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Aug 26, 2005, 9:47 AM
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Re: [ORT-L] pelvic # with urethral injury-CT pictures
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There are predictable (and non-stressful) imaging techniques for safe screw
insertions into dysmorphic segments of the upper sacrum...I'm not sure this
is the best way to try and discuss it...hopefully your fixation is safe and
stable.
Chip
> Thanks to everyone who made helpful suggestions.I put an anterior exfix and
> did a supine percutaneous ilio sacral screw (very very,strssful,I have to
> say!)On the c arm ,the pictures looked ok but am waiting for the proper
> films later on.urologist changed the suprapubic into a transurethral
> catheter.I will post films later on.
>
> thanks very much
>
> rajesh
>
> Mr.K.R.Rajesh,MS,DNB,FRCS,FRCS(Orth)
> Consultant Upper Limb Surgeon,
> Division of Upper Limb & Joint Replacement Surgery.
> Cosmopolitan Hospital,
> Trivandrum,Kerala,
> India.
> Mobile-9847350160
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org]On
> Behalf Of Rajesh
> Sent: 25 August 2005 22:31
> To: ORT-L@www2.aaos.org
> Subject: RE: [ORT-L] pelvic # with urethral injury-CT pictures
>
>
> Thanks chip.
> I have been going through your previous discussions on the OTA boards as
> well as your article in the orthopaedic clinics a couple of years ago.Also
> looked through OKU Trauma2.
>
> I was kind of planning on your option 2 after reading all that. The
> urologist is not too keen on doing anything other than attempting a urethral
> catheterisation to get rid of the SPC at the moment.
> thanks very much
>
> Mr.K.R.Rajesh,MS,DNB,FRCS,FRCS(Orth)
> Consultant Upper Limb Surgeon,
> Division of Upper Limb & Joint Replacement Surgery.
> Cosmopolitan Hospital,
> Trivandrum,Kerala,
> India.
> Mobile-9847350160
>
> -----Original Message-----
> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org]On
> Behalf Of Chip Routt
> Sent: 25 August 2005 22:20
> To: ORT-L@www2.aaos.org
> Subject: Re: [ORT-L] pelvic # with urethral injury-CT pictures
>
>
> Thanks.
>
> Your patient has a comminuted, displaced right parasymphyseal ramus fracture
> (with associated urological issues which to date have been managed with
> suprapubic cystostomy) and a right sided posterior iliac fracture and
> ipsilateral associated sacroiliac disruption. Your patient also has an upper
> sacral dysmorphism.
>
> Your options include but are not limited to-
>
> 1. Routine anterior pelvic external fixation with or without right sided
> distal femoral skeletal traction 10-15 pounds for 6-8 weeks.
>
> 2. Pelvic external fixation, manipulative right hemipelvic closed reduction,
> and iliosacral screw fixation...with or without medullary ramus fixation
> inserted percutaneously
>
> 3. A dorsal surgical exposure for ORIF right iliac fracture supplemented
> with sacroiliac stabilization using an iliosacral screw, with or without
> subsequent pelvic anterior external fixation.
>
> 4. An iliac anterior surgical exposure for ORIF right SI joint using plates
> to stabilize the joint, or an iliosacral screw after open reduction (or
> both)...you can also insert lag screws from the lateral anterior ilium into
> the posterior iliac fragment through the plate or independantly. Standard
> pelvic anterior external fixation is not advocated after the iliac exposure
> because the routine iliac crest fixation pin(s) potentially contaminate(s)
> the iliac surgical wound.
>
> 5. A Pfannenstiel exposure for ORIF right ramus fracture using either plate
> or medullary screw either alone or in combination with one of the above
> posterior pelvic options. The exposure allows you to irrigate and debride
> the anterior pelvis. The urologist can use the exposure as he/she needs. The
> medullary screw provides less surface exposure for bacterial contamination.
>
> 6. Traction alone.
>
> 7. Manipulative closed reduction, percutaneous iliosacral and retrograde
> medullary screw fixations.
>
> And on and on.
>
> At this point, I'd recommend #2 if you well understand the fluoroscopy of
> the dysmorphic upper sacrum and iliosacral screw insertion into it. If not,
> I'd use direct ORIF of the iliac fracture using a dorsal exposure and no
> iliosacral screw because of the dysmorphism, and add an anterior frame.
>
> Sooner is almost always better than later.
>
> Ideally do it on day #1 or #2, and have a management algorithm in place for
> such patients coordinated with your urologist. This won't be the last one
> that you see like this.
>
> Thanks and good luck-
>
> Chip
>
>
>
>
>
>
>
>
>
>> CT pictures.
>> Thanks for your help.
>>
>> rajesh
>>
>> Mr.K.R.Rajesh,MS,DNB,FRCS,FRCS(Orth)
>> Consultant Upper Limb Surgeon,
>> Division of Upper Limb & Joint Replacement Surgery.
>> Cosmopolitan Hospital,
>> Trivandrum,Kerala,
>> India.
>> Mobile-9847350160
>>
>> -----Original Message-----
>> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org]On
>> Behalf Of Jeff Brooks
>> Sent: 25 August 2005 01:05
>> To: ORT-L@www2.aaos.org
>> Subject: Re: [ORT-L] pelvic # with urethral injury
>>
>>
>> If ex-fix with good anterior ring alignment I would still strongly
>> consider posterior fixation on the right. At the very least 2
>> percutaneous screws but preferably more (i.e., plating or a bar, etc)
>>
>> I am in a similar situation as an upper extremity surgeon with
>> additional fellowship trauma training, and interest, but I don't do
>> much pelvic trauma and when something like this comes along I cringe,
>> look in the books and in the literature, and "bite the bullet".
>>
>> Maybe Dr. Routt can comment?
>>
>> Great case, thank you Mr. Rajesh
>>
>> Jeff Brooks, Stamford, CT
>>
>> On 8/24/05, T.I. George <ti.george@gmail.com> wrote:
>>> Dear Rajesh
>>>
>>> At the movement that seem to be the only answer to me.
>>>
>>>
>>> Dr T I George
>>>
>>>
>>>
>>>
>>> On 8/23/05, Rajesh <rajesh84@asianetindia.com> wrote:
>>>>
>>>> Would you do anything at all to the comminuted displaced pubic rami #s
>> or
>>> just reduce the pelvic displacement and put the exfix on?
>>>>
>>>> thanks
>>>> rajesh
>>>>
>>>>
>>>> Mr.K.R.Rajesh,MS,DNB,FRCS,FRCS(Orth)
>>>> Consultant Upper Limb Surgeon,
>>>> Division of Upper Limb & Joint Replacement Surgery.
>>>> Cosmopolitan Hospital,
>>>> Trivandrum,Kerala,
>>>> India.
>>>> Mobile-9847350160
>>>>
>>>>
>>>> -----Original Message-----
>>>> From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org]On
>>> Behalf Of T.I. George
>>>> Sent: 23 August 2005 22:30
>>>> To: ORT-L@www2.aaos.org
>>>> Subject: Re: [ORT-L] pelvic # with urethral injury
>>>>
>>>>
>>>> Rajesh,
>>>>
>>>> If it was day 1, I would have tried to force my Urology colleague to
>> avoid
>>> a SPC and do a transurethral catheter and primary repair(not an easy task
>> to
>>> convince an urologist to do an emergency urethral repair when they are
> all
>>> busy with elctive lists). Now with an SPC almost one week old, I think
> you
>>> are forced to probably have only an ex fix and avoid a plate anteriorly.
>>>>
>>>> Best of luck.
>>>>
>>>> Dr T I George
>>>>
>>>>
>>>> On 8/23/05, Rajesh <rajesh84@asianetindia.com > wrote:
>>>>> Hi,
>>>>> I would greatly appreciate some advice.
>>>>>
>>>>> 25 yr old male who fell from a height 6 days ago and was treated in a
>>>>> peripheral hospital initially has been transferred to our hospital
>>> today.he
>>>>> had a supra pubic catheter inserted for urethral injury on the day of
>>> injury
>>>>> but nothing else has been done so far.
>>>>>
>>>>> He is stable at present.. His main injury is the vertically unstable
>>> right
>>>>> sided injury involving superior and inferior rami and a # through the
>>> iliac
>>>>> side of the sacro-iliac joint on the same side.He also has undisplaced
>>>>> radial neck # on the riht side.No spine injury and no abdominal or
>>> thoracic
>>>>> injury.Long bones ok.
>>>>>
>>>>> I will arrange for some CT as soon as possible.i am sending some xrays
>>> .My
>>>>> pelvic # surgical experience is limited to plating a few pubic rami #s
>>> and a
>>>>> few simple column #s while i was working with a pelvic # surgeon
>> (about
>>> 3
>>>>> yrs ago),so I could do with some advice as to what to do next.
>>>>>
>>>>> Thanks for your input.
>>>>>
>>>>> Mr.K.R.Rajesh,MS,DNB,FRCS,FRCS(Orth)
>>>>> Consultant Upper Limb Surgeon,
>>>>> Division of Upper Limb & Joint Replacement Surgery.
>>>>> Cosmopolitan Hospital,
>>>>> Trivandrum,Kerala,
>>>>> India.
>>>>> Mobile-9847350160
>>>>>
>>>>>
>>>>>
>>>>
>>>>
>>>
>>>
>>
>>
>> --
>> Jeffrey J. Brooks, MD
>> Orthopaedic Surgery & Sports Medicine Center
>> 1290 Summer Street, #4400
>> Stamford, CT 06905
>> ---
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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
> --
>
>
>
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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
--
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