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CLASSIC CASES Lateral compression pelvic injury & extraperitoneal rupture of the bladder Case Presentation A 30 year old female was admitted to the trauma service following a fall from approximately 8 metres. Intubated & ventilated at scene.
Chest X-ray:
Rib fractures 4-6th ribs. No pneumothorax/lung injury.
The pelvis X-ray shows a fracture
of the right sacrum, the right superior & inferior pubic ramii
and of the left superior pubic ramus.. A urinary catheter is inserted, which returns macroscopic haematuria. A full spinal series of radiographs shows no bony spinal injury. An orogastric tube is inserted and the patient transferred to the CT scanner.
CT scan of the abdomen & pelvis: There is no intra-peritoneal injury, but there is a large, extra-peritoneal haematoma surrounding the bladder:
A CT cystogram is performed. 300mls of contrast medium is diluted to 500 mls and instilled into the bladder. The resulting CT scan shows a significant extra-peritoneal bladder rupture:
Rectal examination and sigmoidoscopy were carried out to exclude rectal injury. The extra-peritoneal bladder rupture was treated conservatively with drainage via the urethral catheter only. And a repeat cystogram at 10 days showed no leakage from the bladder. The pelvic injury was deemed stable and the patient allowed to mobilise slowly. She made a complete recovery and was discharged following her check cystogram. Discussion Lateral compression injuries of the pelvis are classically associated with injuries to the intra-pelvic organs, rather than haemorrhage from vascular injury. Severe lateral compression injuries may have an associated external rotation (open-book) type injury on the contralateral side, which may lead to haemorrhage. Some pure lateral compression injuries may cause haemorrhage due to laceration of the inferior epigastric or obturator arteries.
5-10% of pelvic fractures have an associated bladder injury. Extraperitoneal injury is by far the most common, forming 85% of all bladder injuries. Bladder rupture should be suspected in all such injuries, and investigated when macroscopic haematuria is present. Diagnosis depends on retrograde cystography - either standard or CT cystography. 300mls of a 50% dilution of standard contrast agents is instilled via a catheter, to provide adequate bladder distension. In plain film cystography, anteroposterior, oblique and post-voiding films need to be taken. In this case, cystography has a 85-100% accuracy. CT cystography is to be preferred when the patient is undergoing CT scan for other abdominal or pelvic injuries. The technique is the same, and has a sensitivity of 95% and specificity of 100% for bladder injury. Anorectal examination, including sigmoisoscopy is vital to exclude rectal injury. Most mortality associated with this injury pattern is due to sepsis from missed injuries, and can be up to 40%. Extraperitoneal bladder rupture is managed by simple catheterisation for 7-10 days. Check cystography is performed to confirm closure of the leak. Any residual leak is usually due to retained bone fragments and may require surgical exploration. References 1. Burgess AR, Eastridge BJ, Young
JW et al 'Pelvic ring disruptions: effective
classification system and treatment protocols.' J Trauma
1990;30:848-56 trauma.org (7:1) January 2002 |
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