literature review trauma abdomen

Advertisement

Diagnostic options for blunt abdominal trauma

• Review Article
• Published: 23 June 2020
• Volume 48 , pages 3575–3589, ( 2022 )

Cite this article

• Gerhard Achatz   ORCID: orcid.org/0000-0001-5064-5913 1 ,
• Kerstin Schwabe 2 ,
• Sebastian Brill 2 ,
• Christoph Zischek 3 ,
• Roland Schmidt 2 ,
• Benedikt Friemert 1 &
• Christian Beltzer 2  

1724 Accesses

8 Citations

Explore all metrics

A Correction to this article was published on 14 August 2020

This article has been updated

Physical examination, laboratory tests, ultrasound, conventional radiography, multislice computed tomography (MSCT), and diagnostic laparoscopy are used for diagnosing blunt abdominal trauma. In this article, we investigate and evaluate the usefulness and limitations of various diagnostic modalities on the basis of a comprehensive review of the literature.

We searched commonly used databases in order to obtain information about the aforementioned diagnostic modalities. Relevant articles were included in the literature review. On the basis of the results of our comprehensive analysis of the literature and a current case, we offer a diagnostic algorithm.

A total of 86 studies were included in the review. Ecchymosis of the abdominal wall (seat belt sign) is a clinical sign that has a high predictive value. Laboratory values such as those for haematocrit, haemoglobin, base excess or deficit, and international normalised ratio (INR) are prognostic parameters that are useful in guiding therapy. Extended focused assessment with sonography for trauma (eFAST) has become a well established component of the trauma room algorithm but is of limited usefulness in the diagnosis of blunt abdominal trauma. Compared with all other diagnostic modalities, MSCT has the highest sensitivity and specificity. Diagnostic laparoscopy is an invasive technique that may also serve as a therapeutic tool and is particularly suited for haemodynamically stable patients with suspected hollow viscus injuries.

Conclusions

MSCT is the gold standard diagnostic modality for blunt abdominal trauma because of its high sensitivity and specificity in detecting relevant intra-abdominal injuries. In many cases, however, clinical, laboratory and imaging findings must be interpreted jointly for an adequate evaluation of a patient’s injuries and for treatment planning since these data supplement and complement one another. Patients with blunt abdominal trauma should be admitted for clinical observation over a minimum period of 24 h since there is no investigation that can reliably rule out intra-abdominal injuries.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Similar content being viewed by others

Test characteristics of focused assessment with sonography for trauma (FAST), repeated FAST, and clinical exam in prediction of intra-abdominal injury in children with blunt trauma

Emergency Radiology of the Abdomen and Pelvis

Blunt Abdominal Trauma

Change history, 14 august 2020.

A Correction to this paper has been published: https://doi.org/10.1007/s00068-020-01456-4

Iaselli F, et al. Bowel and mesenteric injuries from blunt abdominal trauma: a review. Radiol Med. 2015;120(1):21–322.

Article   PubMed   Google Scholar  

Norcross ED, et al. Application of American College of Surgeons’ field triage guidelines by pre-hospital personnel. J Am Coll Surg. 1995;181(6):539–44.

CAS   PubMed   Google Scholar  

Rossaint R, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20(1):100.

Article   PubMed   PubMed Central   Google Scholar  

Vailas MG, et al. Seatbelt sign in a case of blunt abdominal trauma; what lies beneath it? BMC Surg. 2015;15:121.

McStay C, et al. Hollow viscus injury. J Emerg Med. 2009;37(3):293–9.

Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surg. 1997;63(10):885–8.

Jones EL, et al. Intra-abdominal injury following blunt trauma becomes clinically apparent within 9 hours. J Trauma Acute Care Surg. 2014;76(4):1020–3.

Allgower M, Burri C. “Shock index”. Dtsch Med Wochenschr. 1967;92(43):1947–50.

Liu N, et al. An intelligent scoring system and its application to cardiac arrest prediction. IEEE Trans Inf Technol Biomed. 2012;16(6):1324–31.

Mitra B, et al. Trauma patients with the ‘triad of death’. Emerg Med J. 2012;29(8):622–5.

Wang SY, et al. An outcome prediction model for exsanguinating patients with blunt abdominal trauma after damage control laparotomy: a retrospective study. BMC Surg. 2014;14:24.

Ibrahim I, et al. Is arterial base deficit still a useful prognostic marker in trauma? A systematic review. Am J Emerg Med. 2016;34(3):626–35.

Article   CAS   PubMed   Google Scholar  

Davis JW, Kaups KL. Base deficit in the elderly: a marker of severe injury and death. J Trauma. 1998;45(5):873–7.

Mutschler M, et al. Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU(R). Crit Care. 2013;17(2):R42.

Johansson PI, et al. Thrombelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med. 2009;17:45.

Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification and effect. Curr Opin Crit Care. 2007;13(6):680–5.

Hunt H, et al. (2015) Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) for trauma induced coagulopathy in adult trauma patients with bleeding. Cochrane Database Syst Rev. 2015;2:CD010438.

Google Scholar  

Greenfield RH, Bessen HA, Henneman PL. Effect of crystalloid infusion on hematocrit and intravascular volume in healthy, nonbleeding subjects. Ann Emerg Med. 1989;18(1):51–5.

Stamler KD. Effect of crystalloid infusion on hematocrit in nonbleeding patients, with applications to clinical traumatology. Ann Emerg Med. 1989;18(7):747–9.

Genoa Update on Colorectal Polyp. Proceedings of the advanced course in coloproctology: the colorectal polyps, from genetics to surgery. Genoa, Italy, 11–12 March 2004. Tech Coloproctol, 2004. 8 Suppl 2: p. s239–314.

Thorson CM, et al. Admission hematocrit and transfusion requirements after trauma. J Am Coll Surg. 2013;216(1):65–73.

Mahajan A, et al. Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review. Injury. 2014;45(9):1384–93.

Sabzghabaei A, et al. The accuracy of urinalysis in predicting intra-abdominal injury following blunt traumas. Emerg (Tehran). 2016;4(1):11–5.

Scalea TM, et al. Focused assessment with sonography for trauma (FAST): results from an international consensus conference. J Trauma. 1999;46(3):466–72.

Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364(8):749–57.

Montoya J, et al. From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment. Eur J Trauma Emerg Surg. 2016;42(2):119–26.

Surgeons, A.C.o., Advanced Trauma Life Support. Vol. 9. 2014: Urban and Fischer Verlag/Elsevier.

Unfallchirurgie, D.G.f., S3—Leitlinie Polytrauma und Schwerverletztenversorgung. 2016: AWMF.

Stawicki SP. Trends in nonoperative management of traumatic injuries: a synopsis. Int J Crit Illn Inj Sci. 2017;7(1):38–57.

Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17(1):11–7.

Nandipati KC, et al. Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: experience at a community based level I trauma center. Injury. 2011;42(5):511–4.

Wherrett LJ, et al. Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage. J Trauma. 1996;41(5):815–20.

Hoffmann R, et al. Blunt abdominal trauma in cases of multiple trauma evaluated by ultrasonography: a prospective analysis of 291 patients. J Trauma. 1992;32(4):452–8.

Jehle D, Guarino J, Karamanoukian H. Emergency department ultrasound in the evaluation of blunt abdominal trauma. Am J Emerg Med. 1993;11(4):342–6.

Branney SW, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma. 1995;39(2):375–80.

Stawicki SP, et al. Portable ultrasonography in mass casualty incidents: The CAVEAT examination. World J Orthop. 2010;1(1):10–9.

Soyuncu S, et al. Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma. Injury. 2007;38(5):564–9.

Healey MA, et al. A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful? J Trauma. 1996;40(6):875–83.

McGahan JP, Richards J, Gillen M. The focused abdominal sonography for trauma scan: pearls and pitfalls. J Ultrasound Med. 2002;21(7):789–800.

Carter JW, et al. Do we really rely on fast for decision-making in the management of blunt abdominal trauma? Injury. 2015;46(5):817–21.

Blackstock U, Munson J, Szyld D. Bedside ultrasound curriculum for medical students: report of a blended learning curriculum implementation and validation. J Clin Ultrasound. 2015;43(3):139–44.

Dubois L, Leslie K, Parry N. FACTS survey: focused assessment with sonography in trauma use among Canadian residents training in general surgery. J Trauma. 2010;69(4):765–9.

PubMed   Google Scholar  

Ma OJ, et al. Operative versus nonoperative management of blunt abdominal trauma: Role of ultrasound-measured intraperitoneal fluid levels. Am J Emerg Med. 2001;19(4):284–6.

Ollerton JE, et al. Prospective study to evaluate the influence of FAST on trauma patient management. J Trauma. 2006;60(4):785–91.

Wydo SM, et al. Portable ultrasound in disaster triage: a focused review. Eur J Trauma Emerg Surg. 2016;42(2):151–9.

Stengel D, et al. (2015) Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev. 2015;9:CD004446.

Miele V, et al. Contrast-enhanced ultrasound (CEUS) in blunt abdominal trauma. Br J Radiol. 2016;89(1061):20150823.

Zhang Z, et al. Diagnostic accuracy of contrast enhanced ultrasound in patients with blunt abdominal trauma presenting to the emergency department: a systematic review and meta-analysis. Sci Rep. 2017;7(1):4446.

Sessa B, et al. Blunt abdominal trauma: role of contrast-enhanced ultrasound (CEUS) in the detection and staging of abdominal traumatic lesions compared to US and CE-MDCT. Radiol Med. 2015;120(2):180–9.

Valentino M, et al. Contrast-enhanced ultrasound for blunt abdominal trauma. Semin Ultrasound CT MR. 2007;28(2):130–40.

Pinto F, et al. The use of contrast-enhanced ultrasound in blunt abdominal trauma: advantages and limitations. Acta Radiol. 2014;55(7):776–84.

Wongwaisayawan S, et al. Trauma ultrasound. Ultrasound Med Biol. 2015;41(10):2543–61.

Pinto F, et al. The role of CEUS in the assessment of haemodynamically stable patients with blunt abdominal trauma. Radiol Med. 2015;120(1):3–11.

Deunk J, et al. Predictors for the selection of patients for abdominal CT after blunt trauma: a proposal for a diagnostic algorithm. Ann Surg. 2010;251(3):512–20.

Kokabi N, et al. Specific radiological findings of traumatic gastrointestinal tract injuries in patients with blunt chest and abdominal trauma. Can Assoc Radiol J. 2015;66(2):158–63.

Corwin MT, et al. Utilization of a clinical prediction rule for abdominal-pelvic CT scans in patients with blunt abdominal trauma. Emerg Radiol. 2014;21(6):571–6.

Soto JA, Anderson SW. Multidetector CT of blunt abdominal trauma. Radiology. 2012;265(3):678–93.

Marek AP, et al. CT scan-detected pneumoperitoneum: an unreliable predictor of intra-abdominal injury in blunt trauma. Injury. 2014;45(1):116–21.

Hefny AF, et al. Usefulness of free intraperitoneal air detected by CT scan in diagnosing bowel perforation in blunt trauma: experience from a community-based hospital. Injury. 2015;46(1):100–4.

Gonser-Hafertepen LN, et al. Isolated free fluid on abdominal computed tomography in blunt trauma: watch and wait or operate? J Am Coll Surg. 2014;219(4):599–605.

Park MH, Shin BS, Namgung H. Diagnostic performance of 64-MDCT for blunt small bowel perforation. Clin Imaging. 2013;37(5):884–8.

Yu J, et al. Blunt bowel and mesenteric injury: MDCT diagnosis. Abdom Imaging. 2011;36(1):50–61.

Fu CJ, et al. Computed tomography arterial portography for assessment of portal vein injury after blunt hepatic trauma. Diagn Interv Radiol. 2015;21(5):361–7.

Wallace GW, et al. Imaging the pregnant patient with abdominal pain. Abdom Imaging. 2012;37(5):849–60.

Pearce MS, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012;380(9840):499–505.

Arnold M, Moore SW. Paediatric blunt abdominal trauma - are we doing too many computed tomography scans? S Afr J Surg. 2013;51(1):26–31.

Panda A, et al. Evaluation of diagnostic utility of multidetector computed tomography and magnetic resonance imaging in blunt pancreatic trauma: a prospective study. Acta Radiol. 2015;56(4):387–96.

Tharakan SJ, et al. Laparoscopy in Pediatric Abdominal Trauma: A 13-Year Experience. Eur J Pediatr Surg. 2016;26(5):443–8.

Johnson JJ, et al. The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center. Am J Surg. 2013;205(3):317–20.

Sitnikov V, et al. The role of video-assisted laparoscopy in management of patients with small bowel injuries in abdominal trauma. Surg Endosc. 2009;23(1):125–9.

Nicolau AE, et al. Small bowel perforation caused by compound pelvic fracture found in diagnostic laparoscopy. Chirurgia (Bucur). 2006;101(4):423–8.

CAS   Google Scholar  

Uranus S, Dorr K. Laparoscopy in Abdominal Trauma. Eur J Trauma Emerg Surg. 2010;36(1):19–24.

Kindel T, et al. Laparoscopy in trauma: An overview of complications and related topics. Int J Crit Illn Inj Sci. 2015;5(3):196–205.

Becker HP, Willms A, Schwab R. Laparoscopy for abdominal trauma. Chirurg. 2006;77(11):1007–133.

Khubutiya M, et al. Laparoscopy in blunt and penetrating abdominal trauma. Surg Laparosc Endosc Percutan Tech. 2013;23(6):507–12.

Nicolau AE. Is laparoscopy still needed in blunt abdominal trauma? Chirurgia (Bucur). 2011;106(1):59–66.

Lee PC, et al. Laparoscopy decreases the laparotomy rate in hemodynamically stable patients with blunt abdominal trauma. Surg Innov. 2014;21(2):155–65.

Kaban GK, et al. Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries. Surg Innov. 2008;15(1):26–31.

Gaines BA, Rutkoski JD. The role of laparoscopy in pediatric trauma. Semin Pediatr Surg. 2010;19(4):300–3.

Gregoric PD, et al. Laparoscopy in the evaluation of blunt abdominal trauma. Acta Chir Iugosl. 2010;57(4):33–8.

Addeo P, Calabrese DP. Diagnostic and therapeutic value of laparoscopy for small bowel blunt injuries: A case report. Int J Surg Case Rep. 2011;2(8):316–8.

Fuentes S, et al. Laparoscopy as diagnostic-therapeutic method in abdominal traumatism in the pediatric age. Cir Pediatr. 2011;24(2):115–7.

Van Kerschaver O, et al. An unusual case of blunt abdominal trauma: A bleeding and ruptured gall-bladder managed by laparoscopy. Acta Chir Belg. 2006;106(4):417–9.

Kovachev S, et al. Open laparoscopy–a modified Hasson technique. Akush Ginekol (Sofiia). 2015;54(4):52–6.

Marwan A, et al. Use of laparoscopy in the management of pediatric abdominal trauma. J Trauma. 2010;69(4):761–4.

Lin HF, et al. Value of diagnostic and therapeutic laparoscopy for patients with blunt abdominal trauma: A 10-year medical center experience. PLoS ONE. 2018;13(2):e0193379.

Download references

Author information

Authors and affiliations.

Department for Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, Sportstraumatology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany

Gerhard Achatz & Benedikt Friemert

Department for General-, Visceral- and Thoracic-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany

Kerstin Schwabe, Sebastian Brill, Roland Schmidt & Christian Beltzer

Department for Vascular- and Endovascular-Surgery, German Armed Forces Hospital Ulm, Ulm, Germany

Christoph Zischek

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Gerhard Achatz .

Ethics declarations

Conflict of interest.

Achatz Gerhard, Schwabe Kerstin, Brill Sebastian, Zischek Christoph, Schmidt Roland, Friemert Benedikt and Beltzer Christian declare that there is no conflict of interest regarding this paper and topic.

Ethical approval

For this study there were no test or experiments to humans or animals.

Additional information

The original version of this article was revised: In the author list, the first and last names were tagged incorrectly. The corrected author list is given above.

Rights and permissions

Reprints and permissions

About this article

Achatz, G., Schwabe, K., Brill, S. et al. Diagnostic options for blunt abdominal trauma. Eur J Trauma Emerg Surg 48 , 3575–3589 (2022). https://doi.org/10.1007/s00068-020-01405-1

Download citation

Received : 08 February 2020

Accepted : 18 May 2020

Published : 23 June 2020

Issue Date : October 2022

DOI : https://doi.org/10.1007/s00068-020-01405-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Blunt abdominal trauma
• Radiography
• Diagnostic laparoscopy
• Hollow viscus injury
• Find a journal
• Publish with us
• Track your research

Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma

Published 2022 Citation: J Trauma, 93(3)::e110-e118, September 2022

Mahoney, Eric J. MD, FACS; Bugaev, Nikolay MD; Appelbaum, Rachel MD; Goldenberg-Sandau, Anna DO; Baltazar, Gerard A. DO, FACOS, FACS; Posluszny, Joseph MD; Dultz, Linda MD, MPH; Kartiko, Susan MD, PhD, FACS; Kasotakis, George MD, MPH, FACS, FCCM; Como, John MD; Klein, Eric MD, FACS

Advances in trauma care have improved survival after abdominal catastrophes. [1] Nonetheless, patients with open abdomens (OAs) are at risk of increased morbidity. Multiple techniques have been described to manage the OA, including temporary abdominal closure (e.g., the Bogota bag), [2] negative pressure wound therapy (NPWT), [3 ][4] and fascial traction systems [suture traction, [5] the ABRA system, [6] Wittmann Patch, [7] progressive partial fascial closure, and mesh-mediated fascial traction (MMFT). [8] Volume removal techniques [9] and complex abdominal reconstruction techniques including component separation [10] ; bridging with biologic prostheses, [11 ][12] or placement of synthetic absorbable mesh and eventual skin grafting [13] have also been described. Despite the variety of options, the optimal treatment remains unclear.

In 2011, the Eastern Association for the Surgery of Trauma Practice Management Guidelines (PMG) Committee attempted to address this issue. [14 ][15] The authors concluded that “the populations are so heterogeneous” and that the “current literature remains contentious at best,” such that no recommendations could be provided. Since then, a significant body of evidence has emerged, and an updated systematic review and meta-analysis was deemed prudent. The goal of this article was to provide up-to-date recommendations regarding the optimal strategies for the OA after damage-control laparotomy (DCL).

Two population (P), intervention (I), comparator (C), and outcome (O) (PICO) questions were defined before the literature search:

In hemodynamically normal trauma and emergency general surgery (EGS) patients with OA after DCL in whom intra-abdominal pathology has been addressed and physiology normalized (P), should interventions to reduce visceral edema (diuresis, hypertonic saline, direct peritoneal resuscitation); (I) versus no interventions (C) be performed to help achieve primary myofascial closure during index admission, reduce ventral herniation after primary myofascial closure during index admission, reduce fascial dehiscence after primary myofascial closure, and reduce incidence of enterocutaneous/atmospheric fistula (ECF) and mortality (O)?

In hemodynamically normal trauma and EGS patients with OA after DCL in whom intra-abdominal pathology has been addressed (P), should a fascial traction system be used (I) versus no traction systems (C) to help achieve primary myofascial closure during index admission, reduce ventral herniation after primary myofascial closure during index admission, reduce fascial dehiscence after primary myofascial closure, and reduce incidence of ECF and mortality (O)?

Selection of Outcome Measures

Clinically relevant outcomes were identified and rated on a scale of 1 to 9. Outcomes that averaged 7 to 9 were considered critical and were used for analysis. These included mortality, failure of primary myofascial closure during index admission, ventral herniation after primary myofascial closure during index admission, fascial dehiscence after primary myofascial closure, and ECF. Initially, 3,878 abstracts were identified, of which 19 articles met the inclusion criteria (PRISMA, Supplement Digital Content A, https://links.lww.com/TA/C524).

Identification of References

A professional medical librarian (J.R.) performed searches of citations in , Embase, Cochrane Library, Web of Science and Ovid Medline. The MeSH search terms included: PICO 1: laparotomy, volume removal, goal-directed diuresis, hypertonic saline solution, renal replacement therapy, dialysis; PICO 2: fascia, traction, Wittmann Patch, abdominal reapproximation anchor, ABRA system, progressive partial fascial closure, mesh-mediated fascial mobilization, Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction (VAWCM) technique. Abstract reviews, full-text reviews, and data extraction were performed in duplicate utilizing Covidence (www.covidence.org).

Randomized control trials, observational studies, and retrospective reviews with comparison groups in adults (age, ≥18 years) in English or English-translated articles (1950 to present) were included in the analyses. Case series, case reports, review articles, meta-analyses, and non-peer reviewed open access articles were excluded. Article reference lists were reviewed to ensure that no relevant articles were overlooked.

Data Extraction and Methodology

Each abstract and full text was assigned to two working group members to determine if the article met inclusion criteria. A third member (E.M.) adjudicated any difference in opinion. Data were extracted onto a standardized data collection sheet and collated into a master file.

The meta-analysis was conducted with random effects modeling and forest plots were generated using Review Manager (RevMan5; Version 5.3; Cochrane Collaboration, Oxford). Of note, it was determined the RevMan5 inherently favors outcomes with less incidence (e.g., mortality). Therefore, the outcome for fascial closure was analyzed as “less failure of primary myofascial closure” rather than “group with greater fascial closure.” The degrees of heterogeneity ( I [2] ) were calculated between study populations and were defined as low ( I [2] < 50%) or high ( I [2] > 50%).

“Physiology normalized” was defined as the time after acute resuscitation when shock has been corrected and the end-organ perfusion has been restored, either off pressor medications or on a minimal, stable dose. “Intra-abdominal pathology has been addressed” was defined as the time after infectious source control has been established, and no further resection of intra-abdominal or abdominal wall tissue is anticipated. “Skin only” closure was considered a ventral hernia. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was utilized to determine the impact of selected interventions and to assess the level of evidence. [16] The GRADE evidence profile table was created utilizing online software (gdt.gradepro.org).

The quality of the available evidence was assessed as high, moderate, low, or very low, based on study design, selection bias, inconsistency, indirectness, imprecision, magnitude of effect, and plausible confounding variables. The quality of evidence was graded up or down based on these principles. Recommendation consensus was reached by blinded voting and the group articulated a strong recommendation as “we recommend,” whereas a weak recommendation was listed as “we conditionally recommend.”

Fascial Traction Systems

Progressive fascial closure and suture traction, as described by Cothren and colleagues, [5] is a technique wherein the patient with OA is returned to the operating room at a set interval (usually every 48 hours). During each procedure, fascial sutures are placed in interrupted fashion until tension develops along the incision. The remaining OA is covered with a protective temporary closure. The ABRA system utilizes a series of midline-crossing elastomers that are inserted perpendicular to the fascia and are tightened daily to apply constant fascial tension. [6] The Wittmann Patch utilizes two sheets of complementary material: one hook sheet and one loop sheet to provide adherence. [7] Each sheet is secured to one side of the OA with transfascial sutures. The sheets are pulled taut and pressed together sequentially until the fascia is reapproximated. In MMFT, a polypropylene mesh is sewn circumferentially to the fascia of the OA. [8] The mesh is “pinched” daily to determine if laxity has developed. If laxity is identified, the mesh is sutured to maintain fascial traction. A negative pressure therapy dressing is applied often, creating a VAWCM technique.

PICO Question 1

Qualitative analysis.

Two studies evaluating the use of diuretic therapy after DCL met our criteria. Webb et al. [9] performed a single institution, retrospective review of patients with an OA more than 24 hours who received furosemide compared with those who did not. The selection criteria detailing the choice of patients to receive furosemide therapy was poorly described. The article did not offer a treatment protocol nor the average amount of medication each patients received. Furthermore, the authors did not document volume status nor if a negative fluid balance was achieved after furosemide infusion. The study by Tian and colleagues [17] was a prospective, protocolized design. All patients in the treatment group received 20% Albumin intravenously, followed by 20 mg of Torsemide IV daily for 7 days. This study had several significant limitations as well. Group assignment was based on patients or the health care proxy preference and not by randomization. Moreover, the presence or development of a fistula before abdominal closure excluded the patients from analysis. The use of the diuretic was in conjunction with a treatment protocol that included VAWCM technique and continuous peritoneal instillation of saline, thus making it difficult to ascertain the contribution that diuresis made to patient recovery. Furthermore, 11 of the 16 patients receiving diuretic therapy also underwent dialysis. Finally, the closure technique for all these patients was by component separation, which may not be the case with the study by Webb and colleagues.

Hypertonic Saline

Two studies evaluating the use of hypertonic saline (HTS) to improve the rates of primary myofascial closure met our criteria. The study by Harvin et al. [18] was limited by its retrospective, observational design, and lack of protocolization. The use of HTS was at the discretion of the attending surgeon, which may have introduced bias. The HTS study by Loftus et al. [19] was also a retrospective study in which patients who were treated with HTS as part of a treatment protocol were compared with matched historical controls. Unfortunately, the extensive exclusion criteria, which excluded patients with acute kidney injury Kidney Disease Improving Global Outcomes stage 2 or greater, chronic kidney disease stage 3 or greater, pH less than 7.10, or cirrhosis, created a select treatment group and makes any comparison with the group described by Harvin and colleagues difficult.

Direct Peritoneal Resuscitation

The three studies by Smith and colleagues [20–22] demonstrate a methodical commitment to understand the benefits of direct peritoneal resuscitation (DPR). The studies develop from a retrospective case-matched study of patients undergoing DCL for hemorrhagic shock, progress to a propensity-matched study of peritoneal resuscitation in all EGS patients who required DCL, and then culminate in a prospective randomized controlled trial in a similar cohort. Although these compelling findings demonstrate improved primary myofascial closure rates in patients receiving DPR, one must proceed with some hesitation until additional independent studies provide corroboration.

Quantitative Analysis

In their retrospective review, Webb et al. [9] did not find improved primary myofascial closure rates with the use of a furosemide infusion. Conversely, Tian and colleagues [17] were able to demonstrate a higher incidence of primary myofascial closure when therapeutic diuresis was included. There was no difference in mortality between the groups in either study. Neither study addressed the other outcomes selected for our analysis.

Both studies employed 3% HTS at 30 mL/h. as the maintenance fluid after DCL. Harvin et al. [18] demonstrated that the patients in the control group received significantly more fluid in the 24-hour, 48-hour, and 72-hour timepoints compared with those receiving HTS. This difference translated into a higher rate of failure to achieve primary myofascial closure in the control group versus the HTS group (24% vs. 4%) at discharge; unfortunately, this did not meet statistical significance. Thirty-day mortality was the same in both groups. Similarly, Loftus et al. [19] initiated 3% HTS in patients with OA (plus bolus isotonic fluid to achieve euvolemia). Progressive fascial closure was performed at each staged repeat laparotomy. These researchers found that patients treated with HTS received less total fluid during the first 48 hours after DCL compared to standard therapy, yet the total fluids received between the two groups at 96-hour and 7-day timepoints were the same. Nonetheless, the authors were able to demonstrate improved primary myofascial closure rates in the HTS group compared with the controls without a statistical difference in the incidence of fascial dehiscence nor mortality.

Three studies evaluating the use of DPR were identified. All the studies originated from Smith and colleagues. [20–22] The first study demonstrated that treatment with DPR was associated with a statistical improvement in primary myofascial closure compared with controls. [20] This difference was lost when DPR was compared with controls who were treated with Wittmann Patch. Direct peritoneal resuscitation was associated with a statistically significant decrease in the incidence of hernia development without any statistically significant difference in the incidence of ECF nor mortality. In their second and third studies, Smith et al. were able to demonstrate that patients treated with DPR had a higher incidence of primary myofascial closure compared with controls (Smith et al. [21] primary myofascial closure: 68% vs. 43%, p = 0.03; Smith et al. [22] primary myofascial closure: 83% vs. 67%, p = 0.005). Mortality and the incidence of ECF were not statistically difference between DPR and control groups in either study.

Figure 1: Forest plot, failure of primary myofascial closure with techniques to reduce visceral edema.

The working group determined that it was important to include a comparison of these treatment techniques. Although the techniques varied, they shared the intent of reducing visceral edema to improve fascial closure. Overall, only four studies were suitable for meta-analysis. [9 ][17–19] The studies by Smith and colleagues demonstrated significant overlap in the enrollment timepoints for each of the studies (Smith et al. [20] : January 2005 to December 2008; Smith et al. [21] : January 2008 to December 2012; Smith et al. [22] : January 2011 to December 2015). Thus, we could not include these studies since it seems likely that patients from the overlapping timepoints may be represented in more than one study. Only one study demonstrated a clear improvement in primary myofascial closure with the reduction of visceral edema. [17] There were no difference in in-hospital mortality among any of the studies. None of the studies evaluated ECF, fascial dehiscence or recurrent hernia. In all, 124 patients who underwent a technique to reduce visceral edema and 257 patients with routine care were included in the meta-analysis. This analysis demonstrated that the addition of a technique to reduce visceral edema may lessen the failure of primary myofascial closure in patients with an OA (relative risk [RR], 0.52; 95% confidence interval [CI], 0.33–0.81; Fig. 1). However, the findings are very limited based on the high heterogeneity (as demonstrated by an I [2] of 71%) and the small number of studies.

Grading the Evidence

Methodological variations of the study designs limit direct comparisons. Only two outcomes of interest (primary closure and mortality) were evaluated in the studies. Based on the small number of studies, and the limitations identified in the qualitative analysis, the quality of the evidence was considered very low. A GRADE evidence profile table was deemed fruitless because of the lack of outcomes available and high heterogeneity.

Recommendations

We are unable to make any recommendations regarding the use of techniques to remove visceral edema in hemodynamically normal trauma and emergency general surgery patients with OAs after DCLs.

PICO Question 2

TABLE 1: GRADE Evidence Profile for Fascial Traction vs. No Traction

Most studies were retrospective studies [5–7 ][23–27] and only four of the studies [8 ][28–30] were prospective randomized trials. Nine of the studies [5–7 ][23–27 ][29] did reveal a large magnitude of effect in the intervention groups compared with the control groups. Unfortunately, blinding was not possible in any of the studies and may have affected the outcomes. There appeared to be selection bias in four studies, [6 ][24 ][26 ][28] imprecision in two studies [8 ][23] and confounding variables in two studies. [5 ][28] Sample size plagued many studies, thus limiting the ability to draw firm conclusions on any of the outcomes. [8 ][24 ][27 ][28 ][30] Please see the GRADE Evidence Profile (GRADEpro, Table 1).

Primary myofascial closure during index admission

Figure 2: Forest plot, failure of primary myofascial closure, fascial traction vs. routine care; (A) All studies, (B) Randomized, controlled trials only.

Twelve studies were identified that addressed the outcome measure of fascial traction: four were randomized controlled trials [8 ][28–30] and the remainder were retrospective observational studies. [5–7 ][23–27] Three evaluated MMFT [8 ][23 ][25] as the study group, two Wittmann patch, [7 ][27] three ABRA plus NPWT, [6 ][24 ][28] two suture fascial traction, [5 ][29] one allowed either vessel loop or MMFT as the mode of fascial traction, [26] and one evaluated a novel fascial traction device. [30] Overall, the studies included 378 patients in the fascial traction group, and 304 patients in the control group. Most compared the fascial traction group against NPWT alone, [6 ][8 ][23 ][24 ][28–30] one versus traction plus NPWT, [5] one versus nontraction mesh, [26] and three against various techniques (e.g., Bogota bag, mesh). [7 ][25 ][27] Data from all included studies were suitable for analysis. Three studies did not show a statistically significant improvement [8 ][24 ][28] and nine demonstrated improvement favoring fascial traction. [5–7 ][23 ][25–27 ][29 ][30] When all of the studies were included, the populations were determined to have a low degree of heterogeneity based on an I [2] value of 23% and, fascial traction was favored over non-fascial traction (RR, 0.34; (95% CI, 0.25–0.46). When only randomized, controlled trials were included, fascial traction was still favored (RR, 0.48; 95% CI, 0.26–0.87] but with higher heterogeneity (I [2] = 48%; Fig. 2 A and B ).

Two studies found that the patients with fascial traction strategies had abdominal closure 4 days sooner [8 ][29] and one study reported 43 days sooner. [27] Conversely, two studies found that patients with fascial traction devices had more days with OAs despite less synthetic mesh placement and greater fascial closure rates. [6 ][7] Rasilainen and colleagues [25] reported no difference in the mean number of OA days. The remaining studies did not comment on the time to closure between the groups. [5 ][23 ][24 ][26 ][28 ][30]

Enterocutaneous and Enteroatmospheric Fistulas

Figure 3: Forest plot, incidence of enterocutaneous and enteroatmospheric fistula, fascial traction vs. routine care.

Six studies were suitable for analysis. [5 ][8 ][25–27 ][30] All studies identified the ECF during the index hospitalization. Only one study reported improvement in ECF rates with fascial traction, Wittmann patch, versus Bogota bag placement (1/24 patients with WP developed ECF, vs. 2/4 in Bogota group). [27] Overall, 247 patients with fascial traction versus 168 in control were included in the meta-analysis. These groups were determined to have a low degree of heterogeneity based on an I [2] value of 24%. This analysis demonstrated no statistically significant difference in the incidence of ECF rates (RR, 0.65; 95% CI, 0.40–1.04; Fig. 3).

Fascial Dehiscence

Two studies addressed this outcome in their analysis. [8 ][30] Correa and colleagues [8] identified a fascial dehiscence rate of 15% of patients treated with NPWT alone compared to 6.3% when MMFT was added. These values did not reach statistical significance. Rezende-Neto and Camilotti [30] reported that there were no cases of fascial dehiscence in patients treated with a fascial reapproximation device in addition to NPWT. Unfortunately, the authors did not report the incidence of fascial dehiscence in the control group.

Ventral Herniation

Figure 4: Forest plot, ventral hernia, fascial traction vs. routine care.

Five studies addressed ventral hernia. [6 ][7 ][23 ][25 ][30] The presence of a hernia was determined at the time of discharge in all studies, and included overt hernia, skin only closure, and skin graft onto the OA with planned ventral hernia repair in the future. Two studies evaluated MMFT [23 ][25] versus NPWT without fascial traction, one evaluated the ABRA system plus NPWT versus NPWT alone; [6] one evaluated a novel fascial traction device versus NPWT, [30] and one evaluated the Wittmann patch plus NPWT versus various other techniques (e.g., Bogota bag, NPWT, mesh). [7] The meta-analysis included 246 patients in the study group versus 156 in the control group and favored facial traction (odds ratio, 0.11; 95% CI, 0.06–0.19; Figure 4). Unfortunately, these results are limited by the high heterogeneity identified between study populations (I [2] = 52%).

Figure 5: Forest plot, mortality, fascial traction vs. routine care.

Mortality, which was based upon death before discharge, was addressed in nine studies. [5–8 ][23–26 ][30] The meta-analysis included 421 patients in the study group and 346 in the control group. Only one study demonstrated a survival benefit for fascial traction. [23] The remainder of the studies did not demonstrate any difference in mortality when comparing fascial traction to no fascial traction (RR, 0.82; 95% CI, 0.62–1.10; Fig. 5). The I [2] value of 34% suggests low heterogeneity between the studies.

Based on the retrospective nature of the many of the studies, the small number of studies, and the limitations identified in the qualitative analysis, the quality of the evidence was considered very low.

We conditionally recommend the use of a fascial traction system in hemodynamically normal trauma and emergency general surgery patients with OA after DCL in whom intra-abdominal pathology has been addressed.

Using These Guidelines in Clinical Practice

At times, primary myofascial closure after OA is not possible due to visceral edema and patient physiology. The optimal treatment strategy in this situation has been elusive. Our findings suggest that fascial traction systems improve the rate of primary myofascial closure over routine care without any worsening in mortality or ECF formation.

In the time since the Eastern Association for the Surgery of Trauma guidelines for the management of the OA were published, multiple systematic reviews have been performed. The American Association for the Surgery of Trauma sponsored a multi-institutional study to identify the natural history of the OA at 14 Level I trauma centers. [31] Most facilities (94%) used NPWT alone. Of the 572 patients, 338 had definitive primary fascial closure, and 138 were treated with alternative therapies such as split-thickness skin graft, synthetic mesh, biological matrices, or component separation. This study was limited, however, as an observational study. Importantly, there was no mention of the use of fascial traction.

Quyn et al. [32] performed a systematic review of TAC over 30 years to describe the evolution of techniques and to determine closure rates. Wittmann patch plus NPWT was associate with the highest closure rate (77.8%), the lowest mortality rate (15.7%), and the lowest complication rate (ECF 2.8%, abscess 2.4%). Dynamic retention sutures had the next best results with primary myofascial closure rates of 72%; ECF, 10%; abscess, 2%; and mortality, 18%. These findings support our view that fascial tractions systems improve closure rates with minimal morbidity and mortality.

Atema et al. [33] performed a systematic review of publications addressing the treatment of the OA in patients with peritonitis of nontraumatic origin. The findings suggested that the highest fascial closure rate was seen for NPWT with fascial traction (73.1%) and dynamic retention sutures (73.6%). Moreover, the lowest rate of ECF formation was found in NPWT with fascial traction. The authors postulated that NPWT with continuous fascial traction is superior to NPWT alone and other OA techniques. Based on our findings, we concur with these conclusions.

In 2016, Sharrock et al. [34] performed a meta-analysis comparing the outcomes of the differing techniques. The authors were unable to recommend one technique over another, citing “study heterogeneity and poverty of outcome reporting.” Also, that year, the International Consensus Conference was unable to provide recommendations as to the best method to obtain primary myofascial closure. [35] We think that we have overcome the barriers faced by Sharrock and colleagues by limiting our analysis to only studies with comparison groups and by excluding case series. During our search, we found 20 case series and review articles that evaluated the treatment of the OA with fascial traction methodology (see Supplement B, https://links.lww.com/TA/C525). While these results are mentioned for discussion purposes only, with few exceptions, these studies strongly support our findings that fascial traction provide higher primary myofascial closure rates after OA.

Our findings are different from those of Bee et al. [36] in their randomized controlled trial of OA treated with Vicryl mesh versus NPWT. The authors did not find any difference in the rate of successful closure between these two techniques. However, the method of mesh use did not address the technique of mesh with fascial traction. While the mesh was resutured twice daily if it was found to be loose, the authors did not appear to be actively creating fascial traction. Therefore, the difference between this study and the findings of others appear related to fascial traction improving the incidence of primary myofascial closure.

Our study has several limitations. We did not differentiate outcomes based on the clinical indication for DCL. Previous authors have demonstrated that trauma patients have a higher rate of closure than EGS patients. [37 ][38] Furthermore, several of the studies included were performed before damage-control resuscitation was widely practiced. Therefore, our findings may not reflect the impact that this strategy has on improving success rates of primary myofascial closure. Nonetheless, treating a recalcitrant OA remains a challenge in either cohort, and we think that our results provide important considerations. Moreover, we did not attempt to address the non-mechanical benefits that adjuvant therapies may provide. Smith and colleagues [22] have demonstrated that patients treated with DPR had lower levels of TNF-α and IL-6, which may be associated with less systemic inflammation compared with routine care. A better understanding of this complex interplay between adjuvant therapies and patient outcomes would advance trauma care greatly. Also, the quality of evidence in both PICO questions was considered to be very low. Additional well-designed studies evaluating treatments options for patients with recalcitrant OAs are sorely needed.

Our findings reveal that fascial traction systems improve the rate of primary myofascial closure over routine care without worsening mortality or ECF formation. Therefore, we conditionally recommend their use. We are unable to make any recommendations regarding the use of techniques to reduce visceral edema in patients with OA. Our findings are limited because of the small number of quality studies. Additional studies evaluating different treatment options and complex abdominal wall reconstruction techniques for the OA are urgently needed.

E.J.M. contributed in the study design, chart review, data analysis, article preparation. G.K. contributed in the study design, data analysis, article preparation. J.C. contributed in the study design, article preparation. N.B. contributed in the study design, chart review, data analysis, article preparation. R.A. contributed in the study design, chart review, article preparation. A.G.-S. contributed in the study design, chart review, article preparation. G.A.B. contributed in the study design, chart review, article preparation. L.D. contributed in the study design, chart review, article preparation. J.P., study design, chart review, article preparation. S.K. contributed in the study design, chart review, article preparation. E.K. contributed in the study design, chart review, article preparation.

Acknowledgements

We would like to acknowledge Judy Rabinowitz, Medical Librarian, Hirsh Health Sciences Library, Tufts Medical School, for her invaluable assistance and meticulous literature search. Janis Breeze, MPH, Associate Director, BERD Center, Tufts Clinical and Translational Science Institute aided with statistical analysis (NIH CTSA award number UL1TR002544).

The authors declare no conflicts of interest.

• Diaz JJ Jr., Cullinane DC, Dutton WD, Jerome R, Bagdonas R, Bilaniuk JW, et al. The management of the open abdomen in trauma and emergency general surgery: part 1—damage control. J Trauma . 2010;68(6):1425–1438.
• Fernandez L, Norwood S, Roettger R, Wilkins HE. Temporary intravenous bag silo closure in severe abdominal trauma. J Trauma . 1996;40(2):258–260.
• Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Richart CL, Burns RP. Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients. J Trauma . 2000;48(2):201–206; discussion 206-207.
• Suliburk JW, Ware DN, Balogh Z, McKinley BA, Cocanour CS, Kozar RA, et al. Vacuum-assisted wound closure achieves early fascial closure of open abdomens after severe trauma. J Trauma . 2003;55(6):1155–1160; discussion 1160-1161.
• Cothren CC, Moore EE, Johnson JL, Moore JB, Burch JM. One hundred percent fascial approximation with sequential abdominal closure of the open abdomen. Am J Surg . 2006;192(2):238–242.
• Wang Y, Alnumay A, Paradis T, Beckett A, Fata P, Khwaja K, et al. Management of open abdomen after trauma laparotomy: a comparative analysis of dynamic fascial traction and negative pressure wound therapy systems. World J Surg . 2019;43(12):3044–3050.
• Weinberg JA, George RL, Griffin RL, Stewart AH, Reiff DA, Kerby JD, et al. Closing the open abdomen: improved success with Wittmann patch staged abdominal closure. J Trauma . 2008;65(2):345–348.
• Correa JC, Mejía DA, Duque N, J MM, Uribe CM. Managing the open abdomen: negative pressure closure versus mesh-mediated fascial traction closure: a randomized trial. Hernia . 2016;20(2):221–229.
• Webb LH, Patel MB, Dortch MJ, Miller RS, Gunter OL, Collier BR. Use of a furosemide drip does not improve earlier primary fascial closure in the open abdomen. J Emerg Trauma Shock . 2012;5(2):126–130.
• Poulakidas S, Kowal-Vern A. Component separation technique for abdominal wall reconstruction in burn patients with decompressive laparotomies. J Trauma . 2009;67(6):1435–1438.
• Velmahos GC, Demetriades D, Mahoney E, Burke P, Davis K, Larentzakis A, et al. The worst-case scenario: bridging repair with a biologic mesh in high-risk patients with very large abdominal wall hernias—a prospective multicenter study. Surgery . 2021;169(2):318–324.
• de Moya MA, Dunham M, Inaba K, Bahouth H, Alam HB, Sultan B, et al. Long-term outcome of acellular dermal matrix when used for large traumatic open abdomen. J Trauma . 2008;65(2):349–353.
• Jernigan TW, Fabian TC, Croce MA, Moore N, Pritchard FE, Minard G, et al. Staged management of giant abdominal wall defects: acute and long-term results. Ann Surg . 2003;238(3):349–355; discussion 355-357.
• Diaz JJ Jr., Dutton WD, Ott MM, Cullinane DC, Alouidor R, Armen SB, et al. Eastern Association for the Surgery of Trauma: a review of the management of the open abdomen—part 2 “Management of the open abdomen”. J Trauma . 2011;71(2):502–512.
• Diaz JJ Jr., Cullinane DC, Khwaja KA, Tyson GH, Ott M, Jerome R, et al. Eastern Association for the Surgery of Trauma: management of the open abdomen, part III—review of abdominal wall reconstruction. J Trauma Acute Care Surg . 2013;75(3):376–386.
• Kerwin AJ, Haut ER, Burns JB, Como JJ, Haider A, Stassen N, et al. The Eastern Association of the Surgery of Trauma approach to practice management guideline development using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. J Trauma Acute Care Surg . 2012;73(5 Suppl 4):S283–S287.
• Tian W, Huang Q, Yao Z, Huang M, Yang F, Zhao Y, et al. A preliminary prospective study of patients who underwent vacuum-assisted and mesh-mediated fascial traction techniques for open abdomen management with negative fluid therapy: an observational study. Medicine (Baltimore) . 2019;98(35):e16617.
• Harvin JA, Mims MM, Duchesne JC, Cox CS Jr., Wade CE, Holcomb JB, et al. Chasing 100%: the use of hypertonic saline to improve early, primary fascial closure after damage control laparotomy. J Trauma Acute Care Surg . 2013;74(2):426–430; discussion 431-432.
• Loftus TJ, Efron PA, Bala TM, Rosenthal MD, Croft CA, Walters MS, et al. The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy. J Trauma Acute Care Surg . 2019;86(4):670–678.
• Smith JW, Garrison RN, Matheson PJ, Franklin GA, Harbrecht BG, Richardson JD. Direct peritoneal resuscitation accelerates primary abdominal wall closure after damage control surgery. J Am Coll Surg . 2010;210(5):658–664, 664-667.
• Smith JW, Neal Garrison R, Matheson PJ, Harbrecht BG, Benns MV, Franklin GA, et al. Adjunctive treatment of abdominal catastrophes and sepsis with direct peritoneal resuscitation: indications for use in acute care surgery. J Trauma Acute Care Surg . 2014;77(3):393–398; discussion 398-399.
• Smith JW, Matheson PJ, Franklin GA, Harbrecht BG, Richardson JD, Garrison RN. Randomized controlled trial evaluating the efficacy of peritoneal resuscitation in the management of trauma patients undergoing damage control surgery. J Am Coll Surg . 2017;224(4):396–404.
• Salamone G, Licari L, Guercio G, Comelli A, Mangiapane M, Falco N, et al. Vacuum-assisted wound closure with mesh-mediated fascial traction achieves better outcomes than vacuum-assisted wound closure alone: a comparative study. World J Surg . 2018;42(6):1679–1686.
• Mukhi AN, Minor S. Management of the open abdomen using combination therapy with ABRA and ABThera systems. Can J Surg . 2014;57(5):314–319.
• Rasilainen SK, Mentula PJ, Leppäniemi AK. Vacuum and mesh-mediated fascial traction for primary closure of the open abdomen in critically ill surgical patients. Br J Surg . 2012;99(12):1725–1732.
• Jakob MO, Schwarz C, Haltmeier T, Zindel J, Pinworasarn T, Candinas D, et al. Mesh-augmented versus direct abdominal closure in patients undergoing open abdomen treatment. Hernia . 2018;22(5):785–792.
• Hadeed JG, Staman GW, Sariol HS, Kumar S, Ross SE. Delayed primary closure in damage control laparotomy: the value of the Wittmann patch. Am Surg . 2007;73(1):10–12.
• Long KL, Hamilton DA, Davenport DL, Bernard AC, Kearney PA, Chang PK. A prospective, controlled evaluation of the abdominal reapproximation anchor abdominal wall closure system in combination with VAC therapy compared with VAC alone in the management of an open abdomen. Am Surg . 2014;80(6):567–571.
• Pliakos I, Papavramidis TS, Mihalopoulos N, Koulouris H, Kesisoglou I, Sapalidis K, et al. Vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: a clinical trial. Surgery . 2010;148(5):947–953.
• Rezende-Neto JB, Camilotti BG. New non-invasive device to promote primary closure of the fascia and prevent loss of domain in the open abdomen: a pilot study. Trauma Surg Acute Care Open . 2020;5(1):e000523.
• Dubose JJ, Scalea TM, Holcomb JB, Shrestha B, Okoye O, Inaba K, et al. Open abdominal management after damage-control laparotomy for trauma: a prospective observational American Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg . 2013;74(1):113–120; discussion 1120-1122.
• Quyn AJ, Johnston C, Hall D, Chambers A, Arapova N, Ogston S, et al. The open abdomen and temporary abdominal closure systems—historical evolution and systematic review. Color Dis . 2012;14(8):e429–e438.
• Atema JJ, Gans SL, Boermeester MA. Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg . 2015;39(4):912–925.
• Sharrock AE, Barker T, Yuen HM, Rickard R, Tai N. Management and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis. Injury . 2016;47(2):296–306.
• Chiara O, Cimbanassi S, Biffl W, Leppaniemi A, Henry S, Scalea TM, et al. International consensus conference on open abdomen in trauma. J Trauma Acute Care Surg . 2016;80(1):173–183.
• Bee TK, Croce MA, Magnotti LJ, Zarzaur BL, Maish GO 3rd, Minard G, et al. Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure. J Trauma . 2008;65(2):337–342; discussion 342-344.
• Tsuei BJ, Skinner JC, Bernard AC, Kearney PA, Boulanger BR. The open peritoneal cavity: etiology correlates with the likelihood of fascial closure. Am Surg . 2004;70(7):652–656.
• Loftus TJ, Jordan JR, Croft CA, Smith RS, Efron PA, Mohr AM, et al. Temporary abdominal closure for trauma and intra-abdominal sepsis: different patients, different outcomes. J Trauma Acute Care Surg . 2017;82(2):345–350.

« Back to guidelines

• Case report
• Open access
• Published: 02 October 2020

Combined stomach and duodenal perforating injury following blunt abdominal trauma: a case report and literature review

• Chun-Chi Lai   ORCID: orcid.org/0000-0002-9615-7138 1 ,
• Hung-Chang Huang 1 &
• Ray-Jade Chen 2  

BMC Surgery volume  20 , Article number:  217 ( 2020 ) Cite this article

3194 Accesses

2 Citations

Metrics details

Gastrointestinal injury following blunt abdominal trauma is uncommon; a combined stomach and duodenal perforating injury is even more rare. Because these two organs are located in different spaces in the abdomen, such injuries are difficult to identify.

Case presentation

A young woman involved in a motor vehicle crash presented to our emergency department with concerns of severe peritonitis. Contrast-enhanced computed tomography of the abdomen revealed pneumoperitoneum and retroperitoneal hematoma in zone 1. An emergency laparotomy was performed, revealing a stomach-perforating injury, which was resolved with primary repair. No obvious injury was observed on retroperitoneal exploration. However, peritonitis presented again on the second postoperative day, and a second laparotomy was performed, revealing a duodenum-perforating injury in its third portion. We performed primary repair with multi-tube-ostomy. The patient recovered well without permanent tube placement or internal bypass.

Conclusions

Assessing associated injuries in blunt abdominal trauma is crucial because they may be fatal if timely intervention is not undertaken. These types of complicated injuries require a feasible surgical strategy formulated by experienced surgeons, which gives the patient a better chance of survival.

Peer Review reports

Traumatic gastrointestinal injury is an injury to the stomach, duodenum, small bowel, or colon following blunt or penetrating abdominal trauma. In patients who have sustained blunt abdominal trauma, the incidence rates of gastrointestinal, stomach, and duodenal injuries are 0.81–3.1%, 0.1, and 0.4%, respectively, according to previous studies [ 1 , 2 , 3 ]. Moreover, a perforating injury of both the stomach and duodenum following abdominal trauma has rarely been reported. High morbidity and mortality rates have been reported for patients with traumatic gastrointestinal injury and have been associated with misdiagnosis, severe intra-abdominal infection, and sepsis. In combined-organ injuries, we could easily be distracted by one injury and overlook the other. Therefore, accurate diagnosis and timely surgical intervention are crucial. We report a rare case of a combined stomach and duodenal perforating injury.

A 33-year-old female motorcyclist presented to our emergency department with a 3-h history of severe abdominal pain following blunt abdominal trauma after bumping by a car. She denied any medical or surgical history. We evaluated this patient according to the advanced trauma life support algorithm. The airway was patent, and bilateral breath sounds were clear. The heart rate was mildly elevated to 100 bpm without low blood pressure. She was conscious and clear without any neurologic deficits. No obvious open wounds were observed, except for an erythematous bruise on the right middle abdomen, measuring 3 × 3 cm in size. Contrast-enhanced computed tomography (CT) revealed pneumoperitoneum with mild ascites and a retroperitoneal hematoma in zone 1 (Figs.  1 and 2 ). We performed an emergency exploratory laparotomy suspecting hollow organ perforation and retroperitoneal hematoma. On midline laparotomy, we noted that a considerable amount undigested food had spilled out of the distended stomach onto the gastrohepatic ligament and lesser sac. A transverse full-thickness laceration on the lesser curvature of the stomach was observed, measuring approximately 10 cm in length (Fig.  3 ). On retroperitoneal exploration, we used the Kocher maneuver to examine the first and second portions of the duodenum and observed them to be intact. We then opened the lesser sac to examine the pancreas and fourth portion of the duodenum, which were intact as well. No bilious ascites or active bleeding was noted during retroperitoneal exploration. Therefore, we performed a primary repair of the perforated stomach and sent the patient to the intensive care unit for further resuscitation. However, on the second postoperative day, peritonitis presented again, and the drainage tube showed bilious content. Hence, a second laparotomy was performed. This time, however, we observed bilious ascites in the lower abdomen. The repaired perforated stomach was intact. We then performed a complete right medial visceral rotation (Cattell–Braasch maneuver) and observed a nearly complete transection perforation on the third portion of the duodenum (Fig.  4 ). Hence, we performed a primary repair of the perforated duodenum. We also performed gastrostomy, duodenostomy, and cholecystostomy to relieve compression engendered by digestive juices. A jejunostomy procedure was also performed for enteral nutrition access (Fig.  5 ). However, duodenal leakage was noted on the ninth postoperative day. We controlled sepsis with resuscitation, antibiotics, and thorough drainage of intra-abdominal abscess. Total parenteral nutrition was also administered until sufficient enteral nutrition via the jejunostomy was achieved, which took approximately 1 week. Spontaneous closure of enterocutaneous fistula occurred 5 weeks later. She stabilized gradually, and drainage tubes were removed individually. She was discharged on the 90th postoperative day. All drainage tubes and all tube-ostomy bags were removed. The continuity of the alimentary tact was unchanged without any permanent tube-ostomy or internal bypass (Fig.  6 ). She showed complete recovery at another 3-month outpatient department follow-up.

Massive extraluminal free air in the peritoneal cavity

Zone 1 retroperitoneal hematoma

Grade III stomach injury of the lesser curvature (> 10 cm)

Grade III duodenal injury in its third portion (near complete transection)

Surgical design (primary repair of stomach and duodenal injuries, digestive juice decompression, and enteral nutrition access)

The continuity of the entire alimentary tact was unchanged without any permanent tube-ostomy or internal bypass after the patient recovered

Discussion and conclusions

Gastrointestinal injury following blunt abdominal trauma is rare [ 1 , 2 , 3 ]. One mechanism underlying the onset of such injury involves the compression of a hollow viscus organ against the rigid part of human body (such as vertebra or thoracic cage) because of an external force (such as a force exerted by a seatbelt, handlebar, or steering wheel). Another mechanism involves shearing between the fixed and movable parts of the hollow viscus organ due to sudden deceleration during vehicle braking. According to the EAST (the Eastern Association for the Surgery of Trauma) Hollow Viscus Injury Study, the small bowel is the most commonly injured organ in hollow viscus organ injuries, followed by the colon, duodenum, stomach, and appendix [ 2 ]. Our patient presented with severe abdominal pain after sustaining blunt abdominal trauma caused by a motor vehicle crash. According to her statement, she had just finished eating when the crash occurred; hence, her stomach was distended, which is one of the risk factors for stomach injury following blunt abdominal trauma [ 4 ]. Moreover, the only wound was the erythematous bruise on the right middle abdomen, measuring 3 × 3 cm in size, which indicated a handlebar injury. A handlebar injury causing duodenal perforation is more common in children; only a few relevant cases have been reported in adults [ 5 ]. A CT scan provides accurate assessment for patients with trauma, such as the severity of injury in the peritoneal and retroperitoneal spaces. In our patient, CT revealed pneumoperitoneum and a retroperitoneal hematoma in zone 1. Pneumoperitoneum indicates hollow organ perforation in the peritoneal cavity and requires a laparotomy [ 6 ]. In laparotomy for traumatic injury, the first goal is to stop bleeding; the second goal is to identify gastrointestinal injury. Furthermore, a retroperitoneal hematoma indicates injury to the retroperitoneal organs or great vessels. The retroperitoneum is categorized into three zones. Zone 1 represents the central retroperitoneum, bordered by the aortic hiatus superiorly, sacral promontory inferiorly, and bilateral renal hila on the sides. Zone 1 contains the abdominal aorta, inferior vena cava, duodenum, and pancreas [ 7 ]. For a zone 1 retroperitoneal hematoma, an exploratory laparotomy becomes mandatory in both penetrating and blunt injuries because of the possibility of injury to the vasculature, duodenum, or pancreas. Zone 1 retroperitoneal exploration can be managed with the Kocher maneuver to examine the first and second portions of the duodenum. Subsequently, a right medial visceral rotation (Cattell–Braasch maneuver) can be performed to examine the inferior vena cava, infrarenal aorta, third portion of the duodenum, and head of the pancreas. The lesser sac could be opened to inspect the body and tail of the pancreas [ 8 , 9 ]. For our patient, we had to check not only intraperitoneal but also retroperitoneal spaces. Approaching the third portion of the duodenum requires considerable effort and skill because it is hidden deep in the retroperitoneum and surrounded by vital structures. However, if no reasonable explanation for a zone 1 retroperitoneal hematoma is obtained after the first, second, and fourth portions of the duodenum and pancreas are examined, then exposing the third portion of the duodenum is essential. We ultimately identified a combined grade III (AAST) perforating injury of the stomach and duodenum during surgery [ 10 , 11 ].

The type of surgery is planned according to the severity of injury. The stomach is a well-vascularized organ; therefore, primary repair with an air leak test is widely performed for grade I, II, and III (AAST) injuries of the stomach [ 12 ]. Gastrectomy with reconstruction should be considered for tissue loss or devascularization [ 13 ]. Regarding duodenal injury, primary repairs can be performed for grade I and II (AAST) duodenal injuries. For grade III (AAST) duodenal injuries, various repair approaches can be used. Primary repair in tension-free fashion is the top choice of repair approach. Duodeno-duodenostomy can also be used if tension-free primary repair is not possible. Roux-en-Y duodeno-jejunostomy will be applied if previous 2 approaches are not possible [ 14 , 15 ]. For grade IV and V (AAST) duodenal injuries, damage control or staged Whipple’s surgery can be considered [ 16 ]. Ancillary procedures will be performed for the specific circumstances. Duodenal diversion will be considered for tenuous duodenal repair. Feeding jejunostomy is a good access to build up early enteral nutrition. Periduodenal drains are not always required, but should be placed for tenuous duodenal repair or grade III (AAST) duodenal injuries [ 14 ]. We performed primary repair for the stomach injury in our patient. Concerning the duodenal injury, tension-free primary duodenal repair is a favorable repair approach. In our case, the tension of the approximation of the duodenal perforation was tolerable, therefore, primary repair was performed for the perforation. Nevertheless, because of the infected intra-abdominal environment and high leakage rate, ancillary procedures was also required for this case. There are 3 types of duodenal diversions, which are Berne’s duodenal diverticulization, pyloric exclusion and tube duodenostomy [ 14 ]. Since the stomach perforation has been repaired in the first operation, Berne’s duodenal diverticulization and pyloric exclusion were not possible to be done. Hence, we choose tube-ostomy for duodenal diversion. Furthermore, feeding jejunostomy and periduodenal drains were also performed. Consequently, we performed a primary repair with multi-tube-ostomy.

Duodenal injuries have been reported to have high morbidity and mortality rates (27.1 and 5.3%–30%, respectively). Morbidity was reported to be mostly caused by intra-abdominal abscesses (15%), followed by duodenal fistulae (6%). The mortality rate varied according to the severity of organ injury (AAST): grade I (8.3%), grade II (18.7%), grade III (27.6%), grade IV (30.8%), and grade V (58.8%) [ 17 ]. Risk factors for duodenal repair site leakage were reported to include the severity of organ injury and a time interval from injury to repair exceeding 24 h, which also increase morbidity and mortality [ 18 ]. Weale et al. reported that the leakage rate for a grade III duodenal injury treated with primary repair is as high as 66% [ 19 ]. In our patient, duodenal repair site leakage was noted on the ninth postoperative day. In the acute phase of intra-abdominal abscess, the first step is to control sepsis with adequate drainage and antibiotics. In the chronic phase, an enterocutaneous fistula is another problem following duodenal leakage. An enterocutaneous fistula originating from the upper gastrointestinal tract (proximal to the duodenojejunal junction) would be associated with a higher chance of spontaneous closure (73.3%) than would that originating from the lower gastrointestinal tract (35.3%) [ 20 ]. Nearly 90% of the fistular tract closes spontaneously in the first month, with the remaining 10% closing in the second month [ 21 ]. Nutritional supplements work favorably for spontaneous closure, and enteral nutrition is superior to parenteral nutrition. For patients with a high risk of leakage, digestive juice decompression, distal enteral nutrition access creation, and adequate drainage tube placement are warranted. Our patient showed a high-output enterocutaneous fistula with a daily enteric secretion of approximately 500 mL. Total parenteral nutrition was administered in the acute phase. After the sepsis was controlled, we started ramp enteral feeding through a feeding jejunostomy technique and prescribed somatostatin to suppress the fistular output. Spontaneous closure occurred 5 weeks later.

Accurate diagnosis of a combined stomach and duodenal injury following blunt abdominal trauma is challenging. For such complicated gastrointestinal injuries, a feasible surgical strategy formulated by an experienced surgeon is crucial. From our experience, for treating a combined stomach and duodenal perforating injury following blunt abdominal trauma, we conclude that a primary repair for the stomach injury and primary repair with multi-tube-ostomy for the duodenal injury would be a feasible approach.

Availability of data and materials

Not applicable.

Abbreviations

computed tomography

American Association for the Surgery of Trauma

Hughes TMD, Elton C, Hitos K, Perez JV, McDougall PA. Intra-abdominal gastrointestinal tract injuries following blunt trauma: the experience of an Australian trauma centre. Injury. 2002;33:617–26.

Article   CAS   Google Scholar  

Watts DD, Fakhry SM, E.M.-I.H.V.I.R. Group. Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the East multi-institutional trial. J Trauma. 2003;54(2):289–94.

Article   Google Scholar  

Tejerina Álvarez EE, et al. Gastric rupture from blunt abdominal trauma. Injury. 2004;35(3):228–31.

Bruscagin V, Coimbra R, Rasslan S, Abrantes WL, Souza HP, Neto G, Dalcin RR, Drumond DAF, Ribas JR Jr. Blunt gastric injury. A multicentre experience. Injury. 2001;32:761–4.

Wang AY, Lin T, Chen SC. Isolated traumatic duodenal rupture due to bicycle handlebar injury in an adult patient. Hong Kong J Emerg Med. 2015;22:113–7.

Malhotra AK, Ivatury RR, Latifi R. Blunt abdominal trauma: evaluation and indication for laparotomy. Scand J Surg. 2002; 91 :52–7.

Daly KP, Ho CP, Persson DL, Gay SB. Traumatic retroperitoneal injuries: review of multidetector CT findings. RadioGraphics. 2008;28:1571–90.

Petrone P, et al. Approach and management of traumatic retroperitoneal injuries. Cir Esp. 2018;96(5):250–9.

Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at laparotomy for trauma. Injury. 2014;45(9):1378–83.

Moore EE, et al. Organ injury scaling. VI: Extrahepatic biliary, esophagus, stomach, vulva, vagina, uterus (nonpregnant), uterus (pregnant), fallopian tube, and ovary. J Trauma. 1995;39(6):1069–70.

Moore EE, et al. Organ injury scaling, II: pancreas, duodenum, small bowel, colon, and rectum. J Trauma. 1990;30(11):1427–9.

Hota PK, Babu M, Satyam G, Praveen C. Traumatic gastric rupture following blunt trauma abdomen: a case series. Bali Med J. 2014;3(1):49–52.

Aboobakar MR, et al. Gastric perforation following blunt abdominal trauma. Trauma Case Rep. 2017;10:12–5.

Malhotra A, et al. Western trauma association critical decisions in trauma: diagnosis and management of duodenal injuries. J Trauma Acute Care Surg. 2015;79(6):1096–101.

Ferrada P, et al. Management of duodenal trauma: a retrospective review from the Panamerican Trauma Society. J Trauma Acute Care Surg. 2019;86(3):392–6.

Coleman JJ, Zarzaur BL. Surgical management of abdominal trauma. Surg Clin N Am. 2017;97(5):1107–17.

García Santos E, et al. Duodenal injuries due to trauma: review of the literature. Cir Esp. 2015;93(2):68–74.

Singh S, et al. Blunt duodenal trauma. J Coll Physicians Surg Pak. 2013;23(5):350–2.

PubMed   Google Scholar  

Weale RD, Kong VY, Bekker W, Bruce JL, Oosthuizen GV, Clarke DL, Laing GL. Primary repair of duodenal injuries: a retrospective cohort study from a major trauma centre in South Africa. Scand J Surg. 2019;108(4):280–4.

Quinn M, Falconer S, McKee RF. Management of Enterocutaneous Fistula: outcomes in 276 patients. World J Surg. 2017;41(10):2502–11.

Gribovskaja-Rupp I, Melton GB. Enterocutaneous fistula: proven strategies and updates. Clin Colon Rectal Surg. 2016;29(2):130–7.

Download references

Acknowledgements

The authors wound like to acknowledge the Laboratory Animal Center at TMU for technical support. This manuscript was edited by Wallace Academic Editing.

Author information

Authors and affiliations.

Division of Acute Care Surgery and Traumatology, Department of Surgery, Taipei Medical University Hospital, Taipei City, Taiwan

Chun-Chi Lai & Hung-Chang Huang

Division of General Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei City, Taiwan

Ray-Jade Chen

You can also search for this author in PubMed   Google Scholar

Contributions

RJC formulated the surgical strategy for the patient and guided the general treatment plan for the patient. HCH reviewed the clinical course and analyzed the patient’s data. CCL was the major contributor for the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Chun-Chi Lai .

Ethics declarations

Ethics approval and consent to participate.

The study has been approved by expedited review process of the TMU- Joint Institutional Review Board. TMU- JIRB No.: N202003125.

Consent for publication

Written informed consent was obtained from the patient.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Lai, CC., Huang, HC. & Chen, RJ. Combined stomach and duodenal perforating injury following blunt abdominal trauma: a case report and literature review. BMC Surg 20 , 217 (2020). https://doi.org/10.1186/s12893-020-00882-w

Download citation

Received : 28 April 2020

Accepted : 24 September 2020

Published : 02 October 2020

DOI : https://doi.org/10.1186/s12893-020-00882-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Blunt abdominal trauma
• Stomach perforation
• Duodenum perforation
• Handle-bar injury
• Retroperitoneal hematoma

BMC Surgery

ISSN: 1471-2482

• Submission enquiries: [email protected]
• General enquiries: [email protected]

• Open access
• Published: 23 August 2008

Missed injuries in trauma patients: A literature review

• Roman Pfeifer 1 &
• Hans-Christoph Pape 1  

Patient Safety in Surgery volume  2 , Article number:  20 ( 2008 ) Cite this article

17k Accesses

128 Citations

20 Altmetric

Metrics details

Overlooked injuries and delayed diagnoses are still common problems in the treatment of polytrauma patients. Therefore, ongoing documentation describing the incidence rates of missed injuries, clinically significant missed injuries, contributing factors and outcome is necessary to improve the quality of trauma care. This review summarizes the available literature on missed injuries, focusing on overlooked muscoloskeletal injuries.

Manuscripts dealing with missed injuries after trauma were reviewed. The following search modules were selected in PubMed: Missed injuries, Delayed diagnoses, Trauma, Musculoskeletal injuires. Three time periods were differentiated: (n = 2, 1980–1990), (n = 6, 1990–2000), and (n = 9, 2000-Present).

We found a wide spread distribution of missed injuries and delayed diagnoses incidence rates (1.3% to 39%). Approximately 15 to 22.3% of patients with missed injuries had clinically significant missed injuries. Furthermore, we observed a decrease of missed pelvic and hip injuries within the last decade.

The lack of standardized studies using comparable definitions for missed injuries and clinically significant missed injuries call for further investigations, which are necessary to produce more reliable data. Furthermore, improvements in diagnostic techniques (e.g. the use of multi-slice CT) may lead to a decreased incidence of missed pelvic injuries. Finally, the standardized tertiary trauma survey is vitally important in the detection of clinically significant missed injuries and should be included in trauma care.

Patients who have been severely injured in road accidents [ 1 , 2 ], especially those with head injury [ 1 , 3 , 4 ], a Glasgow Coma Scale (GCS) score of eight or lower [ 5 , 6 ], and a greater Injury Severity Score (ISS) [ 1 – 3 , 5 – 9 ], are more likely to have missed injuries or delayed diagnoses. The majority of treatment errors occur in the emergency department [ 10 – 12 ], the intensive care unit (ICU) [ 10 , 12 ] and the operating room [ 12 ]. Gruen et al. [ 10 ] analysed patterns of error contributing to trauma mortality in 64 trauma patients with recognized errors in care. Errors were found to occur in haemorrhage control (28%), airway management (16%), management of unstable patients (14%) and prophylaxis (11%). The authors suggest that strategies for error-reduction should be addressed in both the emergency department and intensive care unit. However, ongoing documentation describing the incidence rates of missed injuries, clinically significant missed injuries, contributing factors and outcome is necessary to improve the quality of trauma care.

This retrospective series review summarizes the available literature on missed injuries and analyzes whether changes in incidence rates of missed musculoskeletal injuries have occurred over the last three decades. We hypothesize that a decrease of incidence rates of missed injuries occurred due to improvements in treatment and diagnostics. In addition, it evaluates the circumstances that cause missed injuries and describes strategies to limit these pitfalls.

Literature Search

To identify the relevant publications, a Medline database search through PubMed (time period 1980 – July 2008) was performed. Relevant studies were retrieved using the following sequences of key words: Missed injuries, Delayed diagnoses, Trauma, Musculoskeletal injuries. Synonyms were used to find further relevant literature. In addition, we reviewed the references from the resulting publications to identify further potential articles to be included in our study. After Medline searches were completed, all acticles in English- and German-language and articles published after 1980 were screened for inclusion and exclusion criteria.

Selection of Relevant Papers

Missed injuries.

Injuries that were not identified by primary and secondary survey. All diagnoses made in tertiary survey (24 h). [6 studies]

Injuries ditacted after the admission to the ICU (24 h). [4 studies]

Injuries found after complete assessment and diagnostics, and are directly related to the injury. [4 studies]

Injuries that were missed within 6 to12 hours. [2 studies (12 hour time point) 1 study (6 hour time point)]

Clinically significant missed injuries

Missed injuries that are associated with high morbidity and mortality. [2 studies]

Missed injuries that require additional procedures and alterations of therapy. [1 study]

Missed injuries with significant pain, complications, residul disability and death.

Analysis of relevant Papers

A total of seventeen articles satisfied the inclusion and exclusion criteria for this analysis. We reviewed and summarized the findings published in the studies. Variables of interest included authors, year of publication, type of study, sample size, average age of patients in years, Injury Severity Score (ISS), percentage of patients involved in motor vihicle accidents (MVA), percentage of patients with blunt trauma, and incidence rates of missed injuries. Furthermore, missed injuries from the publications above were classified in 3 groups (minor injuries, major injuries, life threatening injuries) to assess the clinical relevance of these overlooked injuries.

Minor injuries

Hand, wrist, foot, ankle, forearm, uncomplex soft tissue injuries and fractures, rupture of ligaments and muscle tendons were defined as minor injuries.

Major injuries

Skull injuries, neurological and arterial lesions, liver, spleen, and intestinal lacerations, femoral, humeral, pelvic, and spine fractures and dislocations were defined as major inuries.

Life threatening injuries

Injuries of main vessels in thorax, Hemothorax and Pneumothorax were defined as life threatening injuries.

All data were summarized in tables and median velues and percantages were calculated using Excel (Microsoft Office).

We found seventeen prospective (6) and retrospective (11) publications that fit the criteria within the three decade time period. The mean study population was 1124 (Median: 709, range 65–3996). Two manuscripts analyzed data between 1980 and 1990, six between 1990 and 2000, and nine between 2000 and July 2008. For the seventeen publications, the median age was 34 points (range, 8.4–39.6), the Injury Severity Score was 17.2 points (range, 14–26), the median percentage of patients involved in motor vehicle accident was 68% (range, 46–84.6%), 92% (median) (range, 88–100%) sustained a blunt trauma, and the median percentage for musculoskeletal injuries was 69.2% (range, 4–100%).

Several studies dealing with missed injuries and delayed diagnoses have been published and report an incidence of 1.3% to 39% [ 1 – 3 , 5 – 9 , 13 – 20 ] (see Table 1 ). The mean percentage of unrecognized injuries in all studies mentioned above is approximately nine. A comparatively small number of studies have distinguished between clinically significant missed injuries and missed injuries in general [ 1 , 2 , 5 , 7 ](Table 2 ). According to these publications, 15–22.3% of patients with missed injuries had clinically significant missed injuries.

Analysis of articles published from 1980 to 2006 (Table 3 ) indicated a lower incidence of missed pelvic and hip injuries from 2000 to 2006 [ 1 – 3 , 5 – 8 , 13 , 14 , 18 – 21 ]. According to available studies from the 1980s, all missed pelvic injury rates exceeded 10%. Out of five publications from the 1990s, one reported missed pelvic injury rates above 10% and four reported results below 10%. All publications found from 2000 to 2006 reported missed pelvic injury rates below 10%. A similar trend was not observed for lower and upper extremity injuries.

Unrecognized injuries listed in studies were classified in three different types: (minor, major, life threatening injuries) to assess the clinical relevance (Table 4 ) [ 1 , 3 , 7 , 8 , 13 , 14 , 18 , 19 ]. Approximately 27–66% of all delayed diagnoses were major injuries. In addition, it can be seen that the most studies identified life threatening injuries. In three publications only a low percentage (1–4%) of life threatening injuries was missed.

Our review demonstrates the following main findings: First, we found a wide spread distribution (1.3%–39%) of incidence rates for missed injuries and delayed diagnoses. Second, approximately 15 to 22.3% of patients with missed injuries have clinically significant missed injuries. Third, incidence rates of missed pelvis and hip injuries have decreased over the last three decades (1980-Present). Fourth, approximately 27–66% of unrecognized diagnoses in studies were major injuries.

The difference between the results of the studies indicates that the true incidence of missed injuries and delayed diagnoses is difficult to determine. A discrepancy in the definition of what constitutes a missed injury may be the major cause. Another possibility is that many authors limited their investigations to a special field of interest. Some investigators report missed injuries in multiple trauma patients [ 5 , 9 , 17 , 19 ], other authors describe unrecognized injuries in patients with abdominal [ 22 ] and orthopaedic trauma [ 13 , 14 , 16 , 18 ]. Differences in study design may also play a role. Enderson et al [ 23 ] reported that prospective studies show a higher incidence of missed injuries as compared with retrospective reviews. Patients with clinically significant missed injuries comprise around 15% to 22.3% of total number of patients with missed injuries. Different studies have used different definitions to determine clinical significance. Some publications focused on those missed injuries that were associated with high morbidity and mortality as a result of a delayed diagnosis [ 1 , 5 ]. Others used the requirement of further surgical procedures as criteria to define clinically significant missed injuries [ 9 ]. Janjua et al [ 2 ] included significant pain, complications, residual disability and death in the definition of a clinically significant missed injury. In general, studies tended to report higher incidence of clinically significant missed injuries if they related the clinical significance to alterations in therapy [ 5 ]. In summary, these findings call for more standardized investigations to provide more exact information about the incidence of missed injuries after trauma.

In twenty seven percent of polytrauma patients a pelvic fracture can be detected [ 24 ]. Especially in severely injured patients, pelvic instability is associated with severe bleeding [ 25 – 31 ] and undetected pelvic injuries may lead to exsanguination or shock [ 29 ]. We observed a decreased incidence in missed pelvic injuries after trauma that has not yet been described. Previous studies have reported limitations of pelvic x-rays in the detection of intra-articular and acetabular fractures [ 32 , 33 ]. However, the widespread availability of Multiple Slice Computed Tomography (MSCT) scans and integration of computed tomography (CT) in the emergency room [ 34 – 36 ] has improved the speed [ 37 , 38 ] and accuracy [ 37 , 39 – 41 ] of diagnostic procedures and has led to early detection of injuries. Furthermore, since the diagnostics of a critically injured patient must focus on life-threatening injuries, the pelvis is usually scanned as part of combined abdomen/pelvis CT examination [ 37 , 42 ]. That also allows for an early detection of pelvic injuries. Less significant extremity injuries are usually detected upon further examinations [ 7 ].

When the publications carried out a classification of missed injuries (minor injuries, major injuries, life threatening injuries), we observed that approximately 27–66% of unrecognized injuries were major injuries. These injuries are potentially clinically significant factors for morbidity and mortality. Several studies demonstrated that trauma patients with missed injuries and delayed diagnoses required significantly longer hospital stays (15.7–42.1 days vs. 7.9–26.7 days) and longer intensive care unit stays (5.4–10.9 days vs. 1.5–5.7 days), than those without missed injuries [ 5 – 8 ]. Some studies report high rates of mortality [ 1 , 6 , 8 , 9 , 22 ] among trauma patients with missed injuries. A possible relationship between delay of diagnoses and morbidity was reported in one study [ 3 ].

Strategies to limit missed injuries

Thorough clinical and radiological examinations represent the main tools for the diagnosis of fractures and injuries. While clinical examination of awake and alert patients leads to the diagnosis of clinically significant missed injuries, further diagnostic methods (radiologic imaging) continue to be beneficial in unconscious patients [ 42 – 44 ]. Several studies report lack of admission radiographs of the specific area of injury (46.3–53.8%) [ 14 , 18 ] and misinterpreted x-rays (15–34.9%) [ 1 , 5 ] as main radiological factors contributed to missed diagnosis. Further factors are clinical inexperience (26.5%) [ 19 ] and assessment errors (33.8–60.5%) [ 1 , 2 , 5 , 6 ]. Other investigations found additional contributing factors such as technical errors [ 2 ], inadequate x-rays [ 5 , 19 , 21 ], interrupted diagnosis [ 17 ], and neighbouring injuries [ 1 ]. Authors [ 2 , 18 ], however, noted that patients with missed injuries and delayed diagnoses tend to have a combination of contributing factors. Janjua et al [ 2 ] found that in 50% of cases, more than one factor was responsible.

To reduce the rate of missed injuries, we must focus on unconscious and intubated patients with severe trauma (ISS↑) and brain injuries (GCS↓) during the primary and secundary survey [ 1 – 3 , 5 – 9 ]. Furthermore, some authors emphasized the role of tertiary trauma survey in patients with multiple injuries, as significant injuries may be missed during the primary and secondary surveys [ 2 , 3 , 6 , 9 ]. Approximately fifty percent of overall missed injuries and ninety percent of clinically significant missed injuries were diagnosed by tertiary trauma survey within 24 hours of admission [ 2 , 3 ]. However, this survey can also be performed after the patient has gained consciousness and is able to voice complaints, or before discharge from the intensive care unit [ 6 ]. The tertiary trauma survey (TTS) should cover: (1) standardized re-evaluation of blood tests, (2) careful review initial x-rays, and (3) clinical assessment for the effective detection of occult injuries. Furthermore, as musculoskeletal injuries are usually missed during the first and second survey, an experienced orthopaedic surgeon must be involved in the tertiary survey.

Missed injuries still occur at an unacceptably high rate in trauma patients. Standardization of tertiary survey will lead to a decrease in missed injuries and an improvement in patient outcome. Therefore, this survey is vitally important and should be a part of trauma care. Furthermore, the lack of standardized studies that use comparable definitions of missed injuries and clinically significant missed injuries calls for further investigations to produce more reliable data.

Houshian S, Larsern MS, Holm C: Missed Injuries in a Level I Trauma Center. J Trauma. 2002, 52: 715-719.

Article   PubMed   Google Scholar  

Janjua KJ, Sugrue M, Deane SA: Prospective Evaluation of Early Missed Injuries and the Role of Tertary Trauma Survey. J Trauma. 1998, 44: 1000-1007.

Article   CAS   PubMed   Google Scholar  

Vles WJ, Veen EJ, Roukema JA, Meeuwis JD, Leenen LPH: Consequences of Delaed Diagnoses in Trauma Patients: A Prospective Study. J Am Coll Surg. 2003, 197: 596-602. 10.1016/S1072-7515(03)00601-X.

Reid DC, Henderson R, Saboe L, Miller JDR: Etiology and Clinical Course of Missed Spine Fractures. J Trauma. 1987, 27: 980-986.

Buduhan G, McRitchie DI: Missed Injuries in Patients with Multiple Trauma. J Trauma. 2000, 49: 600-605.

Kalemoglu M, Demirbas S, Akin ML, Yildirim I, Kurt Y, Uluutku H, Yildiz M: Missed Injuries in Military Patients with Major Trauma: Original Study. Military Medicine. 2006, 171: 598-602.

Rizoli SB, Boulanger BR, McLellan BA, Sharkey PW: Injuries Missed During Initial Assesment of Blunt Trauma Patients. Accid Anal and Prev. 1994, 26: 681-686. 10.1016/0001-4575(94)90030-2.

Article   CAS   Google Scholar  

Robertson R, Mattox R, Collins T, Parks-Miller C, Eidt J, Cone J: Missed Injuries in a Rural Area Trauma Center. Am J Surg. 1996, 172: 564-568. 10.1016/S0002-9610(96)00247-4.

Brooks A, Holroyd B, Riley B: Missed Injury in Major Trauma Patients. Injury. 2004, 35: 407-410. 10.1016/S0020-1383(03)00219-5.

Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV: Patterns of Errors Contributing to Trauma Mortality. Lessons learned from 2594 Deaths. Ann Surg. 2006, 244: 371-280.

PubMed Central   PubMed   Google Scholar  

Esposito TJ, Sanddal ND, Hansen JD, Reynolds S: Analysis of Preventable Trauma Death and Inappropriate Trauma Care in Rural State. J Trauma. 1995, 39: 955-962.

Kreis DJ, Plasencia G, Augenstein D, Davis JH, Echenique M, Vopal J, Byers P, Gomez G: Preventable Trauma Death: Dade County, Florida. J Trauma. 1986, 26: 649-654.

Juhl M, Moller-Madsen B, Jensen J: Missed Injuries in an Orthopaedic Department. Injury. 1990, 21: 110-112. 10.1016/0020-1383(90)90067-5.

Born CT, Ross SE, Iannacone WM, Schwab CW, DeLong WG: Delayed Identification of Skeletal Injury in Multisystem Trauma: The "Missed" Fracture. J Trauma. 1989, 29: 1643-1646.

Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou HJ, Chang CY: Systematic Analysis of Missed Extremity Fracures in Emergency Radiology. Acta Radiol. 2006, 47: 710-717. 10.1080/02841850600806340.

Laasonen EM, Kivioja A: Delayed Diagnosis of Extremity Injuries in Patients with Multiple Injuries. J Trauma. 1991, 31: 257-260.

Pehle B, Kuehne CA, Block J, Waydhas C, Taeger G, Nast-Kolb D, Ruchholtz S: Die Bedeutung von verzögert diagnostozierten Läsionen bei Polytraumatisierten. Der Unfallchirurg. 2006, 109: 964-974. 10.1007/s00113-006-1161-y.

Kremli MK: Missed Musculoskeletal Injuries in a University Hospital in Riyadh: Types of Missed Injuries and Responsible Factors. Injury. 1996, 27: 503-506. 10.1016/0020-1383(96)00044-7.

Chan RNW, Ainscow D, Sikorski JM: Diagnostic Failures in the Multiple Injured. J Trauma. 1980, 20: 684-687.

Soundappan SVS, Holland AJA, Cass DT: Role of an Extended Tertiary Survey in Detecting Missed Injuries in Children. J Trauma. 2004, 57: 114-118.

Guly HR: Diagnostic errors in an accident and emergency department. Emerg Med J. 2001, 18: 263-269. 10.1136/emj.18.4.263.

Article   PubMed Central   CAS   PubMed   Google Scholar  

Sung CK, Kim KH: Missed Injuries in Abdominal Trauma. J Trauma. 1996, 41: 276-278.

Enderson BL, Reath DB, Meadors J, Dallas W, Deboo JM, Maull KI: The tertiary trauma survey: a prospective study of missed injury. J Trauma. 1990, 30: 666-669.

Bardenheuer M, Obertacke U, Waydhas C, Nast-Kolb D, DGU AGP: Epidemiology of Severe Multiple Trauma- A Prospective Registration of Preclinical and Clinical Supply. Unfallchirurg. 2000, 103: 355-363. 10.1007/s001130050550.

Rothenberger DA, Fischer RP, Strate RG, Velasco R, Perry JFJ: The Mortality Associated with Pelvic Fractures. Surgery. 1978, 84: 356-361.

CAS   PubMed   Google Scholar  

Mucha PJ, Farnell MB: Analysis of Pelvic Fracture Management. J Trauma. 1984, 24: 379-386.

Chong KH, DeCoster T, Osler T, Robinson B: Pelvic Fractures and Mortality. Iowa Orthop J. 1997, 17: 114-

Google Scholar  

Poole GV, Ward EF, Muakkassa FF, Hsu HSH, Griswold JA, Rhodes RS: Pelvic Fracture from Major Blunt Trauma. Ann Surg. 1991, 213: 532-538.

Alonso JE, Lee J, Burgess AR, Browner BD: The Management of Complex Orthopedic Injuries. Surgical Clinics of North America. 1996, 76: 880-903. 10.1016/S0039-6109(05)70486-2.

Article   Google Scholar  

Gilliland MD, Ward RE, Barton RM, Miller PW, Duke JH: Factors Affecting Mortality in Pelvic Fractures. J Trauma. 1982, 22: 691-693.

Tien HC, Spencer F, Tremblay LN, Rizoli SB, Brenneman FD: Preventable Death From Hemorrhage at a Level I Canadian Trauma Center. J Trauma. 2007, 62: 142-146.

Gonzalez RP, Fried PQ, Bukhalo M: The Utility of Clinical Examination in Screening for Pelvic Fractures in Blunt Trauma. J Am Coll Surg. 2002, 194: 121-125. 10.1016/S1072-7515(01)01153-X.

Resnik CS, Stackhouse DJ: Diagnosis of Pelvic Fractures in Patients with Acute Pelvic Trauma: Efficacy of Plain Radiographs. Am J Roentgenol. 1992, 158: 109-112.

Hessmann MH, Hofmann A, Kreitner KF, Lott C, Rommens PM: The Benefit of Multislice Computed Tomography in the Emergency Room Management of Polytraumatized Patients. Eur J Trauma. 2005, 31: 231-238. 10.1007/s00068-005-2051-7.

Hilbert P, zur Nieden K, Hoeller I, Koch R, Hofmann GO, Stuttmann R: The Emergency Room-Diagnostics, Therapy and Management Center: a New Care Concept. Notfall Rettungsmed. 2008, 9: 547-552. 10.1007/s10049-006-0845-8.

Kanz KG, Körner M, Linsenmaier U, Kay MV, Huber-Wagner SM, Kreimeier U, Pfeifer KJ, Reiser M, Mutschler W: Use of Multi Detector Computed Tomography for Primary Trauma Survey. Unfallchirurg. 2004, 107: 937-944. 10.1007/s00113-004-0845-4.

Falchi M, Rollandi GA: CT of Pelvic Fractures. Eu J Radiol. 2004, 50: 96-105. 10.1016/j.ejrad.2003.11.019.

Hilbert P, zur Nieden K, Hofmann GO, Hoeller I, Koch R, Stuttmann R: New Aspects in the Emergency Room Management of Critically Injured Patients: A Multi-slice CT-oriented Care Algorithm. Injury. 2007, 38: 552-558. 10.1016/j.injury.2006.12.023.

Sampson MA, Colquhoun KBM, Hennessy NLM: Computed Tomography whole Body Imaging in Multi-Trauma: 7 Years Experience. Clin Radiol. 2006, 61: 365-369. 10.1016/j.crad.2005.12.009.

Killeen KL, DeMeo JH: CT Detection of Serious Internal and Skeletal Injuries in Patients with Pelvic Fractures. Acad Radiol. 1999, 6: 224-228. 10.1016/S1076-6332(99)80209-8.

Pereira SJ, O'Brien DP, Luchette FA, Choe KA, Lim E, Davis K, Hurst JM, Johannigman JA, Frame SB: Dynamic Helical Computed Tomography Scan Accurately Detects Hemorrhage in Patients with Pelvic Fracture. Surgery. 2000, 128: 678-685. 10.1067/msy.2000.108219.

Hilty MP, Behrendt I, Benneker LM, Martinolli L, Stoupis C, Buggy DJ, Zimmermann H, Exadaktylos AK: Pelvic Radiography in ATLS Algorithms: A Diminishing Role. World J Emerg Surg. 2008, 3: 11-15. 10.1186/1749-7922-3-11.

Article   PubMed Central   PubMed   Google Scholar  

Guillamondegui OD, Pryor JP, Gracias VH, Gupta R, Reilly PM, Schwab CW: Pelvic Radiography in Blunt Tram Resuscitation: A Diminishing Role. J Trauma. 2002, 53: 1043-1047.

Pehle B, Nast-Kolb D, Oberbeck R, Waydhas C, Ruchholtz S: Significance of Physical Examination and Radiography of the Pelvis during Treatment in the Shock Emergency Room. Unfallchirurg. 2003, 106: 642-648. 10.1007/s00113-003-0629-2.

Download references

Author information

Authors and affiliations.

Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Building, Suite 1010, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA

Roman Pfeifer & Hans-Christoph Pape

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Roman Pfeifer .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors' contributions

All authors were involved in the research project and preparation of the manuscript. PHC: He made a substantial contribution to conception and design, and gave a critical and final approval. PR: He has collected the data and made an analysis and interpretation of these data. He also made a draft of the manuscript and revisions. All authors read and approved the final version of the manuscript.

Authors’ original submitted files for images

Below are the links to the authors’ original submitted files for images.

Authors’ original file for figure 1

Authors’ original file for figure 2, authors’ original file for figure 3, authors’ original file for figure 4, rights and permissions.

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

Pfeifer, R., Pape, HC. Missed injuries in trauma patients: A literature review. Patient Saf Surg 2 , 20 (2008). https://doi.org/10.1186/1754-9493-2-20

Download citation

Received : 27 May 2008

Accepted : 23 August 2008

Published : 23 August 2008

DOI : https://doi.org/10.1186/1754-9493-2-20

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Trauma Patient
• Injury Severity Score
• Trauma Care
• Musculoskeletal Injury
• Minor Injury

Patient Safety in Surgery

ISSN: 1754-9493

• Submission enquiries: [email protected]
• General enquiries: [email protected]

• Open access
• Published: 09 August 2013

Traumatic appendicitis: a case report and literature review

• Abdesslam Bouassria 1 , 2 ,
• Karim Ibn Majdoub 1 , 2 ,
• Issam Yazough 1 , 2 ,
• Abdelmalek Ousadden 1 , 2 ,
• Khalid Mazaz 1 , 2 &
• Khalid Ait Taleb 1 , 2  

World Journal of Emergency Surgery volume  8 , Article number:  31 ( 2013 ) Cite this article

12k Accesses

5 Citations

38 Altmetric

Metrics details

Appendicitis and trauma may exist together, which causes an interesting debate whether trauma has led to appendicitis. We report a case of appendicitis after an abdominal trauma. Our patient developed acute appendicitis following a stab wound in the right iliac fossa. Surgical exploration confirmed the traumatic origin of appendicitis, appendectomy was performed and our patient made an excellent recovery. In non operative management of abdominal trauma, physical examinations and radiological explorations should be repeated in order to diagnose traumatic appendicitis.

Introduction

Trauma and appendicitis are the commonest emergency conditions requiring surgery, especially in young adults. The pathological process in appendicitis generally starts with obstruction of the appendiceal lumen and may progress to peritonitis and development of intraabdominal abscess via appendiceal inflammation and perforation. An abdominal trauma may be responsible for damage of digestive tract or solid organs (liver or spleen). Occasionally, appendicitis and trauma exist together, which causes an interesting debate whether trauma has led to appendicitis. Actually, the role of abdominal trauma is still uncertain in the etiology of appendicitis. Blunt abdominal trauma or penetrating trauma like a stab wound may lead to an acute inflammatory response which is suggested to be the probable mechanism of traumatic appendicitis.

We report a case of appendicitis after an abdominal trauma (stab wound). To our knowledge, it is the first case of acute appendicitis after a stab wound reported in the literature.

Case report

A 24 year-old man was admitted to the emergency department because of an abdominal injury following a stab wound which occurred on the same day. He said he was assaulted one hour before his admission by a stab wound in the right iliac fossa. His assailant used a sharp instrument (kitchen knife).The physical examination showed a conscious patient hemodynamically stable whose temperature was 37°C, whose pulse rate was 80 beats/min, whose respiratory rate of 20 breaths/min and whose blood pressure was 130/80 mmHg. Abdominal examination was normal out of mild tenderness at the abdominal wound which was located in the right iliac fossa. Laboratory investigations showed that the hemoglobin level was 12.8 g/dl, and the white blood cell count was 9800/mm3. Abdominal ultra sonography (US) was normal. So, a non operative management was decided. The penetrating abdominal wound (2 centimeters in length) was located in the right iliac fossa. It was disinfected and sutured. The day after his hospitalization, he had acute right iliac fossa pain. On examination, he was found to have a blood pressure of 120/80 mmHg, a pulse rate of 80 beats/min and a respiratory rate of 20 breaths/min; he was mildly pyrexial at 37.5°C. Abdominal examination revealed tenderness in the right iliac fossa. Laboratory investigations showed that the hemoglobin level was stable, but the white blood cell count was significant for a leukocyte count of 14,000/mm3 with 80% polymorphonuclear leukocytes. Then, abdominal US showed acute appendicitis (Figure  1 ). An emergency operation was performed. At laparotomy, a right paracolic retroperitoneal hematoma was detected. The patient had pelvic appendix in position. The appendix was hyperemic and edematous. Hematomas of the caecal wall and of the appendiceal wall were found (Figure  2 ). Appendectomy was performed. Histopathology confirmed diagnosis of acute appendicitis. Our patient made an excellent recovery, and he was discharged from the hospital in stable condition 2 days later.

Abdominal ultra sonography of our patient showing appendicitis.

Intra operative photo showing the right para colic retroperitoneal hematoma and the appendicitis.

This study was performed according to the declaration of Helsinki and approved by the Local Ethical Committee.

The acute appendicitis is the most common abdominal surgical emergency. It is an acute inflammation of the appendix related mostly with obstruction of the appendiceal lumen. This obstruction is usually caused by an inspissated stool, a mucus plug, or a foreign body [ 1 ]. Non-obstructive causes are also discussed such as bacterial invasion of the lymphoid tissue of the appendix [ 2 ]. Abdominal trauma was also mentioned as a possible etiologic factor in acute appendicitis. Interest in the association between appendicitis and blunt abdominal trauma may have begun with illusionist Harry Houdini’s untimely death in 1926: he is said to have died from a rupture appendix after a blow to the abdomen. During the 1930s, reports of blunt abdominal trauma and subsequent appendicitis began to appear [ 3 ] (Table  1 ). However, only few cases of minor BAT and TA have been reported in the literature, which may be attributed to the rarity or the difficulty to diagnose this relationship. Hennington and al. reported two cases of blunt abdominal trauma producing acute appendicitis. In both cases, blunt abdominal trauma has produced appendiceal edema with inflammation and hyperplasia of appendix lymphoid tissue, and then, obstruction of the appendiceal lumen, leading to acute appendicitis [ 4 ]. Ciftçi and al reported 5 cases of appendicitis occurring after abdominal trauma suggesting the same mechanism [ 2 ]. It is well known that intra-abdominal pressure increases in varying degrees in every blunt abdominal trauma case [ 5 – 7 ]. According to Ramsook [ 3 ], a sudden increase in intra abdominal pressure may lead to an increased intra ceacal pressure followed by a rapid distention of the appendix which may result in appendicitis.

Serour and al have claimed that direct appendiceal injury is generally coexistent with other intra-abdominal organ injuries, and that the appendix is very rarely affected by direct trauma as it is very mobile and its dimensions very small [ 8 ]. As for our patient, hypothesis of appendicitis and abdominal trauma both existing together was easily dismissed because he was attacked by a sharp instrument. The stab wound in the right iliac fossa produced a penetrating abdominal wound. Then, the sharp instrument traumatized the meso colon and the meso appendix, causing the para colic retroperitoneal hematoma and hematomas of the caecal wall and the appendiceal wall. The result of these anatomic lesions was acute appendicitis due to the consequent luminal obstruction of the appendix.

Appendicitis may follow abdominal trauma. Blunt abdominal trauma leading to appendicitis is rare, and occasionally, appendicitis and trauma exist together, which causes an interesting debate whether trauma has led to appendicitis. We report a case of abdominal trauma due to a sharp instrument which directly led to acute appendicitis. As the abdominal trauma was not a BAT, it was easy to relate the stab wound in the right iliac fossa to acute appendicitis. In non operative management of abdominal trauma, physical examinations, abdominal ultra sonography and/or abdominal computed tomography should be repeated for diagnosis of traumatic appendicitis in order to prevent potential complications of appendicitis.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Authors’ information

School of medicine and pharmacy of fez, Sidi Mohammed Ben Abdellah University department of surgery, university hospital Hassan II, BP: 1893; km2.200, route de sidi Hrazem; fez 30000, morocco.

Etensel B, Yazici M, Gursoy H, Ozkisacik S, Erkus M: The effect of blunt abdominal trauma on appendix vermiformis. Emerg Med J. 2005, 22: 874-877. 10.1136/emj.2004.018895.

Article   PubMed Central   CAS   PubMed   Google Scholar  

Ciftçi AO, Tanyel FC, Buyukpamukçu N: Appendicitis after blunt abdominal trauma: cause or coincidence?. Eur J Pediatr Surg. 1996, 6: 350-353. 10.1055/s-2008-1071013.

Article   PubMed   Google Scholar  

Ramsook C: Traumatic appendicitis: fact or fiction?. Pediatr Emerg Care. 2001, 17: 264-266. 10.1097/00006565-200108000-00011.

Article   CAS   PubMed   Google Scholar  

Hennington MH, Tinsley JR EA, Proctor HJ: Acute appendicitis following blunt abdominal trauma. Ann Surg. 1991, 214: 61-63.

Schein M, Klipfel A: Local peritoneal responses in peritonities-clinical scenarios i: peritoneal compartment responses and its clinical consequences. Sepsis. 1999, 3: 327-334. 10.1023/A:1009861629215.

Article   Google Scholar  

Km S, Pm B, Miller JS: Abdominal compartment syndrome after mesenteric revascularization. J Vasc Surg. 2001, 34: 559-561. 10.1067/mva.2001.117150.

Saggi B, Sugerman H, Ivatury R: Abdominal compartment syndrome. J Trauma. 1998, 45: 597-609. 10.1097/00005373-199809000-00033.

Serour F, Efrati Y, Klin B: Acute appendicitis following abdominal trauma. Arch Surg. 1996, 131: 785-786. 10.1001/archsurg.1996.01430190107026.

Download references

Author information

Authors and affiliations.

School of medicine and pharmacy of Fez, Sidi Mohammed Ben Abdellah University, BP: 1893; km2.200, route de sidi Hrazem, Fez, 30000, Morocco

Abdesslam Bouassria, Karim Ibn Majdoub, Issam Yazough, Abdelmalek Ousadden, Khalid Mazaz & Khalid Ait Taleb

Department of surgery, University Hospital Hassan II, BP: 1893; km2.200, route de sidi Hrazem, Fez, 30000, Morocco

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Abdesslam Bouassria .

Additional information

Competing interests.

All authors declare no competing interests.

Authors’ contributions

AB and KIM participated in writing the case report and revising the draft, IY were involved in literature research and were major contributor in writing the manuscript. AO and KAT and KM participated in the follow up. All authors read and approved the final manuscript.

Authors’ original submitted files for images

Below are the links to the authors’ original submitted files for images.

Authors’ original file for figure 1

Authors’ original file for figure 2, rights and permissions.

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

Bouassria, A., Ibn Majdoub, K., Yazough, I. et al. Traumatic appendicitis: a case report and literature review. World J Emerg Surg 8 , 31 (2013). https://doi.org/10.1186/1749-7922-8-31

Download citation

Received : 22 May 2013

Accepted : 05 August 2013

Published : 09 August 2013

DOI : https://doi.org/10.1186/1749-7922-8-31

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Appendicitis
• Abdominal trauma

World Journal of Emergency Surgery

ISSN: 1749-7922

• Submission enquiries: [email protected]

Radiologic Technology

Skip to main page content

• CURRENT ISSUE
• Institution: Google Indexer

Trauma Imaging: A Literature Review

• Jason Heath Vela , BSRS, R.T.(R)(CT) ,
• Christopher Ira Wertz , MSRS, R.T.(R) ,
• Kimberly L Onstott , MSRS, R.T.(R)(CT)(MR) and
• Joss R Wertz , DO

Purpose To inform radiologic technologists about which imaging modalities and examinations are best suited for evaluating specific anatomical structures in patients who have sustained a traumatic injury.

Methods Two scholarly research databases were searched to identify articles focused on trauma imaging of the head, cervical spine, thorax, abdomen, and pelvis. Articles focused on trauma diagnosis were excluded. Thirty-two articles were selected for analysis.

Discussion Physical examination and plain-film radiographs typically are used to assess nasal bone fracures. Computed tomography (CT) can be used to assess zygomaticomaxillary complex, mandibular, and temporal bone fractures. Traumatic brain injuries are difficult to assess, and broad classifications are used. Depending on the severity of cervical spine trauma, plain-film radiographs or CT imaging is adequate, with magnetic resonance imaging used as a means for further evaluation. Trauma to the thorax typically is assessed with radiography and CT, and CT is recommended for assesment of abdominal and pelvic trauma.

Conclusion The literature was consistent regarding which examinations to perform to best evaluate suspected injuries to the chest, abdomen, and pelvis. The need for, and correct use of, imaging in evaluating trauma to the head and cervical spine is more controversial. Despite the need for additional research, emergency department care providers should be familiar with the structures most commonly injured during trauma and the role of medical imaging for diagnosis.

• trauma imaging
• trauma radiography
• common trauma exams
• interventional radiology
• hepatic trauma
• pelvic trauma
• emergency radiology
• Abbreviated Injury Scale
• Received August 2, 2016.
• Accepted November 2, 2016.

This Article

• radtech January/February 2017 vol. 88 no. 3 263-276
• Full Text (PDF)

Classifications

• Peer Reviewed
• Email this article to a colleague
• Alert me when this article is cited
• Alert me if a correction is posted
• Similar articles in this journal
• Similar articles in Web of Science
• Similar articles in PubMed
• Download to citation manager

Citing Articles

• Load citing article information
• Citing articles via Web of Science
• Citing articles via Google Scholar

Google Scholar

• Articles by Vela, J. H.
• Articles by Wertz, J. R.
• Search for related content
• PubMed citation

Related Content

• Load related web page information

This Week's Issue

• May-June 2024, 95 (5)
• Alert me to new issues of radtech
• Instructions to authors
• Subscriptions
• About the journal
• Editorial Board
• Email alerts
• Advertising

Radiologic Technology is published by the American Society of Radiologic Technologists.

Copyright © 2024 by the American Society of Radiologic Technologists

• Print ISSN: 0033-8397