What is the management for an abdominal wall contusion?

Management of Abdominal Wall Contusion

For isolated abdominal wall contusions without evidence of deeper injury, conservative management with analgesia and clinical observation is appropriate, but you must actively exclude associated intra-abdominal injuries which occur in up to 9% of blunt trauma patients. 1

Initial Assessment and Risk Stratification

The critical first step is determining hemodynamic stability and ruling out concurrent injuries:

• Perform FAST (Focused Assessment with Sonography for Trauma) immediately in any patient with hypotension or concerning vital signs, as it has near 100% sensitivity for detecting intra-abdominal bleeding and takes only 8-10 minutes 2
• Obtain contrast-enhanced CT scan in hemodynamically stable patients to identify the full spectrum of abdominal wall injury and exclude associated visceral injuries 3, 4
• Be aware that abdominal wall contusions are highly associated with more severe injuries including bowel perforation, mesenteric injury, and solid organ damage 1, 4

Imaging Findings That Change Management

The CT findings determine your treatment pathway:

• Isolated abdominal wall contusion (muscle bruising without disruption) can be managed conservatively 4
• Presence of free air, free fluid without solid organ injury, bowel wall thickening, or contrast extravasation mandates prompt surgical exploration 5
• Four or more CT findings from the following list are pathognomonic for bowel injury requiring surgery: free air, free fluid without solid organ injury, intra-mesenteric fluid, contrast extravasation, bowel wall abnormality, mesenteric alteration 5

Conservative Management Protocol

For truly isolated abdominal wall contusions without concerning CT findings:

• Admit to a facility with 24/7 capacity for emergency laparotomy for at least the first 24 hours with continuous monitoring 5
• Continue clinical and biological observation for minimum 3-5 days, as most complications occur within this timeframe 5
• Repeat CT scan if clinical improvement is not apparent within 8 hours, as delayed presentation of bowel injury is common 5
• Monitor for abdominal compartment syndrome in at-risk patients through intra-abdominal pressure measurements 5

Red Flags Requiring Immediate Surgical Intervention

Do not delay surgery if any of these develop:

• Hemodynamic instability despite resuscitation (systolic BP < 90 mmHg, persistent tachycardia) 6, 2
• Development of peritonitis (diffuse abdominal tenderness, guarding, rigidity) 5, 3
• Hemoglobin drop > 2 g/dL without other explanation 5
• Pneumoperitoneum on repeat imaging 5

Common Pitfalls to Avoid

• Do not be distracted by the visible abdominal wall injury and miss associated intra-abdominal pathology - the wall injury is often less clinically significant than concurrent visceral injuries 1, 4
• Do not send hemodynamically unstable patients for CT scan - every 3-minute delay increases mortality by 1%, and CT can delay definitive treatment by up to 90 minutes 6, 2
• Do not discharge patients based solely on negative initial CT - delayed bowel perforation can manifest up to 24 hours later with significantly higher complication rates 5
• Do not assume minor external findings mean minor internal injury - significant intra-abdominal injuries can occur with minimal external signs 1, 4

Specific Management for Abdominal Wall Hematomas

• Rectus sheath hematomas and muscle hematomas typically resolve with conservative management including rest, analgesia, and observation 4
• Consider angio-embolization for expanding hematomas with active arterial extravasation identified on CT, particularly in anticoagulated patients 5
• Surgical evacuation is rarely needed unless there is compartment syndrome or hemodynamic compromise 4