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Viswanathan A, Na HY, Breckenridge L, Muller A, Butts C, Reilly E, Geng T, Sigal A, Michels R, Ong A. Hypotension in the Emergency Department and Contrast Extravasation on Computerized Tomography Predict Blood Transfusion in Low-Energy Pelvic Fractures. J Surg Res 2024; 296:310-315. [PMID: 38306936 DOI: 10.1016/j.jss.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/29/2023] [Accepted: 01/02/2024] [Indexed: 02/04/2024]
Abstract
INTRODUCTION Although low-energy pelvic fractures seldom present with significant hemorrhage, early recognition of at-risk patients is essential. We aimed to identify predictors of transfusion requirements in this cohort. METHODS A 7-y retrospective chart review was performed. Low-energy mechanism was defined as falls of ≤5 feet. Fracture pattern was classified using the Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen system as A, B, or C. Primary outcome was transfusion of ≥2 units of packed red blood cells in the first 48 h. Univariable analysis and logistic regression analysis were performed. A P value ≤0.05 was considered significant. RESULTS Five hundred forty six patients were included with median (interquartile range) age of 86 (79-91) and median (interquartile range) Injury Severity Score of 5 (4-8). Five hundred forty one (99%) had type A fractures. Twenty six (5%) had the primary outcome and 17 (3%) died. Logistic regression found that systolic blood pressure <100 mmHg at any time in the Emergency Department, Injury Severity Score, and pelvic angiography were predictors of the primary outcome. Seventeen percent of those who had the primary outcome died compared with 2% who did not (P = 0.0004). Three hundred sixty four (67%) received intravenous contrast for computerized tomography scans and of these, 44 (12%) had contrast extravasation (CE). CE was associated with the primary outcome but not mortality. CONCLUSIONS Hypotension at any time in the Emergency Department and CE on computerized tomography predicted transfusion of ≥2 units packed red blood cells in the first 48 h in patients with low-energy pelvic fractures.
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Affiliation(s)
| | - Hee Yun Na
- Drexel University College of Medicine, Wyomissing, Pennsylvania
| | - Leigham Breckenridge
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Alison Muller
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Christopher Butts
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Eugene Reilly
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Thomas Geng
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Adam Sigal
- Department of Emergency Medicine, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Ryan Michels
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania
| | - Adrian Ong
- Department of Surgery, Reading Hospital, Tower Health System, West Reading, Pennsylvania.
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Kastanis G, Pantouvaki A, Siligardou MR, Chaniotakis C, Kroustalakis E, Stavrakakis I, Kapsetakis P. Can Nondisplacement Osteoporotic Pubic Rami Fracture Be Life-Threatening Injuries? A Case Report, Overview, and Algorithm Protocol for Management. J Investig Med High Impact Case Rep 2024; 12:23247096241231648. [PMID: 38491774 PMCID: PMC10943755 DOI: 10.1177/23247096241231648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/13/2024] [Accepted: 01/23/2024] [Indexed: 03/18/2024] Open
Abstract
Pubic rami fractures in the geriatric population are usually osteoporotic fractures resulting from low energy trauma and are characterized as stable injuries. Established treatment of these injuries is conservative, including rest, analgesic medication, and progressive active mobilization. These injuries are life-threatened when pubic rami fractures are accompanied by acute bleeding, either from an injury to a vessel (corona mortis) or from medication (anticoagulant or antiplatelet) for comorbidities, then. In this case study, we present the unusual case of an 82-year-old woman admitted to the emergency department 24 hours after a simple fall, causing nondisplacement osteoporotic pubic rami fracture, who, after 48 hours, developed a hematoma on the contralateral side of the pelvis, with progressive anemia and acute abdominal pain. This study has 2 objectives: to increase awareness of this life-threatening injury in the emergency department and to describe diagnosis and treatment modalities.
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Affiliation(s)
| | - Anna Pantouvaki
- General Hospital of Heraklion “Venizeleio-Pananeio,” Greece
- Hellenic Mediterranean University, Heraklion, Greece
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Cantrell CK, Butler BA. A Review on Management of Insufficiency Fractures of the Pelvis and Acetabulum. Orthop Clin North Am 2022; 53:431-443. [PMID: 36208886 DOI: 10.1016/j.ocl.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
"Insufficiency fractures of the pelvis and acetabulum are occurring at increasing rates. Osteoporosis is the most prevalent risk fracture. Diagnosis begins with plain radiographs followed by advanced imaging with computed tomography and/or MRI. Pelvic ring fragility injuries are classified by the Fragility fractures of the pelvis system. Elderly acetabular fractures may be classified by the Letournel system. Management of these injuries is primarily nonoperative with early immobilization when allowed by fracture characteristics. When warranted, percutaneous fixation and open reduction internal fixation are options for both. Both acute and delayed total hip arthroplasty are options for acetabular fractures."
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Affiliation(s)
- Colin K Cantrell
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 1350, Chicago, IL 60611, USA.
| | - Bennet A Butler
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 1350, Chicago, IL 60611, USA
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Post-surgical pseudoaneurysm of the corona mortis artery treated by arterial embolization from two arteries: A case report. Radiol Case Rep 2022; 17:1132-1135. [PMID: 35169415 PMCID: PMC8829527 DOI: 10.1016/j.radcr.2022.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/15/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Sng M, Gentle J, Asadollahi S. Bleeding Risk Associated With Hemodynamically Stable Low-Energy Pelvic Fracture. Geriatr Orthop Surg Rehabil 2020; 11:2151459320911868. [PMID: 32284903 PMCID: PMC7133069 DOI: 10.1177/2151459320911868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 11/23/2019] [Accepted: 12/08/2019] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Marcus Sng
- Department of Orthopaedic Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Juliette Gentle
- Department of Orthopaedic Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Saeed Asadollahi
- Department of Orthopaedic Surgery, Northern Health, Melbourne, Victoria, Australia
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Abstract
Pelvic ring fractures are rare injuries in the elderly though the incidence is increasing due to the increasing age of the population. Main goal of treatment is the quickest possible re-mobilization to prevent side-effects of immobilization such as osteopenia, pulmonary infections or thromboembolic events. Isolated anterior pelvic ring fractures are stable injuries and therefore they usually can be treated conservatively, while pelvic ring injuries with involvement of the posterior ring are considered unstable and should undergo surgical stabilization if the patient’s condition allows for it. Conservative treatment includes adequate analgesia, guided mobilization with partial weight bearing if possible and osteoanabolic medication. The appropriate surgical procedure should be discussed in an interdisciplinary round considering patient’s pre-injury condition, anaesthetic and surgical risks.
Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180062
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Affiliation(s)
- Markus A Küper
- BG Trauma Center, Department for Traumatology and Reconstructive Surgery, Eberhard Karls University, Tübingen, Germany
| | - Alexander Trulson
- BG Trauma Center, Department for Traumatology and Reconstructive Surgery, Eberhard Karls University, Tübingen, Germany
| | - Fabian M Stuby
- BG Trauma Center, Department for Traumatology, Orthopedics and Surgery, Murnau am Staffelsee, Germany
| | - Ulrich Stöckle
- BG Trauma Center, Department for Traumatology and Reconstructive Surgery, Eberhard Karls University, Tübingen, Germany
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Comai A, Zatelli M, Haglmuller T, Bonatti G. The Role of Transcatheter Arterial Embolization in Traumatic Pelvic Hemorrhage: Not Only Pelvic Fracture. Cureus 2016; 8:e722. [PMID: 27625908 PMCID: PMC5010381 DOI: 10.7759/cureus.722] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose: The most common life-threatening complication of pelvic trauma is bleeding. Arterial bleedings frequently require active management, preferably with transcatheter arterial embolization (TAE). Hemodynamic instability and/or contrast extravasation at computer tomography (CT) examination are reliable indicators of arterial injury. Unstable pelvic fractures are much more hemorrhagic than stable fractures. Nevertheless, an absent or isolated pelvic fracture does not exclude pelvic hemorrhage. Materials and Methods: A retrospective study was conducted on our institutional database by collecting data of patients who underwent pelvic angiography and/or embolization due to pelvic blunt trauma in the period between August 2010 and August 2015. Results: In a period of five years, 39 patients with traumatic pelvic bleeding underwent angiography at our institution. Thirty-six of the 39 (92%) patients did show CT signs of active pelvic bleeding. Nineteen of 39 (49%) patients were hemodynamically unstable at presentation. Three of the 39 patients did not require embolization. Technical success was 35/36 (97%), and overall mortality was 3/39 (8%). Notably, 5/39 (13%) patients did not have any pelvic fracture at presentation, and 18/39 (46%) had only isolated or stable pelvic ring fracture. Conclusions: TAE is an effective technique to treat arterial pelvic bleeding after trauma. The absence of a major pelvic fracture does not exclude the risk of active bleeding requiring prompt treatment.
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8
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Weber CD, Herren C, Dienstknecht T, Hildebrand F, Keil S, Pape HC, Kobbe P. Management of Life-Threatening Arterial Hemorrhage Following a Fragility Fracture of the Pelvis in the Anticoagulated Patient: Case Report and Review of the Literature. Geriatr Orthop Surg Rehabil 2016; 7:163-7. [PMID: 27551576 PMCID: PMC4976735 DOI: 10.1177/2151458516649642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Christian David Weber
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
- Christian David Weber, Department of Orthopaedics and Trauma Surgery, Certified Level-1 and Geriatric Trauma Center (German Trauma Society), RWTH Aachen University Medical Center, Pauwelsstr. 30, D-52074 Aachen, Germany.
| | - Christian Herren
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
| | - Thomas Dienstknecht
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
| | - Sebastian Keil
- Department of Radiology and Interventional Radiology, RWTH Aachen University Medical Center, Aachen, Germany
| | - Hans-Christoph Pape
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
| | - Philipp Kobbe
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
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9
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Wagner D, Ossendorf C, Gruszka D, Hofmann A, Rommens PM. Fragility fractures of the sacrum: how to identify and when to treat surgically? Eur J Trauma Emerg Surg 2015; 41:349-62. [PMID: 26038048 PMCID: PMC4523697 DOI: 10.1007/s00068-015-0530-z] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/07/2015] [Indexed: 12/29/2022]
Abstract
The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.
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Affiliation(s)
- D Wagner
- Department of Orthopaedics and Traumatology, University Medical Centre, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany,
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Abstract
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.
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Affiliation(s)
- Timothy J. O’Connor
- Regions Hospital, Department of Orthopaedic Surgery, University of Minnesota, Saint Paul, MN, USA
| | - Peter A. Cole
- Regions Hospital, Department of Orthopaedic Surgery, University of Minnesota, Saint Paul, MN, USA
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11
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Haemorrhage in fragility fractures of the pelvis. Eur J Trauma Emerg Surg 2014; 41:363-7. [PMID: 26037987 DOI: 10.1007/s00068-014-0452-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 09/11/2014] [Indexed: 10/24/2022]
Abstract
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.
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Delayed bleeding and pelvic haematoma after low-energy osteoporotic pubic rami fracture in a warfarin patient: an unusual cause of abdominal pain. Case Rep Emerg Med 2014; 2014:783268. [PMID: 25143839 PMCID: PMC4124805 DOI: 10.1155/2014/783268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 07/05/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction. Acute abdominal pain may be the presenting symptom in a wide range of diseases in the elderly. Acute abdominal pain related to a delayed bleeding and pelvic haematoma after a low-energy pubic rami fracture is rare and can have important consequences; to the best of our knowledge, only one case has been previously described. Case Report. We present an unusual case of an 83-year-old woman taking warfarin for atrial fibrillation, admitted to the Emergency Department (ED) with acute abdominal pain and progressive anemia related to a delayed bleeding and pelvic haematoma 72 hours after a low-energy osteoporotic pubic rami fracture. Warfarin was withheld, anticoagulation was reversed by using fresh frozen plasma and vitamin K, and concentrated red blood cells were given. Haemoglobin level gradually returned to normal with a progressive resorption of the haematoma. Conclusion. Delayed bleeding and pelvic haematoma after osteoporotic pubic rami fracture should be considered in the differential diagnosis of acute abdominal pain in the elderly. This case indicates the need for hospital admission, careful haemodynamic monitoring, and early identification of bleeding in patients with "benign" osteoporotic pubic rami fracture, especially those receiving anticoagulants, to provide an adequate management and prevent severe complications.
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Massive haemorrhage following minimally displaced pubic ramus fractures. Eur J Trauma Emerg Surg 2013; 40:323-30. [PMID: 26816067 DOI: 10.1007/s00068-013-0361-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 12/01/2013] [Indexed: 10/25/2022]
Abstract
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.
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Wee J, Lua W, Louange DT. Massive haemorrhage from the internal iliac artery following a low energy superior pubic ramus fracture in a 73-year-old man. J Clin Orthop Trauma 2013; 4:98-101. [PMID: 26403633 PMCID: PMC3880497 DOI: 10.1016/j.jcot.2013.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/23/2013] [Indexed: 10/27/2022] Open
Abstract
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.
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Affiliation(s)
- James Wee
- Tan Tock Seng Hospital, 11, Jalan Tan Tock Seng, Singapore 308433, Singapore,Corresponding author. Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11, Jalan Tan Tock Seng, Singapore 308433, Singapore. Tel.: +65 6357 7714.
| | - Wensheng Lua
- Tan Tock Seng Hospital, 11, Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Danny Thomas Louange
- Adj Asst Prof, Tan Tock Seng Hospital, 11, Jalan Tan Tock Seng, Singapore 308433, Singapore
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Kong WM, Sun CK, Tsai IT. Delayed presentation of hypovolemic shock after a simple pubic ramus fracture. Am J Emerg Med 2012; 30:2090.e1-4. [PMID: 22425006 DOI: 10.1016/j.ajem.2011.12.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 12/14/2011] [Indexed: 10/28/2022] Open
Abstract
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.
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Affiliation(s)
- Wai-Ming Kong
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
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17
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Garrido-Gómez J, Pena-Rodríguez C, Martín-Noguerol T, Hernández-Cortes P. Corona mortis artery avulsion due to a stable pubic ramus fracture. Orthopedics 2012; 35:e80-2. [PMID: 22229619 DOI: 10.3928/01477447-20111122-25] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A 70-year-old woman with osteoporosis fell at home and presented to our emergency department with intense left hip pain. Radiographs revealed a left iliopubic rami fracture and nondisplaced right ischiopubic rami fracture. She was discharged after a 24-hour observation with no clinical changes. Seventy-two hours later, she was readmitted with a painful abdominal mass, progressive oliguria, tachycardia, hypotension, and profuse perspiration with generalized pallor. On physical examination, a painful mass in the hypogastrium and intense inflammation in the thigh and the proximal portion of left knee were found.Emergent multiphase contrast computed tomography revealed a large nonhomogeneous hematoma neighboring the fractured left iliopubic rami, and contrast extravasation indicated arterial bleeding. Selective angiography showed an active hemorrhage from the distal portion of a small branch of the left obturator artery. After embolization of the arterial vessel, the patient was hemodynamically stable. The fracture was rotationally and vertically stable.These fractures are common, especially among the elderly. This type of injury is usually treated conservatively and with active mobilization once the acute pain has subsided. Supraselective embolization after localization of the bleeding vessels by arteriography is recognized as a minimally invasive procedure with excellent outcomes in hemorrhagic complications of pelvic fractures. An apparently benign pubic rami fracture in the setting of hemodynamic instability should raise the suspicion of a corona mortis injury, especially in elderly and anticoagulated patients.
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Affiliation(s)
- Juan Garrido-Gómez
- Department of Orthopedic Surgery, University Hospital San Cecilio, 68 Duero St, 18194, Churriana de la Vega, Granada, Spain.
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Theodorides AA, Morgan BW, Simmons D. Haemodynamic instability resulting from a low energy pubic ramus fracture in a 78-year-old woman. A case report and review of the literature. Injury 2011; 42:722-4. [PMID: 20926073 DOI: 10.1016/j.injury.2010.08.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 08/22/2010] [Accepted: 08/25/2010] [Indexed: 02/02/2023]
Affiliation(s)
- A A Theodorides
- Department of Trauma & Orthopaedics, University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, United Kingdom.
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The Relationship Between Mortality and Preexisting Cardiac Disease in 5,971 Trauma Patients. ACTA ACUST UNITED AC 2010; 69:645-52. [DOI: 10.1097/ta.0b013e3181d8941d] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dotchin C, Colman A, Shanshal Y. Bladder rupture following osteoporotic pubic ramus and sacral insufficiency fractures. Age Ageing 2010; 39:511-2. [PMID: 20494898 DOI: 10.1093/ageing/afq046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We present a case report of an 86-year-old lady with pubic ramus and sacral insufficiency fractures who developed extra-vesical bladder rupture following displacement of the pubic ramus fracture, a very unusual complication.
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Chiu Y, Wong TC, Yeung SH. Haemodynamic instability secondary to minimally displaced pubic rami fractures: a report of two cases. J Orthop Surg (Hong Kong) 2009; 17:100-2. [PMID: 19398804 DOI: 10.1177/230949900901700122] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We report 2 patients with haemodynamic instability secondary to minimally displaced pubic rami fractures following a fall. Both complained of pain and swelling in the abdomen and groin, and had abdominal distension and bruising in the abdomen, groin, and perineum. All these may be early signs of severe vascular injury and should be treated promptly. Both patients were treated with embolisation of the injured vessels using emergency angiography.
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Affiliation(s)
- Y Chiu
- Department of Orthopaedics and Traumatology, Pamela Youde Nethersole Eastern Hospital, Hong Kong.
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