Causes of Free Fluid in the Abdomen

a Contained splenic rupture b Splenic rupture with active extravasation of blood a Contained splenic rupture

Free Fluid Abdomen
c Liver rupture
Free Fluid Abdomen

Fig. 14.32 a In this patient a splenic tear has occurred, which luckily has not led to a full-blown bleed into the into the peritoneum. This is an incomplete splenic rupture or splenic laceration. b This splenic rupture in another patient exhibits active extravasation of blood into the peritoneum. You recognize the active bleed by appreciating the contrast media-enhanced blood within the intra-abdominal hemorrhage (arrow). This young man was not the victim of an motor vehicle accident but—chained to his own bed—of rather unorthodox sexual habits of his latest boyfriend. In a sexual frenzy the friend attacked and stabbed him with a knife—26 times. Luckily the patient recovered to full health, but he became a little more fussy picking his sexual partners. In any case, the injuries kept the trauma surgeons entertained for quite a while. c This is a liver rupture (compare the normal liver in a and b) due to a blunt abdominal trauma. This lady was treated with thrombocyte aggregation inhibitors because of advanced coronary arteriosclerosis. She called the ambulance during a heart attack. When the ambulance team arrived, she could still open the door but then collapsed. The team resuscitated her successfully on the spot but noted signs of shock a little later. The liver rupture caused by the resuscitation was diagnosed rapidly with an abdominal CTand was later addressed surgically. The patient was lucky: the surgery was successful and she returned home a few weeks later. Hepatic and splenic ruptures and pericardiac injuries occur rarely during resuscitations—rib fractures are common.

I Retroperitoneal Hemorrhage

I Retroperitoneal Hemorrhage

Retroperitoneal Bleed
Fig. 14.33 On this image you see documented a rupture of the left kidney associated with a retroperitoneal bleed. Fractures of the transverse spinous processes were also seen on that side. The patient had severe hematuria after a motor vehicle accident.

his suspicion: There is a considerable amount of fluid between the liver and the right kidney, indicative of visceral organ rupture—most likely of the spleen. The spleen itself is difficult to image in its entirety as it is partially obscured by the overlying lung. Abdominal CT is performed immediately and confirms the diagnosis (Fig. 14.34a).

Radiographs of the spine: Meanwhile, the radiographs of the spine are ready for Joey's analysis (Fig. 14.34b). He studies them with great care and quietly, despite the trauma surgeons' breathing down his neck.

First of all Joey looks at the configuration of the spinal column. Do all the auxiliary lines along the anterior and posterior edge of the vertebral bodies and along the spinous processes appear smooth and well defined? Are the individual vertebral bodies configured normally? Joey looks at every single body, trying to imagine a three-dimensional and complete model of it in the back of his mind.

a Abdominal CT

Fig. 14.34a The spleen is ruptured (arrow). b Note the radiograph of the patient's lumbar spine. Does anything strike you as abnormal? c The second and third right foraminal arches of the sacral bone are interrupted (arrow), which means that the right sacral ala is fractured.

b Radiographs of the spine b Radiographs of the spine

Radiograph Ruptured Spleen
c Radiograph and CT of the pelvis
Radiograph Ruptured SpleenRadiograph Ruptured Spleen

One predominant question in the evaluation of a spinal column fracture is whether the spinal canal and/or the neural foramina are involved and how.

the numerous dislocations and "small" fractures than a good old fashioned movie style row? By the way: all fractures can be classified. Check your favorite trauma surgery book for the latest fashion in nomenclature.

Does a fracture affect the posterior column of the vertebral body? This is always the case if the vertebral body is diminished in height dorsally. To determine this, measure the height of the vertebral body immediately underneath and immediately above—vertebral body height normally increases incrementally in the caudal direction. Does the spinal canal appear narrowed? This is of particular importance above the level of L3 because the spinal cord reaches down to that level. Is the dorsal vertebral arch involved? If that is the case, instability looms, which can seriously damage the spinal nerves along their course through the potentially narrowed neuroforamina. Joey makes up his mind and calls a fracture of the anterior vertebral edge of L3. The keeper of the notes hardly suppresses a yawn because the staff surgeon had called this diagnosis minutes before when Joey was still busy doing the ultrasound.

Radiograph and CT of the pelvis: In the meantime, the radiograph of the pelvis has also been put up on the viewbox (Fig. 14.34c). The evaluation of the pelvis, particularly of the sacral bone, is frequently compromised by the superimposition of bowel content. Helpful structures are the sacral neuroforamina: analyze their outline carefully and in comparison to the contralateral side. Are they completely visible and smooth or are there defects, a step-off, or irregularities? Frequently a fracture of the sacral bone continues on cranially into the lumbar transversal processes. Are these truly intact? In the region of the iliac bone and the anterior pelvic ring, superimposition is less of a problem. But remember that posterior pelvic fractures often go along with another fracture of the anterior pelvic ring and vice versa. If no fractures are found, the width of the pubic symphysis and the iliosacral joints should be scrutinized. Somewhere the pelvic ring must have given way. By the way, the pubic symphysis is wider in women who have given birth than in those who have not.

Joey has not detected any fractures in a first quick glance over the pelvic radiograph. Gregory, who seems to be everywhere at the same time today, puts his finger on the film. The foraminal arch of S2 on the right is interrupted. CT confirms a sacral fracture (Fig. 14.34c).

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