Abdominal

Trauma

dr. Sri Indah Aruminingsih, Sp.Rad

1
 Outline
Introduction
Background Anatomy

Mechanisms and Pathophysiology

Clinical assessment

Conclusion
 INTRODUCTION
Trauma is the commonest cause of death in
young people.
ABDOMINAL TRAUMA STANDS THIRD NEXT
TO HEAD INJURY AND CHEST INJURY
25% of all major trauma victims require
abdominal exploration.
Abdominal evaluation is the challenging
component of evaluating trauma.
Penetrating torso injuries b/n nipple & perineum
is a potential intra abdominal injury.
Mechanism, Force & Location of injury &
Hemodynamic status determine the priority &
best method of assessment. 3
 75% OF ALL BLUNT TRAUMA TO ABDOMEN
INVOLVES ROAD TRAFFIC ACCIDENT

60% OF INJURY OCCUR IN MALES (14-30)

Trauma related deaths form 3 Peaks

First Peak accounts 50% die instantly or
very soon.
Second Peak accounts 30% in hours of
injury due to severe blood loss.
Third Peak accounts 20% in days to
weeks due to infection/multi organ failure.
4
 Background Anatomy
Anterior abdomen
Flank
Back
Intraperitoneal space contents
Retroperitoneal space contents
Pelvic cavity contents

5
 Anterior abdomen:
Trans-nipple line, Anterior axillary lines,
Inguinal ligaments and Symphysis pubis.
Flank:

Anterior and posterior axillary line;

Sixth intercostal to iliac crest.
Back:

Posterior axillary line; Tip of scapula to

Iliac crest.
 Upper Peritoneal cavity
Covered by lower aspect of bony thorax. Includes Diaphragm, Liver,
Spleen, Stomach, Transverse colon.

Lower Peritoneal cavity:

Small bowel Ascending and Descending colon, Sigmoid colon

Retroperitoneal space:
A Potential space Behind true abdominal cavity
Abdominal Aorta, Inferior vena cava, Parts of Duodenum, Pancreas,
kidneys, Ureters and posterior aspects of Ascending and Descending
colons

Pelvic cavity:
Rectum, Bladder, iliac vessels and Internal genitalia in women.
 The Abdomen
Everything between diaphragm and
pelvis
Injuries very difficult to assess
because of large variety of structures

8
 Abdominal Anatomy
Abdomen divided into four quadrants
by body mid-line, horizontal plane
through umbilicus
Organ located by quadrant

9
Abdominal Anatomy
Right Upper Quadrant
Liver
Gall Bladder
Right Kidney
Ascending Colon
Transverse Colon

10
Abdominal Anatomy
Left Upper Quadrant
Spleen
Stomach
Pancreas
Left Kidney
Transverse Colon
Descending Colon

11
 Abdominal Anatomy
Right Lower Quadrant
Ascending Colon
Appendix
Right Ovary (female)
Right Fallopian Tube (female)

12
 Abdominal Anatomy
Left Lower Quadrant
Descending Colon
Sigmoid colon
Left Ovary (female)
Left Fallopian Tube (female)

13
Abdominal Anatomy
Organs can be classified as:
Hollow
Solid
Major vascular

14
 Solid Organs
Liver
Spleen

Kidney

Pancreas

When solid organs are

injured, they bleed heavily
and cause shock
15
 Hollow Organs
Stomach
Gall bladder

Large, small intestines

Ureters, urinary bladder

Rupture causes content

spillage, inflammation of
peritoneum
16
 Major Vascular
Structures
Aorta
Inferior vena cava

Major branches

Injury can cause severe

blood loss ; exsanguination
(bleeding out)
17
 1. Abdominal Aorta
2. Common Iliac Artery
3. Internal Iliac
Vascular Anatomy 4. External Iliac
5. Superior Gluteal
6. Obturator Artery
 Can you tell me
What are the top 3 most commonly
injured organs in the abdomen?
Spleen (40-55%)
Liver (35-45%)
Small bowel (5-10%)
Mechanisms
Blunt trauma:
Motor Vehicle Accident
Seat belt injury
Penetrating injuries:
Stab wounds
Gun Shot wounds
Blast
Bomb
Crush

Building collapse
Thermal
 Blunt Trauma
Motor vehicle collisions

Motorcycle collisions

Pedestrian injuries

Falls

Assault

Blast injuries
Penetrating Trauma
Stab wounds

Gun Shot wounds

Surgical Incisions
Blunt Abdominal trauma is the
commonest cause of death in younger
population with Polytrauma in RTA.

Blunt abdominal injuries carry a

greater risk of morbidity and
mortality than penetrating
abdominal injuries.
Mostly due to
Inadequate diagnosis
Delayed resuscitation
Delayed surgery
Mechanism of Injury:
Blunt
Motor Vehicle Accident

Seatbelt injury
 Pathophysiology
1.Compression/Concussive forces
Direct blow
External compression vs. fixed object (e.g. lap belt, spinal
column)
Cause
Tears & Sub capsular hematoma to solid
viscera.
Deform hollow organs & transiently Inc.
intraluminal pressure.
2. Deceleration forces
Stretching & Linear shearing b/n relatively fixed & free object.

In BAT, Organs that cant yield to impact by elastic

deformation are most likely to be injured i.e. solid
organs
26
 Rapid deceleration
Shearing Force created that cause solid, visceral
organs and vascular pedicles to tear at relatively fixed
points of attachment. Differential movements of fixed
and non-fixed structures
(e.g. liver and spleen laceration at sites of supporting ligaments)
Crushing effect

B/n anterior abdominal wall and vertebral

column/posterior cage
(e.g. direct blow to the epigastrium with crushing of the
pancreas over the spine)
Compressive effect
Sudden dramatic rise in Intra-abdominal pressure due
to external compression, hollow viscus ruptures
(e.g. direct blow to liver or blowout of the bowel)
27
 Motor Vehicle Accidents
The most common cause of blunt trauma
is the motor vehicle Injuries

Major global public health challenge but

most of it occurs in low- and middle-income
countries including Ethiopia.

Every year about 1.2 million people

are killed and more than 20 million
are injured or disabled
28
 Contributing Factors

Poor road network

Absence of knowledge on road traffic safety
Mixed traffic flow system
Poor legislation and failure of enforcement
Poor conditions of vehicles;
Poor emergency medical services

Traffic accident compulsory insurance law is in

effect Recently.
29
 Seatbelt injuries
Although seatbelts reduce mortality overall, they
cause a specific pattern of internal injuries.

Patients with seatbelt marks have been found

to have a fourfold increase in thoracic trauma
and an eightfold increase in intra-abdominal
trauma compared with those without seatbelt
marks

The three-point shoulder-lap belt is the most

effective restraining system and is associated
with the lowest incidence of abdominal injuries.
 Use of seatbelts is thought to reduce the risk
of death or serious injury for front-seat
occupants by approximately 45%.
Unbelted rear-seat occupants are also at
increased risk of serious injury in motor vehicle
accidents (MVAs); they may be ejected or
thrown forward into the back of the front seat;
the impact from unbelted rear-seat passengers
on front-seat occupants can be a major
determinant of injury.
It is estimated that, when rear seatbelts are
worn, the risk of death for belted front-seat
occupants is reduced by 80%.
In direct frontal MVAs, airbags provide a
reduced risk of fatality of approximately 30%. 32
 Compression
Of the bowel between the belt and the
vertebral column, an acute short closed-loop
obstruction occurs along with perforation
secondary to the sudden generation of high
intraluminal pressures.
Clinically, two symptom patterns emerge.

~1/4 of pt. develop evidence of a hemoperitoneum

secondary to mesenteric lacerations.

In the remainder 3/4 of pt. the intestinal injury most

commonly involves the jejunum contusion or
perforation.

Rare cases of acute abdominal aortic dissection

with incomplete or complete occlusion have also
been described, and injuries to the lumbar spine
are not uncommon.
Mechanism of Injury:
Penetrating
Kinetic Energy imparted to body

Low velocity: Knife

Ice pick

Medium velocity: Gunshot wounds

Shotgun wounds

High velocity: High-power hunting rifles

Military weapons
Pathophysiology

Depends on the
Type of weapon
Velocity of bullet
Distance b/n assailant & victim

Typically follow the tract/trajectory of the

inflicting instrument & thus involve
contiguous structures.
 Stab Wounds
Multiple in 20% of cases

Involve the chest in up to 10% of cases

Most stab wounds do not cause an

intraperitoneal injury

The incidence varies with the direction of

entry into the peritoneal cavity

The liver, followed by the small bowel, is the

organ most often damaged by stab wounds.
 Knives are not the sole implement
used in stabbings.

Ice picks, pens, coat hangers,

screwdrivers, and broken bottles.

Most commonly in the upper

quadrants, the left more commonly
than the right???
 Gunshot Wounds
Handguns, Rifles, and Shotguns
crush Bones
The degree of injury depends on
Amount of kinetic energy imparted by the
bullet to the victim
Massstretch
of the bullet and the square of its
Tissues
velocity
Distance
 General Principles of GSW
Low-velocity injury (<1000ft/sec), damage is
confined to missile tract.
High-velocity injury (<2000ft/sec), blast effect
& cavitation occur in addition to damage by
missile tract.
85% of ant. GSW violate the peritoneum; of
these 95% require repair of intra abdominal
injury.
Organs occupying the most space are more
often injured
Small bowel(29%)
Liver(28%)
40
Colon(23%)
 Type I wounds : long range (>7 yards) , a
penetration of subcutaneous tissue and
deep fascia only.

Type II wounds : distance of (3 to 7 yards)

and may create a large number of
perforated structures.

Type III wounds : occur at point-blank

range (<3 yards) and involve a massive
destruction of tissue

*1yard=0.9meter
Small bowel injury is the most
common injury resulting from ___
abdominal trauma.

penetrating
blunt
Small bowel injury is the most
common injury resulting from ___
abdominal trauma.

penetrating
blunt
CLINICAL ASSESSMENT

HISTORY

PHYSICAL EXAMINATION
 Primary goal is to identify that an injury
exists, not necessarily making an accurate
diagnosis.

The patient's history may be unobtainable,

elusive, or temporarily abandoned while
resuscitative measures are carried out.

History from prehospital care team or

transferring hospital : the vital signs,
physical assessment, prehospital course,
and response to therapy should be obtained

Mechanism of injury is an important factor

in developing a high index of suspicion; thus
a detailed history is helpful if available.
 Assessment: History
Mechanism
MVC:
Speed
Type of collision (Frontal, Lateral,
Sideswipe, Rear, Rollover)
Vehicle intrusion into passenger
compartment
Types of restraints
Deployment of air bag
Patient's position in vehicle
Kehrs Sign???
In blunt trauma: MVA
Details about accident

Fatality at the scene

Vehicle type and velocity

Whether the vehicle rolled over

Patient's location within the vehicle

Extent of intrusion into the passenger compartment

Extent of damage to the vehicle

Steering wheel deformity

Whether seat belts were used and, if so, what type

Whether front or side air bags were deployed

All patients involved in deceleration injuries and

bicycle injuries should be suspected of having
intraabdominal injury
In penetrating trauma: GSW/MSW
No. of shots or stabs?

Type of weapon?

Number of shots heard?

Position of the patient when shot?

Distance of the patient from the gun?

What instrument was used?

How long and how wide was the instrument?

How was the patient positioned during the

stabbing?
What path did the implement travel?
Assessment: Physical
Exam
 PHYSICAL EXAMINATION
General Examination : Relating to
hemodynamic stability (Vital Signs)
Abdominal findings:
Inspection :
For abdominal distension
For contusions or abrasions
Lap belt ecchymosis
Mesenteric, Bowel, and Lumbar spine injuries
Periumblical (Cullen sign) and
Flank (Grey Turner Sign) ecchymosis
Retroperitoneal hematoma
 PHYSICAL EXAMINATION cont.
Palpation :
For tenderness, guarding and/or rigidity,
rebound tenderness hemoperitoneum
Percussion :
Dullness/ shifting dullness
Intraabdominal collection
Auscultation : Where to auscultate &
What to listen for??? All four quadrants
for the +/- nce of bowel sounds
The classical
seatbelt sign.
The bruising on
the left breast is
from the shoulder
belt and the low
bruising to the
abdominal wall is
from the lap belt.
 PHYSICAL
EXAMINATION cont..
Rectal findings
Check for gross blood - Pelvic fracture
Determine prostate position High riding
prostate Urethral injury
Assess sphincter tone Neurologic status
Distal pulses
- Assess for absence or asymmetry

Assessment of other associated injuries i.e.

multiple fractures, spinal injuries etc.
 Associated with
fractures
Left lower six ribs Spleen
Right lower six ribs Liver
Upper Lumbar Pancreas and
vertebra Duodenum
Transverse Kidneys
Process
Bladder
Pelvis Urethra
Rectum 54
 Reliability of clinical
evaluation
Low sensitivity
Unreliable in 35/45% of pt.

Why??

Head Injury
Caution
Spinal A missed abdominal
Alcohol injury can cause a
preventable death.
Drug
Repeated physical examination is
55
Mandatory.
The major findings with injury of the solid
abdominal organs are those of
hemorrhagic shock. Signs with solid organ
injury include all of the following EXCEPT:

abdominal pain and tenderness

early bacterial peritonitis
development of rebound, guarding and rigidity
hypotension and tachycardia
palpable mass and radiographic mass effect (may
result from confined hemorrhage)
The major findings with injury of the solid
abdominal organs are those of
hemorrhagic shock. Signs with solid organ
injury include all of the following EXCEPT:

abdominal pain and tenderness

early bacterial peritonitis
development of rebound, guarding and rigidity
hypotension and tachycardia
palpable mass and radiographic mass effect (may
result from confined hemorrhage)
High Index of Suspicion
Mechanism
Tachycardia early, hypotension, and
pale, diaphoretic skin late
Hypovolemic shock with no readily
identifiable cause
Diffusely tender abdomen

Pain in uninjured shoulder

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 Blunt Abdominal Trauma
Direct impact or
movement of organs
Compressive, stretching
or shearing forces
Solid Organs > Blood
Loss
Hollow Organs > Blood
Loss and Peritoneal
Contamination
Retroperitoneal > Often
asymptomatic initially
 Blunt Abdominal Trauma
Direct impact or
movement of organs
Compressive, stretching
or shearing forces
Solid Organs > Blood
Loss
Hollow Organs > Blood
Loss and Peritoneal
Contamination
Retroperitoneal > Often
asymptomatic initially
 Blunt Abdominal Trauma
Direct impact or
movement of organs
Compressive, stretching
or shearing forces
Solid Organs > Blood
Loss
Hollow Organs > Blood
Loss and Peritoneal
Contamination
Retroperitoneal > Often
asymptomatic initially
 Blunt Abdominal Trauma
Direct impact or
movement of organs
Compressive, stretching
or shearing forces
Solid Organs > Blood
Loss
Hollow Organs > Blood
Loss and Peritoneal
Contamination
Retroperitoneal > Often
asymptomatic initially
 Blunt Abdominal Trauma
Direct impact or
movement of organs
Compressive, stretching
or shearing forces
Solid Organs > Blood
Loss
Hollow Organs > Blood
Loss and Peritoneal
Contamination
Retroperitoneal > Often
asymptomatic initially
 Conclusion
Abdominal trauma is often difficult
to evaluate in the prehospital
setting. Therefore the paramedic
must exercise a high degree of
suspicion based on the mechanism
of injury and kinematics.
Death from abdominal injury usually
results from hemorrhage and
delayed surgical repair.
 The KEY to Saving
Lives
The abdomen is the Black Box
i.e, its impossible to know what specific
injuries have occurred at initial evaluation.
The Key to saving lives in abdominal
trauma is NOT to make an accurate
diagnosis, but rather to recognize that
there is an abdominal injury.

65
 Spleen
The spleen is the most commonly
injured organ in blunt abdominal
trauma
40% of all solid organ injuries
 Plain film findings for
spleen trauma
left lower rib fracture
The classic triad indicative of acute splenic
rupture
Left hemidiaphragm elevation

Left lower lobe atelectasis

Pleural effusion
Parenchymal Contusion

Hypodense intraparenchymal
area with irregular contours
 Parenchymal
Laceration
Superficial, linear
hypodensity, usually
less than 3 cm in
length
Fracture - involves
two visceral surfaces,
or if its length is more
than 3 cm
Multiple fractures -
Scattered spleen
 Subcapsular
Hematoma

Crescent-shaped perisplenic
Compresses the splenic parenchyma
Vascular Trauma

The most dangerous vascular

traumatic lesions are arterial lesions
Irregular area of increased density
relative to background spleen
Typically the attenuation value is
within 10 HU of the adjacent artery
Delayed splenic rupture
Bleeding due to splenic injury
occurring more than 48 h after blunt
trauma following an apparently normal
CT examination
Due to ruptures of subcapsular splenic
haematomas.
 Splenic CT Injury Grading Scale
Grade I Laceration(s) < 1 cm deep
Subcapsular hematoma < 1cm diameter
Grade II Laceration(s) 1-3 cm deep
Subcapsular or central hematoma l-3cm
diameter
Grade III Laceration(s) 3-10 cm deep
Subcapsular or central hematoma 3-10 cm
diameter
Grade Laceration(s) > 10 cm deep
IV Subcapsular or central hematoma > 10cm
diameter
Grade V Splenic tissue maceration or devascularization
A way to remember this system is:
Grade 1 is less than 1 cm.

Grade 2 is about 2 cm (1-3 cm).

Grade 3 is more than 3 cm.

Grade 4 is more than 10 cm.

Grade 5 is total devascularization or

maceration.
 American Association for the Surgery of Trauma ( AAST)
organ injury severity scale grading system for splenic injury

Grade 1 Small subcapsular haematoma, less than 10% of

surface area
Grade 2 Moderate subcapsular haematoma on 10 50% of
surface area; intraparenchymal haematoma less than 5
cm in diameter; capsular laceration less than 1 cm deep

Grade 3 Large or expanding subcapsular haematoma on greater

than 50% of surface area; intraparenchymal
haematoma greater than 5 cm diameter; capsular
laceration 1 3cm deep
Grade 4 Laceration greater than 3 cm deep; laceration involving
segmental or hilar vessels producing major
devascularization ( >25%)
Grade 5 Shattered spleen; hilar injury that devascularizes the
spleen
 Liver
The liver is the second most
commonly injured organ in abdominal
trauma.
Between 70 and 90% of hepatic
injuries are minor
Right lobe most commonly affected
 Associated injuries:
2/3 have hemoperitoneum
45% have associated splenic injury
33% have rib fractures
Duodenal or pancreatic injury
Biliary injury: hematobilia, biloma, biliary ascites,
bile duct disruption
Ultrasound sensitive for grade 3 or
greater
 Radiological overview of
liver injury:
Right lobe> left lobe; 3:1
Posterior segment most common
(fixed by coronary ligament)
CT imaging method of choice
Features with impact on
the management and the
prognosis
Number of segments involved by the
lacerations (significant if at least three
segments are involved)
Central or subcapsular location of the
lacerations and contusions
Extension of lesions within the porta
hepatis or the gallbladder fossa
Importance of the hemoperitoneum
Vascular lesions with active bleeding or
sentinel clot sign
The CT report should
Precisely mention the lobar or
segmental
Superficial or central topography of the
contusions
Along with their extent and location in
relation to the vascular elements.
 Classification
(AAST)
I-Subcapsular hematoma<1cm,
superficial laceration<1cm deep.
II-Parenchymal laceration 1-3cm
deep, subcapsular hematoma1-3
cm thick.
III-Parenchymal laceration> 3cm
deep and subcapsular
hematoma> 3cm diameter.
 IV-Parenchymal/supcapsular
hematoma> 10cm in diameter, lobar
destruction,
V- Global destruction or
devascularization of the liver.
VI-Hepatic avulsion
 Retroperitoneal
Hemorrhage
Retroperitoneal hemorrhage may arise
from injuries to major vascular
structures, hollow viscera, solid
organs, or musculoskeletal structures
or a combination
Small zone I (central)
retroperitoneal
hematoma
Large zone I (central)
retroperitoneal
hematoma with active
extravasation
Large zone II (lateral)
retroperitoneal
hematoma
 Pancreas
Uncommon injury
1.1% incidence in penetrating trauma
and only 0.2% in blunt trauma.
Rarely an isolated injury.

Usually part of a 'package injury'

Laceration of the
pancreatic neck
without duct injury
Pancreatic transection
(neck) with duct injury
Subtle pancreatic
contusion
 Indirect Signs
Edema with global pancreatic enlargement
and loss of lobulation
Peripancreatic fat infiltration
Peripancreatic fluid, especially if it is
located around the SMA or the omental
bursa
Hematic fluid between the dorsal surface of
the pancreas and the splenic vein
Thickening of the left anterior pararenal
fascia or fluid in the anterior pararenal
space
Concomitant duodenal injury
 AAST GRADING OF PANCREAS INJURY
Type of
Grade Injury Description of Injury
I Hematoma Minor contusion without duct injury

Laceration Superficial injury without duct injury

II Hematoma Major contusion without duct injury or tissue

loss
Laceration Major laceration without duct injury or tissue
loss
III Laceration Distal transection or parenchymal injury with
duct injury
IV Laceration Proximal transection or parenchymal injury
with probable duct injury (not involving
ampulla)b
Imaging of Renal Trauma
Computed tomography (CT) is the
modality of choice in the evaluation of
blunt renal injury
Injury to the kidney is seen in
approximately 8% 10% of patients
with blunt or penetrating abdominal
injuries
 Renal criteria for
performing CT in
abdominal trauma
Macroscopic hematuria
Microscopic hematuria with shock
Important renal ecchymosis or fracture of
the lumbar transverse process
Open trauma involving the retroperitoneum
Mechanism of deceleration (risk of pedicle
injury)
In children all types of posttraumatic
hematuria
Computed Tomography
Early and delayed CT scans through the
kidneys are necessary
Excretory-phase contrast (3min)
The preferred technique
Helical CT performed from the dome of the
diaphragm
Scanning parameters include
Collimation of 7 mm,
Pitch of 1.3,
Image reconstruction intervals of 7 mm.
Subcapsular hematoma
(category I)

Crescent shaped hyperdensity, located in

the periphery of the kidney
 Laceration
Hypodense, irregularly linear areas,
typically distributed along the vessels
and filled with blood.
They are best analyzed at arterial
phase
Superficial (<1 cm from the renal cortex)
Deep (>1 cm from the renal cortex)
Renal medulla
Collecting tubule system
Simple renal laceration
(category I)
 Major renal laceration
without involvement
of the collecting system
(category II)
 Major renal laceration
involving the collecting
system (category II)
Multiple renal lacerations
(category III)
Shattered kidney
(category III)
 Segmental Infarct
Triangular parenchymal area, with a
widest part at the cortex, which is not
enhanced during the different phases,
with clear delineation
 Segmental renal
infarction (category II)
Traumatic occlusion of
the main renal artery
(category III)
 Traumatic
occlusion of the
main renal
artery (category
III)
Active arterial
extravasation
(category III)
Laceration of the renal
vein (category III)
 Avulsion of the
ureteropelvic junction
(category IV)
 AAST organ injury severity scale grading system for kidney
injury
Grade 1 Contusion or contained and non -expanding
subcapsular haematoma, without parenchymal
laceration; haematuria

Grade 2 Non -expanding, confined, perirenal haematoma or

cortical laceration less than 1 cm deep; no urinary
extravasation
Grade 3 Parenchymal laceration extending more than 1 cm into
cortex; no collecting system rupture or urinary
extravasation
Grade 4 Parenchymal laceration extending through the renal
cortex, medulla and collecting system

Grade 5 Pedicle injury or avulsion of renal hilum that

devascularizes the kidney; completely shattered
kidney;
BLADDER INJURY
 CT Cystography

Empty the bladder

Instill the contrast retrograde through
the foley catheter of avg. 350-400 cc
of contrast
Image the pelvis
 CT classification
TYPES
1. Bladder contusion

2. Intraperitoneal rupture

3. Interstitial bladder injury

4. Extraperitoneal rupture
A. simple
B. complex (bladder neck involved)
5. Combined bladder injury
 Intraperitoneal rupture
(type 2)
Cystography
Contrast in paracolic gutters, around
bowel loops, pouch of Douglas and
intraperitoneal viscera
Pelvic fracture
CT cystography
Contrast in paracolic gutters, around
bowel loops, pouch of Douglas and
intraperitoneal viscera
 Cystogram of
intraperitoneal bladder
rupture
 Extraperitoneal rupture
(type 4)
Cystography
Simple (type 4A): Flame-shaped
extravasation around bladder
Complex (type 4B): Extravasation
extends beyond the pelvis
Extravasation best seen on post-drainage
films
 CT cystography
Perforation by bony spicules
"Knuckle" of bladder: Trapped bladder by
displaced fracture of anterior pelvic arch
Simple (type 4A): Extravasation is
confined to perivesical space
Complex (type 4B): Extravasation extends
beyond perivesical space; thigh, scrotum,
penis, perineum, anterior abdominal wall,
retroperitoneum or hip joint
"Molar tooth sign": Rounded cephalic
contour (due to vertical perivesicle
components of extraperitoneal fluid)
CT of extraperitoneal
bladder rupture

MOLAR TOOTH SIGN

 Type 5
(combined) rupture.
 URETHRAL INJURY
Urethral injury is a
common
complication of
pelvic trauma
Occurs in as many
as 24% of adults
With pelvic
fracturesTypically
involve the proximal
(posterior) portion
 CLASSIFICATION OF URETHRAL INJURIES

Colapinto & McCallum Goldman & Sandler

Grade I Posterior urethra stretched, but Posterior urethra stretched but
intact intact
Grade II Posterior urethral tear above
intact urogenital diaphragm
(UGD)
Partial or complete posterior
urethral tear above intact UGD
Grade III Posterior urethral tear with Partial or complete tear of
extravasation through torn combined anterior and
UGD posterior urethra with torn UGD
Grade IV Bladder neck injury with
extension to the urethra
Grade IVa Injury to bladder base with
extravasation simulating type
IV (pseudo grade IV)
Grade V Isolated anterior urethral injury
 Goldman type I injury

Stretching or elongation of the otherwise intact posterior urethra

Intact but stretched urethra
Goldman type II injury

Urethral disruption above the urogenital diaphragm while the

membranous segment remains intact
Contrast agent extravasation above the urogenital diaphragm only
 Goldman type III

Disruption of the membranous urethra, extending below the

urogenital diaphragm and involving the anterior urethra
Contrast agent extravasation below the urogenital diaphragm,
possibly extending to the pelvis or perineum; intact bladder neck
Goldman type IV injury

Bladder neck injury extending into the proximal urethra

Extraperitoneal contrast agent extravasation bladder neck disruption
Goldman type IVa
injury

Bladder base injury simulating a type IV injury

Periurethral contrast agent extravasation; bladder base disruption
 Intestinal and
Mesenteric Traumas
Bowel or mesentery injury occurs in
5% of patients with abdominal blunt
trauma
More common following open trauma,
especially in injuries caused by
firearms
 Four CT findings should alert the
radiologist
1. Focal fat infiltration
2. Interloop hematoma (sentinel clot sign)
3. Bowel wall thickening
4. Free intraperitoneal air
 Small Bowel Injury
Diffuse circumferential thickening
Hypoperfused "shock" bowel
Focal thickening
Usually non-transmural injury
Specific findings, rare
Bowel content extravasation
Focal bowel wall discontinuity
Most common finding
Unexplained non-physiologic free fluid (84%)
Mesenteric stranding
Focal bowel thickening
Interloop fluid
If in combination, strongly suggestive
 GI Perforation
The direct CT sign
Transparietal continuity solution, mainly
located on the mesenteric side of the bowel
The perforation may occur intraperitoneally
or retroperitoneally
 Indirect findings of
traumatic bowel
perforation
Peritoneal findings
Sentinel clot
Focal mesenteric infiltration
GI findings
Pneumoperitoneal air bubbles localized
within the mesentery
Focal wall thickening