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