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Triple-Contrast Helical CT in Penetrating Torso Trauma

A Prospective Study to Determine Peritoneal Violation and the Need for Laparotomy

¹ Department of Diagnostic Radiology, University of Maryland Medical Center, 22 S. Greene St., Baltimore, MD 21201
² Maryland Shock-Trauma Center, University of Maryland Medical Center, Baltimore, MD 21201.
³ Present address: Forsyth Radiological Associates

View larger version (86K): [in a new window]   Fig. 1A. —Anatomic regions of torso. Drawings show front (A), side (B), and back (C) of thoracoabdominal area. Horizontal lines = back, diagonal lines = abdomen, dots = flank, vertical lines = pelvis. Line A = anterior axillary line; line B = posterior axillary line.

View larger version (41K): [in a new window]   Fig. 1B. —Anatomic regions of torso. Drawings show front (A), side (B), and back (C) of thoracoabdominal area. Horizontal lines = back, diagonal lines = abdomen, dots = flank, vertical lines = pelvis. Line A = anterior axillary line; line B = posterior axillary line.

View larger version (65K): [in a new window]   Fig. 1C. —Anatomic regions of torso. Drawings show front (A), side (B), and back (C) of thoracoabdominal area. Horizontal lines = back, diagonal lines = abdomen, dots = flank, vertical lines = pelvis. Line A = anterior axillary line; line B = posterior axillary line.

View larger version (161K): [in a new window]   Fig. 2A. —Pelvic gunshot wound with peritoneal violation in 20-year-old man. Axial CT images in pelvis show bullet fragments, air, and blood along transsacral wound tract (arrowheads). Largest bullet fragment (arrow, C) is seen within peritoneal cavity. Wound tract extends to sigmoid colon (curved arrow, D). Mesenteric contusion (white arrow) and free intraperitoneal fluid (open arrow) are also seen in D.

View larger version (161K): [in a new window]   Fig. 2B. —Pelvic gunshot wound with peritoneal violation in 20-year-old man. Axial CT images in pelvis show bullet fragments, air, and blood along transsacral wound tract (arrowheads). Largest bullet fragment (arrow, C) is seen within peritoneal cavity. Wound tract extends to sigmoid colon (curved arrow, D). Mesenteric contusion (white arrow) and free intraperitoneal fluid (open arrow) are also seen in D.

View larger version (160K): [in a new window]   Fig. 2C. —Pelvic gunshot wound with peritoneal violation in 20-year-old man. Axial CT images in pelvis show bullet fragments, air, and blood along transsacral wound tract (arrowheads). Largest bullet fragment (arrow, C) is seen within peritoneal cavity. Wound tract extends to sigmoid colon (curved arrow, D). Mesenteric contusion (white arrow) and free intraperitoneal fluid (open arrow) are also seen in D.

View larger version (167K): [in a new window]   Fig. 2D. —Pelvic gunshot wound with peritoneal violation in 20-year-old man. Axial CT images in pelvis show bullet fragments, air, and blood along transsacral wound tract (arrowheads). Largest bullet fragment (arrow, C) is seen within peritoneal cavity. Wound tract extends to sigmoid colon (curved arrow, D). Mesenteric contusion (white arrow) and free intraperitoneal fluid (open arrow) are also seen in D.

View larger version (156K): [in a new window]   Fig. 2E. —Pelvic gunshot wound with peritoneal violation in 20-year-old man. Axial CT image obtained with window and level settings that minimized streak artifact from bullet shows free intraperitoneal fluid (arrowheads) with largest bullet fragment (solid straight arrow) next to sigmoid colon (curved arrow). Blood (open arrow) is seen anterior to sacrum. Sigmoid colon and adjacent mesenteric injury were confirmed at surgery.

View larger version (123K): [in a new window]   Fig. 3A. —21-year-old man with negative findings for peritoneal violation on CT, who was shot in left groin. Pelvic radiograph shows bullet (arrow) at level of lower right sacroiliac joint.

View larger version (172K): [in a new window]   Fig. 3B. —21-year-old man with negative findings for peritoneal violation on CT, who was shot in left groin. CT images of pelvis show blood outlining extraperitoneal bullet tract (arrowheads) with bullet seen in right iliopsoas muscle (arrow, E) adjacent to right common iliac vessels. No free intraperitoneal fluid is seen. Bullet tract extends adjacent to bladder. Cystogram and pelvic arteriogram (not shown) did not show injury to bladder or right iliac vessels.

View larger version (180K): [in a new window]   Fig. 3C. —21-year-old man with negative findings for peritoneal violation on CT, who was shot in left groin. CT images of pelvis show blood outlining extraperitoneal bullet tract (arrowheads) with bullet seen in right iliopsoas muscle (arrow, E) adjacent to right common iliac vessels. No free intraperitoneal fluid is seen. Bullet tract extends adjacent to bladder. Cystogram and pelvic arteriogram (not shown) did not show injury to bladder or right iliac vessels.

View larger version (164K): [in a new window]   Fig. 3D. —21-year-old man with negative findings for peritoneal violation on CT, who was shot in left groin. CT images of pelvis show blood outlining extraperitoneal bullet tract (arrowheads) with bullet seen in right iliopsoas muscle (arrow, E) adjacent to right common iliac vessels. No free intraperitoneal fluid is seen. Bullet tract extends adjacent to bladder. Cystogram and pelvic arteriogram (not shown) did not show injury to bladder or right iliac vessels.

View larger version (185K): [in a new window]   Fig. 3E. —21-year-old man with negative findings for peritoneal violation on CT, who was shot in left groin. CT images of pelvis show blood outlining extraperitoneal bullet tract (arrowheads) with bullet seen in right iliopsoas muscle (arrow, E) adjacent to right common iliac vessels. No free intraperitoneal fluid is seen. Bullet tract extends adjacent to bladder. Cystogram and pelvic arteriogram (not shown) did not show injury to bladder or right iliac vessels.

View larger version (128K): [in a new window]   Fig. 4A. —40-year-old man who fell on metal spike and was impaled. Axial CT images in lower (A) and mid (B) pelvic regions show entry site in right groin (curved arrow, A) with large amount of soft-tissue air in anterior abdominal wall. No free intraperitoneal air or fluid is seen. Surgical débridement of anterior abdominal wall wound tract confirmed lack of peritoneal violation.

View larger version (134K): [in a new window]   Fig. 4B. —40-year-old man who fell on metal spike and was impaled. Axial CT images in lower (A) and mid (B) pelvic regions show entry site in right groin (curved arrow, A) with large amount of soft-tissue air in anterior abdominal wall. No free intraperitoneal air or fluid is seen. Surgical débridement of anterior abdominal wall wound tract confirmed lack of peritoneal violation.

View larger version (128K): [in a new window]   Fig. 5A. —Active bleeding in 30-year-old man admitted for treatment of gunshot wound to left thoracoabdominal region. Two axial CT images show lower pole splenic laceration (solid arrows, A) with active bleeding (open arrows, B) in perisplenic blood (curved arrow). Left rib fracture (arrowheads) is also seen.

View larger version (139K): [in a new window]   Fig. 5B. —Active bleeding in 30-year-old man admitted for treatment of gunshot wound to left thoracoabdominal region. Two axial CT images show lower pole splenic laceration (solid arrows, A) with active bleeding (open arrows, B) in perisplenic blood (curved arrow). Left rib fracture (arrowheads) is also seen.

View larger version (152K): [in a new window]   Fig. 6A. —Rectal contrast extravasation in 39-year-old man who was stabbed in anterior abdomen. Axial CT image shows free intraperitoneal air (arrowheads) anterior to liver and lateral to stomach. Extravasation of contrast material (arrows) is seen adjacent to caudate lobe of liver and in region of hepatoduodenal ligament.

View larger version (122K): [in a new window]   Fig. 6B. —Rectal contrast extravasation in 39-year-old man who was stabbed in anterior abdomen. Axial CT image shows extravasation of rectal contrast material (arrowheads) into region of transverse mesocolon.

View larger version (171K): [in a new window]   Fig. 7A. —Stab wound to stomach in 35-year-old man. CT image shows small amount of free intraperitoneal fluid (arrowheads) anterior to liver.

View larger version (95K): [in a new window]   Fig. 7B. —Stab wound to stomach in 35-year-old man. Two contiguous axial images show defect (arrowheads) in anterior abdominal wall with a wound tract (arrow) extending up to stomach. Perforation to anterior wall of stomach was repaired at surgery.

View larger version (145K): [in a new window]   Fig. 8A. —Diaphragm injury in 34-year-old man who sustained single gunshot wound to right thoracoabdominal area. CT images show right lower lobe lung (solid arrow, A) and right dome of liver (curved arrow, B) lacerations. Right small pleural effusion (open arrow, A) and free intraperitoneal fluid is seen around liver (arrowheads, B). Contiguous injuries are seen on either side of right diaphragm. Right diaphragm injury was repaired using thoracoscopy.

View larger version (124K): [in a new window]   Fig. 8B. —Diaphragm injury in 34-year-old man who sustained single gunshot wound to right thoracoabdominal area. CT images show right lower lobe lung (solid arrow, A) and right dome of liver (curved arrow, B) lacerations. Right small pleural effusion (open arrow, A) and free intraperitoneal fluid is seen around liver (arrowheads, B). Contiguous injuries are seen on either side of right diaphragm. Right diaphragm injury was repaired using thoracoscopy.

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