A 34-year-old male construction worker is brought to the emergency department after fallin… — USMLE Step 2 CK

A $34$ -year-old male construction worker is brought to the emergency department after falling approximately $6\text{ meters}$ ( $20\text{ feet}$ ) from a scaffold. He is fully alert and reports severe lower abdominal and pelvic pain. His temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $115/78\text{ mm Hg}$ , and pulse is $98/\text{min}$ . A focused assessment with sonography for trauma (FAST) reveals no free intraperitoneal fluid. Pelvic radiography demonstrates an unstable "open book" pelvic ring disruption with significant diastasis of the pubic symphysis. The orthopedic surgery team is preparing the patient for emergent open reduction and internal fixation (ORIF) of the pelvis. A retrograde urethrogram is performed and confirms an intact urethra. A transurethral Foley catheter is placed and drains frankly bloody urine. A subsequent computed tomography (CT) cystogram demonstrates contrast extravasation confined to the perivesical space in a "flame-shaped" pattern, with no contrast outlining the bowel loops. Which of the following is the most appropriate management of this patient's urologic injury?

Concurrent open surgical repair of the bladderAnswer
B
Foley catheter drainage and observation for $10$ to $14\text{ days}$
C
Percutaneous bilateral nephrostomy tube placement
D
Administration of broad-spectrum intravenous antibiotics only
E
Cystoscopic fulguration of the bladder defect

Answer

Concurrent open surgical repair of the bladder

The patient has sustained an extraperitoneal bladder rupture, evidenced by the 'flame-shaped' contrast extravasation on the CT cystogram. The standard of care for an isolated, uncomplicated extraperitoneal bladder rupture is nonoperative management with continuous bladder decompression via a transurethral Foley catheter for

10

14\text{ days}

. However, there are absolute indications for open surgical repair of an extraperitoneal rupture. These include concomitant open reduction and internal fixation (ORIF) of the pelvis, bone spicules penetrating the bladder wall, open pelvic fractures, and associated rectal or vaginal injuries. Because this patient is undergoing emergent ORIF, the bladder must be surgically repaired concurrently. If left unrepaired, extravasated urine will pool in the retropubic space around the newly placed orthopedic hardware, carrying a prohibitively high risk of deep tissue infection, hardware failure, and sepsis.

Step-by-Step Solution

Interpret the imaging findings to classify the bladder injury.

The CT cystogram shows 'flame-shaped' contrast extravasation confined to the perivesical space, which is diagnostic of an extraperitoneal bladder rupture.

Classifying the rupture as intraperitoneal versus extraperitoneal dictates the foundational management pathway.

Identify concomitant traumatic injuries and planned interventions.

The patient has an unstable pelvic ring fracture requiring emergent open reduction and internal fixation (ORIF) by orthopedic surgery.

Associated injuries and surgical plans heavily influence and often alter standard trauma management algorithms.

Synthesize findings to determine the definitive urologic management.

Select concurrent open surgical repair of the bladder.

Although extraperitoneal bladder ruptures are typically managed nonoperatively with a Foley catheter, surgical repair is mandatory when orthopedic hardware (ORIF) is being placed to prevent extravasated urine from causing a severe hardware infection.

Key Concept

Extraperitoneal bladder ruptures are generally managed nonoperatively with prolonged Foley catheter drainage; however, concurrent surgical repair is required if the patient is undergoing open reduction and internal fixation (ORIF) of the pelvis to prevent orthopedic hardware infection.

Estimated Time:1m 20s

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