Pelvic hemorrhage in the context of demographic change: frequency and CT-based characterization of pelvic bleeding

PURPOSE: Traumatic pelvic hemorrhage is a major driver of morbidity and mortality in pelvic fractures. Classic literature described pelvic hemorrhage as predominantly venous, whereas arterial injury is considered less common. We evaluated the frequency, anatomical distribution, and presumed sources of pelvic hemorrhage in a contemporary trauma cohort using contrast-enhanced CT (CECT). METHODS: We conducted a single-center, retrospective cohort study of consecutive patients with pelvic fractures treated at a level-I trauma center between 2020 and 2022. All patients underwent CECT at initial presentation. Two experienced pelvic trauma surgeons independently reviewed all scans. Radiologically relevant hemorrhage was defined by contrast extravasation, soft-tissue asymmetry/displacement, or a contained intrapelvic hematoma. Patients with and without hemorrhage were compared regarding age, sex, trauma mechanism, anticoagulation, and fracture type. The presumed bleeding sources were categorized as arterial, venous, cancellous, or mixed. RESULTS: Radiologically relevant hemorrhage occurred in 95/512 (18.6%) patients and was more frequent after high-energy trauma and in men. Iliac sites predominated, whereas presacral bleeding was uncommon. The presumed bleeding source was cancellous in 44.2%, mixed in 29.5%, arterial in 18.9%, and isolated venous in 7.4%. Overall mortality was 7.0% and was significantly higher in patients with hemorrhage (14.7% vs. 5.3%; p < 0.001). CONCLUSION: In this contemporary CECT-based cohort, pelvic hemorrhage was less frequent than historically reported, with CT findings most commonly suggesting cancellous or mixed bleeding sources. These findings suggest that the traditional concept of predominantly venous pelvic hemorrhage may not fully reflect current CT-based observations.