Abdominal Trauma

      Initial Assessment

Common pelvic landmarks are the anterior superior iliac spines (ASIS), posterior superior iliac spines (PSIS), and the anterior inferior iliac spines (AIIS). The majority of trauma-related pelvic injuries treated will be those of a musculotendinous unit. Thus, palpation and testing muscle action against resistance will usually pinpoint the site of injury quickly. Specific assessment procedures following pelvic trauma are described in the Commentary section.

Rectal examination is essential in the presence of bowel symptoms, bleeding, constipation, and low back pain. Overt symptoms of prolonged diarrhea, pelvic disease, referred low back pain, female complaints, urinary symptoms, and suspected malignancy should be referred to evaluation by a specialist.

      Pertinent Reflexes and Signs

Abdominal Reflexes.   Contractions above the navel on sharp downward friction of the abdominal wall indicate normal activity of the spinal cord from the 8th to the 12th thoracic nerves. An absent reflex could indicate a defective arc: upper-quadrant reflex absent, T5--T8; midquadrant reflex absent, T9--T11; lower-quadrant reflex absent, T11--T12; all sites diminished or absent, suspect of upper motor neuron involvement. Abdominal reflexes are normally diminished or absent in the obese and the elderly.

Epigastric Reflex.   Contraction of the abdominal muscles caused by stimulating the skin of the epigastrium or over the 5th and 6th intercostal spaces near the axilla.

Beevor’s Sign.   The examiner notes position of umbilicus when the patient tenses his abdominal muscles as in trying to rise from a supine position with the hands behind the head. Movement of the navel upward signifies paralysis or weakness of lower abdominal muscles, rectus abdominis; if umbilicus moves right, weakness of left abdominal muscles; if umbilicus moves left, weakness of the right abdominal muscles. A positive sign indicates involvement of thoracic segments T8--T10 such as in spinal cord injury or lesion, vertebral tumor, compression fracture, and disc ruptures.

Briquet’s Syndrome.   Hysterical diaphragmatic paralysis resulting in dyspnea and aphonia.

Murphy’s Sign.   Inability to take a deep breath when the palpating fingers are pressed deeply beneath the right costal arch, below the hepatic margin. It is a sign of a gallbladder disorder.

      Roentgenologic Considerations

Evidence of either splenic or hepatic injury is difficult to analyze on standard films. More sophisticated procedures are frequently required (eg, ultrasonic scans, arteriography). The right psoas muscle shadow is normally visualized in 69% of standard abdominal films; the left psoas, in 75% of subjects. Severe retroperitoneal hemorrhage or ascites may be indicated by an obscured psoas muscle margin and displacements of bowel gas. Occasionally, splenic rupture will obscure the left psoas shadow and present a large splenic shadow. Sometimes soft-tissue masses or a sclerosed aorta may be viewed.

      Visceral Injuries

Many deaths have been attributed to blunt trauma to the abdominal area. Any solid or hollow abdominal organ may be involved in abdominal trauma, but the spleen and kidneys appear to be the most vulnerable to injury. Typical physical signs in any visceral injury are shifting dullness, absent peristalsis, hypotension, and a fast pulse rate to suggest hemorrhage.

Ruptured Spleen.   The most common fatality following abdominopelvic trauma is from rupture of the spleen, as well as intrasplenic or subsplenic hematoma and retroperitoneal hemorrhage. Laceration may result from rib fracture, especially that of the 9th or 10th that lie directly behind the spleen. Rupture of the splenic capsule produces severe hemorrhage, often from what is considered minor trauma. It may even rupture spontaneously following infectious mononucleosis. Tenderness in the upper-left quadrant may be the only physical sign present. Pain is aggravated by breathing. Increasing hemorrhage causes diaphragmatic irritation referring pain to the left shoulder and root of the neck, along with generalized abdominal pain, rigidity, shifting dullness, and shock. A falling hematocrit is typical. Hypotension occurs late. Immediate surgical intervention is required to reduce mortality; if not, mortality ranges from 80%-100%. If rupture is not complete, a splenic hematoma may develop leading to delayed bleeding. This may not occur until 2 weeks after injury.

Lacerated Liver.   Liver injury is not common yet the possibility cannot be ignored because the liver easily ruptures and tears with fragmentation, frequently involving the gallbladder and/or ducts. Fortunately, most injuries are limited to a small laceration and hematoma. Tangential forces are usually involved. Usually the dome of the right lobe is affected, referring pain to the right shoulder and upper-right quadrant that is aggravated by breathing. When liver damage occurs, the danger of hemorrhage with consequent sepsis is great. Fortunately, most hepatic vessels have low pressure from the portal circulation that can often be controlled during emergency care by pressure. Acute hemorrhage will show evidence of internal bleeding and shock. Rapid death may occur.

Gallbladder Injury.   Blows to or compression of the lower-right chest may tear a distended gallbladder from the liver so that it lies free in the abdominal cavity or may cut the organ’s wall so gall leaks into the abdominal cavity (bile peritonitis). Diagnosis is extremely difficult, but a mild jaundice sign may appear under the tongue.

Traumatic Hemobilia.   While the incidence is small, blunt abdominal trauma is the most common cause of hemobilia (hemorrhage into the biliary tracts), usually resulting in melena, occult bleeding, or hematemesis. The origin of the bleeding may be from the liver, pancreas, gallbladder, or bile ducts.

Pancreas Rupture.   Although the pancreas is somewhat protected, some blunt injuries in sports have been reported with serious consequences. Injury is likely due to crushing forces against the spine. Symptoms may be dramatic or subtle. There may be epigastric tenderness and pain, often radiating to the back or left scapula, mild muscle resistance, signs of hemorrhage, and moderate shock. A raised serum amylase is usually diagnostic, but surgical exploration is necessary for confirmation.

Enteric Rupture.   Intestine injury, sometimes multiple, is usually the result of an anterior crushing injury against the spine causing a sudden pressure increase of gas or fluid in intestinal loops. Injury to the overlying skin may not be seen yet early diagnosis is vital. Common sites of injury are at the ileocecal junction and fixtures of the duodenum. The latter are often fatal because of lack of signs/symptoms. Diverticula may result when the small intestine is driven through adjacent structures. The clinical picture is often delayed until peristalsis becomes active, producing leakage into the peritoneal cavity. Periodic vomiting often occurs. Shock is usually mild in the early stage. Vague abdominal pain, rigidity, and flank fluid may not develop for 8--12 hours after trauma. Bowel sounds will then be absent. Considerable hemorrhage and infection are associated with colon rupture. Refer immediately upon suspicion.

Kidney Trauma.   Renal damage has the second highest rate of injury in abdominal blunt trauma. The mechanism is typically a loin blow. The extent of damage may be minor bruising or a serious rupture. The most constant feature is hemorrhage, either perirenal or into the urinary tract, or both. There is usually local pain radiating to the genitals, vomiting, shock, tenderness, and muscle spasm in the costovertebral angle. Bleeding does not invade the peritoneal cavity unless the fascial barrier is broken. Predisposing hydronephrosis requires only moderate trauma for severe consequences.

Studies show that albuminuria, casts, and microscopic hematurias occur in football during conditioning exercises and increase during contact practice. About 16% of players show gross hematuria after regular play, with normal values returning in a few days. Basketball, hockey, and boxing also have a high incidence of transient renal signs and symptoms, often leading to permanent structural damage. Exertion proteinuria and myoglobinuria appear to be related to intensity and duration of effort. The latter condition may lead to tubular necrosis.

Urinary Tract Injuries.   Bladder rupture rarely occurs in organized sports due to the absolute necessity of urinating before any practice or competitive event. The urethra is rarely injured outside of contact sports, gymnastics, or cycling where astride blows injure the perineum. Damage often follows coccygeal injury. A swelling between the scrotum and anus and possible slight urethral bleeding that may or may not be associated with micturition are suspicious signs of a ruptured urethra. After healing, a resulting stricture easily leads to chronic bladder and renal disorders if not treated adequately.

Chemical epidymitis is also a concern after urethral trauma. A ruptured urethra from a blow where the spermatic cord enters the urethra may result in urine leaking into the scrotum and produce a chemical epididymitis. A swollen testicle and pain increased on micturition are presented.

Anal Injury.   Anal lacerations are rare. Most complaints will be from a strangulated hemorrhoid that can be easily managed by warm soaks, ointments, and neurotherapy to relax the sphincter. If not, galvanism, surgery, injections, or cauterization should be advised. Pilonidal sinus and chronic fissures can be referred for surgical attention.

Rectal examination is essential in the presence of bowel symptoms, constipation, bleeding, diarrhea, pelvic disease, low back pain, female complaints, urinary symptoms, and suspected pelvic carcinoma. The patient is usually examined in the lateral position with the upper knee flexed (Sims’ position) or by the patient standing and placing the chest on the examining table.

Emergency Care in Abdominal Wounds

People with deep abdominal wounds generally stand a poor chance of recovery in emergency situations. Most gut wounds are grossly contaminated by the contents of the gastrointestinal or urinary tracts. Abdominal wounds require prompt surgery to stop hemorrhage. The immediate attention given is more of a supportive than therapeutic nature. With good supportive care, some patients will stabilize on their own and live to survive surgery. The priority is to dress an open wound and treat for shock while waiting for transportation to a hospital.

Cover the wound with one or more sterile dry dressings to prevent further contamination, but do not touch or try to push protruding organs or tissue into the wound. However, if it is necessary to move an exposed intestine onto the abdomen in order to cover the wound adequately, then do so. Secure the dressing in place with dressing tails and additional bandage. Since internal bleeding cannot be controlled by pressure and excessive pressure can cause further injury, do not bandage the wound tightly. Leave the patient on his back, but turn his head to one side since he will probably vomit. Watch him closely to prevent choking. If the patient is on a litter, raise the foot of the litter 6 inches. Keep him confortably warm. Permit nothing by mouth, but occasionally moisten his lips with a wet cloth to help alleviate thirst.


Hernia

Sudden groin pain following straining suggests hernia. The term hernia refers to a protrusion of a loop or part of an organ through an unusual opening. In themselves, they rarely cause overt symptoms but their complications do (eg, impaired blood supply of the sac). An easily reduced hernia not interfering with blood supply may produce acute pain from the "pinch." If it causes strangulation, the condition becomes far more serious with the onset of necrosis (leading to gangrene) from the obstructed blood supply. If an umbilical, incisional, or epigastric hernia is suspected, having the patient raise the head from the supine position will often cause the hernia to protrude visibly. A person with a demonstrable hernia invites intestinal strangulation when participating in vigorous sports, labor, or scuba diving (due to the intra-abdominal pressure increase).

      Traumatic vs Strain Hernia

True "traumatic" hernia is rare. It is associated with a direct blow and accompanied by evidence of actual tearing of tissues. Most hernias found are "hernias of effort" where the hernia appears after heavy lifting, falling, slipping, or any cause increasing intra-abdominal pressure.

      Examination

Evaluation is initially conducted with either gender with the patient standing and the examiner seated on a stool. Hernia is diagnosed by the presence of a soft, resonant, fluctuating, usually reducible tumor with an impulse on coughing. Hydrocele of the spermatic cord also gives an impulse on coughing but usually shows a distinct limit above. On pulling the cord, the swelling moves too.

      Sites of Abdominopelvic Hernia

Inspect for a bulging mass in the groin suggesting hernia. Have the patient cough, and note any bouncing bulge. A hernia may be felt in this manner even if not visible. Note if the mass returns to the peritoneal cavity when the patient is supine with knees flexed.

Note:   A hernial mass tender to palpation and associated with nausea and vomiting strongly suggests a surgical emergency of a possibly entrapped bowel and should not be attempted to be manually reduced.

Inguinal Hernia.   In the male, the size of the external ring should be noted. With the patient coughing, hernial bulges may appear against either side of the examining finger (direct hernia) or at the tip of the finger as it nears the internal ring (indirect hernia). The processus vaginalis, located anterior and medial to the cord structures, constitutes a potential hernial sac for an indirect inguinal hernia. Direct inguinal hernia results when the posterior inguinal wall weakens and the transversalis fascia attenuates to allow a diffuse medial bulge. If the abdominal ring is fairly large and the posterior wall becomes weakened, both indirect and direct herniation may result (saddlebag hernia).

Femoral Hernia.   The external opening of the femoral canal is located deep to the inguinal ligament and medial to the femoral artery. In examining the right femoral area, the examiner places his right index finger on the patient’s right femoral artery. In so doing, his middle finger will overlie the femoral vein and his ring finger will overlie the femoral canal. A palpable mass felt, upon patient coughing, within the femoral canal suggests a femoral hernia, but it must be differentiated from a psoas abscess, lymphadenitis, or saphenous varix. The most common form of female hernia is femoral canal hernia. The incidence of strangulation is high; thus, it is good procedure to auscultate the swelling for bowel sounds. In the male, a retained testis should be suspected whenever an inguinal tumor is found and only one testis is in the scrotum.

Other Hernial Sites.   Umbilical hernia through the umbilical ring, epigastric hernia through a weakness in the linea alba between the xiphoid and umbilicus, incisional hernia, and spigelian (lateral ventral) hernia at some point in the semilunar line at the lateral margin of the rectus abdominis muscle infrequently occur. Other rare varieties include sciatic hernia through the greater or lesser sacrosciatic foramen, obturator hernia through the obturator foramen, lumbar hernia through the inferior lumbar triangle of Petit, perineal hernia between the muscles or fascia of the pelvic floor, and internal hernias within the peritoneal cavity.

Screening Pelvic Fractures and Dislocations

The first step in evaluation is to note pelvic symmetry, deformity, and carefully palpate for bony crepitus about the ischium, rami, and hip areas. Rolling injuries are usually at fault in pelvic ring fractures such as seen in horseback riding accidents, ski falls against a hard surface, along with cycling and automobile accidents. Vascular, bladder, and perineal injuries are commonly associated. Roentgenography will often help confirm or reject suspicions.


Falls Primarily Involving the Pelvis

All related structures should be carefully evaluated after pelvic injury. Direct buttock falls upon a hard surface (eg, ice or roller skating, skateboarding) can result in sacral fractures, dislocation of the coccyx, and lumbar and/or sacroiliac subluxation. After pelvic or leg injury, hip dislocation is sometimes missed.

Howe points out that after falls or trauma to the back, particularly where the blow is applied to the bottom of the pelvis with force traveling up the spinal column, compression fractures of vertebral bodies frequently occur. The most often missed of these are at the T12--L1 junction, but they may extend as high as T10. They are missed because the pain is usually referred to the lumbosacral area, and there may be no spasm or even tenderness at the fracture site. Thus, if the x-ray beam is centered at the location of pain, the view may not extend high enough to include the lower thoracic area. A compression fracture is frequently not evident until several days later when deformity becomes more pronounced.

      Avulsions

Pelvic fatigue stress and avulsion fractures are far from uncommon. The most typical injuries are associated with muscle, tendon, fascia, and cartilage injuries of the lower extremity. Common sites of avulsion fractures are of the ischial tuberosity at the hamstring origin, the ASIS at the sartorius origin, and the AIIS at the origin of the rectus femoris muscle.

Sports-Related Injury.   Incidence is highest in track and field sports. In sprinters, sudden severe pain in the area of the hip or buttock may be traced to an avulsion of the hamstring attachments at the ischial tuberosity. Roentgenography may show large crescent-shaped bone masses near the injured ischium. Most musculotendinous injuries in sprinters occur during the stride phase or at the transition point between stride and maximum finishing speed.

      Fractures

Pelvic fractures are not common, but the possibility should never be taken lightly. They are reported to be the second most common cause of traumatic death --second only to head injuries.

Pelvic fractures are usually due to violent injuries. They are frequently multiple and result in severe deformity. The most common areas involved are those about the sacroiliac joints and the symphysis pubis. In fact, a fracture or dislocation of the pubis is frequently associated with sacroiliac separation and damage of the neighboring sacrum or ilium.

Symptomatology.   Pelvic fractures often produce severe internal bleeding difficult to halt even on surgery. Shock is present in 40% of the cases. The patient with pelvic fracture, unable to stand or walk, complains of pain in the pelvic region or back and, if the bladder or kidney is injured, passes blood in the urine. A pelvic girth injury is suggested by severe low back pain (especially in retroperitoneal bleeding), severe pain with compression of the iliac crests, and pubic tenderness.

Roentgenography.   Fractures of the ilium are visible as sharply defined lines of diminished density that are possibly stellate. It should be acknowledged during analysis that colon or rectal gas may mimic or obscure a pelvic fracture, but as these shadows are not constant, they can be ruled out on future films. Another source of error are the blood-vessel grooves in the ilium, but their branching character and bilaterality help in identification. In examining the young, remember that the pelvic epiphyses are among the last to unite. They are open until 20--25 years of age.

Emergency Procedure.   Apply firm supporting bandages around the pelvis. Hold the legs together by a Figure-8 bandage wound around the feet and ankles. Also secure the thighs with a bandage. A splint should be provided from armpit to foot. There is often an urgent desire to urinate in pelvic fracture. If possible, this should be avoided to prevent possible extravasation from a ruptured urethra that would lead to perineal cellulitis.

      Pubic Stress Fractures

The adductor muscle attachment area at the inferior pubic ramus may be the site of a stress fracture on rare occasions. This usually occurs from a fall or, for instance, a sudden foul-line stop while delivering a bowling ball in an unbalanced position. Avulsion of the inferior pubic ramus and rupture of the origin of the adductor longus may be associated. Laceration of the scrotal vessels may be associated.


Male Genital Injuries

      Traumatic Testicle Injuries

Contusion.   Testicular contusions are common in most sports and sometimes occur in home and industrial accidents. Even if damage is slight, there is often shock-like pallor, agonizing pain, nausea, and lower abdominal symptoms.

Torsion.   A severe twisting motion may result in torsion (90*--360*) of the testicles and their related cords, muscles, and vessels. The incidence is highest between 13 and 25 years of age. A circulatory block causes immediate pain. Testicular infarction can develop within a few hours, leading to gangrene. If the rotation cannot be reduced manually, surgery is necessary. The direction of rotation can be judged by the direction relieving pain. Recurrence in varying degrees is common and may require surgical fixation.

Displacement or Rupture.   A rare traumatic luxation may occur when one or both testes are jammed upward into the abdominal cavity, exhibiting an empty contracted scrotum with a tender mass near the internal inguinal ring. A knee kick to the groin is the common cause. Adhesions rapidly form to hold the dislodged testes in malposition. Predisposition comes from extreme testicle mobility related to muscular effort. A direct blow may lead to rupture, laceration, hematoma, or a large painful hematocele. If the epididymis is ruptured from a testicle by force, a hematoma develops that may result in a fibrotic scar causing sterility.

Varicocele.   Varicosity of the spermatic cord (varicoceles) usually occurs on the left in mature males. The veins descend to and involve the pampiniform plexus to produce an aching upper scrotal sac that is soft, elastic, and purple. The sac feels like a bag of worms. There is no true impulse on coughing, and the mass disappears for the most part when the patient reclines.

Hydrocele.   Both hydrocele and varicocele occur from a scrotal blow. A straw-colored fluid forms between the testicle and the tunica vaginalis in hydrocele. Both hydrocele of the cord and hernia give an impulse on coughing, but hydrocele usually shows a distinct limit above. It has been explained that pulling the cord also moves the swelling. The mass is painless, irreducible, and does not increase size during coughing. Large indirect hernias may protrude into the scrotum and become mistaken for a hydrocele, but transillumination will differentiate. Cystic hydroceles of the tunica vaginalis transilluminate readily, with an area of normal scrotum above. Tumor of the testis is painless.

Management.   Severe injury requires immediate surgical exploration. Minor injuries can be treated with cool packs, rest, and a firm supporter while resolution gradually occurs. A scrotal cup should be worn for protection for several months during competition. It may take several months to absorb scrotal extravasation.

1. Stage of Acute Inflammation and Active Congestion

The major goals are to control pain and reduce swelling by vasoconstriction, compression, and elevation; to prevent further irritation, inflammation, and secondary infection by disinfection, protection, and rest; and to enhance healing mechanisms. Common electives include:

Disinfection of open skin (eg, scratches, abrasions, etc)
Cryotherapy
Cold packs
Ice massage
Vapocoolant spray
Pressure bandage
Protection (padding)
Indirect therapy (reflex therapy)
Pulsed alternating current
Auriculotherapy
Meridian therapy
Spondylotherapy (mid--lower thoracic)
Bedrest
Abdominal strap or corset
Indicated diet modification and nutritional supplementation.

2. Stage of Passive Congestion

The major goals are to control residual pain and swelling, provide rest and protection, prevent stasis, disperse coagulates and gels, enhance circulation and drainage, maintain muscle tone, and discourage adhesion formation. Common electives include:

Spinotherapy and/or reflex therapy
Alternating superficial heat and cold
Pressure bandage
Protect lesion (padding)
Light nonpercussion vibrotherapy
Mild surging alternating current
Meridian therapy
Spondylotherapy
Bedrest
Abdominal strap or corset
Indicated diet modification and nutritional supplementation.

3. Stage of Consolidation and/or Formation of Fibrinous Coagulant

The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes. Common electives include:

Mild articular adjustment technics
Moist superficial heat
Thermowraps
Trigger point spray-and-stretch
Pool cryokinetics (active exercise)
Moderate active range-of-motion exercises
Meridian therapy
Sinusoidal current
Ultrasound
Vibromassage
Interferential current
Spondylotherapy (mid--lower thoracic)
Mild proprioceptive neuromuscular facilitation techniques
Bedrest
Abdominal strap or corset
Indicated diet modification and nutritional supplementation.

4. Stage of Fibroblastic Activity and Potential Fibrosis

At this stage, causes for pain should be corrected but some local tenderness likely remains. The major goals are to defeat any tendency for the formation of adhesions, taut scar tissue, and area fibrosis and to prevent atrophy. Common electives are:

Deep heat
Spinal adjustment technics
Spondylotherapy (mid--lower thoracic)
Local vigorous vibromassage
Trigger point spray-and-stretch
Active range-of-motion exercises without weight bearing
Ultrasound
Sinusoidal and pulsed muscle stimulation
High-volt therapy
Interferential current
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Bedrest
Abdominal strap or corset
Indicated diet modification and nutritional supplementation.

5. Stage of Reconditioning

Direct articular therapy for chronic spinopelvic fixations
Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Plyometrics
Aerobics
Indicated diet modification and nutritional supplementation.
 

Abdominal Strains

It usually takes severe force to rupture an abdominal muscle unless it is weakened by prior injury. Symptoms of overstress are pain, localized swelling, and tenderness at the point of torn muscle or tendon fibers. Motion increases pain, and ecchymosis develops later. If a rupture has occurred, there are usually a depression and hematoma at the site.

      Management

Local support by strapping in a position of relaxation and cool packs for 24--48 hours are advised. This should be later followed by the judicious use of heat, massage, and other appropriate physiotherapeutic and support measures. Stretching exercises are important during rehabilitation. If proper care is not administered, abdominal contractures may result that can lead to spinal distortion.

      Rectus Abdominis Rupture

Although tearing of the abdominis muscle is rare, diagnosis must be rapid to avoid secondary lesions from hematoma. The common site is at the right-inferior aspect of the abdomen. Because of its sheath of strong transverse bands, bleeding easily pools; and because of its extension from the lower ribs to the pubis, difficult breathing (thoracic) and coughing spells usually arise. These signs are followed by severe "stomach ache," rigidity, and inability to forward flex the trunk when supine. Avulsion from the ASIS may be involved. This is most common in adolescents. Traction stress exhibits localized tenderness at the pubic attachment; later, roentgenography will show osseous sclerosis.

A torn inferior epigastric artery may be involved, which is characterized by shock and a large tender hematoma. When bleeding is suspected, apply padded ice packs to the area and refer immediately for surgical evaluation.


Abdominal Abrasions and Contusions

      Abrasions

Abdominal abrasions are caused by tangential forces producing excoriation of the superficial layers of skin. They are often highly contaminated. Flush with soap and water to help avoid infection. Apply an antiseptic, a sterile dressing, and a cool pack to enhance healing.

      Contusions

Exudation in and around the involved tissues is usually due to a rather strong force. Temporary shock may occur, associated with transient vomiting, localized pain, tenderness, and swelling. Ecchymosis often appears later, and sometimes a hematoma forms from ruptured vessels. Treat by resting the part, applying cold packs for 24 hours, and follow in 3—4 days with mild heat and other appropriate physiotherapy measures. A small hematoma will be controlled by pressure and natural absorption; others must be referred for aspiration or evacuation. Minor contusions readily respond to cool packs, but severe muscle injury can be a clinical problem.


Solar Plexus Impaction

The large celiac plexus of nerves and ganglia located in the peritoneal cavity at the level near L1 contains two large ganglionic masses and a dense network of fibers surrounding the roots of the celiac and superior mesenteric arteries. It supplies nerves to the abdominal viscera and is indirectly associated with respiration. Thus, a blow to the abdominal area can inhibit breathing (winding) that may result in unconsciousness. Such trauma overstimulates the autonomic fibers of the plexus, especially the parasympathetic fibers, and causes delayed venous return to the inferior vena cava.

      Clinical Features

The profile often includes neurologic shock: faintness, prostration, dyspnea, clammy skin, and pallor. Air hunger leads to panic. Fortunately, symptoms subside spontaneously in 1--2 minutes. Then, deep abdominal injury should be ruled out. A serious condition that may be associated is splenic, enteric, or hepatic rupture producing hemorrhage within the abdominal cavity.

      First Aid

In unconsciousness from an abdominal blow, place the victim on his back, moisten the face with a cool damp cloth or sponge, loosen clothing around the neck, waist, and thorax, and encourage the patient to relax and breathe slowly and rhythmically. The knees may be carefully flexed, but forceful spinal flexion or leg pumping is contraindicated because an anterior vertebral injury can occur with forceful flexion from the abdominal blow. The patient should not be allowed to return to stressful physical activity until all signs are normal for at least 15--20 minutes. Delayed hemorrhage is always a risk.

Rest alone will usually allow the temporary bradycardia and bronchiospasm to subside. If unconsciousness is prolonged or possible rupture exists, surgical consultation should be made immediately. The greater the delay in diagnosis, the greater the incidence of fatality.


Abdominal Muscle Shortening or Weakness

Muscle contractures, stitches, strains, ruptures, and direct blows are the most common somatic causes of pain in the abdominal wall. The abdominal muscles offer considerable protection to the viscera when active. When they are relaxed, however, they are easily damaged by intrinsic or extrinsic forces. This is especially true of the rectus abdominis.

Once direct trauma, bleeding, and infection are ruled out, a hypertonic abdominal wall can be secondary to primary pelvic fixations. Gillet believed that these fixations are often related to sacrotuberous ligament shortening, shortening of the lumbar anterior longitudinal ligament, or a pubic articular fixation.

      Postural Clues

Bilateral shortening anteriorly reduces the sternal-pubic distance, especially in the upright position. This tends to produce a flat chest and a long thoracic hyperkyphosis. Unilateral lateral shortening of both obliques reduces the rib-ilium space and produces a C curve of the spine with a contralateral convexity. Ipsilateral shortening of the external oblique with contralateral internal oblique shortening produces an S scoliosis. Bilateral shortening of the internal oblique and lateral stretching of the external oblique produces the anterior rotation of the pelvis and thoracic hyperkyphosis so often seen in a "slumped" posture.

      Rectus Abdominis Weakness and Hyperlordosis

Rectus abdominis debility is reflected in a loss in trunk flexion strength and posterior pelvic rotation strength. In the upright posture, a lengthening of the sternal-pubic distance, lumbar hyperlordosis, and anterior pelvic tilt will be evident. The rectus is almost never shortened by itself.

      Oblique Weakness and Its Relationship to Functional Scoliosis

A weak oblique exhibits decreased respiratory efficiency and loss in abdominal support on that side. Trunk flexion strength and posterior pelvic tilting strength are diminished in bilateral weakness. This is suggested by obvious anterior pelvic tilt and lumbar hyperlordosis or an exaggerated S curve of the spine laterally. Ipsilateral weakness of the external oblique with contralateral weakness of the internal oblique encourages lumbar scoliosis with rotation and tilting, while unilateral weakness of these two muscles promotes a C curve toward the side of weakness.

      Oblique Shortening and Its Relationship to Postural Faults

Bilateral shortening anteriorly reduces the sternal-pubic distance. This tends to produce a flat chest and a long thoracic hyperkyphosis. Unilateral lateral shortening of both obliques reduces the rib-ilium space and produces a spinal C curve with a contralateral convexity. Ipsilateral shortening of the external oblique with contralateral internal oblique shortening produces an S scoliosis. Bilateral shortening of the internal oblique and lateral stretching of the external oblique produces the anterior rotation of the pelvis and thoracic hyperkyphosis so often seen in a "slumped" posture.

      Transversus Abdominis Weakness

A loss of transverse abdominis strength is exhibited best in the lateral bulging of the flanks during arching of the back in the prone position.


Pelvic Contusions and Strains

The gluteus maximus muscle is innervated by an independent nerve (inferior gluteal) from the sacral plexus that exits from the pelvis typically under the piriformis muscle near the lateral edge of the sacrotuberous ligament. This nerve and accompanying inferior gluteal artery and vein commonly pierce the gluteal fascia and then spread between the fascia and the muscle. The gluteus medius is supplied by the superior gluteal nerve and vessels that exit the pelvis above the piriformis muscle.

      Gluteal Contusions

Gluteal contusions sometimes occur in the area of an ischial tuberosity or well-developed athletic buttocks. Incidence is high in hockey and field sports. Just walking may be aggravating, but the related pain is usually not severe. Swelling and bleeding may be extensive, but it is reduced quickly if a cold pack is applied immediately. Recurrent bleeding is always a problem, but its likelihood is reduced if cryotherapy is continued for 3--4 days. Activity can be resumed with padding, but it is rarely adequate protection against reinjury. Full healing without reinjury will usually take place within a month.

      Gluteal Strains

Strain may occur in muscles that rotate the thigh and stabilize the hip such as the glutei, piriformis, gemelli, and quadratus femoris. Awkward slips are the typical mechanism of injury, and the dysfunction is extremely debilitating. When the gluteus maximus is injured, it produces pain on hip extension from a flexed position, walking up stairs, external hip rotation against resistance, thigh adduction against resistance when the limb is extended, and thigh abduction against resistance when the hip is flexed. Injury of the gluteus medius and minimus produces increased pain on resisted thigh abduction and medial rotation of the femur.

      Differentiation

Because the fascia of the gluteus maximus is continuous with that of the fascia lata, differentiation must be made from "hip pointer," iliotibial band dysfunction, and proximal femur lesions. In many cases of what is first thought to be a sacroiliac sprain, palpable tenderness will be most acute just laterally or superolaterally to the PSIS rather than medially over the joint. This suggests gluteal strain (eg, hip overstress), low sacrospinalis strain, or tender hypertonicity emitted from L5 irritation.

Strains at the origin of the hamstring muscles associated with lower buttock pain on exercise and ischial tenderness on forward flexion are common. An unimpeded forceful, full swing of an object (eg, golf club) may cause an avulsion of the ischial apophysis. Sciatica tests will be negative. Prudent heat in the postacute stage, gentle passive stretching, and graduated active exercises should be incorporated into the standard strain management program.

      Superficial Perineal Area Injuries

Contusions and Lacerations.   These are rare, usually occurring from kicks or impaling a hurdle or some other obstacle.

Pudendal Neuritis.   Priapism sometimes occurs in racing cyclists from a poorly fitting saddle that irritates the pudendal nerve. A persistently painful erection is the only major feature.

Saddle Sores.   Bicyclists may exhibit a paniculitis leading to localized areas of fat necrosis from excessive friction between saddle and perineal skin. Rest and release of edema pressure by puncture offers quick relief. If left unattended, ulceration and secondary infection result.

Cyclists Saddle Neuropathy.   Paresthesia of the pudendal nerve is a compression neuropathy seen in bicyclists. It is produced by pressure on the perineum by the narrow seats of racing bicycles. In the male, scrotal and penile numbness may be the complaint.

Groin Strains

Groin strains are often difficult to manage and arise often in athletics early in the season before full conditioning has occurred. They are common in hockey and from slips on muddy fields where severe hip abduction or adduction overstress might occur. A wrenching-type disability usually arises slowly rather than suddenly as in a quickly torn muscle.

      Sports-Related Strains

Sartorius injury is usually mild, but persistent disability frequently occurs. In sports, it is seen with "squatting" football linemen and occasionally with oarsmen. Discomfort is aggravated by abduction, extension, and eased after warm-up. The common "scissors" kick of soccer frequently leads to instability of the sacroiliac and symphysis pubis joints. Groin pain is aggravated during full stride, jumping, and in the stretching motion of kicking with power. Also in soccer players and jockeys, a periosteal reaction may be noted at the origin of the adductor muscles (gracilis syndrome). An unimpeded forceful full golf swing may injure a golfer by causing an avulsion of the ischial apophysis. An adductor strain is frequently suffered by horsemen, cyclists, power bowlers, and runners. The complaint will be stiffness, tenderness, and pain that is high in the groin during abduction.

      Roentgenography

When pain in the area of the symphysis pubis is the complaint, views should be taken in the weight-bearing position, first with full weight on one limb and then the other to exhibit instability. Oval or semicircular lucency and avulsion sites may show on the pubic bone near the symphysis at the origin of the gracilis muscle and adductors longus and brevis. In addition, symphysis widening, instability, frayed corners, fluffy margins, pubic osteoporosis, and muscle attachment periosteal reactions may be seen. Stress scleroses of the iliac portions of the sacroiliac joints is often associated.

      Management

Despite extensive ecchymosis, there is usually immediate relief after correcting attending sacroiliac and pubic subluxations if severe avulsion has not taken place. Cold, compression, pressure by an elastic Figure-8 bandage to prevent hyperextension, and rest rapidly controls the swelling. Standard physiotherapy relieves attending muscle spasm due to irritation from the inflammatory reaction. Carefully monitored graduated exercises must be initiated as soon as logical to avoid posttraumatic contractures that can produce recurrent disability. Return to full-scale activity can usually be expected within a week.


Pubic Area Disorders

      Pubic Sprains and Subluxations

There is a good degree of bone elasticity between the extreme A-P points of the pelvis except in the very elderly or osteoporotic pelvis. Healthy bone is not brittle.

Normal iliac movements are bilaterally reciprocal. This places a torsion on the pubic fibrocartilage that can be likened to slowly wringing a wet cloth by hand. Thus, it is no wonder that this symphysis often becomes fibrotic as the result of frequent yet relatively mild sprains in sports.

Pubic sprains and subluxations are frequently occurring conditions that are often mistaken for sacroiliac slip, although sacroiliac displacement may have occurred and been spontaneously reduced. The syndrome is also associated with lateral hip subluxations. In pure pubic subluxation, the predominant evidence will be found at the pubic symphysis. The sacroiliac area will not be excessively tender; rather, acute tenderness will be found over the painful pubis. After severe trauma, pubic and sacroiliac displacement may coexist.

The pubic articulation is not adjusted directly. Rather, an appropriate contact is applied posteriorly to the ilium or ischium as is necessary.

      Osteitis Pubis

Osteitis pubis is a rare disability that is becoming more common with the increase of poorly conditioned joggers. It is generally defined as a painful inflammation of the pubic symphysis from various causes, but some authorities report an idiopathic form. Regardless, it is usually an episodic condition and often self-limiting. The onset is typically gradual, with symptoms peaking several days after the precipitating traumatic incident.

Diagnosis.   The clinical picture of osteitis pubis reflects severe groin pain that may radiate to the hips, abdomen, or groin (especially in the adductor and rectus abdominis muscles). The cause may be traced to trauma suffered during athletics, a fall, or childbirth. The related pain is aggravated by passive femur abduction or active adduction, abdominal flexion, and sometimes by iliac compression. Swelling and tenderness occur over the symphysis pubis and within adjacent soft tissues. A slight epiphyseal slip may be a predisposing factor during youth. Fever, dysuria, leukocytosis, and an increased sedimentation rate are inconsistent findings. Priority differentiation must be made from ankylosing spondylitis, adductor-origin strain, and perineal disease. Roentgenography may reveal an eroded symphysis with joint widening, tending to calcification, sclerosis, and spotty demineralization in late stages. Early signs are usually absent.

      Management.   Initial rest and cold followed later by diathermy, mild ultrasound, vitamin-mineral supplementation, and attention to lumbar and sacral subluxations are helpful in these often-stubborn cases. Mobilization of frequently associated hip fixations is essential. Graduated return to activity must be carefully monitored to prevent recurrence of acute symptoms. If conservative measures fail, fusion of the symphysis may be advised, but postoperative results are not always good.

      Symphysis Pubis Fixation

Pubic fixation offers a clinical dilemma awaiting resolution. The pubic articulation is not a gliding type as seen in spinal facets, thus one might think it would be prone to only a ligamentous type of fixation. If this were true, a degree of torsion would be possible in spite of fixation. However, motion palpation demonstrates that (1) normal A-P iliac rotation does not take place when pubic mobility is inhibited and (2) adjustment results in a rapid improvement in mobility. Gillet reported that neither of these characteristics is typical of ligamentous fixation.


Visceral Implications in Chronic Balance Faults

Chronic visceral disorders are not usually a topic in traumatology but the subject deserves some attention. Trauma may precipitate a subclinical disorder or the effects of trauma may have noxious influences on visceral function through the formation of scar tissue, adhesions, and/or postural distortion.

It is unwise to consider the various parts of the body as separate entities. All parts share responsibility. Any disturbance in one part causes an immediate and definite functional change in others. In addition, there is no doubt that the relationship of the soma and the viscera forms an interdependence. Disorders in the neuromusculoskeletal system may often be a factor in visceral disorders and disease, and various somatovisceral and viscerosomatic reflexes can frequently be related to specific pathologic states.

      Integrating Reflexes

When an average threshold stimulus is applied to a somatic receptor (eg, the skin), visceral function is influenced via the central connection in the gray matter of the spinal cord. If the sympathetics are involved, the activation occurs in the cells of the mediolateral column in the thoracolumbar area. Since the sympathetic axons end in the contractile mechanism of vascular smooth muscle fibers, the end effect could be vasoconstriction. Other sympathetic fibers affect heart rate, bronchial dilatation, sphincter contraction, etc.

      Body Mechanics

If body mechanics are good, the abdominal cavity is shaped like an inverted pear with adequate space above L4 for the abdominal viscera of an intermediate body type. Nature provides good support for the abdominal organs when the body is normally erect. In the ideal attitude, tissue ledges and shelves exist that partially support the abdominal organs. However, if the lumbar and dorsal curves increase and the abdominal wall relaxes, these vital supports are lost.

Gross spinal distortion and minute articular malalignments or articular fixations in the spine can produce physiologic changes and are considered to be potentially pathologic. But how much deviation is possible without causing severe impairment of health? The effect on function varies among research reports. Most agree, however, that poor body mechanics predisposes certain visceral disorders; ie, the viscera are held in their optimum position for function in good body mechanics.

      The Stomach and Digestive Disturbances

With the stomach lying mainly to the left of the spine and supported by a diaphragmatic attachment behind the transverse sagittal plane, there is little tendency for downward displacement if there is no rib cage deformity or abdominal muscle weakness.

Mild digestive symptoms may present in the apparently healthy person. This is sometimes traced to a degree of visceroptosis producing dysfunction of the displaced organs. Abdominal dilatation and motility disturbances are not infrequent occurrences. This is likely the outcome of stretching of the sympathetic nerves. Pottenger points out that stretched nerves within involuntary or voluntary muscles usually produce a temporary paralysis. In addition, when the abdominal cavity becomes shortened longitudinally, the viscera become crowded as do the glands of internal secretion and nerve ganglia. Thus, orthostatic albuminuria, dysmenorrhea, and constipation may sometimes be associated.

      Position of Other Major Abdominal Organs

The liver usually rests posterior to the transverse sagittal plane. It is partly supported by the surrounding organs and its attachments to the diaphragm, but most of its weight is borne by the concave space at the side of the spine and by the curves of the lower ribs. The spleen lies well back and is held by peritoneal folds. The pancreas depends chiefly on the surrounding organs for support. The hepatic and splenic flexures of the colon attach near the kidney and the posterior surface of the abdominal cavity. About 87% of the weight of the abdominal organs is borne by the psoas shelf and the muscles of the abdominal wall. The kidneys normally rest in definite depressions that begin around the level of L4 and are supported by the psoas muscle, quadratus lumborum, and retroperitoneal fat.

      Effects of Visceral Prolapse

As a result of visceroptosis, a compensating lumbar lordosis, and the insult at the intervertebral foramina, symptoms can be diffuse and subtle. Duodenal stasis may be attributed to increased tension on the superior mesenteric vessels. One study shows that postural correction relieved 65% of cases exhibiting a picture of duodenal obstruction and 75% of cases complaining of gastric distress, nausea, and abdominal pain associated with visceroptosis. Narrowing of one or more middle or lower thoracic IVFs may cause severe pain that has a segmental distribution and evidenced in the skin, muscle, or parietal peritoneum. This condition can be misleading as to origin as it suggests the presence of some intra-abdominal disorder.


Pelvic Entrapment Syndromes

The most common entrapment syndromes related to the pelvis are sciatic nerve compression, lateral femoral cutaneous nerve compression, obturator nerve compression, and adhesive arachnoiditis.

      Extraspinal Sciatic Nerve Compression Syndromes

The most common site for the sciatic nerve to become "caught" is at the sciatic notch as the nerve exits the pelvis between the piriformis and sacrotuberous ligament. At this point, it can become compressed against the bony ridge by piriformis spasm, thickened fascia, or adhesions. It should also be kept in mind that many patients fail to follow this textbook route. In most people, the sciatic nerve courses below the piriformis muscle. However, the nerve sometimes courses over the piriformis or pierces its belly.

Clinical Features.   The major symptom of sciatic entrapment in the pelvis is pain behind the greater trochanter that radiates down the thigh and lateral leg to the foot. This is usually aggravated by walking and relieved by rest. Numbness and tingling are invariably restricted to below the buttocks. The pain is increased by flexing the knee and hip to right angles and forcing the thigh into internal rotation and adduction (ie, piriformis stress). Tenderness will be acute near and below the notch. Major signs usually include a positive Lasegue’s sign and hypesthesia of the weight-bearing surface of the plantar surface.

Diagnostic Complexities.   Differentiation must be made from disc failure, inflammatory sciatica, and acute sacroiliac sprain, but an entrapment syndrome may coexist with these disorders. Tumors within the buttocks, a neurofibroma, or a compartment syndrome can also mimic an entrapment syndrome. A fall on the buttocks or a posteriorly dislocated femur head may injure the nerve at the inferior buttock and produce identical signs and symptoms as those of an entrapment syndrome.

      Femoral Cutaneous Nerve Syndromes

After the lateral femoral cutaneous nerve leaves the L2--L3 roots, it runs across the lateral border of the psoas muscle before it descends along the posterior wall of the pelvic cavity. Here it enters and travels within the fascia covering the iliacus muscle, pierces the lateral V attachment of the inguinal ligament just medial to the ASIS, travels in a fascial tunnel under the ligament, then pierces the fascia lata and enters the thigh. It offers cutaneous branches to the anterolateral thigh from below the hip to the knee and motor branches to the anterior thigh. It is at the point where the nerve leaves the subinguinal tunnel and enters the fascia lata that entrapment of the nerve (meralgia paresthetica) usually occurs. At this site, the nerve’s sheath is firmly fixed to adjacent tissue.

Precipitating Factors.   Thigh adduction increases tensile forces on the nerve, and if this occurs simultaneously with severe trunk movements above or thigh movements below, the nerve can become severely stretched. In some cases, just prolonged sitting with the legs crossed can produce a compression syndrome in the upper thigh. An improperly fitted brace may cause compression, and, in obese women, a tight corset may produce compression. In rare cases, the nerve becomes entrapped by a pelvic tumor or encapsulated psoas abscess, hypertrophic arthritis of the upper lumbar spine, a pregnant uterus, or occupational pressure. Visceroptosis may produce a stretch syndrome.

Clinical Features.   Typical symptoms are severe unilateral burning pain and paresthesia in the anterolateral thigh. The onset is usually spontaneous. The major signs are aggravation of pain when the nerve is pressed against the medial side of the iliac crest, relief of pain when recumbent, and hyperesthesia of the anterior thigh.

      Obturator Nerve Syndromes

The obturator nerve leaves the L3-L4 nerve roots, passes through the pelvis, and supplies the gracilis and adductor muscles and the skin of the hip and medial thigh. An obturator hernia and pressure from the edema of osteitis pubis are common causes of obturator neuritis or neuralgia. Some circulatory impairment may be associated.

Clinical Features.   Pain typically radiates from the groin to the medial thigh and is aggravated by any Valsalva maneuver. Hypesthesia (infrequent) and paresthesia (frequent) may be associated. As the obturator nerve innervates the adductors of the thigh, the major signs are weakness of thigh adductors and an unusual gait (the involved leg is brought outward in a wide arc during the swing phase). Even in chronic cases there is little or no atrophy because of dual innervation from the sciatic nerve.

      Adhesive Arachnoiditis

Adhesive arachnoiditis can produce severe unrelenting sciatica. The common site of entrapment is where the L4 root crosses the transverse process of L5 and the iliolumbar ligament in the nerve’s descent into the pelvis.

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