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Pelvic Fractures for Othopaedic Exams
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Pelvic Fractures for Othopaedic Exams
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Language: EN.
Segment:0 .
Good morning, good afternoon, and good evening, everyone, and welcome to our weekly webinar with the FRCS mentor group. We are privileged today to have Mr Campano delivering a very important topic in the exam. This is pelvic fracture. It comes in many forms and shapes, and many questions are asked around it.
So Mr Campano is well equipped to talk about this and I will be introducing him in more detail in a bit. Before that, I wanted to talk to you about the courses we deliver for the vyver courses, for the farces. If you are interested in that, please go to our website and you can register register for the upcoming course. These are held frequently and manned by experienced staff. In addition, you can register on arteriogram group, where there will be a lot of discussions about this talk or other talks that we've had in the past.
In addition to plenty of resources handling all aspects of the FRCS exam, in addition, we've got a book which you can see the picture behind me about it. This is a summary of the whole exam. Please, you can get that book from all reputable bookstores, including PDF version and sorry, online versions. Now, the talk itself is interactive and at the minute in the middle.
There will be a chance for you to participate in teaching cases, which Mr. campana has prepared. So people who are interested in that, please let Mr. Henry Shawn Henry know that you want and he will keep your name for the interactive part. In addition, today we will be doing a Viva. And if you want to be considered for the Viva session, please let Mr. maiman know.
In both cases, you can please use the chat function to talk to them directly rather than Raise Hand. Because raised hand can mean many things for, you know, we don't know whether you wanted the interactive part or the Viva part or what. Lastly, but not least, if you have questions about this talk, put them on the side and we have two mentors who will be looking after these and delivering them to Mr. Campano at the end of the first part of the talk.
Now that admin bit is over. May I introduce Mr. campanha, who is our consultant in Salford hospital, dealing with pelvic injuries? He had his MS in India and then completed his orthopedic training in the UK. He had two fellowships in Southampton dealing with hip and pelvic surgery for 18 months. Then he was a locum consultant in the MTC in Southampton, then at 18 months as a consultant in MTC, which is Salford.
So he has seen all sorts of trauma and he deals with trauma to the pelvic in all its forms, including femoral head fracture. He is currently an undergraduate examiner, and soon, hopefully he will be an examiner for the FRC. Yes, so who better to talk about this from the FRCS part? Apart from him, without further ado, I give the mic to Mr Campano and the. No, it's not me.
Well, if you. And yeah, thank you. Abdullah, Thanks for giving me this opportunity to speak. Good evening to everybody. My name is Mr Campano Vijay campana, as I said. We were here in Salford and I work before in Southampton as a consultant, so this is the fourth year of as a consultant. So basically, I was being told that the role it's ongoing here, so I don't think that I am a lecturer here, when your experience there.
So this is pretty much interactive, whatever the questions you have and more than happy to answer to my ability. You can interrupt me anytime when we are going. So the public structure itself is a very, very big topic. It takes good at least three four hours if I just have to go through everything in detail. I would just concisely few things which are very likely to be asking.
So we'll just concentrate more on that sort of thing, the examination side, rather than going into a full theoretical which is there in all the books anybody can at any time. So that is. A blow do. Yeah OK, so this is my little introduction, Thanks to Abdullah, so it has given already.
So there are a few facts you need to be aware of this pelvic fracture. So there are so many things which is written in the book, but what is being to be expected in the exam or what? You need to be a very concise few things which you need to be aware. So it's a high energy injury and most of the young people or it's a fragility fractures in elderly patients. So then you need to be just awake.
There is a 15% risk of mortality with diplo's fractures. And it is a 50% open practice, so these are the figures which you just have to be aware of. So there are other injuries which comes later, but the examination was one would like to know there's a 50% mortality for an open fracture. That means every second patient can die off. So you just have to be very well aware of this and how to manage this.
It may come to that. So the other group, which you have to be aware which group of pelvic fracture patients or high risk for a high mortality. So you just have to be aware the elderly patients more than 60 years with the fracture and the systolic blood pressure 90 and below on presentation people with the increased injury severity score.
So the injury severity score, if they really go on to ask exactly, you need to be aware what is the injury severity score? How do you measure this is one of the trauma scores which all of you should be aware of. It's there in most of the textbooks. For this particular pelvic fracture severity score of more than 17 is high risk of mortality. You just have to be aware of that figure.
But generally the figure is around 50. But if they go for specific, say, that is a 70, but please do read what this injury severity score. There is something called a modified injury severity score now, so there is a difference between these two. There were some flaws in the original injury severity score that has been rectified in the modified score. We still read about this. The other category of patients who are high mortality is people who are needing a very high transfusion, especially more than 40 units on average, and they are the high risk of mortality.
And the other category is APC, which is the antero-supero-lateral compression injuries. Three the vertical shear. I'll come to that a little bit later. What is this APC three? What is this vertical sharing? So the other ones need to be just gently aware. Is that associated injuries? So these ones are there in every book.
So any trauma patient with chest injury and bone fractures, spine fracture and one more specifically, we have to mention with the pelvic ring fractures is a sexual dysfunction is up to 50% in the beginning stages, especially anterior risk factors. So that means that one needs to be aware of this complication when you are dealing with the unexpected.
So the other important thing is that had been the abdominal injury, which we'll come to that later and the neurological injury, which is around up to 30% So there are certain guidelines which I'll tell you a bit later, and there is this ones out there on the website. How do we go about managing this? So next, come to mechanism of injury, which you all of you know, which I don't, I just thought that I should just present this ones all in the book.
Don't need to go much details, but I'll just briefly go. So the first one is the APC intraoperatively compression, which is that means you are being hit on the front of your pelvis. The lateral compression, which you are being hit on the lateral side of the pelvis, the vertical shear, which is a heavy pelvis, migrates approximately and the combined AP and lateral compression.
So that can be any form. So this is the classification which some of the world orthopedic surgeons are still using this. So Thailand panel classification, this is basically based on the stability of the pelvis. So these points are being very straightforward, so you can only say that which are the factors which are stable, which are the factors which are occasionally unstable and which are the factors which are not rationally and vertically unstable.
So these are three categories type axilo. So EPA is the stable link factors which are there. So these are the ones. These are the question factors of the tuberosity, which is one of the common things which can happen. The high impact plates of the anterior inferior spine, which you see sometimes in adolescence when there is a secondary acidification sentence, fuses, they say, pull off of the rectus the ADA I'll explain that is a second common.
Then the, you know, the anterior and superior spine, sometimes severely. So these are the sort of coalition factors, but if you take it overall, the ring, the ring is made up of two bones and the sacrament, the backside in the middle and there were two separate joints and the strength is being connected with the symphysis. So the water ring itself is intact in this category. So that's why they are stable.
These are the stable injuries, majority of the damage. They do need surgical intervention. But however, they go for a details and a highly displaced, which is a massively displaced spine or a skill tuberosity. You do fix them. We do fix them in a high performing athletes or high performing individuals, so we don't go and fix these fractures normally. Very unlikely.
Martin, definitely not in a sedentary patients. So pain relief and they can carry on with demobilisation. So the next category is pelvic rings, which are occasionally unstable, politically stable. So these are the ones. Which are weapons in the front? It is an open book type of factor where the terrorists are both highly oppressed, open up with the pubic symphysis.
So they are rotational and stable, whereas vertically they are stable and see that both the Si joints are still intact. The posterior joint ligaments are in. That's why the pelvis will not shift, of course, are downwards. So those are the category of patients. You can see that the compression equilateral type that is another example.
The next comes to type C. Type C is the one where you've got a vertically unstable, which are also rotational and stable. So these are the ones where you see that the APC three posterior compression type of injuries, which I'll show you in a second. What are these and also these are the ones to be vertically unstable is a vertical sharing duty. You can see three LCT. So let us take some pictures of these just so that we can understand better.
So this is a classification, you can see that clearly we will see. So in the first one, sorry. So you see that in the. I'm just. So so you can see that taipei, the. So there is an abortion fracture there, that is the elite wing factor.
And so in taipei, which is a traditionally unstable. So you can see that the open book structures are. Whereas even the lateral competition one of these types, which is also educationally unstable. But these ones got the impact posterior salesman. They are vertically stable, so type III is the one can see that. So they are unstable on the posterior wing, as well as anterior links where the image can be shifted upwards or downwards.
So those are the ones which are type C. So that is the one which used to be the case where the world type of surgeons use. This used to be much more commonly before. But now, most commonly, the practicing surgeons across the country use this one. It is. The England is very concise. It will even by, you know, if you tell me that it is a bc one, I can imagine in my brain how the APC won, what will be this structure.
So that will tell the direction of the force the type of fat and C that. So the. You can see that in the. You can see that in the first line, you've got a lateral compression types. The second line you can see the ABC, you can third one is a vertical shear.
This is the classification of inverted burgers, which is commonly used by a practicing surgeons. There is a one more classification called egawa, or a egawa. Classification is not for people who are practicing. It is more of a research purposes. But this is the one should be aware of. So if you look at the first line lateral compression injuries, so how to remember this?
Remember type one, type 2 typekit? So just for your knowledge, just for majority of the times the exam, they will not ask you. They are not very particular about the type of classification, but if you can show that you know, that will make them much more clear. So the three types of lateral compression you can see, so type 1 is the one where you see the only one side of the pubic is fracture.
So this is a very common thing in practice whenever we see. You see that you get a lot of referrals from a medical side. So they say that, oh, got this 85-year-old patient, the pubic might fracture. What should we do? So if you look at these pelvic ring ring is like a problem, it will never break in one place. When you see a 1 break, it will be invariably there will be a break elsewhere.
So in the LC one or a lateral type compression lateral compression type 1. You can see that the. You can see that the unilateral one side of the pubic Ramsey's factor when you go and see them in the x-ray, you can't see much in the sacrum because of the complex anatomy. But however, if you do a CT scan, you are very likely 95% and chance that you will find a fracture on the sacrum on the backside or be a Si joint.
So it all depends. On the patient, whether you know, whether you want to do a CT scan or whether you can say you don't need any staining scan. So I am happy with this, this compression type 1 injury. So the reason why I say is that most of the textbooks is lateral typekit compression injuries are managed in the. But the things are changing gradually where there are certain category of electro compression injuries or unstable when we fix them.
But in the examination, just to go through to get to the past for all theoretical purposes. If you say lateral type 1 injury is managed conservatively. So that means that you've got a unilateral structure, but the posterior fracture will be in the sacral. So that is a type one, whereas in type two, in the anterior, you can see that same unilateral fracture, but you can see a big microfracture or the iliac crest.
And that means it is a segmental fracture of the ileum, so anteriorly at the might was really just around the AC joint. So you can see that picture so that I will show you some X rays, but later you can see what is that type two? So this is called a Crescent. So this is a Crescent fracture. So it's very typical of.
Yeah, so you can see that it's very clearly. So this is a very typical of type 2 APC poster compression injury or satellite compression. So then comes the typekit. So what is the difference between type III and type two? So type three, you have a bilateral pubic grammar. So when you see a bilateral agreement, you can pretty much imagine it is a type thing.
And invariably when you do a CT scan, you can see that will be either a fracture in the ileum or fracture in the sacrum and the posterior. So these are the type of lateral compression type. So type 1 is managed conservatively. You let them wait with majority or, as I said, a fragility type of fractures. Whereas type Ii and type three, they are unstable type of fractures, they are unstable radiological and the type III lateral compression injury can bleed up to 2 to 2 meters.
So that is one of the high risk bleeding fractures. So that is about the lateral compression. So next comes the APC, which is a very common. And so this is, in other words, it's called open book pelvis. You see open book pelvis when you hear that word that indicates it is an APC, the posterior compression. So type one, you can see again, a small gap, but the pubic symphysis.
So the disruption of the pubic symphysis ligaments here. So usually it says the sensitivities around 2.5 centimeters or less, why 2.5 centimeters? What does it indicate? Why not centimeters. So the 2.5 centimeter of opening at the pubic symphysis here, that indicates the disruption is only at the pubic symphysis ligaments, whereas disruption on the backside at the sideline and the sacrotuberous and the circular spine ligaments are intact.
So that means that only one set of ligaments, which are different, which are damaged, whereas the most important ligaments in this pelvic stability is from the ligaments around the joint posterior joint ligaments are very crucial for the stability of the pelvis. So that is, the type 1 is less than 2 2.5 centimeters opening, whereas type 2 is more than 2.5 centimeter opening and the pubic symphysis.
So what is this 2.5 centimeter? They said you can see that in the picture. So you can see that in the picture. So sacred and the secular spineless ligaments are ruptured here. So what does that do? As soon as that ruptures, we can see on the back side of what I say, joints say joints are just like an inch.
So you've got a 1 in different injuries on the back. So if you walk on the front page back in, just open, so you see that the left Kessler joint is opened up there. So that is the type Ii typekit means the anterior joint ligament or rupture of the posterior joint ligaments are intact. That's why this happens, but it is not completely unstable because the posterior side ligaments are still intact.
So that is type 2 APC, whereas type III. Again, the complete rupture of the pubic symphysis here in the front and the back, both anterior as well as the posterior joint ligaments are completely rupture. This entire ileum is literally about to float, but it is still there in place. But if it moves up or down, then it is called vertical shear vertical.
So one big difference between the vertical shear and the APC tree is that the APC three, it can become a vertical shape. But in the APC three, it is the mainly ligament injury where you want the AC joint ligaments, which are described as the anterior Cramer's symphysis, which are being disrupted. So the entire item on the one side and the left the right.
Or left right is completely unstable. This is one of those nationally and vertically unstable, whereas if you look at this type B or type 2 APC, that is potentially unstable but vertically stable. So next comes is the vertical sharing, getting vertical sharing. You can see that off of the Middle East. And we should get up. So this is one of the most dangerous type of practice which we come across.
The mortality rate is more than 30% to 40% in these vertical share injuries. These are the ones very high risk for bleeding. So the risk of bleeding is very high in this because they can tear apart the important vessels which are just present in front of the joint in front of these important vessels in front of the Kremlin or our external vessels. One in front of the joint is the internal passage so they can bleed like a tap.
So any questions about this, this classification, anybody wants to ask any particular if you feel got any, any doubts or anything or any easy way to remember. So this is what so for the lateral compression, if you see one, do one side. One side of the crema is fractured, usually the C1. But an associated factor is two, as bilateral peel-back is LCT, but there can be compression.
It's just a 2.5 centimeter or more than that. It's opening in the front. So all all, the APC are open. Book just the severity. So just to be aware that sacral fractures are very common, which many of you probably will not come across. If you start doing a CT scan for most of our elderly people, my fractures, you see this.
So majority will have an associated sacral fracture. The role a fragility type of fractures in them, but in the young people, it is the high energy injuries. So just to be aware of this. Normally they won't ask you, but I think you just have to be aware. So there are three types as per the Danish classification. So what is the significance of this classification? Why?
why you need know. So whenever they say, whenever my registrar calls me and say, this is a zone 1 region, I know that this is a very less risk of needing less risk of injury. Whereas if they say type 2 or a zone, then I know that the risk of narrowing it is quite high because it involves the signal from when the narrow routes axilo. So these are the.
And with zone 3 is in the middle of the sacrum where the spinal channel and I quote nice word. So if you look at the zone one, that is this the lateral sacrum, layla, it's called. So this is the area of the second. The risk of nerve injury with these fractures in this zone. Less than 6% Whereas zone two, which is around 25 to 28 percent, don't rate is 55.57. So just to be aware, I'm sure they're not going to ask, but you just have to be aware if you're an Air force is taking it, they just expect you to as they are, at least for a theory, it may not be practical, but here they may ask these things.
So in zone 3 injuries where there is a high risk of nerve injury, they are being further classified by they called right Campbell. You just need to know, but I'm sure this is not going to be asked. This is only people will be aware of this when we start getting worried, some fellowships they will know or some of them even know. So the type III of Dennis classification is further classified by Roy Campbell.
So just say that it is a flexion and extension type, I wouldn't go more than that. You see that flexion type. But it is the distal fragment flexes forwards. Uh, whereas the extension type, the distal fragment displaces distally. But in the example they certain they want us just to be aware the name right classification.
But this is a very, really specialized for police to deal with. So the other thing which you need to be aware is this one. So this is a dangerous variety of fracture we see is not being described in your Danish classification. So this is called spinal fluid dissociation. So whenever you see a bilateral sacral fracture. So that is sort of being classified under the spine of dissociation.
So if you look at this type I where you got a new type, so if you see that this is a yes, one body sacral first, the second body, and if you see that the fracture on both sides, there is a fracture here. So this yes, one is with the rest of the lumbar spine. So the rest of the pelvis from one on either side and below is completely cut off from the rest of the spine. So that is the reason why these injuries are called spinal pelvic dissociation.
That means the pelvis is dissociated from the spine. They are a very serious injury, very easy to miss, and one should be very well aware of this. So these are further classified into hedge type, where the just goes all along on either side and you've got an associated control structure. And you can see that it is a lumbar type. Then it can be a key type. So what is this significance?
Significance is that the spinal dissociation that indicates that a very high energy injury number one number two is that how you discuss nerve injury with this number 3 is that this needs to be sort of managed specifically by a specialist in a specialist center. So that's what you need to be aware of this. The management involves. Unless the patient is medically and one is involving the lumbar fixation and connecting that lumbar fixation to the pelvis.
So just I'm giving a brief idea. I don't think they've lost these things in detail, but just to be aware, the spinal pelvic dissociation management normally involves so. No pelvic fixation, I'll show you some pictures a bit later as we go along. So another thing for the FRC is what the examiner expects you to know that there is a risk of 15% to 30% risk that the urological injury.
This is one of the important things you really have to be aware of. The complex injuries, especially a type III lateral compression type one, the APC open book injuries, the risk of bladder. The bladder is just sitting behind the pubic symphysis, so bladder is just behind. The peel-back comprises any sustaining. If we see a proportional compression injury that is directly in front of you.
So the risk of rupturing a bladder or risk of rupturing the urethra is quite high, around 30% So there are certain signs which you need to be aware. So these are the signs when is that blood test bruising around the groin, bruising around the scrotum, unable to pass the urine and unable for you to pass the catheter with the fear? You can see that highlighting it's all there in the textbooks you don't need.
So I'm only just trying to of, you know, you what you were. How do we diagnose them? So any patient who can't pass the urine or any patients, so or when there is a blood in the urine, what you have a suspicion that this patient is likely to have one of these, either blood or rupture that case. So as an Air Force candidate, you should know that we should try attempting to pass the catheter gently when we want attempt.
If it doesn't go, stop there. Don't try to damage further. You have to involve the urologist at that time. So that is the baseline. So don't try to attempt more than one early one gentle attempt forcing a catheter. So as a pelvic fellow or pelvic guys, what we do, we do do this histogram put the dye directly into the bladder or we do retrograde.
So that will tell us where this rupture is. So there are guidelines for these guidelines is called vague us statements. It is there. There are around 20 points in the various guidelines. You need to know only 20 points, but there are salient features. So just salient features. What we practice normally in normal practice, if it is an extra bladder rupture.
The urologist, they don't repair them what they do. They do manage conservatively. They do either go for a suprapubic catheter or they can manage to pass a catheter by using some sort of methods and they will leave it to heal up if it is an improper toenail rupture. They do repair. So this is just a general guideline, but there are very specific guidelines there if you go to the guidelines.
There are some guidelines. There are some points in the post guideline as well. So please go through those guidelines, which is very important. You have to mention this the example in your answering urological injury associated with pelvic fracture. They're all very clear. So I don't want to go there because it will take a timeout. So other thing which you need to be aware is the source of hemorrhage.
So what is, you know, everybody speaks about fracture means big to them. That's what the imagination impression. What bleeds, really? So 80% of our pelvic fracture bleeding comes from the venous. And part of it. 80% to 90% is from the bleeding wound surface, especially if got a bone fracture. They bleed like a small artery.
In fact, so and we venous there is an extensive venous plexus, which are just in front of the sacral sacrum on the AC joint. So that's why the posterior injury is especially bilateral sacral fractures or SSI joint disruption. So you can see that there is a significant venous bleeding. And so when did 10% with the literature? With our experience, we know that the risk of arterial bleed is 10% So you don't need to be too worried that the film is always builds with the artery artery bleeding is only 10% These figures, you need to be aware.
The reason is that. This comes with the management. So 80% of 80% to 90% comes from the Venus venous system and the bleeding goes. That means you do restore this anatomy and make it a closed space pelvis. When it opens up these venous plexus bleeds. So just contain that pelvis back there with the binder or some form of closure of the pelvis so that it can open it once it bleeds to a certain level, maybe a few liters, then it acts as a component.
So if it is a venous and the bone surfaces, they will stop. But if it is arterial, they continue to bleed. That is only 10% among the factors. So the common arteries, which are likely to bleed, is a superior group of artery external internal alia up to the differential artist. So there are nine branches of the internal area. But if you want to be very specific, so I'm not sure anybody would ask all the nine of you.
So just be aware of the superior artery and the Mortis whenever you see a fracture from Novartis, which is very, very close by. That is a risk that can bleed whenever you see a fracture on the right side. That's where the superior duty rebuilds. Whenever you see a disruption of the posterior ring, especially around the joints, especially the practice of the sacrum.
They are the ones which can cause bleeding from the internal artery, which is just in front of them. So I can tell you, what do we do in these cases. And there is an algorithm, how do we manage these, these unstable that we will tell at the end or I can pass it on? This is the algorithm regarding managing a bleeding pelvis or unstable hemodynamically.
Unstable patient is based on each individual MP system. Everybody has got a different protocol, but I can pass it on to 1. What we have in Salford to beloved later. So this is just a picture to show how big the results are, so extensively vascular. So they can bleed like anything, so just to be away. So let's see that the commonality apart, really wading into external and internal and further into the similarity in.
So whenever we see a pelvic fracture, this is one of the examiners they will put up that x-rays, they will show some sort of you'll see one or two type of fractures and they will give a scenario of unstable hemodynamically, unstable patient scenario. So you have to be aware then this is one source. But there are other sores which you have to have a high suspicion.
So one of them can see that if there is an obvious open wound, she can. You know what is bleeding but the chest? So this is a very, very, you know, easy to miss. These closed spaces, especially for x, can accommodate up to 1.5 to 2 liters of blood. So one has to be very aware that in a chest is a source, it can bleed. Then we have abdomen retroperitoneal space to 2 to 4 liters in the long bone fractures, which you all know of someone who fractures or they can bleed.
So what category of peel-back fractures or high-risk for hemorrhage? These are the ones so vertical shear is highest. Next comes APC three. The next comes is the Limited. So we saw the want, which are very high risk for bleeding. The political factors, the other ones also bleed, but they are not known to cause a mortality. They bleed to death, so they all have some bleeding whenever you see a fracture, like the type one, type 2.
If you see a city report, there will be some bleed. So but they are all, as I said, you know, solid majority stops. But these are the ones that can be associated with arterial bleed and they can tear apart a big vessel. What a small was. A big was like internal or external electric. All that. So it just out to be examination report.
So people do have to be aware these are the high category, high risk category for hemorrhage. So whenever they ask an examination, the stability, when they are putting these X-rays up to the pelvis. You have to be very clear whether it is a radiological instability or it is a patient unstable, which is a hemodynamic instability, you have to make sure. Which which instability they are speaking about.
And you have to be very clear about it. So as I said earlier in the classification type, you know, type two, type three, lateral compression, type two, type three, APC and vertical shear, they're all unstable, ideologically unstable. You've got to be able except type one, type 1 lateral compression, put the APC. Or considered as table rest, all the ideologically unstable, but the hemodynamic instability, which I'm sure you all know, systemic blood pressure pulse the other factors.
So what defines the shock, so hypertensive shock, the all part of this hemodynamic instability? So next, I just wanted to put this picture. The reason why I put this is so everybody has to be aware of this, so sometimes they do keep this in the examination. So this is a pellet binder. This is the we start with the management part here. So management wise, we'll start with this requirement.
So the first and foremost, whenever any quality of operation on site seen by an ambulance crew, the first thing they do is that they will check the blood pressure, check the pulse and see that there are any signs of bleeding anyway. They will go unless it is a long bone open bleeding wound. So our open wounds, they always do and put this spine around. Well, I'm showing this picture, it's not that you don't know. You all know that this is a public binder, but one should be knowing clearly where to apply this correctly.
So the Velvet binder is meant to apply art where you can close the pelvis so that one not at the crest level majority. When we see in practice, we get a lot of these referrals from the peripheral hospitals, bring this binder around the crest where you feel the way you feel you are pressed for stability. It's not. This should be centered or the predator control.
So the Velvet binder should be centered. What the legs should be internally rotated. This two, those two big toes together that itself will help and put this binder and close the binder and tight on this binder. So that is the one which closes the pelvis. So one could think, boy, well, this is quite good for the APC open book pelvis. Yes, you need to close the pelvis, but is open it plausible, but there is no contraindication to apply this.
Any pillow doesn't matter. It's a lateral compression. Doesn't matter. It's a vertical shape. But still you can go and play in a bleeding patient. There's no contraindications for that. And that is the correct side to be applied. One more thing to be aware and in examination, if they ask. So ideally, both guidelines also says clearly this pelvic binder is temporary.
You should not try and leave it for more than 24 hours. With more than 24 hours, there is the risk of pressure sores, risk of skin at risk. So you have to have an alternative after 24 hours, either looking to put an external fixator or looking to do definitely fixation, or you can try using this binder after a certain 4 to six hours. You see sometimes blood clots inside the pelvis, and it is very unlikely to dislodge unless you keep moving the patient.
So you just have to be aware. So this is a sick plant they used to use previously, but not commonly used nowadays. So see, clamps are quite good. If you see here, I just got it, few sharp rods. So these schools will be a staging area. The one downside about this clamp is that those are supposed to be really it doesn't close the ring.
So they used to use this. It is very, very rare. It's only taught in some courses just for sake. Practically, we don't use this one. This could be a red Velvet binder is used everywhere, available in most of the big cities, most of the hospitals across the UK. So just to be aware that this is one of the things which the examiners expect, this is another one.
So this is just like a magic garment. But this is certainly not in the civilian practice. This is used in military practice, but I don't think we need to be aware of the risks comes with that. There's a very specific time we need to apply. So I would be sort of going too much into that. Just the theory said you need to give it of garments were used at one point.
They are like a tourniquet. So this is the one you need to be aware. This is the one you need to be aware you want in the budget. So if you imagine you are a consultant tomorrow. So what the examiner wants to know from you? You are safe. Safe consulting. There are not. You don't need to get the leaks.
Have them to do this. So everybody, every public servant, should have a general skill of putting an ex fix for this service. So this is a temporary sometimes that can be permanent as well. So just to be aware, there are two types of external fixator. So one is this is called an Kessler suture, where you put B pins in the idea. So the next one is the superstar external fixator, so many times this is much more effective and efficient in closing the thing.
But as a general orthopedic surgeon, one should be well aware of this one. So and you should be able to do this in the jungle, set up the examiner. You to know this at least as a temporary measure and until the patient has been transferred safely into the MPC or whatever. So so this is you can do very easily.
They used to do at one time in the emergency department, but now the recommendation is we should be ideally done in theaters. So it does involve using your normal set of things. So Cubans usually 5 prints for a 10 patient in Lady or 6 millimeter prints. So for the males. So that's $0.2 behind from the antero-supero-lateral point. The reason for the anterior superior let's find $0.2 behind is that one you have a lot of cutaneous narrow of time, which is very close to the minor ligament at the side of attachment.
Number two, is that your best bone? And the tick bone is 2 centimeters behind the anterior superior last point. So that is called Kessler. So that is going to keep a decent bone quality. That's where you can put these two things. So you have to be aware. So don't try. You don't need to be very, very small incisions in here.
Inch incision feel the crushed just like take a bone graft open properly. Two inches. Feel the crest. Just fire two of these sanctions, either using a drill or with the handle. So just connect the Connect the. So that is the one thing.
You just have to be aware, and you should be able to do that. So that is the Stabler expects very efficient. But again, this is very sort of it needs quite a bit of training to do this, and it is not easy unless you do this regularly. But just be aware and not aware of this. I am aware of this, but I am not well-versed to do this, but I am quite happy to do the interior space.
So, I mean, these are some of these open method of fixation, which I will show you some pictures just for a theory. Let us just go further and show you this later. So you can see that this is again, very easy to classify. So if somebody wants to see that there is a bilateral agreement fracture here, so very easy to tell this is a three fracture. So usually stabilized on the back side by percutaneous security excuse.
And in the front, we do what is called an infection, which is essentially an external fixator, which everything is under the skin. So I'll just go a bit more further than we will come to that. This is another method of fixation of the sacral factors. It's called posterior front sacral plating, and you can see that there is a screw as well.
That is the idea of simple screw on the top. So this is another picture to show that open reduction of the boat, the boat became more infectious and worksites and see that the long lead going. So you can see that the plate goes along the anterior column all along here, the ideal column, so on the backside, you've got the second scoop.
This is another method open method of fixing the joint. So this is what is called a lumbar pillow fixation, which I was speaking earlier. Whenever there is a spinal dissociation, one should be aware that we do this. So what the examiner wants from you, what exactly examiner wants you. So all this what I was telling you is it's only about this management of a police access, but we need some very unlikely they will just put on leave will be saying that this is a police matter will be managed.
No, the always majority 90% of times you get this as a part of the scenario, they give you the political motivation. The bilateral femoral fracture is that one of those factors? So they just come to the pelvis at the end. But before that? You need to have a broader knowledge of managing this problem. So they look at you, the examiner, always look at as a consultant, the managers, so they are always expecting you to be there.
OK, you are in a big. How do you manage this scenario? That's what they want to see you. How cleverly use your brain or your knowledge to just get out of that situation. So they are just testing you as a day one sales consultant in NHS. That's what you need to be. Keep it in mind.
So what does he? So there's a few things. One is that when they give you a scenario like poly trauma, so they want to see whether you are able to make, we shouldn't make it. Were following in the very urgent scenarios and how you prioritize. So basically, you have to be aware of the principles of damage control outbreaks.
What is fast? If you've got a scenario where you have to structure the open fracture, you've got a bilateral femur fracture, then you need to know what is important, what you are going to do immediately, what you got to, what resources you've got in your budget. So you say a patient comes in, they always give a scenario saying that the patient comes at the Friday NIPE at 11 o'clock, so we will be there at 500 on Friday NIPE at 1100.
You expect every major trauma center consultant sitting there. No so you are immediate patient is being brought into one of these it in the immediate stabilization, although definite stabilization takes place elsewhere later. But you should be able to in a situation where you should be able to manage this to stabilize initially, at least temporarily, until you get this patient transferred safely into the major trauma centers.
So that is a critical thinking that is the one they look at. So you need to be aware. So next after that, you need to be aware of waitlists, which I'm sure you all of you know, the principles and traject patients. So they'll be the temporary stabilization of these people who practice, which said binder. It speaks. These are the two things which you need to be aware of.
You need to be able to do correct application of the binder. So you also should be aware BGH, the resources are limited, your expertise will be limited, so you need to know your limits. So that is another thing which the examiner expects. You can't go and say that I will go and do this, for this purpose.
The got a good knowledge. So you just have to answer in such a way that I am aware of all the principles, but this needs to be done by somebody who does this regularly. Not just that you need to have the resources to do that. And not just doing that in case if something goes wrong, you should have a backup to deal with that complication. So this is what you need to be aware of.
So that means that. So they will look at your limited self limits, what, what, what limits they will give a scenario if they say, OK, you are in a major trauma center. What would you do? Then the next question comes, are you definitely going to learn to manage these cases? Until then, at least the first bit the temporary stabilization resuscitation and what is massive transfusion protocol?
How do you sort of resuscitate any trauma patients? These are all basics. One should be very well aware. So next one you need to be aware in, which has been asked is a massive transmission protocol. So you really need to be aware of this. So there is a protocol in each and every press. But there is also a well known protocol. So what is the connection between what, what hours they should be given and how much blood transfusion in of transfusing is just a blood FFP that is a blood clot and in what ratio?
So that's all day in the book to read that is called Matthew transfusion protocol, and this is the one in an unstable hemodynamically. Unstable patient doesn't need to be restructured. Any polychrome patient, you really need to be doing this. So this is a very key and this has been asked in a lot of Examinations, now. So you need to be aware. So the next one is meant to transfer safely.
So that is called most guidelines, you need to read most guidelines. So sorry, thank you. So, as I said, both guidelines is very key. Everybody should be knowing this was. There are 19 points in the. So for the pelvic fracture, there are no straight lines for everything.
Open fact is all lot of other injuries, but for the kidney structure nowadays since the start of this disease across the country. So this is coming again and again the example. So the Bush guidelines you have to mention when you say both guidelines about the fact that you are red and at least you score, they score some points there. So but you really have to be aware. So there is a real protocol.
So there is a protocol to say that all these pelvic ring injuries are to be ideally stabilized within 72 hours. That means even if the patient comes to visit, you should be safely transferred the patient after patient or after binder after operational bas status to the trauma center nearest trauma center near to the pelvic unit, sort of in 24 hours safely so that they can stabilize the pelvis within 72 hours to get better outcomes.
So same thing with the acetabulum Stabler fractures. So there is a straight guidelines say that it has to be stabilized within 72 hours. So there are again, there are so many other things in that guidelines that you need to be aware. The other thing we need to be aware is that. So all these patients gets a CT scan, and then when you get the CT scan in the binder, you have to have an X-ray out of there.
Please do read that one because if I go into there, you will lose a lot of time. So that's all there. All in all, the websites. It's all in the book. So read this first guidelines for the public sector, which is very clear, and that has been expected in the example. So you need to have a forward thinking.
So whenever this case has been put up in front of you saying that what, this multiple bones broken so fractured you need to have a clear idea. So first, I will stabilize this. Then what I do is stabilize the odoi, stabilize this femur. And once I do stabilize this femur, what we must expect binder to the pelvic pelvis, then bas status all the massive transmission protocol, all these gestation measures.
Once the patient is stable, so you need to transfer to the nearest trauma center, but you need to have an option there. You need to think critically that I can manage this patient here, whether I can't manage here. The other thing to know is that these patients, whether I should get an immediate advice or whether I can stabilize this temporarily, then I can speak. These are the critical steps which you have to take.
So if you don't have the resources, you don't have any experts in your face when you don't have any blood banks open, when you don't have even an X-ray afterwards and you don't have much resources there. So you have to be aware, at least get your protocol, initial resuscitation, the transmission protocol, these sort of things that you need to go one by one, but you need to have to keep thinking whatever the situation, whether you're going to keep transferring and transmitting, is it this NIPE or whether I am transferring tomorrow morning?
So if you need help, you can always say, I need your advice. You can help. Examiners will not. You will never expect you to say, OK, no, no, no, I will do this, I will do this. I will fix this now. So I just say I will take AI will take an L. I will take advice if they want me to do an external fixator.
I am quite happy to do. I know the methods. I will do it, but I will certainly take any advice from a local MPC or local orthopedic consultant. So just to think about this. The last thing is that you need to know the clear algorithm. So whenever they put a scenario in front of you, hemodynamically unstable patient that comes as a part of trauma, you need to be aware whenever they put this up, you need to be aware.
The wouldn't Elvis, how do you go about managing it will be unstable fracture presents with the instability, hemodynamic instability? That's what. So for that, I said, no, they every NPC, if you open the website of any MPC who deals with the practice, there is a protocol for the majority at least. So you can read them and I can forward it to Abdullah.
You can. He can go. So that is there is a clear algorithm. So the way, let me just I can just go to. So the way we go normally is that whenever we see a patient in our enemy. So we assess whether it is a stable more dynamically or unstable. Then the question comes the radiological.
Afterwards, the patient is stable, so you will get a normal visitation with the normal saline or whatever is being according to your protocol. So then we decide whether it is a stable or unstable. So it is a stable patient and we decide when to deal with this fracture, depending on our availability of skills. So many other things are unstable factors.
We do have a protocol that is every MPC has got the protocol. We can look at any MTC. There will be a protocol for them in there. Any protocol? So I can pass it on to bullet if somebody is interested, what we have at Salford. You can take a look at it. So the other guidelines for the purpose really are to be aware, as I said, most of us urological injury.
And this is a un-pc and they will ask, what is not? So there are 22 or 24 empty seats now across the country. So this is a very important. All the pieces are being developed in the UK and across Europe, Germany, UK, us needs to get a better outcome with all these patients. You can have everybody under the same roof. So yeah, just have to be aware there are some outcomes scores which are very rarely been asked.
Not commonly so. They are called mojeed score the egawa score. I know what score in the sport. They're all peel-back related outcomes. I don't think they will expect you to know, but in theory by chance, if you ask, just for the theoretical. So for the discussion was this is what you need to be aware of. So most of the people will know the experts, which I already said types are allowed to do.
One then becomes the caloric package. This is a very hot topic nowadays, with the look packing angiogram and the embolization. What is best in what is best in the hemodynamically unstable patient? This is one of the very hot topics, which is the debate is going on everywhere. So the pelvic packing is the one where we pack the pelvis to stop the bleeding from the venous venous bleeding.
So after packing the pelvis, I'll tell you where to pack. After packing the pelvis, you still have to put an external fixator to close dependence. So just by packing the pellets, it will not stop. So after packing the pelvis, you have to put the external fixator to close the ring so that acts as a tampon in the pelvic packing is packing the pelvis in a likely areas where they bleed. So the likely areas where the body is on both sides of the pubic where the corona is, is there.
So one should be aware of what is this coronavirus disease anastomosis between the operative vessels and the external iliac vessels? So you need to be aware. So they are just sitting on top of the superior and then they rupture since they are very directly connected to the external artery. And when they bleed like a car. So that's why you need to be aware that is one of the sources, so you need to pack their pack just behind me, superior pubic ramus on both sides.
Then the other area where we would say joint on either side of the joint tenotomy, that's where the internal iliac artery vessels to be the venous plexus sacral plexus are there. So these are the four areas which are being described to pack. So cracking. These are the areas packing used to prevent the venous bleeding, but very rarely they are being used to for a arterial bleed arterial bleed.
We need angiography. But as I said earlier, 80 90% chance you're bleeding is likely from a venous. Only 10% is from the artery. You back the pelvis. It could be still bleeding. Then you need to have an angiogram, so identify the need. Then hospital radiologist, be a radiologist.
So what is better with an angiogram embolization? So there are a lot of cities winter across the country, across Europe, across the world. So they looked at both whether the outcomes are better with the tracking outcomes are better with the angiogram and the analyses. So certainly. When we hacking seems to be a better, better option than angiogram, the reason is that.
This much quicker. You don't need to wait for a specialist radiologist to come and do that. Number two is that it can be done by the general surgeon or an orthopedic surgeon who works in the MPC. So all the outcomes in the literature shows parking is better, but on geography, because of these factors, you can get depression to theater well within under one hour.
Whereas angiogram, we look that takes between two to three hours. So that time is very crucial, the outcomes are better with the peel-back. So you can always say the literature, you know, there is a hot debate about, which is better. Public parking is better because of time constraints and better outcomes in the literature. So the other thing which you have to be aware and to read is the egawa egawa is, I think I don't know how many of you are aware.
This is a loss the way it's the last measure to prevent a bleeding, which is in a non compressible area. So say that what we see is. A fracture patient is bleeding and the common iliac artery or heart is bleeding like a tap, it's quite a big muscle. So these are the very paradoxes. It is deep inside the palace, so that's why we have over means it is the resuscitating endovascular balloon operation angioplasty.
Of the aorta, so that means the are inflating a balloon into the aorta. So that there are three zones zone 1 in the thoracic aorta, which is in the classic aorta high up in the chest table, the renal arteries is the body below the artery, the aorta. So on three, we are looking at zone 3 is that well below the renal arteries? You are fluid, the aorta well below the edema like this so that the kidneys are still produced, and this will completely cut off the entire blood supply.
The pelvis, the lower limbs. But it comes with the risks, so it is very critical. You cannot do this for no time. So is only indicated not more than 30 minutes. It is going to be more than 30 minutes. You are risking necrosis of people inside the lower limbs, but also so there are other risks comes with the removal. So something like rupturing the balloon in the aorta, causing a traumatic bleed itself.
So those are the things. So egawa is very rarely rarely indicated. That is the last measure. But you need to be aware that removal means the risk to endovascular balloon occlusion of the aorta that is again done by either a vascular surgeon or by interventional radiologists. That is only a temporary measure that can be done only for up to 30 minutes beyond that time.
So you have to be patient, should be in theater. You should release this balloon. You should every alternative way to stop the bleeding. So let us go to the. So the exotic these are the approaches in the pelvis, which need to be aware of. So most of the. The Uh, that aspect of the ring now, so we fix with the stop approach, please do read what the stop approach and what is modified stop.
It's all there. I won't go into the details. It's you to be aware. And the second one is that earlier inguinal approach used to be the case until last four or five years ago, we used to approach all the anterior aspect of the problem. Using the earlier inguinal approach, developing a three windows theory part is still there. They will still ask what are the three windows or do you what is in each window?
So that has also been asked in the exam because most of the people who sit-in the examination panel, they're not surgeons, any of them, either hand surgeons or surgeons or surgeons. So what they all will watch would be exam question, really emotional approach. We windows. So you really have to be doing this earlier emotional approach.
And what are the structures at risk and what are those and what are the advantages and disadvantages? So that used to be the workhorse of our anterior aspect of the establishment until three or four years ago. It's not anymore. Now, the majority 90% of the practicing surgeons will do this topo, which is an intra intra peel-back approach where we access much better than the inguinal approach.
Very rarely, we do this alone. So just be aware, but please do read these approaches in a posterior one posterior column and anything posterior part of this problem. We do do what is called a line, and the approach we see need to be aware because most of you do this hip replacement using a posterior approach. It's pretty much very close to the same sort of. We'll see an approach to the hill, so we would like them with that approach.
So exactly you need to be aware both to prevent the vascular damage to the family, make sure that you read clearly. So where to cut this from standard? How much tenotomy should be left to the femur before you cut? And what is not disturbed? It is mainly. There is an ascending branch of lateral complex femoral artery, which goes just on top of the quadratus femur is you need to be aware of that.
So that's why you should not disturb that when you do the copper line and that approach to cut these things when it's very close to the bone of this reformist tendon. And if you disturb this ascending branch, they will end up with what is called a rescuer necrosis. So and also again, we have to make an incision over the. Axilo, so not to damage the labor. So we need to be aware of that.
It's all there in the book. I don't need to tell. So you need to be aware of the cockroaches is very common. For example, the last hearing we can ask in the approach is surgical approaches. In the example, there to be a way I would go into the details, you know, the risks of sciatic nerve injury. So it sounded to me very rarely used the idea of female or female approach.
Very, very rare. I have already seen in my fellowship, my training. I've seen only two cases that used to be previously that is 4 or five years ago. We have got various other percutaneous techniques nowadays to deal with this pelvis. So is a very extensive approach which can cause a significant muscle damage to be to the abductors and also the lateral aspect of the, you know, the hip.
So significant actual effect of the classification. Those are the risks. So we actually do those ones most commonly now we do. For cutaneous, the posterior wing is stabilized with the Joint Surgery in school, that is for the second school, which is done percutaneously sleep. So the other one is we do an undisclosed practice. We do call schools.
Then we do something called in6 to stabilize the trend. I'll show you some X-rays what they look like. So this is about some grief. So we will go to some discussion now. So the discussion is just put up some X-rays so you can ask any questions. So I can stop it for five minutes. You can have some little drink.
So then you can come back. We will go through some x-rays. So then you can ask me, what do you what do you expect me to tell you before I can answer you? Or if you want me to give it to, I can give it a bit later, then you can tell me what you need. So we'll go through some of the x-rays. What? what we normally do.
OK, thank you very much, Mr campana. I'll give you a minute or two just to have a bit of water, I think. Yes so if you want, we can tell you The questions that we've had so far from the audience. And please feel free to add more questions, please. I will. If that is OK with you, Mr campana.
Go ahead. Can I just let me make it a little bit louder? I can't hear you. Very Yes. Can can anyone help? Am I can hear me, guys? Yes, we thank you. Yeah, we can. OK, go ahead.
OK, so do you do you mind Mr campana if we start? Oh, I don't mind at all. Perfect so I'll give you the money. You might be telling your theory. It's a waste. Absolutely so I'll give the mic to Joe and Anthony, who will take turns in conveying the questions to the audience. Hello, Mr campana. It was a very nice talk and very descriptive actually, to the extent that till now, I just have two questions.
The first is what is the recommended thromboprophylaxis protocol in pelvic fracture? OK, so the question to answer your question. There is no specific thromboprophylaxis, which has been said this is what the literature says. There are many studies come out. One is from there are studies from Bristol. It is coming from. There are studies from Royal London.
I think Peter Bates is the man who has done some work on it. There are Bristol. Two page two papers are there and there are another one or two from elsewhere. And one from Derby. But the majority they all looked at say this was the originally one of the major trusts which they used to practice the are getting for wrong. So even today, it is a being a major trauma center.
They practice warfarin. So if you go to the royal London, so I think they use a they use a fingerprint or low molecular weight heparin. So the Bristol guys, one of the oldest units. 1998 they established the unit, so they looked at the various things what is most efficient or effective in preventing a weed? So they looked at it, but there is no consensus on that.
But what they come to conclusion is one thing. They looked at it and they come to the conclusion that low molecular weight heparin is better than any of these water agents. What we use for hip and knee replacements, correct? So there are so many hip and knee replacements. We use a single dose daily tablets, so, you know, apixaban or whatever. So many other things, dabigatran and many things, which are they all lucrative, but they are not being approved by any body like a nice or there is no literature to say they're better.
But what does the current literature we have from a distance study or London and the majority of the literature suggest low molecular weight heparin is still a better choice than others. So when you want to answer this in the examination, say that there is no consensus. The literature suggests low molecular weight heparin appears to be in a much more efficacious than other modality.
The other ones with, you know, all these mechanical things. But the chemical wise, this is what the second thing we are about this. So DVT risk is very, very high in these value structures. That's why they recommended these, that as soon as you get the patient into the hospital, any trauma center, any budget, it is recommended that it's efficacious. If you give a first dose of your interferon or any form of low molecular weight heparin within 14 hours, if not within 24 hours.
If you can't give this within 24 hours. This is very high. Then if you miss the first 24 hours, then your bone or your being obliged to do some doubles before you undertake any major surgery on. If you not already a clot sitting in the proximal side, you can try to do any surgical procedure on the pelvis. You may end up with the piece. So that's why the majority of the patients you are born to do this, especially if you miss their first 48 to 72 hours and you really have to have ultrasound the Doppler ultrasound before you do.
If you find any clot anywhere in the legs you are going to put a year later, you have to put the security around. So if you find any DVT DVT evidence. Yeah, so, you know, again, you know, one more thing. That's a good question, you asked. Any political motivation? You need a fix to the theater. Five times, six times.
Best bet is to die with a. But I was a Secretary is not the sort of benign thing you need to be aware. We see Twitter needs to be removed. Look, I use a filter, but it's sometimes got a lot of main downsides. There is a radiologist or interventional radiologists are doing this. They need to try and get this filter out, ideally within three months, if not more than, you know, with more than six months.
If you leave it six months, you can't replace it. Then you render you ended end up with the anticoagulant that man or a patient for lifelong. So you have to be aware of these protocols. The evidence suggests within 24 hours, you need to give a thromboprophylaxis, especially low molecular weight, but they across the country, as I said, warfarin is used in some of the Centers that are this recurrent, though in a daily dose, anticoagulants, which you use frequently, including aspirin, they are being used in some places.
There is no consensus. But this is what the evidence. Is that answer to is that answer? Yes, totally answer the question. The second question is that what approach would you use for pelvic packing? Is it finished or you need a bigger one? So that is another good question. So this is where you are forward thinking or a critical thinking comes into picture.
So for me to do a normal Stabler fracture, say anterior wall, quadrilateral plate microfracture or anterior column fracture, I use a phenoms team with the splitting, the rectus in the midline. But in this case, I will not do pelvis hacking. I will not do that. The reason is that in case if this patient needs a laparotomy, what would you do? So I would do a midline skin incision from umbilicus down all the way to the pubic symphysis.
I would do split the rectus in the midline and the linea Alba. Then I will pack it front and back. So here it's very easy to fracture. Pretty much the part of the directrices is almost damaged already as soon as you open the skin. Most of the time you see that it is pelvises in front of you. So that is a dancer. So I would use the midline. This is just a clear reason is that in case if you need a laparotomy, they can extend upwards.
So rather than me, me, me making a transverse insertion and then comes on the vertical incision, which makes a key which is not a good idea. Yes, thank you. I have another question, is it OK, so what is the diameter of panes of the fat shoes? I can't hear. What is the diameter of panes of the x? Yeah so you probably you missed that, my thing earlier.
So if the patient is thin in a lady with a very thin lady and the bones are expected to be small, I would use a 5 millimeter. If the patient is in a male or is, you know, fairly, fairly decent sized man, these either 5.5 or 6 depends on what is available. So 6 is a very preferable one in a man. So you just have to use normal. The Saudis are normal external fixator.
You don't need anything. But if you are looking to use that as a definite fixation, you could use a means but not separate quoted pins. Less risk of infection. And they could be integrated or the trick with the bone for a better way. So otherwise, you know, off my next week's sentence. OK, I have another question from another candidate, so what's the ideal time for operative management?
So this is what I said. Please do read, please do read the Bush guidelines. Bush guidelines has got 19 points. He clearly says, OK, so the pelvic ring injuries, so the pelvic fractures are being classified clearly as a pelvic ring injury or a Stabler or a combination. So whenever you come across a pelvic injury? Which is an unstable pattern.
Usually, as for the VOA guidelines and as for the research and the evidence clearly suggests we should stabilize the ring within 72 hours. And if you see this patient in a remote. You can stabilize the patient temporarily with some X weeks, and you should make all the arrangements to be transferred to the local MPC or peel-back unit within sort of 24 hours safely with a view to stabilize this place within the ring 72 hours, whereas established practice is a different scenario.
So you can go up to days. Of course, the fracture dislocation of the establishment needs to be reduced. Put it in a function. The other thing about. But he would question just to be aware, whenever you see a vertical share injury, which which we'll go through whenever you see this once.
You and if you are an idiot, you need to put a pelvic binder along with the pelvic binder, you need to protect skeletal traction to pull that pelvis down. OK this is a most minimum you should do. So that answers are you're not clear. It's very clear. Thank you, Mr cabana. I think that was the last question.
So we'll go now to the interactive point. You have one. OK, so one. So if you have moral level lesion associated with pelvic fracture, what is your advice about that? So the model level Legion is, you know, I don't know how many of you are aware, it is nothing but intimately glowing. So you've got an intact skin, very bruised.
But if you look at the family, there is quite a bit of damage to the underlying soft tissue. So that is a moral revolution. So moral revolution depends on where you are moral, legal reasoning and what type of action. So every time you are near where you see and forget about it, you may see this moral practice so you can see this moral revolution made us. So whenever you see what is, the significance signifies the soft tissues are at risk, you need to try and avoid going there if possible.
If not, please do explain clearly the risk of a risk of infection plus 1 breakdown and other soft tissue risks. You've got to be aware if you can't avoid going through the moral revolution you can go through, make sure that you take enough precautions to avoid further damage as little as possible to the surrounding soft tissue, where the blood flow comes in that direction. Yeah, thank you very much.
Thank you. That's that's all I have. Thank you. And you if and if you don't mind, Mr campana, I've got to. Just a follow on question. You ask about the term of Alexis for the factors. We we don't have a consensus. What is your personal practice for the fractures, which you already fixed and patient is now going to be mobile and go home with all the fracture which are inherently stable?
And would they require any further extended prophylaxis for it? For how long? That's a very good question again. See, my practice, I am always, you know, practice what is based on the evidence, so I won't go anything out of that evidence, I will use the low molecular weight. So if the patient, if he is a non weight bearing, I would go up to six weeks of.
Are the thromboprophylaxis? What the literature says would be haematologist says. There is no evidence, even if the patient is not able to wait where even after six weeks, there is no evidence that if you continue beyond six weeks of your thromboprophylaxis, it's not going to make any difference. So you view it, thromboprophylaxis Ahmad, after six weeks.
It is not much of news. OK, so that's why the majority of these thromboprophylaxis has been given. You know, if you look at this, there is a nice guideline if you want to read if you are practicing in UK, this is a nice guideline, one for a fragility fracture. That is nice, says you have to give it for four weeks. That's that is sufficient enough. But in my practice, I just go by whatever the available literature, which is 6 weeks, six weeks of low molecular weight heparin.
Because in the East of England, we actually practice rivaroxaban 10 mg, as you said about this for 70 days, that's a practice from the Addenbrooke's. I'm not sure how does this surge driven, but that's what they normally run with. So I just want to give you a bit of an example for one of the mdc's practicing this. Yeah, I suspect gera will must be doing a trial there, I would imagine.
So he's sort of, you know, very dynamic person. So but there is no literature to say that they were OK so badly that he's been followed for a trauma patients, even by the nice. So there is no literature to suggest or to go why I don't practice, I have seen the people doing it. If something goes wrong tomorrow. You have to find yourself back it up, yeah, you have something to stand on your legs.
Yes, there are guys who does it. That is, you know, they are ready to either be a trial. Maybe it may. It may come with the standard some practice later on, they may say that is the best thing in the years down the line, but we don't know so until something happens. So realistic, stick to that, what is being available. Perfect, thank you. Yeah anything else?
OK so I think that is enough for the questions for the time being, we will need to leave some time for the candidates to get into the interactive part of the session. I will leave that with Mr. Henry Schwann. Our colleague Mike is yours. Thank you. So at the moment, we've only one volunteer. Please do volunteer because the interactive session is not like our Viva session.
It's just a friendly chat to try and improve your presentation and to make this a more interesting topic. Can you speak a little bit louder? Sean, I can't get my apologies. Probably letting me saw some. Yeah so at the moment, only Mohammed mudassar has volunteered. These others please do volunteer because we are looking to make a robust interactive session.
So just to, you know, reassure these people who are in this webinar, this is not an exam. This is not testing anybody's knowledge. This is more of a learning for you. It's learning for me. Don't think that it is any question. I'm not going to ask it just to show some of these real cases what we come across or they can be managed.
Don't think that we are doing anything to test your knowledge. Don't worry, OK, we have more volunteers have come on. So we'll start with Mohammad mudassar and then we'll move on to the others. Egawa test, oh, that's OK. So shall we just go for the first one? Yeah Mohammad, sir, if you could also we can see you. Yeah so Muhammad, look at this images.
So you've got a sort of. I would say. Uh, he's only 50 eight, I think, 58 or 68. Forgotten, exactly. So see this. This is this is you can see that what is this is a CT angiogram is 3D CT angiogram of a pelvis, which shows a fracture of the right.
a sacroiliac joint at the level of its ileum, and probably it is going into the SEC really joint as well and. I do not appreciate any fracture of the interior, political realm and your pelvis. I know there is one on the left pubic RMI fracture, there is a fracture over there, so it's lateral compression type III fracture.
So you heard me telling the two or three times I repeated type III means you are looking either bilateral peel-back bilateral. Yeah so these are bilateral agreements. No, no. It's type lateral compression pipe. Yeah what makes you think? This is a type two, because I told you only one word that just one word will stop the examiner to ask you further because it's only one factor on the one side of the.
It's one that is the case in LC one as well. What made you say this LC two because there is a microfracture or the posterior ileum as well? What is that called? That is the word you need to use. Only one word in. It is. Uh, this is called a Crescent fracture press conference. So whenever you see the fracture of this stadium, you can see that the part of this alien still leftover with the AC joint.
This is like a Crescent. Mm-hmm So when you see a fracture in front of the AC joint here are very adjacent to the AC joint. That is called Crescent fracture. This is the Petagna moniker, very characteristic of type 2 lateral compression to injury. If you see a bilateral pubic railway in front of it along with this, then it becomes a type III. You see a 1 unilateral pubic remanufacture.
Then it is. It is just two years. So the a ring fracture is there in the city, axilo and the kernel Kurtz, I let me just put this is very obvious to just show that this is a fracture when there is a very undisclosed fracture in and coronal cuts in a CT scan. They don't come up in the 3D 3D images.
You just have to be way. This is a 3D city engineer because I can see the muscles is an Ngo or it's just the 3D. I think it's, you know, this is not a city Ngo. This is called contrast city. OK, so they put a contrast so that this is what we do. Whenever we get a patient, we got a more dynamically unstable. We do to a city that gives an idea whether there is an arterial contract, we believe.
So if it is not, then we know that it is a split. Yeah so this is the type Ii LC to and you see that you can see here. You can see here. So what is this one year? Uh, this is Uh, what is this one?
This is the shot top notch, so that is a great sciatic notch. Yeah so what is this one here? You said the superior is a superior radial artery, superior artery at risk. Is that clear? So you can see that, you know, the results are without line there. So this is a, you know, type 2. Like doing injuries, how do we manage this one?
So I will manage this patient, according to atlas, and boast guidelines. I will. Assuming that there is no area breathing as a problem, I would take the two large IV lines taking the Bloods blurred for gripping and cross matching and starts the IV fluids. And then I will examine the pelvis, abdomen and long bones for any bleeding.
If this is the only diagnosis, I would apply a pelvic binder at the level of the greater Rock Center. And according to the blood pressure and pulse, she may need blood transfusion as well. And I will talk to my major trauma center and. If possible, I will shift into major trauma center planned shift to the major trauma center.
I may have to applied to the external fixator if there is, Uh, if there is a time between the shifting, well, OK, that's fine. So you said all the correct steps. So this patient is hemodynamically unstable. You already transfused stay. It is of a normal saline or been collected when the unit of blood is still unstable and you applied the binder.
OK, I will. I will also give a transgenic insert. And this patient may need pelvic packing an external fixator as well. I would like to apply the external fixator in the data, which there are different external fixator type. I will apply the interior external fixator and I will apply.
I will do the packing as well. So shall I just stop you there just out to stop you there? The reason is that I told you this is a LC to fracture. And the LC two factor is, as I said, also that there is an display structure in the front, which is hardly even see here. The only factor which is obvious is here. Mm-hmm And you already applied the binder, which is still unstable.
What is that suggests? But there is some bleeding going on still where this is what this is Venus. Also this is a LC two type of structure. This is not even a sacral fracture. So there will be some bleed from this bleeding surface area crest, maybe some venous bleeding. So what should come into mind, this is what the examiner always you have to think broadly, so don't assume this is the only source of bleeding, but you clearly earlier asked what is this result, which is a superior gluteal artery, which seems to be intact here?
It might have been a little bit stretched. But there will be some bleeding. You've already applied the binder, the police is close. And the old stated, with the one or two units of blood and some fluid, you need to think broadly. There are other places to bleed. There could be. Abdominal so re-appropriate bleed can be a chest bleed, which has not been picked up.
It can be viewed anywhere. So you need to make sure before you, you go in the pack, the police and things, make sure that you exclude the other source of bleeding. So we try to close cavities. Yeah, so this is a LC to. You'll see two fractures can bleed, but they are very rare to bleed on to death. So it is a healthy three, very rarely otherwise vertical shape or APC three vertical.
Yeah so what would you do for this one anyway, if I ask you just isolated fracture, which should be stable? What would you do? Uh, this will need a fixation. You can do the posterior plating or the screws compression screws, Which one?
I will do the plating. So you would do the plating ileum plating because it's in different flat in the back or where exactly you want the plate? I will pay it at the back there, the ileum. At the back, Yeah. The you know, the Christian, the. So just let me tell you.
So the whole purpose here is to stabilize the ring. The anteriorly, as I said, there is hardly you can see any fracture. So here you've got the two options. Option one is that. You played this earlier. The reason is that this fracture very likely that either extends into the AC joint or AC joint is unstable by definition.
So and the fracture is widely displaced. So you've got the option one is to split this fracture from the front. Then you stabilize the joint percutaneous with the screw. The reason I want just to screw is that. So the screw in 3 point almost in there where I pointing myself. So you see that this is a completely flag fragment.
So you have to first make the two fragments into one fragment. You see there. So you make the two fragments into one fragment with the plates. OK then you go and put a screw, either it can go through there because you already joined, you already made this as a 1 1 one vote. You can go there if sometimes you may have to go through a year if you don't plate it, if you go a year, don't it doesn't serve any purpose.
It doesn't give any stability. That's why elderly patient. So they see that because of the osteoporosis, the screws are slightly backing out. In some of them, but they are not causing any trouble for him, just keeping a close eye on it. But the fact, it is here is fully mobile. He's back to work, but we just keep an eye because the metalwork is getting loose, get loose.
We'll have to take it out at some point. It's just more than six months or more than eight months now. It doesn't have any complaints. It just comes with a routine follow. So let us go to the next one. This we did not do anything on the front because it is on display structure, so we don't need to do anything rehabilitation wise. How long you will keep him non weight bearing.
So if you see that on the right side, they say joint is the key here. Whenever you stabilize the right side, I say joint with the screw. So ideally you would believe them non weight bearing or attach weight bearing for six weeks. So if the screw and the joint still looks good after six weeks notice, I let them fully right there.
Well, the key of the thing is that you are a If it is displaced, I would just put an in fix. In fix is the percutaneous procedure which majority of the people, you know, keep it under the skin they won't even see they are working. Many of them have been forgotten. Some of my patients are working with that for more than six months now. They will not come back so.
Just to be aware, intensify or there is something called the column screws. So if the fracture is the fracture is just lateral to this. This is after the formal. The factory is lateral to the substrate for women in this area. It could do even a percutaneous column. Screw it, I'll show you a bit later.
So one of the options is this column, this and this place. There's a displaced. I can plate it, you can go open and I can play it all the way or I can do percutaneous the fix, which I will show you some of the slides next. So what is this one? So there's a question about so about lateral compression fractures, we were talking earlier on about the indications for using the pelvic brace in this situation.
I couldn't get the question. Using pelvic braces for lateral compression fractures, what are the indications in those situations? So I told you to pass the exam. If it is, you'll see one fracture stay. It is a stable majority or stable treated conservatively. If the patient is the elderly, frail wait whereas tolerated, just repeat the X-ray one week begin at six weeks, usually the pelvic ring or you got a 3 views AP inlet and outlet these three views you need to be aware of for a pelvic ring, but a stable of fractures.
You need to do what is called juday debuts. Yeah, you get this, do read them and you can go through. Or if you want me to. There are some rays which you can look at it a bit later, we'll go, I can show you what this dude's view is, what is inlet outlet news? So is that the answer? Sorry, sorry, Mr cabana. My name is Chuan.
I think I was saying that. Is there any contraindication contraindication for using the pelvic binder? I don't know there is, as I said, whether it can be vertical share injury, it can be lateral compression injury, it can be APC any type. There is no contraindication. There is no literature that says even if it is a lateral compression injury, you can still put it on.
It may not help, but still you can put it on. There is no contraindications unless it is you've got a very big open wounds or you've got a very damaged skin or patient is very stable hemodynamically. You don't need one. It is the only one. I don't think there is any indication. Yeah, I agree with you. Thank you, Jason.
They're asking, so that was one of the questions being asked, so I just wanted to clarify that because no, no contraindication, thank you for clearing that up. There's no contraindication. They will criticize you if you don't apply. Exactly but they won't criticize you if you are playing. Thank you. Shall we move on to the next candidate? Yeah, AJ we'll see if you turn your camera and your mic on.
And we ask the other guys who are not participating to mute their mics again, mute your mic, please. So go ahead. Yeah so I can see it's a limited one section of the city, which is coronal images showing the coronal section part of the lower lumbar spine and the part of the pelvis and the right side of the acetabulum, the proximal femur.
On the left side, I can see there's a to increase the space between the AC joint. And also there is a step in the sacroiliac joint and I will check the further sections and check if there is any the injury I'm suspecting. Probably it's maybe a little compression or bas status compression, which involving the extensively on the left side. So what's going through your mind?
What's going through if you only answered now, but you are contradicting yourself? You said that there is a mismatch here. Yeah, it's a mismatch there. So it may be a vertical shear kind of injury or it may be a little compression which involved which may be a little compression type tree injury which involved the anterior as well as the posterior complete injury.
OK, that's fine. What is this one there? So it looks like that is the axilo image of the same patient, and there is an opening of the posterior sacroiliac joint completely and widening of the anterior as well. Yeah so see this one now. Simple that is the 3D reconstruction. The and I can obviously see there is at.
Spivack symphysis is not only open the slap as well, which is up and down and on the left side in PDP vehicle manufacturers and the bas status. There is there is a step in the security joint, so it may be a little compression or it may be a vertical shear injury. So I told you what is lateral compression? Why? how to differentiate vertical share a pure vertical shear versus lateral compression by 3 to be vertical shear.
There is a superior migration of the superior inferior migration of along with the fracture and a type t is the both anterior posture. Part of the cycle ligaments are gone or along with the both ligament is gone and also there is anterior fracture. So what do you see whenever you see this pubic symphysis there stresses? There is no fracture here, no fracture here, no fracture.
So it's an open book, it's open book type three, which is not exactly open book because it is my pelvis is vertically shifted up here. Yes so in an open book type three, you see a wide opening. Do you see a gap as well? But there is no shift in there. Yeah the pelvis is not shifted up. So here it is. Clearly, you can see that it is upward shift of the left hemisphere.
So this is one of those vertical, vertical aiming, you know, vertical shear injury. Yeah so how do you manage that? So obviously is the as per the latest guidelines, I will assess and treat the patient. And as per the post guidelines, I will make sure that he's got the OA oxygenation and like cervical spine is immobilized. And if that is secured, then I'll go further to look for breathing.
If that is secured, that is financial progress. For that to see part, which is the bleeding part and look for the bleeding examined from the top to bottom and check if there is any associated injury. It may be a chest injury. It may be interrupted abdominal or head injury as well, which may bleed. Or is there any open microfracture or any long bone fracture to stop there.
So just imagine this is an isolated injury and it is one of the major depression comes at around 11 o'clock in the NIPE to this patient. If it is isolated injury, it's a vertical shear injury. The mortality is quite high, so because of the bleeding, so I will resuscitate extensively this patient and start with the illegal after taking the bloods, including group and see if I will give the IV fluids and may need probably a few units of transfusion and sometime lead up to the massive transfusion.
In this case, if there is a further bleeding and I will apply the pelvic binder as well and stabilize the patient, and I will be in touch with the local trauma center, major trauma center or the pelvic surgeon as well. And once patient assist, I will scan further to look out for if any other injury is still causing the bleeding so that Friday NIPE that the local pelvic surgeon is drunk and is not to be contacted.
What would he do? So I will. So I will see the patient, whether it's stabilized or not, hemodynamically, if it is not, then I'm suspecting that he's still bleeding despite a blinding pelvic binder. So I will take this patient after taking his consent to the theater and apply the external fixator and which is the common one, is putting the two pin on the boat and behind the antero-supero-lateral spine and connecting with the external fixator to stabilize this temporarily.
And again, I will be in touch with the local major trauma center, the pelvicalyceal system. Yeah so what they expect you to look at is that you apply the binder correctly. You close the thing, but you see that this is a vertical shear. So what the bleeding sources are bleeding sources are when it rains, the home is bleeding surfaces, see that we are joined here is wide open. It's going up here, so you need to pull this leg down.
So should be still some reflection. So put a retraction, put the binder on under the fluoroscopy, try and put the weight so that it comes down and close the closet with the binder and rest it. So then the further steps you need to be aware of transmission protocols and then you can ask for advice. Sorry turning to an exhibit closet as well.
Yeah, that's all. So you are speaking about tranexamic acid. What is the evidence you have? I think there was some trial I forgot, which here I think is 2080 or something, which it is called crash to dress to trial. Yes so what is that says? It says that if it is given within one hour and then followed by 8 hours and three doses, then it reduces the bleeding and reduces the mortality.
I sure. Whenever you want to make sure that correctly, if you don't know these, don't answer. So the answer, as far as I am aware, you should give a tranexamic acid ideally within an hour, if not within three hours maximum. If you tranexamic acid after three hours. It increases the mortality rate. The clear, say, eight hours, which I am not aware.
Maybe I'm going, look at it again. Rush to trial. It's clearly. Within maximum time you are allowed is three hours. Anything after three hours, no benefit, in fact, it causes increased mortality. Yeah exum, so be careful. If the examiner, most clearly, you can just pull you down. Yeah, so very good, so.
Just to show you this is what we do. So you got this. Put the collection on the left side, which has been pulled down the leg, has been pulled down and see that we surge and this is a happy view of the pelvis. If somebody wants to start of be awake, so this is the opinion line here. This represents the period column and this is the clearest line.
This represents the posterior column you. So then you got this posterior wall here. We scored the dome here, dome of the establishment. Just go some, some more views down below. So this is golden in, let me in, let me. So you are seeing the police from. Yeah so what this is useful is to see that there is no antero posterior displacement.
OK, see that. So this is pretty much like rule one pelvic ring, ring, ring. Yeah, it's quite clear. Yeah, Yeah. Yes so and you are seeing this spectrum here. Yes One of the spectrum you are looking for. See that. So that is the anterior margin of the sacrum there and you've got the posterior margin there.
You've got the spinal canal on the back. So you are seeing the pelvis from the elbow. So this is an enlarged view to assess the anterior posterior displacement. Yeah so if you've got that the two screws there, which you saw in the AP bit left. That's what we expect. Yeah, this is all. Well, Elaine, this is called an old plate.
Yeah so I'll let you tell us whether there is a vertical shift. So that gives a good idea it would be a Sergeant. These activists are not very clear. But that is what is meant to be. And also that shows that you see that the four men are here for men should be avoided and put the screws continuously. And also, it will tell us how much longer the screws are there still inside the bone, not outside the boot.
OK, the next one. So just to go through the next one, quickly see that this is another X-ray. Another trauma. So this is how the patient had a CT scan. This is very interesting. Have a look at it. Did you see anything much happening there?
Sorry, sorry. Just a second, Mr schwann, do we have a third candidate just to distribute the benefit for everyone? Sean I think it's as if. OK, so sorry, a.j., it's just to give a chance to other people. Thank you very much. So as if are you on? Can you unmute yourself and put the video on, please, I said.
Excellent Hi. Yes, Mr campanha, sorry, the floor is yours, sorry. So this is again a trauma who came who had a CT scan. This is what the CT scan is. So can you see anything much here or this is a CT scan? I can see the lateral side. I can see ideal bacterial line. But on the right hand side, I cannot see much. So I need to go through the proper coronal and sagittal sections and then I can comment on it.
I can see there is a small flake fracture on the top of the right sacral area. I'm concerned about the anterior, so I need to go through again more sections and coronal sections. One second to 5 minutes. OK you are very good, actually. You picked up very nicely, which is not being picked up by one of the not what hospital it's elsewhere.
One of the axilo reporting radiologists couldn't pick it up picked up very nicely. Very good. Excellent So what is this happening? What else you can see here? So is something going on in the right sacroiliac joint area? It could be central posterior disruption could be tied to could be tie three. So I need to look at the fact that there is no opening up of the anterior seco joint, which is fine, looks fine.
It is less than 2.5 centimeter. So I need to look at the more detail. I mean, the sagittal sections. Uh, this is a axilo card that gives I don't know what you are expecting in a sagittal. There's nothing in the sagittal v, so it is disruption of sacroiliac joint. I have to assess the patient. I will follow the protocol, do the primary and secondary survey, and I will make sure that the patient has no neurological deficits.
That's all done. What else? What else come to your picture here? What else? You can see that this is CT scan. Just so you can see anything else. Have some concern on the right hand side there is. In Alex Bowen, there is some disruption. Yeah, yeah, no, this is a little bit you, you already picked up you on the left hand side, I mean, on the left hand side in the sand?
Yeah, somewhere down. But no. You can see that. What is this one? So there is a pandemic, but a big binder applied already, so it means this could be the misleading. So what happens when we apply the peel-back binder? It compresses.
It brings back all the structures, so it gives you a false impression. And I can see on this section that there is sexual alia, there is a left wing fracture. I so there it is a part of yeah, yeah, I agree there is a small fracture there, but you don't see different already, which I assure you. So just so this is what this is one of the Mr. As you can see that clearly.
What these are the telltale signs. You can see that a say joint ligament is all steel. Mm-hmm But because of the binder, somebody has put the binder in such a nice way. This is completely closed. If you go here. So the guy is in a lot of pain. They took out the binder saying that everything is normal, so. See that what is this?
Yeah, so on a preview, I can see there is opening of a symphysis pubis. It is nearly 2.5 centimeters, so. And looking back with the sacroiliac joint involvement, it is tied to intra posterior compression injury. So if the patient is hemodynamically stable, then I will transfer these images to the local regional center and take their advice. So this is one in the guidelines, it is there.
This is what I wear. What I'm showing in this X-ray is that you need to have an X-ray out of binder, especially because all these trauma patients get a CT scan in binder majority, but it should be done in the theater, you know. So what happens is that when the patient comes to ayeni, they do a CT scan from a city, so they do put the binder on. Once the patient is resuscitated, they're in Haiti, so you can slowly release the binder if the city is normal at that stage.
You need to take an X-ray out of binder. So they see that this is a clear example. So when we see some telltale signs are there, the pubis is well closed. So this is what happened in one of the hospitals because it's not been picked up. Patient was being left like that. A lot of pain thinking that there is nothing wrong. So this has all been picked up.
So this needed further. This is a classical type to APC. So fixing that. Yeah so I can see that it is entirely fixed with the reconstruction plate, with screws and on the back, it is fixed with the ideal sacral screw bilaterally. I suppose it's percutaneous. Yeah, yeah, that's correct.
So I'm taking your time too much. So let us just go here a little bit quicker. Anybody can look at it. So this is again, is this the next case semester, campana? Yeah OK. Thank you, Asif. This is the next case. I think the last one, I think, is Danish LTF Danish. Yes Yes.
Danish are you? Can you unmute yourself? Yeah yeah, I have unlimited myself. Yeah, perfect. Thank you. Danish OK, yes, Mr. Campano. Yeah, so this is another polytrauma. You can see that this is a CT. Coronal views.
Anything we can see clearly. Yeah, from this CT scan, I can see there is an opening of the sacroiliac joint and that joint is here that is not opened. So you see, and there is a fracture of the fracture and the spectrum is probably in zone 1. Yeah Yes. Yeah so far in these sections, this fracture, I can see the fracture more clearly now.
And it might be involving sexual phenomena as well. Yeah, of course, Yeah. And it could be. And that's so it's a little bit of opening there. So what is this one then? So second, but I've not seen any further images to see the injury. Uh, yeah, I think probably missed there.
You can see here, actually. So you can see the interior. Yeah, so it's Uh, and it's a unilateral remedy fracture with the cycle of fracture. So it looks it's LC to LC to compress a little compression fracture of this is a little confusing for you because we don't have in a proper cuts. There there is a UN displaced crack, which is going on here.
There is a factor which you can see. OK Yeah. So factor, this is a classical LC three, LC three. You don't see that it's all being stabilized with the percutaneous screws on the back. That's a big fix was. This is all a fix, which is a percutaneous right. You don't have to make a very big cuts. Small cut.
This is a spinal cord. Screw goes in there. Yeah, the one there supply stapler expects area and connected with the cutaneous rod. Usually, we take them off after four months. So see that already patient probably started healing. Yeah Yeah. I thank you.
Thank you, Dinesh. So I think these are the only candidates who volunteered so far to me one more. Yes I just wanted to say the all, you know, APC two, you'll see three secretaries. So this is another. Another patient hypervelocity, youngblood, I can see that significant injury. So this is what I was trying to show.
The anterior column is fractured here. Posterior column again, that is also factor in. Six of the columns are gone. So the fracture is here. So let's say so. You need to be aware of the established classification that all would be 10 times between been described by Judy. So there are five elementary type. That means only a single fracture line, five of them and the five of them, another five of them has got more than one structure.
They are called an associated type. There are two types totally 10, four, 5 plus 5 in each group. Five so you just have to be aware. So you can see that this patient, in fact, has got some fracture around or a joint widening the associate what we can see there. So you see that the site is pretty much wide open here. Or maybe some factory. So significant established fact.
See the. So that is again. 60, the establishment is fixed, which date back. And see that the head is back in place. It's one of those stupid calls tuberosity nameplate, which we use to push this head out. Yeah, there's some breaks, which we put to. So the essay joint established with the group, we call them Saudi Arabia, Kessler Kessler plates.
Only a significant political subplot, but this is another one, this is just to show that these are on display structure. This is a column fracture on the left side. So obviously. So again, the sun displaced factor in here on this play structure here, you can see that. So there can be managed with what is called the column schools.
So this is a happy view. You can see that this is the anterior column, but the school is in the posterior column you. So this is in the anti-terror column that is in question. Look at the next one. So this is a year. This is the idea. Public with peel-back public view shows you are your column. See that this entire thing is.
It is the skills fight. It is the skill tuberosity that is the question of the is in the posture column. So the entire column is war left here. This is, again, the posture arm of the opposite side. So look at the next one. So this is the. So that school is in the anterior column, that school in the posterior column.
Here you can see that is in the posture column. So on display structures we manage with the percutaneous. What a continuous thing, so any questions, guys? Sorry, I kept you for long. No, actually, thank you very much, Mr. That was a lot of dedication of you, this was very informative and I think people need to digest it, so they probably need to listen to a couple of times because you've covered it really, really nicely.
Fine, guys, this is the chance of you if you have any further questions. This is your last chance to ask because the next bit will be the Viva. I think we have time only for one candidate for the Viva unless everyone is tired. And if you want to the Viva, please the people who volunteered for the Viva, you are allowed to withdraw if you want.
If you feel tired and exhausted. If you still want to go for it, just raise your hand on the near you name on the participants. You know they all need a food. Actually, I think so. I think so. But because we promised some people that I would like them to withdraw rather than me apologize to them.
Yeah, I think all of them all for four of them actually has been involved in interactive talk. Fair enough. Yeah, so perfect. If that is the case, then what remains is to apologize for everyone, for doing, for cutting it short for the Viva. But I think that was worth it because this talk is very important.
And as you can see from this, it can branch into many aspects. It can go into massive hemorrhagic protocol. It can range into battles. Both guidelines fracture classification stabilization, thinking outside the box classification and all of them have been covered nicely by Mr campana. What remains of me go on Mr combiner a lot of time, but right as much as possible. But do let me know if and you can.
You can put our, Uh, the our press got that hemodynamic instability patients protocol. Absolutely I will once I will put it on Telegram group. And guys, if you missed to ask any question and you want to ask it, please put it in the telegram group. I will pass it on to Mr Campano and give you the reply again. Absolutely no, no, no concern at all. No problem at all. Very pleasure.
Thank you very much. Have a nice evening bye. Thank you very much, Mr campana. May I thank you. May I remind everyone that you can request a CBD for this talk? Please get in contact with feras, and he will be very happy to provide that. In addition, please listen to this talk again on the YouTube and it will be on YouTube, hopefully within the coming couple of days.
Again, I thank Mr Campano deeply for this informative talk and looking forward to seeing you again, Mr Campano. No worries, sir. Thanks and we'll see you then. Bye thank you. Thank you. Now, guys, may I ask the members to stay on?
Segment:0 .
Good morning, good afternoon, and good evening, everyone, and welcome to our weekly webinar with the FRCS mentor group. We are privileged today to have Mr Campano delivering a very important topic in the exam. This is pelvic fracture. It comes in many forms and shapes, and many questions are asked around it.
So Mr Campano is well equipped to talk about this and I will be introducing him in more detail in a bit. Before that, I wanted to talk to you about the courses we deliver for the vyver courses, for the farces. If you are interested in that, please go to our website and you can register register for the upcoming course. These are held frequently and manned by experienced staff. In addition, you can register on arteriogram group, where there will be a lot of discussions about this talk or other talks that we've had in the past.
In addition to plenty of resources handling all aspects of the FRCS exam, in addition, we've got a book which you can see the picture behind me about it. This is a summary of the whole exam. Please, you can get that book from all reputable bookstores, including PDF version and sorry, online versions. Now, the talk itself is interactive and at the minute in the middle.
There will be a chance for you to participate in teaching cases, which Mr. campana has prepared. So people who are interested in that, please let Mr. Henry Shawn Henry know that you want and he will keep your name for the interactive part. In addition, today we will be doing a Viva. And if you want to be considered for the Viva session, please let Mr. maiman know.
In both cases, you can please use the chat function to talk to them directly rather than Raise Hand. Because raised hand can mean many things for, you know, we don't know whether you wanted the interactive part or the Viva part or what. Lastly, but not least, if you have questions about this talk, put them on the side and we have two mentors who will be looking after these and delivering them to Mr. Campano at the end of the first part of the talk.
Now that admin bit is over. May I introduce Mr. campanha, who is our consultant in Salford hospital, dealing with pelvic injuries? He had his MS in India and then completed his orthopedic training in the UK. He had two fellowships in Southampton dealing with hip and pelvic surgery for 18 months. Then he was a locum consultant in the MTC in Southampton, then at 18 months as a consultant in MTC, which is Salford.
So he has seen all sorts of trauma and he deals with trauma to the pelvic in all its forms, including femoral head fracture. He is currently an undergraduate examiner, and soon, hopefully he will be an examiner for the FRC. Yes, so who better to talk about this from the FRCS part? Apart from him, without further ado, I give the mic to Mr Campano and the. No, it's not me.
Well, if you. And yeah, thank you. Abdullah, Thanks for giving me this opportunity to speak. Good evening to everybody. My name is Mr Campano Vijay campana, as I said. We were here in Salford and I work before in Southampton as a consultant, so this is the fourth year of as a consultant. So basically, I was being told that the role it's ongoing here, so I don't think that I am a lecturer here, when your experience there.
So this is pretty much interactive, whatever the questions you have and more than happy to answer to my ability. You can interrupt me anytime when we are going. So the public structure itself is a very, very big topic. It takes good at least three four hours if I just have to go through everything in detail. I would just concisely few things which are very likely to be asking.
So we'll just concentrate more on that sort of thing, the examination side, rather than going into a full theoretical which is there in all the books anybody can at any time. So that is. A blow do. Yeah OK, so this is my little introduction, Thanks to Abdullah, so it has given already.
So there are a few facts you need to be aware of this pelvic fracture. So there are so many things which is written in the book, but what is being to be expected in the exam or what? You need to be a very concise few things which you need to be aware. So it's a high energy injury and most of the young people or it's a fragility fractures in elderly patients. So then you need to be just awake.
There is a 15% risk of mortality with diplo's fractures. And it is a 50% open practice, so these are the figures which you just have to be aware of. So there are other injuries which comes later, but the examination was one would like to know there's a 50% mortality for an open fracture. That means every second patient can die off. So you just have to be very well aware of this and how to manage this.
It may come to that. So the other group, which you have to be aware which group of pelvic fracture patients or high risk for a high mortality. So you just have to be aware the elderly patients more than 60 years with the fracture and the systolic blood pressure 90 and below on presentation people with the increased injury severity score.
So the injury severity score, if they really go on to ask exactly, you need to be aware what is the injury severity score? How do you measure this is one of the trauma scores which all of you should be aware of. It's there in most of the textbooks. For this particular pelvic fracture severity score of more than 17 is high risk of mortality. You just have to be aware of that figure.
But generally the figure is around 50. But if they go for specific, say, that is a 70, but please do read what this injury severity score. There is something called a modified injury severity score now, so there is a difference between these two. There were some flaws in the original injury severity score that has been rectified in the modified score. We still read about this. The other category of patients who are high mortality is people who are needing a very high transfusion, especially more than 40 units on average, and they are the high risk of mortality.
And the other category is APC, which is the antero-supero-lateral compression injuries. Three the vertical shear. I'll come to that a little bit later. What is this APC three? What is this vertical sharing? So the other ones need to be just gently aware. Is that associated injuries? So these ones are there in every book.
So any trauma patient with chest injury and bone fractures, spine fracture and one more specifically, we have to mention with the pelvic ring fractures is a sexual dysfunction is up to 50% in the beginning stages, especially anterior risk factors. So that means that one needs to be aware of this complication when you are dealing with the unexpected.
So the other important thing is that had been the abdominal injury, which we'll come to that later and the neurological injury, which is around up to 30% So there are certain guidelines which I'll tell you a bit later, and there is this ones out there on the website. How do we go about managing this? So next, come to mechanism of injury, which you all of you know, which I don't, I just thought that I should just present this ones all in the book.
Don't need to go much details, but I'll just briefly go. So the first one is the APC intraoperatively compression, which is that means you are being hit on the front of your pelvis. The lateral compression, which you are being hit on the lateral side of the pelvis, the vertical shear, which is a heavy pelvis, migrates approximately and the combined AP and lateral compression.
So that can be any form. So this is the classification which some of the world orthopedic surgeons are still using this. So Thailand panel classification, this is basically based on the stability of the pelvis. So these points are being very straightforward, so you can only say that which are the factors which are stable, which are the factors which are occasionally unstable and which are the factors which are not rationally and vertically unstable.
So these are three categories type axilo. So EPA is the stable link factors which are there. So these are the ones. These are the question factors of the tuberosity, which is one of the common things which can happen. The high impact plates of the anterior inferior spine, which you see sometimes in adolescence when there is a secondary acidification sentence, fuses, they say, pull off of the rectus the ADA I'll explain that is a second common.
Then the, you know, the anterior and superior spine, sometimes severely. So these are the sort of coalition factors, but if you take it overall, the ring, the ring is made up of two bones and the sacrament, the backside in the middle and there were two separate joints and the strength is being connected with the symphysis. So the water ring itself is intact in this category. So that's why they are stable.
These are the stable injuries, majority of the damage. They do need surgical intervention. But however, they go for a details and a highly displaced, which is a massively displaced spine or a skill tuberosity. You do fix them. We do fix them in a high performing athletes or high performing individuals, so we don't go and fix these fractures normally. Very unlikely.
Martin, definitely not in a sedentary patients. So pain relief and they can carry on with demobilisation. So the next category is pelvic rings, which are occasionally unstable, politically stable. So these are the ones. Which are weapons in the front? It is an open book type of factor where the terrorists are both highly oppressed, open up with the pubic symphysis.
So they are rotational and stable, whereas vertically they are stable and see that both the Si joints are still intact. The posterior joint ligaments are in. That's why the pelvis will not shift, of course, are downwards. So those are the category of patients. You can see that the compression equilateral type that is another example.
The next comes to type C. Type C is the one where you've got a vertically unstable, which are also rotational and stable. So these are the ones where you see that the APC three posterior compression type of injuries, which I'll show you in a second. What are these and also these are the ones to be vertically unstable is a vertical sharing duty. You can see three LCT. So let us take some pictures of these just so that we can understand better.
So this is a classification, you can see that clearly we will see. So in the first one, sorry. So you see that in the. I'm just. So so you can see that taipei, the. So there is an abortion fracture there, that is the elite wing factor.
And so in taipei, which is a traditionally unstable. So you can see that the open book structures are. Whereas even the lateral competition one of these types, which is also educationally unstable. But these ones got the impact posterior salesman. They are vertically stable, so type III is the one can see that. So they are unstable on the posterior wing, as well as anterior links where the image can be shifted upwards or downwards.
So those are the ones which are type C. So that is the one which used to be the case where the world type of surgeons use. This used to be much more commonly before. But now, most commonly, the practicing surgeons across the country use this one. It is. The England is very concise. It will even by, you know, if you tell me that it is a bc one, I can imagine in my brain how the APC won, what will be this structure.
So that will tell the direction of the force the type of fat and C that. So the. You can see that in the. You can see that in the first line, you've got a lateral compression types. The second line you can see the ABC, you can third one is a vertical shear.
This is the classification of inverted burgers, which is commonly used by a practicing surgeons. There is a one more classification called egawa, or a egawa. Classification is not for people who are practicing. It is more of a research purposes. But this is the one should be aware of. So if you look at the first line lateral compression injuries, so how to remember this?
Remember type one, type 2 typekit? So just for your knowledge, just for majority of the times the exam, they will not ask you. They are not very particular about the type of classification, but if you can show that you know, that will make them much more clear. So the three types of lateral compression you can see, so type 1 is the one where you see the only one side of the pubic is fracture.
So this is a very common thing in practice whenever we see. You see that you get a lot of referrals from a medical side. So they say that, oh, got this 85-year-old patient, the pubic might fracture. What should we do? So if you look at these pelvic ring ring is like a problem, it will never break in one place. When you see a 1 break, it will be invariably there will be a break elsewhere.
So in the LC one or a lateral type compression lateral compression type 1. You can see that the. You can see that the unilateral one side of the pubic Ramsey's factor when you go and see them in the x-ray, you can't see much in the sacrum because of the complex anatomy. But however, if you do a CT scan, you are very likely 95% and chance that you will find a fracture on the sacrum on the backside or be a Si joint.
So it all depends. On the patient, whether you know, whether you want to do a CT scan or whether you can say you don't need any staining scan. So I am happy with this, this compression type 1 injury. So the reason why I say is that most of the textbooks is lateral typekit compression injuries are managed in the. But the things are changing gradually where there are certain category of electro compression injuries or unstable when we fix them.
But in the examination, just to go through to get to the past for all theoretical purposes. If you say lateral type 1 injury is managed conservatively. So that means that you've got a unilateral structure, but the posterior fracture will be in the sacral. So that is a type one, whereas in type two, in the anterior, you can see that same unilateral fracture, but you can see a big microfracture or the iliac crest.
And that means it is a segmental fracture of the ileum, so anteriorly at the might was really just around the AC joint. So you can see that picture so that I will show you some X rays, but later you can see what is that type two? So this is called a Crescent. So this is a Crescent fracture. So it's very typical of.
Yeah, so you can see that it's very clearly. So this is a very typical of type 2 APC poster compression injury or satellite compression. So then comes the typekit. So what is the difference between type III and type two? So type three, you have a bilateral pubic grammar. So when you see a bilateral agreement, you can pretty much imagine it is a type thing.
And invariably when you do a CT scan, you can see that will be either a fracture in the ileum or fracture in the sacrum and the posterior. So these are the type of lateral compression type. So type 1 is managed conservatively. You let them wait with majority or, as I said, a fragility type of fractures. Whereas type Ii and type three, they are unstable type of fractures, they are unstable radiological and the type III lateral compression injury can bleed up to 2 to 2 meters.
So that is one of the high risk bleeding fractures. So that is about the lateral compression. So next comes the APC, which is a very common. And so this is, in other words, it's called open book pelvis. You see open book pelvis when you hear that word that indicates it is an APC, the posterior compression. So type one, you can see again, a small gap, but the pubic symphysis.
So the disruption of the pubic symphysis ligaments here. So usually it says the sensitivities around 2.5 centimeters or less, why 2.5 centimeters? What does it indicate? Why not centimeters. So the 2.5 centimeter of opening at the pubic symphysis here, that indicates the disruption is only at the pubic symphysis ligaments, whereas disruption on the backside at the sideline and the sacrotuberous and the circular spine ligaments are intact.
So that means that only one set of ligaments, which are different, which are damaged, whereas the most important ligaments in this pelvic stability is from the ligaments around the joint posterior joint ligaments are very crucial for the stability of the pelvis. So that is, the type 1 is less than 2 2.5 centimeters opening, whereas type 2 is more than 2.5 centimeter opening and the pubic symphysis.
So what is this 2.5 centimeter? They said you can see that in the picture. So you can see that in the picture. So sacred and the secular spineless ligaments are ruptured here. So what does that do? As soon as that ruptures, we can see on the back side of what I say, joints say joints are just like an inch.
So you've got a 1 in different injuries on the back. So if you walk on the front page back in, just open, so you see that the left Kessler joint is opened up there. So that is the type Ii typekit means the anterior joint ligament or rupture of the posterior joint ligaments are intact. That's why this happens, but it is not completely unstable because the posterior side ligaments are still intact.
So that is type 2 APC, whereas type III. Again, the complete rupture of the pubic symphysis here in the front and the back, both anterior as well as the posterior joint ligaments are completely rupture. This entire ileum is literally about to float, but it is still there in place. But if it moves up or down, then it is called vertical shear vertical.
So one big difference between the vertical shear and the APC tree is that the APC three, it can become a vertical shape. But in the APC three, it is the mainly ligament injury where you want the AC joint ligaments, which are described as the anterior Cramer's symphysis, which are being disrupted. So the entire item on the one side and the left the right.
Or left right is completely unstable. This is one of those nationally and vertically unstable, whereas if you look at this type B or type 2 APC, that is potentially unstable but vertically stable. So next comes is the vertical sharing, getting vertical sharing. You can see that off of the Middle East. And we should get up. So this is one of the most dangerous type of practice which we come across.
The mortality rate is more than 30% to 40% in these vertical share injuries. These are the ones very high risk for bleeding. So the risk of bleeding is very high in this because they can tear apart the important vessels which are just present in front of the joint in front of these important vessels in front of the Kremlin or our external vessels. One in front of the joint is the internal passage so they can bleed like a tap.
So any questions about this, this classification, anybody wants to ask any particular if you feel got any, any doubts or anything or any easy way to remember. So this is what so for the lateral compression, if you see one, do one side. One side of the crema is fractured, usually the C1. But an associated factor is two, as bilateral peel-back is LCT, but there can be compression.
It's just a 2.5 centimeter or more than that. It's opening in the front. So all all, the APC are open. Book just the severity. So just to be aware that sacral fractures are very common, which many of you probably will not come across. If you start doing a CT scan for most of our elderly people, my fractures, you see this.
So majority will have an associated sacral fracture. The role a fragility type of fractures in them, but in the young people, it is the high energy injuries. So just to be aware of this. Normally they won't ask you, but I think you just have to be aware. So there are three types as per the Danish classification. So what is the significance of this classification? Why?
why you need know. So whenever they say, whenever my registrar calls me and say, this is a zone 1 region, I know that this is a very less risk of needing less risk of injury. Whereas if they say type 2 or a zone, then I know that the risk of narrowing it is quite high because it involves the signal from when the narrow routes axilo. So these are the.
And with zone 3 is in the middle of the sacrum where the spinal channel and I quote nice word. So if you look at the zone one, that is this the lateral sacrum, layla, it's called. So this is the area of the second. The risk of nerve injury with these fractures in this zone. Less than 6% Whereas zone two, which is around 25 to 28 percent, don't rate is 55.57. So just to be aware, I'm sure they're not going to ask, but you just have to be aware if you're an Air force is taking it, they just expect you to as they are, at least for a theory, it may not be practical, but here they may ask these things.
So in zone 3 injuries where there is a high risk of nerve injury, they are being further classified by they called right Campbell. You just need to know, but I'm sure this is not going to be asked. This is only people will be aware of this when we start getting worried, some fellowships they will know or some of them even know. So the type III of Dennis classification is further classified by Roy Campbell.
So just say that it is a flexion and extension type, I wouldn't go more than that. You see that flexion type. But it is the distal fragment flexes forwards. Uh, whereas the extension type, the distal fragment displaces distally. But in the example they certain they want us just to be aware the name right classification.
But this is a very, really specialized for police to deal with. So the other thing which you need to be aware is this one. So this is a dangerous variety of fracture we see is not being described in your Danish classification. So this is called spinal fluid dissociation. So whenever you see a bilateral sacral fracture. So that is sort of being classified under the spine of dissociation.
So if you look at this type I where you got a new type, so if you see that this is a yes, one body sacral first, the second body, and if you see that the fracture on both sides, there is a fracture here. So this yes, one is with the rest of the lumbar spine. So the rest of the pelvis from one on either side and below is completely cut off from the rest of the spine. So that is the reason why these injuries are called spinal pelvic dissociation.
That means the pelvis is dissociated from the spine. They are a very serious injury, very easy to miss, and one should be very well aware of this. So these are further classified into hedge type, where the just goes all along on either side and you've got an associated control structure. And you can see that it is a lumbar type. Then it can be a key type. So what is this significance?
Significance is that the spinal dissociation that indicates that a very high energy injury number one number two is that how you discuss nerve injury with this number 3 is that this needs to be sort of managed specifically by a specialist in a specialist center. So that's what you need to be aware of this. The management involves. Unless the patient is medically and one is involving the lumbar fixation and connecting that lumbar fixation to the pelvis.
So just I'm giving a brief idea. I don't think they've lost these things in detail, but just to be aware, the spinal pelvic dissociation management normally involves so. No pelvic fixation, I'll show you some pictures a bit later as we go along. So another thing for the FRC is what the examiner expects you to know that there is a risk of 15% to 30% risk that the urological injury.
This is one of the important things you really have to be aware of. The complex injuries, especially a type III lateral compression type one, the APC open book injuries, the risk of bladder. The bladder is just sitting behind the pubic symphysis, so bladder is just behind. The peel-back comprises any sustaining. If we see a proportional compression injury that is directly in front of you.
So the risk of rupturing a bladder or risk of rupturing the urethra is quite high, around 30% So there are certain signs which you need to be aware. So these are the signs when is that blood test bruising around the groin, bruising around the scrotum, unable to pass the urine and unable for you to pass the catheter with the fear? You can see that highlighting it's all there in the textbooks you don't need.
So I'm only just trying to of, you know, you what you were. How do we diagnose them? So any patient who can't pass the urine or any patients, so or when there is a blood in the urine, what you have a suspicion that this patient is likely to have one of these, either blood or rupture that case. So as an Air Force candidate, you should know that we should try attempting to pass the catheter gently when we want attempt.
If it doesn't go, stop there. Don't try to damage further. You have to involve the urologist at that time. So that is the baseline. So don't try to attempt more than one early one gentle attempt forcing a catheter. So as a pelvic fellow or pelvic guys, what we do, we do do this histogram put the dye directly into the bladder or we do retrograde.
So that will tell us where this rupture is. So there are guidelines for these guidelines is called vague us statements. It is there. There are around 20 points in the various guidelines. You need to know only 20 points, but there are salient features. So just salient features. What we practice normally in normal practice, if it is an extra bladder rupture.
The urologist, they don't repair them what they do. They do manage conservatively. They do either go for a suprapubic catheter or they can manage to pass a catheter by using some sort of methods and they will leave it to heal up if it is an improper toenail rupture. They do repair. So this is just a general guideline, but there are very specific guidelines there if you go to the guidelines.
There are some guidelines. There are some points in the post guideline as well. So please go through those guidelines, which is very important. You have to mention this the example in your answering urological injury associated with pelvic fracture. They're all very clear. So I don't want to go there because it will take a timeout. So other thing which you need to be aware is the source of hemorrhage.
So what is, you know, everybody speaks about fracture means big to them. That's what the imagination impression. What bleeds, really? So 80% of our pelvic fracture bleeding comes from the venous. And part of it. 80% to 90% is from the bleeding wound surface, especially if got a bone fracture. They bleed like a small artery.
In fact, so and we venous there is an extensive venous plexus, which are just in front of the sacral sacrum on the AC joint. So that's why the posterior injury is especially bilateral sacral fractures or SSI joint disruption. So you can see that there is a significant venous bleeding. And so when did 10% with the literature? With our experience, we know that the risk of arterial bleed is 10% So you don't need to be too worried that the film is always builds with the artery artery bleeding is only 10% These figures, you need to be aware.
The reason is that. This comes with the management. So 80% of 80% to 90% comes from the Venus venous system and the bleeding goes. That means you do restore this anatomy and make it a closed space pelvis. When it opens up these venous plexus bleeds. So just contain that pelvis back there with the binder or some form of closure of the pelvis so that it can open it once it bleeds to a certain level, maybe a few liters, then it acts as a component.
So if it is a venous and the bone surfaces, they will stop. But if it is arterial, they continue to bleed. That is only 10% among the factors. So the common arteries, which are likely to bleed, is a superior group of artery external internal alia up to the differential artist. So there are nine branches of the internal area. But if you want to be very specific, so I'm not sure anybody would ask all the nine of you.
So just be aware of the superior artery and the Mortis whenever you see a fracture from Novartis, which is very, very close by. That is a risk that can bleed whenever you see a fracture on the right side. That's where the superior duty rebuilds. Whenever you see a disruption of the posterior ring, especially around the joints, especially the practice of the sacrum.
They are the ones which can cause bleeding from the internal artery, which is just in front of them. So I can tell you, what do we do in these cases. And there is an algorithm, how do we manage these, these unstable that we will tell at the end or I can pass it on? This is the algorithm regarding managing a bleeding pelvis or unstable hemodynamically.
Unstable patient is based on each individual MP system. Everybody has got a different protocol, but I can pass it on to 1. What we have in Salford to beloved later. So this is just a picture to show how big the results are, so extensively vascular. So they can bleed like anything, so just to be away. So let's see that the commonality apart, really wading into external and internal and further into the similarity in.
So whenever we see a pelvic fracture, this is one of the examiners they will put up that x-rays, they will show some sort of you'll see one or two type of fractures and they will give a scenario of unstable hemodynamically, unstable patient scenario. So you have to be aware then this is one source. But there are other sores which you have to have a high suspicion.
So one of them can see that if there is an obvious open wound, she can. You know what is bleeding but the chest? So this is a very, very, you know, easy to miss. These closed spaces, especially for x, can accommodate up to 1.5 to 2 liters of blood. So one has to be very aware that in a chest is a source, it can bleed. Then we have abdomen retroperitoneal space to 2 to 4 liters in the long bone fractures, which you all know of someone who fractures or they can bleed.
So what category of peel-back fractures or high-risk for hemorrhage? These are the ones so vertical shear is highest. Next comes APC three. The next comes is the Limited. So we saw the want, which are very high risk for bleeding. The political factors, the other ones also bleed, but they are not known to cause a mortality. They bleed to death, so they all have some bleeding whenever you see a fracture, like the type one, type 2.
If you see a city report, there will be some bleed. So but they are all, as I said, you know, solid majority stops. But these are the ones that can be associated with arterial bleed and they can tear apart a big vessel. What a small was. A big was like internal or external electric. All that. So it just out to be examination report.
So people do have to be aware these are the high category, high risk category for hemorrhage. So whenever they ask an examination, the stability, when they are putting these X-rays up to the pelvis. You have to be very clear whether it is a radiological instability or it is a patient unstable, which is a hemodynamic instability, you have to make sure. Which which instability they are speaking about.
And you have to be very clear about it. So as I said earlier in the classification type, you know, type two, type three, lateral compression, type two, type three, APC and vertical shear, they're all unstable, ideologically unstable. You've got to be able except type one, type 1 lateral compression, put the APC. Or considered as table rest, all the ideologically unstable, but the hemodynamic instability, which I'm sure you all know, systemic blood pressure pulse the other factors.
So what defines the shock, so hypertensive shock, the all part of this hemodynamic instability? So next, I just wanted to put this picture. The reason why I put this is so everybody has to be aware of this, so sometimes they do keep this in the examination. So this is a pellet binder. This is the we start with the management part here. So management wise, we'll start with this requirement.
So the first and foremost, whenever any quality of operation on site seen by an ambulance crew, the first thing they do is that they will check the blood pressure, check the pulse and see that there are any signs of bleeding anyway. They will go unless it is a long bone open bleeding wound. So our open wounds, they always do and put this spine around. Well, I'm showing this picture, it's not that you don't know. You all know that this is a public binder, but one should be knowing clearly where to apply this correctly.
So the Velvet binder is meant to apply art where you can close the pelvis so that one not at the crest level majority. When we see in practice, we get a lot of these referrals from the peripheral hospitals, bring this binder around the crest where you feel the way you feel you are pressed for stability. It's not. This should be centered or the predator control.
So the Velvet binder should be centered. What the legs should be internally rotated. This two, those two big toes together that itself will help and put this binder and close the binder and tight on this binder. So that is the one which closes the pelvis. So one could think, boy, well, this is quite good for the APC open book pelvis. Yes, you need to close the pelvis, but is open it plausible, but there is no contraindication to apply this.
Any pillow doesn't matter. It's a lateral compression. Doesn't matter. It's a vertical shape. But still you can go and play in a bleeding patient. There's no contraindications for that. And that is the correct side to be applied. One more thing to be aware and in examination, if they ask. So ideally, both guidelines also says clearly this pelvic binder is temporary.
You should not try and leave it for more than 24 hours. With more than 24 hours, there is the risk of pressure sores, risk of skin at risk. So you have to have an alternative after 24 hours, either looking to put an external fixator or looking to do definitely fixation, or you can try using this binder after a certain 4 to six hours. You see sometimes blood clots inside the pelvis, and it is very unlikely to dislodge unless you keep moving the patient.
So you just have to be aware. So this is a sick plant they used to use previously, but not commonly used nowadays. So see, clamps are quite good. If you see here, I just got it, few sharp rods. So these schools will be a staging area. The one downside about this clamp is that those are supposed to be really it doesn't close the ring.
So they used to use this. It is very, very rare. It's only taught in some courses just for sake. Practically, we don't use this one. This could be a red Velvet binder is used everywhere, available in most of the big cities, most of the hospitals across the UK. So just to be aware that this is one of the things which the examiners expect, this is another one.
So this is just like a magic garment. But this is certainly not in the civilian practice. This is used in military practice, but I don't think we need to be aware of the risks comes with that. There's a very specific time we need to apply. So I would be sort of going too much into that. Just the theory said you need to give it of garments were used at one point.
They are like a tourniquet. So this is the one you need to be aware. This is the one you need to be aware you want in the budget. So if you imagine you are a consultant tomorrow. So what the examiner wants to know from you? You are safe. Safe consulting. There are not. You don't need to get the leaks.
Have them to do this. So everybody, every public servant, should have a general skill of putting an ex fix for this service. So this is a temporary sometimes that can be permanent as well. So just to be aware, there are two types of external fixator. So one is this is called an Kessler suture, where you put B pins in the idea. So the next one is the superstar external fixator, so many times this is much more effective and efficient in closing the thing.
But as a general orthopedic surgeon, one should be well aware of this one. So and you should be able to do this in the jungle, set up the examiner. You to know this at least as a temporary measure and until the patient has been transferred safely into the MPC or whatever. So so this is you can do very easily.
They used to do at one time in the emergency department, but now the recommendation is we should be ideally done in theaters. So it does involve using your normal set of things. So Cubans usually 5 prints for a 10 patient in Lady or 6 millimeter prints. So for the males. So that's $0.2 behind from the antero-supero-lateral point. The reason for the anterior superior let's find $0.2 behind is that one you have a lot of cutaneous narrow of time, which is very close to the minor ligament at the side of attachment.
Number two, is that your best bone? And the tick bone is 2 centimeters behind the anterior superior last point. So that is called Kessler. So that is going to keep a decent bone quality. That's where you can put these two things. So you have to be aware. So don't try. You don't need to be very, very small incisions in here.
Inch incision feel the crushed just like take a bone graft open properly. Two inches. Feel the crest. Just fire two of these sanctions, either using a drill or with the handle. So just connect the Connect the. So that is the one thing.
You just have to be aware, and you should be able to do that. So that is the Stabler expects very efficient. But again, this is very sort of it needs quite a bit of training to do this, and it is not easy unless you do this regularly. But just be aware and not aware of this. I am aware of this, but I am not well-versed to do this, but I am quite happy to do the interior space.
So, I mean, these are some of these open method of fixation, which I will show you some pictures just for a theory. Let us just go further and show you this later. So you can see that this is again, very easy to classify. So if somebody wants to see that there is a bilateral agreement fracture here, so very easy to tell this is a three fracture. So usually stabilized on the back side by percutaneous security excuse.
And in the front, we do what is called an infection, which is essentially an external fixator, which everything is under the skin. So I'll just go a bit more further than we will come to that. This is another method of fixation of the sacral factors. It's called posterior front sacral plating, and you can see that there is a screw as well.
That is the idea of simple screw on the top. So this is another picture to show that open reduction of the boat, the boat became more infectious and worksites and see that the long lead going. So you can see that the plate goes along the anterior column all along here, the ideal column, so on the backside, you've got the second scoop.
This is another method open method of fixing the joint. So this is what is called a lumbar pillow fixation, which I was speaking earlier. Whenever there is a spinal dissociation, one should be aware that we do this. So what the examiner wants from you, what exactly examiner wants you. So all this what I was telling you is it's only about this management of a police access, but we need some very unlikely they will just put on leave will be saying that this is a police matter will be managed.
No, the always majority 90% of times you get this as a part of the scenario, they give you the political motivation. The bilateral femoral fracture is that one of those factors? So they just come to the pelvis at the end. But before that? You need to have a broader knowledge of managing this problem. So they look at you, the examiner, always look at as a consultant, the managers, so they are always expecting you to be there.
OK, you are in a big. How do you manage this scenario? That's what they want to see you. How cleverly use your brain or your knowledge to just get out of that situation. So they are just testing you as a day one sales consultant in NHS. That's what you need to be. Keep it in mind.
So what does he? So there's a few things. One is that when they give you a scenario like poly trauma, so they want to see whether you are able to make, we shouldn't make it. Were following in the very urgent scenarios and how you prioritize. So basically, you have to be aware of the principles of damage control outbreaks.
What is fast? If you've got a scenario where you have to structure the open fracture, you've got a bilateral femur fracture, then you need to know what is important, what you are going to do immediately, what you got to, what resources you've got in your budget. So you say a patient comes in, they always give a scenario saying that the patient comes at the Friday NIPE at 11 o'clock, so we will be there at 500 on Friday NIPE at 1100.
You expect every major trauma center consultant sitting there. No so you are immediate patient is being brought into one of these it in the immediate stabilization, although definite stabilization takes place elsewhere later. But you should be able to in a situation where you should be able to manage this to stabilize initially, at least temporarily, until you get this patient transferred safely into the major trauma centers.
So that is a critical thinking that is the one they look at. So you need to be aware. So next after that, you need to be aware of waitlists, which I'm sure you all of you know, the principles and traject patients. So they'll be the temporary stabilization of these people who practice, which said binder. It speaks. These are the two things which you need to be aware of.
You need to be able to do correct application of the binder. So you also should be aware BGH, the resources are limited, your expertise will be limited, so you need to know your limits. So that is another thing which the examiner expects. You can't go and say that I will go and do this, for this purpose.
The got a good knowledge. So you just have to answer in such a way that I am aware of all the principles, but this needs to be done by somebody who does this regularly. Not just that you need to have the resources to do that. And not just doing that in case if something goes wrong, you should have a backup to deal with that complication. So this is what you need to be aware of.
So that means that. So they will look at your limited self limits, what, what, what limits they will give a scenario if they say, OK, you are in a major trauma center. What would you do? Then the next question comes, are you definitely going to learn to manage these cases? Until then, at least the first bit the temporary stabilization resuscitation and what is massive transfusion protocol?
How do you sort of resuscitate any trauma patients? These are all basics. One should be very well aware. So next one you need to be aware in, which has been asked is a massive transmission protocol. So you really need to be aware of this. So there is a protocol in each and every press. But there is also a well known protocol. So what is the connection between what, what hours they should be given and how much blood transfusion in of transfusing is just a blood FFP that is a blood clot and in what ratio?
So that's all day in the book to read that is called Matthew transfusion protocol, and this is the one in an unstable hemodynamically. Unstable patient doesn't need to be restructured. Any polychrome patient, you really need to be doing this. So this is a very key and this has been asked in a lot of Examinations, now. So you need to be aware. So the next one is meant to transfer safely.
So that is called most guidelines, you need to read most guidelines. So sorry, thank you. So, as I said, both guidelines is very key. Everybody should be knowing this was. There are 19 points in the. So for the pelvic fracture, there are no straight lines for everything.
Open fact is all lot of other injuries, but for the kidney structure nowadays since the start of this disease across the country. So this is coming again and again the example. So the Bush guidelines you have to mention when you say both guidelines about the fact that you are red and at least you score, they score some points there. So but you really have to be aware. So there is a real protocol.
So there is a protocol to say that all these pelvic ring injuries are to be ideally stabilized within 72 hours. That means even if the patient comes to visit, you should be safely transferred the patient after patient or after binder after operational bas status to the trauma center nearest trauma center near to the pelvic unit, sort of in 24 hours safely so that they can stabilize the pelvis within 72 hours to get better outcomes.
So same thing with the acetabulum Stabler fractures. So there is a straight guidelines say that it has to be stabilized within 72 hours. So there are again, there are so many other things in that guidelines that you need to be aware. The other thing we need to be aware is that. So all these patients gets a CT scan, and then when you get the CT scan in the binder, you have to have an X-ray out of there.
Please do read that one because if I go into there, you will lose a lot of time. So that's all there. All in all, the websites. It's all in the book. So read this first guidelines for the public sector, which is very clear, and that has been expected in the example. So you need to have a forward thinking.
So whenever this case has been put up in front of you saying that what, this multiple bones broken so fractured you need to have a clear idea. So first, I will stabilize this. Then what I do is stabilize the odoi, stabilize this femur. And once I do stabilize this femur, what we must expect binder to the pelvic pelvis, then bas status all the massive transmission protocol, all these gestation measures.
Once the patient is stable, so you need to transfer to the nearest trauma center, but you need to have an option there. You need to think critically that I can manage this patient here, whether I can't manage here. The other thing to know is that these patients, whether I should get an immediate advice or whether I can stabilize this temporarily, then I can speak. These are the critical steps which you have to take.
So if you don't have the resources, you don't have any experts in your face when you don't have any blood banks open, when you don't have even an X-ray afterwards and you don't have much resources there. So you have to be aware, at least get your protocol, initial resuscitation, the transmission protocol, these sort of things that you need to go one by one, but you need to have to keep thinking whatever the situation, whether you're going to keep transferring and transmitting, is it this NIPE or whether I am transferring tomorrow morning?
So if you need help, you can always say, I need your advice. You can help. Examiners will not. You will never expect you to say, OK, no, no, no, I will do this, I will do this. I will fix this now. So I just say I will take AI will take an L. I will take advice if they want me to do an external fixator.
I am quite happy to do. I know the methods. I will do it, but I will certainly take any advice from a local MPC or local orthopedic consultant. So just to think about this. The last thing is that you need to know the clear algorithm. So whenever they put a scenario in front of you, hemodynamically unstable patient that comes as a part of trauma, you need to be aware whenever they put this up, you need to be aware.
The wouldn't Elvis, how do you go about managing it will be unstable fracture presents with the instability, hemodynamic instability? That's what. So for that, I said, no, they every NPC, if you open the website of any MPC who deals with the practice, there is a protocol for the majority at least. So you can read them and I can forward it to Abdullah.
You can. He can go. So that is there is a clear algorithm. So the way, let me just I can just go to. So the way we go normally is that whenever we see a patient in our enemy. So we assess whether it is a stable more dynamically or unstable. Then the question comes the radiological.
Afterwards, the patient is stable, so you will get a normal visitation with the normal saline or whatever is being according to your protocol. So then we decide whether it is a stable or unstable. So it is a stable patient and we decide when to deal with this fracture, depending on our availability of skills. So many other things are unstable factors.
We do have a protocol that is every MPC has got the protocol. We can look at any MTC. There will be a protocol for them in there. Any protocol? So I can pass it on to bullet if somebody is interested, what we have at Salford. You can take a look at it. So the other guidelines for the purpose really are to be aware, as I said, most of us urological injury.
And this is a un-pc and they will ask, what is not? So there are 22 or 24 empty seats now across the country. So this is a very important. All the pieces are being developed in the UK and across Europe, Germany, UK, us needs to get a better outcome with all these patients. You can have everybody under the same roof. So yeah, just have to be aware there are some outcomes scores which are very rarely been asked.
Not commonly so. They are called mojeed score the egawa score. I know what score in the sport. They're all peel-back related outcomes. I don't think they will expect you to know, but in theory by chance, if you ask, just for the theoretical. So for the discussion was this is what you need to be aware of. So most of the people will know the experts, which I already said types are allowed to do.
One then becomes the caloric package. This is a very hot topic nowadays, with the look packing angiogram and the embolization. What is best in what is best in the hemodynamically unstable patient? This is one of the very hot topics, which is the debate is going on everywhere. So the pelvic packing is the one where we pack the pelvis to stop the bleeding from the venous venous bleeding.
So after packing the pelvis, I'll tell you where to pack. After packing the pelvis, you still have to put an external fixator to close dependence. So just by packing the pellets, it will not stop. So after packing the pelvis, you have to put the external fixator to close the ring so that acts as a tampon in the pelvic packing is packing the pelvis in a likely areas where they bleed. So the likely areas where the body is on both sides of the pubic where the corona is, is there.
So one should be aware of what is this coronavirus disease anastomosis between the operative vessels and the external iliac vessels? So you need to be aware. So they are just sitting on top of the superior and then they rupture since they are very directly connected to the external artery. And when they bleed like a car. So that's why you need to be aware that is one of the sources, so you need to pack their pack just behind me, superior pubic ramus on both sides.
Then the other area where we would say joint on either side of the joint tenotomy, that's where the internal iliac artery vessels to be the venous plexus sacral plexus are there. So these are the four areas which are being described to pack. So cracking. These are the areas packing used to prevent the venous bleeding, but very rarely they are being used to for a arterial bleed arterial bleed.
We need angiography. But as I said earlier, 80 90% chance you're bleeding is likely from a venous. Only 10% is from the artery. You back the pelvis. It could be still bleeding. Then you need to have an angiogram, so identify the need. Then hospital radiologist, be a radiologist.
So what is better with an angiogram embolization? So there are a lot of cities winter across the country, across Europe, across the world. So they looked at both whether the outcomes are better with the tracking outcomes are better with the angiogram and the analyses. So certainly. When we hacking seems to be a better, better option than angiogram, the reason is that.
This much quicker. You don't need to wait for a specialist radiologist to come and do that. Number two is that it can be done by the general surgeon or an orthopedic surgeon who works in the MPC. So all the outcomes in the literature shows parking is better, but on geography, because of these factors, you can get depression to theater well within under one hour.
Whereas angiogram, we look that takes between two to three hours. So that time is very crucial, the outcomes are better with the peel-back. So you can always say the literature, you know, there is a hot debate about, which is better. Public parking is better because of time constraints and better outcomes in the literature. So the other thing which you have to be aware and to read is the egawa egawa is, I think I don't know how many of you are aware.
This is a loss the way it's the last measure to prevent a bleeding, which is in a non compressible area. So say that what we see is. A fracture patient is bleeding and the common iliac artery or heart is bleeding like a tap, it's quite a big muscle. So these are the very paradoxes. It is deep inside the palace, so that's why we have over means it is the resuscitating endovascular balloon operation angioplasty.
Of the aorta, so that means the are inflating a balloon into the aorta. So that there are three zones zone 1 in the thoracic aorta, which is in the classic aorta high up in the chest table, the renal arteries is the body below the artery, the aorta. So on three, we are looking at zone 3 is that well below the renal arteries? You are fluid, the aorta well below the edema like this so that the kidneys are still produced, and this will completely cut off the entire blood supply.
The pelvis, the lower limbs. But it comes with the risks, so it is very critical. You cannot do this for no time. So is only indicated not more than 30 minutes. It is going to be more than 30 minutes. You are risking necrosis of people inside the lower limbs, but also so there are other risks comes with the removal. So something like rupturing the balloon in the aorta, causing a traumatic bleed itself.
So those are the things. So egawa is very rarely rarely indicated. That is the last measure. But you need to be aware that removal means the risk to endovascular balloon occlusion of the aorta that is again done by either a vascular surgeon or by interventional radiologists. That is only a temporary measure that can be done only for up to 30 minutes beyond that time.
So you have to be patient, should be in theater. You should release this balloon. You should every alternative way to stop the bleeding. So let us go to the. So the exotic these are the approaches in the pelvis, which need to be aware of. So most of the. The Uh, that aspect of the ring now, so we fix with the stop approach, please do read what the stop approach and what is modified stop.
It's all there. I won't go into the details. It's you to be aware. And the second one is that earlier inguinal approach used to be the case until last four or five years ago, we used to approach all the anterior aspect of the problem. Using the earlier inguinal approach, developing a three windows theory part is still there. They will still ask what are the three windows or do you what is in each window?
So that has also been asked in the exam because most of the people who sit-in the examination panel, they're not surgeons, any of them, either hand surgeons or surgeons or surgeons. So what they all will watch would be exam question, really emotional approach. We windows. So you really have to be doing this earlier emotional approach.
And what are the structures at risk and what are those and what are the advantages and disadvantages? So that used to be the workhorse of our anterior aspect of the establishment until three or four years ago. It's not anymore. Now, the majority 90% of the practicing surgeons will do this topo, which is an intra intra peel-back approach where we access much better than the inguinal approach.
Very rarely, we do this alone. So just be aware, but please do read these approaches in a posterior one posterior column and anything posterior part of this problem. We do do what is called a line, and the approach we see need to be aware because most of you do this hip replacement using a posterior approach. It's pretty much very close to the same sort of. We'll see an approach to the hill, so we would like them with that approach.
So exactly you need to be aware both to prevent the vascular damage to the family, make sure that you read clearly. So where to cut this from standard? How much tenotomy should be left to the femur before you cut? And what is not disturbed? It is mainly. There is an ascending branch of lateral complex femoral artery, which goes just on top of the quadratus femur is you need to be aware of that.
So that's why you should not disturb that when you do the copper line and that approach to cut these things when it's very close to the bone of this reformist tendon. And if you disturb this ascending branch, they will end up with what is called a rescuer necrosis. So and also again, we have to make an incision over the. Axilo, so not to damage the labor. So we need to be aware of that.
It's all there in the book. I don't need to tell. So you need to be aware of the cockroaches is very common. For example, the last hearing we can ask in the approach is surgical approaches. In the example, there to be a way I would go into the details, you know, the risks of sciatic nerve injury. So it sounded to me very rarely used the idea of female or female approach.
Very, very rare. I have already seen in my fellowship, my training. I've seen only two cases that used to be previously that is 4 or five years ago. We have got various other percutaneous techniques nowadays to deal with this pelvis. So is a very extensive approach which can cause a significant muscle damage to be to the abductors and also the lateral aspect of the, you know, the hip.
So significant actual effect of the classification. Those are the risks. So we actually do those ones most commonly now we do. For cutaneous, the posterior wing is stabilized with the Joint Surgery in school, that is for the second school, which is done percutaneously sleep. So the other one is we do an undisclosed practice. We do call schools.
Then we do something called in6 to stabilize the trend. I'll show you some X-rays what they look like. So this is about some grief. So we will go to some discussion now. So the discussion is just put up some X-rays so you can ask any questions. So I can stop it for five minutes. You can have some little drink.
So then you can come back. We will go through some x-rays. So then you can ask me, what do you what do you expect me to tell you before I can answer you? Or if you want me to give it to, I can give it a bit later, then you can tell me what you need. So we'll go through some of the x-rays. What? what we normally do.
OK, thank you very much, Mr campana. I'll give you a minute or two just to have a bit of water, I think. Yes so if you want, we can tell you The questions that we've had so far from the audience. And please feel free to add more questions, please. I will. If that is OK with you, Mr campana.
Go ahead. Can I just let me make it a little bit louder? I can't hear you. Very Yes. Can can anyone help? Am I can hear me, guys? Yes, we thank you. Yeah, we can. OK, go ahead.
OK, so do you do you mind Mr campana if we start? Oh, I don't mind at all. Perfect so I'll give you the money. You might be telling your theory. It's a waste. Absolutely so I'll give the mic to Joe and Anthony, who will take turns in conveying the questions to the audience. Hello, Mr campana. It was a very nice talk and very descriptive actually, to the extent that till now, I just have two questions.
The first is what is the recommended thromboprophylaxis protocol in pelvic fracture? OK, so the question to answer your question. There is no specific thromboprophylaxis, which has been said this is what the literature says. There are many studies come out. One is from there are studies from Bristol. It is coming from. There are studies from Royal London.
I think Peter Bates is the man who has done some work on it. There are Bristol. Two page two papers are there and there are another one or two from elsewhere. And one from Derby. But the majority they all looked at say this was the originally one of the major trusts which they used to practice the are getting for wrong. So even today, it is a being a major trauma center.
They practice warfarin. So if you go to the royal London, so I think they use a they use a fingerprint or low molecular weight heparin. So the Bristol guys, one of the oldest units. 1998 they established the unit, so they looked at the various things what is most efficient or effective in preventing a weed? So they looked at it, but there is no consensus on that.
But what they come to conclusion is one thing. They looked at it and they come to the conclusion that low molecular weight heparin is better than any of these water agents. What we use for hip and knee replacements, correct? So there are so many hip and knee replacements. We use a single dose daily tablets, so, you know, apixaban or whatever. So many other things, dabigatran and many things, which are they all lucrative, but they are not being approved by any body like a nice or there is no literature to say they're better.
But what does the current literature we have from a distance study or London and the majority of the literature suggest low molecular weight heparin is still a better choice than others. So when you want to answer this in the examination, say that there is no consensus. The literature suggests low molecular weight heparin appears to be in a much more efficacious than other modality.
The other ones with, you know, all these mechanical things. But the chemical wise, this is what the second thing we are about this. So DVT risk is very, very high in these value structures. That's why they recommended these, that as soon as you get the patient into the hospital, any trauma center, any budget, it is recommended that it's efficacious. If you give a first dose of your interferon or any form of low molecular weight heparin within 14 hours, if not within 24 hours.
If you can't give this within 24 hours. This is very high. Then if you miss the first 24 hours, then your bone or your being obliged to do some doubles before you undertake any major surgery on. If you not already a clot sitting in the proximal side, you can try to do any surgical procedure on the pelvis. You may end up with the piece. So that's why the majority of the patients you are born to do this, especially if you miss their first 48 to 72 hours and you really have to have ultrasound the Doppler ultrasound before you do.
If you find any clot anywhere in the legs you are going to put a year later, you have to put the security around. So if you find any DVT DVT evidence. Yeah, so, you know, again, you know, one more thing. That's a good question, you asked. Any political motivation? You need a fix to the theater. Five times, six times.
Best bet is to die with a. But I was a Secretary is not the sort of benign thing you need to be aware. We see Twitter needs to be removed. Look, I use a filter, but it's sometimes got a lot of main downsides. There is a radiologist or interventional radiologists are doing this. They need to try and get this filter out, ideally within three months, if not more than, you know, with more than six months.
If you leave it six months, you can't replace it. Then you render you ended end up with the anticoagulant that man or a patient for lifelong. So you have to be aware of these protocols. The evidence suggests within 24 hours, you need to give a thromboprophylaxis, especially low molecular weight, but they across the country, as I said, warfarin is used in some of the Centers that are this recurrent, though in a daily dose, anticoagulants, which you use frequently, including aspirin, they are being used in some places.
There is no consensus. But this is what the evidence. Is that answer to is that answer? Yes, totally answer the question. The second question is that what approach would you use for pelvic packing? Is it finished or you need a bigger one? So that is another good question. So this is where you are forward thinking or a critical thinking comes into picture.
So for me to do a normal Stabler fracture, say anterior wall, quadrilateral plate microfracture or anterior column fracture, I use a phenoms team with the splitting, the rectus in the midline. But in this case, I will not do pelvis hacking. I will not do that. The reason is that in case if this patient needs a laparotomy, what would you do? So I would do a midline skin incision from umbilicus down all the way to the pubic symphysis.
I would do split the rectus in the midline and the linea Alba. Then I will pack it front and back. So here it's very easy to fracture. Pretty much the part of the directrices is almost damaged already as soon as you open the skin. Most of the time you see that it is pelvises in front of you. So that is a dancer. So I would use the midline. This is just a clear reason is that in case if you need a laparotomy, they can extend upwards.
So rather than me, me, me making a transverse insertion and then comes on the vertical incision, which makes a key which is not a good idea. Yes, thank you. I have another question, is it OK, so what is the diameter of panes of the fat shoes? I can't hear. What is the diameter of panes of the x? Yeah so you probably you missed that, my thing earlier.
So if the patient is thin in a lady with a very thin lady and the bones are expected to be small, I would use a 5 millimeter. If the patient is in a male or is, you know, fairly, fairly decent sized man, these either 5.5 or 6 depends on what is available. So 6 is a very preferable one in a man. So you just have to use normal. The Saudis are normal external fixator.
You don't need anything. But if you are looking to use that as a definite fixation, you could use a means but not separate quoted pins. Less risk of infection. And they could be integrated or the trick with the bone for a better way. So otherwise, you know, off my next week's sentence. OK, I have another question from another candidate, so what's the ideal time for operative management?
So this is what I said. Please do read, please do read the Bush guidelines. Bush guidelines has got 19 points. He clearly says, OK, so the pelvic ring injuries, so the pelvic fractures are being classified clearly as a pelvic ring injury or a Stabler or a combination. So whenever you come across a pelvic injury? Which is an unstable pattern.
Usually, as for the VOA guidelines and as for the research and the evidence clearly suggests we should stabilize the ring within 72 hours. And if you see this patient in a remote. You can stabilize the patient temporarily with some X weeks, and you should make all the arrangements to be transferred to the local MPC or peel-back unit within sort of 24 hours safely with a view to stabilize this place within the ring 72 hours, whereas established practice is a different scenario.
So you can go up to days. Of course, the fracture dislocation of the establishment needs to be reduced. Put it in a function. The other thing about. But he would question just to be aware, whenever you see a vertical share injury, which which we'll go through whenever you see this once.
You and if you are an idiot, you need to put a pelvic binder along with the pelvic binder, you need to protect skeletal traction to pull that pelvis down. OK this is a most minimum you should do. So that answers are you're not clear. It's very clear. Thank you, Mr cabana. I think that was the last question.
So we'll go now to the interactive point. You have one. OK, so one. So if you have moral level lesion associated with pelvic fracture, what is your advice about that? So the model level Legion is, you know, I don't know how many of you are aware, it is nothing but intimately glowing. So you've got an intact skin, very bruised.
But if you look at the family, there is quite a bit of damage to the underlying soft tissue. So that is a moral revolution. So moral revolution depends on where you are moral, legal reasoning and what type of action. So every time you are near where you see and forget about it, you may see this moral practice so you can see this moral revolution made us. So whenever you see what is, the significance signifies the soft tissues are at risk, you need to try and avoid going there if possible.
If not, please do explain clearly the risk of a risk of infection plus 1 breakdown and other soft tissue risks. You've got to be aware if you can't avoid going through the moral revolution you can go through, make sure that you take enough precautions to avoid further damage as little as possible to the surrounding soft tissue, where the blood flow comes in that direction. Yeah, thank you very much.
Thank you. That's that's all I have. Thank you. And you if and if you don't mind, Mr campana, I've got to. Just a follow on question. You ask about the term of Alexis for the factors. We we don't have a consensus. What is your personal practice for the fractures, which you already fixed and patient is now going to be mobile and go home with all the fracture which are inherently stable?
And would they require any further extended prophylaxis for it? For how long? That's a very good question again. See, my practice, I am always, you know, practice what is based on the evidence, so I won't go anything out of that evidence, I will use the low molecular weight. So if the patient, if he is a non weight bearing, I would go up to six weeks of.
Are the thromboprophylaxis? What the literature says would be haematologist says. There is no evidence, even if the patient is not able to wait where even after six weeks, there is no evidence that if you continue beyond six weeks of your thromboprophylaxis, it's not going to make any difference. So you view it, thromboprophylaxis Ahmad, after six weeks.
It is not much of news. OK, so that's why the majority of these thromboprophylaxis has been given. You know, if you look at this, there is a nice guideline if you want to read if you are practicing in UK, this is a nice guideline, one for a fragility fracture. That is nice, says you have to give it for four weeks. That's that is sufficient enough. But in my practice, I just go by whatever the available literature, which is 6 weeks, six weeks of low molecular weight heparin.
Because in the East of England, we actually practice rivaroxaban 10 mg, as you said about this for 70 days, that's a practice from the Addenbrooke's. I'm not sure how does this surge driven, but that's what they normally run with. So I just want to give you a bit of an example for one of the mdc's practicing this. Yeah, I suspect gera will must be doing a trial there, I would imagine.
So he's sort of, you know, very dynamic person. So but there is no literature to say that they were OK so badly that he's been followed for a trauma patients, even by the nice. So there is no literature to suggest or to go why I don't practice, I have seen the people doing it. If something goes wrong tomorrow. You have to find yourself back it up, yeah, you have something to stand on your legs.
Yes, there are guys who does it. That is, you know, they are ready to either be a trial. Maybe it may. It may come with the standard some practice later on, they may say that is the best thing in the years down the line, but we don't know so until something happens. So realistic, stick to that, what is being available. Perfect, thank you. Yeah anything else?
OK so I think that is enough for the questions for the time being, we will need to leave some time for the candidates to get into the interactive part of the session. I will leave that with Mr. Henry Schwann. Our colleague Mike is yours. Thank you. So at the moment, we've only one volunteer. Please do volunteer because the interactive session is not like our Viva session.
It's just a friendly chat to try and improve your presentation and to make this a more interesting topic. Can you speak a little bit louder? Sean, I can't get my apologies. Probably letting me saw some. Yeah so at the moment, only Mohammed mudassar has volunteered. These others please do volunteer because we are looking to make a robust interactive session.
So just to, you know, reassure these people who are in this webinar, this is not an exam. This is not testing anybody's knowledge. This is more of a learning for you. It's learning for me. Don't think that it is any question. I'm not going to ask it just to show some of these real cases what we come across or they can be managed.
Don't think that we are doing anything to test your knowledge. Don't worry, OK, we have more volunteers have come on. So we'll start with Mohammad mudassar and then we'll move on to the others. Egawa test, oh, that's OK. So shall we just go for the first one? Yeah Mohammad, sir, if you could also we can see you. Yeah so Muhammad, look at this images.
So you've got a sort of. I would say. Uh, he's only 50 eight, I think, 58 or 68. Forgotten, exactly. So see this. This is this is you can see that what is this is a CT angiogram is 3D CT angiogram of a pelvis, which shows a fracture of the right.
a sacroiliac joint at the level of its ileum, and probably it is going into the SEC really joint as well and. I do not appreciate any fracture of the interior, political realm and your pelvis. I know there is one on the left pubic RMI fracture, there is a fracture over there, so it's lateral compression type III fracture.
So you heard me telling the two or three times I repeated type III means you are looking either bilateral peel-back bilateral. Yeah so these are bilateral agreements. No, no. It's type lateral compression pipe. Yeah what makes you think? This is a type two, because I told you only one word that just one word will stop the examiner to ask you further because it's only one factor on the one side of the.
It's one that is the case in LC one as well. What made you say this LC two because there is a microfracture or the posterior ileum as well? What is that called? That is the word you need to use. Only one word in. It is. Uh, this is called a Crescent fracture press conference. So whenever you see the fracture of this stadium, you can see that the part of this alien still leftover with the AC joint.
This is like a Crescent. Mm-hmm So when you see a fracture in front of the AC joint here are very adjacent to the AC joint. That is called Crescent fracture. This is the Petagna moniker, very characteristic of type 2 lateral compression to injury. If you see a bilateral pubic railway in front of it along with this, then it becomes a type III. You see a 1 unilateral pubic remanufacture.
Then it is. It is just two years. So the a ring fracture is there in the city, axilo and the kernel Kurtz, I let me just put this is very obvious to just show that this is a fracture when there is a very undisclosed fracture in and coronal cuts in a CT scan. They don't come up in the 3D 3D images.
You just have to be way. This is a 3D city engineer because I can see the muscles is an Ngo or it's just the 3D. I think it's, you know, this is not a city Ngo. This is called contrast city. OK, so they put a contrast so that this is what we do. Whenever we get a patient, we got a more dynamically unstable. We do to a city that gives an idea whether there is an arterial contract, we believe.
So if it is not, then we know that it is a split. Yeah so this is the type Ii LC to and you see that you can see here. You can see here. So what is this one year? Uh, this is Uh, what is this one?
This is the shot top notch, so that is a great sciatic notch. Yeah so what is this one here? You said the superior is a superior radial artery, superior artery at risk. Is that clear? So you can see that, you know, the results are without line there. So this is a, you know, type 2. Like doing injuries, how do we manage this one?
So I will manage this patient, according to atlas, and boast guidelines. I will. Assuming that there is no area breathing as a problem, I would take the two large IV lines taking the Bloods blurred for gripping and cross matching and starts the IV fluids. And then I will examine the pelvis, abdomen and long bones for any bleeding.
If this is the only diagnosis, I would apply a pelvic binder at the level of the greater Rock Center. And according to the blood pressure and pulse, she may need blood transfusion as well. And I will talk to my major trauma center and. If possible, I will shift into major trauma center planned shift to the major trauma center.
I may have to applied to the external fixator if there is, Uh, if there is a time between the shifting, well, OK, that's fine. So you said all the correct steps. So this patient is hemodynamically unstable. You already transfused stay. It is of a normal saline or been collected when the unit of blood is still unstable and you applied the binder.
OK, I will. I will also give a transgenic insert. And this patient may need pelvic packing an external fixator as well. I would like to apply the external fixator in the data, which there are different external fixator type. I will apply the interior external fixator and I will apply.
I will do the packing as well. So shall I just stop you there just out to stop you there? The reason is that I told you this is a LC to fracture. And the LC two factor is, as I said, also that there is an display structure in the front, which is hardly even see here. The only factor which is obvious is here. Mm-hmm And you already applied the binder, which is still unstable.
What is that suggests? But there is some bleeding going on still where this is what this is Venus. Also this is a LC two type of structure. This is not even a sacral fracture. So there will be some bleed from this bleeding surface area crest, maybe some venous bleeding. So what should come into mind, this is what the examiner always you have to think broadly, so don't assume this is the only source of bleeding, but you clearly earlier asked what is this result, which is a superior gluteal artery, which seems to be intact here?
It might have been a little bit stretched. But there will be some bleeding. You've already applied the binder, the police is close. And the old stated, with the one or two units of blood and some fluid, you need to think broadly. There are other places to bleed. There could be. Abdominal so re-appropriate bleed can be a chest bleed, which has not been picked up.
It can be viewed anywhere. So you need to make sure before you, you go in the pack, the police and things, make sure that you exclude the other source of bleeding. So we try to close cavities. Yeah, so this is a LC to. You'll see two fractures can bleed, but they are very rare to bleed on to death. So it is a healthy three, very rarely otherwise vertical shape or APC three vertical.
Yeah so what would you do for this one anyway, if I ask you just isolated fracture, which should be stable? What would you do? Uh, this will need a fixation. You can do the posterior plating or the screws compression screws, Which one?
I will do the plating. So you would do the plating ileum plating because it's in different flat in the back or where exactly you want the plate? I will pay it at the back there, the ileum. At the back, Yeah. The you know, the Christian, the. So just let me tell you.
So the whole purpose here is to stabilize the ring. The anteriorly, as I said, there is hardly you can see any fracture. So here you've got the two options. Option one is that. You played this earlier. The reason is that this fracture very likely that either extends into the AC joint or AC joint is unstable by definition.
So and the fracture is widely displaced. So you've got the option one is to split this fracture from the front. Then you stabilize the joint percutaneous with the screw. The reason I want just to screw is that. So the screw in 3 point almost in there where I pointing myself. So you see that this is a completely flag fragment.
So you have to first make the two fragments into one fragment. You see there. So you make the two fragments into one fragment with the plates. OK then you go and put a screw, either it can go through there because you already joined, you already made this as a 1 1 one vote. You can go there if sometimes you may have to go through a year if you don't plate it, if you go a year, don't it doesn't serve any purpose.
It doesn't give any stability. That's why elderly patient. So they see that because of the osteoporosis, the screws are slightly backing out. In some of them, but they are not causing any trouble for him, just keeping a close eye on it. But the fact, it is here is fully mobile. He's back to work, but we just keep an eye because the metalwork is getting loose, get loose.
We'll have to take it out at some point. It's just more than six months or more than eight months now. It doesn't have any complaints. It just comes with a routine follow. So let us go to the next one. This we did not do anything on the front because it is on display structure, so we don't need to do anything rehabilitation wise. How long you will keep him non weight bearing.
So if you see that on the right side, they say joint is the key here. Whenever you stabilize the right side, I say joint with the screw. So ideally you would believe them non weight bearing or attach weight bearing for six weeks. So if the screw and the joint still looks good after six weeks notice, I let them fully right there.
Well, the key of the thing is that you are a If it is displaced, I would just put an in fix. In fix is the percutaneous procedure which majority of the people, you know, keep it under the skin they won't even see they are working. Many of them have been forgotten. Some of my patients are working with that for more than six months now. They will not come back so.
Just to be aware, intensify or there is something called the column screws. So if the fracture is the fracture is just lateral to this. This is after the formal. The factory is lateral to the substrate for women in this area. It could do even a percutaneous column. Screw it, I'll show you a bit later.
So one of the options is this column, this and this place. There's a displaced. I can plate it, you can go open and I can play it all the way or I can do percutaneous the fix, which I will show you some of the slides next. So what is this one? So there's a question about so about lateral compression fractures, we were talking earlier on about the indications for using the pelvic brace in this situation.
I couldn't get the question. Using pelvic braces for lateral compression fractures, what are the indications in those situations? So I told you to pass the exam. If it is, you'll see one fracture stay. It is a stable majority or stable treated conservatively. If the patient is the elderly, frail wait whereas tolerated, just repeat the X-ray one week begin at six weeks, usually the pelvic ring or you got a 3 views AP inlet and outlet these three views you need to be aware of for a pelvic ring, but a stable of fractures.
You need to do what is called juday debuts. Yeah, you get this, do read them and you can go through. Or if you want me to. There are some rays which you can look at it a bit later, we'll go, I can show you what this dude's view is, what is inlet outlet news? So is that the answer? Sorry, sorry, Mr cabana. My name is Chuan.
I think I was saying that. Is there any contraindication contraindication for using the pelvic binder? I don't know there is, as I said, whether it can be vertical share injury, it can be lateral compression injury, it can be APC any type. There is no contraindication. There is no literature that says even if it is a lateral compression injury, you can still put it on.
It may not help, but still you can put it on. There is no contraindications unless it is you've got a very big open wounds or you've got a very damaged skin or patient is very stable hemodynamically. You don't need one. It is the only one. I don't think there is any indication. Yeah, I agree with you. Thank you, Jason.
They're asking, so that was one of the questions being asked, so I just wanted to clarify that because no, no contraindication, thank you for clearing that up. There's no contraindication. They will criticize you if you don't apply. Exactly but they won't criticize you if you are playing. Thank you. Shall we move on to the next candidate? Yeah, AJ we'll see if you turn your camera and your mic on.
And we ask the other guys who are not participating to mute their mics again, mute your mic, please. So go ahead. Yeah so I can see it's a limited one section of the city, which is coronal images showing the coronal section part of the lower lumbar spine and the part of the pelvis and the right side of the acetabulum, the proximal femur.
On the left side, I can see there's a to increase the space between the AC joint. And also there is a step in the sacroiliac joint and I will check the further sections and check if there is any the injury I'm suspecting. Probably it's maybe a little compression or bas status compression, which involving the extensively on the left side. So what's going through your mind?
What's going through if you only answered now, but you are contradicting yourself? You said that there is a mismatch here. Yeah, it's a mismatch there. So it may be a vertical shear kind of injury or it may be a little compression which involved which may be a little compression type tree injury which involved the anterior as well as the posterior complete injury.
OK, that's fine. What is this one there? So it looks like that is the axilo image of the same patient, and there is an opening of the posterior sacroiliac joint completely and widening of the anterior as well. Yeah so see this one now. Simple that is the 3D reconstruction. The and I can obviously see there is at.
Spivack symphysis is not only open the slap as well, which is up and down and on the left side in PDP vehicle manufacturers and the bas status. There is there is a step in the security joint, so it may be a little compression or it may be a vertical shear injury. So I told you what is lateral compression? Why? how to differentiate vertical share a pure vertical shear versus lateral compression by 3 to be vertical shear.
There is a superior migration of the superior inferior migration of along with the fracture and a type t is the both anterior posture. Part of the cycle ligaments are gone or along with the both ligament is gone and also there is anterior fracture. So what do you see whenever you see this pubic symphysis there stresses? There is no fracture here, no fracture here, no fracture.
So it's an open book, it's open book type three, which is not exactly open book because it is my pelvis is vertically shifted up here. Yes so in an open book type three, you see a wide opening. Do you see a gap as well? But there is no shift in there. Yeah the pelvis is not shifted up. So here it is. Clearly, you can see that it is upward shift of the left hemisphere.
So this is one of those vertical, vertical aiming, you know, vertical shear injury. Yeah so how do you manage that? So obviously is the as per the latest guidelines, I will assess and treat the patient. And as per the post guidelines, I will make sure that he's got the OA oxygenation and like cervical spine is immobilized. And if that is secured, then I'll go further to look for breathing.
If that is secured, that is financial progress. For that to see part, which is the bleeding part and look for the bleeding examined from the top to bottom and check if there is any associated injury. It may be a chest injury. It may be interrupted abdominal or head injury as well, which may bleed. Or is there any open microfracture or any long bone fracture to stop there.
So just imagine this is an isolated injury and it is one of the major depression comes at around 11 o'clock in the NIPE to this patient. If it is isolated injury, it's a vertical shear injury. The mortality is quite high, so because of the bleeding, so I will resuscitate extensively this patient and start with the illegal after taking the bloods, including group and see if I will give the IV fluids and may need probably a few units of transfusion and sometime lead up to the massive transfusion.
In this case, if there is a further bleeding and I will apply the pelvic binder as well and stabilize the patient, and I will be in touch with the local trauma center, major trauma center or the pelvic surgeon as well. And once patient assist, I will scan further to look out for if any other injury is still causing the bleeding so that Friday NIPE that the local pelvic surgeon is drunk and is not to be contacted.
What would he do? So I will. So I will see the patient, whether it's stabilized or not, hemodynamically, if it is not, then I'm suspecting that he's still bleeding despite a blinding pelvic binder. So I will take this patient after taking his consent to the theater and apply the external fixator and which is the common one, is putting the two pin on the boat and behind the antero-supero-lateral spine and connecting with the external fixator to stabilize this temporarily.
And again, I will be in touch with the local major trauma center, the pelvicalyceal system. Yeah so what they expect you to look at is that you apply the binder correctly. You close the thing, but you see that this is a vertical shear. So what the bleeding sources are bleeding sources are when it rains, the home is bleeding surfaces, see that we are joined here is wide open. It's going up here, so you need to pull this leg down.
So should be still some reflection. So put a retraction, put the binder on under the fluoroscopy, try and put the weight so that it comes down and close the closet with the binder and rest it. So then the further steps you need to be aware of transmission protocols and then you can ask for advice. Sorry turning to an exhibit closet as well.
Yeah, that's all. So you are speaking about tranexamic acid. What is the evidence you have? I think there was some trial I forgot, which here I think is 2080 or something, which it is called crash to dress to trial. Yes so what is that says? It says that if it is given within one hour and then followed by 8 hours and three doses, then it reduces the bleeding and reduces the mortality.
I sure. Whenever you want to make sure that correctly, if you don't know these, don't answer. So the answer, as far as I am aware, you should give a tranexamic acid ideally within an hour, if not within three hours maximum. If you tranexamic acid after three hours. It increases the mortality rate. The clear, say, eight hours, which I am not aware.
Maybe I'm going, look at it again. Rush to trial. It's clearly. Within maximum time you are allowed is three hours. Anything after three hours, no benefit, in fact, it causes increased mortality. Yeah exum, so be careful. If the examiner, most clearly, you can just pull you down. Yeah, so very good, so.
Just to show you this is what we do. So you got this. Put the collection on the left side, which has been pulled down the leg, has been pulled down and see that we surge and this is a happy view of the pelvis. If somebody wants to start of be awake, so this is the opinion line here. This represents the period column and this is the clearest line.
This represents the posterior column you. So then you got this posterior wall here. We scored the dome here, dome of the establishment. Just go some, some more views down below. So this is golden in, let me in, let me. So you are seeing the police from. Yeah so what this is useful is to see that there is no antero posterior displacement.
OK, see that. So this is pretty much like rule one pelvic ring, ring, ring. Yeah, it's quite clear. Yeah, Yeah. Yes so and you are seeing this spectrum here. Yes One of the spectrum you are looking for. See that. So that is the anterior margin of the sacrum there and you've got the posterior margin there.
You've got the spinal canal on the back. So you are seeing the pelvis from the elbow. So this is an enlarged view to assess the anterior posterior displacement. Yeah so if you've got that the two screws there, which you saw in the AP bit left. That's what we expect. Yeah, this is all. Well, Elaine, this is called an old plate.
Yeah so I'll let you tell us whether there is a vertical shift. So that gives a good idea it would be a Sergeant. These activists are not very clear. But that is what is meant to be. And also that shows that you see that the four men are here for men should be avoided and put the screws continuously. And also, it will tell us how much longer the screws are there still inside the bone, not outside the boot.
OK, the next one. So just to go through the next one, quickly see that this is another X-ray. Another trauma. So this is how the patient had a CT scan. This is very interesting. Have a look at it. Did you see anything much happening there?
Sorry, sorry. Just a second, Mr schwann, do we have a third candidate just to distribute the benefit for everyone? Sean I think it's as if. OK, so sorry, a.j., it's just to give a chance to other people. Thank you very much. So as if are you on? Can you unmute yourself and put the video on, please, I said.
Excellent Hi. Yes, Mr campanha, sorry, the floor is yours, sorry. So this is again a trauma who came who had a CT scan. This is what the CT scan is. So can you see anything much here or this is a CT scan? I can see the lateral side. I can see ideal bacterial line. But on the right hand side, I cannot see much. So I need to go through the proper coronal and sagittal sections and then I can comment on it.
I can see there is a small flake fracture on the top of the right sacral area. I'm concerned about the anterior, so I need to go through again more sections and coronal sections. One second to 5 minutes. OK you are very good, actually. You picked up very nicely, which is not being picked up by one of the not what hospital it's elsewhere.
One of the axilo reporting radiologists couldn't pick it up picked up very nicely. Very good. Excellent So what is this happening? What else you can see here? So is something going on in the right sacroiliac joint area? It could be central posterior disruption could be tied to could be tie three. So I need to look at the fact that there is no opening up of the anterior seco joint, which is fine, looks fine.
It is less than 2.5 centimeter. So I need to look at the more detail. I mean, the sagittal sections. Uh, this is a axilo card that gives I don't know what you are expecting in a sagittal. There's nothing in the sagittal v, so it is disruption of sacroiliac joint. I have to assess the patient. I will follow the protocol, do the primary and secondary survey, and I will make sure that the patient has no neurological deficits.
That's all done. What else? What else come to your picture here? What else? You can see that this is CT scan. Just so you can see anything else. Have some concern on the right hand side there is. In Alex Bowen, there is some disruption. Yeah, yeah, no, this is a little bit you, you already picked up you on the left hand side, I mean, on the left hand side in the sand?
Yeah, somewhere down. But no. You can see that. What is this one? So there is a pandemic, but a big binder applied already, so it means this could be the misleading. So what happens when we apply the peel-back binder? It compresses.
It brings back all the structures, so it gives you a false impression. And I can see on this section that there is sexual alia, there is a left wing fracture. I so there it is a part of yeah, yeah, I agree there is a small fracture there, but you don't see different already, which I assure you. So just so this is what this is one of the Mr. As you can see that clearly.
What these are the telltale signs. You can see that a say joint ligament is all steel. Mm-hmm But because of the binder, somebody has put the binder in such a nice way. This is completely closed. If you go here. So the guy is in a lot of pain. They took out the binder saying that everything is normal, so. See that what is this?
Yeah, so on a preview, I can see there is opening of a symphysis pubis. It is nearly 2.5 centimeters, so. And looking back with the sacroiliac joint involvement, it is tied to intra posterior compression injury. So if the patient is hemodynamically stable, then I will transfer these images to the local regional center and take their advice. So this is one in the guidelines, it is there.
This is what I wear. What I'm showing in this X-ray is that you need to have an X-ray out of binder, especially because all these trauma patients get a CT scan in binder majority, but it should be done in the theater, you know. So what happens is that when the patient comes to ayeni, they do a CT scan from a city, so they do put the binder on. Once the patient is resuscitated, they're in Haiti, so you can slowly release the binder if the city is normal at that stage.
You need to take an X-ray out of binder. So they see that this is a clear example. So when we see some telltale signs are there, the pubis is well closed. So this is what happened in one of the hospitals because it's not been picked up. Patient was being left like that. A lot of pain thinking that there is nothing wrong. So this has all been picked up.
So this needed further. This is a classical type to APC. So fixing that. Yeah so I can see that it is entirely fixed with the reconstruction plate, with screws and on the back, it is fixed with the ideal sacral screw bilaterally. I suppose it's percutaneous. Yeah, yeah, that's correct.
So I'm taking your time too much. So let us just go here a little bit quicker. Anybody can look at it. So this is again, is this the next case semester, campana? Yeah OK. Thank you, Asif. This is the next case. I think the last one, I think, is Danish LTF Danish. Yes Yes.
Danish are you? Can you unmute yourself? Yeah yeah, I have unlimited myself. Yeah, perfect. Thank you. Danish OK, yes, Mr. Campano. Yeah, so this is another polytrauma. You can see that this is a CT. Coronal views.
Anything we can see clearly. Yeah, from this CT scan, I can see there is an opening of the sacroiliac joint and that joint is here that is not opened. So you see, and there is a fracture of the fracture and the spectrum is probably in zone 1. Yeah Yes. Yeah so far in these sections, this fracture, I can see the fracture more clearly now.
And it might be involving sexual phenomena as well. Yeah, of course, Yeah. And it could be. And that's so it's a little bit of opening there. So what is this one then? So second, but I've not seen any further images to see the injury. Uh, yeah, I think probably missed there.
You can see here, actually. So you can see the interior. Yeah, so it's Uh, and it's a unilateral remedy fracture with the cycle of fracture. So it looks it's LC to LC to compress a little compression fracture of this is a little confusing for you because we don't have in a proper cuts. There there is a UN displaced crack, which is going on here.
There is a factor which you can see. OK Yeah. So factor, this is a classical LC three, LC three. You don't see that it's all being stabilized with the percutaneous screws on the back. That's a big fix was. This is all a fix, which is a percutaneous right. You don't have to make a very big cuts. Small cut.
This is a spinal cord. Screw goes in there. Yeah, the one there supply stapler expects area and connected with the cutaneous rod. Usually, we take them off after four months. So see that already patient probably started healing. Yeah Yeah. I thank you.
Thank you, Dinesh. So I think these are the only candidates who volunteered so far to me one more. Yes I just wanted to say the all, you know, APC two, you'll see three secretaries. So this is another. Another patient hypervelocity, youngblood, I can see that significant injury. So this is what I was trying to show.
The anterior column is fractured here. Posterior column again, that is also factor in. Six of the columns are gone. So the fracture is here. So let's say so. You need to be aware of the established classification that all would be 10 times between been described by Judy. So there are five elementary type. That means only a single fracture line, five of them and the five of them, another five of them has got more than one structure.
They are called an associated type. There are two types totally 10, four, 5 plus 5 in each group. Five so you just have to be aware. So you can see that this patient, in fact, has got some fracture around or a joint widening the associate what we can see there. So you see that the site is pretty much wide open here. Or maybe some factory. So significant established fact.
See the. So that is again. 60, the establishment is fixed, which date back. And see that the head is back in place. It's one of those stupid calls tuberosity nameplate, which we use to push this head out. Yeah, there's some breaks, which we put to. So the essay joint established with the group, we call them Saudi Arabia, Kessler Kessler plates.
Only a significant political subplot, but this is another one, this is just to show that these are on display structure. This is a column fracture on the left side. So obviously. So again, the sun displaced factor in here on this play structure here, you can see that. So there can be managed with what is called the column schools.
So this is a happy view. You can see that this is the anterior column, but the school is in the posterior column you. So this is in the anti-terror column that is in question. Look at the next one. So this is a year. This is the idea. Public with peel-back public view shows you are your column. See that this entire thing is.
It is the skills fight. It is the skill tuberosity that is the question of the is in the posture column. So the entire column is war left here. This is, again, the posture arm of the opposite side. So look at the next one. So this is the. So that school is in the anterior column, that school in the posterior column.
Here you can see that is in the posture column. So on display structures we manage with the percutaneous. What a continuous thing, so any questions, guys? Sorry, I kept you for long. No, actually, thank you very much, Mr. That was a lot of dedication of you, this was very informative and I think people need to digest it, so they probably need to listen to a couple of times because you've covered it really, really nicely.
Fine, guys, this is the chance of you if you have any further questions. This is your last chance to ask because the next bit will be the Viva. I think we have time only for one candidate for the Viva unless everyone is tired. And if you want to the Viva, please the people who volunteered for the Viva, you are allowed to withdraw if you want.
If you feel tired and exhausted. If you still want to go for it, just raise your hand on the near you name on the participants. You know they all need a food. Actually, I think so. I think so. But because we promised some people that I would like them to withdraw rather than me apologize to them.
Yeah, I think all of them all for four of them actually has been involved in interactive talk. Fair enough. Yeah, so perfect. If that is the case, then what remains is to apologize for everyone, for doing, for cutting it short for the Viva. But I think that was worth it because this talk is very important.
And as you can see from this, it can branch into many aspects. It can go into massive hemorrhagic protocol. It can range into battles. Both guidelines fracture classification stabilization, thinking outside the box classification and all of them have been covered nicely by Mr campana. What remains of me go on Mr combiner a lot of time, but right as much as possible. But do let me know if and you can.
You can put our, Uh, the our press got that hemodynamic instability patients protocol. Absolutely I will once I will put it on Telegram group. And guys, if you missed to ask any question and you want to ask it, please put it in the telegram group. I will pass it on to Mr Campano and give you the reply again. Absolutely no, no, no concern at all. No problem at all. Very pleasure.
Thank you very much. Have a nice evening bye. Thank you very much, Mr campana. May I thank you. May I remind everyone that you can request a CBD for this talk? Please get in contact with feras, and he will be very happy to provide that. In addition, please listen to this talk again on the YouTube and it will be on YouTube, hopefully within the coming couple of days.
Again, I thank Mr Campano deeply for this informative talk and looking forward to seeing you again, Mr Campano. No worries, sir. Thanks and we'll see you then. Bye thank you. Thank you. Now, guys, may I ask the members to stay on?
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