46 year old man was knocked off his motor bike by another vehicle 24hrs ago. He was rushed to hospital by passersby.
Examination : Head and neck were fine , Upper and lower airways clear . Chest movement symmetric ,phonation excellent , RR 25cpm
Bp, pulse initially unrecordable
Abdomen was mildly tender and full
Urethral catheter drained clear urine
Sites of injuries:
1.Avulsion injuries to rt arm with deformity of mid arm consistent with fracture
: 2. Severe tenderness of the pubis with large defect over the pubic region
: 3. Deformity of the Right thigh (distal 1/3)
4 Bleeding from a puncture wound at the left pubis
5. Swelling of scrotum with darkening of the scrotal skin
Diagnosis : hemorrhagic shock secondary haemoperitoneum
Closed Fracture Rt humerus
Comminuted supracondylar fracture
Investigations : CXR It revealed pneumothorax which was relieved by thoracostomy
Aggressive resuscitation was done with R/l, N/S, 3units of whole blood.
Patient complained of worsening abdominal pain during resuscitation
Surgery : Trauma laparotomy
Intraoperative Findings :
1.Haemoperitoneum of about 1litre
2. Avulsion of mesentery to segment of ileum (about 25cm long ), 40cm proximal to ICJ
3.There was a huge tear in the distal attachment of the mesentery to the posterior abdominal wall .
4 .liver, spleen , kidney, pancreas all normal.
Resection of gangrenous ileum with primary end to end anastomosis done
Bleeders at the posterior attachment of mesentery was diffuse and so pressure packing applied to stop bleeding , surgicel applied.
RT humeral shaft fracture managed conservatively with plaster of Paris
Knee spanning external fixation done by trauma team. Trauma team wanted to ex fix the pelvic diastasis but Shanz screw too short so pelvic sling applied
Exploration of the wound over the pubis done. Gritty edges of pubic bones palpated, left cord found to be swollen from contussion . Suprapic woumd packed for second look by urologists
Scrotal oedema resolved on conservative managment
Postoperative state : Head CT ordered later was normal. Patient made good recovery
Credits : 1.Drs Adinku (Specialist, General surgery) , Ametih (Resident, General surgery)
2. Dsr Quartey (Orthopaedic surgeon) , Abu ( Medical Officer, Trauma)