A 40-year-old man is brought to the emergency department after a motor vehicle collision. Blood pressure is 130/84 mm Hg and pulse is 102/min. Heart and lung sounds are normal. Abdominal palpation shows fullness and tenderness in the suprapubic region. There is no blood at the urethral meatus, and digital rectal examination reveals a normal prostate. Chest x-ray is normal. Focused Assessment with Sonography for Trauma reveals no intraperitoneal free fluid. Pelvic x-ray reveals fracture of the left pubic ramus. A Foley catheter is placed without resistance, with immediate return of bloody urine. Emergency CT scan of the abdomen and pelvis is performed. Which of the following injuries is most likely to be seen on CT scan in this patient?

Question

A 40-year-old man is brought to the emergency department after a motor vehicle collision.  Blood pressure is 130/84 mm Hg and pulse is 102/min.  Heart and lung sounds are normal.  Abdominal palpation shows fullness and tenderness in the suprapubic region.  There is no blood at the urethral meatus, and digital rectal examination reveals a normal prostate.  Chest x-ray is normal.  Focused Assessment with Sonography for Trauma reveals no intraperitoneal free fluid.  Pelvic x-ray reveals fracture of the left pubic ramus.  A Foley catheter is placed without resistance, with immediate return of bloody urine.  Emergency CT scan of the abdomen and pelvis is performed.  Which of the following injuries is most likely to be seen on CT scan in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d955_84e9_bc81_c52e8e9d7596_MD0003_00 This patient with suprapubic fullness and tenderness and gross hematuria (ie, bloody urine) in the setting of a pelvic fracture likely has a bladder injury. Given the absence of intraperitoneal free fluid (eg, urine) on Focused Assessment with Sonography for Trauma (FAST), the extraperitoneal bladder (eg, anterior bladder wall) is most likely affected. Extraperitoneal bladder injuries are almost always associated with a pelvic fracture (eg, left pubic ramus fracture), and sometimes, a bony fragment can directly puncture and rupture the bladder. Other clinical findings concerning for bladder injury include the following: Gross hematuria Suprapubic pain/tenderness Difficulty voiding Urine leaked from extraperitoneal bladder rupture stays contained within adjacent tissues (eg, retropubic space). Therefore, FAST is negative for intraperitoneal free fluid and pain typically remains localized to the pelvis (eg, suprapubic tenderness). In contrast, intraperitoneal bladder (eg, dome) rupture spills urine into the peritoneal space, causing a positive FAST and, if undiagnosed, abdominal distention (eg, urinary ascites) and/or chemical peritonitis (Choice B). Retrograde cystography, in which the bladder is passively filled (eg, via Foley catheter) with water-soluble contrast and imaged (eg, CT scan, fluoroscopy), can confirm the diagnosis. (Choice C) Ureteral injury may present with hematuria. However, it is overwhelmingly caused by iatrogenic trauma (eg, pelvic surgery) or penetrating trauma rather than blunt trauma. In addition, flank/abdominal pain (depending on the location of the injury) is more common than suprapubic fullness and tenderness. (Choice D) Renal laceration may present with hematuria, but suprapubic fullness and tenderness are unlikely. Patients with renal laceration typically have flank pain and/or hemorrhage into the retroperitoneal space (eg, flank ecchymosis) instead. (Choice E) Urethral injury occurs in approximately 10% of pelvic fractures in male patients. However, this patient lacks findings suggestive of urethral injury (eg, blood at the urethral meatus, high-riding prostate). In addition, the ability to pass a Foley catheter into the bladder without resistance makes urethral injury unlikely. Educational objective: Suprapubic pain and gross hematuria with associated pelvic fracture are concerning for bladder injury. Because of urine containment within adjacent tissues, extraperitoneal bladder rupture typically causes localized (vs diffuse abdominal) symptoms and a negative examination with Focused Assessment with Sonography for Trauma. References: A contemporary review of adult bladder trauma. (http://www.ncbi.nlm.nih.gov/pubmed/30979861) Blunt bladder injury. (http://www.ncbi.nlm.nih.gov/pubmed/23522505) Blunt traumatic bladder rupture: a 10-year perspective. (http://www.ncbi.nlm.nih.gov/pubmed/23711268)

A 40-Year-Old Man Is Brought to the Emergency Department After