Protocolo combinado de fijación externa y arteriografía en fracturas de pelvis con inestabilidad hemodinámica asociada: estudio retrospectivo sobre 79 casos

Abstract

Purpose Frequently pelvic fractures are associated with arterial and/or venous intrapelvic bleeding, resulting in a high mortality rate ranging between 10 and 50%. Numerous treatment protocols have been published for the early control of hemorrhage. All of them agree on the need of a determined and multi-disciplinary approach that combines various therapeutic methods. The purpose of this study is to determine the applicability, clinical evolution and results of a therapeutic diagnostic algorithm used with a group of 79 patients with a pelvis fracture and a related hemodynamic instability. Materials and methods This is a retrospective study of a series of patients with a pelvic fracture associated to hemodynamic instability, who were admitted to our hospital between 1994 and 2004. The inclusion criteria were as follows: patients with a high-energy pelvic fracture and hemodynamic instability. The criteria used to define hemodynamic instability were a systolic blood pressure < 90 mmHg on admission or transfusion needs higher than 2 units of red cell concentrate in the first 12 hours. Results External fixation was used for 45 patients (57%). 48 patients (61%) were subjected to an arteriography, which revealed active arterial intrapelvic bleeding in 44 cases (56%). Twenty-one patients required an arterography plus external fixation, one after the other. twenty-four patients underwent a laparotomy. The incidence of systemic complications was high and mortality stood at 19%. The application of the algorithm was fairly widespread, except for patients requiring a laparotomy and presenting with an open-book type fracture. This group had a high mortality rate. Conclusions The incidence of arteriography-validated arterial lesions was very high. The use of a combined external fixation and arteriography protocol, adapted to the specific health-care characteristics of each hospital makes it possible to check intrapelvic bleeding in quite a large number of cases. Indications for laparotomy should be restricted to the treatment of the hemoperitoneum and of open fractures, and should always be accompanied by some external fixation device.