Clinical case 11 - Polytrauma due to a very high-speed single light vehicle road traffic accident

Very high-speed single light vehicle road traffic accident; would appear to have fallen asleep at the wheel, frontal impact, trapped with instrument panel on knees.

At the arrival of the Fire department: conscious Glasgow = 15, blood pressure: 110/70 mmHg, heart rate: 100, saturation: 97% in 9 l of oxygen, in considerable pain, reactive intermediate pupils, Morphine titration during release, no signs of respiratory distress, soft abdomen, no guarding, no loss of distal sensitivity.

Dislocation fracture of the left elbow, fracture of the right wrist, open fracture of the left femur, possible fracture of the left foot. Hemodynamic stability during transport. The patient was sent directly to the university hospital for treatment.

At the university hospital: Stable hemodynamics, reactive and symmetric pupils, marked reduction in left breath sounds, pain at peripheral fractures and pain in lumbar spine, abdomen soft, compressible, painless.
The body scan is provided.



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Answer 1: D and E

Posttraumatic diaphragmatic hernias are more common on the left side and are usually located at the myotendinous junction of the diaphragm. There are a number of classic CT signs for the latter, this patient presents with the most conventional, i.e. the presence of intra-abdominal organs in the thoracic cavity. This is the "collar sign" in the coronal section. Note also the very posterior position of the spleen with close contact with the posterior thoracic wall ("fallen sign") with no pleural interface, which is another indication of diaphragmatic rupture.

There is left pleural fluid effusion with the density measured at 48 Hounsfield units, suggestive of hemothorax.
The left parenchymatous opacification is retractile with passive atelectasis associated with the diaphragmatic rupture. There are probably associated parenchymatous contusions (fractured ribs) but there is no indication of pneumopathy.

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Answer 2: A, B, C, F.

A subcapsular hematoma of the liver can be seen over segment IV, which is clearly visible due to its imprint on the liver parenchyma.

Lacerations are linear lesions and contusions are hypodense areas of parenchymatous "ecchymosis". Both of these types of lesion can be seen on the spleen.

Renal artery injury is observed with no active bleeding but with a hematoma over the renal pedicle. This is most likely indicative of a sub-adventitial rupture of the renal artery with complete downstream devascularization of the kidney.

The dense aspect of the mesenteric fat corresponds to mesenteric panniculitis, which is unrelated to the injury.

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Answer 3: C.

Burst fractures are axial compression fractures associated to a variable extent with bending forces. They result in anterior AND middle column damage. They are characterized by the existence of comminution of the vertebral body with the presence of a sagittal line, which induces extension of the interpedicular, distance which is characteristic in this type of fracture. Posterior wall damage is always observed and often causes retraction of the bone fragments into the vertebral canal.

This type of fracture is unstable by definition due to the damage of both columns, but in our case, it can be considered to be stable as it is only a "bony" fracture with no recession of the posterior wall. Treatment will therefore be orthopedic.
Posterior wall damage does not usually occur in compression fractures.