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Almaguer J, Murray D, Murray M, Murray R. Differentiating Between Obturator and Inferior Epigastric Arterial Injury in Traumatic Pelvic Hemorrhage: A Case Report. Cureus 2023; 15:e44593. [PMID: 37667785 PMCID: PMC10475151 DOI: 10.7759/cureus.44593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2023] [Indexed: 09/06/2023] Open
Abstract
The pubic branches of the inferior epigastric and obturator arteries are subject to injury from pelvic trauma or surgery within the retropubic space. Such injuries can result in severe internal hemorrhage that can lead to hemodynamic instability if not adequately controlled. Due to their anatomical proximity and anastomosis, it is critical to determine which artery is hemorrhaging in order to provide accurate embolization. In the presented case, a geriatric patient suffered a fall from standing height that resulted in bilateral and multiple pelvic fractures. CT angiography of the abdomen demonstrated active left-sided pelvic hemorrhage and a resultant 10 cm anterior extraperitoneal hematoma, likely exacerbated by existing anticoagulant usage. Urgent embolization of the inferior epigastric artery was performed in addition to multiple transfusions. The patient recovered without any procedural complications and was later discharged for rehabilitation.
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Affiliation(s)
- Joey Almaguer
- Department of Radiology, Texas Tech University Health Sciences Center School of Medicine, Amarillo, USA
| | - Dylan Murray
- Department of Surgery, University College Dublin, Dublin, IRL
| | - Matthew Murray
- Department of Surgery, Royal College of Surgeons, Dublin, IRL
| | - Richard Murray
- Department of Diagnostic and Interventional Radiology, Northwest Texas Healthcare System, Amarillo, USA
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Frequency and Clinical Review of the Aberrant Obturator Artery: A Cadaveric Study. Diagnostics (Basel) 2020; 10:diagnostics10080546. [PMID: 32751771 PMCID: PMC7459979 DOI: 10.3390/diagnostics10080546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/12/2020] [Accepted: 07/29/2020] [Indexed: 11/20/2022] Open
Abstract
The occurrence of an aberrant obturator artery is common in human anatomy. Detailed knowledge of this anatomical variation is important for the outcome of pelvic and groin surgeries requiring appropriate ligation. Familiarity with the occurrence of an aberrant obturator artery is equally important for instructors teaching pelvic anatomy to students. Case studies highlighting this vascular variation provide anatomical instructors and surgeons with accurate information on how to identify such variants and their prevalence. Seven out of eighteen individuals studied (38.9%) exhibited an aberrant obturator artery, with two of those individuals presenting with bilateral aberrant obturator arteries (11.1%). Six of these individuals had an aberrant obturator artery that originated from the deep inferior epigastric artery (33.3%). One individual had an aberrant obturator artery that originated directly from the external iliac artery (5.6%).
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Importance of Both Internal and External Iliac Artery Interrogation in Pelvic Trauma as Evidenced by Hemorrhage from Bilateral Corona Mortis with Unilateral Aberrant Origin off the External Iliac Artery. Case Rep Radiol 2019; 2019:6734816. [PMID: 31360574 PMCID: PMC6644275 DOI: 10.1155/2019/6734816] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 06/27/2019] [Indexed: 11/17/2022] Open
Abstract
Transcatheter angiography and embolization has long been recognized as the gold standard for patients with hemodynamic instability secondary to blunt pelvic trauma. While often the bleeding source can be readily localized based on the distribution of extravasation on preprocedural Computed Tomographic Angiography, one should be cautious in assessment for aberrant anatomy. A variant obturator artery originating from the inferior epigastric branch of the external iliac artery is commonly referred to as the corona mortis. We present a case of blunt pelvic trauma in which a patient demonstrated extravasation in the anterior distributions of both internal iliac arteries. Following embolization of bilateral internal iliac arteries, identification and embolization of bilateral corona mortis branches was crucial to achieving hemodynamic stability in this patient.
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Wang J, Cao L, Wu J, Wang Q, Bi C. Clinical and radiological short-term outcomes of pubic symphysis diastasis treated with modified pedicle screw-rod fixation. Eur J Trauma Emerg Surg 2018; 46:865-871. [PMID: 30443777 DOI: 10.1007/s00068-018-1050-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 11/13/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Pubic symphysis diastasis with an incidence of approximately 20% in pelvic fractures is a severe lesion which needs to be treated properly. The objective of this retrospective study was to describe and evaluate the clinical and radiological outcomes including its advantages and limitations of this modified minimal invasive technique. METHODS Totally 29 patients with pubic symphysis diastasis, with or without posterior ring instability, were treated by modified pedicle screw-rod fixation (modified PSRF) between January 2010 and December 2016. The duration from injury to surgery, operation time, intraoperative blood loss as well as complications were recorded. During follow-up, the functional outcomes were assessed according to the Majeed evaluation criteria 1 year postoperatively. The evaluation of the postoperative reduction quality was carried out according to Matta criteria. RESULTS According to Tile classification, there were 9 cases of Type B1 underwent only anterior-modified PSRF and 20 cases of Type C1 experienced anterior-modified PSRF combined with posterior fixation. The duration from injury to operation, operation time and intraoperative blood loss were 3.27 days (range 1-6 days), 42.07 min (range 38-45 min), and 46.14 ml (range 40-55 ml). The results of reduction quality were rated as excellent in 16, good in 11 and fair in 2 based on Matta criteria. The Majeed functional scores ranged from 68 to 95 and there were excellent in 15, good in 12 and fair in 2. No patients experienced incision infection. Slight loosening of middle-two screws was verified during follow-up in one patient. Two patients underwent femoral nerve palsy. Irritation to the LFCN was detected in four patients. CONCLUSIONS Modified PSRF can be performed as an alternative to manage pubic symphysis diastasis due to its merits of minimal invasive, less blood loss, less soft tissue injuries as well as shorter operation time, even with the early weight-bearing. TRIAL REGISTRATION Researchregistry3905.
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Affiliation(s)
- Jiandong Wang
- Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China.,Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China
| | - Lei Cao
- Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China
| | - Jianhong Wu
- Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China
| | - Qiugen Wang
- Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China. .,Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China.
| | - Chun Bi
- Department of Orthopedics Trauma, Trauma Center, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xin Songjiang Road, Shanghai, 201620, People's Republic of China.
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Lázaro Gonzálvez Á, Martínez Reina J, Cano Luis P, Jiménez Baquero J, Sueiro Fernández J, Giráldez Sánchez MÁ. Is cannulated-screw fixation an alternative to plate osteosynthesis in open book fractures? A biomechanical analysis. Injury 2016; 47 Suppl 3:S72-S77. [PMID: 27692112 DOI: 10.1016/s0020-1383(16)30610-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The current biomechanical work compares the symphyseal and sacroiliac stability obtained with two systems of bone osteosynthesis. The two methods of fixation compared were the 6-hole suprapubic non-locked plate and pubic fixation with two cannulated screws, a novel technique that can be applied percutaneously in the clinical practice. The aim of this study was to examine the validity of the use of two-cannulated-screws osteosynthesis in order to minimize the secondary effects of open fixation, especially in patients in whom an open reduction is contraindicated. MATERIALS AND METHODS A biomechanical study was designed in 9 fresh, human pelvis specimens, simulating an AO B1.1 type injury, using both fixation systems sequentially in each specimen. In both parts of the test, the specimens were subjected to an axial load of 300N. Displacements and rotations between the different pelvic elements were studied by means of a discrete set of points. The absence of differences between the two systems has been set as the null hypothesis. RESULTS There were significant differences in favor of the cross-cannulated screws in most of the displacements measured at the pubic symphysis and sacroiliac joint. CONCLUSIONS Fixation of the AO B1.1 type fractures with cross cannulated screws restores the biomechanical behavior of the pubic symphysis, obtaining better stability than fixation with the 6-hole non-locked plate. To date, no comparative, biomechanical studies have been conducted with these two systems of osteosynthesis. This study demonstrates that cross-cannulated screws fixation of the pubic symphysis in AO B1.1 pelvic fractures should be considered as an alternative to the conventional plating system.
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Affiliation(s)
- Ángel Lázaro Gonzálvez
- Clinical Orthopedics, Trauma Surgery and Rheumatology Management Unit, Virgen del Rocío University Hospital, Seville, Spain
| | - Javier Martínez Reina
- Department of Mechanical Engineering, University of Seville, Escuela Superior de Ingeniería, Seville, Spain
| | - Pedro Cano Luis
- Clinical Orthopedics, Trauma Surgery and Rheumatology Management Unit, Virgen del Rocío University Hospital, Seville, Spain
| | | | | | - Miguel Ángel Giráldez Sánchez
- Clinical Orthopedics, Trauma Surgery and Rheumatology Management Unit, Virgen del Rocío University Hospital, Seville, Spain
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Weber CD, Herren C, Dienstknecht T, Hildebrand F, Keil S, Pape HC, Kobbe P. Management of Life-Threatening Arterial Hemorrhage Following a Fragility Fracture of the Pelvis in the Anticoagulated Patient: Case Report and Review of the Literature. Geriatr Orthop Surg Rehabil 2016; 7:163-7. [PMID: 27551576 PMCID: PMC4976735 DOI: 10.1177/2151458516649642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Life-threatening arterial bleeding from fragility fractures of the pelvis are very rare but associated with significant mortality, especially in anticoagulated patients. Case Description: We report the successful interdisciplinary management of a 78-year-old woman under anticoagulation and antiplatelet therapy who had life-threatening arterial hemorrhage from the pubic rami following a fragility fracture of the pelvis. Our management strategy included early hemorrhage control by means of selective arterial embolization followed by surgical fracture stabilization and surgical hematoma evacuation. Literature Review: We identified 6 cases within the English literature, all involving females older than 70 years. All patients under anticoagulation developed hemorrhagic shock, and in 2 cases selective embolization contributed to survival of the patient. However, a combined management including fracture stabilization and hematoma evacuation has not been reported, allowing an excellent clinical outcome and discharge to geriatric rehabilitation. Clinical Relevance: This case illustrates that elderly patients with apparently benign pelvic fragility fractures might develop severe hemorrhage due to arterial injury, especially when under dual anticoagulation, and stresses the importance of a high index of suspicion. If bleeding is suspected, detailed imaging studies are necessary to determine the source of bleeding and immediate angiographic or surgical interventions in combination with volume resuscitation and coagulation therapy should be readily available.
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Affiliation(s)
- Christian David Weber
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
- Christian David Weber, Department of Orthopaedics and Trauma Surgery, Certified Level-1 and Geriatric Trauma Center (German Trauma Society), RWTH Aachen University Medical Center, Pauwelsstr. 30, D-52074 Aachen, Germany.
| | - Christian Herren
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
| | - Thomas Dienstknecht
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
| | - Sebastian Keil
- Department of Radiology and Interventional Radiology, RWTH Aachen University Medical Center, Aachen, Germany
| | - Hans-Christoph Pape
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
| | - Philipp Kobbe
- Department of Orthopaedics and Trauma Surgery, RWTH Aachen University Medical Center, Aachen, Germany
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Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CAN J EMERG MED 2015; 10:392-5. [DOI: 10.1017/s1481803500010447] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT
Extraperitoneal bleeding from the inferior epigastric artery (IEA) and its branches is a rare complication of blunt pelvic trauma; however, it can result in life-threatening hemorrhage, even in cases of minimally displaced fractures of the pelvic ring. We report the case of a patient who had post-traumatic pelvic hematoma and cardiovascular collapse caused by avulsion of the right pubic branch of the IEA related to undisplaced fractures of the pubic rami. CT scanning followed by angiography showed leakage of contrast from the IEA. Transcatheter arterial embolization was performed to successfully control the hemorrhage. There have been very few previous reports of IEA injury related to stable fractures of the pubic rami successfully treated by transcatheter arterial embolization.
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Cano-Luis P, Giráldez-Sanchez MA, Martínez-Reina J, Serrano-Escalante FJ, Galleguillos-Rioboo C, Lázaro-Gonzálvez A, García-Rodríguez J, Navarro A. Biomechanical analysis of a new minimally invasive system for osteosynthesis of pubis symphysis disruption. Injury 2012; 43 Suppl 2:S20-7. [PMID: 23622987 DOI: 10.1016/s0020-1383(13)70175-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We analysed the effectiveness of a new percutaneous osteosynthesis system for the treatment of pelvis fractures with rotational instability. METHODS A pre-clinical cross-sectional experimental study wherein Tile type B1 injuries (open-book fractures) were produced in 10 specimens of fresh human cadavers, including the L4-5 vertebrae, pelvic ring, and proximal third of the femur, keeping intact the capsular and ligamentous structures, is presented in this paper. The physiological mobility of the intact pelvis in a standing position post-injury was compared to that following the performance of a minimally invasive osteosynthesis of the symphysis with two cannulated screws. A specially designed test rig capable of applying loads simulating different weights, coupled with a photogrammetry system, was employed to determine the 3D displacements and rotations in three test cases: intact, injured and fixed. RESULTS After applying an axial load of 300 N, no differences were observed in the average displacement (mm) of the facet joints of the intact pubic symphysis in comparison to those treated with screws (p >0.7). A statistical difference was observed between the average displacements of the sacroiliac facet joints and pelvises with symphyseal fractures treated with screws after the application of a load (p <0.05). CONCLUSION The symphyseal setting with two crossed screws appears to be an effective alternative to osteosynthesis in pelvic fractures with rotational instability.
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Affiliation(s)
- P Cano-Luis
- Clinical Orthopaedics, Trauma Surgery and Reumatology Management Unit, Hospital Universitario Virgen del Rocío, Seville, Spain.
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Damage Control. POLISH JOURNAL OF SURGERY 2009. [DOI: 10.2478/v10035-009-0092-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Macdonald DJM, Tollan CJ, Robertson I, Rana B, Rana BS. Massive haemorrhage after a low-energy pubic ramus fracture in a 71-year-old woman. Postgrad Med J 2006; 82:e25. [PMID: 17068268 PMCID: PMC2653916 DOI: 10.1136/pgmj.2006.047381] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We describe a case of a patient receiving warfarin who presented with a superior pubic ramus fracture after a trivial fall at home. She developed a massive retroperitoneal haematoma as a result of vascular injury and subsequently died. This case emphasises the importance of admitting and observing patients with pubic rami fractures who are receiving antithrombotic treatment, and haemorrhage should be considered if they become haemodynamically compromised.
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Affiliation(s)
- D J M Macdonald
- Department of Orthopaedic Surgery, Western Infirmary, Glasgow, UK
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Abstract
The objectives of this study are to describe the anatomic findings relative to anterior pelvic endoscopy, determine the potential use of endoscopy for reduction and fixation of fractures of the anterior pelvic ring, and report two illustrative cases performed using this method. Using the windows described, endoscopy permits placement of plates and screws on top of the symphysis pubis, reduction of internally displaced fragments, and performance of percutaneous procedures that do not harm anatomic structures.
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Affiliation(s)
- Iván Federico Rubel
- Department of Orthopedic Surgery, University of Louisville Hospital, Louisville, Kentucky 40292, USA
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Goettler CE, Fallon WF. Blunt thoraco-abdominal injury. Curr Opin Anaesthesiol 2001; 14:237-43. [PMID: 17016408 DOI: 10.1097/00001503-200104000-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent advances in blunt thoraco-abdominal trauma management include improvements in imaging, particularly in trauma bay ultrasound. Indications for non-operative management have expanded for solid organ and aortic injury. The physiology of abdominal compartment syndrome continues to be defined, with resulting improvements in care.
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Affiliation(s)
- C E Goettler
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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