{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T19:49:47Z","timestamp":1770752987525,"version":"3.50.0"},"reference-count":38,"publisher":"MDPI AG","issue":"23","license":[{"start":{"date-parts":[[2024,11,28]],"date-time":"2024-11-28T00:00:00Z","timestamp":1732752000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: The aim was to investigate diagnostic, treatment and preventive options to establish an overview of the existing evidence on hemorrhage in pelvic fractures in older adults. Methods: A systematic review was conducted. Due to the rarity of this complication, only case reports and series with individuals older than 55 years with a pelvic ring fracture that is caused by a low-energy trauma or no apparent trauma, along with hemorrhage, were eligible. A search was performed on four databases. The CARE checklist was used to investigate the reporting integrity of the included studies. Analysis was performed narratively, and this study was registered on the Open Science Framework. Results: 21 patients from 19 studies were included (17 females and 4 males) with an average age of 82.1 years. The 21 patients suffered a total of 29 fractures. Pubic ramus fractures were present in 48.3% of all fractures. In 42.9%, an active hemorrhage was reported. Arterial vessels were injured in direct anatomical relationship to the fracture. Abdominal pain and hemorrhagic instability were the main red flag symptoms reported. Active arterial hemorrhage was diagnosed by CT with angiogram and treated by embolization with or without additional surgery. Conclusions: Clinically relevant hemorrhage in pelvic fractures due to low-energy trauma is rare. However, these fractures, combined with clinically relevant hemorrhage, account for an increased mortality and morbidity in elderly people. This systematic review was able to create a clinical decision tree for hemorrhage in ramus pubic fractures.<\/jats:p>","DOI":"10.3390\/jcm13237223","type":"journal-article","created":{"date-parts":[[2024,11,28]],"date-time":"2024-11-28T07:28:01Z","timestamp":1732778881000},"page":"7223","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Hemorrhage in Pelvic Ring Fractures After Low-Energy Trauma: A Systematic Review"],"prefix":"10.3390","volume":"13","author":[{"given":"Alina","family":"Ro\u00dfler","sequence":"first","affiliation":[{"name":"Department of Orthopaedics and Trauma Surgery, BG Klinik Ludwigshafen, 67071 Ludwigshafen, Germany"},{"name":"TraumaEvidence @ German Society of Trauma Surgery, 10623 Berlin, Germany"},{"name":"Medical Faculty, University of Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lara","family":"Lukhaup","sequence":"additional","affiliation":[{"name":"Department of Orthopaedics and Trauma Surgery, BG Klinik Ludwigshafen, 67071 Ludwigshafen, Germany"},{"name":"TraumaEvidence @ German Society of Trauma Surgery, 10623 Berlin, Germany"},{"name":"Medical Faculty, University of Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Max","family":"Seidelmann","sequence":"additional","affiliation":[{"name":"Department for Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, Germany Armed Forces Central Hospital Koblenz, 56072 Koblenz, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-9116-2838","authenticated-orcid":false,"given":"Catharina","family":"Gaeth","sequence":"additional","affiliation":[{"name":"TraumaEvidence @ German Society of Trauma Surgery, 10623 Berlin, Germany"},{"name":"Department for Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, Germany Armed Forces Central Hospital Koblenz, 56072 Koblenz, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sven-Oliver","family":"Dietz","sequence":"additional","affiliation":[{"name":"Center for Orthopaedics and Trauma Surgery, University Medical Center, Johannes Gutenberg University Mainz, 55131 Mainz, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christof","family":"Audretsch","sequence":"additional","affiliation":[{"name":"Department of Trauma and Reconstructive Surgery, Eberhard Karls University of Tuebingen, BG Clinic Tuebingen, 72076 T\u00fcbingen, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0730-4782","authenticated-orcid":false,"given":"Paul","family":"Gr\u00fctzner","sequence":"additional","affiliation":[{"name":"Department of Orthopaedics and Trauma Surgery, BG Klinik Ludwigshafen, 67071 Ludwigshafen, Germany"},{"name":"Medical Faculty, University of Heidelberg, 69120 Heidelberg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joachim","family":"Windolf","sequence":"additional","affiliation":[{"name":"TraumaEvidence @ German Society of Trauma Surgery, 10623 Berlin, Germany"},{"name":"Department of Orthopedics and Traumatology, University Hospital and Medical Faculty, Heinrich-Heine-University Duesseldorf, 40225 D\u00fcsseldorf, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6323-3747","authenticated-orcid":false,"given":"Anne","family":"Neubert","sequence":"additional","affiliation":[{"name":"TraumaEvidence @ German Society of Trauma Surgery, 10623 Berlin, Germany"},{"name":"Department of Orthopedics and Traumatology, University Hospital and Medical Faculty, Heinrich-Heine-University Duesseldorf, 40225 D\u00fcsseldorf, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2024,11,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"663","DOI":"10.1007\/s00113-011-2020-z","article-title":"Beckenringfrakturen im Alter: Die untersch\u00e4tzte osteoporotische Fraktur","volume":"114","author":"Fuchs","year":"2011","journal-title":"Unfallchirurg"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"673","DOI":"10.1016\/j.jamda.2013.03.012","article-title":"Pelvic Fracture Rates in Community-Living People with and without Disability and in Residents of Nursing Homes","volume":"14","author":"Benzinger","year":"2013","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"997","DOI":"10.1016\/j.injury.2011.03.053","article-title":"Survival trends and predictors of mortality in severe pelvic trauma: Estimates from the German Pelvic Trauma Registry Initiative","volume":"42","author":"Pohlemann","year":"2011","journal-title":"Injury"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"363","DOI":"10.1007\/s00068-014-0452-1","article-title":"Haemorrhage in fragility fractures of the pelvis","volume":"41","author":"Dietz","year":"2015","journal-title":"Eur. J. Trauma Emerg. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"646","DOI":"10.1136\/pmj.76.900.646","article-title":"Closed pelvic fractures: Characteristics and outcomes in older patients admitted to medical and geriatric wards","volume":"76","author":"Morris","year":"2000","journal-title":"Postgrad. Med. J."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"648","DOI":"10.1093\/ageing\/aft212","article-title":"Increasing rates of pelvic fractures among older adults: The Netherlands, 1986\u20132011","volume":"43","author":"Nanninga","year":"2014","journal-title":"Age Ageing"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1080\/17453674.2020.1771827","article-title":"The incidence of pelvic fractures and related surgery in the Finnish adult population: A nationwide study of 33,469 patients between 1997 and 2014","volume":"91","author":"Rinne","year":"2020","journal-title":"Acta Orthop."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_9","unstructured":"Veritas Health Innovation (2024, September 30). Covidence Systematic Review Software. [Internet]. Melborne: Veritas Health Innovation. Available online: www.covidence.org."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1016\/j.jclinepi.2017.04.026","article-title":"CARE guidelines for case reports: Explanation and elaboration document","volume":"89","author":"Riley","year":"2017","journal-title":"J. Clin. Epidemiol."},{"key":"ref_11","unstructured":"Eden, J., Levit, L., Berg, A., and Morton, S. (2024, September 18). Finding What Works in Health Care: Standards for Systematic Reviews [Internet], Available online: http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK209518\/."},{"key":"ref_12","first-page":"e44593","article-title":"Differentiating Between Obturator and Inferior Epigastric Arterial Injury in Traumatic Pelvic Hemorrhage: A Case Report","volume":"15","author":"Almaguer","year":"2023","journal-title":"Cureus"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Burghardt, R., Siebenlist, S., Dobele, S., Lucke, M., and Stockle, U. (2010). Compartment syndrome of the thigh. A case report with delayed onset after stable pelvic ring fracture and chronic anticoagulation therapie. BMC Geriatr., 10.","DOI":"10.1186\/1471-2318-10-51"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1275","DOI":"10.1302\/0301-620X.87B9.16696","article-title":"Fatal haemorrhage following a low-energy fracture of the pubic ramus","volume":"87","author":"Coupe","year":"2005","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_15","first-page":"E80","article-title":"Corona Mortis Artery Avulsion Due to a Stable Pubic Ramus Fracture","volume":"35","year":"2012","journal-title":"Orthopedics"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1016\/j.jbspin.2007.07.008","article-title":"Sacral stress fracture as a cause of gluteal artery injury: An unusual complication of a common fracture","volume":"75","author":"Peris","year":"2008","journal-title":"Jt. Bone Spine"},{"key":"ref_17","unstructured":"Hagiwara, A., Fukushima, H., Inoue, T., Murata, A., and Shimazaki, S. (2024, September 18). Brain Death Due to Abdominal Compartment Syndrome Caused by Massive Venous Bleeding in a Patient with a Stable Pelvic Fracture. Available online: https:\/\/www.livivo.de\/doc\/M14714237."},{"key":"ref_18","first-page":"E14","article-title":"Hemodynamic instability following an avulsion of the corona mortis artery secondary to a benign pubic ramus fracture","volume":"62","author":"Henning","year":"2007","journal-title":"J. Trauma"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Kastanis, G., Pantouvaki, A., Siligardou, M.R., Chaniotakis, C., Kroustalakis, E., Stavrakakis, I., and Kapsetakis, P. (2024). Can Nondisplacement Osteoporotic Pubic Rami Fracture Be Life-Threatening Injuries? A Case Report, Overview, and Algorithm Protocol for Management. J. Investig. Med. High Impact Case Rep., 12.","DOI":"10.1177\/23247096241231648"},{"key":"ref_20","unstructured":"Li, K., Peng, Y., Chen, Y., Zhong, Z., Ma, Y., Yao, T., Zhang, L., and Lv, F. (2024, September 18). Robot-Assisted Teleultrasound-Guided Hemostasis and Hematoma Catheterization and Drainage for Osteoporosis Pelvic Fracture with Giant Hematoma and Active Bleeding. Available online: https:\/\/www.base-search.net\/Search\/Results?lookfor=baseid:ftdoajarticles:oai:doaj.org\/article:82c9513d2519432babebba4144158558."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e25","DOI":"10.1136\/pgmj.2006.047381","article-title":"Massive haemorrhage after a low-energy pubic ramus fracture in a 71-year-old woman","volume":"82","author":"Macdonald","year":"2006","journal-title":"Postgrad. Med. J."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"722","DOI":"10.1136\/emj.2009.084475","article-title":"Haemorrhage requiring embolisation after low energy pelvic fracture in an elderly patient: A case report","volume":"27","author":"Martin","year":"2010","journal-title":"Emerg. Med. J."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"342.e1","DOI":"10.1016\/j.ajem.2017.10.062","article-title":"Nondisplaced pubic ramus fracture associated with exsanguination and death","volume":"36","author":"Rich","year":"2018","journal-title":"Am. J. Emerg. Med."},{"key":"ref_24","unstructured":"Sandri, A., Regis, D., and Bizzotto, N. (2024, September 18). Delayed Bleeding and Pelvic Haematoma After Low-Energy Osteoporotic Pubic Rami Fracture in a Warfarin Patient. Available online: https:\/\/www.livivo.de\/doc\/M25143839."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"E546","DOI":"10.3928\/01477447-20161229-03","article-title":"Obturator Artery Injury Resulting in Massive Hemorrhage From a Low-Energy Pubic Ramus Fracture","volume":"40","author":"Solarz","year":"2017","journal-title":"Orthopedics"},{"key":"ref_26","first-page":"323","article-title":"Massive haemorrhage following minimally displaced pubic ramus fractures","volume":"40","author":"Bezemer","year":"2014","journal-title":"Eur. J. Trauma Emerg. Surg."},{"key":"ref_27","unstructured":"Weber, C.D., Herren, C., Dienstknecht, T., Hildebrand, F., Keil, S., Pape, H.C., and Kobbe, P. (2024, September 18). Management of Life-Threatening Arterial Hemorrhage Following a Fragility Fracture of the Pelvis in the Anticoagulated Patient. Available online: https:\/\/www.livivo.de\/doc\/M27551576."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1016\/j.jcot.2013.03.004","article-title":"Massive haemorrhage from the internal iliac artery following a low energy superior pubic ramus fracture in a 73-year-old man","volume":"4","author":"Wee","year":"2013","journal-title":"J. Clin. Orthop. Trauma"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"323","DOI":"10.3109\/17453678809149374","article-title":"Acetabular fracture causing hip joint tamponade. A case report","volume":"59","author":"Wingstrand","year":"1988","journal-title":"Acta Orthop. Scand."},{"key":"ref_30","first-page":"350","article-title":"Simple Pelvic Fracture - Presentation of Life-Threatening Complications and Their Therapy","volume":"151","author":"Wohlrath","year":"2013","journal-title":"Z. Orthop. Unfallchirurgie"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"437","DOI":"10.1097\/TA.0b013e31822ad41f","article-title":"Hemorrhage after low-energy pelvic trauma","volume":"72","author":"Krappinger","year":"2012","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"111773","DOI":"10.1016\/j.injury.2024.111773","article-title":"Pelvic ring fracture in the older adults after minor pelvic trauma \u2013 is it an innocent injury?","volume":"55","author":"Jammal","year":"2024","journal-title":"Injury"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1097\/00005373-200207000-00004","article-title":"Pelvic Fracture in Geriatric Patients: A Distinct Clinical Entity","volume":"53","author":"Henry","year":"2002","journal-title":"J. Trauma Inj Infect. Crit. Care"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"728","DOI":"10.1001\/archsurg.139.7.728","article-title":"Angiographic Embolization for Pelvic Fractures in Older Patients","volume":"139","author":"Kimbrell","year":"2004","journal-title":"Arch. Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1016\/j.injury.2004.11.037","article-title":"Life threatening stable pubic rami fracture","volume":"36","author":"Wong","year":"2005","journal-title":"Inj Extra"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Sng, M., Gentle, J., and Asadollahi, S. (2020). Bleeding Risk Associated with Hemodynamically Stable Low-Energy Pelvic Fracture. Geriatr. Orthop. Surg. Rehabil., 11.","DOI":"10.1177\/2151459320911868"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1016\/S1873-9598(08)70026-7","article-title":"Acute Abdominal Pain in the Elderly","volume":"1","author":"Chang","year":"2007","journal-title":"Int. J. Gerontol."},{"key":"ref_38","first-page":"70","article-title":"Osteoporotic Pelvic Fractures","volume":"115","author":"Oberkircher","year":"2018","journal-title":"Dtsch. \u00c4rztebl. Int."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/23\/7223\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T16:41:13Z","timestamp":1760114473000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/23\/7223"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,11,28]]},"references-count":38,"journal-issue":{"issue":"23","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["jcm13237223"],"URL":"https:\/\/doi.org\/10.3390\/jcm13237223","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,11,28]]}}}