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Aug 29, 2005, 10:09 AM
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Re: [ORT-L] pelvic # with urethral injury-postop xrays
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It may be stable.
I donıt know if you should return to OR or not...thatıs up to you and him.
Itıs late for manipulative reduction to be successful.
If you have imaging trouble intraop for whatever reason, always consider
ORIF...you can clean the fracture, see the reduction, and use direct
fixation....sometimes we push percutaneous fixation and manipulative
reduction when we should just do ORIF.
Iıll try to write down some dysmorphic details sometime soon with some
clinical examples and send along.
If your frame is in the way of the C-arm, either reassemble/reorient it
differently, or tilt the C-arm a bit and the frame bars will clear, or use
carbon bars to image through, or all of the above.
Chip
> Thanks chip.
>
> Good points.
>
> I did not try to assess stability at each stage - Good idea . will do next
> time.
>
> I chickened out of drilling any more into the sacral body as i could not make
> out where it was going because of bowel gas and poor c arm clarity. The screw
> probably has suffered a bit due to overtightening. I did try to make sure that
> it has reached the lateral wall of the ilium by taking different views of the
> pelvis.
>
> I might take him back to theatre to try and reduce the # using the frame like
> you suggested.Should I remove /loosen the iliosacral screw? If i leave it
> there,i can probably use that as a guide to where the body of S1 is ? Will it
> interfere with reduction?
>
> Clinically patient is much better, sitting propped up, pain control is better
> etc so I was hoping it was stable :-(
>
> You mentioned methods for use in dysmorphic vertebrae.Is there somewhere I can
> get access to articles dealing with this? I had a really tough time trying to
> figure out which one was S1 on the AP but I seem to have missed it anyways.
> Also if the frame is getting in the way of the Carm,is it better to dismantle
> it and lose the reduction (not in this case where there was no reduction to
> lose, but generally).
>
> 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 Chip Routt
>> Sent: 29 August 2005 20:48
>> To: ORT-L@www2.aaos.org
>> Subject: Re: [ORT-L] pelvic # with urethral injury-postop xrays
>>
>> Well, multiple factors have come together and determined your treatment and
>> radiographic early appearance.
>>
>> The delayed patient presentation and previous suprapubic cystostomy caused
>> you to have concern for infection after anterior pelvic ORIF...so you ruled
>> that out...and you elected to not do ORIF of the posterior pelvic ring
>> injury.
>>
>> Youıve applied an anterior pelvic external frame to avoid the risk of
>> infection anteriorly.
>>
>> The reduction suffers a bit due the ³percutaneous² treatment without
>> manipulative reduction, but we have a tough time understanding the residual
>> deformity because the films are of a limited field.
>>
>> You can use the frame intraoperatively to manipulate the reduction in many
>> scenarios, especially in concert with distal femoral traction...then tighten
>> it and support it with sturdy/sufficient posterior fixation.
>>
>> Holding a comminuted and displaced unstable anterior ring fracture securely
>> to union is difficult with routine anterior pelvic external fixation, unless
>> there is sufficient posterior ring injury fixation.
>>
>> The single iliosacral lag screw appears to be located into the second sacral
>> alar zone of the dysmorph, and already has loosened a bit or was not
>> tightened completely or was over-tightened and lost itıs ³bite²...if it is
>> early screw disengagement, that reflects poor local stability and can be due
>> to numerous reasons...poor bone quality, short screw, screw over-tightening
>> resulting in loss of firm fixation, screw mis-positioning, single screw,
>> insufficient anterior ring fixation, among others.
>>
>> The residual deformity/malreduction also impacts overall ring stability
>> because good quality reductions improve site stability...and also good
>> reductions improve implant safety.
>>
>> Itıll heal, but you may notice progressive hemipelvic deformity if the
>> overall fixation construct is insufficient...do you use an exam under
>> fluoroscopy before, during, and after fixation to grossly assess the
>> progressive stability achieved as you operate? If so, were the fracture
>> sites stable after frame and screw applications? If not, you may choose to
>> do this for several reasons...you can understand the power of certain
>> implants as they are inserted, and you can continue to work until itıs
>> unstable injury zones become stable.
>>
>> Chip
>>
>>
>>
>>
>>
>>
>>
>>
>>> > I am not very clear about what I have or have not achieved here,but would
>>> be
>>> > great to have your comments so that I can do a bit better if it happens
>>> > again.
>>> >
>>> > Thank you 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: 26 August 2005 22:17
>>> > To: ORT-L@www2.aaos.org
>>> > Subject: Re: [ORT-L] pelvic # with urethral injury-CT pictures
>>> >
>>> >
>>> > 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
>>>>> >>> ---
>>>>> >>> [This E-mail scanned for viruses by Declude Virus]
>>>> >>
>>>> >> 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
>>>> >> --
>>>> >>
>>>> >>
>>>> >>
>>>> >> ---
>>>> >> [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]
>>>> >>
>>> >
>>> > 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
>>> > --
>>> >
>>> >
>>> >
>>> > ---
>>> > [This E-mail scanned for viruses by Declude Virus]
>>
>> 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
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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