Penetrating lower limb trauma: An unexpected source of hemoperitoneum

Abstract text (incl. references and figure legends)

A 17-year-old male presented after stumbling over a fence and getting pierced by one of the metal spikes. He complained abdominal and right lower limb pain. The patient was agitated and his Glasgow Coma Scale scored 14. The primary survey conducted following ATLS principles¹ was altered at "C" due to hemodynamic instability. A 3cm hole at the root of the right thigh showed no external bleeding. FAST proved evidence of left and right upper quadrants and pelvic free fluid. A transitory response to fluid challenge allowed the execution of a full CT scan with contrast that confirmed hemoperitoneum and showed left pelvic hematoma (Fig1-2) without arterial blush.

The patient was transferred to the operating room for emergency laparotomy. Abdominal packing was performed starting from the left lower quadrant. Once the patient was stable, investigating the origin of the bleeding, liver, spleen and intestinal mesentery were found intact. A retroperitoneal hematoma was evident in the left hypogastric vein region, connected to the peritoneal cavity through a tearing of the serosa. The left colon was medialized to perform a focused pelvic packing. Total blood loss was 1500cc (1/3 reinfused through blood salvage). Open abdomen treatment allowed revision of the abdominal cavity after 48h in presence of a vascular surgeon. Hemostasis was granted and the area compartmentalized with a peritoneal oversewing. Air-leak tests of rectum and bladder were negative, and the thigh wound was explored and dressed. The abdomen was then closed. The post-operative course was uneventful. Hypogastric vein injury without pelvic fracture or direct penetration is a rare and dangerous entity²; immediate recognition and packing can be lifesaving.

ATLS 10th ed, American College of Surgeons Iliac vascular injury in the absence of a pelvic fracture, N. Helton et al. J Trauma Nurs 2017

Fig1: Left and right upper quadrants free fluid (blue); hematoma (red); air/spike route (green arrows)

Fig2: Spike route

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