We report a case of fatal haemorrhage following a low-energy fracture of the pubic ramus in an 85-year-old woman

This study was undertaken to assess the contribution of fat embolism (FE) to the development of acute lung injury in the presence of resuscitated hemorrhagic shock. Twenty-seven NZW rabbits were randomly assigned into four groups: resuscitated hemorrhagic shock and FE (HR/FE), resuscitated hemorrhagic shock, FE, and control. FE was induced via intramedullary femoral canal pressurization using a 1–1.5 ml bone cement injection. Only HR/FE animals displayed significant proinflammatory cytokine release as compared to controls. These findings suggest that the combination of resuscitated shock with FE initiates an inflammatory response, which may lead to the development of fat embolism syndrome. The objective of this study was to assess the contribution of fat embolism caused by intramedullary femoral canal pressurization to the development of acute lung injury in the presence of resuscitated hemorrhagic shock. Only the animals that underwent resuscitated shock and fat embolism displayed amplified BALF proinflammatory cytokine expression. These findings suggest that the combination of resuscitated shock with fat embolism initiates an inflammatory response, which may play a role in the development of fat embolism syndrome. Only HR/FE BALF IL-8 and MCP-1 levels were significantly higher than controls (0.72 ng/ml vs. 0.26ng/ ml, p=0.03; 18.3 ng/ml vs. 2.0 ng/ml, p=0.01, respectively). Twenty-seven NZW rabbits were randomly assigned into four groups: resuscitated hemorrhagic shock + fat embolism (HR/FE), resuscitated hemorrhagic shock (HR), fat embolism (FE), and control. Shock was induced via carotid bleeding for one-hour prior to resuscitation. For FE induction, the intramedullary cavity was drilled, reamed and pressurized with a 1–1.5 ml bone cement injection. Four hours later, postmortem bronchoalveolar lavage was performed through the right mainstem bronchus. Analyses of bronchoalveolar lavage fluid (BALF) of interleukin-8 (IL-8) and monocyte chemoattractant protein-1 (MCP-1) were carried out in triplicate and blinded fashion using the ELISA technique. Our findings suggest that FE by itself does not initiate inflammatory lung injury, as there were no apparent differences between the control and FE cytokine levels. Only the HR/FE animals revealed elevated levels of pro-inflammatory cytokines in BALF. These findings are in agreement with our previous results, which displayed neutrophil activation only in the HR/FE group

This study was undertaken to assess the contribution of pulmonary fat embolism caused by intramedullary femoral canal pressurization to the development of acute lung injury in the presence of resuscitated hemorrhagic shock. Twenty-seven NZW rabbits were randomly assigned into one of four groups: resuscitated hemorrhagic shock and fat embolism, resuscitated hemorrhagic shock, fat embolism, and control. Fat embolism was induced via intramedullary cavity with a 1–1.5 ml bone cement injection. Only the animals that underwent resuscitated shock and fat embolism displayed amplified neutrophil activation and alveolar infiltration. These findings suggest that the combination of resuscitated shock with fat embolism initiates an inflammatory response, which may play a role in the development of fat embolism syndrome. The objective of this study was to assess the contribution of pulmonary fat embolism caused by intramedullary femoral canal pressurization to the development of acute lung injury in the presence of resuscitated hemorrhagic shock. Only the animals that underwent resuscitated shock and fat embolism displayed amplified neutrophil activation and alveolar infiltration. These findings suggest that the combination of resuscitated shock with fat embolism initiates an inflammatory response, which may play a role in the development of fat embolism syndrome. CD11b mean channel florescence was only significantly elevated in the HR/FE group at two and four hours post knee manipulation. Moreover, greater infiltration of alveoli by leukocytes was only significantly higher in the HR/FE group as compared to controls. Twenty-seven NZW rabbits were randomly assigned into one of four groups: resuscitated hemorrhagic shock + fat embolism (HR/FE), resuscitated hemorrhagic shock (HR), fat embolism (FE), and control. Hypovolemic shock was induced via carotid bleeding for one-hour prior to resuscitation. For fat embolism induction, the intramedullary cavity was drilled, reamed and pressurized with a 1–1.5 ml bone cement injection. For evaluation of neutrophil activation, blood was stained with antibodies against CD45 and CD11b and analyzed with a flow cytometer. Animals were mechanically ventilated for four hours post surgical closure. Postmortem thoracotomy was performed, and three stratified random blocks of each lung were processed for histological examination. Our findings suggest that FE by itself does not cause lung injury, as there were no apparent differences between the control and FE animals. Only the HR/FE animals revealed a higher number of infiltrating neutrophils into alveolar spaces and greater neutrophil activation

Haemorrhage is the main cause of preventable death on the modern battlefield. As IEDs in Afghanistan become increasingly powerful, more proximal limb injuries occur. Significant concerns now exist about the ability of the CAT tourniquet to control distal haemorrhage following mid thigh application. Aim. To evaluate the efficacy of the CAT windlass tourniquet in comparison to the newer EMT pneumatic tourniquet. Method. Serving soldiers were recruited from a military orthopaedic outpatient clinic. Participants' demographics and blood pressure were recorded and a short medical history obtained to exclude any arteriopathic conditions. Doppler ultrasound was used to identify the popliteal pulses bilaterally. The CAT was randomly self-applied by the participant at mid thigh level and the presence or absence of the popliteal pulse on Doppler was recorded. The process was repeated on the contralateral leg with the CAT now applied by a trained researcher. Finally the EMT tourniquet was self applied to the first leg and popliteal pulse change Doppler recorded again. Results. 40 consecutive patients were invited to participate in the study. 15 declined to participate. 1 was excluded via pre-determined exclusion criteria. A total of 24 participants were recruited. The self applied CAT occluded popliteal flow in only 4 subjects (16.6%). The CAT applied by a researcher occluded popliteal flow in 2 subjects (8.3%). The EMT prevented all popliteal flow in 18 subjects (75%). Discussion. This study demonstrates that the CAT tourniquet is ineffective in controlling arterial blood flow when applied at mid thigh level. The EMT was successful in a significantly larger number of participants

Despite improved body armour haemorrhage remains the leading cause of preventable death on the battlefield. Trauma to the junctional areas such as pelvis, goin and axilla can be life threatening and difficult to manage. The Abdominal Aortic Tourniquet (AAT) is a pre-hospital device capable of preventing pelvic and proximal lower limb haemorrhage by means of external aortic compression. The aim of the study was to evaluate the efficacy of the AAT. Serving soldiers under 25 years old were recruited. Basic demographic data, height, weight, blood pressure and abdominal girth were recorded. Doppler Ultrasound was used to identify blood flow in the Common Femoral Artery (CFA). The AAT was applied whilst the CFA flow was continuously monitored. The balloon was inflated until flow in the CFA ceased or the maximum pressure of the device was reached. 16 soldiers were recruited. All participants tolerated the device. No complications were reported. Blood flow in the CFA was eliminated in 15 out of 16 participants. The one unsuccessful subject was above average height, weight, BMI & abdominal girth. This study shows the Abdominal Aortic Tourniquet to be effective in the control of blood flow in the pelvis and proximal lower limb and potentially lifesaving

1. Three cases of severe retroperitoneal haemorrhage complicating fractures of the pelvis are described. In two patients haemorrhage was immediately controlled by ligation of the internal iliac artery. The third patient died before the bleeding could be controlled. 2. Ligature of the internal iliac artery may be a life-saving measure when fracture of the pelvis is complicated by severe haemorrhage

Introduction: Patients with complex pelvic fractures with uncontrollable haemorrhage have a very mortality from pelvic haemorrhage and associated injuries. Management remains controversial and includes an number of techniques including pelvic stabilisation, angiography and direct surgical control of haemorrhage. Packing the pelvic cavity is a technique used rarely in this situation but is popular to control haemorrhage from other sources in similar situations. We have reviewed our experience of pelvic packing for uncontrollable haemorrhage to assess the effectiveness of this technique. Materials & Methods: From a prospectively gathered database of 132 patients with significant pelvic fractures admitted between April 2002 and December 2005, 8 patients (5 males and 3 females) with an average age of 52.9 yrs were identified who underwent pelvic stabilisation and packing as an emergent life saving procedure for uncontrolled haemorrhage associated with pelvic fracture. Basic data including their presenting vital signs, pelvic fracture pattern and associated injuries were recorded. All were subject to pelvic stabilisation packing and their subsequent clinical course including their transfusion requirements and additional management was also assessed. Results: 6 out of these 8 patients died, 5 within the first 24 hrs after injury and one after 14 days from sepsis & MOF/MODS. The exact source of bleed could not be identified in any of these patients and was assumed to be venous and from large fractured bony surfaces. 4 patients had angiography and embolisation in addition and 2 of these survived. Conclusion: The mortality of haemodynamically unstable pelvic fractures remains high and all modalities of treatment should be used to control bleeding. Pelvic packing may form an important part in the armamentarium of haemostatic measures; its role, however, needs to be better defined by larger multi-centre studies. Although difficult to conclude, the pelvic packing may have been responsible for reducing the mortality in this subgroup from a 100% to 75%

We describe three cases of postoperative haemorrhage, two after total hip and one after total knee replacement, treated by percutaneous embolisation. After diagnostic angiography, this is the preferred method for the treatment of postoperative haemorrhage due to the formation of a false aneurysm, after hip or knee arthroplasty. This procedure, carried out under local anaesthesia, has a low rate of complications and avoids the uncertainty of further surgical exploration

Introduction. Haemorrhage is the main cause of preventable death on the modern battlefield. As Improvised Explosive Devices (IED) in Afghanistan become increasingly powerful, more proximal limb injuries are occurring. Significant concerns now exist about the ability of the windlass Combat Application Tourniquet to control distal haemorrhage following mid-thigh application. Aim. To evaluate the efficacy of the CAT windlass tourniquet in comparison to the newer pneumatic Emergency Military Tourniquet (EMT). Method. Serving soldiers were recruited from a military orthopaedic outpatient clinic. Participants' age, Body Mass Index and blood pressure were recorded and a short medical history obtained to exclude any arteriopathic conditions. Doppler ultrasound was used to identify the popliteal pulses bilaterally. The CAT was randomly self-applied by the participant at mid-thigh level and the presence or absence of the popliteal pulse on Doppler was recorded. This process was repeated on the contra lateral leg with the CAT now applied by a trained researcher. Finally, the EMT tourniquet was applied to the first leg and the presence of a popliteal pulse on Doppler recorded again. Results. 50 consecutive patients were invited to participate in the study. 15 declined to participate. 1 was excluded via pre-determined exclusion criteria. A total of 24 participants were recruited. The self applied CAT occluded popliteal flow in only 4 subjects (16.6%). The CAT applied by a researcher occluded popliteal flow in 2 subjects (8.3%). The EMT prevented popliteal flow in 18 subjects (75%). Statistical analysis demonstrated significance in the performance difference between the two tourniquets (p=0.001), but no significant difference between the two applications of the CAT (p=0.25). The BMI and systolic BP were significantly higher in those patients in whom the EMT failed (p=0.01 & p=0.04 respectively). Conclusion. This study demonstrates that the CAT tourniquet is ineffective in controlling arterial blood flow when applied at mid-thigh level. The EMT was successful in a significantly larger number of participants, and its failures may be related to increased BMI and systolic pressure

1. A case of fractured pelvis with massive haemorrhage from the right superior gluteal artery and thrombosis of the right ilio-femoral venous system is reported. 2. The treatment included ligature of the artery and extensive thrombectomy. Ten litres of blood were transfused

We have studied core biopsy specimens from 16 femoral heads affected by idiopathic avascular necrosis at the silent stage, when there were no clinical or radiographic manifestations but scintigraphy was positive. All the specimens showed necrosis of trabeculae and of bone marrow, but the most common and characteristic feature was evidence of old and new haemorrhage in the marrow. In the areas of intramedullary haemorrhages, trabeculae and bone marrow were completely necrotic, with a transitional area of incomplete necrosis between these areas and those without haemorrhagic lesions, where the trabeculae and bone marrow were normal. There was good correlation between necrosis and haemorrhagic episodes, and it was concluded that repeated intramedullary haemorrhage at the silent stage is probably related to the pathogenesis of idiopathic avascular necrosis of the femoral head

1. Paralysis of the femoral nerve secondary to haemorrhage of the iliopsoas muscle is described. 2. Four cases are presented. None of the patients had haemophilia, but one was receiving anticoagulant treatment–the second reported case in the literature. Only one case in a non-haemophiliac not receiving anticoagulants has been described previously. We have added three more such cases. 3. This condition can usually be managed conservatively because recovery can be expected. We believe that operation is indicated only if the lesion progresses and the symptoms and signs increase. 4. These cases underline the importance of assessing the femoral nerve in patients with hip symptoms after trauma. Iliopsoas haemorrhage should be suspected as the cause of femoral nerve neuropathy in cases of trauma to the back in adolescents or in those receiving anticoagulants

Purpose: The report of a case o f a patient, who underwent a total hip arthroplasty and sustained cerebral hemorrhage due to low molecular weight heparin. Case report: A 46-years-old woman had a total hip replacement due to secondary osteoarthritis after a congenital hip dislocation. She had a free medical record. Treatment with LMWH started the day of the surgery. The patient was dismissed from the hospital the sixth postoperative day, being well, and came back the ninth postoperative day, complaining of hypertension, headache and motor disturbances of her left upper limb. Neurological examination did not revealed any particular findings except reduced strength of her left upper limb. A brain CT scanning showed no significant findings, while her blood platelet count was126000 while immediately postoperatively was 180000 and preoperatively 220000. The following day the patient established a paresis of her left arm and the platelet count fell to 35000, while a new CT scan, revealed small hemorrhages in both parietal cortexes of the brain. LMWH was discontinued. The patient deceased the 11th postoperative day. Conclusion: Heparin Induced Thrombocytopenia type II and hemorrhage due to LMWH is very rare but should be bared in mind from the orthopaedic surgeon who uses LMWH for DVT prophylaxis. Clinical suspicion mandates immediate discontinuation of the agent and consideration of an alternative anticoagulation therapy along with general support of the patient

In a series of 150 consecutive patients with unstable fractures of the pelvis, angiography was performed in 23 (15%) who had uncontrolled hypotension. There were three anteroposterior compression (APC), eight lateral compression (LC) and 12 vertical shear (VS) injuries. Arterial sources of haemorrhage were identified in 18 (78%) patients and embolisation was performed. Angiography was required in 28% of VS injuries. The morphology of the fracture was not a reliable guide to the associated vascular injury. Ten (43%) patients died, of whom six had had angiography as the first therapeutic intervention. Five of these had a fracture which was associated with an increase in pelvic volume (APC or VS) which could have been stabilised by an external fixator. Based on our findings we recommend skeletal stabilisation and, if indicated, laparotomy to deal with sources of intraperitoneal blood loss before pelvic angiography. Embolisation of pelvic arterial bleeding is a worthwhile procedure in patients with hypotension which is unresponsive to these interventions

Aims. Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters. Methods. We searched PubMed, EMBASE, Scopus, and Web of Science databases using variations of the term “electric scooter”. We excluded studies conducted prior to 2015, studies with a population of less than 50, case reports, and studies not focused on electric scooters. Data were analyzed using t-tests and p-values < 0.05 were considered significant. Results. We studied 5,705 patients from 34 studies. The mean age was 33.3 years (SD 3.5), and 58.3% (n = 3,325) were male. The leading mechanism of injury was falling (n = 3,595, 74.4%). Injured patients were more likely to not wear a helmet (n = 2,114; 68.1%; p < 0.001). The most common type of injury incurred was bony injuries (n = 2,761, 39.2%), of which upper limb fractures dominated (n = 1,236, 44.8%). Head and neck injuries composed 22.2% (n = 1,565) of the reported injuries, including traumatic brain injuries (n = 455; 2.5%), lacerations/abrasions/contusions (n = 500; 7.1%), intracerebral brain haemorrhages (n = 131; 1.9%), and concussions (n = 255; 3.2%). Standard radiographs comprised most images (n = 2,153; 57.7%). Most patients were treated and released without admission (n = 2,895; 54.5%), and 17.2% (n = 911) of injured patients required surgery. Qualitative analyses of the cost of injury revealed that any intoxication was associated with higher billing costs. Conclusion. The leading injuries from e-scooters are upper limb fractures. Falling was the leading mechanism of injury, and most patients did not wear a helmet. Future research should focus on injury characterization, treatment, and cost. Cite this article: Bone Jt Open 2022;3(9):674–683

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy.

This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.

Cite this article: Bone Joint J 2014; 96-B:1143–54.

Objective: To assess the impact of EPP on physiological parameters in hemodynamically unstable patients with blunt pelvic trauma.

Methods: Of 661 patients treated for pelvic trauma, 18 consecutive patients in shock underwent EPP with the intent to control massive pelvic bleeding. These patients constituted the study population. Data collected from the medical records and the Ullev̊l Trauma Registry included: demographics, fracture classification, additional injuries, blood transfusions, surgical interventions, angiographic procedure, physiological parameters and outcome. An association between continuous variables was calculated using the Spearman correlation coefficient. A comparison between means was calculated using the t-test.

Results: Mean patient age was 44 years (range 16–80). ISS 47 (9–66). 39 % had non-measurable blood pressure at admission. Survival rate within 30 days was 72% (13/18) and correlated inversely to the age of the patient (p=0.038). Only one non-survivor died of exsanguination from multiple bleeding foci. A significant increase in systolic blood pressure (p=0.002) and hemoglobin count (p=0.012) was observed immediately after EPP. Arterial injury was observed in 80% of patients who underwent angiography after EPP.

Conclusions: 30-day survival rate after EPP was 72 %. A significant increase in systolic blood pressure and hemoglobin count was observed immediately after EPP, indicating that EPP as part of a multi-interventional resuscitation protocol may be life-saving in patients with exsanguinating pelvic injury. However, the high rate of arterial injuries seen after EPP indicates that the procedure should be supplemented with angiography once the patient is stabilized for transfer to the angiography suite.