The pelvic ring is defined by the structural relationship between the ilium, ischium, pubis and sacrum [Citation1]. Functionally, the structures of the pelvic ring act as a protective scaffold for the urinary bladder and urethra that are positioned within it. Therefore, with pelvic ring fractures (PRFs) these structures are injured in approximately 5% of patients [Citation2]. lnjuries to the bladder and urethra are referred to as lower urinary tract injuries (LUTIs) and typically occur after high-energy trauma like road traffic accidents and after falls from a significant height [Citation3, Citation4]. Associations between PRFs and LUTIs after high energy trauma are through direct mechanisms (e.g. contact with a bone spicule) and indirect mechanisms (e.g. ligamentotaxis injury) [Citation1].
The Tile Classification grades pelvic ring fractures from A-C1. In the Tile Classification, grade A corresponds to a stable pelvic fracture, B is a rotationally unstable injury that is vertically stable, and C is a rotationally unstable injury that is vertically unstable [Citation1]. In this issue of the Journal of Investigative Surgery, the association between LUTIs and a pelvic ring fractures was investigated in the form of a case series [Citation5]. Specifically, the authors analyzed the risk of LUTI in PRF patients based on the Tile classification [Citation5].
In total, 614 PRF patients were retrospectively studied, of which 25 (4.6%) sustained a concomitant injury to the bladder (n = 17) and urethra (n = 8). Their incidence rate of LUTI after PRF of 4.6% is consistent with the literature [Citation2]. The main finding of the study is that LUTIs are associated with unstable fractures of the pelvic ring (i.e. Tile classification B and C) compared to stable PRFs (i.e. Tile Classification A). In addition, the authors investigated the incidence of LUTI in more detail among the 25 patients with bladder or urethral injury. Using the Tile classification, there was a lower rate of LUTI in type A PRF (2.2%) compared to B (6.8%,) and C (10.8%). Notably, Tile Classification type C3 was associated with a LUTI in 22.2% of patients.
A strength of this study is that the Tile classification system was used to accurately characterize all analyzed PRFs. Conversely, limitations of the study are that the extent, grade, management and outcomes of each LUTI were not measured or analyzed in detail. Therefore, it is difficult to clearly determine whether more unstable PRFs resulted in higher grades of bladder and urethral injuries [Citation4]. In addition, it is difficult to make definitive conclusions based on the relatively small numbers in the subgroup analysis. For example, the LUTI incidence rate of 22.2% in Tile C3 factors is based on a subgroup analysis of only 9 patients.
This study, however, does provide important data that is relevant to trauma surgeons, orthopedic surgeons and urologists alike. The authors’ findings emphasize the importance of a multidisciplinary management approach to patients with PRFs; in particular, Tile B and Tile C PRFs as this subgroup of patients are at the highest risk of concomitant injury to the bladder and/or urethra. Emphasizing the increased risk of GU injury in patients with Tile C fractures will be important to increase awareness of trauma providers to have a higher suspicion for potential urological injury.
Disclosure statement
The authors report no conflicts of interest
References
- Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg – Ser B. 1988;70B(1):1–12. doi:10.1302/0301-620X.70B1.3276697.
- Johnsen NV, Dmochowski RR, Young JB, et al. Epidemiology of blunt lower urinary tract trauma with and without pelvic fracture. Urology. 2017;102:234–239. doi:10.1016/j.urology.2016.11.015.
- Andrich DE, Day AC, Mundy AR. Proposed mechanisms of lower urinary tract injury in fractures of the pelvic ring. BJU Int. 2007;100(3):567–573. doi:10.1111/j.1464-410X.2007.07020.x.
- Bhatt NR, Merchant R, Davis NF, et al. Incidence and immediate management of genitourinary injuries in pelvic and acetabular trauma: A 10-year retrospective study. BJU Int. 2018;122(1):126–132. doi:10.1111/bju.14161.
- Association between stability and urologic lesions in pelvic ring fractures. A case series report. J Invest Surg. 2021;34(7):786–789. doi:10.1080/08941939.2019.1692100.