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J Trauma Inj > Volume 35(3); 2022 > Article
Heo, Kang, and Kim: Exercise-induced traumatic muscle injuries with active bleeding successfully treated by embolization: three case reports

Abstract

Muscle injuries caused by indirect trauma during exercise are common. Most of these injuries can be managed conservatively; however, further treatment is required in extreme cases. Although transcatheter arterial embolization is a possible treatment modality, its role in traumatic muscle injuries remains unclear. In this case series, we present three cases of exercise-induced muscle hemorrhage treated by transcatheter arterial embolization with successful outcomes. The damaged muscles were the rectus abdominis, adductor longus, and iliopsoas, and the vascular injuries were accessed via the femoral artery during the procedures.

INTRODUCTION

Muscle injuries are common, accounting for 10% to 55% of all injuries that occur during exercise. Traumatic muscle injuries can be classified into four groups: strain due to indirect stretching, contusion after a direct impact, laceration caused by penetrating trauma, and compartment syndrome due to increased pressure [1,2]. Strains or tears are the most common type of muscle injuries caused by an indirect mechanism in noncontact activities [1].
Traumatic muscle injuries are generally managed conservatively with rest, ice compression, immobilization, or medication. However, more aggressive treatments, such as surgery or percutaneous transcatheter arterial embolization (TAE), may be required in the following situations: hypovolemia with a large hematoma or active bleeding, complete rupture of the muscle belly or musculotendinous junction, or failure of nonoperative management [26].
Herein, we report the first case series of exercise-induced traumatic muscle ruptures (the rectus abdominis, adductor longus, and iliopsoas muscles) with active bleeding from indirect trauma that were successfully managed using TAE. Based on these cases, we would like to discuss the role of TAE in bleeding control of such injuries.
The Institutional Review Board and the Ethics Committee of Dankook University Hospital approved the study (No. DKUH 2022-01-019). The Institutional Review Board waived the need for informed consents because the study was conducted as a secondary review of the charts.

CASE REPORTS

Case 1

A 55-year-old female patient was admitted to the emergency room (ER) with abdominal pain that had occurred while she was performing a sit-up exercise. She had received successful curative treatment for gastric cancer and megaloblastic anemia. Her initial vital signs were stable, with a blood pressure (BP) of 138/86 mmHg and a heart rate (HR) of 87 beats per minute (bpm). A physical examination revealed tenderness in the right lower quadrant (RLQ) of the abdomen without definite signs of peritoneal irritation. The initial hemoglobin level was 13.3 g/dL. Abdominopelvic computed tomography (APCT) showed an organized hematoma in the right rectus abdominis muscle (RAM) with active bleeding (Fig. 1A, B). The patient underwent angiography, and focal active contrast leakage was found in the branch of the right inferior epigastric artery (Fig. 1C). TAE was then performed at the proximal site of bleeding using n-butyl cyanoacrylate and gel-foam (350–560 μm), and the distal part was also embolized with microcoils (Fig. 1D). Since collateral vessels to the inferior epigastric artery arise from the superior epigastric artery, both proximal and distal protection was necessary. On hospital day 5, the patient was discharged without any complications.

Case 2

A 50-year-old male patient was transferred to the ER with swelling and pain in the right inguinal area after kicking a ball while playing soccer. He had a history of hypertension and dyslipidemia. His initial vital signs were stable (BP, 138/86 mmHg; HR, 87 bpm) with a hemoglobin level of 13.5 g/dL. Despite the patient’s hemodynamic stability, APCT showed a large and non-liquefied hematoma in the right adductor longus muscle with focal contrast extravasation (Fig. 2). Contrast leakage on angiography was not obvious, despite a thorough inspection of the right profunda femoris, obturator, and medial circumflex arteries. Therefore, nonselective embolization with gel-foam was performed on the corresponding vessels in the CT. On hospital day 4, the patient was discharged with a full recovery.

Case 3

A 66-year-old male patient with a history of diabetes was admitted to the ER complaining of abdominal pain in the RLQ caused by kicking straw in a barn. The patient’s BP was 145/67 mmHg and HR was 88 bpm on arrival. A physical examination showed RLQ tenderness but no rebound tenderness. Initially, the hemoglobin level was 9.0 g/dL, but it dropped to 7.6 g/dL an hour later. APCT showed intramuscular hematoma with contrast leakage in the right iliopsoas muscle (Fig. 3). On subsequent angiography, no contrast leakage was visible in the right iliolumbar, obturator, and deep circumflex iliac arteries. However, systematic TAE of the corresponding vascular areas based on the CT scan was performed using gel-foam, and the postprocedural hemoglobin level increased to 8.5 g/dL. There were no immediate complications, and the patient was transferred to another hospital according to his request.

DISCUSSION

In indirect trauma of muscles, the main cause of injury is an eccentric contraction beyond tolerable forces of the affected muscles. Therefore, biarticular muscles containing fast-twitch type II fibers with a pennate structure are frequently involved [1,3,7]. Likewise, the injuries in all three of these cases occurred in the eccentric phase of muscle contraction after an indirect insult. In case 1, an abdominal wall injury occurred after overuse of the torso by repetitive activities. In cases 2 and 3, the thigh muscles were ruptured, corresponding to the most common location of injuries in professional kickers [8].
Although CT is the gold-standard diagnostic tool for blunt trauma, ultrasonography and magnetic resonance imaging are prioritized in acute muscle injuries due to their excellent spatial and soft-tissue contrast resolution [1,9]. Nonetheless, CT was used to establish the definitive diagnosis in the current cases, for two reasons. First, common intraabdominal pathologies should be ruled out, especially if pain is present in the RLQ and inguinal region. Second, a traumatic hemorrhage was suspected in the case 3 due to dropped hemoglobin level. A jet of contrast material within the hematoma on CT is a sign of active bleeding [6]. This radiologic finding is associated with unsuccessful conservative management, and therefore can serve as an indication of TAE [6]. Although TAE has been extensively utilized for various types of traumatic hemorrhage (e.g., solid organ injuries or pelvic fractures), with its advantages of being selective and relatively noninvasive, it has been suggested less frequently for hemostasis in muscles due to the scarcity of available data [6].
The superiority of surgery over TAE in muscle injuries, or vice versa, has not yet been proven by a well-designed study. The surgical ligation of bleeders within the muscle is limited due to the inability to localize the vascular pedicles, while an advantage of surgery is the ability to remove the entire hematoma or necrotic tissue [1,2,5]. According to Rimola et al. [5], who described the use of TAE to treat 12 patients with spontaneous RAM hematoma, a 100% hemostasis rate with no recurrence or complications was obtained. Although these results were confined to patients who underwent anticoagulation therapy, the study was the largest series demonstrating that TAE could be an effective and safe option for persistent RAM bleeding. Moreover, a lack of contrast leakage on angiography cannot guarantee the cessation of active bleeding in 10% to 20% of cases [10]. Therefore, TAE can be performed at suspicious vessels based on CT scans, as in our cases 2 and 3. Gel-foam is an excellent agent for prophylactic embolization, which promotes temporary vascular occlusion, allowing reperfusion within 2 weeks [10].
Hence, we propose reserving surgery for the following situations in traumatic muscle bleeding: TAE failure, the need to evacuate a very large hematoma or area of necrotic tissue, hemodynamic instability, and the development of compartment syndrome in any extremity. An earlier diagnosis and TAE may produce better clinical outcomes in traumatic muscle hemorrhage, if the candidates are properly selected. This suggestion must be adopted with caution, since future studies with larger samples are needed to establish detailed selection criteria for performing TAE in trauma patients.

Notes

Ethical statements

The Institutional Review Board and the Ethics Committee of Dankook University Hospital approved the study (No. DKUH 2022-01-019). The Institutional Review Board waived the need for informed consents because the study was conducted as a secondary review of the charts.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

None.

Author contributions

Conceptualization: YH, DHK; Data curation: YH, HLK; Formal analysis: YH, DHK; Methodology: DHK; Project administration: DHK; Visualization: YH, HLK; Writing–original draft: HLK; Writing–review & editing: YH, DHK.

All authors read and approved the final manuscript.

Fig. 1.
Case 1. (A) Axial and (B) coronal views of computed tomography, showing a hematoma in the right rectus abdominis muscle with extravasation (arrows). (C) Angiography showing contrast leakage in the right inferior epigastric artery branch (arrow). (D) Disappeared extravasation (arrow) after successful embolization (asterisks).
jti-2022-0028f1.jpg
Fig. 2.
Case 2. (A) Axial and (B) coronal views of computed tomography showing a hematoma with extravasation in the right adductor longus muscle (arrows).
jti-2022-0028f2.jpg
Fig. 3.
Case 3. (A) Axial and (B) coronal views of computed tomography showing an intramuscular hematoma with extravasation in the right iliopsoas muscle (arrows).
jti-2022-0028f3.jpg

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