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Re: APC III pelvis fx
послал Chip Routt 29 Ноябрь 2005, 20:25
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It's hard to manage pelvic ring instability, and early decisions usually have dramatic impact on the result.
I don't think that this is іa great caseІ... it's a human, and it's a sad scenario.
Here are some observations, comments, and suggestions that are based on learning experiences-
1. Please consider strongly not waiting until day 5 to stabilize a patient with an unstable pelvic ring disruption...it makes no sense...if you can't get to it, transfer him urgently to someone who can and will.
2. Work with your urologists to coordinate bladder repair with early symphyseal reduction and fixation at the same anesthetic and exposure... if they don't want to play nicely, get your patient to someone with a urologist who will work on such injuries... this relationship is vital.
3. Reduction of the symphysis will improve posterior ring reductions for certain posterior ring injuries, especially if done within the first 2 days... you can always reduce and just clamp the symphysis, pack that wound, expose the SI joint anteriorly, reduce and stabilize it, return to the front and fix the symphysis, wash and close the wounds.
4. When you reduce such an iliac fracture-SI joint articular disruption using an anterior iliac exposure, you can use lag screws for the iliac
component along with iliosacral screws (or a plating technique) for the SI joint component, similar to what you did from the back... the articular reduction is visible and predictable within the field... it's so much easier
than clamping thru the notch and then feeling around hoping that it's reduced anteriorly while the body weight confounds your efforts.
5. Your caudal iliosacral screw is/was in his spinal canal... it's low and posterior and the lateral fluoro image confirms this... a postop CT will show it (or it's trail at this point)... canal screws do not hold.
6. Frames (even fancy new-style low ones) have poor mechanical stability when compared to symphyseal internal fixation...unstable rings in fat (and skinny) folks demand stable anterior and posterior stabilities... a frame
can't get you there... consider it a helper/support at best.
7. A beer-belly does not complicate symphyseal reduction and fixation...it's just a deeper wound, and so you need a friend to hold a retractor or
two.... and if you can fluoro the patient's posterior pelvic ring intraop, he's not so fat!
8. If you are aware of the fixation failure before you vacate town, sometimes you just have to miss a holiday in order to help the patient... or at least have a plan to pass the patient along to a competent colleague to care for while you are away.
9. At this point, (if he's alive) get busy get a CT so you can understand what's happened, where the implants were, what fixation zones remain, remove the failed posterior implants, turn him supine, expose the symphysis and SI joint, reduce and clamp them both, fix them according to the CT info, close the wounds if clean, pack open if not, get another CT to assure adequate reductions and implant safety, treat his wound culture results with appropriate antibiotics, and nourish him.
I'm very sorry for you and the patient that this has happened, thank you for sharing it, and considering the above.
I hope that he can survive-
Chip
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