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13 Trauma
Hepatic injury
Mechanism Most common organ injured in blunt trauma
Diagnosis Diagnostic modality Characteristics Radiology
FAST Fluid in Morison’s
pouch
Negative FAST does not
exclude hepatic injury
CT scan of abdomen Hemoperitoneum
Extravasation of contrast
Axial chest CT image with IV contrast
demonstrates a grade 4 right hepatic liver
laceration (arrow), with areas of active
contrast
extravasation (arrowhead). Adjacent
hemoperitoneum is faintly seen
473
Management
Key steps Perihepatic packing
In hemodynamically stable → non-operative management (higher rates of failure for grades
IV and V)
CTA with blush → hepatic embolization
Hemodynamically unstable → operative management
Take down ligaments to expose injury (divide triangular ligaments and falciform)
Suture ligation of bleeding vessels
Pringle Maneuver: clamp of the hepatoduodenal ligament which can stop portal and hepatic arterial
ow → Failure to stop bleeding indicates HV or IVC injury
Retrohepatic IVC injury: packing → bleeding not controlled→ IVC to right atrial shunt (Shrock) or
veno-venous bypass
Total hepatic isolation
• Suprahepatic IVC
– Incise right lateral pericardium (through chest)
– Gentle traction on dome of liver with upward traction on diaphragm (intraperitoneal)
– Incise peritoneal side of diaphragm into pericardium
• Intrahepatic IVC
– Right medial visceral rotation with a kocher maneuver
– Clamp above renal veins
• Pringle
– Supra celiac aortic clamp
Do not explore non-bleeding retrohepatic IVC injuries
474
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Hepatic injury
R. C. Gooding et al.
Recurrent bleeding
Hyperpyrexia
Complications
Hepatic necrosis
Intraabdominal/intrahepatic collection (abscess, bile)
Hemobilia: present as upper gastrointestinal bleed → CT angiography for diagnosis →
embolization
American Association of Surgery of Trauma Liver Injury scale and management
Grade Characteristics Management
Grade I Hematoma: subcapsular <10%
Laceration: capsular tear <1cm depth
Grade II Hematoma: Subcapsular 10–15%
Laceration: 1–3cm depth or <10cm length
Grade III Hematoma: subcapsular >50% or ruptured
Laceration: Intraparenchymal hematoma
>10cm and/or expanding >3cm depth
Grade IV Disrupt 25–75% lobe or 1–3 segments Nonoperative
Nonoperative management
Nonoperative management
Nonoperative
If hemodynamically unstable → operative management
(Packing →Pringle maneuver)
Consider angioembolization
Operative (packing → pringle maneuver →possible
resectional
Debridement)
Grade V Laceration >75% of a lobe or >3 segments
within 1 lobe
Juxtahepatic venous injury
Grade VI Hepatic avulsion Consider angioembolization
Consider angioembolization
Consider angioembolization
If hemodynamically unstable → operative management
Operative (packing → pringle maneuver →possible
resectional
Debridement)
Consider angioembolization
Operative (packing → pringle maneuver →possible
resectional Debridement)
13 Trauma
Splenic injury
Mechanism Most commonly occur after blunt trauma
475
Diagnosis Diagnostic
modality
FAST Fluid in splenorenal space
CT scan of
abdomen
Management Hemodynamically stable patients without active contrast extravasation, or a blush on CT scan
→ nonoperative management
Hemodynamic unstable patient or patient who met transfusion threshold (2u PRBC) or patient
who failed interventional management or patient with moderate or severe traumatic brain
injury → operative intervention
Key operative
steps
Mobilize the spleen by dividing ligamentous attachments (splenocolic ligament,
splenophrenic ligament, gastrosplenic ligament, and the splenonephric ligament)
Divide short gastric vessels
Characteristics Radiology
Negative FAST does not
exclude splenic injury
Hemoperitoneum
Hypodensity
(intraparenchymal hematoma
or subcapsular hematoma)
Contrast blush or
extravasation
Pseudoaneursym
Axial abdominal CT image with IV
contrast demonstrates extensive
splenic irregularity with areas of
hypodensity (arrow), indicating splenic
shatter. There are areas of active IV
contrast extravasation (arrowhead) and
resultant hemoperitoneum (star)
Develop a plane deep to the spleen and tail of the pancreas (identify tail of pancreas and
protect)
Obtain hilar control
Ligate and divide hilar vessels
American Association of Surgery of Trauma Splenic Injury scale and management
Grade Characteristics Management
Grade I Subcapsular hematoma <10% surface area
Parenchymal laceration <1cm in depth
Grade II Subcapsular hematoma 10–50% surface area; intraparenchymal
hematoma <5cm
Parenchymal laceration 1–3cm in depth
Grade III Subcapsular hematoma >50% of surface area; ruptured
subcapsular or intraparenchymal hematoma ≥5cm
Parenchymal laceration >3cm in depth
Nonoperative if hemodynamically
stable
Nonoperative if hemodynamically
stable
Nonoperative if hemodynamically
stable
476
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R. C. Gooding et al.
American Association of Surgery of Trauma Splenic Injury scale and management
Grade Characteristics Management
Grade IV Any injury in the presence of a splenic vascular injury or active
bleeding conned within splenic capsule
Parenchymal laceration involving segmental or hilar vessels
producing >25 percent of devascularization
Grade V Any injury in the presence of splenic vascular injury with
active bleeding extending beyond the spleen into the
peritoneum
Shattered spleen
Research
Reference Findings
Miller PR, Chang MC, Hoth JJ, Mowery NT,
Hildreth AN, Martin RS, Holmes JH, Meredith
JW, Requarth JA.Prospective trial of angiography
and embolization for all grade III to V blunt
splenic injuries: nonoperative management success
rate is signicantly improved. J Am Coll Surg.
2014;218(4):644–8
One hundred and fty-three patients with grade III–V
injuries underwent attempted NOM.Failure rate was
signicantly higher than for the protocol group (15%, p =
0.04). Protocols involving angiography and possible
embolization result in decrease failure rates of non-operative
management in grades III–V blunt splenic injuries
Colon and rectal injury
Nonoperative if hemodynamically
stable
Angioembolization
Nonoperative if hemodynamically
stable
Angioembolization
Characteristics
Presentation
Colon and rectal injuries occur more commonly after penetrating than blunt trauma
Blunt trauma more commonly causes injury to the retroperitoneal portion of colon
Rectal injuries are more common after pelvic fractures
Blood on a rectal examination
Intraperitoneal colon and rectal injuries → present with peritonitis
Retroperitoneal injuries → present with sepsis or abscess formation
13 Trauma
Colon and rectal injury
477
Diagnostic modality Indication Findings
Diagnosis
Management
Sigmoidoscopy Indicated when patient
has blood per rectum
CT abdomen and pelvis with IV Indicated when colon
or rectal injury is
suspected
CT with triple contrast (IV, oral and per
rectum)
Case Management
Extraperitoneal rectal injury Fecal diversion (loop or end colostomy)
Colon or intraperitoneal rectal injury that
involve <50% of bowel circumference
Colon or intraperitoneal rectal injury that
involve >50% of bowel circumference
Colon or intraperitoneal rectal injury that
involve >50% of bowel circumference
with signicant blood loss or prolonged
operative times
Patient with colon or intraperitoneal
injury that involve >50% of bowel
circumference + coagulopathy, acidosis,
or hypothermia
Indicated when
retroperitoneal injury
is suspected
Primary repair
Resection and primary anastomosis
Resection and end colostomy
Damage control laparotomy
Hematoma/defect in rectum
Pneumoperitoneum/contrast
extravasation/pericolonic or
mesenteric stranding
Retroperitoneal air/contrast
extravasation/pericolonic
stranding
Pelvic Injury
Pelvic injury
Mechanism Pelvic injuries most commonly happen after motor vehicle crashes
Types Lateral compression, vertical shear, open book
Presentation Flank ecchymosis (Gray Turner sign), umbilical ecchymosis (Cullen sign), proximal thigh
ecchymosis (Fox sign), or scrotal ecchymosis (Bryant sign)
478
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Pelvic injury
Diagnosis Diagnostic modality Characteristics Images
Pelvic X-ray Displacement of public
symphysis >2.5cm → unstable
injury
FAST Not sensitive for retroperitoneal
hemorrhage
CT with IV contrast Gold standard in
hemodynamically stable patients
→ localizes arterial bleed and
associated pelvic fractures
AP pelvic radiograph
demonstrates pubic symphysis
diastasis (double-ended arrow)
measuring 3.9cm
a
R. C. Gooding et al.
(a) Axial pelvic CT image with
IV contrast demonstrates a right
sacral alar fracture (arrowhead),
with widening of the sacroiliac
joint space. There is active
arterial contrast extravasation
(arrow) into a right hemi-pelvic
iliopsoas hematoma along the
right internal iliac artery.
Subsequent (b) conventional
catheter pelvic angiogram
demonstrates active contrast
extravasation (arrow) from the
iliolumbar branch of the posterior
division right internal iliac artery
Management Case Management
Severe pelvic injury
Wrapping pelvis with pelvic binder → if remain unstable →
Resuscitative endovascular balloon (REBOA) → angioembolization
or preperitoneal packing
Look for associated injuries
b
13 Trauma
Upper Urinary Tract Injuries
Renal injuries
Mechanism Renal injuries are associated with blunt trauma more than penetrating trauma
Presentation Hematuria, ank ecchymosis
Diagnostic modality Characteristics Findings
479
Diagnosis
American
Association for the
Surgery of Trauma
(AAST) organ
injury scale for renal
injuries
Management
CT with IV contrast +
delayed images
Grade of injury Characteristics
Grade I Subcapsular hematoma without laceration or renal contusion
Grade II Nonexpanding perirenal hematoma, or lacerations <1cm deep
Grade III Parenchymal laceration >1cm deep without collecting system
Grade IV Laceration extending into the collecting system or vascular
Grade V Completely shattered parenchyma or avulsion of the renal
Renal injury case Management
Hemodynamically stable
patient + renal injury
Patients with renal injuries
+ urinary extravasation
Hemodynamically unstable
patient with renal injuries or
penetrating renal injuries
with active bleeding
Indicated when renal
injury is suspected
without urinary extravasation
injury
injury to the main hilar vessels with contained hemorrhage
hilum with devascularized kidney parenchyma
Nonoperative management
Operative exploration
Operative exploration
Contrast extravasation/disrupted
renal capsule/ uid collection in
retroperitoneum
Ureteral injuries
Anatomy The ureters run anterior to the psoas muscle and cross over the bifurcation of the common iliac
arteries
Mechanism Ureteral trauma most associated with iatrogenic injury
Presentation Hematuria, worsening renal function, fever, ileus, and increased drain output
Diagnosis Contrast-enhanced CT with delayed images
480
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Ureteral injuries
R. C. Gooding et al.
Ureteral injury Management
Management
Injury distal to iliac Ureteroneocystostomy ± psoas hitch
Proximal ureter injury + short injured
segment
Proximal ureteral injury + long injured
segment
Injury at ureteropelvic junction Dismembered pyeloplasty
Unstable patient + ureteral injury Ligate ureter + postop nephrostomy
Lower Urinary Tract Injuries
Bladder injuries
Mechanism of
injury
Bladder injuries are most common after blunt trauma
Bladder injuries are usually associated with pelvic fracture
The dome and posterior bladder are intraperitoneal → result in intraperitoneal injuries
The anterior wall, lateral wall, and base of the bladder are extraperitoneal → result in
extraperitoneal injuries
Ureteroureterostomy
Ureteroneocystostomy + psoas hitch
or
Boari ap if ureter not able to be implanted into bladder
Ureteral stent → externalize to drain urine
Presentation Most common presentation is gross hematuria
Diagnosis Diagnostic modality Findings
Retrograde cystography Extraperitoneal rupture: contrast extravasation
forming a starburst
Management Bladder injury type Management
Intraperitoneal bladder
Complicated extraperitoneal bladder
injuries (concomitant vaginal or rectal
injuries or bony fragments within the
bladder)
Failure of nonoperative management
Uncomplicated extraperitoneal injuries Nonoperative management (foley catheter +
Key steps Repair bladder with two-layer absorbable sutures, watertight closure
Operative repair
Retrograde cystography after 14 days
retrograde cystography after 14 days)
Membranous
Posterior urethra
13 Trauma
Urethral injuries
481
Mechanism
Anterior urethra → penetrating trauma and or blunt trauma
Posterior urethra → blunt trauma is more common than penetrating trauma
Presentation Blood at the meatus, inability to pass a foley catheter, and a high-riding prostate
Diagnosis A retrograde urethrogram
Management See table below
Urethral injuries and their management
Urethral
injury Anatomy Management
Anterior urethral
injury
Posterior Urethral
Injury
Composed of the fossa
navicularis, penile
urethra, and the bulbar
urethra.
Composed of the
membranous urethra
which ends at the
bladder neck
Prostatic
urethra
Bulbous
urethra
Anterior urethra
Fossa
navicularis
Bladder
urethra
Penile
urethra
Penetrating injuries →
exploration and primary
closure at the time of injury +
Foley catheter placement
Blunt injuries → urinary
drainage (percutaneous
suprapubic tube placement or
Foley catheter)
Blunt injuries → percutaneous
suprapubic tube placement +
primary realignment with
cystoscopy when patient is
stable
Extremity Injuries
Extremity injuries
Presentation Patients with limb threatening injury need to be assessed for clinical signs of deformity,
dislocation, and limb ischemia
Diagnosis Diagnostic modality Characteristics
X-ray Important to image joint or long bone
proximal and distal to a fracture or
dislocation
Re-image after reduction
Vascular indices
• Ankle-brachial
• Ankle-ankle
• Radial-radial
Radial-brachial
CT angiogram All high-risk injuries
Examine the extremity for compartment syndrome (repeat exam after joint reduction)
Pain, pallor, pulselessness, paresthesia, paresis, and poikilothermia
If <0.9 perform CTA
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Extremity injuries
Mangled extremity
severity score
(MESS)
Skeletal/soft-tissue injury
Low energy (stab, simple fx, pistol GSW) 1
Medium energy (open or multiple fx,
dislocation)
High energy (high speed MVC or rie GSW) 3
Very high energy (high speed trauma + gross
contamination)
Limb ischemia (score doubled for ischemia >6 h)
Pulse reduced or absent but perfusion normal 1
Pulseless; paresthesia, diminished capillary
rell
Cool, paralyzed, insensate, numb 3
Shock
Systolic BP always > 90 mmHg 0
Hypotensive transiently 1
Persistent hypotension 2
Age (years)
<30 0
30–50 1
>50 2
Score of 7 or higher correlates well with primary amputation
Operative treatment
R. C. Gooding et al.
2
4
2
Management
Open fracture Formal irrigation and debridement within 24 h
MESS >10 at the knee AKA
Irreducible joint Prosthetic joint replacement
Compartment syndrome Emergent decompression
Non-operative treatment
Open injuries Emergent antibiotic
therapy (Ancef +
Gentamicin or Zosyn
depending on the degree
of contamination)
Reduce bone fragments
Open book pelvic fractures Emergent reduction via
binder and/or traction
±pelvic embolization
A/P shoulder or hip dislocation Sedation and closed
reduction
MC posterior hip dislocation: exion/internal rotation/traction/adduction of the leg
MC anterior shoulder dislocation: anterior/inferior traction with an assistant pulling
posterior/superior countertraction
Open injuries
Open book
pelvic fractures
A/P shoulder or
hip dislocation
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