Dalal S A, Burgess A R, Siegel J H, Young J W, Brumback R J, Poka A, Dunham C M, Gens D, Bathon H
University of Maryland, Baltimore 21201.
J Trauma. 1989 Jul;29(7):981-1000; discussion 1000-2.
Three hundred forty-three multiple trauma patients with major pelvic ring disruption were studied and subdivided into four major groups by mechanism of injury: antero-posterior compression (APC), lateral compression (LC), vertical shear (VS), and combined mechanical injury (CMI). Acetabular fractures which did not disrupt the pelvic ring were excluded. The mode of injury was: MVA, 57.4%; motorcycle, 9.3%; fall, 9.3%; pedestrian, 17.8%; crush, 3.8%. The LC and APC groups were divided into Grades 1-3 of increasing severity. The pattern of organ injury: including brain, lung, liver, spleen, bowel, bladder, pelvic vascular injury (PVASI), retroperitoneal hematoma (RPH) and complications: circulatory shock, sepsis, ARDS, abnormal physiology, and 24-hr total fluid volume administration were all evaluated as a function of mortality (M). As LC grade increased from 1 to 3 there was increased % incidence of PVASI, RPH, shock, and 24-hr volume needs. However, the large incidence of brain, lung, and upper abdominal visceral injuries as causes of death in Grade 1 and 2 fell in LC3, with limitation of the LC3 injury pattern to the pelvis. As APC grade increased from 1 to 3 there was increased % injury to spleen, liver, bowel, PVASI with RPH, shock, sepsis, and ARDS, and large increases in volume needs, with important incidence of brain and lung injuries in all grades. Organ injury patterns and % M associated with vertical shear were similar to those with severe grades of APC, but CMI had an associated organ injury pattern similar to lower grades of APC and LC fractures. The pattern of injury in APC3 was correlated with the greatest 24-hour fluid requirements and with a rise in mortality as the APC grade rose. However, there were major differences in the causes of death in LC vs. APC injuries, with brain injury compounded by shock being significant contributors in LC. In contrast, in APC there were significant influences of shock, sepsis, and ARDS related to the massive torso forces delivered in APC, with large volume losses from visceral organs and pelvis of greater influence in APC, but brain injury was not a significant cause of death. These data indicate that the mechanical force type and severity of the pelvic fracture are the keys to the expected organ injury pattern, resuscitation needs, and mortality.
对343例伴有严重骨盆环破坏的多发伤患者进行了研究，并根据损伤机制将其分为四大组：前后挤压伤（APC）、侧方挤压伤（LC）、垂直剪切伤（VS）和复合机械伤（CMI）。未累及骨盆环的髋臼骨折被排除。损伤方式为：机动车事故，57.4%；摩托车事故，9.3%；坠落伤，9.3%；行人事故，17.8%；挤压伤，3.8%。LC组和APC组又根据严重程度分为1 - 3级。对器官损伤模式进行评估，包括脑、肺、肝、脾、肠、膀胱、骨盆血管损伤（PVASI）、腹膜后血肿（RPH）以及并发症：循环性休克、脓毒症、急性呼吸窘迫综合征（ARDS）、生理异常和24小时总液体输入量，并将其作为死亡率（M）的函数进行分析。随着LC分级从1级升至3级，PVASI、RPH、休克的发生率以及24小时液体需求量均增加。然而，1级和2级中作为死亡原因的脑、肺和上腹部脏器损伤的高发生率在LC3级中下降，LC3级损伤模式局限于骨盆。随着APC分级从1级升至3级，脾脏、肝脏、肠、伴有RPH的PVASI、休克、脓毒症和ARDS的损伤发生率增加，液体需求量大幅增加，且各级中脑和肺损伤的发生率均较高。垂直剪切伤的器官损伤模式和死亡率百分比与严重APC分级相似，但CMI的器官损伤模式与较低级别的APC和LC骨折相似。APC3级的损伤模式与最大的24小时液体需求量相关，且随着APC分级升高死亡率上升。然而，LC伤和APC伤的死亡原因存在重大差异，脑损伤合并休克是LC伤死亡的重要因素。相比之下，在APC伤中，休克、脓毒症和ARDS受到APC传递的巨大躯干力量的显著影响，APC中内脏器官和骨盆的大量液体丢失影响更大，但脑损伤不是主要死亡原因。这些数据表明，骨盆骨折的机械力类型和严重程度是预期器官损伤模式、复苏需求和死亡率的关键。
