The role of angioembolization and C-clamp fixation: Damaged control orthopaedic in haemodynamically unstable pelvic fracture

Abstract

Introduction: Unstable pelvic fracture may emerge to major bleeding complication. Angioembolization is one of method to stop the bleeding effectively. This case series aims to analyze whether the bleeding of unstable pelvic fracture is managed by angioembolization to achieve the better functional outcome.

Presentation of case: Three cases of haemodynamically unstable pelvic fracture were studied retrospectively and prospectively. A staged approach using damage control orthopaedic surgery was performed. Initial resuscitation began from fluid resuscitation, pelvic wrapping using binder. All patients followed with pelvic external fixation, while 2 patients immediately replaced binder to C-Clamp, and 1 patient with anterior frame. Angioembolization was done to all patients. All patients required definitive internal fixation, while only 2 patients reach the definitive surgery. Finally, we measured the functional outcome of all patients using Hannover Pelvic score, Majeed pelvic score, and Iowa Pelvic score.

Discussion: We review some literatures regarding pelvic angioembolization. The previous study suggested to resuscitate patients when the hemodynamic is unstable, the angioembolization procedure is still preferred. The indication and successful definition of this procedure is still unclear, yet it shows decrease of mortality rate of pelvic injury if this procedure starts ahead a schedule.

Conclusion: Angioembolization as a part of damaged control orthopaedic has been shown a favorable result in managing unstable pelvic injury.

Keywords: Angiographic embolization; Pelvic fracture; Pelvic injury.

Fig. 1

The algorithm of the treatment for pelvic fractures in Cipto Mangunkusumo Hospital.

Fig. 2

Patient A, 43-years-old female, with polytrauma ISS score 25 consist of C2 type of pelvic fracture and open fracture of left distal tibia fibula. The pelvic binder was applied then immediately exchanged into C-clamp; Patient B, 41-years-old male, with polytrauma ISS score 13 consist of B1 type of pelvic fracture and closed fracture of right proximal fibula. The pelvic binder was applied then immediately exchanged into C-clamp; Patient C, 22-years-old male, with polytrauma ISS score 25 pelvis MTC 2, Faringer zone 1. The pelvic binder was applied then immediately replaced into anterior frame.

Fig. 3

Angioembolization perfomed on special room. With sedation and local anesthetic, a small catheter is inserted at the groin, guided under the fluoroscopy to the arteries of interest. a. A contrast visipaque is injected through the catheter to fill the vessels and visualize the anatomy, showed extravasated right cervicovaginal artery branch, inferior to the distal branches of the right uterine artery. b. Superior gluteal artery was inflated using coil, while c. The same manner as patient B (disruption of superior gluteal artery) but the disrupted blood vessel was ocluded by gelfoam.

Fig. 4

Post operative inlet and outlet x-ray after ORIF, patient B refused to underwent definitive treatment thus no x-ray was taken.

Fig. 5

Clinical outcome postoperatively taken, all of the patients were be able to squat and could tolerate moderate activities like walking in distance (approximately 100 m), doing daily activities like climb the stairs, sexual intercourse and pray.