Acute renal failure and paraplegia in a patient with a pelvic-ring fracture

(Section Editor: K. Kühn)

Rita Rachmani1, Zohar Levi1, Rivka Zissin2, Jacques Bernheim,3 and Ze'ev Korzets3

1 Departments of Internal Medicine D, 2 Diagnostic Imaging and 3 Nephrology Meir Hospital Sapir Medical Center, Kfar-Saba and the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

Keywords: hydronephrosis; paraplegia; pelvic compartment syndrome; retroperitoneal haematoma

Introduction

Acute renal failure (ARF) is a common sequela of trauma. The major factors responsible for ARF in this setting are hypovolaemic shock, sepsis, and the use of nephrotoxic agents. Pelvic-ring fractures are often associated with injuries of the urinary tract in an incidence of 12–40% [13]. They are also normally accompanied by retroperitoneal bleeding [3,4]. The presence of anuria in such cases requires the initial exclusion of injuries to the urethra and/or bladder. Although hypotension-induced acute tubular necrosis (ATN) should be considered, obstructive uropathy due to ureteric or bladder compression by a retroperitoneal/pelvic haematoma is a possibility. We observed a patient with an ‘open book’ pelvic-ring fracture who developed a huge pelvic haematoma after being given enoxaparin. The ensuing pelvic-compartment syndrome resulted in bilateral hydronephrosis and paraplegia, alleviated only by evacuation of the haematoma.

Case

A 50-year-old male was admitted to the orthopaedic department with a pelvic-ring fracture (‘open book’ fracture) sustained when he fell from a height of 4 m. Relevant past history included non-insulin-dependent diabetes mellitus, hypertension, myocardial infarction 5 years previously, and percutaneous coronary angiooplasty performed a year prior to the present admission. Because of unstable angina, the patient was scheduled for repeat coronary catheterization but delayed undergoing this procedure. An ultrasound examination of the abdomen and pelvis, 4 h after admission, showed no evidence of any fluid collection. On the following day the patient experienced severe precordial pain with marked ST segment depression in the anterior chest leads.

Acute coronary insufficiency was diagnosed and acetylsalicylic acid 75 mg and enoxaparin 80 mg were administered. A few hours later, haemorrhagic shock ensued (systolic blood pressure 60 mmHg, serum haemoglobin 5.0 g/dl). On examination, a large lower abdominal mass was palpable. The patient was ventilated and resuscitated with large volumes of crystalloids and packed cells. Abdominal computerized tomography (CT) revealed a huge pelvic haematoma with extravasation of injected contrast material, indicating ongoing bleeding (Figure 1Go). The bladder was laterally displaced to the left and its volume markedly diminished. A repeat CT, 12 h later, showed the haematoma to be enlarging (Figure 2Go). The kidneys demonstrated prolongation of the cortical nephrographic phase and persistent corticomedullary differentiation (Figure 3Go). Embolization of the superior gluteal artery was performed.



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Fig. 1. Contrast-enhanced CT at the level of the pelvis showing a large right-sided pelvic haematoma (H). Within the haematoma a hyperdense fluid level (thick arrow) of the same density as the iliac vessels (thin arrows) is seen, indicating active bleeding.

 


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Fig. 2. Non contrast enhanced CT performed 12 h after that of Figure 1Go, showing the urinary bladder (B) with the catheter balloon (arrow) to be markedly compressed and displaced to the left by the enlarging haematoma.

 


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Fig. 3. The same CT as in Figure 2Go at the level of the kidneys showing a persistent nephrographic phase with a prolonged corticomedullary differentiation and slight dilatation of the renal pelvis.

 
The patient became oligo-anuric with an elevation of serum creatinine to 7.8 mg/dl. Haemodialysis was initiated. Renal function initially improved with a gradual increase in urine output. However, 6 weeks after admission, serum creatinine had stabilized at 5 mg/dl and urine output was again seen to decrease to the point of anuria. An abdominal ultrasound revealed bilateral hydronephrosis. Bilateral nephrostomes were inserted, resulting in the immediate onset of post-obstructive diuresis. Serum creatinine declined to 1.4 mg/dl. The patient was gradually weaned off mechanical ventilation, at which stage paraplegia became evident. Surgical evacuation of the haematoma was performed. Following this procedure, the nephrostomes were removed. Urinary output was well maintained with serum creatinine stabilizing at 1.4 mg/dl. No immediate neurological improvement was seen. The patient was referred to a rehabilitation centre. Currently, 3 months after the evacuation, he is able to walk with the aid of a cane.

Discussion

Massive retroperitoneal/pelvic haematoma has only infrequently been described as a cause of obstructive uropathy [2,3,57]. Obstruction of the urinary tract in this condition can be caused either by direct compression of both ureters or by collapse of the bladder. The latter situation leads to a change in the anatomical angulation between the bladder and the ureters due to displacement of the bladder. Conjointly, the intramural vesical segment of the ureter is subjected to greatly increased intrapelvic pressure. The end result is anuric ARF. An added result of retroperitoneal haematoma may be neurological deficit caused by nerve or nerve-root compression. Femoral nerve palsy has been described as part of the iliacus haematoma syndrome [8]. Early operative decompression is advocated in order to relieve the urinary obstruction and to prevent irreversible nerve damage [8].

This patient was admitted with an ‘open book’ pelvic-ring fracture. Massive extraperitoneal bleeding developed only after he was anticoagulated with a combination of acetylsalicylic acid and enoxaparin, given as part of the therapeutic regimen for an acute coronary syndrome. Anuric ARF was initially attributed to hypovolaemic shock. In keeping with the course of ATN, urine output began to increase. However, failure of complete recovery of renal function and the renewed appearance of anuria prompted further evaluation, and sonography revealed bilateral hydronephrosis with almost complete obliteration of bladder volume. Normal renal function was rapidly restored on the insertion of bilateral nephrostomes. Associated paraplegia became apparent. Definitive treatment consisted of operative decompression, namely, evacuation of the retroperitoneal/pelvic haematoma. As previously reported and substantiated by our patient's course, neurological improvement is gradual and may be incomplete [8]. Permanent nerve damage can result even after a delay of only a week. The importance of early diagnosis of the pelvic compartment syndrome is therefore essential.

Teaching points

(i) Beware anticoagulant therapy in a patient with pelvic-ring fracture.
(ii) Diagnostic differentiation of anuria in patients with pelvic-ring fractures must include obstructive uropathy due intrapelvic compartment syndrome.
(iii) Early operative decompression is the treatment of choice in such cases.

Notes

Supported by an educational grant from

Fresenius Medical Care

Correspondence and offprint requests to: Prof. Jacques Bernheim, Department of Nephrology, Meir Hospital, Kfar-Saba, 44281, Israel. Back

References

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  4. Riemer BL, Butterfield SL, Diamond DL et al. Acute mortality associated with injuries to the pelvic ring: The role of early patient mobilization and external fixation. J Trauma1993; 35: 671–677[ISI][Medline]
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  8. Colapinto V, Comisarow RH. Urologic manifestations of the iliacus hematoma syndrome. J Urol1979; 122: 272–275[ISI][Medline]




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