management of pelvic trauma: neurological damage, urinary...

JFMS CLINICAL PRACTICE 347

C L I N I C A L R E V I E W

Journal of Feline Medicine and Surgery (2011) 13, 347–361

Clinical Practice

Richard Meeson and Sandra Corr

Practical relevance Cats commonlypresent with pelvic trauma following road traffic accidents (RTAs). A logical step-wise approach to diagnostics and subsequent management cansignificantly improve the prognosis in themajority of cases. This article provides a practicalguide to assist decision-making and optimisemanagement of these cats. Clinical challenges Affected cats may have sustained trauma to several body systems and,hence, their management can be complex, requiringgood clinical, diagnostic and surgical skills (oftenboth soft tissue and orthopaedic!). Patient group Any cat allowed access to theoutdoors is potentially at risk of being involved in anRTA and sustaining pelvic trauma. Young male catsare most commonly affected.Evidence base Many original articles and textbookchapters have been published on aspects of pelvictrauma. However, to the authors’ knowledge, this isthe first comprehensive overview of the assessmentand management of the feline pelvic trauma case.The review begins by discussing initial triage andneurological examination, and then focuses, in turn,on assessment and management of the ‘tail pull’injury, the diagnosis and management of urinarytract rupture, and the approach to managingspecific pelvic fractures.

Richard Meeson MA VetMB MRCVS*

The Queen Mother Hospital for Animals, Royal Veterinary College,

London University, Hawkshead Lane, Hertfordshire AL9 7TA, UK

Sandra Corr BVMS CertSAS PhD DipECVS FHEA MRCVSSchool of Veterinary Medicine and Science,

University of Nottingham, LE12 5RD, UK*Corresponding author. Email: [email protected]

For cats with access to the outdoors, road traffic accidents (RTAs) represent a significant hazard – in the UK, they rank as the fourth most common cause of death after old age, cancer and renal failure.1 Catsinvolved in RTAs are typically young males (mean age 16 months),which sustain trauma to multiple body systems, including the bonypelvis and adjacent soft tissues.2 Due to the relatively large surroundingmuscle mass, great forces are required to cause pelvic fractures and con-current non-orthopaedic injuries are seen in 59–72% of cases.3,4 Pelvicfractures are considered a true emergency in humans, due to the highrisk of rapid, fatal haemorrhage. In contrast, cats (and dogs) rarely dieacutely as a direct result of pelvic fractures, but can suffer significantmorbidity and mortality due to associated injuries to adjacent soft tissue structures.

Initial triage and management

Major body systems assessmentWhen a cat is presented following an RTA, initial assessment shouldalways include a primary survey of the major body systems, to identi-fy and treat any potentially life-threatening injuries.5,6

✜ Cardiovascular system Evaluate heart rate and rhythm, mucousmembrane colour, capillary refill time and pulse quality. Packed cellvolume/total solids should be checked at presentation and 24 h later.Although fatal haemorrhage is rare following pelvic fractures, bleedingmay be severe or prolonged enough to produce significant anaemia,necessitating a blood transfusion, or other support (eg, Oxyglobin;Biopure Corporation), prior to general anaesthesia for surgery.

✜ Respiratory system Observe respiratory rate and character, thencarefully and systematically auscultate the thorax. Lack of normallung sounds may indicate the presence of abnormal fluid (haemo -

thorax) or vis-cera (ruptured

d i a p h r a g m ) .Gentle palpation

may detect ribfractures.

Auscultate first, radiograph laterPulmonary contusions are the most common causeof dyspnoea in the feline trauma patient, followed bypneumothorax, both of which can be detected byauscultation. Radiography is not indicated until thepatient is stable.

Wound management during triageLarge wounds, grazes or open fractures should becovered with sterile dressings/support bandagesduring triage, and then fully assessed and treatedwhen the cat is stable.

MANAGEMENT OF PELVIC TRAUMANeurological damage, urinary tractdisruption and pelvic fractures

1098-612X/11/050347+15 $36.00/0© 2011 ISFM and AAFP. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.jfms.2011.03.011

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347_361_Meeson_Pelvic trauma:FAB 6/4/11 11:52 Page 348

348 JFMS CLINICAL PRACTICE

✜ Abdominal assessment The abdomenshould be carefully palpated to evaluatebladder integrity and continuity of thebody wall (ie, any ruptures or prepubic ten-don injuries), and to assess pain. Theabdomen may feel ‘empty’ if abdominalcontents have displaced into the thoraxthrough a ruptured diaphragm.

✜ Neurological system An in-depth neuro-logical examination is not necessary duringtriage: the key aspects to assess are menta-tion, gait and pain perception. In catswith pelvic trauma, careful assessmentmust be made of hindlimb deep pain,and anal and perineal reflexes (seebox above). Lumbosacral plexusdamage and sciatic nerve entrap-ment are both seen with pelvic trau-ma. Peripheral nerve injury is com-mon (reported incidence of 13.9%),3but usually resolves (Fig 1).

AnalgesiaFollowing initial assessment, appropriate analgesia must be provided. Non-steroidalanti-inflammatory drugs (NSAIDs) should beavoided initially, as many cats with pelvictrauma will be hypovolaemic, and risks maybe compounded by renal insufficiency inolder cats. Rather, opioids are the drugs ofchoice.

✜ A full agonist is recommended as the first-line treatment (morphine ormethadone; 0.1–0.4 mg/kg IM/slow IV/SC q4h).

✜ There is some evidence that the partialagonist buprenorphine (0.01–0.03 mg/kgIM/IV/SC/sublingual q6h) may be anacceptable alternative to morphine in cats.7

✜ Fentanyl patches (25 µg/cat) are useful forlonger term analgesia, but therapeuticlevels of analgesia are not reached for upto 24 h, so they must be combined withother analgesia initially.

✜ Pethidine (2–5 mg/kg) is not generallyuseful due to its short duration ofanalgesia (up to 1–2 h); it should only beadministered IM, and animals becomeresentful of repeated administration.

✜ Butorphanol is not appropriate as it provides only a short duration (up to 45 mins) of weak analgesia, and itssedative effects make it difficult to assess pain.

REV IEW / Pelvic trauma management in the cat

Hindlimb deep pain sensationCareful evaluation of conscious pain perception is essential:lack of deep pain carries a very poor prognosis for regainingnormal neurological function. Begin by manually squeezing the digits and, if no response is seen, gradually increase the stimulus by applying haemostats to thedigits and squeezing progressively harder (toelicit periosteal pain). Withdrawal of a limb inresponse to a toe pinch is a spinal reflex anddoes not confirm the presence of deep pain –the cat must be seen to acknowledge the pain(eg, by turning round or vocalising).

Pudendal nerve reflexes ✜ Anal sphincter reflex can be tested using a

thermometer – on withdrawal, the anal

sphincter should close normally. ✜ The bulbocavernosus reflex is demonstrated by a sharp

contraction of the anal sphincter in response to a squeeze ofthe bulb of the penis or the clitoris.

✜ The perineal reflex is present if there is contraction of the analsphincter in response to stimulation of the perineal region.

✜ Urethral sphincter tone is assessed by manual bladder expression (this tests exter-nal urethral sphincter tone).

Motor and sensory function of the tailCoccygeal nerve function is assessed bypinching the tail at different levels usinghaemostats and observing for tail movementand cerebral acknowledgement of pain (eg, vocalising or turning round).

N e u r o l o g i c a l e v a l u a t i o n o f t h e c a t w i t h p e l v i c t r a u m a

FIG 1 Cat withreduced sciaticfunctionsubsequent topelvic fractures

Prerequisite to opioid useIt is important that deep pain is assessedprior to administration of opioids, which canmask normal responses.

Withdrawal of a

limb in response

to a toe pinch

does not confirm

the presence of

deep pain.

MULTIMEDIA A video recording showing

assessment of reflexes associatedwith urinary function is included inthe online version of this article at:

10.1016/j.jfms.2011.03.011

347_361_Meeson_Pelvic trauma:FAB 6/4/11 11:53 49


The ‘tail pull’ cat –sacrococcygeal nerve injury

During an RTA, the tail may become trappedunderneath a car wheel; the resultant tractioncan cause subluxation/luxation or fracture atthe tail base and stretching of the sacrococ-cygeal nerve roots/cauda equina, colloquiallyknown as a ‘tail pull injury’8 (Fig 2). Dependingon the extent of damage to the nerves, affectedcats may present with a flaccid tail, bladderparaly sis and/or urinary incontinence.

Cats with tail pull injuries are difficult casesto manage: the severity of nerve damage cannot be ‘measured’ and, therefore, the like-lihood and extent of recovery is difficult topredict. While cats with neuropraxia (nervebruising) should have a good prognosis forfull recovery, those with completely severednerves (neurotmesis) clearly will not.

DiagnosisDepending on the type of neurological injury,a cat may either have a large bladder that isdifficult to express (‘upper motor neuron blad-der’), or a soft bladder that is easy to express(‘lower motor neuron bladder’). Urinaryincontinence can be seen in both scenarios.

There is a high degree of correlationbetween urinary and faecal continence,because of the common dependence onpudendal and pelvic nerve function.Therefore, if anal tone is decreased, it is likelythat urinary incontinence will also be present.

Careful neurological assessment is critical.

Prognostic indicatorsThe presence of an intact anal reflex is a posi-tive prognostic sign for return of urinary func-tion. In addition, intact pain sensation (within5 cm of the tail base, assessed within 48 h ofthe trauma) is strongly predictive of earlyreturn of bladder control. However, absenceof tail base pain sensation does not precludeeventual recovery, as 60% of cats without sensation at the tail base will also recover.8

Good owner communication is essential,given that it is not possible to predict whethera cat will recover or will remain incontinent,


FIG 2 Lateral and ventrodorsal pelvicradiographs revealing sacrococcygealluxation

Urinary functionFinding urine in the cat’s cage does notindicate that the cat has normal urinaryfunction – conscious and controlled urination must be observed.

and the bladder has to be managed in themeantime. Cases may be complicated by con-current pelvic fractures, which cannot be leftuntreated for 4–6 weeks to ‘wait and see’ if thecat becomes continent.

The prognosis based on a case series of 51cats with sacrococcygeal injuries was good

for return of normal urinary functionin cats that had intact anal reflex

and perineal sensation at thetime of initial presentation.9 If

normal urination returned, itdid so between 2–30 days(mean 13 days). Every catthat could not urinate nor-mally within 1 monthremained incontinent dur-ing the 2–36 month follow-

up period. Tail function maytake several months or longer

to improve. In the same study,tail function returned to its fullest

extent between 7–150 days (mean 31days). For this reason the authors do not

recommend early tail amputation.

Tail amputationSome authors recommend early tail amputation

to decrease soiling and pain from dragging a non-functional tail. We would not recommend that thisis undertaken at initial presentation as function mayreturn and, if not, surgery can be performed at alater stage. Stabilisation of the sacrococcygealregion with pins and wires would potentially

decrease ongoing nerve root impingementand chronic pain, but results have been

variable and this is not routinelyrecommended.

Of 51 cats with sacrococcygeal injuries, every cat that could not urinate normally

within 1 month remained incontinent during the 2–36 month follow-up period.




d

f

g

b

P l a c i n g a n d m a n a g i n g a c y s t o s t o m y t u b e

Placement✜ With the cat in dorsal recumbency, clipand surgically scrub the abdomen from thexiphoid to caudal to the pubis, ensuring theclip extends laterally to mid-flank on bothsides. Make a caudal midline abdominalincision from the umbilicus to the pubis.

✜ Gently move the bladder against the left abdominal wall to see where it willcomfortably sit.

✜ In that location, push against the innerabdominal wall with a Kelly (curved)haemostat and then make a small incisionfrom the external abdomen, cutting downonto the tips of the haemostat using thescalpel blade. Gently push the haemostattips through the incision (from inside theabdomen to outside) (image a).

✜ Using either a mushroom-tipped tube (BardUrological Diversion, CR Bard, GA, USA) or,preferably, a silicone-based Foley catheter(8–14 Fr silicone), grasp the Foley/mushroomend of the tubing with the forceps and pull itinto the abdomen from outside (image b).

✜ Pack off the bladder from the rest of the abdomen using moistened laparotomyswabs. Count all swabs used.

✜ Place a stay suture (2 metricmonofilament) in the cranial pole of thebladder to facilitate atraumatic manipulation(image c).

✜ Place a purse-string suture in the ventralor ventrolateral aspect of the bladder,towards the apex (using a 2 metric slowlyabsorbable monofilament suture [eg,polydioxanone, PDSII; Ethicon]). Althoughmany authors recommend only including thesubmucosa with the sutures, this is oftenpractically difficult and full-thickness bites of bladder wall are acceptable. Make a stabincision in the middle of the purse-stringsuture, preferably with a number 11 scalpelblade, and insert the catheter tip into thebladder. If using a Foley catheter, the bulbshould be inflated with an appropriate volumeof saline solution (image d). The purse-stringsuture is then tightened (image e).

✜ To reduce the risk of leakage of urine into the abdomen, place four simple interrupted sutures between thebladder wall (non-lumen or lumen penetrating) and the abdominal wall to create a ‘box pexy’ around the tube(image f). A slowly absorbable suture material (eg, PDS) should be used for this and omentum can additionally be wrapped around it.

✜ The abdomen should be lavaged with warm sterile saline, prior to routine three-layer closure of rectus fascia,subcutaneous fat and skin.

✜ The tube should be secured with a ‘Chinese finger trap’ or ‘Roman Sandal’ suture pattern using 3 metric nylon or similar non-absorbable suture material, anchored to the skin (image g). The tube should be connected to a closedurinary bag collection system or incorporate a bung or three-way tap for intermittent emptying. A small self-adhesivesterile dressing should be applied to the tube where it enters the skin. It is also helpful to place a small bodystockinette (Surgifix size 4 or 5; Smith & Nephew) to prevent the tube getting caught and becoming dislodged.

MaintenanceThe tube should be drained three or four times a day and must remain in place for at least 7–10 days to allow the pexy to seal. Unless an infection develops at the stoma, routine cleaning of the area is not recommended. If early inadvertent removal occurs, the cat must be checked for the presence of uroabdomen withradiographs/ultrasound ± abdominocentesis.

RemovalIf a Foley catheter was used, it is deflated, the Chinese finger trap suture is cut,a hand is placed against the body wall, and then traction is applied to the tube– you often have to pull very hard! (Although rare, it is possible for the tip of amushroom-tipped catheter to break off – should this occur a cystostomywould need to be performed in order to remove it. For this reason, wegenerally prefer to use a silicone Foley catheter.) The stoma will heal bysecond intention and does not require surgical closure. This procedure,therefore, can be undertaken in the conscious or sedated animal.

a

c

e

Risk of infectionThe development of a UTI is not uncommon, and it is difficult toeliminate infection when a tube is in place. Development of ascendinginfections can be minimised by good practice: wearing examinationgloves when draining the tube, and cleaning the end of the tubewhere the syringe is connected with alcohol. Prophylactic antibioticuse is not recommended, as this will only select for resistance; when indicated, antibiotics must be used judiciously.

Images courtesy of Stephen Baines




Options for bladder management Appropriate management of the cat’s bladderis of primary importance to ensure that it doesnot overdistend and overstretch the tight junctions, leading to irreversible damage.Irrespective of the management approach,animals with neurological bladder dysfunc-tion will often have a concurrent urinary tractinfection (UTI) and, therefore, urinalysis andurine culture should routinely be performed.Routine antibiotic ‘cover’ is not recommend-ed, how ever, as it predisposes to resistantinfections.

Daily manual expressionManual expression may be appropriate in theshort term if the bladder is easily expressed, butmay eventually become painful and distressingto the cat. It is not possible to completely emptythe bladder manually, and so residual urinevolume should be checked periodically byultrasound or catheterisation, as large residualvolumes will predispose to UTIs. If continenceis not regained within a few days, an indwellingcatheter can provide further time forimprovement or a tube cystostomy can allowlonger term management.

Indwelling catheterisationIndwelling catheterisation simplifies manage -ment and prevents urine scalding in the shortterm. Intermittent catheterisation (every 6–8 h) isassociated with a lower risk of UTI than anindwelling catheter; however, it may be moretraumatic and can trigger urethral spasm. In theauthors’ opinion, if continence is not regainedwithin 5 days, then a cystostomy tube should beplaced.

Tube cystostomyTube cystostomy is a recognised technique forurinary diversion that allows stress-freemanagement of cats with tail pull injuries. It is arelatively straightforward surgery to perform(see page 350), and may also be performed as an emergency procedure (eg, where urethralobstruction cannot be managed by catheter -isation), or electively (eg, where detrusor muscleactivity has been affected).10–12 Compli cationssuch as catheter dislodgement and subsequenturoperitoneum can occur;11 how ever, with goodsurgical technique this is extremely unlikely. In the authors’ experience, most cats toleratecystostomy tubes surprisingly well for severalmonths, and most owners are happy to managethese cats at home. However, if normal urinationhas not returned within a month or two, then itwill not, and the ethics of life-long cystostomytube use may be questionable. In addition, thelonger the cystostomy tube is present, the greaterthe risk of UTI and potential ascending infectionleading to pyelonephritis and renal damage.

If continence is not regained within 5 days, a

cystostomy tube should be placed.

Medical treatmentDepending on the type of neurological dys -function, medical management (Table 1) can beused to facilitate manual bladder expression, or asa means to encourage normal urinary functionwhile a catheter or cystostomy tube is in place.

Rationale Drug Dose Comments

For urethralspasm

Prazosin 0.25–1 mg PO q12h or q8h

1st choice treatmentAvoid in hypotensivepatients

Phenoxybenzamine 1 mg/kg PO q8h 2nd choice treatmentAvoid in hypotensivepatients

To encouragebladder emptying

Bethanechol 1–2 mg/kg PO q12h or q8h

This drug is best used as a last resort and should notbe used if the cat’s bladdercannot be expressedmanually (ie, with markedlyincreased urethral sphinctertone), or the bladder mayrupture. It can also causediarrhoea, so treatmentshould be started with a low dose

NB These drugs can take several days to work and are often required in combination

Medical treatment of bladder dysfunctionTABLE 1

DiazepamDiazepam (a striated muscle relaxant) should not beused in cats due to reported fatal hepatocellular necro-sis in some cats following repeated administration.13

Urinary tract trauma

DiagnosisDamage to the urinary tract is common withpelvic trauma, but is easily missed as clinicalsigns can be vague and non-specific, and maytake some time to become apparent. Early signsinclude haematuria, dysuria, abdominal painand/or distension, lack of a palpable bladder,free abdominal fluid, and abdominal and peri -neal bruising. Any animal with rising urea andcreatinine levels should be investigated further,as this may indicate post-renal azotaemiadeveloping as a result of leakage of urine froma tear or rupture in the bladder or urethra.

Urinary tract integrityThe ability of a cat to urinate or the presenceof a palpable bladder does not indicate anintact urinary tract – a cat with a bladder tearcan still pass streams of urine.




Either plain radiography or ultrasoundexamination can be used for initial evaluationand assessment of the bladder or the presenceof free abdominal fluid.

RadiographyA plain lateral abdominal radiograph shouldbe assessed for: ✜ increased opacity/loss of detail within the

abdomen or retroperitoneal space, indicativeof fluid (blood, urine, bile or exudates);

✜ free abdominal gas, which could indicaterupture of a hollow viscus or a full-thickness body wall rupture.

The retroperitoneal space runs linearly fromthe diaphragm to the pelvis, ventral to the ver-tebrae and dorsal to the intestines, and usuallycontains the kidneys and ureters. The kidneysare generally easily visualised because of thepresence of large amounts of perirenal adiposetissue. However, the ureters are too small to be visualised. Urine extravasation or haemor-rhage relating to the kidneys or ureters may beidentified by a generalised opacification of thisarea with obscuring of the kidney(s). Although substantial renal or ureteral damage is rare, if suspected, intravenous excretory urographyshould be performed (Fig 3).3

Ultrasound examinationOn abdominal ultrasonography any abnormalaccumulations of fluid within the abdomenwill appear as hypoechoic regions (blackpockets). If only a small volume of fluid ispresent, it will most likely be found aroundthe bladder neck and liver lobes.

What to do when urinary tract rupture is suspected Abdominocentesis should be carried out: it is asafe and well-tolerated procedure, even whenperformed blind, but is often more successfulif performed under ultrasound guidance.

Abdominocentesis can be undertaken withthe cat standing or in lateral recumbency. Ifultrasound is available, needle placement isdetermined by observing fluid next to theabdominal wall. If abdominocentesis is to beperformed blind, initially sample the right cranial quadrant of the ventral abdomen byadvancing a 21 G needle slowly through theabdominal wall, without a syringe attached.Fluid may drip out of the hub and can be col-lected for analysis. If no fluid is retrieved, a 2.5ml syringe can be attached and a small amountof suction applied. If this too fails to producefluid, continue to four-quadrant abdomino -centesis, following the same procedure in theright caudal, left cranial and left caudal zones.Depending on the type, severity and durationof injury, the volume of fluid retrieved mayvary from a few drops to many millilitres.

FIG 3 Lateral and ventrodorsalpelvicradiographsfollowingintravenousurography,revealing leakageof contrast fromthe right ureter

Abdominocentesis

is a safe and

well-tolerated

procedure,

even when

performed blind,

but is often more

successful if

performed

under ultrasound

guidance.

The origin of the fluid is determined by itscytological and biochemical characteristics.The fluid can be tested in a biochemistrymachine: if the creatinine level is higher thannormal plasma levels, the fluid is urine. If bacteria are seen on cytology, rapid surgicalintervention is required. If no bacteria areseen, uroperitoneum can be managed in theacute stages of stabilisation by abdominocen-tesis, and placement of a urethral catheter.

Further evaluation of the urinary tractIf free urine is identified within the abdomen,the bladder cannot be identified after 12 h ofhospitalisation, or there is ongoing suspicionof undisclosed urinary tract trauma (risingazotaemia with no clear cause, necrosis ofhindlimb soft tissues, or no urination after12–24 h) then contrast studies should be performed.




The most common type of urinary tract trau-ma involves the bladder or urethra, and thiscan be investigated by performing a positive-contrast retrograde urethrocystogram (see boxabove). Contrast seen outside of the bladder orurethra is diagnostic of rupture. If rupture isstrongly suspected, but no contrast is seen out-side the bladder on the initial radio graphs, thecat should be left in the appropriate positionand a further small volume (2–5 ml, depend-ent on the cat’s weight) of positive contrastshould be instilled into the bladder, and theradiographs repeated.

If the radiographs or ultrasound examinationindicate fluid within the retroperitoneal space,an intravenous urogram is performed (see boxbelow) to investigate possible damage to thekidneys or ureters, although this is quite rare.

Lateral radiograph showing a retrogradeurethrocystogram, which reveals leakage

of contrast around the urinary bladder

✜ A plain lateral radiograph should be taken initially, to optimise exposuresand positioning, and for subsequent comparison with the contraststudies. Sometimes the diagnosis is evident on the plain film, negatingthe need for a contrast study.

✜ Catheterise and drain the bladder, retaining a sterile sample for culture. ✜ Withdraw the catheter to the tip of the penis, or perform urethral

catheterisation of a female cat, and instil contrast under pressure, takinga lateral radiograph while instilling. Continue to instil the contrast until thebladder can be felt to be moderately distended, and take another lateraland a ventrodorsal radiograph. A non-ionic water-soluble iodine-containing contrast medium, such as iohexol (Omnipaque; GE Healthcare), is recommended to reduce the risk of an inflammatoryreaction should contrast medium leak into the abdomen. However, ionicsolutions can be used if there is no alternative available. The authorsrecommend using 2 ml/kg of undiluted contrast to identify urethraldamage. If a bladder rupture is suspected, either undiluted or a 50:50 mixof sterile isotonic fluid mixed with 2 ml/kg contrast can be more helpfulas the bladder may need to be significantly filled to identify leakage.

✜ If this is an elective procedure, an enema should be administered 24 h in advance, to preventsuperimposition of a full colon on the region of interest.

✜ Plain lateral and ventrodorsal radiographs should be taken to optimise exposures and positioning,and for subsequent comparison with the contrast studies. Sometimes the diagnosis is clear on theplain film, negating the need for a contrast study.

✜ Catheterise and drain the bladder, retaining a sterile sample for culture. ✜ Administer 2 ml/kg of non-ionic water-soluble iodine-containing contrast medium rapidly intravenously

through an intravenous catheter. Iohexol (Omnipaque) is recommended.✜ Take ventrodorsal and lateral projections at 3-, 5-, 10- and 15-minute intervals. The early films are

centred on the kidneys, while the later ones are centred on the ureters and bladder neck.

Management of bladder ruptureBladder rupture is the most common organdamage associated with pelvic fractures.3 Itcan occur due to a full bladder being com-pressed and bursting on impact followingblunt trauma, from penetrating fracture frag-ments, or due to bruising resulting in localisedareas of necrosis.3 In a recent unpublished sur-vey of 110 cats with pelvic fractures, 12 cats(10.9%) suffered lower urinary tract trauma,eight involving the urethra and four involvingthe bladder.14 The cats with concurrent urinary tract injuries were reported to have aworse outcome than those with pelvic frac-ture(s) alone.14

Bladder contusion is suspected when mildhaematuria is present in an otherwise well catwith normal urinary function, and such cases

R e t r o g r a d e u r e t h r o c y s t o g r a m ( f o r u r e t h r a a n d b l a d d e r )

I n t r a v e n o u s u r o g r a m ( f o r k i d n e y s a n d u r e t e r s )

Second pair of handsIt helps to take the radiograph while injecting the contrast so that the bladder andurethra are under pressure and expand. Therefore, a lead-gowned assistant is essential.



should be managed conservatively. Smalltears in the bladder wall may go undetectedand can be expected to heal spontaneously.

Larger tears require surgical debridement oftissue (where indicated) and repair. However,if the cat is not sufficiently stable for anaes -thesia, short-term management by regular ab dominocentesis or passing of a urinarycatheter can be used for 24 h while the cat isstabilised.

Management of urethral trauma Urethral trauma can result in bruising, rup-ture or varying degrees of obstruction, andtends to occur almost exclusively in male ani-mals due to their longer, narrower urethra.19

If the urethra is ruptured, urine will leak andslowly accumulate within the abdomen,pelvic canal or subcutaneous tissues, resultingin azotaemia and uraemia. Accumulation ofurine within the subcutaneous tissues of thecaudal abdomen and hindquarters results intissue necrosis, which will usually take at least24–48 h to become apparent. Urinary diver-sion is therefore a priority to reduce urineleakage, either via placement of an indwellingurinary catheter, or via surgical placement of acystostomy tube.

Partial ruptures of the urethra may healonce urinary diversion has been achieved, andlarger defects can also heal if an intact strip of urethral mucosa remains. A transurethralcatheter should be maintained for 3 weeks,while healing occurs; however, strictures canbe a frequent complication,19 potentially dueto the presence of the catheter itself. Currentlythere is no clear evidence as to whether urethral catheters or cystotomy tubes are lesslikely to result in stricture formation.19

Definitive urethral surgery should be performed, as necessary, but is beyond thescope of this review (see Fossum for furtherreading).20 Referral should be considered.

Management of renal or ureteral damageRenal or ureteral damage may require anasto-mosis, stenting or re-implantation. Such surgery is complex and delicate, requiringspecialist equipment and training. If referral isnot an option, and ureteral/renal damage isunilateral, ureteronephrectomy is a viablealternative. (See Fossum for further reading.)20

Pelvic fractures

Pelvic fractures account for 20–22% of allfeline fractures.3,21 In 103 cats with pelvic frac-tures, 90% involved the pelvic floor, 60% hadsacroiliac luxation and 48.5% had iliac bodyfractures.3 It is common for combinations ofthese fractures to be seen (Fig 4).

Specific orthopaedic examinationFollowing stabilisation and appropriate analgesia, a full orthopaedic examinationshould be performed. Observe whether thecat is able to stand unsupported or ambulate.Gently palpate the dorsal aspects of the pelvisfor symmetry between the two ilial wings, or palpable crepitus, and exert gentle pressureover the ilial wings cranially to determine ifthere is sacroiliac discomfort. Manipulateindividual joints, checking for instability or


A caudal ventral midline exploratory laparotomy should beperformed. The bladder should be packed off from the rest of theabdomen with sterile moistened laparotomy swabs (count them!).A temporary stay suture (2 metric monofilament, full thickness),should be placed in the ventral cranial pole of the bladder tofacilitate bladder manipulation without overtly or repeatedlytraumatising the bladder wall.

The ventral, dorsal and lateral aspects of the bladder should be carefully examined. Damage to the bladder will usually be evident as haemorrhage and bruising. Any heavilytraumatised/necrotic areas should be trimmed using delicatescissors so that sutures are placed into viable tissue. The trigone is the critical area: as long as the trigone remains intact, 75% of the bladder can beremoved and the bladderwill still heal andeventually regain normalsize and function.15,16

Viable edges can besutured using a single-layer appositional closure(ie, simple continuous or simple interrupted) with the knots placedextraluminally; suturesshould preferably notpenetrate the lumen.Alternatively, a two-layerappositional or single/two-layer inverting pattern can be used.16,17

Monofilament absorbable suture material is preferred (eg, monocrylor PDS), 1.5 or 2 metric in size. Sutures should be quite tight tofacilitate a seal and should be spaced 3–5 mm apart and from theedge. The integrity of the repair should be tested by injectingsterile saline into the bladder, and this will also help to identify anyother damage that might have been missed. Should there beconcern, the repair can be oversewn using a Lembert or Cushinginverting pattern, or a serosal patch (usually jejunum) can beplaced.

Although the bladder itself is weak, it heals quickly, regainingnear 100% of presurgical strength by 14–21 days post-surgery.16,18

B l a d d e r s u r g e r y

The trigone is the critical

area: as long as the

trigone remains intact,

75% of the bladder can be

removed and the bladder

will still heal and regain

normal size and function

over time.

Pelvic fractures account for 20–22% of all feline

fractures . . . Bladder rupture is the most common

organ damage associated with pelvic fractures.




other orthopaedic trauma; an acetabular frac-ture, for example, may be indicated by pain onhip manipulation.

If possible, a careful rectal examinationshould be performed when the cat is sedated oranaesthetised, to assess the degree of displace-ment of any pelvic fractures and the resultantpelvic canal width. The anal sphincter reflexshould have already been assessed as part ofthe initial evaluation of the patient, but shouldbe re-evaluated at this stage.

Diagnostic imagingOrthogonal lateral and ventrodorsal radio -graphs (Fig 5) are essential for proper assess-ment of fractures, and this is particularly true of pelvic fractures, where additional obliqueviews may be required. Radiographs should betaken under sedation or general anaesthesia tofacilitate proper patient positioning, as poorlypositioned radiographs can be very misleading.

In human orthopaedics, the question ofwhether plain radiographs are adequate forfracture assessment, or whether advancedimaging such as computed tomography (CT) isnecessary, is the subject of much debate. Arecent veterinary study found that, in practicalterms, plain radiography is often sufficient, asalthough 60% of fractures were misclassified(on configuration), this did not significantly

affect the surgical plan.22 In that study, ilial frac-tures were consistently detectable on radio -graphs but the degree of comminution andspatial orientation was more obvious on CT.Acetabular fractures were more readily evalu-ated on CT, however, and this imaging modal-ity was helpful for determining whether or notthey were reconstructable.22

Decision makingThe traditional belief has been that pelvic frac-tures in cats can usually be managed conserv-atively. However, there is no evidence to support this, as few studies exist that considerhow the cat’s quality of life is affected in thelong term. As a profession, we should be aiming to give all our patients as good a quali-ty of life as possible, and not simply basing ourdecisions on whether they can ‘manage’.

FIG 4 Ventrodorsal pelvicradiograph revealing left-sided ilial, ischial and pubic fractures and right-sided sacroilial luxation

FIG 5 Lateral and ventrodrosal radiographs of the pelvisrevealing pubic and ischial fractures and hip luxation, withcraniodorsal displacement and sacroiliac luxation

Orthopaedic versus neurological problemIt can be difficult to differentiate betweenorthopaedic disease and neurological damage,particularly if the cat is in pain, and so repeatedexamination may be necessary.




General guidelines for surgical versus conservative management of pelvic fracturesare given in the box above.

Surgical management ofspecific fractures

Ilial fracturesIlial fractures are common, usuallyeasy to diagnose and can be techni-cally straightforward to repair. Theilium is part of the weightbearingaxis, and so surgical stabilisation isbeneficial in most cases. The mostcommon configuration of ilial frac-ture is a long oblique fracture; how-ever, transverse (Fig 6), comminut-ed and ilial fractures with concur-rent acetabular, ischial and pubicinjuries are seen.3,4 Medial displace-ment of fragments (Fig 6) candecrease the width of the pelviccanal leading to increased risk ofconstipation and subsequent obsti-pation (Fig 7). In such cases, catsmay have to undergo pelvicosteotomy and/or subtotal colectomy at a laterstage.24,25 These procedures are much moreinvasive, and associated with significant poten-tial morbidity: it is, therefore, preferable torepair the ilial fracture on original presentation.

Ilial fractures are most commonly repairedusing a lateral plate and screws (Fig 8).However, other fixation methods have beenreported including use of Kirschner wires, lagscrews (for long oblique fractures) and inter-fragmentary wiring.26–28

Although a lateral bone plate is a successfuland relatively straightforward method of

FIG 7 Lateral abdominal radiograph revealing megacolon as a sequela to pelvic fracturemalunion

✜ The fractures involve the weightbearing axis (eg, ilial fractures or sacroiliac luxations).

✜ The fractures involve the acetabulum.✜ Multiple injuries exist (eg, bilateral fractures, ipsilateral

ilial fracture with hip luxation).✜ Significant pelvic canal narrowing is seen on a

ventrodorsal radiograph (ie, greater than 50% reduction in pelvic canal width).

✜ Refractory or severe pain is evident. ✜ Sciatic nerve deficits exist that may be associated

with a fracture (eg, of the ilium).✜ Conservative management was initially attempted,

but the cat is still non-ambulatory after 3 days of strict rest.

✜ The fractures involve non-weightbearingsegments.

✜ The fractures are minimally displaced, non-articular fractures that are stable.

✜ The fractures involve the ‘pelvic floor’ and do not significantlycompromise the widthof the pelvic canal.

If opting for conservative management . . . Dedicated owners are required who are willing,and able, to manage their cats for potentiallyup to 8 weeks of strict cage rest. It is advisableto repeat radio graphs 1 week after fractureto ensure that the previously ‘non-surgical’

fractures have remained stable duringthe initial rest period and have not

become surgical.23

YES, if: NO, if:

Should pelvic fractures be treated surgically?

treating ilial fractures, the onlystudy evaluating long-term out-come in cats revealed a 62% screwloosening complication rate, and all cats suffered varying degrees ofpelvic canal narrowing in the follow-up period.29 An alternativeoption is to place a plate on the dor-sal aspect of the ilium and, in onestudy, this was associated with asignificant reduction in screw loos-ening and pelvic canal narrowing,but was more technically challeng-ing (Fig 9).30

FIG 6 Ventrodorsal pelvicradiograph revealing atransverse ilial fracture and pubic fractures



Sacroiliac fractures/luxationsSacroiliac fractures/luxations are common incats that suffer blunt trauma to the hind -quarters, and account for 27% of pelvicorthopaedic injuries. Due to the rigid box-likestructure of the pelvis, they are always accom-panied by other fractures, or are bilateralwhere the pelvis has been shunted cranial-ly.4,32 Management may be surgical or conser-vative, depending on whether the luxation isunilateral or bilateral, and the degree of discomfort, displacement and instability.32,33

FIG 8 Lateral and ventrodorsal pelvicradiographs of an ilial fracturestabilised with a laterally applied 2.0 dynamic compression plate andscrews. Courtesy of Gareth Arthurs

FIG 9 Lateral and ventrodorsal pelvicradiographs of an ilial fracture stabilised with adorsally applied 2.0 dynamic compression plateand screws. In addition, this cat had a caudalvertebral (Cd 2–3) subluxation


✜ A ventrolateral approach to the ilium, with a gluteal roll-up,31 gives good exposure.

✜ The caudal fragment is often displacedmedially. Therefore, take care duringmanipulation not to damage intrapelvicstructures or the sciatic nerve.

✜ In cats, a 2.0 or 2.7 mm dynamic compressionplate or stacked 1.5/2.0 or 2.0/2.7 veterinarycuttable plates are the most useful implants.

✜ Remember to accurately contour the plate tothe bone. Time can be saved by preoperativecontouring (eg, from radiographs or aspecimen pelvis). Contour to the correct side!

✜ It is usually possible to fix the plate to thecaudal fragment and then use the plate to leverthe fracture fragments into realignment.

I l i a l f r a c t u r e : s u r g i c a l t i p s

Due to the rigid box-like structure of the pelvis,

displaced sacroiliac fractures are always

accompanied by other fractures, or are bilateral.




The most common method of surgical fixationis placement of a screw in a lag fashion fromthe ilial wing into the sacrum, with or withouta transilial pin (Fig 10).

Acetabular fracturesAcetabular fractures account for 17.5% offeline pelvic fractures,4 but can be easilymissed, as affected cats can show remarkablymild clinical signs. Oblique lateral pelvic radio -graphs may be required to identify and char-acterise the fractures, due to superimpositionof the femur on standard views. Do not mis-take the normal growth plate within theacetabulum for a fracture line in cats that areunder 5–6 months of age37 and/or neutered.

Acetabular fractures are articular and,therefore, require perfect anatomical reduc-tion and rigid internal fixation, ideally withinterfragmentary compression (Fig 11).However, in cases of highly comminuted frac-tures, reconstruction may be impossible, and afemoral head and neck excision is a viablealternative, and relatively straightforward toperform (Fig 12).

Early studies on acetabular fractures insmall animals suggested that the cranial andcentral thirds of the acetabulum were theload-bearing areas, and that the caudal thirdof the acetabulum was non-load-bearing.38,39

This led to a widely accepted idea that caudalacetabular fractures could be managed con-servatively.40 However, this is contradicted bya more recent experimental evaluation of thefeline acetabulum during various phases ofweightbearing, which demonstrated thatweightbearing was focused over the centraland caudal thirds of the acetabulum.41 Thedecision to manage acetabular fractures con-servatively should not, therefore, be based ontheir location, but rather on the key factors ofdegree of displacement, comminution, con-current injuries and pain. Long-term evalua-tion of cats with acetabular fractures managed

FIG 10 Lateral andventrodorsal pelvicradiographs of a sacroiliacluxation stabilised with a 2.0lag screw and a transilial pin.Courtesy of Gareth Arthurs

✜ A dorsal approach to the sacrum, with detachment of the middle gluteal andsupraspinalis muscles,31 gives best exposure.

✜ Retracting the ilial wing ventrally exposes the lateral aspect of the sacralwing for pilot hole placement – the pilot hole should be drilled at theintersection of the centre of the cranial–caudal axis and slightly dorsal to themid-point of the dorsoventral axis of the wing of the feline sacrum.34

✜ There are important differences in sacral anatomy between cats and dogs.35

A cadaveric study looking at safe corridors for screw placement in catssuggested that in the absence of fluoroscopic guidance, positioning the drillat 90º to the articular surface in the dorsoventral plane is best.34 There islittle margin for error: when misaligned by only 4º, the drill bit will exitventrally in 58% of cases (ie, into the neural canal).34 In the craniocaudaldirection, the hole should be drilled at an angle that is perpendicular to thecraniocaudal angle of the vertebral column, rather than the sacral wing: thiscan be approximated with the cat in lateral recumbency by drillingperpendicular to the table.32,35

✜ A glide hole should be drilled in the ilium from the lateral aspect. (Tip: palpatethe articular surface on the medial side of the ilial wing, and use a towel clampor pointed reduction forceps clamped mediolaterally across the wing of theileum to help localise the site for the drill hole on the lateral aspect.)

✜ When securing the ilial wing to the sacrum, a washer can be used inimmature animals with soft bone to prevent the screw head sinking into the bone as the screw is tightened.

✜ There appears to be no advantage in placing a second screw, or Kirschnerwire, in addition to a single well-placed lag screw.

✜ The screw must engage the sacral body to reduce the risk of screw loosening,and ideally should engage at least 60% of the width of the sacrum.36

✜ Perfect anatomical realignment is not as important as achieving adequatestabilisation for a good return to function.

✜ Stabilisation of sacroiliac fractures/luxations can be technically demanding,and referral to a specialist orthopaedic surgeon should be considered.

S a c r o i l i a c f r a c t u r e : s u r g i c a l t i p s




conservatively has shown that many developa painful hip and muscle atrophy42 and, there-fore, where appropriate, surgery is usuallyrecommended.

FIG 11 Lateral and ventrodorsalpelvic radiographs of anacetabular fracture stabilisedwith a custom acetabular plate

FIG 12 Ventrodorsal radiograph showing a femoral head and neck excision in a cat

✜ A dorsal approach to the hip, including a trochanteric osteotomy orgluteal tenotomy, provides good exposure of the acetabulum.30

✜ The sciatic nerve should be identified and protected.✜ Incising the joint capsule allows visualisation of the intra-articular

surface for fracture reduction.✜ A mini-approach to the ischial tuberosity and placement of

bone-holding forceps facilitates manipulation of the caudal fragments.✜ Fracture reduction can be maintained using pointed reduction forceps

or a temporary Kirschner wire.✜ The preferred location for implants is the dorsal aspect of the

acetabulum. However, contouring a plate to this region is difficult. Usea reconstruction plate or acetabular plate (prior contouring of the platewill save a significant amount of time).

✜ Ensure that screws do not penetrate the articular cartilage of theconcave surface of the acetabulum – this may be visualised, ordetected by gently running a small probe across the cartilage.

✜ If the fracture line is transverse through the middle of the acetabulum,placing one screw on either side of the fracture line, with orthopaedicwire between the screws in a figure-of-eight pattern and tightened, canwork well. Bone cement is then placed over and around the wire (it isessential to protect the sciatic nerve from the exothermic reaction atthis stage, using copious lavage).

✜ Repair of acetabular fractures requires a high level of skill and experience,and referral to an orthopaedic specialist should always be considered.

A c e t a b u l a r f r a c t u r e : s u r g i c a l t i p s

Long-term evaluation of cats with acetabular fractures managed conservatively

has shown that many develop a painful hip and muscle atrophy.

Therefore, surgery is usually recommended.

Postoperative management

AnalgesiaAll cats should receive postoperative opioids,preferably a full agonist for 24 h followed by apartial agonist for a further 24–72 h, dependingon the level of discomfort. Where appropriate,many benefit from multimodal analgesia, and treatment with NSAIDs (eg, meloxicam )




is recommended once blood pressure, volumestatus and renal status are within normallimits. This can be continued for up to 14 days postoperatively at a dose of 0.05 mg/kg PO q24h.

RestAll cats with pelvic fractures, whethermanaged conservatively or surgically, shouldhave strict cage rest for up to 6 weeks.Physiotherapy may be helpful once sutures/staples are removed after 10–14 days. Whenthere is radiographic evidence of healing, agraduated increase in indoor exercise isallowed for 2–4 weeks before allowing fulloutside access again.

References

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2 Rochlitz I. The effects of road traffic accidents on domesticcats and their owners. Animal Welfare 2004; 13: 51–55.

3 Lanz O. Lumbosacral and pelvic injuries. Vet Clin North AmSmall Anim Pract 2002; 32: 949–62.

4 Bookbinder PF, Flanders JA. Characteristics of pelvic fracturein the cat. Vet Comp Orthop Traumatol 1992; 5: 122–27.

5 Aldrich J. Assessment and diagnosis of shock. In: King LG,Boag A (eds). BSAVA manual of canine and feline emergencyand critical care. 2nd edn. Gloucester, UK: BSAVA, 2007: 17–29.

6 Adamantos S, Corr S. Emergency care of the cat with multi-trauma. In Pract 2007; 29: 388–96.

7 Robertson SA, Taylor PM. Pain management in cats – past,present and future. Part 2. Treatment of pain – clinical pharma-cology. J Feline Med Surg 2004; 6: 321–33.

8 Tatton B, Jeffery N, Holmes M. Predicting recovery of urina-tion control in cats after sacrocaudal injury: a prospectivestudy. J Small Anim Pract 2009; 50: 593–96.

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10 Williams JM, White RAS. Tube cystostomy in the dog and cat.J Small Anim Pract 1992; 32: 598–602.

11 Beck AL, Grierson JM, Ogden DM, Hamilton M, Lipscomb VJ.Outcome of and complications associated with tube cystos -tomy in dogs and cats: 76 cases (1995–2006). J Am Vet Med Assoc2007; 230: 1184–89.

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13 Hughes D, Moreau RE, Overall KL, Van Winkle TJ. Acute

All cats with pelvic fractures, whether managed conservatively or surgically,

should have strict cage rest for up to 6 weeks.

DefecationCats with pelvic trauma can become constipatedand faecal softeners (eg, lactulose) or the use ofenemas can be important for comfort.

Follow-up examinationAll cats that have undergone surgery shouldbe re-radiographed at 3–4 weeks (if skeletallyimmature) or 6 weeks (if skeletally mature), toassess fracture healing.

Implants Implants are typically not removed unlessthere is a problem associated with them (eg,loosening, infection, implant failure). Suchproblems are unusual.

✜ Cats that have sustained pelvic traumacommonly have damage to multiple bodysystems.

✜ Early, thorough evaluation of all bodysystems is critical, as neurologicaldysfunction and damage to the urinarytract will significantly affect the prognosis.

✜ Suspected urinary tract trauma should beinvestigated using appropriate diagnosticimaging: radiographic contrast studies areoften most useful.

✜ Tube cystostomy is simple to perform andeasy to manage: cystostomy tubes arebetter tolerated by cats than repeatedbladder expression or catheterisation.

✜ Conservative management should not be a first-line treatment in most feline pelvicfracture cases. If conservative managementis undertaken, the cat’s progress must be carefully monitored, with frequentreassessment ± radiography, to ensure that progress is satisfactory and surgicalintervention does not become indicated.

✜ Pelvic fractures that are markedly painful, prevent weightbearing,significantly narrow the pelvic canal or are associated with nerve damage should be surgically repaired.

KEY POINTS




Available online at www.sciencedirect.com

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