Crush injury

Case contributed by Yaïr Glick

Presentation

A horse fell on him.

Patient Data

Age: 55 years
Gender: Male
ct

Shattered spleen with active arterial bleeding (AAST grade V). Large perisplenic hematoma.

Renal lacerations spanning the entire parenchyma, with detachment of anterior part of the inferior pole and active arterial bleeding (AAST grade IV). Large perirenal hematoma. The left kidney enhances less than its right counterpart.

Right sternoclavicular joint dislocation and cartilaginous fracture of the 1st sternocostal synchondrosis. Small accompanying retrosternal hematoma.
Fractured 1st-12th (all) right ribs; 1st, 5th, 9th, 11th and 12th fractured in 2 places. Posterior fracture of 11th and lateral of 12th are comminuted. Minimal pneumothorax around lung apex, minimal hemothorax. Subcutaneous emphysema adjacent to upper ribs.
Fractured 1st-11th left ribs. 3rd-5th fractured in 2 places. Fracture of 1st rib is comminuted.
Minimal bilateral pneumothorax and hemothorax.
Bilateral subcutaneous emphysema in the chest - adjacent to upper ribs on right and more widespread on the left.
Fracture of left transverse process of L2 vertebra.

dsa

 

The right CFA was punctured using the Seldinger technique, after administering local anesthesia under sterile conditions. The celiac trunk-splenic artery was catheterized with a catheter on a guidewire. Angiography revealed several foci of bleeding in the spleen. The splenic artery was embolized at its middle third by 6 mm and 8mm coils with a satisfactory angiographic result.
Next, the left renal artery was catheterized. Many parenchymal filling defects were demonstrated, more prominent in the inferior part of the kidney. During one of the injections, extravasation from the inferior pole was demonstrated, in agreement with the CT angiogram. Selective catheterization of the bleeding branch was performed and embolization with a Tornado® 2/3 embolization coil. Satisfactory angiographic result.
Hemodynamic improvement at the end of the procedure.
Hemostasis was carried out with ExoSeal® and manual pressure.

 

Case Discussion

Bystanders reported to the evacuating paramedics that the person fell off a horse, which fell on him.
Arrived at the ER fully conscious. BP 90-100/65-70 mmHg, pulse 120/min, 25 breaths/minute.
Among traumatic findings, CT angiography showed a shattered spleen and a grossly lacerated left kidney, both with significant arterial bleeding (AAST grade V and IV, respectively). The head and neck (not shown) were unharmed.
Embolization of the ruptured splenic artery and of a segmental left renal artery was carried out.

Disclaimer:
I, Dr Yair Glick, have no actual or potential ethical or financial conflict of interest in relation to the aforementioned devices. This case is not intended to be a personal endorsement or recommendation of these products.

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