Avulsion of the pubic branch of the inferior epigastric artery: a cause of hemodynamic instability in minimally displaced fractures of the pubic rami

Differentiating Between Obturator and Inferior Epigastric Arterial Injury in Traumatic Pelvic Hemorrhage: A Case Report

The pubic branches of the inferior epigastric and obturator arteries are subject to injury from pelvic trauma or surgery within the retropubic space. Such injuries can result in severe internal hemorrhage that can lead to hemodynamic instability if not adequately controlled. Due to their anatomical proximity and anastomosis, it is critical to determine which artery is hemorrhaging in order to provide accurate embolization. In the presented case, a geriatric patient suffered a fall from standing height that resulted in bilateral and multiple pelvic fractures. CT angiography of the abdomen demonstrated active left-sided pelvic hemorrhage and a resultant 10 cm anterior extraperitoneal hematoma, likely exacerbated by existing anticoagulant usage. Urgent embolization of the inferior epigastric artery was performed in addition to multiple transfusions. The patient recovered without any procedural complications and was later discharged for rehabilitation.

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.

Life-Threatening Bleeding from the Pubic Branch of the Inferior Epigastric Artery after Pubic Ramus Fracture

Isolated pubic ramus fracture with concurrent life-threatening bleeding caused by injury to the inferior epigastric artery (IEA) or its branches has rarely been reported and can frequently be overlooked. This paper reports two cases of isolated pubic ramus fracture with concomitant injury to the pubic branch of the IEA, causing serious bleeding and hemodynamic instability. Pelvic angiography showed leakage of contrast from the pubic branch of the IEA. The complication in both cases was successfully treated with transcatheter arterial embolisation.

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.

Corona mortis: in vivo anatomical knowledge and the risk of injury in totally extraperitoneal inguinal hernia repair

PURPOSE

Corona mortis (CMOR) is the arterial and/or venous vascular communication(s) between the obturator and external iliac vessels. Totally extraperitoneal (TEP) inguinal hernioplasty can be associated with vascular complications especially during the fixation of the mesh. Theoretically, CMOR is an important nominee. But, the data in literature are insufficient about CMOR injury. Additionally, most of the studies about CMOR have been usually performed on cadavers. We aimed to reveal the preperitoneal vascular anatomy of inguinal area and provide in vivo knowledge about CMOR. The risk of arterial injury was also evaluated.

MATERIALS

The data of preperitoneal vascular anatomy of 321 patients who underwent TEP procedure between January 2005 and July 2014 were retrospectively evaluated.

RESULTS

Mean age was 46 ± 8.9 years, 53 females vs 268 males. 391 hemipelvises were evaluated. Two types of arterial structure were identified; (1) an aberrant obturator artery forming an anastomosis with branches of ordinary obturator artery; (2) a pubic branch of inferior epigastric artery. The incidence of arterial CMOR was 28.4 % and of any arterial structure was 45.0 %. An arterial CMOR was considered as thick (≥2 mm) or thin (<2 mm). Injury of arterial CMOR during tack stapling on Cooper's ligament was seen in six cases (1.5 %). All of them were thin (<2 mm) in structure. Venous CMOR was visible only under low pressure in work space.

CONCLUSION

During TEP hernia repair, CMOR and/or pubic branch of inferior epigastric artery can be damaged. To prevent this complication, tacks should be stapled to Cooper's ligament close to symphysis pubis and dissection should be careful on the posterior surface of superior pubic ramus. Small caliber (<2 mm) arterial CMOR is more prone to be injured during TEP procedure. To explore venous structures properly, pressure in workspace should be kept as low as possible.

Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization

Extraperitoneal bleeding from the inferior epigastric artery (IEA) and its branches is a rare complication of blunt pelvic trauma; however, it can result in life-threatening hemorrhage, even in cases of minimally displaced fractures of the pelvic ring. We report the case of a patient who had post-traumatic pelvic hematoma and cardiovascular collapse caused by avulsion of the right pubic branch of the IEA related to undisplaced fractures of the pubic rami. CT scanning followed by angiography showed leakage of contrast from the IEA. Transcatheter arterial embolization was performed to successfully control the hemorrhage. There have been very few previous reports of IEA injury related to stable fractures of the pubic rami successfully treated by transcatheter arterial embolization.

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.

Delayed bleeding and pelvic haematoma after low-energy osteoporotic pubic rami fracture in a warfarin patient: an unusual cause of abdominal pain

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.

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.

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.

Corona mortis artery avulsion due to a stable pubic ramus fracture

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.

Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature

PURPOSE

The purpose of this study was to evaluate the relation between pelvic fracture patterns and the angiographic findings, and to assess the effectiveness of the embolisation.

METHODS

This retrospective study, included patients with pelvic fractures and angiographic evaluation. Demographics, Injury Severity Score (ISS), associated injuries, embolisation time, blood units needed, method of treatment and complications were recorded and analysed. Fractures were classified according to the Burgess system.

RESULTS

Between 1998 and 2008, 34 patients with pelvic fractures underwent angiographic investigation. Twenty six were males. The mean age was 41 years. Twenty-seven were motor vehicle accidents and seven were falls. There were 11 anterior posterior (APC) fractures, 12 lateral compression (LC), eight vertical shear (VS) patterns and three with combined mechanical injuries. The median ISS was 33.1 (range 5-66). From the 34 who underwent angiography, 29 had positive vascular extravasations. From them, 21 had embolisation alone, two had vascular repair and embolisation, five required vascular repair alone and one patient died while being prepared for embolisation. Five cases were re-embolised. The findings suggested that AP fractures have a higher tendency to bleeding compared with LC fractures. Both had a higher chance of blood loss compared to VS and complex fracture patterns. We reported 57 additional injuries and 65 fractures. The complications were: one non lethal pulmonary embolism, one renal failure, one liver failure, one systemic infection, two deep infections and two psychological disorientations. Seven patients died in hospital.

CONCLUSION

Control of pelvic fracture bleeding is based on the multidisciplinary approach mainly related to hospital facilities and medical personnel's awareness. The morphology of the fracture did not have a predictive value of the vascular lesion and the respective bleeding.

Haemodynamic instability secondary to minimally displaced pubic rami fractures: a report of two cases

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.

Transarterial embolization for inferior epigastric artery injury

The inferior epigastric artery represents a potentially overlooked source of pelvic arterial hemorrhage. The authors describe 3 patients with massive inferior epigastric artery bleeding following cesarean section, paracentesis, and blunt trauma that were successfully treated with transarterial embolization. The inferior epigastric artery should be considered as a possible source of arterial hemorrhage if arteriography of internal iliac artery branches does not yield a bleeding source.

Corona mortis: An anatomical study with clinical implications in approaches to the pelvis and acetabulum

The "corona mortis" is an anatomical variant, an anastomosis between the obturator and the external iliac or inferior epigastric arteries or veins. It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (range 40-96 mm). The name "corona mortis" or crown of death testifies to the importance of this feature, as significant hemorrhage may occur if accidentally cut and it is difficult to achieve subsequent hemostasis. It constitutes a hazard for orthopedic surgeons especially in the anterior approach to the acetabulum. We carried out forty cadaver dissections (80 hemi-pelvises) through the ilioinguinal approach. A vascular anastomosis was found in 83% of specimens. Of these, 60% had a large diameter (>3 mm) channel along the posterior aspect of the superior pubic ramus. In clinical practice, however, 492 anterior approaches (to the best of our knowledge the largest series described) have been carried out over the last 15 years by the senior author (MB) and only five of these problematic vessels were discovered, and in only two cases was there troublesome bleeding. This study confirms a paradox: in anatomical dissections a large vessel was identified behind the superior pubic ramus, whereas in clinical practice this vessel does not seem to be as great a threat as initially perceived. Orthopedic surgeons planning an anterior approach to the acetabulum, such as the ilioinguinal or the intrapelvic approach (modified Stoppa), have to be cautious when dissecting near the superior pubic ramus. Despite the high prevalence of these large retropubic vessels in the dissecting room, surgeons should exercise caution but not alter their surgical approach for fear of excessive hemorrhage.

A protocol for angiographic embolization in exsanguinating pelvic trauma: a report on 31 patients

BACKGROUND

The indication for acquiring angiographic embolization in the initial treatment of severe pelvic fractures is controversial. We describe the characteristics and outcome of 31 patients with traumatic pelvic bleeding who underwent percutaneous angiography with embolization according to a standardized protocol.

PATIENTS AND METHODS

During an 8.5-year period, 1,260 patients were treated for pelvic trauma. We performed a prospective registration of the 46 patients who underwent angiography, and report the 31 patients who had signs of significant arterial injury on angiography, necessitating embolization.

RESULTS

The rate of significant arterial injury after pelvic trauma was 2.5%. All patients had been subjected to high-energy injuries and all were severely injured as measured by the Injury Severity Score: 41 (17-66). Pelvic arterial injury was observed with all types of pelvic trauma, including isolated acetabular (4/31) and sacral fractures (3/31). The internal iliac artery or its branches was injured in 28 of 31 patients. Survival rate after embolization was 84%, and correlated inversely with increasing patient age. None of the patients died of bleeding.

INTERPRETATION

Our findings show that significant pelvic arterial injuries occur in a minority of patients after pelvic trauma, and predominantly affect patients with multiple high-energy injuries regardless of fracture type. The effect of angiographic embolization was good.

Blunt thoraco-abdominal injury

Recent advances in blunt thoraco-abdominal trauma management include improvements in imaging, particularly in trauma bay ultrasound. Indications for non-operative management have expanded for solid organ and aortic injury. The physiology of abdominal compartment syndrome continues to be defined, with resulting improvements in care.