Transcript for:
Pelvic Fracture Management Essentials

okay welcome to the the a of trauma North America internet live pelvic and acetabular fracture management essentials course were pleased and excited to welcome you on behalf of a on North America so on behalf of myself and the co-chairs I'm Steven Sims I am the chief of what speak trauma hit Carolinas Medical Center in Charlotte North Carolina dr. Marc Riley is the chief of orthopedic trauma at Rutgers hospital in the Rutgers University and newer cosmography hospital and dr. David Stephen from Sunnybrook Hospital in Toronto we welcome you to this course we will serve as your moderators but over the next eight weeks at least at least a couple of us will be on for every session and we are very excited to proceed with this so the concept of the this internet course of course was born out of the koban pandemic where our scheduled course had to be cancelled as well as multiple other a of scheduled courses and we modeled this course after several other successful courses that we've seen which included the osteotomy course which just completed that which ran successive 9 Saturday mornings and that's kind of how we will base this course as well it is set up to be a blended course which means that we will hopefully have a face-to-face session right now we're looking at probably early January for when that would be it would be a cadaver session at the of Quinta Center in Las Vegas and we will be offering CME credit for those people who sign on to watch live I will bring your attention to the if you see at the bottom this YouTube channel which is a ou trauma in North America you go to youtube and sign under this channel you can watch a tremendous amount of video which would include the video that will be eventually available from this course this is the outline of the course it will run eight successive Saturday mornings beginning at 10:00 a.m. and it will last 90 minutes for each the first one you see here is July the 11th the first two will be the pelvis and then we'll have a third session that will be an expert panel on the pelvis and we'll go through some interesting cases well then have three weeks going through the various fracture patterns for acetabular fractures and then we will have a fourth acetabular session which will be an expert panel session then the eighth Saturday we'll end up with special problems and around public and acetabular fractures so it should be a very good course one of the beautiful things about doing an internet course is that we didn't have to skimp at all on faculty because there's really no problem with inviting the absolute best speakers and people with the most experience and we're really pleased you can see the slide here with the faculty that we've assembled and you'll hear from everybody on this page at some point during these next eight weeks it just would just ask you is to make your experience the best first of all let's say please bear with the technical challenges that we have as we all are scattered across North America in various places and I'm sure there'll be some pitches as we work our way through this stay engaged now we do want you to ask questions the questions would be asked on the on the Q&A questions and answers tab not through the chat sets tab so if you want to ask a question make sure you go there now we encourage you to ask questions and we will be giving some ability for you to review the talks that were done today by video it will also be giving some assignments that you can do to look at videos for the upcoming sessions as well and I think preparing by watching those will make a big difference and how much you get out of the course and I would say keep an open mind because there are a lot of different ways to treat a lot of different fractures and with that you'll you'll you know you may find things that are different from what you do but take that as an opportunity to learn how other people do it so today's the first week will be the introduction that we just said we will have a 15-minute discussion of radiographic evaluation and classification by dr. mark Adams from from Rutgers Hospital in New Jersey and then we'll hear from from Hans creature who's a division chief at in Sunnybrook Hospital in New Jersey on the emergency management and hemorrhage control and then the remaining of this session will be dr. chip route from Memorial Hermann Hospital and in UT Houston on percutaneous techniques and he'll go through a very thorough evaluation and treatment plan for how to go about that so our learning objectives we want to define the key elements for the initial evaluation I demonstrate the radiology and pelvic fractures be able to classify the fractures and understand how that affects treatment and then to be able to go through the techniques and indications of a percutaneous fixation here are our speakers again today as you heard much mark Adams dr. Heinz critter dr. chip route all of them are experts in treatment of pelvic fractures and we'll give you some incredibly good information in today's talk your microphones have all been zoomed again if you have questions put it under the Q&A tab not the chat tab and the moderators will try to answer your questions in that same area and some of them will be brought through as live questions so with that I'd like to introduce our first speaker will be dr. mark Adams from Rutgers University and University Hospital there he is will be speaking to us on the radio bed radiographic evaluation and classification of pelvic ring injuries so pelvis radiographic evaluation and classification I'm finished with this talk I would like to be able to describe what makes for quality tell the grader graphs on these radiographs I would like you to be able to visualize the bony structure they represent and describe the relationships between certain bony structures and the adjacent neurovascular structures there are relevant associated injuries and issues that are apparent on imaging that I would like you to identify lastly I would like you to be able to use the classifications to describe the injury accurately and as a result guide treatment and predict associated injuries the experts that evaluate money to determine whether or not it is counterfeit when they are in school they study the intricate details of the real thing not to think similarly we will study normal Anatomy to start so that the issues that arise from disrupted Anatomy become more obvious when we look at this we want to be able to picture the skeleton it represents but also this in our mind be able to picture the muscular and neurologic Anatomy and their relationship with the bone as well as the vascular anatomy of the pelvis understanding these relationships helps us anticipate injuries to these structures when we examine a radiograph of an injured pelvis the AP pelvis is generated with the patient in the supine position the beam naturally is perpendicular to the patient a well centered AP pelvis anteriorly consists of symmetric operator Femina symmetric tear drops impossible a Simpson that is midline with respect to the sacrum most eerily the spinous processes of the sacrum should be midline the parameter should be symmetric and if there is no scoliosis and the patient is lying flat the similar lumbar spine features our helper are helpful to in the setting of a covering injury with deformity one needs to key in on the posterior structures to know whether or not the silk film is well centered it is difficult to characterize deformity without a well centered image the outlet view is an AP of the sacrum seeing it on fuss as such the foramina are well visualized and circular in appearance many of the same characteristics of a well centered AP pelvis are also applied to the outlet let's notice the intimate relationship between the l5 nerve root and the sacral Eila the s-1 nerve root is also visible coursing out laterally from its frame the internal iliac and its branches are also in close proximity to the lateral sacral Ayla and the median sacral artery is adjacent to the sacral bodies in the midline more anteriorly the external iliac courses over the anterior pelvic ring just medial to that iliotibial eminence the Inlet view is relatively orthogonal to the outlet viewing the sacral body stacked one on top of the other and needs to be well centered and symmetric appearing sacrum once again we see the intimate relationship between the lumbosacral neurologic plexus and the anterior sacrum as well as the plexus created by the internal iliac branches and the external iliac descending by the ilium continual eminence again naturally there is the corresponding venous network here as well it is important to distinguish the dysmorphic sacrum for the normal sacrum and review some of the do graphic features of dismorphism the bottom line creating this distinction is that a trans sacral screw is possible in the normal sacrum but not in the dysmorphic you'll notice that the dysmorphic sacrum has this acute Aylor slope when compared to the normal sacrum furthermore the upper sacral segments is not as recessed in the pelvis on the inlet view we also see a difference at the sacral Leila radio graphically there is a cortical indentation of the same anterior Eila on the inlet radiographic view which is represented with these arrows to further understand this acute Aylor slope we're going to look at the lateral note equality pelvic lateral has overlapping greater sciatic notches and matching iliac cortical densities this line maduk marks the iliac cortical density for the osseous fixation pathway and neural tunnel of the first sacral segments of the normal pelvis have marked them here for the osseous fixation pathway in neural tunnel for the first sacral segments in the dysmorphic pelvis I have marked them here for the osseous fixation pathway please note that this does not represent a calm of bone that runs uninterrupted from one ileum to the other like the osseous fixation pathway in the normal pelvis I just outlined rather this pathway is oblique as we have seen on the inlet and outlet views so far furthermore this osseous fixation pathway in the dysmorphic in the dysmorphic sacrum cannot run uninterrupted from one ileum to the other as the majority of this oblique osseous fixation pathway in the dysmorphic pelvis is cranial - that iliac cortical density in other words the acute anus slope does not correlate with the iliac cortical density however in the normal pelvis Aylor slope corresponds with the iliac cortical dance when we look at the axial CT images of both types of pelvis we can see that there is an uninterrupted quarter of bone in the normal pelvis that a size born with this same quarter of bone does not exist in the dysmorphic pelvis however the posterior line violates the neural tunnels that 1st April segment this is why a safe trans sacral screw is not possible that dysmorphic pelvis furthermore with a more anterior starting point the neurovascular structures answers to the sacral Eila that we just reviewed would be put at risk with a trans sacral screw chip route we'll further review how to safely execute ilio sacral screws later in this session now our natural tendency is to dive into the particulars of the skeletal injury for our patient but before we do that our patient's imaging provides a real opportunity to learn about our patient we're going to go through a few examples just to illustrate this point the soft tissue windows setting on the CT scan can be very helpful and I encourage you to use it in this example not only would this large fibroid complicate work about the anterior pelvic ring but this large mirela level a has implications for work about the poster ring sometimes our pelvic ring injuries controlling pregnant now on this example are lies you know may be drawn to those cam lesions bilaterally but if you know this patient has staples and those indicate that he had a previous laparoscopic hernia repair with mesh conversely this patient has bowel in a scrotum fatty atrophy about the bilateral gluteus maximus and the redundant bible skin common in malnourished patients this patient has a right sacral fracture and it is associated with significant osteopenia in the bilateral sacral Aylor furthermore there are calcifications in our arteries believe it or not this patient is a 25 year old which is diabetic and based on what we see here physiologically she would be comparable to a geriatric patient in this example we see the abdominal wall attaching nicely to the ileum but on this side see a traumatic herniation here we see a swollen left rectus muscle a bladder full contrast and there's extravasation on the left in extravasation inferiorly as well they're just a few examples but by getting to know our patient in this way we can anticipate problems early they have comprehensive plans as a result now there are three classifications in dealing with the pelvis the tile ATO to me AO OTA and the young and Burgess these classifications approach the injury from different perspectives by combining what we learn from each of them we can engage a patient's injury radiograph thoughtfully and more completely they will help us describe the injury organize our thoughts and guide treatment the tile classification approaches the pelvic ring from the perspective of stability breaks down into three categories stable rings vertically stable but rotationally unstable and both rotationally and vertically unstable in terms of guiding treatment patients with unstable pelvic rings are indicated for surgery and O's with stable pelvic rings or not classification by jung and Burgess is based on the presumed mechanism of injury from this we were able to predict associated injuries and resuscitation requirements the APC injury is a volume expanding injury to the pelvis tearing that vasculature that we reviewed earlier it can have significant bleeding as a result hans-peter will go into depth on this next the lateral compression injuries are associated with head injuries now the OTA AO classification takes a more anatomic approach to the pelvic ring injury but also include reference to the type of instability pattern like in the tile classification and labeling examples with the corresponding category in the young and Burgess classification a types have an intact posterior arch B types have an incomplete disruption to post your arch and C types are complete listen there is an increasing amount of instability through the class education this classification also includes a description of the deformity produced which helps guide treatment whatever the deformity is it needs to be reversed in order to obtain a reduction increasing amounts of instability require increasingly durable fixation constructs to maintain the reduction starting with our incomplete injuries this injury is limited to the symphysis and is rotationally stable as a result this would be consistent with in young emerges APC one where the injury extends to the sacroiliac joint hinging on the posterior ligaments and the Hemi pelvis is unstable and external rotation this is consistent with an APC to this sacral fracture is anterior and incomplete accompanied by an answering injury this category is rotationally stable and would correspond with an LC one here we have an increasing amount of injury to the sacrum on the bottom injury on the bottom image creating instability although this fracture the ilium illustrated is technically complete it is classified as a B due to the presumed rotational nature of the injury naturally this Hemi pelvis will become vertically unstable as well due to unopposed muscular forces there are bilateral versions of these incomplete posterior ring injuries as well that are in the beat category the C types our our complete injuries are more severe injuries in the same and atomic locations with increasing amounts of instability and cranial displacement of the injured Hemi pelvis this complete injury to the left SI joint with the symphysis disruption is consistent with an AP c3 and this complete cranially displays sacral fracture corresponds with a vertical shear also in the C category our bilateral injuries with one side complete and the other incomplete as well as bilateral with both sides complete now let's apply these classifications here the anatomic sites of injury are to the symphysis and left sacroiliac joint it is unilateral incomplete unstable and external rotation and has no vertical instability for treatment an internal rotation force is necessary as a reduction maneuver to reverse this deformity as this is an APC to the patient is at risk for bleeding when we contrast this to the previous patient we see a major difference at the SI joint it is cranially displaced which is obvious when we compare to the other side which shows the edge of the posterior ilium caudal to the sacral foramen of the second sacral segments this means that the injury is complete and that would be consistent with an APC 3 time for treatment not only does this Hemi pelvis need internal rotation for a reduction but it needs to be manipulated in a caudal direction as there is no posterior ligamentous integrity it would likely require a more substantial fixation construct to maintain the reduction than the previous patient with an incomplete injury just to comment on the limits of our classifications here is this patient's right Hemi pelvis now although it is true that this is a complete injury through the symphysis and at side joint to characterize this as an APC 3 would be inadequate to say the least this patient has unilateral injuries to the left sacrum in Perris m-seal ramus which are incomplete with internal rotation of the left hand compass discernment of instability in this injury pattern that warrants operative treatment will be discussed in an upcoming lecture this is in the LC category and these patients are at higher risk for head injuries we see an increasing amount of displacement deformity and instability in this patient there was t-bone creating this lateral compression injury this is a complete injury to the sacrum that is certainly unstable in internal rotation when we look at the outlet view however we see cranial displacement as well due to the unopposed pull of the iliopsoas therefore this patients Hemi pelvis needs to be manipulated in a caudal direction and externally rotated force to reverse this deformity and obtain a reduction so both a caudal manipulation and external rotation conversely this patient jumped off a three-story building and has bilateral calcaneus fractures in addition to this pelvic ring injury this is consistent with a vertical shear mechanism and we see significant cranial displacement of the right Hemi penis through the complete unilateral right sacral fracture the l5 nerve was injured as a result which is understandable given its intimate relationship with the bone traction will be necessary to correct this cranial displacement so in summary we discussed normal skeletal and neurovascular anatomy in the pelvis and correspond to this to a radiographs we defined what makes for good views of the pelvis we went through the comparison of normal and dysmorphic sacrum there are other relevant associated issues and injuries that can be anticipated on imaging as we discussed we then review the three classifications from their different perspectives and apply these classifications to several patient examples this helped us describe the injuries organize our thoughts predict associated injuries in issues and also directed us toward the treatment right Thank You Marc that's a that's a great review of the radiology of the pelvis that'll be a great lead-in and great foundation for the remainder of the course as we all know that some of the difficulty when we talk about instability is deciding what's unstable we're going to have some good talks on indications chip will cover some of those for the percutaneous techniques and then Brett Chris next Saturday we'll have a talk on indications for operative treatment of pelvic fractures which will go through a lot of a lot of what you've built the foundation for in your talk there so Sunnybrook Hospital has been one of the mainstays of pelvic education and pelvic fracture treatment for many many years as the home of Marvin tile it's where I took my very first public and ask to have your fracture course I think for about thirty years ago when dr. tile was in his prime taking care of television asked a pure fracture so with that our next speaker is dr. hans crete ER it was served as the division chief of orthopedic trauma at Sunnybrook Hospital and at the University of Toronto it has a very vast experience with treatment of injuries around the pelvis and acetabulum and it's going to talk to us about the emergency treatment and and hemorrhage control for pelvic ring injuries so Hans thank you very much thank you Steve and greetings to colleagues that I see have signed on from across the ocean good afternoon and good evening to those of you who are joining us from across the way so what I've been asked to do is to talk about the essentials of the initial management and at the end of this talk I'm hoping that you'll be able to understand your role as a trauma surgeon an orthopaedic trauma surgeon and managing a trauma patient as part of a team in to perform an emergency assessment of the pelvic ring in to control hemorrhage we're not going to talk about definitive fixation that's going to be later on and chip we'll start that after this talk and to stabilize the pelvis provisionally and this is all aimed at the early intervention that can hopefully save a life so looking at this patient who is a 47 year old crushed in an industrial accident you can see that pelvic trauma is often extremely high-energy and over the majority of patients who died as a result of blunt trauma had a pelvic ring injury and the early deaths are due to hemorrhage and the later deaths of course organ failure and sepsis and what can we do to mitigate this is the substance of the talk that I'm giving right now and just to start things off let's start with a little simpler case just to organize our our algorithms and our thoughts so here's the 37 year old she's involved in a motorcycle crash and she's hypotensive and you know what's our role in managing this patient well our role is very simple it's to look for pelvic bleeding and when we find it to deal with it and so just have a look at that and in your own mind think of what you think this patient is bleeding from in terms of the pelvis and how you would mitigate that and we'll start how to look for bleeding well some of you may have thought about looking for external bleeding but many of you would have thought well I'm going to put a sheet on and I'm going to maybe put an emergency X fix on or whatever but don't forget to look for bleeding externally bleeding externally has to be sought sometimes there's blood all over the place from various other injuries look for open wounds in the perineum the rectum the vagina and don't forget to log-roll the patient at some point and look for bleeding posterior and although this wound right now looks fairly innocuous it's just a matter of a clot letting go before it turns into this so when you see an open wound pack that wound to stop any bleeding this ongoing or that may happen as a clot that sort of tentative there might dissolve and let go of course internal bleeding is what we generally think about when we look at a pelvis that's open like this this is an APC type of injury and if it's an open pelvis it really can't contain the blood it there's no tamponade effect because it just keeps expanding and you can hide a lot of bleeding and a pelvis that looks like this so the formula for a sphere is 4/3 PI R cubed and four cylinders R squared H as the as the radius of this pelvis increases you get the square of the amount of blood that can be held in there you've seen a a slight similar to this from Jason for mark four and you can imagine that if there's a fracture anywhere in that pelvic ring and if that pelvic ring is moving around it's going to bleed and have another look at this patient of ours and you can imagine how much disruption of those vasculature of that vasculature there is and one of the things that happens when you've got a moving pelvis is it can't form a clot things are moving around you can't form a clot and it's going to continue to bleed and just remember that every single pelvis that has an injury is going to bleed to some extent the majority are going to be venous but 10% of cases where there's a major contribution from the pelvis to shock is going to be arterial and these need to be managed maybe a little bit differently and we'll get back to this as a further on on this top so how do we identify a pelvis that's at risk of major venous bleeding or arterial bleeding well it starts with a physical exam you've seen some x-rays here but the basis is the physical examination so here's a patient and and of course what we're looking at here as part of the team is the SI part of covering of trauma resuscitation in terms of looking for the pelvis that's at risk for internal bleeding after somebody else hopefully has dealt with the airway and the breathing and put in the chest tube and so on so here's a patient that looks like in Canada at least we've got frogs that traverse the highways and when they get run over they look like this and this patient has a very abnormal position and that's either due to a pelvic ring injury that's opened up or the proximal femur x' or something else is fractured but if you see an abnormal position like this that's a pelvis at risk if the pelvis moves when you examine it then that's a pelvis that's at risk for bleeding because again you're going to have disruption of those vascular structures and if you've got hematomas in the flank or in the perineum again an indication that the soft tissues are torn and as part of a pelvic ring injury that this injury is bleeding so a pelvic ring that's moving and a patient that's in shock that's an emergency and you don't have to do anything fancy you can just tie the knees together and that's going to help if the patient has a short leg or if on a gentle manipulation you feel that the the fracture is vertically unstable as well well you can apply traction as well now I we don't advocate doing an aggressive examination to see if that pelvis moves vertically because again you're going to disrupt blood clots and potentially nerve roots as well but these are the principles if there's vertical movement you might want to add traction most of you probably use some sort of commercial binder and the old folks like me prefer the sheets but they're not really so much available and the paramedics put these on the field so we have to deal with them but if you are one of those places that uses sheets this is a slide from chip route and you can see the nice reduction that you're able to get and the beauty of this is that you can cut holes in for your arteriogram or your angiogram if needed you can cut holes into this reduced pelvic sheet and put in Ilia sacral screws or whatever you need and the general surgeons can usually cut into the top of it and do a laparotomy but again it's almost at least in our centre historical because everybody comes in with a binder so what's next we've recognized the pelvis at risk at least for venous bleeding we'll talk about our tool and minute and we packed open wounds we've immobilized a pelvis that moves with either a sheet or binder or traction or combination so what's next well continual reassessment is key to managing a trauma patient and the next stage probably involves doing some imaging so far all we've done as a physical exam and we can do this in minutes in the emergency department so you've seen a talk from from mark Nixon talked about radiology and we certainly won't go through that but these are the images that we usually want to get when we're planning for the next stage and one of the things that I think is important to do especially for the younger learners is look at this pelvis and just formulate in your mind what's going on and then bare with me look at the spinous processes and you know sort of think about where the rotation of that pelvis has gone and you need to explain why this area looks widened here when you know this and this look widened here so having that symmetry and trying to understand why things look the way they do in the front can often lead you to other injuries as in a simple pubic ramus fracture high fever grimace fracture on the left side in this case here's a patient who has an AP pelvis and it looks pretty dramatic but the way she comes in with the paramedics bringing her in the binder it looks like this so often you can see if you if you have the luxury of seeing an injury film in an outside Hospital you can see more of the amount of displacement and the severity of the injury then you may appreciate once the binder or the sheet is in place you've seen these inlet/outlet views and this is the inlet view and what to look for the outlet view and the CT scan is really important if you're going to do any kind of surgical planning and you look at this new you might want to know well if you're going to do a resuscitation screw which we'll talk about in a minute or an urgent fixation with a c-clamp at the back well is the other joint open or is the fracture such that you couldn't possibly safely put a seat clamp or a resuscitation screw without reducing that fracture so these are important when you're doing the next steps of treatment beyond a sheet and beyond traction so what are some of those options well here's a case of Dave Stephens that he put the c-clamp on while the patient was having a laparotomy and this stabilized the pelvis so that the general surgeons could deal with it so this is one example the c-clamp of urgent stabilization beyond a binder in traction this is a picture of chipper out a very nice picture showing the cut in the sheets and putting a so-called resuscitation screw in that can be done with the sheet holding the pelvis and then getting a final reduction with the leg screw as you see there so these are things that can be done urgently if you have the expertise and if you have the equipment available but you know this patient could have been kept in the sheet potentially as well so here's my patient and you can see there the reduction pushing the left side are pulling the left side down and pushing the right side up and putting an external fixator on through the anterior inferior iliac spines and applying traction on the left side and you can see the tension sutures there from the laparotomy with the patient head so what are the corridors or what types of external fixation can we do well we like the anterior inferior iliac spine corridor or the super acetabular corridor it's a little bit by mechanically better than the iliac wing and it controls the pelvis at least in the rotational pelvic deformity in the plane of displacement that is if it's open an APC type of injury then it is really in the plane of pulling that together and closing it down and here the fluoroscopic views the obturator outlet for you and with a displaced pelvis it's difficult because the iliac we may be open so again if you've got a sheet or something that holds the pelvis reduced it's a little bit easier to get the pin in the right place this is a superacid tabata corridor but there's nothing wrong with aiming the pin into the static buttress or into the area of the sciatic notch as long as you don't go too far so the dangerous here are if you go to lateral the lateral femoral cutaneous nerve sensory nerve the hip joint if you go to loan it's easier to go to low than you might think and if you're aiming at the greater sciatic notch which is fine just make sure you don't over insert the pin and the iliac oblique view is this helpful for for that if you use the gluteus medius pillar pins you have to make sure you're in the bone and in the dense part of the bone and it's easier than you think to go out the side and of course if you're pulling an APC type of pelvis together that's not going to be very helpful it's just simply going to break out so if you are going to air on an APC injury and you're using the gluteus medius piller pins you might want to err on bringing it to the inner table so that it's not going to break out as you reduce that pelvis what else can we do well when when sorry when should we consider such emergency fixation or should we just leave the patient and the sheep in traction initially well for for us it's often if the general surgeons are planning a laparotomy they don't like the binder they don't like the sheets so we tend to put on a seat clamp or an external fixator or something like that and we can do that fairly quickly while they're scrubbing to get ready to do the abdomen it's better to do it before in most cases because that way the general surgeons have something stable to work with but it requires some communication with your general surgical trauma team and if you're transporting the patient if you're in a community setting and you're going to transport that patient maybe it's reasonable to put on a more a frame or some more provisional fixation rather than just a sheet but you can certainly transport a patient in a sheet to another institution if needed and you just have to keep a bit of an eye on the skin well what if you've done all that you've done the laparotomy you put on the seat clamp you've stabilized the pelvis and the patient is still in shock and the general surgeons tell you there's a lot of retroperitoneal bleeding and you know what what's the next step well if you've gone through this very simple algorithm if the patient move if the ring moves if the pelvic ring moves you immobilize it you stop it from moving well if you've done that then it doesn't move anymore and you might be in one of these situations where it's an arterial bleed and we'll talk a little bit about some of the options to deal with arterial bleeds but one of the most common historically has been an angiography and embolization of said arterial bleed so here's the patient that I took pictures of when I was a resident so mark varus was the fellow and Marvin towel was the staff on call and this patient came in and had a massive bleed as you can see on this this isn't a CT angiogram this is just an old-fashioned angiogram and what was remarkable to me as a resident at the time was the butt hematoma the butt Okimoto mom was expanding before our very eyes and this was a branch of the superior gluteal artery so if you see an expanding but Hakeem automa that's a sign of some fairly significant serious bleeding this is the same patient and you can see the bladder is displaced by that blood on the sister urethra Graham and again that's a sign of fairly significant bleeding in the other side of the Hemi pelvis there and we've talked about you know the buttock and pernil hematoma but this is a different patient and Dave Stevens written about this and others if you see a blush on a CT angiogram that's usually a sign of some fairly significant arterial bleeding and of course we're all we're talking here the the most significant hint that you might have an arterial bleed is if you've got a non responder to immobilizing the pelvis with a sheet or traction or both well one of the things if you're in the operating room for example already and general surgeons notice retroperitoneal bleeding one of the options is pelvic packing and we used to do some of this here at Sunnybrook and in Denver this is a very popular thing and it's somewhat institution dependent but pelvic packing is putting those large lap sponges in and really trying to include the venous but perhaps also any arterial bleeding that there might be which means that you're really packing that area quite tightly that retroperitoneal space another option is ribeaux uh and that includes all of the arteries below where you've got the balloon inflated except for the collateral flow very effective way of eliminating the the bleeding but again institution dependent so final thoughts on the emergency management of the pelvic ring that's at risk as it's a team responsibility to warm the patient and give them fluids you saw earlier on that patient with the externally rotated hips you know that patient needs to be covered they need to be warmed and given warm fluids and sometimes people forget in the trauma resuscitation frenzy your job as an orthopedic trauma surgeon is to pack open wounds bring the legs together tie it with a sheet apply traction if you think so and that can be done immediately just after doing a physical examination and then maybe after imaging you can do external fixation a resuscitation screw or some other sort of fixation and if there's arterial bleeding if there are positive signs such as we've talked about it or if it's a non responder then you've got your options of angiography and embolization maybe pelvic packing or Ebola again depending on your institution and the important thing is to keep reassessing that patient to make sure that they're improving and that you haven't sort of missed anything this is a patient that was hit by a subway train and and sometimes you you will just fail the paramedics are bringing in patients from the field now that are very very extremely injury and sometimes despite your best efforts you will fail but if you adhere to the principles that we've just talked about hopefully we'll save some lives that are savable thank you very much for your attention Thank You Hans that's a great talk I think you hit all the high points there that we need to discuss so I'm sure there be a lot of good questions to come out of that and we should have a few minutes at the end to try to address some of those that are commonly being asked our next speaker is dr. chip route dr. route it's been a good part of his career at Harborview Hospital in Seattle and has been for the last several years and UT Houston at Memorial Hermann Hospital chip has got incredibly large experience and insight into the treatment of pelvic ring injuries and acetabular fractures probably one of the largest experiences in the world he trained many of the faculty that you'll hear speak over the next little bit and really needs no introduction in this topic so the next talk will be dr. chip route it will speak to us on the indications and techniques for percutaneous fixation around the pelvis thank you mark I'd like to just welcome everyone and give you good greetings from Texas very hot down here and it's hot from temperature wise and we're we're covert hot as well and these are the patient of the people they're keeping me safe throughout all of this and I'm really grateful for for their help this is our orthopedic trauma crew my task today is to go through percutaneous fixation and we'll stick mostly to the posterior pelvis as a result of the time but I'm challenged by presenting to you the indications as well as the contraindications the osseous fixation pathways in a little bit more detail they've already been introduced to you and then I'd like to just go through some of the planning and some of the technical aspects of just taking care of a patient this patient actually to see before you in a fairly urgent manner when she wasn't doing so well I think you all understand that close reduction in percutaneous fixation was born out of just some of the problems that were published in the 80s from the earlier attempts at open reduction have been improved of course over the past decade or two but those things still threaten us we also realized that this was been a patient when I was a resident that would have been in the hospital for about four to six weeks in traction and then maybe a week or two in a body cast or a little bit I mean a month or two in a body cast and you can understand that maybe after about an hour and a half in the operating room as a result of the SI arm and some knowledge of osteology and a little bit of traction we can make some stab wounds put some screws in and on he goes about three days later Oh a big a big transformation of care came along with the knowledge of osteology and fluoroscopy and these techniques that we've learned over the past two thirty years along with the evolution of learning comes issues and perhaps you can see that this patients had their synthesis plated they've had some spine issues and you can see the the guide can going in for the only other sacral screw on the outlet view and then you can see on the inlet view that the guide pin has been applied but it may be the details of some of these things that we're going to go over in the next few minutes we'll alert you when we're through that this is not as safe as it looks and if you're really keen on what dr. mark adams introduced to you as just some of these osteological details that we see in the imaging how critical is maybe you wouldn't be be so surprised to know that the surgeon had an avoidable complication as a result of just not understanding the osteology though has a fairly significant complication to deal with so minor little details an understanding of the osteology hopefully when you finish the next 30 minutes you'll be a little bit more knowledgeable and also motivated to learn some more we do recognize the daunting nature of this and really it's just what win and how so let's start with the indications and then we'll ease on into the contraindications in reality you have to have the posterior ring and reduced and so it can be essentially any injury to the posterior ring a sacral fracture or sacroiliac injury a combination injury but we have to get a reduction and you can see in this situation the chances of getting this accurately reduced with a closed reduction are probably about zero and so we do still use open reduction and then use the percutaneous fixation sometimes it's as simple as just taking the circumferential rap and applying some traction this is a patient of mine from 1994 right after we had gotten cannulated screws and you could see that we were able to do a nice percutaneous job with two stab wounds on her to get her realigned and stabilized quite nicely so we can do sometimes very simple things to help our patients get reduced and then stabilized one of the things we learned very early on was that the sacroiliac joint injuries were very different from the sacral fractures and we realized that the pathology for an ileocecal screw was pretty small or not very lengthy for our sacroiliac injury but it's different from a standpoint of using the screw how it starts where it aims where it goes does it avoid the joint and which way should we insert it and start it and aim it as opposed to the sacral fracture pathology which is a little more medial and gives us a larger area of instability for the screw to gain purchase in and you can see the dotted line represents the now popular trans sacral screws that weren't really available until 2006 you may say well what was going on before 2006 there weren't screws that were made beyond 130 millimeters in length and so it took a long time for screws to be long enough for us to be able to use trans sacral fixation other indications are just any indicating disruption of the post your pelvic ring that can be reduced and put back sometimes we have to redo the ilium in order to just do the ileocecal screws and then it's not just for adults and elders it can be for children as well that's a three year old that took care of about six months ago who was inadvertently run over and you can see that she's three years old but she's got an open pelvic injury that's a fairly potentially catastrophic and you can see the the the problem that she had and so people say well you know do you have to use smaller screws those are three five screws in the ilium and 700 screws in her SI joint so we can put them back together a lot of people say well children really don't need this because they just they remodel so well but you can tell that to some of these patients like this nine-year-old who was also run over when she was five years old and this is how she's lived for the last four years and with the early open reduction and stable fixation this would have been a fair simple fix but at five years later this is a really difficult situation to negotiate it also happens in the resuscitation phase you've seen this already described to you and there's an example of a patient with some fairly severe injuries but despite the overall resuscitation not so good and then just just a patient that we put a hole in the sheets we can put some towels on and then we can become a part of this resuscitation effort where we can use in a direct adílio sacral screw for certain injuries in the back and as we insert the lag screw you can see we get a nice compressive reduction of the posterior pelvic green if you'll take your attention away from the injured right SI joint and look at the left SI joint you'll realize that it has some problems as well and if you were paying attention when we looked and back to the injury film you can see now in retrospect though both sacroiliac joint injuries have a fairly significant injury to them and then you can see that in the circumferential wrap the left side looks pretty good but then as soon as we compress if the left side reveals itself so we can go ahead and just do the same thing on the other side support the posterior ring and get a nice reduction interestingly usually when you do this these patients respond to this very well and within about five to ten minutes they usually start to plane out very well so this is a good technique and it's similar to using a c-clamp but it's just a more definitive measure some of our patients are we always hear those that this thing that but you're the patient is too sick for with the Phoenix T SFO to 6/4 of Phoenix but sometimes they're so sick they need orthopedics or their SST you know and so we'd like to do early percutaneous fixation and reduction of some of these fairly difficult injuries to help the patient have a stable pelvis and then just get an upright chest so that other injuries and poly trauma can be dealt with and so sometimes we can do simple maneuvers to manipulate the pelvis get a reduction then use percutaneous fixation and then finally just this stability issue I think we all have been taught that if you just close the book like you can see here in the upper right corner the sacroiliac joint looks like it's an incomplete injury should just be able to snap the symphysis back together plate the symphysis be okay but you can see in the operative views the symphysis has been plated but the SI joint forgot that it was supposed to be an incomplete injury in fact it's a complete injury so we have to be prepared to use the screws in the situation as well we also have soft tissue implications where we might want to really do an open reduction but it's probably not a smart thing to do and then we have at least in North America the the rampant obesity where when we have to use techniques to get the abdomen away from our planned operative field and sometimes it's only eight inches deep to the symphysis and maybe 20 inches deep to the SI joint and so we choose to do percutaneous of the posterior pelvic ring after doing the anterior ring open we also have patients with chronic instability oftentimes it's postpartum females you can see this patient has a residual distraction and chronic instability five years after having a child and we can do the Ilia sacral screws to help stabilize the posterior pelvic ring it happens in males as well this is a man that was injured when he played college baseball 330 years earlier and he has chronic pelvic instability as well with sacral iliac arthritis and so it's a good good situation for them and then we have patients that have unusual situations where they have these long spinal instrumentations they tend to break down their posterior ring sometimes like this patient had infections anteriorly end post early and once we can control the infections a little bit we can provide stability we can also use it for pathological conditions and not just just tumors but also other pathological condition this of course is a primary tumor and we can work with our colleagues in the oncology areas to sort of help provide stability for those we see the residual of cancer treatment and some of our prostate patients where they've had radiation that was a little bit less than directed if it's a little bit older radiation they get radiation necrosis and they can have you shake sacral fractures as a result of this and then we can see just sometimes the privilege of maturity as people age and continue to be active sometimes they'll have bone quality issues this lady just fell down three steps and you can see she's got a unstable why Quebec word we can just do percutaneous for that so the percutaneous is really nice for a lot of different things and then you can also remember that we'll have patience with acetabular injuries and we'll get real focused on the left acetabular injury but then we have to look in the posterior pelvic ring on the other side and we can see a complete disruption as well and usually if we get the acetabulum tidied up and the symphysis put back together we get a nice close reduction of the contralateral posterior pelvic ringing can we we can use ileocecal screws to stabilize that percutaneously I would say the contraindications are what we said earlier is when you can't really get the reduction right or your manipulation fails and so we see a lot of mal reduction as a result of people being a pretty bullheaded about just doing close reductions and so if you're close reductions not working or if the injury is not amenable and needs an open reduction then you have to do an open reduction you also see people with debris and their tunnels that needs to come out and then also there there are other indications where you just need an open reduction with a closed technique doesn't work we also want you to realize that just because this body of knowledge is not so new and the evolution has been going on for thirty years a lot of people are still struggling with this and so hopefully by the end of this situation you won't be one of the strugglers that has these wayward screws it cost them a lot of money sometimes it hurts the patients and it costs the doctors money you can see here just some of the randomness to ileocecal screws all done by people that are pretty experienced so I'm gonna I'm not able to access the Q&A right now and so hopefully that there are questions about evolution of learning or indications or contraindications you can send those through into the QA area and then if there's something that I need to get to or discuss it we can do it in the in the decompression area later later I'm going to switch gears and go from indications and contraindications to the O fps and Mark has already alluded to that and we're going to talk about the osseous fixation pathways and you know that on the pelvis there are osseous fixation pathways everywhere the problem is most of them are curved and we usually have straight screws so far and so what we want to try to do is to use a term we would like to straighten out these curved areas and this is sort of what we come up with when we look at the pelvic model and superimpose these osseous fixation pathways and the colored ones are the ones that we use the red the yellow the black the blue the white the green these are the ones that we use most commonly and so today we're just going to focus on the posterior pelvic ring or the ileocecal or one and when I first started doing this there was a lot of tension to the starting-point and where it was in relationship to the posterior Ridge on the lateral ilium the crista glooty and so we realized that pretty quickly that on just a single axial image you can see you can have a variety of starting points and they can all be very safe screws depending on where you aim them and where you stopped them but we see that the starting point is important but just like aim and direction and length they're all important everything is important simplistically if you just want to get a better handle on the osteology of the upper sacral segments it's pretty simple just to think about ellipsoids tunnels and cylinders and if you'll take some cylinders and if you have a kid maybe you've got some building blocks at your house if you're child plays with building blocks and you can stack some cylinders and then you can add some ellipsoid cubes on to them as well under the sides and imagine where the foramen are these tunnels would be that go back toward the spinal canal that allow the nerve roots to drape over the ellipsoids and through the tunnels and you can see that the nerve roots are going to go from central cranial and posterior when the spinal canal over the åland through the tunnels to a peripheral caudal anterior area and so sometimes it's just simplistically stacking cylinders adding on some ellipsoids putting in a tunnel and then you can understand this a little bit more if you turn it on its side you can see the the cylinders sort of look like the upper sacrum the ellipsoids have the look of the sacral ayla and then the orange tube shows the pathway of the s-1 nerve root where those nerve roots again going from central cranial and posterior to peripheral caudal and anterior usually if you look at little kids or young kids or adolescents they've got the best osteology for lateral sacral imaging and so if you want to see it better sometimes the kids have the the best look and you can see this child has a really nice set of osteology and we can add on our cylinder to one and we can stack one onto two and understand how those go and then we can superimpose the ellipsoids with a lor and then we can add in pull away and just look at this to try to understand where these tunnels go relative to where the ellipsoids are in the tunnel for one in the tunnel for two and the nerve root of l5 the nerve root through the one tunnel and the nerve root through the two tunnel and so we start to see things a little bit differently when we start to superimpose the geometrical figures on to them you can also sort of circle up the tunnel exit points the foramen we call it foramen but these are just nothing more than tunnel exit points and actually represent a chute rather than a circle when you look at the 3d modeling this is the you know I really would have given a lot of money or I would have given probably a finger in donations who have had 3d surface rendered images when I was first learning this I think y'all's generation is so lucky for so many reasons and I'm really jealous to the point of almost resentful that I don't I didn't have these three dimensional surface rendered images but all that sin confessing I'm gonna just say I'm very happy to still be able to partake in this and I hope you can see that when you start looking at this modeling you'll start to see a lot of the things that you really need to see and hopefully you'll look at them differently after we finish today I'd also start to alert you to thinking about what you're not seeing on the surface rendered images and remember we're talking about these tunnels and these pathways that go through the bone and then what we're trying to do is correlate it to what we see in the operating room and so one of the things that might help you is to go back and forth between plain film imaging and the like this is also an outlet image and you can see that we can start to see what we can see with the modeling see what we can see by knowing what the anatomy is and then looking at the imaging that we would see in the operating room and maybe identifying that there are tunnels and pathways and exit points to these tunnels for the upper and second sacral segments and maybe when we pull that away when we look at this you can see it and when we pull it away maybe you can see this little Lucent spike a cast a little bit better than you saw it 30 minutes ago mark got into the dismorphism and on the upper row here and the unblocked background you can see what we would call a normal osteology on the bottom row see this this upper sacral segments particularly on the far right if you look at the outlet image you'll be able to really get an alert as to the dismorphism off of the outlet images and if we go in that a little bit deeper you can see the two side-by-side and you can get a clue to these radiographic hallmarks that you'd know otis on an outlet view for dismorphism I'll just say this morphism doesn't mean a thing to anybody unless they're trying to stabilize a post your pelvic ring injury and get a screw into that conduit of bone safely so maybe a skeletal radiologist in some remote dark reading room is interested in dismorphism but in reality nobody really cares about dismorphism except us when we're trying to put screws in them safely and the patient's of course care that you know about it also but we can look at that outlet view on the right side and we can sort of see that one of the early clues that you can quickly identifies when the l5 s1 or the upper sacral lumbar transition disc is at the level of the iliac crest like you see in the disc more on the normal or what we call normal you can see it's recessed relative to the iliac crest we can also notice that there's a residual disc on the disc morphe usually reflecting a segmentation error or delay in segmentation and then we can see also the residual transverse process of that vertebra as we call them mammillary bodies or mammillary processes or some people call them just residual transverse process you can also see the acuity of Baelor slope and it goes from central cranial to peripheral on a lateral caudal and you can also see it goes from cranial posterior to caudal anterior and the acuity of the slope or the angular nature of the slope is much greater with the dysmorphic n that's going to impact our screws so much and then of course the exit points are misshapen they're not quite circular all the time for the dis morphs as they are for what we call the normals and if you look at the normals you can see that there's lots of different pathways as Mark showed you he's already shown you these pathways at the upper and the second sacral segments and a normal and then if you look at the dysmorphic changes a whole lot you can see especially in the upper sickle segment you can do obliques and trans sacral for the normal but at the disc more if you've got to really do oblique and again that's a caudal posterior stop to a cranial anterior endpoint if we go back to the normal you can see we can make the oblique screws in the upper sacral segments yellow or the pathways yellow we can make the trans sacral blue and we can make the orange at the second sacral segments where it is and you notice that orange and blue are anterior on the inlet view if you look in the upper right view there anterior and that anterior location especially caudally on the upper sacral segment is where the bone is that's why we put it there's where the bone is on the lateral view you can see that we can kind of confirm the safety of all of these implants as we put them in and you can see that the obliquity of the yellow or the upper sacral segments oblique pathway that's gonna be a little bit tough because a lot of you like the iliac cortical density to represent where the Eila is and in people who are non dysmorphic usually the iliac cortical density will give you a good reflection of where the Aylor slope is but it really depends on where you're looking at the point or the end of that screw if you look at this one where those screws are in being on the inlet view you see up the top right you see the yellow screws are ending in the vertebral body and just barely beyond the midline but you can understand that those keep it very safe and so that lateral look of a screw above the ICD and the lower right you see the screw tip for that pathway is above the ICD but again they're staying contained within the vertebral body if you get a little aggressive and you forget about these these limits remember there's an Eila on the other side and so that oblique look or that lateral look of the oblique screw it's gonna look the same for a screw that's safe like you see here focus on the lower right corner and you'll see that when we extrude through the contra la Leila the lateral is going to look the same if you look above now you'll see the inlet and the outlet views would look pretty safe to us even though the screw is superimposed in the operating room the screw is going to be superimposed on the bone if we forget that high anterior of the Aylor area has no bone we would not understand that our screw had extruded beyond the cortical limit on the left again the caudal anterior location within the osseous fixation pathway the upper sacral segments of a normal it's a caudal anterior location and you can look at this ellipsoid and understand that there is room and a lot of patients that's just a slight bit cranial and posterior to it but again the take off where the spinal canal enters into the nerve root tunnel that sometimes will impact that area so that's a little bit more of a risky screw I always tell people it's like putting a big fat guy in an elevator that blue screw that trans sacral screw in the lower anterior corner if you're filling up an elevator especially these days with social distancing you want the biggest guy in the farthest corner so that then you have room to put in others in the elevator it's the same thing for the trans sacral screw in the upper in the sacral sex in the second sacral segment we want to put the first screw low and anterior so we have room cranial and poster if we go right down the middle and try to optimize our safety then we don't and we're not going to have room for that second screw if we need it you can also go to the second sacral segment again the low anterior or the low interior area and the osseous fixation pathway is an ideal spot for it and again some patients like this patient would have room for a second screw at s2 as well again slightly cranial and a little posterior to the first one nice you can see it's marked there on the inlet and the outlet is the the beige or the white conduit one of the things that people get in trouble with is they see that white bar or that white tube superimposed on the tunnel of s1 on the outlet image so if you look at the top left image there that's an outlet view and you could see that if that white tube wasn't post yearly located within the ellipsoid of the Eila it would be in the nerve root so if it was anterior if that white tube was anteriorly located and you can look over to the inlet on the right and see that it's posterior if it was anterior it would not be safe it would be in the tunnel exit area of one and so I'll draw your attention to these tunnels now I'd really like you to sort of focus on what you're seeing with the radiology we see these four Raymond or we see these circular areas and I want to discounts for you that when we're looking at these circular areas we want to a little bit more specific and detailed about it because we want to think about the playground shoot that our kids come slow on out and we probably all enjoy doing this and come shooting out of but you can see the this the tube has a exit point but then there's a shoot that allows the child not to just fall onto the sawdust there and now the bone is just like that in the front of those sacral tunnel and don't you see the exit point is not just a circle it's a shoot and so it's just like the playground shoots that we we can see and so we want to think about that when we're doing our outlet imaging and we want to recognize the the spherical openings but we want to also realize that there shoots there so if we put that screw high in anterior it's not going to be safe at all it's gonna be in that chute and condemned that s one nerve root needs to be posterior like we show here like we talked about so this is all just the normal pathways and we we've gone through this I think enough so if you have questions please put them in and we'll get through those related to the osseous fixation pathways to the upper sacral and second sacral segments for then the non dismal I want to just amplify the dips more for a little bit more because it's so important and you saw that wayward screw earlier and we want to recognize on the outlet view and the lower left all of these radiographic markers of just more some dismorphism that we saw but in the operating room when the critical impacts is the yellow and the white arrows and I'll call your attention to the right side of the screen because the white arrows represent the Aylor or anterior cortical limit now the upper sacral segments the dysmorphic upper sacral segments and in the operating room we have to tilt the fluoroscopy on the inlet view appropriately to where we can see the entire cortical limit of the upper sacral segments the white arrows and we can distinguish them the entire cortical limit of the second sacral segments because we may want to put us through there as well and we want to see the yellow arrows representing the anterior cortical limit of the second sacral segments as well this is imaging that we can plan preoperatively based on the three-dimensional surface and volume rendered images that we have in front of us just like I'm doing right here so I can plan what views are going to give me the discrete osteo she limits that I need in order to keep me safe I know I've got to keep my screw behind the interquartile limit of s1 and s2 the upper and the second sacral segments and I realize I've got a direct the screws obliquely in order to accommodate that at the upper sacral segments so pay attention to the inlets when you're looking at the surface rendered images because they're going to help you get the appropriate Inlet tilt for s1 and s2 as you're doing these screws and they're gonna reveal to you these a l'heure anterior cortical limits so that you can keep your screws just behind these at these two different levels so when we look at the upper sacral segments we've got to do oblique screws caudal posterior to cranial anterior directed and we pretty much have to stop in the midline in order to be safe in the upper sacral segments of a disc morph in the second sacral segments you can see we can do trans sacral screws but again we've got a located away from the chute of the upper sacral segments we can also do oblique screws so the second sacral segments if we want to I'm not sure many people do that but from a technical aspect and it is Ostia logically possible it's just not probably something that people do too much I'm not sure I've ever done that screw of my whole life but I do know that it's possible if I ever would want to do something like that it's always nice to know stuff I guess know so again I just want to recap this dismorphism and I just I want to really alert you to going a little bit cranial and anterior and lurch it to that chute can't can't emphasize it enough so we've now hit the osseous fixation pathways hopefully you know about the normal and dist more for the outlet are though where we really get the identifier is radiographically to alert us to this and then those indentations recognizing the anterior limits that's so important on the inland adjusted and customized to fit and for the upper sacral segments screws remember we're going called with cranial and published your anterior in order to accommodate that and don't forget the chutes reductions I could spend we could go on reductions for four hours but we're not where it's going to say that for the poster pelvic ring and for ileocecal screws and lining up these tubes it's like a Venn diagram or lights like putting tubes together as well because we've got a the reduction back we got to put the bone fracture fragments back together or the sacroiliac joint back together in alignment so that we can make safer screws and we have a improved area for access of our screws and also for a better outcome of our patient and we can do whatever it takes if you're doing close reduction you need traction wrap up the knees like Hans just showed you external fixers Universal distractors clamping through open wounds circles are you know working portals in a sheet sometimes oblique frames a lot of different things work so to wrap up we're just gonna go through a planning and just sort of take the patient we showed you earlier with the fairly dramatically displaced left Hemi pelvis and we're gonna use all of our radiographic clues to help us go through this planning and so you can see our patient does she's a 38 year old female she's recurving a recovering narcotic addict she's in the backseat of a car she's in a rollover motor vehicle accident she wasn't tossed out but probably wasn't belted and she's got some injuries and you can see a left sacroiliac injury that's fairly complicated and displaced bilateral pubic ramus fractures and I would say a fairly significant deformity and if we look at her or volume rendered views we can get an idea of the amount of displacement that she shows when she's in her circumferential wrap so the wrapped her pelvic rap is really accentuated her deformity and we can see this pretty dramatically on the Inlet view and you can take things away if that helps you you can superimpose the surface rendered images on the volume rendered images and adjust the tilt so you can see and maybe some of you have noticed that she has a left-sided asymmetrical dismorphism she had a segmentation error that was mostly on the left side and then we can also take these 3-dimensional these surface rendered images and we can correlate in the operating room what we're gonna see and we can magnify these and even superimpose these in our preoperative planning so that we can understand when we're looking in the operating room I'd like you to be able to see this surface rendered image in your brain when you're looking at these fluoroscopy views and then things become a little bit clearer same thing with the volume rendered outlet you can see here a Hemi dismorphism of the upper segment I don't even know that's a you know I don't know what you'd call it it doesn't matter to me that's just a place we're probably not going to put a screw is what I would call it but you can see it now and you can see some of the radiographic markers on the outlet but this that next segment what we would call the normal sacral segments we can see pretty well and realize when you're looking at the outlet view in the operating room that yellow bar represents the cranial limit of the Eila but that's way posterior it doesn't really give you any indication about the Aylor slope especially from posterior to anterior much less from central to peripheral so realize what you're looking at are these radiographic lines or these densities that occur and we're trying to make this thing 3-dimensional in our brain you can also use these surface rendered image it is like you see on the right to sort of ghost into what you're planning for the operating room as well and we'd like you again to start seeing these when you're looking at this in the operating room it'll help you so much if you can see that when you're in the operating room looking at that so in planning the axial images become really critical as well because the axial images are going to give you a lot of information like dr. Adams has gone over with you you can see the injury sites in the front down the back you can see whether there's going to be an opportunity for a trend sacral sprue you can see and measure with it the PAX machine the length I you know when we had clean films there was no way to do this type of planning but we can know if we have screws that are long enough to accommodate the links should we be able to get that left sided post your pelvic ring reduced we can also see how the width or the breadth of this conduit at least on their single axial image so we know that if we can put a seven millimeter screw in that or how many seven millimeter screws we can fit into that interval we also can plan on the normal side if there's a contralateral normal side we can plan maybe the oblique pathway if we want to it because the normal side was is reduced assuming it's symmetrical and you can use your eyeballs there to see that that left side the injured side that conduit a bone for the olio sacral screw would be a little wider or you'd have a even greater safety on the injured side and then you're gonna have here and you can again measure say well gonna be about an 80 millimeter screw and I've got 16 millimeters if I go oblique as opposed to the 11 millimeters that I had if I went trans sacral so when we go trans sacral we complicate things by narrow narrowing those ellipsoids of availability or that osseous fixation pathway and then when we go oblique we improve the safety because it gives us a wider area to go so a lot of people like oblique screws because they're a safer screw it's a wider conduit of bone to hit a lot of people think about the these osseous fixation pathways as our glasses where the lateral ilium is the base of the hourglass and the waist of the hourglass is where the tunnel and the l5 nerve root are and then the other part of the hourglass is the other base is where the vertebral body is and so you can think about it however you want that gives you the ability to sort of see it in your brain we also can plan for the second sacral segments but in this patient you can see if we don't get a reduction we got no action going on here we're gonna have a screw that doesn't even get in the unstable part so we've got to get a reduction and we can see that it's also much narrower in its breadth than it the the upper sacral segments and then we also have to realize that we're much more caudally located and closer to the greater notch and so we have to start paying attention to where the gluteal trunk is when we're in the upper sacral segments usually we're up in the branches of the gluteal tree the the trunk is arbor eyes dan when we're down here by the greater notch we're putting the gluteal trunk at risk so I would also tell you that you and your x-ray tech can plan even things as the oblique WA t the lateral cortical surface of where the screw is gonna land and where the screw is going to exit if you do a trans sacral screw and that amount of obliquity may vary depending upon which side you're on and how much reduction you get but you can plan for this and you can cite it and see what that lateral cortical surface looks like so you can get a good image I like the x-ray techs to also just look at the sagittal imaging so they know what kind of tilt they're gonna need in order to stack the cranial two or the upper and second sacral segments not always are they like a bamboo pole sometimes they've got arthritis at the l5 s1 just it changes things but you can see we've just got a supine patient here up on a bump in traction on the left and then we're just sort of getting our x-ray the way we want to super so we can reliably go there the tech can mark the machine mark the floor and then just go right back and forth between the inlet and the outlet again suit from imposing the upper symphysis on the s1 area so s2 area so we could see the s1 tunnel exit point and if you look this is a non orthogonal system and so you can realize that when you make a an anterior move like that arrow shows here on the inlet view you're gonna make an inadvertent caudal move on the outlet view it's always best if these are completely by planar orthogonal but they're not always that way so we have to adjust dr. graves wrote a paper about that and again you can do this cruise prone or supine it doesn't matter to me you can just plan your inlet and your outlet tilt based on whatever position it is that you like to put the patient in and then finally you can take the sagittal image and you can put the cursor in the conduit of bone let's just say that when we put it right here in this caudal anterior upper sacral segments area and then we can just scroll from side to side as we go and see if that trans sacral screw is even possible in that conduit same thing for the cranial posterior one and then the second sacral segments you can see that ellipsoid gets a little tight right there and this is looking just off of the the midline area this is looking out where the tunnels are occurring you can see the one in two tunnels occurring in that area anyway lots of planning can happen off of the sagittal by just scrolling on the on the machine so we come up with a plan we're going to get a reduction of some sort and we'd laugh like to use a low anterior yellow trans sacral screw at upper sickle segment we'd like to use a the white one a second one that's a little bit more cranial and posterior within the safest his fixation pathway the upper cycle segment we probably are gonna need an open reduction of the back and the front somehow that would be our ideal is to really make this thing as perfect as possible and that would be our goal and we can see that's our incision we plan for the front and then we'll decide how we're going to get to the back and we may want to go to the second sacral segments if we can get a reduction only probably missed as a patient doesn't read our plan and our Ostia logical or fluoroscopic plans may not coincide with what's going on and this patient has an extra peritoneal and intraperitoneal bladder injury and so she's going to get along midline laparotomy sort of in an urgent way and then we to meet her this way they're gonna say it's Saturday at 7 a.m. can you please come to 28 and as I walk in the trauma surgeon says she's kind of sick if you're gonna do something you know to be really good for a pelvis but don't do too much well this kind of hurts me because now I'm limited I realized she's got an art line and her groin she's got a long venous line and her groin as well she's lost some blood as a result of laparotomy and I've been presented with a fairly I would say not a critically ill patient but are not well patient so we're gonna stay with a supine we're gonna put her in some traction put her up on the bump this is just some folded blankets that we put under the sacrum to elevate them off and keep them balanced to where they're not teeter-tottering it's got to be wide enough to where it keeps them from teetering it's got to be long enough to where it sort of supports their sacrum and there their entire sacrum in their lumbar spine works out just fine then we can square them up with a prep and drape we can prep and drape both sides and then we can sit down and do the surgery that we want to do assuming we can get the reduction our landmarks remember we stacked the upper sacral segments and we already planned this on the sagittal z-- we've adjusted like dr. Crider has taught us to make sure we get down the midline and make sure we've got the SI arm rotated the patient rotated right and now we can sort of work on correcting the deformity and sometimes we can just add traction and when we add traction we can restore this arc and it may not be always exactly the way we want to but we also have to realize the white stripe realize rec represents the intrusion of the articular area of the SI joint as well and so that's a little bit of a false distractor for us but this art is improved as a result of just putting the patient in 10 pounds or 15 pounds of traction and so you can see we've adjusted this she's well enough for us to do something but not much and so we're going to assess our symmetry on the outlet like dr. Cretors already taught us the arc of congruity in the front is much better than what we had earlier and we're gonna proceed with our ilio sacral screw we're gonna see those tunnel exit points and remember their chutes we've planned out where it needs to go we see the limits to where we are with this little spike cast want to be in front of that and above that s1 tunnel below l5 we've already gone below l5 because we're low and anterior again caudal and anterior this safe spot for putting the first guy in the elevator you may say well I'd like to have an bleep screw first to do and improve reduction if I do an oblique screw first I might get a better reduction if I sort of start at posterior and go caudal to cranial and low to high I could I could do that and but I'm worried that it I want to get that trans sacral fixation and maybe I'm gonna have a crash I'd rather use a trans sacral screw and so you may want to sort out your planning how you're gonna orient the screws and what your sequencing is going to be so if you want to do an oblique screw first in order to help with their reduction this is going to be its pathway then you can add in the trans sacral screw and see where those screws cross and you can just mark it and you see it the screws would cross on the inlet view on the end of you the screws would have conflict right there on the right side of the mid mid body and then on the outlet view you see they would have conflict out here out in the Aylor area so we know that the screws can be done in sequence and without interfering one another as long as we position them as we plan we can't make a real precise plan and then go rogue in the operating room and not be precise because then we're gonna have trouble with our implants so the plan has to be precise and then the execution of the plan has to be precise as well so we opted to just do a trans sacral screw as a result of situation we were in we do the inlet we do the outlet you can see in the lateral allows us to see we're not as anterior as we might have thought in the ellipsoid and then we proceed with our Inlet outlets to follow across and we go through this conduit of bone just like we plan that's the yellow dot that we plan preoperatively in the upper sacral segments the caudal anterior area and then we realize when we get to this point we may be wandering a little bit anteriorly and so we can recorrect with a guide pen guide can just like you do for a femur to help you recreate or redirect the drill where you'd like to go and then put the guide pin through now comes the time to put the guide pin in and we're going to put it through the pathway that we prepare but we're not gonna go drilling through the lateral cortex until the guide pin gets right next to it then we're gonna use this oblique view that we planned on and we're gonna see and feel the guide pin hit it and then we're gonna see and feel the guide pin exit it and then we're gonna be able to have a real accurate depth assessment and for this patient we want to bit of compression so we have to do a little bit of fast math so maybe it measures 170 or 130 150 and we're gonna pull a centimeter and a half or two centimeters off so that when we put the lag screw in and use this oblique view to see exactly where the washer should land later before we start to tighten we want to make sure that we've got it to where the washer doesn't intrude we like washers because they help us improve the the force distribution and then we want to see if our math was right when we rolled on the other side want to make sure that we have the right length screw in this situation we do is an initial lag screw that you can see here and the lower anterior quadrant of the upper cycle segment we added in then a subsequent fully threaded screw in a more cranial posterior area of s1 that was safe and then we took the risk of the nine-millimeter conduit and put in the seven millimeter screw again anterior and within the safe area of the screw and so we're left with a fairly symmetrical pelvis not so good we're down the middle as far as the in the outlet goes and you can see that if we rotate the patient and get the greater sciatic notches off like you see the yellow arrow here we can look down the barrel of our screws that didn't really mean much it just means our screws are probably crooked and if we bring this greater sciatic notches back into alignment than our screws are a little bit crooked so for some reason people love taking pictures of their cannulated screws looking right down the hole in the screw and I don't know why especially when it's crooked like this but so be it anyway when we finish we want to make sure that we land the screws we don't intrude the screws once the screws intrude they lose their function sometimes like you see here the second screw in the upper sacral segment was a little close to the first washer so we didn't stack the washers or pancake the washers we just used it without a washer and we were careful in the landing it we go to figure out what to do in the front and you can see the laparotomy is quite low and then we stressed if the pelvis in the front and she has not much movement we can convert add a frame duo RAF whatever it is that you would choose to do you can see if the result we've got a ring reduction that looks like this we've corrected or deformity on the outlet and then if you look at her axials you can see how on the left is her injury CT at the s1 and at the quadrille service and you can see this matriz been somewhat restored and then the poster ring is a mess as a result of a lot of things she's not quite perfectly reduced and of course she's got the inter sacral crush that you see and then she lived happily ever after except she's had three separate follow-up pelvic CT scans over the last seven years dissipation did seven years ago and she's had three subsequent pelvic CTS for abdominal pain for pelvic inflammatory disease so I've had the ability to follow her on post-operative CT scans for a variety of other ailments that she has that are non orthopedics so I'm gonna stop and I appreciate y'all's attention and I appreciate y'all being a part of this there's there's just um again today we've given you the drip the tip of the iceberg of knowledge regarding these implants and this technique but hopefully you've got some idea of the indications and contraindications I would think that you've noticed the pattern through all of the speaker's of the osteology and the variety of the upper sacral segments especially and then how important the radiology is radiology is so important to pelvic successful diagnosis and planning and surgery and then not just the preoperative radiology but the intraoperative radiology as well and how those axial and surface rendered and also the sagittal images helped so much and again we talked about the precision is good from the planning and it has to be executed as well and then I I like the post-op CT scan just because it allows me to do a lot of post post-op critique and so with that Steve I'm gonna stop and I appreciate your attention and thank y'all for letting me be a part of your webinar great Thank You chip that's a huge amount of information to absorb I'm sure that there have been many many really good questions we're a little short on time so I've asked mark maybe think you just assimilate maybe two or three very common questions from the speaker so far and maybe we could just answer a couple of those real quick and then and then I have just about five minutes for the slides just to wrap up and prepare you for what's up coming over next week what what how you can review these videos because I think with the amount of information that was presented I think a couple of minutes to be able to review through this again would be very helpful for everybody and then I also how you get your CME credit as well so mark is there anything that were burning questions that seem to be repeated that we might take it could cover quickly yes Steve so there was a one that came up a couple of times for Hans to address or any of those speakers to address which is does it seem that rabo'ah is falling out of favor in terms of hemodynamic resuscitation or does it still play a significant role in the management of the unstable patient with the unstable pelvis injury well yeah so I probably deferred to one of my colleagues where Robbo is used commonly at Sunnybrook we we don't really use Robbo in the resuscitation pathway we have in the past used pelvic packing I noticed one of the participants was asking about pelvic packing pelvic packing needs to be done in the context of a stable pelvis so you know you have to do something else to stabilize the pelvis or you're just sort of packing something that's going to expand rabo'ah has a theoretical advantage of you know stopping all the arterial bleeding but there are some downsides and again I defer to some of my colleagues who user Ebola in their practice to answer that question yeah I would say our institution is used uncommon ly i but it is certainly in the pathway that is usually used with someone who has brisk RT really the last one we used was a person who actually came in with a laceration in that area and actually had an external iliac artery bleeding and they used rubella up through that in the emergency department the difficulty with it is it ties up a trauma surgeon for about 10 to 15 minutes while he does that and if you have a patient who's in extremis that can be difficult but it it has the same indications as cross clamp on the aorta basically and if you can keep it in for renal you have a lot less difficulty if you can leave it in for a very short time usually if it's used just used to get the patient to the operating room and someone who's truly in extremis and then when they're in the operating room other things are done to stop the bleeding so I don't know if anybody else has he experienced with it I've I've seen some really dramatic saves from it that otherwise there's no way they would have survived and and when it's when it's right it's incredible and I think sometimes it gets a little bit right now sometimes overused it gets used to the point where maybe the patient's really aren't so great but boy I'll tell you what I've seen a [ __ ] of ten patients who would really benefit from it so Steve there were a number of other questions regarding percutaneous fixation I realize that's gonna open a big bag of worms but to summarize the questions were typically when is percutaneous posterior fixation enough when you have to add anterior fixation when you have to augment your posterior fixation with something else like lumbo-pelvic fixation or trans sacral plating and if you're relying on posterior percutaneous fixation alone how many screws does it take to rely on that chip can get tighter that just version of that answer and probably about the last question that's it I'll just I'll just go decade by decade and so in the 90s we were just trying to safely insert a single screw in the upper sacral segments and we were pretty heavy on an tearing fixation in the 2000s then we started using multiple screws at multiple levels especially when the longer screws came and we could go trans sacral so trans sacral became very popular the good thing about that is we saw failures of fixation not go away but really go down a lot greg Blaisdell wrote a paper and showed the really not the elimination of fixation payers but a dramatic decrease in doing multiple screws at multiple layers the trouble you have sometimes with the ante ring it can also help the poster ring so much biomechanically we know that fixing every point of instability is a good thing to do and so it becomes a clinical stew of what the patient has already had what the patient can take how big they are how old they are what opportunities you have as far as their overall clinical situation but ideally multiple points of fixation to post your pelvic ring at multiple levels and also fixing every part that's unstable is is ideal there's a final comment not a question but next week when we're talking about definitive fixation of pelvic ring injuries there will be coverage of the question of augmenting post posterior ring fixation with open techniques probably a good bit about the order of fixation as well so we'll try to answer some more of the questions online over the next few minutes but I think in to respect everybody's time and not to try to be over too far on our very first session which is maybe setting a theme for how we'll probably do throughout this course we would we'll just wrap it up real quick so I just missed some take-home points i think mark adams did a great job but the bony normal bunny anatomy and radiographic anatomy it's incredible to understand that that really is the basis for everything we do as far as fixation goes they examined the entire radiograph look for soft tissue problems classification is important to help guide what we do and we covered the different classification systems the from dr. craters talk again you and I identify patients that are at risk and there's a sort of pattern recognition you know looking at the exam and the radiographs recognize those people that are going to have problems early you need to be involved in the process the idea is to keep the patient warm resuscitate them with blood and fluids and then to stop the bleeding and they're things that this was where we really can be helpful we stabilize the pelvis and we talked about the different ways to do that but sheets binders external fixators in different positions c-clamps and and even sometimes a percutaneous fixation or even sometimes open reductions angiography and pelvic packing have their place in rebo I think still does have a place in the treatment of these patients in the appropriate patient and again I think the real key is to reassess continuously which should be both examining the patient and looking at their lactate and their base deficit to decide how you're doing before you hang it up and then checking up really gave us some incredible insights into sort of the history and how how this is processes evolved and it it seems to be somewhat straightforward when he talks about it but I can tell you that it's been a 30-year learning process to get where we are right now and and you guys are fortunate that you're starting at a point way ahead of where where we all started 30 years ago with just trying to figure out what was back there so be thoughtful about your approach this is something that requires a good deal of preoperative planning and thought process understand the potential Bonnie corridors and the radiographic views and the limits of those and think about how to stay out of trouble with this process so so with that we'll wrap up there'll be a link that will be sent out and after this webinar so you can apply for you're seeing me it will ask you to evaluate the course and then and then these this you'll get a link to how to review these videos as well so you can actually watch the whole thing again and listen to these talks if you think you may have missed things as they went through there's a homework assignment we're gonna give you some videos this is a link that again will be sent to you so you don't have to write this down and remember it but there are several videos that are available on the YouTube channel that that you'll get a link to that will go through some of the approaches the open approaches that we'll talk about next week but there also are some videos that go through the percutaneous techniques from a previous course that we had that you can review to kind of review some of the issues that we just talked about when they'll talk about the other corridors a little bit more as well so so next week to remind you this will be more about pelvis and it will be really the open reduction techniques open reduction internal fixation techniques for pelvic fractures and this will I think very nicely with what we heard today with percutaneous techniques and as chip said there are people that well everybody would prefer to operate through small incisions there are people that that's not possible and that will require open reduction so to get them taken care of in this and if you spend your life never having done that then you'll you'll never do it you'll always be accepting things or getting yourself in trouble by doing something you shouldn't do so with that I'll wrap it up I really appreciate your attention appreciate those of you who hung in there to the bitter end which is really about 400 participants that started out and we have about 400 now so so we appreciate your attention I think thank the speakers for their hard work in preparing these talks and the amount of information they were able to share with us so thank you and with that we'll sign off and close you