|Year : 2017 | Volume
| Issue : 6 | Page : 200-208
Pelvic fracture does not increase mortality in adult trauma patients: A propensity score analysis
Ching-Hua Hsieh1, Chih-Che Lin2, Shiun-Yuan Hsu1, Hsiao-Yun Hsieh1
1 Department of Plastic Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung City, Taiwan
2 Department of General Surgery, College of Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung City, Taiwan
|Date of Submission||29-Dec-2016|
|Date of Decision||03-Mar-2017|
|Date of Acceptance||17-Aug-2017|
|Date of Web Publication||08-Dec-2017|
Dr. Ching-Hua Hsieh
No. 123, Ta-Pei Road, Niao-Song District, Kaohsiung City 833
Source of Support: None, Conflict of Interest: None
Background: This study was designed to investigate the impact of pelvic fracture on the outcome of trauma patients.
Methods: Detailed data of 512 and 20,159 adult patients with and without pelvic fracture, respectively, hospitalized between January 1, 2009, and December 31, 2015 were retrieved from the Trauma Registry System of a level I regional trauma center. Two-sided Fisher exact or Pearson Chi-square tests were used to compare categorical data. The unpaired Student t-test and Mann–Whitney U-test were used to analyze normally and nonnormally distributed continuous data, respectively. Propensity score matching was performed using NCSS software to evaluate the effect of pelvic fracture on mortality and expenditure.
Results: Patients with pelvic fracture presented with a longer hospital stay, a higher likelihood of being admitted to the Intensive Care Unit, and a significantly higher incidence of mortality (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.3–3.5; P = 0.003) than those without pelvic fracture. However, the logistic regression analysis of 316 well-balanced pairs of patients with matched propensity scores (to eliminate the difference in sex, age, comorbidity, Glasgow coma scale, and injury severity score) showed that the association of pelvic fracture did not significantly influence mortality (OR 1.2, 95% CI 0.6–2.5; P = 0.581).
Conclusions: This study revealed that the higher odds of mortality in patients with pelvic fracture can be attributed to a combination of multiple injuries to different body regions and risk factors of the patients.
Keywords: Hospital cost, in-hospital mortality, length of stay, pelvic fracture
|How to cite this article:|
Hsieh CH, Lin CC, Hsu SY, Hsieh HY. Pelvic fracture does not increase mortality in adult trauma patients: A propensity score analysis. Formos J Surg 2017;50:200-8
|How to cite this URL:|
Hsieh CH, Lin CC, Hsu SY, Hsieh HY. Pelvic fracture does not increase mortality in adult trauma patients: A propensity score analysis. Formos J Surg [serial online] 2017 [cited 2020 Sep 23];50:200-8. Available from: http://www.e-fjs.org/text.asp?2017/50/6/200/220346
| Introduction|| |
Pelvic fractures usually result from high-energy trauma  and have a significant impact on morbidity and mortality in trauma patients.,,,,, In addition, pelvic fractures are frequently associated with other serious injuries. Of all fractures, the reported incidence of pelvic fracture is 2% to 8%;, however, in multiple-trauma patients, the frequency of pelvic ring fractures is around 25%.,,, A combination of complex fractures and severe injuries in other body regions, such as the skull and abdomen, can lead to a fatality rate up to 50%., Therefore, in the assessment of the impact of pelvic fracture on trauma patients, other variables must be considered in relation to pelvic fracture. Some studies have also claimed that the primary cause of death in most trauma mortalities with pelvic fractures is associated injuries and not pelvic fracture alone.,
In the case of trauma patients, mortality may be influenced by the severity of the injury, the patient's age, comorbidities, and even the efficiency of the treatment. injury severity score (ISS) is a measurement of the cumulative injuries per body area and it has been evaluated in relation to mortality, with a higher ISS being associated with a higher risk of mortality.,, In patients with pelvic fracture, ISS > 25 had identified as the only pronounced risk factor associated with mortality , and an ISS cutoff of 27–28 had been proposed to be a good indicator of mortality risk. Moreover, it has been reported that all pelvic trauma patients with ISS > 50 died within 1 week, with 75% of these patients dying within 1 h of hospital admission. Older age is also correlated with increased mortality in pelvic trauma patients ,,, and has been identified as an independent determinant of mortality in a multivariate analysis. In addition, the presence of injuries in other regions such as the head ,, or trunk,, Glasgow coma scale (GCS) score,, early physiologic derangement,,,, and severity of the pelvic fracture  are associated with increased mortality rates in pelvic trauma patients.
To investigate the impact of pelvic fracture on the outcome of trauma patients, this study used the selected propensity score-matched subjects to reduce the probable noise of associated variables in the assessment and aimed to illustrate the outcome using the data retrieved from the Trauma Registry System of a level I trauma center.
| Methods|| |
This study was preapproved by the Institutional Review Board (IRB) of the Chang Gung Memorial Hospital (approval number 201600496B0). Informed consent was waived according to IRB regulations.
This retrospective study reviewed data of all 23,705 hospitalized patients registered in the Trauma Registry System of a level I regional trauma center from January 1, 2009, to December 31, 2015. Those patients who were dead on hospital arrival or at the accident scene were excluded from the study. Only adult patients (≥20 years of age) with complete registered data were included in this study. In addition, annual inpatient claim files with any diagnostic codes in the range of 800 (808.00–808.99), defined as pelvic fracture according to the International Classification of Diseases, 9th revision, Clinical Modification, were included in the study. There were 512 patients who had pelvic fracture and 20,159 patients without pelvic fracture. Detailed patient information retrieved from the Trauma Registry System of our institution included the following: age, sex, injury mechanism, preexisting comorbidities, and chronic diseases including diabetes mellitus (DM), hypertension (HTN), coronary artery diseases (CAD), cerebrovascular accidents (CVA), and end-stage renal disease (ESRD); vital signs assessed on arrival at the emergency department (ED); shock index (SI), defined as the ratio of heart rate and systolic blood pressure (SBP); GCS; ISS; the amount of transfusion including packed red blood cells or whole blood (during initial 24 h and entire hospitalization); computed tomography (CT) examination, magnetic resonance imaging (MRI), and angiography performed in the pelvic region; hospital length of stay (LOS); admission in Intensive Care Unit (ICU); in-hospital mortality; and total expenditure, which included the cost of operation (operation fee and operation supply fee), cost of examination (physical examination, hematology testing, radiography examination, pathological examination, electrocardiography examination, echocardiogram, endoscopy, electromyography, cardiac catheterization, and electroencephalography monitoring), cost of pharmaceuticals (medical service, medicine, and narcotics), and other costs (fees for registration, administrative tasks, wards, nursing, blood/plasma tests, hemodialysis, anesthesia, rehabilitation treatment, special material costs, and personal expenses), expressed as cost per victim in US dollars. The ISS is expressed as the median and interquartile range (IQR, Q1–Q3). Odds ratios (ORs) of the associated conditions and injuries of the patients were calculated with 95% confidence intervals (CIs). The data collected were compared using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armonk, NY, USA). Two-sided Fisher exact or Pearson Chi-square tests were used to compare categorical data. The unpaired Student's t-test was used to analyze normally distributed continuous data, which was reported as mean ± standard deviation. The Mann–Whitney U-test was used to compare nonnormally distributed data. A 1:1 matched study group was created by the Greedy method using NCSS software (NCSS 10; NCSS Statistical Software, Kaysville, Utah). After adjusting for confounding factors, binary logistic regression was used to evaluate the effect of intervention for pelvic fracture on mortality. To assess the adjusted effect of pelvic fracture on patient outcomes, two comparable populations of patients with and without pelvic fracture were selected in a 1:4 ratio by the Greedy method using NCSS software, according to the propensity-matched scores, which were calculated using a logistic regression model with sex, age, comorbidity, GCS, and ISS as covariates. P < 0.05 was considered statistically significant.
The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.
| Results|| |
Demographics and injury characteristics of patients with pelvic fracture
As shown in [Table 1], the mean age of patients with pelvic fracture was less than for those without pelvic fracture (44.7 ± 20.6 years and 46.9 ± 22.9 years, respectively; P = 0.016). There were significantly fewer men with pelvic fracture than were women. There was a significantly lower incidence rate of preexistent comorbidities such as HTN and ESRD in patients with pelvic fracture than those without. No significantly different incidence rates of comorbidities such as DM, CAD, and CVA were found between patients with or without pelvic fracture. Pelvic fracture occurred more frequently in drivers and passengers of motor vehicles including motorcycles, in pedestrians, and in patients with a height of fall ≥6 m. In contrast, pelvic fracture occurred less frequently in patients with a height of fall <6 m and in those patients who were struck by or against an object. Compared to those who did not have pelvic fracture, patients with pelvic fracture presented a significantly lower SBP (132 ± 33 vs. 148 ± 33 mm Hg, respectively, P < 0.001) and a higher SI (0.9 ± 0.4 vs. 0.7 ± 0.5, respectively, P < 0.001).
|Table 1: Demographics and injury characteristics of patients with and without pelvic fracture|
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Injury severity and outcome of patients with pelvic fracture
As shown in [Table 1], patients with pelvic fracture had a lower GCS than those without pelvic fracture (14.0 ± 2.8 vs. 14.4 ± 2.1, respectively, P < 0.001); however, the difference in the scores was <1 point. In addition, a significantly larger number of patients with pelvic fracture had a GCS ≤8 and GCS of 9–12, and a smaller number of patients had a GCS ≥13 compared to patients without pelvic fracture. A significantly higher ISS was found in patients with pelvic fracture than in those without pelvic fracture (median [IQR: Q1–Q3], 10,,,,,,,, vs. 6,,,,,, respectively; P < 0.001). When stratified by ISS (1–8, 9–15, 16–24 or ≥25), more patients with an ISS of 9–15, 16–24, and ≥25, and fewer patients with an ISS of 1–8 had sustained pelvic fracture. Patients with pelvic fracture had received more units of blood within 24 h (2.0 ± 4.9 vs. 0.5 ± 2.2 units, respectively, P < 0.001) and during the entire hospitalization (3.0 ± 8.6 vs. 0.7 ± 4.5 units, respectively, P < 0.001). Patients with pelvic fracture present a longer hospital LOS (17.5 ± 13.2 vs. 8.9 ± 9.6 days, respectively; P < 0.001), a significantly higher rate of admission to the ICU (29.1% vs. 18.4%, respectively; P < 0.001), and a significantly higher incidence of mortality (crude OR 2.2, 95% CI 1.3–3.5; P = 0.003) than those without pelvic fracture.
Associated injuries of patients with pelvic fracture
As shown in [Table 2], the associated injuries of patients with pelvic fracture were mainly located in the thorax, which included rib fracture, hemothorax, pneumothorax, hemopneumothorax, lung contusion, thoracic vertebral fracture, and pulmonary embolism, and in the abdominal region, which included intra-abdominal injury, hepatic injury, retroperitoneal injury, renal injury, urinary bladder injury, lumbar vertebral fracture, and sacral vertebral fracture. Notably, patients with pelvic fracture had a 9.9-fold chance of sustaining a pulmonary embolism than those patients without pelvic fracture (OR, 9.9; 95% CI, 3.3–29.8; P = 0.001). In addition, patients with pelvic fracture were more likely to have sustained a subarachnoid hemorrhage (OR, 1.6; 95% CI, 1.2–2.2; P = 0.003) in the head/neck region as well as femoral fracture (OR, 1.8; 95% CI, 1.4–2.2; P < 0.001) and pelvic vessels injury (OR, 49.7; 95% CI, 13.3–185.6; P < 0.001) in the extremities.
|Table 2: Significant associated injuries among trauma patients with and without pelvic fracture|
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Adjusted mortality in propensity score-matched patient population
To reduce the impact of demographic differences, preexisting comorbidities, and injury severity of the patient population on the mortality assessment between patients with or without pelvic fracture, 316 well-balanced pairs of patients were selected for comparison [Table 3]. In these propensity score-matched patients, there was no significant difference in sex, age, comorbidity, GCS, and ISS. The logistic regression analysis of these well-balanced pairs of patients showed that the association of pelvic fracture did not significantly influence mortality (OR 1.2, 95% CI 0.6–2.5; P = 0.581), implying that the higher odds of mortality in patients with pelvic fracture can be attributed to a risky population that was associated with mortality, but not the pelvic fracture per se.
|Table 3: Covariates of trauma patients with and without pelvic fracture before and after propensity score matching (1:1 greedy matching) for mortality assessment|
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Expenditure for patients with pelvic fracture
To compare the outcome, including hospital LOS, proportion of patients admitted into the ICU, and cost for patients with and without pelvic fracture, 512 well-balanced pairs of patients were assessed for outcome assessment, using a 1:4 ratio after propensity score matching of sex, age, comorbidity, GCS, and ISS [Table 4]. In these propensity score-matched patients, who present no significant difference in variables of sex, age, comorbidity, GCS, and ISS, patients with pelvic fracture present a longer hospital LOS (17.6 ± 13.2 days vs. 11.5 ± 11.4 days, respectively; P < 0.001) but not a significantly different proportion of patients admitted to the ICU as 132 of 510 (26.7%) patients with pelvic fracture and 597 of 2033 (29.4%) patients without pelvic fracture had been admitted to the ICU (P = 0.230). Furthermore, before matching, those who had pelvic fracture had a significantly higher total expenditure (69.5% higher), cost of operation (42.5% higher), cost of examination (102.2% higher), and cost of pharmaceuticals (82.8% higher) in comparison with patients without pelvic fracture [Table 5]. On comparing the selected well-balanced pairs of patients with and without pelvic fracture, those who had pelvic fracture had significantly higher total expenditure (18.5% higher) and cost of examination (26.1% higher) but not cost of operation or cost of pharmaceuticals [Table 5]. Further cost analysis revealed a significantly higher incidence of patients with pelvic fracture had received CT (51.2% vs. 42.2%, respectively; P < 0.001) and angiography (4.7% vs. 2.1%, respectively; P = 0.001) but not MRI (1.2% vs. 1.7%, respectively; P = 0.439).
|Table 4: Covariates of trauma patients with and without pelvic fracture adjusted for 1:4 greedy propensity score matching for cost assessment|
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|Table 5: The cost of examinations performed during the hospitalization of trauma patients with and without pelvic fracture|
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| Discussion|| |
The primary causes of death in patients with pelvic fracture include massive hemorrhage, head injury, and multiorgan failure.,,,,,, Mortality within the first 6 h of arrival in the ED is commonly caused by hemodynamic instability from bleeding abdominal viscera and pelvic fracture, and deaths in the 6- to 24-h time span commonly occur due to an associated head injury. Statistically significant median survival time recorded for such patients with hemorrhage and head injury was around 160 and 1,100 min, respectively. Patients who died after 24 h deteriorated to a multiple organ dysfunction syndrome and these patients required ICU care, with their time of death varying from days to weeks. In recent years, with advances in rapid control of retroperitoneal hemorrhage by early external fixation, angiography with embolization, development of transfusion protocols, and damage control, the deaths caused by massive hemorrhage alone have become less frequent; in fact, many deaths are caused by concomitant injuries, especially to the head.,,,, In a study of 5,048 patients with pelvic ring fractures enrolled in the German Pelvic Trauma Registry, all-cause in-hospital mortality declined from 8% (39/466) in 1991 to 5% (33/638) in 2006. A review of records of 10,109 patients with pelvic fracture admitted during the 3 years spanning 2001–2003 from the annual inpatient expenses database of the Bureau of National Health Insurance in Taiwan, Chien et al. reported an overall mortality rate of 3.8%. In this study, patients were investigated in the period spanning 2009–2015, and the mortality of patients with pelvic fracture was 3.5%, which is higher than those patients without pelvic fracture (1.6%). The higher mortality is in accordance with those reports in the literature ,,, and could be attributed to a higher injury severity associated with the patients with pelvic fractures. Notably, these patients with pelvic fracture were associated with more injuries to thorax and the abdominal region, with a higher incidence of sustaining subarachnoid hemorrhage, femoral fracture, and pelvic vessels injury, all above-associated injuries could result in a higher mortality of the patients with pelvic fractures. These associated injuries could also attribute to a prolonged LOS and a higher rate of ICU admission that reported in the literature., Further analysis of the selected pairs of propensity score-matched patients showed that mortality was not caused by the pelvic fracture, but by a combination of multiple injuries to different body regions and risk variables associated with mortality, including sex, age, comorbidity, GCS, and ISS.
The management of hemorrhagic instability linked to pelvic ring disruption involves a sequence of therapeutic events. The discovery of a significant amount of intraperitoneal fluid by CT, or ultrasound is considered an indication for laparotomy and/or angiography. It has been reported that 3.5% of patients with complex pelvic fractures had an associated blunt iliac artery injuries., In a series of 35 pelvic ring fractures, 75% of patients sustained simultaneous bleeding from multiple arteries that required angiography, with the bleeding sources depending on the location and degree of skeletal instability. If the patients remain hemodynamically unstable after application of an external fixator, angiography is strongly suggested. In addition, although plain radiographs identify pubic rami fractures, sacral fractures are difficult to diagnose with this technology and require examinations such as CT scans or MRI. Many institutions have abandoned the routine for selective pelvic X-ray for initial imaging in blunt trauma patients undergoing CT scanning. With the advantage for detection of fractures at all sites of the pelvic bone and for determining the severity, CT scan is now recommended as the initial diagnostic imaging technique in the patients with suspected pelvic fracture., CT scan although help to detect the contrast medium extravasation the arterial phase,, which phenomenon would be an indication for performing a pelvic angiography., Angiographic embolization remains the mainstay of treatment of the hemodynamic instability due to pelvic fractures, which has a high rate of mortality., In contrast, MRI is the preferred modality to diagnose occult hip fractures in the condition that a patient presents with negative radiographs and high clinical suspicion of fracture., In this study, a significantly higher incidence of patients with pelvic fracture was found to have received CT or angiography may explain the significantly higher total expenditure (18.5% higher) and cost of examination (26.1% higher) than those selected patient pairs without pelvic fracture. However, the patients with pelvic fractures did not present a significant higher cost of operations than those matched pairs of patients without pelvic fractures. This phenomenon may be attributed by a widely used noninvasive external pelvic compression binder or garment in the initial management of patients,, a low surgical fee (140 US dollars) of applying external fixation apparatus in Taiwan, and relatively rare pelvic fractures requiring an aggressive surgical fixation.
For patients with pelvic fracture, a prolonged LOS  and a higher rate of ICU admission  led to significantly higher direct costs for patients. In this study, patients with pelvic fracture spent significantly more money in comparison with those without pelvic fracture. However, in the selected propensity score-matched patients, patients with pelvic fracture had a longer hospital LOS (17.6 ± 13.2 days vs. 11.5 ± 11.4 days, respectively; P < 0.001); however, the proportion of patients admitted to the ICU was not significant, implying that some indication of admission into the ICU may be related to worse injury severity or a higher risk patient population. In addition, the longer hospital LOS may also explained a higher total expenditure associated with the patients with pelvic fractures. However, the length of hospitalization and the related costs should also be interpreted with caution since vast geographical differences exist. In the United States, a mean time of 9.2 days in surgical wards with mean 3.1 days in the ICU after pelvic and acetabular fractures was reported. In Italy, the median period of hospitalization for patients in the surgical unit following an acetabular or pelvic fracture is 2 weeks  and for those patients in a rehabilitation unit, is 2 months. In the United Kingdom, the median in-hospital LOS of patients with osteoporotic pelvic fracture is 30 days for women and 39 days for men, with an overall range of 5–170 days., In Germany, the mean hospitalization length ranges from 30 to 56 days. Notably, huge differences between hospitalization costs exist in different countries. For example, in Taiwan, <200 dollars for a single day of hospitalization has been charged; however, in the United States, the estimated cost is 1944 dollars per day. Previously, Chien et al. had reported a mean hospital LOS as 11.3 ± 11.2 days and the average total inpatient cost as US$ 1644 ± 2605 for patients with pelvic fracture in Taiwan between 2001 and 2003. In this study, mean hospital LOS was 17.5 ± 13.2 days and average total inpatient cost was US$ 4949 ± 5403. Some differences may explain the discrepancy between our results and the results by Chien et al. The cost of hospitalization is increasing after a decade and the patients stay longer and spend more money in medical centers. Moreover, compared to the total average hospital LOS mortality significantly shorten the average hospital LOS in these cases, and in these recent years, the incidence of mortality is decreasing. However, the comparison between these two studies seemed to be unsuitable and irrelevant to the scope of the present study because of differences in population composition. Therefore, we emphasized the results from this study by comparing the selected well-balanced pairs of patients with and without pelvic fracture; those who had pelvic fracture had significantly higher total expenditure (18.5% higher) and cost of examination (26.1% higher), indicating a higher in-hospital cost of trauma patients with pelvic fracture across a more similar patient population.
Our study has some limitations that should be acknowledged. First, owing to the retrospective design of the study, there is inherent selection bias. A second source of potential bias may result from the exclusion of patients declared dead on hospital arrival and injured patients who were discharged against the advice of the ED. The latter group may represent more patients with a higher ISS or with massive hemorrhage. This bias also potentially skews the assessment of mortality. Further, the descriptive study design assumes a uniform assessment and management of patients with or without pelvic fracture and prevents assessment of the effects of any particular treatment intervention. Furthermore, functional impairment in patients with injuries to the pelvic ring is common and has a long-lasting effect. Finally, long-term medical expenditure was not assessed in this study.
| Conclusion|| |
This study revealed that, based on the analysis of selected propensity score-matched subjects, the higher odds of mortality in patients with pelvic fracture can be attributed to a combination of multiple injuries to different body regions and risk factors of the patients.
We appreciated the Biostatistics Center, Kaohsiung Chang Gung Memorial Hospital for statistics work.
Financial support and sponsorship
This research was supported by a grant from CMRPG8E1271.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]