Post-traumatic rupture of the right ovary and liver after blunt abdominal trauma: A case report

Highlights • Traumatic rupture of the ovary due to blunt abdominal trauma is very rare and usually connected to ovarian cyst or teratoma.• FAST and CT-angiography missed the ovary rupture, which was revealed by the exploratory research laparotomy.• In a hemodynamic instable patient hemostasis is performed by ovarian artery ligation through laparotomy.• Injury of the ovary should always be included in the differential diagnosis of blunt abdomen trauma in female patients.


Introduction
Traumatic rupture of the ovary, due to blunt abdominal trauma, is rarely described in literature [1]. Presented here, is the case of a 21-year-old Greek, female patient who was transported to the Emergency Department complaining of abdominal pain as the result of a catapulting fall from a bicycle. It was determined that she was suffering from both right ovary and liver rupture. To our knowledge, this is the first such ever documented case in Greece.
The work has been reported in line with the SCARE criteria [2].

Presentation of case
A 21-year-old Greek, female patient attended the Emergency Department of our hospital complaining of abdominal pain after being catapulted and falling from her bicycle. The patient slipped and fell approximately five meters down a cliff. Her body weight landed on her bike and the handlebars impacted her abdomen forcefully. She had no previous medical history of trauma to the abdomen. Physical examination revealed abdominal pain of the right hypochondrium on palpation. She also exhibited scratches on her face and body. Focused Assessment with Sonography for Trauma (FAST) scan and spiral Computed tomography of the abdomen and retroperitoneal space revealed hepatic parenchyma rupture at 5, 6, 7, and 8 segments, centrally and extending to the organ capsule at the segments 6 and 7. The exploratory research laparotomy which followed showed haemoperitoneum, large liver rupture of segments 6, 7 and active bleeding at the site of the ruptured right ovary. Blood clots were present in both the Douglas and Morison spaces. The patient was treated with rinsing of the peritoneal cavity, subhepatic packing and right ovary hemostasis. Two days later, unpacking and abdomen rinsing took place. The patient had a smooth post-operative recovery and was released without any complications.
Traumatic rupture of the ovary, due to blunt abdominal trauma, is very rare and it is usually connected to former ovarian cysts or teratomas [5]. So far in the literature a multi trauma patient run over by a tractor proved to suffer from ruptured cyst of the left ovary [3]. Two cases of an 18 year-old and a 15-year-old female respectively who were overrun by high-speed vehicles are also described. They proved to suffer from ovarian rupture involving a dermoid cyst [5,6]. Another case of a 45 year-old female patient involved in a car accident also proved to suffer from ovarian rupture related to ovarian teratoma [7].
Two very rare cases of ovarian artery damage, due to ovarian artery rupture, have been reported related to aneurysm and after childbirth respectively [1,8]. Our patient was catapulted from her bicycle and fell approximately five meters down a cliff. Her body weight landed on her bike and the handlebars impacted her abdomen forcefully. As a result, extensive liver damage and ovarian rupture occurred.
Focused Assessment with Sonography in Trauma (FAST) is a worldwide accepted tool, by all medical specialties, to access trauma patients. It is a scanning protocol which provides accurate diagnoses of internal organ hemorrhage, such as hemoperitoneum, hemothorax, and hemopericardium [9]. In combination with computed tomography, angiography accurately assesses the bleeding area [1]. In our presented case, the above referred to diagnostic tools missed the ovary rupture, which was revealed by the exploratory research laparotomy (Fig. 1).
The treatment of hemorrhage, due to ovarian rupture, depends on the patients' vital signs. In a hemodynamically stable patient selective vascular embolization is performed. In a hemodynamic unstable patient, hemostasis is performed by ovarian artery ligation through laparotomy [1]. Our patient had combined liver and ovarian rupture and was therefore treated by laparotomy where ovarian artery ligation and subhepatic packing were performed.

Conclusion
Injury of the ovary following blunt abdominal trauma, although rare, should always be included in the differential diagnosis of acute abdomen in female patients.