BLADDER ENTRAPMENT DURING INTERNAL FIXATION OF A PELVIC FRACTURE

Abstract

A 30-year-old white man was admitted to the emergency room after a motor vehicle accident for left lateral shock. At presentation the patient was hemodynamically stable but he required intubation for light coma. Clinical examination demonstrated extensive ecchymoses over the left side of the body, left lower quadrant guarding and left pulmonary hypoventilation. After ruling out urethral injury catheter placement yielded clear urine and urinalysis was negative. Radiographic evaluation showed a ruptured left diaphragm, fractures of the left hemipelvis (ischiopubic segment, acetabulum and iliac crest), peritoneal effusion and moderate cerebral edema. Emergency laparotomy revealed splenic laceration and diaphragmatic dome rupture, which were repaired. Pelvic hematoma that was also discovered a t exploration remained undisturbed. Initial orthopedic management involved traction of the lower left leg. By day 15 of the hospital course, the patient had recovered neurological function and the acetabular fracture was internally fixed. At the completion of surgery moderate hematuria had developed, which was treated with continuous bladder lavage through a double lumen urethral catheter. Excretory urography with the catheter clamped showed bladder compression by an intrapelvic hematoma. Hematuria worsened 2 days later, requiring endoscopic clot evacuation with the patient under general anesthesia. Bladder inspection at the time was unrevealing due to hematuria and inflammation. To determine the bleeding source retrograde cystography was performed, which suggested incarceration of the left lateral bladder wall at the site of the acetabular fracture (fig. 1). This diagnosis was confirmed by pelvic computerized tomography (CT) (fig. 2). At repeat surgery the pelvic hematoma was evacuated and longitudinal cystotomy was performed. This procedure permitted the localization of invagination of the cystic mucosa, where the bladder wall was incarcerated in the left acetabular osseous defect. The bladder was freed from the fracture site, and a small bleeding branch of the obturator artery was noted, explaining the massive hematuria. Hemostasis was achieved by arterial dissection, clamping with verified hemostasis and then ligature at the involved branch of the left hypogastric artery. The bladder was closed in 2 layers with placement of an indwelling urethral catheter. Convalescence was uneventful.