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Jun 12, 2007, 9:33 AM
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Re: [ORT-L] ORIF and suprapubic tube?
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Dan
Lateral sacral or pelvic films was suggested based on the mechanism-crushed between vehicle and pavement- and not based on diastasis seen on admission, additionally a lateral sacral view for sacral dysplasia i always a good idea when attempting bilateral iliosacral screw stabilization, nes paux?
Thanks for the clinico-pathologic update
Samuel G. Agnew MD FACS
Orthopaedic Trauma
On Monday, June 11, 2007, at 01:16PM, "dan schlatterer" <danschlatterer@yahoo.com> wrote:
>hello sam
>it is good to hear from you. this lady is an independent ambulator, lives alone, drives a pick-up
>truck (which ran her over), and she is healthy. GYN pelvic exam was completed pre-operatively and
>CT scan with contrast did not show any bladder/urethral leaks. no blood has ever been noted from
>foley catheter or from the vagina. pretty amazing given the diastasis.
>
>in terms of stressing the pelvis intra-operatively to assess overall stability, the trauma AP
>pelvis and CT scan provided plenty of info. I suppose one could stress the vertical stability, but
>again to what end? this pt had nearly 8cm of diastasis. rotational instability was a given. in
>terms of a lateral pelvic xray, I cannot say that besides a false profile lateral for hip
>dysplasia, I am not aware of lateral pelvic xrays for pelvic ring disruptions. if this is
>something that you do I would be interested in seeing an xray or two.
>
>your final question is a good one. why not place the SI screws at the time of the I/D and pelvic
>ex-fix. the time involved is not that great. I place a lot of SI screws (at least I think I do
>although I am sure others place more) and they can take very little time. no one factor made the
>decision. it was a combo of poor fluoro (views and tech), time from injury, meaning these pts can
>turn suddenly for the worse. so I started to feel that we were pushing too much (pts' pressure was
>up/down, she was getting blood, etc), and so on. if I stayed in the OR longer and the pt crashed
>(which I have seen) questions would arise. If I left the OR and the pt had no further problems and
>retrospective it looked like I could have stayed in the OR longer then questions would arise. in
>the middle of the night I am happy (relatively) to work but the goals of this case (emergent I/D
>and pelvic stabilization) were met so I decided not to proceed any further. for a lot of folks
>this will not be acceptable but to me less was more.
>
>thank you for your input.
>
>dan schlatterer
>--- Sam Agnew <sagnewotpc@mac.com> wrote:
>
>> Dan
>> More information is needed, please --before any realistic advice can be rendered:
>> What was/is her ambulatory and health status prior to her crushing injury
>> After your primary and secondary examination-what is the stability or instability pattern of her
>> pelvic injury exactly?
>> No GU or GYN issues -based on what studies/examinations?
>> True inlet outlet and lateral (following AP crush) would be most helpful
>> CT scan images of necessary anatomic points both anterior and posterior
>>
>> My concern is overall pelvic stability in addition to the wound factors.
>>
>> As an aside I found it interesting that you can place a Supra-acetabular frame, pelvic washout
>> in the 'dead of night' but could you elaborate more on your decision not to proceed with more
>> definitive treatment as you eluded to?
>>
>> Thanks
>> Samuel G. Agnew MD FACS
>> Orthopaedic Trauma
>>
>>
>> On Monday, June 11, 2007, at 07:39AM, "dan schlatterer" <danschlatterer@yahoo.com> wrote:
>> >good morning to all,
>> >attached are images of a 70 year old female after peds versus car. her own car ran her over.
>> >injuries are limited to the pelvis. left rami open and visible in a 10cm vertical laceration
>> just
>> >lateral to left labia majora. wound is grossly clean. no vaginal and no urinary issues. CT scan
>> >shows widening of both SI joints anteriorly but I think this is vertically stable pattern.
>> >
>> >pt treated that night with I/D and supra-acetabular frame to close the
>> >ring. consideration was given for SI screws bilateraly, but given time of night and other
>> factors
>> >decision made not to proceed.
>> >
>> >so the question is what next operatively if anything? concerns
>> >are infection, nonunion anteriorly and possible incompetence of the pelvic floor which may lead
>> to
>> >prolapse
>> >issues. right rami are comminuted and plating may entail ilioinguinal approach to extend plate
>> >laterally to right iliac wing. retrograde screw up right rami is an option but I am not
>> convinced
>> >it will add much. adding SI screws very doable, but major concern is restoring anterior ring.
>> so
>> >far wound is clean and closed over a drain, and I have no plans to open it back up and wash
>> again.
>> >maintaining pelvic alignment in ex-fix in 70 yo female for any length of time may be
>> challenging.
>> >any thoughts? would anyone plate the pubic symphysis to close the gap and leave the more
>> lateral
>> >rami fractures alone? the most recent pelvic case on this website involved pts with suprapubic
>> >catheters and antibiotic options including resorbable beads. I wonder how many people would
>> plate
>> >and place antibiotic beads. thanks.
>> >
>> >dan schlatterer
>> >
>> >--- Chip Routt <mlroutt@u.washington.edu> wrote:
>> >
>> >> Sorry to be late...here’s an old reference.
>> >>
>> >> Chip
>> >>
>> >>
>> >>
>> >>
>> >>
>> >> Internal fixation in pelvic fractures and primary repairs of associated
>> >> genitourinary disruptions: a team approach.
>> >> Routt ML, Simonian PT, Defalco AJ, Miller J, Clarke T.
>> >> Harborview Medical Center, Department of Orthopaedic Surgery, Seattle,
>> >> Washington 98104, USA.
>> >> Associated urological and orthopedic injuries of the pelvic ring are complex
>> >> with numerous potential complications. These patients are treated optimally
>> >> using a team approach. The combined expertise is not only helpful initially
>> >> when managing these difficult patients, but also later as problems develop.
>> >> This study describes a treatment protocol and reports the early results of
>> >> 23 patients with unstable pelvic fractures and associated bladder or
>> >> urethral disruptions, or both, treated surgically with open reduction and
>> >> internal fixation of the anterior pelvic ring injuries at the same
>> >> anesthetic and using the same surgical exposure as the urethral realignments
>> >> or bladder repairs or both. Early complications occurred in four patients
>> >> (17%): one patient sustained a fifth lumbar nerve injury caused by the
>> >> pelvic reduction procedure, and three patients had anterior pelvic internal
>> >> fixation failures. Late complications occurred in eight patients (35%).
>> >> There was one deep wound infection (4.3%) that presented 6 weeks after
>> >> injury. Late urological complications occurred in seven patients (30%). Four
>> >> of the nine male patients with urethral disruptions had urethral stricture
>> >> after their primary urethral realignments (44%). Three of the 18 male
>> >> patients admitted to impotence (16.7%). One of the three had a residual
>> >> thoracic paraplegia caused by a burst fracture. One of the five female
>> >> patients had urinary incontinence and required a bladder suspension
>> >> operation to restore normal function (20%). A low infection rate can be
>> >> expected despite the use of internal fixation. Early urethral "indirect"
>> >> realignments avoid more difficult delayed open repairs; however, late
>> >> urological complication rates are still high. Early "direct" bladder repairs
>> >> are easily performed at the time of anterior pelvic open reduction and
>> >> internal fixation. Suprapubic tubes are not necessary to adequately divert
>> >> the urine when large diameter urethral catheters are used in these patients.
>> >>
>> >>
>> >>
>> >>
>> >> > I'm currently working on a manuscript with Dr. Matta on this topic. his
>> >> > protocol which i use now is to prep the SP catheter into the field, do your
>> >> > normal approach, repair bladder as indicated and place a new SP catheter or
>> >> > foley.
>> >> >
>> >> > no other special measures
>> >> >
>> >> > no infections in 19 patients
>> >> >
>> >> > dave
>> >> >
>> >> >
>> >> >
>> >> > David P. Zamorano, MD
>> >> > Assistant Chief, Orthopaedic Trauma Service
>> >> > Dept. of Orthopaedic Surgery
>> >> > Harbor/UCLA Medical Center
>> >> > Office (310) 222-2716
>> >> > Fax (310) 533-8791
>> >> >
>> >> > dpzamorano@hotmail.com
>> >> >>
>> >> >> From: Alexander Chelnokov <alex@orto.unets.ru>
>> >> >> Reply-To: ORT-L@www2.aaos.org
>> >> >> To: ORT-L@www2.aaos.org
>> >> >> Subject: [ORT-L] ORIF and suprapubic tube?
>> >> >> Date: Thu, 31 May 2007 16:17:29 +0600
>> >> >>> >Dear colleagues,
>> >> >>> >
>> >> >>> >If a patient has a suprapubic tube, is it possible to perform open
>> >> >>> >reduction and plating of the anterior part of the ring? Any special
>> >> >>> >measures to prevent infection? THX!
>> >> >>> >
>> >> >>> >--
>> >> >>> >Best regards,
>> >> >>> > Alexander N. Chelnokov
>> >> >>> >Ural Scientific Research Institute
>> >> >>> >of Traumatology and Orthopaedics
>> >> >>> >7, Bankovsky str. Ekaterinburg 620014 Russia
>> >> >>> >
>> >> >>> >---
>> >> >>> >[This E-mail scanned for viruses by Declude Virus]
>> >> >>> >
>> >> >>
>> >> >>
>> >> >> Make every IM count. Download Messenger and join the i‚m Initiative now.
>> >> >> It‚s free. <http://g.msn.com/8HMBENUS/2737??PS=47575> --- [This E-mail
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>> >>
>> >> 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
>> >> --
>> >>
>> >>
>> >>
>> >
>> >
>> >Daniel Schlatterer, DO
>> >Interim Program Director, Dept. of Orthopaedic Surgery
>> >Director, Orthopaedic Trauma
>> >Atlanta Medical Center
>> >303 Parkway Dr. NE
>> >Atlanta, GA 30312
>> >404-265-1578
>> >
>> >
>> >
>> >____________________________________________________________________________________
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>> >
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