Traumatic aortic injury and bowel injury

Case contributed by Dr Heather Pascoe


MVA driver – collision into drivers side cabin. FAST positive

Patient Data

Age: 20 years
Gender: Male

Chest, Abdomen and Pelvis



  • Traumatic aortic injury with pseudoaneurysm of the aortic arch and associated mediastinal hematoma.
  • Right lower lobe contusion.
  • Small left anterior pneumothorax.
  • Small pneumomediastinum.


  • Hemoperitoneum with blood around the liver and spleen. No identifiable injury identified but presumed minor superficial lacerations.
  • Free intraperitoneal gas clustered in the mid and lower abdomen with suspected distal ileal injury, subsequently confirmed at surgery.
  • Comminuted fracture of the right acetabulum involving the anterior column and roof, with medial displacement into the pelvis. The fracture extends into the right ilium and the superior and inferior pubic rami. No pubic symphysis or sacro-iliac joint widening. 
  • Subluxation of the right hip joint.
  • Large intramuscular hematoma of the right iliacus and psoas muscles - no active bleeding.
  • Right flank contusion.

Incidential findings:

  • Bilateral cervical ribs.
  • L4 limbus vertebra.
  • Partial sacralization of L5 on the left.
  • Schmorl’s nodes.

Case Discussion

TAI has a high mortality rate at the scene. Of those who make it to hospital, a prompt diagnosis and treatment is crucial. Direct signs of TAI include: an intimal tear/flap; irregularity of the aortic wall; a pseudoaneurysm; abrupt change in aortic caliber (pseudocoarctation) and active extravasation of intravenous contrast. The sagittal plane is usually the best plate to evaluate the contour of the aorta.

CT diagnosis of bowel and mesenteric injury can be difficult. Whilst free gas, as seen in this case, is highly specific for a diagnosis of bowel perforation, it may be seen in the absence of bowel perforation. Gas originating from a bowel rupture usually accumulates in locations deep to the anterior abdominal wall and may be seen at the porta hepatis, mesentery or mesenteric veins and portal vein. It may also be found remote to the site of perforation in the upper abdomen near the surface of the liver or along the under surface of the peritoneum.

Other CT signs of bowel injury include bowel wall thickening more than 3-4mm and abnormal enhancement. Fluid and/or air in the mesentery or fat stranding may also be secondary to bowel injury alone. Free intraperitoneal fluid is an indirect sign of both bowel and mesenteric injury however the specificity is low because of other injuries can also cause this. 

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