Presentation
Motor cycle accident.
Patient Data
Age: 40
Gender: Male
Chest, Abdomen and Pelvis
From the case:
Multitrauma with diaphragmatic rupture and pelvic fractures
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Chest
- Left central diaphragmatic rupture with intrathoracic displacement of the stomach, small bowel, splenic flexure and mesentery.
- Left lower lobe collapse and left 10-12th rib fractures.
- Small left pneumothorax.
- Pneumomediastinum - may be related to the diaphragmatic rupture or reflect an esophageal or tracheobronchial injury.
Abdomen/Pelvis
- Comminuted fractures of the superior and inferior pubic rami bilaterally without widening of the pubic symphysis.
- The markedly comminuted left superior pubic ramus fracture extends intra-articularly into the left acetabulum (anterior column and roof) and superiorly into the left iliac crest.
- The right superior pubic ramus fracture extends into the anterior wall of the right acetabulum.
- Hip joints are congruent bilaterally.
- Comminuted fracture of the anterior aspect of the right sacral ala extending into a slightly widened right sacroiliac joint.
- Minimally displaced fractures of S1-S3 with extension into the right anterior S1-S3 foramina and the right posterior S2 foramen. Adjacent presacral hematoma.
- Minimally displaced fracture through the posterior cortex of the right PSIS.
- Right internal oblique and piriformis muscle hematoma. Bilateral adductor hematomas.
- No active bleeding associated with the pelvic fractures (delayed images of the pelvis were also obtained which did not demonstrate any active bleeding).
- Right L2-L5 transverse process fractures.
- Left L2 transverse process fracture.
- Small amount of fluid adjacent to the superior pole of the left kidney which may be related to a small traumatic renal injury.
- Large volume of extraperitoneal blood anterior to the grossly distended urinary bladder and within the presacral space.
Incidental findings
- A prominent serpiginous bronchial artery arises from the medial aspect of the junctions of the thoracic arch and descending thoracic aorta responsible for the appearance of a contrast filled structure of the origin of the descending thoracic aorta.
- Calcified right hilar lymph nodes.
Case Discussion
In the trauma setting, pneumomediastinum can be due to blunt chest trauma or, less commonly, from injury to the tracheobronchial tree or esophagus. CT is useful for evaluating for a suspected tracheobronchial or esophageal tear but even if present, the injury may not be visible.
The pelvis functions as a ring and hence when a disruption is identified, there must be a high suspicion for disruption at another location. Hence if you find one fracture, look hard for another. Pelvic fractures increase the risk of mortality primarily because of hemorrhage so always look for active bleeding.
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