Abdominal & Genitourinary Injuries

Question 1

What does abdominal exam consist of?

Answer 1

1.Observe (no clothing covering) both anterior and posterior (have them sit up)
2. Auscultation: Listen for bowel sounds (should occur every 2-5 seconds). No sounds for 30 seconds is concern for significant intra-abdominal pathology
3. Palpation: use pads of fingers. Start with more gentle pressure and then move into deep, firmer pressure. Feel for firm/enlarged organs
4. Check rebound tenderness
5. Percussion: Place one hand over belly and then tap with another finger on top of the finger and listen (normal sounds like drum, abnormal/solid organs sound distant and dull)

Question 2

Signs of shock?

Answer 2

1. Tachycardia
2. Hypotension
3. SOB
4. Diaphoretic
5. Anxious
6. Potentially confusion

Question 3

Kehr Sign, Cullen sign, Gery Turner Sign

Answer 3

Kehr sign= pain radiating to left shoulder that suggests diaphragm irritation from free fluid
Cullen sign = bluish discoloration at umbilicus suggestive of hemoperitoneum
Grey Turner Sign = bluish discoloration of the flank suggestive of hemiperitoneum

Question 4

What to do with shock?

Answer 4

Transport to ER for detailed exam/monitoring. May want to put them in trendelenburg/modified trendelenburg position (on the side to help splint the injury).

Question 5

Contents of abdominal quadrants?

Answer 5

Upper Right: Liver (protected by lower ribs), gallbladder, portions of transverse colon
Right Lower: Dominated by bowel, appendix
Upper Left: Spleen (protected by lower ribs), stomach (under sternum and maybe small shift to upper left quadrant)
Lower Left: Dominated by descending colon

Kidneys are retroperitoneal (outside of abdominal cavity; behind peritoneum)

Question 6

Where is McBurney’s Point

Answer 6

1/3 the distance from ASIS to umbilicus in lower right quadrant

Question 7

Most common organ injuries?

Answer 7

Liver is most frequently injured overall (not including sports) but spleen is most common injured in sports.

Question 8

Liver injury presentation

Answer 8

Broken ribs could cause liver laceration. Complain of right upper quadrant pain that may radiate to shoulder or neck. May have rapid HR, low BP, nausea, and blood in vomit/feces/urine. MD monitors blood levels for hemoglobin and hematocrit every 6-12 hours and monitored for 2-3 days. If decline in this or injury large then will need surgery.

Question 9

Purpose of spleen

Answer 9

Filters your blood and platelets. Old blood and platelets are confiscated and destroyed.

Question 10

Mechanism of injury for liver and spleen

Answer 10

Direct blow or deceleration injury that can cause laceration. Spleen is not fully covered by ribs (especially in younger athletes).

Question 11

Bleeding with liver and spleen?

Answer 11

Delayed bleeding no common with liver, it is more common with spleen. Sometimes they may be okay to play still but as they continue playing they get ill due to delayed bleeding into the abdomen. Initial CT scans may not see the bleeding and might not show up until later.

Question 12

How long to go back after spleen issue?

Answer 12

Recommend 3 months (that’s usually with mono and we use that data). Imaging plays no role as radio graphic healing lags behind clinical healing)

Question 13

How to identify kidney injuries and the severity?

Answer 13

1. Hematuria (2-4% of renal injuries don’t have this though)
2. Hypotension

You’re not able to palpate the kidneys so you need to know the mechanism of injury and if the following are present.

Question 14

Pancreatic injury

Answer 14

Very rare in sports but will usually occur with direct trauma. Very serious because of role with digesting fatty foods and making insulin. Will usually have pain initially that diminishes in the first 2 hours and returns again after 6-8.

Question 15

Aorta injury

Answer 15

Usually deceleration injury with tearing (like a seat belt).

Question 16

Bladder injury

Answer 16

Unlikely to be affected from trauma because the bony pelvis protects it. Micro-trauma from running with empty bladder can occur (opposing sides rub together) and get some blood in the urine. Usually have Supra-pubic pain, difficulty voiding, and hematuria.

Question 17

Ureter Injury

Answer 17

Very rare to injure in sports (usually a surgical injury). Immediate flank pain, SOB, pain in lower abdomen, high levels of pain (these are very sensitive). May not have blood in urine if this is severed (no longer connected to bladder).

Question 18

Diaphragm injury

Answer 18

Most often with contusion the muscle will spasm and feel like wind is knocked out of them and resolve spontaneously and able to return to play shortly after.

Question 19

Solar Plexus Injury

Answer 19

Solar plexus is a collection of 2 nerve bundles in the central abdomen that cross and a hit to the stomach can cause momentary paralysis of the diaphragm and cause the sensation of “wind knocked out of you.” Need to recognize this and just calm the athlete and help them regain their breath.

Question 20

Most common sites of hernia?

Answer 20

Inguinal (above inguinal ligament) and femoral (under the inguinal ligament through femoral canal [just medial to femoral vein]).

Question 21

Time course for organ hemorrhage?

Answer 21

It is possible for it to happen more slowly for days or weeks before systemic dysfunction or organ failure will be displayed.

Question 22

Red flag for abdominal injury

Answer 22

1. Altered vital signs
2. c/o serious abdominal or systemic symptoms

Question 23

How to manage shock until EMT arrives?

Answer 23

Don’t give them anything to drink. Elevate legs to assist blood flow to head.

Question 24

Side stitch?

Answer 24

Exercise-related transient abdominal pain. Most common theory is diaphragm ischemia. May be due to large meals/fluids or certain fluids/foods prior to event.

Question 25

Carnette’s Sign

Answer 25

Abdominal pain that is recreated when tensing the abdominals in supine (like a crunch or sit up). Suggests MSK cause.

Question 26

Rectus abdominis strain vs rectus sheath hematoma?

Answer 26

1. Hematoma will likely have more pronounced nausea
2. Hematoma likely will feel better in more trunk flexion
3. Probably a palpable mass over abdominal wall with hematoma.

Question 27

Best imaging to rule out intra-abdominal pathology?

Answer 27

CT but MRI and US can be helpful.

Question 28

Osteitis Pubis Imaging Findings?

Answer 28

Pubic bone edema is a nonspecific finding in asymptomatic athletes (no MRI) and can’t be considered diagnostic of this. Plain films often show pubic symphysis widening or sclerosis at the margins.

Question 29

Athletic/Sports Hernia Treatment and Findings?

Answer 29

Usually needs surgery. There isn’t a frank herniation. Findings during surgery usually include:
1. Posterior wall and inguinal canal defects (almost all people have posterior wall findings)
2. Nerve entrapment
3. Disruption of conjoint tendon
4. Tears of EO aponeurosis
5. Other abdominal wall defects

Question 30

General consensus on what a sports hernia is? How to diagnose it?

Answer 30

Constellation of posterior abdominal wall defects with impending inguinal hernia. It’s a diagnosis of exclusion. Symptoms:
1. Patient must be pain-free at rest.
2. Deep, diffuse pain with activity in medial thigh, perineum, and sometimes the nuts.
3. Side of complaint don’t always correspond with which side the problem is on (40% with unilateral symptoms have defects on opposite side)

Question 31

Potential physical exam findings with sports hernia?

Answer 31

1. TTP at external/superficial ring
2. Mildly dilated external/superficial ring
3. Pubic tubercle TTP (insertion of Add Longus)
4. Pain with adduction or resisted sit up
5. Palpable hernia excludes sports hernia

Question 32

What will you see with kidney contusion and how to manage?

Answer 32

Likely some blood in the urine and back/abdominal pain, butt, or front of thigh.

If blood in urine, likely miss 2 weeks of training and minimize ADL’s. If bleeding re-occurs then may miss remainder of season.

Question 33

Pathophysiology and presentation of appendicitis?

Answer 33

Appendix is small pouch at beginning of large intestine. Can get blocked by feces or foreign object. Symptoms/signs:
1. Pain around belly button
2. Reduced appetite
3. Nausea/vomiting
4. Low fever
5. Pain in right lower abdomen
6. Chills
7. Constipation/diarrhea
8. Shaking
9. Tenderness at McBurney’s point

Question 34

Signs/Symptoms of Spleen Issue?

Answer 34

1. Left abdominal pain just below rib cage
2. Left shoulder pain
3. Decrease in BP
4. Blurred vision
5. Confusion
6. Lightheadedness
7. Fainting
8. Kerr’s Sign

Question 35

Spermatic cord torsion pathophysiology and S/S’s?

Answer 35

The testicle and spermatic cord twist and become locked in abnormal position. S/S’s:
1. Sudden/severe pain in scrotum
2. Scrotal swelling
3. Nausea/vomiting

Need surgery immediately (within 6 hours has good chance of survival; after 24 hours unlikely to save). One testicle is all that is needed for normal growth/maturation/fertility.