Ben Menachem Y, Coldwell DM, Young JW and Burgess AR (1991). 'Hemorrhage associated with pelvic fractures: causes, diagnosis, and emergent management.' AJR Am J Roentgenol 157(5): 1005-1014. 'Physicians are often reluctant, for no valid reason, to transport hemodynamically unstable patients to the angiography suite. We urge them to abandon this attitude. Patients in hemorrhagic shock, with surgically correctable injuries, should be transported to the operating theatre, regardless of shock. By the same token, patients in hemorrhagic shock, with unknown sources of hemorrhage - as well as those with hemorrhage best treated by embolization - should be transported to the angiographic suite, regardless of shock. Left where they are, be it the emergency department of intensive care unit, they may die of exsanguination.'

'Three basic principles should guide the angiographer in performing embolization.

• The purpose is to slow the bleeding to the extent that the body will control its own hemorrhage, rather than create large areas of ischemia or necrosis.
     
• If ischemia and necrosis must be created it should be limited to the smallest area possible.
     
• The procedure must be done expidetiously.'

Overall 7-11% of pelvic fractures will require embolization. Only 2% of lateral compression fractures have demonstrable arterial haemorrhage, compared to 20% of anteroposterio compression, vertical shear or combined mechanism injuries. (Burgess A, Eastridge BJ, Young JWR, Ellison TS, Ellison PS, Poka A, Bathon GH, Brumback RJ 'Pelvic Ring Disruptions: Effective Classification System and Treatment Protocols.' J Trauma 30(7);848-856:1990)

Evidence

Level I

Level IIa

Bassam, D., G. A. Cephas, et al
A protocol for the initial management of unstable pelvic fractures.
Am Surg 1998 64(9): 862-7

'We conclude that patients with anterior-posterior compression type 2 and 3, lateral compression type 2 and 3, or vertical shear injuries, who are hemodynamically unstable as a result of their pelvic fracture, should undergo immediate ANGIO if laparotomy is not indicated.'

Design: Prospective Cohort Study
Fracture Type: Tile B,C, Young & Burgess APC2 & 3, LC2 & 3, VS
Study Population: 15
Methods: Patients with anteriorly unstable inguries underwent emergent external fixation, while primarilyu posterior injuries underwen emergent angiography.
Results: Blood product & hospital stay similar in the two groups. Complication rate higher in external fixation group, due to failure to adequately control haemorrhage.
Conclusions: APC 2&3, LC 2&3 and VS injuries who are unstable due to their pelvic injuries should undergo immediate angiography if laparotomy is not indicated.

Comments: Non-randomised, small study. However no patient undergoing emergent angiography required a second intervention to control bleeding, compared to 50% of the external fixation group, who went on to angiography. Also massive thigh/buttock/flank haematomas seen in the ex-fix group.

Level IIb

Level III

Daniel N. Segina, Samuel G. Agnew, Tim Daniel et al
Hemodynamicaly Unstable Pelvic Fractures: Retrospective Review of Early Embolization.
OTA Annual Meeting 2000

'embolization in conjunction with binding the thighs or skeletal traction may facilitate the resuscitation process and preclude emergent frame application.'

Objectives: To determine the incidence of patients requiring embolization and the correlation with their pelvic injury and vascular lesions and associated morality.

Design: Retrospective retrieval

Methods: Review of consecutive series of patients presenting to the Trauma Center with angiographically confirmed arterial injury, and subsequent life saving endovascular embolization prior to any other intervention constitute the study cohort. The time from injury until embolization, mode of embolization and incidence of soft tissue problems were data points sought.

Measures: The patient population identified all sustained some type of pelvic fractures, as classified by the OTA modified of the Tile Classification system. Mechanism of injury-Location of artery-Morality rate was correlated.

Results: Three hundred and sixty five consecutive patients sustaining pelvic fractures exclusively from road or industrial trauma between October 1995 and December 1999 constitute the base population. Using the modified resuscitation protocol described one emergency external fixation frame was applied over the study period. Pelvic fractures were temporized with binding of the thigh (11) or skeletal traction (4) applied on arrival, where appropriate for the injury type. Fifty-six patients (15%) underwent embolization as a method of acute resuscitation for persistent hemodynamic instability with a negative abdominal ultrasound in Trauma Center. Nineteen patients (33%) underwent therapeutic embolization of bilateral Hypogastric system injuries. Mechanism of injury: MVC (22), Auto vs. Pedestrian (18), Crush (7), Ejection (6), MCC (4) The average time from injury until embolization completion was 3.3 hr. (1.5-5.2). Multiple named vessel injury occurred in 30 (52.6%). Gelfoam and coil combination was utilized in 50/57 procedures. Forty patients (76%) survived the initial trauma and resuscitation, 22 male and 18 female. The nonsurvivors reviewed died from non-hemorrhagic sources in all cases: Brain Injury, MSOF, and sepsis. All patients reviewed sustained significant multi-system trauma with average ISS of 42 (19-66). The skeletal profile of pelvic fractures undergoing resuscitative embolization: Rotationally unstable OTA B type (24), Rotationally and vertically unstable OTA C type (28), and four patients with mechanically stable A type injuries. Those requiring bilateral systems or vessel embolization: Title OTA C type (17) 40%, and B type (5) 8%, and A type (1) 2%.  

Discussion: The use of emergent embolization has been employed routinely at our institution prior to any other intervention for four years in the hemodynamically unstable patients with a negative abdominal ultrasound. Fifty-two consecutive patients presented with mechanically unstable pelvic injury and remained hemodynamically unstable in the Trauma center, the use of emergency external fixation was rare (1). 75% of patients presenting with combination C3 pelvic injuries and bilateral arterial injuries sustained an unsurvivable amount of trauma. Wound problems developed following subsequent hemipelvis operative fixation in only one patient with massive degloving; despite 33% of patient cohort sustaining traumatic loss of Hypogastric systems bilaterally, and 52% having multiple arterial injuries and concomitant massive truncal trauma. Conclusion: The placement of angiography and embolization in the decision algorithm for the hemodynamically unstable pelvic fracture patient is typically in the later stages of the decision scheme. These data suggest that embolization in conjunction with binding the thighs or skeletal traction may facilitate the resuscitation process and preclude emergent frame application, as well. No evidence of perineal dysvascular changes were detected.

O'Neill PA; Riina J; Sclafani S; Tornetta P
Angiographic findings in pelvic fractures.
Clin Orthop 1996 Aug;(329):60-7

'Posterior arterial bleeding (internal iliac or its posterior branches) was statistically more common in patients with unstable posterior pelvic fractures, and anterior arterial bleeding (pudendal or obturator) was more common in patients with lateral compression injuries.'

Abstract: Pelvic fractures are high energy injuries indicative of significant trauma. Hypotension and significant blood loss is common in skeletally unstable pelvic fractures. Potential sites of intrapelvic bleeding include fractured bone edges, venous injuries and/or arterial vascular injuries. In an attempt to define the relationship of fracture pattern to arterial injury, a specific subset of 39 patients with pelvic fractures who underwent angiography for hemodynamic instability or ongoing blood loss were reviewed retrospectively. In 35 patients with definable arterial injuries, 20 (57%) had multiple bleeding sites. Posterior arterial bleeding (internal iliac or its posterior branches) was statistically more common in patients with unstable posterior pelvic fractures, and anterior arterial bleeding (pudendal or obturator) was more common in patients with lateral compression injuries. The pudendal artery was the most commonly injured vessel in this series. The superior gluteal artery was the most commonly injured vessel associated with posterior pelvic fractures. There was no correlation between fracture pattern and survival. The injury severity score however, did indirectly correlate to survival. In addition, the presence of hypotension (systolic blood pressure < or = 90) at the time of arrival to the trauma center was found to significantly increase mortality.

Guide to Evidence Appraisals

The definitions of the types of evidence and the grading of recommendations used originate from the US Agency for Health Care Policy and Research