INVESTIGATIONS
Trauma X-rays in the emergency department included a pelvic X-ray
(Figure 1), which showed the radiopaque metal pipe’s path from the right
buttock entry point, traversing obliquely through the pelvis and lower
abdomen, with the tip lying in the left upper abdominal quadrant. No
bony injury or free air was identified.
In view of the position of the foreign object, the pelvic and abdominal
neurovascular structures, rectum, urinary bladder, uterus, vagina and
bowel were all considered to be at risk of injury. Removal of the object
in theatre under general anaesthesia was considered the safe option,
with colorectal, gynaecological, orthopaedic, vascular and
interventional radiological expertise on standby in case needed.
The case was discussed with the regional Major Trauma Centre for
immediate transfer. Their advice, however, was to perform a Computerised
Tomography (CT) scan locally prior to transfer, in order to fully assess
the extent of the injury. The extracorporeal length of the metal pipe
and base plate were unable to fit through the donut of the CT scanner.
Sawing off the base plate was considered risky in case the movement
exacerbated any internal injuries. Assistance was sought from the local
fire department, who used metal cutters to snap off and shorten the stem
to a manageable length.
The CT scan (3D reconstructed images Figures 2 and 3) demonstrated the
foreign body penetrating the right buttock close to the sciatic nerve,
traversing through the sciatic foramen, crossing the midline in contact
with the sigmoid colon, loops of small bowel within the pelvis and the
left common iliac artery. It terminated in the left upper abdomen
adjacent to multiple small bowel loops. A small volume haematoma within
the pelvis was also noted but no free air or other abdominal visceral
injuries were seen.
The above investigations required a significant amount of time including
one and a half hour for fire brigade to cut off the metal pole for the
patient to fit in the CT scanner, forty minutes for the CT scan and
report and two and a half hours of debating for trauma specialities to
accept the transfer. The total delay of transfer was three hours and
forty minutes.