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[ORT-L] Approach to crescent fractures

 
 


jjbrooksmd at gmail
New User

Mar 19, 2008, 11:53 AM

Post #1 of 6 (711 views)
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[ORT-L] Approach to crescent fractures Can't Post
esteemed colleagues,

what in your opinion is the best approach to the crescent fracture?
(see attached powerpoint slides)

1) prone posterior ORIF with second anterior L SP ramus exposure or
perc for the front (L sup ramus in attached case)?
2) supine all-ilioinguinal for L ramus and crescent Fxs?
3) all perc? (adam, you out there?)
4) other pearls you might offer?
--------------------------------------------------
this 22 year-old was in MVA 4d ago, with closed head injury
(subarrachnoid blood, some diffuse axonal injury, but a chance at
decent recovery according to neurosurgeons...). hemodynamics stable
since the injury. no fixator or traction applied - on simple bedrest
right now. (getting inlet/outlet & judets when extubated tomorrow)

i'd love to hear some thoughts on surgical aproach and fixation
techniques. the list has been kinda quiet for a while.

thanks!

Jeff Brooks
Stamford, CT



--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center
1290 Summer Street, #4400
Stamford, CT 06905
Attachments: PT M.T. L crescent Fx + L Rami.ppt (325 KB)


Adam.Starr at UTSouthwestern
New User

Mar 19, 2008, 12:12 PM

Post #2 of 6 (711 views)
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Re: [ORT-L] Approach to crescent fractures [In reply to] Can't Post
Hi Jeff,

The good news is that the literature on these shows pretty good results
with a variety of treatments - at least in the hands of good surgeons.

The way we do them here is with perc methods - we usually reduce the
iliac wing fracture using a ball-spike pusher and get a guide wire (or
2) across it, then stabilize with cannulated screws. perc fixation of
the sup ramus would also help restore the ring alignment.

The LC 2 fracture is my favorite pelvic fracture, because they're so
much fun to fix and the results are good.

Good luck,

Adam
On Mar 19, 2008, at 1:53 PM, Jeff Brooks wrote:

> <PT M.T. L crescent Fx + L Rami.ppt>

---
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rahulbanerjee7 at hotmail
New User

Mar 19, 2008, 12:33 PM

Post #3 of 6 (711 views)
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RE: [ORT-L] Approach to crescent fractures [In reply to] Can't Post
Jeff,

I think that either an anterior or posterior approach would be reasonable
for this fracture. If you go anterior, you could also fix the ramus
fracture, but if you choose posterior, once you reduce and stabilize the
crescent fracture, the ramus may already be reasonably reduced and may not
require additional fixation.

Borrelli J Jr, Koval KJ, Helfet DL.Operative stabilization of fracture
dislocations of the sacroiliac joint. Clin Orthop Relat Res. 1996
Aug;(329):141-6.

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Jeff Brooks
Sent: Wednesday, March 19, 2008 12:53 PM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] Approach to crescent fractures

esteemed colleagues,

what in your opinion is the best approach to the crescent fracture?
(see attached powerpoint slides)

1) prone posterior ORIF with second anterior L SP ramus exposure or perc
for the front (L sup ramus in attached case)?
2) supine all-ilioinguinal for L ramus and crescent Fxs?
3) all perc? (adam, you out there?)
4) other pearls you might offer?
--------------------------------------------------
this 22 year-old was in MVA 4d ago, with closed head injury (subarrachnoid
blood, some diffuse axonal injury, but a chance at decent recovery
according to neurosurgeons...). hemodynamics stable since the injury. no
fixator or traction applied - on simple bedrest right now. (getting
inlet/outlet & judets when extubated tomorrow)

i'd love to hear some thoughts on surgical aproach and fixation
techniques. the list has been kinda quiet for a while.

thanks!

Jeff Brooks
Stamford, CT



--
Jeffrey J. Brooks, MD
Orthopaedic Surgery & Sports Medicine Center 1290 Summer Street, #4400
Stamford, CT 06905

---
[This E-mail scanned for viruses by Declude Virus]



jjbrooksmd at gmail
New User

Mar 22, 2008, 4:46 AM

Post #4 of 6 (699 views)
Shortcut
Re: [ORT-L] Approach to crescent fractures [In reply to] Can't Post
does anyone think that, as an articular fracture, that the reduction
of the crescent fracture is better when viewed open, from the front?
perhaps an anatomic articular reduction makes the incidence of late
pain & SI joint arthrosis less?


On Mar 19, 2008, at 3:33 PM, Rahul Banerjee wrote:
> Jeff,
>
> I think that either an anterior or posterior approach would be
> reasonable
> for this fracture. If you go anterior, you could also fix the ramus
> fracture, but if you choose posterior, once you reduce and
> stabilize the
> crescent fracture, the ramus may already be reasonably reduced and
> may not
> require additional fixation.
>
> Borrelli J Jr, Koval KJ, Helfet DL.Operative stabilization of fracture
> dislocations of the sacroiliac joint. Clin Orthop Relat Res. 1996
> Aug;(329):141-6.
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org]
> On Behalf
> Of Jeff Brooks
> Sent: Wednesday, March 19, 2008 12:53 PM
> To: ORT-L@www2.aaos.org
> Subject: [ORT-L] Approach to crescent fractures
>
> esteemed colleagues,
>
> what in your opinion is the best approach to the crescent fracture?
> (see attached powerpoint slides)
>
> 1) prone posterior ORIF with second anterior L SP ramus exposure
> or perc
> for the front (L sup ramus in attached case)?
> 2) supine all-ilioinguinal for L ramus and crescent Fxs?
> 3) all perc? (adam, you out there?)
> 4) other pearls you might offer?
> --------------------------------------------------
> this 22 year-old was in MVA 4d ago, with closed head injury
> (subarrachnoid
> blood, some diffuse axonal injury, but a chance at decent recovery
> according to neurosurgeons...). hemodynamics stable since the
> injury. no
> fixator or traction applied - on simple bedrest right now. (getting
> inlet/outlet & judets when extubated tomorrow)
>
> i'd love to hear some thoughts on surgical aproach and fixation
> techniques. the list has been kinda quiet for a while.
>
> thanks!
>
> Jeff Brooks
> Stamford, CT
>
>
>
> --
> Jeffrey J. Brooks, MD
> Orthopaedic Surgery & Sports Medicine Center 1290 Summer Street, #4400
> Stamford, CT 06905
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>

---
[This E-mail scanned for viruses by Declude Virus]



mlroutt at u
New User

Mar 22, 2008, 9:44 AM

Post #5 of 6 (690 views)
Shortcut
Re: [ORT-L] Approach to crescent fractures [In reply to] Can't Post
This is not an easy injury complex to discuss in this format.

So briefly....

Posterior Iliac (³Crescent²) Fracture With Associated Sacro-Iliac Joint
Anterior Articular Disruptions are quite variable injuries...each with its
unique character, specifics, and underlying osteology.

Some cause a significant crushing fracture involving the lateral-anterior
sacral articular surface...some donıt.

Some have a very small iliac fracture component....some large...some in
between.

Some have comminution involving the iliac articular surface, as your patient
has....some comminute in other areas...some donıt comminute.

Some have a large iliac component...giving it the appearance of a ³half
moon² rather than a ³crescent moon².

Some injure the superior gluteal vascular trunk.

In most, the posterior iliac fragment is stable and we rely on it and the
stable sacrum as foundations to reconstruct upon...but in some the posterior
iliac fragment is also unstable...uncommon but it happens.

Many are noted in association with sacral dysmorphism/dysplasia...and that
can impact fixation options.

Many can be partially (some definitively) stabilized using iliosacral
screws, but some cannot because of the fracture location.

We should always seek the optimal reduction and fixation.

The surgeon can reduce and then stabilize the unstable component to (1) the
sacrum, (2) the posterior ilium fragment (if itıs stable), and (3) the
ipsilateral ring injury (ramus in your patient).

I could go on and on...and we havenıt even touched on the patientıs age,
bone quality, body habitus, local soft tissue conditions, associated
injuries, etc....all these details matter.

So itıs really difficult to make sweeping statements about a
universal-optimal method for exposure, reduction, and fixation of such
variable injury complexes...the specific treatment should be selected for
each injury pattern based on its unique details.

For your patient, if you use an anterior iliac exposure youıll be pleased
because you can see, clean, reduce, and fix the articular
component...especially since your patientıs iliac articular area is
comminuted according to the sent images...but you may also need to expose
and clean the ramus component to accomplish the posterior reduction quality
that you seek.

The anterior exposure allows the surgeon to extend the exposure for ramus
(ipsi- or contra-lateral) and/or symphyseal access as needed.

But does all that improve clinical results???...it makes sense that it
could/should...but if you injure the fifth lumbar nerve root or lateral
femoral cutaneous nerve while retracting, or if the iliac wound becomes
infected, or if you choose an insufficient fixation construct that fails, or
the patient develops symptomatic ectopic bone in the ipsilateral iliolumbar
ligaments or abdominal oblique repair area, among others...then no, you
shouldıve just shoved it around, tossed in some screws, and called it a
great operation....and some patients need exactly that.

Itıs just not such an easy injury to cookbook with one recipe.

Chip










> does anyone think that, as an articular fracture, that the reduction
> of the crescent fracture is better when viewed open, from the front?
> perhaps an anatomic articular reduction makes the incidence of late
> pain & SI joint arthrosis less?
>
>
> On Mar 19, 2008, at 3:33 PM, Rahul Banerjee wrote:
>> Jeff,
>>
>> I think that either an anterior or posterior approach would be
>> reasonable
>> for this fracture. If you go anterior, you could also fix the ramus
>> fracture, but if you choose posterior, once you reduce and
>> stabilize the
>> crescent fracture, the ramus may already be reasonably reduced and
>> may not
>> require additional fixation.
>>
>> Borrelli J Jr, Koval KJ, Helfet DL.Operative stabilization of fracture
>> dislocations of the sacroiliac joint. Clin Orthop Relat Res. 1996
>> Aug;(329):141-6.
>>
>> -----Original Message-----
>> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org]
>> On Behalf
>> Of Jeff Brooks
>> Sent: Wednesday, March 19, 2008 12:53 PM
>> To: ORT-L@www2.aaos.org
>> Subject: [ORT-L] Approach to crescent fractures
>>
>> esteemed colleagues,
>>
>> what in your opinion is the best approach to the crescent fracture?
>> (see attached powerpoint slides)
>>
>> 1) prone posterior ORIF with second anterior L SP ramus exposure
>> or perc
>> for the front (L sup ramus in attached case)?
>> 2) supine all-ilioinguinal for L ramus and crescent Fxs?
>> 3) all perc? (adam, you out there?)
>> 4) other pearls you might offer?
>> --------------------------------------------------
>> this 22 year-old was in MVA 4d ago, with closed head injury
>> (subarrachnoid
>> blood, some diffuse axonal injury, but a chance at decent recovery
>> according to neurosurgeons...). hemodynamics stable since the
>> injury. no
>> fixator or traction applied - on simple bedrest right now. (getting
>> inlet/outlet & judets when extubated tomorrow)
>>
>> i'd love to hear some thoughts on surgical aproach and fixation
>> techniques. the list has been kinda quiet for a while.
>>
>> thanks!
>>
>> Jeff Brooks
>> Stamford, CT
>>
>>
>>
>> --
>> Jeffrey J. Brooks, MD
>> Orthopaedic Surgery & Sports Medicine Center 1290 Summer Street, #4400
>> Stamford, CT 06905
>>
>> ---
>> [This E-mail scanned for viruses by Declude Virus]
>>
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>

M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA 98104-2499
phone 206-731-3658
FAX 206-731-3227
--




saklmmq at optonline
New User

Mar 22, 2008, 10:47 AM

Post #6 of 6 (687 views)
Shortcut
Re: [ORT-L] Approach to crescent fractures [In reply to] Can't Post
regarding " posterior pelvis preaching "
so endeth the lesson ..thanks chip
stephen kottmeier

----- Original Message -----
From: Chip Routt
Date: Saturday, March 22, 2008 11:44 am
Subject: Re: [ORT-L] Approach to crescent fractures
To: ORT-L@www2.aaos.org

> This is not an easy injury complex to discuss in this format.
>
> So briefly....
>
> Posterior Iliac (³Crescent²) Fracture With Associated Sacro-
> Iliac Joint
> Anterior Articular Disruptions are quite variable
> injuries...each with its
> unique character, specifics, and underlying osteology.
>
> Some cause a significant crushing fracture involving the lateral-
> anteriorsacral articular surface...some donıt.
>
> Some have a very small iliac fracture component....some
> large...some in
> between.
>
> Some have comminution involving the iliac articular surface, as
> your patient
> has....some comminute in other areas...some donıt comminute.
>
> Some have a large iliac component...giving it the appearance of
> a ³half
> moon² rather than a ³crescent moon².
>
> Some injure the superior gluteal vascular trunk.
>
> In most, the posterior iliac fragment is stable and we rely on
> it and the
> stable sacrum as foundations to reconstruct upon...but in some
> the posterior
> iliac fragment is also unstable...uncommon but it happens.
>
> Many are noted in association with sacral
> dysmorphism/dysplasia...and that
> can impact fixation options.
>
> Many can be partially (some definitively) stabilized using iliosacral
> screws, but some cannot because of the fracture location.
>
> We should always seek the optimal reduction and fixation.
>
> The surgeon can reduce and then stabilize the unstable component
> to (1) the
> sacrum, (2) the posterior ilium fragment (if itıs stable), and
> (3) the
> ipsilateral ring injury (ramus in your patient).
>
> I could go on and on...and we havenıt even touched on the
> patientıs age,
> bone quality, body habitus, local soft tissue conditions, associated
> injuries, etc....all these details matter.
>
> So itıs really difficult to make sweeping statements about a
> universal-optimal method for exposure, reduction, and fixation
> of such
> variable injury complexes...the specific treatment should be
> selected for
> each injury pattern based on its unique details.
>
> For your patient, if you use an anterior iliac exposure youıll
> be pleased
> because you can see, clean, reduce, and fix the articular
> component...especially since your patientıs iliac articular area is
> comminuted according to the sent images...but you may also need
> to expose
> and clean the ramus component to accomplish the posterior
> reduction quality
> that you seek.
>
> The anterior exposure allows the surgeon to extend the exposure
> for ramus
> (ipsi- or contra-lateral) and/or symphyseal access as needed.
>
> But does all that improve clinical results???...it makes sense
> that it
> could/should...but if you injure the fifth lumbar nerve root or
> lateralfemoral cutaneous nerve while retracting, or if the iliac
> wound becomes
> infected, or if you choose an insufficient fixation construct
> that fails, or
> the patient develops symptomatic ectopic bone in the ipsilateral
> iliolumbarligaments or abdominal oblique repair area, among
> others...then no, you
> shouldıve just shoved it around, tossed in some screws, and
> called it a
> great operation....and some patients need exactly that.
>
> Itıs just not such an easy injury to cookbook with one recipe.
>
> Chip
>
>
>
>
>
>
>
>
>
>
> > does anyone think that, as an articular fracture, that the reduction
> > of the crescent fracture is better when viewed open, from the front?
> > perhaps an anatomic articular reduction makes the incidence of late
> > pain & SI joint arthrosis less?
> >
> >
> > On Mar 19, 2008, at 3:33 PM, Rahul Banerjee wrote:
> >> Jeff,
> >>
> >> I think that either an anterior or posterior approach would be
> >> reasonable
> >> for this fracture. If you go anterior, you could also fix the ramus
> >> fracture, but if you choose posterior, once you reduce and
> >> stabilize the
> >> crescent fracture, the ramus may already be reasonably
> reduced and
> >> may not
> >> require additional fixation.
> >>
> >> Borrelli J Jr, Koval KJ, Helfet DL.Operative stabilization of
> fracture>> dislocations of the sacroiliac joint. Clin Orthop
> Relat Res. 1996
> >> Aug;(329):141-6.
> >>
> >> -----Original Message-----
> >> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org]
> >> On Behalf
> >> Of Jeff Brooks
> >> Sent: Wednesday, March 19, 2008 12:53 PM
> >> To: ORT-L@www2.aaos.org
> >> Subject: [ORT-L] Approach to crescent fractures
> >>
> >> esteemed colleagues,
> >>
> >> what in your opinion is the best approach to the crescent
> fracture?>> (see attached powerpoint slides)
> >>
> >> 1) prone posterior ORIF with second anterior L SP ramus exposure
> >> or perc
> >> for the front (L sup ramus in attached case)?
> >> 2) supine all-ilioinguinal for L ramus and crescent Fxs?
> >> 3) all perc? (adam, you out there?)
> >> 4) other pearls you might offer?
> >> --------------------------------------------------
> >> this 22 year-old was in MVA 4d ago, with closed head injury
> >> (subarrachnoid
> >> blood, some diffuse axonal injury, but a chance at decent recovery
> >> according to neurosurgeons...). hemodynamics stable since the
> >> injury. no
> >> fixator or traction applied - on simple bedrest right now.
> (getting>> inlet/outlet & judets when extubated tomorrow)
> >>
> >> i'd love to hear some thoughts on surgical aproach and fixation
> >> techniques. the list has been kinda quiet for a while.
> >>
> >> thanks!
> >>
> >> Jeff Brooks
> >> Stamford, CT
> >>
> >>
> >>
> >> --
> >> Jeffrey J. Brooks, MD
> >> Orthopaedic Surgery & Sports Medicine Center 1290 Summer
> Street, #4400
> >> Stamford, CT 06905
> >>
> >> ---
> >> [This E-mail scanned for viruses by Declude Virus]
> >>
> >
> > ---
> > [This E-mail scanned for viruses by Declude Virus]
> >
>
> M.L. Chip Routt, Jr.,M.D.
> Professor-Orthopedic Surgery
> Harborview Medical Center
> 325 Ninth Avenue
> Box 359798
> Seattle, WA 98104-2499
> phone 206-731-3658
> FAX 206-731-3227
> --
>
>
>

 
 
 


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