e-CASES: Traumatic perforation of small intestine, fracture of lumbar vertebra
High-speed road traffic accident, light vehicle against light vehicle, patient driving and wearing belt. Stable hemodynamics but abdominal contracture. Anterior tilt articular fracture of left wrist and fracture of the 5th metacarpus of the right hand (evaluated using X-rays).
The body scan is provided.
No posttraumatic intracerebral lesions (significant metallic artefacts on the posterior fossa, possible left temporal hypodensity with suspected artefact, to be re-examined if required).
Cervical spinal space:
No posttraumatic lesions.
No posttraumatic lesions other than fractures of the anterior arches of the 10th and 11th right ribs.
Bronchogenic distribution of micronodules in the middle lobe, suggestive of an infection rather than a traumatic lesion.
Unchanged known 12 mm nodule of the left anterobasal segment.
Free pneumoperitoneum with thickening of the jejunal loops, suggesting perforation (and possible wound on the right part of transverse colon).
Moderate intraperitoneal fluid effusion.
Posttraumatic eventration in left iliac fossa with disinsertion of the left abdominal oblique muscle.
No other posttraumatic lesions of the intra-abdominal solid organs.
Right superior articular fracture of S1 with widening of the contralateral L5-S1 joint space. Fracture of the right anteroinferior angle of L1 and fracture of the spinal processes of L4 and L5. All of which are suggestive of a dislocation fracture with an extension-rotation mechanism suggesting disk-ligament damage: unstable fracture.
Traumatic perforation of small intestine, fracture of lumbar vertebra
- Transfer to gastrointestinal surgery for exploratory laparotomy: edematous but viable small intestine, suture of a double jejunal perforation 50 cm from the duodeno-jejunal junction, no hematoma in the mesentery.
- Lumbar spine MRI revealed rupture of the inter-spinous ligament, yellow ligaments, and the common anterior ligament in L5-S1 with asymmetric compression of the distal endplate of L5. No L5-S1 disk signal abnormality. Aggravation of rotatory instability in corset, thus surgical treatment with lumbar arthrodesis by the anterior approach with intersomatic cage screwed in L5-S1 completed by posterior arthrodesis.
- Treatment of peripheral fractures with reduction and screw plate osteosynthesis on the left wrist and reduction and T-plate osteosynthesis of the fracture of the 5th right metacarpal.
- Posttraumatic intestinal parietal thickening is non-specific and may be caused by contusion, perforation, intestinal distress, reactional thickening to intraperitoneal effusion, etc.
- Posttraumatic perforations are more common in the small intestine than on the colon.
- It is important to know how to detect signs of rotatory instability in all cases of spinal fracture: asymmetrical posterior articular damage, asymmetric fracture of the costovertebral junctions, unilateral articular dislocation, etc.