Session VII - Pelvic Trauma

Pelvic Fracture Patterns and Their Corresponding Angiographic Sources of Hemorrhage

Christopher M. Metz, MD, David J. Hak, MD, James A. Goulet, MD, David Williams, MD

Taubman Center, Ann Arbor, Michigan, USA

Purpose: This study investigates and correlates sources of arterial hemorrhage in patients with stable and unstable fractures of the pelvic ring. In addition, this study demonstrates fracture patterns that are associated with significant arterial hemorrhage and hemodynamic instability that may require angiographic examination.

Methods: We conducted a retrospective review of 49 patients with pelvic ring fractures and hemodynamic instability or ongoing blood loss treated with angiography. Angiographic findings were correlated with pelvic radiographs using the Young and Burgess fracture classification and the Journal of Orthopaedic Trauma's Fracture and Dislocation Compendium. Data regarding age, sex, Injury Severity Score (ISS), mechanism of injury, hemodynamic parameters, initial resuscitation transfusion requirements and patient survival was also recorded. The treatment protocol included fracture stabilization with an unstable hemipelvis using anterior external fixation prior to consideration of angiography.

Results: The average age of the patient population was 46 years (range 16-88) with 27 males and 22 females. The average ISS score was 32 (range 9-75). The most common mechanism of injury was a motor vehicle accident (27 patients), followed by motor vehicle versus pedestrian (11), pelvic crush injuries (5), motorcycle accidents (4) and fall from a height (2). Seventeen of 18 patients (94%) with a systolic blood pressure greater than 90mmHg survived the injury whereas 20 of 31 patients (64%) with a systolic blood pressure less than or equal to 90mmHg survived. The overall mortality rate was 24%. In those patients who did not survive, the average time to death was 5.3 days (range 1-16) with causes including brain death, multi-system organ failure, cardiac arrest, hemorrhage and sepsis.

The current group included 27 lateral compression injuries (LCI, II, III), 21 anteroposterior compression injuries (APCI, II, III) and one vertical shear injury (VS). Patients in the LC group had an average ISS of 28 and average transfusion requirement of 13 units of packed red blood cells (PRBC). Fifteen of these patients (56%) were hemodynamically unstable (systolic blood pressure less than or equal to 90mmHg) on admission. The most common bleeding source was the internal iliac artery (12 lesions), followed by the pudendal (10), obturator (7) and inferior epigastric (7) arteries. Five of these patients died (19%). No source of pelvic arterial hemorrhage was identified in 9 patients.

In the APC group, the average ISS score was higher (37), the average transfusion requirement was higher (29 units PRBC'S) and the mortality rate was higher (33%). Fourteen patients (72%) were hemodynamically unstable on admission. The most common bleeding sources were the superior gluteal and internal iliac arteries (6 lesions) followed by the inferior epigastric (2) and obturator (1) arteries. No source of pelvic arterial hemorrhage was identified in 11 of these patients.

Discussion and Conclusion: Specific patterns of pelvic ring fractures have previously been closely correlated to the overall severity of injury and to mortality rates. The patients in this series with APC fracture patterns had more hemodynamic instability and had a higher mortality rate than patients with other fracture patterns, similar to what other authors have previously reported. In contrast to previous reports, a higher percentage of patients in this series presented in shock and all underwent pelvic angiography. The current series correlates specific sites of blood loss and specific fracture patterns. All APC injuries have a high risk of vascular injury and should be approached aggressively.