Bladder incarceration following anterior external fixation of a traumatic pubic symphysis diastasis treated with immediate open reduction and internal fixation
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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.
KeywordsPelvic Fracture Sacroiliac Joint Postoperative Compute Tomography Ramus Fracture Short Musculoskeletal Function Assessment
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, 2, 3, 4, 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, 7, 8, 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, 18, 19, 20, 21, 22, 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, 7, 8, 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.
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