Bladder incarceration in a traumatic symphysis pubis diastasis treated with external fixation: a case report and review of the literature

Bladder incarceration within a displaced pelvic ring nonunion

Pelvic ring injuries can be challenging to manage and may have a range of associated injuries. When bladder injuries occur in combination with pelvic ring fractures, a multidisciplinary approach may be required to plan the best course of treatment. Acute entrapment or injury to the urinary bladder after a pelvic fracture is well reported. Here, we present an interesting case of chronic bladder incarceration within a lateral compression pelvic ring injury nonunion after failed nonoperative management of the initial pelvis fracture. Treatment of the nonunion was complicated by an incidental diagnosis of lymphoma.

Bladder incarceration following anterior pelvic infix of a traumatic pubic symphysis diastasis treated with immediate open reduction and internal fixation

Stabilization after a pelvic fracture can be accomplished using multiple techniques. The anterior external fixator has been traditionally used in variety of unstable pelvis either singly or in combination of posterior screws. These devices are cumbersome and restrict side turning and sitting particularly in obese patients. An alternative, anterior subcutaneous pelvic internal fixation technique (ASPIF) was developed which is well tolerated by patients for mobility and comfort and biomechanically more stable construct Complications of this construct included irritation of the lateral femoral cutaneous nerve, femoral nerve palsy &heterotypic ossification with reduced rates of infections and aseptic loosening as compared to external fixator. Bladder incarceration following treatment has never been reported and we encountered such a problem during management which we want to highlight.

A rare case of paediatric pelvic ring injury with lower urinary tract obstruction secondary to a combat blast mechanism

Paediatric pelvic ring fractures are rare, and typically the result of high-energy mechanisms that yield other potentially fatal visceral and solid organ injuries. Specific pelvic fracture patterns have been associated with injury to the lower urinary tract, with the most severe involving laceration of the bladder or transection of the urethra. We report a unique case of paediatric pelvic ring disruption causing an isolated obstruction of the lower urinary tract without laceration or discontinuity. Although most paediatric pelvic fractures are managed non-operatively, we postulate that significant ring deformity contributing to urinary retention be considered an indication for open surgical treatment.

Acute bladder entrapment without perforation after trauma

Acute bladder entrapment within a pubic bone fracture is a rare entity. Computed tomography revealed bladder entrapment without perforation in a man who had been struck by an automobile and had presented with mild hematuria. At the pelvic stabilization surgery, the bladder was manually reduced into its normal anatomic position without complications.

Emergent management of APC-2 pelvic ring injuries with an anteriorly placed C-clamp

OBJECTIVE

Can anteriorly placed pelvic C-clamps be used successfully in the emergent management of APC-2 pelvic fractures?

DESIGN

Prospective cohort.

SETTING

Level 1 trauma center.

PATIENTS

A single-surgeon series of 24 patients with an anteroposterior compression type 2 pelvic fracture.

INTERVENTION

Application of an anteriorly placed pelvic C-clamp within 2 hours of presentation.

MAIN OUTCOME MEASUREMENTS

Response to hypotension, complications related to pin placement, application time, and symphyseal reduction measured on anteroposterior radiograph.

RESULTS

Twenty-four patients with a mean age of 29 years (14-58 years) had an APC-2 pelvic fracture diagnosed by an anteroposterior radiograph of the pelvis on presentation. All patients were emergently managed with an anteriorly placed C-clamp applied in the emergency room (10), angiography suite (9), or operating room (5). Eleven patients presented with hypotension (systolic blood pressure <90 mm Hg) and had an average elevation of their blood pressure of 23 mm Hg (10-44 mm Hg). The symphyseal separation was reduced from a mean of 4.5 cm (3-9 cm) to <2 cm in all cases and to <1 cm in 21 of 24 cases. Complications included 1 misdiagnosis of an APC-3 injury and 2 cases in which the clamp became dislodged when the patients were rolled in the intensive care unit. Thirteen patients required laparotomy or angiography for further management after the C-clamp was applied. The C-clamp was easily draped out of the field for both procedures.

CONCLUSIONS

The pelvic C-clamp can be placed anteriorly as a part of the early management of APC-2 pelvic fractures with a short application time in a variety of patient care areas.

Bladder incarceration following anterior external fixation of a traumatic pubic symphysis diastasis treated with immediate open reduction and internal fixation

Anterior pelvic ring disruptions are often associated with injuries to the genitourinary structures with the potential for considerable resultant morbidity. Herniation of the bladder into the symphyseal region after injury with subsequent entrapment upon reduction of the symphyseal diastasis has seldom been reported in the literature. We report such a case involving bladder herniation and subsequent entrapment after attempted closed reduction with anterior pelvic external fixation immediately treated with open reduction and internal fixation along with a review of the literature.

[Refixation of the M. recti abdomini on the symphysis in traumatic pubis symphysis disruption. Reconstruction to the original anatomic situation]

Pelvic fractures may accompany other injuries and can be life-threatening. In addition, the rectus abdominis muscles might also be torn. During fracture reduction, these muscles are fixed to their insertions. The goal should be reconstruction as close as possible to the original anatomic situation. Refixation of the vertical rectus muscles that have retreated cranially results in preventing development of lower abdominal wall hernia.A hernia in combination with a symphysis disruption has been reported very seldom in the available literature. We report here on a case of hernia that developed postoperatively after treatment of traumatic pubic symphysis rupture. Primary open reduction of the symphysis was carried out and the rectus abdominis muscles were refixed to the bones. An attempt was made to repair the incisional hernia that developed by tightening the fascia. Two and a half years after the accident, the patient developed a diastasis and an abdominal wall hernia, which were repaired by refixation of the rectus abdominis muscles to the bones with Mersilene bands. Results nine months after the reconstructive surgical intervention show a firm abdominal wall without recurrence.This case shows that even 2.5 years after an accident, the rectus abdomini muscles can be fixed with Mersilene bands to the bone and anatomic reconstruction of the abdominal wall can be carried out.

Successful repair of a bladder herniation after old traumatic pubic symphysis diastasis using bone graft and hernia mesh

Bladder herniation associated with pubic symphysis diastasis is a very rare condition. We report a case with bladder herniation after traumatic pubic symphysis disruption. The patient was treated with open reduction of the bladder and definitive internal fixation of the pubis. We used a bone allograft for closure of the diastasis and a prolene mesh graft for supporting the abdominal wall. We obtained a successful outcome during a 12-month follow-up period.

[Severe pelvic fractures, associated injuries and hemodynamic instability: incidence, management and outcome in our center]

INTRODUCTION

The aim of this study was to review the incidence, treatment and outcome of severe pelvic fractures, as well as associated injuries, in our center.

PATIENTS AND METHOD

We performed a retrospective study of patients included in our trauma registry between June 1993 and January 2005. Pelvic fractures were classified according to the system proposed by Tile. Clinical and demographic data such as age, gender, mechanism of injury, transfer time, hemodynamic status, and trauma scores were compared and analyzed statistically. Shock was defined as a systolic blood pressure of < or = 90 mmHg during the primary assessment. Mortality and associated risk factors were analyzed, with emphasis on patients in shock on admission.

RESULTS

Of 1274 patients with severe trauma admitted during the study period, 192 (15%) had pelvic fracture. Only 6.7% were isolated fractures and 6% were open fractures. Twenty percent of the patients were in shock on admission. The mean Injury Severity Score of the series was 28.5 +/- 14 and that of patients in shock was 38 +/- 16. The most frequently associated injuries were thoracic (70%), abdominal (55%), long bone fractures (52%), and head injuries (40%). Twenty-three percent of the patients had retroperitoneal hematoma. Arteriograms were performed in 16 patients, with four embolizations. Eight patients underwent external orthopedic fixation, and none posterior orthopedic fixation. Five patients underwent pelvic packing and two patients underwent ligation of hypogastric arteries. Overall mortality was 30% and mortality in patients in shock was 61%. Predictors of mortality were shock on admission, a Glasgow Coma Scale score of < or = 8, ISS > 25 and age > 55 years.

CONCLUSIONS

Patients in shock with pelvic fractures have a poor prognosis in our center, frequently related to the severity of associated injuries, the relative rarity of these fractures, and the lack of a clearly defined management protocol. The main cause of death was massive hemorrhage.

Contemporary management of pelvic fractures

BACKGROUND

Pelvic fractures occur when there is high kinetic energy transfer to the patient such as would be expected in motor vehicle crashes, auto-pedestrian collisions, motorcycle crashes, falls, and crush injuries. High-force impact implies an increased risk for associated injuries to accompany the pelvic fracture, as well as significant mortality and morbidity risks. Choosing the optimum course of diagnosis and treatment for these patients can be challenging. The purpose of this review is to supply a contemporary view of the diagnosis and therapy of patients with this important group of injuries.

METHODS

A comprehensive review of the medical literature, focusing on publications produced in the last 10 years, was undertaken. The principal sources were found in surgical, orthopedic, and radiographic journals.

CONCLUSIONS

The central challenge for the clinician evaluating and managing a patient with a pelvic fracture is to determine the most immediate threat to life and control this threat. Treatment approaches will vary depending on whether the main threat arises from pelvic fracture hemorrhage, associated injuries, or both simultaneously. Functional outcomes in the long-term depend on the quality of the rigid fixation of the fracture, as well as associated pelvic neural and visceral injuries.

Endoscopy for anterior pelvis fixation

The objectives of this study are to describe the anatomic findings relative to anterior pelvic endoscopy, determine the potential use of endoscopy for reduction and fixation of fractures of the anterior pelvic ring, and report two illustrative cases performed using this method. Using the windows described, endoscopy permits placement of plates and screws on top of the symphysis pubis, reduction of internally displaced fragments, and performance of percutaneous procedures that do not harm anatomic structures.

Posterior locked lateral compression injury of the pelvis: report of three cases

Lateral compression injuries to the pelvis typically result in a rotationally unstable and vertically stable condition including an impaction and compression fracture of the posterior pelvic ring. The operative and postoperative management, as well as the morbidity and mortality, of these fractures differs significantly from vertical shear injuries to the pelvis, which are characterized by vertical and rotational instability. We report on three unusual lateral compression injuries to the pelvis, resulting in a complete disruption of the pelvic ring with vertical and rotational instability, by definition. Nevertheless, in these patients, locking of the posterior pelvic ring with medial translation of the iliac wing anterior to the sacrum resulted in a pseudostable condition. Their high rate of fracture-related associated injuries and possible complications, as well as the malalignment of the pelvis, required surgical restoration of the pelvic ring. Fracture reduction was successfully performed through an anterior approach in one patient and a posterior approach in two patients; the posterior approach was preferred. Open reduction and internal fixation of these pelvic ring fractures can result in a satisfactory outcome if the associated injuries are successfully dealt with.