Thoracic and abdominopelvic multitrauma

Case contributed by RMH Core Conditions

Presentation

Trauma call - pedestrian versus train. Multiple open wounds.

Patient Data

Age: 25
Gender: Male

Trauma Series

Modality: X-ray

Right upper and mid zone opacity. No displaced rib fractures identified. Right sided pneumothorax with no mediastinal shift. Cardiomediastinal contour within normal limits. 

The patient had proceeded directly to angiography before CT as they were haemodynamically unstable for management of presumed pelvic bleeding secondary to pelvic fractures. 

Angiography demonstrated distal branches of the internal iliac artery had been transected and were actively bleeding. This was successfully coiled. Gel foam embolisation was then performed for the right internal iliac artery. 

Chest

Modality: CT

Moderate right pneumothorax with an ICC in situ. Moderate subcutaneous emphysema also noted. Right upper lobe and posterior right lower lobe collapse which can be a combination of contusion and collapse/atelectasis. Minor pneumomediastinum also noted along the descending aorta.

No mediastinal haematoma. No evidence of great vessels injury. Cardiomediastinal contour within normal limits.

Significantly displaced left oblique manubrial fracture with small underlying haematoma. Mildly displaced right 1st - 4th and 6th to 9th and 11th rib fractures.

Abdomen/Pelvis

Modality: CT

Contrast extravasation within the anterior pelvis predominantly anterior to the bladder and around the embolization site, with small amount of the contrast extending superior and mixing with the moderate haemoperitoneum. Although this can be contributed from the recent intra-arterial injection, however it appears that there is disruption within the anterior bladder neck communicating with the pelvic collection.

Contrast injected during the retrograde urethrogram also noted mainly subcutaneously and within the perineum which also appears communicating with the pelvic collection. Contrast density also noted within the medial compartment of the right upper thigh which may be vascular in source.

No active upper abdominal bleeding. 3.5cm right adrenal haematoma with haematoma tracking superiorly posterior to the IVC. No extravasation of contrast from the IVC. The left adrenal gland has surrounding haemorrhage but is intact. Small left perirenal and perisplenic haematoma with allowing for the respiratory motion artifact no active bleeding or evidence of solid organ laceration identified.

Large right femoral venous line and left arterial sheath. Severely comminuted, moderately displaced, bilateral sacral fractures involving neural exit foramina. Right SIJ disruption with right acetabular and inferior pubic ramus fracture as well as pubis diastasis.

Displaced T11 - L5 right transverse process fractures.

Case Discussion

Injuries sustained:

  • right pneumothorax
  • multiple right rib fractures
  • bladder rupture at the neck with extraperitoneal and possible intraperitoneal urine leak 
  • large pelvic, moderate intraperitoneal and minor retroperitoneal haematoma
  • right adrenal haematoma
  • complex pelvis and sacral fractures
  • thoracolumbar spine transverse process fractures
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Case Information

rID: 26331
Case created: 13th Dec 2013
Last edited: 7th Mar 2016
Inclusion in quiz mode: Included

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