DOI: https://doi.org/10.21203/rs.2.11694/v1
Pelvic fractures are often caused by high energy trauma with high mortality reported from 8% to 15%[1, 2]. Urethra and rectum were often involved in pelvic fractures[3, 4] while vaginal injuries were rarely reported[5, 6]. Because of the hidden position of the vagina and the severe injuries of other organs caused by pelvic fracture, vaginal injuries are likely to be missed and potentially lead to various complications.
Previous studies of pelvic fractures associated with vaginal injuries were mostly case reports, and lack of a systemic study. Therefore, we reviewed patients treated in our institute with an aim to promote early diagnosis, evaluate the relationship between pelvic fracture pattern and vaginal injury and uncover prognostic factors of outcome.
We analyzed all patients with pelvic fracture associated with vaginal injuries (n=25) treated in our department from January 2004 to April 2017. Permission for this study was obtained from the authors’ institution. Informed consent was obtained from all individual participants. This study adhered to CONSORT guidelines.[7] The data gathered from each patient included: age, type of pelvic fracture, mechanism of injury, associated vaginal injury, orthopedic management of pelvic fracture, Injury Severity Score(ISS)[8].
The pelvic injury was categorized using Tile[9] and Young-Burgess classification[10]. Given that there is no grading scale of vaginal injury related to trauma, we proposed a classification referring to degree of obstetric laceration[11]: first degree means mucosal injury only; second degree means involvement of vaginal muscularis but not penetrating through rectum or urethra; third degree means vaginal injury with penetration of the tear through the other natural orifice (rectum or urethra).
The functional outcome was evaluated using Majeed scoring system[12] and the residual displacement was graded according to the method of Tornetta and Matta[13].
Statistical analysis was done using SPSS version 16.0 for windows (SPSS Inc., Chicago, Illinois). The non-parametric Kruskal-Wallis test was used to assess the relationship between fracture patterns and degree of vaginal injury and to identify factors which were associated with clinical outcome. The Fisher exact test was used to identify factors which were associated with sexual function. The Spearman rank correlation coefficient was used to examine the relationship between radiological and pelvic outcome. A p value of 0.05 or less was considered to be statistically significant.
Patient details
Twenty-five pelvic fracture patients with vaginal injury met the inclusion criteria during the study period. The mean age was 32.8±12.4 years old (range, 17-55). The mean ISS was 31.4±14.9, (ranged, 10-57). Nine patients in this series had an ISS of greater than 25. The mean time from injury to emergency department is 2.02±0.8 hours (range, 1-3.5). Most injuries were caused by traffic accidents (22 patients, 88%) while 2 patients falling from height and one patient encountered with crush injury.
Information of vaginal injuries
Based on our vaginal injury classification, 6 patients (24%) with mucosal injury suffered were categorized as first degree. Twelve patients (48%) suffered second degree injury, presented with involvement of vaginal muscularis but not penetrating through rectum or urethra. Seven patients (28%) suffered third degree injury. Four of them suffered vaginal-rectal penetrating injury and vaginal-urethral penetrating wound was presented in 3 patients. All diagnoses were made by a gynecologist and vaginal speculum was used when necessary.
Pattern of pelvic fractures and vaginal injury
According to Tile classification, the most common injury pattern was type B fracture, occurring in 18 patients (72%). Another 7 patients (28%) sustained a type C fracture, and none had type A fracture. The severity of vaginal injury didn’t differ between type B and C fractures according to our classification (p=0.208, Table 1). In Young-Burgess system, twenty patients sustained anterior-posterior compression (APC), five patients sustained vertical shear (VS) injuries and no one showed lateral compression (LC) injuries. The VS fracture patients showed higher severity of vaginal injury compared to patients with APC fracture (p=0.034, Table 1).
All patients suffered disruption of anterior pelvic ring. Most patients suffered pubic ramus fracture (20 patients, 80%). Among them, 10 patients presented unilateral fracture and 10 presented bilateral fracture. Four patients also combined with pubic symphysis separation. Totally 9 patients showed pubic symphysis separation. Four patients presented a rather rare floating pubic symphysis which means fractures of the bilateral superior and inferior pubic rami and ischial rami. We divided patients into 2 groups based on the presence of compromised pubic symphysis. There was significant difference identified between the two groups (p=0.024, Table 1).
Treatment of pelvic fracture
Twenty-four patients survived initial resuscitation phase. External fixation was performed for 11 patients and 5 patients didn’t receive further surgery. Fourteen patients had open reduction and internal fixation (ORIF), among them first-stage ORIF was only performed for 5 patients. The other 9 patients had second-stage or delayed surgery due to unstable hemodynamic condition and abscess formation (7-14 days). In these 9 patients, external fixation was applied in 6 patients at first stage and pelvic binder was used for 2 patients. Conservative treatment was done in the other 5 patients.
Treatment of vaginal injury
No special treatment but only gauze packing was done in the 6 patients with mucosal injury and one patient with second degree injury. All the other patients with second or third degree injury went through surgical repair. Fourteen patients had primary closure and 4 patients had secondary vaginal repair. The wound was sutured through interrupted suture by a gynecologist with 1-0 absorbable sutures
Treatment of associated injury
Anorectal injury occurred in 15 patients, all of them were performed colostomy except for one patient died in emergency room. Another patient with severe vaginal-perineal laceration but no injury of rectum also had protective colostomy. All these patients were performed primary debridement and colostomy with anal sphincter repaired and distal lumen rinsed to avoid secondary contamination. Fifteen patients complicated with urinary tract injuries. Of these 3 were bladder injuries. One patient acquired laparotomy with surgical repair of the bladder due to serious damage, two patients had slight damage and were treated with indwelling catheter. Twelve patients suffered urethral disruption. Six of them required primary suprapubic drainage and subsequent delayed repair. Two patients had vaginal-urethral penetration had urethral realignment. The others were treated conservatively.
Outcome evaluation
Totally 24 patients were followed up at mean 17.7 months (range, 10-36). No patient showed signs of radiographic nonunion. The average time of fracture healing was 4.3±1.2 months (range 3-7 months). The radiologic outcome was assessed using Tornetta and Matta criteria. Only 2 patients showed unsatisfactory results. One was fair and one was poor, and both of them suffered abscess and were only stabilized with external fixation. The function evaluation was done at least 12 months after discharge. The average postoperative Majeed score was 85.9±8.49 (range 56-96). Eighteen patients were assessed as excellent, four patients were good, two patients were fair and none was poor. Factors associated with pelvic outcomes are shown in Table 2. Pelvic outcome was better significantly among younger patients (p=0.043) and patients without urethral injury (p=0.02). Infected patients showed worse results (p=0.005). There was a statistically significant association between an excellent Matta radiological result and a good Majeed clinical score (p=0.01). Management of pelvic fractures especially using external fixation in isolation has significant influence on pelvic function (p=0.024).
Four patients complained of pain in sex intercourse at last follow-up. The patients with abnormal sex life did not demand further treatment. Nine patients were still virgin at the last follow-ups. Sexual function was assessed in the other 15 patients using Fisher exact test but no significant factors related to sexual pain were found (Table 4). All surviving patients had normal menstruation while one patient in menopause at last follow-up. Nine patients had at least one child delivered and one patient was pregnant at the time of the latest follow-up, six patients were performed cesarean section and three patients had natural birth.
Complications
Infection occurred in 6 patients. Four patients developed pelvic abscess and were treated with abscess incision and drainage. Two patient showed incision infection after the surgery and was treated with debridement and changing dressings. Sensitive antibiotic drugs were chosen for infected patients based on the drug sensitivity tests. Vaginal stenosis occurred in 2 patients. No patient showed associated vessel or nerve injuries. Mechanical complications like instrumentation failure didn’t occur.
Vaginal injury after pelvic trauma was rare with incidence about 4% in previous reports[5, 6, 14]. From January 2004 to April 2017, 341 female patients with pelvic fractures were treated at our institution. The incidence of vaginal injury after pelvic trauma was 7.3% according to our data. Most trauma were caused by motor vehicle accident (88%). All injuries were caused by blunt forces and no penetrating wound by external sharp objects presented in these patients. Niemi and Noaon[5] depicted that the vaginal wall may be pulled, penetrated by the fracture ends of pelvic anterior ring as well as separated or floating pubic symphysis or pressed by the decreased pelvic volume. Tayal[15] also emphasized that the pubis and ischium could bruise or penetrate vaginal wall. Since all patients suffered disruption of anterior pelvic ring, we think that vaginal injury should be highly suspected when patients presented fracture of pelvic anterior ring. The assessment of the relationship of pelvic fracture and vaginal injury also showed fractures caused by vertical shear forces and compromised pubic symphysis purported severe vaginal injury (Table 1).
Vaginal injuries were associated with the displaced fracture segments. However, treatment for pelvic fractures remains controversial. Toro et al[16] suggested that patients with non-displaced or minimally displaced acetabular fractures can be treated conservatively. We previously reported that the clinical outcomes were evaluated better for the operative group than non-operative group by Majeed score[17]. In present study, five patients with pelvic fracture were performed non-operatively and all achieved excellent outcome. For 11 patients with unstable hemodynamics or infection, external fixations were used to acquire temporal stabilization and hemostasis through limiting pelvic volume. Six patients received further open reduction and internal fixation at second stage and showed satisfactory results. While 5 patients treated with external fixation in isolation depicted relative unsatisfactory results (p=0.024). All 5 patients sustained Tile B and APC fractures. Two patients with fair pelvic outcome treated by external fixation in isolation also showed unsatisfactory radiological results. Compared with internal fixation technique, limited reduction can be obtained by external fixation. The accuracy of reduction significantly correlated clinical outcome (p=0.01) which is consistent with previous reports.[18, 19] From our experiences, satisfactory results could be obtained from patients with non-displaced or minimally displaced fractures but for patients with unstable fracture pattern, internal fixation was recommended.
Identification of degree of vaginal injury is conducive for guiding clinical therapy. Given no existing grading scale of vaginal injury related to trauma, we proposed a classification referring to degree of obstetric laceration. Gauze packing and surgical repair by suturing are common methods for vaginal injury. For patients with minor damage in vagina, simply gauze packing was sufficient for hemostasis and capable of preventing vaginal adhesion and narrow. No significant relationship was found between degree or treatment of vaginal injury and pelvic outcome. Harvey-Kelly KF[20] reported that rate of sexual dysfunction after pelvic fracture could be as high as 40%. In 15 patients with sexual experience, four patients complained of pain in sex. One patient suffered mucosal injury and two presented with second degree injury. The rest one patient suffered vaginal-urethral penetration with developed pelvic abscess and accepted vaginal repair at second stage. Due to small case series, no influence factor was found correlated to sexual function. Spontaneous conception is possible after pelvic fracture[21], the result from this study supported this conclusion. Twenty-three patients of survived 24 patients were women of childbearing age, nine patients concepted and deliveried successfully, additionally, one patient was pregnant at the time of the latest follow-up. Six patients were performed cesarean section and three patients had natural birth, the rate is higher than average rate over the world, we think that this phenomenon was relative to the condition of obstetrics in China.
Infection was the most common complication which occurred in 6 patients. Two were postoperative incision infection. Four patients developed pelvic abscess because of undiagnosed vaginal injury on admission. Diagnoses of laceration were delayed 30, 36, 36 and 48 hours for the 4 patients after the occurrence of abscess. Vagina has rich blood supply but the contraction of smooth muscle due to post-traumatic stress response may lead to insignificant bleeding. No obvious symptoms on admission led to the omission of diagnosis. Long-term complications of delayed diagnosis included vaginal stenosis, atresia and urethra-or recto-vaginal fistula[22]. Vaginal stenosis occurred in two patients with delayed diagnosis but neither of them received further treatment at the last follow-ups. We reviewed previous articles and found that the main reason of missed diagnosis was lack of thorough examination[22]. From our experience, since delayed diagnosis may lead to increased risk of infection and late complications, female patients with fractures of anterior pelvic ring especially those whose pelvic fractures presented vertical shear injury and associated with urethral or rectal injury should be suspected of vaginal injury and a thorough vaginal examination should be performed by a senior gynecologist in a trauma center.
Associated injuries are not rare in patients with pelvic fractures including perineal laceration, rectal or anal injury and retroperitoneal hematoma which increase the risk of infection. It has reached an agreement that patients with rectal injuries should be performed colostomy to avoid sepsis due to contamination from fecal matter[23, 24]. However, whether colostomy is necessary for patients with perineal lacerations but no rectal injuries is still controversial. Perry[25] suggested colostomy should be performed for perineal injured patients with vaginal and rectal injuries. Faringer[26] suggested whether or not associated with vaginal or rectal injuries, colostomy should be implemented for patients suffered perineal injuries. Deepti Goswami[21] concluded that the role of colostomy in open pelvic fractures remains unresolved and the decision for fecal diversion should be based on the surgeon’s subjective judgment. In current study, 15 patients with anorectal injury and one patient without anorectal injury but showed perineal injury were treated with fecal diversion. Thirteen patients achieved satisfactory clinical outcomes except for 2 patients who developed pelvic abscess due to delayed dignoses. In our institute, colostomy is applicable for patients with extensive perineal injury regardless of whether anorectal injury presents. From our experiences, although no statistical data for now, we think colostomy helps lower the risk of wound infection caused by feces.
Conclusions
Here we concluded our experiences in treating patients with pelvic fractures associated with vaginal injury in our institution. From our data, pelvic fractures caused by vertical shear forces and compromise pubic symphysis showed higher severity of vaginal injury. Age, associated urethral injury, fixation technique and infection are prognostic factors of pelvic result. There was also a significant relationship between radiological and clinical outcomes. We propose a thorough vaginal examination should be performed in female patients with pelvic fractures especially those with disruption of anterior pelvic ring to avoid missed diagnosis of vaginal laceration. No factor found related to sexual disfunction and more cases need to be analysed in future study.
ISS: Injury Severity Score; APC: Anterior-posterior compression; VS: vertical shear; LC: lateral compression; ORIF: open reduction and internal fixation
Acknowledgments No
Authors’ contributions PL and DZ drafted the manuscript. BF helped collected clinical materials. JD and WS revised the manuscript. All the authors have read and approved the final manuscript.
Funding The design, collection and analysis of the data and follow-up materials in the study were financially supported by the National Natural Science Foundation of China (No. 81301556).
Availability of data and materials The data used in the current study are available from the corresponding author on reasonable request.
Ethics approval and consent to participate The study is approved by The Medical Ethical Committee of Shandong Provincial Hospital Affiliated to Shandong University. The written informed consent was obtained from all patients included in this study
Consent for publication Not applicable.
Competing interests The authors declare no conflict of interest.
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Table 1. Facture patterns and vaginal injury
Type |
Subtype |
Vaginal injury |
No. of patients |
P value |
||
1 |
2 |
3 |
||||
Tile |
A |
0 |
0 |
0 |
0 |
0.208 |
|
B |
5 |
10 |
3 |
18 |
|
|
C |
1 |
3 |
3 |
7 |
|
Young-Burgess |
APC |
6 |
11 |
3 |
20 |
0.034* |
|
VS |
0 |
2 |
3 |
5 |
|
|
LC |
0 |
0 |
0 |
0 |
|
Compromised pubic symphysis |
Yes |
5 |
6 |
1 |
12 |
0.024* |
No |
1 |
7 |
5 |
13 |
|
*Statistically significant P value
Table 2. Factors affecting pelvic outcome
Group |
Subgroups |
Pelvic outcome |
P value |
||||
Excellent |
Good |
Fair |
Poor |
Total |
|||
Age |
≤30 |
14 |
0 |
1 |
0 |
15 |
0.043* |
>30 |
4 |
4 |
1 |
0 |
9 |
|
|
ISS |
≥25 |
8 |
1 |
0 |
0 |
9 |
0.208 |
<25 |
10 |
3 |
2 |
0 |
15 |
|
|
Tile classification |
A |
0 |
0 |
0 |
0 |
0 |
0.510 |
B |
14 |
2 |
2 |
0 |
18 |
|
|
C |
4 |
2 |
0 |
0 |
6 |
|
|
Young-Burgess classification |
LC |
0 |
0 |
0 |
0 |
0 |
0.913 |
APC |
15 |
3 |
2 |
0 |
20 |
|
|
VS |
3 |
1 |
0 |
0 |
4 |
|
|
Compromised Pubic symphysis |
Yes |
9 |
3 |
0 |
0 |
12 |
0.515 |
No |
9 |
1 |
2 |
0 |
12 |
|
|
Vaginal injury |
1st degree |
6 |
0 |
0 |
0 |
6 |
0.284 |
2nd degree |
8 |
3 |
1 |
0 |
12 |
|
|
3rd degree |
4 |
1 |
1 |
0 |
6 |
|
|
Vagina repairing |
Gauze packing |
6 |
0 |
0 |
0 |
6 |
0.113 |
Surgical repair |
12 |
4 |
2 |
0 |
18 |
|
|
Fixation technique
Infection
|
Non-operative |
5 |
0 |
0 |
0 |
5 |
0.024* |
Isolated external fixation |
2 |
1 |
2 |
0 |
5 |
|
|
ORIF Yes No |
11 2 16 |
3 2 2 |
0 2 0 |
0 0 0 |
14 6 18 |
0.005* |
|
Urinary tract injury |
Yes |
8 |
4 |
2 |
0 |
14 |
0.020* |
No |
10 |
0 |
0 |
0 |
10 |
|
|
Anorectal injury |
Yes |
9 |
3 |
2 |
0 |
14 |
0.142 |
No |
9 |
1 |
0 |
0 |
10 |
|
*Statistically significant P value
ISS, Injury Severity Score; ORIF, open reduction and fixation
Table 3. Pelvic and radiological outcome relationship
Radiological outcome |
Pelvic outcome |
P value |
||||
Excellent |
Good |
Fair |
Poor |
Total |
||
Excellent |
14 |
1 |
0 |
0 |
15 |
0.001* |
Good |
4 |
3 |
0 |
0 |
7 |
|
Fair |
0 |
0 |
1 |
0 |
1 |
|
Poor |
0 |
0 |
1 |
0 |
1 |
|
*Statistically significant P value
Table 4. Factors affecting sexual function
Group |
Subgroups |
Pain in sexual intercourse |
P value |
||||
No |
Yes |
Total |
|||||
Age |
≤30 |
5 |
3 |
8 |
0.569 |
||
>30 |
6 |
1 |
7 |
|
|||
ISS |
≥25 |
5 |
1 |
6 |
0.604 |
||
<25 |
6 |
3 |
9 |
|
|||
Tile classification |
A |
0 |
0 |
0 |
0.999 |
||
B |
7 |
3 |
10 |
|
|||
C |
4 |
1 |
5 |
|
|||
Young-Burgess classification |
LC |
0 |
|
0 |
|
0 |
0.999 |
APC |
9 |
3 |
12 |
|
|||
VS |
2 |
1 |
3 |
|
|||
Compromised pubic symphysis |
Yes |
6 |
1 |
7 |
0.569 |
||
No |
5 |
3 |
8 |
|
|||
Vaginal injury |
1st degree |
2 |
|
1 |
|
3 |
0.590 |
2nd degree |
5 |
|
3 |
|
8 |
|
|
3rd degree |
4 |
|
0 |
|
4 |
|
|
Vagina repairing |
Gauze packing |
2 |
|
1 |
|
3 |
0.736 |
Surgical repair |
8 |
|
2 |
|
10 |
|
|
Fixation technique
Infection |
Non-operative |
1 |
|
1 |
|
2 |
0.110 |
Isolated external fixation |
1 |
|
2 |
|
3 |
|
|
ORIF Yes No |
9 3 8 |
|
1 2 2 |
|
10 5 10 |
0.560
|
|
Urinary tract injury |
Yse |
7 |
|
3 |
|
10 |
0.999 |
No |
4 |
|
1 |
|
5 |
|
|
Anorectal injury |
Yes |
7 |
|
4 |
|
11 |
0.516 |
No |
4 |
|
0 |
|
4 |
|
|
Radiological result |
Excellent |
7 |
|
1 |
|
8 |
0.385 |
Good |
3 |
|
2 |
|
5 |
|
|
Fair |
1 |
|
0 |
|
1 |
|
|
Poor |
0 |
|
1 |
|
1 |
|
ISS, Injury Severity Score; ORIF, open reduction and fixation