RESUMEN

Determining the true availability of resources and understanding the level of training of surgeons involved in the treatment of patients with pelvic fractures and haemorrhagic shock is critical. In the herein study, the availability of technical, technological, and human resources for the care of this injury in Latin America region was analysed, and the preferences of orthopaedic trauma surgeons when performing interventions for the diagnosis and treatment of patients with pelvic trauma and associated haemorrhagic shock was described. A cross sectional web-based survey containing questions on knowledge, attitudes, and practices with respect to imaging resources, emergency pelvic stabilization methods, and interventions used for bleeding control was sent to 948 Latin America orthopaedic trauma surgeons treating pelvic fractures in the emergency department. Differences between regional clusters, level of training, type of hospital, and pelvic surgery volume were assessed. 368 responses were obtained, with 37.5% of respondents reporting formal training in pelvic surgery and 36.0% having available protocol for managing these patients. The most frequently used interventions were the supra-acetabular pelvic external fixator and pelvic packing. Limited hospital and imaging resources are available for the care of patients with pelvic trauma and associated haemorrhagic shock throughout Latin America. In addition, the training of orthopaedic trauma surgeons dealing with this type of injury and the volume of pelvic surgeries per year is heterogeneous. It should be urgently considered to develop management protocols adapted to Latin America according to the availability of resources, as well as to promote training in this severe life-threatening traumatic condition.

Asunto(s)

RESUMEN

Abstract: Superior pubic rami fractures are commonly associated with a posterior pelvic ring disruption. It has been shown that fixing both the anterior pelvic arch and the posterior ring increases stability and enhances clinical results. Several techniques for fixing the superior pubic rami exist, and multiple studies showed that minimally invasive methods decrease wound-related complications, with the advantage of preserving soft tissues. We describe a surgical procedure to treat simple pubic rami fractures associated with posterior pelvic ring disruptions by placing an intramedullary elastic titanium nail (TEN). We propose this technique as an alternative fixation method for superior pubic rami fractures.

Resumen: Las fracturas de la rama superior del pubis se asocian con frecuencia a una alteración del anillo pélvico posterior. Se ha demostrado que la fijación tanto del arco pélvico anterior como del anillo posterior aumenta la estabilidad y mejora los resultados clínicos. Existen varias técnicas para fijar la rama superior del pubis, y múltiples estudios han demostrado que los métodos mínimamente invasivos disminuyen las complicaciones relacionadas con la herida, con la ventaja de preservar los tejidos blandos. Describimos un procedimiento quirúrgico para tratar fracturas simples de la rama púbica asociadas a disrupciones del anillo pélvico posterior mediante la colocación de un clavo intramedular elástico de titanio (TEN). Proponemos esta técnica como método de fijación alternativo para las fracturas superiores de la rama púbica.

RESUMEN

Superior pubic rami fractures are commonly associated with a posterior pelvic ring disruption. It has been shown that fixing both the anterior pelvic arch and the posterior ring increases stability and enhances clinical results. Several techniques for fixing the superior pubic rami exist, and multiple studies showed that minimally invasive methods decrease wound-related complications, with the advantage of preserving soft tissues. We describe a surgical procedure to treat simple pubic rami fractures associated with posterior pelvic ring disruptions by placing an intramedullary elastic titanium nail (TEN). We propose this technique as an alternative fixation method for superior pubic rami fractures.

Las fracturas de la rama superior del pubis se asocian con frecuencia a una alteración del anillo pélvico posterior. Se ha demostrado que la fijación tanto del arco pélvico anterior como del anillo posterior aumenta la estabilidad y mejora los resultados clínicos. Existen varias técnicas para fijar la rama superior del pubis, y múltiples estudios han demostrado que los métodos mínimamente invasivos disminuyen las complicaciones relacionadas con la herida, con la ventaja de preservar los tejidos blandos. Describimos un procedimiento quirúrgico para tratar fracturas simples de la rama púbica asociadas a disrupciones del anillo pélvico posterior mediante la colocación de un clavo intramedular elástico de titanio (TEN). Proponemos esta técnica como método de fijación alternativo para las fracturas superiores de la rama púbica.

Asunto(s)

RESUMEN

Resumen: El trauma pélvico grave es una situación de extrema gravedad con alta mortalidad, siendo la principal causa de muerte el shock hemorrágico persistente, secundario a varias fuentes de sangrado óseas, viscerales y principalmente venosas y arteriales. Las medidas iniciales van dirigidas a disminuir el volumen de la cavidad pélvica y la reposición hemostática. En los últimos años evidencia creciente respalda la utilización de la angioembolización en el manejo de estos pacientes. Presentamos a través de un caso clínico el primer reporte en Uruguay de angioembolización no selectiva de ambas arterias hipogástricas en el manejo del trauma pélvico grave. Discutiremos a través de un caso clínico la fisiopatología del trauma pélvico grave y principalmente las indicaciones, resultados y complicaciones de la angioembolización.

Summary: Pelvic trauma is an extremely severe condition accounting for high mortality rates, and is the first cause of death in persistent hemorrhagic shock, secondary to several sources of bleeding, such as bone, viscera and mainly veins and arteries. Initial measures aim to reduce the volume of the pelvic cavity and to restore hemostasis. In recent years, growing evidence supports the use of angioembolization in the handling of these patients. The study presents, through a clinical case, the first report in Uruguay of non-selective angioembolization of both hypogastric arteries in the handling of severe pelvic trauma. We will discuss the pathophysiology of severe pelvic trauma through a clinical case, mainly in terms of indications, results and complications of angioembolization.

Resumo: O traumatismo pélvico grave é uma situação extremamente complicada com alta mortalidade, sendo a principal causa de morte o choque hemorrágico persistente, secundário a várias fontes de sangramento ósseas, viscerais e principalmente venosas e arteriais. As medidas iniciais têm como objetivo diminuir o volume da cavidade pélvica e a reposição hemostática. Nos últimos anos, evidências crescentes apoiam o uso da angioembolização no gerenciamento desses pacientes. Apresentamos um caso clínico com o primeiro registro no Uruguai de angioembolização não seletiva de ambas as artérias hipogástricas no manejo de traumas pélvicos graves. Discutiremos a fisiopatologia do traumatismo pélvico grave e principalmente as indicações, resultados e complicações da angioembolização.

Asunto(s)

RESUMEN

Resumen Introducción: La hemorragia no compresible de torso, actualmente tiene una alta morbimortalidad aún en los centros de referencia más especializados. El REBOA es una herramienta emergente que se utiliza como control hemostático precoz en este tipo de pacientes. Caso Clínico: Presentamos el caso de una paciente femenina de 25 años que sufre un trauma pélvico grave tras caer de altura. Ingresa hemodinámicamente inestable por lo cual se activa protocolo de transfusión masiva y realiza acceso arterial femoral común derecho. Al presentar una respuesta transitoria a la reanimación, se instala balón de REBOA en zona 3, logrando aumentar presión sistólica hasta 130 mmHg, trasladando posteriormente a quirófano. Se realiza packing pélvico preperitoneal y fijación externa, desinflando el balón después de 29 min en zona 3. La paciente sale a unidad de cuidados intensivos sin drogas vasoactivas, para completar cirugía a las 48 h y fijación definitiva 6 días después. La paciente evoluciona en buenas condiciones generales.

Introduction: Non-compressible torso hemorrhage currently has a high morbidity and mortality even in the most specialized referral centers. REBOA is an emerging tool that is used as early hemostatic control in this type of patient. Clinical Case: We present the case of a 25-year-old female patient who suffers severe pelvic trauma after falling from a height. He was admitted hemodynamically unstable, for which a massive transfusion protocol was activated and a right common femoral arterial access was performed. After presenting a transient response to resuscitation, a REBOA balloon was installed in zone 3, increasing systolic pressure up to 130 mmHg, later transferring to the operating room. Preperitoneal pelvic packing and external fixation were performed, deflating the balloon after 29 minutes in zone 3. The patient left the intensive care unit without vasoactive drugs, to complete surgery 48 hours later and definitive fixation 6 days later. The patient evolves in good general condition.

Asunto(s)

RESUMEN

INTRODUCTION: There exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement. METHODS: A 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question. RESULTS: Nineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement. DISCUSSION: This study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.

Asunto(s)

RESUMEN

Hemicorporectomy is an ultra-radical surgery used only in extreme circumstances. Initially used for advanced pelvic neoplastic diseases and intractable pelvic infection, it may also be the only treatment option in patients with crushed pelvic trauma, in cases there are no reconstruction options. This procedure has a high mortality, and its success depends on the multidisciplinary approach, both in the initial phase and in the rehabilitation process. We present the case of a young patient with severe pelvic trauma that required a hemicorporectomy as the only treatment option and review of the literature.

Asunto(s)

RESUMEN

Objetivos: La incidencia de lesión uretral bulboprostática secundaria a fractura pelviana es del 5-10%. Una uretroplastia exitosa garantiza el comienzo de la rehabilitación de los pacientes. Presentamos nuestra experiencia en el manejo quirúrgico de la estenosis uretral secundaria a fractura pelviana y resultados funcionales: tasa de éxito, reestenosis, disfunción eréctil e incontinencia urinaria. Evaluamos si existe asociación entre la falta de erecciones postrauma y la reestenosis. Materiales y métodos: Cincuenta y tres pacientes fueron operados durante el período comprendido entre 2001 y 2015. Todos fueron estudiados con cistoscopia flexible, cistouretrografía retrógrada y miccional. La técnica quirúrgica empleada fue la resección y anastomosis primaria. Se utilizó siempre la sistemática del abordaje perineal progresivo para lograr una anastomosis sin tensión. Interrogamos sobre la calidad de las erecciones posterior al trauma y después de la cirugía, y su estado de continencia urinaria. Se realizó un análisis estadístico donde se evaluó si la falta de erecciones era un factor de riesgo para recaída. Resultados: La edad promedio de los pacientes fue de 34,5 (r=17-67) años. La longitud promedio de la estenosis fue de 2,28 cm, siendo la uretra bulbomembranosa la más afectada (89%). La tasa de éxito fue del 86% (46/53), que asciende al 94% (50/53) al asociar un procedimiento endoscópico. Un solo paciente refirió disfunción eréctil postcirugía (1/19; 5,3%). Dos (3,7%) pacientes evolucionaron con incontinencia de orina de esfuerzo. No se hallaron diferencias estadísticamente significativas entre el grupo de pacientes con erecciones y aquellos sin erecciones en cuanto a la posibilidad de reestenosis. Conclusiones: La anastomosis bulbomembranosa por vía perineal es el tratamiento de elección de la estenosis uretral postfractura pelviana. Los índices de incontinencia de orina y disfunción eréctil no aumentan significativamente luego de la uretroplastia. En nuestra experiencia, la falta de erecciones preoperatoria no predice mayor índice de recaídas(AU)

Objectives: Bulboprostatic urethral stricture after pelvic fracture occurs in about 5-10%. A successful urethroplasty guarantees the beginning of patient recovery. We present our experience in the surgical management of posterior urethral stricture after pelvic fracture and functional outcomes (success and failure rates, erectile dysfunction and urinary incontinence). The association between the lack of erections post-trauma and the incidence of restenosis was also evaluated. Materials and methods: 53 patients were operated between 2001- 2015. Preop workout included a flexible cystoscopy and a combination of retrograde and voiding cystourethrogram to define the site and length of urethral stricture. Resection and primary anastomosis was the technique always employed. In all cases the progressive perineal approach was followed in order to achieve a tension free anastomosis. Erectile function and urinary continence were evaluated before and after surgery. Statistical analysis was performed to evaluate if lack of erections was a failure predictor. Results: Median age was 34.5 (r=17-67) years. Median urethral stricture length was 2.28 cm. Bulbomembranous junction was the most affected portion (89%). Success rate was 86% (46/53) ascending to 94% (50/53) when an endoscopic procedure was associated. One patient referred erectile dysfunction after surgery (1/19; 5.3%). Two patients (3.7%) developed stress urinary incontinence. The restenosis rate did not show statiscally differences between the erectile dysfunction and non-erectile dysfunction group. Conclusions: Perineal bulbomembranous anastomosis is the elected procedure for urethral stricture after pelvic fracture. Incidence of urinary incontinence and erectile dysfunction are not significantly elevated after urethroplasty. In our experience, lack of erections before surgery does not predict a higher rate of restenosis(AU)

Asunto(s)