Presentation
Pedestrian vs car. Blown right pupil.
Patient Data
Brain:
extradural hematoma measuring up to 30mm in depth with a marked mass effect, including midline shift and uncal herniation. Early entrapped left lateral ventricle
subarachnoid blood in the left Sylvian fissure
sulcal effacement
right temporal bone fracture extending into the mandibular fossa. Fluid in the right mastoid air cells, but no clear fracture
Chest:
ETT
bilateral dependent changes
minor contusion anterior segment RUL
Abdomen/Pelvis:
comminuted and displaced left acetabular fracture extending into the iliac wing and superior pubic ramus. The femoral head remains in the acetabulum, but the acetabulum is displaced medially into the pelvis
displaced fracture of the left inferior pubic ramus.
small fracture of the right pubic body adjacent to the pubic symphysis. There was no widening of the pubic symphysis
extensive left-sided retroperitoneal and pelvic hematomas related to the fractures
small focus of active hemorrhage medial to the acetabulum
gluteal and iliacus hematomas
Incidental findings:
previous fixation of bilateral mandibular fractures
left ovarian dermoid containing fat and tooth
physiological trace-free fluid in the pelvis
Case Discussion
Prompt identification of extradural hemorrhages is critical, as evacuation may be necessary. More than 90% of extradural hemorrhages are associated with temporoparietal, frontal, or parieto-occipital fractures.
Pelvic fractures increase the risk of mortality primarily because of hemorrhage, so always look for active bleeding when a pelvic fracture is identified.