Bladder incarceration following anterior external fixation of a traumatic pubic symphysis diastasis treated with immediate open reduction and internal fixation
© Finnan et al; licensee BioMed Central Ltd. 2008
Received: 29 July 2008
Accepted: 19 October 2008
Published: 19 October 2008
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.
Pelvic fractures are a small but clinically significant percentage of all fractures. Associated injuries to the genitourinary structures ranging from urethral and prostatic injuries to complete bladder rupture with resultant morbidity have been described in the literature [1–5]. The use of anterior pelvic external fixation has been shown to be a reliable and effective means to stabilize pelvic injuries in the acute resuscitative phase of the trauma patient [6–9]. However, urologic injuries, particularly bladder entrapment, remain a concern with the use of closed reduction of symphyseal disruption and anterior pelvic external fixation [10, 11]. We report a case involving bladder herniation through a traumatic symphyseal diastasis with subsequent incarceration after attempted reduction with pelvic external fixation and a review of the literature.
A review of the literature returned nine previous reports of bladder herniation through a traumatic symphyseal diastasis, only two of which involved actual bladder incarceration after anterior external fixation [10, 11, 17–23]. The first report by Fuhs and associates  describes a patient treated in a pelvic sling with initial adequate reduction of the symphyseal diastasis. Persistent, intermittent microscopic hematuria and eventual gross hematuria one year after the injury led to open reduction and internal fixation with intraoperative findings of pubic bone erosion through the bladder wall.
Cass and associates  reported two cases involving bladder problems with pelvic external fixation. One case involved the acute reduction of both the bladder herniation and symphyseal disruption with external fixation. Six months post-injury, the diastasis recurred and bladder herniation was found at the time of open reduction and internal fixation eight months after the injury. The authors recommended intra-operative inlet-view cystograms with external fixator symphyseal reduction and consideration of internal fixation. Neser and Lindeque  also warned against the possibility of interposed bladder and soft tissue with open-book pelvic injuries. They reported symphyseal diastasis that was irreducible with multiple closed attempts and found interposed bladder and perivesicular soft tissue at the time of open reduction and fixation.
Cespedes and colleagues  reported spontaneous reduction of a bladder herniation through a 3.5 cm pubic diastasis. Microhematuria was present on admission and a cystogram showed the herniated bladder. The patient refused to undergo the planned open reduction, and one week later a voiding cystourethrogram revealed spontaneous reduction of the bladder herniation. The patient remained asymptomatic at four months.
Only two of these five reports actually describe incarceration of the bladder after anterior external fixation and reduction of a pubic diastasis. Bartlett and colleagues  reported the case of a man initially treated with anterior pelvic external fixation for an open-book pelvic injury. The entrapped bladder was recognized with a postoperative CT cystogram and re-manipulation of the pelvis and fixator failed to reduce the incarcerated bladder. The patient underwent open reduction and fixation of the pubic symphyseal diastasis 10 days post-injury. Persistent bladder incarceration was noted and reduced. Gerraci and Morey reported a similar case where closed reduction and external fixation of the pelvic fracture were performed in an unstable multi-injured patient11. Twenty-four hours later, postoperative CT revealed bladder entrapment in the reduced pubic diastasis. Definitive internal fixation was performed without complication.
The use of anterior pelvic external fixation has been shown to be a reliable and effective means to stabilize pelvic injuries in the acute resuscitative phase of the trauma patient [6–9]. Our patient presented with 4 cm of pubic symphysis diastasis and disruption of the right sacroiliac joint. Injury to the supporting soft tissue structures (puboprostatic and pubovesical ligaments and pelvic fascia) is expected for bladder herniation to occur . With adequate reduction and stabilization, these structures heal by scar tissue . However, interposition of soft tissue within the pubic symphysis impedes healing and potentially leads to late widening, as in the cases reported by Fuhs et al  and Cass et al .
Signs of urological injury include blood at the urethral meatus, a high-riding prostate gland, and gross and microscopic hematuria [3, 4]. If signs of urological injury are present, retrograde urethrography prior to Foley catheter insertion is commonly performed. However, the detection of lower urologic injuries can be difficult. Ziran et al  reported that 23% of bladder and urethral disruptions associated with pelvic fracture were initially missed in their series of 43 patients. In this case, only microhematuria was noted on presentation, and the urinary catheter was placed without difficulty. Bladder herniation was first noted when the patient underwent abdominal and pelvic CT scanning. However, because the scan was obtained with the catheter clamped and the bladder distended, it was felt that decompression of the bladder upon release of the clamp would allow reduction of the herniation.
In our case, adequate reduction of the symphyseal disruption was not obtained by closed means. Immediate postoperative CT scanning of the pelvis showed persistent herniation, which was addressed through formal open treatment. We agree with previous recommendations that when difficulty in obtaining a closed reduction is experienced, incarcerated soft tissue should be considered [10, 11, 20].
Although bladder herniation into a traumatic pubic symphyseal disruption is rare, an index of suspicion is warranted. If herniation is observed preoperatively and the patient's status allows, consider direct open reduction and internal fixation. If an external fixator or pelvic binder is used, then a post-operative CT cystogram should be obtained shortly thereafter to confirm bladder position. If incarceration is identified, timely open reduction and anterior ring stabilization are recommended to minimize the risk of bladder necrosis or perforation.
Written consent for publication of this case report was obtained from the patient. The authors also acknowledge Ronald Markert, PhD for his editorial assistance in manuscript preparation.
- Hochberg E, Stone NN: Bladder rupture associated with pelvic fracture due to blunt trauma. Urology. 1993, 41: 531-533. 10.1016/0090-4295(93)90099-V.View ArticlePubMedGoogle Scholar
- Lee J, Abrahamson BS, Harrington TG, Singh BV, Lee J, Trocchia AM, Khan SA: Urologic complications of diastasis of the pubic symphysis: a trauma case report and review of world literature. J Trauma. 2000, 48: 133-136.View ArticlePubMedGoogle Scholar
- Avey G, Blackmore CC, Wessells H, Wright JL, Talner LB: Radiographic and clinical predictors of bladder rupture in blunt trauma patients with pelvic fracture. Acad Radiol. 2006, 13: 573-579. 10.1016/j.acra.2005.10.012.View ArticlePubMedGoogle Scholar
- Fallon B, Wendt JC, Hawtrey CE: Urological injury and assessment in patients with fractured pelvis. J Urol. 1984, 131: 712-714.PubMedGoogle Scholar
- Ziran BH, Chamberlin E, Shuler FD, Shah M: Delays and difficulties in the diagnosis of lower urologic injuries in the context of pelvic fractures. J Trauma. 2005, 58: 533-537.View ArticlePubMedGoogle Scholar
- Gylling SF, Ward RE, Holcroft JW, Bray TJ, Chapman MW: Immediate external fixation of unstable pelvic fractures. Am J Surg. 1985, 150: 721-723. 10.1016/0002-9610(85)90416-7.View ArticlePubMedGoogle Scholar
- Riemer BL, Butterfield SL, Diamond DL, Young JC, Raves JJ, Cottington E, Kislan K: Acute mortality associated with injuries to the pelvic ring: the role of early patient mobilization and external fixation. J Trauma. 1993, 35: 671-677.View ArticlePubMedGoogle Scholar
- Riska EB, von Bonsdorff H, Hakkinen S, Jaroma H, Kiviluoto O, Paavilainen T: External fixation of unstable pelvic fractures. Int Orthop. 1979, 3: 183-188. 10.1007/BF00265710.View ArticlePubMedGoogle Scholar
- Mason WT, Khan SN, James CL, Chesser TJ, Ward AJ: Complications of temporary and definitive external fixation of pelvic ring injuries. Injury. 2005, 36: 599-604. 10.1016/j.injury.2004.11.016.View ArticlePubMedGoogle Scholar
- Bartlett CS, Ali A, Helfet DL: Bladder incarceration in a traumatic symphysis diastasis treated with external fixation: a case report and review of the literature. J Orthop Trauma. 1998, 12: 64-67. 10.1097/00005131-199801000-00012.View ArticlePubMedGoogle Scholar
- Geracci JJ, Morey AF: Bladder entrapment after external fixation of traumatic pubic diastasis: importance of follow-up computed tomography in establishing prompt diagnosis. Mil Med. 2000, 165 (6): 492-493.PubMedGoogle Scholar
- Burgess AR, Eastridge BJ, Young JWR, Ellison TS, Ellison PS, Poka A, Bathan GH, Brumback RJ: Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990, 30: 848-856.View ArticlePubMedGoogle Scholar
- Tile M: Acute pelvic fractures: I. causation and classification. J Am Acad Orthop Surg. 1996, 4: 143-151.PubMedGoogle Scholar
- Olson SA, Willis MD: Initial Management of Open Fractures. Rockwood and Green's Fractures in Adults. Edited by: Bucholz RW, Heckman JD, Court-Brown C, eds. 2006, Philadelphia, PA: Lippincott Williams & Wilkins, 389-424. 6Google Scholar
- Swiontkowski MF, Engelberg R, Martin DP, Agel J: Short Musculoskeletal Function Assessment Questionaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 1999, 81: 1245-60. 10.1302/0301-620X.81B6.9794.View ArticlePubMedGoogle Scholar
- Quality Metric Incorporated. SF-36.org: A community for measuring health outcomes using SF tools. 2007, [http://www.sf-36.org/]Google Scholar
- Fuhs SE, Herndon JH, Gould FR: Herniation of the bladder: an unusual complication of traumatic diastasis of the pubis. J Bone Joint Surg Am. 1978, 60: 704-707.PubMedGoogle Scholar
- Cass AS, Behrens F, Comfort T, Matsuura JK: Bladder problems in pelvic injuries treated with external fixator and direct urethral drainage. J Trauma. 1983, 23: 50-53.View ArticlePubMedGoogle Scholar
- Neser CP, Lindeque BG: Bladder interposition in traumatic diastasis of the sympysis pubis: a case report. S Afr Med J. 1986, 69: 640-641.PubMedGoogle Scholar
- Cespedes RD, Roettger RH, Peretsman SJ: Herniation of the urinary bladder: a complication of traumatic pubic symphysis diastasis. South Med J. 1995, 88: 849-850.View ArticlePubMedGoogle Scholar
- Foster EJ, Murray DG, Gregg RO: Chronic bladder herniation associated with pubic diastasis. J Trauma. 1981, 21: 80-81.View ArticlePubMedGoogle Scholar
- Jacques LF, Gloviczki P, Patterson DE, Sarr MG: Successful repair of an unusual hernia associated with traumatic pubic diastasis. Mayo Clin Proc. 1988, 63: 492-495.View ArticlePubMedGoogle Scholar
- Ponka JL, Obeid FN: Posttraumatic hernia of the bladder. Henry Ford Hosp Med J. 1983, 31: 173-176.PubMedGoogle Scholar
- Domisse GF: Diametric fractures of the pelvis. J Bone Joint Surg Br. 1960, 42-B: 432-443.Google Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.