Pre-op the patient. Get a CT of the abdomen and pelvis with IV contrast.
The xray doesn’t look so bad from afar. If you look closely, you will see that there is a fracture of the pelvis (the proximal femur is fine, it’s not your typical hip fracture). There is a clear disruption of the cortex of the left acetabulum (compare it to the right). If you follow the left superior pubic ramus laterally, you will see another break. This is a big time fracture. Find me if you can’t see it.
The teaching point here is that even with minor pelvis fractures, patients may bleed like crazy. Do not be fooled when the patient is smiling at you and watching Netflix on their phone. Get a contrast scan. Keep an eye on the patient.
On the CT, the patient had big hematomas and multiple areas of blush. She went to IR / SICU. The Hct dropped from 45 to 30. She was never shocky and appeared well the entire time, even when she dropped her pressure a little.
Oh, btw, she was on warfarin for a mechanical valve. Her INR was therapeutic. Do you reverse the AC?
The residents didn’t expect the findings and there was an “oh my gosh” response. It’s no biggie. We’re a team. It’s a learning lesson for the next time.
