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.