Is CT-A Always Reliable in Detecting Active Bleeding in Closed Pelvic Fractures? Management of a Case with Multiple Closed Pelvic Fratures and Internal Iliac Artery Bleeding

Introduction: One of the most important complications of pelvic injuries is haemorrhage which can be attributed to the venus plexus of the pelvis, the damaged bone on the fracture site, or in 15% of cases to arterial cause. In the last case mortality could reach 70%. Clinical case presentation, 77 years old man, presented in the emergency department of our hospital haemodynamically unstable due to fall from height with comminuted bilateral fractures of the pubic rami, right sacral and iliac wing fracture, right acetabular fracture, fractures of transverse processes of the 1st , 2nd and 5th Lumbar spine vertebrae and a periprothetic fracture of the right femur. Results: Advanced Trauma Life Support protocol was followed throughout. Computed Tomography (CT) scans and CT Angiography performed, showed the above mentioned pelvic fractures that did not require stabilisation, without further injuries, and a well described retroperitoneal haematoma without any evidence of active bleeding. The patient remained unstable and an angiography was then performed that revealed internal iliac artery bleeding and embolism of the internal iliac artery was performed. The patient was stabilized and was transferred to the Intensive Care Unit for further management. Conclusion: Arterial haemorrhage due to pelvic injury is less common, however presents with high rates of mortality. CT Angiography may in some cases not reveal existing active bleeding, misleading the clinician. Therefore, in patients with high clinical suspicion of arterial pelvic haemorrhage who remain unstable during the initial resuscitation , an angiography and embolism should be performed as soon as possible.