[ORT-L] comminuted crescent fx


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[ORT-L] comminuted crescent fx

jeffrichmondmd at hotmail
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Sep 25, 2007, 5:52 AM

Post #1 of 7 (3192 views)
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[ORT-L] comminuted crescent fx	Can't Post

Any advice would be appreciated:

40 ish female ejected from car. Unstable, DPL negative, went to angio and
had her pelvic bleeds embolized after many units of blood. GCS 6, floating
elbow, clavicle, bothbones, etc.

My standard approach to this pelvis would be posterior, reduce/lag/plate
thecrest, reduce/plate the caudal extent on the posterior crest and 1-2 lags
back to front. In this case, the crest comminution seems to make plating all
the way to the ASIS useless, as the plate would be on free floating
fragments. Would plating the posterior extent of the fracture to secure the
reduction at the SI joint and 2 screws back to front be sufficient fixation?
Would anyone do a perc reduction and perc back to front screws, and would
that be sufficient if the SI joint could be reduced (although I don't see
how this could be accurately reduced closed). Would an ilioninguinal with a
pelvic brim plate and posterior column screws be a better approach, although
reducing the SI would be more indirect and less accurate?

Thanks

Jeff Richmond

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mlroutt at u
New User

Sep 25, 2007, 7:27 AM

Post #2 of 7 (3191 views)
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Re: [ORT-L] comminuted crescent fx [In reply to]	Can't Post

It's a comminuted iliac fracture involving the GS notch and all that
implies...use the lateral interval of an ilioinguinal, sequentially reduce,
and fix...if you want to, you can attach the dominant unstable fragment to
both the stable posterior iliac fragment and also to the anterolateral
portion of the sacrum using plates...if you choose to anchor to both, the
implants get congested on the iliac side of the SI joint so be precise with
contouring and such applications...perhaps and based on the images shown, an
iliosacral screw would only augment the construct if applied to the second
sacral segment (but this is difficult to assess on the images shown). The
crest components can be held securely with screws and/or peripheral plating.

Chip

> Any advice would be appreciated:
>
> 40 ish female ejected from car. Unstable, DPL negative, went to angio and
> had her pelvic bleeds embolized after many units of blood. GCS 6, floating
> elbow, clavicle, bothbones, etc.
>
> My standard approach to this pelvis would be posterior, reduce/lag/plate
> thecrest, reduce/plate the caudal extent on the posterior crest and 1-2 lags
> back to front. In this case, the crest comminution seems to make plating all
> the way to the ASIS useless, as the plate would be on free floating
> fragments. Would plating the posterior extent of the fracture to secure the
> reduction at the SI joint and 2 screws back to front be sufficient fixation?
> Would anyone do a perc reduction and perc back to front screws, and would
> that be sufficient if the SI joint could be reduced (although I don't see
> how this could be accurately reduced closed). Would an ilioninguinal with a
> pelvic brim plate and posterior column screws be a better approach, although
> reducing the SI would be more indirect and less accurate?
>
> Thanks
>
> Jeff Richmond
>

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
--

jeffrichmondmd at hotmail
New User

Sep 25, 2007, 7:57 AM

Post #3 of 7 (3191 views)
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Re: [ORT-L] comminuted crescent fx [In reply to]	Can't Post

Thanks. I probably didn't include enough images on the CT, but it didn't
look to me like an SI screw would be of value except into S2, which I am not
comfortable placing. I will post finals if the neurosurgeons let me operate
on her. ICPs still a problem.

Thanks

Jeff

>From: Chip Routt <mlroutt@u.washington.edu>
>Reply-To: ORT-L@www2.aaos.org
>To: <ORT-L@www2.aaos.org>
>Subject: Re: [ORT-L] comminuted crescent fx
>Date: Tue, 25 Sep 2007 07:27:11 -0700
>
>It's a comminuted iliac fracture involving the GS notch and all that
>implies...use the lateral interval of an ilioinguinal, sequentially reduce,
>and fix...if you want to, you can attach the dominant unstable fragment to
>both the stable posterior iliac fragment and also to the anterolateral
>portion of the sacrum using plates...if you choose to anchor to both, the
>implants get congested on the iliac side of the SI joint so be precise with
>contouring and such applications...perhaps and based on the images shown,
>an
>iliosacral screw would only augment the construct if applied to the second
>sacral segment (but this is difficult to assess on the images shown). The
>crest components can be held securely with screws and/or peripheral
>plating.
>
>Chip
>
>
>
>
>
>
> > Any advice would be appreciated:
> >
> > 40 ish female ejected from car. Unstable, DPL negative, went to angio
>and
> > had her pelvic bleeds embolized after many units of blood. GCS 6,
>floating
> > elbow, clavicle, bothbones, etc.
> >
> > My standard approach to this pelvis would be posterior,
>reduce/lag/plate
> > thecrest, reduce/plate the caudal extent on the posterior crest and 1-2
>lags
> > back to front. In this case, the crest comminution seems to make plating
>all
> > the way to the ASIS useless, as the plate would be on free floating
> > fragments. Would plating the posterior extent of the fracture to secure
>the
> > reduction at the SI joint and 2 screws back to front be sufficient
>fixation?
> > Would anyone do a perc reduction and perc back to front screws, and
>would
> > that be sufficient if the SI joint could be reduced (although I don't
>see
> > how this could be accurately reduced closed). Would an ilioninguinal
>with a
> > pelvic brim plate and posterior column screws be a better approach,
>although
> > reducing the SI would be more indirect and less accurate?
> >
> > Thanks
> >
> > Jeff Richmond
> >
>
>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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Adam.Starr at UTSouthwestern
New User

Sep 25, 2007, 10:50 AM

Post #4 of 7 (3191 views)
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Re: [ORT-L] comminuted crescent fx [In reply to]	Can't Post

Hi Jeff,

I always manage these percutaneously. The basic idea is to peg the AIIS
fragment to the crescent frag still attached to the sacrum.

But the reported results of open treatment are very good, so your plan
of ORIF should yield acceptable results.

Adam
On Sep 25, 2007, at 7:52 AM, Jeff Richmond wrote:

> Any advice would be appreciated:
>
> 40 ish female ejected from car. Unstable, DPL negative, went to angio
> and had her pelvic bleeds embolized after many units of blood. GCS 6,
> floating elbow, clavicle, bothbones, etc.
>
> My standard approach to this pelvis would be posterior,
> reduce/lag/plate thecrest, reduce/plate the caudal extent on the
> posterior crest and 1-2 lags back to front. In this case, the crest
> comminution seems to make plating all the way to the ASIS useless, as
> the plate would be on free floating fragments. Would plating the
> posterior extent of the fracture to secure the reduction at the SI
> joint and 2 screws back to front be sufficient fixation? Would anyone
> do a perc reduction and perc back to front screws, and would that be
> sufficient if the SI joint could be reduced (although I don't see how
> this could be accurately reduced closed). Would an ilioninguinal with
> a pelvic brim plate and posterior column screws be a better approach,
> although reducing the SI would be more indirect and less accurate?
>
> Thanks
>
> Jeff Richmond
>
> <image.jpg><image2.jpg><image3.jpg><image4.jpg><image5.jpg><image6.jpg>
> <image7.jpg><image8.jpg>

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wdburman at frontiernet
New User

Sep 26, 2007, 10:37 AM

Post #5 of 7 (3151 views)
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Re: [ORT-L] comminuted crescent fx [In reply to]	Can't Post

Originally sent: Tue, 25 Sep 2007 14:47:23 -0400

This appears to be a highly comminuted, possible "humpty-dumpty" type
fracture pattern
(http://en.wikipedia.org/wiki/Humpty_Dumpty)

Is there a place for non-operative rx?

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

>Hi Jeff,
>
>I always manage these percutaneously. The basic idea is to peg the
>AIIS fragment to the crescent frag still attached to the sacrum.
>
>But the reported results of open treatment are very good, so your
>plan of ORIF should yield acceptable results.
>
>Adam
>On Sep 25, 2007, at 7:52 AM, Jeff Richmond wrote:
>
>>Any advice would be appreciated:
>>
>>40 ish female ejected from car. Unstable, DPL negative, went to
>>angio and had her pelvic bleeds embolized after many units of
>>blood. GCS 6, floating elbow, clavicle, bothbones, etc.
>>
>>My standard approach to this pelvis would be posterior,
>>reduce/lag/plate thecrest, reduce/plate the caudal extent on the
>>posterior crest and 1-2 lags back to front. In this case, the crest
>>comminution seems to make plating all the way to the ASIS useless,
>>as the plate would be on free floating fragments. Would plating the
>>posterior extent of the fracture to secure the reduction at the SI
>>joint and 2 screws back to front be sufficient fixation? Would
>>anyone do a perc reduction and perc back to front screws, and would
>>that be sufficient if the SI joint could be reduced (although I
>>don't see how this could be accurately reduced closed). Would an
>>ilioninguinal with a pelvic brim plate and posterior column screws
>>be a better approach, although reducing the SI would be more
>>indirect and less accurate?
>>
>>Thanks
>>
>>Jeff Richmond
>>
>><image.jpg><image2.jpg><image3.jpg><image4.jpg><image5.jpg><image6.jpg><image7.jpg><image8.jpg>
>
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fx77 at optonline
New User

Sep 26, 2007, 10:44 AM

Post #6 of 7 (3151 views)
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RE: [ORT-L] comminuted crescent fx [In reply to]	Can't Post

Essentially an iliac wing reconstruction which can be repaired through the
I.ing. approach witn fixation across the SIJ. SI Screws may not be needed.

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On Behalf
Of Jeff Richmond
Sent: Tuesday, September 25, 2007 8:52 AM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] comminuted crescent fx

Any advice would be appreciated:

40 ish female ejected from car. Unstable, DPL negative, went to angio and
had her pelvic bleeds embolized after many units of blood. GCS 6, floating
elbow, clavicle, bothbones, etc.

My standard approach to this pelvis would be posterior, reduce/lag/plate
thecrest, reduce/plate the caudal extent on the posterior crest and 1-2 lags

back to front. In this case, the crest comminution seems to make plating all

the way to the ASIS useless, as the plate would be on free floating
fragments. Would plating the posterior extent of the fracture to secure the
reduction at the SI joint and 2 screws back to front be sufficient fixation?

Would anyone do a perc reduction and perc back to front screws, and would
that be sufficient if the SI joint could be reduced (although I don't see
how this could be accurately reduced closed). Would an ilioninguinal with a
pelvic brim plate and posterior column screws be a better approach, although

reducing the SI would be more indirect and less accurate?

Thanks

Jeff Richmond

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frg at myfastmail
New User

Sep 26, 2007, 11:11 AM

Post #7 of 7 (3151 views)
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RE: [ORT-L] comminuted crescent fx [In reply to]	Can't Post

The unilateral SI screws are from the byomechanic point of view
insufficients. If one can obtain the stabilization, is not thanks to
them, but in spite of them. For this reason today news technics
prevail, as the pediculats screws with short bars and bone graft.

----- Original message -----
From: "Bruce Meinhard" <fx77@optonline.net>
To: ORT-L@www2.aaos.org
Date: Wed, 26 Sep 2007 13:44:49 -0400
Subject: RE: [ORT-L] comminuted crescent fx

Essentially an iliac wing reconstruction which can be repaired through
the
I.ing. approach witn fixation across the SIJ. SI Screws may not be
needed.

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org] On
Behalf
Of Jeff Richmond
Sent: Tuesday, September 25, 2007 8:52 AM
To: ORT-L@www2.aaos.org
Subject: [ORT-L] comminuted crescent fx

Any advice would be appreciated:

40 ish female ejected from car. Unstable, DPL negative, went to angio
and
had her pelvic bleeds embolized after many units of blood. GCS 6,
floating
elbow, clavicle, bothbones, etc.

My standard approach to this pelvis would be posterior,
reduce/lag/plate
thecrest, reduce/plate the caudal extent on the posterior crest and 1-2
lags

back to front. In this case, the crest comminution seems to make plating
all

the way to the ASIS useless, as the plate would be on free floating
fragments. Would plating the posterior extent of the fracture to secure
the
reduction at the SI joint and 2 screws back to front be sufficient
fixation?

Would anyone do a perc reduction and perc back to front screws, and
would
that be sufficient if the SI joint could be reduced (although I don't
see
how this could be accurately reduced closed). Would an ilioninguinal
with a
pelvic brim plate and posterior column screws be a better approach,
although

reducing the SI would be more indirect and less accurate?

Thanks

Jeff Richmond

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