Life-threatening vascular injury in an elderly patient with isolated pubic ramus fracture: A case report

BACKGROUND

Pubic ramus fractures are generally considered fragility fractures in the elderly population, commonly deriving from a low-impact fall. Treatment is ordinarily conservative and hemodynamic complications are exceedingly infrequent. Notwithstanding, patients with copious comorbidities should be carefully monitored for potential vascular injury.

CASE SUMMARY

This case report presents the management of a 75-year-old male patient with a history of diabetes mellitus and arterial hypertension who was admitted to the emergency room with a superior pubic ramus fracture. The patient experienced a significant drop in hematocrit and hemoglobin levels post-admission, necessitating urgent intervention. A computed tomography angiography revealed active bleeding, leading to the embolization of the medial femoral branch. The patient was stabilized hemodynamically and was discharged after 15 days, with recommendations for home-based follow-up care.

CONCLUSION

This report denotes the various challenges and strategies in managing simple fractures that are treated conservatively, but need prompt monitoring for occult vascular injuries that can be fatal.

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.

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.

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.