A RARE CONSTELLATION OF DEVASTATING INJURIES - OPEN PELVIC FRACTURE WITH TESTICULAR DISRUPTION, A CASE REPORT.

Objectives:

Background:
Open pelvic fracture is an uncommon injury with an extremely high mortality. Early mortality is related to exsanguinating hemorrhage and late with sepsis. Genitourinary tract injuries occur in 3-10% of trauma patients. Perineum and scrotal area injuries can occur due to motorcycle accidents; known as “fuel tank” or “straddle type” injuries in which the driver collides with a fixed object resulting in deceleration forces and blunt trauma. We present a case of a patient who sustained devastating polytrauma including open pelvic fracture and testicular rupture.

Case Description:
A 40 year old male presented as a level 1 trauma following a motorcycle accident. He was intubated in the field and found to have an open pelvic fracture with testicular evisceration, bilateral pulseless open upper extremity fractures, and complex facial and extremity lacerations upon arrival. FAST exam was positive in the upper quadrants and pericardial window. Massive transfusion protocol was initiated for hemorrhagic shock, pelvic binder was placed, and the patient emergently underwent exploratory laparotomy. He was found to have left testicular rupture, urethral transection at the bladder neck, and intraperitoneal bladder rupture. He underwent repair of intraperitoneal bladder injury, suprapubic catheter placement, and left orchiectomy. The patient had a protracted ICU course with multi-organ failure, but eventually made a successful recovery.


Discussion:
Open pelvic fracture is a devastating injury not only because of the high mortality rate during the trauma, but also due to increased incidence rate of infection during the subsequent hospital course. The colonized bacteria may originate from contamination by the environment or more likely due to presence of fecal content in the retroperitoneal cavity. Faringer et al reported the infection rates in relation to open wounds and classified them into zones I,II and III.

Testicular rupture occurs when the tunica albuginea is torn, resulting in testicular parenchyma extrusion. Testicular rupture may present clinically with scrotal swelling, hematocele, ecchymosis, tenderness, and loss of contours . Prompt diagnosis and early surgical intervention is crucial in preventing future complications of impaired fertility, chronic pain, hypogonadism, delayed orchiectomy, testicular atrophy, and altered self-image.

Conclusion:
Pelvic ring fractures with genitourinary injuries were associated with a higher rate of intensive care unit admission and longer hospital stays. Attention should be paid in ruling out testicular injuries in unstable pelvic ring disruptions. Limited literature exists on incidence and outcomes, but multidisciplinary approach is pivotal to maximizing outcomes in these devastating injuries.

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Results:

Conclusion: