Facial subcutaneous emphysema due to rectum injury after pelvic fracture

Background

Pelvic fractures account for 3% of all skeletal injuries, of which 2%–4% are open pelvic fractures.1 In children, the incidence of open pelvic fractures is 12.9%.2 An open pelvic fracture exists when there is direct communication between the fracture and a skin, vaginal or rectal wound. Open pelvic fractures are associated with a high morbidity and high mortality (up to 80%).1–3 It is a rare condition, so one has to be aware of it to recognise it. There are only few case reports about open pelvic fractures and urethral, vaginal or rectal injuries.4–6 Cases with progressive subcutaneous emphysema following pelvic fractures have not been published before.7 This case shows that it is important to consider rectal injuries when a patient presents with subcutaneous crepitus due to subcutaneous emphysema. Despite all additional studies and different specialists involved, there was still a significant delay in diagnosis. Here, we describe the features of rectal injury in a patient with an open pelvic fracture, to give better direction and hopefully shorten the time to diagnosis and treatment in future cases.

Case presentation

A 35-year-old healthy male dockworker with no prior medical history was brought to the trauma room of the Erasmus Medical Center in Rotterdam by the mobile medical team.8 He was found in the harbour in a loading site for corn underneath a large clamshell grab. Patient was analysed according to the advanced trauma life support (ATLS) protocol.9 He was haemodynamically unstable, but had a maximum Glasgow Coma Score. Main injury was a large inguinal laceration, which ran to the medial side of the upper left leg.

Investigations

Laboratory testing showed a haemoglobin level of 129 g/L and lactate of 2.7 mmol/L, chest X-ray revealed no signs of pneumothorax and X-ray of the pelvis revealed an open book fracture with corn contamination (figure 1A). In addition, extended focused assessment with sonography for trauma was negative, CT of the cerebrum/cervical spine/thorax–abdomen showed no traumatic lesions or signs of arterial, intestinal, urethral or bladder injuries. Skeletal CT scan showed a medial tibial plateau fracture on the left side and more than 6-cm diastasis of the symphysis pubis with ipsilateral widening of the sacroiliac joint making it a grade 3 anterior posterior compression pelvic injury (APC-3 according to the Young-Burgess classification).10 Urethral injury was ruled out by a retrograde urethrogram.

The patient was taken to the operating room for stabilisation by pelvic closure, fixation and wound debridement. Following inspection, debridement and irrigation, the plastic surgeon treated the soft tissue injury, while the orthopaedic surgeon performed an open reduction and plate fixation of the symphysis pubis with a plate screw osteosynthesis through a separate (clean) horizontal incision over the pubic bone (‘Pfannenstiel’) (figure 1B).

On the second postoperative day, patient experienced a snapping sensation followed by a swelling on his right jaw, during mobilising. His vital signs were normal and stable. A chest X-ray showed massive subcutaneous emphysema with no signs of pneumothorax (figure 2A). The consulted surgeon suspected an injury of the thoracic cavity, due to the compression injury and advised to rule out locoregional causes. The consulted pulmonologist performed a CT scan of the chest (figure 2B) and a bronchoscopy, during which subcutaneous emphysema was seen in the vocal cords, without an explanation for the air leakage. In the following days, the subcutaneous emphysema expanded further to his face. A new CT scan of thorax and abdomen confirmed an increase of subcutaneous emphysema, without an apparent cause. Because a gastroenteric origin of air leakage was now more likely, the gastroenterologist ruled out an oesophageal lesion on a CT of the thorax and abdomen with oral contrast. Subsequently, the ear, nose and throat specialist examined and excluded the upper airways as a cause for the subcutaneous emphysema. While we still had no explanation for the facial emphysema, our patient developed surgical wound leakage and signs of infection. The patient was clinically stable, but his C reactive protein remained high (344 mg/L) despite adequate drainage of the large wound bed and prolonged antibiotic treatment. A wound debridement was scheduled on day 8.

Treatment

Prior to surgery, faecal contamination was observed in his surgical pubic wound. Therefore, the orthopaedic surgeon performed the second surgery together with a gastrointestinal (GI) surgeon. The surgical transverse pubic incision was opened; inflamed tissue and pus were seen under the pubic bone and tissue cultures were taken. No severe contamination was seen in the lower pelvic and groin area. The GI surgeon performed a digital rectal examination and felt a big ventral rectal laceration, 2 cm proximal from the anus. It was possible to digitally enter the surgical wound from the rectal laceration. Death tissue was excised and extensive lavage with 3 L of NaCl was performed, after which two drains were left and the wound was closed. Subsequently, the GI surgeon performed a laparoscopic double loop colostomy. After surgery, patient received intravenous antibiotics for a total of 2 weeks for an Escherichia coli, followed by 4-week oral antibiotics according to the guidelines for fracture-related infections (FRI).11

Outcome and follow-up

During the postoperative days, the subcutaneous emphysema, inflammation parameters and wound drain production steadily decreased. His colostomy had normal output. Four weeks after trauma, he was transferred to a rehabilitation centre. Patient was frequently seen at the orthopaedic outpatient clinic, while he was still rehabilitating with his physiotherapist.

After half a year, he was able to ambulate by himself the whole day. The X-ray of his pelvis showed a stable osteosynthesis. Patient visited the GI surgeon to reverse his colostomy after 11 months. At the outpatient clinic, we observed a skin fistula, which produced small amounts of pus. After 15 months, the plate and screws were removed from his pubic bone and sent for culturing. Postoperatively, he was treated for osteomyelitis of the pubic bone according to the FRI protocol. Afterwards, the wound healed well, inflammation parameters improved and follow-up visits were discontinued.