mlroutt at u
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Jan 14, 2009, 8:02 AM
Post #2 of 3
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Re: [ORT-L] [ORT-L} Transverse Acetab Fx/APC Ring Followup
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Sure.
It would be great if you'd push the "invert video" button on your C-arm video unit to make the fluoro images look like xrays...it's a simple thing to do and reveals details so much better than inverted images...most clinicians are helped by "seeing" familiar imaging techniques...compare the techniques next time and you'll find imaging details that are not easily seen with inverted images.
The SI reduction is good.
Your lateral C-arm image sights down the 2 screws cannulated portions which is fine, but looking down the screws' holes doesn't really help us assess much except that in fact those are cannulated screws. In order to show that "down the barrel" view, you tilted the patient or C-arm unit away from a true lateral sacral image...improved so-called "safe" screws are inserted using a true lateral image along with the inlet and outlet images...align the GSNotches and ICDs for an accurate true lateral sacral image.
I can't tell from your images if your right sided external frame iliac pin will obstruct antegrade pubic ramus medullary screw insertion...if it's low, it'll likely obstruct...when you insert these low anterior pins, always anticipate if you might need such fixation and adjust the pin application accordingly.
Acute PE is unusual, but not for him!! We don't use prophylactic vena caval filters...they always seem very smart in retrospect, but once you've seen a VC filter tumbling around in your patient's right ventricle and the EKG changes and emergent operation associated with such, you think twice about prophylactic filters. Everything carries a risk. It's worse to see someone dead when they didn't need to be dead. You'll have to sort that.
His renal result seems unusual in 2009...we used to see such contrast load related renal problems 20 years ago, but essentially never now...I wonder how that went?
At this point in your and his clinical courses, you'd be wise to simply open his anterior ring, routinely reduce and clamp his symphysis, accept the resultant indirect realignment of the acetabular injury, and secure them both with implants as you'd choose...his operative blood loss for the Pfannenstiel exposure will be minimal and you can remove his anterior ring old hematoma at the same time. If that simple procedure hurts his kidneys, then haul out a renal expert and dialysis machine for a few days. You can stab him with spikes and poke all around and push things around thru small holes and call it percutaneous and minimal surgery and what-not, but the impact of a routine Pfannenstiel exposure at this point will likely be much less invasive that poking around in his inguinal zone with pointed devices that tend to plunge...but you can do it, it will realign somewhat, and you can even screw the symphysis "percutaneously" using a trans-symphyseal screw for fixation too.
You can also support the posterior column component with a screw if you'd choose to...enclosed is an old patient from 1992-3 or so that we used similar, but ran the symphyseal and cotralateral ramus fixation with a frame only for obvious reasons...the follow-up Judets films were at one year after injury...it was when 7mm cannulated screws had just arrived...I didn't know at the time that 7mm screws just don't fit the superior ramus for most adults...but no one else seemed to at the time either! He ended up with a comfortable, functional hip and pelvis, and some scarring as you'd guess. He was depressed and that's why he let the dump truck crush him in a suicide gesture...his depression lingered on and dominated his complaints.
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