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A rare consequence of very common osteoporotic pubic rami fracture in a patient with myeloproliferative disease
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  1. Chathuri Liyanapthirana,
  2. Rosie Neal,
  3. Todor Iordanov,
  4. Aktham Nahhas
  1. Geriatrics, Eastbourne District General Hospital, Eastbourne, East Sussex, UK
  1. Correspondence to Dr Chathuri Liyanapthirana, chathuril{at}live.com

https://doi.org/10.1136/bcr-2017-221079

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    Description

    An 80-year-old female with janus kinase 2 positive myeloproliferative disease with stable blood parameters on aspirin and anagrelide admitted to the emergency department after a fall over the kerb complaining of pain limiting mobility. Initial assessment was stable without any external injuries noted. Pelvic X-ray demonstrated a stable pubic rami fracture (figure 1). Later on, her haemoglobin dropped 106 g/dL to 67 g/dL for no apparent cause. She was also noted to have an abdominal fullness and examination revealed a suprapubic mass. CT scan showed a well-defined hypointense collection measuring 85×60×105 mm extending superiorly from the symphysis pubis compressing bladder (figure 2-4). It was compatible with a late development of a haematoma. There was no contrast extravasation suggesting active bleeding. Her platelets and coagulation were normal. She was managed conservatively with blood transfusions but there was a place for angiography if she was to remain unstable.

    Figure 1
    Figure 1

    X-ray pelvis showing the fractures of superior and inferior pubic rami on the left.

    Figure 2
    Figure 2

    CT pelvis showing the well-defined hypointense collection seen in the superficial pelvis. Also note the fractures in the left rami.

    Figure 3
    Figure 3

    Parasagittal section of the CT showing the well-defined collection situated anterior to the bladder extending to superficial pelvis.

    Figure 4
    Figure 4

    Cross-sectional image over pelvis showing the anteriorly situated hypointense collection (haematoma) compressing bladder posteriorly.

    Unlike with high-energy pelvic fractures seen in young males following poly trauma, it is not very common to have bleeding with low-energy osteoporotic fractures.1 This is an uncommon occurrence of a large palpable haematoma,1 2 secondary to fragility pubic rami fracture in the presence of a prothrombotic condition. This unusual delayed development of haematoma seen in her can be attributed to the following facts. She being on aspirin despite normal platelets, the prophylactic enoxheparin given to prevent deep vein thrombosis and the fact that geriatric patients have lost their ability to mount an effective tamponade effect due to loss of vasospasm and tissue elasticity.1

    Learning points

    • Low-energy osteoporotic fractures despite being stable injuries, being managed conservatively pose a serious health hazard to elderly patients.

    • Even in the presence of a prothrombotic conditions, it is better to be cautious when prescribing deep vein thrombosis prophylaxis for patients with pelvic fractures who are otherwise of low risk category (mobilising).

    Acknowledgments

    To Nicholas Taylor, MIMI,MRCR(Hon) Honorary Teaching Fellow in Brighton and Sussex medical school for image set up.

    References

    1. ↵
      1. Krappinger D,
      2. Kammerlander C,
      3. Hak DJ, et al
      . Low-energy osteoporotic pelvic fractures. Arch Orthop Trauma Surg 2010;130:1167–75.doi:10.1007/s00402-010-1108-1
      OpenUrlCrossRefPubMed
    2. ↵
      1. Sandri A,
      2. Regis D,
      3. Bizzotto N
      . Delayed bleeding and pelvic haematoma after low-energy osteoporotic pubic rami fracture in a warfarin patient: an unusual cause of abdominal pain. Case Rep Emerg Med 2014;2014:1–4.doi:10.1155/2014/783268
      OpenUrl
    View Abstract

    Footnotes

    • Contributors CL was involved in managing the patient and writing up the case. RN was responsible for arranging investigations and getting the images. TL did the initial clerking and management of the patient. AN reviewed the case.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.