OTA 1997 Posters - Pelvic & Acetabular Fractures

Therapeutic Embolisation of Major Pelvic Fractures

J. F. Keating, MD, R. Cook, I. Gillespie

Royal Infirmary, Scotland, United Kingdom

Purpose: The purpose of this study was to evaluate the current role of pelvic angiography and embolisation in the management of major pelvic fractures.

Methods: In the time interval between 1988 and 1994, there were 90 unstable pelvic fractures admitted. Of these, pelvic angiography was performed in 17 cases (19%). There were 13 males and 4 females with a mean age of 35 years (range 8 to 70). The median injury severity score was 34 (range 11 to 57). Using the AO classification there were 8 rotationally unstable patterns (6 type B1 and 2 type B2) and 9 vertically unstable patterns (3 type C1, 4 type C2 and 2 type C3). Fourteen patients were hypotensive on admission and the remainder became hypotensive within 24 hours. The mean time from admission to the angiography procedure was 4 hours. The mean duration of the angiography procedure was 102 minutes (range 30 to 150 minutes).

Results: Angiography demonstrated significant vascular injuries in 13 cases (76%). The remaining four angiograms were negative. Embolisation with gelatin sponge and Gianturco stainless steel coils of both internal iliac arteries in one case, the left internal iliac in 2 cases. Embolisation of branches of the internal iliac was performed on the right in 5 cases, the left in 4 cases and bilaterally in 1 case. External fixation was performed in 13 cases, and internal fixation in one case. The embolisation was successful in stopping angiographic sources of hemorrhage in all cases. One patient remained hypotensive and died. Another 5 patients died who all had severe head injuries, giving an overall mortality of 35%. There were 3 deaths in the type B fractures and 3 in the type C injuries. The fracture morphology was not a reliable guide to the associated vascular injury.

Discussion: Severe hemorrhage in association with pelvic fractures carries a grave prognosis. In fractures with an increase in pelvic volume application of external fixation may help control bleeding but in other configurations has a doubtful role in stabilizing the patient. Pelvic angiography demonstrated sources of pelvic bleeding in 76% of the present series and embolisation controlled these vessels. It should be considered in hypotensive patients with unstable pelvic fractures who remain hemodynamically unstable following external fixation.

Conclusion: Pelvic angiography and embolisation has a useful role in the management of hypotensive patients with type B or type C pelvic fractures.