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Forum: OWL Lists: OTA:
[ORT-L] Tranvserse sacral fx with retroperitoneal air

 
 


pckrause at mac
New User

Nov 5, 2007, 4:14 AM

Post #1 of 8 (4040 views)
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[ORT-L] Tranvserse sacral fx with retroperitoneal air Can't Post
To: ORT-L@www2.aaos.org
From: Krause Peter <pckrause@mac.com>
Subject: Tranvserse sacral fx with retroperitoneal air
Date: Sun, 4 Nov 2007 16:15:00 -0600
X-Mailer: Apple Mail (2.752.3)

30 yo male MVC yesterday transiently hemodynamically unstable with
symphysis pubis diastasis, right SI diastasis, and transverse sacral
fracture about 4 cm from the tip translated 100% anteriorly. CT
showed retroperitoneal air. The general surgeons presumed a rectal
injury and performed an ex lap (no positive findings) and a diverting
colostomy. They did not want to explore the rectum from this
exposure because of concerns about possibly disrupting hematoma and
causing bleeding. I placed an anterior ex fix.

I plan to definitively fix his pelvis tomorrow (symphyseal plate and
perc SI
screws). I had not planned on fixing the sacral fracture but I am
concerned that if I do not explore the fracture and debride it, it
will become a source of infection. One general surgeon told me that
diversion is sufficient. Another suggested presacral drainage in the
lithotomy position (after pelvic fixation). I apologize that I do
not have any scans or xrays to share at this point but I am having
trouble with our PACS system. Any experience with this sort of
injury or suggestions?


Thanks,

Peter Krause, MD
LSU - New Orleans
---
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wdburman at frontiernet
New User

Nov 6, 2007, 11:26 AM

Post #2 of 8 (3989 views)
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Re: [ORT-L] Tranvserse sacral fx with retroperitoneal air [In reply to] Can't Post
>>>One general surgeon told me that diversion is sufficient. Another
>>>suggested presacral drainage in the lithotomy position (after
>>>pelvic fixation).

A prospective, randomized trial from J Trauma:

The Role of Presacral Drainage in the Management of Penetrating
Rectal Injuries.

Gonzalez, Richard P. MD; Falimirski, Mark E. MD; Holevar, Michele R.
MD, Journal of Trauma-Injury Infection & Critical Care.
45(4):656-661, October 1998.

http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-199810000-00002.htm;jsessionid=HwKGqyySvkJNmvzNvqbG9qpCTGqGyJdzQL66JDlGc6tJpKvLZPDm!-1947435345!181195628!8091!-1

Bill Burman, MD
HWB Foundation
http://www.hwbf.org



>To: ORT-L@www2.aaos.org
>From: Krause Peter <pckrause@mac.com>
>Subject: Tranvserse sacral fx with retroperitoneal air
>Date: Sun, 4 Nov 2007 16:15:00 -0600
>X-Mailer: Apple Mail (2.752.3)
>
>30 yo male MVC yesterday transiently hemodynamically unstable with
>symphysis pubis diastasis, right SI diastasis, and transverse sacral
>fracture about 4 cm from the tip translated 100% anteriorly. CT
>showed retroperitoneal air. The general surgeons presumed a rectal
>injury and performed an ex lap (no positive findings) and a diverting
>colostomy. They did not want to explore the rectum from this
>exposure because of concerns about possibly disrupting hematoma and
>causing bleeding. I placed an anterior ex fix.
>
>I plan to definitively fix his pelvis tomorrow (symphyseal plate and perc SI
>screws). I had not planned on fixing the sacral fracture but I am
>concerned that if I do not explore the fracture and debride it, it
>will become a source of infection. One general surgeon told me that
>diversion is sufficient. Another suggested presacral drainage in the
>lithotomy position (after pelvic fixation). I apologize that I do
>not have any scans or xrays to share at this point but I am having
>trouble with our PACS system. Any experience with this sort of
>injury or suggestions?
>
>
>Thanks,
>
>Peter Krause, MD
>LSU - New Orleans
>---
>[This E-mail scanned for viruses by Declude Virus]

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



fbwilson at earthlink
New User

Nov 6, 2007, 8:39 PM

Post #3 of 8 (3987 views)
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Re: [ORT-L] Tranvserse sacral fx with retroperitoneal air [In reply to] Can't Post
 
Peter,

Do you have imaging studies yet? It would be very helpful to be better able to characterize the fracture. From Bill Burman's reference, it doesn't sound as though presacral drainage will add anything. My biggest concern with your mention of iliosacral screws is that if there is a spinopelvic dissociation, I don't believe that screws alone would be sufficient.

Again, would love to see radiographs. I am in Chicago for the Orthopaedic Educators course but will follow with interest.

Fred
Frederic B. Wilson, M.D.
Trauma & Adult Reconstruction
Department of Orthopaedic Surgery
Ochsner Healthcare Foundation
1514 Jefferson Highway
New Orleans, LA, 70121
504-842-3970
Fax: 504-842-6823
Cell: 504-994-4555
fbwilson@earthlink.net
fwilson@ochsner.org

-----Original Message-----
>From: Bill Burman <wdburman@frontiernet.net>
>Sent: Nov 6, 2007 1:26 PM
>To: ORT-L@www2.aaos.org
>Subject: Re: [ORT-L] Tranvserse sacral fx with retroperitoneal air
>
>>>>One general surgeon told me that diversion is sufficient. Another
>>>>suggested presacral drainage in the lithotomy position (after
>>>>pelvic fixation).
>
>A prospective, randomized trial from J Trauma:
>
>The Role of Presacral Drainage in the Management of Penetrating
>Rectal Injuries.
>
>Gonzalez, Richard P. MD; Falimirski, Mark E. MD; Holevar, Michele R.
>MD, Journal of Trauma-Injury Infection & Critical Care.
>45(4):656-661, October 1998.
>
>http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-199810000-00002.htm;jsessionid=HwKGqyySvkJNmvzNvqbG9qpCTGqGyJdzQL66JDlGc6tJpKvLZPDm!-1947435345!181195628!8091!-1
>
>Bill Burman, MD
>HWB Foundation
>http://www.hwbf.org
>
>
>
>>To: ORT-L@www2.aaos.org
>>From: Krause Peter <pckrause@mac.com>
>>Subject: Tranvserse sacral fx with retroperitoneal air
>>Date: Sun, 4 Nov 2007 16:15:00 -0600
>>X-Mailer: Apple Mail (2.752.3)
>>
>>30 yo male MVC yesterday transiently hemodynamically unstable with
>>symphysis pubis diastasis, right SI diastasis, and transverse sacral
>>fracture about 4 cm from the tip translated 100% anteriorly. CT
>>showed retroperitoneal air. The general surgeons presumed a rectal
>>injury and performed an ex lap (no positive findings) and a diverting
>>colostomy. They did not want to explore the rectum from this
>>exposure because of concerns about possibly disrupting hematoma and
>>causing bleeding. I placed an anterior ex fix.
>>
>>I plan to definitively fix his pelvis tomorrow (symphyseal plate and perc SI
>>screws). I had not planned on fixing the sacral fracture but I am
>>concerned that if I do not explore the fracture and debride it, it
>>will become a source of infection. One general surgeon told me that
>>diversion is sufficient. Another suggested presacral drainage in the
>>lithotomy position (after pelvic fixation). I apologize that I do
>>not have any scans or xrays to share at this point but I am having
>>trouble with our PACS system. Any experience with this sort of
>>injury or suggestions?
>>
>>
>>Thanks,
>>
>>Peter Krause, MD
>>LSU - New Orleans
>>---
>>[This E-mail scanned for viruses by Declude Virus]
>
>---
>[This E-mail scanned for viruses by Declude Virus]
>

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



pckrause at mac
New User

Nov 8, 2007, 8:27 PM

Post #4 of 8 (3932 views)
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Re: [ORT-L] Tranvserse sacral fx with retroperitoneal air [In reply to] Can't Post
Follow-up:

The patient had ORIF of his symphysis and perc SI screws on HD#3.
The general surgeons did a flex-sig and found no injury up to the
level of the sigmoid colon. The patient is currently afebrile and
stable. On initial presentation the patient had right foot weakness
of TA and EHL which has now completely resolved and his sensation is
intact.

Enclosed are xrays and selective CT cuts.

Questions: are the transverse sacral fracture and an undetected
rectal injury the source of the retroperitoneal air? is there
another source for the gas? how should the sacral fracture be managed?

Thanks for your input.

Peter Krause
LSU - New Orleans
Attachments: Pelvic XFix.jpg (45.0 KB)
  Pelvic XFix.jpg (244 KB)
  Pelvic XFix Outlet.jpg (41.3 KB)
  Pelvic XFix Outlet.jpg (228 KB)
  Pelvic XFix Inlet.jpg (40.2 KB)
  Pelvic XFix Inlet.jpg (240 KB)
  CT.jpg (41.3 KB)
  CT.jpg (196 KB)
  Sagittal CT Recon.jpg (39.2 KB)
  Sagittal CT Recon.jpg (129 KB)
  Sagittal CT Recon2.jpg (42.3 KB)
  Sagittal CT Recon2.jpg (112 KB)
  Post ORIF.jpg (45.7 KB)
  Post ORIF.jpg (207 KB)


wdburman at frontiernet
New User

Nov 10, 2007, 3:38 PM

Post #5 of 8 (3789 views)
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Re: [ORT-L] Tranvserse sacral fx with retroperitoneal air [In reply to] Can't Post
>I sent in the xrays and CT on Thursday, but there hasn't been any
>response. Can you post them on the web site?

Hello Peter,

Your transverse sacral fx case has been automatically archived at:
http://www.orthopaedicweblinks.com/forum/OWL_Lists_C2/OTA_F9/%5BORT-L%5D_Tranvserse_sacral_fx_with_retroperitoneal_air_P4452/
The images are at the bottom. Select the larger file sizes to view them.

As can be seen on the web page, the posts have had over 100 views
thus far. Only Fred Wilson has replied. You may have stumped everyone
else.

In an attempt to stir some discussion:

There is a case report by Sommer in JOT 19(7) August 2005 pp 487-490
of a 15 year old female with an 200 -300% anteriorly displaced
transverse sacral fx at S3 (looks more proximal than yours) with
associated perianal numbness and poor sphincter tone. Trans-anal
closed reduction failed. A 3.5 LCP locking T plate was applied thru a
posterior midline approach. The fx healed. The patient had complete
neuro recovery and no pain.

A Martin Bircher letter to Injury Volume 34, Issue 3, March 2003,
Page 247 - says flex sigmoidoscopy is unreliable because of bowel
prep/positioning problems with pelvic fxs and ex fix. Presacral gas
is probably secondary to a missed rectal tear/open sacral fx. If the
patient shows signs of infection the J Trauma article mentioned
previously (Gonzalez et al 45(4):656-661, October 1998) which saw no
benefit to routine presacral drainage, suggested percutaneous CT
guided C&S and drainage.

Bill Burman, MD
HWB Foundation
http://www.hwbf.org

>Date: Sat, 10 Nov 2007 12:18:38 -0800
>From: Peter Krause
Subject: sacral fracture f/u

>Bill,
>
>I sent in the xrays and CT on Thursday, but there hasn't been any
>response. Can you post them on the web site?
>
>Thanks,
>
>Peter

---
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zsoltbalogh at yahoo
New User

Nov 11, 2007, 12:37 AM

Post #6 of 8 (3750 views)
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Re: [ORT-L] Tranvserse sacral fx with retroperitoneal air [In reply to] Can't Post
Any pneumothorax?

Krause Peter <pckrause@mac.com> wrote: Follow-up:

The patient had ORIF of his symphysis and perc SI screws on HD#3.
The general surgeons did a flex-sig and found no injury up to the
level of the sigmoid colon. The patient is currently afebrile and
stable. On initial presentation the patient had right foot weakness
of TA and EHL which has now completely resolved and his sensation is
intact.

Enclosed are xrays and selective CT cuts.

Questions: are the transverse sacral fracture and an undetected
rectal injury the source of the retroperitoneal air? is there
another source for the gas? how should the sacral fracture be managed?

Thanks for your input.

Peter Krause
LSU - New Orleans









On Nov 6, 2007, at 1:26 PM, Bill Burman wrote:

>>>> One general surgeon told me that diversion is sufficient.
>>>> Another suggested presacral drainage in the lithotomy position
>>>> (after pelvic fixation).
>
> A prospective, randomized trial from J Trauma:
>
> The Role of Presacral Drainage in the Management of Penetrating
> Rectal Injuries.
>
> Gonzalez, Richard P. MD; Falimirski, Mark E. MD; Holevar, Michele
> R. MD, Journal of Trauma-Injury Infection & Critical Care. 45(4):
> 656-661, October 1998.
>
> http://www.jtrauma.com/pt/re/jtrauma/abstract.
> 00005373-199810000-00002.htm;jsessionid=HwKGqyySvkJNmvzNvqbG9qpCTGqGyJ
> dzQL66JDlGc6tJpKvLZPDm!-1947435345!181195628!8091!-1
>
> Bill Burman, MD
> HWB Foundation
> http://www.hwbf.org
>
>
>
>> To: ORT-L@www2.aaos.org
>> From: Krause Peter

>> Subject: Tranvserse sacral fx with retroperitoneal air
>> Date: Sun, 4 Nov 2007 16:15:00 -0600
>> X-Mailer: Apple Mail (2.752.3)
>>
>> 30 yo male MVC yesterday transiently hemodynamically unstable with
>> symphysis pubis diastasis, right SI diastasis, and transverse sacral
>> fracture about 4 cm from the tip translated 100% anteriorly. CT
>> showed retroperitoneal air. The general surgeons presumed a rectal
>> injury and performed an ex lap (no positive findings) and a diverting
>> colostomy. They did not want to explore the rectum from this
>> exposure because of concerns about possibly disrupting hematoma and
>> causing bleeding. I placed an anterior ex fix.
>>
>> I plan to definitively fix his pelvis tomorrow (symphyseal plate
>> and perc SI
>> screws). I had not planned on fixing the sacral fracture but I am
>> concerned that if I do not explore the fracture and debride it, it
>> will become a source of infection. One general surgeon told me that
>> diversion is sufficient. Another suggested presacral drainage in the
>> lithotomy position (after pelvic fixation). I apologize that I do
>> not have any scans or xrays to share at this point but I am having
>> trouble with our PACS system. Any experience with this sort of
>> injury or suggestions?
>>
>>
>> Thanks,
>>
>> Peter Krause, MD
>> LSU - New Orleans
>> ---
>> [This E-mail scanned for viruses by Declude Virus]
>
> ---
> [This E-mail scanned for viruses by Declude Virus]
>



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pckrause at mac
New User

Nov 11, 2007, 7:59 AM

Post #7 of 8 (3737 views)
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Re: [ORT-L] Tranvserse sacral fx with retroperitoneal air [In reply to] Can't Post
No.

Good idea, though.


On Nov 11, 2007, at 2:37 AM, Zsolt Balogh wrote:

> Any pneumothorax?
>
> Krause Peter <pckrause@mac.com> wrote:
> Follow-up:
>
> The patient had ORIF of his symphysis and perc SI screws on HD#3.
> The general surgeons did a flex-sig and found no injury up to the
> level of the sigmoid colon. The patient is currently afebrile and
> stable. On initial presentation the patient had right foot weakness
> of TA and EHL which has now completely resolved and his sensation is
> intact.
>
> Enclosed are xrays and selective CT cuts.
>
> Questions: are the transverse sacral fracture and an undetected
> rectal injury the source of the retroperitoneal air? is there
> another source for the gas? how should the sacral fracture be managed?
>
> Thanks for your input.
>
> Peter Krause
> LSU - New Orleans
>
>
>
>
>
>
>
>
>
> On Nov 6, 2007, at 1:26 PM, Bill Burman wrote:
>
> >>>> One general surgeon told me that diversion is sufficient.
> >>>> Another suggested presacral drainage in the lithotomy position
> >>>> (after pelvic fixation).
> >
> > A prospective, randomized trial from J Trauma:
> >
> > The Role of Presacral Drainage in the Management of Penetrating
> > Rectal Injuries.
> >
> > Gonzalez, Richard P. MD; Falimirski, Mark E. MD; Holevar, Michele
> > R. MD, Journal of Trauma-Injury Infection & Critical Care. 45(4):
> > 656-661, October 1998.
> >
> > http://www.jtrauma.com/pt/re/jtrauma/abstract.
> >
> 00005373-199810000-00002.htm;jsessionid=HwKGqyySvkJNmvzNvqbG9qpCTGqGyJ
> > dzQL66JDlGc6tJpKvLZPDm!-1947435345!181195628!8091!-1
> >
> > Bill Burman, MD
> > HWB Foundation
> > http://www.hwbf.org
> >
> >
> >
> >> To: ORT-L@www2.aaos.org
> >> From: Krause Peter
> >> Subject: Tranvserse sacral fx with retroperitoneal air
> >> Date: Sun, 4 Nov 2007 16:15:00 -0600
> >> X-Mailer: Apple Mail (2.752.3)
> >>
> >> 30 yo male MVC yesterday transiently hemodynamically unstable with
> >> symphysis pubis diastasis, right SI diastasis, and transverse
> sacral
> >> fracture about 4 cm from the tip translated 100% anteriorly. CT
> >> showed retroperitoneal air. The general surgeons presumed a rectal
> >> injury and performed an ex lap (no positive findings) and a
> diverting
> >> colostomy. They did not want to explore the rectum from this
> >> exposure because of concerns about possibly disrupting hematoma and
> >> causing bleeding. I placed an anterior ex fix.
> >>
> >> I plan to definitively fix his pelvis tomorrow (symphyseal plate
> >> and perc SI
> >> screws). I had not planned on fixing the sacral fracture but I am
> >> concerned that if I do not explore the fracture and debride it, it
> >> will become a source of infection. One general surgeon told me that
> >> diversion is sufficient. Another suggested presacral drainage in
> the
> >> lithotomy position (after pelvic fixation). I apologize that I do
> >> not have any scans or xrays to share at this point but I am having
> >> trouble with our PACS system. Any experience with this sort of
> >> injury or suggestions?
> >>
> >>
> >> Thanks,
> >>
> >> Peter Krause, MD
> >> LSU - New Orleans
> >> ---
> >> [This E-mail scanned for viruses by Declude Virus]
> >
> > ---
> > [This E-mail scanned for viruses by Declude Virus]
> >
>
>
> __________________________________________________
> Do You Yahoo!?
> Tired of spam? Yahoo! Mail has the best spam protection around
> http://mail.yahoo.com



wdburman at frontiernet
New User

Nov 11, 2007, 3:26 PM

Post #8 of 8 (3715 views)
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Re: [ORT-L] Tranvserse sacral fx with retroperitoneal air [In reply to] Can't Post
>> Any pneumothorax?

Thanks for the pneumoretroperitoneal pearl, Zsolt. Didn't realize
that air near the tail bone can come from so far away.

According to Pretre et al, Pathophysiology, recognition and
management of pneumoretroperitoneum. Br J Surg. 1993 Sep;80(9):1138-40

"One patient with pneumoretroperitoneum and pneumoperitoneum
secondary to a lung lesion underwent unnecessary laparotomy."

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8402114&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Bill Burman, MD
HWB Foundation
http://www.hwbf.org


Date: Sun, 11 Nov 2007 00:37:35 -0800 (PST)
From: Zsolt Balogh <zsoltbalogh@yahoo.com>

>Any pneumothorax?
>
>Krause Peter <pckrause@mac.com> wrote:
>Questions: are the transverse sacral fracture and an undetected
>rectal injury the source of the retroperitoneal air? is there
>another source for the gas? how should the sacral fracture be managed?
>
>Thanks for your input.
>
>Peter Krause
>LSU - New Orleans
---
[This E-mail scanned for viruses by Declude Virus]


 
 
 


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