Blunt Hepatic Trauma: A study
Author(s): Devi Th. Meera, Nabachandra H., Singh Th. Sudhirchandra
Vol. 6, No. 3 (2006-07 - 2006-09)
(1)Devi Th. Meera, (2)Nabachandra H., (3)Singh Th. Sudhirchandra
(1)Assistant Professor, Department of Forensic Medicine, (2)Professor,
Department of Forensic Medicine and (3)Associate Professor, Department of Surgery,
Regional Institute of Medical Sciences, Imphal – 795004.
ABSTRACT
Aim: To study blunt hepatic trauma cases
as regards the pattern, the risk factors involved
and association with diaphragmatic injuries and
rib fractures.
Material and method: 65 cases of blunt
hepatic trauma brought for autopsy to the
mortuary of the Regional Institute of Medical
Sciences, Imphal have been considered for this
study. The age incidence of the victims, causative
agents, incidence of external injuries to the
thoraco-abdominal region, types of blunt trauma
observed, frequency of right and left lobe
involvement, extent of lacerations,
diaphragmatic injuries and rib fractures
associated with blunt hepatic trauma have been
analysed.
Result: The commonest age group of the
victims was 21-30 years (27.69%) followed by
the age group of 31-40 yrs (18.46%). Vehicular
accident (86.15%) was the leading cause of blunt
hepatic trauma. 84.62% of the cases showed
associated external injuries to the thoracoabdominal
region and the remaining 15.38% did
not show any external injuries. The right lobe
was more frequently involved (73.85%) and the
convex surface of the right lobe was the common
site (56.25%). Extensive lacerations of the liver
were observed in 41.67% and deep lacerations in
33.33% of the cases. 12.5% of liver lacerations
were associated with injuries to the diaphragm
while 54.16% were associated with rib fractures,
and 22.92% were without rib fractures or
diaphragmatic injuries. In assessing blunt
trauma cases, awareness about the commonest
sites, types and degrees of hepatic injuries sustained by the victims as have been observed
in the present study will be of great help in timely
intervention and prompt treatment of these
victims.
KEYWORDS: Blunt trauma, rib fracture,
diaphragmatic injuries, hepatic contusion,
hepatic laceration
INTRODUCTION
Blunt thoraco-abdominal injuries are often
encountered in vehicular accidents, blows or kicks
on the region or following fall from heights.
According to Reddy K.S.N., (2002)1, the
structures most likely to be damaged in blunt
abdominal trauma in order of frequency are:
liver, spleen, kidney, intestines, abdominal wall,
mesentery, pancreas and diaphragm. The
abdominal wall usually escapes gross injury by
transmitting the force of violence to more resistant
organs inside the abdominal cavity. Following a
blunt trauma, unyielding organs like the liver
because of its bulky size, superficial location
and relatively fixed position in the abdominal
cavity are commonly injured. The hepatic injury
may result from simple compression against the
fixed ribs, spine, or posterior abdominal wall.
Hepatic injury may also result from transmission
of excessively high venous pressure from remote
body sites occurring at the time of impact. The
liver injury is often seen in pedestrian victims of
vehicular accidents2. Interestingly, the right lobe
of the liver is 5 times more commonly affected
than the left. They usually involve the convex
surface and the inferior border but may involve
only the deep substance of the organ1.
MATERIAL AND METHODS
65 cases of blunt hepatic trauma to the
mortuary of the Forensic Medicine Department,
Regional Institute of Medical Sciences, Imphal
have been considered for this study. The age
incidence of the victims, causative agents,
incidence of external injuries to the abdominal region, types of blunt trauma observed,
frequency of right and left lobe involvement,
extent of lacerations, diaphragmatic injuries and
rib fractures associated with blunt hepatic trauma
have been analyzed. In this study, the degree of
hepatic laceration was studied broadly under the
headings of superficial (<1 cm), deep (>1 to 5
cm) and extensive (>10 cm or more).
OBSERVATION
Age incidence of the victims
Out of the 65 cases of blunt trauma studied,
the commonest age group of the victims was 21-
30 years (27.69%) followed by the age group of
31-40 yrs (18.46%) (Table-1).
Table – 1 Showing age incidence
Sl.No.
Age Group Years
No.
P.C. (%)
1.
0-10
4
6.15
2.
11-20
10
15.38
3.
21-30
18
27.69
4.
31-40
12
18.46
5.
41-50
10
15.38
6.
51-60
8
12.31
7.
61-70
3
4.62
8.
71-80
0
0.00
Total
65
100.00
Types of blunt trauma
As shown in Table – 2, it was observed that
vehicular accident was the commonest cause of
blunt hepatic trauma accounting for 86.15% of
the cases. Other causes included assault by blunt
weapon in 6 cases (9.23%) and fall from a height
in 3 (4.62%) cases. 2 (66.67%) out of the 3 victims
of fall from heights were mentally deranged
people and they deliberately jumped down to
their death. The approximate heights of fall were
70 to 80 feet in 2 cases and 30 feet in one case.
Table – 2 Showing the types of trauma
Sl. No.
Type Of Trauma
No.
P.C. (%)
1.
Vehicular Accident
56
86.15
2.
Assault by Blunt Weapon
6
9.23
3.
Fall from Height
3
4.62
Total
65
100.00
Incidence of associated external injuries
In the present study of 65 cases, 55 (84.62%)
cases showed associated external injuries on the
thoraco-abdominal region. The remaining 10
(15.38%) did not show any external injuries. But
all the victims showed some amount of injuries
in the form of abrasions, bruises and lacerations
on the face and limbs (Table-3).
Table – 3 Showing the relationship between
blunt hepatic injuries and associated external
injuries
Sl.No.
Hepatic injuries
No.
P.C. (%)
1.
With associated external injuries
55
84.62
2.
Without associated external injuries
10
15.38
Total
65
100.00
Liver injuries
The right lobe was more frequently involved
and was observed in 48(73.85%) cases. It was
lacerated in 66.67% and contused in 33.33% of
the 48 cases. The convex surface of the right lobe
of the liver was commonly involved in most of
the cases (56.25%) as compared to other surfaces
i.e. 29.15% on the inferior surface and 14.58% on
the diaphragmatic surface. The left lobe was
injured in only 4(6.15%) cases. It was lacerated in
3 (75%) cases, while the remaining 1(25%) showed
contusion. Both the lobes were lacerated in
13(20%) cases. The incidence and the type of liver
injuries are shown in Bar Diagram No. 1.
All together, 48 (73.85%) cases showed
lacerations of the liver, out of which 25% showed
superficial lacerations, while 33.33% showed deep
lacerations and the remaining 41.67% showed
extensive lacerations of the liver (Bar Diagram
No. 2). It was observed that 12.5% of liver
lacerations were associated with injuries to the diaphragm. The liver lacerations were associated
with rib fractures in 54.16% of the cases, while
22.92% were without rib fractures or
diaphragmatic injuries (Bar diagram No.3). The
lower rib fractures i.e. 6th to 9th rib fractures were
mostly associated with the deep and extensive
lacerations of the liver (64.58%).
Bar Diagram No. 1. Showing the details of
liver injuries (Total no. of cases = 65).
Bar Diagram No. 1. Showing the details of liver injuries (Total no. of cases = 65).
Bar Diagram No. 2. Showing the details of liver lacerations (Total no. of cases = 48).
DISCUSSION
Similar findings of the causative agent i.e.
vehicular accident being the commonest causative
agent were observed by several workers3-8. Gooneteleke U.K.D.A.9 observed that liver
injuries were the most common injuries seen in
falls more than 70 feet of height. This holds true
in the present study since the victims who
sustained liver injuries (2 [66.67%] cases) fell
down from heights of more than 70 feet. The right
lobe was involved more frequently (74.60%) and
it was mostly injured on its convex surface
(58.06%). This is in agreement with the statement
of Reddy K.S.N., 20011. This could be because of
its location and bulkier size which makes it prone
to bear more impact. Sugimoto K. et al., (1993)10
reviewed 106 cases of blunt liver injuries and
found that superficial liver laceration was present
in 27 cases (25.5%), deep liver injuries of simple
type in 18 cases (17%) and of complex type in 21
cases (19.8%). The findings of superficial
lacerations are comparable with the findings in
the present study.
Boulanger B.R., (1993)8 reviewed 80 cases of
blunt traumatic diaphragmatic rupture and
observed that 20% of the cases with right
diaphragmatic rupture had associated
intraabdominal injuries which included liver in
93%. However, in the present study liver injury
was mostly associated with rib fractures (54.16%)
followed by diaphragmatic injuries (12.5%).
The presence of liver lacerations in 15.22% of
the cases without associated external injuries to
the region emphasizes the fact that the thoracoabdominal
wall usually escapes gross injury to
its wall by transmitting the force of violence to
more resistant organs inside the abdominal cavity.
CONCLUSION
Liver injuries may occur in absence of any
associated external injuries. At the same time, rib
fractures are often associated with liver injuries,
which may also occur without any external
injuries. This emphasizes the need of proper
monitoring of victims with blunt thoracoabdominal
trauma. Most of the victims of fall
from heights were mentally deranged people who
committed suicide. A proper scrutiny of their
condition and restraint, if necessary are
recommended. In assessing blunt trauma cases, awareness about the commonest sites, types and
degrees of hepatic injuries sustained by the
victims as has been highlighted in the present
study will be of great help in timely intervention
and prompt treatment of these victims.
Reference
- Reddy K.S.N: Regional Injuries, The essentials of
Forensic Medicine and Toxicology; K.Suguna Devi,
Hyderabad, 21st Edn., 223-228, 2002.
- Mason J.K.: Injuries and death in road traffic
accidents and Pedestrian injuries and death, The pathology
of trauma; Edward Arnold, Hodder & Stoughton Ltd.,
London, 2nd Edn, 1-29, 1993.
- Chandulal R: Fatal road accidents, J.Police
Research and Development; 17-19, July-September 1971.
- Chandra J. and Dogra T.D.: Pattern of injuries in
various road users involved with different vehicles in fatal
accidents, J. Police Research and Development; 26-28, April-
June 1978.
- Bergvist D., Hedelin H., Karlson G., Lindblad B.
and Matzsch T.: Abdominal trauma and fatal outcomeanalysis
of a thirty year studies, J-Trauma; 23:499-502, 1983.
- Sharma O.P.: Traumatic diaphragmatic rupturenot
an uncommon entity – personal experience with
collective review of the 1980s, J-Trauma; 29 (5): 678-682,
May 1989.
- Ghosh P.K.: Post mortem study of pattern of injury
involving pedestrian victims, J. For Med Tox.; Vol. VIII, No.
3&4:1-8, July-Dec 1991.
- Boulanger B.R., Milzman D.P., Rosati C. and
Rodriguez A.: A comparison of right and left blunt traumatic
diaphragmatic rupture, J-Trauma; 35 (2): 255-260, August
1993.
- Gooneteleke U.K.D.A: Intra-abdominal injuries
due to fall from height, Med-Sci-Law; 20:262-275, 1980.
- Sugimoto K., Asari Y., Sakaguchi T., Owada Tand
Maekawa K.: Endoscopic retrograde cholangiography in
the non-surgical management of blunt liver injury, JTrauma;
35 (2): 192-195, Aug 1993.
Reprint request: Dr Th. Meera Devi
Assistant Professor,
Department of Forensic Medicine, Regional
Institute of Medical Sciences, Imphal – 795004.
e-mail: [email protected]
(1)Devi Th. Meera, (2)Nabachandra H., (3)Singh Th. Sudhirchandra
(1)Assistant Professor, Department of Forensic Medicine, (2)Professor, Department of Forensic Medicine and (3)Associate Professor, Department of Surgery, Regional Institute of Medical Sciences, Imphal – 795004.
ABSTRACT
Aim: To study blunt hepatic trauma cases as regards the pattern, the risk factors involved and association with diaphragmatic injuries and rib fractures.
Material and method: 65 cases of blunt hepatic trauma brought for autopsy to the mortuary of the Regional Institute of Medical Sciences, Imphal have been considered for this study. The age incidence of the victims, causative agents, incidence of external injuries to the thoraco-abdominal region, types of blunt trauma observed, frequency of right and left lobe involvement, extent of lacerations, diaphragmatic injuries and rib fractures associated with blunt hepatic trauma have been analysed.
Result: The commonest age group of the victims was 21-30 years (27.69%) followed by the age group of 31-40 yrs (18.46%). Vehicular accident (86.15%) was the leading cause of blunt hepatic trauma. 84.62% of the cases showed associated external injuries to the thoracoabdominal region and the remaining 15.38% did not show any external injuries. The right lobe was more frequently involved (73.85%) and the convex surface of the right lobe was the common site (56.25%). Extensive lacerations of the liver were observed in 41.67% and deep lacerations in 33.33% of the cases. 12.5% of liver lacerations were associated with injuries to the diaphragm while 54.16% were associated with rib fractures, and 22.92% were without rib fractures or diaphragmatic injuries. In assessing blunt trauma cases, awareness about the commonest sites, types and degrees of hepatic injuries sustained by the victims as have been observed in the present study will be of great help in timely intervention and prompt treatment of these victims.
KEYWORDS: Blunt trauma, rib fracture, diaphragmatic injuries, hepatic contusion, hepatic laceration
INTRODUCTION
Blunt thoraco-abdominal injuries are often encountered in vehicular accidents, blows or kicks on the region or following fall from heights. According to Reddy K.S.N., (2002)1, the structures most likely to be damaged in blunt abdominal trauma in order of frequency are: liver, spleen, kidney, intestines, abdominal wall, mesentery, pancreas and diaphragm. The abdominal wall usually escapes gross injury by transmitting the force of violence to more resistant organs inside the abdominal cavity. Following a blunt trauma, unyielding organs like the liver because of its bulky size, superficial location and relatively fixed position in the abdominal cavity are commonly injured. The hepatic injury may result from simple compression against the fixed ribs, spine, or posterior abdominal wall. Hepatic injury may also result from transmission of excessively high venous pressure from remote body sites occurring at the time of impact. The liver injury is often seen in pedestrian victims of vehicular accidents2. Interestingly, the right lobe of the liver is 5 times more commonly affected than the left. They usually involve the convex surface and the inferior border but may involve only the deep substance of the organ1.
MATERIAL AND METHODS
65 cases of blunt hepatic trauma to the mortuary of the Forensic Medicine Department, Regional Institute of Medical Sciences, Imphal have been considered for this study. The age incidence of the victims, causative agents, incidence of external injuries to the abdominal region, types of blunt trauma observed, frequency of right and left lobe involvement, extent of lacerations, diaphragmatic injuries and rib fractures associated with blunt hepatic trauma have been analyzed. In this study, the degree of hepatic laceration was studied broadly under the headings of superficial (<1 cm), deep (>1 to 5 cm) and extensive (>10 cm or more).
OBSERVATION
Age incidence of the victims Out of the 65 cases of blunt trauma studied, the commonest age group of the victims was 21- 30 years (27.69%) followed by the age group of 31-40 yrs (18.46%) (Table-1).
Table – 1 Showing age incidence
| Sl.No. | Age Group Years | No. | P.C. (%) |
|---|---|---|---|
| 1. | 0-10 | 4 | 6.15 |
| 2. | 11-20 | 10 | 15.38 |
| 3. | 21-30 | 18 | 27.69 |
| 4. | 31-40 | 12 | 18.46 |
| 5. | 41-50 | 10 | 15.38 |
| 6. | 51-60 | 8 | 12.31 |
| 7. | 61-70 | 3 | 4.62 |
| 8. | 71-80 | 0 | 0.00 |
| Total | 65 | 100.00 |
Types of blunt trauma
As shown in Table – 2, it was observed that vehicular accident was the commonest cause of blunt hepatic trauma accounting for 86.15% of the cases. Other causes included assault by blunt weapon in 6 cases (9.23%) and fall from a height in 3 (4.62%) cases. 2 (66.67%) out of the 3 victims of fall from heights were mentally deranged people and they deliberately jumped down to their death. The approximate heights of fall were 70 to 80 feet in 2 cases and 30 feet in one case.
Table – 2 Showing the types of trauma
| Sl. No. | Type Of Trauma | No. | P.C. (%) |
|---|---|---|---|
| 1. | Vehicular Accident | 56 | 86.15 |
| 2. | Assault by Blunt Weapon | 6 | 9.23 |
| 3. | Fall from Height | 3 | 4.62 |
| Total | 65 | 100.00 |
Incidence of associated external injuries
In the present study of 65 cases, 55 (84.62%) cases showed associated external injuries on the thoraco-abdominal region. The remaining 10 (15.38%) did not show any external injuries. But all the victims showed some amount of injuries in the form of abrasions, bruises and lacerations on the face and limbs (Table-3).
Table – 3 Showing the relationship between blunt hepatic injuries and associated external injuries
| Sl.No. | Hepatic injuries | No. | P.C. (%) |
|---|---|---|---|
| 1. | With associated external injuries | 55 | 84.62 |
| 2. | Without associated external injuries | 10 | 15.38 |
| Total | 65 | 100.00 |
Liver injuries
The right lobe was more frequently involved and was observed in 48(73.85%) cases. It was lacerated in 66.67% and contused in 33.33% of the 48 cases. The convex surface of the right lobe of the liver was commonly involved in most of the cases (56.25%) as compared to other surfaces i.e. 29.15% on the inferior surface and 14.58% on the diaphragmatic surface. The left lobe was injured in only 4(6.15%) cases. It was lacerated in 3 (75%) cases, while the remaining 1(25%) showed contusion. Both the lobes were lacerated in 13(20%) cases. The incidence and the type of liver injuries are shown in Bar Diagram No. 1. All together, 48 (73.85%) cases showed lacerations of the liver, out of which 25% showed superficial lacerations, while 33.33% showed deep lacerations and the remaining 41.67% showed extensive lacerations of the liver (Bar Diagram No. 2). It was observed that 12.5% of liver lacerations were associated with injuries to the diaphragm. The liver lacerations were associated with rib fractures in 54.16% of the cases, while 22.92% were without rib fractures or diaphragmatic injuries (Bar diagram No.3). The lower rib fractures i.e. 6th to 9th rib fractures were mostly associated with the deep and extensive lacerations of the liver (64.58%). Bar Diagram No. 1. Showing the details of liver injuries (Total no. of cases = 65).
Bar Diagram No. 1. Showing the details of liver injuries (Total no. of cases = 65).
Bar Diagram No. 2. Showing the details of liver lacerations (Total no. of cases = 48).
DISCUSSION
Similar findings of the causative agent i.e. vehicular accident being the commonest causative agent were observed by several workers3-8. Gooneteleke U.K.D.A.9 observed that liver injuries were the most common injuries seen in falls more than 70 feet of height. This holds true in the present study since the victims who sustained liver injuries (2 [66.67%] cases) fell down from heights of more than 70 feet. The right lobe was involved more frequently (74.60%) and it was mostly injured on its convex surface (58.06%). This is in agreement with the statement of Reddy K.S.N., 20011. This could be because of its location and bulkier size which makes it prone to bear more impact. Sugimoto K. et al., (1993)10 reviewed 106 cases of blunt liver injuries and found that superficial liver laceration was present in 27 cases (25.5%), deep liver injuries of simple type in 18 cases (17%) and of complex type in 21 cases (19.8%). The findings of superficial lacerations are comparable with the findings in the present study.
Boulanger B.R., (1993)8 reviewed 80 cases of blunt traumatic diaphragmatic rupture and observed that 20% of the cases with right diaphragmatic rupture had associated intraabdominal injuries which included liver in 93%. However, in the present study liver injury was mostly associated with rib fractures (54.16%) followed by diaphragmatic injuries (12.5%). The presence of liver lacerations in 15.22% of the cases without associated external injuries to the region emphasizes the fact that the thoracoabdominal wall usually escapes gross injury to its wall by transmitting the force of violence to more resistant organs inside the abdominal cavity.
CONCLUSION
Liver injuries may occur in absence of any associated external injuries. At the same time, rib fractures are often associated with liver injuries, which may also occur without any external injuries. This emphasizes the need of proper monitoring of victims with blunt thoracoabdominal trauma. Most of the victims of fall from heights were mentally deranged people who committed suicide. A proper scrutiny of their condition and restraint, if necessary are recommended. In assessing blunt trauma cases, awareness about the commonest sites, types and degrees of hepatic injuries sustained by the victims as has been highlighted in the present study will be of great help in timely intervention and prompt treatment of these victims.
Reference
- Reddy K.S.N: Regional Injuries, The essentials of Forensic Medicine and Toxicology; K.Suguna Devi, Hyderabad, 21st Edn., 223-228, 2002.
- Mason J.K.: Injuries and death in road traffic accidents and Pedestrian injuries and death, The pathology of trauma; Edward Arnold, Hodder & Stoughton Ltd., London, 2nd Edn, 1-29, 1993.
- Chandulal R: Fatal road accidents, J.Police Research and Development; 17-19, July-September 1971.
- Chandra J. and Dogra T.D.: Pattern of injuries in various road users involved with different vehicles in fatal accidents, J. Police Research and Development; 26-28, April- June 1978.
- Bergvist D., Hedelin H., Karlson G., Lindblad B. and Matzsch T.: Abdominal trauma and fatal outcomeanalysis of a thirty year studies, J-Trauma; 23:499-502, 1983.
- Sharma O.P.: Traumatic diaphragmatic rupturenot an uncommon entity – personal experience with collective review of the 1980s, J-Trauma; 29 (5): 678-682, May 1989.
- Ghosh P.K.: Post mortem study of pattern of injury involving pedestrian victims, J. For Med Tox.; Vol. VIII, No. 3&4:1-8, July-Dec 1991.
- Boulanger B.R., Milzman D.P., Rosati C. and Rodriguez A.: A comparison of right and left blunt traumatic diaphragmatic rupture, J-Trauma; 35 (2): 255-260, August 1993.
- Gooneteleke U.K.D.A: Intra-abdominal injuries due to fall from height, Med-Sci-Law; 20:262-275, 1980.
- Sugimoto K., Asari Y., Sakaguchi T., Owada Tand Maekawa K.: Endoscopic retrograde cholangiography in the non-surgical management of blunt liver injury, JTrauma; 35 (2): 192-195, Aug 1993.
Reprint request: Dr Th. Meera Devi
Assistant Professor,
Department of Forensic Medicine, Regional
Institute of Medical Sciences, Imphal – 795004.
e-mail: [email protected]
