injuries are prevalent, increasing management complexity. This population-based study investigated predictors of mortality following severe pelvic ring fractures managed in an organised trauma system. Cases aged greater than 15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based state-wide Victorian State Trauma Registry for analysis. Patient demographic, pre-hospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated. There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged greater than 65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15–34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), while patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres). The findings highlight the importance of the need for effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches

Introduction. Following National patient safety alert on cement use in hip fracture surgery, we investigated the incidence and pattern of 72 hours peri-operative mortality after hip fracture surgery in a District General Hospital. Methods. We reviewed all patients who had hip fracture surgery between 2005-April, 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, peri-operative haemodynamic status, time and cause of death. Results. Over a 64 month period 15 cases were identified. Peri-operative death (PAD) was 1% (15/1402). 4/15 patients died intra-operatively. PAD was highest following Exeter Trauma Stem (ETS) implantation (5/85, 6%) and nil following Bipolar arthroplasty, Austin-Moore arthroplasty (AMA) or Cannulated screw fixation. PAD following total hip arthroplasty was 4% (1/25), Thompson's hemi-arthroplasty 2% (3/191), and Dynamic Hip Screw fixation 1% (6/695). Overall mortality after cemented implant was 2%. ETS implantation led to significantly increased peri-operative mortality compared to AMA (p=0.004). Operations were performed by both trainees (12) and Consultants (3). Both trainees (9) and Consultants (6) anaesthetised the patients. None of the patients belonged to ASA I or II (ASA III 6 and IV 9). All patients had significant cardio-vascular or pulmonary co-morbidity (Ca Lung 2, pulmonary fibrosis 1, end stage COAD 1, AF 6). Cemented implant insertion was followed by immediate haemodynamic collapse and death in 4/15, intra-operative haemodynamic instability in 1/15 and peri-operative instability in 5/15. Post-mortem was performed in 5/15: 2/5 were Pulmonary Embolism (PE), 2/5 bronchopneumonia and 1/5 Myocardial infarction (MI). 4/15 had suspected MI and 1/15 suspected PE. Conclusion. There was 1% risk of peri-operative death after hip fracture surgery. This risk was increased following cemented hemiarthroplasty and highest after ETS implantation. Risk was exacerbated in patients with pre-existing cardiovascular morbidity and independent of the seniority of the surgeon or the anaesthetist

Aims: To evaluate need for fast and correct diagnosis of pelvic fracture. Correlation of plain (AP) pelvic X-ray and and mortality and resultant necessity of emergency pelvic external þxation. Methods: We performed retrospective analysis of 152 patients with mechanically unstable pelvic fractures treated in period of 1996–2000. Observed pelvic ring fractures were type B1, B2 or C (and its subcroups) according to classiþcation of Tile, modiþed by Kellam and Browner. All of them (152) had at least two body regions injurie and ISS> 17 (mean ISS=29.2). 79 (52%) patients were haemodynamically unstable at admission. Parameters examined were as follows: injury severity, fracture type, hemodynamics at admission, time to and device of þxation, mortality. Results: Signiþcant differece was found in mortality in different fracture types: B1 11.1%, B2 Ð 5.6%, C Ð 37.5%. Also, a marked difference was seen in haemodynamic instability in different fracture types: B1- 55,5%, B2 Ð 20%, C Ð 73,6%. Mean injury severity scores: B1 -30,6 B2 -30,0 C Ð32,0. The need for emergency pelvic þxation was B1 Ð 44%, B2 Ð 5,6%, C Ð 42,4%, mostly AO tubular Ex. Fix was used. The study showed obvious correlation between the type of pelvic fracture and mortality. Conclusion: In pelvic fractures correct and fast diagnosis should be made in emergency room by plain AP x-ray. We found Tile pelvic fracture classiþcation to correlate patients haemodynamical state and guide fracture management and to be important prognostic criteria. Pelvic fracture which leads to increase of pelvic volume (B1, C) is prognostically worse and has higher mortality