A complicated pelvic fracture in an octogenarian
QJM: Quarterly journal of medicine
We have read with interest the case report by C. Dotchin et al. 1 regarding a patient with bladder rupture following pubic ramus fracture (PRF) and sacral insufficiency fracture (SIF). We recently had a case that illustrated similar learning points. An 86-year-old female had a fall from a standing height, while on holiday abroad. Previously she was fit and well, with unlimited mobility and no history of osteoporosis or fragility fracture. She was admitted to the local hospital and was diagnosed
... l and was diagnosed with left superior and inferior PRFs. Her initial admission was brief but she was readmitted several days later due to severe left leg pain and macroscopic haematuria and was treated for presumed urinary tract infection (UTI). On her return to UK 2 weeks after the injury, she was admitted to the acute medical ward as her left leg pain continued, mobility did not improve and she was only able to transfer from chair to bed. A plain pelvic X-ray confirmed left superior and inferior PRFs and trauma team recommended mobilization. Her pain settled somewhat and she was discharged after 15 days. However, she continued to suffer with persistent left leg pain, difficulties with mobilizing, lethargy and malaise and was readmitted 33 days after herinitial injury. She had persistently high inflammatory markers, her urine was positive for leucocytes, blood and protein and her blood cultures grew extendedspectrum-beta-lactamase (ESBL) Escherichia coli. She was treated for presumed urosepsis and discharged home. Three days later (36 days after initial fall and injury), she was admitted again to the acute medical ward with melena and ongoing urosepsis. Computed tomography (CT) of the abdomen and pelvis with contrast reported left-sided symphysis fracture with osteomyelitis, associated abscess and separate intramuscular collection within the pectineus, as well as fractures of the left ischium and left sacrum. 2 Magnetic resonance imaging (MRI) of the pelvis showed a soft tissue abnormality surrounding the bladder base suggestive of bladder perforation and urine leak, fractures of the left sacral ala and pubic rami, with the evidence of osteomyelitis in the pubic bones bilaterally and intramuscular abscess in the left pectineus. A flexible cystoscopy was performed, which showed visible bone protruding 2 cm into the bladder, and a subsequent cystography demonstrated a leak on the left side of her bladder ( Figure 1) . Eventually, 114 days after the initial injury and after seven separate hospital admissions, the perforated bladder was surgically repaired and she had debridement of the osteomyelitic bones. This was complicated with abdominal wound dehiscence for which she needed another laparotomy. Afterwards, she was treated with a prolonged course of teicoplanin and ertapenem and follow-up cystogram showed no leak. At her most recent review, 156 days after initial injury, she was pain free and walking well with a zimmer frame at home.