Article, Radiology

Evaluation of pelvic fracture stability and the need for angioembolization: pelvic instabilities on plain film have an increased probability of requiring angioembolization

Original Contribution

Evaluation of pelvic fracture stability and the need for angioembolization: pelvic instabilities on plain film have an increased probability of requiring angioembolization

Chih-Yuan Fu MD, Shih-Chi Wu MD, Msc, Ray-Jade Chen MD, Msc?, Yu-Chun Wang MD, Ping-Kuei Chung MD, Chun-Chieh Yeh MD, Hung-Chang Huang MD

Trauma and Emergency Center, China Medical university hospital, Taichung, Taiwan

Received 9 June 2008; accepted 23 June 2008

Abstract

Background: The use of pelvic x-rays (PXRs) as an early diagnostic adjunct in the evaluation of blunt trauma patients has become widely accepted, and computed tomographic (CT) scanning is now used universally in the assessment of abdominal and pelvic injuries. In this study, we have attempted to identify patients with pelvic fractures who might be at risk for vessel hemorrhage and determine if early angioembolization was required in these patients.

Material and Methods: We retrospectively reviewed patients who presented with pelvic fractures from June 2005 to August 2007. Both PXRs and CT scans were reviewed. Patients who presented with bleeding due to other Associated injuries or who did not receive a CT scan were excluded. Patients with either initial hemodynamic instability or contrast extravasation on enhanced CT scan underwent angioembolization. Patient demographics, Injury Severity Score, the amount of blood transfused, and the relationship between the Fracture pattern and angioembolization were analyzed.

Results: A total of 54 patients were enrolled. A diagnosis of an unstable pelvic fracture on PXR was associated with a higher probability of angioembolization. Seven patients received incompatible diagnoses from the PXR and CT scan; these patients received larger amounts of transfused blood and demonstrated an increased need for angioembolization.

Conclusions: Although CT scan is more sensitive in the identification of acetabular or small pelvic fractures, PXR is sufficient for the early evaluation of pelvic fracture stability. Based on the current series, early angioembolization is suggested for patients with an Initial diagnosis of an unstable pelvic fracture. In addition, patients receiving large amounts of transfused blood are more likely to require early angioembolization.

(C) 2009

Introduction

* Corresponding author. Tel.: +886 4 22052121×5043; fax: +886 4

22334706.

E-mail address: [email protected] (R.-J. Chen).

Pelvic fractures usually occur from high kinetic energy blunt trauma. They are often associated with a high mortality rate and chest, abdominal, and pelvic Organ injuries [1-6]. Pelvic fractures can result in bleeding from the fracture site

0735-6757/$ – see front matter (C) 2009 doi:10.1016/j.ajem.2008.06.014

surface, associated venous structures, or retroperitoneal arteries [3]. Achieving hemostasis after pelvic fractures can be difficult, and the difficulties of hemostasis may result in hemodynamic instability or death [4]. Therefore, in the evaluation of pelvic fractures, the assessment of pelvic stability and the identification of any concomitant associated hemorrhage are critically important.

The use of anteroposterior pelvic radiographs, or pelvic x-rays (PXRs), as an early diagnostic adjunct in the evaluation of blunt trauma patients has been widely accepted and is recommended by the Advanced Trauma Life Support protocol [7]. However, a secondary pelvic computed tomographic (CT) scan may provide better resolution than PXR and may augment the detection of small fractures, soft tissue injuries, and/or active arterial bleeding [8-10]. As a result, the CT scan has become a universally used procedure for the assessment of most abdominal and pelvic injuries. However, although the benefits of CT scans are clear, PXR remains an essential component of initial fracture and stability screening at many institutions.

Life-threatening retroperitoneal arterial bleeding often occurs in association with unstable pelvic fractures that result from major ligamentous disruption [11]. Therefore, immedi- ate recognition of pelvic ring disruption, determination of pelvic stability, and assessment of concomitant vessel injuries are essential in the evaluation of blunt abdominal trauma [12]. The combination of Pelvic angiography and emboliza- tion has been reported as an effective method for controlling hemorrhage caused by pelvic fractures, and this technique is commonly used to treat fracture-associated arterial hemor- rhage [13-17]. However, controversy remains regarding the need for embolization in the context of major ligamentous disruption [18]. Importantly, there are discrepancies between institutions in the ability to perform angioembo- lization. Therefore, we performed this retrospective study to evaluate the indications and applications of angioemboliza- tion, based on the evaluation of pelvic fracture stability

via PXR.

Materials and methods

We reviewed the trauma registry and medical records of patients with pelvic fractures who presented to the China Medical University Hospital between June 2005 and August 2007. China Medical University Hospital serves as a mid- Taiwan major trauma referral center for Taichung and the adjacent counties. During this 26-month period, patients with pelvic fractures underwent PXR during the primary assess- ment of their injuries. The use of CT scans was reserved for evaluation of intra-abdominal organ injuries during the secondary assessment of patients with relatively stable hemodynamics. Patients with concomitant unstable pelvic fractures and unstable hemodynamics, or those with contrast extravasation seen on tomographic scans, were candidates for angioembolization. Because CT scan was thought to provide

the most accurate assessment of pelvic stability, only patients who underwent both PXR and CT scan were enrolled in this study. Patients with bleeding from other associated injuries were excluded. Therefore, all blood transfusions were related to pelvic fractures. Patient demographics, Injury Severity Score (ISS), milliliters of blood transfused in the first 24 hours, and the need for angioembolization were evaluated. The Young-Burgess classification system was used to evaluate the patterns of pelvic fracture [10]. Lateral compression type I and anteroposterior compression type I fractures were defined as stable. Other patterns were considered to be unstable.

    1. Statistical analysis

Cohen’s ? statistic was used to assess agreement between the two diagnostic tools (PXR and CT scan). The level of agreement was considered poor when ? <= 0.20, fair when ? = 0.21-0.40, moderate when ? = 0.41-0.60, substantial when ? = 0.61-0.80, and very good when ? N 0.80 [19]. Patient demographics and characteristics are listed in Table 2. Continuous variables are expressed as the mean +- SD, and categorical variables are reported as percentages. Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables were used to test for significant differences in age, sex, and the need for angiography.

Results

During the 26-month period examined, 104 patients with fractures of the pelvis were admitted to our hospital. Fifty patients were excluded due to a lack of final CT scans. Therefore, a total of 54 patients that had received both PXR and CT scans were enrolled. The sensitivity and specificity of PXR were 0.53 and 1.00, respectively, in the diagnosis of pelvic stability (Table 1). The ? value of homogeneity between PXR and CT scan was 0.6228 (Table 1). The mean age for all patients was 41.1 +- 20.9 years, the mean ISS was

14.3 +- 11.4, and the mean volume of blood transfused was 1410 +- 849 mL. Patients were classified as having a stable or an unstable fracture based on PXR results (Table 2). No

Table 1 Agreement between PXR and CT scan diagnoses of pelvic stability

Stability under PXR

Stability under CT scan

Total

Stable

Unstable

The ? statistic measures the degree of agreement between the 2 diagnostic tools. The ? value for this series of 0.6228 indicates good agreement.

Stable

39

7

46

Unstable

0

8

8

Total

39

15

54

PXR stability evaluation

CT stability evaluation

Stable (n = 46)

Unstable (n = 8)

Stable (n = 39)

Unstable (n = 15)

Mean +- SD

Mean +- SD

Mean (SD)

Mean (SD)

Age

43.0 +- 21.3

34.8 +- 16.8

44.1 +- 22.0

35.8 +- 17.0

P b

.3005

.2235

Sex (n)

Male

23

4

21

6

Female

23

4

18

9

P a

1.0000

.5444

ISS

11.9 +- 8.3

28.0 +- 17.3

11.5 +- 8.5

21.7 +- 14.8

P b

.0057

.0051

Blood transfusion (mL)

891 +- 1719

4375 +- 3260

577 +- 1453

3567 +- 2840

P b

.0002

b.0001

Angioembolization (n)

Yes

7

5

3

9

No

39

3

36

6

P a

.0095

b.0001

a Wilcoxon rank sum test.

b Fisher exact test.

significant differences in age or gender were found between these two groups. The mean ISS for patients with Unstable fractures, as assessed by PXR, was higher than that for patients with stable fractures (28.0 vs 11.9). Patients with unstable fractures on PXR received a greater amount of transfused blood than did patients with stable fractures (4375 vs 891 mL). In addition, a greater number of patients with unstable fractures received angioembolization (Table 2).

Table 2 Patient demographics, amount of blood transfusion, and need for angioembolization

Among the 54 patients enrolled in the study, PXR and CT scan gave incompatible diagnoses of pelvic stability for seven patients. For all 7 patients, stable fractures were initially diagnosed based on PXR; however, subsequent CT

Table 3 The demographics of patients with incompatible diagnosis stability after PXR and CT scan

Stability No change (n = 47)

Mean +- SD

Change (n = 7)

Mean +- SD

P a

P b

scans demonstrated unstable fractures. This group of patients received a greater amount of transfused blood than did patients whose fractures were characterized as stable on both PXR and CT scan (2643 vs 1223 ml, P = .00255). This group also showed a higher incidence of angioembolization (P =

.0172) (Table 3).

Discussion

Pelvic fractures can result from high kinetic energy collisions. They frequently occur in patients with multiple

Age

42.5 +- 21.5

37.0 +- 17.0

.9876

Sex (n)

.2242

Female

22

5

Male

25

2

Shock (n)

.0756

SBP N 90

40

4

SBP b 90

7

3

ISS

14.3 +- 12.0

14.6 +- 7.3

.4260

Blood transfusion (mL)

1,223 +- 2,333

2643 +- 2135

.0255

Blood transfusion (n)

.0434

b1500

37

3

>=1500

10

4

Angioembolization (n)

.0172

Yes

8

4

No

39

3

SBP, systolic blood pressure.

a Parametric test: Fisher’s exact test.

b Nonparametric test: Wilcoxon rank sum test.

traumas, and associated mortality rates range from 6% to

18 % [20]. Pelvic fracture is often associated with concomitant hemorrhage and additional injuries, which cause hemodynamic instability in roughly 5% to 20% of patients [3,16,21]. It has been proposed that several specific pelvic fracture patterns are associated with major ligamen- tous disruption, which often results in pelvic instability and Life-threatening hemorrhage [6]. Current treatment options for pelvic fracture and hemorrhage include surgical fixation, preperitoneal packing, angioembolization, or close observa- tion [12,22-26]. However, there has been a trend toward using angioembolization instead of surgical intervention for hemorrhage resulting from pelvic fractures [27-29].

The sensitivity and specificity of CT scans have been reported to be higher than those of PXR for both the diagnosis of pelvic fractures and the evaluation of pelvic stability [8,9,30]. However, CT scans can be time-consuming, and the indication for angioembolization when contrast extravasation is seen on CT scan remains controversial [31-33]. Although CT scans might reveal small fractures potentially missed by PXR, it has been reported that use of CT scans does not change subsequent management or patient outcome [34]. Therefore, it appears that CT scans may not be necessary for the initial evaluation of patients with pelvic fractures.

While most isolated stable pelvic fractures are associated with stable hemodynamics and can be treated conservatively, unstable pelvic fractures can involve hemodynamic instabil- ity and may require angioembolization due to concomitant hemorrhage. Time-consuming procedures, such as CT scans, may not be practical for patients in critical condition with unstable hemodynamics. Similarly, surgery often plays a less important role than angioembolization in the management of patients with unstable pelvic fractures and hemodynamic instability [13,15,17]. Therefore, the early identification of patients in need of angioembolization is critical. It has been reported that delays in achieving hemostasis can increase mortality rates [35]. In the current series, the evaluation of pelvic fracture stability was similar between PXR and CT scans (Table 1, ? = 0.6228). In addition, the use of time- consuming CT scans could delay the treatment of potentially life-threatening hemorrhage in some critical cases. There- fore, we suggest that when an unstable fracture is indicated by PXR, early angioembolization should be considered as a method to achieve hemostasis.

In the current series, seven patients initially diagnosed with stable pelvic fractures via PXR later demonstrated unstable pelvic fractures on secondary CT scans. These patients received larger amounts of transfused blood (2643 +- 2135 mL) and showed a higher incidence of angioemboliza- tion (57.1 % [4/7]) than patients who demonstrated stable fractures on both PXR and CT scan (Table 3). Although the small number of patients in this study prevented these results from reaching statistical significance, we suggest that greater attention should be paid to patients with stable pelvic fractures on x-ray who require large amounts of transfused blood, as these patients may be more likely to require

angioembolization. Furthermore, because arterial bleeding is not always recognized on CT scans due to vessel spasms or neglected contrast extravasation [31,36,37], angiography with possible embolization should be considered a viable alternative Diagnostic procedure and potential treatment for patients requiring large amounts of transfused blood.

While plain x-ray is available at most hospitals, obtaining angioembolization may be more difficult at some institu- tions. Hence, we propose that, for patients with unstable pelvic fractures diagnosed via PXR, or patients with stable pelvic fractures who receive large amounts of transfused blood, angiography should be considered early in treatment and, if necessary, facilities capable of performing this procedure should be located.

This study was limited by the small number of cases examined and by its retrospective nature. We recognize that the limitations of this study, with its small sample size and possible bias of case selection, may restrict the analytical conclusions that can be extracted. However, these results indicate that angioembolization might be necessary in patients with an initial diagnosis of an unstable pelvic fracture by PXR, or in patients with a stable fracture pattern who receive large amounts of transfused blood. Further studies with larger sample sizes, long-term follow-up, and comparisons of different diagnostic modalities are needed to establish the Optimal treatment of pelvic fractures in the emergency department.

Summary

Pelvic fractures are often associated with high mortality and additional associated injuries. In the current series, early angioembolization is suggested as being superior to CT scan for patients with an initial diagnosis of an unstable pelvic fracture. In addition, patients receiving a great deal of transfused blood are likely to demonstrate active hemorrha- ging, even if their pelvic fracture appears stable on x-ray. Early consideration of angiography and/or the location of qualified facilities are proposed for these patients.

Acknowledgments

The authors thank Chen-An Tsai, Huai-Chih Tsui and China Medical University Biostatistics Center for their assistance in statistical analysis.

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