ORIGINAL ARTICLE

Does Anterior Plating of Pelvic Ring Fractures Increase

Infection Risk in Patients With Bladder or Urethral Injuries?
Suman Medda, MD,a Mario Cuadra, MD,a Ziqing Yu, PhD,a Givenchy Manzano, MD,a Clay Spitler, MD,b
Paul Matuszewski, MD, c David Patch, MD,b Tyler Pease, MD, c Andrew Chen, MD,d
Victoria Garrard, BS,d Madhav Karunakar, MD,a and the EMIT Pelvic Fracture Study Group*

CONCLUSIONS: Surgeons should approach operative pelvic

OBJECTIVES: Evaluate the effect of anterior fixation on fractures with associated urologic injuries with caution given the
infection in patients with operative pelvic fractures and bladder or high risk of infection. Further work must be done to elucidate the
urethral injuries. effect of anterior implants and SPC use and duration.
METHODS: KEY WORDS: pelvic fracture, urethral injury, bladder injury,
Design: Retrospective. anterior pelvis plate fixation

Setting: Eight centers.
Patient Selection Criteria: Adult patients with closed pelvic
fractures with associated bladder or urethral injuries treated with
anterior plating (AP), intramedullary screw (IS), or no anterior
internal fixation (NAIF, including external fixation or no fixation).
Outcome Measures and Comparisons: Deep infection.
RESULTS: There were 81 extraperitoneal injuries and 57 urethral
injuries. There was no difference in infection between fixation
groups across all urologic injuries (AP: 10.8%, IS: 0%, NAIF: 4.9%,
P = 0.41). There was a higher rate of infection in the urethral injury
group compared with extraperitoneal injuries (14.0% vs. 2.5%, P =
0.016). Among extraperitoneal injuries, specifically, there was no
difference in deep infection related to fixation (AP: 2.6%, IS 0%,
NAIF: 2.9%, P = 0.99). Among urethral injuries, there was no sta-
tistical difference in deep infection related to fixation (AP: 23.1%,
IS: 0%, NAIF: 7.4%, P = 0.21). There was a higher rate of supra-
pubic catheter (SPC) use in urethral injuries compared with extrap-
eritoneal injuries (57.9% vs. 4.9%, P , 0.0001). In the urethral
injury group, SPC use did not have a statistically significant differ-
ence in infection rate (SPC: 18.2% vs. No SPC: 8.3%, P = 0.45).
Early removal of the SPC before or during the definitive orthopaedic
intervention did not significantly affect infection rate (early: 0% vs.
delayed: 25.0%, P = 0.16).
Accepted for publication December 14, 2023.
From the aDepartment of Orthopaedic Surgery, Atrium Health Musculoskeletal
Institute, Charlotte, NC; bDepartment of Orthopaedic Surgery, University
of Alabama at Birmingham, Birmingham, AL; cDepartment of Orthopaedic
Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
d
UNC Orthopaedics, University of North Carolina at Chapel Hill, UNC
School of Medicine, Chapel Hill, NC.
The authors report no conflict of interest.
*EMIT Pelvic Fracture Study Group members are listed in an Appendix.
Reprints: Suman Medda, MD, 1025 Morehead Medical Dr. Ste. 300,
Charlotte, NC 28204 (e-mail: suman.medda1@atriumhealth.org).
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000002745
LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2024;38:129–133)
INTRODUCTION
Lower urinary tract (bladder or urethral) injuries can
occur in 10%–15% of pelvic ring fractures.1,2 Bladder injuries
can be characterized as intraperitoneal (IP) or extraperitoneal.
IP bladder injuries generally occur because of compression of
a distended bladder. Rupture occurs at the dome of the blad-
der, causing urine to drain into the peritoneal cavity.
Therefore, IP bladder ruptures do not contaminate the anterior
ring of the pelvis. IP bladder ruptures are typically managed
with surgical exploration (laparotomy) and repair to prevent
peritonitis. Extraperitoneal bladder injuries occur more com-
monly than IP injuries in the traumatic setting due to either
direct compression or direct injury from a bony fragment.3
Extraperitoneal bladder ruptures allow urine to drain in com-
munication with the anterior pelvic ring, potentially increas-
ing the risk of infection in the setting of orthopaedic implants.
Extraperitoneal bladder ruptures can be managed by catheter
drainage and follow-up cystogram, with most ruptures heal-
ing in 3 weeks.3 However, surgical repair may be indicated in
the setting of complex bladder injury, concurrent exploratory
laparotomy, fracture fragment abutment of the bladder, or
open fixation of pelvic fractures.4,5 Certain bladder injuries
may extend through both the IP and extraperitoneal regions.
When the urethra is injured in the setting of pelvic
fractures, the posterior urethra is most commonly injured.
This allows communication of urine with the anterior pelvic
ring. The relationship between pelvic ring fracture morphol-
ogy and urethral injury (UI) has been analyzed.6–8 Urethral
injuries can be treated by primary realignment, primary repair,
delayed repair and realignment, or delayed urethroplasty.
There is no consensus on the ideal treatment of urethral in-
juries.9 A suprapubic catheter (SPC) is often used to drain the
bladder and bypass the zone of injury while awaiting primary
urethral repair or delayed urethral reconstruction procedures.

J Orthop Trauma  Volume 38, Number 3, March 2024 www.jorthotrauma.com | 129

Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Medda et al
Unstable pelvic ring injuries may require anterior
fixation. Options for anterior fixation include internal fixation
with plates and screws, fixation with intramedullary screws,
internal external fixation (infix), or external fixation. Internal
fixation provides increased stability compared with external
fixation and could be preferred in certain clinical settings.10,11
There is no consensus on the management of pelvic
ring fractures with concomitant lower urinary tract injuries
among genitourinary reconstructive surgeons and orthopaedic
surgeons.12 The risk of infection with anterior internal fixa-
tion is unclear in the setting of an active urinary leak or SPC.
Regarding extraperitoneal bladder ruptures, a difference in
surgical site infection of orthopaedic implants has been sug-
gested but not definitively shown between surgical bladder
repair and catheter drainage.13,14 The use of suprapubic cath-
eters potentially increases the risk of infection due to their
proximity to the anterior pelvic ring; however, no definitive
difference in infection risk has been elucidated.12,15 The
American Urologic Association’s position is that a SPC can
be safely placed in patients undergoing pelvic fixation.16
The purpose of this study was to assess the effect of the
type of anterior fixation on the rate of deep infection after
operative treatment of pelvic ring fractures with associated
lower urinary tract injuries. A secondary aim was to evaluate
whether the type of urologic injury or the utilization of a SPC
impacted the rate of infection.
MATERIALS AND METHODS
After institutional review board approval, patients aged
18 years and older with operatively treated closed pelvic ring
fractures and concomitant genitourinary injuries sustained
from trauma were retrospectively identified and included
from 8, level 1, academic medical centers. Patients with
combined pelvic ring and acetabular fractures were included
if operative intervention included a plate that spanned any
portion of the anterior pelvic ring or if an IS was used in the
superior ramus. Open fractures were excluded because they
were considered a substantial confounding variable.
Pelvic ring fractures were classified based on the OTA/
AO17 and Young and Burgess18 systems. The type of poste-
rior fixation was not analyzed in this study. Anterior fixation
was classified as anterior plating (AP), IS, external fixation, or
no anterior fixation. Internal external fixation (infix) was cat-
egorized into the external fixation group.
After the initial analysis, the external fixation group and
no anterior fixation group were combined to a no anterior
internal fixation (NAIF) group for further comparative
analysis with the AP group and IS group. External fixation
theoretically decreases the potential for communication of
implants with urine, and this combination simulates clinical
scenarios where no anterior fixation is not always possible for
appropriate treatment of pelvic ring instability.
Initially, all patients with IP bladder injuries, extraper-
itoneal bladder injuries and urethral injuries were collected.
Isolated IP bladder injuries were then excluded due to the lack
of communication with the anterior arch of the pelvis.2
However, IP bladder injuries with concomitant extraperito-
neal or urethral injuries were included. After the initial
130 | www.jorthotrauma.com
Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma  Volume 38, Number 3, March 2024
subgroup analysis of all lower urinary tract injury combina-
tions, patients were divided into a UI group or extraperitoneal
(EP) group. The UI group included isolated urethral injuries
and combined urethral and extraperitoneal and/or IP bladder
injuries. The extraperitoneal (EP) group included isolated ex-
traperitoneal bladder injuries and combined extraperitoneal
and IP bladder injuries.
Patients’ urologic management was recorded, including
whether a repair was performed, whether a SPC was used,
and when the SPC was removed. “Early removal” of the SPC
was denoted when it was removed before or during the defin-
itive orthopaedic intervention. “Delayed removal” was de-
noted when it was removed after definitive fracture
stabilization.
Before surgery, we contacted our urology colleagues to
coordinate operative timing. In most cases in which primary
repair of the urologic injury was planned, the approach was
performed by the orthopaedic team through a Pfannenstiel
incision. Following exposure of the retrosymphyseal space,
the case was transitioned to the urology service for repair. The
case was then resumed by the orthopaedic service. The
incision was thoroughly irrigated, followed by reduction and
fixation of the anterior pelvic ring.
The primary outcome was deep surgical site infection
as defined by the Center for Disease Control Guidelines.19
This included any infection with deep purulence, advanced
imaging consistent with deep abscess, or any infection requir-
ing operative intervention within 90 days of the definitive
orthopaedic operative procedure. Superficial infection was
also collected, which included wound dehiscence, cellulitis,
or pin-site infections requiring antibiotic therapy only and no
operative intervention. Culture-proven aseptic hematoma or
seroma, nonunion, and implant failure were also collected.
All cases of nonunion and implant failure were thoroughly
reassessed to confirm that infection was not the source of the
complication.
Descriptive statistics were used to describe demo-
graphic characteristics. Chi-square tests, Fisher exact tests,
and nonparametric tests were used to determine the signifi-
cance of complication rates. A P value of 0.05 was used for
significance. Analysis was performed using SAS software
(Cary, NC, USA).
RESULTS
One hundred thirty-eight patients between 2008 and
2020 met inclusion criteria. One hundred five patients
(76%) were male. The median age was 40 years (interquartile
range [IQR]: 32–53 years). Median body mass index was
25.8 (IQR: 23.0–33.7). Median follow-up was 8.9 months
(IQR: 3.1–15.0 months). Median length of stay was 12 days
(IQR: 8–22 days). The mechanism of injury included motor
vehicle occupant (n = 38, 27.5%), motorcyclist (n = 27,
19.6%), pedestrian struck by vehicle (n = 24 17.4%), bicyclist
(n = 9, 6.5%), fall from height (n = 11, 7.9%), and crush
injury (n = 9, 6.5%). The remaining 20 mechanisms varied.
Twenty-seven patients had combined pelvic ring and
acetabular injuries (19.5%). Of the remaining 111 patients
with isolated pelvic ring injuries, 47 (42.34%) had anterior
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 38, Number 3, March 2024 Does Anterior Plating Increase Infection Risk

to posterior compression (APC)–type injuries (APC I: 4,
3.3%. APC II: 25, 22.5%. APC III: 18, 16.2%) and 56
(50.5%) had lateral compression (LC)–type injuries (LC I:
20, 18.0%. LC II: 21, 19.0%. LC III: 15, 13.5%). Eight pa-
tients (7.2%) sustained vertical shear injuries. Four (2.9%)
were 61A, 87 (63.0%) were 61B, and 47 (34.1%) were 61C.
Posterior fracture management varied and included no
fixation (anterior fixation only), iliosacral screws, transsacral
screws, plating along the posterior pelvic ring, and lumbo-
pelvic fixation. No infections were present in direct connec-
tion with posterior fixation.
Sixty-five patients (47.1%) underwent AP, 12 (8.7%)
had intramedullary screws, 40 (28.9%) underwent external
fixation, and 21 (15.22%) had no anterior fixation. The over-
all rate of deep infection was 7.2% across all urologic injuries
among all fixation groups. The deep infection rate but did not
differ significantly between the 4 anterior fixation groups
among all urologic injuries (AP: 7 (10.77%), IS: 0 (0%),
external fixation: 3 (7.5%), no fixation: 0 (0%), P = 0.39).
The deep infection rate did not differ significantly between
the AP, IS, and NAIF (external fixation and no fixation com-
bined) groups (AP: 7 (10.8%), IS: 0 (0%), NAIF: 3 [4.9%],
P = 0.41) across all lower urinary tract injuries (Table 1).
Overall, there was a 12.0% deep infection rate in patients
with isolated urethral injuries and a 2.7% infection rate in
patients with isolated extraperitoneal bladder injuries regardless
of fixation. The infection rate of all patients with an UI
(isolated UI, urethral plus extraperitoneal, and/or IP bladder
injury) was higher (14.0%) than the infection rate of all patients
with an extraperitoneal bladder injury (isolated extraperitoneal,
extraperitoneal and IP, 2.5%, P = 0.016, Table 2).
Of the 81 patients in the extraperitoneal group, 39
underwent AP with 1 infection (2.6%), 8 had intramedullary
screws with no infections (0%), and the remaining 34 patients
had NAIF with 1 infection (2.9%). There was no difference in
infection rate between fixation groups for extraperitoneal
injuries (P = 0.99). Seventy-three percent of extraperitoneal
bladder repairs occurred during the same anesthetic event as
AP. Of the 57 patients in the UI group, 26 underwent AP with
6 infections (23.1%), 4 had intramedullary screws with no
infections (0%), and 27 had NAIF with 2 infections (7.4%).
There was a not a statistically significant difference in infec-
tion rate between fixation groups for urethral injuries (P =
0.21). Twenty-one percent of urethral repairs occurred during
the same anesthetic event as AP (Table 3).
There was a higher rate of SPC use in urethral injuries
(57.9%) compared with extraperitoneal bladder injuries
(4.9%, P , 0.0001). In the UI group, there was no statisti-
cally significant difference in the rate of infection with SPC
use (18.2% vs. 8.3%, P = 0.45). In the UI group, there was no
statistically significant difference in infection rate with de-
layed removal of the SPC after definitive orthopaedic man-
agement (early removal: 0%, delayed removal 25.0%, P =
0.16, Table 4).
DISCUSSION
The overall infection rate in this study was 7.2% in
patients with an operative pelvic ring injury and extraper-
itoneal bladder rupture or UI. This was higher than an initial
study of 23 patients with urethral and bladder injuries, which
had 1 deep infection (4.3%) after sustaining a complete UI.20
The infection rate in the extraperitoneal injury group in
this study was 2.47%, which was lower than previously
reported values of 5%–33%.13,14 Close communication with
genitourinary reconstruction colleagues to coordinate

TABLE 1. Type of Anterior Fixation and Complications Across all Genitourinary Injuries (N = 138)
NAIF
AP IS External Fixation No Fixation P
N (%) 65 (47.1) 12 (8.7) 40 (29.0) 21 (15.2)
Age (median, IQR) 40 (33–49) 43 (35–60) 39 (28–60) 38 (28–48)
Sex (% male) 57 (87.7) 5 (41.7) 29 (72.5) 14 (66.7)
Isolated pelvic ring injury 50 9 37 15
APC I 1 (1.5%) 0 1 (2.5%) 2 (9.5%)
APC II 21 (32.3%) 0 3 (7.5%) 1 (4.8%)
APC III 11 (16.9%) 0 7 (17.5%) 0
LC I 3 (4.6%) 5 (41.7%) 9 (22.5%) 3 (14.3%)
LC II 4 (6.2%) 2 (16.7%) 8 (20%) 7 (33.3%)
LC III 6 (9.2%) 2 (16.7%) 5 (12.5%) 2 (9.5%)
Vertical shear 4 (5.9%) 0 4 (9.1%) 0
61A 1 (1.5%) 1 (8.3%) 0 2 (9.5%)
61B 33 (50.8%) 10 (83.3%) 26 (65%) 18 (85.7%)
61C 31 (47.7%) 1 (8.3%) 14 (35%) 1 (4.8%)
Deep infection (%) 7 (10.8) 0 3 (7.5) 0 0.39
Combined deep infection (%) 7 (10.8) 0 3 (4.9) 0.41
Superficial infection 2 (3.1%) 0 3 (7.5%) 0
Hematoma/seroma 1 (1.5%) 0 1 (2.5%) 0
Implant failure 2 (3.1%) 0 1 (2.5%) 0
Nonunion 3 (4.6%) 0 1 (2.5%) 0

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.jorthotrauma.com | 131

Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Medda et al J Orthop Trauma  Volume 38, Number 3, March 2024

TABLE 2. Genitourinary Injuries and Infection Rate

EP, N = 81 UI, N = 57 P
Urologic injury Isolated EP EP + IP Isolated UI UI + IP UI + EP UI + IP + EP
N (%) 75 (54.4) 6 (4.4) 50 (36.2) 1 (0.7) 5 (3.6) 1 (0.7)
Deep infection (%) 2 (2.7) 0 6 (12.0) 0 2 (40.0) 0
Combined deep infection (%) 2 (2.5) 8 (14.0) 0.016

concomitant extraperitoneal bladder repair during the same
anesthetic event as AP may had led to this. A lower rate of
infection has been suggested with operative repair of bladder
rupture in the setting of pelvic internal fixation.13 In certain
cases, coordination between services was not possible, and
this is an area that should be improved upon. There was no
difference in infection rate in the extraperitoneal group
between the fixation groups. Based on these findings, in the
setting of extraperitoneal bladder rupture, surgeons should
choose the type of anterior fixation which best suits the frac-
ture pattern. In addition, coordination should be planned with
the genitourinary surgeon for the possibility of concomitant
extraperitoneal bladder repair.
The rate of infection in the combined UI group was
14.0%. This was consistent with studies suggesting urethral
injuries as a statistically significant predictor of complica-
tion.14 The infection rate in the UI group in this study was
higher than the reported complication rates of 5.9% without
a SPC and 11.4% with a SPC.15 The difference in deep infec-
tion rate between AP, intramedullary screws, and NAIF in the
UI group did not reach significance. There was a high rate of
SPC placement in the UI group. In this study, there was no
significant difference in the rate of infection with SPC use in
urethral injuries. These results are similar to the study by
Johnsen et al,15 which also showed no significant difference
in the rate of infection with SPC use for urethral injuries in the
setting of internal fixation. There was not a statistically sig-
nificant difference in the rate of infection in the UI group
when the SPC was retained after the definitive orthopaedic
intervention. More severe urologic injuries potentially
required prolonged SPC use, and both of these factors could
contribute to increased contamination. A larger cohort could
have elucidated this difference. Based on these findings, pa-
tients should be counseled on the high-risk nature of pelvic
ring fractures with associated urethral injuries requiring
operative stabilization. Further work must be done to evaluate
the role of external fixation and intramedullary screws. A
discussion should occur with the genitourinary surgeon
regarding the utilization of a SPC and the planned duration
of its retention.
Limitations of this study include the retrospective
design. The primary outcome was surgical site infection
within 90 days of the definitive orthopaedic procedure as
defined by the Centers for Disease Control. Later sequelae
could have potentially been missed. A larger study size could
have allowed for more comparisons to reach statistical
significance and for additional subgroup and multivariate
analysis. There was no standardized protocol across all sites
regarding debridement, antibiotic use, and drain placement.
There was a limited number of cases per surgeon per site.
There was no standardized protocol across all sites regarding
urology comanagement. Urologic injuries were not stratified
by their severity. The quality and timing of the urologic repair
was not evaluated. More proximal and incomplete injuries
can be repaired more adequately, which drives outcomes.
Delayed removal of the SPC was categorized in relation to
timing of definitive fixation but did not discretely analyze the
length of delay. A prolonged course likely carries an increase
in infection risk.
Surgeons should approach operative pelvic fractures
with associated urologic injuries with caution given the risk of
infection. Further work must be done to elucidate the effect of
anterior implants and SPC use and duration.
APPENDIX. EMIT Pelvic Fracture Study Group
The following individuals meet ICMJE criteria for
authorship. Site affiliations are as of time of study unless
otherwise noted. Nicholas Andring, MD, Sharon Babcock,
MD, Eben Carroll, MD, Jason Halvorson, MD, Thea Lance,
Natalie Marenghi, MD, Robert Miles Mayberry, BS, Holly

TABLE 3. Infection Rate as Related to Fixation and Urologic Treatment

EP UI
Fixation AP IS NAIF AP IS NAIF
N 39 8 34 26 4 27
SPC? 1 0 3 13 1 19
Repair/realignment done (%) 26 (66.7) 2 (25.0) 11 (32.3) 19 (73.1) 3 (75.0) 20 (74.1)
SPC and repair 1 0 3 13 1 17
SPC only 0 0 0 0 0 2
Repair only 25 2 8 6 2 3
Concurrent urologic repair with definitive fixation? (%) 19 (73.1) 0 1 (9.1) 4 (21.1) 0 1 (5.0)
Deep infection (%) 1 (2.6) 0 1 (2.9) 6 (23.1) 0 2 (7.4)
P 0.99 0.21

132 | www.jorthotrauma.com Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma  Volume 38, Number 3, March 2024 Does Anterior Plating Increase Infection Risk

TABLE 4. Utilization of SPC, Timing of Removal, and Infection Rate

EP, N = 81 UI, N = 57
SPC No SPC SPC No SPC
4 (4.9%) 77 (95.1%) 33 (57.9%) 24 (42.1%)
Early removal Delayed removal Early removal Delayed removal
0 4 9 24
Days from injury to definitive fixation (median, IQR) 2 (1–3) 2 (1–3) 4 (1–6) 2 (2–9) 3 (2–3)
Deep infection 0 0 2 (2.6%) 0 6 (25.0%) 2 (8.3%)
0.16
0 2 (2.6%) 6 (18.2%) 2 (8.3%)
P 0.99 0.45
Early removal: removed before or during definitive orthopaedic fixation.

Pilson, MD, Madeline Rieker, BS (Department of Orthopaedic
Surgery, Wake Forest University School of Medicine,
Winston-Salem, North Carolina); Benjamin Averkamp, MD,
Christine Churchill, MA, Madison Colcord, BS, Erica
Grochowski, MPH, Kate Hickson, BS, Laurence Kempton,
MD, Virgenal Owens, MD, Jeremiah Parham, BS, Kevin
Phelps, MD, Hannah Pollock, BS, Tamar Roomian, MPH,
Rachel Seymour, PhD, Stephen Sims, MD, Juliette Sweeney,
BS, Catherine Young, BS (Department of Orthopaedic
Surgery, Atrium Health Musculoskeletal Institute, Charlotte,
North Carolina); Kayla Bell, BS, Lucy Bowers, BS
(Department of Orthopaedic Surgery and Sports Medicine,
University of Kentucky, Lexington, Kentucky); Patrick Curtin,
MD (Department of Orthopaedic Surgery, University of
Massachusetts Medical School, Worcester, Massachusetts);
Zachery Hong, MS, Anna N. Miller, MD (Department of
Orthopaedic Surgery, Washington University School of
Medicine in St. Louis, St. Louis, Missouri); Alysa Nash,
MD, Timothy C. Yin (UNC Orthopaedics, University of North
Carolina at Chapel Hill, UNC School of Medicine, Chapel Hill,
North Carolina); Owen Ross, MD (Department of Orthopaedic
Surgery, University of Alabama at Birmingham, Birmingham,
Alabama).
REFERENCES
1. Durrant JJ, Ramasamy A, Salmon MS, et al. Pelvic fracture-related ure-
thral and bladder injury. J R Army Med Corps. 2013;159(suppl 1):i32–
i39.
2. Figler B, Hoffler CE, Reisman W, et al. Multi-disciplinary update on
pelvic fracture associated bladder and urethral injuries. Injury. 2012;43:
1242–1249.
3. Kong JPL, Bultitude MF, Royce P, et al. Lower urinary tract injuries
following Blunt trauma: a review of contemporary management. Rev
Urol. 2011;13:119–130.
4. Mahat Y, Leong JY, Chung PH. A contemporary review of adult bladder
trauma. J Inj Violence Res. 2019;11:101–106.
5. Khabiri SS, Keihani S, Myers JB. Extraperitoneal bladder injuries asso-
ciated with pelvic fracture requiring internal fixation: what is the evi-
dence? Am Surg. 2021;87:1203–1206.
6. Aihara R, Blansfield J, Millham FH, et al. undefined. Fracture locations
influence the likelihood of rectal and lower urinary tract injuries in pa-
tients sustaining pelvic fractures. J Trauma. 2002;52:205–208.
7. Koraitim MM. Pelvic fracture urethral injuries: evaluation of various
methods of management. J Urol. 1996;156:1288–1291.
8. Lowe MA, Mason JT, Luna GK, et al. Risk factors for urethral injuries in
men with traumatic pelvic fractures. J Urol. 1988;140:506–507.
9. Light A, Gupta T, Dadabhoy M, et al. Outcomes following primary
realignment versus suprapubic cystostomy with delayed urethroplasty
for pelvic fracture-associated posterior urethral injury: a systematic
review with meta-analysis. Curr Urol. 2019;13:113–124.
10. Matta JM, Tornetta P. Internal fixation of unstable pelvic ring injuries.
Clin Orthop Relat Res. 1996;329:129–140.
11. Wojahn RD, Gardner MJ. Fixation of anterior pelvic ring injuries. J Am
Acad Orthop Surg. 2019;27:667–676.
12. Johnsen NV, Firoozabadi R, Voelzke BB. Treatment discrepancy for
pelvic fracture patients with urethral injuries: a survey of orthopaedic
and urologic surgeons. J Orthop Trauma. 2019;33:E280–E284.
13. Yao HHI, Esser M, Grummet J, et al. Lower risk of pelvic metalware
infection with operative repair of concurrent bladder rupture. ANZ J Surg.
2018;88:560–564.
14. Anderson RE, Keihani S, Moses RA, et al. Current management of
extraperitoneal bladder injuries: results from the multi-institutional
genito-urinary trauma study (MiGUTS). J Urol. 2020;204:538–544.
15. Johnsen NV, Vanni AJ, Voelzke BB. Risk of infectious complications in
pelvic fracture urethral injury patients managed with internal fixation and
suprapubic catheter placement. J Trauma Acute Care Surg. 2018;85:536–540.
16. Morey AF, Brandes S, Dugi DD, et al. Urotrauma: AUA guideline.
J Urol. 2014;192:327–335.
17. Pelvic ring. J Orthop Trauma. 2018;32:S71–S76.
18. Burgess AR, Eastridge BJ, Young JWR, et al. Pelvic ring disruptions:
effective classification system and treatment protocols. J Trauma. 1990;
30:848–856.
19. Centers for Disease Control and Prevention (CDC). Web-Based Inquiry
Statistics Query and Reporting System. WISQARS). Atlanta, Georgia:
Centers for Disease Control and Prevention (CDC); 2016.
20. Routt MLC, Simonian PT, Defalco AJ, et al. Internal fixation in pelvic
fractures and primary repairs of associated genitourinary disruptions:
a team approach. J Trauma. 1996;40:784–790.

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.jorthotrauma.com | 133

Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.