Haemodynamic instability resulting from a low energy pubic ramus fracture in a 78-year-old woman. A case report and review of the literature

Post-surgical pseudoaneurysm of the corona mortis artery treated by arterial embolization from two arteries: A case report

Post-surgical pseudoaneurysm in the pelvis is rare. However, when it does occur, it may cause life-threatening hemorrhage. Hemostatic treatment for pelvic pseudoaneurysms may be complicated because the blood vessels in the pelvis may present with various anastomoses. Herein, we describe a case of a pseudoaneurysm that necessitated embolization of two arteries. A 47-year-old woman had undergone a total hysterectomy, a bilateral adnexectomy, and a pelvic lymphadenectomy for endometrial cancer; 13 days after surgery, she complained of sudden abdominal pain. Contrast-enhanced computed tomography revealed a retroperitoneal hematoma and a pseudoaneurysm with contrast leakage. The pseudoaneurysm had two feeding arteries (from the external and internal iliac systems). The first feeding artery was the obturator artery, which arose from the anterior trunk of the internal iliac artery. The second feeding artery was the aberrant obturator artery, which arose from the medial femoral circumflex artery. Both feeders were embolized and hemostasis was achieved. Pseudoaneurysms in the pelvis may have double origins from the external and internal iliac systems, and the aberrant obturator artery may arise from the medial femoral circumflex artery. Therefore, radiologists should be aware of these variations to effectively address post-surgical pseudoaneurysms of the corona mortis artery.

Anatomical position of the corona mortis relative to the anteroposterior and inlet views

PURPOSE

Although pubic ramus fractures are common in the elderly, resultant hemodynamic instability is a rare complication. The corona mortis, a vascular anastomosis between the obturator vessels and the external iliac vessels in the retropubic space, is occasionally damaged by fractures of the pubic ramus, causing significant hemorrhage. The purpose of this study was to evaluate the incidence and anatomical position of the corona mortis on the anteroposterior and inlet views.

METHODS

Sixty-one cadavers (122 hemipelvizes) were dissected and the incidence of the corona mortis was evaluated. Photographs were then taken simulating anteroposterior and inlet radiographs, and labeled as the anteroposterior and inlet views. The distance from the pubic symphysis to the corona mortis was measured on each of the two views.

RESULTS

The corona mortis was present in 76.1% of hemipelvizes. The corona mortis traverses along the periosteum of the dorsal surface of the pubis. The incidence of arterial corona mortis was 28.3% and that of venous corona mortis was 76.1%. The distance from the superior margin of the symphysis pubis to the corona mortis measured 47.7 ± 9.9 (45.9-49.6) mm on the anteroposterior view, and 59.4 ± 9.2 (57.3-61.5) mm on the inlet view.

CONCLUSIONS

In order to predict possible hemodynamic instability of the corona mortis following pubic ramus fractures, it is of clinical significance to precisely establish the anatomical position of the corona mortis on the anteroposterior and inlet views.

Bleeding Risk Associated With Hemodynamically Stable Low-Energy Pelvic Fracture

Introduction:

Life-threatening hemorrhage associated with low-energy pelvic fracture has been described in single cases in the literature. However, there is limited evidence available on the bleeding risk associated with hemodynamically stable osteoporotic pelvic fractures. The objective of this study was to estimate the bleeding risk associated with low-energy osteoporotic pelvic fractures in the elderly population.

Materials and Methods:

A retrospective review of patients aged > 65 years old with pelvic fractures admitted between 2015 and 2018 was performed. Eighty-two patients were identified: 12 males and 70 females with a median age of 86 years. The median Charlson comorbidity index was 6 (interquartile range = 5-7). Eighty-one fractures were classified as lateral compression I or Tile A2, and 1 fracture was classified as lateral compression II or Tile B2. Forty patients were on concurrent anticoagulation treatment. In 4 patients on warfarin, this treatment was reversed on admission.

Results:

The mean hemoglobin (Hb) level on arrival was 12.36 g/dL (±1.67 g/dL). There were significant drops in Hb levels on day 1 (Hb = 11.22 ± 1.86 g/dL, P < .001) and day 4 (Hb = 10.97 ± 1.6 g/dL, P < .001). Nine percent of patients required a blood transfusion. The mean baseline Hb level pre-transfusion was 8.33 g/dL (±1.15). Preexisting anticoagulation treatment did not predispose patients to greater decreases in Hb levels on day 1 (mean difference = 0.16 g/dL, P = .62) or day 4 (mean difference = 0.29 g/dL, P = .48) post-admission.

Discussion:

An observed mean decrease in Hb level of up to 1.4 g/dL can occur in hemodynamically stable elderly patients with osteoporotic pelvic fractures, reflecting an approximate loss of 1.4 units of packed red blood cells.

Conclusion:

This degree of decrease in Hb may be clinically significant in geriatric patients with chronic anemia and a history of cardiovascular disease.

Corona Mortis: anatomical and surgical description on 60 cadaveric hemipelvises

OBJECTIVE

to report the prevalence of arterial corona mortis and to describe its surgical and clinical applicabilities.

METHODS

We dissected 60 hemipelvises (50 men and 10 women) fixed in a 10% formalin solution for the purpose of gathering information on corona mortis. We measured the caliber and length of the obturator artery and its anastomotic branch with the aid of a digital caliper and submitted the data to statistical analyzes and comparisons with the GraphPad Prism 6 software.

RESULTS

arterial corona mortis was present in 45% of the studied sample. The most common origin of the obturator artery was the internal iliac artery; however, there was one exceptional case in which it originated from the femoral artery. The caliber of the anastomotic branch was on average 2.7mm, whereas the caliber of the obturator artery was 2.6mm.

CONCLUSION

the vascular connections between the obturator, internal iliac, external iliac and inferior epigastric arterial systems are relatively common over the upper pubic branch. The diameter and a trajectory of the anastomotic artery may vary. Thus, iatrogenic lesions and pelvic and acetabular fractures can result in severe bleeding that puts the patient's life at risk.

Management of Life-Threatening Arterial Hemorrhage Following a Fragility Fracture of the Pelvis in the Anticoagulated Patient: Case Report and Review of the Literature

Background:

Life-threatening arterial bleeding from fragility fractures of the pelvis are very rare but associated with significant mortality, especially in anticoagulated patients.

Case Description:

We report the successful interdisciplinary management of a 78-year-old woman under anticoagulation and antiplatelet therapy who had life-threatening arterial hemorrhage from the pubic rami following a fragility fracture of the pelvis. Our management strategy included early hemorrhage control by means of selective arterial embolization followed by surgical fracture stabilization and surgical hematoma evacuation.

Literature Review:

We identified 6 cases within the English literature, all involving females older than 70 years. All patients under anticoagulation developed hemorrhagic shock, and in 2 cases selective embolization contributed to survival of the patient. However, a combined management including fracture stabilization and hematoma evacuation has not been reported, allowing an excellent clinical outcome and discharge to geriatric rehabilitation.

Clinical Relevance:

This case illustrates that elderly patients with apparently benign pelvic fragility fractures might develop severe hemorrhage due to arterial injury, especially when under dual anticoagulation, and stresses the importance of a high index of suspicion. If bleeding is suspected, detailed imaging studies are necessary to determine the source of bleeding and immediate angiographic or surgical interventions in combination with volume resuscitation and coagulation therapy should be readily available.

Pelvic Insufficiency Fractures

Pelvic insufficiency fractures may occur in the absence of trauma or as a result of low-energy trauma in osteoporotic bone. With a growing geriatric population, the incidence of pelvic insufficiency fracture has increased over the last 3 decades and will continue to do so. These fractures can cause considerable pain, loss of independence, and economic burden to both the patient and the health care system. While many of these injuries are identified and treated based on plain radiographs, some remain difficult to diagnose. The role of advanced imaging in these cases is discussed. In addition to treating the fracture, medical comorbidities contributing to osteoporosis should be identified and corrected. Specific attention has been given to 25-OH serum vitamin D screening and repletion. Treatment generally consists of providing pain control and assisting patients with mobilization while allowing weight bearing as tolerated. In those unable to do so, invasive techniques such as sacroplasty as well as internal fixation may be beneficial. The role of operative fixation in insufficiency fractures is also discussed.

Haemorrhage in fragility fractures of the pelvis

INTRODUCTION

Fragility fractures of the pelvis (FFP) are one of the most visible and debilitating consequences of osteoporosis. In contrast to pelvic ring fractures of the young, fragility fractures are caused by falls from a standing height or even by repetitive physiological loads. Even though haemorrhage is rarely found in fragility fractures of the pelvis, one must be aware of the potential risk.

MATERIALS AND METHODS

In a computer literature search, we identified eight papers about patients with haemorrhage and/or haemodynamic instability as a complication of a low-velocity pelvic ring fracture, all of which were case reports.

CONCLUSION

In our review, an overview of the case reports is provided, risk factors identified and a recommendation for the treatment and clinical observation given.

Massive haemorrhage following minimally displaced pubic ramus fractures

BACKGROUND

Fractures of the pubic rami are the most frequent osteoporotic pelvic fracture. Although generally innocuous, epidemiologic research demonstrated a decreased survival in patients with pubic rami fractures compared to healthy controls. Sporadic cases of potentially lethal bleedings have been reported. The aim of this study was to report a consecutive series and review of the literature of patients with severe bleeding following minimally displaced pubic ramus fractures.

MATERIALS AND METHODS

We report on four cases who presented at our emergency department in 2012 and 2013. A systematic review was performed to find other cases of pubic ramus fracture with severe bleeding from the literature.

RESULTS

Four elderly patients presented with severe bleeding following os pubis fracture after trivial falls from ground level. Successful arterial embolisation was performed in two cases. These patients were discharged in good clinical condition. Two other patients were refrained from further treatment due to a pre-existing poor prognosis. Twenty-two additional cases were found in the literature. Successful arterial embolisation was performed in 20 cases, of whom 17 survived.

CONCLUSIONS

Severe bleeding, mostly secondary to corona mortis avulsions, is a rare but potentially lethal complication of pubic ramus fractures. Physicians should be aware of this complication and actively look for symptoms of bleeding. Super-selective arterial embolisation seems safe and highly effective to control bleeding secondary to pubis rami fractures in elderly patients.

Pelvic fractures presenting with haemodynamic instability: treatment options and outcomes

The management of trauma patients with haemodynamic instability and an unstable pelvic fracture is an issue of vivid debate in "trauma community". A multidisciplinary approach needs to be instituted regarding the required diagnostic and therapeutic measures. Control of haemorrhage is the first priority. Arterial embolization and/or preperitoneal pelvic packing follow the provisional skeletal pelvic stabilization. The sequence of these interventions still remains an issue of controversy. It needs to be determined on an institutional basis based on the available local resources such as angiography suite and whole-body CT scan and the expertise of the treating surgical team. Despite the fact that recent advances in diagnostic modalities and trauma care systems have improved the overall outcome of patients with pelvic fractures, the early mortality associated with high-energy pelvic injuries presenting with haemodynamic instability remains high. Any suspected injured person with pelvic ring injury should automatically be taken to a level one-trauma centre where all the facilities required are in place for these patients to survive.

Massive haemorrhage from the internal iliac artery following a low energy superior pubic ramus fracture in a 73-year-old man

We report a case of a 73-year-old man with a background of aspirin use who fell and sustained a minimally displaced right superior pubic ramus fracture. He subsequently developed hypotension that necessitated fluid resuscitation, associated with a significant drop in blood haemoglobin levels that required a packed red blood cell transfusion. CT scans revealed the presence of two pelvic haematomas, with ongoing bleeding. An angiogram demonstrated bleeding from the superior vesical branch of the anterior division of the right internal iliac artery, which was successfully embolised with gelfoam slurry. The patient recovered uneventfully thereafter. This is a unique case involving an unexpected injury to the superior vesical branch of the anterior division of the internal iliac artery following low energy trauma to an elderly man. We recommend that patients who develop hypotension following a seemingly-benign isolated pubic ramus fracture be evaluated for concomitant arterial injuries with the relevant CT imaging and angiography.

Delayed presentation of hypovolemic shock after a simple pubic ramus fracture

Although trauma-induced simple pubic ramus fracture is common in the emergency department (ED), it can result in life-threatening hemorrhagic shock. We describe a 58-year-old woman with closed minimally displaced simple pubic ramus fracture. Hemodynamic instability became apparent 2 hours later. She was successfully treated with transarterial embolization and discharged uneventfully 10 days later. Literature review showed involvement of the superior pubic ramus in all reported cases probably because of hemorrhage from “corona mortis” with delay in shock presentation mostly within 6 hours, suggesting at least an equivalent observation period for these patients, particularly those at high risk for hemorrhage.