To investigate the clinical efficacy and feasibility of controlling unstable pelvic fracture haemorrhage with the dual measures of external fixation stent fixation of the pelvic fracture and double ligation of the bilateral internal iliac artery trunk and its vulnerable major branches. Methods We retrospectively analyzed 23 cases of unstable pelvic fracture hemorrhage treated in our department from 1999 to 2006. The pelvic fracture was fixed with an external fixation brace, and then double ligation of the main trunk of the internal iliac artery and its vulnerable major branches was performed via the pelvis.
After the disease stabilized, definitive fixation surgery was performed. Results Among the 23 patients in this group, 19 cases had controlled hemorrhage within 24 h, and 4 cases died. 17 cases were followed up for 12-18 months, and all pelvic fractures healed normally, and no ischemia was observed in the later pelvic organs. Conclusion The dual measures of fixation of the pelvic fracture with an external fixation brace and double ligation of the main trunk of the internal iliac artery and its vulnerable major branches can completely control the hemorrhage caused by unstable pelvic fractures and reduce early mortality. Due to the extensive presence and reconstruction of collateral circulation, ligation of bilateral internal iliac artery trunks and their vulnerable major branches has no significant effect on pelvic fracture healing and blood supply to the intrapelvic organs.
Unstable pelvic fractures are one of the common traumas in orthopedics, often leading to hemorrhage, and most patients combine multiple injuries with severe injuries, and some patients die of hemorrhagic shock due to untimely or improper management. The incidence of shock in severe pelvic fractures has been reported in the literature as high as 30% or even 60%, and the mortality rate is as high as 25%-39%, so timely and effective control of hemorrhage has become a priority task to save and treat hemorrhage in pelvic fractures and reduce mortality. From October 1999 to October 2006, 19 cases of unstable pelvic fracture haemorrhage (23 cases in total and 4 cases of death) were successfully treated with the dual measures of external fixation stent fixation and double ligation of bilateral internal iliac artery trunks and their vulnerable major branches, with satisfactory results, which are reported below.
1. Clinical data
1.1 General data There were 23 cases of unstable pelvic fractures in this group, 13 cases in men and 10 cases in women, aged 23-57 years old, with an average of 39 years old. The causes of injury: 13 cases of traffic accident injury, 7 cases of fall from height injury, and 3 cases of heavy object smash injury. Fracture type (using Tile classification): 3 cases of B1 type, 6 cases of B3 type, 8 cases of C1 type, 4 cases of C2 type, and 2 cases of C3 type.
Other combined injuries: 5 cases of head and face injury, 4 cases of chest injury, 2 cases of intra-abdominal organ injury, 3 cases of bladder and urethra injury, 2 cases of kidney contusion, 9 cases of limb fracture (5 cases of femur fracture, 3 cases of tibiofibular fracture, 1 case of humerus fracture), and 3 cases of spine fracture. All cases were associated with varying degrees of hemorrhagic shock, and the estimated blood loss was greater than 20% in 19 cases. The time from injury to surgery: 2 to 12 h, average 6 h.
1.2 Treatment methods
1.2.1 The ward or emergency department used external fixation braces to stabilize the pelvic fracture quickly and simply, taking care not to interfere with the surgical exploration as much as possible. At the same time, anti-shock is actively administered. Those with aggressive bleeding who are expected to have poor efficacy or those who are still hemodynamically unstable after 1 to 2 h of 3000-4000 ml of fluid transfusion or blood transfusion of 2000 ml or more are decisively admitted to the operating room.
Under general anesthesia or continuous epidural block anesthesia, a median exploration incision was made in the lower abdomen to reveal the posterior peritoneum via the pelvis, and the posterior peritoneum was incised, and the main trunk of the internal iliac arteries and their vulnerable major branches were dissected bilaterally, and ligation was first performed at their main trunk sites, and then the vulnerable major branches of the internal pubic artery, occluded artery, superior gluteal artery, inferior gluteal artery, lumbar iliac artery, and lateral sacral artery were ligated again; if In case of combined venous plexus injury, they were ligated together. Definitive surgery was performed 5 to 10 d after the disease stabilized.
1.2.2 Five cases of combined head and facial injury, four cases of chest injury, two cases of intra-abdominal organ injury, three cases of vesicourethral injury and two cases of renal contusion were treated with the assistance of relevant specialists at the same time. Nine cases with combined extremity fractures were fixed quickly and simply with external fixation braces. Definitive surgery was performed 5 to 10 d after the disease stabilized. Three cases of spinal fractures were treated conservatively because of the absence of spinal stenosis and nerve compression.
1.3 Postoperative treatment Postoperative rehydration and blood transfusion were continued according to blood tests to completely correct shock, water and electrolyte disorders and hemodynamic disorders, prevent multi-organ insufficiency and coagulation disorders. And to prevent infection for 5-7 d, strengthen support and symptomatic treatment. Pay high attention to the nutritional status of patients.
① Review blood routine: for patients with hemoglobin (Hb) below 90g/L, routinely transfuse red blood cell suspension or whole blood to make hemoglobin (Hb) reach above 90g/L;
②Retest albumin: for patients whose albumin is less than 30g/L, routinely transfuse albumin or plasma to make the albumin reach more than 30g/L;
③Pay attention to the patient’s diet and instruct the patient to eat high-energy nutritious food.
2.Results
Among the 23 patients in this group, 19 cases of hemorrhage were controlled within 24 h after emergency surgery. 1 case died from severe multiple injuries before surgery, 2 cases died directly from uncontrolled hemorrhage during surgery, and 1 case of hemorrhage from combined lung laceration died from multi-organ failure and coagulation disorders 48 h after surgery. 7 patients showed transient lower abdomen, hip or hip pain in the early stage, which was considered to be caused by insufficient blood supply to the local tissues and improved after 1 to 2 weeks of symptomatic treatment. ～Seven of the patients had early onset of transient lower abdominal, hip or hip pain, which was considered to be due to inadequate blood supply to local tissues and improved with symptomatic treatment for 1 to 2 weeks. All pelvic fractures healed normally, with clinical healing time ranging from 12 to 16 weeks, averaging 13 weeks, and bony healing time ranging from 9 to 13 months, averaging 11 months; all cases had basically equal length of both lower extremities, with no cases of claudication, and no ischemic manifestations in the pelvic organs in the late stage.
3.Discussion
3.1 Anatomical characteristics of the blood supply to the pelvis
(i) Pelvic wall arteries.
(1) Internal iliac artery and branches: lumbar iliac artery, superior gluteal artery, inferior gluteal artery, lateral sacral artery, foramen ovale artery and internal pubic artery;
(2) Median sacral artery;
(3) The deep spinococcygeal artery;
(4) Pubic branch of the inferior abdominal wall artery;
(5) Spinomedial femoral artery;
(6) Spinolateral femoral artery.
(ii) Pelvic wall vein: the same name as each of the above arteries accompanying it.
(iii) Pelvic venous plexus.
(1) Anterior sacral plexus;
(2) Pudendal plexus;
(3) Vesicouterine plexus;
(4) Uterine venous plexus;
(5) Vaginal venous plexus;
(6) Rectal venous plexus.
(iv) Main routes of vascular anastomosis within and outside the pelvis.
(1) Bilateral internal iliac arteries form an extensive anastomosis in the median plane;
(2) Anastomosis of the internal pubic artery with the inferior gluteal artery;
(3) Anastomosis of the obturator artery with the inferior abdominal wall, the inferior gluteal artery and the medial rotor femoral artery;
(4) The superior gluteal artery, the inferior gluteal artery, the medial rotor femoral artery, the lateral rotor femoral artery, and the deep femoral artery form a cross anastomosis of the hip;
(5) The iliac branch of the lumbar iliac artery anastomoses with the 4th lumbar artery, the deep rotary iliac artery, the lateral rotary femoral artery, the superior gluteal artery and the iliac branch of the occulta artery;
(6) Anastomosis of the median sacral artery with the lateral sacral artery;
(7) Anastomosis of the inferior rectal artery with the superior rectal artery and the anorectal artery;
(8) Anastomosis of the vas deferens artery with the testicular artery;
(9) Anastomosis of the uterine artery with the ovarian artery;
(10) Anastomosis of the inferior abdominal wall artery with the superior abdominal wall artery, the lower intercostal artery, the occlusal artery and the iliolumbar artery.
3.2 Causes of pelvic fracture hemorrhage Unstable pelvic fracture hemorrhage mainly originates from the large fracture section (supplied by the internal iliac artery system), due to the high content of cancellous bone components in the pelvis, the large number of intraosseous venous sinuses, and its abundant blood supply. The second is the combined internal iliac vein or pelvic venous plexus injury, which is easily damaged because of the thin wall of the venous vessels, the poor contractility of the ruptured veins, and the flimsy structure of the surrounding tissues, which makes it difficult to produce compression for hemostasis. Less common are injuries to the internal pelvic arteries, pelvic wall muscles, and internal pelvic organs.
The arterial wall is thick and elastic, so the chance of injury rupture is lower than that of the vein, and the ruptured artery is highly contractile, so the chance of hemorrhage is lower. However, with the wide development of interventional angiography in recent years, most scholars agree that pelvic fracture hemorrhage mainly comes from the rupture of internal iliac artery or its branches, Zhang Yingze et al. reported that 41 of 44 cases of pelvic fracture hemorrhage were confirmed by angiography as internal iliac artery or its branches, accounting for 93.2%. Zhang Jiong-Hua et al. reported 13 cases of pelvic fracture with hemorrhage and 9 cases were confirmed to be injury to the internal iliac artery or its branches. The most common injuries were found in the internal pubic artery, occluded artery and superior gluteal artery, followed by the main internal iliac artery and the lumbar iliac artery.
3.3 Methods of hemostasis in unstable pelvic fractures The main control measures for hemorrhage in unstable pelvic fractures are revision and fixation of the pelvic fracture, arteriography and embolization by intervention, and internal iliac artery ligation.
3.3.1 Because hemorrhage from pelvic fractures mainly originates from large fracture sections, initial revision and fixation of the fracture is the primary measure to control hemorrhage. If the fracture is unstable, handling or turning the patient often leads to re-injury of the fracture site and dislodgement of blood clots from the bleeding site, which aggravates bleeding. Repeated bleeding consumes a large amount of platelets and coagulation factors, leading to coagulation insufficiency and further aggravating bleeding.
External fixation stents are effective in fixing pelvic fractures, simple and quick to operate, less traumatic, and less disturbing to the systemic condition, and Riemer et al [6] confirmed that immediate external fixation in hemodynamically unstable patients can reduce the mortality rate from 22% to 8%, so they can be used routinely when available. When not available, simple fixation of the pelvis using a simple wide cloth band around a tight compression will also achieve some hemostasis.
3.3.2 Arteriography through intervention to find the exact site of bleeding and embolization is considered to be the most ideal method of hemostasis, because it can embolize not only the main stem of the internal iliac artery, but also the major branches of the internal iliac artery, blocking the collateral circulation, with a definite hemostatic effect and a success rate of 50% to 87.1% or even higher [3], and its greatest advantage is small trauma and accurate localization.
3.3.3 Because the main blood supply to the pelvis comes from the internal iliac artery system, internal iliac artery ligation is also feasible for those who do not achieve good results with massive fluid and blood transfusion and other anti-shock treatments. Because the internal iliac arteries form an extensive anastomosis in the median plane bilaterally, bilateral internal iliac artery ligation is recommended, and most patients can achieve bleeding control.
Since the internal and external pelvic vessels have abundant side branch anastomoses, ligation of the internal iliac artery trunks can only control bleeding to a certain extent, but cannot achieve complete hemostasis; only double ligation of the internal iliac artery trunks and major branches that are easily damaged can block the side branch circulation and better control bleeding. We found that the hemostatic effect was significantly more accurate than that of bilateral internal iliac artery trunk ligation alone. Qu Yuxing et al. also pointed out that the main reason for the superior hemostatic effect of embolization over internal iliac artery ligation is that only the main trunk of the internal iliac artery is ligated, while there is still a rich collateral circulation, whereas a series of branches of the internal iliac artery will be embolized when embolization is performed.
Therefore, the hemostatic effect of our method is almost equal to that of embolization. Also, because of the rich network of collateral vessels inside and outside the pelvis and the postoperative reconstruction of the collateral circulation, ligation of the main trunk of the internal iliac artery and its easily damaged major branches will not have a significant effect on the blood supply to the pelvic organs. Therefore, this method is relatively safe and effective because it can control hemorrhage without significantly affecting the blood supply to the pelvic organs, and it is feasible because there is no significant effect on pelvic fracture healing in this group of cases.
Compared with interventional arteriography and embolization, the shortcomings are that it is more invasive, the procedure again increases traumatic bleeding, incises the posterior peritoneum, and weakens the hemostatic effect of compression of the posterior peritoneal hematoma; at the same time, its goal of controlling bleeding is relatively blind, and it is less effective for patients whose main bleeding does not come from the internal iliac artery system; it may lead to insufficient blood supply to the pelvic organs in the early stage, and even the possibility of necrosis.
Because of the obvious advantages of interventional arteriography and embolization, internal iliac artery ligation has almost replaced internal iliac artery ligation in large hospitals in recent years, but it is not yet widely available. In the absence of conditions for interventional arteriography and embolization, bilateral internal iliac artery ligation can still be considered when the effect of anti-shock treatment such as massive infusion and blood transfusion is poor and the patient’s life is threatened.
3.4 Improvements of our method over the traditional method We use a double measure of quick and simple fixation of the external fixation stent to stabilize the pelvic fracture and double ligation of the main trunk of the internal iliac artery and its vulnerable major branches. In other words, when performing bilateral internal iliac artery ligation, we not only ligated the main trunk but also re-ligated the vulnerable major branches of the internal pubic artery, occluded artery, superior gluteal artery, inferior gluteal artery, lumbar iliac artery and lateral sacral artery, respectively, blocking the major collateral circulation and achieving a more satisfactory hemostasis effect, which is almost equivalent to embolization.
Some scholars previously disagreed with internal iliac artery ligation because the traditional method only ligated the main trunk (1 cm after the bifurcation of the common iliac artery), but did not ligate the main branches again, so the hemostatic effect was not good. Qu Yuxing et al. also pointed out the main reason for the poor hemostatic effect.