The visceral injuries accompanying fracture of the pelvic girdle are far more important than the fracture itself, being responsible for the high mortality following this fracture. Rupture of the urethra, rupture of the bladder, rupture of the bowel, injury to vessels (especially the external iliacs) and injury to nerves (especially the sacral and coccygeal) are among the complications most common in fracture of the pelvis. Renal injury sometimes occurs as an associated condition.
<Callout type="warning" title="Urethral Rupture">If the tear is complete, retention is the rule with occasional dribbling of bloody urine.</Callout>
Treatment of rupture of the urethra. — In rupture of the urethra the prime indication is for prompt, continuous and complete drainage of the bladder. Cases in which the passage of the catheter has been possible have been successfully treated by means of continuous catheterization and suction apparatus. By far the safest method however consists in prompt external urethrotomy followed by direct drainage of the bladder through a rectal tube in the perineum connected by means of rubber tubing with a bottle beneath the bed. Perineal drainage instituted early will accomplish more in preventing urinary infiltration than anything else.
<Callout type="important" title="Bladder Rupture">Rupture of the bladder calls for immediate operative intervention if we expect to save the patient.</Callout>
Treatment of rupture of the Madder. — Rupture of the bladder calls for immediate operative intervention if we expect to save the patient. In the intraperitoneal form of rupture the rent must be closed through an abdominal incision and the bladder drained from below through a permanent perineal tube to prevent distention of the viscus and tension on the sutures. In extraperitoneal rupture the tear is frequently situated in the lower anterior aspect of the bladder or the region of the trigone, and should be repaired with fine absorbable suture material. The situation, however, of these extraperitoneal tears is inaccessible and difficult to operate upon and the condition of shock in which we find the patient often precludes any prolonged operation or anesthetic. It is therefore best in many cases of extraperitoneal tear to establish free perineal drainage at once, leaving the rent to take care of itself.
<Callout type="tip" title="Bladder Drainage">Perineal drainage instituted early will accomplish more in preventing urinary infiltration than anything else.</Callout>
Key Takeaways
- Prompt and complete drainage of the bladder is crucial for treating urethral and bladder ruptures.
- Immediate surgical intervention is necessary to save patients with intraperitoneal bladder ruptures.
- Extraperitoneal bladder tears are challenging to repair due to their location and patient condition.
Practical Tips
- Always prioritize early perineal drainage to prevent urinary infiltration in pelvic fracture cases.
- Use a rectal tube for direct bladder drainage when catheterization is not possible.
- Be prepared for the possibility of intraperitoneal rupture during pelvic trauma assessment.
Warnings & Risks
- Do not delay surgical intervention for intraperitoneal bladder ruptures, as it can be fatal.
- Avoid prolonged operations or anesthesia in cases with extraperitoneal bladder tears due to shock.
- Be cautious when using catheters and introduce them only as far as necessary.
Modern Application
While the techniques described here are rooted in early 20th-century medical practices, the principles of prompt diagnosis and treatment remain crucial. Modern survival preparedness should include understanding these basic concepts to handle severe trauma scenarios effectively.
Frequently Asked Questions
Q: What is the most critical complication of a pelvic fracture?
The visceral injuries accompanying a pelvic fracture are far more important than the fracture itself, as they can lead to high mortality rates. Common complications include urethral and bladder ruptures.
Q: How should a complete tear in the urethra be treated?
In cases of complete urethral tears, retention is typically the rule with occasional dribbling of bloody urine. Treatment involves prompt external urethrotomy followed by direct drainage through a rectal tube connected to a bottle.
Q: What are the treatment options for an extraperitoneal bladder rupture?
Extraperitoneal bladder tears can be challenging to repair due to their location and patient condition. In many cases, it is best to establish free perineal drainage at once, leaving the rent to take care of itself.