title: Management of Life-Threatening Arterial Hemorrhage Following a Fragility Fracture of the Pelvis in the Anticoagulated Patient: Case Report and Review of the Literature.
abstract: BACKGROUND
  Life-threatening arterial bleeding from fragility fractures of the pelvis are very rare but associated with significant mortality, especially in anticoagulated patients.
  
  
  METHODS
  We report the successful interdisciplinary management of a 78-year-old woman under anticoagulation and antiplatelet therapy who had life-threatening arterial hemorrhage from the pubic rami following a fragility fracture of the pelvis. Our management strategy included early hemorrhage control by means of selective arterial embolization followed by surgical fracture stabilization and surgical hematoma evacuation.
  
  
  METHODS
  We identified 6 cases within the English literature, all involving females older than 70 years. All patients under anticoagulation developed hemorrhagic shock, and in 2 cases selective embolization contributed to survival of the patient. However, a combined management including fracture stabilization and hematoma evacuation has not been reported, allowing an excellent clinical outcome and discharge to geriatric rehabilitation.
  
  
  CONCLUSIONS
  This case illustrates that elderly patients with apparently benign pelvic fragility fractures might develop severe hemorrhage due to arterial injury, especially when under dual anticoagulation, and stresses the importance of a high index of suspicion. If bleeding is suspected, detailed imaging studies are necessary to determine the source of bleeding and immediate angiographic or surgical interventions in combination with volume resuscitation and coagulation therapy should be readily available.
authors.affiliation: Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany.
authors.forename: Christian David
authors.initials: CD
authors.lastname: Weber
authors.affiliation: Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Herren
authors.affiliation: Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Dienstknecht
authors.affiliation: Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Hildebrand
authors.affiliation: Department of Radiology and Interventional Radiology, RWTH Aachen University Medical Center, Aachen, Germany.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Keil
authors.affiliation: Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany.
authors.forename: Hans-Christoph
authors.initials: HC
authors.lastname: Pape
authors.affiliation: Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany.
authors.forename: Philipp
authors.initials: P
authors.lastname: Kobbe
keywords: anticoagulation; fragility fractures; geriatric trauma; interventional radiology; pelvic injury