What is the management for a 50-year-old patient with an anterior abdominal wall contusion in the suprapubic region?

Management of Anterior Abdominal Wall Contusion in the Suprapubic Region

Initial Management

For a 50-year-old patient with an anterior abdominal wall contusion in the suprapubic region, conservative management with clinical observation, analgesia, and serial examinations is the appropriate initial approach, provided there are no signs of underlying visceral or vascular injury. 1, 2

Immediate Assessment Priorities

Rule Out Associated Injuries

• Perform CT imaging of the abdomen and pelvis with IV contrast to exclude concurrent intra-abdominal injuries, as abdominal wall injuries are highly associated with potentially grave visceral and vascular injuries in approximately 9% of blunt trauma patients 1, 2
• Specifically evaluate for:
  • Bladder injury (given suprapubic location) - look for intraperitoneal or extraperitoneal bladder rupture, bladder wall thickening, or perivesical fluid 3
  • Bowel injury - assess for free air, bowel wall thickening, mesenteric stranding, or free fluid 3
  • Vascular injury - evaluate for active extravasation or hematoma expansion 1
  • Pelvic fractures - particularly important in suprapubic trauma 3

Clinical Examination Focus

• Assess for peritoneal signs (guarding, rigidity, rebound tenderness) that would indicate intra-abdominal injury requiring surgical exploration 3
• Monitor vital signs for hemodynamic instability 3
• Examine for gross hematuria or inability to void, which suggests bladder or urethral injury 3
• Document the extent of ecchymosis, swelling, and tenderness 2

Conservative Management Protocol

When Conservative Management is Appropriate

• Hemodynamically stable patient 3
• No peritoneal signs on examination 3
• CT scan negative for visceral injury, bladder rupture, or significant hematoma 3, 1
• Simple contusion without muscle tear or hematoma requiring intervention 2

Treatment Components

• Analgesia - NSAIDs or acetaminophen for pain control 2
• Ice application in the acute phase (first 48-72 hours) 2
• Activity modification - avoid strenuous activity until pain resolves 2
• Serial clinical examinations - monitor for development of delayed complications 3

Monitoring for Complications

Serial Examination Requirements

• Perform serial abdominal examinations at regular intervals (every 4-8 hours initially) by experienced clinicians to detect evolving peritonitis or hemodynamic changes 3
• Monitor hemoglobin levels - any decrease >2 g/dL without other explanation warrants further investigation 3
• Track vital signs continuously for the first 24-48 hours 3
• Repeat imaging if clinical deterioration occurs - worsening pain, development of peritoneal signs, or hemodynamic instability 3

Specific Complications to Monitor

• Rectus sheath hematoma - can develop or expand over 24-48 hours, may require intervention if causing hemodynamic compromise 2
• Delayed bladder injury recognition - urinary extravasation may be missed on initial CT in 0.2% of cases 3
• Traumatic abdominal wall hernia - can develop as a delayed complication if fascial disruption was not initially apparent 1, 2

Indications for Surgical Intervention

Immediate Surgical Exploration Required

• Hemodynamic instability despite resuscitation 3
• Peritoneal signs on examination 3
• CT evidence of intraperitoneal bladder rupture - requires surgical exploration and primary repair 3
• CT evidence of bowel injury (free air, bowel wall defect, oral contrast extravasation) 3
• Expanding or large hematoma causing mass effect or hemodynamic compromise 2

Delayed Surgical Consideration

• Traumatic abdominal wall hernia with fascial defect - typically requires surgical repair to prevent bowel incarceration or strangulation 1, 2
• Persistent or expanding rectus sheath hematoma despite conservative management 2

Common Pitfalls to Avoid

• Do not discharge based solely on negative initial CT - clinical examination remains paramount, and serial assessments are required for at least 24-48 hours 3
• Do not overlook abdominal wall injuries when distracted by other injuries - they are frequently missed but highly associated with grave visceral injuries 1, 2
• Do not assume isolated contusion without imaging - approximately 9% of blunt abdominal trauma patients have associated intra-abdominal injuries 1
• Do not miss bladder injury - specifically request delayed/excretory phase imaging if bladder injury is suspected, as early imaging may miss urinary extravasation 3

Disposition and Follow-up

• Admit for observation if any concern for associated injuries, even with negative initial imaging 3
• Minimum 24-48 hours of observation with serial examinations if CT shows any concerning findings or if clinical examination is equivocal 3
• Outpatient follow-up in 1-2 weeks for uncomplicated contusions to assess for delayed complications 2
• Return precautions - instruct patient to return immediately for worsening pain, abdominal distension, fever, or inability to void 3, 2