Department of Orthopaedic Surgery, Faculty of Medicine.
Physical Therapy Course of Study, Faculty of Welfare and Health Sciences, Oita University, Oita, Japan.
Medicine (Baltimore). 2021 Mar 12;100(10):e25056. doi: 10.1097/MD.0000000000025056.
Sacral fracture is the most frequent posterior injury among unstable pelvic ring fractures and is prone to massive hemorrhage and hemodynamic instability. Contrast extravasation (CE) on computed tomography (CT) is widely used as an indicator of significant arterial bleeding. However, while CE is effective to detect significant arterial bleeding but negative result cannot completely rule out massive bleeding. Therefore, additional factors help to compensate CE for the prediction of early hemodynamically unstable condition.We evaluated the risk factors that predict CE on enhanced computed CT in patients with sacral fractures. Patients were classified into 2 groups: CE positive on enhanced CT of the pelvis [CE(+)] and CE negative [CE(-)]. We compared age, sex, injury severity score (ISS), systolic blood pressure (sBP), type of sacral fracture based on Denis classification, platelet (PLT), base excess, lactate, prothrombin time-international normalized ratio, hemoglobin (Hb), activated partial thromboplastin time, D-dimer, and fibrinogen between the 2 groups.A total of 82 patients were treated for sacral fracture, of whom 69 patients were enrolled. There were 17 patients (10 men and 7 women) in CE(+) and 52 patients (28 men and 24 women) in CE(-). Age, ISS, and blood transfusion within 24 hours were significantly higher in the CE(+) group than in the CE(-) group (P = .023, P < .001, P < .001). sBP, Hb, PLT, fibrinogen were significantly lower in the CE(+) group than in the CE(-) group (P < .001, P < .001, P < .001, P < .001). D-dimer and lactate were higher in the CE(+) group than in the CE(-) group (P = .036, P < .001) with significant differences. On multivariate analysis, the level of fibrinogen was an independent predictor of CE(+). The area under the curve value for fibrinogen was 0.88, and the optimal cut-off value for prediction was 199 mg/dL.The fibrinogen levels on admission can predict contrast extravasation on enhanced CT in patients with sacral fractures. The optimal cut-off value of fibrinogen for CE(+) prediction in sacral fracture was 199 mg/dL. The use of fibrinogen to predict CE(+) could lead to prompt and effective treatment of active arterial hemorrhage in sacral fracture.
骶骨骨折是不稳定骨盆环骨折中最常见的后向损伤，容易发生大量出血和血流动力学不稳定。CT 上的对比外渗 (CE) 被广泛用作显著动脉出血的指标。然而，CE 虽然能有效地检测到显著的动脉出血，但阴性结果并不能完全排除大出血。因此，其他因素有助于补偿 CE 对早期血流动力学不稳定情况的预测。我们评估了预测骶骨骨折患者增强 CT 上 CE 的危险因素。患者分为两组：骨盆增强 CT 上有 CE [CE(+)]和 CE 阴性 [CE(-)]。我们比较了两组间年龄、性别、损伤严重程度评分 (ISS)、收缩压 (sBP)、根据 Denis 分类的骶骨骨折类型、血小板 (PLT)、碱剩余、乳酸、凝血酶原时间-国际标准化比值、血红蛋白 (Hb)、活化部分凝血活酶时间、D-二聚体和纤维蛋白原。共治疗 82 例骶骨骨折患者，其中 69 例纳入研究。CE(+)组 17 例（男 10 例，女 7 例），CE(-)组 52 例（男 28 例，女 24 例）。CE(+)组的年龄、ISS 和 24 小时内输血均显著高于 CE(-)组（P=0.023，P<0.001，P<0.001）。sBP、Hb、PLT、纤维蛋白原在 CE(+)组显著低于 CE(-)组（P<0.001，P<0.001，P<0.001，P<0.001）。D-二聚体和乳酸在 CE(+)组显著高于 CE(-)组（P=0.036，P<0.001），差异有统计学意义。多因素分析显示，纤维蛋白原水平是 CE(+)的独立预测因子。纤维蛋白原的曲线下面积值为 0.88，预测 CE(+)的最佳截断值为 199mg/dL。入院时的纤维蛋白原水平可预测骶骨骨折患者增强 CT 上的 CE 外渗。预测骶骨骨折 CE(+)的纤维蛋白原最佳截断值为 199mg/dL。使用纤维蛋白原预测 CE(+)可导致及时有效的治疗骶骨骨折的活跃性动脉出血。
