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TRAUMA /

SOLID ORGAN INJURY

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SPLENIC TRAUMA / INJURY

• Blunt splenic trauma occurs when a significantimpact to the spleen from some outside source(i.e. automobile accident) damages or rupturesthe spleen .

• Causes :

- automobile accident ( leading cause of internalbleeding)

- any type of major impact directed to the spleen(bicycling accidents )

*degree of injury ranges from subcapsularhematoma to splenic rupture.

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Sign and symptoms

• The primary symptom: hemorrhage( presentsdifferently depending on the degree of injury,with the symptoms of major hemorrhage, shock,abdominal pain, and distention being clinically

obvious)• Minor hemorrhage often presents as upper left

quadrant pain.

• Patients with unexplained left upper quadrantpain, particularly if there is evidence ofhypovolemia or shock, are generally inquiredregarding any recent trauma.

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CT SCAN

• Although many plain radiographic imaging findingssuggest spleen trauma injury, CT is the radiographicmodality used at most institutions.

•  CT scanning should be performed in conjunction with

the intravenous administration of contrast material tomaximize density differences between the splenicparenchyma and hematomas.

• In this fashion, CT provides the best evaluation of thespleen and the surrounding tissues. An additionaladvantage of CT is the ability to use it to image all ofthe abdominal organs simultaneously in excluding asecondary injury.

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Contrast-enhanced arterial-phase CT scan of the abdomen shows a mottledappearance of the spleen. This finding should not be mistaken for splenic injury.Confirmation of a normal spleen can be shown by repeat imaging in a later phase ofcontrast enhancement. The spleen then appears homogeneously enhanced.

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Contrast-enhanced CT scan of the abdomen in the equilibrium phase shows

perisplenic fluid with mass effect on the spleen. The spleen appears

compressed by the fluid, reminiscent of subcapsular fluid collections.

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Contrast-enhanced CT scan of the abdomen shows some perisplenic fluid inthe anterior aspect. A small well-defined irregularity is noted in the splenicwall posteriorly. This was a congenital splenic cleft in a patient with perisplenicfluid secondary to nonsplenic injury.

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Grade I injuries include the following:Subcapsular hematoma of less than

10% of surface area

Capsular tear of less than 1 cm in

depth

Contrast-enhanced CT scan of the

abdomen shows a perisplenic fluid

collection with internal increased

attenuation. The splenic border is

displaced by mass effect. This was a

subacute subcapsular hematoma. Thisis a grade I injury.

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Grade II injuries include the followingSubcapsular hematoma of 10-50% of

surface area

Intraparenchymal hematoma of less

than 5 cm in diameter

Laceration of 1-3 cm in depth and not

involving trabecular vessels

. Contrast-enhanced CT scan of the

abdomen shows a complex lower polesplenic laceration. This is a grade II

injury.

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Grade III injuries include the following:Subcapsular hematoma of greater

than 50% of surface area or expanding

and ruptured subcapsular or

parenchymal hematoma

Intraparenchymal hematoma of

greater than 5 cm or expanding

Laceration of greater than 3 cm indepth or involving trabecular vessels

. Contrast-enhanced CT scan of the

abdomen shows a massive fluid

collection in the upper abdomen. Thiswas a chronic subcapsular splenic

hematoma and a grade III injury.

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Grade IV injuries include lacerationinvolving segmental or hilar vessels,

with devascularization of more than

25% of the spleen (see the images

below).

PIC 1

Contrast-enhanced CT scan of theabdomen shows a small hilar

laceration. This is a grade III-IV injury.

PIC 2

Contrast-enhanced CT scan of the

abdomen shows a complex laceration

extending to the hilum. This is a gradeIV injury.

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Grade V injuries include a shatteredspleen or hilar vascular

Contrast-enhanced CT scan shows a

localized area of dense contrast

collection in the splenic hilum, with a

massive amount of surrounding

fluid/blood. Findings here are

indicative of active extravasation of

contrast in a patient with traumatic

autosplenectomy. This is a grade Vinjury.

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ULTRASOUND

• The primary goal of splenic ultrasonography in

the setting of blunt abdominal trauma is to

detect the presence of blood in the left upper

quadrant (LUQ). 

• Acute blood is hypoechoic and can be almost

anechoic.

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PIC 1oblique scans though the spleen and

left kidney.

PIC 2

Oblique and transverse scans through

the spleen.

The spleen was enlarged (173mm) and

had ill-defined, multiple eco-poor

areas within it pic1. There was fluid in

the peritoneal cavity pic2. These

features were in keeping with splenic

rupture.

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Oblique scan of the spleen showingsplenomegally (165mm-pole to pole)

and an irregularly marginated

hypoechoic area within the spleen.

Fluid is seen in the peritoneal cavity,

implying haemoperitoneum (i.e

splenic rupture)

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• The liver is the largest solid abdominal organ witha relatively fixed position, which makes it proneto injury.

•

The liver is the second most commonly injuredorgan in abdominal trauma, but damage to theliver is the most common cause of death afterabdominal injury .

• The most common cause of liver injury is bluntabdominal trauma, which is secondary to motorvehicle accidents in most instances.

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EXAMINATION

• Plain radiographic findings are nonspecific, but they may be usefulin showing the extent of associated skeletal trauma. Contrast-enhanced CT scanning remains the examination of choice inpatients with blunt abdominal trauma.

• Radionuclide study with technetium-99m (99m Tc) iminodiacetic acid

(IDA) is the examination of choice in patients in whom bile leaks aresuspected. Magnetic resonance imaging (MRI) has yet to find a rolebut can be used to monitor liver injury. Magnetic resonancecholangiopancreatography (MRCP) may be used for the diagnosisand follow-up observation of bile duct injuries.

• Angiography is useful in localizing the site of hemorrhage and in

providing an opportunity for the interventional radiologist toproceed to transcatheter embolization of bleeding sites.

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PLAIN RADIOGRAPHS

• Plain radiographic findings are nonspecific,but they are useful in evaluating rib and spinal

injuries in patients with blunt abdominal

trauma.• Fractures of the right lower ribs should

suggest the possibility of underlying liver

injury.•  Pneumoperitoneum, major diaphragmatic

injury, gross organ displacement, and metallic

foreign bodies may be identified.

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CT SCAN

• CT scanning, particularly contrast-enhanced CTscanning, is accurate in localizing the site and extent ofliver injuries and associated trauma, providing vitalinformation for treatment in patients CT scanning

without intravenous contrast enhancement is oflimited value in hepatic trauma, but it can be useful inidentifying or following up a hemoperitoneum.

• CT scans can be used to monitor healing. Trauma to theliver may result in subcapsular or intrahepatic

hematoma, contusion, vascular injury, or biliarydisruption. CT scan criteria for staging liver traumabased on the AAST liver injury scale include thefollowing:

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Grade 1 - Subcapsular hematoma lessthan 1 cm in maximal thickness,

capsular avulsion, superficial

parenchymal laceration less than 1 cm

deep, and isolated periportal blood

tracking (see the images below)

Grade 1 hepatic injury in a 21-year-old

man with a stabbing injury to the right

upper quadrant of the abdomen. Axial,

contrast-enhanced computed

tomography (CT) scan demonstrates a

small, crescent-shaped subcapsular

and parenchymal hematoma less than

1 cm thick.

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Grade 2 - Parenchymal laceration 1-3cm deep and

parenchymal/subcapsular hematomas

1-3 cm thick (see the images below)

A 20-year-old man with systemic lupus

erythematosus presented with grade 2

liver injury after minor blunt

abdominal trauma. Nonenhanced axial

CT scan at the level of the hepatic

veins shows a subcapsular hematoma

3 cm thick.

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Grade 3 - Parenchymal laceration morethan 3 cm deep and parenchymal or

subcapsular hematoma more than 3

cm in diameter (see the images below)

Grade 3 liver injury in a 22-year-oldwoman after blunt abdominal trauma.

Contrast-enhanced axial CT scan

through the upper abdomen shows a

4-cm-thick subcapsular hematoma

associated with parenchymal

hematoma and laceration in segments

6 and 7 of the right lobe of the liver.

Free fluid is seen around the spleen

and left lobe of the liver consistent

with hemoperitoneum.

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Grade 4 - Parenchymal/subcapsularhematoma more than 10 cm in

diameter, lobar destruction, or

devascularization (see the images

below)

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Grade 5 - Global destruction ordevascularization of the liver (see the

images below)

Grade 5 injury in a 36-year-old man

who was involved in a motor vehicle

accident demonstrates global injury to

the liver. Bleeding from the liver wascontrolled by using Gelfoam.

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Grade 6 - Hepatic avulsion

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MRI

• MRI has a limited role in the evaluation of

blunt abdominal trauma, and it has no

advantage over CT scanning.

• Theoretically, MRI can be used in follow-up

monitoring of patients with blunt abdominal

trauma, and the modality may be useful in

young and pregnant women with abdominaltrauma in whom the radiation dose is a

concern.

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ULTRASOUND

• Ultrasonograms can demonstrate a number of

traumatic lesions, such as hematomas,

contusions, bilomas, and hemoperitoneum.

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Mechanism of renal trauma

• Blunt trauma ( 80 % ) : MVA , falls , assaults

• Penetrating trauma ( 20 % ) : gunshot ,

stabbing , impalement

• Predisposing factors : preexisting renal

conditions ( tumours , hydronephrosis ) ,

children , associated abdominal injuries

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Radiolody imaging :

1) CT with IV contrast

• Gold standard

• High sensitivity

• Immediate and delayed post contrast images

to view collecting system

• Allows diagnosis and staging

•

Images abdomen and retroperitoneum• Not for haemodynamically unstable patients

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Kidney trauma. Grade 1 renal injury,contusion. Image from a contrast-

enhanced CT scan of the abdomen in a

patient with hematuria after a motor

vehicle collision shows ill-defined area

of hypoenhancement in the medial

right kidney.

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Kidney trauma. Grade 1 renal injury,contusion. Image from a contrast-

enhanced CT scan of the abdomen in a

patient with hematuria after a motor

vehicle collision shows ill-defined area

of hypoenhancement in the medial left

kidney.

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Kidney trauma. Grade 1 renal injury,subcapsular hematoma. CT scan of the

abdomen with intravenous contrast in

a patient after a motor vehicle collision

shows crescentic high-density fluid

collection around the left kidney. Note

the well-defined outer margin.

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Kidney trauma. Grade 5 renal injury.Shattered kidney. Contrast-enhanced

CT scan of the abdomen in a patient

with hematuria and hypotension after

a motor vehicle collision shows

transection of the right kidney with a

large hematoma around and between

the 2 halves of the kidney. The 2

halves are both perfused becausethere were 2 renal arteries. Delayed

images show urinary contrast

extravasation.

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Renal rupture with a large hematoma 

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Renal contusion in a 9 year old child

with a small perirenal effusion at the

upperpole 

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Urinary bladder

Cli i l i di f bl dd

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Clinical indicator of bladder

rupture

- Suprapubic pain or tenderness

- Inability to void

- Clots in urine

- Swelling or hematoma

- Blood at urethral meatus

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Test available

• Retrograde urethrogram ( plain film )

- Assess the patency of anterior urethra in

males

• Cystogram ( plain film )

•

CT cystogram

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• Retrograde urethrogram (RUG)

- Fluoroscopy study ( ant urethra )

- Rules out urethral tear

- Procedure : pediatric foley catheter inserted

into tip of urethra and inflated

- Gentle injection of 5-30 cc of 30% contrastsolution from the tip of the urethra retrograde

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Urethra, trauma. Normal retrograde

urethrogram. Pericatheter retrograde

urethrogram is negative for urethral traumaand shows continuous filling of contrast

material through the extent of the urethra and

into the bladder without extravasation. 

Urethra, trauma. Straddle injury. Retrograde

urethrogram shows a type V urethral injury

with extravasation of contrast material from

the distal bulbous urethra. 

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• Cystogram- Fluoroscopy or static image

- Foley catheter in bladder

- Use diluted contrast ( 30 – 50 % ) contrast in saline

- Use 300 – 400 cc total , slowly fill bladder by gravity ( source of fluid is

held above level of pelvis )

- Films taken ( pre filling , full ( 300 cc ) , post drainage )

- Views : AP view if necessary , lateral and or oblique if possible

- * post drainage view : to catch any extravasation hidden by distendedbladder

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Intraperitoneal rupture

-Contrast has smooth regular contours

-- contrast accumulates near dome of

bladder

-Extends laterally filling the peritoneal

cavity

- contarst can surround loops of bowel, intraperitoneal viscera and fill the

paracolic gutters

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Computed tomography (CT) cystogram

demonstrating a simple extraperitoneal

bladder rupture with fluid in the perivesical

space (predominantly in the space of Retziusanteriorly). 

Computed tomography (CT) cystogram

demonstrating a complex extraperitoneal

bladder rupture with contrast material

extending through the fascial planes of thepelvis.