The management of an extraperitoneal bladder injury associated with a pelvic fracture

Abstract

A 26-year-old female was involved in a motor vehicle accident as a belted driver after losing control at highway speeds and rolling multiple times into a ditch. There was a prolonged extrication and due to inclement weather conditions, the patient was unable to be evacuated by air ambulance. She was transferred by EMS to a peripheral hospital before expedited transfer to a tertiary trauma centre was possible. Primary resuscitation & imaging At the time of transfer to a tertiary care centre, she was stable without any other injuries. Her pelvis was stable and a focused trauma ultrasound exam revealed no evidence of intra-abdominal fluid. As per advanced trauma life support (ATLS) protocol, a Foley catheter was inserted without difficulty and frank hematuria was seen. She underwent an initial computed tomography (CT) abdomen/pelvis, which demonstrated (among other non-operative injuries): - Multiple pelvic fractures, including a comminuted left sacrum fracture extending to the left sacro-iliac (SI) joints and multiple left inferior and superior pubic rami fractures. - A potential extraperitoneal bladder rupture with hemoperitoneum. A CT cystogram was ordered, which showed a defect in the left anteroinferior bladder wall measuring approximately 0.8 cm (axial) and 1.3 cm (sagittal). There was a small amount of extraluminal contrast extending through this defect. On imaging review, it was not felt to be involving the bladder neck. There was an intermediate density fluid in the pelvis surrounding the bladder, extending superiorly and abutting the colon and a loop of small bowel (Fig. 1).