A missile hits the body just above the pubic ramus through the anterior abdominal wall it will pierce which of the following structure?
Correct Answer: Urinary bladder
Description: To answer this first we have to know the location of each option. Left renal vein is at the level of L2, Abdominal aoa at the level of T12, Spinal cord terminates at the lower border of L1. Urinary bladder when empty is located within the pelvis, as it fills it expands and extends upwards into the abdominal cavity, reaching up to the umbilicus or even higher. Thus in a penetrating injury of lower abdomen urinary bladder is the only structure that could have been pierced.Penetrating injuries of bladder: Bladder injuries can occur as a result of either penetrating or blunt trauma. Bladder injuries are classified as extraperitoneal (60%), intraperitoneal (30%), or both (10%). Stab or gun shot wound to the lower abdomen or perineum can injure the bladder. Gross hematuria is seen in 90% of patients. Classification: Bladder injury can be classified by AAST Bladder Organ Injury Scale.GradeType of injuryInjury DescriptionAIS 90IHaematomaContusion, intramural haematoma2ILacerationPaial thickness3ILacerationExtraperitoneal bladder wall laceration <2cm4IIILacerationExtraperitoneal (>2cm) or intra-peritoneal (4IVLacerationIntraperitoneal bladder wall laceration >2cm4VLacerationLaceration extending into bladder neck or ureteral orifice (trigone)4 Advance one grade for multiple injuries Management: Cystography is the most accurate method. CT cystography also has similar value. Contusions can be managed by catheter drainage alone. Intraperitoneal and extraperitoneal penetrating injury needs surgical exploration. Morbidity is related to the associated injuries. Ref: Ballistic Trauma, edited by Adam Brooks, 3rd Edition, page 474
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