8am Jodie Bachman AOASM Case Presentation · 2018. 4. 1. · structures, and the gastrointestinal...

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JodieBachmanD.O.SportsMedicineFellow

SaintBarnabasMedicalCenterAOASMNationalConference

History!  17-year-oldmalehighschool

footballplayerwhowastackledhightohisrightsidewhileoutstretchedtocompleteareception

!  Helandedonthegroundonhisleftside

!  Wasunabletogetupoffthegroundfollowingtheplay

!  EvaluatedonthefieldbyhisATC&assistedoffthefieldoncestable

History!  reportfromtheATCwasthathe“hadthewindknockedoutofhim”

!  initialevaluationonthesidelinerevealedmildshortnessofbreathandsub-sternaltenderness

!  re-evaluationseveralminuteslaterwaspositiveforRUQtenderness,worseningshortnessofbreath,andaninabilitytotakedeepbreaths

!  hewasmovedbygolfcartfromthesidelinetothefacilitiestrainingroom

!  re-evaluationrevealedstablevitalssignwithminorhypotension,cold/clammyskin,andworseningRUQpain

!  decisionwasmadetotransferathletebyambulancetotheERforfurtherevaluation

Differen3alDiagnosis!  sternalcontusion!  ribcontusion!  ribfracture!  livercontusion!  liverlaceration

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EmergencyRoomEvalua3on!  vitalswerestable!  bloodworkwaswithin

normallimits!  CTrevealedagrade3hepatic

lacerationextendingfromthegallbladderfossaanterolaterallytothesurfaceoftheliver

!  lacerationmeasuredapproximately6cminlengthandcontainedhyperdensematerialpossiblyrepresentingactiveextravasation

HospitalStay!  admittedfor48hourobservation

!  CTscanrepeatedpriortodischarge

!  instructedbysurgicalteamathospitaltorefrainfromphysicalactivityforfourweeks,andnotreturntofullcontactsportsparticipationuntilatleastsixweekspostinjury

Anatomy!  abdominalorgansareprotectedfromdirecttraumabythelowerribsandmusclesoftheabdominalwall!  liveristhelargestsolidorgan!  locatedintheRUQoftheabdominalcavitybeneaththediaphragmandontopofthestomach,rightkidney,andsmallintestine

Anatomy!  enclosedbytheribcageanteriorlyandlaterally!  shapedlikeacone&weighs~3lbs!  dividedintorightandleftlobes!  receives20%ofit'sbloodsupplyfromthehepaticarteryand80%

fromtheportalvein

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Anatomy!  childrenandadolescents

!  compacttorsowithsmalleranteriortoposteriordiameter

!  smallerareaoverwhichforcecanbedissipated

!  relativelylargerviscera!  lessoverlyingfat!  weakerabdominalmusculature

Anatomy!  Livermoresusceptibletoinjurydueto

!  largesize!  softconsistency!  locationinupperthreequadrantsoftheabdomen!  highvascularity

AbdominalInjuryandTrauma!  typicallyassociatedwithcontactsports!  canoccurinnon-contactsportswheretheinjurycanbecausedbyanindirectdecelerationmechanism

•  ex:trafficaccidents,falls

AbdominalInjury&Trauma!  Signsandsymptoms

!  abdominalpain!  tendernessovertheinjuredarea!  rigidabdomen!  painreferredtotheupperextremities!  coldsweatyskin(shock)!  bluishdiscolorationofthebelly!  nausea!  vomiting!  rapidpulse!  lowbloodpressure!  lossoforalteredlevelofconsciousness!  laboredbreathing

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LiverInjury!  secondmostcommonsolidorganinjuredintheabdomenduringparticipationinsportactivities

!  occursinabout10%ofabdominaltrauma! mostcausedbydirectblowtotheRUQ!  rightlobemostcommonlyinjuredbecauseofit’slargersizeandjuxtapositiontotheribs

LiverInjury!  SignsandSymptoms

!  nausea!  vomiting!  lightheadedness!  ecchymosis!  chesttenderness!  abdominaltenderness!  fractureofribs10-12!  abdominaldistension!  muscleguarding

Imaging!  CTisthediagnosticmodalityofchoiceforevaluationofbluntlivertrauma!  Pros

!  sizeofinjury!  extentandshapeoflesion

!  linear!  round!  branchingareasofdecreasedattenuationwithintheliverparenchyma

!  identifyhepaticparenchymalinjuries!  quantifythedegreeofinjurytohemoperitoneum!  revealassociatedinjuriestootherabdominalorgans,retroperitoneal

structures,andthegastrointestinaltract!  Cons

!  littlecapabilitydetectinginjurytohollowviscousstructure!  procedureistimeconsuming!  contraststudy!  requiresexpertiseforaccurateinterpretationofsubtlefindings

Imaging!  DiagnosticPeritonealLavage

!  oftenperformedtoevaluatebluntabdominalinjuriesforthepresenceofhemoperitoneum

!  Pros!  98.5%sensitivity

!  Cons!  sourceofbleedingisnotcertain!  hasapoorcapabilitytodetectretroperitonealbleeding!  smallriskassociatedwiththeinvasivenessoftheprocedure

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Imaging!  Ultrasound

!  Pros!  idealchoiceinthehemodynamicallyunstablepatient!  sensitivityofapproximately85%andaspecificityof99%in

detectingintra-abdominalinjuries!  canvisualizefreeintraperitonealfluid

!  Cons!  operatordependent!  lesssensitivethanCT!  pooratgradingtheinjuryandidentifyingtheinjuredorgan!  conditionsidentifiedonultrasoundinstablepatientswill

eventuallyrequireCTtoidentifytheinjuryandtoguidemanagement)

LiverLacera3ons!  acutelacerationscanrangefromasmalltearwithlittlebleedingtoadeepseverelesionscausingsignificantbleeding

!  ifsevereenoughsurgicalinterventionmaybenecessary!  classifiedonagradingscalefrom1-6!  gradedaccordingto

!  size!  depth!  extentofinjury

!  superficiallacerationsarelessthanorequalto3cm!  deeplacerationsaregreaterthan3cm

LiverLacera3ons Management! CTdocumentationofresolutionwasoncestandardofcare

! nolongerrecommendedunlessclinicallyindicated! healingofasimpleliverlacerationsandsubcapsularhematomarequires2-4months

!  alargeandcomplexlacerationcanrequireupto6monthsforcompletehealing

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ReturntoAc3vity!  restrictionofactivityisrecommendedasfollows:

!  gradeI–3weeks!  gradeII–4weeks!  gradeIII–5weeks!  gradeIV–6weeks

Backtoourcase…..

Outcome!  Seenforfollowup4weekspost-injury

!  abdominalultrasoundatthattimewasinconclusive&repeatCTrequestedbyradiologist

! CTshowedlacerationhaddecreasedinsizefrom6cmto6X3mm

Outcome! finalCTdone3weekslater(10weekspost-injury)

!  completeresolutionoflaceration

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ReturntoAc3vity!  clearedtoreturntosportsconditioningworkat4weekspost-injury

!  returntofullsportsactivitywithnorestrictionsat10weeks

!  athletewillwearprotectivepaddingduringsportsparticipation

TakeHomePoints!  liverlacerationscanbelifethreatening&mustberecognizedandtreatedpromptly

!  CTisthebestchoiceforimagingtheseinjuries!  ifathleteremainsstabletheycanusuallyreturntolightexerciseat4weekswithreturntofullcontactsportsbetween3-6months

!  athleteshouldnotcompeteuntilanatomicandfunctionalhealingoccurs!  CTresolution!  normalizationofliverenzymes

!  timingofreturntofullcontactsportsparticipationshouldbedeterminedbytheteamphysicianonanindividualbasis

Acknowledgements! Dr.MicheleGilsenan! Dr.VaibhavMangrulkar

Questions?