Hx: A 56 yo female presents by EMS after a motor vehicle collision. She was a restrained driver in a head-on collision with another vehicle. Her airbags deployed. She denies losing consciousness. EMS noted the patient was hypotensive on scene with a systolic blood pressure in the low 90’s. They also noted bilateral ankle deformities, one of which they splinted because it was open. They administered a 250cc bolus of normal saline enroute and the patient responded with SBP climbing to the 140’s. She was given oxygen via non-rebreather mask and transported without any other interventions. The patient complains of bilateral ankle and foot pain but when asked, also notes she has some lower abdominal pain as well. Abdominal pain is dull, constant, and severe.
Soc Hx: none
• Vitals – pulse 110, BP 85/50, resp 18, O2 sat 99% on NRB mask
• General- the patient appears her stated age. She also appears to be in pain.
• HEENT- no scalp or head abnormalities. Normal TMs. Oral mucosa is dry. EOM intact. Normal nose and midface. Normal teeth.
• Neck- supple, no tenderness of cervical spine, no cervical collar.
• Cardiovascular – tachycardia, regular, pale feet with no palpable pulses bilaterally. Normal femoral and upper extremity pulses.
• Lungs- clear bilaterally
• Chest wall – abrasion of left clavicle consistent with seat belt distribution. No bony deformity or crepitance.
• Abdomen- soft, non-distended. There is ecchymosis along the lower abdomen, especially the left side, in the seat belt distribution. There is significant tenderness in the same area. No rebound or guarding.
• Neurological – awake, alert, oriented. Normal strength and sensation except at feet. Right foot “tingling” .
• Musculoskeletal – left foot with medial dislocation, pale, with no palpable or Doppler dorsalus pedis pulse, and no cap refill. Right foot with lateral dislocation and 5 cm open wound over the medial portion of the calcaneuos. Right foot also pale with no cap refill and no palpable or Doppler dorsalus pedis pulse. Also absent posterior tibialis doppler signal on right. She is able to wiggle toes but with pain.
• FAST exam is negative for free intra-abdominal fluid or pericardial effusion.
• Chest xray negative
• Pelvis xray negative
• 2 liter IVFbolus with improvement in BP. Now 124/83, HR 95.
• Reduction of bilateral foot dislocations with simple traction and splinting restores capillary refill and pulses. Xray images are obtained (see below)
• CT scans of the head, neck, and chest are obtained and normal. CT of the abdomen and pelvis is also obtained (images below)
• Labs show WBC 23k, HGB 12, otherwise normal.
• While awaiting surgery the patient’s blood pressure drifts down again and she receives another liter of NS as well as a 2 units pRBC transfusion.
Discussion: The patient suffered a traumatic left sided abdominal wall hernia. Small bowel present within the hernia contained hyperdense fluid seen on CT (red arrow, image below) consistent with blood, as no oral contrast was administered. There was also a small amount of free pelvic blood without any other visible intra-abdominal injury. Additionally, X-rays demonstrated a calcaneal fracture on the right (open) and a medial maleolar fracture dislocation on the left (closed).
Traumatic abdominal hernias are rare. A search of the medical literature reveals numerous case reports of similar traumatic abdominal hernias with varied outcomes. Most report repair of the hernias during the same hospitalization without significant injury to the bowel. However, there are more severe cases with significant bowel injury requiring resection, as was the case with this patient. Interestingly, associated injuries to solid organs appear to be uncommon in the cases reported. Management of this injury is primarily driven by the patient’s hemodynamic stability and physical examination. Due to the rare occurrence of this injury, there is no consensus on surgical approach. Successful management has been reported with open repair as well as laparoscopic repair. One study suggests that laparoscopic intervention may allow for easier repair when the abdominal wall association with the iliac spine has been disrupted.
Hospital course: This patient was emergently taken to the operating room for repair of her hernia. She underwent laparoscopic resection of approximately 3 ft of ischemic small bowel with reanastamosis, and repair of the traumatic hernia (see laparoscopic images below). She did develop a secondary midline hernia noted on exam when she complained of pain on post op day 5. She underwent a second procedure for repair however there was no evidence for any new injury to the bowel. She also underwent orthopedic washout of her open calcansous and placement of an external fixation device. The remainder of her hospital course was unremarkable for any complications of her abdominal injury.