Abstract
The treatment of the multi-trauma, hemodynamically unstable patient, with pelvic fractures is a major challenge for the trauma team. The use of selective embolization, in early stage when hemodynamic instability persists despite control of other sources of bleeding, is well established. In these cases bleeding from an injured artery, cannot be controlled through indirect means such as an external fixation device, and must be directly addressed, through laparotomy and retroperitoneal packing or direct embolization of the bleeding artery. This procedure is part of the C phase of the ATLS, and therefore must be carried out in an emergency setup requiring a well trained team that can be alerted 24 hours a day. We present our experience and preferred protocol for the treatment of these complex injuries.
Material and Methods: Between the years 2000 and 2004, 732 patients with pelvic fractures were treated in our center. Of these, 11 patients with complex pelvic fractures required emergency arteriography and embolization. All the cases involved high energy injuries, eight motor vehicle accidents, two falls from height and one crush injury.
The average age was 32 (range 21 to 78). The pelvic fracture type was an anterior posterior mechanism in eight cases where the artery injured was the pudendal artery. In three cases iliac wing injury in a lateral compression or sheer mechanism, caused a gluteal artery injury. Timing of treatment: in 5 cases angiography was performed directly after an initial CT, in 4 cases the embolization was performed following an emergent laparotomy. In the remaining two cases, instability was recognized later in the course of treatment, one following amputation of a mangled leg and the second after secondary deterioration in a head injured multi-trauma patient.
Five patients went through pelvic fixation by an external fixation device, applied prior to angiography of which two were surgically applied and three were treated with a pelvic belt.
In five patients no pelvic fixation was needed either initially or definitively.
Discussion: When available angiographic embolization can be used affectively in these selected cases. Pelvic fractures can present with arterial injury even with a clinically stable pelvic ring. An arterial injury must be considered in all severe pelvic injuries regardless of the pelvic ring stability. We recommend strongly to use the belt as an intermittent way of controlling the hemodynamic instability and not to delay direct means of hemorrhage control such as laparotomy or embolization – if there is a team ready in the hospital. We must consider that the delay in treatment, short as it may be, needed for application the external fixation devices, may be crucial for the survival of the patient.
The abstracts were prepared by Ms Orah Naor. Correspondence should be addressed to Israel Orthopaedic Association at PO Box 7845, Haifa 31074, Israel.
