ABDOMINAL AND

PELVIC INJURY

Associate professor Visokai V., Ph.D.

Dept. of Surgery of the First Faculty of Medicine
and Thomayer Teaching Hospital
Prague
Despite the multitude of intraabdominal
organs, and the wide variation of
presentation of injured patients, the
question is:
“Is there blood or peritoneal
contamination?”
Evaluate the abdomen during the secondary
survey. The primary goal is to decide if
surgery is necessary. If you find no need
for immediate surgery, further evaluation
of the abdomen can wait until other
urgent problems are treated.
 Regions of the abdomen
 peritoneal cavity subdivided into:
intrathoracic segment
covered by bony thorax and includes diaphragm, liver,
spleen, stomach and transverse colon
abdominal segment
 retroperitoneum
aorta, vena cava, pancreas, kidneys, ureters and
portions of duodenum and colon (injuries to this
region notoriously difficult to diagnose because
the area is remote from physical examination and is
not sampled by peritoneal lavage)
 pelvic organs
rectum, bladder, iliac vessels, internal genitalia of
women (injury also difficult to diagnose early because
of anatomical location )
 Mechanism of injury
 Blunt injury (nonpenetrating):
– time of injury
– mechanism
– estimated speed of impact
– damage to involved vehicles
– use and type of restraining device
– condition of injured persons

 Penetrating injury:
– time of injury
– type of weapon (eg knife length, handgun calibre)
– distance from assailant (particularly for shotgun wounds)
– number of stab attempts or shots
– amount of blood at scene
– prophylactic antibiotics for 24h are satisfactory for penetrating
injuries
Mechanism of injury

Blunt trauma
Pathophysiology of blunt trauma
Injury to intra-abdominal structures can be classified into 2 primary
mechanisms of injury–compression forces and deceleration forces.

 Compression or concussive forces may result from direct blows or

external compression against a fixed object (eg, lap belt, spinal
column). Most commonly, these crushing forces cause tears and
subcapsular hematomas to the solid viscera. These forces also may
deform hollow organs and transiently increase intraluminal pressure,
resulting in rupture. This transient pressure increase is a common
mechanism of blunt trauma to the small bowel.

 Deceleration forces cause stretching and linear shearing between

relatively fixed and free objects. These longitudinal shearing forces
tend to rupture supporting structures at the junction between free
and fixed segments. Classic deceleration injuries include hepatic tear
along the ligamentum teres and intimal injuries to the renal arteries.
As bowel loops travel from their mesenteric attachments,
thrombosis and mesenteric tears, with resultant splanchnic vessel
injuries, can result.
Pathophysiology of blunt trauma
 The liver and spleen seem to be the most
frequently injured organs, although
reports vary. Small and large intestines are
the next most injured organs, respectively.
Recent studies show an increased number
of hepatic injuries, perhaps reflecting
increased use of CT scanning and
concomitant identification of more injuries.
 Pathophysiology of penetrating
trauma
A GSW is caused by a missile propelled by combustion of
powder. These wounds involve high-energy transfer and,
consequently, can have an unpredictable pattern of
injuries. Secondary missiles, such as bullet and bone
fragments, can inflict additional damage. Military and
hunting firearms have higher missile velocity than
handguns, resulting in even higher energy transfer.
Close-range shotgun injuries often cause significant
tissue damage and should be considered high-energy
transfer injuries as well.
Stab wounds are caused by penetration of the abdominal
wall by a sharp object. This type of wound generally has
a more predictable pattern of organ injury. However,
occult injuries can be overlooked, resulting in
devastating complications.
 Clinical examination
 should include thoracic cage, back and pelvis including
perineal and rectal examination for anal tone, prostatic
position, blood or other evidence of injury
 gastric aspirate and urine should be inspected for blood
 listening for bowel sounds is not useful
 serious intra-abdominal pathology cannot be excluded in
presence of impaired consciousness, intellectual
disability or other injury. Even in alert patients abdominal
tenderness is absent in 25-30% of with intra-abdominal
injury. As many as 20% of patients with acute
haemoperitoneum will have benign abdominal
examination when first seen in A&E
 Clinical examination
Inspection

 Examine the abdomen to determine the presence of external signs of injury.

Note patterns of abrasion and/or ecchymotic areas.
 Note injury patterns that predict the potential for intra-abdominal trauma
(eg, lap belt abrasions, steering wheel–shaped contusions). In most studies,
lap belt marks have been correlated with rupture of the small intestine and
an increased incidence of other intra-abdominal injuries.
 Observe the respiratory pattern because abdominal breathing may indicate
spinal cord injury. Note abdominal distention and any discoloration.
 Bradycardia may indicate the presence of free intraperitoneal blood in a
patient with blunt abdominal injuries.
 The Cullen sign (ie, periumbilical ecchymosis) may indicate retroperitoneal
hemorrhage; however, this symptom usually takes several hours to develop.
Flank bruising and swelling may raise suspicion for a retroperitoneal injury.
 Inspect genitals and perineum for soft tissue injuries, bleeding, and
hematoma.
 Clinical examination
Auscultation
 Abdominal bruit may indicate underlying vascular disease or traumatic arteriovenous fistula.
 During auscultation, gently palpate the abdomen while noting the patient's reactions.

Palpation
 Carefully palpate the entire abdomen while assessing the patient's response. Note abnormal
masses, tenderness, and deformities.
 Fullness and doughy consistency may indicate intra-abdominal hemorrhage. Crepitation or
instability of the lower thoracic cage indicates the potential for splenic or hepatic injuries
associated with lower rib injuries.
 Pelvic instability indicates the potential for lower urinary tract injury as well as pelvic and
retroperitoneal hematoma. Open pelvic fractures are associated with a mortality rate exceeding
50%.
 Perform rectal and bimanual vaginal pelvic examinations to identify potential bleeding and injury.
 Perform a sensory examination of the chest and abdomen to evaluate the potential for spinal cord
injury. Spinal cord injury may interfere with the accurate assessment of the abdomen by causing
decreased or absent pain perception.
 Abdominal distention may result from gastric dilation secondary to assisted ventilation or
swallowing of air.
 Signs of peritonitis (eg, involuntary guarding, rigidity) soon after an injury suggest leakage of
intestinal content. Peritonitis due to intra-abdominal hemorrhage may take several hours to
develop.

Percussion
 Percussion tenderness constitutes a peritoneal sign.
 Tenderness mandates further evaluation and probably surgical consultation.
 Diagnosis
Lab Studies
In recent years, laboratory evaluation of trauma victims has been a
matter of significant discussion. Commonly recommended studies
include serum glucose, complete blood count (CBC), serum
chemistries, serum amylase, urinalysis, coagulation studies, blood
type and match, arterial blood gas (ABG), blood ethanol, urine drug
screens, and a urine pregnancy test (for females of childbearing
age).
 Complete blood count
 Serum chemistries
 Liver function studies
 Amylase measurement
 Urinalysis
 Coagulation profile
 Blood type, screen, and crossmatch
 Arterial blood gas measurement
 Drug and alcohol screens
 Investigations
 CXR
- (preferably erect) essential.
- ? free intraperitoneal gas, herniation of abdominal contents through ruptured
diaphragm or other abnormalities
 AXR - of no benefit
 "One-shot" IVU
- inaccurate in delineating renal injury and can delay definitive treatment
 Diagnostic peritoneal lavage
indicated when there is haemodynamic instability with unreliable clinical findings (eg
due to head injury, intoxication or paraplegia) or if abdominal examination is
equivocal (eg lower rib, lumbar spine or pelvic fractures causing abdominal
tenderness and tensing) or if abdominal examination of a repeated nature is
impractical because of anticipated lengthy x-ray studies or GA for extra-abdominal
injuries
detects free blood in abdominal cavity with 97% accuracy
Clinical criteria for DPL:
Initial aspiration of >10 ml frank blood
Egress of lavage fluid through chest drain or urinary catheter
Bile or vegetable material in lavage fluid
 Rigid sigmoidoscopy: Patients with blood on rectal examination who are otherwise
being managed expectantly (mostly stab wounds) should undergo rigid
sigmoidoscopy to rule out rectal injury.
 Investigations
 CT (contrast enhanced): can detect very small quantities of blood in abdominal cavity, sensitive
method of detecting injury to solid organs (eg up to 98% sensitive for splenic injuries when IV
contrast given), detection of bowel and pancreatic lesions is less sensitive, although helical
abdominal CT has higher sensitivity for detecting blunt bowel injury , has advantage of
delineating nature of intra-abdominal injury , in absence of splenic or liver injuries the presence
of free fluid in the abdominal cavity on CT suggests an injury to GI tract and/or its mesentery,
and mandates further surgical evaluation
indications:
– to assess retroperitoneum
– indeterminate diagnostic peritoneal lavage
– DPL contraindicated
– persistent abdominal pain despite a negative DPL
– penetrating flank trauma
– mild abdominal tenderness in alert patients
contraindications: haemodynamically unstable patients

 Ultrasound : can be performed in resuscitation room without compromising resuscitation. 91-

100% sensitive and >98% specific in detecting haemoperitoneum. Less sensitive in detecting
nature of injury, particularly in liver, pancreas and bowel.
-FAST:
focused abdominal sonography for trauma
aim of assessment is to detect haemoperitoneum
sensitivity is poor in some series although specificity is high. As a result patients with a
normal FAST require further evaluation
~30% of patients with intra-abdominal injury do not have haemoperitoneum (majority do
not require intervention).
 Investigations

Ultrasound image of right flank. Ultrasound image of the left

A clear hypoechoic stripe exists flank in the same patient, with
between the right kidney and the a thin hypoechoic stripe above
liver in the area known as the the spleen and a wider
Morrison pouch. hypoechoic stripe in the
splenorenal recess.
 Diagnosis
 Angiography : almost no role in diagnosis of abdominal
trauma however transcatheter embolisation has a role in
management of persistent hepatic bleeding (not stopped
by surgery) and in patients with bleeding from a
traumatized lumbar or intercostal artery
 Diagnostic laparoscopy
-may be useful in haemodynamically stable patient
-good for looking at diaphragm and identifying need for
laparotomy but may miss specific organ injuries,
particularly of bowel
-best suited for evaluation of equivocal penetrating
wounds
 Laparotomy
 Treatment
 The patient who has free air on abdominal x-ray needs rapid laparotomy,
rather than an attempt to localize the organ rupture.

 Similarly, the patient with hypotension, left upper quadrant pain, and a
positive peritoneal lavage needs surgery now. Assume a ruptured spleen. If
it turns out to be a bruised left abdomen and a laceration of the mesenteric
blood vessels, so what? Your goal is to identify the need for surgery.

 The exam notes the location and relative severity of tenderness, and seeks
any clues such as broken ribs, or a steering wheel mark across the
abdomen. If any evidence of injury is present, make a decision about
further evaluation after the secondary survey, when the patient’s other
problems are known.

 All gunshot wounds will require surgical exploration. Some knife wounds are
managed conservatively.

 X-rays and peritoneal lavage may be used to screen for bowel laceration or
major bleeding.
 Treatment
Stabilization of Abdominal Injury
Complete the primary (ABC) survey. Infuse fluid
rapidly for the patient with evidence of shock. Examine
the abdomen during the secondary survey.
Place an NG tube and foley catheter. Cover any open
wounds to protect the viscera.
The abdominal compartment of anti-shock trousers
must NOT be inflated if the patient is pregnant, if there
is an open abdominal wound, or if rupture of the
diaphragm is suspected. Rupture of the diaphragm is
more common than realized. It should be anticipated
with any patient with a penetrating wound of the upper
abdomen or lower chest.
 Specific injuries
- blunt injuries most common cause. GI injury associated
with use of seat belts. Abdominal and pelvic injuries
more likely with side-on collisions whether occupants are
on impact or non-impact side. Liver, spleen and kidneys
organs most likely to be damaged in blunt trauma

- stab and laceration wounds. Entry sites do not accurately

predict nature of deeper injury. Thoracic injury should be
suspected with upper abdominal wounds and vice versa.
Note that the diaphragm extends as high as T4 in
expiration Intra-abdominal injury occurs in 44% of
anterior abdominal wounds, 29% of flank wounds and
15% of back wounds. Organs most likely to be affected
are liver, small bowel, colon and stomach
 Splenic injury

 the spleen is the most commonly injured organ in blunt

abdominal trauma. Hypotension from hemorrhage is the
most common presenting finding
 when associated chest or neurological injuries are severe
minor splenic injury may not initially be detected unless
further investigation is undertaken. Left rib fractures
associated with a 4 times increased odds of splenic
injury but if this is the only risk factor the incidence of
splenic injury is low.
 minor trauma may cause injury to enlarged spleen (eg
from malaria, lymphoma, haemolytic anaemia )
 Splenic injury
Clinical Findings:

The injury should be suspected when the 9-10th

ribs on the left are fractured, or when left upper
quadrant tenderness and tachycardia are
present. Commonly the patient complains of
pain in the left shoulder — but this is usually not
present for an hour or two. Peritoneal signs such
as rebound sensitivity and guarding will be
delayed until the blood has had time to cause
local irritation of the peritoneum.
 Splenic injury
Diagnosis:

Any patient with tachycardia or hypotension and

left upper quadrant tenderness is assumed to
have a ruptured spleen until proven otherwise.
Establish the diagnosis by peritoneal lavage in
patients with evidence of significant
hemorrhage, or by CT scanning in those who are
stable.
 Splenic injury

Splenic laceration Subcapsular haematoma

 Splenic injury
Treatment:

 immediate splenectomy indicated in patients with severe multiple injuries,

splenic avulsion, fragmentation or rupture, extensive hilar injuries, failure of
haemostasis, peritoneal contamination from GI injury or rupture of diseased
spleen
 conservative non-operative approach:
-stable patients <55 yrs in whom associated abdominal injuries have
been excluded
-observe in hospital for 10-14 days, bed rest for 1 week
-no strenous activity for 6-8 weeks
-no contact sports for 6 months
-NB delayed rupture and haemorrhage may occur. Usually in first 48 h
 nonoperative management of children with splenic or hepatic injury
-if patient is haemodynamically stable
-requires replacement of <1/2 of estimated blood volume (ie requires
<40 ml/kg)
-free of concomitant intra-abdominal injury requiring exploration
-splenectomy avoided in >90% of children (only 13-50% of adults).
 polyvalent pneumococcal vaccine should be given after splenectomy
Splenic injury
 Hepatic injury
 the liver may be lacerated by either blunt or penetrating trauma.
Liver laceration is common. Biliary tract injury is unusual, and
harder to diagnose
 second most commonly injured after blunt abdominal trauma
 most frequently missed injury in trauma deaths
 diagnosis made at laparotomy in unstable patients and by CT in
stable patients. Latter enables conservative treatment in selected
patients, particularly children. Patients should be stable, have no
associated abdominal injuries, and be assessed repeatedly, including
follow up CT
 dilutional coagulopathy and thrombocytopaenia are common
following hepatic repair
 complications of liver injury:
– early: relate to hypoperfusion or massive blood transfusion
– late: sepsis
 Hepatic injury
Clinical Findings:

In blunt trauma, there will often be fractures of

the 7-9th ribs overlying the liver. Right upper
quadrant tenderness will be present. Rebound
sensitivity and guarding will not be present until
blood has been in the abdomen long enough to
cause peritoneal irritation — about two hours.
 Hepatic injury
Diagnosis:

Suspect liver laceration when penetrating trauma

involves the right lower chest or right upper abdomen,
or when right upper quadrant tenderness accompanies
blunt trauma. If the patient is stable, a CT scan of the
abdomen may demonstrate a laceration that can be
managed non-operatively. If the patient is in shock, or
has other urgent injuries, perform peritoneal lavage to
confirm intraperitoneal hemorrhage. Finding bile on
peritoneal lavage means biliary tract injury.
Hepatic injury

Liver laceration
 Hepatic injury
Tretament:

 Non-operative management. Criteria:

– haemodynamically stable
– absence of peritoneal signs
– other intra-abdominal injury can be excluded with
reasonable certainty
– limited on-going transfusion requirements
 Operative management
– packing and limited surgery may be best initial
procedure particularly when coagulopathy or
hypothermia develops
 Hepatic injury
Liver injuries are also classified by grade:
(I) nonbleeding capsular tears, <1 cm deep;
(II) lacerations, 1-3 cm deep and <10 cm long;
(III) laceration, >3 cm deep;
(IV) parenchymal disruption involving 25-75% of
a lobe or 1-3 segments;
(V) parenchymal disruption of >75% of a lobe or
>3 segments or juxtahepatic venous injury; and

(VI) hepatic avulsion.

 Hepatic injury
 Operative management of liver injuries

can involve many techniques, including simple packing

or wrapping, local hemostasis, and resectional
debridement. Knowledge of hepatic anatomy is crucial,
because exposure and vascular control are necessary for
the safe repair of injuries. Packing may successfully
control minor hemorrhage; however, packs may need to
be left in place and the abdomen closed temporarily.
After resuscitation is complete, the patient may return to
the operating room for removal of the packs, at which
point bleeding is most often resolved.
Hepatic injury

Liver laceration
 GI tract injury
 more common following penetrating trauma
 <5% of patients following blunt trauma. More
common following direct blow to epigastrium
 both DPL and CT may fail to diagnose duodenal
perforation or haematoma. A high index of
suspicion should be maintained in patients with
persistent abdominal pain and tenderness
 appearance of transverse linear ecchymosis on
abdominal wall (seat belt sign) or presence of
anterior lumbar compression fracture should
raise suspicion of intestinal injury
 GI tract injury
 stomach:

exposure and thorough inspection of the

stomach is necessary to evaluate and treat
penetrating injuries to the stomach. This is
facilitated by opening of the gastrocolic
ligament, which allows entrance into the lesser
sac. Injuries extending into the lumen may be
repaired quickly with a stapling device.
 GI tract injury
 duodenal rupture
-classically encountered in the intoxicated unrestrained driver
involved in a frontal impact RTA. 40% have associated injury
-bloody NG aspirate should raise suspicion of injury
-contrast CT are indicated in high-risk patient following
completion of secondary survey. (Alternative: duodenal "C-
loop" gastrograffin studies
Injuries to the duodenum are graded as follows:
(I) hematoma;
(II) partial thickness laceration;
(III) laceration disrupting <50% circumference of D1, D3, D4, or
50-75% circumference of D2;
(IV) laceration disrupting 50-100% circumference of D1, D3, D4, or
>75% circumference of D2, or involving the ampulla or distal
common bile duct; and
(V) massive disruption of the duodenopancreatic complex or
devascularization of the duodenum.
 GI tract injury
 duodenal rupture
-classically encountered in the intoxicated
unrestrained driver involved in a frontal impact RTA.
40% have associated injury
-bloody NG aspirate should raise suspicion of
injury
-contrast CT are indicated in high-risk patient
following completion of secondary survey.
(Alternative: duodenal "C-loop" gastrograffin
studies
 colon injury
-rare following blunt trauma
 GI tract injury
Clinical Findings:

Symptoms are caused by the intestinal contents,

rather than blood loss. Stomach rupture causes
rapid onset of burning epigastric pain, followed
quickly by rigidity and rebound sensitivity. Small
bowel and colon injury may present only with
vague generalized pain, with peritonitis following
after hours. Duodenal injury may cause back
pain.
 GI tract injury
Diagnosis:

The diagnosis of bowel rupture is made by

finding free air on abdominal x-ray. Use a
decubitus or cross-table view for the patient who
cannot stand for an upright view. Duodenal or
sigmoid colon injury may result in
retroperitoneal air only. Peritoneal lavage will
show WBCs and intestinal content, except for
retroperitoneal duodenal or sigmoid rupture.
Contrast examination may be required in
equivocal cases, if surgery is not indicated for
another reason.
 GI tract injury
Treatment:

Surgical repair is required.

- duodenum: the Kocher maneuver is used to mobilize the duodenum, along

with the pancreatic head and distal common bile duct, so that penetrating
injuries can be fully explored. Grade V injuries require
pancreaticoduodenectomy, which is often done as a staged procedure in the
unstable trauma patient.
- If less than 50% of the bowel circumference is disrupted, the defect can be
closed in a transverse fashion with sutures or staples.
- In the unstable patient, a damage-control procedure may be performed,
with control of contamination and resection of devitalized segments without
anastomosis. The patient returns to the operating room within 24-48 hours
for reexploration, resection of any further devitalized segments, and
restoration of continuity with one or more anastomoses.
GI tract injury

Rupture of the ileum

 Pancreatic injury
 often associated with duodenal, hepatic and splenic
trauma
 clue to diagnosis is in history. Most often due to direct
epigastric blow compressing pancreas against vertebral
column
 also occurs in association with lower thoracic or upper
lumbar vertebral #s
 contrast CT most useful investigation but may not
identify significant pancreatic trauma in the immediate
post-injury period. Helical abdominal CT identifies
approximately 2/3.
 initial raised plasma amylase does not predict pancreatic
or hollow viscus injury. Subsequent rise in amylase over
next 24 h more useful
 Pancreatic injury
 Pancreatic injuries are graded according to the
presence or absence of ductal injuries:

Grades I and II include superficial or major

laceration or contusion without ductal injury,
respectively.
Grade III injuries are distal transections without
duct injury or tissue loss.
Grade IV lacerations involve proximal transection
or parenchymal injury involving the ampulla.
Grade V injuries are massive disruptions of the
pancreatic head.
 Pancreatic injury
Clinical Findings:

Suspect the injury with any localized blow to the

abdomen. The patient often experiences vague
upper and mid-abdominal pain that radiates into
the back. Hours after the injury, generalized
peritoneal irritation may reveal the presence of
traumatic pancreatitis.
 Pancreatic injury
Diagnosis:

Serum amylase determinations are usually not

helpful in the acute setting. A CT scan
establishes the diagnosis. Equivocal cases can
be investigated with ERCP (endoscopic
retrograde canulation of the pancreas) once
other injuries have been stabilized.
 Pancreatic injury
 Treatment

Grade I and II injuries can be managed conservatively, but

Grade III injuries are best treated with distal pancreatectomy and
splenectomy.
Grade IV injuries require near total pancreatectomy with
reconstruction of pancreatic drainage into the gastrointestinal tract
with either Roux-en-Y pancreaticojejunostomy or
pancreaticogastrostomy. If the patient is too unstable, wide
drainage of pancreatic tissue without anastomosis may be
necessary.

-severe injuries to the body of the pancreas are best managed by

distal pancreatectomy
-the majority of penetrating injuries can be managed with stump
drainage alone.
-pancreaticoduodenectomy indicated in -fewer than 5% of
cases.
 Pancreatic injury
 Complications:

1. fistulae
2. abscess
3. pseudocyst are common
 Urinary tract and renal injury
 more common after blunt than penetrating
injury
 identification and treatment of other major
injuries takes precedence
 gross haematuria requires investigation (CT is
examination of choice if haemodynamically
stable), while microscopic haematuria does not
unless there is unexplained shock. Degree of
macroscopic haematuria not related to severity
of injury
 Urinary tract and renal injury
 majority of renal injuries can be treated conservatively
 bladder rupture commonly associated with pelvic
fractures
>95% have macroscopic haematuria
Retrograde cystography is investigation of choice
Intraperitoneal rupture requires operative repair
while extraperitoneal rupture can be treated
conservatively
 urethral trauma should be suspected if there is blood at
meatus, perineal injury or abnormal position of prostate.
Treatment is suprapubic drainage and delayed definitive
repair
 Kidney injury
 Kidney injury is common with falls and
automobile accidents. Suspect it with
fractures of the 11th-12th ribs or flank
tenderness. If hematuria (to any degree)
is present, the nature of the injury must
be determined. Kidney lacerations can
bleed extensively into the retroperitoneal
space.
 Kidney injury
Clinical Findings:

The ruptured kidney usually presents with pain

on inspiration in the abdomen and flank, and
CVA tenderness. Gross hematuria will almost
invariably be present, but the injury can still
occur with only microscopic hematuria. Flank
discoloration is a late finding that will never be
present in the emergency department. The
contused kidney can present with identical
findings.
 Kidney injury
Diagnosis:

Differentiating between the lacerated kidney and the

contused kidney requires IVP examination or CT scan. If
a contrast study such as an aortogram is required for
another reason, the kidneys can be assessed during the
course of that study. The lacerated kidney will show
leakage of dye, whereas the contused kidney will either
be normal or show a “blush” of dye in the kidney
stroma. A non-visualizing kidney implies severe rupture
or avulsion of the renal pedicle.
 Kidney injury
Treatment:

The contused kidney is simply observed.

Some kidney lacerations can be managed
non-operatively. Surgical consultation is
mandatory for any kidney that shows
extravasation of dye.
 Kidney injury
Injuries to the kidney are also graded according to
severity, as follows:

(I) contusion;
(II) lacerations, <1 cm;
(III) lacerations, >1 cm;
(IV) lacerations to the collecting system; and
(V) vascular avulsion.
 Diaphragmatic injury
 <5% of cases of blunt trauma
 left sided in 80%
 suspect with penetrating injury below 5th rib
 diagnosis may be difficult, especially in presence
of IPPV, and may only become evident when
ventilatory support withdrawn
 ultrasound may be better than CT because of its
variable angle of view. Laparoscopy provides
good views of diaphragm
 spontaneous healing does not occur
 Diaphragmatic injury
 Penetrating injuries to the diaphragm are graded
as follows:
– (I) contusion;
– (II) laceration, <2 cm;
– (III) laceration, 2-10 cm;
– (IV) laceration, >10 cm; and
– (V) total tissue loss, >25 cm2.

 Lower grade injuries may be repaired either via

laparotomy or with laparoscopic or thoracoscopic
techniques.
 Pelvic injury
 Associated with a mortality of 13-23% and
significant morbidity. In majority of
patients massive retroperitoneal
haemorrhage is direct cause or a major
contributing factor to mortality
 Mechanism of injury:
Significant pelvic fractures are due to high
energy blunt trauma. Usually a RTA, fall or
crush injury.
 Pelvic injury
 Clinical features:
-suggested by pain on movement,
structural instability, gross haematuria,
peripelvic ecchymoses
-rectal examination mandatory to identify
rectal injury and prostatic position
-if patient has a stable pelvic fracture
hypotension is probably due to
haemoperitoneum
 Pelvic injury
Management:
 bleeding is usually bony or venous in origin
 if patient is still haemodynamically unstable perform early open DPL.
If grossly positive laparotomy should precede external fixation or
angiography. If positive by cell count only risk of major intra-
abdominal haemorrhage is low and control of pelvic bleeding
becomes main priority
 early stabilization with external fixators helps to minimize bleeding
from veins and small arterioles near # sites. Also reduces volume of
an open pelvis and thus improves tamponade
 pelvic angiography with embolization often successful in controlling
arterial haemorrhage but logistically difficult
 large vessel bleeding requires surgical control
 early operative stabilization of complex pelvic fractures preferred in
ICU: facilitates respiratory care, pain control and early mobilization
 compound fractures involving perineum, rectum or vagina require
aggressive surgery to avoid high mortality
 Complications of comminuted
fracture of the pelvis
Acute:
 major haemorrhage (leading cause of death); shock, elevated intra-
abdominal pressure
 visceral and soft tissue injury: fractures may be compound into the
perineum or vagina, or be associated with lacerations into the rectum or
bladder (esp. with lateral compression and vertically unstable injuries).
 urethral injuries common in males. Iinsertion of a urethral urinary catheter
contraindicated
 sacral plexus injury
 ileus
 pain
 fat embolization
 acute respiratory distress syndrome: in about 15%. This is possibly related
to the frequent occurrence of associated thoracic injuries, multiple blood
transfusions, shock, and fat embolization.
 DVT because of stasis resulting from prolonged bed rest, and prophylaxis is
often contraindicated
 Complications of comminuted
fracture of the pelvis
Late:
 infection-second most common cause of
death
 disability/immobility/instability
 incontinence
 pain
 Retroperitoneal haemorrhage
- frequent following blunt trauma
- commonly caused by injury to:
lumbar spine
pelvis
bladder
kidney
- less commonly pancreas, duodenum, major vessels:
cause central rather than lateral or pelvic haematomas
- CT with enteral contrast most useful investigation in
stable patient
- central haematoma should be explored with proximal
vascular control
- lateral or pelvic haematomas should not be explored
unless there is evidence of major arterial injury,
intraperitoneal bladder rupture or colonic injury
Thank for your attention