Case report
Severe hemorrhage secondary to an osteoporotic pelvic fracture: Presentation of a case
Hemorragia severa secundaria a fractura osteoporótica de la pelvis: a propósito de un caso
Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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Palacio, J. Albareda" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Palacio" "email" => array:1 [ 0 => "jess_palacio@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Albareda" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemorragia severa secundaria a fractura osteoporótica de la pelvis: a propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 736 "Ancho" => 976 "Tamanyo" => 71776 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Anteroposterior radiograph of the pelvis showing fractures of the left iliac and ischiopubic rami.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Osteoporotic pelvic fractures in elderly patients are frequent processes in Orthopedic Surgery Services, since about 80 cases per 100,000 elderly occur every year, with superior (iliopubic) ramus fractures being by far the most common (26 cases per 100,000 elderly per year).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These fractures without disruption of the posterior ring are stable and do not normally pose a threat to the life of patients, thus being treated conservatively with analgesia, thromboprophylaxis and early mobilization.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The pelvic bone structure is closely related to major vascular structures whose injury, although rare, is possible in these fractures and may cause severe hemorrhages which endanger the life of the patient.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of an elderly patient in whom a low-energy trauma caused a stable fracture of the pelvic rami, associated with severe intrapelvic hemorrhage by vascular lesion which threatened her life.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was an 87-year-old female who attended our Emergency Department following an accidental fall at her home. She was allergic to penicillin and derivatives, presented a medical history of chronic venous insufficiency, peptic ulcer, hiatal hernia, arterial hypertension, positive hepatitis C virus and gallstones.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient reported pain and functional deficit at the level of the left hemipelvis and lower limb, with normal abdominal clinical examination and vital constants within normal limits.</p><p id="par0030" class="elsevierStylePara elsevierViewall">An osteoporotic fracture of the left ilium and pubic branches, without displacement, was diagnosed by simple anteroposterior pelvic radiography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient was admitted at our department for follow-up, and conservative treatment was indicated. Blood tests performed upon admission showed a hemoglobin (Hb) level of 13.9<span class="elsevierStyleHsp" style=""></span>g/dl and a hematocrit (Hct) level of 42.1%.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">At 12<span class="elsevierStyleHsp" style=""></span>h of admission, the patient presented a respiratory rate of 25 breaths per minute, tachycardia of 110 beats per minute, hypotension (80/47<span class="elsevierStyleHsp" style=""></span>mmHg), mucocutaneous pallor, signs of dehydration and drowsiness. Her abdomen was distended, spontaneously painful on palpation and with decreased peristalsis. We obtained an abdominal radiograph which showed air distension, as well as a new analytical study which reported Hb values of 8.3<span class="elsevierStyleHsp" style=""></span>g/dl and Hct of 25%. Due to the sharp decline of these values, the hemodynamic impact and the existing abdominal symptoms, we started treatment through absolute diet, two transfused packed red blood cells and observation. The vital signs returned to normal values, with post-transfusion blood test values reflecting Hb 10.4<span class="elsevierStyleHsp" style=""></span>g/dl and Hct 30.9%.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Within 24<span class="elsevierStyleHsp" style=""></span>h the patient presented renewed and progressive hemodynamic instability, with Hb values of 5<span class="elsevierStyleHsp" style=""></span>g/dl and Hct of 17%. We performed an abdominopelvic ultrasound and computed tomography (CT) scan without intravenous contrast which confirmed the presence of a 15<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm retroperitoneal hematoma compressing adjacent structures, including the bladder, and affecting the anterior and posterior pararenal fascia, as well as the posterolateral abdominal muscles. The posterior arch of the pelvis was intact and without fracture (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">This hematoma presented no criteria for immediate surgical indication, so we proceeded to transfuse a further two packed red blood cells. We also obtained a selective angiography of the external iliac artery and the left and right hypogastric arteries which highlighted bleeding of the pubic branch of the inferior epigastric artery, which was embolized using three microcoils (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b). In the immediate postoperative period we conducted a new transfusion of three packed red blood cells.</p><p id="par0050" class="elsevierStylePara elsevierViewall">During the rest of her admission, the patient presented symptoms of metabolic acidosis with decompensated heart failure secondary to a complete arrhythmia by atrial fibrillation, hypertension and volumetric overload with scarce bilateral pleural effusion. She recovered from these processes progressively within 10 days, after which she tolerated a sitting position and was discharged from hospital. Blood analysis values during the days following therapeutic embolization remained normal and stable.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patient has attended outpatient reviews regularly, being permanently discharged within 3 months of the fracture.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">When orthopedic surgeons consider studying pelvic fractures, they refer to those caused by high energy trauma, due to the severity involved and the technical difficulty of their treatment. Osteoporotic pelvic fractures are scarcely studied and are given little importance, as they are usually stable fractures which do not require surgical treatment, with good prognosis in terms of fracture healing, and where the therapeutic goal is pain control and early mobilization of patients. For these reasons, the literature on this topic is scarce, almost always referring to the epidemiology and frequency, without assigning more importance to specific treatment. However, the mortality figures which have been published are similar to those occurring in hip fractures among elderly patients. These figures are surprising given the characteristics of the fracture and the conservative treatment applied. Such high mortality figures reflect possible complications, usually vascular, which could go unnoticed and which would endanger the lives of patients, mainly due to the deteriorated clinical characteristics that these patients already present in many cases,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> or else the frequent association of a fracture of the posterior arch in up to 90% of the cases, which would go unnoticed in most patients.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> This was not the case with our patient.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Performing an immediate CT scan is recommended<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> after a pelvic fracture associated with anemia or hemodynamic instability. In our case, this test was performed without contrast, so it could not detect the presence of active bleeding.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Once the hematoma was diagnosed, we established that urgent surgery was not indicated,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> since it did not present associated intraabdominal hemorrhage, perineal wound, gastrointestinal perforation, pulsating or rapidly expanding hematoma, there was no loss of inguinal pulses and no injuries to the bladder or urethra.</p><p id="par0075" class="elsevierStylePara elsevierViewall">However, given the situation of two repeated episodes of anemia, we decided to perform an angiography,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which enabled us to identify the site of active bleeding and perform the corresponding therapeutic embolization.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Following a pelvic fracture, in cases presenting severe and/or potentially lethal arterial bleeding, the most commonly affected arteries are usually the internal iliac and/or its branches. In order of increasing importance, we find the inferior gluteal, inferior vesical, obturator, iliolumbar and the sacral arteries.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Performing an angiography followed by supraselective embolization of the affected branches has been established as the treatment of choice in these cases, given their minimally invasive characteristics.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,10</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Corona Mortis</span> is an anatomical variation consisting of a vascular anastomosis which may be arterial, venous or arteriovenous. Its name, which literally means “crown of death”, is derived from the fact that the injury is frequently associated with severe hemorrhage. This anastomosis generally occurs between the obturator vessels and the inferior epigastric artery. There is considerable variability in the origin of the obturator. In most cases it is a branch of the internal iliac artery, whereas the inferior epigastric artery leaves the external iliac on the inguinal ligament.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,11–13</span></a> According to Pick et al.,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> in 70% of cases, the obturator artery originates directly from the internal iliac, in 28% of cases it originates from the external iliac as a branch of the inferior epigastric and only in 2% does it originate directly from the external iliac. Rusu et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> elaborated a classification based on the vessels which participated in <span class="elsevierStyleItalic">Corona Mortis</span> to facilitate the knowledge of its morphology and topographic possibilities for surgeons, given its potentially harmful characteristics. It is usually located in the retropubis at the level of the superior pubic ramus and at a variable distance from the symphysis (40–96<span class="elsevierStyleHsp" style=""></span>mm).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,11,12,16</span></a> Its existence ranges between 30% and 43% of the general population according to different authors,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,12,16,17</span></a> with the incidence of purely arterial anastomosis being 10–43% and that of venous anastomosis of approximately 60%.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Its involvement during endopelvic or inguinal surgery or surgery due to fractures of the acetabulum or the pelvis, as in the present case, can cause dangerous hemorrhaging. Clinically, the signs which may lead to suspicion of the injury are hematomas, edema and abdominal pain in the groin and perineum.</p><p id="par0095" class="elsevierStylePara elsevierViewall">In the case of surgeries, its location and subsequent preventive ligation of vessels are vital, because once it appears it is difficult to control due to its retraction through the obturator orifice of the pelvis.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This severe risk has led some authors to suggest preventive embolization in patients with major pelvic trauma.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">As an anatomical variant, <span class="elsevierStyleItalic">Corona Mortis</span> is an important communication between the system of internal and external iliac vessels, and may be bilateral or not.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In osteoporotic pelvic fractures, this rare but possible injury will produce hemodynamic instability and, if not adequately controlled, could even cause death. Therefore, it should be taken into account as a potential risk factor in these fractures.</p><p id="par0110" class="elsevierStylePara elsevierViewall">It is especially important to conduct a careful hemodynamic monitoring of elderly patients with stable pelvic fractures during the first 24<span class="elsevierStyleHsp" style=""></span>h due to the risk of hemorrhage. If there is a rapid deterioration of the vital constants, it is necessary to perform a CT scan and, if necessary, an angiography of the iliac arterial trunks, seeking a vascular injury and performing a selective embolization of the damaged artery. This vascular complication, although rare, may appear with stable fractures of the anterior arch of the pelvis in elderly patients, and may even endanger their lives.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Level of evidence</span><p id="par0115" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">V</span>.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of people and animals</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that this investigation did not require experiments on humans or animals.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data and that all patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare having obtained written informed consent from patients and/or subjects referred to in the work. This document is held by the corresponding author.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Financing</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have not received any kind of financing for the elaboration of this work.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres337283" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec318819" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres337282" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec318818" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Level of evidence" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Financing" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-05-26" "fechaAceptado" => "2013-07-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec318819" "palabras" => array:6 [ 0 => "Pelvis" 1 => "Osteoporotic fracture" 2 => "Arteriovenous anastomosis" 3 => "Hemorrhage" 4 => "Angiography" 5 => "Therapeutic embolization" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec318818" "palabras" => array:6 [ 0 => "Pelvis" 1 => "Fractura osteoporótica" 2 => "Anastomosis arteriovenosa" 3 => "Hemorragia" 4 => "Angiografía" 5 => "Embolización terapéutica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Low-energy osteoporotic pelvic fractures in the elderly are a very common problem. They are usually stable fractures, non-life threatening and only require conservative treatment.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The pelvic bone structure is closely related to important vascular structures. The Corona Mortis, located in the retropubis, has an important anastomotic value as it serves as communication between the internal and external iliac vessels.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The case is presented of an 87-year-old woman, who, after a casual fall, was diagnosed with an osteoporotic fracture of the left pubic rami associated to a lesion of the Corona Mortis, which led to a severe picture of hemodynamic instability.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">After angiography with supra-selective embolization of the lesioned vessel, and the transfusion of several haemoderivatives, the patient progressed satisfactorily, and was discharged after a few days.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La fractura osteoporótica de pelvis del anciano por baja energía es un proceso muy frecuente. Habitualmente son fracturas estables, no suelen suponer un riesgo vital y, únicamente precisan de tratamiento conservador.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La estructura ósea pélvica tiene relación de proximidad con importantes estructuras vasculares. La Corona Mortis, de localización en el retropubis, posee un importante valor anastomótico ya que constituye una comunicación entre el sistema de los vasos ilíacos internos y externos.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Presentamos a una mujer de 87 años, que tras una caída casual fue diagnosticada de fractura osteoporótica de las ramas pubianas izquierdas asociada a la lesión de la Corona Mortis, lo que provocó un grave cuadro de inestabilidad hemodinámica.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Tras una angiografía con embolización supraselectiva del vaso lesionado y a la transfusión de varios hemoderivados la paciente evolucionó satisfactoriamente siendo dada de alta a los pocos días.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Palacio J, Albareda J. Hemorragia severa secundaria a fractura osteoporótica de la pelvis: a propósito de un caso. Rev Esp Cir Ortop Traumatol. 2014;58:192–195.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 736 "Ancho" => 976 "Tamanyo" => 71776 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Anteroposterior radiograph of the pelvis showing fractures of the left iliac and ischiopubic rami.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 804 "Ancho" => 1301 "Tamanyo" => 173535 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(a) Images from an abdominopelvic CT scan showing the different axial sections of a bilateral retroperitoneal hematoma measuring 10<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>cm. (b) Supraselective angiography of the external iliac artery and the left and right hypogastric arteries with embolization through three microcoils.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Haemodynamic instability resulting from a low energy pubic ramus fracture in a 78-year-old woman. A case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.A. Theodorides" 1 => "B.W. Morgan" 2 => "D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 16 | 2 | 18 |
| 2024 September | 21 | 11 | 32 |
| 2024 August | 22 | 3 | 25 |
| 2024 July | 17 | 6 | 23 |
| 2024 June | 16 | 3 | 19 |
| 2024 May | 13 | 2 | 15 |
| 2024 April | 18 | 7 | 25 |
| 2024 March | 19 | 2 | 21 |
| 2024 February | 17 | 6 | 23 |
| 2024 January | 26 | 5 | 31 |
| 2023 December | 14 | 3 | 17 |
| 2023 November | 17 | 8 | 25 |
| 2023 October | 10 | 3 | 13 |
| 2023 September | 12 | 1 | 13 |
| 2023 August | 7 | 3 | 10 |
| 2023 July | 15 | 3 | 18 |
| 2023 June | 8 | 5 | 13 |
| 2023 May | 12 | 5 | 17 |
| 2023 April | 11 | 0 | 11 |
| 2023 March | 24 | 7 | 31 |
| 2023 February | 20 | 2 | 22 |
| 2023 January | 22 | 3 | 25 |
| 2022 December | 25 | 3 | 28 |
| 2022 November | 29 | 7 | 36 |
| 2022 October | 20 | 9 | 29 |
| 2022 September | 15 | 2 | 17 |
| 2022 August | 11 | 8 | 19 |
| 2022 July | 8 | 4 | 12 |
| 2022 June | 14 | 5 | 19 |
| 2022 May | 9 | 6 | 15 |
| 2022 April | 14 | 10 | 24 |
| 2022 March | 18 | 9 | 27 |
| 2022 February | 7 | 3 | 10 |
| 2022 January | 7 | 7 | 14 |
| 2021 December | 13 | 9 | 22 |
| 2021 November | 10 | 8 | 18 |
| 2021 October | 12 | 9 | 21 |
| 2021 September | 8 | 8 | 16 |
| 2021 August | 11 | 7 | 18 |
| 2021 July | 9 | 5 | 14 |
| 2021 June | 13 | 9 | 22 |
| 2021 May | 11 | 8 | 19 |
| 2021 April | 15 | 15 | 30 |
| 2021 March | 13 | 9 | 22 |
| 2021 February | 10 | 9 | 19 |
| 2021 January | 8 | 6 | 14 |
| 2020 December | 1 | 0 | 1 |
| 2018 February | 5 | 2 | 7 |
| 2018 January | 10 | 1 | 11 |
| 2017 December | 7 | 2 | 9 |
| 2017 November | 10 | 2 | 12 |
| 2017 October | 13 | 1 | 14 |
| 2017 September | 14 | 5 | 19 |
| 2017 August | 15 | 4 | 19 |
| 2017 July | 13 | 3 | 16 |
| 2017 June | 22 | 13 | 35 |
| 2017 May | 23 | 25 | 48 |
| 2017 April | 15 | 14 | 29 |
| 2017 March | 18 | 19 | 37 |
| 2017 February | 10 | 6 | 16 |
| 2017 January | 11 | 5 | 16 |
| 2016 December | 24 | 4 | 28 |
| 2016 November | 31 | 5 | 36 |
| 2016 October | 29 | 5 | 34 |
| 2016 September | 24 | 6 | 30 |
| 2016 August | 18 | 1 | 19 |
| 2016 July | 19 | 2 | 21 |
| 2016 June | 26 | 8 | 34 |
| 2016 May | 19 | 16 | 35 |
| 2016 April | 0 | 4 | 4 |
| 2016 March | 0 | 7 | 7 |
| 2016 February | 0 | 1 | 1 |
| 2015 December | 0 | 2 | 2 |
| 2015 November | 0 | 2 | 2 |
| 2015 October | 0 | 1 | 1 |
| 2015 July | 0 | 1 | 1 |
| 2014 June | 1 | 0 | 1 |
| 2014 May | 0 | 1 | 1 |
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