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

Hong Kong Journal of Emergency Medicine Life-threatening bleeding from the pubic branch of the inferior epigastric artery after pubic ramus fracture ...
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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 Uncontrolled haemorrhage in unstable pelvic fractures is a common life-threatening complication, 1 usually Correspondence to: Liliang Po Chou, MD E-Da Hospital, Department of Neurosurgery, I-Shou University, No. 1, Yi-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung County, 824, Taiwan Email: [email protected]

resulting from vascular disruption. However, 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,2-4 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 haemodynamic instability. The complication was successfully treated with transcatheter arterial embolisation.

Liang Cheng Loong, MD E-Da Hospital, Department of Orthopedics, I-Shou University, No. 1, Yi-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung County, 824, Taiwan Lu Chun Kuan, MD E-Da Hospital, Department of Radiology, I-Shou University, No. 1, Yi-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung County, 824, Taiwan Lee Yu Chang, MD Sun Po Lin, MD

Case reports Case 1 A 67-year-old woman was involved in a high-speed car collision while riding her motorcycle in September 2008. In the emergency room, she was lethargic with a Glasgow Coma Scale (GCS) score of 8 (E3V1M4). Initially, her haemodynamic condition was relatively stable, with a pulse rate of 90 beat/min and a blood

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Lu et al./Bleeding after pubic ramus fracture

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 endotracheal intubation, she was put on a ventilator for respiratory support. In the chest radiograph, fractures were spotted on the right third to fifth ribs. The abdomen was soft and no muscle guarding was 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 received 2 more units of RBCs and then 4 units of fresh frozen plasma. In the pelvic angiography, active 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

microcoils and n-butyl cyanoacrylate (NBCA) glue. The burst vessel was successfully occluded (Figure 1C), and the patient's haemodynamic parameters were stabilised. She recovered well and was discharged from the hospital 26 days later.

Figure 1B. Angiographic image showing active bleeding (extravasation of contrast medium, black arrow) from the pubic branch (PB) of the right inferior epigastric artery.

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

Case 2 A 56-year-old woman was sent to the emergency room in November 2008 after a low-speed motorcycle accident in which she tripped and landed on her right 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 abdomen and right hip. A large mass and tenderness in the lower abdomen were detected in the preliminary physical examination. After she was resuscitated with 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 2C). Transcatheter arterial embolisation of the IEA by way of the left common femoral artery was performed with the application of Gelfoam emulsion and microcoils. The burst vessel was successfully

Hong Kong j. emerg. med. „ Vol. 17(4) „ Sep 2010

occluded (Figure 2D). After the procedure, stable haemodynamic condition ensued and the repeated angiography confirmed no more active bleeding. She recovered well and was discharged 10 days later.

Discussion The IEA is a branch of the external iliac artery arising from the ventral side, proximal to the inguinal ligament

Figure 2B. Pelvic CT image showing a large pelvic hematoma (white arrow), with active extravasation of contrast medium (black arrow).

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.

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Lu et al./Bleeding after pubic ramus fracture

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.

Figure 2D. After transcatheter arterial embolisation with microcoils and Gelfoam (black arrow), no active bleeding is observed.

and ascends obliquely toward the umbilicus along the medial margin of the deep inguinal ring. Here, it branches out the cremasteric artery which accompanies the spermatic cord in male (or the artery of the round ligament in female) and the pubic branch which runs medially and downward to reach the back of the pubis close to the femoral ring. Continuing its course upward, the IEA pierces the transversalis fascia below the arcuate line and enters the rectus sheath to reach the deep surface of the rectus abdominis muscle.5 Life-threatening arterial haemorrhage has mainly been reported in unstable pelvic fractures. 1 Cases of

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 haemodynamic instability.6 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 of the pubic branch of the IEA after an accidental fall. Loffroy et al4 reported another case in which the patient receiving anticoagulant therapy sustained a low-speed motor vehicle accident and resulted in life-threatening haemorrhage. Transcatheter arterial embolisation with NBCA glue, microcoils, or Gelfoam emulsion appears to be a good choice in treatment. With liquid agents and microcoils, the bleeding branch (or the whole IEA) could be occluded without complication. Sometimes, the pubic branch of the IEA anastomoses with the obturator 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 Meyers et al

2

Macdonald et al3 Loffroy et al4 Present cases

Age/gender

Manifestation

Cause of injury

Risk factor

Outcome

86/F 43/M 71/M 83/M 67/F 56/F

Groin pain, shock Shock Groin pain, shock Abdominal pain, abdominal mass, shock Shock Abdominal and hip pain, shock

Trivial fall 20-foot fall Fall MVA MVA MVA

− − Anticoagulant Anticoagulant − −

Recovery Recovery Died Recovery Recovery Recovery

F=female; M=male; MVA=motor vehicle accident.

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described a case with life-threatening pubic ramus fracture with the bleeding vessel arising from the internal iliac artery. It is therefore important to perform internal iliac arteriography after embolisation in such injuries to confirm that active bleeding does not persist from anastomoses with the obturator branch of the internal iliac artery.

embolization in patients with unstable pelvic fractures: rate of blood transfusion as a predictive factor. J Trauma 2000;49(1):71-5. Meyers TJ, Smith WR, Ferrari JD, Morgan SJ, Franciose RJ, Echeverri JA. Avulsion of the pubic branch of the inferior epigastric artery: a cause of hemodynamic instability in minimally displaced fractures of the pubic rami. J Trauma 2000;49(4):750-3. 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. Postgrad Med J 2007;83(980):433. Rana BS [corrected to Rana B]. Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé D. Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CJEM 2008;10(4):392-5. Kawai K, Honma S, Koizumi M, Kodama K. Inferior epigastric artery arising from the obturator artery as a terminal branch of the internal iliac artery and consideration of its rare occurrence. Ann Anat 2008; 190(6):541-8. Ben-Menachem Y, Coldwell DM, Young JW, Burgess AR. Hemorrhage associated with pelvic fractures: causes, diagnosis and emergent management. AJR Am J Roentgenol 1991;157(5):1005-14. Wong TC, Chan WL, Wu WC. Life threatening stable pubic rami fracture. Injury Extra 2005;36:300-2.

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3.

Conclusion Life-threatening bleeding may result from isolated pubic ramus fracture and can frequently be overlooked. In the case of a haemodynamically unstable patient with pubic ramus fracture, the possibility of injury of the IEA or its branches should be considered. Early diagnosis and prompt embolisation can control serious haemorrhage.

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5.

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References 1.

Wong YC, Wang LJ, Ng CJ, Tseng IC, See LC. Mortality after successful transcatheter arterial

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