Abdominal, Pelvis and Hip Trauma

Question 1

What are the most common forms of abdominal trauma?

Answer 1

• Blunt abdominal trauma
  
  • • Compression forces
  • • Deceleration forces
• Penetrating abdominal trauma

Question 2

What effect do compression/concussive forces have on the abdomen as a form of blunt trauma?

Answer 2

Cause tears and subcapsular haematomas in solid organs (liver) and increase intraluminal pressure in hollow ones (stomach)

• Rupture or burst injury of a hollow organ by sudden rises in intra-abdominal pressures
• Crushing effect

Question 3

What effect do deceleration forces have on the abdomen as a form of blunt trauma?

Answer 3

Cause stretching and linear shearing between relatively fixed and free objects

• “seat belt sign” - linked with intraperitoneal injury
• lap belts cause hyperflexion at the waist

Question 4

How is abdominal trauma assessed?

Answer 4

• establish if a haemoperitoneum that is increasing in size exists - determines the need for a laparotomy
• plain film radiograph is not indicated unless there is a suspicion of a foreign body

Question 5

What is projection imaging used for in cases of abdominal trauma?

Answer 5

• Fractures – nearby visceral damage
• Free intraperitoneal air
• Foreign bodies and missiles

Question 6

How is CT used for imaging abdominal trauma?

Answer 6

• Accurate for solid visceral lesions and intraperitoneal hemorrhage
• Guide nonoperative management of solid organ damage
• IV not oral contrast

Question 7

What are the disadvantages of CT when imaging abdominal trauma?

Answer 7

• insensitive for injury of the pancreas, diaphragm, small bowel, and mesentery

Question 8

Why is angiography used for diagnosing/assessing abdominal trauma?

Answer 8

• To embolize bleeding vessels or solid visceral hemorrhage from blunt trauma in an unstable pt
• Rarely for diagnosing intraperitoneal and retroperitoneal hemorrhage after penetrating abdominal trauma

Question 9

Why is ultrasound used for imaging abdominal trauma?

Answer 9

• To detect whether intra-abdominal free fluid is increasing rather than defining the exact site of injury
• To triage patients who might require surgery
• F A S T - Focused Assessment for the Sonographic examination of the Trauma patient
  
  • • kidney, spleen, liver, subcostal heart view

Question 10

What is a Diagnostic Peritoneal Lavage (DPL) and how is it performed?

Answer 10

A surgical diagnostic procedure to determine if there is free-floating fluid in the peritoneal cavity

• Local anaesthesia
• Vertical incision at point 1/3 distance from umbilicus to pubic symphysis
• Linea alba divided
• Catheter inserted
• Aspiration attempted
• Washout with saline and analysis

Question 11

What does the physiological evaluation of penetrating abdominal injuries focus on?

Answer 11

• Peritonitis - inflammation of peritoneum (from organ rupture or infection_
• Haemodynamic instability - unstable/abnormal blood pressure

Question 12

What are the common intra-abdominal injuries from stab wounds?

Answer 12

31% stab wounds

• Liver - 40%
• Small bowel - 30%
• Diaphragm - 20%
• Colon - 15%

Question 13

What are the common intra-abdominal injuries from gunshot wounds?

Answer 13

64% gunshot wounds

• Small bowel - 50%
• Colon - 40%
• Liver - 30%
• Abdominal vascular structures - 25%

Question 14

How is penetrating abdominal trauma managed?

Answer 14

Thoracoabdomen

• Big concern is diaphragmatic injury
• • 7% of thoracoabdominal wounds
• Diagnostic evaluation:
  
  • • CXR (haemothorax or pneumothorax)
  • • Diagnostic peritoneal lavage
  • • FAST
  • • Thoracoscopy

Question 15

What types of pelvic fracture are there?

Answer 15

• Pelvic ring fractures
• Acetabular fractures
• Avulsion fractures

Question 16

What are the signs of a major injury to the pelvis?

Answer 16

• Lots of force required to disrupt the ring
• Bruising, swelling, tenderness, pain and crepitus
• Hypovolaemic shock
• Ruptured urethra
• Other viscera
• Neurological signs

Question 17

What do we look for to spot pelvic ring fractures?

Answer 17

• Main pelvic ring
• Two secondary rings (obturator foramen)
• Sacro-iliac joints - widths should be equal
• Symphysis pubis
  
  • • superior surfaces should be in alignment
  • • joint width of approximately 5mm
• Acetabulum

Question 18

How do acetabular fractures occur?

Answer 18

• Young - high energy trauma

* Later life - post-traumatic arthritis

Question 19

What is Judet classification?

Answer 19

A system for classifying types of acetabulular fractures.

A - posterior wall
B - posterior column
C - anterior wall
D - anterior column
E - transverse acetabular fractures

Question 20

What avulsion fractures occur in the pelvis?

Answer 20

• From muscle contractions at the site of insertion
• Athletic injuries in adolescence
  
  • • ASIS (sartorius)
  • contraction with hip extended and knee flexed (sprinting, swinging bat)
  • • Ischial tuberosity (hamstring)
    • contraction while flexed (running, hurdling)

Question 21

What is Garden’s classification?

Answer 21

System for classifying femoral neck fractures and displacements.

• Stage I - incomplete # (including impacted)
• Stage II - complete #, no displacement
• Stage III - complete #, partial displacement
• Stage IV - complete #, full displacement

Question 22

How do we judge the displacement of femoral neck fractures on a radiograph?

Answer 22

Judged by the amount of mal-alignment between the trabecular lines in the femoral head and neck on either side of the fracture line on an AP hip radiograph.

Question 23

How does hip dislocation occur?

Answer 23

• Many follow severe trauma
• 80% are posterior dislocations
• Associated fracture of acetabulum or femoral head are common

Question 24

What is developmental dysplasia of the hip?

Answer 24

• Hip joint has not formed normally
• Head is loose in socket and may be easily disolocated
• Femoral heads may appear to rest by the iliac spine