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A previously healthy 38 year old male presented to the Emergency Department from a local outside hospital approximately 4 hours after being crushed between a truck and metal dumpster. He arrived to the trauma room intubated, sedated with a heart rate of 99 BPM, BP of 83/46, and RR of 18.
Secondary trauma survey was positive for abdominal distension, bilaterally weak pulses in the lower extremities, and decreased rectal tone. FAST exam was negative, and the patient was unresponsive to initial fluid resuscitation. Pelvic radiographs revealed multiple minimally displaced fractures of the left pubic ramus, sacrum, and iliac wing. Pelvic CT revealed an arterial injury of the left common iliac artery with an associated retroperitoneal hematoma and active contrast extravasation without distal reconstitution of the vessel. Fig. 1(a).
Pelvic angiography revealed abrupt termination of the left internal iliac artery with the left superior gluteal artery perfused via collateral circulation. The left internal iliac artery was then embolized immediately proximal to the point of termination with only Angioseal, no other procoagulants or gel foam was used. Post-embolization imaging demonstrated successful occlusion and the absence of distal collateral vessels. Fig. 1(b).
Upon weaning of sedation, the patient was noted to have complete paralysis of the left lower extremity. Rectal tone was absent. On day five after injury, digital rectal exam revealed perianal ecchymosis and the absence of rectal tone. Subsequent exam under anaesthesia, revealed the perianal region to have skin necrosis circumferentially around the anal verge extending throughout the entire anal canal. Fig. 1(c). Speculum exam demonstrated mucosal necrosis involving the entire anal canal with a distinct transition to normal mucosa at the anorectal angle. The rectal mucosa appeared pink and healthy. The necrotic mucosa and some internal anal sphincter were debrided, and the patient underwent loop sigmoid colostomy two days later. Four weeks post injury, examination demonstrated complete absence of the patient’s internal and external anal sphincters. Fig. 1(d).
Pelvic fractures remain a complex clinical issue within the trauma population. These injuries to the pelvis are most often the result of blunt traumatic injury, occurring in approximately 4-9.3% of trauma presentations (1). The mortality rates quoted in this population ranges from 5.4-15% to up to 60% in the haemodynamically unstable category (1,2,3). Therefore, despite their relatively uncommon occurrence, the management of pelvic fractures remains an important area of interest and development.
Varying treatment algorithms exist in the setting of hemodynamically unstable pelvic fractures, often depending on the source of bleeding. While preperitoneal packing is often used to stabilize the patient suffering from venous bleeding, angiography and embolization was first described in 1972 and is now used widely to control arterial bleeding (1,3). Angiography and subsequent therapeutic embolization for pelvic fractures may have success rates as high as 62-100%, with the use of proper patient selection criteria and algorithms (1,2).
The hemorrhage, hypotension and retroperitoneal hematoma formation seen in many pelvic crush trauma cases is often accompanied by injury to the hypogastric circulation, often secondary to embolization. (4,5,6,7). Multiple authors have previously discussed the sequelae of interrupting the hypogastric circulation after pelvic fractures which include gluteal necrosis, impotence, rectal necrosis and lower limb paresis (5,6,7,8). The incidence of such morbid complications remains largely unknown, given the infrequent nature of pelvic fractures treated with embolization.
Isolated necrosis of the anal canal has not been reported following pelvic crush injury. As the patient’s pelvic fractures were minimally displaced, his anal necrosis is more likely attributable to multiple ischemic aetiologies: pelvic hematoma compression of the vasculature, systemic hypotension, and arterial disruption after TAE. The possibility of ischemic events, including anal necrosis should be considered in patients with pelvic crush injury with any of these risk factors or interventions.
- Barentsz MW, Vonken EPA, van Herwaarden JA, Leenan LPH, Maili WPThM, van den Bosch MAAJ. Clinical outcome of intra-arterial embolization for treatment of patients with pelvic trauma. Radiology Research and Practice. 2011; 2011:1-7.
- Salim A, Teixeira PRG, DuBose J, Ottochian M, Inaba K, Margulies DR, Demetriades D. Predictors of positive angiography in pelvic fractures: A prospective study. J Am Coll Surgery. 2008; 207:656-662.
- Thorson CM, Ryan ML, Otero CA, Vu T, Borja MJ, Jose J, Shulman CI, Livingstone AS, Proctor KG. Operating room or angiography suite for hemodynamically unstable pelvic fractures. J Trauma. 2012;72:364-372.
- Duff C, Simmen HP, Brunner U, Bauer E, Turina M. Gluteal necrosis after acute ischemia of the internal iliac arteries. Vasa. 1990;19(3):252-6.
- Iliopoulos JI, Howanitz PE, Pierce GE, Kueshkerian SM, Thomas JH, Hermreck AS. The critical hypogastric circulation. Am J Surg. 1987 Dec;154(6):671-5.
- Travis T, Monsky WL, London J, Danielson M, Brock J, Wegelin J, et al. Evaluation of short-term and long-term complications after emergent internal iliac artery embolization in patients with pelvic trauma. J Vasc Interv Radiol. 2008 Jun;19(6):840-7.
- Yasumura K, Ikegami K, Kamohara T, Nohara Y. High incidence of ischemic necrosis of the gluteal muscle after transcatheter angiographic embolization for severe pelvic fracture. J Trauma. 2005 May;58(5):985-90.
- Suzuki T, Shindo M, Kataoka Y, Kobayashi I, Nishimaki H, Yamamoto S, et al. Clinical characteristics of pelvic fracture patients with gluteal necrosis resulting from transcatheter arterial embolization. Arch Orthop Trauma Surg. 2005 Sep;125(7):448-52.
Authors: John S. Berry, IV, M.D., Captain, United States Army, Medical Corps Alfred F. Trappey, III, M.D., Captain, United States Air Force, Medical Corps Joseph L. Petfield, M.D., Captain, United States Army, Medical Corps Julia M. Greene, M.D., Captain, United States Army, Medical Corps Katherine Markell, M.D., Major, United States Army, Medical Corps
Department of Surgery, Brooke Army Medical Center, San Antonio, Texas
Correspondence at John.firstname.lastname@example.org