Internal Pudendal Artery Injury Following An Open Book Pelvic Fracture: A Case Report

Abstract

Arterial haemorrhage is a potentially life threatening complication in severe pelvic ring injuries such as "open book" fractures. These injuries mostly implicate the posterior branches of the internal iliac artery. However, we report an unusual case wherein the source of bleeding was identified to be the internal pudendal artery and its branches. Patient was a 27-year-old male who presented to the emergency following an alleged history of road traffic accident and was diagnosed as a case of pelvic fracture (Young and Burgess Antero-Posterior Compression II) with sacral fracture (Denis type 2) with suspected urethral injury. Computerised Tomography (CT) angiogram revealed contrast extravasation from the right internal pudendal artery. However, digital subtraction angiography (DSA) was normal indicating spontaneous closure of the arterial bleeder. Surgical stabilisation of the fracture was carried out and subsequently, patient was discharged. This report serves to highlight that although uncommon, internal pudendal artery can be injured in hemodynamically unstable "open book" pelvic fractures and hence, must be always ruled out.

Keywords: internal pudendal artery; pelvic haemorrhage; pubic diastasis; “open book” injury.

Fig. 1:

(a) Clinical image showing bruising involving right lower anterior abdominal wall with extension into scrotal sac. (b) Radiograph of pelvis reveals “open-book” pelvic injury with fracture of the left side of the sacrum.

Fig. 2:

a) CT abdomen with pelvis, volume rendered image reveal fracture pattern identical to that seen on radiographs. (b) CT angiography reveal a small blob of contrast extravasation (black arrow) seen in right side of corpora cavernosa close to cavernosal branch of internal pudendal artery, (c) and hematoma (asterix) in right anterior abdominal wall and underlying part of peritoneal cavity.

Fig. 3:

((a) Digital substraction angiography, selective right internal iliac artery (b) and superselective internal pudendal artery angiogram did not reveal any active contrast leak. (c) Post-operative radiograph of pelvis reveals posterior plating of the sacral fracture alongwith supra-acetabular fixator application for the pubic diastasis injury.