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Urinary and Rectal Injuries from Pelvic Frx

 



- Urinary Injuries:
    - see: renal / urogenital trauma
    - frx patterns at risk:
          - Malgaigne frx: rupture of bladder & urethra occurs in 20 % of patients;
          - pubic rami frx: (especially from straddle injuries);
               - urinary injuries common w/ pubic diastasis & frx of pubic rami;
               - prevalance of injury is < 20% w/ unilateral injuries but may be over 40 w/ bilateral pubic ramus frx;
    - evaluation of hematuria:
    - male urethral injuries:
          - anatomy:
                  - male urethra may be divided into anterior and posterior portions;
                         - posterior urethra consists of the prostatic and membranous segments;
                               - prostatic urethra is about 3.0 cm long and traverses the prostate gland between the bladder neck and verumontanum;
                               - membranous urethra:
                                       - 2.0 to 2.5 cm long
                                       - it traverses and is firmly fixed to the urogenital diaphragm;
                                       - urethral injury is most common in the bulbomembranous urethral junction with the prostate;
                                       - w/ posterior urethra injury, extravascation of contrast material is classically seen above the genitourinary diaphragm, but in practice, extravasation also occurs below the diaphram;
          - urethral injuries occur in upto 15% of men but rare in women;
          - in males supramembranous portion of urethra (? bulbous urethra) is most common site of injury;
          - injury may also occur in the cavernous and or prostatic portion of the urethra.
          - indicators of urethral injury:
                  - blood at the meatus;
                  - high-riding prostate on rectal examination;
                  - straddle-type fracture of pelvic ring;
          - management:
                  - patients with displaced rami fractures and sacroiliac joint disruptions may be at especially high risk of urethral injuries, and consideration is given to initial retrograde urethrograms before urethral instrumentation;
                  - w/ suspected urethral injury perform retrograde cytourthrogram prior to attempted foley insertion (goal is to avoid completing a partial tear or contaminating a retroperitoneal hematoma);
                  - if RUG is positive, then a suprapubic cystostomy tube needs to be inserted;
                          - consider need for angiography before performing RUG since extravasation of contrast medium from bladder rupture could potentially cloud findings on arteriography;
                  - if foley has been inserted into a patient with a suspected urethral injury, a pericatheter retrograde urethrogram can be performed;
                  - w/ partial urethral tear, attempt catheter placement as the initial treatment;
                  - controversies:
                          - management of anterior symphyseal injuries w/ concomitant urethra injury:
                                  - consider anterior plating of symphyseal injuries at either the time of supra-pubic catheter insertion or within a 24-48 hour window;
                                  - after 48 hours, risk of infection is unacceptably high;



    - bladder rupture:
         - requires prompt diagnosis so as to avoid hyperkalemia, hypernatremia, uremia, acidosis, and peritonitis;
         - can be extraperitoneal or intraperitoneal (or both);
         - extraperitoneal rupture:
               - most often, the rupture is anterior and extraperitoneal;
               - in rare may result from laceration from sharp bone spike;
               - in many cases, may be treated non operatively w/ suprapubic drainage;
         - intraperitoneal rupture:
               - occurs in about 15% of major pelvic fractures;
               - most often occurs from contussion to lower abdomen or to the symphyseal region;
               - may occurs w/o associated pelvic ring disruptions as the result of a seatbelt or steering wheel injury;
               - usually requires operative correction;

- Rectal & Gastrointestinal Injury
    - occur in less than 1% of pelvic fractures;
    - may include lacerations of the rectum, perforations of small or large bowel;
    - often rectal tears will be accompanying by perineal wounds;
    - during the rectal examination, the examiner can gently palpate the sacrum for tenderness or asymmetry;
    - if rectal exam is suspicious, then consider Renografin enema;
    - when rectal laceration is present, diverting colostomy is often indicated, accompanied by thorough irrigation and debridement of frx communicating with the laceration;
            - there is some indication that colosotomy diversion does not necessarily reduce incidence of infection;
            - ref: Open pelvic fracture and fecal diversion
    - consequences of a missed rectal tear include contamination and infection of the retroperitoneal hematoma;
           - always consider the possibility of rectal perforation in any patient w/ pelvic frx w/ unexplained fever, elevated WBC, abdominal tenderness;
    - w/ these injuries consider need for external fixation;

- Gynecologic Injury
    - may involve lacerations of vagina
    - results from dislocations of symphysis pubis or  frxs of pubic rami;
    - larger peritoneal lacerations can involve the perineum and rectum;
    - urethral injuries in females are uncommon;
           - female urethra is short and mobile and less susceptible to injury as compared to the male urethra;
    - inferior pubic ramus fractures that produce vaginal impingement are treated operatively



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