Pelvic fracture instability-associated L5 transverse process fracture, fact or myth? A systematic review and meta-analysis

Objective: Pelvic fracture can be complicated by posterior urethral injury (PUI) in up to 25% of cases. PUI can produce considerable morbidity, including urethral stricture, erectile dysfunction (ED), and urinary incontinence. Optimal management of PUI is unclear, however, the current gold standard is placement of a suprapubic cystostomy with delayed urethroplasty (SCDU) performed several months later. Another option is early primary realignment (PR) with urethral catheter, performed either open or endoscopically. Through a systematic review and meta-analysis, we aimed to compare PR and SCDU regarding stricture, ED, and urinary incontinence rates. In light of advancing endoscopic techniques, we also aimed to compare early endoscopic realignment (EER) alone with SCDU. Methods: PubMed, Medline, and Embase were searched for eligible studies comparing PR, including EER, and suprapubic cystostomy plus delayed urethroplasty from database inception until July 17th, 2018. We also reviewed reference lists from relevant articles. Study quality assessment was conducted using a modified Newcastle-Ottawa (mNOS) scale (maximum score 9). Results: From 461 identified articles, 13 studies encompassing 414 PR and 308 SCDU patients met our eligibility criteria. Twelve studies were retrospective non-randomized case studies, with 1 prospective randomized case study. Included studies were of moderately low quality (mNOS mean score: 6.0 ± 0.6). Meta-analysis demonstrated that PR and SCDU had similar stricture rates [odds ratio (OR): 2.14; 95% confidence interval (CI): 0.67-6.85; p = 0.20], similar rates of ED (OR: 1.06; 95% CI: 0.62-1.81; p = 0.84), and similar rates of urinary incontinence (OR: 0.94; 95% CI: 0.49-1.79; p = 0.86). Six studies compared EER alone (229 patients) versus SCDU (195 patients). Meta-analysis demonstrated that these modalities also had similar stricture rates (OR: 4.14; 95% CI: 0.76-22.45; p = 0.10), similar rates of ED (OR: 0.79; 95% CI: 0.41-1.54; p = 0.49), and similar rates of urinary incontinence (OR: 1.10; 95% CI: 0.48-2.53; p = 0.82). Conclusion: For PUI patients, neither PR nor EER produces superior outcomes compared to SCDU regarding stricture, ED, and urinary incontinence rates. The quality of studies in the literature, however, is very poor, with the majority of studies being non-randomized retrospective case studies with potentially high bias. Additional high-quality research, particularly prospective studies and randomized controlled trials, are needed to strengthen the evidence base.

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Is a fracture of the transverse process of L5 a predictor of pelvic fracture instability?

Journal of Bone and Joint Surgery - British Volume ◽

10.1302/0301-620x.93b7.26772 ◽

2011 ◽

Vol 93-B (7) ◽

pp. 967-969 ◽

Cited By ~ 27

Author(s):

I. Starks ◽

A. Frost ◽

P. Wall ◽

J. Lim

Keyword(s):

Pelvic Fracture ◽

Transverse Process ◽

Fracture Instability

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Diagnostic Accuracy of Physical Examination for Detecting Pelvic Fractures Among Blunt Trauma Patients: A Systematic Review and Meta-Analysis

10.21203/rs.3.rs-62425/v1 ◽

2020 ◽

Author(s):

Yohei Okada ◽

Norihiro Nishioka ◽

Shigeru Ohtsuru ◽

Yasushi Tsujimoto

Keyword(s):

Systematic Review ◽

Physical Examination ◽

Diagnostic Accuracy ◽

Blunt Trauma ◽

Pelvic Fracture ◽

Clinical Utility ◽

Meta Analysis ◽

Pelvic Fractures ◽

Trauma Patients ◽

Threshold Probability

Abstract Background: Pelvic fractures are common among blunt trauma patients, and timely and accurate diagnosis can improve patient outcomes. However, it remains unclear whether physical examinations are sufficient in this context. This study aims to perform a systematic review and meta-analysis of studies on the diagnostic accuracy and clinical utility of physical examination for pelvic fracture among blunt trauma patients.Methods: Studies were identified using the MEDLINE, EMBASE, and CENTRAL databases starting from the creation of the database to January 2020. A total of 20 studies (49,043 patients with 8,300 cases [16.9%] of pelvic fracture) were included in the quality assessment and meta-analysis. Two investigators extracted the data and evaluated the risk of bias in each study. The meta-analysis involved a hierarchical summary receiver operating curve (ROC) model to calculate the diagnostic accuracy of the physical exam. Subgroup analysis assessed the extent of between-study heterogeneity. Clinical utility was assessed using decision curve analysis.Results: The median prevalence of pelvic fracture was 10.5% (interquartile range: 5.1–16.5). The pooled sensitivity (and corresponding 95% confidence interval) of the hierarchical summary ROC parameters was 0.859 (0.761–0.952) at a given specificity of 0.920, which was the median value among the included studies. Subgroup analysis revealed that the pooled sensitivity among patients with a Glasgow Coma Scale score ≥ 13 was 0.933 (0.847–0.998) at a given specificity of 0.920. The corresponding value for patients with scores ≤ 13 was 0.761 (0.560–0.932). For threshold probability < 0.01 with 10%–15% prevalence, the net benefit of imaging tests was higher than that of physical examination. Conclusion: Imaging tests should be performed in all trauma patients regardless of findings from physical examination or patients’ levels of consciousness. However, the clinical role of physical examination should be considered given the prevalence and threshold probability in each setting.

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Preperitoneal packing for pelvic fracture-associated hemorrhage: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma

The American Journal of Surgery ◽

10.1016/j.amjsurg.2020.05.037 ◽

2020 ◽

Vol 220 (4) ◽

pp. 873-888

Author(s):

Nikolay Bugaev ◽

Rishi Rattan ◽

Michael Goodman ◽

Kaushik Mukherjee ◽

Bryce R.H. Robinson ◽

...

Keyword(s):

Systematic Review ◽

Pelvic Fracture ◽

Meta Analysis ◽

Practice Management ◽

Management Guideline

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Diagnostic accuracy of physical examination for detecting pelvic fractures among blunt trauma patients: a systematic review and meta-analysis

World Journal of Emergency Surgery ◽

10.1186/s13017-020-00334-z ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Yohei Okada ◽

Norihiro Nishioka ◽

Shigeru Ohtsuru ◽

Yasushi Tsujimoto

Keyword(s):

Systematic Review ◽

Physical Examination ◽

Diagnostic Accuracy ◽

Blunt Trauma ◽

Pelvic Fracture ◽

Clinical Utility ◽

Meta Analysis ◽

Pelvic Fractures ◽

Trauma Patients ◽

Threshold Probability

Abstract Background Pelvic fractures are common among blunt trauma patients, and timely and accurate diagnosis can improve patient outcomes. However, it remains unclear whether physical examinations are sufficient in this context. This study aims to perform a systematic review and meta-analysis of studies on the diagnostic accuracy and clinical utility of physical examination for pelvic fracture among blunt trauma patients. Methods Studies were identified using the MEDLINE, EMBASE, and CENTRAL databases starting from the creation of the database to January 2020. A total of 20 studies (49,043 patients with 8300 cases [16.9%] of pelvic fracture) were included in the quality assessment and meta-analysis. Two investigators extracted the data and evaluated the risk of bias in each study. The meta-analysis involved a hierarchical summary receiver operating curve (ROC) model to calculate the diagnostic accuracy of the physical exam. Subgroup analysis assessed the extent of between-study heterogeneity. Clinical utility was assessed using decision curve analysis. Results The median prevalence of pelvic fracture was 10.5% (interquartile range, 5.1–16.5). The pooled sensitivity (and corresponding 95% confidence interval) of the hierarchical summary ROC parameters was 0.859 (0.761–0.952) at a given specificity of 0.920, which was the median value among the included studies. Subgroup analysis revealed that the pooled sensitivity among patients with a Glasgow Coma Scale score ≥ 13 was 0.933 (0.847–0.998) at a given specificity of 0.920. The corresponding value for patients with scores ≤ 13 was 0.761 (0.560–0.932). For threshold probability < 0.01 with 10–15% prevalence, the net benefit of imaging tests was higher than that of physical examination. Conclusion Imaging tests should be performed in all trauma patients regardless of findings from physical examination or patients’ levels of consciousness. However, the clinical role of physical examination should be considered given the prevalence and threshold probability in each setting.

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Diagnostic accuracy of physical examination for detecting pelvic fractures among blunt trauma patients: A systematic review and meta-analysis

10.21203/rs.3.rs-62425/v2 ◽

2020 ◽

Author(s):

Yohei Okada ◽

Norihiro Nishioka ◽

Shigeru Ohtsuru ◽

Yasushi Tsujimoto

Keyword(s):

Systematic Review ◽

Physical Examination ◽

Diagnostic Accuracy ◽

Blunt Trauma ◽

Pelvic Fracture ◽

Clinical Utility ◽

Meta Analysis ◽

Pelvic Fractures ◽

Trauma Patients ◽

Threshold Probability

Abstract Background: Pelvic fractures are common among blunt trauma patients, and timely and accurate diagnosis can improve patient outcomes. However, it remains unclear whether physical examinations are sufficient in this context. This study aims to perform a systematic review and meta-analysis of studies on the diagnostic accuracy and clinical utility of physical examination for pelvic fracture among blunt trauma patients. Methods: Studies were identified using the MEDLINE, EMBASE, and CENTRAL databases starting from the creation of the database to January 2020. A total of 20 studies (49,043 patients with 8,300 cases [16.9%] of pelvic fracture) were included in the quality assessment and meta-analysis. Two investigators extracted the data and evaluated the risk of bias in each study. The meta-analysis involved a hierarchical summary receiver operating curve (ROC) model to calculate the diagnostic accuracy of the physical exam. Subgroup analysis assessed the extent of between-study heterogeneity. Clinical utility was assessed using decision curve analysis. Results: The median prevalence of pelvic fracture was 10.5% (interquartile range: 5.1–16.5). The pooled sensitivity (and corresponding 95% confidence interval) of the hierarchical summary ROC parameters was 0.859 (0.761–0.952) at a given specificity of 0.920, which was the median value among the included studies. Subgroup analysis revealed that the pooled sensitivity among patients with a Glasgow Coma Scale score ≥ 13 was 0.933 (0.847–0.998) at a given specificity of 0.920. The corresponding value for patients with scores ≤ 13 was 0.761 (0.560–0.932). For threshold probability < 0.01 with 10%–15% prevalence, the net benefit of imaging tests was higher than that of physical examination. Conclusion: Imaging tests should be performed in all trauma patients regardless of findings from physical examination or patients’ levels of consciousness. However, the clinical role of physical examination should be considered given the prevalence and threshold probability in each setting.

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