Extraperitoneal bladder rupture

Case contributed by Dr Vikas Shah

Presentation

Fall from height.

Patient Data

Age: 20 years
Gender: Male
X-ray

Pelvis x-ray

Urinary catheter in situ. Left superior and inferior pubic rami fractures and widening of the left sacroiliac joint. 

Ultrasound

Ultrasound renal tract for hematuria

The kidneys have a normal appearance. The bladder is thick-walled with a poorly defined anterior wall. There is a large volume of free fluid in the hepatorenal and splenorenal spaces.

It is unclear as to why a trauma protocol (i.e. full body) CT was not acquired on presentation. Instead, disparate investigations such as pelvic x-ray and renal tract ultrasound were requested. Upon review of the x-ray findings, the orthopaedic team requested a CT; however, this was a plain CT of the pelvis only.

CT

CT pelvis

CT confirms fractures of the left superior and inferior pubic rami. There are also fractures involving the left iliac bone extending into the sacroiliac joint, with widening of the left SI joint. There is free fluid and gas, particularly anterior to the catheterized urinary bladder. Some gas is also present in the urinary bladder.

At a clinicoradiologic meeting to discuss the pelvic fractures, the radiologist summarised the findings in a patient who had fallen from a height: pelvic fractures, haematuria with free fluid on ultrasound, and extensive free fluid and gas on CT. An urgent whole-body CT with an additional cystogram phase was organised by the radiologist.

CT

Body CT

The CT shows a large volume of free fluid throughout the abdominal cavity, and in particular anteriorly within the pelvis. Here there is also some higher density immediately adjacent to the urinary bladder, and also multiple locules of gas. There is no sign of another musculoskeletal injury, nor of any other solid organ, pulmonary or vascular injury. Moderate sized left pleural effusion with bibasal atelectasis.

CT

CT cystogram

200 ml of 2% Urograffin was instilled via the urinary catheter, and the timing of acquisition was approximately 10 minutes following the intravenous contrast. There is leak of contrast anteriorly from the bladder wall into the soft tissues of the pelvis, but not into the peritoneal space. The "molar tooth sign" is observed. Incidental finding of duplex right ureter.

Case Discussion

A fall from a significant height is an indication for a "trauma protocol" whole-body CT. This case illustrates plain film and CT signs of pelvic ring fractures, and the ultrasound and CT studies show free fluid and urine leak due to the associated bladder injury. Instillation of diluted contrast via the urinary catheter can be quickly done while the patient is on the CT table to definitively identify a bladder rupture. The standard management of an extraperitoneal bladder rupture is conservative and this man recovered after a few months of urinary catheter management.

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Case information

rID: 61059
Published: 15th Jun 2018
Last edited: 14th Aug 2019
System: Trauma
Inclusion in quiz mode: Included

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