Massive haemorrhage from the internal iliac artery following a low energy superior pubic ramus fracture in a 73-year-old man (original) (raw)
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Life-Threatening Bleeding Following a Stable Fracture of the Superior Pubic Ramus: A Case Report
Curēus, 2024
Corona mortis, an anatomical variant documented in the literature, presents a noteworthy concern due to its proximity to the superior pubic ramus. Consequently, it remains susceptible to injury, even in stable, benign fractures of the pelvis, typically addressed through conservative management. Stable pelvic fractures are infrequently associated with complications; therefore, diligent monitoring is often overlooked in clinical practice. However, it becomes crucial, particularly in the elderly population given their suboptimal hemostatic capabilities. The standard approach for managing bleeding associated with pelvic fractures involves superselective embolization, a minimally invasive procedure with favorable outcomes. We present a case involving a 61-year-old female who experienced a stable pelvic fracture following low-energy trauma. Despite the ostensibly benign nature of the fracture, the patient exhibited hemodynamic instability attributable to bleeding from the corona mortis, necessitating embolization. The pelvic fracture itself was managed conservatively, leading to the patient's subsequent discharge in a stable condition. Therefore, we advocate for a comprehensive physical examination, serial hemoglobin monitoring, and additional imaging modalities based on the patient's clinical condition.
Delayed presentation of hypovolemic shock after a simple pubic ramus fracture
The American Journal of Emergency Medicine, 2012
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-yearold 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.
Turkish Journal of Trauma and Emergency Surgery, 2013
Pelvic fracture is associated with high mortality. The management of major pelvic injuries remains one of the most important issues in modern trauma care. A 39-year-old male patient presented at the emergency department after being hit with a 500 kg load. His general condition was average with unstable vital signs. Pelvic tomography revealed fractured bone structure, thickening secondary to hematoma in both iliopsoas muscles, and hemorrhage-related active extravasation in the left internal iliac trace. The patient's hemodynamics worsened despite fluid and blood replacement, and angiographic embolization was scheduled. Bilateral embolization of the iliac artery was performed. Control angiography confirmed that full embolization was established. The patient was monitored in intensive care, but expired after three days due to acute kidney failure, disseminated intravascular coagulation, and multi-organ failure. Angiographic embolization is a technique improves hemorrhage control in pelvic trauma but can also increase risk of complications such as ischemia and necrosis.
Do Patients With Acute Isolated Pubic Ramus Fractures Have To Be Hospitalized?
PubMed, 2017
A total of 129 patients were included in the study. Haemoglobin levels on admission and at 24 hours were evaluated. Radiographs and computed tomography of the pelvis were also evaluated. The patients were divided into subgroups, according to the accompanying occult posterior pelvic injuries, whether they received anticoagulant-antiaggregant treatment, the number of pubic ramus fractures (single or multiple), the level of energy (low or high) and the zone(s) of the fracture(s). The mean haemoglobin decrease was 1.21 g/dL. Forty-six of the patients were under anticoagulant or antiaggregant treatment. Fifty-one of the fractures occurred due to low energy trauma. Posterior ring injuries were observed in 75 of the patients. Haemoglobin level decreases were statistically significant in injuries with high energy trauma aetiology, in patients using antiaggregant or anticoagulant and in fractures of the lateral half of the superior pubic ramus. It is important to follow all pubic ramus fractures closely because, even in low energy trauma, haemoglobin levels could decrease significantly. We recommend hospitalization to monitor this group of patients.
Bladder necrosis secondary to internal iliac artery embolization following pelvic fracture
Urology Annals, 2014
A 49-year-old man following a road traffic accident (RTA) had an unstable pelvic fracture with urethral injury. Internal pelvic fixation with Supra-pubic catheter (SPC) drainage of his bladder was done. This failed to stop the bleeding and a pelvic angiography with bilateral internal iliac embolization using steel coils was performed successfully controlling the bleeding. After 4 weeks, the patient developed wound infection (Clavien Grade III) and on exploration, bladder necrosis was found. A urinary diversion using ileal conduit with excision of bladder was performed. A biopsy of the excised bladder confirmed bladder necrosis with a foreign material (coil) in one arterial lumen.
Archives of Orthopaedic and Trauma Surgery, 2006
Introduction: Most pelvic haemorrhages are thought to be caused by injury to small arteries or veins in the fractured cancellous pelvic bone or in the surrounding soft-tissues, and only 6-18% of patients with unstable pelvic fractures have haemorrhage from larger arteries. When arterial injuries are present, the majority involve branches of the internal iliac artery with only few published reports of injuries to the external iliac artery or its branches. Materials and methods: We report of a patient who sustained a combined pelvic and acetabular fracture with multifocal bleeding involving branches of both the internal iliac as well as the external iliac arteries after a crush injury. The primary attention was focused on the most probable arterial injury, the internal iliac artery and only at repeat angiography was the injury to the internal epigastric artery, caused by degloving injury to the trunk, recognized. Results: Arterial control was achieved only following aggressive fluid resuscitation, pelvic packing, repeated embolization and ligation of the peripelvic inferior epigastric artery. After initial haemodynamic control was achieved, the patient sustained multiple complications, partly as a consequence of the injury, but also as a consequence of the life-saving treatments. Conclusion: The case describes a rare combination of arterial injuries in a complex pelvic fracture constituting a partially stable pelvic fracture and a dislocated acetabular fracture in a patient with pelvic crush injury and a degloving injury to the trunk. The case also describes the complex nature of these injuries and rarely reported problems related to the treatment of them.
Case Reports in Radiology, 2019
Transcatheter angiography and embolization has long been recognized as the gold standard for patients with hemodynamic instability secondary to blunt pelvic trauma. While often the bleeding source can be readily localized based on the distribution of extravasation on preprocedural Computed Tomographic Angiography, one should be cautious in assessment for aberrant anatomy. A variant obturator artery originating from the inferior epigastric branch of the external iliac artery is commonly referred to as the corona mortis. We present a case of blunt pelvic trauma in which a patient demonstrated extravasation in the anterior distributions of both internal iliac arteries. Following embolization of bilateral internal iliac arteries, identification and embolization of bilateral corona mortis branches was crucial to achieving hemodynamic stability in this patient.
High velocity pelvic injury with limb vascular injury poses difficulties as immediate surgery for limb reperfusion is indicated. However immediate vascular intervention deviates from conventional principles of damage control following major injuries. We present two cases of this rare combination of injuries. In both cases, early limb revascularization is possible despite presented with multiple injuries and pelvic fracture.