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Brief description/objective

Objective:
A 100 year old woman was admitted to the emergency department due to a fall in the nursing home the day before. She complained about pain in her right pelvis and the inability to walk or to bear weight on her right leg. X-ray examinations of the pelvis revealed a minimally displaced fracture of the right inferior pubic ramus only. The patient was in good health otherwise without relevant past medical and surgical history. She was admitted to the surgical ward for nonoperative treatment including analgesia and mobilisation with physical therapy. After an uneventful course with a notable improvement of her condition the patient complained about increasing abdominal pain, distension, nausea and vomiting on the seventh day after admission.

Methods:
Blood samples revealed a mild increase of the CRP level (48 mg/l) and a normal leucocyte count. Ultrasound and CT-scans of the abdomen showed a massive small bowel obstruction and fractures of the right superior and inferior pubic rami. An urgent median laparotomy was performed.

Results:
The small bowel obstruction was shown to be caused by an entraped segment of the distal ileum between the fracture fragments of the right superior pubic ramus. Manual extraction of the entraped ileum segment and closing of the peritoneal lesion was performed. As the affected small bowel was intact and well perfused no resection was necessary. The postoperative recovery was uneventful.

Conclusion:
A posttraumatic small bowel obstruction due to bowel entrapment in a pelvic fracture is a rare but severe complication if not detected and managed on time. The first recognized case of bowel entrapment in a pelvic fracture was reported in 1907. A rewiev of the literature shows 22 cases of intestinal entrapments or herniations associated with pelvic fractures. Twenty of these cases have been recorded after acetabular, sacral and iliac wing fractures due to blunt high-energy trauma. Only 2 cases of entrapment after fractures of the pubic ramus have been reported in the literature so far. It appears that we had the opportunity to observe the third case of its kind of this rare complication, this time after what is considered to be a common, low-energy injury in an elderly patient.