Trauma

The term trauma (plural: traumas) or traumatic injury refers to damage or harm of sudden onset caused by external factors or forces requiring medical attention.

Polytrauma or multiple trauma has been defined as a pattern of potentially life-threatening injuries involving at least two body regions.  

Epidemiology

Traumatic injuries are very common and major trauma is the leading cause of death in children and young adults ^1-3 and is a major cause of deaths and disability globally with different distribution patterns beyond the age of 35 years of age ¹.

Risk factors

Risk factors are diverse and include socioeconomic, occupational, political, cultural and environmental parameters ^1,2.

Clinical presentation

The clinical presentation involves typical injury mechanisms as road traffic accidents, sports or work-related injuries, falls, interpersonal violence, cuts, stabs or gunshot wounds, natural disasters, burns and other injury types ¹. Depending on the extent and severity of the traumatic injury patients might seek medical attention from their primary physician within the scope of a routine visit or might be found unconscious in the field and brought to the hospital by ambulance or helicopter.

Complications

There is a wide spectrum of complications resulting from traumatic injuries.Major complications include ^3,4:

• major bleeding
• shock
• trauma-induced coagulopathy
• hypothermia
• acidosis
• arrhythmia
• embolism
• infections and , abscess and sepsis
• compartment syndrome
• limb amputation
• osteoarthritis
• loss of consciousness/coma
• post-traumatic stress disorder (PTSD) or anxiety
• permanent disability
• death

Pathology

Pathogenesis

Pathogenesis of trauma and/or traumatic injuries include:

• physical injury
  • blunt injuries
  • penetrating injuries
• thermal injury
• chemical injury
• electrical injury
• ionising radiation injury
• barotrauma
• acoustic trauma

Aetiology

Causes of trauma and traumatic injuries include the following ^1,2:

• traffic collisions
• occupational injuries
• falls
• recreational and/or sports-related injuries
• interpersonal violence and/or assault
• self-inflicted injuries
• other accidents
• natural disasters

Location

Traumatic injuries can occur in any conceivable location of the body.

The Abbreviated Injury Scale (AIS), which also forms a basis for the calculation of the Injury Severity Score specifies the following locations: 

• head (without face)
• face
• neck
• thorax
• abdomen
• spine
• upper extremities
• lower extremities
• external injuries and other traumatic injuries

Classification

Traumatic injuries are usually classified based on their location, their extent and their severity with different classification schemes for various organs and tissues. 

Based on their severity, traumatic injuries can be subdivided into the following ¹:

• injuries treated outside the health care system
• injuries treated in primary care centres
• injuries requiring emergency care
• injuries requiring hospital admission
• lethal injuries

In consideration of the respective tissue traumatic injuries can be subdivided into the following types:

• bone: bruises, fractures
• cartilage: fissures, fractures, osteochondral injuries
• muscles: contusions, tears, ruptures
• tendons: tears, ruptures
• ligaments: sprain, tears
• parenchymal organs: contusions, lacerations, devascularisation, parenchymal disruption or transection
• hollow organs: contusions, lacerations with or without perforation, transection, devascularisation
• vascular injury: irregularity or minimal injury, dissection, pseudoaneurysm, occlusion, transection
• skin: incision, laceration, abrasion, puncture, penetration, contusion, avulsion, degloving

An overview of various traumatic injuries based on their location is given here ^3-13:

• traumatic head injury
  • skull fractures
  • traumatic brain injury
    • epidural, subdural, subarachnoid or parenchymal haemorrhage
    • diffuse axonal injury (DAI)
    • low-velocity penetrating brain injury
    • high-velocity penetrating brain injury
  • scalp haematoma
• facial injury
  • facial fractures
  • temporomandibular joint trauma
  • injuries to the orbit and the eye
  • ocular foreign body
  • dental trauma
• neck injuries
  • blunt neck injury
  • cervical vascular injury
  • strangulation trauma
  • salivary gland trauma
  • laryngeal trauma
  • brachial plexus injury
  • penetrating neck injury
• thoracic trauma
  • chest wall injury
  • lung injury
    • haematothorax
    • pneumothorax
    • lung contusion or laceration
  • tracheobronchial injury
  • thoracic aortic injury
  • cardiac injury
    • blunt cardiac injury
    • penetrating cardiac injury
  • diaphragmatic injury
  • oesophageal injury
  • penetrating thoracic trauma
• abdominal trauma
  • abdominal wall injury
  • splenic injury
  • liver injury
  • bile duct injury
  • pancreatic injury
  • bowel and mesenteric trauma
    • gastric injury
    • duodenal injury
    • small bowel injury
    • colon injury
    • rectal injury
  • adrenal injury
  • renal injury
  • ureteral injury
  • penetrating abdominal trauma
• pelvic trauma
  • pelvic fractures
  • bladder injury
  • urethral injury
  • traumatic injury of the uterus
  • traumatic injuries of adnexa and/or ovaries
  • trauma in pregnancy
  • testicular trauma
  • scrotal trauma
  • penile injury
• spinal injuries
  • cervical spine fractures
  • thoracolumbar spine fractures
  • lumbar spine fractures
  • discoligamentous injuries
  • spinal cord injury
• injuries to the extremities (most common)
  • injuries of the upper extremities
    • shoulder dislocation
    • humeral fractures
    • elbow dislocation
    • radial and ulnar fractures
    • wrist injury and carpal fractures
    • injuries to the hand and fingers
  • injuries of the lower extremities
    • hip dislocation
    • femoral fractures
    • knee dislocation
    • tibial and fibular fractures
    • ankle injuries
    • talar and calcaneal fractures
    • midtarsal injury
    • midfoot and forefoot injuries
  • muscle tears and muscle contusions
  • ligament and tendon injuries
  • peripheral vascular injuries
  • peripheral nerve injuries
  • traumatic limb amputation

Additional types of trauma or traumatic injuries include ^2,7:

• blast trauma
• crush injury
• burns
• barotrauma
• acoustic trauma
• birth trauma
• psychological trauma

Trauma scores

Trauma scores can be used to describe the extent of the whole injury such as the following:

• Abbreviated Injury Scale (AIS): body region, anatomic structure and severity of the injury
• Injury Severity Score (ISS): body region, injury severity

Radiographic features

Typical radiographic features of traumatic injuries include fractures, tears, contusions and lacerations in various degrees as well as the presence of haemorrhage or air in the soft tissues and outside the hollow organs.

Plain radiograph

Plain radiographs can nicely demonstrate and characterise fractures in the extremities and small joints ¹⁴. However, the diagnostic power in the detection of injuries in the trunk including the spine, thorax and pelvis is low as compared to MDCT ^5,8.

Ultrasound

Ultrasound is widely and easily available and can be even used in the ambulance. A focussed assessment with sonography for trauma (FAST) scan is particularly useful for the rapid detection of intra-abdominal and pericardial fluid ^7-12 as well as the recognition of penetrating cardiac injuries. It is an important tool for assessing and triaging unstable patients in need of emergent surgery ^5,7.

CT

CT is the gold standard and workhorse in the evaluation of severe and multiple traumatic injuries in haemodynamically stable or stabilised patients. It allows an effective detection and characterisation of life-threatening and unexpected injuries within a few minutes and can shorten hospital stay ⁵. In the setting of suspected polytrauma, it is usually acquired as a trauma-specific whole-body CT protocol ⁵. It has a crucial role in the evaluation of fractures and dislocations of the head and neck area, spine, chest wall and pelvis, and the assessment of the lungs ⁵. It is also a safe and accurate modality to evaluate deep-seated foreign bodies ⁷.

Non-contrast CT is required in the assessment of hyperacute traumatic brain injuries ⁵.

CT angiography allows for a fast and accurate evaluation of vascular injuries ⁵.

Contrast-enhanced CT is the modality of choice in the evaluation of traumatic abdominal organ injuries and the only radiographic modality for which dedicated organ injury scores within the diagnostic algorithm of traumatised patients exist ^{5,6, 8-12}.

Angiography

Angiography might be performed in the setting of specific vascular injuries or for endovascular treatment of various injuries ^8-11.

MRMRI

MRI can nicely depict the soft tissues, including the brain, the spinal cord, the muscles, tendons and ligaments, and the myocardium and the parenchyma of abdominal organs.

Due to the long acquisition times, MRI is rarely used in the hyperacute or acute setting and it might be even contraindicated in penetrating injuries, in which there is suspicion of retained metallic foreign bodies, e.g. shrapnel.

However, it plays an important role in the workup of spinal cord injuries as well as musculoskeletal injuries such as joints, muscles tendons and ligaments. It might be also indicated in specific brain injuries, pancreatic or bile duct injuries ^5,12.

Further applications include a cardiac MRI in the setting of blunt cardiac injuries in haemodynamically stable patients or the parenchymal abdominal organs in patients and situations where radiation plays a major issue.

Angiography

Angiography might be performed in the setting of specific vascular injuries or for endovascular treatment of various injuries ^8-11.

Radiology report

The radiological report should include the following:

• type and extent of the traumatic injury
• fracture classification
• organ injury score
• associated complications

Treatment and prognosis

Management and prognosis depend entirely on the type and extent of the specific injury and the complications associated with it ¹.

Minor traumatic injuries might be seen and evaluated only clinically or might need further radiographic evaluation before definitive treatment.

Major traumatic events with multiple traumatic injuries will need immediate attention, care and possibly resuscitation on-site. Initial treatment follows the ABCDE rule and is focused on stabilising the patient ¹⁵. Once in hospital and stabilised, patients might get whole body polytrauma CT and further operative, non-operative or interventional treatment will be determined on the findings ¹⁶.

The initial radiographic evaluation of unstable patients might only include an ultrasound assessment before they directly go to the operating room for emergency surgery ¹⁷. However, those patients will most likely get further advanced support, intensive care and imaging after surgery ¹⁸ for a more comprehensive evaluation followed by further therapeutic and rehabilitative measures ¹.

History and etymology

Trauma is directly taken from the Greek word τραυμα (trauma) meaning 'wound' and was first recorded in English in 1693 meaning a physical wound ^24,25.

See also

• AAST injury scoring scales
• AO Spine classification systems
• CT polytrauma (approach)
• CT polytrauma (technique)
• brain trauma protocol (MRI)