Case Presentation: A 63 yr old gentleman with a history of ischemic stroke and hypertension presented to the ED from his assisted living center for evaluation of R hip & knee pain. The patient reported that, 5 days prior, he had bumped into another resident and fallen on his right side. He had experienced pain in his hip and knee since the fall, although was seen in another ED the day of the fall and underwent radiographic imaging which was reportedly negative. On this subsequent presentation to an ED, plain films of the hip and femur were repeated, as well as a CT of the right knee, and were unremarkable. Basic laboratory evaluation revealed a hemoglobin of 6.0, down from the last known value of 11 from two years earlier, and the patient was admitted to the hospitalist service for anemia workup. Blood pressure in the ED was 112/58 and it was noted that the patient was on three blood pressure medications at home. A full exam was not undertaken by the admitting physician in the ED due to the patient’s placement in a hallway bed, although it was noted that despite the patient’s dark skin tone, areas of ecchymosis were visible across the lateral aspect of the right hip and knee. Upon arrival to the inpatient unit, the patient’s blood pressure was 99/62 and a repeat CBC revealed a hemoglobin of 5.1. Rectal exam revealed no gross bleeding and stool was guaiac negative. The patient’s abdomen was soft and nontender; however, palpation of the entire right thigh revealed it to be swollen, tense and painful. Bruising along the inner aspect of the thigh was also noted. Occult hemorrhage into the thigh was suspected and the Trauma Surgery team was consulted for a rapid evaluation. Bedside FAST exam revealed no free abdominal fluid, but an abdominal/pelvic CT revealed extravasation into the right thigh. In light of the full CT scan, review of the earlier CT of the knee suggested the presence of a hematoma in the most superior cuts. The patient underwent urgent angiography which identified two subcentimeter pseudoaneurysms extending from the superior gluteal artery with evidence of active bleeding; both pseudoaneurysms were successfully embolized by Interventional Radiology and the patient’s condition stabilized with transfusion of three units of packed red cells.
Discussion: Anemia is a common admission diagnosis and, in the setting of syncope evaluation, hospitalists may also be asked to treat patients who have suffered from a ground-level fall. While not presently discussed in hospital medicine literature, traumatic injury to the superior gluteal artery in the setting of pelvic or acetabular trauma has been reported, albeit as case reports, in the trauma and orthopedic literature. Although a relatively rare complication, injury of this particular vessel is thought to be related to the anatomic location of this vessel in the sciatic notch, which makes it vulnerable to injury during blunt trauma to the pelvis. What is unusual about this case is both the delay in hemodynamically significant presentation of this injury and the fact that the injury occurred without concurrent pelvic fracture, as is most typically seen. Because of its anatomic location, preferred treatment of a superior gluteal artery injury is embolization as opposed to open surgical intervention.
Conclusions: Suspicion and recognition of the potential superior gluteal artery injury in a patient presenting with hypotension or new anemia in the setting of an acute or subacute fall is imperative so that the patient can be transferred, if necessary, to a facility with Interventional Radiology resources.