Abdominal and Pelvic Trauma

Question 1

How can fractures of the lower ribs or penetrating wounds between the nipple line and the costal margins result in injury to abdominal viscera?

Answer 1

This is because the diaphragm rises to the 4th IC space during full expiration so the abdominal organs can still be injured.
-also worry about diaphragm, liver, spleen and stomach injuries which can lie beneath the rib cage.

Question 2

Name the retroperitoneal organs (8)

Answer 2

1. Abdominal aorta
2. IVC
3. Most of the duodenum
4. Pancreas
5. Kidneys
6. Ureters
7. Posterior aspects of the ascending and descending colons
8. Retroperitoneal components of the pelvic cavity (bladder, rectum, reproductive organs)

These can be injured from a penetrating or traumatic back injury.

Question 3

What is the most frequently injured abdominal organ in blunt trauma?
-2nd and 3rd most frequently injured abdominal organ?

Answer 3

Spleen!!!! (40-55%)

• 2nd = liver
• 3rd = small bowel

Question 4

What is a bucket handle injury of the bowel and what is the most common mechanism of injury causing bucket handle injuries?

Answer 4

Bucket handle injury = tear or avulsion of the mesentery off the bowel
-usually caused by a lap seat belt

Question 5

What historical features should be obtained for every patient in an MVC?

Answer 5

1. Speed of vehicle
2. Type of collision (frontal, lateral, side, rear, rollover)
3. Vehicle intrusion into the passenger compartment
4. Types of restraints
5. Deployment of air bags
6. Patient’s position in the vehicle
7. Status of passengers

Question 6

In patients who have sustained injuries from an explosive device, what two factors increase the likelihood of visceral overpressure injuries?

Answer 6

1. If explosion occurred in an enclosed space

2. Injuries increase with decreasing distance of the patient from the explosion

Question 7

What are physical exam findings of an open pelvic fracture?

Answer 7

1. Blood at the urethral meatus
2. Swelling or bruising or laceration of the perineum, vagina, rectum or buttocks
3. High riding prostate

Question 8

What are contraindications to foley catheter insertion in a trauma patient?

Answer 8

1. Blood at the urethral meatus
2. Unstable pelvic fracture
3. High riding prostate
4. Scrotal hematoma or perineal ecchymoses
5. Inability to void

**Get a retrograde urethrogram to confrm an intact urethra before inserting a foley catheter

Question 9

You would like to insert an NG tube to decompress a patient’s belly but they have signs of facial fractures/basilar skull fractures on exam. What should you do instead?

Answer 9

Can insert OG tube instead so that you don’t pass the tube through the cribiform plate into the brain

Question 10

What 3 types of injuries can be easily missed by CT abdomen?

Answer 10

1. Diaphragmatic injuries
2. GI injuries
3. Pancreatic injuries

Question 11

What is the best test to diagnose the following injuries:

• urethral injury
• bladder rupture
• kidney injuries

Answer 11

• urethral injury: retrograde urethrogram (urethrography)
• bladder rupture: cystogram or CT cystography
• kidney injuries: CT with contrast (intravenous pyelogram is an alternative if CT isn’t available)

Question 12

What are the indications for laparotomy in patients with penetrating abdominal wounds? (4)

Answer 12

1. Any hemodynamically abnormal patient
2. Gunshot wound with transperitoneal trajectory
3. Signs of peritoneal irritation
4. Signs of abdominal fascia penetration

Question 13

What are the indications for laparotomy in adult patients with abdominal injury?

Answer 13

1. Blunt abdo trauma with hypotension with a positive FAST or clinical evidence of intraperitoneal bleeding
2. Blunt or penetrating abdo trauma with a positive DPL
3. Hypotension with a penetrating abdominal wound
4. Gunshot wounds traversing the peritoneal cavity or visceral/vascular retroperitoneum
5. Evisceration
6. Bleeding from the stomach, rectum or GU tract from penetrating trauma
7. Peritonitis
8. Free air, retroperitoneal air or rupture of hemidiaphragm
9. Contrast enhanced CT that demonstrates ruptured GI tract, intraperitoneal bladder injury, renal pedical injury, severe visceral parenchymal injury after blunt or penetrating trauma

Question 14

What are the 3 organs predominantly injuries after blunt trauma?

Answer 14

1. Spleen
2. Liver
3. Kidney

Question 15

What are signs of a possible diaphragmatic injury on CXR?

Answer 15

1. Elevation or blurring of the hemidiaphragm
2. Hemothorax
3. Abnormal gas shadow that obscures the hemidiaphragm
4. Gastric tube positioned in the chest

***A lot of these may be asymptomatic on presentation so need to keep a high clinical suspicion!

Question 16

Which is more common: left diaphragm injury or right diaphragm injury?

Answer 16

Left!

Question 17

What are two common mechanisms of injury causing duodenal injuries?

• what clinical features should raise your suspicion for a duodenal injury?
• what is the best diagnostic test?

Answer 17

1. Bicycle handlebar injuries (direct blow to abdomen)
2. Unrestrained drivers in frontal-impact MVCs

• **Clinical features:
  1. Bloody gastric aspirate
  2. Retroperitoneal air on a supine AXR or abdo CT

***Best diagnostic test: remember that regular CT scans can miss duodenal injuries so instead, order an upper GI or double-contrast CT (ie. IV + oral contrast)

Question 18

What is the percentage of patients with blunt renal injuries who are treated non-operatively?

Answer 18

> 95%! Only rarely do you need surgical repair of blunt renal injuries

Question 19

How do you differentiate between an anterior and posterior urethral injury?
-what are the most common mechanisms of injury for each?

Answer 19

Anterior = below/anterior to the urogenital diaphragm
-usually results from a straddle impact and can be isolated injuries
Posterior = above/posterior to the urogenital diaphragm
-usually seen in patients with multisystem injuries and pelvic fractures

Question 20

What is the management of solid abdominal organ injuries in hemodynamically stable patients?
-what about hemodynamically unstable patients?

Answer 20

Hemodynamically stable patients = non-operative

Hemodynamically unstable patients = urgent laparotomy

Question 21

What two vascular structures can be injured by pelvic fractures?

Answer 21

1. Pelvic venous plexus

2. Internal iliac arterial system

Question 22

What is the mortality in patients with any type of pelvic fractures?

Answer 22

1 in 6!!! (ie. 5-30%)

Question 23

What are the 4 patterns of force leading to pelvic fractures?

Answer 23

1. AP compression: usually from auto-pedestrian collision or MVC, direct crushing injury to pelvis or fall from height > 12 feet
   - usualy get disruption of the pubic symphysis and tearing of the posterior osseous ligamentous complex (ie. all the ligaments holding the sacrum in place) and thus, get a sacroiliac fracture/dislocation or sacral fracture = this is considered an UNSTABLE pelvic fracture!!!
   - with opening of the pelvic ring, there is increased risk of hemorrhage from the posterior pelvic venous complex and occasionally branches of the internal iliac artery
2. Lateral compression: usually from MVCs = get internal rotation of the involved hemipelvis which actually compresses the pelvic volume and thus life-threatening hemorrhage is not common since the pelvis is already squished in
3. Vertical shear: can disrupt the sacral ligaments and thus lead to pelvic instability and bleeding
   - usually results from a fall
4. Complex/combination

Question 24

A patient comes in with a suspected pelvic fracture and is hemodynamically unstable. What can you do to slow or stop the bleeding?

Answer 24

1. Internally rotate the lower limb to reduce the pelvic volume (since pelvic fractures usually cause external rotation of the pelvis)
2. Place a pelvic binder or sheet at the level of the greater trochanters of the femur to compress the pelvis together
3. Arrange for emergent angiographic embolization