Docstoc

Life threatening bleeding from the pubic branch of the inferior

Document Sample
Life threatening bleeding from the pubic branch of the inferior Powered By Docstoc
					Hong Kong Journal of Emergency Medicine



Life-threatening bleeding from the pubic branch of the inferior epigastric
artery after pubic ramus fracture



CK Lu           , YC Lee            , PL Sun            , CL Liang           , PC Liliang




        Isolated pubic ramus fracture with concurrent life-threatening bleeding caused by injury to the inferior
        epigastric artery (IEA) or its branches has rarely been reported and can frequently be overlooked. This paper
        reports two cases of isolated pubic ramus fracture with concomitant injury to the pubic branch of the IEA,
        causing serious bleeding and hemodynamic instability. Pelvic angiography showed leakage of contrast from
        the pubic branch of the IEA. The complication in both cases was successfully treated with transcatheter
        arterial embolisation. (Hong Kong j.emerg.med. 2010;17:372-376)




        Keywords: Angiography, bone fractures, hemorrhage, pelvic bones, therapeutic embolization




Introduction                                                         resulting from vascular disruption. However, isolated
                                                                     pubic ramus fracture with concurrent life-threatening
Uncontrolled haemorrhage in unstable pelvic fractures                bleeding caused by injury to the inferior epigastric
is a common life-threatening complication, 1 usually                 artery (IEA) or its branches has rarely been reported,2-4
                                                                     and can frequently be overlooked. This paper reports
Correspondence to:                                                   two cases of isolated pubic ramus fracture with
Liliang Po Chou, MD                                                  concomitant injury to the pubic branch of the IEA,
E-Da Hospital, Department of Neurosurgery, I-Shou University,        causing serious bleeding and haemodynamic instability.
No. 1, Yi-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung        The complication was successfully treated with
County, 824, Taiwan
Email: ed100172@edah.org.tw
                                                                     transcatheter arterial embolisation.

Liang Cheng Loong, MD
                                                                     Case reports
E-Da Hospital, Department of Orthopedics, I-Shou University,
No. 1, Yi-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung
County, 824, Taiwan                                                  Case 1
Lu Chun Kuan, MD                                                     A 67-year-old woman was involved in a high-speed
                                                                     car collision while riding her motorcycle in September
E-Da Hospital, Department of Radiology, I-Shou University,
                                                                     2008. In the emergency room, she was lethargic with
No. 1, Yi-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung
County, 824, Taiwan                                                  a Glasgow Coma Scale (GCS) score of 8 (E3V1M4).
Lee Yu Chang, MD                                                     Initially, her haemodynamic condition was relatively
Sun Po Lin, MD                                                       stable, with a pulse rate of 90 beat/min and a blood
Lu et al./Bleeding after pubic ramus fracture                                                                                  373



p re s s u re o f 1 1 8 / 7 3 m m H g . A f t e r r e c e i v i n g   microcoils and n-butyl cyanoacrylate (NBCA) glue.
endotracheal intubation, she was put on a ventilator                  The burst vessel was successfully occluded (Figure 1C),
for respiratory support. In the chest radiograph,                     and the patient's haemodynamic parameters were
fractures were spotted on the right third to fifth ribs.              stabilised. She recovered well and was discharged from
The abdomen was soft and no muscle guarding was                       the hospital 26 days later.
detected in the preliminary physical examination. The
abdominal ultrasound images showed no peritoneal
fluid. The anteroposterior pelvic radiograph revealed
fractures on the right superior and inferior pubic rami
(Figure 1A). Subarachnoid haemorrhage over the left
temporal and bilateral parietal lobes without mass effect
was observed in the brain computed tomography (CT).
She was admitted to the intensive care unit for
comprehensive and continued care. Two hours later,
her blood pressure dropped to 92/60 mmHg and her
pulse rate rose to 114 beat/min. She received 2 litres
of crystalloid fluid and 4 units of packed red blood
cells (RBCs). After receiving fluid resuscitation, she
remained haemodynamically unstable, with a pulse rate
of 136 beat/min and a blood pressure of 86/62 mmHg.
An emergency CT with contrast on the thorax,
abdomen, and pelvis was subsequently performed,
showing a large pelvic haematoma. After the scan, she                 Figure 1B. Angiographic image showing active bleeding
received 2 more units of RBCs and then 4 units of                     (extravasation of contrast medium, black arrow) from the pubic
fresh frozen plasma. In the pelvic angiography, active                branch (PB) of the right inferior epigastric artery.
bleeding from the pubic branch of the right IEA was
observed (Figure 1B). Therefore, transcatheter arterial
embolisation of the IEA by way of the left common
femoral artery was performed with the application of




Figure 1A. Anteroposterior pelvic radiograph showing                  Figure 1C. After transcatheter arterial embolisation with
minimally displaced fractures of the superior and inferior pubic      microcoils and n-butyl cyanoacrylate glue, the bleeding artery
rami.                                                                 is completely occluded (black arrows).
374                                                                    Hong Kong j. emerg. med.          Vol. 17(4)      Sep 2010



Case 2                                                            occluded (Figure 2D). After the procedure, stable
A 56-year-old woman was sent to the emergency room                haemodynamic condition ensued and the repeated
in November 2008 after a low-speed motorcycle                     angiography confirmed no more active bleeding. She
accident in which she tripped and landed on her right             recovered well and was discharged 10 days later.
torso. After admission, the initial vital signs showed
hypotension (96/58 mmHg) and rapid pulse rate (116
beat/min). She complained of sharp pain in the lower              Discussion
abdomen and right hip. A large mass and tenderness
in the lower abdomen were detected in the preliminary             The IEA is a branch of the external iliac artery arising
physical examination. After she was resuscitated with             from the ventral side, proximal to the inguinal ligament
2 litres of crystalloid fluid, her haemodynamic
parameters were temporarily stabilised. A minimally
displaced fracture on the right superior pubic ramus
was found in the anteroposterior pelvic radiograph
(Figure 2A). A large pelvic haematoma with contrast
extravasation was spotted in the subsequent CT thorax,
abdomen, and pelvis (Figure 2B). An hour later, the
blood pressure dropped to 86/54 mmHg and her pulse
rate rose to 140 beat/min. She was then administered
a further 2 litres of crystalloid fluid and 4 units of
packed RBCs. Subsequently, she was sent to the
interventional radiology department for emergency
pelvic angiography. The angiography revealed active
bleeding from the pubic branch of the right IEA                   Figure 2B. Pelvic CT image showing a large pelvic hematoma
(Figure 2C). Transcatheter arterial embolisation of the           (white arrow), with active extravasation of contrast medium
IEA by way of the left common femoral artery was                  (black arrow).
performed with the application of Gelfoam emulsion
and microcoils. The burst vessel was successfully




Figure 2A. Anteroposterior pelvic radiograph showing a            Figure 2C. Angiographic image showing active bleeding
minimally displaced fracture of the superior pubic ramus (white   (extravasation of contrast medium, black arrow) from the pubic
arrow).                                                           branch (PB) of the right inferior epigastric artery.
Lu et al./Bleeding after pubic ramus fracture                                                                               375



                                                                   haemodynamic instability due to isolated pubic ramus
                                                                   fractures with arterial haemorrhage are extremely
                                                                   rare. Only four such cases have been reported in the
                                                                   literature (Table 1). 2-4 In Case 1, the diagnosis was
                                                                   overlooked at the beginning.

                                                                   Lower abdominal painful masses can be detected
                                                                   through physical examination. After identifying such
                                                                   a mass in a hypovolemic patient with pubic ramus
                                                                   fracture, one must suspect injury of the IEA or its
                                                                   branches. CT scan can rapidly detect the exact location
                                                                   of the haematoma and bleeding. In addition, it can
                                                                   also rule out intra-abdominal injuries which potentially
                                                                   require surgical intervention. Some authors have
                                                                   advocated pelvic angiography as the first choice of
                                                                   investigation in patients with pelvic fracture and
Figure 2D. After transcatheter arterial embolisation with          haemodynamic instability.6
microcoils and Gelfoam (black arrow), no active bleeding is
observed.                                                          Anticoagulant therapy is a documented risk factor for
                                                                   severe bleeding in some cases. 3,4 Macdonald et al 3
                                                                   reported a case in which the patient received warfarin
                                                                   and suffered from life-threatening bleeding due to burst
and ascends obliquely toward the umbilicus along                   of the pubic branch of the IEA after an accidental fall.
the medial margin of the deep inguinal ring. Here, it              Loffroy et al4 reported another case in which the patient
branches out the cremasteric artery which accompanies              receiving anticoagulant therapy sustained a low-speed
the spermatic cord in male (or the artery of the round             motor vehicle accident and resulted in life-threatening
ligament in female) and the pubic branch which runs                haemorrhage.
medially and downward to reach the back of the pubis
close to the femoral ring. Continuing its course                   Transcatheter arterial embolisation with NBCA glue,
upward, the IEA pierces the transversalis fascia below             microcoils, or Gelfoam emulsion appears to be a good
the arcuate line and enters the rectus sheath to reach             choice in treatment. With liquid agents and microcoils,
the deep surface of the rectus abdominis muscle.5                  the bleeding branch (or the whole IEA) could be
                                                                   occluded without complication. Sometimes, the pubic
Life-threatening arterial haemorrhage has mainly                   branch of the IEA anastomoses with the obturator
been reported in unstable pelvic fractures. 1 Cases of             branch of the internal iliac artery. 5 Wong et al 7


Table 1. Reports on life-threatening bleeding from the pubic branch of the inferior epigastric artery after isolated pubic ramus
fracture
Author                  Age/gender                 Manifestation               Cause of injury       Risk factor      Outcome
Meyers et al   2
                           86/F                 Groin pain, shock                Trivial fall            −             Recovery
                           43/M                        Shock                     20-foot fall            −             Recovery
Macdonald et al3           71/M                 Groin pain, shock                    Fall          Anticoagulant         Died
Loffroy et al4             83/M        Abdominal pain, abdominal mass, shock       MVA             Anticoagulant       Recovery
Present cases              67/F                        Shock                       MVA                   −             Recovery
                           56/F           Abdominal and hip pain, shock            MVA                   −             Recovery
F=female; M=male; MVA=motor vehicle accident.
376                                                                Hong Kong j. emerg. med.         Vol. 17(4)    Sep 2010



described a case with life-threatening pubic ramus                 embolization in patients with unstable pelvic fractures:
                                                                   rate of blood transfusion as a predictive factor. J Trauma
fracture with the bleeding vessel arising from the
                                                                   2000;49(1):71-5.
internal iliac artery. It is therefore important to perform   2.   Meyers TJ, Smith WR, Ferrari JD, Morgan SJ, Franciose
internal iliac arteriography after embolisation in such            RJ, Echeverri JA. Avulsion of the pubic branch of the
injuries to confirm that active bleeding does not persist          inferior epigastric artery: a cause of hemodynamic
                                                                   instability in minimally displaced fractures of the pubic
from anastomoses with the obturator branch of the                  rami. J Trauma 2000;49(4):750-3.
internal iliac artery.                                        3.   Macdonald DJ, Tollan CJ, Robertson I, Rana B. Massive
                                                                   haemorrhage after a low-energy pubic ramus fracture
                                                                   in a 71-year-old woman. Postgrad Med J 2006;82(972):
                                                                   e25. Erratum in: Postgrad Med J 2008;84(988):110.
Conclusion                                                         Postgrad Med J 2007;83(980):433. Rana BS [corrected
                                                                   to Rana B].
Life-threatening bleeding may result from isolated            4.   Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé
                                                                   D. Stable fracture of the pubic rami: a rare cause of
pubic ramus fracture and can frequently be overlooked.
                                                                   life-threatening bleeding from the inferior epigastric
In the case of a haemodynamically unstable patient                 artery managed with transcatheter embolization. CJEM
with pubic ramus fracture, the possibility of injury of            2008;10(4):392-5.
the IEA or its branches should be considered. Early           5.   Kawai K, Honma S, Koizumi M, Kodama K. Inferior
                                                                   epigastric artery arising from the obturator artery as a
diagnosis and prompt embolisation can control serious              terminal branch of the internal iliac artery and
haemorrhage.                                                       consideration of its rare occurrence. Ann Anat 2008;
                                                                   190(6):541-8.
                                                              6.   Ben-Menachem Y, Coldwell DM, Young JW, Burgess
                                                                   AR. Hemorrhage associated with pelvic fractures:
References                                                         causes, diagnosis and emergent management. AJR Am
                                                                   J Roentgenol 1991;157(5):1005-14.
1.    Wong YC, Wang LJ, Ng CJ, Tseng IC, See LC.              7.   Wong TC, Chan WL, Wu WC. Life threatening stable
      Mortality after successful transcatheter arterial            pubic rami fracture. Injury Extra 2005;36:300-2.