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Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases
G Model
JINJ-6178; No. of Pages 6 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case Report
Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases George W. Chaus *, Marilyn Heng, Raymond M. Smith Harvard University, Department of Orthopaedics, Massachusetts General Hospital, Boston, MA, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 25 April 2015
We present two cases of occult internal iliac arterial injury identified during operative reduction of a widely displaced posterior column posterior wall acetabular fracture. This complication was not recognised until reduction of the column fracture. There were no preoperative signs or symptoms indicative of a vascular injury. These cases emphasise the heightened awareness one must have when treating widely displaced posterior column fractures of the acetabulum, especially those fractures with extension into the greater sciatic notch, as previously formed clot can become dislodged and hemostasis lost. We also present management options when this complication occurs. We believe any surgeon treating acetabular fractures should be aware of this serious and potentially fatal complication. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Acetabular fracture Vascular injury Internal iliac artery
Introduction Vascular injuries are well described in pelvic ring disruptions, especially patterns that disrupt the posterior pelvic ring [3–5,7,11,14,19]. These injuries carry a significant morbidity and mortality [3–5,7,11,14,19]. In contrast, vascular injuries in acetabular fractures are much less common [15,18]. Most that have been documented in the literature exist as single case reports or small case series [2,6,8–10,12,13,16,17,20]. These injuries can be associated with significant morbidity and mortality, including reports of exsanguination and death from these vascular injuries [2,16]. One must have a heightened sense of awareness when treating these injuries and be prepared to treat them should they occur. In this article, we describe two illustrative cases of an occult internal iliac artery injury that became evident during open reduction internal fixation of a posterior column posterior wall acetabular fracture and propose subsequent management options. Case report Case 1 A 49-year-old healthy male was riding his motorcycle at speeds of 15–20 miles per hour when he sustained a collision with another
* Corresponding author at: Harvard University, Department of Orthopaedics, Massachusetts General Hospital, The Yawkey Center, Suite 3C, Boston, MA 02114, United States. Tel.: +1 801 558 4279; fax: +1 617 726 8214. E-mail address: [email protected] (G.W. Chaus).
vehicle. He was initially taken to and evaluated at a community hospital and then transferred to our level 1 trauma centre. Prior to transfer, a right-sided acetabular fracture dislocation was identified and closed reduction of the hip was performed. Upon arrival to our trauma centre, a full trauma evaluation was undertaken. The patient had stable blood pressures with tachycardia to 130 beats/minue. His initial lactate level was 4 mmol/L (nl 0.5–2.2 mmol/L) and his haemoglobin (HGB) was 10.8 g/Dl (nl 13.5–17.5 g/Dl). On physical examination, he presented with a sciatic nerve palsy with absent ankle dorsiflexion and great toe extension and absent sensation of the superficial and deep peroneal nerve distributions. Peripheral pulses were easily palpable. Radiographic imaging with an anteroposterior (AP) pelvis x-ray confirmed a grossly displaced right posterior column posterior wall acetabular fracture (Fig. 1). In addition, a right-sided posterior tibial spine avulsion was noted. Computed tomography (CT) of the patient’s abdomen and pelvis with intravenous contrast was obtained. These images revealed a pelvic haematoma, but did not show any active contrast extravasation (Fig. 2). No other orthopaedic or non-orthopaedic injuries were identified. The patient was placed into distal femoral skeletal traction and admitted to the intensive care unit for resuscitation. During his resuscitation, he received a total of 4 L of crystalloid and two units of packed red blood cells. His tachycardia as well as his lactic acidosis resolved overnight (AM lactate 1 mmol/L). The following morning, with clinical and laboratory markers showing adequate resuscitation, he was taken to the operating room for open reduction and fixation of his acetabular fracture. The patient was placed prone on a radiolucent table with the right limb in skeletal traction. A standard Kocher-Langenbeck
http://dx.doi.org/10.1016/j.injury.2015.04.030 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
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Fig. 1. AP pelvis and Judet reformatted radiographs showing a displaced posterior column posterior wall acetabular fracture. Note the significant displacement of the posterior column in the greater sciatic notch. This was thought to be the cause of the vascular injury.
approach to the posterior acetabulum was performed. A significant amount of clot was identified during the surgical approach. The free articular fragment (denoted by an * in Fig. 2) was removed from the main fracture plane; clot and debris were cleaned from the fracture lines. While reducing and cleaning the large spike on the posterior column, active arterial bleeding from the greater sciatic notch was encountered. Despite several attempts, it was not possible to stop the bleeding thus, the area was tightly packed for temporizing haemorrhage control and the decision was made to proceed with emergent angioembolization. The posterior column was fixed in a reduced position by a single 3.5 mm lag screw. This screw was placed to prevent any further vascular injury by the column fragment and protect the endovascular
intervention. The wound was provisionally closed and the patient was transported to the angiography suite for endovascular assessment. Angiography demonstrated active contrast extravasation from the internal iliac artery (Fig. 3A). An intravascular coil was placed to completely obstruct flow just proximal to this portion of the artery (Fig. 3B). With the haemorrhage controlled, the patient was transferred back to the intensive care unit for further resuscitation. Two days later, he returned to the operating room for completion of the acetabular fracture fixation. Postoperatively, the patient’s postoperative course was uneventful and he was discharged to a rehabilitation facility on postoperative day number five.
Fig. 2. Computed tomographic scans showing the acetabular fracture dislocation from the anterior inferior iliac spine through the articular surface. Note the * marking the intervening articular fragment preventing reduction of the posterior column through skeletal traction.
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
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Fig. 3. (A) Selective angiography of the internal iliac artery showing active contrast extravasation (arrow). (B) Coil placement in the internal iliac artery. There is no longer active extravasation past the arterial injury. Note the single screw holding the posterior column reduction and the retained packing.
At six week follow-up, the surgical incision had healed without any complication of infection. There was no evidence of gluteal muscle necrosis. The patient had a persistent peroneal nerve palsy that is being treated expectantly with passive stretching and an ankle foot orthosis. A current AP pelvis radiograph is shown in Fig. 4. Case 2 An 80-year-old male with type 2 diabetes mellitus and history of prostate cancer was installing siding on his home when he fell approximately ten feet off his porch. He was initially evaluated at an outside hospital and subsequently transferred to our level 1 trauma centre. On arrival to our trauma centre a full trauma evaluation was undertaken. The patient arrived with normal vital signs and
Fig. 4. Six week post operative AP pelvis radiograph.
normal laboratory parameters. On physical examination, he had a dense sciatic nerve palsy with absent ankle dorsiflexion and great toe extension and absent superficial and deep peroneal nerve sensation. He had 2+ and symmetric dorsalis pedis and posterior tibial peripheral pulses. Radiographs confirmed a grossly displaced right posterior column posterior wall acetabular fracture (Fig. 5). Additionally, a right-sided proximal humerus fracture and rightsided ankle fracture was noted. A CT scan of the patient’s abdomen and pelvis did not show any active contrast extravasation (Fig. 6). No other injuries were identified. Given the patient’s age and bone quality, surgical management of the acetabular fracture with an acute total hip arthroplasty with
Fig. 5. AP pelvis radiograph showing a displaced posterior column posterior wall acetabular fracture.
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
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Fig. 6. Computed tomographic scans showing the acetabular fracture from the anterior inferior iliac spine through the articular surface.
Fig. 7. (A) Angiography of the external and internal iliac arteries. An arrow identifies an abrupt stoppage of flow in the posterior division of the internal iliac artery with surgically applied vessel clips. (B) Coil placement in the posterior division of the internal iliac artery.
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
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a cage construct was planned. In the operating room, the patient was placed in the lateral position on a radiolucent table. A direct lateral Hardinge approach to the hip was performed. The hip was dislocated and the femoral neck cut made with an oscillating saw. After removal of the femoral head, the posterior column was directly reduced through the hip joint prior to placement of the cage fixation. As the posterior column was reduced, active arterial bleeding from the sciatic notch commenced. Approximately 2.5 L of blood was lost in approximately 2 minutes. The bleeding was temporarily controlled with sponge packing. A trochanteric osteotomy and resection of a portion of the greater sciatic notch was performed through the space provided by the femoral neck resection in order to provide access to the bleeding vessel. A large vessel was identified, isolated, and ligated with clips. Given the large volume of blood loss and continued oozing from the greater sciatic notch the area was packed, provisional wound closure performed and the patient taken emergently to the angiography suite. Angiography of the internal iliac artery showed an interruption of flow in the posterior division at the level of the multiple surgical clips (Fig. 7A). A coil was placed obstructing flow to this portion of the artery (Fig. 7B). The patient was then transferred back to the intensive care unit for further resuscitation and two days later was taken back to the operating room for completion of the posterior column fixation and total hip arthroplasty. The posterior column was reduced and held in place by screws placed through the cage construct. A cemented acetabular liner and cemented femoral stem was placed. Postoperatively, the patient did well without further complication and was subsequently discharged to a rehabilitation facility. At initial follow-up, the surgical wound had healed without any concerns for infection. As with Case number 1, there was no evidence of gluteal muscle necrosis. A postoperative AP pelvis radiograph is shown in Fig. 8. Discussion Unlike pelvic ring injuries, vascular injuries in association with acetabular fractures are less common [15,18]. The published literature includes a few case reports and small case series [2,6,8– 10,12,13,16,17,20]. In a series of 323 acetabular fractures reviewed by Porter, only 16 vascular injuries were identified [15]. All of these vascular injuries occurred with associated both column or anterior column fracture patterns. There were no vascular injuries in isolated posterior acetabular fractures. The majority of published reports we have identified in our literature search describe vascular injuries in association with anterior fracture patterns and involve the external iliac system [2,6,8,17]. Other articles report iatrogenic vascular injury or thrombosis that were identified following open reduction and fixation and were not due to the injury itself [10,12,16]. Furthermore, external iliac injury can usually be detected through a peripheral vascular examination and frequently does not present in a delayed fashion as the vascular injuries we have presented in this article. In this article, we report a significantly different clinical scenario from what has been previously reported in the literature regarding posterior acetabular fractures and associated vascular injury. Most commonly, the literature describes injury to the superior gluteal vessels and not the main internal iliac artery as illustrated by the cases in this paper. In a series of 131 posterior pattern acetabular fractures reviewed by Russell [18], there were three superior gluteal vein injuries or entrapment noted at surgery. All of these fractures were treated through a posterior approach and all three had displaced fractures extending into the greater sciatic notch. The exact fracture pattern associated with these three cases was not described. Letournel [13] reported on seven cases of superior gluteal vascular injury with displaced fractures
Fig. 8. Six week post operative AP pelvis radiograph showing a cage and cemented total hip arthroplasty.
into the greater sciatic notch. Lastly, Bosse [1] reported on the preoperative angiography of eight acetabular fractures with extension into the greater sciatic notch that were planned for an extended iliofemoral approach to determine the vascularity of the gluteal muscle flap. They incidentally identified three injuries to the superior gluteal artery. Only one other case of internal iliac arterial injury described with an isolated acetabular fracture has been reported in the literature. In a report of two cases by Ruotolo, their second case concerns a T-type acetabular fracture with internal iliac and superficial femoral arterial lacerations [7]. However, this case presented very differently from our cases. This case involved a hypotensive patient in haemorrhagic shock that went immediately to angiography and subsequently to the operating room for femoral arterial repair. This is in stark contrast to the occult internal iliac arterial injuries we present above that were identified while attempting to repair the fracture. When a vascular injury is identified, the surgical team must act quickly and definitively to obtain control of the bleeding vessel and stop the significant haemorrhage that can ensue. There is a relative paucity of specific treatment recommendations in the literature. Direct identification of the bleeding vessel and ligation versus repair of the vessel has been discussed. In the series by Russell et al. [18] they were able to isolate and ligate all three of the gluteal vein
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
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injuries identified in their series. They specifically discouraged the use of surgical clips and stress the importance of direct visualization of the bleeding vessel to prevent any injury to the remaining neurovascular bundle. If the bleeding is too brisk to identify and isolate the injured vessel, we advocate temporary packing. Letournel [13] first described temporary packing in his large series of acetabular fracture fixation. After 30 minutes, the packing was removed and often the bleeding had slowed to a point that it was no longer an issue. If after removal of the packing, the bleeding resumes we recommend re-packing, wound closure, and endovascular evaluation as was described in our cases. We believe that though the presentation of occult internal iliac arterial injuries with a widely displaced posterior column posterior wall acetabular fracture is uncommon and unique, it should be considered by all surgeons treating these complex injuries.
Conclusion Vascular injuries associated with acetabular fractures are rare but they can have grave consequences if they are not identified or if the surgeon is not prepared to deal with them should they occur. We presented two cases of an occult internal iliac arterial injury identified during the reduction of a widely displaced posterior column posterior wall acetabular fracture. It is important to recognise this possibility when there is a large posterior column fracture with extension into the greater sciatic notch. Preparedness to deal with high volume intraoperative bleeding should considered in these cases. Clear communication and coordination between the anaesthetic team, the surgical team, and interventional radiology is required to stabilise these critical injuries. Given these two recent cases, we propose the use of preoperative angiography in widely displaced posterior column acetabular fractures with extension into the greater sciatic notch. Preoperative angiography may serve to identify these occult vascular injuries prior to open reduction internal fixation, and prevent the surgical haemorrhage presented in this report.
Funding The authors have not received any funding for the completion of this manuscript.
Conflict of interest statement The authors report no relevant conflicts of interest in regard to this manuscript.
Ethics The two patients whose clinical history and images appear in this manuscript have given permission for its use in this published manuscript. References [1] Bosse MJ, Poka A, Reinert CM, Brumback RJ, Bathon H, Burgess AR. Preoperative angiographic assessment of the superior gluteal artery in acetabular fractures requiring extensile surgical exposures. J Orthop Trauma 1988;2:303–7. [2] Cheng SL, Rosati C, Waddell JP. Fatal hemorrhage caused by vascular injury associated with an acetabular fracture. J Trauma 1995;38:208–9. [3] Dalal SA, Burgess AR, Siegel JH, Young JW, Brumback RJ, Poka A, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma 1989;29: 981–1000. [4] Eastridge BJ, Burgess AR. Pedestrian pelvic fractures: 5-year experience of a major urban trauma center. J Trauma 1997;42:695–700. [5] Eastridge BJ, Starr A, Minei JP, O’Keefe GE, Scalea TM. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002;53:446–50. [6] Frank JL, Reimer BL, Raves JJ. Traumatic iliofemoral artery injury: an association with high anterior acetabular fractures. J Vasc Surg 1989;10:198–201. [7] Gustavo Parreira J, Coimbra R, Rasslan S, Oliveira A, Fregoneze M, Mercadante M. The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures. Injury 2000;31:677–82. [8] Huijbregts JE, Luitse JSK, Goslings JC, Eijer H. Entrapment of the external iliac vein in a both-collumn acetabular fracture. J Orthop Trauma 2004;18:630–3. [9] Hummami MN. An aneurysm of the superior gluteal artery presenting as buttock pain 6 months after a missed fracture of the acetabulum. Br J Surg 1981;68:442–4. [10] Johnson EE, Eckhardt JJ, Letournel E. Extrinsic femoral artery occlusion following internal fixation of an acetabular fracture: a case report. Clin Orthop 1987;217:209–13. [11] Klein SR, Saroyan RM, Baumgarter F, Bongard FS. Management strategy of vascular injuries associated with pelvic fractures. J Cardiovasc Surg 1992;33:349–57. [12] Langford JR, Trokhan S, Strauss E. External iliac artery thrombosis after open reduction of an acetabular fracture: a case report. J Orthop Trauma 2008;22:59–62. [13] Letournel E, Judet R. Fractures of the acetabulum. 2nd ed. New York: SpringerVerlag; 1993. [14] Moreno C, Moore EE, Rosenberger A, Cleveland HC. Hemorrhage associated with major pelvic fracture: a multispecialty challenge. J Trauma 1986;26: 987–94. [15] Porter Se, Schroeder AC, Dzugan SS, Graves ML, Zhang L, Russell GV. Acetabular fracture patterns and their associated injuries. J Orthop Trauma 2008;22:165–70. [16] Probe R, Reeve R, Lindsey RW. Femoral artery thrombosis after open reduction of an acetabular fracture. Clin Orthop 1992;283:258–60. [17] Ruotolo C, Savarese E, Khan A, Ryan M, Kottmeier S, Meinhard BP. Acetabular fractures with associated vascular injury: a report of two cases. J Trauma 2001;51:382–6. [18] Russell GV, Nork SE, Routt MLC. Perioperative complications associated with operative treatment of acetabular fractures. J Trauma 2001;51:1098–103. [19] Starr AJ, Griffin DR, Reinert CM, Frawley WH, Walker J, Whitlock SN, et al. Pelvic ring disruptions: prediction of associated injuries, transfusion requirement, pelvic arteriography, complications, and mortality. J Orthop Trauma 2002;16:553–61. [20] Wolinsky PR, Johnson KD. Delayed catastrophic rupture of the external iliac artery after an acetabular fracture. J Bone Joint Surg 1995;77:1241–4.
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
JINJ-6178; No. of Pages 6 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case Report
Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases George W. Chaus *, Marilyn Heng, Raymond M. Smith Harvard University, Department of Orthopaedics, Massachusetts General Hospital, Boston, MA, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 25 April 2015
We present two cases of occult internal iliac arterial injury identified during operative reduction of a widely displaced posterior column posterior wall acetabular fracture. This complication was not recognised until reduction of the column fracture. There were no preoperative signs or symptoms indicative of a vascular injury. These cases emphasise the heightened awareness one must have when treating widely displaced posterior column fractures of the acetabulum, especially those fractures with extension into the greater sciatic notch, as previously formed clot can become dislodged and hemostasis lost. We also present management options when this complication occurs. We believe any surgeon treating acetabular fractures should be aware of this serious and potentially fatal complication. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Acetabular fracture Vascular injury Internal iliac artery
Introduction Vascular injuries are well described in pelvic ring disruptions, especially patterns that disrupt the posterior pelvic ring [3–5,7,11,14,19]. These injuries carry a significant morbidity and mortality [3–5,7,11,14,19]. In contrast, vascular injuries in acetabular fractures are much less common [15,18]. Most that have been documented in the literature exist as single case reports or small case series [2,6,8–10,12,13,16,17,20]. These injuries can be associated with significant morbidity and mortality, including reports of exsanguination and death from these vascular injuries [2,16]. One must have a heightened sense of awareness when treating these injuries and be prepared to treat them should they occur. In this article, we describe two illustrative cases of an occult internal iliac artery injury that became evident during open reduction internal fixation of a posterior column posterior wall acetabular fracture and propose subsequent management options. Case report Case 1 A 49-year-old healthy male was riding his motorcycle at speeds of 15–20 miles per hour when he sustained a collision with another
* Corresponding author at: Harvard University, Department of Orthopaedics, Massachusetts General Hospital, The Yawkey Center, Suite 3C, Boston, MA 02114, United States. Tel.: +1 801 558 4279; fax: +1 617 726 8214. E-mail address: [email protected] (G.W. Chaus).
vehicle. He was initially taken to and evaluated at a community hospital and then transferred to our level 1 trauma centre. Prior to transfer, a right-sided acetabular fracture dislocation was identified and closed reduction of the hip was performed. Upon arrival to our trauma centre, a full trauma evaluation was undertaken. The patient had stable blood pressures with tachycardia to 130 beats/minue. His initial lactate level was 4 mmol/L (nl 0.5–2.2 mmol/L) and his haemoglobin (HGB) was 10.8 g/Dl (nl 13.5–17.5 g/Dl). On physical examination, he presented with a sciatic nerve palsy with absent ankle dorsiflexion and great toe extension and absent sensation of the superficial and deep peroneal nerve distributions. Peripheral pulses were easily palpable. Radiographic imaging with an anteroposterior (AP) pelvis x-ray confirmed a grossly displaced right posterior column posterior wall acetabular fracture (Fig. 1). In addition, a right-sided posterior tibial spine avulsion was noted. Computed tomography (CT) of the patient’s abdomen and pelvis with intravenous contrast was obtained. These images revealed a pelvic haematoma, but did not show any active contrast extravasation (Fig. 2). No other orthopaedic or non-orthopaedic injuries were identified. The patient was placed into distal femoral skeletal traction and admitted to the intensive care unit for resuscitation. During his resuscitation, he received a total of 4 L of crystalloid and two units of packed red blood cells. His tachycardia as well as his lactic acidosis resolved overnight (AM lactate 1 mmol/L). The following morning, with clinical and laboratory markers showing adequate resuscitation, he was taken to the operating room for open reduction and fixation of his acetabular fracture. The patient was placed prone on a radiolucent table with the right limb in skeletal traction. A standard Kocher-Langenbeck
http://dx.doi.org/10.1016/j.injury.2015.04.030 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
G Model
JINJ-6178; No. of Pages 6 2
G.W. Chaus et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Fig. 1. AP pelvis and Judet reformatted radiographs showing a displaced posterior column posterior wall acetabular fracture. Note the significant displacement of the posterior column in the greater sciatic notch. This was thought to be the cause of the vascular injury.
approach to the posterior acetabulum was performed. A significant amount of clot was identified during the surgical approach. The free articular fragment (denoted by an * in Fig. 2) was removed from the main fracture plane; clot and debris were cleaned from the fracture lines. While reducing and cleaning the large spike on the posterior column, active arterial bleeding from the greater sciatic notch was encountered. Despite several attempts, it was not possible to stop the bleeding thus, the area was tightly packed for temporizing haemorrhage control and the decision was made to proceed with emergent angioembolization. The posterior column was fixed in a reduced position by a single 3.5 mm lag screw. This screw was placed to prevent any further vascular injury by the column fragment and protect the endovascular
intervention. The wound was provisionally closed and the patient was transported to the angiography suite for endovascular assessment. Angiography demonstrated active contrast extravasation from the internal iliac artery (Fig. 3A). An intravascular coil was placed to completely obstruct flow just proximal to this portion of the artery (Fig. 3B). With the haemorrhage controlled, the patient was transferred back to the intensive care unit for further resuscitation. Two days later, he returned to the operating room for completion of the acetabular fracture fixation. Postoperatively, the patient’s postoperative course was uneventful and he was discharged to a rehabilitation facility on postoperative day number five.
Fig. 2. Computed tomographic scans showing the acetabular fracture dislocation from the anterior inferior iliac spine through the articular surface. Note the * marking the intervening articular fragment preventing reduction of the posterior column through skeletal traction.
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
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Fig. 3. (A) Selective angiography of the internal iliac artery showing active contrast extravasation (arrow). (B) Coil placement in the internal iliac artery. There is no longer active extravasation past the arterial injury. Note the single screw holding the posterior column reduction and the retained packing.
At six week follow-up, the surgical incision had healed without any complication of infection. There was no evidence of gluteal muscle necrosis. The patient had a persistent peroneal nerve palsy that is being treated expectantly with passive stretching and an ankle foot orthosis. A current AP pelvis radiograph is shown in Fig. 4. Case 2 An 80-year-old male with type 2 diabetes mellitus and history of prostate cancer was installing siding on his home when he fell approximately ten feet off his porch. He was initially evaluated at an outside hospital and subsequently transferred to our level 1 trauma centre. On arrival to our trauma centre a full trauma evaluation was undertaken. The patient arrived with normal vital signs and
Fig. 4. Six week post operative AP pelvis radiograph.
normal laboratory parameters. On physical examination, he had a dense sciatic nerve palsy with absent ankle dorsiflexion and great toe extension and absent superficial and deep peroneal nerve sensation. He had 2+ and symmetric dorsalis pedis and posterior tibial peripheral pulses. Radiographs confirmed a grossly displaced right posterior column posterior wall acetabular fracture (Fig. 5). Additionally, a right-sided proximal humerus fracture and rightsided ankle fracture was noted. A CT scan of the patient’s abdomen and pelvis did not show any active contrast extravasation (Fig. 6). No other injuries were identified. Given the patient’s age and bone quality, surgical management of the acetabular fracture with an acute total hip arthroplasty with
Fig. 5. AP pelvis radiograph showing a displaced posterior column posterior wall acetabular fracture.
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
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Fig. 6. Computed tomographic scans showing the acetabular fracture from the anterior inferior iliac spine through the articular surface.
Fig. 7. (A) Angiography of the external and internal iliac arteries. An arrow identifies an abrupt stoppage of flow in the posterior division of the internal iliac artery with surgically applied vessel clips. (B) Coil placement in the posterior division of the internal iliac artery.
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
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a cage construct was planned. In the operating room, the patient was placed in the lateral position on a radiolucent table. A direct lateral Hardinge approach to the hip was performed. The hip was dislocated and the femoral neck cut made with an oscillating saw. After removal of the femoral head, the posterior column was directly reduced through the hip joint prior to placement of the cage fixation. As the posterior column was reduced, active arterial bleeding from the sciatic notch commenced. Approximately 2.5 L of blood was lost in approximately 2 minutes. The bleeding was temporarily controlled with sponge packing. A trochanteric osteotomy and resection of a portion of the greater sciatic notch was performed through the space provided by the femoral neck resection in order to provide access to the bleeding vessel. A large vessel was identified, isolated, and ligated with clips. Given the large volume of blood loss and continued oozing from the greater sciatic notch the area was packed, provisional wound closure performed and the patient taken emergently to the angiography suite. Angiography of the internal iliac artery showed an interruption of flow in the posterior division at the level of the multiple surgical clips (Fig. 7A). A coil was placed obstructing flow to this portion of the artery (Fig. 7B). The patient was then transferred back to the intensive care unit for further resuscitation and two days later was taken back to the operating room for completion of the posterior column fixation and total hip arthroplasty. The posterior column was reduced and held in place by screws placed through the cage construct. A cemented acetabular liner and cemented femoral stem was placed. Postoperatively, the patient did well without further complication and was subsequently discharged to a rehabilitation facility. At initial follow-up, the surgical wound had healed without any concerns for infection. As with Case number 1, there was no evidence of gluteal muscle necrosis. A postoperative AP pelvis radiograph is shown in Fig. 8. Discussion Unlike pelvic ring injuries, vascular injuries in association with acetabular fractures are less common [15,18]. The published literature includes a few case reports and small case series [2,6,8– 10,12,13,16,17,20]. In a series of 323 acetabular fractures reviewed by Porter, only 16 vascular injuries were identified [15]. All of these vascular injuries occurred with associated both column or anterior column fracture patterns. There were no vascular injuries in isolated posterior acetabular fractures. The majority of published reports we have identified in our literature search describe vascular injuries in association with anterior fracture patterns and involve the external iliac system [2,6,8,17]. Other articles report iatrogenic vascular injury or thrombosis that were identified following open reduction and fixation and were not due to the injury itself [10,12,16]. Furthermore, external iliac injury can usually be detected through a peripheral vascular examination and frequently does not present in a delayed fashion as the vascular injuries we have presented in this article. In this article, we report a significantly different clinical scenario from what has been previously reported in the literature regarding posterior acetabular fractures and associated vascular injury. Most commonly, the literature describes injury to the superior gluteal vessels and not the main internal iliac artery as illustrated by the cases in this paper. In a series of 131 posterior pattern acetabular fractures reviewed by Russell [18], there were three superior gluteal vein injuries or entrapment noted at surgery. All of these fractures were treated through a posterior approach and all three had displaced fractures extending into the greater sciatic notch. The exact fracture pattern associated with these three cases was not described. Letournel [13] reported on seven cases of superior gluteal vascular injury with displaced fractures
Fig. 8. Six week post operative AP pelvis radiograph showing a cage and cemented total hip arthroplasty.
into the greater sciatic notch. Lastly, Bosse [1] reported on the preoperative angiography of eight acetabular fractures with extension into the greater sciatic notch that were planned for an extended iliofemoral approach to determine the vascularity of the gluteal muscle flap. They incidentally identified three injuries to the superior gluteal artery. Only one other case of internal iliac arterial injury described with an isolated acetabular fracture has been reported in the literature. In a report of two cases by Ruotolo, their second case concerns a T-type acetabular fracture with internal iliac and superficial femoral arterial lacerations [7]. However, this case presented very differently from our cases. This case involved a hypotensive patient in haemorrhagic shock that went immediately to angiography and subsequently to the operating room for femoral arterial repair. This is in stark contrast to the occult internal iliac arterial injuries we present above that were identified while attempting to repair the fracture. When a vascular injury is identified, the surgical team must act quickly and definitively to obtain control of the bleeding vessel and stop the significant haemorrhage that can ensue. There is a relative paucity of specific treatment recommendations in the literature. Direct identification of the bleeding vessel and ligation versus repair of the vessel has been discussed. In the series by Russell et al. [18] they were able to isolate and ligate all three of the gluteal vein
Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030
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injuries identified in their series. They specifically discouraged the use of surgical clips and stress the importance of direct visualization of the bleeding vessel to prevent any injury to the remaining neurovascular bundle. If the bleeding is too brisk to identify and isolate the injured vessel, we advocate temporary packing. Letournel [13] first described temporary packing in his large series of acetabular fracture fixation. After 30 minutes, the packing was removed and often the bleeding had slowed to a point that it was no longer an issue. If after removal of the packing, the bleeding resumes we recommend re-packing, wound closure, and endovascular evaluation as was described in our cases. We believe that though the presentation of occult internal iliac arterial injuries with a widely displaced posterior column posterior wall acetabular fracture is uncommon and unique, it should be considered by all surgeons treating these complex injuries.
Conclusion Vascular injuries associated with acetabular fractures are rare but they can have grave consequences if they are not identified or if the surgeon is not prepared to deal with them should they occur. We presented two cases of an occult internal iliac arterial injury identified during the reduction of a widely displaced posterior column posterior wall acetabular fracture. It is important to recognise this possibility when there is a large posterior column fracture with extension into the greater sciatic notch. Preparedness to deal with high volume intraoperative bleeding should considered in these cases. Clear communication and coordination between the anaesthetic team, the surgical team, and interventional radiology is required to stabilise these critical injuries. Given these two recent cases, we propose the use of preoperative angiography in widely displaced posterior column acetabular fractures with extension into the greater sciatic notch. Preoperative angiography may serve to identify these occult vascular injuries prior to open reduction internal fixation, and prevent the surgical haemorrhage presented in this report.
Funding The authors have not received any funding for the completion of this manuscript.
Conflict of interest statement The authors report no relevant conflicts of interest in regard to this manuscript.
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Please cite this article in press as: Chaus GW, et al. Occult internal iliac arterial injury identified during open reduction internal fixation of an acetabular fracture: A report of two cases. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.030