How Abdominopelvic Imaging Can Guide Trauma Management
Moving imaging from detection to direction in high-stakes clinical care
This is the third in a series of articles focused on abdominal imaging. Read the first and second articles in the series.
Abdominopelvic trauma is a time-critical, life-threatening emergency where any delay in diagnosis can significantly increase the risk of mortality. Because time is of the essence, imaging plays an active role.
“Trauma CT is not just about detection, it’s about correct interpretation and clear communication of findings that directly impact whether a patient is managed non-operatively, sent for embolization or taken to surgery,” said Sameer Raniga, MD, FRCR, a consultant radiologist at the University Medical City, Sultan Qaboos University Hospital in Muscat, Oman.
“The decision to manage surgically or nonoperatively should be based on both clinical and imaging parameters,” added Arjun Kalyanpur, MD, DABR, chief radiologist and co-founder of Teleradiology Solutions.
Drs. Raniga and Kalyanpur, together with Elizabeth Dick, MD, a consultant radiologist and professor of practice at Imperial College London, and Ana Blanco Barrio, MD, a radiologist at Hospital General Universitario J.M. Morales Meseguer in Murcia, Spain, participated in an RSNA 2025 session focused on providing practical, decision-oriented imaging in abdominopelvic trauma.
The session highlighted the benefits of taking a systematic approach to multidetector (MD) CT interpretation and covered common diagnostic blind spots for imaging solid organ and urinary tract injuries, pelvic ring disruptions and bowel and mesenteric trauma.
Recognizing Best Practices and Common Pitfalls
As Dr. Raniga explained, when it comes to imaging abdominopelvic trauma, the best practice starts with protocol discipline. “A well-timed contrast-enhanced MDCT tailored to the clinical question is absolutely essential,” he said.
Yet despite the importance of critical context, Dr. Raniga said that many radiologists are too reliant on grading systems. “Active hemorrhage, vascular injury, mesenteric devascularization or pelvic instability often outweigh the numeric grade,” he explained.
Another frequent pitfall in abdominopelvic trauma imaging is missing the subtle injuries. Common examples include bowel and mesenteric injuries with minimal early CT findings or masked pelvic instability in patients imaged with pelvic binders in place.
“Because their imaging findings can be subtle and non-specific, bowel and mesenteric injuries are among the most frequently missed findings on the initial trauma CT,” Dr. Blanco Barrio remarked.
According to Dr. Blanco Barrio, overlooking these critical findings can be problematic, as a delayed diagnosis can have a big impact on patient outcomes. For instance, because certain bowel and mesenteric injuries require early surgical intervention, even a five- to eight-hour delay in surgical management can significantly increase morbidity and mortality, primarily due to sepsis.
“The best way to avoid missing these subtle injuries is to adopt a structured search pattern, increase our awareness of the mechanism of injury and deliberately evaluate such commonly overlooked areas as the mesentery, pelvic sidewalls and retroperitoneum,” Dr. Raniga said.
“The best way to avoid missing these subtle injuries is to adopt a structured search pattern, increase our awareness of the mechanism of injury and deliberately evaluate such commonly overlooked areas as the mesentery, pelvic sidewalls and retroperitoneum.”
— SAMEER RANIGA, MD
How Imaging Can Guide Trauma Management
Radiology’s role in trauma care shouldn’t stop with imaging an injury. “Because imaging is key to triage, radiologists need to actively guide trauma management rather than merely describe it,” Dr. Raniga noted.
For example, in pelvic trauma, identifying an unstable pelvic ring injury with associated arterial bleeding will change the entire management pathway, triggering urgent hemorrhage control and often involving interventional radiology, surgical stabilization, or both.
Another area where radiology plays a key role in trauma management is urethral injury. “By picking up a urethral injury early, the patient can be treated early, which significantly decreases the risk of strictures later on,” Dr. Dick noted.
The radiological signs of urethral injury include loss of the normal fat plane anterior to the prostate due to hemorrhage or urine leak, along with hematoma in the perineal muscles. “If these are seen, then a diagnostic urethrogram should be suggested,” Dr. Dick said.
According to Dr. Kalyanpur, if a patient is hemodynamically stable with low grade liver or spleen injury, nonoperative management is indicated. However, if the patient is hemodynamically stable with evidence of high-grade liver or spleen injury with active hemorrhage, then interventional radiology management should be considered.
Yet, if the patient is hemodynamically unstable despite resuscitation, then imaging may be bypassed altogether in favor of emergency surgical exploration.
“By determining triage and guiding management, radiology can help anticipate and detect delayed complications, establish prognosis and, ultimately, help determine patient outcomes,” Dr. Kalyanpur said.
Effective Communication Improves Patient Outcomes
As a central decision point between diagnosis and treatment, radiologists must communicate these management-changing findings to trauma surgeons, emergency physicians and interventional radiologists.
“Effective communication is another way radiologists can help improve patient outcomes,” Dr. Raniga said.
Drs. Raniga, Kalyanpur, Dick and Blanco Barrio all agree that effective communication starts with clear and concise reports and structured impressions. They emphasized that it also involves building trust within the trauma team and being able to directly communicate critical findings that could reduce delays and prevent misinterpretation.
“At my institution, we maintain communication with a weekly multidisciplinary meeting where we review patients from the previous weeks, learn from each other, and reflect on what went well and what could have gone better,” Dr. Dick said.
Communicating with the trauma team can be further improved by using standard reporting protocols such as the American Association for the Surgery of Trauma, or AAST, grading protocol, as well as emerging technologies. “By enhancing abdominal trauma imaging and prioritizing findings, AI will help reduce the time it takes for a radiologist to communicate critical findings to the trauma team,” Dr. Kalyanpur added.
“The goal isn’t just to diagnose injuries, but to guide the right treatment at the right time,” Dr. Raniga concluded. “If trauma imaging does not change how we manage an injury, then we’ve missed a golden opportunity.”
For More Information
Read previous RSNA News stories on trauma imaging: