Pelvic Fracture Urethral Injury – the Nature of the Causative Injury Correlates Strongly with Surgical Treatment and Outcome
It is well recognised that pelvic fracture urethral injury (PFUI) is related to the nature of the pelvic ring disruption and that this disruption can be of several different types. We have assessed the specific nature of the injury and its relationship to outcome.
We have studied 106 consecutive patients who had no previous open repair and had assessable pelvic CT scans at the time of injury as well as urethrography and a minimum of two years of follow-up. 66 patients (62%) had been involved in a road traffic accident (RTA) - half of them (n=33) as a driver or passenger in a car. 38 (36%) had been involved in work (n=32) or recreational activities (n=6). 2 patients had attempted suicide by jumping from a height (2%).
Of the 33 car accidents, 27 were lateral compression (LC) injuries and 4 were open-book (OB). Of the 33 patients who were pedestrians or who were RTA victims who had had motorcycle or bicycle accidents, 16 were LC, 12 were OB and 4 were vertical shear disruptions (VS). Of the work or recreational group 23 were LC, 11 were OB and 4 were VS. The remaining 4 patients were unclassifiable in this simple way. Of the 69 lateral compression fractures, 34 were "straight forward", 22 were crush injuries and the other 13 were not easily classifiable. Of the 34 "straightforward" injuries: 30 were car injuries, 2 were pedestrians and 2 were work injuries. Of the 22 crush injuries: 1 was a car injury, 18 were pedestrian injuries and 3 were work injuries. The surgery in these patients was step 1 - mobilisation and anastomosis - in 7%, step 2 - crural separation - in 52.5%, step 3 - inferior pubectomy - in 15%; and step 4 - supra-crural re-routing - in 17.5%. Other procedures were used in 8%. The success rate of surgery deteriorated from 95% for step 1 to 84% for Step 4 with each successive step. 60% of the step 3 cases and 67% of the step 4 patients were crush injuries.
Car drivers and passengers in accidents with other similar-sized vehicles tended to have less serious injuries and a better outcome than the other groups mainly because LC fractures seemed to cause less local trauma in the pelvis and were associated with shorter defects to bridge. Specifically, in a car driver or passenger, there was an 88% chance that the injury would be a "straightforward" "LC" injury causing an incomplete rupture with a 92% chance that it can be treated by a step 1 or step 2 BPA with a success rate of 93% - 96%. This interrelationship between the causative injury and the degree of trauma and the scale of surgery and the outcome might explain why the results of surgery in different areas of the world may give different results.