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To evaluate outcomes using an interlocking antibiotic cement-coated nail and culture-specific systematic antibiotics in the treatment of infected nonunion after intramedullary nailing.Retrospective observational cohort study.Urban level I trauma center.Forty-one nonconsecutive patients who presented to a level I trauma center who underwent interlocked antibiotic nailing for treatment of infected nonunion status after primary intramedullary nailing.Eradication of infection, radiographic union by 2-year follow-up.Antibiotic nailing successfully eradicated infection and led to fracture healing in 35 patients (85.4%), while 6 patients (14.6%) had persistent infection and required further surgical treatment. Of the 6 patients who required further treatment, 5 eventually went on to heal with fracture union and eradication of their infection, while 1 required a salvage procedure. Of the 5 patients who eventually went on to heal, 4 of them healed with repeat antibiotic or intramedullary nails, while 1 required segmental resection and bone grafting before healing.This study suggests that the proposed interlocked antibiotic nailing technique is a viable therapeutic option to eradicate infected nonunion and support fracture healing.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Triangular osteosynthesis is a technique used to stabilize posterior pelvic ring injuries. Conventional triangular fixation can be problematic for several reasons, including the need for advanced skill sets to place instrumentation, difficulty with pelvic reduction and placing the connecting construct, and prominent instrumentation. The purpose of this study is 2-fold: (1) to describe in detail a technique for lumbopelvic fixation using implants that are easy to connect, allow distraction for complex lumbosacral displacements, and are placed in a location minimizing soft tissue prominence and (2) to present our initial case series using this technique. We present a retrospective review of 18 consecutively treated patients with this technique. Inclusion criteria were patients with complete disruption through the sacrum or sacroiliac joint from blunt trauma (OTA/AO type C injuries). Outcomes included pelvic reduction/malreduction, wound healing, and complications. Fourteen patients underwent unilateral fixation (81%), and 4 patients underwent bilateral fixation (19%). All patients (18 of the 18) had a well-reduced pelvis after fixation. No patient (0%) required a return trip to the operating room for loss of reduction/malreduction, wound breakdown, or implant failure. This study presents an updated technique for a low-profile triangular osteosynthesis construct with straightforward application for unstable posterior pelvic ring injuries. This technique does not require rod bending, results in a consistently more recessed iliac screw and connecting rod, and can be used in a wide variety of unstable posterior pelvic ring injuries, including comminuted sacral fractures, L5/S1 facet fractures, and vertical shear injuries.

Objectives To compare immediate internal fixation with primary wound closure to temporary fixation/stabilization with delayed fixation and wound closure protocols for management of open ankle fractures. Design Retrospective case-control study. Setting Level 1 trauma center. Patients Eighty-eight consecutive patients who presented with a Gustilo-Anderson type I, II, or IIIa open ankle fracture to a single center. Intervention Patients were divided into 2 cohorts: either immediate internal fixation with primary wound closure (EARLY) or temporary fixation/stabilization with delayed fixation and wound closure (STAGED) due to practice differences of the attending surgeons. Main outcome measures Infection, length of stay, number and type of operations, and clinical measures. We also assessed the 2 groups with regard to demographics and radiographic classification. Results Overall, incidence of infection was 6 (6.8%) with no significant difference between patients treated with EARLY versus STAGED protocols. The EARLY cohort had a significantly shorter length of hospital stay, fewer number of reoperations but similar clinical outcomes for pain, ambulation, and radiographic evidence of osteoarthritis for patients followed for >12 months. Conclusion Our study showed that early definitive treatment compared with a staged protocol for Gustilo-Anderson type I, II, and IIIa open ankle fractures has similar rates of infection, shorter hospital stay, fewer surgical interventions, and similar clinical outcomes. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION Fracture treatment has been documented since the times of ancient Egyptian and Greek civilization, with fracture reduction techniques and the apparatus for immobilization developed over three millennia. Over the last 150 years, aseptic technique, anesthesia, antibiotics, and internal implants have changed how orthopedic specialists approach fracture care. More recently, there has been an increased promotion in the medical literature to evaluate the clinical outcomes of nonsurgical treatment of common upper and lower extremity closed fractures. METHODS In this paper, the authors review the history of closed extremity fracture treatments, outline contemporary studies regarding treatments of non-displaced fractures, and discuss the recent literature that has informed orthopedic surgeon-patient decision-making discussions regarding closed fracture management. CONCLUSIONS Based on the results of this literature review, orthopedic providers should consider the preferable outcomes associated with nonoperative fracture management such as lower infection rates, the possibility of rapid functional improvements and lower healthcare costs. Nonoperative methods for closed fractures can sometimes be more safely delivered even with more difficult fractures. This may be of particular benefit to patients with higher surgical risks, minimizing exposure to treatments that are not only more invasive and expensive, but that can impose greater postoperative risks.

INTRODUCTION The treatment of Lumbar Disc Herniation (LDH) in elite athletes is a debated topic that lacks consensus in the literature due to varying outcome reporting methods. The objective of this study was to quantify the overall performance of a sample of professional athletes before and after receiving a lumbar discectomy or microdiscectomy in a cohort of players in the National Football League (NFL), National Basketball Association (NBA), National Hockey League (NHL) and Major League Baseball (MLB). METHODS The authors identified publicly accessible data from a cohort of different types of professional players who received either a lumbar discectomy or a microdiscectomy. These records were identified through newspaper archives, injury reports, player profiles and press releases between 1993 through 2015. Fantasy and Wins Above Replacement (WAR) scores were calculated for each player. RESULTS A total of 38 professional players met study inclusion criteria. NFL players had the lowest return-to-play (RTP) at nine of 14 (64%). The RTP for NBA, NHL and MLB players were comparable with 6/7 (86%) vs 8/9 (89%) vs 7/8 (88%). NFL players had the lowest average career length after surgery at 34.8 months, while NBA players had the longest average career length at 48 months. MLB players on average required the longest time to return to presurgical level of performance (24 months) and required the longest average recovery time at 12 months. CONCLUSIONS Based on these results, the average performance of most elite athletes are likely to decrease after undergoing a lumbar discectomy. Although it appears that performance peaks in the initial years after the operation for some players, there was an overall long-term decline in this sample of elite athletes. Study limitations included small sample size, lack of controlling for possible confounding variables (e.g., age, etc.) and use of variable reporting sources. Additional studies with larger sample sizes and age-matched controls are needed to examine the effects of lumbar discectomy more comprehensively in elite athletes.

Introduction: The objective of this study was to (1) construct a pain scale that improves communication between healthcare providers and patients (Interventional Pain Assessment [IPA] tool) and (2) to validate this new pain scale with the numeric rating scale of 0 to 10 Numerical Rating System (NRS). Methods: The IPA uses only three categories: 0 = “I have no pain,” 1 = “My pain is tolerable (no intervention needed),” and 2 = “my pain is intolerable, (intervention needed).” An Institutional Review Board–approved study was done on 322 consecutive patients who were recovering from fracture treatment. We compared ratings of the IPA with NRS. We also asked patients which scale they preferred. Statistical analysis included Kendall rank correlation (Kendall τ) and Spearman rho to determine correlation with the NRS. Results: The IPA exhibited a statistically significant association with the NRS (τ = 0.58, P < 0.0001). Discordant answers were provided by 23.6% patients; 4.7% regarded their mild-to-moderate pain as intolerable (15/322) while 18.9% reported their severe pain as tolerable (61/322). Eighty-two percent of patients preferred the IPA. Conclusion: The IPA is a valid pain scale and has exhibited strong correlation with the NRS 0 to 10, displays simple minimally clinical important difference calculation, and provides meaningful information on the effect of pain control modulation.

Case Type C pelvic ring fractures account for only 0.34% of all pelvic fractures (Zhang, 2012 [1]). Anterior and posterior pelvic fixation is necessary in these injuries and can be accomplished using a variety of techniques. This study presents a case of bilateral vertical shear sacroiliac joint dislocations with an associated hip dislocation and pubic rami fractures that was treated with bilateral triangular osteosynthesis and INFIX. Conclusion This is the first reported case of bilateral vertical shear sacroiliac joint dislocation treated with triangular osteosynthesis. Anterior pelvic fixation with INFIX and posterior fixation with lumbopelvic and percutaneous sacroiliac screws resulted in excellent radiographic and clinical outcomes.

Objective The purposes of this article were to (1) compare our combined pelvic ring and acetabular fracture patients' rate of mortality and Injury Severity Score (ISS) to those of patients with isolated injuries at our center and to those with combined injuries as reported in the literature, (2) describe our treatment algorithm using the INFIX for these combination injuries, and (3) report our patients' radiographic and functional outcomes. Design Retrospective IRB-approved case series and literature review. Setting US Level 1 Trauma Center. Patients/participants Thousand six hundred ninety-seven with acetabular or pelvic ring injury, 174 patients with combination pelvic ring acetabular injuries, and 39 patients with 41 acetabular injuries treated with a surgical protocol. Intervention Pelvic ring reduction using INFIX and posterior fixation followed by acetabular reduction fixation. Anterior injury fixed with INFIX. Main outcome Mortality, ISS, pelvic reduction by Keshishyan index, acetabular reduction by the Matta criteria, and functional outcome by the Majeed score. Results Mortality was 5.7% and ISS was 12.5 for 174 combined injury patients. In the 39 patients with 41 injuries, excellent pelvic reduction was found in 39, and acetabular reduction was anatomic in 25 (61%), imperfect in 12 (29%), and poor in 4 (10%). Clinically 78% of the patients had good or excellent outcome and 22% had a fair or poor outcome. Nonanatomic acetabular reduction, persistent sciatic nerve palsy, and heterotopic ossification associated with poor clinical outcome. Conclusions Our treatment protocol resulted in excellent pelvic reduction, anatomic acetabular reduction in 61% of patients, and 78% good to excellent clinical outcome. Level of evidence Case series Level IV.

The potential of powdered roots of Water Hyacinth (WH) for decolourization of Congo red (CR) dye has been studied, in both batch as well as continuous packed bed systems. The suitable conditions for the CR removal (pH 7.4, contact time 180 min, adsorbent dosage 10 g/L and temperature 323 K) were studied, through detailed evaluation of parameters. The kinetic evaluation of the process revealed that the data best adhered to pseudo-first-order kinetics. Freundlich, Langmuir, Dubinin–Radushkevich and Temkin isotherms were utilized for modelling the CR removal at equilibrium, the results of which have described the adsorption of CR as a monolayer process following the Langmuir Isotherm. Maximum adorption capacity was found to be 93.82 mg/g at 323 K. Continuous packed bed studies were also carried out for different bed heights on 100 mg/L of CR solution and the respective breakthrough curves were studied. The above studies have demonstrated WH to be an effective adsorbent for the treatment of water contaminated by Congo red dye.

Histologic diagnosis of the lesion is important while intramedullary nailing of a pathologic or impending fracture of a long bone. A biopsy can be performed extramedullary using a targeted sampling device such as a pituitary rongeur or intramedullary from the bone removed from the reamer during preparation of the intramedullary canal. The purpose of this study is to compare a cup pituitary rongeur vs. a reaming biopsy from the intramedullary canal during the treatment of pathologic bone lesions with an intramedullary nail. An IRB approved retrospective case control study was performed on 46 consecutive patients who underwent an IMN for pathologic fracture or impending pathologic fracture with an obvious lytic lesion with a known metastatic primary. A laryngeal cup pituitary forceps’ rongeur was used in 25 patients and the intramedullary reamer as it passed the lesion was used in 21 patients. Histopathology reports were assessed for (1) adequacy of bone sample (defined as containing sufficient bone and marrow-derived tissue to allow complete histological analysis) and (2) tumor tissue diagnosis. A standard approach for IMN was used. Twenty-three of 25 cup biopsy cases (92%) had positive pathology that corresponded to the primary cancer. Eleven of 21 reaming cases (52.4%) had positive pathology that corresponded to the primary cancer (p = 0.0117). The use of an intramedullary cup biopsy forceps is better than reamings to diagnose pathological lesions of impending and pathological fractures in long bones caused by metastatic lesions.

A novel and injectable polymeric dicalcium phosphate dehydrate cement (P-DCPD) was developed that is mechanically strong and has excellent cohesion. Methotrexate (MTX) is an anticancer drug for many tumors including bone cancer. The current study assessed the performance of MTX loaded P-DCPD (MTX-P) in vitro. The applied properties of MTX-P include MTX release, effects on cell viability of human breast cancer MCF 7 cells and murine osteoblastic MC3T3 cells. The impacts of MTX-P on the injectability, setting time, material microstructure and mechanical strength were also evaluated. A slow and sustained MTX release from MTX-P was observed. Eluents collected from MTX-P were cytotoxic to MCF7 cells. MT3T3 cells, however, were much less sensitive to MTX-containing eluents. MTX-P was injectable. A remarkable delay of the setting time was observed in 0.5% MTX-P (45.7 ± 1.9 min) and 1% MTX-P (49.5 ± 3.4 min) as compared to control-P (11.8 ± 1.2 min), respectively. The compressive strength was significantly reduced in 0.5% MTX-P (16.49 ± 2.43 MPa) and in 1% MTX-P (10.68 ± 3.97 MPa) as compared to control-P (53.09 ± 8.64 MPa). The inferior performance of MTX-P observed might be due to the insufficient crystal formation and uneven distribution of MTX within P-DCPD matrices. Our data may shed some light on the future application of MTX-P in the treatment of bone defects after tumor excision with a plethora of applications by including other anticancer drugs because of its safety and degradability. Further material optimization and in vivo validation are required to achieve a clinically applicable product.

Background: External fixators that span the wrist have been the historical norm in treating distal radius fractures. We have modified a dorsal distraction approach by using a subcutaneously applied locked bridge plate through 2 small incisions superficial to the extensor tendons and outside the extensor compartment. The purpose of this study was to biomechanically evaluate this modified method of fixation for comminuted distal radius fractures in comparison with two established constructs. Methods: Matched cadaver specimens were used to model an AO Type 23-C3 distal radius fracture. Biochemical testing for stiffness during axial compressive loading was done on three constructs: a conventional Burke distraction plate, the subcutaneous internal fixation plating technique and an external fixator. All specimens were cyclically loaded for 3000 cycles and then retested. Results: The modified construct was found to be stiffer than the external fixator (p=0.013). When compared to the Burke plate, the modified construct was significantly less stiff before axial cycling (p=0.025). However, the difference was not maintained after cycling and the post-axial loading stiffness difference was non-significant (p=0.456).Conclusion: Our data demonstrate the biomechanical integrity of the subcutaneous plating technique for the fixation of comminuted distal radius fractures. It is stiffer than an external fixator and has the theoretical advantage of avoiding pin-tract infections. In addition, it is subcutaneous, and not a cumbersome external construct. Our construct is minimally invasive and does not violate the dorsal extensor compartments allowing movement of the fingers while the construct is in place.

The use, timing, and priority of angioembolization in the management of bleeding pelvic fractures remain ambiguous. The most common vessels for angioembolization are, in decreasing order, the internal iliac artery and its branches, the superior gluteal artery, the obturator artery, and the internal pudendal artery. Technical success rates for this treatment option range from 74% to 100%. The fracture patterns most commonly requiring angioembolization are the Young and Burgess lateral compression and anterior-posterior compression types and Tile type C. Mortality rates after angioembolization of 16% to 50% have been reported, but deaths are usually related to concomitant injuries. The sensitivity and specificity of contrast-enhanced CT in detecting the need for angioembolization range from 60% to 90% and 92% to 100%, respectively. Angioembolization can be effective in the management of bleeding pelvic fractures, but as with any treatment, the risks of complications must be considered. Availability of angioembolization and institutional expertise/preference for the alternative strategy of pelvic packing influence its use.

Supplemental Digital Content is Available in the Text., Objective: To describe our experience using the anterior internal pelvic fixator (INFIX) for treating pelvic ring injuries. Design: Case Series. Setting: Level 1 Trauma Center. Patients: Eighty-three patients with pelvic ring injuries were treated with INFIX. Follow-up average was 35 months (range 12–80.33). Intervention: Surgical treatment of pelvic ring injuries included reduction, appropriate posterior fixation, and INFIX placement. Outcome Measurements: Reduction using the pelvic deformity index and pubic symphysis widening, Majeed functional scores, complications; infection, implant failure, heterotopic ossification (HO), nerve injury, and pain. Results: All patients healed in an appropriate time frame (full weight bearing 12 weeks postoperation). The average pelvic deformity index reduction (injury = 0.0420 ± 0.0412, latest FU = 0.0254 ± 0.0243) was 39.58%. The average reduction of pubic symphysis injuries was 56.92%. The average Majeed score of patients at latest follow-up was 78.77 (range 47–100). Complications were 3 infections, 1 case of implant failure, 2 cases implantation too deep, 7 cases of lateral femoral cutaneous nerve irritation, and 3 cases of pain associated with the device. HO was seen in >50% of the patients, correlated with increased age (P < 0.007), injury severity score (P < 0.05) but only 1 case was symptomatic. Conclusions: The pelvic injuries had good functional and radiological outcomes with INFIX and the appropriate posterior fixation. The downside is removal requiring a second anesthetic, there is a learning curve, HO often occurs, the lateral femoral cutaneous nerve may get irritated which often resolves once the implants are removed. Surgery-specific implants need to be developed. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study is to compare INFIX to plating in the treatment of unstable pelvic ring injuries with disruption of the symphysis. Twenty-four patients treated with INFIX were compared to 28 patients fixed by plating. All patients had anterior and posterior fixation. Injuries were classified using the Young and Burgess and AO/OTA classification systems. Reductions of the pelvic ring were assessed using the pelvic deformity index (PDI) and symphyseal widening. Patients were contacted to get functional outcomes using the Majeed scoring system and complications were tabulated . INFIX was inferior to plating at reducing symphyseal widening (INFIX 10.72± 5.0 Plates 6.97 ± 3.39 P = 0.012) but similar in reducing the pelvic deformity index. (INFIX 0.0221± .015 Plates 0.0190 ± .0105 P = 0 .38). Majeed scores were similar 83.95 ± 15.2 (median 89, range 51-100) for INFIX and 77.67± 16.7 (median 79, range 54-100) for plating. Complications included infection (1 (4%) INFIX , 4 (14%) plates), improper hardware placement or failure (2 (8%) INFIX, 3 (11%) plates), and heterotopic ossification (11 (46%) INFIX, 16 (57.1%) plates). Infection in the plated patients was related to urological injury in 3/4 cases. Plating provides better reduction of the pubic symphysis and requires only one surgery. Outcomes scores were similar. INFIX may be preferable in obese patients, young women of childbearing age or those with urological injury.

In regard to a recent paper published in your journal Sicot J: The use of anterior subcutaneous internal fixation (INFIX) for treatment of pelvic ring injuries in major trauma patients, complications and outcomes by Richard Steer, Ganesh Balendra, Justin Matthews, Martin Wullschleger, and James Reidy. We have an issue with the introduction of the article on the origins of the INFIX technique. The authors state “The earliest description of an INFIX was published in the German literature in 2009 [9] with a subsequent mid-term follow-up cohort from the same authors in the English literature in 2013 [8]” [1]. The problem of anterior external fixation was recognized by many groups and pelvic surgeons over the last 50 years. Three separate innovations were developed to address this issue in publications and patents from 2007 to 2012 (and we are certain many more will follow). The “Pelvic Bridge” was developed with plates that connected the iliac crest to the symphysis lying above the external oblique fascia and inguinal ring. It was originally formed with two plates and screws and modified to two-plate rod constructs by Parsell DE, Cole PA in 2007 [2, 3] (Figure 1). The “INFIX” is a construct that uses supraacetabular pedicle screws placed at or above the Anterior Inferior Iliac Spine with a rod that sits in the subcutaneous space in an area called the “bikini line” by Vaidya R in 2008 [4–6] (Figure 2). The Crossover Pelvic Internal Fixator is a construct using Pedicle screws on the inner table of the Ilium with rods similar to the Pelvic Bridge which travel to the area of the symphysis pubis and could be constructed with 1 rod or 2 described by the German Group Kuttner M, Klaiber A, Lorenz T, Fuchtmeier B, Neugebauer R in 2009 [7] (Figure 3). All these techniques are used in conjunction with posterior fixation in unstable pelvic ring injuries and have the ability to distract or compress the anterior injury. Significant thought and work went into these innovations which all address anterior pelvic instability. We commend the other innovators on their work and techniques for which clinical results have already been reported [2, 3, 7, 8]. Figure 1 Parsells and Cole (2007) “Pelvic Bridge.” Figure 2 “INFIX” Vaidya (2008). Figure 3 Kuttner et al. (2009) “The Cross-over Pelvic Internal Fixator”. The technique described in this paper by Steer et al. is the INFIX first described in 2008 by Vaidya [4]. Steer et al. [1] go on to say that the German Group published a clinical report with subsequent midterm follow-up of their technique in 2013 [8]: “with a subsequent mid-term follow-up cohort from the same authors in the English literature in 2013.” In 2013 the German Group published a second paper now using the INFIX technique described by Vaidya et al. in 2008 and 2012, having switched their construct now using supraacetabular screws instead of intra pelvic screws and the space noted to be the bikini line instead of the bar coming to the symphysis first described by Cole et al. in 2007 [2, 3]. The reason patents were awarded to Parsells and Cole [2] and Vaidya [4] were that they were the first to describe the respective techniques. Conflict of interest Dr. Vaidya: US patent for anterior subcutaneous internal pelvic fixator. But no conflict of interest with this paper except that mentioned in the letter on the history of INFIX.

A novel injectable polymeric dicalcium phosphate dehydrate (P-DCPD) cement was developed with superior mechanical strength and excellent cohesion. The purpose of this study was to assess the in vitro performance of P-DCPD loaded with vancomycin (VAN-P), tobramycin (TOB-P) and combination of both (VAN/TOB-P) (10%, w/w). There is a distinctive release profile between VAN and TOB. VAN-P showed decreased initial burst (90% of VAN was released within 3 d (p < 0.05). Slow and limited TOB release was observed both in TOB-P (Staphylococcus aureus growth showed that eluents collected from VAN-P had stronger and longer ZOI (28 d) than that from TOB-P (14 d, p < 0.05). Direct contact of VAN-P, TOB-P and VAN/TOB-P cements displayed persistent and strong ZOI for >3 weeks. Interestingly, the cement residues (28 d after drug release) still maintained strong ZOI ability. P-DCPD with or without antibiotics loading were nontoxic and had no inferior impacts on the growth of osteoblastic MC3T3 cells. VAN-P and TOB-P were injectable. No significant influence on setting time was observed in both VAN-P (11.7 ± 1.9 min) and VAN/TOB-P (10.8 ± 1.5 min) as compared to control (12.2 ± 2.6 min). We propose that a distinctive release profile of VAN and TOB observed is mainly due to different distribution pattern of VAN and TOB within P-DCPD matrix. A limited release of TOB might be due to the incorporation of TOB inside the crystalline lattice of P-DCPD crystals. Our data supported that the bactericidal efficacy of antibiotics-loaded P-DCPD is not only depend on the amount and velocity of antibiotics released, but also probably more on the direct contact of attached bacteria on the degrading cement surface.

Objectives To assess the diagnostic sensitivity of computed tomography (CT) in patients with an unstable pelvic ring injury after application of a pelvic binder. Design An institutional review board approved retrospective study from 2003 to 2010. Setting Level 1 trauma center. Patients Inclusion criteria were patients in our trauma database with AO/OTA B or C type pelvic ring injury, which first had an anterior-posterior pelvic x-ray followed by application of a pelvic circumferential compression device (PCCD), then a CT, and a fluoroscopic stress examination under anesthesia (FEUA) (used as gold standard). Of 867 patients, 43 met the inclusion criteria. Intervention A senior Orthopaedic Resident and Trauma Attendings assessed x-rays, CTs, and FEUAs. Binomial test was used to compare imaging against final diagnosis. Results In Anterior Posterior Compression/Vertical Shear (OTA 61-B1, 61-B3.1, 61-C) injury patterns, prebinder x-rays were diagnostic in 69.4% (CI, 51.9%-83.7%) of cases, compared with 50% (CI, 32.9%-67.1%) with CT + PCCD. The x-ray was superior to CT + PCCD for identification of the anterior pelvic injury (McNemar exact P = 0.0352). If x-ray and CT + PCCD were viewed in tandem, 83.3% (CI, 67.2%-93.6%) of classifications were in agreement with the FEUA. For lateral compression mechanisms, the binder did not effect of the sensitivity of the CT except in the open book component of an lateral compression 3 (61-B3.2) mechanism. Conclusions The placement of a pelvic binder has the potential to mask the severity of unstable pelvic ring injuries when relying only on CT for diagnosis. Fluoroscopic manual pelvic stress examination under anesthesia is an essential adjunct when a binder is placed before imaging. Level of evidence Diagnostic level III. See Instructions for Authors for a complete description of levels of evidence.

Mortality in patients sustaining pelvic fractures has been reported to be 4% to 15%. We sought to investigate the cause of death based on timing and evaluate if type of fracture and Injury Severity Score have an influence on the survival time.Sixty-nine patients of eight hundred sixty seven with a pelvic fracture who died during their hospital admission were included. Fractures were classified using the Arbeitsgemeinschaft Osteosynthesefragen/Orthopaedic Trauma Association system. Cause determined by autopsy in 48/69.The leading cause of death within 6 hours was abdominal and pelvic hemorrhage; 6 to 24 hours head injury, and greater than 24 hours multiple organ dysfunction syndrome. Survival time did not correlate between fracture type (P.12) or Injury Severity Score. Only 2 patients died of isolated pelvic hemorrhage.Despite the advances made in acute management of the traumatized patient in the emergency department, mortality is unavoidable in a small group of patients with hemorrhage being the commonest cause of early death but isolated pelvic hemorrhage rare.