Background: Pelvic fractures are frecuently associated with massive intrapelvic bleeding from venous or arterial sources. Different treatment algorithms has been proposed in order to stablish early control of haemorragic sites, mostly based on external fixation/angiography. The aim of present study was to evaluate the clinical evolution of 70 pelvic fractures with uncontrolled hypotension treated with combined ex fix/angio based on fracture pattern.

Materials and methods: Case serie . We analyzed a serie of patients admitted at our center between 1994 and 2004 with pelvic fracture and haemodinamic instability , treated by the same algorithm. Decision-making for the first treatment(angio vs external fixation) were based on the type of pelvic fracture. Patients was considered unstable if PAS was less than 90mmHg or the patients needs more than two blood products replacement in first 24 hours.

Results: External fixation was used in 45 patients(64%) and 37 patients were treated by angio. We found active arterial bleeding in 31 cases (44%). The combination of both treatment was used in 20 patients. Laparotomy was performed in 21 patients. Incidence of sistemic complications were high . Mortality was 26% . Mortality were higher in two groups: patients with TBI and those treated by laparotomy.

Conclusions: Arterial lesions demostrated by angio were high in our study(44%). In our experience a combined algorithm using both external fixation or angio based on type fracture control intrapelvic bleeding in most cases , although mortality in patients with pelvic fractre and haemodinamic instabilty remains high.

Introduction: Terrorist bombings, with catastrophic resultant blast injuries, have been increasing in frequency during past 25 years. Limbs injuries is common among survivors. Four crowded trains were attacked in Madrid on March 11, 2004. Injuries were sustained by 1550 people, 198 of whom died, mostly at the scene. Because the building station did not collapse, as in other attacks, the number of multiple injured patients who survive were high. 509 patients were attended at our Hospital in the emergency unit during the first six hours after the explosions, 80 of whom require hospitalization. Three patients died on arrival. Data about transport from the scene, injury type, diagnostic test and treatment and functional outcome were obtained from the Hospital Trauma Registry.

The day at the Hospital:

The first patient arrived at 08:00, when the daily clinical meeting for the trauma admissions began. During the first hour, an effort was made in order to triage victims and organize the requirements for operating room and ICU treatment. All scheduled operations were aborted and six orthopaedic trauma teams were prepared to start operations immediately. A separate area in the Hospital was established to treat minor injuries. All patients were operated within the first 8 hours.

Injury characteristics: 39 patients admitted with an ISS higher than 9 presented the most severe injuries. A study group was made with these patients. Mean age were 33,6. The mean RTS were 6,87, mean ISS 21,94, and mean NISS 26,15, revealing the high frequency of multisistemic injuries. The most frequently injury in these group were pulmonary blast injury, with a mean AIS for thorax of 2,7 points.74% of patients had some type of pulmonary blast injury.

Limb injuries: 12 (25%) patients had open fractures, combined in all cases with pulmonary blast. Open Gustilo IIIb and IIIc occur in seven patients. Soft tissue injuries caused by small fragments were also frequent. Two patients presented SCIWORA like injuries of the thoracic medullary cord. All patients were operated in the first six hours after the explosion. A detailed description of the injuries, treatment and functional outcome will be presented. Functional outcome were analyzed by physical and psychological scales at six and twelve months after the attack. Scales used were SF-36(short form 36), EQ-5D (Euroqol), CES-D( Center for Epidemiologic Studies Depression Scale) and AVS. Comparison with a similar general trauma group revealed poorer functional outcome at six months for the study group.

Conclusions: The bombing attack in Madrid was the first massive attack over civilian population in Europe since WW II. Functional outcomes were worse than expected in patients with skeletal injuries. In spite of the good results of initial treatment in our experience, we think that there is no country prepared sufficiently to treat this new type of massive casualties.