9 PELVIC FRACTURE URETHRAL INJURIES IN CHILDREN AND OLDER PATIENTS

Abstract

INTRODUCTION AND OBJECTIVES: The subject of pelvic fracture urethral injuries usually has been discussed including children and older patients together. In this study we attempted to learn if pelvic fractures and associated urethral injuries in children and older patients differ. METHODS: A total of 203 consecutive male patients, 2 to 80 years old (mean 31), with fracture of the bony pelvis were enrolled in this study. All patients were entered into a prospective protocol including documentation of age, type of pelvic fracture, and presence of urethral injury and its type. The urethral injury was classified as complete rupture, partial rupture, and urethral stretch which refers to an elongation of the intact posterior urethra. All 203 patients underwent radiographic examination of the pelvis while retrograde urethrography was performed in 194 patients. As was confirmed later, 8 of the other 9 patients had no urethral injury and 1 had sustained partial urethral rupture. In analyzing our data patients were categorized as being children up to 15 years old(43 patients, group 1) or older patients (160 patients, group 2). RESULTS: Of fractures involving the ischiopubic rami, the less serious fractures including single and ipsilateral rami fractures were more common in older patients (47 versus 32%, p 0.05). On the other hand, the more serious fractures including straddle (fractures of all 4 ischiopubic rami) and Malgaigne’s (fracture of both ischiopubic rami with disruption of ipsilateral sacroiliac joint) fractures were more common in children (56 versus 24%, p 0.05). Fractures not involving the ischiopubic rami were more common in older patients (29 versus 12%, p 0.05). Urethral injury was more common in children than in older patients (30 versus 24%). Whereas the incidence of partial urethral injury was similar in both groups, stretching of an intact posterior urethra was more common in older patients (32 versus 8%) and complete rupture was more common in children (69 versus 42%). In 3 children with partial rupture, the injury involved the prostatic urethra and bladder neck. CONCLUSIONS: The young boy who sustains a pelvic fracture is much more unfortunate than the older patient who receives the same bone injury. Certain characteristics set him apart from an older patient. First; the pelvic fracture is more liable to be one of the serious fractures that cause a higher incidence of urethral injury. Second; urethral injury is more likely to be a complete rupture with a higher incidence of stricture formation. Third; urethral injury may implicate the bladder neck which increases the risk of urinary incontinence.