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Upper abdominal visceral injury resulting from blunt trauma to the pelvis: a specific variant of shockwave injury?
D J Emby, MB BCh, FFRAD (D) SA
AngloGold Ashanti Health, Western Deep Levels Hospital, Carletonville
Corresponding author: D Emby (demby@anglogoldashanti.com)
Case histories and imaging findings
Patient 1
While working underground in a goldmine, a
35-year-old man was struck on the right side of his upper pelvis by a
large rock during a rock-fall. Owing to delays in the extraction
process (he remained buried from the waist down for approximately 4
hours), the patient reached casualty approximately 7 hours following
the acute injury. On arrival he was fully conscious and orientated, but
had a low blood pressure of 84/56 and a pulse rate of 101. He
complained of pain over the right ilium; external bruising and swelling
was visible in the region. A pelvic radiograph demonstrated a
comminuted but undisplaced fracture of the anterior portion of the body
of the right ilium (Fig. 1). There was also a comminuted fracture of
the left medial tibial plateau and evidence of a compartment syndrome
involving the left calf. In addition, there was marked tenderness over
the entire abdomen and intraperitoneal haemorrhage was suspected. The
chest X-ray was clear and no rib fractures were shown. The patient was
taken to theatre where a laparotomy revealed extensive intraperitoneal
haemorrhage from a ruptured spleen. (In addition to the laparotomy,
internal fixation of the left medial tibial plateau was performed;
together with a medial fasciotomy of the left calf).
Patient 2
A 23-year-old man was struck on the right side of
the pelvis by a large boulder following an underground rock-fall. He
was haemodynamically stable on arrival in casualty. On physical
examination, the right side of the pelvis was found to be unstable and
a pelvic radiograph showed disruption of the right sacro-iliac joint
and diastasis of the pubic symphysis (Fig. 2). As with Patient 1, the
chest X-ray was clear and no rib fractures were shown. The upper
abdomen was non-tender. Blood was found to be dripping from the penile
meatus. A diagnosis of a ruptured (or possibly severed) urethra was
made and a sonar examination was requested to examine the bladder for
evidence of rupture and for localisation for the insertion of a
supra-pubic catheter. On examination, the bladder was mildly distended
with no visible injury to the bladder wall and no peri-vesical free
fluid. Following examination of the pelvis, a full abdominal ultrasound
examination was performed. A large fluid collection (slightly
echogenic, consistent with haematoma) was shown surrounding the spleen
(Fig. 3). Although there was no visible splenic injury, a presumptive
diagnosis of splenic rupture was made and the patient underwent
immediate laparotomy. This revealed a rupture of the pancreas with
extensive retroperitoneal and also intraperitoneal haemorrhage. The
spleen was found to be intact.
Discussion
Tissue injury owing to the propagation of a
shockwave is well described in ballistic injuries where the energy
transfer from the missile to the tissue is responsible for the
increased severity of the wound.1 The relationship between kinetic energy and the projectile can be derived from the following formula:
Kinetic energy (KE) = 0.5 x mass x (velocity)2
In the case of bullet wounds where the mass of the
projectile is relatively small, the extent of the damage to the
surrounding tissues is largely determined by the bullet velocity.
Shockwave damage to body tissues has been described in association with
blast injuries.² In addition, shockwave injury to adjacent tissue
is a well-recognised complication of extracorporeal shockwave
lithotripsy.3
In the patients described above, the falling rock
– although non-penetrating – can be equated to a missile.
In both these cases, the large (estimated to be between 50 and100 kg)
mass, despite its relatively low velocity, had sufficient kinetic
energy to cause bony pelvic injury.
In the first patient, the pelvic injury was
relatively superficial and the splenic rupture could be explained by
the propagation of a shockwave across the abdomen from the impact site
inferiorly on the right to the left upper quadrant.
In the second patient, as the pelvic injury was
predominantly retroperitoneal, it is postulated that the resulting
shockwave might have propagated predominantly through the
retroperitoneal tissues, resulting in the rupture of a retroperitoneal
organ, i.e. the pancreas.
Conclusion
A syndromic pattern of injury is described where a
direct blow to the pelvis resulted in rupture of a distant, upper
abdominal viscus. Shockwave propagation across the abdomen is the
likely explanation for this phenomenon.4
The possibility of injury to an upper abdominal organ should be
considered in all cases where there is a severe, direct blow to the
pelvis.
1. 1. Cooper GJ, Ryan JM. Interaction of penetrating missiles with
tissues: some common misapprehensions and implications for wound
management. Br J Surg 1990;77:606-610.
1. 1. Cooper GJ, Ryan JM. Interaction of penetrating missiles with
tissues: some common misapprehensions and implications for wound
management. Br J Surg 1990;77:606-610.
2. 2. Stapley SA, Canon LB. An overview of the pathophysiology of
gunshot and blast injury with resuscitation guidelines. Current
Orthopaedics 2006; 20:322-332.
2. 2. Stapley SA, Canon LB. An overview of the pathophysiology of
gunshot and blast injury with resuscitation guidelines. Current
Orthopaedics 2006; 20:322-332.
3. 3. Ilnyckyj A, Hosking DH, Pettigrew NM, Bernstein CN.
Extracorporeal shock wave lithotripsy causing colonic injury. Dig Dis
Sci 1999;44(12):2485-2487.
3. 3. Ilnyckyj A, Hosking DH, Pettigrew NM, Bernstein CN.
Extracorporeal shock wave lithotripsy causing colonic injury. Dig Dis
Sci 1999;44(12):2485-2487.
4. 4. Salomone JA, Salomone JP. Abdominal trauma, blunt.
http://emedicine.medscape.com/article/821995-print (accessed 9 November
2010).
4. 4. Salomone JA, Salomone JP. Abdominal trauma, blunt.
http://emedicine.medscape.com/article/821995-print (accessed 9 November
2010).
Summary
Two patients who sustained severe blunt injury to
the pelvis without external injury to the upper abdomen or lower chest,
yet who were found to have a ruptured solid upper abdominal viscus, are
reported. The first patient on delayed arrival revealed clinical
features suggestive of intra-abdominal bleeding and was found to have a
grade 3 ruptured spleen. With the second patient, upper abdominal
injury (in this instance, a pancreatic laceration) was not initially
suspected owing to the absence of clinical evidence of injury to the
abdomen. It is postulated that both the splenic and pancreatic injuries
were the result of a shockwave propagated through the abdomen following
the severe external impact to the pelvis.
Fig. 1. X-ray of the pelvis showing fracture (arrows) of the right ilium in patient 1.
Fig.
2. Pelvic X-ray showing disrupted right sacro-iliac joint (arrow heads)
and diastasis (arrows) of the pubic symphysis in patient 2.
Fig. 3. Sonar image showing haematoma (arrow) around spleen.