Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is
physical trauma
An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, ...
s, and particularly in the elderly who
fall
Autumn, also known as fall in American English and Canadian English, is one of the four temperate seasons on Earth. Outside the tropics, autumn marks the transition from summer to winter, in September (Northern Hemisphere) or March ( Southe ...
.
It is contrasted with
penetrating trauma
Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or ''non-penetrating'' trauma may have some deep dama ...
which occurs when an object pierces the skin and enters a
tissue of the body, creating an open
wound
A wound is a rapid onset of injury that involves laceration, lacerated or puncture wound, punctured skin (an ''open'' wound), or a bruise, contusion (a ''closed'' wound) from blunt force physical trauma, trauma or compression. In pathology, a '' ...
and
bruise
A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close ...
.
Blunt trauma can result in
contusion
A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close ...
s,
abrasions,
laceration
A wound is a rapid onset of injury that involves lacerated or punctured skin (an ''open'' wound), or a contusion (a ''closed'' wound) from blunt force trauma or compression. In pathology, a ''wound'' is an acute injury that damages the epiderm ...
s,
internal hemorrhage
Internal bleeding (also called internal hemorrhage) is a loss of blood from a blood vessel that collects inside the body. Internal bleeding is usually not visible from the outside. It is a serious medical emergency but the extent of severity depen ...
s,
bone fracture
A bone fracture (abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a '' ...
s, as well as death.
Blunt trauma represents a significant cause of disability and death in people under the age of 35 years worldwide.
Classification
Blunt abdominal trauma
![Leftrenalarteryinjury](https://upload.wikimedia.org/wikipedia/commons/0/09/Leftrenalarteryinjury.png)
Blunt abdominal trauma (BAT) represents 75% of all blunt trauma and is the most common example of this injury. 75% of BAT occurs in motor vehicle crashes,
in which rapid deceleration may propel the driver into the
steering wheel
A steering wheel (also called a driving wheel (UK), a hand wheel, or simply wheel) is a type of steering control in vehicles.
Steering wheels are used in most modern land vehicles, including all mass-production automobiles, buses, light and ...
,
dashboard For business applications, see Dashboard (business).
A dashboard (also called dash, instrument panel (IP), or fascia) is a control panel set within the central console of a vehicle or small aircraft. Usually located directly ahead of the driver ...
, or seatbelt, causing
contusions
A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close ...
in less serious cases, or rupture of internal organs from briefly increased
intraluminal
In biology, a lumen (plural lumina) is the inside space of a tubular structure, such as an artery or intestine. It comes .
It can refer to:
*The interior of a vessel, such as the central space in an artery, vein or capillary through which blood f ...
pressure in the more serious, depending on the force applied. Initially, there may be few indications that serious internal abdominal injury has occurred, making assessment more challenging and requiring a high degree of clinical suspicion.
There are two basic physical mechanisms at play with the potential of injury to intra-abdominal organs:
compression
Compression may refer to:
Physical science
*Compression (physics), size reduction due to forces
*Compression member, a structural element such as a column
*Compressibility, susceptibility to compression
* Gas compression
*Compression ratio, of a ...
and
deceleration
In mechanics, acceleration is the rate of change of the velocity of an object with respect to time. Accelerations are vector quantities (in that they have magnitude and direction). The orientation of an object's acceleration is given by the ...
. The former occurs from a direct blow, such as a punch, or compression against a non-yielding object such as a seat belt or steering column. This force may deform a hollow organ, increasing its
intraluminal
In biology, a lumen (plural lumina) is the inside space of a tubular structure, such as an artery or intestine. It comes .
It can refer to:
*The interior of a vessel, such as the central space in an artery, vein or capillary through which blood f ...
or internal pressure and possibly lead to rupture.
Deceleration, on the other hand, causes stretching and
shearing
Sheep shearing is the process by which the woollen fleece of a sheep is cut off. The person who removes the sheep's wool is called a '' shearer''. Typically each adult sheep is shorn once each year (a sheep may be said to have been "shorn" or ...
at the points where mobile contents in the
abdomen
The abdomen (colloquially called the belly, tummy, midriff, tucky or stomach) is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the torso. ...
, like
bowel
The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organs of the digestive system, in humans and ...
, are anchored. This can cause tearing of the
mesentery
The mesentery is an organ that attaches the intestines to the posterior abdominal wall in humans and is formed by the double fold of peritoneum. It helps in storing fat and allowing blood vessels, lymphatics, and nerves to supply the intestines ...
of the bowel and injury to the
blood vessel
The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away ...
s that travel within the mesentery. Classic examples of these mechanisms are a
hepatic
The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it i ...
tear along the
ligamentum teres and injuries to the
renal arteries
The renal arteries are paired arteries that supply the kidneys with blood. Each is directed across the crus of the diaphragm, so as to form nearly a right angle.
The renal arteries carry a large portion of total blood flow to the kidneys. Up to a ...
.
When blunt abdominal trauma is complicated by 'internal injury,' the
liver
The liver is a major Organ (anatomy), organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of proteins and biochemicals necessary for ...
and
spleen
The spleen is an organ found in almost all vertebrates. Similar in structure to a large lymph node, it acts primarily as a blood filter. The word spleen comes . (see
blunt splenic trauma) are most frequently involved, followed by the
small intestine
The small intestine or small bowel is an organ in the gastrointestinal tract where most of the absorption of nutrients from food takes place. It lies between the stomach and large intestine, and receives bile and pancreatic juice through the p ...
.
In rare cases, this injury has been attributed to medical techniques such as the
Heimlich maneuver
Abdominal thrusts, also known as the Heimlich maneuver or Heimlich manoeuvre, is a first aid procedure used to treat upper airway obstructions (or choking) by foreign objects. American doctor Henry Heimlich is often credited for its creation. ...
, attempts at
CPR
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore sponta ...
and manual thrusts to clear an
airway
The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa.
Air is breathed in through the nose to th ...
. Although these are rare examples, it has been suggested that they are caused by applying excessive pressure when performing these life-saving techniques. Finally, the occurrence of splenic rupture with mild blunt abdominal trauma in those recovering from
infectious mononucleosis
Infectious mononucleosis (IM, mono), also known as glandular fever, is an infection usually caused by the Epstein–Barr virus (EBV). Most people are infected by the virus as children, when the disease produces few or no symptoms. In young adult ...
or 'mono' is well reported.
Blunt abdominal trauma in sports
The supervised environment in which most sports injuries occur allows for mild deviations from the traditional trauma treatment algorithms, such as
ATLS, due to the greater precision in identifying the mechanism of injury. The priority in assessing blunt trauma in sports injuries is separating contusions and musculo-tendinous injuries from injuries to solid organs and the gut and recognizing potential for developing blood loss, and reacting accordingly. Blunt injuries to the
kidney
The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blood ...
from helmets, shoulder pads, and knees are described in American football, association football, martial arts, and all-terrain vehicle crashes.
Blunt thoracic trauma
The term blunt thoracic trauma, or, more informally, blunt chest injury, encompasses a variety of injuries to the
chest
The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the crea ...
. Broadly, this also includes damage caused by direct blunt force (such as a fist or a bat in an assault), acceleration or deceleration (such as that from a rear-end automotive crash),
shear force
In solid mechanics, shearing forces are unaligned forces acting on one part of a body in a specific direction, and another part of the body in the opposite direction. When the forces are collinear (aligned with each other), they are called t ...
(a combination of acceleration and deceleration),
compression
Compression may refer to:
Physical science
*Compression (physics), size reduction due to forces
*Compression member, a structural element such as a column
*Compressibility, susceptibility to compression
* Gas compression
*Compression ratio, of a ...
(such as a heavy object falling on a person), and
blasts
In cell biology, a precursor cell, also called a blast cell or simply blast, is a partially differentiated cell, usually referred to as a unipotent cell that has lost most of its stem cell properties. A precursor cell is also known as a pro ...
(such as an
explosion
An explosion is a rapid expansion in volume associated with an extreme outward release of energy, usually with the generation of high temperatures and release of high-pressure gases. Supersonic explosions created by high explosives are known ...
of some sort). Common signs and symptoms include something as simple as
bruising
A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur clos ...
, but occasionally as complicated as
hypoxia,
ventilation-perfusion mismatch In respiratory physiology, the ventilation/perfusion ratio (V/Q ratio) is a ratio used to assess the efficiency and adequacy of the matching of two variables:
* V – ventilation – the air that reaches the alveoli
* Q – perfusion – the blood ...
,
hypovolemia
Hypovolemia, also known as volume depletion or volume contraction, is a state of abnormally low extracellular fluid in the body. This may be due to either a loss of both salt and water or a decrease in blood volume. Hypovolemia refers to the los ...
, and reduced
cardiac output
In cardiac physiology, cardiac output (CO), also known as heart output and often denoted by the symbols Q, \dot Q, or \dot Q_ , edited by Catherine E. Williamson, Phillip Bennett is the volumetric flow rate of the heart's pumping output: t ...
due to the way the
thoracic
The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the crea ...
organs may have been affected. Blunt thoracic trauma is not always visible from the outside and such internal injuries may not show
signs or
symptom
Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showin ...
s at the time the trauma initially occurs or even until hours after. A high degree of clinical suspicion may sometimes be required to identify such injuries, a
CT scan may prove useful in such instances. Those experiencing more obvious complications from a blunt chest injury will likely undergo a focused assessment with sonography for trauma (
FAST) which can reliably detect a significant amount of blood around the heart or in the lung by using a special machine that visualizes sound waves sent through the body. Only 10–15% of thoracic traumas require surgery, but they can have serious impacts on the
heart
The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide t ...
,
lung
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
s, and
great vessels
Great vessels are the large vessels that bring blood to and from the heart. These are:
*Superior vena cava
*Inferior vena cava
*Pulmonary arteries
*Pulmonary veins
*Aorta
Transposition of the great vessels is a group of congenital heart defect ...
.
![Common Blunt Thoracic Injuries](https://upload.wikimedia.org/wikipedia/commons/6/69/Common_Blunt_Thoracic_Injuries.png)
The most immediate life-threatening injuries that may occur include
tension pneumothorax
A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...
, open pneumothorax,
hemothorax
A hemothorax (derived from hemo- lood+ thorax hest plural ''hemothoraces'') is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may incl ...
,
flail chest
Flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall. Two of the symptoms of flail chest are chest pain and shortness of breath ...
,
cardiac tamponade
Cardiac tamponade, also known as pericardial tamponade (), is the buildup of fluid in the pericardium (the sac around the heart), resulting in compression of the heart. Onset may be rapid or gradual. Symptoms typically include those of obstruct ...
, and
airway obstruction/rupture.
![Main bronchus laceration](https://upload.wikimedia.org/wikipedia/commons/b/b1/Main_bronchus_laceration.jpg)
The injuries may necessitate a procedure, most commonly the insertion of an
intercostal drain, or chest tube. This tube is typically installed because it helps restore a certain balance in pressures (usually due to misplaced air or surrounding blood) that are impeding the lungs' ability to inflate and thus exchange vital gases that allow the body to function. A less common procedure that may be employed is a
pericardiocentesis
Pericardiocentesis (PCC), also called pericardial tap, is a medical procedure where fluid is aspirated from the pericardium (the sac enveloping the heart).
Anatomy and Physiology
The pericardium is a fibrous sac surrounding the heart composed o ...
which by removing blood surrounding the heart, permits the heart to regain some ability to appropriately pump blood.
In certain dire circumstances an emergent
thoracotomy
A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the hea ...
may be employed.
Blunt cranial trauma
The primary clinical concern with blunt trauma to the head is damage to the brain, although other structures, including the skull, face,
orbits
In celestial mechanics, an orbit is the curved trajectory of an object such as the trajectory of a planet around a star, or of a natural satellite around a planet, or of an artificial satellite around an object or position in space such as a p ...
, and neck are also at risk.
Following assessment of the patient's airway, circulation, and breathing, a
cervical collar
A cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck. It is also applied by emergency personnel to those who have had traumatic head or neck injuries, and can be used to treat chronic m ...
may be placed if there is suspicion of trauma to the neck. Evaluation of blunt trauma to the head continues with the secondary survey for evidence of cranial trauma, including bruises, contusions, lacerations, and abrasions. In addition to noting external injury, a comprehensive neurologic exam is typically performed to assess for damage to the brain. Depending on the mechanism of injury and examination, a CT scan of the skull and brain may be ordered. This is typically done to assess for
blood within the skull, or
fracture of the skull bones.
Traumatic brain injury
Traumatic brain injury
A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity (ranging from mild traumatic brain injury TBI/concussionto severe traumatic b ...
(TBI) is a significant cause of morbidity and mortality and is most commonly caused by falls, motor vehicle crashes, sports- and work-related injuries, and assaults. It is the most common cause of death in patients under the age of 25. TBI is graded from mild to severe, with greater severity correlating with increased morbidity and mortality.
Most patients with more severe traumatic brain injury have of a combination of intracranial injuries, which can include
diffuse axonal injury
Diffuse axonal injury (DAI) is a brain injury in which scattered lesions occur over a widespread area in white matter tracts as well as grey matter. DAI is one of the most common and devastating types of traumatic brain injury and is a major cause ...
,
cerebral contusion
Cerebral contusion, Latin ''contusio cerebri'', a form of traumatic brain injury, is a bruise of the brain tissue.
Like bruises in other tissues, cerebral contusion can be associated with multiple microhemorrhages, small blood vessel leaks into ...
s, and intracranial bleeding, including
subarachnoid hemorrhage
Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consci ...
,
subdural hematoma
A subdural hematoma (SDH) is a type of bleeding in which a Hematoma, collection of blood—usually but not always associated with a traumatic brain injury—gathers between the inner layer of the dura mater and the arachnoid mater of the meninges ...
,
epidural hematoma
Epidural hematoma is when bleeding occurs between the tough outer membrane covering the brain (dura mater) and the skull. Often there is loss of consciousness following a head injury, a brief regaining of consciousness, and then loss of consciou ...
, and
intraparenchymal hemorrhage
Intraparenchymal hemorrhage (IPH) is one form of intracerebral bleeding in which there is bleeding within brain parenchyma. The other form is intraventricular hemorrhage (IVH).
Intraparenchymal hemorrhage accounts for approximately 8-13% of all ...
.
The recovery of brain function following a traumatic injury is highly variable and depends upon the specific intracranial injuries that occur, however there is significant correlation between the severity of the initial insult as well as the level of neurologic function during the initial assessment and the level of lasting neurologic deficits.
Initial treatment may be targeted at reducing the
intracranial pressure
Intracranial pressure (ICP) is the pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is measured in millimeters of mercury (mmHg) and at rest, is normally 7–15 Millimeter of mercury, mmHg ...
if there is concern for swelling or bleeding within this skull, which may require surgery such as a
hemicraniectomy, in which part of the skull is removed.
Blunt trauma to extremities
![Pad abi](https://upload.wikimedia.org/wikipedia/commons/e/ee/Pad_abi.jpg)
Injury to
extremities (like arms, legs, hands, feet) is extremely common.
Falls are the most common
etiology
Etiology (pronounced ; alternatively: aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek (''aitiología'') "giving a reason for" (, ''aitía'', "cause"); and ('' -logía''). More completely, e ...
, making up as much as 30% of
upper and 60% of
lower extremity
The human leg, in the general word sense, is the entire lower limb of the human body, including the foot, thigh or sometimes even the hip or gluteal region. However, the definition in human anatomy refers only to the section of the lower lim ...
injuries. The most common mechanism for solely upper extremity injuries is machine operation or tool use. Work related accidents and vehicle crashes are also common causes. The injured extremity is examined for four major
functional components which include
soft tissue
Soft tissue is all the tissue in the body that is not hardened by the processes of ossification or calcification such as bones and teeth. Soft tissue connects, surrounds or supports internal organs and bones, and includes muscle, tendons, ligam ...
s,
nerves
A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system.
A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the e ...
,
vessels, and
bones
A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, an ...
.
Vessels are examined for expanding
hematoma
A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillary, capillaries. A he ...
,
bruit
Bruit, also called vascular murmur, is the abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial obstruction or a localized high rate of blood flow through an unobstructed artery.
The bruit may be hear ...
,
distal
Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...
pulse exam, and signs/symptoms of
ischemia
Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems wi ...
, essentially asking, "Does blood seem to be getting through the injured area in a way that enough is getting to the parts past the injury?" When it is not obvious that the answer is "yes", an injured extremity index or
ankle-brachial index may be used to help guide whether further evaluation with
computed tomography arteriography
Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen (anatomy), lumen, of blood vessels and organs of the body, with particular interest in the artery, arteries, veins, and the Heart#Chambers, heart ...
. This uses a special scanner and a substance that makes it easier to examine the vessels in finer detail than what the human hand can feel or the human eye can see. Soft tissue damage can lead to
rhabdomyolysis
Rhabdomyolysis (also called rhabdo) is a condition in which damaged skeletal muscle breaks down rapidly. Symptoms may include muscle pains, weakness, vomiting, and confusion. There may be tea-colored urine or an irregular heartbeat. Some of th ...
(a rapid breakdown of injured
muscle
Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of muscl ...
that can overwhelm the
kidney
The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blood ...
s) or may potentially develop
compartment syndrome
Compartment syndrome is a condition in which increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space. There are two main types: acute and chronic. Compartments of the ...
(when
pressure
Pressure (symbol: ''p'' or ''P'') is the force applied perpendicular to the surface of an object per unit area over which that force is distributed. Gauge pressure (also spelled ''gage'' pressure)The preferred spelling varies by country and e ...
builds up in
muscle compartments damages the
nerve
A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system.
A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the e ...
s and vessels in the same compartment). Bones are evaluated with
plain film x-ray or computed tomography if deformity (misshapen), bruising, or joint laxity (looser or more flexible than usual) are observed.
Neurologic
Neurology (from el, νεῦρον (neûron), "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the brain, the spinal c ...
evaluation involves testing of the major nerve functions of the
axillary,
radial
Radial is a geometric term of location which may refer to:
Mathematics and Direction
* Vector (geometric), a line
* Radius, adjective form of
* Radial distance, a directional coordinate in a polar coordinate system
* Radial set
* A bearing f ...
, and
median
In statistics and probability theory, the median is the value separating the higher half from the lower half of a data sample, a population, or a probability distribution. For a data set, it may be thought of as "the middle" value. The basic fe ...
nerves in the
upper extremity
The upper Limb (anatomy), limbs or upper extremities are the forelimbs of an upright posture, upright-postured tetrapod vertebrate, extending from the scapulae and clavicles down to and including the digit (anatomy), digits, including all the musc ...
as well as the
femoral,
sciatic
The sciatic nerve, also called the ischiadic nerve, is a large nerve in humans and other vertebrate animals which is the largest branch of the sacral plexus and runs alongside the hip joint and down the lower limb. It is the longest and widest si ...
,
deep peroneal, and
tibial nerves in the
lower extremity
The human leg, in the general word sense, is the entire lower limb of the human body, including the foot, thigh or sometimes even the hip or gluteal region. However, the definition in human anatomy refers only to the section of the lower lim ...
.
Surgical
Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...
treatment may be necessary depending on the extent of injury and involved structures, but many are managed nonoperatively.
Blunt pelvic trauma
The most common causes of blunt pelvic trauma are
motor vehicle crashes and multiple-story falls, and thus pelvic injuries are commonly associated with additional traumatic injuries in other locations.
In the pelvis specifically, the structures at risk include the
pelvic bones
The hip bone (os coxae, innominate bone, pelvic bone or coxal bone) is a large flat bone, constricted in the center and expanded above and below. In some vertebrates (including humans before puberty) it is composed of three parts: the ilium, ischi ...
, the
proximal femur, major blood vessels such as the
iliac arteries, the
urinary tract
The urinary system, also known as the urinary tract or renal system, consists of the kidneys, ureters, bladder, and the urethra. The purpose of the urinary system is to eliminate waste from the body, regulate blood volume and blood pressure, con ...
,
reproductive organs
A sex organ (or reproductive organ) is any part of an animal or plant that is involved in sexual reproduction. The reproductive organs together constitute the reproductive system. In animals, the testis in the male, and the ovary in the female, a ...
, and the
rectum
The rectum is the final straight portion of the large intestine in humans and some other mammals, and the Gastrointestinal tract, gut in others. The adult human rectum is about long, and begins at the rectosigmoid junction (the end of the s ...
.
![FractureRtSandIRami(Sin2)](https://upload.wikimedia.org/wikipedia/commons/4/49/FractureRtSandIRami%28Sin2%29.png)
One of the primary concerns is the risk of
pelvic fracture
A pelvic fracture is a break of the bony structure of the pelvis. This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. Symptoms include pain, particularly with movement. Complications may include internal ble ...
, which itself is associated with a myriad of complications including bleeding, damage to the
urethra
The urethra (from Greek οὐρήθρα – ''ourḗthrā'') is a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body of both females and males. In human females and other primates, the urethra con ...
and
bladder
The urinary bladder, or simply bladder, is a hollow organ in humans and other vertebrates that stores urine from the kidneys before disposal by urination. In humans the bladder is a distensible organ that sits on the pelvic floor. Urine enters ...
, and
nerve damage
Nerve injury is an injury to nervous tissue. There is no single classification system that can describe all the many variations of nerve injuries. In 1941, Seddon introduced a classification of nerve injuries based on three main types of nerve f ...
.
If pelvic trauma is suspected, emergency medical services personnel may place a
pelvic binder on patients to stabilize the patient's pelvis and prevent further damage to these structures while patients are transported to a hospital. During the evaluation of trauma patients in an emergency department, the stability of the pelvis is typically assessed by the healthcare provider to determine whether fracture may have occurred. Providers may then decide to order imaging such as an
X-ray
An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...
or CT scan to detect fractures; however, if there is concern for life-threatening bleeding, patients should receive an X-ray of the pelvis. Following initial treatment of the patient, fractures may need to be treated surgically if significant, while some minor fractures may heal without requiring surgery.
A life-threatening concern is
hemorrhage
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...
, which may result from damage to the
aorta
The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes ...
, iliac arteries or
veins
Veins are blood vessels in humans and most other animals that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated b ...
in the pelvis. The majority of bleeding due to pelvic trauma is due to injury to the veins.
Fluid (often blood) may be detected in the pelvis via
ultrasound
Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...
during the
FAST scan that is often performed following traumatic injuries. Should a patient appear hemodynamically unstable in the absence of obvious blood on the FAST scan, there may be concern for bleeding into the
retroperitoneal space
The retroperitoneal space (retroperitoneum) is the anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum on their ...
, known as
retroperitoneal hematoma. Stopping the bleeding may require
endovascular intervention or surgery, depending on the location and severity.
Diagnosis
In most settings, the initial evaluation and stabilization of traumatic injury follows the same general principles of identifying and treating immediately life-threatening injuries. In the US, the
American College of Surgeons
The American College of Surgeons is an educational association of surgeons created in 1913.American College of Surgeons Online "What is the American College of Surgeons?"/ref>
See also
*American College of Physicians
The American College o ...
publishes the Advanced Trauma Life Support guidelines, which provide a step-by-step approach to the initial assessment, stabilization, diagnostic reasoning, and treatment of traumatic injuries that codifies this general principle.
The assessment typically begins by ensuring that the subject's airway is open and competent, that breathing is unlabored, and that circulation—i.e. pulses that can be felt—is present. This is sometimes described as the "A, B, C's"—Airway, Breathing, and Circulation—and is the first step in any resuscitation or triage. Then, the history of the accident or injury is amplified with any medical, dietary (timing of last oral intake) and history, from whatever sources such as family, friends, previous treating physicians that might be available. This method is sometimes given the mnemonic "
SAMPLE
Sample or samples may refer to:
Base meaning
* Sample (statistics), a subset of a population – complete data set
* Sample (signal), a digital discrete sample of a continuous analog signal
* Sample (material), a specimen or small quantity of s ...
". The amount of time spent on diagnosis should be minimized and expedited by a combination of clinical assessment and appropriate use of technology, such as
diagnostic peritoneal lavage
Diagnostic peritoneal lavage (DPL) or diagnostic peritoneal aspiration (DPA) is a surgical diagnostic procedure to determine if there is free floating fluid (most often blood) in the abdominal cavity.
Indications
This procedure is performed when ...
(DPL), or
bedside ultrasound examination (FAST) before proceeding to
laparotomy
A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.
Origins and history
The first successful laparotomy was performed without ane ...
if required. If time and the patient's stability permits, CT examination may be carried out if available. Its advantages include superior definition of the injury, leading to grading of the injury and sometimes the confidence to avoid or postpone surgery. Its disadvantages include the time taken to acquire images, although this gets shorter with each generation of scanners, and the removal of the patient from the immediate view of the emergency or surgical staff. Many providers use the aid of an algorithm such as the ATLS guidelines to determine which images to obtain following the initial assessment. These algorithms take into account the mechanism of injury,
physical examination
In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patien ...
, and patient's
vital signs
Vital signs (also known as vitals) are a group of the four to six most crucial medical signs that indicate the status of the body's vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of a ...
to determine whether patients should have imaging or proceed directly to surgery.
Recently, criteria have been defined that might allow patients with blunt abdominal trauma to be discharged safely without further evaluation. The characteristics of such patients include:
* absence of intoxication
* no evidence of lowered blood pressure or raised pulse rate
* no abdominal pain or tenderness
* no blood in the urine.
To be considered low risk, patients would need to meet all low-risk criteria.
Treatment
When blunt trauma is significant enough to require evaluation by a healthcare provider, treatment is typically aimed at treating life-threatening injuries, which requires ensuring the patient is able to breathe and preventing ongoing blood loss. If there is evidence that the patient has lost blood, one or more
intravenous lines may be placed and
crystalloid solutions and/or
blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the c ...
will be administered at rates sufficient to maintain the circulation.
Some patients may require a surgical operation called an
exploratory laparotomy
An exploratory laparotomy is a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury or disease. It is the standard of care in various blunt and penetrating trauma situations in which there may be ...
to repair internal injuries.
Epidemiology
Worldwide, a significant cause of disability and death in people under the age of 35 year is trauma, of which most are due to blunt trauma.
See also
*
Blunt kidney trauma
The kidney is injured in approximately 10 percent of all significant blunt abdominal trauma. Of those, 13 percent are sports-related when the kidney, followed by testicle, is most frequently involved. However, the most frequent cause by far is t ...
*
Blunt cardiac injury
A blunt cardiac injury is an injury to the heart as the result of blunt trauma, typically to the anterior chest wall. It can result in a variety of specific injuries to the heart, the most common of which is a myocardial contusion, which is a term ...
*
Blunt trauma personal protective equipment
References
{{Authority control
Injuries
Medical emergencies
Causes of death
Trauma types
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