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: firstname.lastname@example.org 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.
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