Polytrauma with intraperitoneal bladder rupture

Case contributed by Michael P Hartung

Presentation

Motor vehicle collision.

Right flank subcutaneous edema related to rib fractures and pneumothorax (not completely shown). 

Extensive multifocal body wall muscular injury with small foci of bleeding. 

Traumatic right lumbar hernia. 

Bilateral iliac wing fractures. Transverse and spinous process fractures. 

Small amount of pelvic ascites (not dense). Irregularity and thickening of the bladder dome. 

CT cystogram

ct

Laceration of the bladder dome with free intraperitoneal spillage of contrast following instillation of 500 cc CT contrast via Foley catheter. 

Case Discussion

There are many distractors from the bladder injury in this case. The pattern of injury is unusual for motor vehicle collision, with extensive body wall muscular injury and bleeding, and iliac wing fractures indicating a crush-type injury of the pelvis.  

There are no findings of intraperitoneal bleeding or solid organ injury. The only indicator of a problem is the small amount of pelvic ascites. It is crucial to account for this. While very subtle on axial images, the bladder dome thickening and irregular enhancement is easier to see on the coronal and sagittal images. The patient was recalled for a CT cystogram which clearly showed the laceration of the dome with free intraperitoneal spillage of contrast (notice how it surrounds the small bowel loops), which was repaired surgically. 

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