14.3 Abdominal & Pelvic Trauma

Question 1

Abdominal trauma

Answer 1

• Abdominal organs only partially protected by skeletal structures
• Injury patterns vary (stab = predictable, gunshot = varying)
• Solid organ injury vs Hollow organ injury vs Mixed
• Direct vs Indirect

Slide 2

Question 2

Organs involved: Solid organ injury

Answer 2

• Liver (1) and spleen (2) most commonly injured intra- abdominal organs
• Biliary tree also vulnerable to penetrating injury
• Blood loss and Hypovolaemic shock
• Infection risk after splenectomy (OPSI) – S. Pneumonia, H. Influenza and N. Meningitides, Malaria

Question 3

Organs involved: Hollow organ injury

Answer 3

• Distal Oesophagus, Stomach, Duodenum, Small Bowel and Colon
• Penetrating injury risks
• Specific injury patterns such as the handle bars from a bicycle that can cause small bowel perforations

Question 4

Retroperitoneal organ injury

Answer 4

• Diagnostic challenge due to lack of symptoms
• Hollow retroperitoneal = parts of the Duodenum, the descending and ascending colon, and distal part of the rectum
• Solid organs = pancreas and the kidneys
• Great vessels also retroperitoneal

Specific injury patterns can injure specific structures (high level of clinical suspicion is mandated to not miss these injuries):
- Penetrating wound to the flank (ascending and descending colon)
- Blunt trauma to epigastrium (duodenum)
- Fractures of the T12 to L2 vertebral bodies (pancreas)
- Rectum is retroperitoneally for 2/3 of its lateral wall and 1/3 of its anterior wall

Question 5

Vascular injury

Answer 5

• Large vessels in retroperitoneal area (venous structures = low pressure system)

Retroperitoneal haematomas have different management depending on the vessel injured, as well as the mechanism:
- Zone 1 haematomas (centrally located, between the renal hilum and above the pelvic brim. The IVC and Aorta, along with major branches are the concern)
- Zone 2 haematomas (lateral to the renal hilum, and mostly includes bleeding from the kidney itself)
- Zone 3 Haematomas (pelvic haematomas past the pelvic brim. These vessels are difficult to access surgically and therefor bleeding can be difficult to control, making endovascular a popular treatment option)

Question 6

Urogenital organ injury

Answer 6

• Kidneys are partially protected by partially the ribcage, surrounding muscles, and the retroperitoneal location (both blunt and penetrating trauma)
• Ureters are not particularly susceptible to blunt trauma, however penetrating trauma does carry a risk
• Bladder, similar to the rectum, has both and intra and an extra peritoneal component

Question 7

Diaphragmatic injuries

Answer 7

• Blunt -, penetrating- and often occult injury

Left > Right
- Most tears occur posterolateral and larger than 10cm
- Due congenital weakness of the fusion between the costal and lumbar diaphragmatic muscular attachments

Varied presentation and based on:
- extent and location of injury (right versus left hemidiaphragm)
- presence and extent of abdominal viscera displacement
- presence of other injuries

• Chest = negative pressure, Abdomen = positive pressure
• Presence of small defect in the diaphragm = blood supply is compromised leaving bowel strangulated or necrotic. Viscera can even rupture into the pleural cavity

Slide 8

Question 8

Pathophysiology

Answer 8

• bleeding
• peritonitis
• bile peritonitis
• pancreatitis
• urine
• renal failure
• GIT failure

Question 9

Injury location

Answer 9

Slide 10

• Thoracoabdominal
• Anterior abdominal
• Posterior abdomen and flank
• pelvis

Question 10

Pelvic trauma
Mechanism

Answer 10

• Small linear fractures or fractures of the inferior and superior pubic Rami (in isolation, these fractures are often not clinically relevant)
• The following patterns however, can result in significant bleeding, with the patient potentially loosing 1/3 of their blood volume into their pelvis (vascular or bone). In addition to the fracture, the high velocity needed to create these injuries often mean that additional pelvic organs are injured.

Question 11

Associated injuries with pelvic fractures

Answer 11

• Blood vessels (may cause haemodynamic instability)
• Nerves (sacral plexus)
• Urinary system
• Bladder injury can be both intraperitoneally (i.e. freely ruptured into abdominal cavity such as occurs with penetrating trauma or blunt trauma to a full bladder) or extra peritoneally (in such cases as pelvic fractures
• Gynaecological system
• Rectum