Surgical Science, 2011, 2, 493-495
doi:10.4236/ss.2011.210108 Published Online December 2011 (http://www.SciRP.org/journal/ss)
Bareback Equestrian Trauma: Pubic Symphysiolysis and
Abdominal Arterial Hemorrhage*
David Spelt#, Herman Frima#, Lijckle van der Laan#
Department of Surgery, Amphia Hospital, Breda, Netherlands
Received April 11, 2011; accepted July 15, 2011; accepted September 6, 2011
Abstract
Pubic symphysiolysis and retroperitoneal arterial vessel rupture after bareback horse riding is a rare trau-
matic combination. We report a case of a 59-year-old man who experienced severe pubic, abdominal and
lower back pain due to a bounce after a asynchronous rhythm of horseback riding without a saddle. The pa-
tient was referred to our Emergency Department because of a suspected ruptured abdominal aortic aneurysm.
Computer tomography demonstrated diastasis of the pubic symphysis, active bleeding of a branch of the left
internal iliac artery and a massive retroperitoneal haematoma. The arterial bleeding was directly coiled in the
emergency setting, the stable pubic symphysiolysis was treated conservatively and the haematoma was sur-
gically drained after three days. Bareback horse riding can lead to a pelvic fracture and severe bleeding lead-
ing to haemodynamical instability and life threatening situations. Using proper protective equipment includ-
ing a saddle to prevent equestrian injury should be emphasized.
Keywords: Equestrian, Pubic Symphysiolysis, Hemorrhage, Trauma
1. Background
This report describes the case of a 59-year-old man with
a type Tile B1 Stage 1 pelvic fracture [1] and rupture of a
ventral branch of the left internal iliac artery after bare-
back horse riding. This traumatic injury after bareback
horse riding is a rare feature and a comparable case has
only been reported once [2]. Late diagnosis of intra-ab-
dominal hemorrhage can cause severe hypovolemic shock
and death, potential functional problems of the gastro-
intestinal and urogenital tract due to compression and he-
morrhagic adhesion or infection of the haematoma. The
arterial bleeding of our patient was treated with angio-
graphic coil embolisation by the interventional radiolo-
gist [3], the pubic symphysiolysis was treated conserva-
tively and the haematoma was surgically removed three
days post trauma. After three weeks of clinical recovery
there was an indication for a second laparotomy and re-
moval of remaining haematoma.
2. Case Presentation
A General Practitioner (GP) referred a 59-year-old man
to our Emergency Department under suspicion of a rup-
tured abdominal aortic aneurysm. The patient complained
of severe lower abdominal pain with radiation to the
lower back. In supine position the blood pressure was
stable at 125/90 mmHg with a solid pulse of 70 BPM.
But after trying to stand up from the bed the man had
collapsed three times. The patient arrived by ambulance
at our Emergency Department (ED). He mentioned he
had been horseback riding without a saddle that morning.
Just before the incident he was riding an asynchronous
rhythm and suddenly he landed on the bare back of the
horse with excessive force. Immediately he experienced
intense pain in the pubic region, the abdomen and suc-
cessively progressive radiating pain in the left side of the
lower back. In a few hours the abdominal pain became
unbearable and he consulted his GP. His medical history
mentioned severe obstructive pulmonary pathology, spon-
taneous pneumothorax, primary thrombocytosis, diagnosed
many years before the traumatic accident and surgical
correction of a right lateral inguinal hernia twenty-six
years earlier. His daily medication consisted of budeson-
ide/formoterolfumerate (Symbicort®) 400/12 mg inspi-
*Competing interests: The author(s) declare that they have no com-
p
eting interests.
#Authors’ contribution: All three authors were equally involved in
the manuscript design, and collection and interpretation of data. The
manuscript was written by all three authors. All authors have read and
given final approval of the version to be published and they take re-
sponsibility for appropriate portions of the content.

D. SPELT ET AL. 494
rator, tiotropium (Spiriva®) 18 mcg and Aspirin (Ace-
tosal®) 80 mg.
On arrival, we saw a very painful man with a blood
pressure of 105/65 mmHg, a heart rate of 115 BPM and
pulse oximetry indicated a peripheral saturation degree
of 99%. A swelling was visible in de midline of the
lower abdomen of 8 by 12 cm diameter with 2 cm out-
ward protrusion. No bowel sounds were heard, percus-
sion and palpation was very painful in the entire pubic
and abdominal region. Intense abdominal muscle resis-
tance was felt. There was no palpable pain over the lum-
bar spine, the pelvis was stable in all directions, but the
patient experienced severe compression pain over the
pubic region. Rectal examination was normal. The pa-
tient produced normal clear urine and no meatal blood
was seen. Pulsations of both femoral arteries were palpa-
ble, there was no pulsating abdominal mass. Neurologic
examination was normal. Haemoglobin concentration was
6.3 mmol/L (normal 8.5 - 11.0 × 10E9/L), WBC count
was 41.6 × 10E9/L (normal 4 - 10 × 10E9/L) and throm-
bocyte count was 1830 × 10E9/L (normal 150 - 400 ×
10E9/L).
Direct computer tomography (CT-scan) of the pelvis
and abdomen with early arterial and late venous contrast
was performed. This demonstrated diastasis of the sym-
physis pubis of 11.4 mm but without posterior lesions,
fracture classification Tile B1 Stage 1 [1]. In the midline,
ventral in the small pelvis, there was an active blush of
the left obturator artery with a massive haematoma (9 ×
10 × 13 cm) around this bleeding. The SI joint and hae-
matoma are seen in (Figure 1). Angiographic endovas-
cular coil embolisation (Cook, Tornado®, macro coils 6
and 3 mm) of the damaged artery was performed by the
interventional radiologist. His haemoglobin level was lo-
wered to 4.6 mmol/L for which he received two units of
packed red blood cells. The patient was admitted at the
Intensive Care Unit (ICU) of our hospital for observation
of haemodynamical parameters. After one day the patient
was transferred to a general surgery nursing unit. The
third day he developed pulmonary embolisms and a de-
crease in haemoglobin level (5.3 mmo/L). There was an
indication to start therapeutic anticoagulant treatment.
Therefore a midline laparotomy was performed to re-
move the haematoma and search for any persisting leak-
age but no active bleeding was found. During surgery
there was absence of significant pelvic instability but
evident pubic symphysiolysis. Continuation of bed rest
was indicated.
Sixteen days later a new CT-scan was performed be-
cause of progressive abdominal pain and decrease of ha-
emoglobin level (4.7 mmol/L). The scan demonstrated a
new haematoma that again was surgically removed with-
out evidence of active bleeding. Seven days later the pa-
tient fully recovered and could be dismissed from the ho-
Figure 1. CT scan: normal alignment of the posterior sacro-
iliac joint with massive retroperitoneal haematoma.
spital. Follow-up at two and six weeks revealed moderate
pain in lower abdomen and pubic region but he was fully
able to walk and had no genitourinary dysfunction or
complaints.
3. Discussions and Conclusions
Horseback riding is a common sports activity. But it
tends to be more dangerous than motorcycle riding, ski-
ing, automobile racing, football and rugby [4]. One in
four to five equestrians will be seriously injured during
their riding career [5,6]. The combination of height,
weight, force, unpredictability of the horse and the riders
position makes the latter so vulnerable [4,7]. Serious
equestrian injuries are due to falling or being bucked of a
horse and most commonly occur at home or at recrea-
tional and sporting facilities [7,8]. Of this trauma popula-
tion 11% - 14% is admitted for one or more days. Men
are less frequently (34% - 41%) involved in non-fatal
equestrian injuries. Fractures are diagnosed in 25% till
32% of all emergency room visits. 12% - 30% of all frac-
tures concern the lower trunk, lumbar spine with or with-
out a fractured pelvis [5,8]. In 6.6% of all fractures it
concerns a pelvic fracture.
Although excessive splaying force on the pelvis will
first lead to rupture of the symphysis ligament [9], it is
not known to be a common type of equestrian injury. A
combination of a fracture and haematoma is frequently
diagnosed in any type of trauma but pelvic symphysioly-
sis and arterial bleeding has rarely been documented. So
far eight cases of horse saddle-related pelvic injuries are
published in English literature. In all of these cases the
equestrian used a saddle and the type of injury was buck-
ing of the horse leading to comparable pain sensation
[1,10,11]. Together with our report eight out of nine pa-
tients were male. A reasonable explanation comes from

D. SPELT ET AL. 495
the fact that the male pelvic arch is narrower than the fe-
male arch and therefore more vulnerable to forced sepa-
ration by the horses back causing pubic symphysiolysis
[1]. Including our report three cases demonstrated ac-
companying arterial injury with severe complications. But
in two patients besides our case there was obvious pelvic
instability due to significant widening of the sacroiliac
joint [1,11]. Presumably during the accident pelvic dia-
stasis was larger than seen during imaging at the hospital.
The sacroiliac ligaments of the posterior part of the pel-
vic ring were intact causing the left and right pubic bones
to approach each other again after the impact and sym-
physiolysis.
We couldn’t find review articles that differentiated be-
tween equestrians injuries caused by horseback riding
with or without a saddle. Both utilization of proper pro-
tective equipment and implementation of safety stan-
dards are recommended regularly [4-8,12-14]. Adequate
usage of a securing saddle is mentioned less frequently
[5] although we concern a saddle as a primary prevention
safety measure. Without a saddle a rider can’t use stir-
rups that tend to give the equestrian stability and an op-
portunity to rise up from the saddle. Our patient men-
tioned he was riding in asynchronous rhythm before he
landed very hard on the bare back of the horse. With a
securing saddle and stirrups he might have been able to
correct this asynchronous rhythm and thereby preventing
his severe injury. Usage of a securing saddle should
therefore be recommended to all equestrians.
This report describes a male patient with pelvic sym-
physiolysis and accompanying arterial vessel rupture
caused by excessive pelvic forces after an asynchronous
rhythm during bareback horse riding. The bleeding in our
haemodynamical instable patient was treated with an-
giographic endovascular coil embolisation and the pa-
tient received two packed red blood cells. The pubic
symphysiolysis was treated conservatively. A retroperi-
toneal haematoma was surgically removed. Bareback
horse riding can cause pelvic fractures and arterial bleed-
ing leading to a haemodynamically instable equestrian.
The relatively low energy of the injury may create a false
sense of security; it can be a life threatening situation.
Besides the regularly recommended protective equipment
in horse riding it should be emphasized to use a securing
saddle at all times.
4. Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
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