OTA 1997 Posters - Pelvic & Acetabular Fractures

Characteristics of Missed Genitourinary Injuries in Pelvic Fractures

Eric Chamberlin, MD, Bruce H. Ziran, MD, Munir Shah, MD, Gary S. Gruen, MD

Pittsburgh, Pennsylvania, USA

Purpose: The need for accurate diagnosis of bladder ruptures and urethral tears in patients with pelvic fractures has been noted by many authors. The purpose of this study is to determine how often diagnoses are missed, how they are eventually discovered and how the patient's treatment course is affected.

Method: The trauma registry at our institution revealed that 635 patients were treated for traumatic pelvic fractures between 1991 and 1996. From these patients, 43 were noted to have concommitant bladder ruptures or complete urethral disruptions. A retrospective review of these patient's records was done to determine Tile classification, urethrogram and cystogram results, and for the 14 patients found to have initially missed diagnoses, the average delay to diagnosis and treatment, the reasons for the delays and the way the genito-urinary injury was discovered.

Results: The overall incidence of genitourinary injuries was 6.7%. Of the 43 patients, 15 had intraperitoneal bladder ruptures (IBR), 14 had extraperitoneal bladder raptures (EBR), 13 had complete urethral tears (UT) and one had both an EBR and a UT. Average age of the patients was 33.3 years (range 17-76 years). All of the urethral injuries were in males. All patients sustained trauma to the anterior pelvic ring. There were 12 Tile A, 10 Tile B, 21 Tile C fractures. Fourteen patients were discovered to have had missed diagnoses on initial evaluation. Of the missed diagnoses, six patients had intraperitoneal bladder ruptures (40% of the patients with IBR), four patients had extraperitoneal bladder ruptures (26.6% of the patients with EBR), and four patients had complete urethral tears (28.6% of patients with UT). Of the patients with missed IBR, all had gross blood with foley placement, two of these had no cystograms performed, one had a false negative cystogram, one had an incorrect cystogram read as extraperitoneal rupture and two had inconclusive cystograms. Only the patient with the false negative cystogram had a delay in diagnosis and treatment with the tear discovered three days after admission at the time of ORIF of the patient's pelvis. All other IBR patients (5 of 6) had their tears diagnosed at the time of emergent exploratory laparotomy. The average delay in diagnosis in this group was 12 hours.

Four patients had EBR's missed initially. All had gross return of blood with foley placement. The cystogram was misread as intraperitoneal in one patient and not performed in one; both of these patient's injuries were discovered at the time of exploratory laparotomy. The third patient had an inconclusive cystogram with a question as to whether the lesion was intra- or extraperitoneal, with bladder repair taking place at the time of pelvic ORIF three days after admission. The fourth patient had a negative cystogram, but 17 days after admission, had retention of urine, and EBR was diagnosed by cystoscopy and repair at that time. In this group the delay for both diagnosis and treatment averaged 5 days.

Four patients had urethral tears missed initially, two of whom had UT's discovered at time of exploratory laparotomy following exams with no meatal blood and normal prostate and gross return of blood with foley placement. One of these two had a cystogram consistent with UT and the other had a concomitant EBR discovered on cystogram. The third patient was a transfer from another institution with an identical presentation, with foley in place at the time of transfer, but the nature of UT was never clearly delineated. The fourth patient had meatal blood, normal prostate exam, no retrograde urethrogram performed, the gross return of blood with foley placement, and a negative cystogram.

Seven days later, the patient's foley was removed revealing gross meatal blood and cystoscopy revealed a UT which was endoscopically realigned. Average delay of diagnosis and treatment was 1.75 days (7 days in one patient). There were no significant differences in the Tile classification, the ISS, or the patterns of this group from those in whom the diagnosis was not missed.

Discussion: In this study there were a high number of patients (15 of 43) on whom the initial diagnosis of bladder or urethral injury was missed. Average delay to diagnosis was greatest for the EBR group (5 days) and least for the IBR group (12 hours). The group with the most missed diagnosis was IBR's with six, but five of these were discovered immediately at the time of exploratory laparotomy. Two of four EBR's were found at exploratory laparotomy as were two of four UT's. Genito-urinary injury in two patients in this series (4.7%) were diagnosed at the time of operative fixation of the pelvis.

Conclusion: The need for accurate determination of bladder rupture and urethral tears in patient with traumatic pelvic fractures has been noted by many authors. This study suggests that in a level one trauma center, both of these injuries can escape detection and these missed diagnoses in general are found quickly at the time of exploratory laparotomy and have no repercussions for the treating orthopaedist. However, some injuries escaped detection until the time of pelvic ORIF and can have profound implications for surgical management. Hence, we suggest that any patient with anterior pelvic injury have genitourinary trauma specifically ruled out even in the absence of suggestive physical findings (e.g. meatal blood, high prostate).