Pelvic injuries and associated injuries

PELVIC INJURIES
DR.A.PRANEETH
2ND YEAR PG RESIDENT
DEPT OF GENERAL SURGERY
DR PSIMS & RF

Pelvic Trauma : epidemiology
 The incidence of this injury that jeopardize not only the function, but the very
life of the patient has increased for past two decades due to high speed
motor vehicle accidents.
 Mortality 6 to 19%. If hypotensive, mortality increases to 13- fold
 30% due to falls.
 60% due to MVAs.
 65% of deaths due to haemorrhage.
 Fractures of the pelvis account for less than 5% of all skeletal injuries,
Among the polytrauma patients, the incidence has risen to 25%.

Complex pelvic fractures (higher energy) – younger patients,
M:F = 3:1
50 to 60% of deaths due primarily to pelvic fracture occur within
first nine hours of hospital admission.
Hemorrhage is leading cause of death overall.
closed head injury is the most common for lateral compression
injuries.

Immediate Sequelae of
Pelvic Trauma
 Massive haemorrhage.
 Bony disruption of pelvis.
 Vascular interruption (major and minor).
 Urologic injury.
 Bowel and vaginal tears of perforations.
 Neurologic injury.

ANATOMY
 The pelvic ring is composed of the sacrum and 2 innominate bones joined
anteriorly at the symphysis and posteriorly at the paired sacroiliac joints.
 Ileum is the largest contributor to the hemipelvis, is the primary structural
element in the transference of body weight from the spine to the lower
extremities in erect position.
 Ischium Serves as terminal point of weight transmission in sitting position.
 Pubis has three parts - Superior rami , Inferior rami , Symphysis.

 Sacrum - thin large triangular bone inserted like a key stone or wedge
between two innominate bones
 The pelvic brim is formed by the arcuate lines that join the sacral
promontory posteriorly and the superior pubis anteriorly.
 Below this is the true or lesser pelvis, in which are contained the pelvic
viscera.
 Above this is the false or greater pelvis that represents the inferior aspect of
the abdominal cavity.

Functional biomechanics of the pelvis
 Pelvis allows transfer of weight from 5th lumbar vertebra to the upper three
segments of sacrum, SI joint, to the thick strut of ilium that forms roof of greater
sciatic notch and then to roof of acetabulum in standing position and ischial
tuberosity in sitting position

Regions of the abdomen
peritoneal cavity subdivided into:
intrathoracic segment
covered by bony thorax and includes diaphragm,
liver, spleen, stomach and transverse colon
abdominal segment
retroperitoneum
aorta, vena cava, pancreas, kidneys, ureters and portions
of duodenum and colon (not sampled by peritoneal lavage)
pelvic organs
rectum, bladder, iliac vessels, internal genitalia of
women (injury also difficult to diagnose early because of
anatomical location )

PELVIC FRACTURES
 Fractures of the pelvis, exclusive of the acetabulum, generally
are either stable fractures resulting from lowenergy trauma, such
as falls in elderly patients, or fractures caused by highenergy
trauma that result in significant morbidity and mortality.

Pelvic stability
Definition : the ability of pelvis to withstand physiological forces
without significant displacement.
The pelvic bones themselves have no inherent stability and
therefore the integrity of the ligamentous structures is crucial to
the preservation or the loss of stability

Mechanism of injury
 Impact injuries - result when a moving victim strikes a stationary object
or vice versa.
 Direction, magnitude, and nature of the force all contribute to the type
of fracture.
 Crush injuries - occur when a victim is trapped between the injurious
force, such as motor vehicle, and an unyielding environment, such as
the ground or pavement.
 Low-energy injuries: Typically resulting in fractures of individual bones.
May result from sudden muscular contractions in young athletes that
cause an avulsion injury, a low-energy fall,or a straddle-type injury

 High-energy fractures
 May result in pelvic ring disruption
 Typically due to MVA, pedestrian-struck, motorcycle
 accident, fall from heights, or crush mechanism.
 Blunt injury (nonpenetrating):
 Rapid deceleration, (accidents or falls from heights)
 Direct anteroposterior crushing, (seat belts)
 Direct laceration of a major vessel by a bone fragment, as occurs in severe
pelvic fractures.
 time of injury , condition of injured persons , mechanism
 estimated speed of impact
 damage to involved vehicles

 Penetrating injury
 time of injury
 Low-velocity missiles cause direct injury to the vessel.
 High-velocity missiles and blasts can also cause vascular trauma
by means of the shock wave and transient cavitation.
 distance from assailant (particularly for shotgun wounds)
 may be associated with injury to the genitourinary system and
rectum
 number of stab attempts or shots
 amount of blood at scene
 type of weapon (eg knife length, handgun calibre)

Pelvic fractures classification
Tile classification

pelvic ring disruption
stable unstable
rotational vertical
 Stable injuries include non displaced fractures of the pelvic ring and
fractures resulting in <2.5cms of displacement of anterior structures ,
anterior pubic rami or symphysis.
 Rotational instability is characterized by widening of symphysis pubis or
displacement of pubic ramus fractures by > 2.5 cms.
 Vertical disruption of SI joint by > 1cms constitute vertical instability.

LC type – 1 : a posteriorly directed force causing a sacral crushing injury &
ipsilateral horizontal pubic ramus fractures.

LC type – 2 : a more anteriorly directed force causing horizontal pubic
ramus fractures with an anterior crushing injury and either disruption of of
the posterior SI joints or fractures through the wing.

LC type – 3 : an manteriorly directed force that is continued and leads to
a type 1 or 2 ipsilateral fracture with an external rotation component to
the contralateral side; SI joint is opened posteriorly.

APC type 1 : an AP directed force opening the pelvis but with the posterior
ligamentous structures intact.

APC type 2 : continuation of type 1 fracture with disruption of
sacrospinous and potentially the sacrotuberous ligaments & an anterior
SI joint opening.

APC type 3 : a completely unstable or vertical instability pattern with
complete disruption of all ligamentous supporting structures.

Vertical shear fractures : a vertically directed force at right angles to the
supporting structures of the pelvis ,leading to vertical fractures in the rami
and disruption of all the ligamentous structures.

Diagnosis
History:
 Mechanism of injury forms the key component in the
diagnosis, classification and management of pelvic injuries.
 HO road traffic accident, fall from a height or crush injury.

Clinical evaluation
 Primary assessment (ABCDE): airway, breathing, circulation, disability, and
exposure.(ATLS PROTOCOL)
 Initiate resuscitation: Address life-threatening injuries.
 Evaluate injuries to head , chest,abdomen and spine.
 Identify all injuries to extremities and pelvis, with careful assessment of distal
neurovascular status.
 AP-LC test for pelvic instability should be performed once only and involves
rotating the pelvis internally and externally.
 “The first clot is the best clot”.

 Once disrupted, subsequent thrombus formation of a retroperitoneal hemorrhage
is difficult because of hemodilution by administered IV fluids and exhaustion of
the body’s coagulation factors by the original thrombus
 Massive flank or buttock contusions and swelling with hemorrhage are indicative
of significant bleeding.
 The perineum must be carefully inspected for the presence of a lesion
representing an open fracture.
 Inspect the patient for bleeding from the urethral meatus, vagina, or rectum.

 Pelvic instability may result in a leg-length discrepancy involving
shortening on the involved side or a markedly internally or externally
rotated lower extremity.
 External rotation and shortening of one of the lower extremities is a sign of
“open-book” or vertical shear (VS) injury.
 Palpation of the posterior aspect of the pelvis may reveal a large
hematoma, a defect (representing the fracture), or a dislocation of the
sacroiliac joint.
 Neurological examination should be done to exclude sacral and lumber
plexus injury.
 Palpation femoral, popliteal and DPA pulses.
 Rectal examination should be done in every case.

 Destot’s Sign: A large superficial hematoma formation
beneath the inguinal ligament or in the scrotum.
 Roux’s Sign: A decrease in distance of greater trochanter to
pubic spine on affected side in lateral compression injury.
 Earle’s Sign: A bony prominence or large hematoma, as well
as tenderness on rectal examination

Degloving injuries (Morel-Lavallee lesion)

Diagnostic peritoneal lavage(DPL)
 DPL is a rapidly performed, invasive procedure that is considered 98%
sensitive for intraperitoneal bleeding.
 Now a days rarely used due to availability of CT and ultrasound.
 Relative contraindications to DPL include previous abdominal
operations, morbid obesity, advanced cirrhosis, and pre existing
coagulopathy.
 Free aspiration of blood, gastrointestinal contents, vegetable fibers, or bile
through the lavage catheter in patients with hemodynamic abnormalities
mandates laparotomy.
 A positive test is indicated by >10ml of gross blood, >100,000 red blood
cells (RBC)/mm3, 500 white blood cells (WBC)/mm3, or a Gram stain with
bacteria present.

Focused Assessment Sonography in Trauma(FAST)
 In FAST, ultrasound technology is used by properly trained individuals to
detect the presence of hemoperitoneum.
 In experienced hands, ultrasound has a sensitivity, specificity, and accuracy
in detecting intraabdominal fluid comparable to DPL.
 Rapid, noninvasive, accurate, and inexpensive means of diagnosing
hemoperitoneum that can be repeated frequently
 After the initial scan is completed, a second scan may be performed after an
interval of 30 minutes. This scan can detect progressive hemoperitoneum.
 Factors that compromise the utility of ultrasound are obesity, the presence
of subcutaneous air, and previous abdominal operations.

Pericardial sac
Hepatorenal
fossa
Splenorenal fossa
Pelvis or douglas
pouch

 The Iliopectineal line should be traced back to its intersection
with lateral margin of ala.
 It should be at the same level ( usually at superior margin of
S2 foramen) bilaterally.

 best demonstrates ring configuration of
pelvis, & narrowing or widening of diameter
of ring is immediately apparent.
 evaluates for posterior displacement of
pelvic ring or opening of pubic symphysis

shows the anterior ring superimposed on the posterior ring.
- evaluates for vertical shift of pelvis (migration of
hemipelvis);
- proximal or distal displacements of anterior or posterior
portion of ring are best appreciated on this view;
- sacrum appears in its longest dimension, w/ neural
foramina
evident.

shows iliopectineal line anterior column of
pelvis & posterior wall;
Judet views

Stress views
Push-pull radiographs are performed under general anesthesia to
assess vertical stability.
Tile defined instability as ≥0.5 cm of motion.
Kellam, and Browner consider ≥ 1 cm of vertical displacement
unstable.

CT SCAN
CT scan gives accurate details and much information about the
injury.
sacral fractures: 2mm to 3mm axial sections are recommended.
 CT is excellent for assessing the posterior pelvis, including the
sacrum and sacroiliac joints.
 The presence of a pelvic blush seen on CT,strongly suggests,
even in stable patients, ongoing bleeding and the need for
therapeutic angiography.
 The negative predictive value of CT angiography is above 90%.

Radiographic Signs of Instability
 Sacroiliac displacement of 5 mm in any plane.
 Posterior fracture gap (rather than impaction).
 Avulsion of the 5th lumbar transverse process, the lateral border
of the sacrum (sacrotuberous ligament), or the ischial spine
(sacrospinous ligament).

1.Early
management
2.Management of
severe bleeding
3.Mnagaemnet of
urethra and
bladder , bowel
injuries
4.Treatment of
fracture Mx

Haemodynamic status
 Attention must be paid to signs of hypovolemic shock.
-- this can be a silent killer. As 30% of the blood volume will be lost before
hypotension noted.
PRBC:FFP:Platelets ideally should be transfused 1:1:1

 Pelvic fracture hemorrhage results most frequently from the venous
structures and bleeding bone edges.
 Arterial bleeding can overcome the tamponade effect of the retroperitoneal
tissues, leading to shock; this is the most common cause of death related to
the pelvic fracture itself.
 Arterial bleeding usually arises from branches of the internal iliac system
with the superior gluteal and pudendal arteries being the most commonly
identified source.

Hypovolemic shock : why it bleeds so much….
pre-sacral venous plexus overlies the joint pelvis forms a limited container
fracture disrupts SI joint disrupted pelvic ring opens this
container
tears the veins
haemorrhage leaks into retroperitoneum
BLEEDS
MASSIVE BLEED
(5-6 LITRES)

Definitive treatment
Haemorrhage control methods :
 pelvic containment
- sheets
- pelvic binder
- c- clamp
- external fixator
- PASG (pneumatic anti shock garments)/MAST
- vaccuum bean bags
 Angiography/embolization
 Laparotomy
 Pelvic packing-removed after 48 hours.

Extra peritoneal pelvic
packing

Non-Operative Management
Lateral impaction type injuries with minimal (< 1.5 cm)
displacement
 Pubic rami fractures with no posterior displacement
 Minimal gapping of pubic symphysis
 Without associated SI injury
 2.5 cm or less, assuming no motion with stress or mobilization
 Tile A (stable) injuries can generally bear weight as tolerated

 Tile A (stable) injuries can generally bear weight as tolerated
 Walker/crutches/cane often helpful in early mobilization
 Tile B (partially stable) injuries can be treated non-operatively if
deformity is minimal
 Weight bearing should be restricted (toe-touch only) on side of
posterior ring injury
 Failure of non-operative treatment may be due to displacement
after mobilization
 Excessive pain which precludes early mobilization may also be
failure of non-operative treatment

LC - 1 : protected weight bearing on the side of injury,repeat x-rays 2-5
days after injury.
LC - 2 & LC - 3 : anterior and posterior fixation.
APC - 1 : symptomatic management only.
APC – 2 : ORIF
APC - 3 : haemorrhage control by fracture reduction and stabilization.
VS : reduction with traction, percutaneous ilio-sacral screw fixation,
ORIF.

Principles of Operative Treatment
 Posterior ring structure is important.
 Goal is restoration of anatomy and enough stability to maintain
reduction during healing.
 Most injuries involve multiple sites of injury.
 This does NOT mean that all sites of injury need fixation.
 Anterior ring fixation may provide structural protection of
posterior fixation.

Surgical Treatment : Preoperative Planning
 Surgical clearance, resuscitation
 Coordination of care
 Trauma surgeon, intensivist, neurosurgeon
 Timing of surgery
 Reduction may be easiest in first 24-48 hours
 May aid in percutaneous reduction
 Patients often not adequately resuscitated in first 24 hours
 Potential for surgical “secondary hit” on post-injury days 2-5
 May be a significant issue in open procedures

Surgical Approaches
Anterior pelvic ring :
Pfannenstiel
 Exposure of symphysis pubis and pubic bones
 Avoid transection of rectus tendons
 Elevate rectus subperiosteally
Stoppa extension
 Exposes symphysis to SI joint along pelvic brim

Posterior pelvic ring :
Anterior approach
 Iliac window of the ilioinguinal
 Exposure of SI joint
Posterior approach
 Exposure of sacrum and posterior ilium
 Iliac fracture dislocations of the SI joint
(crescent fracture

Reduction & fixation
Weber clamp on pectineal
eminences
Pelvic reconstruction plate
Medullary screw fixation
Anterior External Fixation
Clamp applied from lateral, posterior
ilium to anterior sacral ala

Post operative management
Aggressive pulmonary toilet.
- incentive spirometry.
- encourage deep inspirations and coughing
- chest physiotherapy.
Aggressive pulmonary toilet.
- elastic stockings.
- duplex ultrasound .
 Full weight bearing on the uninvolved lower extremity within
several days.

Outcomes
 Pain common
 Infection rate (0-25%). This risk is minimized by a percutaneous posterior ring fixation.
 Thromboembolism
 Malunion and non union
 Improvement occurs for at least a year in most patients
 Neurologic injury most common predictor of poor outcome
 SI dislocations have poor tolerance for residual displacement
 Sacral fractures have more tolerance for displacement.

BLADDER INJURIES
 The urinary bladder is generally protected from external trauma because of its deep
location in the bony pelvis.
 Most blunt bladder injuries are the result of rapid-deceleration motor vehicle
Collisions, but many also occur with falls, crush injuries.
 Disruption of the bony pelvis tends to tear the bladder at its fascial attachments, but
bone fragments also can directly lacerate the organ.
 The most common associated injury is pelvic fracture, which is associated with 83%
to 95% of bladder injuries
 Conversely, bladder injury has been reported to occur in only 5% to 10% of pelvic
fractures

Types of bladder injuries
1. Extraperitoneal bladder injury is usually associated with pelvic
fracture.
2. Intraperitoneal bladder injuries can be associated with pelvic
fracture but are more commonly due to penetrating injuries or burst
injuries at the dome by direct blow to a full bladder.
 Blunt trauma more likely to result in intraperitoneal rupture in
children than adults ; pediatric bladder is more intraperitoneal.

CLINICAL INDICATORS OF BLADDER INJURY :
 Suprapubic pain or tenderness
 Inability to void or low urine output
 Enlarged scrotum with ecchymosis
 Abdominal distention or ileus
 Free intraperitoneal fluid on CT or ultrasound examination
 Clots in urine or clots noted in bladder on CT

Investigations
 X ray pelvis
Ultrasound of abdomen and pelvis
Cystography
Urethrogram – Ascending / Descending
CT scan and concomitant CT cystography
Routine Bloods

 After blunt external trauma, the absolute indication for immediate
cystography is gross hematuria.
 Conversely, penetrating injuries of the buttock, pelvis, or lower abdomen
with any degree of hematuria warrant cystography.
 Retrograde or stress cystography is nearly 100% accurate for bladder
injury.
 The bladder should be filled in cooperative and conscious patients to a
sense of discomfort and otherwise to 350 mL.

Bladder Trauma : AAST Organ Injury Severity Scale
• Grade 1: Hematoma (contusion, intramural hematoma)
Laceration (partial thickness)
• Grade 2: Laceration (extraperitoneal, <2cm)
• Grade 3: Laceration (extraperitoneal, ≥ 2cm)
Laceration (intraperitoneal, <2cm)
• Grade 4: Laceration (intraperitoneal, ≥ 2cm)
• Grade 5: Laceration (intra- or extraperitoneal, extending into bladder
neck, ureteral orifice, trigone).

A dense, flame-shaped collection of contrast material
in he pelvis is characteristic of extraperitoneal
extravasation
Intraperitoneal extravasation is identified when
contrast material outlines loops of bowel and/or the lower
lateral portion of the peritoneal cavity
Ground glass appearance.

Management
 The usual treatment of uncomplicated extraperitoneal bladder ruptures, when conditions are
ideal, is conservative management with urethral catheter drainage alone for 7-14 days,
 A large-bore (22-Fr) Foley catheter should be used to promote adequate drainage.
 if output is poor, fluoroscopic cystography should be considered to ensure proper catheter
placement.
 Cystography is necessary to verify complete healing before catheter removal 14 days after
injury .

 Intra peritoneal injuries are often larger than suggested on cystography and are
unlikely to heal spontaneously, and continued leak of urine causes a chemical
peritonitis.
 When concurrent rectal or vaginal injuries exist, the organ walls should be
separated, overlapping suture lines should be avoided.
 every attempt should be made to interpose viable tissue in between the repaired
structures.
 Fibrin sealant injected over the bladder wall closure may help reduce complications
when intervening tissue is unavailable
 Multi-layer closure of bladder injury,Bladder drainage with Foley catheter ±
suprapubic catheter & Perivesical drain.

Indicators for immediate repair of bladder injury
 Intraperitoneal injury from external trauma
 Penetrating injury.
 Inadequate bladder drainage or clots in urine
 Bladder neck injury
 Rectal or vaginal injury
 Open pelvic fracture
 Pelvic fracture requiring open reduction and internal fixation
 Selected stable patients undergoing laparotomy for other reasons
 Bone fragments projecting into bladder

Outcomes and complications
 Unrecognized bladder injuries - acidosis, azotemia, fever and sepsis, low
urine output, peritonitis, ileus, urinary ascites, or respiratory difficulties.
 Unrecognized bladder neck, vaginal, and rectal injury associated with the
bladder rupture - incontinence, fistula, stricture, and difficult delayed major
reconstruction.
 Transient or permanent neurologic injury and result in voiding difficulties.

Urethral injuries
 Urethral injuries are categorized as posterior (from the bladder neck to the
membranous urethra) or anterior (from the bulbar urethra to the meatus).
 Urethral disruption injuries typically occur in conjunction with multisystem
trauma from vehicular accidents, falls.
 Fracture of the anterior pelvic ring or pubic diastasis are almost always
present when urethral disruption is encountered.
 They are also commonly associated with pelvic fractures (up to 10 %) as the
posterior urethra is adherent to the pubic symphysis.

 “Straddle fractures” involving all four pubic rami and fractures resulting in vertical
and rotational pelvic instability are associated with the highest risk of urologic injury.
 Because the posterior urethra is densely adherent to the pubis via the urogenital
diaphragm and the puboprostatic ligaments, the bulbo-membranous junction is
more vulnerable to injury during pelvic fracture than the prostate-membranous
junction.
 Endoscopic and urodynamic evaluation has confirmed that the membranous
urethral sphincter complex tends to remain functionally intact while being avulsed
vertically, posteriorly, or laterally from the underlying bulb.
 In children, injuries are less common but are more likely to extend proximally to the
bladder neck because of the rudimentary nature of the prostate.

Diagnosis
 Urethral disruption is heralded by the triad of blood at the meatus, inability to urinate, and
palpably full bladder.
 female patients also may develop proximal urethral avulsion injuries. They present with vulvar
edema and blood at the vaginal introitus.
 Urethrography : When blood at the urethral meatus is discovered, an immediate retrograde
urethrogram should be performed to rule out urethral injury.
 A small-bore (16-Fr) urethral catheter is placed unlubricated 1 cm into the fossa navicularis
 the balloon is filled with 1 ml of water to achieve a snug fit 25 mL of contrast medium is
injected gently by a 60-mL catheter-tip Syringe, and the film is taken during injection.
 Direct inspection by urethroscopy is suggested instead of urethrography in female patients with
suspected urethral injury.

Retrograde urethrogram shows
complete disruption of the posterior
urethra.

Management
 Immediate anastomotic reconstruction of posterior urethral disruption injuries in men has been
abandoned because of its association with unsatisfactory outcomes, such as impotence and
incontinence, stricture formation, and operative blood loss.
 In cases of female urethral disruption related to pelvic fracture, suggest immediate primary
repair, or at least urethral realignment over a catheter, to avoid subsequent urethrovaginal
fistulae or urethral obliteration .
 Delayed reconstruction is problematic because the female urethra is too short (about 4 cm) to
be amenable for mobilization.
 In men, either suprapubic catheter with delayed reconstruction or primary antegrade or
retrograde endoscopic realignment over a catheter is preferred.
 a large-bore (24-Fr) Foley catheter placed high in the bladder and tunneled through the skin as
high as possible on the lower abdominal midline to keep the tube away from the plated
symphysis.

 When the urethral catheter is removed after 4 to 6 weeks, it is imperative to retain a
suprapubic catheter because many patients, despite realignment, will develop
posterior urethral stenosis.
 If the patient voids satisfactorily through the urethra, the suprapubic catheter can be
removed 7 to 14 days later.
 Incomplete urethral tears are best treated by stenting with a urethral catheter.
 If a catheter has been placed, a peri-catheter RUG should be obtained to confirm
appropriate placement.
 Some authors advocate open exploration with realignment in cases of “high-riding
or “pie-in-the-sky” bladder or associated bladder neck tear in male patients.

 Delayed reconstruction : At 3 months, scar tissue at the urethral disruption site is
stable enough to allow posterior urethroplasty , provided that associated injuries
are stabilized and the patient is ambulatory.
 Endoscopic Treatments : Endoscopic treatments such as direct vision internal
urethrotomy are best reserved for selected short urethral stenoses.
 Surgical Reconstruction : Open posterior urethroplasty through a perineal
anastomotic approach is the treatment of choice for most urethral distraction
injuries because it definitively cures the patient without the need for multiple
procedures .
 Alternatively, a combined abdominoperineal approach (with or without partial
pubectomy) has proved helpful in cases of severe fibrosis, fistula, previous failed
anastomotic urethroplasty, and associated bladder neck injury and in pediatric
cases.

Complications
Erectile dysfunction : seen in 85% of patients with pelvic fractures &
urethral injuries.
- The etiology is multifactorial attributed to cavernous nerve injury,
arterial insufficiency, venous leak, and direct corporeal injury.
Recurrent Stenosis : After posterior urethroplasty, 5% to 15% of
patients have recurrent stenosis at the anastomosis.
Incontinence : Incontinence rates after reconstruction are low—less than
4%.

Anterior urethral injuries
 In contrast to posterior urethral distraction, anterior injuries are most often
isolated.
 Anterior urethral injuries generally occur during a straddle injury and involve the
bulbar urethra.
 Penile urethral injury is rare and may result from penetrating injuries to the penis.
 Clinical signs of anterior urethral injuries include blood at the meatus, perineal
hematoma, gross hematuria, and urinary retention.
 The primary morbidity of straddle injury is urethral stricture, which may become
symptomatic years later.

Management
 Initial suprapubic cystostomy is the standard of care for major straddle injuries involving the
urethra
 Primary surgical repair is recommended for low-velocity urethral gunshot injuries.
 Debridement can be minimized as the robust blood supply to the sponge often results in
spontaneous healing.
 Delayed reconstruction : Anastomotic urethroplasty is the procedure of choice in the Totally
obliterated bulbar urethra after a straddle injury.
 2-month period of suprapubic urinary diversion may be prudent preoperatively to optimize
conditions for repair of complex or recurrent strictures that have been catheter dependent.

Penile injuries
 In selected uncircumcised patients, mobilization of redundant foreskin may allow
primary closure of middle to distal penile skin loss.
 Scrotal rotation flaps can be used for more proximal defects if skin loss is limited,
but the hair-bearing nature of scrotal skin risks an unacceptable cosmetic result.
 Thick , nonmeshed, split-thickness skin grafts are preferred for penile
reconstruction.
 care must be taken to remove any subcoronal skin remaining after debridement.
Lymphatic obstruction of this distal foreskin, if it is not excised, results in
circumferential Lymphedema.
 circumferential vacuum dressings.

Scrotal injuries
 Testicular injury results from blunt trauma in about 75% of cases.
 Although only 1.5% of blunt testis injury involves both gonads, about 30% of
penetrating scrotal trauma results in bilateral injury.
 Ultrasonography can be helpful to assess the integrity and vascularity of the testis
in equivocal cases.
 Ultrasound findings suggestive of testicular fracture include a heterogeneous echo
pattern of the testicular parenchyma and disruption of the tunica albuginea.
 Penetrating scrotal injuries should be surgically explored to inspect for vascular
and vasal injury.

Testis trauma : AAST Organ Injury Severity Scale
• Grade 1: Contusion/Hematoma
• Grade 2: Subclinical laceration of tunica albuginea
• Grade 3: Laceration of TA with <50% parenchymal loss
• Grade 4: Major laceration of TA with ³50% parenchymal loss
• Grade 5: Total testicular destruction or avulsion

 The tunica albuginea should be closed with small absorbable sutures after removal of
necrotic and extruded seminiferous tubule.
 Testicular salvage rates exceed 90% with exploration and repair within 3 days versus
orchidectomy rates threefold to eightfold higher with conservative management and
delayed surgery
 Scrotal skin loss defects of up to 50% can often be closed directly.
 For extensive injuries, the testes may be placed in thigh pouches, treated with wet
dressings, or placed under vacuum pressure dressings until reconstruction.
 Thigh pouches are not recommended initially, until the infection is stabilized, because
transmission of the infectious process into uninvolved tissues may occur

Rectal injuries
 Most commonly, injuries to the rectum occur with penetrating rather than blunt pelvic
trauma.
 Although less common with blunt bony pelvic injury, 25 % of patients with an open pelvic
fracture have an associated rectal laceration.
 Extraperitoneal space for the rectum is divided into retroperitoneal high up in the abdomen
and subperitoneal low in presacral space.
 Suspicion of Injury :
- proper inspection of perineal region
- per rectal examination
- rigid proctoscopy or flexible sigmoidoscopy
- CT of the rectum with rectal contrast should be used with caution as immediate
imaging may not accurately assess high energy wounds to the rectum that are only a partial
injury to the wall that subsequently convert into a full thickness wound.

Investigations
 Recently CT abdomen and to a lesser extent the ultrasound examination is
replacing the DPL.
 Sigmoidoscope, (the preferred method of investigation) for the rectum and the
pelvic colon.
 If an enema is to be used, water soluble contrast (gastrographin) is a must
and barium should never be used.
 DRE.(diagnostic accuracy ranges from 80% to 95%)
 The diagnosis of extraperitoneal rectal injuries is more challenging because of
the lack of peritoneal signs.

Management
 Traditionally, rectal trauma had been managed with the principle of the four Ds: divert,
drain, direct repair, and distal washout.
 The extraperitoneal rectum is not easily mobilized, and mobilization,resection, and
anastomosis are difficult in the elective setting and even more so in trauma.
 Therefore, diversion of the fecal stream with a proximal colostomy with or without presacral
drainage and primary repair is the current standard of care.
 Primary diversion regardless of the size of the rectal injury is the most prudent and
conservative management option.

No primary suturing is allowed in following conditions :
 If lacerated lesion is more than 2cm after debridement.
 the presence of multiple sites of injury.
 If more than 8 hours of injury.
 If spillage is for a distance of more than 5 cm from the large
bowel site of injury.

 In contrast, intraperitoneal rectal injuries should be treated in a similar fashion to
colon injuries with either primary repair or resection and anastomosis with or
without diversion.
 several retrospective studies in civilian trauma have shown no increase in pelvic
sepsis or infection with the omission of presacral drainage when diverting
colostomy is performed.
 Two to 3 months following the injury, the rectum and distal colon can be evaluated
for healing and patency with a barium enema and, if adequate, the colostomy may
be reversed with high rates of success.
 Currently, injuries to the rectum should be managed with proximal diversion with
additional consideration for tissue debridement and omental flap placement when
there is concomitant GU injury.

 In perineal and anal canal injuries, no attempt should be done for primary
sphincteric or tissue repair, only debridement and hemostasis are done.
 It is however, mandatory to divert the fecal stream totally from the wound in
the perineum if the lesion is even moderately extensive and specially if
involving the sphincteric complex of the anal canal.
 Abdominal cavity should be irrigated with copious amounts of warm saline.
 The fascia is closed with monofilament interrupted sutures.
 The skin is better left open and dressed twice daily, Secondary sutures are
done after 4 to 5 days.

CONCLUSION
 Multidisciplinary approach(general
surgery,urology,neurosurgery,interventional radiology).
 Do something immediately(sheet,binder,ex fix, c-clamp).
 Treatment based on comprehensive understanding of potential pelvic
ring instability, displacement, and associated injuries.
 Diagnosing the sources and resuscitation.
 Surgical techniques for reduction and stabilization continue to evolve.
 Close coordination.

REFERENCES
 Wheeless’ Textbook of Orthopedics.
 Campbell-Walsh Urology, 11th Edition.
 Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71,
Number 6, December 2011 EAST Pelvic Fracture Guidelines.
 Farquharson's Textbook of Operative General Surgery, 10E.
 Sabiston textbook of general surgery.
 Gray’s anatomy.
 Internet source.

Pelvic injuries and associated injuries

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