Delayed unilateral testicular rupture and symphysis pubis diastasis post negative trauma whole-body CT

Clinical History

A 29-year-old motorcyclist involved in a high speed road traffic collusion was brought to a major trauma centre. On arrival, the patient complained of diffuse severe pelvic pain.

Imaging Findings

A whole body trauma CT demonstrates fat stranding in anterior left pelvis of unclear significance (Figure 1).

Plain radiograph demonstrates symphyseal diastasis when the pelvic binder was removed despite normal CT positioning with pelvic binder in situ (Figure 2).

Urethrogram confirmed no acute urethral injury (Figure 3).

Ultrasound imaging of scrotum showed right testicular rupture with evidence of intra-testicular haematoma (Figure 4).

Discussion

Less than 1% of all trauma-related injuries is attributed to scrotal trauma which is usually a blunt trauma mechanism [1]. Causes of blunt scrotal trauma are usually 50% athletic injury, 9-17% road traffic collusion (RTC) and 10% assault [2].
Ultrasound imaging is the first line imaging modality for the evaluation of scrotal contents, testicular integrity, blood flow and haematomas. Delay in diagnosis can lead to infertility, delayed orchidectomy, infection, ischaemia, infarction or atrophy. Delayed diagnosis reduces salvage rate from 80% to 45% [3].
The case presents a 29-year-old motorcyclist involved in a high speed RTC. The patient complained of diffuse severe pelvic pain. A whole body trauma CT demonstrates fat stranding in anterior left pelvis of unclear significance.
The pelvic binder was removed. Plain radiograph demonstrates symphyseal diastasis despite normal CT positioning with pelvic binder in situ.
Patient had normal external genitalia, and per rectum and perineum examination was performed. However, in view of radiological findings on CT and a plain pelvic radiograph, urethrogram was performed and confirmed no acute urethral injury.
On day 4, the patient developed acute painful swelling of the right testis. Ultrasound imaging confirmed right testicular rupture (contralateral side to initial CT fat stranding) with evidence of intra-testicular haematoma.
Delayed presentation of this case led to atrophic testis. Evidence has long suggested that conservative treatment results in 21% of potential loss of testis versus 6% with surgical exploration [4]. The literature demonstrates these injuries all presenting with pain and swelling or testis position change on examination. An EMJ case report of motorcycle RTC reported testicular fracture with tender and high-riding testis on examination unlike this case report where it was delayed with normal examination initially [5].
In conclusion, this case demonstrates symphyseal diastasis post pelvic binder removal, after negative whole body trauma CT examination. It reiterates the need to undertake plain pelvic radiograph after binder removal. In addition, it demonstrates a delayed testicular rupture despite normal examination serially. It influences the need for robust and careful urological examination of trauma patients; an area sometimes neglected in primary, secondary and tertiary surveys.
Finally, we advocate using scrotal ultrasound imaging in the presence of symphyseal diastasis and pelvic pain without a cause on clinical examination or radiological findings.

Differential Diagnosis List

Final Diagnosis

Delayed unilateral testicular rupture

URL:	https://www.eurorad.org/case/12218
DOI:	10.1594/EURORAD/CASE.12218
ISSN:	1563-4086