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Fracturile Deschise de Bazin Tradus
Fracturile Deschise de Bazin Tradus
urgenta in
leziunea inelului
pelvin
Sean E. Nork, MD
Harborview Medical Center, Seattle, Washington
Energie înaltă
Morbiditate/Mortalitate
Hemoragie
• Osteologie
Structură de inel format din sacrum și două oase
nenumite
Stabilitatea depinde de structurile ligamentare
puternice din jur
Deplasarea poate avea loc doar cu întreruperea
inelului în două locuri
Structurile neurovasculare sunt intim legate cu
ligamentele pelvine posterioare
indice ridicat de suspiciune de leziune a vaselor
iliace interne sau plexului lumbosacral
Ligamentele
o anterior
ligamentele symphyseal
rezista rotație externă
o podea pelvin
ligamentele sacrospinous
rezista rotație externă
ligamentele sacrotuberous
rezista forfecare și de flexie
o complexă sacroiliace posterior ( banda de tensiune posterior )
puternice ligamentele din organism
mai important decât structurile anterioare de stabilitate inel pelvin
ligamentele sacroiliace anterioare
rezista rotație externă , după eșecul de planseului pelvin și structurile anterioare
sacroiliace interosoasa
rezista traducere antero- posterior al pelvisului
sacroiliace posterior
rezista deplasare cephalad - caudad de pelvis
iliolombar
rezista rotație și spori ligamentele SI posterioare
complexul sacroiliac posterior ( banda de
tensiune posterioara )
Degloving injuries
Limb shortening
Limb rotation
Open wounds
Radiografic
Hemodinamic
Mecanic
Un singur examinator
R-TV dacă este posibil
Cele mai experimentate mîini
Semnele radiologice ale instabilităţii
15% incidence
Interne: Torace
Oasele lungi
Abdomenul
Retroperitoneal
Sursele de hemoragie
Definitions Confusing
Potentially based on multiple factors & measures
Lactate
Base Deficit
SBP < 90 mmHg
Ongoing drop in Hct
Response to fluid challenge
Pelvic Fractures & Hemorrhage
Fracture pattern associated with risk of vascular injury
(Young & Burgess)
ER & VS > IR
APC & VS at increased risk
ER & VS > IR
APC & VS at increased risk
Controlul hemoragiei
Mneţinerea bazinului
Sheet (cearşaf)
Centură plevină
(Pelvic Binder)
Fixator extern
Angiografia
Laparotomia
Pelvic Packing
(Tamponaj)
Circumferential Sheeting
Decubit dorsal 2
2 “cearşăfari” 1
Trohanter=Gîtul mîinii
Aplicarea şi tensionarea
“Fixarea”
(30 secunde) 4 3
SIAI Resuscitative
SIAS Augmentative
C-clamp Definitive
Biomecanica fixării externe
No designs work
Biomechanics of External Fixation
Pin size
Number of pins
Frame design
Biomechanics: Pin Location
AIIS:
Biomechanically
equivalent
(superior?)
AIIS:
Biomechanically
equivalent
(superior?)
AIIS:
Biomechanically
equivalent
(superior?)
AIIS:
Biomechanically
equivalent
(superior?)
To decrease pain in
polytraumatized patients?
As an adjunct to ORIF
To decrease pain in
polytraumatized patients?
As an adjunct to ORIF
To decrease pain in
polytraumatized patients?
As an adjunct to ORIF
To decrease pain in
polytraumatized patients?
As an adjunct to ORIF
Fluoro dependent
3 to 5 cm posterior to the ASIS
Incisions directed toward the
anticipated final location
1/3 from the medial aspect
(lateral overhang)
Inner Table
Outer Table
ASIS
Outlet Oblique Image
Inner Table
Outer Table
ASIS
Check Pin Placement
Technical Details: AIIS frames…
Fluoro dependent:
30/30 outlet/obturator oblique
Iliac oblique
Inlet/obturator oblique
Incisions directed toward the
anticipated final location
Blunt dissection
Apply in fluoro/OR?
Apply in fluoro/OR?
Apply in fluoro/OR?
Arterial only
5-15%
Timing
Institution dependent
Role of Angiography???
Fracture Pattern!
Contrast CT suggests
Effective in retrospective
studies!!!
Vascular Injuries
Arterial vs Venous vs
Cancellous
Role of angiography
Cryer et al, JT, 1988
O’Neill et al, CORR, 1996
Goldstein et al, JT, 1994
Acute Hemipelvectomy….
Acute Hemipelvectomy….
Acute Hemipelvectomy….
Retrospective Evidence Suggests…
Hypotensive with stable pelvic pattern…
Laparotomy (85% with abdominal hemorrhage)
Changes: Patients more severely injured (52% vs 35% SBP < 90)
DPL phased out for U/S
Pelvic binders and C-clamps replaced traditional ex fix
Protocol for Management
Biffl et al, Evolution of a mutlidisciplinary clinical pathway for the
management of unstable patients with pelvic fractures. JOT, 2001
HMC Faculty
Barei, Beingessner, Bellabarba, Benirschke, Chapman, Dunbar, Hanel,
Hanson, Henley, Mirza, Routt, Sangeorzan, Smith, Taitsman