In the shadow of stability lies ruin: Occult vascular injuries in geriatric pelvic trauma

Abstract

Frailty fractures of the pelvis, particularly isolated pubic ramus fractures, are often perceived as benign, especially in elderly patients. However, this perception can obscure the risk of delayed hemorrhage from occult vascular injuries. Clinical deterioration is frequently subtle, with signs like fatigue or confusion misattributed to baseline status. In frail patients, these injuries may rapidly evolve into life-threatening scenarios. Conservative management, while standard, may be insufficient when vascular frailty or anticoagulation are present. Early clinical suspicion, serial hemoglobin checks, and multidisciplinary involvement are crucial. A dynamic assessment model that incorporates frailty, comorbidities, and physiological reserve alongside radiographic findings can better guide intervention and monitoring. Clinicians must lower the threshold for advanced imaging, such as computed tomography angiography, and consider early vascular consultation even in seemingly stable cases. Adopting a holistic, risk-based approach can mitigate complications and improve outcomes for this vulnerable population

Key Words: Pelvic fractures; Frailty; Hemorrhage; Vascular surgical procedures; Embolization; Multidisciplinary care team; Anticoagulants; Critical care; Geriatric

Core Tip: Isolated pubic ramus fractures, often labeled as stable on imaging, can pose serious risks in elderly patients. Frailty, anticoagulant therapy, and vascular fragility increase the likelihood of delayed hemorrhage from small arterial branches, even after low-energy trauma. Clinical decline is often subtle, with signs like confusion or fatigue mistaken for baseline status. Overreliance on fracture morphology can delay recognition of life-threatening bleeding. Incorporating frailty screening, serial hemoglobin checks, and early vascular consultation supports timely diagnosis and intervention. A dynamic, multidisciplinary approach is essential to reduce complications and ensure safer outcomes for this high-risk, frequently underestimated population.

INTRODUCTION: THE PARADOX OF STABILITY

Isolated pubic ramus fractures, particularly those resulting from low-energy mechanisms such as ground-level falls, are often categorized as stable and inconsequential injuries. While this holds true for most cases, this assumption can obscure the potential for serious complications in elderly patients. Occult vascular injuries, though rare, can result in life-threatening hemorrhage and rapid deterioration if not identified and managed promptly[1,2].

Clinical deterioration may be insidious, as elder adults often exhibit blunted physiological responses to blood loss. Hypotension may not manifest until late in the course, and signs such as weakness, confusion, or reduced mobility may be mistaken for baseline frailty rather than indicators of progressive internal bleeding. In this context, overreliance on initial radiographic appearance can delay diagnosis and treatment.

The widespread adoption of the fragility fracture of the pelvis (FFP) classification system[3] standardize language and inform treatment decisions. However, the term “stable fracture”—particularly in reference to FFP type I injuries—may inadvertently downplay risk in vulnerable elderly populations. While Type I fractures (isolated anterior ring involvement) are usually treated conservatively, this radiographic classification does not account for patient-specific factors such as frailty, anticoagulant use, or vascular calcification. In such settings, even these "stable" injuries can trigger life-threatening bleeding from small arterial branches. Reframing “stability” as a dynamic clinical assessment rather than a static imaging label may help clinicians identify patients at risk of delayed decompensation earlier and act proactively[4,5]. However, the FFP classification was not designed to predict vascular complications. Its focus on fracture morphology can obscure underlying clinical risk factors such as anticoagulation, vascular calcification, or anatomical variants like the corona mortis, which may increase the chance of bleeding even in FFP type I injuries[6].

Although anatomically distant from major vascular structures, fractures of the anterior pelvic ring can occasionally disrupt small arterial branches such as the obturator or inferior epigastric arteries. In the presence of vascular Frailty or anticoagulant therapy, this can lead to concealed retroperitoneal hemorrhage[7].

Reports have documented cases in which seemingly benign pubic ramus fractures were followed by hypovolemic shock or fatal outcomes. The incidence may be low, but the consequences are significant. One large observational study found that even “stable” Frailty fractures of the pelvis (FFP type I) were associated with functional decline and increased care dependency[3].

Similarly, recent investigations have questioned whether these injuries are truly as benign as once thought, particularly in patients with multimorbidity or functional impairment[7]. This growing body of literature supports the view that early hemodynamic instability in elderly pelvic trauma, regardless of radiographic stability, should not be underestimated[8]. Recent studies highlight the risk of concealed bleeding in patients with bilateral pubic rami fractures or vascular frailty, supporting the need for early vigilance regardless of fracture morphology[9,10].

FRAILTY AS A FORCE MULTIPLIER

Frailty has emerged as one of the most important predictors of trauma outcomes in older patients. Defined by reduced physiological reserve and increased vulnerability to stressors, frailty independently correlates with higher mortality, longer hospital stays, delayed mobility, and institutionalization following injury[11,12].

In pelvic fractures, frail individuals are also more likely to experience long-term complications, prolonged bed rest, and loss of autonomy[1,13]. Functional recovery is frequently incomplete, particularly in those not immediately admitted to hospital following injury[14-16].

Emerging studies have shown that frailty not only influences outcomes after fractures but may also correlate with the radiographic progression of injury[17]. A frail patient with an initial FFP type I fracture may develop instability due to impaired bone healing, prolonged immobility, or falls during hospitalization. These progressions are often subtle and may not be captured on initial imaging, particularly if follow-up radiographs are delayed or omitted. This underscores the need for closer monitoring and possibly routine follow-up imaging in high-risk geriatric patients. The intersection of frailty and fracture progression highlights how static injury classification may underestimate the dynamic nature of pelvic frailty trauma[18,14,13].

Notably, frailty is not synonymous with chronological age. Standard trauma scoring systems often fail to capture functional impairment or geriatric syndromes while tools such as the Clinical Frailty Scale (CFS) or comprehensive geriatric assessment can support early recognition of high-risk patients and guide decision-making[15].

Incorporating frailty assessments into early trauma triage may allow clinicians to identify high-risk individuals who may require closer monitoring, even in the context of seemingly minor injuries. For example, a CFS score ≥ 5 has been associated with increased odds of adverse outcomes following low-energy trauma, independent of injury severity score (ISS)[19]. In elderly patients with anterior pelvic ring injuries, elevated frailty scores should prompt routine monitoring of ΔHb, early repeat imaging, and multidisciplinary involvement (e.g., geriatrics, hematology, and interventional radiology). Future risk-based clinical models should formally integrate frailty metrics alongside physiologic markers like ΔHb and clinical variables such as anticoagulation use, enabling a more holistic and predictive approach to early hemorrhage detection and management.

In patients with elevated frailty scores, particularly those on anticoagulants or with known cardiovascular compromise, clinicians should adopt enhanced monitoring protocols, including more frequent vital sign checks, serial hemoglobin measurement (ΔHb), and a lower threshold for ordering repeat imaging such as contrast-enhanced computed tomography (CT) angiography. Moreover, high frailty scores may serve as a trigger for early multidisciplinary involvement, including consultation with geriatrics, hematology, and interventional radiology, as well as early mobilization and discharge planning support[20].

Importantly, future risk-based clinical models and decision-support tools should formally incorporate frailty metrics alongside physiologic markers like ΔHb and established trauma indices (e.g., ISS, Revised Trauma Score). Such integrative models can enable more nuanced patient stratification, guiding both diagnostic vigilance and resource allocation[21]. The incorporation of frailty scoring into trauma registries and prospective studies will further clarify its predictive validity and utility in real-world trauma systems. Ultimately, embedding frailty assessments into trauma protocols promotes a more individualized, proactive, and safety-conscious approach to managing seemingly minor injuries in high-risk older adults, reducing the likelihood of missed hemorrhages, delayed interventions, and adverse outcomes[22].

DIAGNOSTIC VIGILANCE

Although anterior pelvic ring fractures are generally considered low-risk for hemorrhage, postmortem and angiographic studies have revealed that even low-energy injuries can disrupt branches of the external pudendal arteries. The absence of active extravasation on imaging does not exclude vascular injury; small-vessel bleeding may be intermittent, self-tamponading, or obscured by delayed presentation. CT angiography in elderly patients with unexplained anemia or persistent fatigue following pubic ramus fracture has shown a diagnostic yield of over 15% in some institutional reviews. Incorporating a risk-stratified approach—based on anticoagulation status, frailty score, and delta hemoglobin (ΔHb)—can improve detection rates of clinically relevant bleeding [9,16].

Conventional imaging remains essential in pelvic trauma evaluation, but, by itself, should not dictate clinical vigilance. A stable fracture pattern on X-ray or CT scan does not exclude hemodynamically significant bleeding. In older patients—especially those on anticoagulants or with impaired autoregulation—compensation may mask ongoing blood loss until decompensation occurs[23].

In such scenarios, laboratory and physiologic markers play a key role. A sudden drop in hemoglobin, mild tachycardia, or unexplained fatigue may be early warning signs. Serial hemoglobin levels, focused assessment with sonography for trauma (FAST), and timely CT angiography should be considered when suspicion arises[16,24]. ΔHb, in particular, may provide early evidence of ongoing bleeding even when radiographic findings are equivocal. Integrating this marker into risk stratification can prompt earlier imaging or vascular consultation[11,16].

ΔHb, the change in hemoglobin concentration over time, serves as a dynamic marker of ongoing blood loss. Unlike a single hemoglobin measurement, which may be misleadingly normal in early stages of bleeding or fluid resuscitation, serial values can reflect subtle but clinically meaningful trends. A falling ΔHb, especially when accompanied by subtle clinical signs such as mild tachycardia, orthostasis, or fatigue, should prompt heightened suspicion even in the absence of radiographic evidence. This is particularly crucial in elderly or frail patients, whose physiological compensation may delay overt hemodynamic instability.

The utility of ΔHb lies in its ability to bridge the gap between clinical intuition and radiological confirmation. For instance, a decrease in hemoglobin of > 2 g/dL within 24–48 hours post-injury, without an obvious source, should be index of suspicion for a unrecognized active bleeding[25]. Specifically, in patients with pubic ramus fractures ΔHb can reveal occult vascular injuries not seen on initial CT scans. This laboratory trend can serve as a trigger for repeat imaging or angiographic evaluation, particularly when correlated with ongoing transfusion requirements or persistent anemia[26].

Institutions should adopt protocols that trigger further investigation based on clinical deterioration, not just fracture morphology. Early imaging not only detects bleeding but facilitates intervention such as embolization if needed, minimizing delays in care and improving outcomes[27].

MULTIDIMENSIONAL MODEL OF CARE

Elderly trauma patients often present with a complex interplay of clinical variables: Frailty, comorbidities, cognitive decline, and multi-drug therapy[28]. A multidisciplinary, individualized model of care that integrates functional assessment with radiologic and physiologic evaluation is needed to effectively manage this population[15].

Early geriatric consultation and co-management models have shown promise in improving outcomes, reducing complications, and facilitating safer discharge planning[29]. These models emphasize early mobilization, medication review, nutritional optimization, and careful monitoring—all of which are essential for patients with frailty fractures.

Importantly, this approach does not advocate for unnecessary imaging or overtreatment but calls for context-aware vigilance and timely escalation. A patient with a stable fracture may require only basic care—or they may require intervention within hours[30]. Differentiating between these trajectories depends not just on imaging, but on clinical judgment informed by systemic risk assessment.

THE EXPANDING ROLE OF VASCULAR SURGERY IN FRAILTY PELVIC TRAUMA

While vascular injury following low-energy pelvic fractures in the elderly is rare, it carries a disproportionate burden of morbidity and mortality when it does occur[31]. The anatomical distance of the pubic rami from major vascular structures may lead to an underestimation of bleeding risk. In older adults, even minor arterial injury—especially in the context of anticoagulation, vascular frailty, or platelet dysfunction—can result in significant and concealed hemorrhage[32]. Importantly, these injuries often evade early detection, presenting with nonspecific symptoms or delayed hemodynamic decline. These injuries, though uncommon, are often underreported and can rapidly deteriorate clinical outcomes due to delayed detection and limited compensatory reserve[32,33].

DIAGNOSTIC UNCERTAINTY AND THE ROLE OF INTERVENTIONAL VASCULAR TECHNIQUES

In such scenarios, vascular surgeons are not ancillary consultants but represent essential members of the trauma care team. Their involvement is critical not only for definitive hemorrhage control but also for diagnostic clarification when conventional imaging yields inconclusive results. Rapid access to vascular expertise enables the use of CT angiography and diagnostic angiography to localize active bleeding, followed by minimally invasive endovascular interventions such as coil or microspheres embolization. These procedures, when performed promptly, can arrest hemorrhage with far less perioperative impact than open surgical approaches—an especially important consideration in frail elderly patients[18].

Despite their central role in management, vascular teams are often engaged only after clinical deterioration has occurred[34]. To improve outcomes, trauma systems must proactively integrate vascular surgery into early decision-making algorithms, particularly for elderly patients with pelvic fractures and unexplained anemia, persistent tachycardia, or subtle changes in mentation or mobility[35]. A low threshold for vascular referral should be adopted, even when initial imaging suggests a stable fracture morphology. In these cases, the clinical picture—guided by frailty status, anticoagulant use, and subtle physiologic cues—should drive escalation of care[36].

The evolution of endovascular techniques has made bleeding control both safer and more accessible[37], yet systemic barriers remain. Not all hospitals have round-the-clock interventional radiology or vascular surgery coverage, and interdepartmental referral pathways may be poorly defined. Addressing these gaps requires institutional commitment to trauma infrastructure, including the establishment of on-call vascular teams, shared imaging protocols, and rapid activation workflows. Trauma centers should also consider embedding vascular surgery consultation into multidisciplinary frailty fracture pathways[38], ensuring that elderly patients with subtle signs of hemorrhage receive timely intervention.

Looking ahead, system-level improvements must be informed by data. Currently, the incidence of occult vascular injury in low-energy pelvic trauma is likely underreported, owing to diagnostic delays and variability in clinical suspicion[39]. Developing regional or national registries to track vascular complications in geriatric trauma could provide critical insights into risk factors, time-to-intervention metrics, and patient outcomes. Such data would help refine screening criteria, guide resource allocation, and support the development of consensus guidelines.

Education also plays a vital role. Frontline clinicians must be trained to recognize the subtle signs of pelvic vascular injury. Simulation-based training[40] and interdisciplinary case reviews can reinforce the importance of early vascular consultation in at-risk populations[41]. Additionally, frailty assessments should be coupled with bleeding risk stratification tools to flag patients who may require advanced imaging or interventional evaluation early during care.

THE HEMORRHAGIC MAGNIFIER: ANTICOAGULATION IN THE ELDERLY

Anticoagulant and antiplatelet therapies have become the cornerstone of modern cardiovascular medicine, particularly in aging populations. However, these therapies dramatically alter the physiological response to trauma, converting what might otherwise be a benign fracture into a potentially life-threatening hemorrhagic event[42]. In the context of frailty pelvic fractures, the elderly may face a perfect storm: Reduced bone density, fragile vasculature, and a pharmacologically thinned hemostatic buffer. These factors together amplify the clinical consequences of even seemingly minor vascular injuries.

Commonly prescribed agents—including warfarin, direct oral anticoagulants (DOACs), aspirin, and P2Y12 inhibitors like clopidogrel—interfere with clot formation at multiple levels[43,44]. In patients receiving these medications, injury to small-caliber pelvic arteries or venous plexuses can lead to prolonged bleeding that is not immediately apparent[45]. This phenomenon is especially dangerous because early imaging may not reveal active extravasation, leading to an underestimation of the severity of the injury. By the time hypotension or anemia becomes clinically evident, significant blood loss may have already occurred.

This reality underscores the critical need for early risk stratification. In any elderly trauma patient, a full anticoagulant history should be obtained immediately, along with coagulation studies tailored to their medication profile. Importantly, trauma teams must be equipped with standardized reversal protocols—such as the use of prothrombin complex concentrate for warfarin or specific reversal agents for DOACs like idarucizumab and andexanet alfa[46]. However, reversal alone may not be sufficient. These patients often require active vascular intervention to halt bleeding, making the early involvement of vascular surgery not optional but essential. A collaborative, algorithm-driven approach that integrates anticoagulation management with endovascular capability is vital to reduce morbidity and mortality in this high-risk group[47].

A particularly underexplored clinical dilemma lies in the initiation or resumption of anticoagulation in conservatively managed anterior pelvic fractures. These injuries, often managed with early mobilization protocols, present a paradox: While immobility increases the risk of venous thromboembolism, early weight-bearing may provoke or exacerbate vascular injury in anticoagulated patients[48]. The literature remains inconclusive on the safety of prophylactic or therapeutic anticoagulation in this subset. Thus, a patient-specific approach—balancing thrombotic risk scores (e.g., CHA₂DS2-VASc, Padua) against bleeding risk indices (e.g., HAS-BLED, ABC)—is imperative until more robust evidence emerges. Further research, ideally in the form of multicenter prospective studies or clinical trials, is urgently needed to delineate anticoagulation strategies in this nuanced and growing clinical scenario.

THE QUIET BLEED: COGNITIVE IMPAIRMENT AND DELAYED PRESENTATION

Cognitive decline, social isolation, and communication barriers represent significant factors that can delay both the recognition and presentation of trauma in elderly individuals[49]. It is not uncommon for a patient with dementia to fall at home, sustain a fracture, and present only days later—often after becoming increasingly lethargic or confused, which may be wrongly attributed to their baseline mental status[50].

By the time these patients enter the clinical system, patients may become anemic, volume-depleted, and at the tipping point of hemodynamic collapse. In these scenarios, imaging may show no active extravasation, yet vascular injury may have occurred days earlier, with bleeding having slowed or tamponaded[51]. The insidious nature of these cases often leads to underestimation of the injury's severity.

Imaging in these cases may be deceptively reassuring. Vascular injury may have occurred earlier, but the absence of active contrast extravasation on CT angiography. CT angiography is not uncommon due to spontaneous tamponade or intermittent bleeding[52]. Such presentations highlight the limitations of relying solely on early imaging and underscore the need for heightened clinical suspicion. Unexplained hypotension, declining hemoglobin, or altered mental status in the context of recent trauma should prompt consideration of occult hemorrhage, even in the absence of dramatic radiologic findings.

In this context, CT angiography remains a critical tool for identifying vascular injury but should be applied using a risk-stratified approach that incorporates clinical, pharmacologic, and temporal variables. We propose the following framework outlines a decision model for imaging based on clinical stability and bleeding risk (Table 1).

Table 1 Risk-based model for computed tomography angiography utilization in elderly patients with suspected pelvic injury.

Risk category	Criteria	Recommended imaging approach
High risk	Hemodynamic instability, ongoing transfusion requirement, anticoagulant use (e.g., warfarin, DOACs), delayed presentation (> 48 hours), cognitive impairment with unexplained anemia or clinical deterioration	Immediate CTA of the abdomen and pelvis with early consideration for repeat imaging if clinical trajectory worsens
Intermediate risk	Stable hemodynamics but presence of high-risk features: Frailty, minor trauma with early hemoglobin drop, cognitive impairment, or multi-drug therapy	Consider early CTA; monitor clinical and laboratory trends closely
Low risk	No anticoagulation, early presentation, normal mental status, stable hemoglobin, and no concerning clinical features	Observation with serial exams and labs; CTA only if deterioration occurs

DOACs: Direct oral anticoagulants. CTA: Computed tomography angiography.

This model aligns with accumulating evidence suggesting that elderly patients, particularly those on anticoagulation or with delayed presentations, may harbor clinically silent yet significant vascular injuries[53]. In such cases, delayed but targeted embolization has demonstrated survival benefit, particularly when guided by an algorithmic approach to imaging and clinical assessment[54].

The principle of “treat the patient, not the scan” remains central in this population. Clinical judgment must take precedence over static imaging, especially in those with impaired cognition and unreliable symptom reporting. Early involvement of interventional radiology or vascular surgery should be considered in all high-risk presentations, regardless of initial imaging findings.

SYSTEMIC DISPARITIES: RURAL HOSPITALS AND RESOURCE-LIMITED SETTINGS

While high-volume trauma centers often have immediate access to vascular surgery and interventional radiology, this is not the case in many rural or resource-limited hospitals[55]. For elderly trauma patients living in remote areas, the absence of endovascular capability can result in critical delays in diagnosis and management[56].

These disparities can translate directly into outcome inequities[57]. A patient in an urban trauma center with 24/7 access to embolization may survive the same injury that would prove fatal in a rural setting. Bridging this gap requires both systemic planning and policy advocacy. Regionalized trauma systems must establish clear transfer pathways to centers with vascular expertise, including prearranged transport agreements and real-time bed availability dashboards.

Telemedicine also holds promise as a bridge solution[58]. Vascular surgeons at tertiary centers can provide remote consultation to rural teams, helping interpret CT angiograms or guiding the decision to transfer[59]. As the aging population grows and more elderly patients live in rural or semi-urban areas, trauma systems must expand their capacity to offer timely vascular care regardless of geography.

BRINGING VASCULAR INTO THE TRAUMA CURRICULUM: EDUCATION AND SIMULATION

The subtlety and rarity of vascular injury in frailty fractures can lead to under-recognition by front-line clinicians. Emergency physicians, orthopedic surgeons, and even trauma team members may be unfamiliar with the nuanced presentations of retroperitoneal bleeding in the elderly[60]. As a result, key signs such as persistent tachycardia, progressive anemia, or unexplained pain may be misattributed to baseline frailty or medication effects.

To address this, vascular injury should be incorporated into standard trauma education and simulation curricula. High-fidelity simulation scenarios can reinforce the importance of early suspicion, imaging interpretation, and appropriate escalation of care. Teaching modules should focus on red flags such as unexplained hypotension, expanding hematoma, and discordance between clinical status and radiographic findings[61].

Additionally, interdisciplinary case reviews involving vascular surgery, trauma, and geriatrics can help identify missed opportunities and educate providers on best practices. When front-line teams are trained to recognize potential vascular injury, referral to vascular specialists becomes proactive rather than reactive. This shift in mindset can dramatically improve patient outcomes, particularly in elderly individuals whose physiologic reserve is limited[62].

ETHICAL DIMENSIONS: ALIGNING INTERVENTION WITH GOALS OF CARE

While the technical ability to control bleeding via endovascular intervention has expanded, not all elderly patients are appropriate candidates for aggressive management. Severe cognitive impairment, advanced frailty, and multimorbidity raise important ethical considerations in the trauma setting. The decision to transfer a patient for embolization, or to proceed with invasive intervention, must be balanced against their previously stated goals, quality of life, and overall prognosis[63].

Shared decision-making is critical. Families should be engaged early in conversations about goals of care, ideally before the patient’s condition deteriorates. When time permits, input from palliative care or geriatrics can help guide these decisions in a manner consistent with the patient’s values[64]. Vascular teams should be prepared not only to offer intervention but also to help clarify likely outcomes, potential complications, and recovery trajectories.

It is essential that trauma systems embed ethical reflection into their protocols, especially when dealing with geriatric patients. While the impulse to “do everything” in the face of hemodynamic collapse is strong, interventions that prolong suffering without meaningful recovery are not victories. The best trauma care includes not only technical excellence but also humanism, discernment, and compassion.

CONCLUSION

Isolated anterior pelvic fractures in elderly patients should not be considered as uniformly low risk injuries. While conservative management remains appropriate for most, clinicians must remain alert to early deviations in clinical status. Even in the absence of overt trauma or displacement, these injuries can precipitate significant deterioration in vulnerable patients[65].

A structured approach incorporating frailty screening, hemodynamic monitoring, and low-threshold use of advanced imaging can identify complications earlier and guide appropriate care. Trauma systems must continue to evolve by integrating geriatric principles into routine evaluation and promoting interdisciplinary collaboration[66].

Ultimately, it is not about replacing established protocols, but about refining them—ensuring they reflect the true complexity of geriatric trauma. Early recognition and response can change the course of care, prevent avoidable morbidity, and uphold the standard of safety and dignity that elderly patients deserve.

Recognizing the limits of static classification systems and embracing dynamic, patient-centered vigilance will be the cornerstone of safer care. The invisible hemorrhage, the subtle decompensation, the overlooked frail phenotype—all demand a shift from protocol-based rigidity to nuanced, anticipatory practice.