DISCUSSION
In emergency situations, orthopedic surgeons may be heavily occupied
with life-saving measures, potentially leading to limited attention to
obvious wounds and fractures. This oversight can be particularly
problematic in cases of occult open pelvic fractures in the female
perineal area. It is characterized by a blood clot in the perineal
wound, often mistaken for a menstrual blood clot. Failing to diagnose
and treat promptly can result in the spreading and progressive worsening
of the infection, posing a life-threatening situation. The diagnosis and
management of this specific damage involve five key points as below.
Characteristic images on pelvic CT
In pelvic CT scans, the ’free black air bubble sign’ and ’fracture blade
sign’ distributed around the urethra and vagina. Open pelvic fracture
diagnosis is established when both of these signs are observed.
Female Perineal Area Examination
If ’free black air bubble sign’ is detected on pelvic CT, and there are
no wounds in the lower abdomen, pelvis, hips, buttocks, and
sacrococcygeal area, the perineal area should be examined for skin
wounds. Blood in the perineal area might be misdiagnosed as menstrual
clots and need colposcopy.
One-stage colostomy
Faringer [2] suggested that injuries involving zone I (pubic node,
perineum, sacrum, rectum, and vagina) should undergo colostomy. In 1997,
Jones-Powell [3] proposed categorizing injuries to the peripelvic
soft tissue and organs as injuries to the rectal and perineal area. In
2015, Fu et al [4] introduced a modified classification, dividing
the perineal area into the genitourinary and rectal-anal area. Those
involving injuries in the rectal-anal area should undergo colostomy.
Open pelvic fractures with fracture site puncturing the rectum and
vagina can lead to extensive deep contamination, triggering pelvic
infections, sepsis and even multiple organ failure (MOF). The mortality
rate is as high as 26% [5-6]. Performing colostomy proactively can
improve outcomes and reduce the mortality rate [7-12]. It is also a
prerequisite for subsequent internal fixation [13]. According to
Jones et al [3], performing colostomy within 48 hours after injury
can reduce the morbidity and mortality rate from 75% to 20%.
This case may support the indications for colostomy, emphasizing the
rationale for a one-stage colostomy. ①Fecal bacteria entering the
perineal wound can lead to infection. ②Accumulated fecal bacteria in the
intestines may infiltrate the wound area through the colon wall and
greater omentum, causing secondary infection. Toxins from feces and
bacteria can potentially damage the patient’s liver and kidney function.
③Colostomy prevents absorption of fecal toxins, enables an early
resumption of eating, promotes the recovery of digestive tract function,
and effectively absorbs nutrients from food.
Timely and correct management of Morel-Lavallée injuriesHudson et al [14] reported that approximately one-third of
patients experienced an early missed diagnosis. This oversight can
lead to complications such as infection, skin necrosis, sepsis, and
the potential development of septic shock, posing a serious threat to
the patient’s life and influencing the course of fracture treatment.
The following cases should be heightened vigilance. ①There is a clear
history of blunt trauma, such as wheel crushing or heavy impact,
particularly involving the thigh and pelvic acetabulum. ②Abnormal skin
color in the affected area, loss of sensation, and swelling may be
observed. Additionally, ovoid liquid mass under the skin with distinct
fluctuating sensations could be present. ③MRI suggests mixed high and
low signals in both T1WI and T2WI. Both CT and MRI examinations can
accurately confirm the injury’s location and assess the extent of its
cystic wall [15-16]. Ultrasound reveals anechoic characteristics
located between the subcutaneous fat and deep fascia. These
characteristics may be combined with strong echogenic nodular imaging
manifestations of fat globules distributed along the capsule wall.
For subcutaneous effusions with a diameter of less than 15.0 cm and no
skin necrosis, negative pressure drainage and elastic bandages can be
employed to prevent the fluid accumulation and promote close
apposition of the skin to the deep tissues. This facilitates
re-establishing the subcutaneous blood circulation pathway. If the
diameter is more than 15.0 cm, irrigation are necessary. In the case
of skin necrosis, scab removal and debridement are required. Minimal
invasive debridement with closed suction drainage has the advantage of
the evacuation of the hematoma, providing drainage, reducing the
bacterial burden, and preserving the soft-tissue envelope [17].
Due to the accumulation of necrotic tissue and exudate in the wound,
leading to the blockage of the sponge hole of the VSD, requires
regular flushing 2-3 times a day.
Laboratory IndicatorsBlood routine, liver and kidney function, CRP, ESR, PCT and IL-6
levels should be monitored to detect any signs of systemic sepsis or
MODS. It is crucial to comprehensively assess the severity of the
infection, along with the patient’s immune, nutritional, dietary,
defecation, and sleep status.