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Pelvic Fractures For Postgraduate Orthopaedic Exams
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Pelvic Fractures For Postgraduate Orthopaedic Exams
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Segment:0 .
SHWAN HENARI: Welcome, everybody to another Wednesday session of the FRCS Mentors. Today, I am very pleased to be able to present Mr Paul Harnett of Kings Hospital as Kings College Hospital in London, as well as the Cleveland Clinic. He's going to talk to us about pelvic and acetabular trauma, focusing on the FRCS as always. Thank you very much, Mr Harnett.
PAUL HARNETT: OK. Thank you very much. So we also own King's College Hospital. I run the trauma, league of the trauma, been a consultant about seven years. I have 500 pelvis, case operative pelvis cases on and we just hit the 500 mark last month on our database. About half of those are acetabular and half of them are pelvis ring.
PAUL HARNETT: Probably half of them are young patients, half of them are geriatric so it's a full mixed bag and so we're operating on almost 100, 100 cases per year now. We also run one of our own FRCS courses, and this tends to be the theme of the, so, what I've shown, I've sort of split this into {INAUDIBLE} pelvis so there's pelvis rings
PAUL HARNETT: and then particularly for the FRCS we um, you're going to be dealt with an acute emergency situation. I have to say it would be it's very higher level stuff to start to talk about any detail of operative approaches and things. If you start to get that far, you're doing very well. And again, as with the technique of FRCS VIVA's is not to suddenly jump into the you know minutia detail of a stopper approach, because then you've, you've skipped out the part of your ABCs and resuscitation and nerve assessment so we'll talk about all that.
PAUL HARNETT: So the patient is adequately prepared for the surgery because as you know, the FRCS is designed to be you as a day one consultant likely to be at a district general hospital, and that's possibly dealing with the initial treatment. Not necessarily and have an idea and an understanding of the fixation and the principles, but not necessarily the intricate details.
PAUL HARNETT: So if you suddenly dive too deep, then the rest of the VIVA will be spent on that fine detail. And so your FRCS technique is to swim in the shallow end and only dip into the deep end if you're really prepared and have some control about that. So without further ado, let's move on. So we can start off with acetabular fractures. I have to say, when I was a very young, not the FRCS level, but like a year one registrar, I remember thinking, I hardly even know the difference between a pelvis and an acetabular fracture.
PAUL HARNETT: They make people go, oh, it's pelvis fracture, pelvis fracture, well, no, it's an acetabular fracture and it's like saying the difference between a tibial plateau and a fracture and a pilon fracture. They are completely other ends of the spectrum. Occasionally you can have both, just like you could have a plateau and a pilon fracture both ends of the tibia. So generic and you don't need to know about this.
PAUL HARNETT: We'll skip through this. And so when we talk about that femoral head, obviously it's impacting into the acetabulum sometimes that can be from, just from standing height, their poor osteoporotic bone. And sometimes, obviously it's high velocity injuries and occasionally acetabular fractures do cause significant damage to vessels. You can have an obturator artery injury. Very rarely
PAUL HARNETT: you could have a superior gluteal and then particularly when the head dislocates at the back, it can damage the sciatic nerve. We get all very excited about foot drops and partially dislocated hips. A very classic question is you know, what are the six lines seen on a standard AP pelvis? And I'll quickly skim by this but obviously this iliopectineal line, which is the brim of the acetabulum and that represents the anterior wall.
PAUL HARNETT: We can see this, though, and this is a normal AP pelvis and the problem about a normal AP pelvis, as you allude to on other views, is it's actually an obliqueogram of every part of the acetabulum, and it's an obliqueogram of the state of the pelvis and the pelvis ring. But from these obliqueograms, there are still some standard things that we look at. And so this iliopectineal line represents our anterior column and I'll come onto that.
PAUL HARNETT: We're obviously looking at the dome of the acetabulum, the teardrop is this strange configuration you can actually see on a normal pelvis, but it's a configuration of the bones that as a viewing point and this ilioischial line representing the push to your column and then you basically with the anterior wall and posterior wall, you kind of squint and pretend you can kind of see it. You'd be lucky if you could.
PAUL HARNETT: Occasionally you can see a subtle push to your wall. And to be honest, most trauma patients are going straight to CT scanners. And then, in fact, we don't even get judet views and things because we and then with a 3D CT scan, you then make a simulated X-ray and then you can rotate it so you do a simulated judet views. So moving on; classic textbook I have to say what I was learning my acetabular classification I never understood these pictures were very foreign to me because you never see an ex ray in this picture,
PAUL HARNETT: you never see a pelvis in this view, and yet someone's drawn all these funny lines but er and so it's really difficult to try to understand these you know, this is a 2D not even 2D drawings of the acetabulum yet This is a Judet Letournel from their series who are sort of the godfathers of acetabular surgery throughout the sixties, '70s and 80s and they and their presentation of 500 operative cases, all based on young, young patients.
PAUL HARNETT: And so you quite often find that the geriatric acetabular fractures or and we will come on to this on with the quadrilateral plate is blown out and yet the posture column's intact and the anterior columns intact and it's poorly classified. But when we are thinking and speaking to each other, we classify things and my entire database is all based on the Judet Letournel classification and there are some prognostic indicators.
PAUL HARNETT: One of the, one of the big mistakes that people say is they think that there's, for example, this transverse fracture to a column and there's a fracture, the posterior column. Therefore it's a both column fracture. And so people associated both column fracture and ABC. But yet, a transgressed fracture is not an ABC and so it's a very common mistake to consider both columns that are involved with a fracture to call it an ABC and then this has prognostic indicators and approach problems as well
PAUL HARNETT: and so then the real distinction part of ABC fracture is that no part so there's not near this posterior part or this anterior part is attached to the posterior. The constant fragment: for all articular cartilage fracture treatment throughout the whole body, we're always trying to build things back onto the constant fragment. And so when there is no element of articular cartilage attached to the constant fragment, therefore it's an ABC and in a simple way what is really, really smashed up, if your best bet is to call that an ABC.
PAUL HARNETT: So here we see this anterior column posterior transverse where we see as an anterior column and I've got some better pictures of this, but you see that the anterior column is fractured, the posterior column is fractured but yet here we see there's still a little bit element that's remained to the constant fragment and that has prognostic indicators and how we fix it.
PAUL HARNETT: I'll just run through as quickly so anterior columns, we don't see that very often. Anterior wall, it's not very exciting. We don't operate on that very often. An isolated posterior column. It's pretty unusual, to be honest. It's usually an associate posterior wall if it's just the posterior column that can be fixed percutaneously.
PAUL HARNETT: So I'll go on a little bit about that posterior wall fractures that's our most common that's the highest we're fixing those once a week with maybe not quite once a week, but certainly two or three times a month. With a hip fracture dislocation that disconnects the hip and it takes a little fragment with it, and now it's unstable. When we talk about how we describe that as stable and unstable, most of them are all unstable. Some people can dislocate without a fracture
PAUL HARNETT: and that becomes a bit of a conundrum. And I can talk all about lots and lots of posterial arthritis, these transverse fractures, that's a high velocity. And you'll often see that the head is medialised. So this is old school, rather central dislocation of the femoral head, and that's often the transverse type fracture. And I'll talk about your approaches about reform.
PAUL HARNETT: TType, it's quite rare in that series. It's only about 5%, but it's really tricky because you can see you can fix it from the we'll talk about how you do the approaches when you fix it from the front and fix it on the back. But here often needs a dual approach, this transverse posterior wall. I think that anything that involves the posterior wall has to be fixed with a Kocher-Langenbach approach.
PAUL HARNETT: We'll talk about that as we go along. And then there's transverse elements so that when you're doing the Kocher-Langenbeck approach, you can't actually access the anterior column. And the anterior column and quadrilateral plate needs to be fixed through an intra pelvis approach. Posterial column, posterior wall, you can fix that with your Kocher-Langenbeck approach.
PAUL HARNETT: All fairly straightforward. And this is the most common. I think that we're seeing this more and more now because of our geriatric injuries. So we move on. I'm going to give you some 3D examples of this. I just got a pint of Stella. I just got home from work. I was operating at 6.30, so I did well to get home on time.
PAUL HARNETT: So this example is a transverse fracture. So when you're seeing a bit more of a 3D image here. So it's going from the front to the back and here, like I was talking about, you'd see this central medialisation. We see this iliopectineal line, it's particularly disrupted. We're seeing this ischium which is medialised and disrupted. So some people are that's both columns are fractured. But no, no, no.
PAUL HARNETT: That's just the transverse fracture. The CT scan, you'll see the fracture line going from the anterior column to the posterior column and therefore, this is the transverse element. And here when you see lines going across in the CT, reading axial CT scans is quite difficult in trying to orientate it. Actually, to be honest, these days we just click on the 3D button, 3D recon button, and it creates a 3D scan for us.
PAUL HARNETT: When you're reading X rays, you, I, I teach my fellows, my acetabular pelvis fellows, you have to be able to read X-rays because intraoperatively all you've got is an II. So if you're just always used to looking at CT scans and 3D, 3D recons, you can't get that in theaters although actually we've just started doing interop CT scans and you can then get 3D scans, but that's cutting edge stuff and not applicable to most of the centers.
PAUL HARNETT: So and on the X-rays in theater, you do still get the Judet views, which we'll talk about, which are the 45 degree oblique views looking at those both. So we're still on to this our acetabular fixations and so and the reason that Judet Letournel is such a great classification system is because once you classified it correctly, then the treatment algorithm works very well. Like, oh, it is this type of, it is a transverse posterior wall fracture,
PAUL HARNETT: therefore, I do this approach. Actually, if we go back there, post transverse fractures we debate, can you fix this from the back or for the front? And actually, we now often try to fix you a dual approach. So this needs buttressing back and then the posterior column needs fixing from a Kocher-Langenbeck or percutaneous, to be honest, if you can get it really snug tight, but you can see how this pretty much has to get buttress back on.
PAUL HARNETT: And if you're trying to fix that from behind the Kocher-Langenbeck approach, you are very difficult, you often pinch it at the back and it opens at the front and you can't access both the front and the back at the same time. You can just about get that posterior column, but the fixation of it is inadequate. And so here, when we see this as a t type, so here we see it, which is essentially this transverse here, and then there's an extension through vertically, through the condyloid fossa, and then through this obturator foramen, and sometimes it can exit high and low
PAUL HARNETT: so there are variations of this, but you can see how once you could fix this perfectly here, the posterior column, you've got no access to this anterior column fracture and vice versa. You could fix it all here, but you've got no access here. And so these T types often require pretty much every time that they need a dual approach. There are some times where if you thought you could intropel, you could see, you could fix that perf, you could fix that perfectly.
PAUL HARNETT: You could visualize that and then fire a posterior column screw, which is starting here and finishing here. People will debate whether you can get that a nice compression across that it's quite some people even put in internal posture column plate but that's very deep high learning stuff. Don't let me I try not to confuse you. So so here we're seeing that both this is transverse and the posterior wall is damaged quite common.
PAUL HARNETT: And again so you have to go through the back approach to fix here and then you squeeze that down. Now whether you then you probably you'd be able to get at what's called a young bluff. There is only a few. A few particular pelvis instruments that are on the pelvis set and one's called. Some people call it the JB young spot with a Jay and a fair boof, which grabs the iliac crest.
PAUL HARNETT: But the young bluff is where you drill it in here and drill it in here like a hint. But with k wise, some people might have used for foot and ankle type surgery, but here you actually drill it with a small fragment screws, and then you can clamp it down here. And sometimes you can get a finger and see it. Somebody will even do a surgical dislocation or against osteotomy to visualize that.
PAUL HARNETT: And getting that fixation is difficult, difficult and whether you need an anterior approach. But again for your FRCS level, you want to don't get bogged down in the classification system. You can see there's not if you just said there's an acetabular fracture, there is disruption of the iliopectineal just describe what you see. There is disruption of the iliopectineal line, there is a posterior wall element to this.
PAUL HARNETT: This is grossly unstable. I'd have to make sure that the vessels were not damaged and that the nerve is intact, and that's it. Don't go deeper than that. If you do, oh, there's a Judet nail and they go, oh really? Tell us all about the Judet nail classifications. So once you mention that, then you'd have to be able, you'd be obliged to describe all 10. But if you simply describe what you see, you say, oh, I see that there's a disruption of this
PAUL HARNETT: this, this and then that's it. And then they'll let them maybe take you, do as I say, or do you know, classification, you say, yes, I know Judet Letournel which you could but again you just say stay superficial? You say, oh, there's a simple, there are five simple fractures and 5 associated fractures. Stop that's it. OK, so you know that there's a general principle.
PAUL HARNETT: The general principles are that there are simple fractures and more complex fractures. You don't necessarily have to remember all 10. Here we go. Go going a little bit deeper. So here this is our classical anteriorThe m column fracture. And then it's a half a transverse, immediate French me transverse.
PAUL HARNETT: You have to say it with an outrageous French accent. Why do you say that? And neither actually the ones you see, geriatric fractures, which I'll describe, which I'll show you, then they fall over. They've got osteoporotic bone, the quadrilateral platelets with this tiny little blow out to it. The quadrilateral plate is poorly described from all this classification system.
PAUL HARNETT: Essentially, you can see the quadrilateral plate is the posterior column. So the quadrilateral plate is blown out by in large the posterior column is part of that because we know that these what these Judet they were initially describing this large anterior column, this large posterior column. It's just a strong bones that are piercing the acetabulum, which is dome shaped, which is very difficult for us orthopedic surgeons,
PAUL HARNETT: we're normally dealing with straight bone, but now we're dealing with this spherical bone. But the way we get around that is that we have straight anterior column and posterior column, we can fix that with straight screws and straight plates. Here's another example of this trend, this posterior column fracture and a posterior wall. And so here we see this posterior wall fracture and then here on this unit,
PAUL HARNETT: so this is an example of what ah, you probably should be expected to notice that your Judet views which is 45 degrees both ways So 45 degrees this side and the 45 degrees on this side is your iliac oblique. So obliques are both. So it's an iliac oblique looking at the posterior column and then your obturator oblique. So this is on the left and here on the right this is an obturator oblique
PAUL HARNETT: and then you can almost this Alt puu {?}. So the posterior wall is seen on the obturator oblique and obturator oblique view is essentially an AP of the obturator foramen at 45 degrees and then you'll see the posterior wall. It's not quite coming out on that X-ray and then you realize that everything follows on from that. If it's posterior wall is on the obturator oblique, then that must be anterior column,
PAUL HARNETT: posterior wall interior column and then posterior column and interior wall; interior wall fractures are unusual. And then here, smashed to shit when you think it's all smashed and you can't see anything, think about an ABC fracture. There's no part of articular cartilage, which is attached to the constant fragment. All right, so here we're seeing these obturator oblique views,
PAUL HARNETT: again, old fashioned, they used to put triangles and things. In reality, we were doing these simulated with the CT scan. But I see them in post-op, post-op, in clinic, all in clinic at six weeks. I don't get another CT scan. I do get post-op CT scans of all of my patients. And so here, this obturator oblique, I'm seeing AP of the arbitrator foramen, which shows me that my posterior wall and my anterior column and here I'm seeing the posterior column of my iliac oblique and the anterior wall.
PAUL HARNETT: And you do need to know these because like I say, intraoperatively you need to be able to see all of these. So if you can't read, play an AP pelvis X-rays or obturator reviews, then you can't operate on acetabular fractures in theater. All right. So there's some more examples of that. So now you've classified your fracture.
PAUL HARNETT: Patient stable. You've. Quite a common question is FRCS says you've got a hip that's fracture dislocated. What should you do? And like a shoulder, you should try to reduce it and think, oh, but you're not the acetabular unit, well, you know, like a shoulder, you try to reduce a shoulder that's you're not necessarily a surgeon that could do an open approach to a shoulder,
PAUL HARNETT: although most of us could, you don't have, it's very, very, very unusual for a acetabular fracture to be irreducible. And so and yes, there is pressure on the sciatic nerve, as you can see there, sciatic nerve coming out here of the sciatic notch. I think I'll go back a bit pictures, if it's dislocated out the back here, that damaging that sciatic nerve.
PAUL HARNETT: So you'll reduce that fracture and then and traction, it needs about 10% so you're looking at least 5 kilos. It doesn't have to be skeletal traction. It can be skin traction to prevent that hip from dislocating back again. So you've pulled it, you've reduced it, but that needs to have traction. We've had, I started my FRCS course or my pelvis course specifically,
PAUL HARNETT: we had several cases where they reduced it and left it and then transferred and by the time they arrived to us with no traction, the hip had dislocated again. It can be grossly unstable and very unusually it's so damaged that even traction doesn't keep it very well reduced. But traction, traction is important and even traction to take attention off those fragile articular cartilage and then particularly the sciatic nerve, which runs right behind the acetabulum.
PAUL HARNETT: So that's why we worry about the sciatic nerve getting damaged. And it can be damaged and the, it's damaged about 10% of the time with a dislocation and then you pull the hip jackpot. What we want to know is, was it damaged the whole time, which it often is? Or can it be damaged so it was working
PAUL HARNETT: then you've done the closed reduction and then the sciatic nerve isn't working. To be honest, I've never seen that, but my colleague, he's seem that So that when we do the open and that's a surgical emergency, you've managed somehow the nerve has been trapped inside the joint after the reduction, and then it's a huge skipping rope sized nerve inside the joint.
PAUL HARNETT: So you've got to get to that within 6 hours. But we need to know the status of the nerve right from the get go. And it often it is damaged and there's not much treatment except for wait about a year. Sometimes they do get scar tissue around the nerve and there are peripheral nerve injury. Colleagues can help decompress that at a later stage.
PAUL HARNETT: When we talk about some surgical approaches, really the old school is this ilioinguinal. When we don't do this, it's very unusual when they need to do this again. We used to do the big ilioinguinal, which would be from the iliac crest all the way through; isolate the vessels and get down and clamp that. Now, 98% of the time we will be doing and I'll explain to you what this is on my next slide.
PAUL HARNETT: The stoppa approach. Then sometimes what we'll do is we'll start off with the stoppa approach and then we do a lateral window, which is the proximal part of the ilioinguinal will come underneath so we'll get to see all of this but we just leave and then we'll do our stoppa and then we leave this big gap here so we don't dissect out all of this and we stay miles away from the vessels and we can push the vessels laterally
PAUL HARNETT: we can push the vessels medially. It's only occasionally where the fracture line is right here, right near the vessels. And that's where our reduction and that's where our fixation needs to go. That's we will extend and connect the two and isolate the vessels. But often with carbon elevator underneath the idiopathic fascia, which is this sort of it's almost like a fascia fascia that it's poorly described so that we can push the we get a cob under here and they push the vessels out of the way.
PAUL HARNETT: So here's our stoppa approach, we're standing on the other side and the reason we're doing the stoppa approach is that we medialise so we can get plates on the inner brim and we can buttress here. We're often got a buttress plate right here and there's even those anatomical plates that we sometimes use or they don't always fit. And then the ability now to buttress this quadrilateral plate and here is often constant fragment and here is fractured fragment.
PAUL HARNETT: So we take down the corona cortis, which was, which is a vessel we see 95% of the time. And it's connecting the obterator to the external iliac vein and it runs here and we ligate that. And then once we ligate, we just cobb cobb cobb underneath this iliopectineal fascia here, which we cut through with a 15 blade or diathermine, and then you often don't see the vessels at all. You just know that you're underneath and you're very, very gently gentle and you can mobilize and push all of this. Occasionally, sometimes that in older patients we will see we call this a big blue or a big whale
PAUL HARNETT: and we're like, oh my god, that's the size of a garden hose. And you could theoretically, you could slip with a cobb and pop through something to one of my colleagues. But you know, we've done literally 250 of these. And so our indications to operate are sometimes we can do it just through the stoppa, it's like a pfannenstiel incision or it is a pfannenstiel incision, but very low morbidity, a few hundred mils of blood loss, the buttress that's down and then getting it out
PAUL HARNETT: and so our indications to operate are because we're doing this week in week out to stabilize it just like we do, we do more and more total effort placements to allow early full weight bearing and also knowing that anything more than 0.5 millimeters in the acetabulum is prone to post traumatic arthritis and the ability to put full weight bear so we're much more aggressive. You can see here,
PAUL HARNETT: sometimes when we do this, the view from the iliac crest, we slide the plate underneath and you can get through that, this lateral window. I actually often walk around to the other side and then you can connect the two into your sliding the plate underneath the vessels, but you're connecting both these lateral window and this, but you're just leaving the skin so you can slide the plate underneath, underneath.
PAUL HARNETT: Well, so we'll move on. We've talked about these disruptions here. We've talked about this. We've talked about this. So this we talk about CT scans and so we like the dome, which is essentially what we're fixing so you can see that we need to fix this. Anterior column, back to the posterior column, so you know that sometimes you need to get a shannon spin
PAUL HARNETT: And if I wanted to put a shannon spin in here and then internally rotate and clamp it down here. That would be my, everything's always about the reduction and the exposure to that. And so I know that would be my maneuver and I know that this would be my constant fragment. I remember we got our post op CT scans or now or sometimes getting inter-op CT scans
PAUL HARNETT: this is what we're really concerned about. This is the dome, this is the articular cartilage. And this we're trying to get to within 1 millimeter. And so here we're seeing this multi fragmented, this is representing our quadrilateral plate and we know that this buttress is back onto here and then this anterior column flips back down to here. And what to do about this posterior wall element. You can also look at the soft tissues you can see there's lots of hematoma here, disrupting and pushing onto the bladder.
PAUL HARNETT: So this is this classic picture. So you're like, OK, how do I fix this? You know? And this is the view you're getting from a stoppa approach and this is your anterior column, this is anterior column and a half a transverse. And so the quadrilateral plate here is blown out and the head is sitting in here
PAUL HARNETT: and actually though what is often on these 3D reconstructions and this is actually a bit of an old school 3D reconstruction, but you still wouldn't see it because it morphs it but on the point 625 CT scans, you'll see a tiny little fracture line here. It's almost always complete or sometimes it is incomplete so the posterior columns intact so then that does really fall into the Judet/Letournel classification system. But this is and some people say it's trying, that's a great part, trying to be an ACP anterior column and half a transverse. Again you don't have to get bogged down if you've got this and it's like, OK, well I can see there is a displaced acetabular fracture,
PAUL HARNETT: it's involving the anterior column and the quadriplegic. My basic principle is, is that this will require operative fixation. This is an unstable fracture that will require, I think, if the patient is fit and stable, would require operative fixation to stabilize that fracture, to allow for early mobilization. Then you could go on about whether they need a total hip replacement, either that day or the following week or whatever.
PAUL HARNETT: But there are some other indications that require total hip replacement, such as dome impaction or femoral head damage. And you can see again, you're like, well, how do we fix this? You're like, well, basically, I need to put this back to you. So I buttress this down and I buttress this down and unfortunately with acetabular surgery is that we just can't put screws on either side of the fracture because those screws would go into the joint
PAUL HARNETT: so what we do is we put a few screws here, we can put a few screws here and the whole plate just acts as a big buttress. Occasionally we can augment it with a plate here and again here. This is our constant fragment and we just need to buttress it back down. And then we've talked about the classification system and how it helps treat us.
PAUL HARNETT: The Kocher-Langenbeck approach is essentially the very similar to your posterior wall, sorry, your posterior INAUDIBLE. We've all done probably a lot of hip replacements for your posterior approach. It's a classic FRCS question is what's the difference of Kocher-Langenbeck and a posterior wall and I'm sorry, posterior approach. And the key thing here is that you're not taking the capsule down, you're just taking a period forward and the obturator internus and you're preserving.
PAUL HARNETT: And the reason you take that, you always describe and you learn about the approach is that you take it 1 to 2 centimeters away from the greater trochanter, whereas normally when you're doing that normal posture approach, trying to detach the piriformis as high up into the greater trochanter as you can, and then you come all the way down towards the quadratus femoris and then often when you're doing the push, you approach taking the capsule some time and you hit that bleeder.
PAUL HARNETT: That bleeder sword is blue, blue, blue and that is the circumflex, medial circumflex vessel and that's what we're preserving, and that is the femoral blood supply to the capsule. So when we do our posterior wall, that's where we stay miles away from that so we're just taking the piriformus and we just take the obturator internis and then we peel back the capsule trying to preserve the blood supply to the femoral head. Classic FRCS question; we just talked about that stoppa approach and the thumbs have to be both [?].
PAUL HARNETT: And then some classic; one of the complications of acetabular fracture. There's obviously in cases you can have an instability, a post traumatic arthritis, heterotopic ossification. People used to give it in medicine. We don't do that quite so much anymore. It doesn't actually work and it can have quite a lot of gastric problems and things.
PAUL HARNETT: And actually, it can be a problem. And then the nerve and occasionally the vessels, but the sciatic nerve damages is a constant big one. Good so so here's a case that you can see. This posterior wall is damaged. We can see this here in the surgery simply to push that back down and so, you know, you can only treat that with a Kocher-Langenbeck approach where not dissimilar to your posterior approach
PAUL HARNETT: but we take a cobb, cobb, cobb, cobb and we find that fragment and we pin it back down, again you can't you have to buttress it with here and screws through here and these screws have to go from here and outside the joint and that's why we get our Judet views and we look down the barrel of the screw to see it's not intra articular. Here, sort of an example of again, just basic principles.
PAUL HARNETT: How would I fix this fracture? Well, I need, I know that this fracture needs to go back to here, and this is constant fragments, so I can buttress that back down and this is quite difficult to see but this was an anterior column element to it and I'd want to fix that. And then through the CT scans, you'd want to see that there's
PAUL HARNETT: what's going on? Is that exactly the posterior wall? Well, again, for keen people here, this is a combined pelvis ring injury that's very severe and unusual, but this would probably also need fixation as well. And then you've got some wide and thick rock joints. You can actually have a pelvis and an acetabular fracture. You can imagine this massive lateral force and everything breaks.
PAUL HARNETT: We haven't delved into the fix and replace geriatric type things, but again, the principles are that I would achieve fixation such that patient could wait bear as tolerated. And if you thought your fixation was feeble or through osteoporotic bone, the damaged femoral head osteoporotic dome impaction and those are classic indications for urgent total hip replacement surgery.
PAUL HARNETT: So that's the acetabular fixation or acetabular true classification. Predominantly, almost all displaced acetabular fractures require operative fixation. You go, so what is stable and unstable? Like it is displaced and acetabular fractures do not tolerate this displacement very well at all.
PAUL HARNETT: So the only things we don't operate on are undisplaced fractures, and even if lasing on those ones, we will percutaneously fix them with potentially anterior column screws or posterior column screws to prevent any migration. That is debatable whether if they're undisplaced, they probably don't move at all anyways. But if they do, then you've missed the boat.
PAUL HARNETT: Good, so take our message that if its displaced and fractured it requires fixation. If there's medialization of the femoral head, that requires a intra pelvis. Some people have rebranded the stoppa approach to anti or intra pelvis, but you can just say that if there's mobilization of a femoral head, then that would require an intra pelvis fixation. And then if the posterior wall is involved or any particularly posteriorly not require a Kocher-Langenbeck type approach and then leave it at that.
PAUL HARNETT: So it's going to get true. Now we'll just carry on. I wonder if we're can have a break for 2 minutes, but we'll just carry on, or any questions. We're not going to go into pelvis ring injuries. I can't hear you. You're on mute.
SHWAN HENARI: Sorry my apologies. The, that's terrific. I was just one quick question. If if you don't mind me asking. Often with the quadrilateral plate fractures, drawing from my experience, we always put a pin in to pull the femur out. Would that be a worthwhile point to make in the exam demonstrating that you've seen these approaches and surgeries?
PAUL HARNETT: So, yeah. So, so, how, how to achieve traction in intraoperatively. So that can be with your, I'll just go back. Let's go back. So here. So how to traction will help. So these will just fold back in rather than during the intra-pelvis, which is fighting up against the vessels.
PAUL HARNETT: So sometimes even just if there's a small amount, an assistant pulling on the leg, a third assistant. Fourth assistant. But what a nice trick, which is to put a shance pin up, just like the track of a DHS or even into this stronger cacar bone, stop it about here. attach it to a T handle chuck, and then lateralise it. We have actually written a paper ,with a few papers I've written, which is on the star frame website due to be published
PAUL HARNETT: but it's a white paper at the moment where the problem is if you just pull on it, then you can just pull the whole hemipelvis and so the star frame STARR about a Dallas it's just the half of it is a carbon fiber rods attach the table to which you can attach a ball spike pusher to act as counter traction. So you have a pin here attached counter traction and here your shance pin attached to what is essentially an A0 driver and then you can wind it out.
PAUL HARNETT: And then once what you achieve is like a hip arthroscopy, once you achieve two or three or 2 centimeters 1centremetre of distraction, then these fragments can fold back into place much easier.
PAUL HARNETT:
SHWAN HANARI: Thank you. So in exam, some, a couple of previous candiates have said that they were asked what do you do in with the evidence of a Morel-Lavelle lesion associated with an acetabular fracture, a de-gloving injury.
PAUL HARNETT: Yeah Yeah. So the Morel-Lavallee injury is you have a shearing forces of the fatty layer against that, your fascia lata, typically. It can be a part of that glute marks, but typically your fascia lata and then that which actually you do a total hip replacement.
PAUL HARNETT: And you get your Bristowe and you push it, you're creating a mini little Morel-Lavelle iatrogenic injury yourself. So I mean, we do get away with it quite a lot, but you can get huge amounts of edema. And actually there's not there's not whenever there's seven different treatment methods, it means none of them work terribly well. You can just ignore it and eventually it can go away.
PAUL HARNETT: There can be huge seroma, you can try to aspirate it. You, some people have talked about putting a sclerosing agent, whether that's some sort of erythromycin type powder or talc type powders. Plastic surgeons will try to weave, stitch it back on. It's a large seroma type thing. So that's your Morel-Lavallee lesion.
PAUL HARNETT: Whether would that stop you from operating? Probably not, because SHWAN HENARI: would you put a drain in that scenario after you've finished the help, the seroma, or would you wait until seroma develops and then? We don't, like probably like all orthopedic, we, we don't use, we don't use things I suppose. And then it's likely trends, oh I won't use a pico type dressing but there's no evidence for that after our risk trial,
PAUL HARNETT: so, so a {SHWAN HANARI} A couple of more questions sorry: if there is poly-trauma that people are very interested in this topic, if there is poly-trauma needing a laparotomy, for example, by general surgeons, do you fix the acetabular fracture at the same time or do you wait until a later date?
PAUL HARNETT: So pelvis ring fractures often need stabilization, whether that's temporary, whether a pelvis x-fix, which is unusual, or the binder, that's the pelvis
PAUL HARNETT: stability is more important for their entire stress scores, as it were. But the acetabular surgery can wait, often waiting that 7 to 14 days. The only caveat to that is if there's a fragment so they would say certainly that would be the time to put a distal femur retraction pin and then they can have that distal
PAUL HARNETT: they can have the skeletal traction. It's more effective with that sort of 5 plus kilograms and these days we don't seem to have weights, it's just saline bags. So you're looking at five saline bags or two, 3 liter bags and yeah I mean, so the only caveat to that would be is if there's an incarcerated, fractured fragment of the posterior wall that's stuck inside the joint
PAUL HARNETT: and then we have, I've got a lot of tips and tricks that you can try to fish that out percutaneously by if you've got a long, you can get a long artery clip and fish it out and just stick it somewhere knowing that when he's better, a week, seven days down the line when you do your push your wall or if it's there. So you don't want it. Sometimes it's the size of a dice crunching around inside the joint and you don't really want that there for 7 to 10 days
PAUL HARNETT: so you can just fish it out but that's very unusual.
PAUL HARNETT:
[SHWAN HENARI]: Now, we're moving a little bit away from the FRCS level questions, but you could give a simple, quick one line answer, that would be great; asking about suitable time for doing an acetabular fracture surgery. Do you prefer to do early fixation or late while maintaining traction, as you were describing, for the open, sorry, for the open laparotomy type patients?
PAUL HARNETT: And then yeah, so so when, when, when the patient's fit. So if you, if you really want to go on their lactate but umm if it's they're, but it's not absolute, like a shaftsbury six but actually our soft tissue envelope and window is not as fragile as a proximal tibia, for example. So we and this I think we are let's let it settle down.
PAUL HARNETT: I mean, a posterior wall, acetabular fracture, isolated injury. We could fix that within a day or so. There's no saying. There's nothing to say, you, you have to wait but obviously, in poly trauma situations, you can wait. That's fine.
[SHWAN HENARI]: And again, this is outside, but just a simple combined acetabular and pelvic fracture, which one to be tackled first surgically?
PAUL HARNETT:
[SHWAN HENARI]: Which how would you approach which one? Yes so pelvis ring. Thank you. Your pelvis ring is more important. And then sometimes you can't reduce a fracture of your acetabular fracture because your whole sacroiliac joint is disrupted and that is your constant fragment. So we typically say you have to build from the back forwards would be the criteria.
PAUL HARNETT: So pelvis ring instability is more serious. Can be, it can be life threatening. There are very few orthopedic injuries that you die from. So if you hit the femoral artery from a femoral femur fracture, we almost never seen that. But the exsanguinating pelvis can be a major life threatening injury.
PAUL HARNETT: Actually, with the advent of pre resuscitation care, we're much better. Interesting when you go to some of the North American conferences, they still have pretty poor hospital care compared to actually our NHS. So they don't always have binders. They don't have blood on scene. They don't have the hems type doctors. Well, this generalization of all of America.
PAUL HARNETT: And so in America, they're still going on and on about these. Should they go to Ngo or should they be pelvis packing? And actually, they're probably just under resuscitated. And once you've missed that golden hour of poorly resuscitated, then you can go into a coagulopathy and then you're then you're constantly chasing and you never catch up again. So can have very high mortality when you're uncontrolled bleeding.
PAUL HARNETT: Actually, now, if we're getting that binder on very quickly, we're creating a clot or getting our coagulopathy under control actually, the death from an exsanguinating pelvis is very few and far between. So and again, when we think about the
PAUL HARNETT: imaging that we get the sort of pelvis binder straight through into a CT scanner. But your normal X-ray things, your normal to look at is, again, an obliqueogram and so we actually want to see is the inlet view where you're looking down into the pelvis and an outlet view where you're looking at essentially an AP of the sacrum and so it's here where you can see if there's displacement. And if it's just displacement on its own, you're like, well, that's not a big deal
PAUL HARNETT: but you can look at a cranial picture here, all the vessels here of your sacral plexus, both the venous plexus and the arterial plexus can be hemorrhaging. There's a superior gluteal, all of the branches of the internal iliac are like, oh, go to angio, go to angio. Well, angio can only deal with the arterial bleeding, which is actually pulsating and dramatic, but you can still have lots of venous sacral plexus bleeding, which you can't treat with an angiogram
PAUL HARNETT: and so that needs some sort of pressure to essentially and whether that pressure comes from pelvis packing or whether that pressure is actually often from the binders, what are the binders are doing? And just like you imagine if something's bleeding, your first reaction is to press on it and that's essentially what the binder is doing. So nothing to do with the fracture configuration and we'll talk about binders a bit more, but people are like ah can we take the binder off?
PAUL HARNETT: Is it OK to ask the orthopedic surgeon to take the binder off? Like, that's nothing to do with it, it's just all it's a hemodynamic, stabilize it. And if this patient is hemodynamically stable for a good period of time, called that 12 hours, 24 hours, then the binder can come off. People can have an open book pelvis, they're hemodynamically stable. They can sit on the ward for five days plus waiting for their surgery.
PAUL HARNETT: You don't need that binder on; the binder is a hemodynamic stabilizer, and so that's the resuscitation team, the ITU team who can make that call. It's safe to come off and very rare, if it needs to come off within that first 24 hours because it can cause it can cause pressure ulcers. And then very occasionally, the binder, the very next day, typically we take it off
PAUL HARNETT: the next day, you got to take the binder off and then the patient can crash or the blood pressure can drop you know so you slowly take it off. See the blood pressure is all ok, if they've got a big bleed or clot. But if they start to drop the blood pressure, then you do it back up again. You can't just leave it at that because you can't leave these binders on for what we've seen, big pressure sores
PAUL HARNETT: and that is the occasional once every year or two years where they will need an external fixator. So there are two unwell to have a large orif type thing in their pelvis, but they can't have the binder on for too long so then they do need not just a pins in the iliac crest and that iliac crest or this tether. And then and so then the ex fix they're all pelvis ex fix. We really do put these on very rarely these days because the binder has done the work.
PAUL HARNETT: So the common working classification system that we use again over the phone is this Young and Burgess classification. And so again, you don't have to get bogged down with this. I remember that at my FRCS, I was like, oh, so if it's being compressed from the lateral side and then I see a left pubic fracture, but then it's from the right.
PAUL HARNETT: And I don't really get it. And that's because just ignore the period where you might fractures again, and again, just try to describe what you see but umm when, when, as pelvis and referring centers are talking to us, they're like, oh, that's a stable. LC one, that's an unstable LC two and, and so we kind of know what that talks about and I'll go through this in a bit more detail. And you have to remember that this really important, the Young and Burgess classification was actually probably just invented in the pub on the back of a pack of napkins going, OK, we've got all these unstable pelvises, let's try to put them into four or five groups
PAUL HARNETT: and then when we make our databases, we can, we can help work it out. But actually there's lots and lots of overlap and most of them require operative fixation ans so this combined mechanism can make up 40, 50% of injuries. So if you are getting bogged down and go, oh, well, this is probably a combined mechanism and almost all of these injuries are unstable,
PAUL HARNETT: kind of, what is stable, what is unstable and so unstable requires operative fixation. And the only thing that doesn't require operative fixation is this lateral compression and we'll talk about it in a bit more detail is classified into two parts a stable and an unstable LC on. And the stable LC ones is the highest volume I get referred every, every day, twice like 200 stable, LC ones, actually, probably just peuvent ramp fractures
PAUL HARNETT: but now that everyone's getting a CT scan, we see a pubis raymus fracture and a bucket fracture almost like a taurus fracture of the sacrum and that's stable. It's only when it's a complete sacrum fracture we call that unstable. Now, what's a complete sacrum fracture and what's a vertical shear? No one knows,
PAUL HARNETT: There's nothing, it's almost one and the same. But the vertical shear sheared up a bit but still, it's unstable. So stable lateral compressions, unstable lateral compression, type 1 and then everything else is unstable. Let's move on. So here we go. Here's our LC one fractures.
PAUL HARNETT: Now, a really important mistake is that, oh, it's a bad LC one. It must be an LC two, like all orthopedics. One is OK. Two is worse. No, it's like an LC two factor is the ilium. This this bone here. I see. One factor here is this buckle of the sacrum. So there's two completely different bones.
PAUL HARNETT: It's like saying, a radius fracture, an ulnar fracture that they're just two different bones. So an LC2 fracture has nothing to do with an LC1 fracture. OK? So this fracture here, this is our stable LC1, we often, and the sacrum and the sacral complex make up 90% of the stability of the pelvis.
PAUL HARNETT: So just to ignore the pubic ramus fractures, we'll always want to look at the back here. So at the back and so I see this fracture line and then I'll scroll through with the mouse and I'll see if this line extends and it's obviously it doesn't buckle here. You'll have that pubic ramus fracture and these patients can weight
PAUL HARNETT: bear tolerated, I don't follow them up. In reality, it means that although we say weight bear is tolerated, there probably can be a bit of pain here on this left side. So you say you'll probably have to have some crutches for about four weeks, which will be full weight bearing on the right and partial on the left until the pain settles
PAUL HARNETT: and then we don't. Some people are absolutely fine and some people really do need those crutches for four weeks. Interestingly, I see some people come across from Europe for some injuries and they've been told to total best rest for four weeks and they come back three weeks later. And I just push on the heels and get them walking. They're like, oh, wow, you fixed me, but I didn't do anything.
PAUL HARNETT: So it's just the evolution of our weight bearing status and that's still evolving, we still don't have any good imaging of weight bearing and how stable or unstable fractures are and weight bearing, it's still a big conundrum. Moving on, So these LC2 fractures, this can, so you have a fracture of this ileum, which I'm just going to move this box here.
PAUL HARNETT: And so it's a fracture dislocation, this gets into the sacroiliac joint and sometimes if this fracture dislocation can be fixed percutaneous with an iliosacral screw because the fracture is posterior enough such that the screw would be here again to our constant fragment or whether just along these lines where you can actually fix the percutaneous screw from front to back and old school, you have actually used to do a push to put a little plate across that.
PAUL HARNETT: So that's LC2 and then LC3 is actually just both sides. Both sides of the sacrum and the sacriatic joint are fractured. So there's LC1, 2 and 3 and so and then over the phone you're like, oh, actually it's an LC1 on one side and LC2 on the other side. They do kind of add up actually. LC3 or you can have just both sacroiliac joints gone, that's an LC3.
PAUL HARNETT: Any very bad disruption is an LC3. Again, it just means they all need fixing, so, but it helps us understand that over the end of the phone. And again, that's why this one is so important, is that the forces that go through a pelvis to fracture it, so we concentrate on the bone but there's a lot of other shit going on sometimes literally so that they can those fragments of bone can penetrate the rectum.
PAUL HARNETT: That's why we say that the rectal MPV examination is critical and a missed perineal rectal injury can cause devastating injuries. I've seen entire scrotum skin die over the course of days and patients can die if they have fecal fecal contamination of this poly-traumatized area. So that's why these patients need a fairly urgent de-functioning colostomy and usually external fixator initially to sort of just stabilize it there or thereabouts.
PAUL HARNETT: And so these are things you really don't want to miss. Their pelvis fracture is one of multiple sort of abdominal type injuries. Sometimes those fragments of bone can puncture into the bladder, so they can puncture into the vagina. Again, we've had caught out with big chlamydia, actually, for the bone fragments in that sometimes bone fragments have penetrated into bowel and caused it, causing devastating injury.
PAUL HARNETT: So one of the keys is if you don't focus on the bone, focus on the soft tissues, but lots of orthopedic surgeons, we always get caught out when we ignore the soft tissues. This anterior anterior APC, anterior posterior compression type injuries, pop pelvis basically, the symphysis is fairly binary. It's either popped or not popped; something the classification system really talked about whether you have a minor disruption that doesn't actually exist and in their series it doesn't exist
PAUL HARNETT: so you call it a sprain if you're symphysis, that's basically full weight bearing so that's a change of management and APC2 so that's the most common. So it's a pop symphysis, a little bit of disruption of your sacral ligaments at the front, but the sacral ligaments in the back are intact. APC3 injuries, that's when your whole sacroiliac joint is disrupted
PAUL HARNETT: and that has prognostic indicators and you know it's likely you'll have to do a lateral window and open approach or an anterior approach to reduce and clamp that sacroiliac joint and plate that. And then this image on the right, you're like, well, but it's not vertical shear and you're right, it is. And so a roomful of pelvis surgeons, half of them would say this is a vertical shear injury because this whole hemipelvis has migrated and half might say that's an APC type 3.
PAUL HARNETT: Again, it's irrelevant. The treatment is to reduce it, plate it and fix it. And this injury, you can see this entire left hemi-pelvis can cause major disruptions to the arteries, the veins, the lumbar sacral plexus so I've seen complete lumbar sacral plexus injuries like a brachial plexus injury, except like unlike a brachial plexus injury, there's no treatment. So they're basically paralyzed on that leg.
PAUL HARNETT: Here we see this vertical shear injury and so and the fractures of the sacrum, also within the classification for that they need type classification, whether it's one two through the foramen or three medial to the foramen and again, that sort of prognostic, if you've got a fracture through the foramen, the chances of your sacral nerves being damaged is quite high.
PAUL HARNETT: Just like here we see this here, here you can imagine the nerves popping out through here, they're all going to be damaged and whether this is associated popped. That's just a post-op CT scan, very, very close anteriorly, whether it's fully threaded or partially, it's not for your concern but that's the sort of fixation we can achieve.
PAUL HARNETT: Somebody can talk about resuscitative screws so you can just put a screw across. Really to clamp it down to get some sort of compression. Can you put it in a quick iliosacral screw because if you had a huge 5 centimetre diastasis here and that's where it's all bleeding, you just need to compress it down. Again, high level stuff.
PAUL HARNETT: So I've got one case example to go to, to finish off with. But the take home messages from their pelvis ring injuries is that they are hemodynamic stable, your ATLS principles obviously hemodynamic unstable patients are not responsive to, to their initial resuscitation. Can be treated with interventional,
PAUL HARNETT: discussed with interventional radiology if they see a suitable and they're much, much quicker at it now I think; in the old days you're like, oh, we've got it's going to take two hours and then they'll die by the time they get there. But actually they're really quick and good. And so they can get in there and they can treat that or they get rushed straight up to theater and they have a laparotomy and you can do packing and they can have both.
PAUL HARNETT: They can have a laparotomy, they can see that because often on a CT scan, they can see that bleeding, they were like, I know, I'll get that. They can get it. They can stop that bleeding. And then they have a, then they might have a laparotomy for something else.
PAUL HARNETT: I need some pelvis packing; again you have the pelvis pack against something stable you can imagine if this is, if we go back, if you just pack up against here, it's all going to bleed. You're, you're packing against something unstable so you need to put that quickly, put on your iliac crest pins and pack against something that's stable and again, where do you pack? And it's in that stoppa approach which that space of rictus and you're like, oh, there are these three little swabs just in the right place.
PAUL HARNETT: In reality, you're stuffing as many large packs into that area as you can and you're getting this massive bulk and that's creating some compression in some sort of hemostasis, and you can pack it and then you're still bleeding, and then they go off to IR. So in my mind, I'm thinking that the packing is dealing with the venous bleeding and the interventional radiology is specifically seen in this as isolated now,
PAUL HARNETT: they used to do quite large internal iliac, but they can be very specific, they can see that super gluteal, that's the bleeding. I know I can get that, I can get there within 20 minutes whilst he's being resuscitated. These are the sort of conversations, and then this FRCS level, this might be suitable for my patient and this might be suitable for interventional radiology or this might need to go emergency to theater depending on how the resuscitation and that's to do with their blood volumes and things ready to be able to stabilize that fracture to allow with my trauma general surgeons.
PAUL HARNETT: Onto a case study and I'll take some questions and do some VIVA's. So I was a VIVA's consultant. This is as I still look as a consultant within my first year, this guy came in. You can't quite see it, but he weighed 220 kilos and he was doing some wheelies and he ran into a van and then the petrol tank blew up
PAUL HARNETT: So he had three third degree burns. He was in shock. They couldn't get a urinary catheter in, they had to find his urethral meatus, they could hardly get him into theaters. They couldn't, he didn't fit in the CT scanner. They took some x-rays they um, this was the picture of his bike, which was all burnt.
PAUL HARNETT: This was the poor van that he hit, like 220 kilograms. This is the x-rays taken that so you see, you can see he didn't, he didn't fit. So this is one X-ray this was the other X-ray and you have to piece them together and still going, what on Earth is going on? And then the sort of keen eyes in there, you see that actually this part of the sacrum belongs to this bit of the spine.
PAUL HARNETT: So this huge diastasis here and this huge this is a vertical shear combined injury. And you can imagine this blood just pouring from here. Binder didn't, it was absolutely enormous. But he was just about holding in there but for the first 24 hours but we did have to do
PAUL HARNETT: He wasn't stable and we did do fairly urgent surgery the following day to reduce that with ball spike pushers pushing that, pushing against that side. He had 40 - can you imagine normal people, you can feel your great scrochanter, you can push on that one or centimeters or gluteal, I'll do my percutaneous screws. This guy had 30 centimeters of adipose tissue before I even got to the bone.
PAUL HARNETT: So then my, my guidewire which was then all the way here couldn't I couldn't grab it, so I had to make a 15 centimeter incision about the size of hip replacement to then put the drill guide, to the drill bit all the way into basically what's this buttock to then get the screw there to then fire it across and you can see with the adipose tissue these, so this was up to it up there thereabouts and this was the diastasis and I'm just about hoping that the power of the screw and luckily he had actually very, very strong bone.
PAUL HARNETT: He's only 26 years old. And that bone being Wolfe's law becoming very, very strong to accommodate for the 220 kilograms. So actually it was a very strong bone that the screws actually did the work and the threads and the partial compression compressed it down. He was the one. He had a permanent plexus palsy and never recovered. And he eventually did go to the post CT scan.
PAUL HARNETT: It was actually near the Olympic stadium. They have to have a bariatric CT scanner to hold the Olympics. We tried calling the zoo because your standard CT scanner won't take this patient and this is a few film of them. And then, you know, these are 116 centimeter screws and this tiny little pelvis stuck inside this huge patient. And it turns out if you are 26 years old and paralyzed at 220 kilograms, you basically need to go to a nursing home
PAUL HARNETT: but there's no such thing as a nursing home for young people. He spent 390 days waiting for his young adult nursing home placement. And there you are. I still didn't quite get the full reduction there. He also had this really unusual scapula fracture for the upper limb surgeons there. Ok, so that's me done. Questions and then we'll do a couple of VIVA's.
PAUL HARNETT:
[SHWAN HENARI]: Well, I can definitely, I'm sure I'm speaking for everybody, That was quite impressive But also that was an amazing talk. Thank you very much, Mr Paul Harnett. I do have a comment/question for myself, if you don't mind. The exam is all about safety as a DGH, you're one of these DGH consultants.
PAUL HARNETT: And when you're asked where you're going to go with one patient who's not dynamically responsive, I've always thought the safest answer is to say, I'll take them to theater because we can get embolization and angiogram on the operating table as well as have surgeons ready to go if we fail to or if we can't get quick enough. So so depending on radiology being on the wall.{SHWAN HENARI ENDS]
PAUL HARNETT: So, so really you're talking about that's really a hybrid theater which doesn't only one place in the UK theater you'll have a combined resuscitative theater with interventional radiology and basically the interventional radiologists
PAUL HARNETT: don't play outside their own, they don't. they don't go. It can be done in some places where they'll use just a pelvis table and there and kind of get away with the CR. But no, they have these crazy special CE arms and all their toys and all their kit and everything is all lovely, set up, often quite close to recuss.
PAUL HARNETT: And the patients would go there to the interventional radiology suite. It's almost like saying, in fact, just think about it now. It's like asking your surgeon to not operate in theaters. So can your surgeon put a pelvis X fixed on in recuss? You're like, well, I suppose I could, but I don't really want to and don't like to and it's not safe, so I'm not going to do it. So we've never put a pelvis X fix on in recuss.
PAUL HARNETT: And, and equally so at the moment, they are still separated. And certainly in the DJH case stable they would be separated. But ultimately you'd think, why don't we have a hybrid theater where you could do everything in one place?
PAUL HARNETT:
{SHWAN HENARI]: Yeah so if this came up to you, you're in the DJH center as opposed to the trauma center, or even if you're in the trauma center. And so what do you do?
PAUL HARNETT: You just have interventional radiology, not also so. So this hopefully this patient, we could say, well, this patient with a new guy should never have arrived. You shouldn't have an unstable poly traumatized pelvis, ring, instability, arrival at District General Hospital. But should they then? My principles are to stabilize with the pelvis binder and ensure adequate resuscitation with blood and tranexamic.
PAUL HARNETT: We didn't talk about tranexamic acid and that they could then be transferred to their specialist unit whilst they're having the resuscitated blood which they can have and the pelvis binder. And that will have to suffice because actually if they go to theater. You put an x? Yeah no, I think places where they have interventional radiology and pelvic trauma patients with trauma laparotomy and/or pelvis packing, That would be a safer place.
[SHWAN HENARI]: Perfect. Thank you.
PAUL HARNETT: I can see some of these comments here. Any role of using Judet views at all or we just rely on CT. Yeah, just CT. And then you can do simulated Judet views.
PAUL HARNETT:
SHWAN HENARI: I think. But there's also the argument that if you, oh sorry, I'm not disagreeing with you.
PAUL HARNETT:
[SHWAN HENARI: So at the six week mark, when you're doing a check X ray, you use Judet views, with the role, local Judet views. Sorry, I think that was the question.
PAUL HARNETT: Here we go. So I didn't accept the management and comment, Morel-Lavellee, et cetera there is a very high risk of infection there. No, I think that wouldn't be the risk. There will always be some sort of, if there is some,
PAUL HARNETT: that's not a contract, that's not a contraindication and the risk of infections are not drastically higher. You'd cut through that you can treat if you are doing say a Kocher-Langenbeck approach, that's typically where you might see that Morel-Lavallee and that you would wash and take that because the risks of non operative surgery you know post traumatic arthritis is then severe and your Morel-Lavallee lesion is not going to unlike say a Shaftsbury six where the soft tissues might settle down, the skin might settle down over 7 to 10 days.
PAUL HARNETT: Your Morel-Lavallee lesion is never going to settle down, so you kind of just have to bite the bullet and I don't, the risks are very high. No, they're just a little bit from 1% to 5% and again, we probably would treat that with the weaving stitch through the fatty layer, just like we do a fascia stitch. but then you can combine that into the fascia.
PAUL HARNETT: Is sacroiliac screw positional or lag screw? So we try to achieve the reduction. About half the time it's fixed in situ, but sometimes we try to achieve the reduction with the ball spike pushing and pushing, but sometimes that the partially threaded screw and the washer, the few turns will actually close down the displacement.
PAUL HARNETT: That's a pretty technical question. Sometimes people will do an open approach to the sacroiliac joint to clamp it, to clean out the gunk inside the sacroiliac so all those ligaments being torn and washed out. Some people would do a posterior approach, the sacroiliac joint to clamp it and then reduce it and so then the screw is, it doesn't, yeah, it can help reduce it, but often it's like lots of things in orthopedics,
PAUL HARNETT: you can't rely on your hardware to do the reduction, but sometimes you can.
PAUL HARNETT:
[SHWAN HENARI]: If there is no more questions, I want to thank Mr Paul Harnett again for an amazing talk. Acetabulum and pelvic injuries are complex and difficult often to understand, but you've made it very simple and straightforward and a much more
PAUL HARNETT: concise way of preparing for the exam than a lot of the textbooks.
PAUL HARNETT: OK
Segment:0 .
SHWAN HENARI: Welcome, everybody to another Wednesday session of the FRCS Mentors. Today, I am very pleased to be able to present Mr Paul Harnett of Kings Hospital as Kings College Hospital in London, as well as the Cleveland Clinic. He's going to talk to us about pelvic and acetabular trauma, focusing on the FRCS as always. Thank you very much, Mr Harnett.
PAUL HARNETT: OK. Thank you very much. So we also own King's College Hospital. I run the trauma, league of the trauma, been a consultant about seven years. I have 500 pelvis, case operative pelvis cases on and we just hit the 500 mark last month on our database. About half of those are acetabular and half of them are pelvis ring.
PAUL HARNETT: Probably half of them are young patients, half of them are geriatric so it's a full mixed bag and so we're operating on almost 100, 100 cases per year now. We also run one of our own FRCS courses, and this tends to be the theme of the, so, what I've shown, I've sort of split this into {INAUDIBLE} pelvis so there's pelvis rings
PAUL HARNETT: and then particularly for the FRCS we um, you're going to be dealt with an acute emergency situation. I have to say it would be it's very higher level stuff to start to talk about any detail of operative approaches and things. If you start to get that far, you're doing very well. And again, as with the technique of FRCS VIVA's is not to suddenly jump into the you know minutia detail of a stopper approach, because then you've, you've skipped out the part of your ABCs and resuscitation and nerve assessment so we'll talk about all that.
PAUL HARNETT: So the patient is adequately prepared for the surgery because as you know, the FRCS is designed to be you as a day one consultant likely to be at a district general hospital, and that's possibly dealing with the initial treatment. Not necessarily and have an idea and an understanding of the fixation and the principles, but not necessarily the intricate details.
PAUL HARNETT: So if you suddenly dive too deep, then the rest of the VIVA will be spent on that fine detail. And so your FRCS technique is to swim in the shallow end and only dip into the deep end if you're really prepared and have some control about that. So without further ado, let's move on. So we can start off with acetabular fractures. I have to say, when I was a very young, not the FRCS level, but like a year one registrar, I remember thinking, I hardly even know the difference between a pelvis and an acetabular fracture.
PAUL HARNETT: They make people go, oh, it's pelvis fracture, pelvis fracture, well, no, it's an acetabular fracture and it's like saying the difference between a tibial plateau and a fracture and a pilon fracture. They are completely other ends of the spectrum. Occasionally you can have both, just like you could have a plateau and a pilon fracture both ends of the tibia. So generic and you don't need to know about this.
PAUL HARNETT: We'll skip through this. And so when we talk about that femoral head, obviously it's impacting into the acetabulum sometimes that can be from, just from standing height, their poor osteoporotic bone. And sometimes, obviously it's high velocity injuries and occasionally acetabular fractures do cause significant damage to vessels. You can have an obturator artery injury. Very rarely
PAUL HARNETT: you could have a superior gluteal and then particularly when the head dislocates at the back, it can damage the sciatic nerve. We get all very excited about foot drops and partially dislocated hips. A very classic question is you know, what are the six lines seen on a standard AP pelvis? And I'll quickly skim by this but obviously this iliopectineal line, which is the brim of the acetabulum and that represents the anterior wall.
PAUL HARNETT: We can see this, though, and this is a normal AP pelvis and the problem about a normal AP pelvis, as you allude to on other views, is it's actually an obliqueogram of every part of the acetabulum, and it's an obliqueogram of the state of the pelvis and the pelvis ring. But from these obliqueograms, there are still some standard things that we look at. And so this iliopectineal line represents our anterior column and I'll come onto that.
PAUL HARNETT: We're obviously looking at the dome of the acetabulum, the teardrop is this strange configuration you can actually see on a normal pelvis, but it's a configuration of the bones that as a viewing point and this ilioischial line representing the push to your column and then you basically with the anterior wall and posterior wall, you kind of squint and pretend you can kind of see it. You'd be lucky if you could.
PAUL HARNETT: Occasionally you can see a subtle push to your wall. And to be honest, most trauma patients are going straight to CT scanners. And then, in fact, we don't even get judet views and things because we and then with a 3D CT scan, you then make a simulated X-ray and then you can rotate it so you do a simulated judet views. So moving on; classic textbook I have to say what I was learning my acetabular classification I never understood these pictures were very foreign to me because you never see an ex ray in this picture,
PAUL HARNETT: you never see a pelvis in this view, and yet someone's drawn all these funny lines but er and so it's really difficult to try to understand these you know, this is a 2D not even 2D drawings of the acetabulum yet This is a Judet Letournel from their series who are sort of the godfathers of acetabular surgery throughout the sixties, '70s and 80s and they and their presentation of 500 operative cases, all based on young, young patients.
PAUL HARNETT: And so you quite often find that the geriatric acetabular fractures or and we will come on to this on with the quadrilateral plate is blown out and yet the posture column's intact and the anterior columns intact and it's poorly classified. But when we are thinking and speaking to each other, we classify things and my entire database is all based on the Judet Letournel classification and there are some prognostic indicators.
PAUL HARNETT: One of the, one of the big mistakes that people say is they think that there's, for example, this transverse fracture to a column and there's a fracture, the posterior column. Therefore it's a both column fracture. And so people associated both column fracture and ABC. But yet, a transgressed fracture is not an ABC and so it's a very common mistake to consider both columns that are involved with a fracture to call it an ABC and then this has prognostic indicators and approach problems as well
PAUL HARNETT: and so then the real distinction part of ABC fracture is that no part so there's not near this posterior part or this anterior part is attached to the posterior. The constant fragment: for all articular cartilage fracture treatment throughout the whole body, we're always trying to build things back onto the constant fragment. And so when there is no element of articular cartilage attached to the constant fragment, therefore it's an ABC and in a simple way what is really, really smashed up, if your best bet is to call that an ABC.
PAUL HARNETT: So here we see this anterior column posterior transverse where we see as an anterior column and I've got some better pictures of this, but you see that the anterior column is fractured, the posterior column is fractured but yet here we see there's still a little bit element that's remained to the constant fragment and that has prognostic indicators and how we fix it.
PAUL HARNETT: I'll just run through as quickly so anterior columns, we don't see that very often. Anterior wall, it's not very exciting. We don't operate on that very often. An isolated posterior column. It's pretty unusual, to be honest. It's usually an associate posterior wall if it's just the posterior column that can be fixed percutaneously.
PAUL HARNETT: So I'll go on a little bit about that posterior wall fractures that's our most common that's the highest we're fixing those once a week with maybe not quite once a week, but certainly two or three times a month. With a hip fracture dislocation that disconnects the hip and it takes a little fragment with it, and now it's unstable. When we talk about how we describe that as stable and unstable, most of them are all unstable. Some people can dislocate without a fracture
PAUL HARNETT: and that becomes a bit of a conundrum. And I can talk all about lots and lots of posterial arthritis, these transverse fractures, that's a high velocity. And you'll often see that the head is medialised. So this is old school, rather central dislocation of the femoral head, and that's often the transverse type fracture. And I'll talk about your approaches about reform.
PAUL HARNETT: TType, it's quite rare in that series. It's only about 5%, but it's really tricky because you can see you can fix it from the we'll talk about how you do the approaches when you fix it from the front and fix it on the back. But here often needs a dual approach, this transverse posterior wall. I think that anything that involves the posterior wall has to be fixed with a Kocher-Langenbach approach.
PAUL HARNETT: We'll talk about that as we go along. And then there's transverse elements so that when you're doing the Kocher-Langenbeck approach, you can't actually access the anterior column. And the anterior column and quadrilateral plate needs to be fixed through an intra pelvis approach. Posterial column, posterior wall, you can fix that with your Kocher-Langenbeck approach.
PAUL HARNETT: All fairly straightforward. And this is the most common. I think that we're seeing this more and more now because of our geriatric injuries. So we move on. I'm going to give you some 3D examples of this. I just got a pint of Stella. I just got home from work. I was operating at 6.30, so I did well to get home on time.
PAUL HARNETT: So this example is a transverse fracture. So when you're seeing a bit more of a 3D image here. So it's going from the front to the back and here, like I was talking about, you'd see this central medialisation. We see this iliopectineal line, it's particularly disrupted. We're seeing this ischium which is medialised and disrupted. So some people are that's both columns are fractured. But no, no, no.
PAUL HARNETT: That's just the transverse fracture. The CT scan, you'll see the fracture line going from the anterior column to the posterior column and therefore, this is the transverse element. And here when you see lines going across in the CT, reading axial CT scans is quite difficult in trying to orientate it. Actually, to be honest, these days we just click on the 3D button, 3D recon button, and it creates a 3D scan for us.
PAUL HARNETT: When you're reading X rays, you, I, I teach my fellows, my acetabular pelvis fellows, you have to be able to read X-rays because intraoperatively all you've got is an II. So if you're just always used to looking at CT scans and 3D, 3D recons, you can't get that in theaters although actually we've just started doing interop CT scans and you can then get 3D scans, but that's cutting edge stuff and not applicable to most of the centers.
PAUL HARNETT: So and on the X-rays in theater, you do still get the Judet views, which we'll talk about, which are the 45 degree oblique views looking at those both. So we're still on to this our acetabular fixations and so and the reason that Judet Letournel is such a great classification system is because once you classified it correctly, then the treatment algorithm works very well. Like, oh, it is this type of, it is a transverse posterior wall fracture,
PAUL HARNETT: therefore, I do this approach. Actually, if we go back there, post transverse fractures we debate, can you fix this from the back or for the front? And actually, we now often try to fix you a dual approach. So this needs buttressing back and then the posterior column needs fixing from a Kocher-Langenbeck or percutaneous, to be honest, if you can get it really snug tight, but you can see how this pretty much has to get buttress back on.
PAUL HARNETT: And if you're trying to fix that from behind the Kocher-Langenbeck approach, you are very difficult, you often pinch it at the back and it opens at the front and you can't access both the front and the back at the same time. You can just about get that posterior column, but the fixation of it is inadequate. And so here, when we see this as a t type, so here we see it, which is essentially this transverse here, and then there's an extension through vertically, through the condyloid fossa, and then through this obturator foramen, and sometimes it can exit high and low
PAUL HARNETT: so there are variations of this, but you can see how once you could fix this perfectly here, the posterior column, you've got no access to this anterior column fracture and vice versa. You could fix it all here, but you've got no access here. And so these T types often require pretty much every time that they need a dual approach. There are some times where if you thought you could intropel, you could see, you could fix that perf, you could fix that perfectly.
PAUL HARNETT: You could visualize that and then fire a posterior column screw, which is starting here and finishing here. People will debate whether you can get that a nice compression across that it's quite some people even put in internal posture column plate but that's very deep high learning stuff. Don't let me I try not to confuse you. So so here we're seeing that both this is transverse and the posterior wall is damaged quite common.
PAUL HARNETT: And again so you have to go through the back approach to fix here and then you squeeze that down. Now whether you then you probably you'd be able to get at what's called a young bluff. There is only a few. A few particular pelvis instruments that are on the pelvis set and one's called. Some people call it the JB young spot with a Jay and a fair boof, which grabs the iliac crest.
PAUL HARNETT: But the young bluff is where you drill it in here and drill it in here like a hint. But with k wise, some people might have used for foot and ankle type surgery, but here you actually drill it with a small fragment screws, and then you can clamp it down here. And sometimes you can get a finger and see it. Somebody will even do a surgical dislocation or against osteotomy to visualize that.
PAUL HARNETT: And getting that fixation is difficult, difficult and whether you need an anterior approach. But again for your FRCS level, you want to don't get bogged down in the classification system. You can see there's not if you just said there's an acetabular fracture, there is disruption of the iliopectineal just describe what you see. There is disruption of the iliopectineal line, there is a posterior wall element to this.
PAUL HARNETT: This is grossly unstable. I'd have to make sure that the vessels were not damaged and that the nerve is intact, and that's it. Don't go deeper than that. If you do, oh, there's a Judet nail and they go, oh really? Tell us all about the Judet nail classifications. So once you mention that, then you'd have to be able, you'd be obliged to describe all 10. But if you simply describe what you see, you say, oh, I see that there's a disruption of this
PAUL HARNETT: this, this and then that's it. And then they'll let them maybe take you, do as I say, or do you know, classification, you say, yes, I know Judet Letournel which you could but again you just say stay superficial? You say, oh, there's a simple, there are five simple fractures and 5 associated fractures. Stop that's it. OK, so you know that there's a general principle.
PAUL HARNETT: The general principles are that there are simple fractures and more complex fractures. You don't necessarily have to remember all 10. Here we go. Go going a little bit deeper. So here this is our classical anteriorThe m column fracture. And then it's a half a transverse, immediate French me transverse.
PAUL HARNETT: You have to say it with an outrageous French accent. Why do you say that? And neither actually the ones you see, geriatric fractures, which I'll describe, which I'll show you, then they fall over. They've got osteoporotic bone, the quadrilateral platelets with this tiny little blow out to it. The quadrilateral plate is poorly described from all this classification system.
PAUL HARNETT: Essentially, you can see the quadrilateral plate is the posterior column. So the quadrilateral plate is blown out by in large the posterior column is part of that because we know that these what these Judet they were initially describing this large anterior column, this large posterior column. It's just a strong bones that are piercing the acetabulum, which is dome shaped, which is very difficult for us orthopedic surgeons,
PAUL HARNETT: we're normally dealing with straight bone, but now we're dealing with this spherical bone. But the way we get around that is that we have straight anterior column and posterior column, we can fix that with straight screws and straight plates. Here's another example of this trend, this posterior column fracture and a posterior wall. And so here we see this posterior wall fracture and then here on this unit,
PAUL HARNETT: so this is an example of what ah, you probably should be expected to notice that your Judet views which is 45 degrees both ways So 45 degrees this side and the 45 degrees on this side is your iliac oblique. So obliques are both. So it's an iliac oblique looking at the posterior column and then your obturator oblique. So this is on the left and here on the right this is an obturator oblique
PAUL HARNETT: and then you can almost this Alt puu {?}. So the posterior wall is seen on the obturator oblique and obturator oblique view is essentially an AP of the obturator foramen at 45 degrees and then you'll see the posterior wall. It's not quite coming out on that X-ray and then you realize that everything follows on from that. If it's posterior wall is on the obturator oblique, then that must be anterior column,
PAUL HARNETT: posterior wall interior column and then posterior column and interior wall; interior wall fractures are unusual. And then here, smashed to shit when you think it's all smashed and you can't see anything, think about an ABC fracture. There's no part of articular cartilage, which is attached to the constant fragment. All right, so here we're seeing these obturator oblique views,
PAUL HARNETT: again, old fashioned, they used to put triangles and things. In reality, we were doing these simulated with the CT scan. But I see them in post-op, post-op, in clinic, all in clinic at six weeks. I don't get another CT scan. I do get post-op CT scans of all of my patients. And so here, this obturator oblique, I'm seeing AP of the arbitrator foramen, which shows me that my posterior wall and my anterior column and here I'm seeing the posterior column of my iliac oblique and the anterior wall.
PAUL HARNETT: And you do need to know these because like I say, intraoperatively you need to be able to see all of these. So if you can't read, play an AP pelvis X-rays or obturator reviews, then you can't operate on acetabular fractures in theater. All right. So there's some more examples of that. So now you've classified your fracture.
PAUL HARNETT: Patient stable. You've. Quite a common question is FRCS says you've got a hip that's fracture dislocated. What should you do? And like a shoulder, you should try to reduce it and think, oh, but you're not the acetabular unit, well, you know, like a shoulder, you try to reduce a shoulder that's you're not necessarily a surgeon that could do an open approach to a shoulder,
PAUL HARNETT: although most of us could, you don't have, it's very, very, very unusual for a acetabular fracture to be irreducible. And so and yes, there is pressure on the sciatic nerve, as you can see there, sciatic nerve coming out here of the sciatic notch. I think I'll go back a bit pictures, if it's dislocated out the back here, that damaging that sciatic nerve.
PAUL HARNETT: So you'll reduce that fracture and then and traction, it needs about 10% so you're looking at least 5 kilos. It doesn't have to be skeletal traction. It can be skin traction to prevent that hip from dislocating back again. So you've pulled it, you've reduced it, but that needs to have traction. We've had, I started my FRCS course or my pelvis course specifically,
PAUL HARNETT: we had several cases where they reduced it and left it and then transferred and by the time they arrived to us with no traction, the hip had dislocated again. It can be grossly unstable and very unusually it's so damaged that even traction doesn't keep it very well reduced. But traction, traction is important and even traction to take attention off those fragile articular cartilage and then particularly the sciatic nerve, which runs right behind the acetabulum.
PAUL HARNETT: So that's why we worry about the sciatic nerve getting damaged. And it can be damaged and the, it's damaged about 10% of the time with a dislocation and then you pull the hip jackpot. What we want to know is, was it damaged the whole time, which it often is? Or can it be damaged so it was working
PAUL HARNETT: then you've done the closed reduction and then the sciatic nerve isn't working. To be honest, I've never seen that, but my colleague, he's seem that So that when we do the open and that's a surgical emergency, you've managed somehow the nerve has been trapped inside the joint after the reduction, and then it's a huge skipping rope sized nerve inside the joint.
PAUL HARNETT: So you've got to get to that within 6 hours. But we need to know the status of the nerve right from the get go. And it often it is damaged and there's not much treatment except for wait about a year. Sometimes they do get scar tissue around the nerve and there are peripheral nerve injury. Colleagues can help decompress that at a later stage.
PAUL HARNETT: When we talk about some surgical approaches, really the old school is this ilioinguinal. When we don't do this, it's very unusual when they need to do this again. We used to do the big ilioinguinal, which would be from the iliac crest all the way through; isolate the vessels and get down and clamp that. Now, 98% of the time we will be doing and I'll explain to you what this is on my next slide.
PAUL HARNETT: The stoppa approach. Then sometimes what we'll do is we'll start off with the stoppa approach and then we do a lateral window, which is the proximal part of the ilioinguinal will come underneath so we'll get to see all of this but we just leave and then we'll do our stoppa and then we leave this big gap here so we don't dissect out all of this and we stay miles away from the vessels and we can push the vessels laterally
PAUL HARNETT: we can push the vessels medially. It's only occasionally where the fracture line is right here, right near the vessels. And that's where our reduction and that's where our fixation needs to go. That's we will extend and connect the two and isolate the vessels. But often with carbon elevator underneath the idiopathic fascia, which is this sort of it's almost like a fascia fascia that it's poorly described so that we can push the we get a cob under here and they push the vessels out of the way.
PAUL HARNETT: So here's our stoppa approach, we're standing on the other side and the reason we're doing the stoppa approach is that we medialise so we can get plates on the inner brim and we can buttress here. We're often got a buttress plate right here and there's even those anatomical plates that we sometimes use or they don't always fit. And then the ability now to buttress this quadrilateral plate and here is often constant fragment and here is fractured fragment.
PAUL HARNETT: So we take down the corona cortis, which was, which is a vessel we see 95% of the time. And it's connecting the obterator to the external iliac vein and it runs here and we ligate that. And then once we ligate, we just cobb cobb cobb underneath this iliopectineal fascia here, which we cut through with a 15 blade or diathermine, and then you often don't see the vessels at all. You just know that you're underneath and you're very, very gently gentle and you can mobilize and push all of this. Occasionally, sometimes that in older patients we will see we call this a big blue or a big whale
PAUL HARNETT: and we're like, oh my god, that's the size of a garden hose. And you could theoretically, you could slip with a cobb and pop through something to one of my colleagues. But you know, we've done literally 250 of these. And so our indications to operate are sometimes we can do it just through the stoppa, it's like a pfannenstiel incision or it is a pfannenstiel incision, but very low morbidity, a few hundred mils of blood loss, the buttress that's down and then getting it out
PAUL HARNETT: and so our indications to operate are because we're doing this week in week out to stabilize it just like we do, we do more and more total effort placements to allow early full weight bearing and also knowing that anything more than 0.5 millimeters in the acetabulum is prone to post traumatic arthritis and the ability to put full weight bear so we're much more aggressive. You can see here,
PAUL HARNETT: sometimes when we do this, the view from the iliac crest, we slide the plate underneath and you can get through that, this lateral window. I actually often walk around to the other side and then you can connect the two into your sliding the plate underneath the vessels, but you're connecting both these lateral window and this, but you're just leaving the skin so you can slide the plate underneath, underneath.
PAUL HARNETT: Well, so we'll move on. We've talked about these disruptions here. We've talked about this. We've talked about this. So this we talk about CT scans and so we like the dome, which is essentially what we're fixing so you can see that we need to fix this. Anterior column, back to the posterior column, so you know that sometimes you need to get a shannon spin
PAUL HARNETT: And if I wanted to put a shannon spin in here and then internally rotate and clamp it down here. That would be my, everything's always about the reduction and the exposure to that. And so I know that would be my maneuver and I know that this would be my constant fragment. I remember we got our post op CT scans or now or sometimes getting inter-op CT scans
PAUL HARNETT: this is what we're really concerned about. This is the dome, this is the articular cartilage. And this we're trying to get to within 1 millimeter. And so here we're seeing this multi fragmented, this is representing our quadrilateral plate and we know that this buttress is back onto here and then this anterior column flips back down to here. And what to do about this posterior wall element. You can also look at the soft tissues you can see there's lots of hematoma here, disrupting and pushing onto the bladder.
PAUL HARNETT: So this is this classic picture. So you're like, OK, how do I fix this? You know? And this is the view you're getting from a stoppa approach and this is your anterior column, this is anterior column and a half a transverse. And so the quadrilateral plate here is blown out and the head is sitting in here
PAUL HARNETT: and actually though what is often on these 3D reconstructions and this is actually a bit of an old school 3D reconstruction, but you still wouldn't see it because it morphs it but on the point 625 CT scans, you'll see a tiny little fracture line here. It's almost always complete or sometimes it is incomplete so the posterior columns intact so then that does really fall into the Judet/Letournel classification system. But this is and some people say it's trying, that's a great part, trying to be an ACP anterior column and half a transverse. Again you don't have to get bogged down if you've got this and it's like, OK, well I can see there is a displaced acetabular fracture,
PAUL HARNETT: it's involving the anterior column and the quadriplegic. My basic principle is, is that this will require operative fixation. This is an unstable fracture that will require, I think, if the patient is fit and stable, would require operative fixation to stabilize that fracture, to allow for early mobilization. Then you could go on about whether they need a total hip replacement, either that day or the following week or whatever.
PAUL HARNETT: But there are some other indications that require total hip replacement, such as dome impaction or femoral head damage. And you can see again, you're like, well, how do we fix this? You're like, well, basically, I need to put this back to you. So I buttress this down and I buttress this down and unfortunately with acetabular surgery is that we just can't put screws on either side of the fracture because those screws would go into the joint
PAUL HARNETT: so what we do is we put a few screws here, we can put a few screws here and the whole plate just acts as a big buttress. Occasionally we can augment it with a plate here and again here. This is our constant fragment and we just need to buttress it back down. And then we've talked about the classification system and how it helps treat us.
PAUL HARNETT: The Kocher-Langenbeck approach is essentially the very similar to your posterior wall, sorry, your posterior INAUDIBLE. We've all done probably a lot of hip replacements for your posterior approach. It's a classic FRCS question is what's the difference of Kocher-Langenbeck and a posterior wall and I'm sorry, posterior approach. And the key thing here is that you're not taking the capsule down, you're just taking a period forward and the obturator internus and you're preserving.
PAUL HARNETT: And the reason you take that, you always describe and you learn about the approach is that you take it 1 to 2 centimeters away from the greater trochanter, whereas normally when you're doing that normal posture approach, trying to detach the piriformis as high up into the greater trochanter as you can, and then you come all the way down towards the quadratus femoris and then often when you're doing the push, you approach taking the capsule some time and you hit that bleeder.
PAUL HARNETT: That bleeder sword is blue, blue, blue and that is the circumflex, medial circumflex vessel and that's what we're preserving, and that is the femoral blood supply to the capsule. So when we do our posterior wall, that's where we stay miles away from that so we're just taking the piriformus and we just take the obturator internis and then we peel back the capsule trying to preserve the blood supply to the femoral head. Classic FRCS question; we just talked about that stoppa approach and the thumbs have to be both [?].
PAUL HARNETT: And then some classic; one of the complications of acetabular fracture. There's obviously in cases you can have an instability, a post traumatic arthritis, heterotopic ossification. People used to give it in medicine. We don't do that quite so much anymore. It doesn't actually work and it can have quite a lot of gastric problems and things.
PAUL HARNETT: And actually, it can be a problem. And then the nerve and occasionally the vessels, but the sciatic nerve damages is a constant big one. Good so so here's a case that you can see. This posterior wall is damaged. We can see this here in the surgery simply to push that back down and so, you know, you can only treat that with a Kocher-Langenbeck approach where not dissimilar to your posterior approach
PAUL HARNETT: but we take a cobb, cobb, cobb, cobb and we find that fragment and we pin it back down, again you can't you have to buttress it with here and screws through here and these screws have to go from here and outside the joint and that's why we get our Judet views and we look down the barrel of the screw to see it's not intra articular. Here, sort of an example of again, just basic principles.
PAUL HARNETT: How would I fix this fracture? Well, I need, I know that this fracture needs to go back to here, and this is constant fragments, so I can buttress that back down and this is quite difficult to see but this was an anterior column element to it and I'd want to fix that. And then through the CT scans, you'd want to see that there's
PAUL HARNETT: what's going on? Is that exactly the posterior wall? Well, again, for keen people here, this is a combined pelvis ring injury that's very severe and unusual, but this would probably also need fixation as well. And then you've got some wide and thick rock joints. You can actually have a pelvis and an acetabular fracture. You can imagine this massive lateral force and everything breaks.
PAUL HARNETT: We haven't delved into the fix and replace geriatric type things, but again, the principles are that I would achieve fixation such that patient could wait bear as tolerated. And if you thought your fixation was feeble or through osteoporotic bone, the damaged femoral head osteoporotic dome impaction and those are classic indications for urgent total hip replacement surgery.
PAUL HARNETT: So that's the acetabular fixation or acetabular true classification. Predominantly, almost all displaced acetabular fractures require operative fixation. You go, so what is stable and unstable? Like it is displaced and acetabular fractures do not tolerate this displacement very well at all.
PAUL HARNETT: So the only things we don't operate on are undisplaced fractures, and even if lasing on those ones, we will percutaneously fix them with potentially anterior column screws or posterior column screws to prevent any migration. That is debatable whether if they're undisplaced, they probably don't move at all anyways. But if they do, then you've missed the boat.
PAUL HARNETT: Good, so take our message that if its displaced and fractured it requires fixation. If there's medialization of the femoral head, that requires a intra pelvis. Some people have rebranded the stoppa approach to anti or intra pelvis, but you can just say that if there's mobilization of a femoral head, then that would require an intra pelvis fixation. And then if the posterior wall is involved or any particularly posteriorly not require a Kocher-Langenbeck type approach and then leave it at that.
PAUL HARNETT: So it's going to get true. Now we'll just carry on. I wonder if we're can have a break for 2 minutes, but we'll just carry on, or any questions. We're not going to go into pelvis ring injuries. I can't hear you. You're on mute.
SHWAN HENARI: Sorry my apologies. The, that's terrific. I was just one quick question. If if you don't mind me asking. Often with the quadrilateral plate fractures, drawing from my experience, we always put a pin in to pull the femur out. Would that be a worthwhile point to make in the exam demonstrating that you've seen these approaches and surgeries?
PAUL HARNETT: So, yeah. So, so, how, how to achieve traction in intraoperatively. So that can be with your, I'll just go back. Let's go back. So here. So how to traction will help. So these will just fold back in rather than during the intra-pelvis, which is fighting up against the vessels.
PAUL HARNETT: So sometimes even just if there's a small amount, an assistant pulling on the leg, a third assistant. Fourth assistant. But what a nice trick, which is to put a shance pin up, just like the track of a DHS or even into this stronger cacar bone, stop it about here. attach it to a T handle chuck, and then lateralise it. We have actually written a paper ,with a few papers I've written, which is on the star frame website due to be published
PAUL HARNETT: but it's a white paper at the moment where the problem is if you just pull on it, then you can just pull the whole hemipelvis and so the star frame STARR about a Dallas it's just the half of it is a carbon fiber rods attach the table to which you can attach a ball spike pusher to act as counter traction. So you have a pin here attached counter traction and here your shance pin attached to what is essentially an A0 driver and then you can wind it out.
PAUL HARNETT: And then once what you achieve is like a hip arthroscopy, once you achieve two or three or 2 centimeters 1centremetre of distraction, then these fragments can fold back into place much easier.
PAUL HARNETT:
SHWAN HANARI: Thank you. So in exam, some, a couple of previous candiates have said that they were asked what do you do in with the evidence of a Morel-Lavelle lesion associated with an acetabular fracture, a de-gloving injury.
PAUL HARNETT: Yeah Yeah. So the Morel-Lavallee injury is you have a shearing forces of the fatty layer against that, your fascia lata, typically. It can be a part of that glute marks, but typically your fascia lata and then that which actually you do a total hip replacement.
PAUL HARNETT: And you get your Bristowe and you push it, you're creating a mini little Morel-Lavelle iatrogenic injury yourself. So I mean, we do get away with it quite a lot, but you can get huge amounts of edema. And actually there's not there's not whenever there's seven different treatment methods, it means none of them work terribly well. You can just ignore it and eventually it can go away.
PAUL HARNETT: There can be huge seroma, you can try to aspirate it. You, some people have talked about putting a sclerosing agent, whether that's some sort of erythromycin type powder or talc type powders. Plastic surgeons will try to weave, stitch it back on. It's a large seroma type thing. So that's your Morel-Lavallee lesion.
PAUL HARNETT: Whether would that stop you from operating? Probably not, because SHWAN HENARI: would you put a drain in that scenario after you've finished the help, the seroma, or would you wait until seroma develops and then? We don't, like probably like all orthopedic, we, we don't use, we don't use things I suppose. And then it's likely trends, oh I won't use a pico type dressing but there's no evidence for that after our risk trial,
PAUL HARNETT: so, so a {SHWAN HANARI} A couple of more questions sorry: if there is poly-trauma that people are very interested in this topic, if there is poly-trauma needing a laparotomy, for example, by general surgeons, do you fix the acetabular fracture at the same time or do you wait until a later date?
PAUL HARNETT: So pelvis ring fractures often need stabilization, whether that's temporary, whether a pelvis x-fix, which is unusual, or the binder, that's the pelvis
PAUL HARNETT: stability is more important for their entire stress scores, as it were. But the acetabular surgery can wait, often waiting that 7 to 14 days. The only caveat to that is if there's a fragment so they would say certainly that would be the time to put a distal femur retraction pin and then they can have that distal
PAUL HARNETT: they can have the skeletal traction. It's more effective with that sort of 5 plus kilograms and these days we don't seem to have weights, it's just saline bags. So you're looking at five saline bags or two, 3 liter bags and yeah I mean, so the only caveat to that would be is if there's an incarcerated, fractured fragment of the posterior wall that's stuck inside the joint
PAUL HARNETT: and then we have, I've got a lot of tips and tricks that you can try to fish that out percutaneously by if you've got a long, you can get a long artery clip and fish it out and just stick it somewhere knowing that when he's better, a week, seven days down the line when you do your push your wall or if it's there. So you don't want it. Sometimes it's the size of a dice crunching around inside the joint and you don't really want that there for 7 to 10 days
PAUL HARNETT: so you can just fish it out but that's very unusual.
PAUL HARNETT:
[SHWAN HENARI]: Now, we're moving a little bit away from the FRCS level questions, but you could give a simple, quick one line answer, that would be great; asking about suitable time for doing an acetabular fracture surgery. Do you prefer to do early fixation or late while maintaining traction, as you were describing, for the open, sorry, for the open laparotomy type patients?
PAUL HARNETT: And then yeah, so so when, when, when the patient's fit. So if you, if you really want to go on their lactate but umm if it's they're, but it's not absolute, like a shaftsbury six but actually our soft tissue envelope and window is not as fragile as a proximal tibia, for example. So we and this I think we are let's let it settle down.
PAUL HARNETT: I mean, a posterior wall, acetabular fracture, isolated injury. We could fix that within a day or so. There's no saying. There's nothing to say, you, you have to wait but obviously, in poly trauma situations, you can wait. That's fine.
[SHWAN HENARI]: And again, this is outside, but just a simple combined acetabular and pelvic fracture, which one to be tackled first surgically?
PAUL HARNETT:
[SHWAN HENARI]: Which how would you approach which one? Yes so pelvis ring. Thank you. Your pelvis ring is more important. And then sometimes you can't reduce a fracture of your acetabular fracture because your whole sacroiliac joint is disrupted and that is your constant fragment. So we typically say you have to build from the back forwards would be the criteria.
PAUL HARNETT: So pelvis ring instability is more serious. Can be, it can be life threatening. There are very few orthopedic injuries that you die from. So if you hit the femoral artery from a femoral femur fracture, we almost never seen that. But the exsanguinating pelvis can be a major life threatening injury.
PAUL HARNETT: Actually, with the advent of pre resuscitation care, we're much better. Interesting when you go to some of the North American conferences, they still have pretty poor hospital care compared to actually our NHS. So they don't always have binders. They don't have blood on scene. They don't have the hems type doctors. Well, this generalization of all of America.
PAUL HARNETT: And so in America, they're still going on and on about these. Should they go to Ngo or should they be pelvis packing? And actually, they're probably just under resuscitated. And once you've missed that golden hour of poorly resuscitated, then you can go into a coagulopathy and then you're then you're constantly chasing and you never catch up again. So can have very high mortality when you're uncontrolled bleeding.
PAUL HARNETT: Actually, now, if we're getting that binder on very quickly, we're creating a clot or getting our coagulopathy under control actually, the death from an exsanguinating pelvis is very few and far between. So and again, when we think about the
PAUL HARNETT: imaging that we get the sort of pelvis binder straight through into a CT scanner. But your normal X-ray things, your normal to look at is, again, an obliqueogram and so we actually want to see is the inlet view where you're looking down into the pelvis and an outlet view where you're looking at essentially an AP of the sacrum and so it's here where you can see if there's displacement. And if it's just displacement on its own, you're like, well, that's not a big deal
PAUL HARNETT: but you can look at a cranial picture here, all the vessels here of your sacral plexus, both the venous plexus and the arterial plexus can be hemorrhaging. There's a superior gluteal, all of the branches of the internal iliac are like, oh, go to angio, go to angio. Well, angio can only deal with the arterial bleeding, which is actually pulsating and dramatic, but you can still have lots of venous sacral plexus bleeding, which you can't treat with an angiogram
PAUL HARNETT: and so that needs some sort of pressure to essentially and whether that pressure comes from pelvis packing or whether that pressure is actually often from the binders, what are the binders are doing? And just like you imagine if something's bleeding, your first reaction is to press on it and that's essentially what the binder is doing. So nothing to do with the fracture configuration and we'll talk about binders a bit more, but people are like ah can we take the binder off?
PAUL HARNETT: Is it OK to ask the orthopedic surgeon to take the binder off? Like, that's nothing to do with it, it's just all it's a hemodynamic, stabilize it. And if this patient is hemodynamically stable for a good period of time, called that 12 hours, 24 hours, then the binder can come off. People can have an open book pelvis, they're hemodynamically stable. They can sit on the ward for five days plus waiting for their surgery.
PAUL HARNETT: You don't need that binder on; the binder is a hemodynamic stabilizer, and so that's the resuscitation team, the ITU team who can make that call. It's safe to come off and very rare, if it needs to come off within that first 24 hours because it can cause it can cause pressure ulcers. And then very occasionally, the binder, the very next day, typically we take it off
PAUL HARNETT: the next day, you got to take the binder off and then the patient can crash or the blood pressure can drop you know so you slowly take it off. See the blood pressure is all ok, if they've got a big bleed or clot. But if they start to drop the blood pressure, then you do it back up again. You can't just leave it at that because you can't leave these binders on for what we've seen, big pressure sores
PAUL HARNETT: and that is the occasional once every year or two years where they will need an external fixator. So there are two unwell to have a large orif type thing in their pelvis, but they can't have the binder on for too long so then they do need not just a pins in the iliac crest and that iliac crest or this tether. And then and so then the ex fix they're all pelvis ex fix. We really do put these on very rarely these days because the binder has done the work.
PAUL HARNETT: So the common working classification system that we use again over the phone is this Young and Burgess classification. And so again, you don't have to get bogged down with this. I remember that at my FRCS, I was like, oh, so if it's being compressed from the lateral side and then I see a left pubic fracture, but then it's from the right.
PAUL HARNETT: And I don't really get it. And that's because just ignore the period where you might fractures again, and again, just try to describe what you see but umm when, when, as pelvis and referring centers are talking to us, they're like, oh, that's a stable. LC one, that's an unstable LC two and, and so we kind of know what that talks about and I'll go through this in a bit more detail. And you have to remember that this really important, the Young and Burgess classification was actually probably just invented in the pub on the back of a pack of napkins going, OK, we've got all these unstable pelvises, let's try to put them into four or five groups
PAUL HARNETT: and then when we make our databases, we can, we can help work it out. But actually there's lots and lots of overlap and most of them require operative fixation ans so this combined mechanism can make up 40, 50% of injuries. So if you are getting bogged down and go, oh, well, this is probably a combined mechanism and almost all of these injuries are unstable,
PAUL HARNETT: kind of, what is stable, what is unstable and so unstable requires operative fixation. And the only thing that doesn't require operative fixation is this lateral compression and we'll talk about it in a bit more detail is classified into two parts a stable and an unstable LC on. And the stable LC ones is the highest volume I get referred every, every day, twice like 200 stable, LC ones, actually, probably just peuvent ramp fractures
PAUL HARNETT: but now that everyone's getting a CT scan, we see a pubis raymus fracture and a bucket fracture almost like a taurus fracture of the sacrum and that's stable. It's only when it's a complete sacrum fracture we call that unstable. Now, what's a complete sacrum fracture and what's a vertical shear? No one knows,
PAUL HARNETT: There's nothing, it's almost one and the same. But the vertical shear sheared up a bit but still, it's unstable. So stable lateral compressions, unstable lateral compression, type 1 and then everything else is unstable. Let's move on. So here we go. Here's our LC one fractures.
PAUL HARNETT: Now, a really important mistake is that, oh, it's a bad LC one. It must be an LC two, like all orthopedics. One is OK. Two is worse. No, it's like an LC two factor is the ilium. This this bone here. I see. One factor here is this buckle of the sacrum. So there's two completely different bones.
PAUL HARNETT: It's like saying, a radius fracture, an ulnar fracture that they're just two different bones. So an LC2 fracture has nothing to do with an LC1 fracture. OK? So this fracture here, this is our stable LC1, we often, and the sacrum and the sacral complex make up 90% of the stability of the pelvis.
PAUL HARNETT: So just to ignore the pubic ramus fractures, we'll always want to look at the back here. So at the back and so I see this fracture line and then I'll scroll through with the mouse and I'll see if this line extends and it's obviously it doesn't buckle here. You'll have that pubic ramus fracture and these patients can weight
PAUL HARNETT: bear tolerated, I don't follow them up. In reality, it means that although we say weight bear is tolerated, there probably can be a bit of pain here on this left side. So you say you'll probably have to have some crutches for about four weeks, which will be full weight bearing on the right and partial on the left until the pain settles
PAUL HARNETT: and then we don't. Some people are absolutely fine and some people really do need those crutches for four weeks. Interestingly, I see some people come across from Europe for some injuries and they've been told to total best rest for four weeks and they come back three weeks later. And I just push on the heels and get them walking. They're like, oh, wow, you fixed me, but I didn't do anything.
PAUL HARNETT: So it's just the evolution of our weight bearing status and that's still evolving, we still don't have any good imaging of weight bearing and how stable or unstable fractures are and weight bearing, it's still a big conundrum. Moving on, So these LC2 fractures, this can, so you have a fracture of this ileum, which I'm just going to move this box here.
PAUL HARNETT: And so it's a fracture dislocation, this gets into the sacroiliac joint and sometimes if this fracture dislocation can be fixed percutaneous with an iliosacral screw because the fracture is posterior enough such that the screw would be here again to our constant fragment or whether just along these lines where you can actually fix the percutaneous screw from front to back and old school, you have actually used to do a push to put a little plate across that.
PAUL HARNETT: So that's LC2 and then LC3 is actually just both sides. Both sides of the sacrum and the sacriatic joint are fractured. So there's LC1, 2 and 3 and so and then over the phone you're like, oh, actually it's an LC1 on one side and LC2 on the other side. They do kind of add up actually. LC3 or you can have just both sacroiliac joints gone, that's an LC3.
PAUL HARNETT: Any very bad disruption is an LC3. Again, it just means they all need fixing, so, but it helps us understand that over the end of the phone. And again, that's why this one is so important, is that the forces that go through a pelvis to fracture it, so we concentrate on the bone but there's a lot of other shit going on sometimes literally so that they can those fragments of bone can penetrate the rectum.
PAUL HARNETT: That's why we say that the rectal MPV examination is critical and a missed perineal rectal injury can cause devastating injuries. I've seen entire scrotum skin die over the course of days and patients can die if they have fecal fecal contamination of this poly-traumatized area. So that's why these patients need a fairly urgent de-functioning colostomy and usually external fixator initially to sort of just stabilize it there or thereabouts.
PAUL HARNETT: And so these are things you really don't want to miss. Their pelvis fracture is one of multiple sort of abdominal type injuries. Sometimes those fragments of bone can puncture into the bladder, so they can puncture into the vagina. Again, we've had caught out with big chlamydia, actually, for the bone fragments in that sometimes bone fragments have penetrated into bowel and caused it, causing devastating injury.
PAUL HARNETT: So one of the keys is if you don't focus on the bone, focus on the soft tissues, but lots of orthopedic surgeons, we always get caught out when we ignore the soft tissues. This anterior anterior APC, anterior posterior compression type injuries, pop pelvis basically, the symphysis is fairly binary. It's either popped or not popped; something the classification system really talked about whether you have a minor disruption that doesn't actually exist and in their series it doesn't exist
PAUL HARNETT: so you call it a sprain if you're symphysis, that's basically full weight bearing so that's a change of management and APC2 so that's the most common. So it's a pop symphysis, a little bit of disruption of your sacral ligaments at the front, but the sacral ligaments in the back are intact. APC3 injuries, that's when your whole sacroiliac joint is disrupted
PAUL HARNETT: and that has prognostic indicators and you know it's likely you'll have to do a lateral window and open approach or an anterior approach to reduce and clamp that sacroiliac joint and plate that. And then this image on the right, you're like, well, but it's not vertical shear and you're right, it is. And so a roomful of pelvis surgeons, half of them would say this is a vertical shear injury because this whole hemipelvis has migrated and half might say that's an APC type 3.
PAUL HARNETT: Again, it's irrelevant. The treatment is to reduce it, plate it and fix it. And this injury, you can see this entire left hemi-pelvis can cause major disruptions to the arteries, the veins, the lumbar sacral plexus so I've seen complete lumbar sacral plexus injuries like a brachial plexus injury, except like unlike a brachial plexus injury, there's no treatment. So they're basically paralyzed on that leg.
PAUL HARNETT: Here we see this vertical shear injury and so and the fractures of the sacrum, also within the classification for that they need type classification, whether it's one two through the foramen or three medial to the foramen and again, that sort of prognostic, if you've got a fracture through the foramen, the chances of your sacral nerves being damaged is quite high.
PAUL HARNETT: Just like here we see this here, here you can imagine the nerves popping out through here, they're all going to be damaged and whether this is associated popped. That's just a post-op CT scan, very, very close anteriorly, whether it's fully threaded or partially, it's not for your concern but that's the sort of fixation we can achieve.
PAUL HARNETT: Somebody can talk about resuscitative screws so you can just put a screw across. Really to clamp it down to get some sort of compression. Can you put it in a quick iliosacral screw because if you had a huge 5 centimetre diastasis here and that's where it's all bleeding, you just need to compress it down. Again, high level stuff.
PAUL HARNETT: So I've got one case example to go to, to finish off with. But the take home messages from their pelvis ring injuries is that they are hemodynamic stable, your ATLS principles obviously hemodynamic unstable patients are not responsive to, to their initial resuscitation. Can be treated with interventional,
PAUL HARNETT: discussed with interventional radiology if they see a suitable and they're much, much quicker at it now I think; in the old days you're like, oh, we've got it's going to take two hours and then they'll die by the time they get there. But actually they're really quick and good. And so they can get in there and they can treat that or they get rushed straight up to theater and they have a laparotomy and you can do packing and they can have both.
PAUL HARNETT: They can have a laparotomy, they can see that because often on a CT scan, they can see that bleeding, they were like, I know, I'll get that. They can get it. They can stop that bleeding. And then they have a, then they might have a laparotomy for something else.
PAUL HARNETT: I need some pelvis packing; again you have the pelvis pack against something stable you can imagine if this is, if we go back, if you just pack up against here, it's all going to bleed. You're, you're packing against something unstable so you need to put that quickly, put on your iliac crest pins and pack against something that's stable and again, where do you pack? And it's in that stoppa approach which that space of rictus and you're like, oh, there are these three little swabs just in the right place.
PAUL HARNETT: In reality, you're stuffing as many large packs into that area as you can and you're getting this massive bulk and that's creating some compression in some sort of hemostasis, and you can pack it and then you're still bleeding, and then they go off to IR. So in my mind, I'm thinking that the packing is dealing with the venous bleeding and the interventional radiology is specifically seen in this as isolated now,
PAUL HARNETT: they used to do quite large internal iliac, but they can be very specific, they can see that super gluteal, that's the bleeding. I know I can get that, I can get there within 20 minutes whilst he's being resuscitated. These are the sort of conversations, and then this FRCS level, this might be suitable for my patient and this might be suitable for interventional radiology or this might need to go emergency to theater depending on how the resuscitation and that's to do with their blood volumes and things ready to be able to stabilize that fracture to allow with my trauma general surgeons.
PAUL HARNETT: Onto a case study and I'll take some questions and do some VIVA's. So I was a VIVA's consultant. This is as I still look as a consultant within my first year, this guy came in. You can't quite see it, but he weighed 220 kilos and he was doing some wheelies and he ran into a van and then the petrol tank blew up
PAUL HARNETT: So he had three third degree burns. He was in shock. They couldn't get a urinary catheter in, they had to find his urethral meatus, they could hardly get him into theaters. They couldn't, he didn't fit in the CT scanner. They took some x-rays they um, this was the picture of his bike, which was all burnt.
PAUL HARNETT: This was the poor van that he hit, like 220 kilograms. This is the x-rays taken that so you see, you can see he didn't, he didn't fit. So this is one X-ray this was the other X-ray and you have to piece them together and still going, what on Earth is going on? And then the sort of keen eyes in there, you see that actually this part of the sacrum belongs to this bit of the spine.
PAUL HARNETT: So this huge diastasis here and this huge this is a vertical shear combined injury. And you can imagine this blood just pouring from here. Binder didn't, it was absolutely enormous. But he was just about holding in there but for the first 24 hours but we did have to do
PAUL HARNETT: He wasn't stable and we did do fairly urgent surgery the following day to reduce that with ball spike pushers pushing that, pushing against that side. He had 40 - can you imagine normal people, you can feel your great scrochanter, you can push on that one or centimeters or gluteal, I'll do my percutaneous screws. This guy had 30 centimeters of adipose tissue before I even got to the bone.
PAUL HARNETT: So then my, my guidewire which was then all the way here couldn't I couldn't grab it, so I had to make a 15 centimeter incision about the size of hip replacement to then put the drill guide, to the drill bit all the way into basically what's this buttock to then get the screw there to then fire it across and you can see with the adipose tissue these, so this was up to it up there thereabouts and this was the diastasis and I'm just about hoping that the power of the screw and luckily he had actually very, very strong bone.
PAUL HARNETT: He's only 26 years old. And that bone being Wolfe's law becoming very, very strong to accommodate for the 220 kilograms. So actually it was a very strong bone that the screws actually did the work and the threads and the partial compression compressed it down. He was the one. He had a permanent plexus palsy and never recovered. And he eventually did go to the post CT scan.
PAUL HARNETT: It was actually near the Olympic stadium. They have to have a bariatric CT scanner to hold the Olympics. We tried calling the zoo because your standard CT scanner won't take this patient and this is a few film of them. And then, you know, these are 116 centimeter screws and this tiny little pelvis stuck inside this huge patient. And it turns out if you are 26 years old and paralyzed at 220 kilograms, you basically need to go to a nursing home
PAUL HARNETT: but there's no such thing as a nursing home for young people. He spent 390 days waiting for his young adult nursing home placement. And there you are. I still didn't quite get the full reduction there. He also had this really unusual scapula fracture for the upper limb surgeons there. Ok, so that's me done. Questions and then we'll do a couple of VIVA's.
PAUL HARNETT:
[SHWAN HENARI]: Well, I can definitely, I'm sure I'm speaking for everybody, That was quite impressive But also that was an amazing talk. Thank you very much, Mr Paul Harnett. I do have a comment/question for myself, if you don't mind. The exam is all about safety as a DGH, you're one of these DGH consultants.
PAUL HARNETT: And when you're asked where you're going to go with one patient who's not dynamically responsive, I've always thought the safest answer is to say, I'll take them to theater because we can get embolization and angiogram on the operating table as well as have surgeons ready to go if we fail to or if we can't get quick enough. So so depending on radiology being on the wall.{SHWAN HENARI ENDS]
PAUL HARNETT: So, so really you're talking about that's really a hybrid theater which doesn't only one place in the UK theater you'll have a combined resuscitative theater with interventional radiology and basically the interventional radiologists
PAUL HARNETT: don't play outside their own, they don't. they don't go. It can be done in some places where they'll use just a pelvis table and there and kind of get away with the CR. But no, they have these crazy special CE arms and all their toys and all their kit and everything is all lovely, set up, often quite close to recuss.
PAUL HARNETT: And the patients would go there to the interventional radiology suite. It's almost like saying, in fact, just think about it now. It's like asking your surgeon to not operate in theaters. So can your surgeon put a pelvis X fixed on in recuss? You're like, well, I suppose I could, but I don't really want to and don't like to and it's not safe, so I'm not going to do it. So we've never put a pelvis X fix on in recuss.
PAUL HARNETT: And, and equally so at the moment, they are still separated. And certainly in the DJH case stable they would be separated. But ultimately you'd think, why don't we have a hybrid theater where you could do everything in one place?
PAUL HARNETT:
{SHWAN HENARI]: Yeah so if this came up to you, you're in the DJH center as opposed to the trauma center, or even if you're in the trauma center. And so what do you do?
PAUL HARNETT: You just have interventional radiology, not also so. So this hopefully this patient, we could say, well, this patient with a new guy should never have arrived. You shouldn't have an unstable poly traumatized pelvis, ring, instability, arrival at District General Hospital. But should they then? My principles are to stabilize with the pelvis binder and ensure adequate resuscitation with blood and tranexamic.
PAUL HARNETT: We didn't talk about tranexamic acid and that they could then be transferred to their specialist unit whilst they're having the resuscitated blood which they can have and the pelvis binder. And that will have to suffice because actually if they go to theater. You put an x? Yeah no, I think places where they have interventional radiology and pelvic trauma patients with trauma laparotomy and/or pelvis packing, That would be a safer place.
[SHWAN HENARI]: Perfect. Thank you.
PAUL HARNETT: I can see some of these comments here. Any role of using Judet views at all or we just rely on CT. Yeah, just CT. And then you can do simulated Judet views.
PAUL HARNETT:
SHWAN HENARI: I think. But there's also the argument that if you, oh sorry, I'm not disagreeing with you.
PAUL HARNETT:
[SHWAN HENARI: So at the six week mark, when you're doing a check X ray, you use Judet views, with the role, local Judet views. Sorry, I think that was the question.
PAUL HARNETT: Here we go. So I didn't accept the management and comment, Morel-Lavellee, et cetera there is a very high risk of infection there. No, I think that wouldn't be the risk. There will always be some sort of, if there is some,
PAUL HARNETT: that's not a contract, that's not a contraindication and the risk of infections are not drastically higher. You'd cut through that you can treat if you are doing say a Kocher-Langenbeck approach, that's typically where you might see that Morel-Lavallee and that you would wash and take that because the risks of non operative surgery you know post traumatic arthritis is then severe and your Morel-Lavallee lesion is not going to unlike say a Shaftsbury six where the soft tissues might settle down, the skin might settle down over 7 to 10 days.
PAUL HARNETT: Your Morel-Lavallee lesion is never going to settle down, so you kind of just have to bite the bullet and I don't, the risks are very high. No, they're just a little bit from 1% to 5% and again, we probably would treat that with the weaving stitch through the fatty layer, just like we do a fascia stitch. but then you can combine that into the fascia.
PAUL HARNETT: Is sacroiliac screw positional or lag screw? So we try to achieve the reduction. About half the time it's fixed in situ, but sometimes we try to achieve the reduction with the ball spike pushing and pushing, but sometimes that the partially threaded screw and the washer, the few turns will actually close down the displacement.
PAUL HARNETT: That's a pretty technical question. Sometimes people will do an open approach to the sacroiliac joint to clamp it, to clean out the gunk inside the sacroiliac so all those ligaments being torn and washed out. Some people would do a posterior approach, the sacroiliac joint to clamp it and then reduce it and so then the screw is, it doesn't, yeah, it can help reduce it, but often it's like lots of things in orthopedics,
PAUL HARNETT: you can't rely on your hardware to do the reduction, but sometimes you can.
PAUL HARNETT:
[SHWAN HENARI]: If there is no more questions, I want to thank Mr Paul Harnett again for an amazing talk. Acetabulum and pelvic injuries are complex and difficult often to understand, but you've made it very simple and straightforward and a much more
PAUL HARNETT: concise way of preparing for the exam than a lot of the textbooks.
PAUL HARNETT: OK
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