Presentation
This 58 year old male was driving his car and had a head on collision with a caravan driving at approximately 80km/hr. There was significant cabin intrusion and prolonged extraction time for the patient. He was tender to both wrists, sternum and lower right leg. He also had a headstrike with 5 minutes of resulting loss of consciousness. A CT trauma series was performed.
Patient Data
- Likely right adrenal contusion. The right adrenal gland appears bulky with ill defined margin and minor surrounding fat stranding which extends to the celiac trunk. This is suspicious for traumatic adrenal injury.
- Undisplaced right L3 transverse process fracture. No other fracture or dislocation identified.
- Right minimally displaced cominnuted intertrochanteric femoral fracture. Small adjacent hematoma.
- 2.5cm soft tissue density mass anteroinferior to the liver and gallbladder with well defined margin. It appears to abut the inferior surface of the liver, likely representing an exophytic liver lesion.
Case Discussion
This the patient has a right sided adrenal contusion. Adrenal contusions are a type of adrenal injury. It is an uncommon injury due to its retroperitoneal location2. It has been noted to occur in 2-3% of blunt abdominal injury3, with motor vehicle accident being the most common cause. It is worth noting that right sided adrenal trauma is much more common than the left, with a ratio of 3-4:1 being quoted1,2. This has been suggested to be caused by the short right adrenal vein which directly connects to the inferior vena cava. In blunt trauma, rapid increases in IVC pressure are likely associated with right adrenal trauma.
Complications of adrenal injury include uncontrolled hemorrhage and adrenal insufficiency.
This gentleman also has a minimally displaced comminuted intertrochanteric femoral fracture. There are three main types of hip fractures, which are:
- Neck of femur fractures
- Intertrochanteric fractures
- Subtrochanteric fractures
The usual mechanism is traumatic injury, although patients are often elderly who have had a fall.
The incidental hepatic lesion is relatively common in the modern day world with CT scans. In this case, the lesion was asymptomatic and followed up by the hepatobilliary team.
Case contributed by A/Prof. Pramit Phal.
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