Lateral Compression Type 1 Pelvic Fractures in Elderly Anticoagulated Patients

Key words: Anticoagulation, fractures, pelvic fractures.
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Pelvic fractures are a major cause of morbidity and mortality in the elderly population, in whom treatment of these fractures remains a challenge. Age is a known independent predictor of mortality in open or otherwise severe fractures of the pelvis,^1,2 but few reports have addressed low-energy pelvic fractures (ie, fractures that result after a low amount of force is delivered to the pelvic bones) or nondisplaced fractures (ie, the fractured bone maintains its natural alignment) in elderly patients.^3,4 Because these fracture are less severe, they are often thought to be benign fractures that require minimal intervention³; however, even when such fractures appear radiographically benign, there may be adverse outcomes in elders, particularly those on anticoagulation medications for preexisting conditions.

We report two cases of lateral compression type 1 (LC-1) pelvic fracture in elderly trauma patients (aged ≥85 years) who were on long-term anticoagulation therapy, which increased their risk of clinical deterioration. We suggest that patients similar to ours may benefit from rigorous diagnostic screening, temporary cessation of anticoagulation therapy, and close monitoring in the intensive care unit (ICU).

Case 1

An 85-year-old woman presented to the hospital after slipping and falling on ice. Her medical history was significant for osteoporosis, atrial fibrillation (treated with warfarin), chronic renal insufficiency, myocardial infarction, stroke, and resected colon cancer. Radiographic imaging was undertaken, which revealed a left distal radius fracture and an LC-1 pelvic fracture. The patient was hemodynamically stable with a hematocrit of 33.3% and an international normalized ratio (INR) of 3.6. A computed tomography (CT) scan of her abdomen and pelvis revealed a characteristic LC-1 pelvic fracture pattern (ie, minimally displaced bilateral superior and inferior pubic rami fractures and a left sacral ala compression fracture). The CT scan also showed a pelvic arterial hemorrhage with perivascular hyperdensities, consistent with active extravasation, and a 3-mm pseudoaneurysm in the right internal iliac artery.

Within 9 hours of presenting to the hospital, her nadir hematocrit dropped to 22.2%. She was taken for emergent embolization of the pseudoaneurysm. Thereafter, we continued closely monitoring her in the trauma ICU. Her hematocrit stabilized after the intervention, and she was not transfused. An open reduction internal fixation of her wrist fracture was performed on hospital day 4. She was discharged to a rehabilitation facility on hospital day 7 on aspirin 325 mg daily and heparin 5000 units three times daily as prophylaxis for deep venous thrombosis (DVT) while her warfarin was temporarily discontinued.

Case 2

A 90-year-old man presented to the hospital after falling approximately 10 feet from a ladder, landing on his left hip. His medical history included hypertension, for which he was taking metoprolol (the dose was unknown), and daily 325-mg aspirin therapy. On physical examination, he was in pain, and lateral compression of the pelvis and internal and external rotation of the hip were noted. Bilateral lower extremity pulses were palpable. The patient was normotensive and his hematocrit was 37.5%. A CT scan confirmed pelvic fractures involving the bilateral superior and inferior pubic rami, the medial left acetabulum, the left sacral ala, and the posterior left iliac bone. It also showed two pseudoaneurysms in the left internal iliac artery (Figure). He was taken for immediate coil embolization of the left internal iliac artery and was moved to the ICU for subsequent serial hematocrit monitoring. On hospital day 3, his nadir hematocrit dropped to 21.2%, requiring transfusion of 2 units of packed red blood cells, after which his hematocrit rose to 27.9%. On hospital day 5, he experienced atrial fibrillation with rapid ventricular response, which was controlled with intravenous amiodarone and diltiazem. He also developed a urinary tract infection, which was treated with ciprofloxacin. The patient was discharged to a rehabilitation facility on hospital day 6 on digoxin 125 µg daily and heparin 5000 units three times daily for DVT prophylaxis while his aspirin was temporarily discontinued.

Discussion

The annual incidence of fractures of the pubic rami is estimated to be 6.9 per 100,000 in the general population and 25.6 per 100,000 among individuals older than 60 years.⁵ These fractures are generally treated conservatively and are usually associated with a lateral compression injury of varying degrees of energy, with the lowest impact resulting in sacral ala compression. This constitutes an LC-1 pelvic fracture when using the Young-Burgess classification system, which is the most widely used system to classify pelvic fractures (Table).^6-8

Previous studies have demonstrated that age is a predictor of mortality in open or otherwise severe fractures of the pelvis,^1,2 but low-energy pelvic fractures in elders have not been as extensively studied. In 2011, Bramos and colleagues⁹ reported that a hematocrit of 30% or less on admission, a pelvic hematoma on CT scan, and a systolic blood pressure of 90 mm Hg or less were independent predictors of bleeding from stable pelvic fractures in the general population.Patients with significant bleeding caused by the pelvic fracture tended to be older, had a lower injury severity score and hematocrit level on admission, and were less likely to be admitted to the ICU.⁷ Several cases have been reported of elderly patients who have had life-threatening bleeding requiring embolization after sustaining a stable pelvic fracture.^3,4,10

Because LC-1 pelvic fractures are commonly considered benign low-energy fractures that can be treated immediately with full weight bearing, it is thought that no intervention is merited beyond physical therapy; however, these fractures should be considered high-risk injuries in elderly patients, particularly those on anticoagulants. Both of our elderly case patients had bleeding complications from the internal iliac artery because of LC-1 pelvic fractures. Geriatric patients are susceptible to such complications and to poor outcomes following pelvic fractures because they are more likely to have multiple comorbidities and to be using anticoagulation therapies. One of our patients presented with multiple comorbidities, including renal insufficiency, atrial fibrillation, and a history of myocardial infarction, stroke, and colon cancer resection. Both of our patients were taking an anticoagulant upon presentation. We believe that anticoagulation in the geriatric age group compounds the risk of bleeding and the need for intervention. Both case patients required angiographic intervention, and one patient received a transfusion.

LC-1 pelvic fractures are characterized by rami fractures apparent on anteroposterior pelvic plain film radiographs, which are usually taken on presentation. It is less commonly known that LC-1 pelvic fractures can be associated with a sacral fracture, leading to a great potential for significant dynamic displacement. Plain film radiographs showing the rami fractures represent a static time point in the presentation of the fracture and they will not reveal the sacral component. Upon acute lateral compression, the rami fracture can displace significantly and then return to fair anatomic alignment. This initial dynamic displacement in a geriatric patient with atherosclerosis and rigid vessels can result in vessel disruption and slow but persistent bleeding. This risk is increased in patients who are anticoagulated. The corona mortis (the vascular connection between the external iliac artery and the obturator artery) is most often at risk for injury in these situations.¹¹ Elderly anticoagulated patients presenting with LC-1 fractures and pelvic bleeding benefit from CT angiography and frequent hematocrit evaluation, preferably conducted every 12 hours.

If anticoagulation is continued, atrial fibrillation remains a risk. Goldstein and Greenberg¹² have suggested a waiting period of 24 to 72 hours without clinical signs of bleeding as a threshold before resuming anticoagulation therapy. Anticoagulation may be restarted to previous INR targets. Low-molecular-weight heparin bridging can be used if the patient is at severe cardiovascular risk, but prudent monitoring for recurrent bleeding is advised.⁹

Conclusion

Clinicians should have a high degree of suspicion when assessing geriatric patients with apparently benign pelvic fractures, such as LC-1 pelvic fractures, particularly if they are on anticoagulation therapy. We recommend close hemodynamic monitoring in elders presenting with any type of pelvic fracture pattern, including low-energy fractures or any sign of minimal displacement and instability of the fracture. Significant pelvic hemorrhage may occur, and a low threshold for angiography and embolization is necessary. Patients meeting these criteria should be admitted for serial hematocrit evaluation and hemodynamic monitoring.

Elderly patients on anticoagulation therapy presenting with severe bleeding in the setting of pelvic fractures should be aggressively resuscitated following established trauma protocols, and any anticoagulation should be reversed. If the risk of peripheral embolization is present, a vena cava filter may be considered when bleeding is being controlled. Ideally, patients should be discharged back on their preadmission anticoagulation regimen.

References

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2.       Sánchez-Tocino JM, Turégano-Fuentes F, Pérez-Díaz D, et al. Severe pelvic fractures, associated injuries and hemodynamic instability: incidence, management and outcome in our center [in Spanish]. Cir Esp. 2007;81(6):316-323.

3.       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.

4.       Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé 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):392-395.

5.       Hill RM, Robinson CM, Keating JF. Fractures of the pubic rami. Epidemiology and five-year survival. J Bone Joint Surg Br. 2001;83(8):1141-1144.

6.       Young JW, Burgess AR. Radiologic Management of Pelvic Ring Fractures: Systematic Radiographic Diagnosis. Baltimore, MD: Urban & Schwarzenberg; 1987.

7.       McCormack R, Strauss EJ, Alwattar BJ, Tejwani NC. Diagnosis and management of pelvic fractures. Bull NYU Hosp Jt Dis. 2010;68(4);281-291.

8.       Dyer GS, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury. 2006;37(7):602-613.

9.       Bramos A, Velmahos GC, Butt UM, Fikry K, Smith RM, Chang Y. Predictors of bleeding from stable pelvic fractures. Arch Surg. 2011;146(4):407-411.

10.       Martin S, Casey N. Haemorrhage requiring embolisation after low energy pelvic fracture in an elderly patient: a case report. Emerg Med J. 2010;27(9):722-723.

11.       Garrido-Gόmez 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-e82.

12.        Goldstein JA, Greenberg SM. Should anticoagulation be resumed after intracerebral hemorrhage? Cleve Clin J Med. 2010;77(11):791-799.

Disclosures:

The authors report no relevant financial relationships.

Address correspondence to:

Stephen R. Odom, MD, FACS

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Boston, MA 02215

sodom@bidmc.harvard.edu