polytrauma patients with pelvic fractures challenge the surgeon 's diagnostic , operative , and peri - operative management skills , especially because of the frequent associated injuries to the abdominal viscera .
the use of an external fixator for the initial and , in some cases , the definitive fixation of unstable , complex pelvic injuries with hemodynamic instability is effective for multiply injured patients .
we present a documented case of small bowel entrapment in a sacral fracture stabilized with an external fixator .
a 51-year - old man , with no medical history of note , was in a motorcycle accident . in the emergency room
, he presented with hemodynamic instability due to a pelvic fracture and a concomitant catastrophic soft tissue injury involving the scrotum , perineum , and anus with absence of the anal reflex .
the pelvis x - ray showed ischiopubic and ileopubic fractures associated with symphyseal disruption ( anterior posterior fracture apii , see young and burgess ) .
after the resuscitation phase , the patient underwent full - body computed tomography ( ct ) [ figure 1 ] and was subsequently transferred to the operating theater .
the white vertical arrow indicates the sacral fracture pelvis x - ray showing the external screws an exploratory laparotomy was performed to exclude abdominal organ damage , and a loop colostomy was performed for the anal incompetence .
then , the patient was admitted to our intensive care unit ( icu ) , where no bowel function was observed for the first 6 post - operative ( po ) days . on po day 7 , the patient presented with abdominal distension , elevated inflammatory indices , and fever , so we performed abdominal ct with oral and intravenous contrast looking for signs of intestinal obstruction .
the clinical hypothesis of obstruction was confirmed by the presence of numerous dilated small bowel loops with air / fluid levels ; ct showed an ileum segment trapped in the sacral fracture [ figure 3 ] .
the white horizontal arrow shows the ileum segment trapped in the sacral fracture the patient underwent an exploratory laparotomy that confirmed the cause of the obstruction ; a small bowel resection and an end - to - end manual anastomosis were thus performed .
the second post - operative period was uneventful , and the patient was discharged from the icu to a ward .
an evaluation of the rectal sphincter showed normal function ; therefore , after the peroneal wound healed , the colostomy was closed .
injured arteries , veins , and bony structures are all likely sources of blood loss .
angio - embolization is the accepted method for treating arterial bleeding , while reduction and stabilization with external fixation or other methods are considered the most appropriate for controlling blood loss from veins and bony surfaces .
the risk of hemorrhage makes major pelvic fractures one of the most serious skeletal injuries , with substantial mortality .
in addition , pelvic fractures are often associated with other major injuries , which can contribute to an increased mortality .
the mortality following pelvic fractures has declined radically since introduction of more effective methods of controlling hemorrhages and general trauma management .
hemorrhage control , fracture stabilization , and infection prophylaxis in cases of open fracture can be achieved with the placement of schanz screws .
post - traumatic bowel entrapment was first described in 1907 . since then , there have been only occasional reports in the literature . in a literature review , stubbart and merkley documented 19 similar cases .
the diagnosis of entrapment is often difficult and delayed . with the introduction of multi - detector ct and the associated reformatting capabilities
patients with pelvic fractures and disruptions have usually sustained high - energy trauma and have myriad other possible reasons for symptoms of ileus , obstruction , perforation , or intra - abdominal problems .
bowel injury associated with pelvic fractures or the surgical treatment thereof is relatively rare and is consequently not always ranked highly in the differential diagnosis . as with our case , most cases of distension and nausea post - pelvic fracture are thought to be due to adynamic ileus and not to mechanical obstruction .
hurt et al . stated that such ileus usually lasts 5 days , but can persist longer than 2 weeks . reported cases of bowel entrapment in pelvic fractures , especially in sacral fractures , are exceedingly rare . in most situations ,
the iliac and psoas muscles serve as buffers between the abdominal contents and posterior pelvic ring injury , protecting the peritoneum from injury and preventing the bowel from communicating with the fracture site .
although accurate prediction and prevention of this type of complication might be impossible , earlier recognition and proper treatment are reasonable ways to obtain good results .
the diagnosis is often delayed due to the difficulty distinguishing entrapment from the more common adynamic ileus .
therefore , all general surgeons who care for patients with pelvic injuries should be conscious of this potential complication and consider it in their workup of patients with post - operative abdominal symptoms after major pelvic trauma or subsequent pelvic surgery , especially in patients treated with a percutaneous technique that prevents direct visualization of the fracture and abdominal or pelvic contents .
in conclusion , clinicians and radiologists should be aware of this potentially lethal complication of pelvic fractures treatment . to exclude bowel entrapment , patients with a persistent ileus or sepsis
 the use of external fixation for the initial treatment of unstable , complex pelvic injuries with hemodynamic instability remains an effective treatment for multiply injured patients . 
 bowel entrapment within a pelvic fracture is a rarely reported , potentially fatal complication . here 
 , we report a polytrauma patient with pelvic fractures who developed an intestinal obstruction after an external fixation . at an explorative laparotomy 
 , we found an ileum segment trapped in the sacral fracture . 
 reported cases of bowel entrapment in pelvic fractures , especially in sacral fractures , are exceedingly rare . 
 the diagnosis is often delayed due to difficulty distinguishing entrapment from the more common adynamic ileus . in conclusion , clinicians and radiologists should be aware of this potentially lethal complication of pelvic fractures treatment . to exclude bowel entrapment , patients with persistent ileus or sepsis should undergo early investigations . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSIONS