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

Abstract

Haemorrhage Hypotension shock a b s t r a c tWe 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.

Bleeding Risk Associated With Hemodynamically Stable Low-Energy Pelvic Fracture

“…Hemorrhage from cancellous bony surfaces, small caliper veins and muscles is common in patients with pelvic fragility fractures and is generally self-limiting. 15 Although there are a few case reports of life-threatening bleeding from low-energy pelvic fractures in the elderly, [15][16][17][18][19][20][21][22][23][24][25][26] to our knowledge, this is the first study that has estimated blood loss in the setting of hemodynamic stability. The mean decrease in Hb level of 1.4 g/dL, corresponding to 1.4 units of a packed red cell, 27 can be expected in patients admitted with low-energy pelvic fractures.…”

Intrapelvic Hematoma Following Low-Energy Osteoporotic Pubic Ramus Fracutre: A Rare Case Report

“…Sandri et al presented a similar case with an osteoporotic pubic ramus fracture requiring blood-transfusions due to arterial injury and corresponding anemia in a patient receiving more aggressive anticoagulatory treatment (Warfarin) [1]. Cases by Wee et al and Martin et al described similar conditions, however these patients were treated with embolization [4,5]. The literature is ambiguous on the matter of embolization versus conservative treatment, although some data show a reduced mortality rate in embolized patients [6].…”

“…Pelvic hemorrhage due to dislocated fractures of either the superior-or inferior rami are well described in the setting of high-energy traumas [2]. Few reports in the case of low-energy fractures have been described with corresponding treatment consisting of various conservative measures or more invasive procedures, such as vascular coiling [3,4].…”