Pelvic fracture and associated urologic injuries

Bladder injuries after external trauma: 20 years experience report in a population-based cross-sectional view

OBJECTIVES

Report 20 years experience of bladder injuries after external trauma.

METHODS

Gender, age, mechanism/location of damage, associated injuries, systolic blood pressure (SBP), Revised Trauma Score (RTS), Injury Severity Score (ISS), Trauma Injury Severity Score (TRISS), complications, and length of stay (LOS) were analyzed in a prospective collected bladder injuries AAST-OIS grade ≥ II database (American Association for the Surgery of Trauma Organ Injury Scaling) from 1990 to 2009 in a trauma reference center.

RESULTS

Among 2,575 patients experiencing laparotomy for trauma, 111 (4.3 %) presented bladder ruptures grade ≥ II, being 83.8 % (n = 93) males, mean age 31.5 years old (± 11.2). Blunt mechanism accounted for 50.5 % (n = 56)-motor vehicle crashes 47.3 % (n = 26), pedestrians hit by a car (29.1 %). Gunshot wounds represented 87.3 % of penetrating mechanism. The most frequent injury was grade IV (51 patients, 46 %). The mean ISS was 23.8 (± 11.2), TRISS 0.90 (± 0.24), and RTS 7.26 (± 1.48). Severity (AAST-OIS), mechanism (blunt/penetrating), localization of the bladder injury (intra/extraperitoneal, associated), and neither concomitant rectum lesion were related to complications, LOS, or death. Mortality rate was 10.8 %. ISS > 25 (p = 0.0001), SBP <90 mmHg (p = 0.0001), RTS <7.84 (p = 0.0001), and pelvic fracture (p = 0.0011) were highly associated with grim prognosis and death with hazard ratios of 5.46, 2.70, 2.22, and 2.06, respectively.

CONCLUSIONS

Trauma scores and pelvic fractures impact survival in bladder trauma. The mortality rate has remained stable for the last two decades.

Bilateral testicular dislocation with pelvic ring fracture: a case report and literature review

We report a case of a bilateral testicular dislocation with B1-1 pelvic-ring fracture according to the modified Tile AO classification, in a patient of 62 years. The mechanism of injury was impaction on the tank of a motorcycle. Symphyseal plate fixation using a Pfannenstiel approach was associated to bilateral orchidopexy through scrotal approach. The posterior pelvic ring was stabilized by iliosacral screwing because the left sacroiliac joint was open. The outcome was favorable without disorders of gonadal function. Systematic testicular palpation and careful CT analysis of the genital organs enabled identification and effective management of these rare urinary tract lesions.

Blunt bladder injury

Bladder injury should be suspected when trauma is followed by gross hematuria, suprapubic or abdominal pain, and difficulty in voiding or the inability to void. Bladder rupture with blunt abdominal trauma is uncommon; however, because of its high mortality rate, recognition of the early signs and symptoms can be life saving. The most common type of injury is a bladder contusion, which is a diagnosis of exclusion. Extraperitoneal bladder ruptures are almost exclusively associated with a pelvic fracture.

Laparoscopic repair of traumatic intraperitoneal bladder rupture: Case report and review of the literature

We present a case of intraperitoneal bladder rupture in a 42-year-old man repaired by a laparoscopic approach. Details of the case and a description of the operative procedure are outlined. We also review the literature on laparoscopic repair of traumatic bladder rupture.

The outcome of surgically treated traumatic unstable pelvic fractures by open reduction and internal fixation

BACKGROUND

This study was performed to evaluate functional and radiological results of pelvic ring fractures treatment by open reduction and internal fixation.

METHODS

Thirty eight patients with unstable pelvic fractures, treated from 2002 to 2008 were retrospectively reviewed. The mean patients' age was 37 years (range 20 to 67). Twenty six patients were men (4 patients with type B and 22 patients with type C fracture) and 12 women (7 patients with type B and 5 patients with type C fracture). The commonest cause was a road traffic accident (N=37, about 97%). Internal fixation was done by plaque with ilioinguinal and Kocher-Langenbeek approaches for anterior, posterior pelvic wall and acetabulum fracture respectively. Quality of reduction was graded according to Majeed score system.

RESULTS

There were 11 type-C and 27 type-B pelvic fractures according to Tile's classification. Thirty six patients sustained additional injuries. The commonest additional injury was lower extremity fracture. The mean follow-up was 45.6 months (range 16 to 84 months).The functional outcome was excellent in 66%, good in 15%, fair in 11% and poor in 7% of the patients with type B pelvic fractures and functional outcome was excellent in 46%, good in 27%, fair in 27% and poor in 0% of the patients with type C pelvic fractures. There were four postoperative infections. No sexual functional problem was reported. Neurologic problem like Lateral cutaneous nerve of thigh injury recovered completely in 2 patients and partially in 2 patients. There was no significant relation between functional outcome and the site of fracture (P greater than 0.005).

CONCLUSIONS

Unstable pelvic ring fracture injuries should be managed surgically by rigid stabilization. It must be carried out as soon as the general condition of the patient permits, and even up to two weeks.

High rates of sexual and urinary dysfunction after surgically treated displaced pelvic ring injuries

BACKGROUND

Pelvic ring injuries may be associated with genitourinary injury (GUI) and result in urinary or sexual dysfunction.

QUESTIONS/PURPOSES

We determined (1) incidence of new sexual and urinary dysfunction after surgically treated pelvic ring injuries, (2) association of sexual or urinary dysfunction to fracture type and GUI, and (3) incidence and association between new sexual and urinary dysfunction in male and female patients without GUI.

METHODS

We retrospectively studied 151 patients by postal questionnaire after pelvic reconstruction. Presence, type, and severity of new sexual dysfunction and urinary dysfunction were related to GUI and type of pelvic fracture using the Young and Burgess classification. Minimum followup was 1 year (median, 5 years; range, 1-12 years).

RESULTS

New sexual dysfunction occurred in 61 of 143 (43%) and urinary dysfunction in 61 of 150 (41%) responding patients. Neither new sexual nor urinary dysfunction was associated with sex or GUI. In patients with no GUI, new sexual dysfunction was associated with chronologic age (odds ratio [OR], 1.04/year; 95% CI, 1.01-1.07) and pelvic fracture type. Lateral compression injury was less likely to result in new sexual or urinary dysfunction compared with AP type (sexual OR, 1.73; 95% CI, 0.67-4.47; urinary OR, 2.97; 95% CI, 1.15-7.66) and vertical shear type (sexual OR, 2.60; 95% CI, 1.02-6.64; urinary OR, 4.6; 95% CI, 1.81-11.73).

CONCLUSIONS

Our data suggest new sexual and urinary dysfunction occur at relatively high rates after pelvic fracture in patients with or without GUI. We recommend early assessment and referral for specialist treatment.

LEVEL OF EVIDENCE

Level III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review

BACKGROUND

Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice.

METHODS

Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence.

RESULTS

Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing?

CONCLUSIONS

Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

Assessment and initial management of urologic trauma

This article discusses the appropriate assessment, initial management, timely referral to a urologist for abdominal, bladder, urogenital, and renal/renal collecting system injury. Appropriate laboratory and physical examinations, as well as radiologic imaging, are paramount to obtaining accurate diagnosis and to providing appropriate treatment.

Fractures of the pelvis

High energy fractures of the pelvis are a challenging problem both in the immediate post-injury phase and later when definitive fixation is undertaken. No single management algorithm can be applied because of associated injuries and the wide variety of trauma systems that have evolved around the world.

Initial management is aimed at saving life and this is most likely to be achieved with an approach that seeks to identify and treat life-threatening injuries in order of priority. Early mortality after a pelvic fracture is most commonly due to major haemorrhage or catastrophic brain injury. In this article we review the role of pelvic binders, angiographic embolisation, pelvic packing, early internal fixation and blood transfusion with regard to controlling haemorrhage.

Definitive fixation seeks to prevent deformity and reduce complications. We believe this should be undertaken by specialist surgeons in a hospital resourced, equipped and staffed to manage the whole spectrum of major trauma. We describe the most common modes of internal fixation by injury type and review the factors that influence delayed mortality, adverse functional outcome, sexual dysfunction and venous thromboembolism.

Delayed presentation of bladder entrapment secondary to nonoperative treatment of a lateral compression pelvic fracture

Entrapment of the bladder secondary to pelvic fracture is infrequently described in the literature. Entrapment has most commonly been found to occur through the actions of internal or external fixation. This case report presents bladder entrapment that was not detected until the patient developed genitourinary symptoms and dyspareunia 8 months after nonoperative treatment of a stable lateral compression pelvic fracture.

Pelvic Fractures: Soft Tissue Trauma

Severe open injuries of the pelvis go with a high complication, morbidity and mortality rate. A stepwise approach is the way to achieve reasonable results; however, final clinical outcome is in a large number of cases suboptimal.

Value of transrectal ultrasonography in female traumatic urethral injuries

OBJECTIVES

To estimate the value of transrectal ultrasonography (TRUS) in traumatic urethral injuries of various types in females.

METHODS

A total of 30 female patients with symptoms of urethral injuries after trauma underwent TRUS between January 2005 and July 2008. Of them, 28 patients with operative indications undertook operation; the other 2 received conservative management and then a follow-up ultrasonography. All outcomes were used to validate the results of TRUS.

RESULTS

Urethral injuries were clearly observed in 30 cases with TRUS. The continuity of urethral wall, unblocking of urethral lumen, and homogeneous echo of surrounding structures had been changed. Urethral injuries varied in types, including urethrovaginal fistula, urethral stricture, urethral rupture, and urethral hematoma. It was common to find several injury patterns simultaneously in 1 patient. The outcomes in 28 cases with operative indications were consistent with results of surgery. The other 2 cases were diagnosed as urethral hematoma by TRUS which disappeared in a follow-up sonography after 3 months' conservative management.

CONCLUSIONS

TRUS is a reliable technique to exhibit abnormalities in injured urethra associated with trauma in female.

The sentinel clot sign: a useful CT finding for the evaluation of intraperitoneal bladder rupture following blunt trauma

Objective

To evaluate the frequency and relevance of the "sentinel clot" sign on CT for patients with traumatic intraperitoneal bladder rupture in a retrospective study.

Materials and Methods

During a recent 42-month period, 74 consecutive trauma patients (45 men, 29 women; age range, 12-84 years; mean age, 50.8 years) with gross hematuria were examined by the use of intravenous contrast-enhanced CT of the abdomen and pelvis, followed by retrograde cystography. Contrast-enhanced CT scanning was performed by using a helical CT scanner. CT images were retrospectively reviewed in consensus by two radiologists. The CT findings including the sentinel clot sign, pelvic fracture, traumatic injury to other abdominal viscera, and the degree of intraperitoneal free fluid were assessed and statistically analyzed using the two-tailed χ² test.

Results

Twenty of the 74 patients had intraperitoneal bladder rupture. The sentinel clot sign was seen for 16 patients (80%) with intraperitoneal bladder rupture and for four patients (7%) without intraperitoneal bladder rupture (p < 0.001). Pelvic fracture was noted in five patients (25%) with intraperitoneal bladder rupture and in 39 patients (72%) without intraperitoneal bladder rupture (p < 0.001). Intraperitoneal free fluid was found in all patients (100%) with intraperitoneal bladder rupture, irrespective of an associated intraabdominal visceral injury, whereas 19 (35%) of the 54 patients without intraperitoneal bladder rupture had intraperitoneal free fluid (p < 0.001).

Conclusion

Detection and localization of the sentinel clot sign abutting on the bladder dome may improve the accuracy of CT in the diagnosis of traumatic intraperitoneal bladder rupture, especially when the patients present with gross hematuria.

Retrograde urethrocystography impairs computed tomography diagnosis of pelvic arterial hemorrhage in the presence of a lower urologic tract injury

BACKGROUND

There is controversy about the appropriate sequence of urologic investigation in patients with pelvic fracture. Use of retrograde urethrography or cystography may interfere with regular pelvic CT scanning for arterial extravasation.

STUDY DESIGN

We performed a retrospective study at a regional trauma center in Toronto, Canada. Included were adult blunt trauma patients with pelvic fractures and concomitant bladder or urethral disruption who underwent initial pelvic CT before operation or hospital admission. Exposure of interest was whether retrograde urethrography (RUG) and cystography were performed before pelvic CT scanning. Main outcomes measures were indeterminate or false negative initial CT examinations for pelvic arterial extravasation.

RESULTS

Sixty blunt trauma patients had a pelvic fracture and either a urethral or bladder rupture. Forty-nine of these patients underwent initial CT scanning. Of these 49 patients, 23 had RUG or conventional cystography performed before pelvic CT scanning; 26 had cystography after regular CT examination. Performing cystography before CT was associated with considerably more indeterminate scans (9 patients) and false negatives (2 patients) for pelvic arterial extravasation (11 of 23 versus 0 of 26, p < 0.001) compared with performing urologic investigation after CT. In the presence of pelvic arterial hemorrhage, indeterminate or false negative CT scans for arterial extravasation were associated with a trend toward longer mean times to embolization compared with positive scans (p=0.1).

CONCLUSIONS

Extravasating contrast from lower urologic injuries can interfere with the CT assessment for pelvic arterial extravasation, delaying angiographic embolization.

Long-term outcome in patients with combined spinal and pelvic fractures

The outcome of 30 patients with combined spinal and pelvic fractures (C group) was retrospectively investigated and compared with matched group of similar number of isolated spinal fractures (S group) and isolated pelvic fractures (P Group), admitted to our institution between Jan 1998 and May 2002, following a high-energy trauma. After a mean follow-up of 57 months their outcomes were studied using EuroQol questionnaire and return to work status. The EQ-5D scores for patients in the S group were 0.71 (SD 0.29) compared to 0.60 (SD 0.14) for patients in the P group and 0.63 (SD 0.23) for patients in the C group. The EQ-VAS scores were similarly favourable towards patients in the S group. Seventy percent of patients in the S group returned to their previous level of employment after a mean duration of 5.3 months compared to 55% in the P group and 57% in the C group after a mean duration of 9.4 months and 12.8 months, respectively. Patients with isolated spinal fractures had an overall satisfactory outcome compared with patients in the other 2 groups. However, no difference was noted while analysing the outcomes in the later 2 groups (p<0.05), suggesting that the pelvic fracture contributes to the poor outcome, and the presence of a spinal fracture does not influence the long-term outcome. However, problems related to associated injuries and motor neurological deficits have profound confounding effect on the outcome in all 3 groups.

Specific Fracture Configurations Predict Sexual and Excretory Dysfunction in Men and Women 1 Year After Pelvic Fracture

PURPOSE

We determined the prevalence and predictors of sexual and excretory dysfunction in patients 1 year after pelvic fracture.

MATERIALS AND METHODS

The multicenter Pennsylvania Trauma Outcomes Study enrolled 1,238 patients and contacted them 1 year after injury. Sexual limitations and excretory dysfunction (bladder/bowel incontinence) were defined based on responses from the Functional Capacity Index. Health related quality of life was determined using SF-36. The relationship between specific fracture patterns and dysfunction along with the effect of dysfunction on quality of life in patients with pelvic fracture were evaluated by multivariate analysis.

RESULTS

Of 1,160 eligible patients 292 (26%) had pelvic fractures. Sexual dysfunction was reported in 21% vs 14% of those with vs without pelvic fractures and bowel or bladder incontinence was reported in 8% vs 4%. On multivariate analysis men with sacroiliac fractures were at higher risk for sexual (RR 4.0, 95% CI 2.3 to 6.8) and excretory (RR 4.3, 95% CI 1.4 to 13.5) dysfunction. In women symphyseal diastasis was associated with sexual (RR 4.8, 95% CI 2.0 to 11.2) and excretory (RR 12.5, 95% CI 1.9 to 80.2) dysfunction. Of patients with pelvic fractures men with sexual dysfunction and women with excretory dysfunction had significantly worse quality of life than those without dysfunction.

CONCLUSIONS

One year after trauma men with sacroiliac fractures and women with symphyseal diastasis were at increased risk for sexual and excretory dysfunction independent of overt pelvic organ injury. In patients with pelvic fracture male sexual dysfunction and female excretory dysfunction were associated with decreased quality of life. Our data highlight the need for further study of dysfunction following pelvic trauma and interventions to decrease the risk of long-term disability.

Auditing 655 Fatalities with Pelvic Fractures by Autopsy as a Basis to Evaluate Trauma Care

BACKGROUND

To determine the role of pelvic fractures in auditing mortality resulting from trauma.

STUDY DESIGN

This retrospective case-control study based on autopsy-evaluated circumstances of the deaths of patients with pelvic fractures.

RESULTS

Of 2,583 patients injured in motor-vehicle collisions, 655 (25.4%) constituted the pelvic fracture (PFx) group, and 1,928 (74.6%) constituted the control group. One-third of the PFx group's fatalities had an Injury Severity Score (ISS) of 75 and were not preventable. The PFx group had a substantially higher median ISS than the control group (50 versus 34; p < 0.0001). Four hundred fifty-four patients (69.3%) in the PFx group with ISS 16 to 74 had substantially higher rates of associated injuries. Nearly half of the PFx group patients with ISS <or= 74 had a potential cause of major hemorrhage other than pelvic fracture. Twenty-three (3.5%) deaths were directly attributable to pelvic fractures. Postinjury median survival time was 55 minutes for the PFx group and 100 minutes for the control group (p < 0.0001). The time limit for management of the patients with pelvic fractures was short, as 527 (81.5%) died in the first 6 hours. It was evident that the more severe the injuries were, the sooner the deaths occurred. Of 151 subjects who left the emergency department alive, 61.6% were subjected to operation and 48.3% to abdominal operation.

CONCLUSIONS

Pelvic fracture is an indicator of severe multiple trauma, but a small proportion of deaths are directly attributable to pelvic fracture. A method based on autopsy audited patients with pelvic fractures as a paradigm of injury revealed that pelvic fracture is an important injury to consider in auditing trauma care and indicated several issues that should be considered to reduce mortality.

The effectiveness of early primary realignment in children with posterior urethral injury

AIM

The aim of this retrospective study was to compare the results of delayed repair and early primary realignments in patients with posterior urethral injury.

METHODS

From 1990 to 2003, 20 children were admitted to the Medical Faculty of Uluday University, Bursa, Turkey, for posterior urethral injuries. Traffic accidents were the most common cause of injury (n = 17). Twelve patients (60%) who were referred early (1-10 days) underwent early realignment over a urethral tube. A total of eight patients (40%) underwent delayed repair using transpubic route. In these patients, surgical repair of the urethra was performed 5-6 months later.

RESULTS

Of the 12 patients who underwent early urethral realignment, six required at least one visual internal urethrotomy following the removal of the urethral catheter. Urethral stricture developed in two of 12 patients (16.6%) who underwent early urethral realignment. Of the eight patients who underwent delayed repair, six required at least one visual internal urethrotomy following removal of the urethral catheter. Urethral stricture developed in three of eight patients (37.5%) who underwent delayed repair. This difference was statistically significant (P < 0.05).

CONCLUSION

The urethral stricture in patients who underwent early primary realignment was less developed than the stricture that developed in those who underwent delayed management. According to these results we recommend early primary realignment in children with posterior urethral injury.

Open pelvic fractures: epidemiology, current concepts of management and outcome

Open pelvic fractures constitute one of the most devastating injuries in musculo-skeletal trauma and must be treated aggressively, incorporating a multidisciplinary approach. Early treatment, focusing on prevention of haemorrhage and sepsis, is essential. The management of associated soft tissue injuries must also be aggressive, including early administration of broad-spectrum antibiotics and repeated, meticulous wound debridement and irrigation. Selective faecal diversion, based on wound location, is compulsory and safe, minimising the risk of sepsis and reducing mortality rates.