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Seat-belt aortic injury
Eur J Vasc Surg 4, 649-650(1990)
CASE REPORT Seat-belt Aortic Injury A. K. Siriwardena Vascular Surgical Unit, Royal Infirmary of Edinburgh, U.K. A case of blunt injury to the abdominal aorta is presented. A deceleration injury with seat-belt compression caused dislodgement of atheromatous fragments as emboli from an atherosclerotic aorta. Atherosclerosis is common, and the compulsory wearing of seat-belts may make this injury more frequent.
Case Report A 6 7-year-old male was a front seat passenger in a car involved in a head-on collision. He had no previous history of claudication and was a non-smoker. He was wearing a seat-belt. At the casualty department of the local hospital he complained of central chest pain and of weakness and numbness in both legs. On examination he was conscious and alert and was not shocked. Positive findings were of bruising over the sternum and bilateral weakness of all the muscle groups in the lower limbs. There was reduced sensation over the L5-$2 dermatomal distribution. Xrays revealed a minimally displaced sternal fracture. He was transferred to the Royal Infirmary. X-rays of the lumbar spine were thought to show a stable fracture of the L5 vertebral body and a radiculogram was arranged. The next day the feet were noted to be cool, mottled and pulseless and a vascular opinion was obtained. An urgent transfemoral arteriogram revealed irregularity of the aortic outline suggestive of atheromatous disease. There was no filling of the arterial system of either limb beyond the proximal calf level. He was taken to theatre. Bilateral fasciotomies were made to decompress the calf muscles. The left posterior tibial artery was explored. Pulsation was seen to stop at the mid-calf level. An arteriotomy was
Please address all correspondenceto: A. K. Siriwardena, 32 LongCrook, South Queensferry,EH309XR,U.K. 0950-821X/90/060649+02$03.00/0© 1990Grune & Stratton Ltd.
made at this level. The artery was free of atheroma but occluded by embolus which was removed by the balloon embolectomy catheter technique. The left anterior tibial and peroneal arteries were then explored and embolic material was retrieved. The right tibio-peroneal trunk was then explored and also found to contain embolic material which was removed by a similar method. Postoperatively the limbs remained critically ischaemic and bilateral amputations were subsequently required. The lumbar spine X-rays were later reported as normal by a radiologist. Histological examination of the material retrieved from both posterior tibial arteries revealed laminated thrombus encapsulating 5 m m fragments of atheromatous material. On the basis of the histological report and the operative findings of a vessel free of atheroma but occluded by flesh clot, it was concluded that these were embolic fragments of atherosclerotic vessel intima. The probable source was thought to be the abdominal aorta.
Discussion In retrospect it is possible to highlight several deficiencies in the management of this case. These deficiencies illustrate several important points in practice. Firstly, the recorded accident details make no mention of the estimated impact velocity or of the type of seat-belt worn. Secondly, the presence of a sternal fracture should raise
650
A . K . Siriwardena
the suspicion of m a j o r visceral injury. 1 Finally, if a n embolic occlusion h a d b e e n diagnosed a n d treated earlier, a m p u t a t i o n m a y h a v e been avoided. Rapid deceleration, together with t r a n s i e n t compression of the aorta w o u l d set up stresses in the vessel wall. 2'3 These s h e a r i n g forces could dislodge a t h e r o m a tous m a t e r i a l from the a o r t a as embolic fragments. This was t h o u g h t to be the m e c h a n i s m of i n j u r y in this case. A l t h o u g h b l u n t i n j u r y of the a b d o m i n a l aorta has been u n c o m m o n d u r i n g the past 20 years, 4' s the incidence of atherosclerotic disease of the aorta is t h o u g h t to be rising a n d m a y be a m a n i f e s t a t i o n of a n ageing population. 6 It is generally accepted t h a t the legislation m a k i n g the w e a r i n g of a seat-belt c o m p u l s o r y for front seat passengers has saved m a n y lives. However this case report illustrates t h a t other types of injury, possibly related to the w e a r i n g of seat-belts, m a y become more c o m m o n . I n conclusion, if a n elderly p a t i e n t presents w i t h a blunt, deceleration type of i n j u r y to the a b d o m e n , the possibility of aortic i n j u r y should be considered. A detailed history together w i t h careful physical e x a m i n a -
Eur J Vasc Surg Vol 4, December 1990
tion (including the peripheral pulses) will reduce the c h a n c e s of this treatable i n j u r y b e i n g missed.
Acknowledgement
I wish to thank Mr B. Nolan for permissionto publish details of this case.
References 1 BANCEWICZ], YATESD. Blunt injury to the heart. B r Med ] 1983;286: 497-498. 2 BLACKLAYPF, DUGGANE, WooD RFM. Vascular trauma. Br ] Surg 1987; 74:1077-1083. 3 DAJEEH, RICHARDSONIW, IYPEMO. Seat belt aorta: Acute dissection and thrombosis of the abdominal aorta. Surgery 1979 ; 75 :263-267. 4 NOLANB. Vascular injuries. J R Coil Surg Edin 1968; 13 : 72-83. 5 LASSONDE], LAURENDEAUF. Blunt injury of the abdominal aorta. AnnSurg 1981 ; 194: 745-748. 6 GOWLANDHOPKINSNF, Abdominal aortic aneurysms. Br IVied] 1987; 294:790-791. Accepted 28 Februa~ 1989
CASE REPORT Seat-belt Aortic Injury A. K. Siriwardena Vascular Surgical Unit, Royal Infirmary of Edinburgh, U.K. A case of blunt injury to the abdominal aorta is presented. A deceleration injury with seat-belt compression caused dislodgement of atheromatous fragments as emboli from an atherosclerotic aorta. Atherosclerosis is common, and the compulsory wearing of seat-belts may make this injury more frequent.
Case Report A 6 7-year-old male was a front seat passenger in a car involved in a head-on collision. He had no previous history of claudication and was a non-smoker. He was wearing a seat-belt. At the casualty department of the local hospital he complained of central chest pain and of weakness and numbness in both legs. On examination he was conscious and alert and was not shocked. Positive findings were of bruising over the sternum and bilateral weakness of all the muscle groups in the lower limbs. There was reduced sensation over the L5-$2 dermatomal distribution. Xrays revealed a minimally displaced sternal fracture. He was transferred to the Royal Infirmary. X-rays of the lumbar spine were thought to show a stable fracture of the L5 vertebral body and a radiculogram was arranged. The next day the feet were noted to be cool, mottled and pulseless and a vascular opinion was obtained. An urgent transfemoral arteriogram revealed irregularity of the aortic outline suggestive of atheromatous disease. There was no filling of the arterial system of either limb beyond the proximal calf level. He was taken to theatre. Bilateral fasciotomies were made to decompress the calf muscles. The left posterior tibial artery was explored. Pulsation was seen to stop at the mid-calf level. An arteriotomy was
Please address all correspondenceto: A. K. Siriwardena, 32 LongCrook, South Queensferry,EH309XR,U.K. 0950-821X/90/060649+02$03.00/0© 1990Grune & Stratton Ltd.
made at this level. The artery was free of atheroma but occluded by embolus which was removed by the balloon embolectomy catheter technique. The left anterior tibial and peroneal arteries were then explored and embolic material was retrieved. The right tibio-peroneal trunk was then explored and also found to contain embolic material which was removed by a similar method. Postoperatively the limbs remained critically ischaemic and bilateral amputations were subsequently required. The lumbar spine X-rays were later reported as normal by a radiologist. Histological examination of the material retrieved from both posterior tibial arteries revealed laminated thrombus encapsulating 5 m m fragments of atheromatous material. On the basis of the histological report and the operative findings of a vessel free of atheroma but occluded by flesh clot, it was concluded that these were embolic fragments of atherosclerotic vessel intima. The probable source was thought to be the abdominal aorta.
Discussion In retrospect it is possible to highlight several deficiencies in the management of this case. These deficiencies illustrate several important points in practice. Firstly, the recorded accident details make no mention of the estimated impact velocity or of the type of seat-belt worn. Secondly, the presence of a sternal fracture should raise
650
A . K . Siriwardena
the suspicion of m a j o r visceral injury. 1 Finally, if a n embolic occlusion h a d b e e n diagnosed a n d treated earlier, a m p u t a t i o n m a y h a v e been avoided. Rapid deceleration, together with t r a n s i e n t compression of the aorta w o u l d set up stresses in the vessel wall. 2'3 These s h e a r i n g forces could dislodge a t h e r o m a tous m a t e r i a l from the a o r t a as embolic fragments. This was t h o u g h t to be the m e c h a n i s m of i n j u r y in this case. A l t h o u g h b l u n t i n j u r y of the a b d o m i n a l aorta has been u n c o m m o n d u r i n g the past 20 years, 4' s the incidence of atherosclerotic disease of the aorta is t h o u g h t to be rising a n d m a y be a m a n i f e s t a t i o n of a n ageing population. 6 It is generally accepted t h a t the legislation m a k i n g the w e a r i n g of a seat-belt c o m p u l s o r y for front seat passengers has saved m a n y lives. However this case report illustrates t h a t other types of injury, possibly related to the w e a r i n g of seat-belts, m a y become more c o m m o n . I n conclusion, if a n elderly p a t i e n t presents w i t h a blunt, deceleration type of i n j u r y to the a b d o m e n , the possibility of aortic i n j u r y should be considered. A detailed history together w i t h careful physical e x a m i n a -
Eur J Vasc Surg Vol 4, December 1990
tion (including the peripheral pulses) will reduce the c h a n c e s of this treatable i n j u r y b e i n g missed.
Acknowledgement
I wish to thank Mr B. Nolan for permissionto publish details of this case.
References 1 BANCEWICZ], YATESD. Blunt injury to the heart. B r Med ] 1983;286: 497-498. 2 BLACKLAYPF, DUGGANE, WooD RFM. Vascular trauma. Br ] Surg 1987; 74:1077-1083. 3 DAJEEH, RICHARDSONIW, IYPEMO. Seat belt aorta: Acute dissection and thrombosis of the abdominal aorta. Surgery 1979 ; 75 :263-267. 4 NOLANB. Vascular injuries. J R Coil Surg Edin 1968; 13 : 72-83. 5 LASSONDE], LAURENDEAUF. Blunt injury of the abdominal aorta. AnnSurg 1981 ; 194: 745-748. 6 GOWLANDHOPKINSNF, Abdominal aortic aneurysms. Br IVied] 1987; 294:790-791. Accepted 28 Februa~ 1989