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European Journal of Trauma and Emergency Surgery

Published in:

01-06-2014 | Original Article

Massive haemorrhage following minimally displaced pubic ramus fractures

Authors: R. P. G. ten Broek, J. Bezemer, F. A. Timmer, R. M. H. G. Mollen, F. D. Boekhoudt

Published in: European Journal of Trauma and Emergency Surgery | Issue 3/2014

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.

Callaway DW, Wolfe R. Geriatric trauma. Emerg Med Clin North Am. 2007;25(3):837–60.PubMedCrossRef

Boufous S, Finch C, Lord S, Close J. The increasing burden of pelvic fractures in older people, New South Wales, Australia. Injury. 2005;36(11):1323–9.PubMedCrossRef

Cosker TD, Ghandour A, Gupta SK, Tayton KJ. Pelvic ramus fractures in the elderly: 50 patients studied with MRI. Acta Orthop. 2005;76(4):513–6.PubMedCrossRef

Krappinger D, Kammerlander C, Hak DJ, Blauth M. Low-energy osteoporotic pelvic fractures. Arch Orthop Trauma Surg. 2010;130(9):1167–75.PubMedCrossRef

Hill RM, Robinson CM, Keating JF. Fractures of the pubic rami. Epidemiology and five-year survival. J Bone Joint Surg Br. 2001;83(8):1141–4.PubMedCrossRef

Coupe NJ, Patel SN, McVerry S, Wynn-Jones CH. Fatal haemorrhage following a low-energy fracture of the pubic ramus. J Bone Joint Surg Br. 2005;87(9):1275–6.PubMedCrossRef

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(1):e80–2.PubMed

Tan EC, van Stigt SF, van Vugt AB. Effect of a new pelvic stabilizer (T-POD®) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures. Injury. 2010;41(12):1239–43.PubMedCrossRef

Dyer GS, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury. 2006;37(7):602–13.PubMedCrossRef

10.

Rusu MC, Cergan R, Motoc AG, Folescu R, Pop E. Anatomical considerations on the corona mortis. Surg Radiol Anat. 2010;32(1):17–24.PubMedCrossRef

11.

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(1):100–2.

12.

Daeubler B, Anderson SE, Leunig M, Triller J. Hemorrhage secondary to pelvic fracture: coil embolization of an aberrant obturator artery. J Endovasc Ther. 2003;10(3):676–80.PubMedCrossRef

13.

Ferrada PA, Jain K. Aberrant obturator artery: a hidden threat after pelvic fracture. Am Surg. 2011;77(6):e126.PubMed

14.

Grainger MF, Porter KM. Life threatening haemorrhage from obturator vessel tear as a result of pubic ramus fracture. Injury. 2003;34(7):543–4.PubMedCrossRef

15.

Henning P, Brenner B, Brunner K, Zimmermann H. Hemodynamic instability following an avulsion of the corona mortis artery secondary to a benign pubic ramus fracture. J Trauma. 2007;62(6):E14–7.PubMedCrossRef

16.

Herrera Perez MU, Alcover HA. Hypovolaemic shock due to a fracture of the superior pubic ramus in a young man. Injury. 2004;35(1):80–2.PubMedCrossRef

17.

Huang YC, Liu P, Su JS, Lin YL. Contrecoup haemorrhage in a patient with left pubic fracture but right obturator artery bleeding. Emerg Med J. 2007;24(8):598–9.PubMedCrossRef

18.

Kong WM, Sun CK, Tsai IT. Delayed presentation of hypovolemic shock after a simple pubic ramus fracture. Am J Emerg Med. 2012;30(9):2090–4.PubMedCrossRef

19.

Lu CK, Lee YC, Sun PL, Liang CL, Liliang PC. Life-threatening Bleeding from the Pubic Branch of the Inferior Epigastric Artery after Pubic Ramus Fracture. Hong Kong Journal of Emergency Medicine. 2010;17(4):372–6.

20.

Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krause D. Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CJEM. 2008;10(4):392–5.PubMed

21.

Macdonald DJ, Tollan CJ, Robertson I, Rana B. Massive haemorrhage after a low-energy pubic ramus fracture in a 71-year-old woman. Postgrad Med J. 2006;82(972):e25.PubMedCentralPubMedCrossRef

22.

Sivan M, Glyn-Jones S, Phillips HJ, Willett K. Arterial injury following a low energy pubic rami fracture. J Orthop Traumat. 2006;7(4).

23.

Meyers TJ, Smith WR, Ferrari JD, Morgan SJ, Franciose RJ, Echeverri JA. Avulsion of the pubic branch of the inferior epigastric artery: a cause of hemodynamic instability in minimally displaced fractures of the pubic rami. J Trauma. 2000;49(4):750–3.PubMedCrossRef

24.

Mouzopoulos G, Tzurbakis M, Mouzopoulos D, Ierodiakonou V, Tsembeli A, Georgilas I. Massive haemorrhage due to minimally displaced pubic ramus fracture. Eur J Emerg Med. 2009;16(5):271–2.PubMedCrossRef

25.

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(7):722–4.PubMedCrossRef

26.

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(2).

27.

Wong TC, Chan WL, Wu WC. Life threatening stable pubic rami fracture. Injury Extra. 2005;36:300–2.CrossRef

Title: Massive haemorrhage following minimally displaced pubic ramus fractures
Authors: R. P. G. ten Broek
J. Bezemer
F. A. Timmer
R. M. H. G. Mollen
F. D. Boekhoudt
Publication date: 01-06-2014
Publisher: Springer Berlin Heidelberg
Published in: European Journal of Trauma and Emergency Surgery / Issue 3/2014
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-013-0361-8

At a glance: The STEP trials

Springer Medicine

Massive haemorrhage following minimally displaced pubic ramus fractures

Abstract

Background

Materials and methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Materials and methods

Results

Conclusions

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