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.