Emergency Medicine

Additional Orthopaedic Injuries in Multiple Trauma

244 Surgical Emergencies

MANAGEMENT

1 Resuscitate the patient with i.v. f luids, commence antibiotics such as gentamicin

5 mg/kg i.v. and ampicillin 1 g i.v. and give tetanus prophylaxis as indicated.

2 Refer the patient to the surgical team for admission.

Bladder and urethral injuries

DIAGNOSIS

1 These injuries are more commonly associated with direct blunt trauma to

the lower abdomen and with major pelvic fractures.

2 Bladder rupture

This may be intraperitoneal or extraperitoneal.

(i) Intraperitoneal is associated with shock and peritonism.

(ii) Extraperitoneal:

(a) causes signs of urine extravasation and local bruising

(b) >95% have macroscopic haematuria.

3 Urethral rupture

This may occur to the membranous or bulbous urethra.

(i) Membranous urethra:

(a) associated with difficulty voiding urine and urethral bleeding,

which mimics extraperitoneal rupture of the bladder

(b) rectal examination reveals a high-riding prostate, often with

an underlying boggy haematoma.

(ii) Bulbous urethra:

(a) caused by a straddle injury (falling astride an object)

(b) results in local perineal bruising, pain and meatal bleeding.

MANAGEMENT

1 Call for a senior ED doctor and attempt to gently catheterize the bladder, but

stop if any resistance at all is encountered.

2 Treat the patient for pain and blood loss, and give antibiotics such as

gentamicin 5 mg/kg i.v. and ampicillin 1 g i.v.

3 Refer to the surgical team for an ascending urethrogram or cystogram,

before a CT scan of t he abdomen wit h i.v. contrast is performed.

ADDITIONAL ORTHOPAEDIC INJURIES IN MULTIPLE TRAUMA

Early orthopaedic team involvement is common for pelvic trauma particularly if

associated with haemorrhage, as well as for thoracic and lumbosacral spine

injury, and limb injury.