Can Nondisplacement Osteoporotic Pubic Rami Fracture Be Life-Threatening Injuries? A Case Report,Overview,and Algorithm Protocol for Management

Abstract

Pubic rami fractures in the geriatric population are usually osteoporotic fractures resulting from low energy trauma and are characterized as stable injuries. Established treatment of these injuries is conservative, including rest, analgesic medication, and progressive active mobilization. These injuries are life-threatened when pubic rami fractures are accompanied by acute bleeding, either from an injury to a vessel (corona mortis) or from medication (anticoagulant or antiplatelet) for comorbidities, then. In this case study, we present the unusual case of an 82-year-old woman admitted to the emergency department 24 hours after a simple fall, causing nondisplacement osteoporotic pubic rami fracture, who, after 48 hours, developed a hematoma on the contralateral side of the pelvis, with progressive anemia and acute abdominal pain. This study has 2 objectives: to increase awareness of this life-threatening injury in the emergency department and to describe diagnosis and treatment modalities.

Introduction

The incidence of pelvic fractures increases with age and has a bimodal distribution. ¹ In patients older than 65 years, these injuries are low energy trauma (characterized as osteoporotic fractures), whereas in younger population, these injuries are unstable and have a high mortality rate of 19% to 31%. ² Osteoporotic pelvic fractures are low energy injuries which present an incidence of female to male ratio of 1.25 in people 60-69 years of age; this ratio increases to 2.7 in patients older than 80 years. ³ The main cause of osteoporotic fracture is a simple fall from standing, whereas vertigo and sedative medication may cause these falls in older population. ¹ Runge ⁴ has studied the fall risk factors in a geriatric population and concluded that any condition that impairs gait and balance must be referred to as an age-associated multifactorial gait disorder.

General pubic rami fracture account for 2-thirds and acetabular fractures account for 11% to 19% of osteoporotic pelvic fractures. ¹ These fractures appear as lateral compression fractures after direct impinge on the injured side; according to the AO/ASIF classification system, they are characterized as stable type A2 fractures or B2 as internal rotation injuries. ⁵ Hemodynamic instability and hemorrhage are common complications in unstable pelvic fractures but are extremely rare in geriatric pubic rami stable fractures.^1,6 Osteoporotic stable pubic rami fractures with hemodynamic disturbance have been reported as a consequence of either tearing of corona mortis vessels (anastomosis between the inferior epigastric and obturator vessels) or dysfunctional hemostasis mechanisms (because of anticoagulant or antiplatelet medications). ⁷

The aim of this study was to present the unusual case of an 82-year-old woman who admitted to the emergency department 24 hours after a simple fall, caused an un-displacement osteoporotic pubic rami fracture, after 48 hours developed a hematoma in contralateral side of pelvis with progressive anemia and acute abdominal pain. With this case report, we hope to increase awareness of these life-threatening injuries in the emergency department and to present the diagnosis and treatment modalities according to the literature.

Case Report

An 82-year-old woman with osteoporosis presented to the emergency department with intense pain in the right groin following a fall from standing height 24 hours earlier. The patient was unable to stand or place weight on the affected hip and leg. Her past medical history included arterial hypertension, osteoporosis, and hypothyroidism. In addition, the patient indicated regular use of acetylsalicylic acid (100 mg once daily) for secondary prevention of coronary artery disease. The patient underwent a complete clinical examination and laboratory testing. Clinical examination of the pelvis showed pelvic tenderness with no deformities or gross motion. A focused lower extremity neurologic evaluation yielded normal findings. The femoral, popliteal, posterior tibial, and dorsalis pedis arteries were palpable in the lower extremities. Radiography revealed a displaced right superior pubic ramus fracture and a nondisplaced right inferior pubic ramus fracture (Figure 1). The patient was admitted to our orthopedic department to evaluate her hemodynamically status. Her hemoglobin was 10 g/dL (normal level: 11.9–14.7 g/dL) and her hematocrit was 30.6% (normal level: 36.8- 45.6%). All other blood tests results were normal. Prophylactic anticoagulation therapy (Bemiparin 3500 IU/day), analgesics (paracetamol 4 g per day) and intravenous fluid therapy (Ringer’s lactate solution 1000 mL/day) were administrated to the patient. The patient remained hemodynamically stable within 48 hours and did not show any coagulopathy disorders.

Figure 1.

Radiographic examination (AP view) of the pelvis with stable right pubic rami fractures (superior white arrow, inferior gray arrow).

Forty-eight hours later, her hemoglobin and the hematocrit decreased to 8.1 g/dL and 25.6%, respectively. The patient presented progressive oliguria, tachycardia (120 bpm), hypotension, and profuse perspiration with generalized pallor. She received a transfusion with packed red blood cells (PRBC). Her hemoglobin increased after the transfusion (9.2 g/dL), she showed clinical improvement and remained hemodynamically stable. The next morning (DAY), her hemoglobin again decreased to 7.9 g/dL and the systolic blood pressure had slightly decreased to 90 mm Hg, without any change in diastolic blood pressure. A clinical examination revealed a painful abdominal mass on the left lower abdominal quadrant. Consequently an emergent transfusion with fresh frozen plasma (FFP) and 2 packed red blood cell transfusions (PRBC) were performed. Emergent multiphase contrast computed tomography (CT) angiography revealed a large hematoma neighboring the left superior pubic ramus (contralateral side of the fracture), with no contrast extravasation indicating arterial bleeding (Figure 2A and B]. Bemiparin was discontinued for 72 hours, until her hemoglobin stabilized. Forty-eight hours later, the patient remained hemodynamically stable (normal blood pressure and the hemoglobin was 10.2 g/dL) and Bemiparin was continued again to prevent deep venous thrombosis. The patient was discharged after a 48-hour observation with stable hematocrit and hemoglobin and no clinical changes. Finally at a follow-up 3 months post-injury, the patient was able to walk with full weight bearing by using an assistive device and all blood tests results were stable.

Figure 2.

CT angiography-coronal view (A) and axial view (B) revealed dimension (13.45 × 6.55 cm) of hematoma on the left side, and pubic ramus fractures on the right side.

Discussion

Osteoporotic pubic rami fractures are a low energy injury appearing after a simple fall in most cases. This type of lesion is characterized as stable injury and proper treatment is conservative, initially involving bed rest and analgesic medication and later entailing progressive active mobilization when the pain has diminished. Acute or delaying bleeding as a consequence of stable pubic rami fracture is extremely rare but, when present, is a life-threatening vascular complication. ⁸

The incidence of acute abdominal pain from a misdiagnosed lesion in older patients is 40% and 10% of these cases result in mortality. ⁹ Acute abdominal pain secondary to stable pubic rami fracture has been described in the literature to correlate with pelvic hematoma or delayed bleeding.^8,10,11 Delaying bleeding described initial by Garrido-Gomez et al in a 70-year-old woman who developed a painful abdominal mass and hemodynamic inconstancy 72 hours after a left iliopubic rami fracture and a right ischiopubic rami fracture. Selective angiography revealed an active hemorrhage from corona mortis artery avulsion. ⁷ Subsequently, Sandri et al ³ reported the case of an 83-years-old woman with abdominal pain, anemia, pelvic hematoma on the contralateral side from the pubic rami fracture 72 hours after a fall who had received warfarin medication. Our case presented hemodynamic instability and painful abdominal mass 72 hours after the injury and the hematoma was on contralateral side from the fracture.

Hagiwara et al ¹² have indicated that 2 major factors are responsible for postinjury bleeding and hematoma in osteoporotic stable pubic rami fracture: first, inability of the connective tissue of skeletal muscles renders vessels to be more susceptible to minor trauma; second, atherosclerosis restricts the ability of injured vessels to deploy vasospasm and spontaneous tamponade. Henry et al ¹³ have shown that several comorbidities in patients, and a confined cardiovascular reserve decrease vasospasm or tamponade capability. Other studies have shown that anticoagulant medication modify the tamponade effect and clotting, and that bleeding complications during treatment with warfarin are associated with an age above 80 years, the intensity of anticoagulation therapy and deviations in the prothrombin time ratio.^1,14

Krappinger et al have shown that use of anticoagulant medication increases the risk of acute hemodynamic instability within 6 hours after fracture. ¹ Macdonald et al ¹⁰ and Loffroy et al ¹⁵ have presented cases involving anticoagulant therapy, with presentation of acute hemodynamic inconstancy after a stable geriatric pubic rami fracture treated by embolization. In general, when acute bleeding is present rapid warfarin inversion must be performed, to increase coagulation. Simultaneous use of warfarin with analgesic agents (paracetamol) or low-molecular- heparin is risk factor for initiation or intermittent bleeding. ³

Controversy exists in the literature regarding whether CT/scanning must be performed after plain radiographic imaging in pubic rami fractures. ⁵ Schädel-Höpfner et al ¹⁶ have suggested that CT is not required for the routine diagnosis of isolated pubic rami fractures, whereas opponents have argued that primary CT scanning is mandatory for diagnosis.

We believe that the decision to perform CT scanning should be based on clinical examination, the patient’s clinical history, comorbidities, and hemodynamic stability on an individual patient basis (Figure 1).

Another question is whether all bleeding lesions in osteoporotic pubic rami fracture must be treated. Soto et al ¹⁷ have suggested that bleeding arising from bony surfaces at the fracture area, muscles, major vascular elements, pelvic veins and small arteries require early diagnosis and hemostasis. In such cases contrast-enhanced CT is advantageous to diagnose active bleeding, whereas in patients who are hemodynamic unstable, convectional angiography may enable immediate embolization. ¹⁷ When hemorrhage originates from small veins, muscles and broad cancellous bone have a low flow; therefore, conservative treatment with resuscitation management is necessary to stop the bleeding. ¹

This case report indicates that although these stable bone lesions do not require orthopedic surgical intervention, a patient`s comorbidities (including anticoagulant medication) and general condition (such as atherosclerosis) can lead to life-threatening lesions. The protocol for management of this lesion type applied in our department is suggested (Figure 3).

Figure 3.

Protocol of management of osteoporotic pubic rami fractures.

Conclusion

Osteoporotic pubic rami fractures are stable fractures occurring after low energy injury and are very common among the older population. The gold standard treatment is conservative (rest, analgesic, and progressive active mobilization). Suspicion of delayed bleeding or pelvic hematoma particularly in patients taking anticoagulant medications, and obligatory hemodynamic monitoring should compose the basic management protocol for these lesions to avoid life-threatening complications. Angiographic embolization is a minimally invasive procedure with excellent results for pelvic fractures with vascular complications.