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The European Trauma Course Manual

Edition 4.0
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7.
Pelvic trauma
Learning outcomes
Following this part of the course you will be able to demonstrate competence in:
QAssessing pelvic injuries
QThe clinical examination of patients with suspected pelvic injury
QInitial life-saving management in severe pelvic bleeding
QInterpretation of pelvic imaging
QUnderstand the principles of further management of patients with pelvic fractures
Introduction
The pelvis is the largest and strongest osteo-
ligamentous structure in the human body and
disruption is usually the result of high energy injuries.
These occur in high velocity road traffic collisions, falls
from a great height, or crush injury. Patients with pelvic
ring injuries therefore have to be considered severely
injured even if it is an isolated pelvic injury. It should
be remembered that, when the pelvic ring is injured, it
is almost always disrupted in 2 or more places.
It is important, however, to be aware that lower energy
mechanisms, such as falls from < 2m, can result in
pelvic ring injuries in the elderly, more osteoporotic
population.
Pelvic ring injuries occur in 8-9% of all blunt force
trauma. The mortality rates for pelvic ring injuries
range from 10 – 50%, depending on haemorrhage and
associated injuries to the head, spine, chest, abdomen
and limbs. 5 – 10 % of pelvic fractures will have a major
urological injury. Due to the vascular anatomy within
the pelvis, pelvic ring fractures should be treated as a
type of vascular emergency.
Pelvic applied anatomy
The pelvis can be divided into the dorsal hemipelvis
consisting of the sacrum, sacroiliac ligaments and
iliac bones and the ventral pelvis consisting of the
symphisis pubis and pubic and ischial bones with their
rami. The intrinsic stability of the pelvic ring is due to a
combination of the bony structures and the ligaments
which connect the sacrum and two innominate bones
with each other; the thin anterior and large posterior
sacroiliac ligaments, the strong sacrotuberal and
sacrospinal ligaments and the thin ligaments of the
symphysis pubis.
The space contained by this ring of bones and
ligaments is divided in two:
1. The large or false pelvis is the volume above the
pelvic brim and between the iliac wings. It contains
the organs of the lower abdomen.
2. The small or true pelvis lies between the sacrum,
both acetabula and the symphysis pubis and
contains the infraperitoneal organs such as the
bladder, prostate, urethra, rectum, uterus, and
vagina. In addition large vessels and nerves run
from the retroperitoneal space through this space
towards the lower extremities. The vessels also form
multiple anastomoses within the small pelvis, which
supply the above mentioned organs with blood.
Types of pelvic fractures
The pelvic ring may suffer a number of different types
of fractures. They are usually classified by the direction
of the force applied.
Anteroposterior force (e.g. frontal collision)
This drives the left and right sides of the pelvic ring
apart causing external rotation and instability of the
two hemipelvises. This is likened to the pages when
a book is opened, hence the injury is often described
as an ‘open book’ fracture (figure 7.1a,b). To permit this
rotation either the symphysis pubis dislocates or the
pubic and ischial rami are fractured. In contrast the
dorsal hemipelvis is incompletely broken because the
large posterior sacroiliac ligaments remain intact while
the thin anterior sacroiliac ligaments are torn. This
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injury is associated with massive blood loss because

the volume of the small pelvis increases and multiple
vascular anastomoses are torn filling this expanded
infraperitoneal space with blood. In addition structures
connected to the pelvic floor (e.g. urethra) may be
ruptured. These injuries are rotationally unstable, but
vertically stable.

Figure 7.2a,b X-ray and diagrammatic representation of lateral

compression fracture

Vertical force (e.g. fall from great height)

Figure 7.1a,b X-ray and diagrammatic interpretation of open book
type fracture
Lateral force (e.g. lateral collision)
With this force the two sides are driven together with
one hemipelvis being internally rotated. Typically
there is also a crush injury of the lateral mass of the
sacrum on the same side (lateral compression injury,
figure 7.2a,b). Rotational instability results, but in the
opposite (internal) direction when compared to the
open book lesion. Unless there is massive displacement
(e.g. rollover trauma), lateral compression injuries are
not as mechanically unstable as open book lesions
and are less often associated with massive blood
loss. Nevertheless, organs inside the true or small
pelvis may be damaged by the increase in pressure at
the moment of trauma (e.g. bladder rupture). These
injuries are rotationally unstable, but vertically stable.
With this mechanism of injury the left and right
hemipelvis are completely separated from each
other as the affected side is displaced upwards. It is
therefore described as ‘vertical shear’ injury (figure
7.3a,b). Such a displacement means there is complete
rupture of the anterior and posterior hemipelvis and
floor of the pelvis. As a result there is vertical instability
and massive damage to the structures surrounding
and inside the pelvic ring. There are no anatomical
borders anymore, allowing blood to leak from the
infraperitoneal into the retroperitoneal space, as high
as the diaphragm. These are highly unstable injuries
and in many cases, larger vascular structures also are
damaged resulting in life-threatening haemorrhage.
These injuries are both rotationally and vertically
unstable.

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Figure 7.3a,b X-ray and diagrammatic representation of vertical
shear injury
Combination of forces
These are a variable mixture of any of the above forces
that can result in combinations of types of pelvic
fractures. They are usually due to high energy transfer,
e.g. an unrestrained passenger in rollover accident.
Open pelvic fractures, degloving and impalement
injuries (figure 7.4) and traumatic amputations are
specific pelvic ring injuries with a poor outcome. Besides
the above mentioned damage, there is contamination,
continuous blood loss through open traumatic wounds
and/or irreversible damage to large vessels and nerves.
Figure 7.4 Impalement injury
When the pelvic ring is disrupted, bony structures will
be broken and ligaments torn. Soft tissue structures
surrounding the pelvic ring such as skin, subcutaneous
tissue and muscles may be damaged as well.
Retroperitoneal organs inside the pelvic ring may also
be disrupted, with immediate and important blood loss
and late functional deficits as consequences. Pelvic ring
disruptions must therefore be considered as a specific
combination of injuries rather than a solitary lesion.
Pelvic ring lesions are combined with intraperitoneal
lesions in more than 10% of cases. Both have to be seen
as separate entities and treated separately. That is why it
is vital to perform a thorough neurovascular and pelvic
examination in the primary, secondary and tertiary
surveys in these patients. An open pelvic fracture
with the risk of faecal contamination will require an
urgent defunctioning colostomy to prevent any further
contamination.
Standby preparation and transfer
Although all equipment must be checked regularly,
for the team members responsible for managing the
circulation this includes equipment for stabilizing the
pelvis.
Pelvic lesions relevant to the 5-second round will include
those associated with massive haemorrhage e.g. open
fractures, which can cause hypovolaemic cardiac arrest.
The MHP should be activated and Tranexamic acid (1g
over 10 min + 1g over 8h i.v.) applied.
Primary survey
The same plan as described in chapter 2 is used
with members of the team carrying out their tasks
simultaneously. The circulation personnel will need to
look specifically for indications of actual or potential
pelvic injury. Although there may be obvious clues,
if these are not apparent, diagnosis may be initially
based on the mechanism of injury and evidence of
hypovolaemia with no other obvious cause. If a trauma
or orthopedic surgeon is not primarily part of the trauma
team, it is essential to involve him/her at the earliest
possible opportunity as part of the clinical examination
should be performed by an expert to identify if the
injury is unstable and to distinguish between rotational
and vertical unstable pelvic ring lesions.
Clinical examination of pelvic fractures
Look for possible lesions of soft tissues and internal
organs outside and inside the pelvic ring: skin
lacerations around the iliac crests, degloving injuries
(Morelle-Lavallée lesions, figure 7.5a,b) at the greater
trochanter and the upper thigh or at the lumbosacral
junction in the back. The perineal region needs a
special inspection: a large haematoma in the scrotum
(figure 7.6) or in the labiae is an indirect sign of a lesion
of the pelvic floor. Spontaneous blood loss at the
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external urethral meatus is a hint of a lesion in the
lower urogenital tract (bladder rupture or urethral
tear). Skin lacerations around the anus or vagina or
impalement injuries are possible sources of major
bleeding and contamination. All patients suffering
high energy trauma must have an examination of
the perineum and genitalia plus a rectal examination
and the findings recorded in the notes (BOAST 14: see
appendix to chapter 7). If visual inspection suspects a
vaginal injury eg blood coming from the vagina, then
a vaginal examination should also be performed.
Usually this is carried out in the operating room.
Figure 7.5a Degloving injury
Figure 7.5b Degloving injury
Figure 7.6 Scrotal haematoma
100 | EUROPEAN TRAUMA COURSE
The examination of the pelvis should be performed by
one of the circulation personnel who is both trained
to do so and capable of interpreting the findings. For
the first stage, the examiner should stand beside the
supine patient at the level of the pelvis. It is no longer
recommended to rock or spring the pelvis to assess for
pelvic instability, as this is likely to aggravate bleeding
by disruption of any early clot. Palpation for tenderness
over the iliac crests and pubis gently can be performed
to assess for tenderness (Fig 7.7). This assessment must
only be performed once.
Figure 7.7 Examination for pelvic instability – stage 1
The second stage of the pelvic examination must be
conducted by a trained trauma or orthopaedic surgeon.
This is normally only performed in the haemodynamically
stable patient. In the correct hands it gives additional
information that will aid surgical planning. It has no role in
the hyper-acute situation. The examiner stands beside the
lower leg of the supine patient. One hand is used to lift the
patient’s leg carefully off the table, while the other hand
is placed on the ipsilateral iliac crest to control movement.
When the examiner is able to pull down or up one
hemipelvis while the opposite hemipelvis does not move
nor rotate, a vertical instability exists (figure 7.8). A vertical
instability never exists without rotational instability. With
two simple tests, the examiner is able to differentiate
between different forms of pelvic ring lesions, which
correspond with different severities of trauma.
Figure 7.8 Examination for pelvic instability – stage 2
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The examination for pelvic stability should
only be performed once, since repeated
manipulations can aggravate bleeding.
Imaging
If CT is not immediately available and part of the
primary survey process, an antero-posterior x-ray of
the pelvis is compulsory in every polytrauma patient.
Large disruptions and displacements will be detected
immediately. Analysis of the posterior hemipelvis
is difficult and fractures or dislocations may be
overlooked due to overlying soft tissue structures,
bowel content and intrapelvic haematoma. For a
definitive diagnosis, CT imaging is indispensable.
Total body multislice CT with contrast is performed
with high speed CT scanners in patients who are
haemodynamically stable or compensated. In cases,
when the CT is adjacent to the Emergency Department
and resuscitation can be maintained, this examination
can be carried out immediately, and conventional
x-rays can be omitted.
Pelvic x-ray (see skills section)
KEY POINTS
Indication: every polytrauma patient, unless CT
immediately available
Procedure: plain x-ray
Complications: none
Common failure to recognize a fracture or its
pitfalls: significance, particularly posterior ones
Management
Pelvic ring disruptions are the result of high energy
transfer and so need to be considered a life-threatening
injury. The immediate threat to life is haemorrhage.
This has three main origins: the large bone fragments
of the dorsal pelvic ring; multiple small vessels of the
plexus anterior to the sacrum and around the organs
of the small pelvis; and bleeding from arteries in and
around the small pelvis. Active arterial bleeding is
present in less than 10% of patients with pelvic trauma.
Initial management therefore focuses on the
haemodynamic situation of the patient, rather than
on the stabilization of the fractures. The standard
approach described in chapter 2 is followed. Different
methods are available to diminish or minimize blood
loss, they are not competitive, but complementary,
and their working mechanism is indirect or direct.
Pelvic immobilization
A pelvic binder or sheet have the same working
mechanism; when applied around the pelvic ring to
create direct pressure on the disrupted elements,
reduce the volume of the small pelvis and hinder
large movements during manipulation or transport.
A further advantage of using a pelvic binder is the
region of the pelvis and abdomen remains free and
accessible for interventions. In the absence of a pelvic
binder at scene, a sheet may be used instead.
Pelvic sheet and pelvic binder (see skills section)
KEY POINTS
Indication: unstable pelvic fracture, haemodynamic
instability
Procedure: immobilization of the pelvis using sheets
or binder
Complications: increased blood loss
Common insufficient immobilization
pitfalls:
A pelvic binder should be applied as soon as an unstable
pelvic ring with hypotension is suspected, before
transport or immediately after arrival in the hospital.
In these situations imaging is not a prerequisite for
immobilization. A pelvic binder can be left in place
for several hours and should only be taken off in the
presence of a resuscitation team, as recurrent bleeding
with hypovolaemia can occur. However application
must be done carefully; the broken pelvic ring must be
tilted for only a short time. The binder should be left
in situ until the risk of pelvic bleeding has stopped.
It should then be removed AFTER consultation with
the appropriate specialist and should be removed
ideallywithin 6 hours of injury and certainly by 24 hours.
If an unstable, bleeding pelvic ring fracture is excluded
following CT scan then the binder can be removed in
the resuscitation room in the presence of the trauma
team. A post-binder removal plain pelvic radiograph
should be taken in resuscitation room in all cases.
Urinary catheter
A single, gentle attempt at urinary catheterisation, by
an experienced doctor, is permissible, even if the clinical
or CT findings suggest a urethral or bladder injury. The
procedure and the presence of clear or blood-stained
urine must be recorded. The finding of blood-stained
urine mandates a retrograde urethrogram via the
catheter. If the catheter will not pass, or passes and
only drains blood, do not inflate the balloon, withdraw
the catheter and perform a retrograde urethrogram.
The presence of a urethral or bladder injury mandates
informing the on call urologist. If a catheter cannot
be passed, then a suprapubic catheter will be
required. This can be performed percutaneously in
the resuscitation bay or via open technique in theatre.
Placement of the suprapubic catheter can affect the
timing of any pelvic surgery and so the pelvic team
should be involved at an early stage.
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Further management Surgical packing (see skills section)

The following interventions are undertaken when
the patient has left the Emergency Department.
Nevertheless, the decision to perform them must
be taken as early as possible based on the clinical
findings and the response to resuscitation measures.
The trauma team leader must be aware of which is
the most appropriate intervention for their patient in
order to plan further treatment.
Pelvic clamp (see skills section)
This is a surgical procedure which must only be carried
out by those trained to do so. The device consists of
two large K-wires and a large C-shaped clamp. It is
used to restore stability of the dorsal hemipelvis and
its application is part of the resuscitation of a patient in
extremis or with borderline haemodynamics. Although
not taught on the ETC, trauma team members must be
familiar with the indications for its use and application.
External fixator (see skills section)
To provide provisional management in resuscitated
patients until definitive reduction and fixation is possible.
Most appropriate in those patients who are, or rapidly
become, haemodynamically stable with resuscitation.
Used in transient responders who continue to bleed
following pelvic clamping or external fixation and who
need more aggressive management. It is important to
recognize that surgical packing is useless and dangerous
when no pelvic clamping or external fixation has been
performed as lack of stabilization of the bone fragments
will drive them further apart and increase blood loss.
Selective angiography and embolization
Interventional radiology is being increasingly used
in the management of bleeding pelvic fractures. It is
indicated when there is a blush identified on the Trauma
CT with contrast indicating continuous arterial bleeding,
a patient requiring ongoing transfusion of more than
0.5 units of blood per hour, or patients with repeated
episodes of hypotension despite resuscitation. Often
it is used after pelvic packing if there is still evidence
of an ongoing small arterial bleed. As it is rather time-
consuming, it is not indicated in the presence of large
vessel active bleeding.
A commonly used algorithm is shown in figure 7.9.

Unstable Patient

Apply Pelvic Binder

YES
Haemodynamics Stabilize?

NO
NO Intra-peritoneal or external YES
haemorrhage

Operating Room
Angio available < 30 mins?
NO
Extra-Peritoneal Pack
YES Damage Control Laparotomy

Angio-embolization

ICU
Definitive Imaging

Definitive Fixation

Figure 7.9. Aintree MTC Pelvic fracture management algorithim

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Summary
Pelvic ring disruptions are the result of high
energy transfer and patients with this trauma
must be considered as severely injured. Simple
examination techniques can be applied, x-ray
and CT scan are used to confirm the diagnosis.
Pelvic binders reduce the pelvic volume and
reduce mechanical instability.
Having worked through this chapter you are now
ready to apply the following knowledge in the
abdominal and pelvic trauma workshop:
Qunderstanding the different types of pelvic
fractures;
Qthe signs of pelvic injury;
Qthe principles of examining the pelvis;
Qinterpretation of pelvic imaging;
Qplan further treatment that may be required.
These cognitive abilities will be integrated with
the practical skills during the course workshops.
Further information
Q Orthopaedic Trauma Association committee
for coding and classification. Fracture and
dislocation compendium. J Orthop Trauma 1996;
10 Suppl.1:1-154.
Q Rommens PM, Hofmann A, Hessmann MH.
Management of acute hemorrhage in pelvic
trauma: an overview. Europ J Trauma Emerg Surg
2010;36:91-99.
Q Bottlang M, Krieg JC, Mohr M, Simpsom TS, Madey
SM. Emergent management of pelvic ring fractures
with use of circumferential compression. J Bone
Joint Surg Am 2002;84A Suppl 2:43-47.
Q Ganz R, Krushell RJ, Jakob RP, Küffer J. The antishock
pelvic clamp. Clin Orthop Rel Res 1991;267:71-78.
Q Osborn PM, Smith WR, Moore EE, Cothren
CC, Morgan SJ, Williams AE, Stahel PF. Direct
retroperitoneal pelvic packing versus pelvic
angiography: a comparison of two management
protocols for haemodynamic unstable pelvic
fractures. Injury 2009;40:54-60.
Q Tile M. Acute pelvic fractures: 1. Causation and
Classification. J Am Acad Orthop Surg 1996;4:143-151.
Q Haemorrhage in fragility fractures of the pelvis.
Q Dietz SO, Hofmann A, Rommens PM.
Q Eur J Trauma Emerg Surg. 2015 Aug;41(4):363-7. doi:
10.1007/s00068-014-0452-1. Epub 2014 Sep 23.
Q Rommens, PM Kuhn, S Hofmann, A
Q Chapter 16 “Becken” in Management des
Schwerverletzten
Q Herausgeber: Pape, Hans-Christoph, Hildebrand,
Frank, Ruchholtz, Steffen, Springer, 2018 DOI:
10.1007/978-3-662-54980-3
Q BOAST 14:THE MANAGEMENT OF UROLOGICAL TRAUMA
ASSOCIATED WITH PELVIC FRACTURES Aug 2016
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Pelvic trauma – skills
Interpretation of the pelvic x-ray
Indication:
Qpolytrauma patients.
Procedure:
QAh!:
Ou se the first 10 seconds to simply look at the
image and note any immediately obvious
abnormalities. Then explore the image in more
detail using the AAABCS systematic review.
QAccuracy and Adequacy:
Oc heck the name and the date of the x-ray for
accuracy, to ensure it is the correct x-ray of the
patient;
Oa n adequate pelvic x-ray should include the
whole pelvis and the proximal 1/3 of femurs with
an overall exposure that allows for interpretation.
QAlignment:
Othere are three rings to be checked. The sacrum
and the pelvic brim form the main pelvic inlet
(large ring). The two small ones are the obturator
foramina. If one of these circles is broken a search
should be made for fractures or joint separation
elsewhere in the ring;
Oi n correctly aligned images the pubic symphysis
is in line with the spinous processes. Deviation
from this alters the relative shape of the right and
left hemipelvises;
Othe last check of alignment is a smooth curved
line continuous with the obturator foramen
and the inner surface of the neck of femur
(Shenton’s line).
QBones (fractures):
Ot race along the cortical margins to detect a
fracture, which may show up as a lucency,
density or trabecular disruption;
Oi nterruptions of the ilioischial and iliopubic line
are hallmarks for an acetabular fracture;
Oc heck the acetabular margin for fractures.
QCartilage and joints:
Ot he sacroiliac joints and the symphysis pubis
should be checked for widening. Normal values
are 2-4 mm for the sacroiliac joints and 5mm
(10 in adolescents) for symphysis pubis.
QSoft tissues:
Oa haematoma inside the small pelvis may be
detected by bladder displacement.
Complications:
Qfailure to recognize injury to the posterior pelvis.
Classification of pelvic fractures
The Tile system, adapted by the Association for the
Study of Internal Fixation (ASIF), is used worldwide. It
distinguishes between three groups of lesions, which
significantly differ in morbidity and outcome.
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In Type A, the pelvic ring remains stable. There are
marginal lesions such as fractures of the iliac wing,
avulsion fractures of the ischial tuberosities or the
spines; or minimally displaced fractures of the pubic
and ischial rami. There is no threat to the general
condition of the patient.
In Type B, there is rotational instability. Open book
lesions, lateral compression injuries or combinations
of both are part of this group (figures 7.1a,b. 7.2a,b).
When larger displacement exists, type B lesions may
be dangerous because of major blood loss.
In Type C, (figure 7.3a,b) there is rotational and vertical
instability. Vertical shear injuries belong to this group.
They can be unilateral, combined with a contralateral
rotational instability or bilateral. These represent
major trauma, which are a threat to life if not managed
early and aggressively.
Application of a pelvic binder (figure 7.9):
Indication:
Qpatients with rotational or vertically unstable
pelvic fractures.
Procedure:
QUndress patients completely or if impossible
remove all objects from patient’s pockets and
pelvic area.
Qremember to check for the 5 p’s
Pulses
Pockets
Phones
Penis (genitalia)
Pulses
QSlide binder underneath the patient’s knees and
slide upwards to the level of trochanters.
QWith the legs in slight flexion and internal rotation
close binder. The closing mechanism depends on
the various models.
Complications:
Qincreased blood loss;
Qmisplaced binder.
Figure 7.9 Application of pelvic binder
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Application of an external fixator
This is a procedure that is rarely undertaken in the
resuscitation room. It is not a skill that is practiced
on the course and the information is provided as an
insight into potential treatment of an unstable pelvic
injury.
Indications:
Qpatients who arrive and are initially
haemodynamically unstable but respond well
to resuscitation. External fixation is not used
as a definitive treatment, but a provisional
one and is performed in the operating theatre
under sterile conditions by an experienced
trauma surgeon.
Procedure:
QSeveral pins are inserted percutaneously into
the iliac wing or in the iliac bone above the
acetabulum (figure 7.10).
QThe pelvic ring is reduced carefully.
QThe pins are connected to each other with bars,
which bridge the pelvic ring anteriorly.
QThis creates good anterior stability, additional
stabilization of the posterior pelvic ring is needed
in vertically unstable pelvic ring lesions.
Complications:
Qmisplaced pins;
Qaseptic pin loosening;
Qpin tract infection.
Figure 7.10 Application of an external pelvic fixator
Surgical packing
Indications:
Qpatients who continue to bleed despite
application of a pelvic clamp or external fixation.
Procedure:
This involves opening of the small (true) pelvis and
filling it with sterile gauze bandages to create local
pressure against the soft tissues and stop bleeding.
QAn incision is made from the umbilicus to the
symphysis pubis. Through this incision, lesions of
the abdomen can also be treated, when needed.
Alternatively, a Pfannenstiel incision can be used.
QAfter incision of the linea alba, the infero- and
retroperitoneal space is opened while the
abdomen remains closed.
QFrank bleeding will occur as the pelvic haematoma
is released and the patient’s blood pressure can
fall dramatically.
QThe void, which has been created by the
disrupted soft tissues and the haematoma, is
packed with sterile gauze bandages. The counter
pressure provided by the stabilized pelvis on the
traumatized soft tissues and torn small vessels
arrests bleeding.
QThe abdominal wall is closed over the gauzes. A
second look, in which the gauzes will be removed
or replaced, is scheduled within 48 hours (figure
7.11 a,b).
Complications:
Qdamage to organs within the true pelvis;
Qmassive haemorrhage, cardiac arrest;
Qinfection.
Figure 7.11a,b Pelvic packing
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BRITISH ORTHOPAEDIC ASSOCIATION

AUDIT STANDARDS for TRAUMA
August 2016

BOAST 14: THE MANAGEMENT OF UROLOGICAL TRAUMA

ASSOCIATED WITH PELVIC FRACTURES
Background and Justification:
Urological trauma is rare and the incidence of severe urethral trauma is 1/million population/year. The majority of cases are
due to blunt high-energy trauma with associated multi-system injuries and 80% of these cases are associated with pelvic
fractures. Urological injuries are potentially fatal and can result in severe long-term disability.

Inclusions: Patients of all ages with potential bladder or urethral trauma.

Standards for practice audit:

1. All Major Trauma Centres and Trauma Units should have agreed written guidelines for the management of suspected urological
trauma and these must be easily available within the Emergency Department.
2. All patients suffering high-energy trauma must have examination of the perineum and genitalia plus a rectal examination and
the findings recorded in the medical records.
3. A single, gentle attempt at catheterization, by an experienced doctor, is permissible, even if the clinical or CT findings suggest
urethral injury. In adults a 16F soft, silicone catheter should be used. The procedure and the presence of clear or blood stained
urine must be recorded in the medical records.
4. The finding of blood stained urine mandates a retrograde cystogram via the catheter.
5. If the catheter will not pass or passes and drains only blood, do NOT inflate balloon. Withdraw catheter and perform a
retrograde urethrogram.
6. If there is a urethral or bladder injury, the on-call urologist should be informed immediately so that a treatment plan can be
formulated and recorded in the notes.
7. If a urethral catheter cannot be passed, a suprapubic catheter is required. This can be inserted during emergency laparotomy
but otherwise a percutaneous suprapubic catheter should be placed.
8. A percutaneous, suprapubic catheter should be placed using a Seldinger technique under ultrasound control by a doctor
experienced in this technique. The skin insertion point MUST be in the midline and should be 3 to 4 fingers-breadths above
the symphysis. A 16F silicone catheter should be used.
9. The placement of a suprapubic catheter may alter the timing of pelvic fracture surgery and so the pelvic fracture service
should be involved at an early stage.
10. If there is a urine leak from either the bladder or urethra, the pelvic fracture should be treated like an open long-bone fracture
with appropriate antibiotics for 72 hours and early fracture fixation if the patient’s physiology allows.
11. Intraperitoneal bladder rupture requires emergency laparotomy and direct repair.
12. Extraperitoneal rupture of the bladder may be treated by catheter drainage alone. However, in the presence of an unstable
pelvic fracture, it is recommended that fracture reduction and fixation is performed along with primary repair of the bladder.
13. Extraperitoneal rupture of the bladder neck continues to leak even in the presence of a catheter and requires primary repair.
14. Bladder injuries identified during pelvic fracture surgery should be repaired at the same time and bladder drainage (via urethral
or suprapubic catheter, as appropriate) ensured.
15. Bladder injury in children is rare but often more complex than adults. A paediatric urologist should always be involved early in
the care of these injuries.
16. All urethral injuries in females and children must be discussed at a very early stage with the appropriate supra-regional
specialist in urology.
17. The indications for primary (within 48 hours) urethral repair are: associated ano-rectal injury, perineal degloving, bladder neck
injury, massive bladder displacement and penetrating trauma to the anterior urethra.
18. The recommended definitive treatment for urethral rupture in adult males is delayed repair at 3 months post injury. Each MTC
should have a clear referral pathway to a recognised centre for reconstructive urethral surgery with a named urological lead
consultant.
19. Primary re-alignment of the urethra during fracture surgery is not recommended as, in the hands of an inexperienced (urethral)
surgeon, the risk of additional damage probably out-weighs the benefits. Accurate reduction of the bony pelvic ring indirectly
re-aligns the urethra and facilitates delayed repair.
20. Male and female patients suffering displaced anterior pelvic fractures or urethral injury have a high incidence of urinary and
sexual dysfunction. All patients should be provided with a written information sheet on this issue.
21. All Major Trauma Centres must have a linked Andrological service and all patients with displaced anterior pelvic fractures
should be offered access to this service.
22. Hospitals receiving patients with these severe injuries must be part of the Trauma Audit and Research Network (TARN) and all
centres performing delayed urethral reconstruction should participate in the national audit of this procedure.

Evidence base: Consensus meeting BOA and BAUS 2015. www.nice.org.uk/guidance/ng37 PTO

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