What can you rule out from this 4-wheeler injury?

The paramedics call-in a trauma alert on a 45 year old who ran his 4-wheeler into a tree. He was wearing a helmet, and his only obvious injury is an open fractured distal tib-fib on the right. They splint his fracture, give him morphine 8mg IV per protocol, and apply diesel fuel to the rest of the situation. The trauma team awaits (minus the surgeon, who is in a case).On arrival, the patient is obviously very intoxicated (+1 point for wearing a helmet, -1 point for EtOH use on the 4-wheeler). He knows his name, thinks he is at the hospital, and gives the year as “2000”. Close but no cigar. Vitals are P 110, BP 150/95, RR 28, sat 96% RA. He has bruising on the anterior chest and abdominal walls, but no other major truncal or head/neck findings. His abdomen is soft and slightly tender only to palpation. The neuro exam is non-focal. Portable X-rays and lab are done, and you rapidly irrigate the open fracture followed by a little reduction, a clean dressing and a splint.

This case shows nicely how mechanism of injury correlates with actual injury. Even without abdominal wall bruising, this fellow had enough mechanism of injury to get a blow to the head as well as an open tib-fib. To me, that implies “flying through the air” or some such thing. Sure enough, in-between the head and the fractured extremity lies…the rest of him! So we know to hunt for internal truncal injuries in this setting. In children, the combination of the head injury, abdominal solid organ injury and femur fracture is “Waddell’s triad” (found infrequently, perhaps 2% of the time). However, it is prudent to rule out what might be the adult version of this problem.The CT scan shows a nice example of a mesenteric hematoma (see labeled image). There is no free fluid in the abdomen, but you see blood – as increased density – lying along the folds of the mesentery. This comes from presumed “renting” or twisting of the bowel, or simply direct trauma. This injury can be associated with bowel perforation, and can develop into an abscess (late). My surgeon chose to manage this conservatively, and we called for transport to the trauma center.