Irreducible Locked Symphysis Pubis Disruption Caused by Incarcerated Urinary Bladder in a 14-year-Old Boy, a Case Report and Review of the Literature

Abstract

Urinary bladder entrapment or incarceration within pelvic fracture have been described in many reports in the literature, most of which were reported in adult patients. We describe a case of a 14-year-old boy presented with isolated locked symphysis pubis disruption after falling from a height. His initial evaluation was negative for any other associated injuries. The decision was made to treat him surgically by open reduction and internal fixation using a symphyseal plate; however, upon completing the Pfannenstiel incision, the surgeon faced a soft tissue mass hindering bony fragment dissection; upon careful examination, the soft tissue mass turned out to be entrapped urinary bladder within the symphyseal disruption. After careful soft tissue dissection, and with the help of Jungbluth distractor, the disruption was over-distracted, the bladder was freed entirely (which was intact) and reduced to its position, followed by the application of a symphyseal plate in a reduced symphysis pubis position. The patient did well postoperatively, and at three months follow up, the disruption and fracture united, and there were no urinary-related symptoms. Although rare, urinary bladder entrapment within an element of anterior pelvic fracture could be a reason for the difficult reduction; careful evaluation and steady soft tissue dissection are paramount for avoiding undue iatrogenic urinary bladder injury.

Keywords: bladder entrapment; case report; pediatric pelvic fracture.

Figure 1

Preoperative imaging studies, plain radiographs: (A) anteroposterior view. (B) Inlet view. (C) Outlet view. (D) computed tomography different scans. The red arrowheads indicate the locked symphyseal disruption and the green arrowheads indicate the right pubic rami fractures.

Figure 2

Intraoperative images. (A) after performing the Pfannenstiel incision (white arrowhead), initial soft tissue dissection, and retractor placement, a soft tissue mass (the urinary bladder) was evident in the field (white asterisk), hindering the fracture reduction. (B) after placement of more retractors, the urinary bladder (white asterisk) was dissected from the surroundings. (C) a Schanz screw (red arrowhead) was placed on the right pubic rami to ease fracture manipulation. (D) after gentle manipulation of the fracture, the right pubic rami (yellow arrowhead) and the left pubic rami (green arrowhead) started to be evident through the surgical approach, while the urinary bladder (white asterisk) is freed from the entrapment side and swept proximally. (E and F) after complete dissection and reduction of the urinary bladder, the overlapping of the locked symphyseal disruption is evident.

Figure 3

Intraoperative fluoroscopic images indicating the steps of symphyseal disruption reduction and internal fixation. (A and B) initial imaging before fracture manipulation showing the locked symphyseal disruption (red arrowheads). (C) a Schanz screw was placed in the right pubic rami (blue arrowhead), and another one was placed in the left supraacetabular area (black arrowhead). One screw was inserted in the pubic rami on each side (green arrowhead) for Jungbluth distractor assembly. (D and E) after attaching the Jungbluth distractor (white arrowhead), symphyseal disruption reduction was achieved; it is noted that the Orange arrowhead throughout the images indicates the abdominal towel placed in the retropubic space of Retzius. (F) after obtaining preliminary optimum reduction, it was held using a temporary K-wire (yellow arrowhead). (G) the initial plate application and initial fixation, while the K-wire (yellow arrowhead) is still in place. (H) after final internal fixation using a symphyseal plate.

Figure 4

Immediate postoperative radiographs (A) anteroposterior. (B) inlet. (C) outlet views show symphysis pubis reduction, correct plate placement, and screws length; however, it was noted that the sacroiliac joint on the right side was disrupted (indicated by red arrowheads).

Figure 5

Plain radiographs (A) anteroposterior. (B) inlet. (C) outlet views obtained at the final follow up (at three months) showed the addition of a transiliac screw (which was inserted to fix the posterior element disruption), maintained symphyseal reduction, and union of the right pubic rami fracture.