Severe pelvic injury: vascular lesions detected by ante- and post-mortem contrast medium-enhanced CT and associations with pelvic fractures

Abstract

ObjectivesThe objectives of this study were to compare arterial and venous contrast medium extravasation in severe pelvic injury detected by ante- and post-mortem multi-detector CT (MDCT) and determine whether vascular injury is associated with certain types of pelvic fracture.MethodsWe retrospectively included two different cohorts of blunt pelvic trauma with contrast medium extravasation shown by MDCT. The first group comprised 49 polytrauma patients; the second included 45 dead bodies undergoing multi-phase post-mortem CT-angiography (MPMCTA). Two radiologists jointly reviewed each examination concerning type, site of bleeding and pattern of underlying pelvic ring fracture.ResultsAll 49 polytrauma patients demonstrated arterial bleeding, immediately undergoing subsequent angiography; 42 (85%) had pelvic fractures, but no venous bleeding was disclosed. MPMCTA of 45 bodies revealed arterial (n = 33, 73%) and venous (n = 35, 78%) bleeding and pelvic fractures (n = 41, 91%). Pelvic fracture locations were significantly correlated with ten arterial and six venous bleeding sites in dead bodies, with five arterial bleeding sites in polytrauma patients.In dead bodies, arterial haemorrhage was significantly correlated with the severity of pelvic fracture according to Tile classification (p = 0.01), unlike venous bleeding (p = 0.34).ConclusionsIn severe pelvic injury, certain acute bleeding sites were significantly correlated with underlying pelvic fracture locations. MPMCTA revealed more venous lesions than MDCT in polytrauma patients. Future investigations should evaluate the proportional contribution of venous bleeding to overall pelvic haemorrhage as well as its clinical significance.

Where and what arteries are most likely injured with pelvic fractures?

“…This makes the overall estimated risk of injury to the aberrant obturator artery less than 1% (one patient in our multicenter study; Dzupa et al, ). Injury to the obturator artery proper is likewise rare (one patient in our multicenter study; Dzupa et al, ; Requarth and Miller, ; Hussami et al, ); it is suspected to occur in an incidence of a vertical or dorsal dislocation fracture running on the lateral side of the obturator foramen. Fractures in this area tend to be oblique or horizontal and affect the anterior wall of the acetabulum.…”

“…Another possible explanation can be that bleeding from large arteries in the pelvic region is often rapidly fatal (Requarth and Miller, 2011;Romano et al, 2012;Tosounidis and Giannoudis, 2013;Pascarella et al, 2014;Comai et al, 2016;Rudloff and Triantafillou, 2016;Hussami et al, 2017). However, we believe that the fundamental explanation of this discrepancy is behind the morphological features of the fracture (Pascarella et al, 2014;Hussami et al, 2017). Hereby, we discuss in particular correlated patterns of fracture lines to the course of arteries as listed in Table 4.…”

“…One probable explanation can be the strength and elasticity of the arterial wall, which is able to flex in response to pressure from dislocated bony fragments. Another possible explanation can be that bleeding from large arteries in the pelvic region is often rapidly fatal (Requarth and Miller, ; Romano et al, ; Tosounidis and Giannoudis, ; Pascarella et al, ; Comai et al, ; Rudloff and Triantafillou, ; Hussami et al, ). However, we believe that the fundamental explanation of this discrepancy is behind the morphological features of the fracture (Pascarella et al, ; Hussami et al, ).…”

“…In Area 2: fractures of the superior pubic ramus may result in injury to the femoral, external iliac, obturator proper, or aberrant obturator (arterial corona mortis) arteries (Requarth and Miller, ; Pascarella et al, ; Hussami et al, ). Injuries to the femoral or external iliac arteries can be caused by vertical fracture lines of both the superior and inferior pubic rami directly beneath the arteries as well as in dislocations caused by shear forces, which are typical in Type C fractures.…”

“…In Area 2: fractures of the superior pubic ramus may result in injury to the femoral, external iliac, obturator proper, or aberrant obturator (arterial corona mortis) arteries (Requarth and Miller, 2011;Pascarella et al, 2014;Hussami et al, 2017). Injuries to the femoral or external iliac arteries can be caused by Internal pudendal 4…”