Page 13 - Journal of Special Operations Medicine - Fall 2014

mission. Of the cases demonstrated in our series, two re- imaging, though the sensitivity for detection of hema-
quired ICU admission, one required transfer to a facility toma in blunt pelvic trauma may be low. 6
with ICU care, and two others required admission to our
step-down unit and general surgery service, respectively.
Pelvic hematoma can cause frank hemorrhage requiring Conclusion
blood products and has been linked to femoral nerve Military operations, including routine training missions,
4,5
palsy from extension deep to the iliacus. These injuries are fraught with risk. Injuries from static-line parachute
may be treated surgically, with angiographic emboliza- operations abound and vary widely in presentation, al-
6–8
tion, or nonoperatively. At the least, they will cause though, due to their mechanism, such injuries usually fit
acute pain and functional restriction for the patient last- a common pattern. In this case series, we report on an
ing days to several weeks. 2,4,5 This functional delay can injury commonly overlooked. While pelvic hematoma
9
be disastrous in combat operations. accompanying fracture is well reported in the medical
literature, hematoma without fracture remains ob-
7,8
In line with the Eastern Association for the Surgery of scure. Cunningham et al. reported only two previously
2
Trauma Evaluation of Blunt Abdominal Trauma Guide- documented cases of the injury in the civilian medical
lines, we recommend a reasoned approach to the patient literature—and, until now, only one single case of pelvic
presenting with blunt abdominal or pelvic trauma from hematoma without fracture after blunt trauma from mil-
2
10
parachute injury. For management of such patients, we itary parachute injury was known. Unlike each of our
initially recommend ruling out a pelvic fracture. If any cases, this previously reported patient was discharged
signs of hypotension are present, the patient should be from the ED and managed conservatively, although he
resuscitated accordingly. When satisfaction of search for presented several additional times for care and required
other causes of hypotension is complete, a pelvic hema- close follow-up.
toma should be considered. These injuries can be noted
on FAST exam, but the study of choice is CT with in- Pelvic vascular injury from blunt trauma remains an
travenous contrast of the pelvis. We finally recommend important cause of morbidity and mortality in military
early surgical evaluation and admission. When in an parachute operations and civilian trauma alike. In this
austere or nonpermissive environment, we cannot stress series, we report five cases of pelvic hematoma without
enough the importance of a high index of suspicion and associated pelvic fracture requiring immediate inpa-
serial exams. tient medical or surgical management. We posit that
this injury is far more commonplace and with greater
Each of the patients in our case series was evaluated morbidity than currently thought. Further studies are
with careful exam and CT (Table 1). A FAST exam, used needed to determine the rate at which these pelvic he-
in two cases, provided important initial evaluation of matomas expand and to extrapolate what determines
hematoma size, notably in one of the patients presenting admission criteria. Additionally, the exact mechanism
with acute hemodynamic instability. In that case, FAST of these injuries must be determined. We know that
led to the initial discovery of a large fluid collection in the rate of descent with the improved parachute de-
the pelvis that was later classified as displacing hema- sign is slower—could this injury be due to the opening
toma on CT. shock of the parachute, the shearing forces caused by
a full bladder coupled with the opening shock of the
Our case series reinforced the use of CT in the hemody- parachute, or the shearing forces caused by a full blad-
namically stable patient presenting after blunt trauma der on impact with the parachute-landing fall? Further
to the lower abdomen or pelvis, even in the setting of analysis is required. The consequences of nonrecogni-
negative plain films. For those patients presenting with tion or inappropriate management of these injuries in
hemodynamic instability, FAST remains an important a military unit focused on combat readiness could be
first step, with follow-on CT for further evaluation and catastrophic.
localization of injury once the patient becomes stable.

Acknowledgments
Additionally and importantly, we note that plain films
alone might be insufficient in the patient presenting with The authors would like to thank Dr Y. Sammy Choi, Dr
acute pelvic, inguinal, or back pain after blunt trauma. Cristobal Berry-Caban, and MAJ Grigory Charny, MD,
The diagnosis in each of our cases was made with CT, MS, for their assistance with the manuscript.
and in cases of delayed presentation, diagnosis has been
confirmed with magnetic resonance imaging. Ultra-
4
sound may play a role in the acute setting either before Disclosures
further study or in the absence of availability of further The authors have nothing to disclose.

Traumatic Pelvic Hematoma After a Parachute Jump 5