jjbrooksmd at gmail
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Jan 11, 2009, 2:05 PM
Post #3 of 7
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Re: [ORT-L] APC pelvic ring fracture and R acetabular fracture
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Thank you, Chip. As always, I appreciate your insights. Attached are
some higher res CT cuts...
Pt. is currently PID 4. 36h after injury patient had a large PE
requiring embolectomy. I've been tempted to place a c-clamp to buy
some more time but he's done OK with a t-pod (initially loose but
snugness tightened enough to bring the symphysis to about 2cm
diastasis). Hgb drop to 7.0 but is stable above 10 after 4u PRBC. (Has
only been hypotensive during PE but never below 88 amazingly)
So this is behaving as a hemodynamically stable injury. I'd take him
tomorrow but now he has renal failure (Cr 7.0) and oliguria from the
embolectomy IV contrast load, so a big open procedure with lots of
anesthesia time and blood loss is not possible until Cr normalizes.
Thus, I plan to place a c-clamp as the R SI joint does significantly
widen without t-pod and symphyseal diastasis under same conditions is
5cm. But, percutaneous column fixation without the symphysis anatomic
thru an open approach I believe is unwise as it almost guarantees
acetabular malreduction so that too will have to wait. I hope to
better reduce the symphysis, R SI and acetabular fx with simple
internal rotation using a c-clamp but doubt wether I can get the ant
column and symphysis anatomic due to the rotation (extension) of the R
SPR/IPR ring segment just with a c-clamp. The open surgery will have
to wait unfortunately and therefore column fixation.
a question for the list:
is there data on how long someone can be in a t-pod before skin
necrosis ensues? I usually loosen the device and check the skin q12h
and have used one for 48 once but i cannot find clear guidelines in
the literature to guide the application time of this valuable orthosis.
Thanks again
Jeff
--
On Jan 11, 2009, at 3:39 PM, Milton L. Routt wrote:
> The sent images are indistinct when expanded, so some details get
> lost on us that you can perhaps better see.
>
> The loose t-pod makes no sense to me...a patient with an unstable
> pelvic ring injury either needs a snugly applied pelvic wrap to
> diminish their expanded pelvic volume during resuscitation and
> provide comfort, or not...a loose t-pod is like a loose belt on
> baggy pants...fashion without function.
>
> This patient’s combination injury isolates the right anterior pelvic
> area as “unstable” due to its acetabular fracture component
> functioning as the symphyseal’s “posterior ring” matching
> lesion...the pelvic wrap, even if snugly applied, likely has little
> impact on this injury’s focal area of instability...his hemodynamic
> behavior and imaging details confirm this.
>
> The right SI injury is not well seen on these CT images as
> sent...the plain films demonstrate an anterior SI width asymmetry
> that may or may not reflect true associated pelvic ring instability
> in this specific scenario.
>
> As seen, I’d use a right sided extended Pfannenstiel to expose the
> symphysis and right acetabular anterior wall-low anterior column-
> quadrilateral surface areas, clean both injury sites, manipulate the
> symphysis and clamp it...the anterior column component should follow
> the accurate symphyseal reduction...you can then adjust/refine the
> acetabular reduction and secure it also with a clamp if needed, then
> definitively stabilize with either antegrade or retrograde medullary
> screw fixaton, and/or an intrapelvic plate application...then
> stabilize the symphysis with standard plate techniques or screws.
>
> Or you can expose all components with a routine ilioingunal exposure
> and sequence reductions and fixations as you’d like.
>
> The inverted posterior column screw inserted from ischium to pelvic
> brim can also be inserted from pelvic brim to ischium if you’d
> prefer and your patient needs such....just because you “don’t do” a
> certain technique doesn’t always mean that your patient doesn’t need
> that technique...my advice is to learn how to use an ischium to
> pelvic brim posterior column screw should you ever need to use it
> for a certain patient...it’s just not so difficult to simply avoid
> learning it and deny that technique to a needy patient.
>
> Once the acetabular and symphyseal reductions and fixations are
> completed, I’d evaluate the SI joint using fluoroscopy to assess
> potential instability...my bet is that it’ll be quite stable and
> very well reduced...if not stable, I’d insert an iliosacral screw or
> 2 after the reduction was achieved or approved...you’ll protect his
> load bearing on that side as well.
>
> Chip
>
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> sorry, sending again (initial .ppt was too large) slides in order as
> JPEGs. server rejected to 5Mb file.
>
> From: "Jeff Brooks" <jjbrooksmd@gmail.com>
> Date: January 8, 2009 5:26:03 PM EST
> To: ORT-L@www2.aaos.org
> Subject: [ORT-L] APC pelvic ring fracture and R acetabular fracture
>
>
> Esteemed colleagues,
>
> Happy new year. I would love input on the attached case of a 45 y.o.
> guy ped struck by car with a minimal head injury (GCS15) and this
> pelvic ring injury with R transverse 'tab Fx. Hemodynamics stable with
> only a 3 point drop in Hgb (14-->10.8)
>
> Curious about need for more than one approach (adding posterior) to
> address the very low (thru ischial spine) posterior component of the
> 'tab, as well as preferred order of fixation. Also, stoppa vs
> ilioinguinal - what is your preference given the pattern shown? Of
> course, other pearls are appreciated.
>
> Thanks very much in advance for your comments.
>
> Jeff Brooks
> Stamford, CT
>
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> ><image.jpg><image.jpg><image.jpg><image.jpg><image.jpg><image.jpg>
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