International Orthopaedics

, Volume 35, Issue 9, pp 1381–1390 | Cite as

Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature

  • Efthimios J. KaradimasEmail author
  • Tony Nicolson
  • Despoina D. Kakagia
  • Stuart J. Matthews
  • Paula J. Richards
  • Peter V. Giannoudis
Review Article



The purpose of this study was to evaluate the relation between pelvic fracture patterns and the angiographic findings, and to assess the effectiveness of the embolisation.


This retrospective study, included patients with pelvic fractures and angiographic evaluation. Demographics, Injury Severity Score (ISS), associated injuries, embolisation time, blood units needed, method of treatment and complications were recorded and analysed. Fractures were classified according to the Burgess system.


Between 1998 and 2008, 34 patients with pelvic fractures underwent angiographic investigation. Twenty six were males. The mean age was 41 years. Twenty-seven were motor vehicle accidents and seven were falls. There were 11 anterior posterior (APC) fractures, 12 lateral compression (LC), eight vertical shear (VS) patterns and three with combined mechanical injuries. The median ISS was 33.1 (range 5–66). From the 34 who underwent angiography, 29 had positive vascular extravasations. From them, 21 had embolisation alone, two had vascular repair and embolisation, five required vascular repair alone and one patient died while being prepared for embolisation. Five cases were re-embolised. The findings suggested that AP fractures have a higher tendency to bleeding compared with LC fractures. Both had a higher chance of blood loss compared to VS and complex fracture patterns. We reported 57 additional injuries and 65 fractures. The complications were: one non lethal pulmonary embolism, one renal failure, one liver failure, one systemic infection, two deep infections and two psychological disorientations. Seven patients died in hospital.


Control of pelvic fracture bleeding is based on the multidisciplinary approach mainly related to hospital facilities and medical personnel’s awareness. The morphology of the fracture did not have a predictive value of the vascular lesion and the respective bleeding.


Injury Severity Score Pelvic Fracture Vertical Shear Anterior Posterior Pelvic Ring 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Stein DM, O’Toole R, Scalea TM (2007) Multidisciplinary approach for patients with pelvic fractures and hemodynamic instability. Scand J Surg 96:272–280PubMedGoogle Scholar
  2. 2.
    Demetriades D, Karaiskakis M, Toutouzas K, Alo K, Velmahos G, Chan L (2002) Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 195:1–10PubMedCrossRefGoogle Scholar
  3. 3.
    Agolini SF, Shah K, Jaffe J, Newcomb J, Rhodes M, Reed JF 3rd (1997) Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage. J Trauma 43:395–399PubMedCrossRefGoogle Scholar
  4. 4.
    Routt M, Falicov A, Woodhouse E, Schildhauer TA (2002) Circumferential pelvic antishock sheeting: a temporary resuscitation aid. J Orthop Trauma 16:45–48PubMedCrossRefGoogle Scholar
  5. 5.
    Croce MA, Magnotti LJ, Savage SA, Wood GW 2nd, Fabian TC (2007) Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg 204:935–942PubMedCrossRefGoogle Scholar
  6. 6.
    Dickinson K, Roberts I (2000) Medical anti-shock trousers (pneumatic anti-shock garments) for circulatory support in patients with trauma. Cochrane Database Syst Rev 2:CD001856Google Scholar
  7. 7.
    Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR (2007) Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma 62:834–842PubMedCrossRefGoogle Scholar
  8. 8.
    Totterman A, Madsen JE, Skaga NO, Røise O (2007) Extraperitoneal pelvic packing: a salvage procedure to control massive traumatic pelvic hemorrhage. J Trauma 62:843–852PubMedCrossRefGoogle Scholar
  9. 9.
    Osborn PM, Smith WR, Moore EE, Cothren CC, Morgan SJ, Williams AE, Stahel PF (2009) Direct retroperitoneal pelvic packing versus pelvic angiography: a comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury 40:54–60PubMedCrossRefGoogle Scholar
  10. 10.
    Nicodemo A, Decaroli D, Pallavicini J, Sivieri R, Aprato A, Massè A (2008) A treatment protocol for abdomino-pelvic injuries. J Orthop Traumatol 9:89–95PubMedCrossRefGoogle Scholar
  11. 11.
    Maull KI, Sachatello CR (1976) Current management of pelvic fractures: a combined surgical-angiographic approach to hemorrhage. South Med 69:1285–1289CrossRefGoogle Scholar
  12. 12.
    Frevert S, Dahl B, Lönn L (2008) Update on the roles of angiography and embolisation in pelvic fracture. Injury 39:1290–1294PubMedCrossRefGoogle Scholar
  13. 13.
    Baker S, O’Neill B, Haddon W Jr, Long WB (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187–196PubMedCrossRefGoogle Scholar
  14. 14.
    Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ (1990) Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 30:848–856PubMedCrossRefGoogle Scholar
  15. 15.
    Pape HC, Giannoudis PV, Krettek C, Trentz O (2005) Timing of fixation of major fractures in blunt polytrauma: role of conventional indicators in clinical decision making. J Orthop Trauma 19:551–562PubMedCrossRefGoogle Scholar
  16. 16.
    Geeraerts T, Chhor V, Cheisson G, Martin L, Bessoud B, Ozanne A, Duranteau J (2007) Clinical review: initial management of blunt pelvic trauma patients with haemodynamic instability. Crit Care 11:204–213PubMedCrossRefGoogle Scholar
  17. 17.
    Dyer GS, Vrahas MS (2006) Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury 37:602–613PubMedCrossRefGoogle Scholar
  18. 18.
    Van Vugt AB, Van Kampen A (2006) An unstable pelvic ring. J Bone Joint Surg Br 88-B:427–433CrossRefGoogle Scholar
  19. 19.
    Mucha P, Farnell MB (1984) Analysis of pelvic fracture management. J Trauma 24:379–386PubMedCrossRefGoogle Scholar
  20. 20.
    Cook RE, Keating JF, Gillespie I (2002) The role of angiography in the management of haemorrhage from major fractures of the pelvis. J Bone Joint Surg Br 84–2:178–182CrossRefGoogle Scholar
  21. 21.
    Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC (2003) External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 54:437–443PubMedCrossRefGoogle Scholar
  22. 22.
    Panetta T, Sclafani SJ, Goldstein AS, Phillips TF, Shaftan GW (1985) Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 25:1021PubMedGoogle Scholar
  23. 23.
    Fangio P, Asehnoune K, Edouard A, Smail N, Benhamou D (2005) Early embolization and vasopressor administration for management of life-threatening hemorrhage from pelvic fracture. J Trauma 58:978–984PubMedCrossRefGoogle Scholar
  24. 24.
    Jeroukhimov I, Ashkenazi I, Kessel B, Gaziants V, Peer A, Altshuler A, Nesterenko V, Alfici R, Halevy A (2009) Selection of patients with severe pelvic fracture for early angiography remains controversial. Scand J Trauma Resusc Emerg Med 17:62–68PubMedCrossRefGoogle Scholar
  25. 25.
    Fu CY, Wu SC, Chen RJ, Wang YC, Chung PK, Yeh CC, Huang HC (2009) Evaluation of pelvic fracture stability and the need for angioembolization: pelvic instabilities on plain film have an increased probability of requiring angioembolization. Am J Emerg Med 27:792–796PubMedCrossRefGoogle Scholar
  26. 26.
    Salim A, Teixeira PG, DuBose J, Ottochian M, Inaba K, Margulies DR, Demetriades D (2008) Predictors of positive angiography in pelvic fractures: a prospective study. J Am Coll Surg 207:656–662PubMedCrossRefGoogle Scholar
  27. 27.
    Sánchez-Tocino JM, Turégano-Fuentes F, Pérez-Díaz D, Sanz-Sánchez M, Lago-Oliver J, Zorrilla-Ortúzar J, Martínez-Baena D (2007) Severe pelvic fractures, associated injuries and hemodynamic instability: incidence, management and outcome in our center. Cir Esp 81:316–323PubMedCrossRefGoogle Scholar
  28. 28.
    Kimbrell BJ, Velmahos GC, Chan LS, Demetriades D (2004) Angiographic embolization for pelvic fractures in older patients. Arch Surg 139:728–733PubMedCrossRefGoogle Scholar
  29. 29.
    Wong YC, Wang LJ, Ng CJ, Tseng IC, See LC (2000) Mortality after successful transcatheter arterial embolization in patients with unstable pelvic fractures: rate of blood transfusion as a predictive factor. J Trauma 49:71–75PubMedCrossRefGoogle Scholar
  30. 30.
    Shapiro M, McDonald AA, Knight D, Johannigman JA, Cuschieri J (2005) The role of repeat angiography in the management of pelvic fractures. J Trauma 58:227–231PubMedCrossRefGoogle Scholar
  31. 31.
    Gilliland MG, Ward RE, Flynn TC, Miller PW, Ben-Menachem Y, Duke JH Jr (1982) Peritoneal lavage and angiography in the management of patients with pelvic fractures. Am J Surg 144:744–747PubMedCrossRefGoogle Scholar
  32. 32.
    Travis T, Monsky WL, London J, Danielson M, Brock J, Wegelin J, Link DP (2008) Evaluation of short-term and long-term complications after emergent internal iliac artery embolization in patients with pelvic trauma. J Vasc Interv Radiol 19:840–847PubMedCrossRefGoogle Scholar
  33. 33.
    Sieber PR (1994) Bladder necrosis secondary to pelvic artery embolization: case report and literature review. J Urol 151:422PubMedGoogle Scholar
  34. 34.
    Obaro RO, Sniderman KW (1995) Case report: avascular necrosis of the femoral head as a complication of complex embolization for severe pelvic haemorrhage. Br J Radiol 68:920–922PubMedCrossRefGoogle Scholar
  35. 35.
    Hare WS, Holland CJ (1983) Paresis following internal iliac artery embolization. Radiology 146:47–51PubMedGoogle Scholar
  36. 36.
    Bergreen PW, Woodside J (1976) Distal embolization complicating therapeutic renal infarction. N Engl J Med 294:1406–1407PubMedCrossRefGoogle Scholar
  37. 37.
    Matalon TS, Athanasoulis CA, Margolies MN, Waltman AC, Novelline RA, Greenfield AJ, Miller SE (1979) Hemorrhage with pelvic fractures: efficacy of transcatheter embolization. Am J Roentgenol 133:859–864Google Scholar
  38. 38.
    Kataoka Y, Maekawa K, Nishimaki H, Yamamoto S, Soma K (2005) Iliac vein injuries in hemodynamically unstable patients with pelvic fracture caused by blunt trauma. J Trauma 58:704–710PubMedCrossRefGoogle Scholar
  39. 39.
    Velmahos GC, Toutouzas KG, Vassiliu P, Sarkisyan G, Chan LS, Hanks SH, Berne TV, Demetriades D (2002) A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries. J Trauma 53:303–308PubMedCrossRefGoogle Scholar
  40. 40.
    Sarin EL, Moore JB, Moore EE, Shannon MR, Ray CE, Morgan SJ, Smith WR (2005) Pelvic fracture pattern does not always predict the need for urgent embolization. J Trauma 58:973–977PubMedCrossRefGoogle Scholar
  41. 41.
    Cryer HM, Miller FB, Evers BM, Rouben LR, Seligson DL (1988) Pelvic fracture classification: correlation with hemorrhage. J Trauma 28:974–980Google Scholar
  42. 42.
    Grainger MF, Porter KM (2003) Life threatening haemorrhage from obturator vessel tear as a result of pubic ramus fracture: a case report. Injury 34:543–544PubMedCrossRefGoogle Scholar
  43. 43.
    Meyers TJ, Smith WR, Ferrari JD, Morgan SJ, Franciose RJ, Echeverri JA (2000) Avulsion of the pubic branch of the inferior epigastric artery: a cause of hemodynamic instability in minimally displaced fractures of the pubic rami. J Trauma 49:750–753PubMedCrossRefGoogle Scholar
  44. 44.
    Pérez MU, Alocover HA (2004) Hypovolemic shock due to a fracture of the superior pubic ramus in a young man. Case report. Injury 35(1):80–82CrossRefGoogle Scholar
  45. 45.
    Moreno C, Moore EE, Rosenberger A, Cleveland H (1986) Haemorrhage associated with major pelvic fracture: a multispecialty challenge. J Trauma 26:987–994PubMedCrossRefGoogle Scholar
  46. 46.
    Perez JV, Hughes TM, Bowers K (1998) Angiographic embolization in pelvic fracture. Injury 29(3):187–191PubMedCrossRefGoogle Scholar
  47. 47.
    Pereira SJ, O'Brien DP, Luchette FA, Choe KA, Lim E, Davis K Jr, Hurst JM, Johannigman JA, Frame SB (2000) Dynamic helical computed tomography scan accurately detects hemorrhage in patients with pelvic fracture. Surgery 128(4):678–685PubMedCrossRefGoogle Scholar
  48. 48.
    Patel NH, Matsuo RT, Routt ML Jr (1996) An acetabular fracture with superior gluteal artery disruption. Am J Roentgenol 166:1074–1079Google Scholar
  49. 49.
    Ruotolo C, Savarese E, Khan A, Ryan M, Kottmeier S, Meinhard BP (2001) Acetabular fractures with associated vascular injury: a report of two cases. J Trauma 51:382–386PubMedCrossRefGoogle Scholar
  50. 50.
    O’neill PA, Riina J, Sclafani S, Tornetta P 3rd (1996) Angiographic findings in pelvic fractures. Clin Orthop Relat Res 329:60–67PubMedCrossRefGoogle Scholar
  51. 51.
    Evers BM, Cryer HM, Miller FB (1989) Pelvic fracture haemorrhage: priorities in management. Arch Surg 124:422–424PubMedGoogle Scholar
  52. 52.
    Sriussadaporn S, Sirichindakul B, Pak-Art R, Tharavej C (2002) Pelvic fractures: experience in management of 170 cases at a university hospital in Thailand. J Med Assoc Thai 85:200–206PubMedGoogle Scholar
  53. 53.
    Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S (2004) The usefulness of trans-catheter arterial embolization for patients with blunt polytrauma showing transient response to fluid resuscitation. J Trauma 57:271–276PubMedCrossRefGoogle Scholar
  54. 54.
    Sadri H, Nguyen-Tang T, Stern R, Hoffmeyer P, Peter R (2005) Control of severe hemorrhage using C-clamp and arterial embolization in hemodynamically unstable patients with pelvic ring disruption. Arch Orthop Trauma Surg 125:443–447PubMedCrossRefGoogle Scholar
  55. 55.
    Brasel KJ, Pham K, Yang H, Christensen R, Weigelt JA (2007) Significance of contrast extravasation in patients with pelvic fracture. J Trauma 62:1149–1152PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Efthimios J. Karadimas
    • 1
    • 6
    Email author
  • Tony Nicolson
    • 2
  • Despoina D. Kakagia
    • 3
  • Stuart J. Matthews
    • 4
  • Paula J. Richards
    • 5
  • Peter V. Giannoudis
    • 1
  1. 1.Academic Orthopaedic DepartmentLeeds General InfirmaryLeedsUK
  2. 2.Interventional Radiology DepartmentLeeds General InfirmaryLeedsUK
  3. 3.Department of Plastic SurgeryDemocritus University of ThraceKomotiniGreece
  4. 4.Oxford Radcliffe Trauma UnitOxfordUK
  5. 5.Musculoskeletal Radiology DepartmentUniversity Hospital of North Staffordshire NHS TrustStaffordshireUK
  6. 6.AthensGreece

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