danschlatterer at yahoo
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Jun 11, 2007, 9:30 AM
Post #12 of 17
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Re: [ORT-L] ORIF and suprapubic tube?
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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]
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> >> >>
> >> >>
> >> >> Make every IM count. Download Messenger and join the i‚m Initiative now.
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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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