Now, let’s leave the abdomen for
now and go into the pelvis.
Specific pelvic injuries are
really pelvic fracture related.
Can an eFAST detect
which is most likely associated
with a pelvic fracture?
The answer is no and that’s
a major downfall of eFAST.
So, just because there is
no fluid in the peritoneum
doesn’t mean that there is actually
no bleeding in the retroperitoneum.
That will be a miss.
Now, take a look
at these x-rays.
This patient has a pretty
bad pelvic fracture.
In fact, you see the
widening of the symphysis.
It may be an open
book pelvic fracture.
Significant pelvic fracture
like this is associated
hematomas and bleeding.
Although in general
these are self-limited,
in this instance on
you also see a little bit of contrast
and of course the bad pelvic fracture.
In a patient who is unstable, and
this is an important caveat,
who demonstrates active extravasation
instead of rushing to the operating room,
what we actually do is
take patient to the
interventional suite after
placing a pelvic binder.
So again, remember, if you have an isolated
pelvic fracture and unstable patient,
you want to wrap their
pelvis in a pelvic binder
and then take them to the
This is because unlike intra-abdominal organs
that are bleeding, opening of the abdomen
potentially makes the bleeding worse because
the previous tamponade has been released.
Here, you see an interventional
angiography demonstrating extravasation.
Here, our interventional radiology
colleagues can do selective embolization.
And in the lower quadrant of the
image, you see the fixation.
Oftentimes particularly when the
patient is hemodynamically unstable,
our orthopedic colleagues will place
what’s called an external fixator
just temporizing and stabilizing the
pelvis so that no further bleeding occurs.
This also reduces the
volume of space that’s
available in the
retroperitoneum for bleeding.
Now, what are some associated
injuries with pelvic fractures?
Don’t forget these,
these are important.
Bladder and urethral injuries.
Let’s go over them quickly.
First, we’ll take a look
at bladder injuries.
In bladder injury, the most important
differentiation is whether or not
the bladder injury is in intraperitoneal
or extraperitoneal position.
Now, for extraperitoneal bladder injuries
as demonstrated by this contrast study,
there’s contrast exiting the bladder but
limited itself to the extraperitoneal space.
This is an important
distinction because in
this situation fully
drainage alone is enough.
As opposed to intraperitoneal
where there is free contrast flowing
or urine flowing intra-abdominally,
this usually requires surgery to
repair the bladder multiple layers.
Now, remember pelvic fractures are also
associated with urethral injuries.
What are some classic exam
findings of a urethral injury?
Well, high-riding prostate
and blood at the meatus.
In fact, if you take ATLS or Advanced
Trauma Life Support systems,
these are important clinical findings that
we record at every trauma activation.
If there is suspicion of a
urethral injury prior to
placing a Foley catheter, you
must perform a urethrogram.
This is generally either done under
fluoroscopy or under CT where contrast
is place at the tip of the penis and
goes retrograde into the bladder.
Any disruption of the urethra
needs to be handled by urologist.
Although oftentimes, you’ll see
the urologist simply place a
stented Foley across the urethral
injury obviously very carefully.
Urethral injuries are also
associated with bladder injuries.
That’s why it’s not good enough
just to look at the urethra.
You should also look
at the bladder.
Now it’s time to review
some very important
clinical pearls and
First, don’t take an unstable
patient to the CAT scanner.
It’s a disaster ready to happen.
And remember, any clinical scenario
presented to you where the patient
becomes hemodynamically unstable
requires immediate intervention,
no further diagnostic studies.
They can either go to interventional radiology
for example in a patient that has a
pelvic fracture or the vast majority of the
time, they need an exploratory laparotomy.
I strongly recommend that that’s the
choice that you pick on your examinations.
Thank you very much for
joining me on this
discussion of abdominal
and pelvic injuries.