Introduction: Arterial bleeding following pelvic fractures is widely recognized as an indication for angiography and embolization although controversy persists as to the timing of this procedure in the treatment algorithm. Less well appreciated is its application in similar circumstances following blunt injury to the pelvic arteries and limb injuries. We describe our experience in a variety of haemorrhagic orthopaedic pathologies.

Patients and Methods: Angiography was performed in 29 patients- 16 with pelvic fractures, 9 with extremity injuries, and 4 with tumors. Seldinger technique was used for angiographic access, usually from the groin although on occasion extensive local injury required use of the brachial approach. Following the initial diagnostic study the a selective catheter was placed at the target, appropriate embolic material was selected and the source of haemorrhage was closed off.

Results: In our experience of pelvic traumatic bleeding (14 associated with fracture, 2 without) embolization was successful in promptly arresting hemorrhage in all but one case of advanced DIC. Mortality was confined to this last case and two others, all of whom were referred for embolization following prolonged hypotension and commenced angiographic intervention with blood pressure unmeasureable or of the order of 30mm systolic. With 9 cases of extremity injury, 1 iatrogenic, 5 penetrating, 2 blunt and one following fracture of the femur, embolization successfully treated the hemorrhage. Finally we present our experience in preventing hemorrhage in 4 cases, 3 of which were vertebral body tumours and 1 pathological fracture of the humerus due to RCC. At surgery following embolization none bled significantly.

Conclusions: The present study describes our experience in various orthopedic conditions. Less well recognized is its role in preventing hemorrhage; as a prelude to bloody operations on vertebral body metastases, aneurysmal bone cysts and hemangiomata as well as open reduction and internal fixation of pathological extremity fractures. We conclude that this technique is a valuable addition to the tools available to the orthopedic surgeon and whose application is not necessarily limited to the examples quoted, but should be applied in any case where the direct surgical approach is considered hazardous or ineffective.

Introduction: Penetrating injuries of the foot are very common. Although apparently straightforward, inappropriate approach and treatment can lead to complications and unsatisfactory results. We present our diagnostic and therapeutic approach using an outcomes approach, clinical results and complication rate.

Patients & Methods: Between 2001 and 2003, 63 patients (57 M and 6 F; mean age- 38, range 8 to 63; follow-up: mean 2.5Y range of follow-up 2–4 years) were treated for penetrating foot injury. Each patient had a routine x-ray and foot sonography. The most common injuries were those that penetrated shoes (45/63 pts) – nails (39/45) and wood pieces (6/45), – or bare feet (18/63 Pts) – nails (10/18), glass (5/18), wood pieces (2/18) and even seashells (1/18). The medical files of all these patients were searched for the relevant parameters.

Results: The presence of a foreign body inside the foot tissues was detected in 58/63 Pts (92%) and they were operated upon by meticulous debridement and removal of FB. In the remaining 5 Pts we could not trace any FB and they were treated initially by IV antibiotics. In these 53 Pts (91%) penetrating foreign bodies were detected by sonography, most of them on arrival. Only 5% of the cases could be diagnosed initially by x-ray. The false negative rate of sonography was 19% (11/58 pts). In 6 of these 11 pts, the presence of FB was detected only by a second sonography. In the remaining 5 pts, foreign bodies were not detected even in the second sonography, but found only during surgery. Complete healing was observed in 62/63 (98%) of patients, although 6 /63 (9%) underwent secondary debridement. One patient (diabetic) developed chronic osteomyelitis of the second metatarsal bone and needed repeated surgical interventions.

Conclusions: In order to avoid complications and poor clinical outcome, penetrating injuries of the foot must be approached in an orderly and appropriate manner. The main purpose is to confirm the presence of a foreign body. Plain x-rays and sonography should be used in order to identify or rule out the presence of FB. Sonography is a good diagnostic technique, but it is operator dependent; thus a high index of suspicion must be maintained when the imaging study is negative and there is no clinical improvement despite appropriate systemic and local treatment. In our experience, repeated sonography and sometimes surgical exploration in such circumstances are likely to reveal the presence of a FB. It should be emphasized that injury through a shoe rather than a bare foot may result in local infection secondary to the penetrating object and also complications related to the additional presence of fiber, rubber or leather foreign body. Excellent results are observed following meticulous debride-ment combined with systemic antibiotics.