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They're at the front of the ring and sometimes that front ring injury can be an acetabular fracture. And if it's an acetabular fracture, like one that kept me awake the other night, it's very, very difficult and it's called a combined injury. And that's often associated with a transverse acid tablet, a fracture and a disruption, either of the ipsilateral or the contralateral sacroiliac joint. All right. So that is pelvic classifications in a nutshell. Hossein. Can we flick through the slides next one, please? Lovely. And, and I'm going to go to my normal talk now. So forgive me for that slight divergence and introduction. But what we have is an understanding that pelvic ring fractures have been around since time. Memorial. Okay. This is a, this is an X ray. You must have heard this talk before. So I'm sorry about that. This is a drawing actually, it's before they had x rays, but it was a drawing of um I think that's postmortem mortem of some that got run over by a horse drawn carriage and they've had a massive injury to their pelvis and they survived bizarrely enough to the pelvis to the acetabulum. It's a bilateral anterior ring disruption one bit going through the acetabulum and the other bit going through the posterior ring. It's huge, isn't it? Next, I pleased to say. And next, I, and often these injuries are high energy, you know, falls from the horse's ejected from motor vehicles, keep going and sometimes they're old people that have had a bit of a tumble. Okay. And the funny thing is that old people can have high energy injuries and they can have low energy injuries. We've got to think about pelvic, bring injuries in the context of a whole patient for a second. And what we know is that the higher energy your injury, the more it's probably associated with both the brain and an abdominal or a thoracic injuries. So there's a morbidity associated from it in itself and there's a morbidity associated and mortality associated with it because of its other associated injuries, particularly heads, particularly abdomens. Next side, please keep going the same. We'll probably flick through this and the next one good. Um So one of the most important hemostatic agents and saying we'll talk about this, I think when it comes to the bleeding processes and things is the application of a binder in pelvic bring injuries. So Tranexamic acid and the crash choose trial which will, I'm sure you'll talk about. Um and the application of a binder have really saved lives more than that. The binder is probably more effective as a team a static agent than let's say a pelvic c clamp or an external fixator. Okay. And next side and what we know is that when you compare them and you compare them and you look at whether you know a sheet over the front or an ex fix or etcetera is better. We know that probably the binder is the most reproducible, reliable and easiest to apply. So there is evidence for its use. And next time please, when you look at what bleeds, why do stuff bleed around the pelvis? Why do these classifications sort of create worry when you're vertical shear. If you have Polhemus pelvises moved, is that the osseous corridors for those vessels typically a around here, the sciatic sciatic notch where the super glue thiel's come out or the internal and bifurcation of the internal external iliac veins or the idea lumber. That's where they tear, they tear where they're anchored, vessels are anchored by ligamentous structures. Let's take the idea picked in your fashion. That's a ligamentous fascial structure that attaches, you know, the common uh the external iliac artery and vein to the eye iliac bone to keep it in place so that it doesn't wander around. Well, problem is when you break it, it tears it, then you get major hemorrhage and we'll talk about pelvic packing another day. So click on a flick on three or four slides. Here we are um because that's important. Now, one of the ideas, one of the things that you'll get in your talk from you saying I'm sure is about the management of resuscitation, um and the management of these patient's that are either stable responders and non responders. And that's something that's very important. Now, I've brushed over this just quickly next time, please. And what we know, um go back piece the same. What we know is that when you're talking about pelvic green disruption is that you're disrupting both arterial venous and neural elements. So, one of the biggest factors that affects outcome of um pelvic ring trauma is actually the functional deficit that comes from having a nerve injury that lumber sacred plexus injury or the innovation to the bowel, the bladder, um urinary retention, sexual dysfunction, etcetera. So all of these things affect long term outcome. All right. Keep going. Here we go. Here's our slide of stability. Next slide. Here we are. So these are the ligamentous. We're talking about sacred tuberous sacred spine, iss and teary sacroiliac joint ligaments post your sacroiliac joint ligaments and the connection to the I'll go lumber ligaments. So, from t the transverse process of L5 uh to the back of the back of the sacrum, it's really important. That's a really short, really tight ligamentous structure. So, actually, when we see markers on X rays of instability, because what we're doing an X ray for is to infer stability or instability. When we see, let's say a complete sacred a lot fracture on an L C one. And we see a transverse process disruption and we see bilateral anterior injuries. We know it's an L C one plus. That group is quite a heterogeneous group. It encompasses a lawful lot of injuries of varying stability. So that's the disadvantage of our classification system. Carry on, please, sir. This is what I talked about on the tile. So there's a keep going, please. There's one more slide and this is a young and burgess. So just running through it, we talked about lateral compression, we talked about anterior posterior forces and vertical shares and one can think about mechanistically lateral compression being forced from side. And the stability of ligament structure is being important. Their anterior posterior compression isn't really anti pasta compression. It's an external rotation deformity to either one hemi pelvis or both hemi pelvis is now when you have a vertical shear, I'd like to think of it as either going backwards or superior Lee so or both, right? It's a disruption in a direction that isn't the other two. So when you have a vertical share, it's highly unstable and injures those, those neural elements and Elsie three injures those neural elements. But I guess you got to understand what that, what is stability and those have been through through Cambridge often hear me kind of it's the only question I can really asking a trauma mean, what is stability? And I guess stability means not falling over next slide, please the same. And if we take a normal looking pelvis, this is an L C one. Um you got a left sided cycle, a large fraction, a right parasymphyseal injury and you apply lateral compression onto it. Next slide, you can get quite a lot of deformity and you can think where the hell does all that deformity come from? This look like a stable ring injury. But yet this doing that when it weight bears or when it loads from his actual compression. So stability can be both thought of as being clinical. They're in a lot of pain. Um They can't mobilise, etcetera, they've had a high mechanism injuries. So you've got these clinical markers, then you've got some radiographic markers of instability. I where the fracture is the pattern of that fracture. Um If it's got a complete sell critical a lot for actually more medial, it is more unstable. It is the more involves the transverse process and more likely it is to mark instability and then you've got functional test. So loading, how it performs under loading? Uh sounds a bit like the Punjabi in white classification. They're or let's say um you do a, you do a clinical assessment in theater so we can do an E U A. So you've got these parameters of assessing stability. Okay. Carry on. Please think. So this is a purpose of an eu A it's not only assess your stability and find out what's going on in theater. But also, and whether you're going to fix it, but also to find the unexpected injury that L C three, that injury to the contralateral um side of the pelvis. All right, thanks the same next one. So, reiterating about what's the, I mean, it's about, you know, functional pain, pain on from examination, on loading, radiographic predictors and special test. So I think if you borrowed, if there's anything I could take away for you today, if you took that snapshot of that assessment of stability and you could apply it to anything, it will work. All right. Uh In fact, you know, find me if you found something that you can't apply to. Okay. So here's some cases. Um can someone look out for if there are any questions and if you do have questions and feel free to carry on and ask me them who's up, I'm going to ask some questions. Uh No swearing, Jake. I'm going to ask who's up for some questions. I can do that. Mr Well, awesome. I've just seen your little note saying the audio is working but might need to log out and log back in again. Is that moment? That was one of the audience. I think they couldn't hear. You're, you're all good. J and SEB is ready to answer questions. All right. All right. All right. Step step gone. Then I've run through sort of, I mean, you might have seen my bloody youtube talk, right? Uh What do we see here? So what do we see here? Step? Um So, I mean, I've got a uh actual view for the pelvis. I think on the right hand side, I can see a fracture through the right side of so called ALA. Yeah, which so far looks like an L C one type pattern, right? And where's it's orientation to the frame and the say called Framan uh across the medial lateral to the to the format for a man. All right, super easy, right? So if you have a guess at this, would you say it's stable or unstable? Um I think at the moment looks stable. Yeah, it probably is, isn't it? I think there's an association between anterior sequel combination and instability, but it's probably stable. Okay. So I'm glad you kind of understood it. I think hopefully the clarity of what I was trying to get through is got through. Brilliant. All right. Cheers. The next slide I'm liking this. It's like I'm important. Uh So that fracture goes down but it doesn't really complete out the back as far as I can tell and keep going the same. Probably the next case is probably more useful. Yeah, keep going. I think I fixed it because it was demonstrating. Oh yeah, there it is instability. Hey said we both got that wrong. Not good, but you don't know until you push, right. Uh You know, so that's why he got an EU A, that's why he got compressed and we found it to be unstable and I guess it's that sacred a lar combination, you know, maybe there's something in that. I'm sure someone's writing a project on that. Uh, anyway, carry on next slide. I think it's next case. Great. Another volunteer. How does it take it? It's hasn't here. Hey, Hassan. Are you downstairs? No, I'm enjoying it dot Okay, I got you. Um uh This is a bit of a tricky one. Uh But what do you see here? And what's going in your head? High energy, low energy, firstly, high energy. Yeah, actually cut and it's going through the, the Valium and that is from that view. It's suggesting an L C too. Yeah, still need further assessment but doesn't NLC to go through the Sacroiliac joint. So we cannot see this full sacred area joint here. This is one isolated image. Yeah. Yeah, that's right. Um There's a, there's a funny thing about L C two S and I think there's a bit of a spectrum on there and I think some of them will go through the sacroiliac joint and disrupt in the traditional pattern of the description. But people don't always break as per traditional classifications or traditional descriptions and occasionally they break right at the back like a crescent but just managed to come out um and avoid the Islay um but create just the same amount if not more disruption because of where they are and how unstable they might be. So, I think this one has just managed to miss the S I joint, but to all intents and purposes, it's behaving like an L C too. So it's unstable because the sacred ligaments are bypassed and it's only held together by glutes and gluteal fascia. Yeah. Makes sense. All right. Next level and look at that disruption, arson. What do you think about that? What vessels and nerves might be injured by this, by this pattern of injury? This is a pelvic plexus of veins here are more at risk and they would be writing anterior to the uh S I joint and there would be a high risk of share ing of what else. What, what's um and obviously that uh the neural framing um contents will be exiting at that level. So the S one S 234, five others would be highly likely disrupted. So if we think about where L5 comes across, it comes across the sacral ala like this and then joins the sciatic nerve down through the sciatic notch. All right. L four's joined it a little bit higher unless one comes and joins it. And you take this pelvis and you translate it 50% towards the sacred uh midline, those structures under a massive stretch. And that's where the lumber plexus injury comes from a sacred plexus may or may not be spared, but it's probably injured. As well. Okay. So that's why they get such a big disruption and then you've got the vein, all right, internal, external and the common and they're under tension as well, but they run detention yet. Yet the superior grew teals in the same place as something is under a huge amount of stretch and therefore may tear. Okay. Good stuff. Next side. Oh, this is uh this is when I fixed and you know, that's an enormous amount of disruption, right? Ok. Case three need another volunteer. I like the volunteering. This is emotional fun. Can I ask a question about the previous case? Please? Got the first case, actually, only panels only if that means that you are volunteering for the next case. I thought you might say that, but I'm hopefully going to open up a discussion. Uh What, what makes you decide to take them for an epi you a in that case panos what makes you decide that you're going to take them for an eu a it's just that I was thinking about this and you probably the advice would probably be that the patient is not weight bearing or toe touch, weightbearing. And I was expecting to me. So even before you give advice, you take a history, right? So in the history, you're thinking high energy or low energy. Yeah. Yes. Pain. So what what factors about pain make you worried about a patient? Well, I'm thinking of whether if they have significant pain even at rest or even in simple actions like transferring from the bed to the chair that is not controlled. If you think about let's take a pelvis. Okay. And we think about the most common times that it does its own lateral compression, weight bearing on a lateral compression injury. It's not going to really make a difference, right? It's a, that's a vertical force on a lateral compression. That's not, it's not going to affect it. Okay. What makes a difference is when let's say that patient lies on their side. Yeah, turns rolls, moves in bed. So you see these patient's and in bed if they don't move, they're not in pain. Yeah, that's actually, you know, that's the actual skeleton for you. Take a spine fracture. Yeah. And you don't move it. They're not in pain. They're only in pain when they try and move it. So you take your patient and you say, can you roll or turn in bed and you know, from the history that they can't roll all, turn in bed, they say no, it's real agony. I have to lie still and then you go, ok, ask another question. Can you cough, laugh, sneeze. And I'm really trying not to cough because it hurts my pelvis. Okay. So you've got an idea that they've got an unstable actual injury. It's not like examining a limb, right? You've got a broken thumb and you give it a wiggle, it hurts but if you keep it still, it doesn't. Yeah, but a patient can't not roll or adjust their position because that's what we do with fidgets. And so that's the history that tells you that it's bad. And then the examination findings will be, you know, you can do a little lateral squeeze and you can say, does that hurt? Or you examine a neurological elements, if they've got neural stability, you ask them to roll and turn in bed and they can't tell they can't. So then I'm looking at a CT scan I'm thinking, has it got the hall markers as it? What's what's a posterior injury? Is it a complete secret? Vraylar is a transverse process fracture? Is the anterior cervical combination? And what is it bilateral anterior ring injury? And if it starts ticking my boxes, you know, three out of the five of the Raul indicators for pelvic instability. I've got to name something after myself. Panels. It's, it's about time then then I'm probably gonna do anyway. Yeah. Alright. Case three panels, unlucky. I can't remember this one panel. So after you what you see, so we're looking at an 80 pelvis uh really rough. I think the suspicion here firstly is that they have given contrast and we are either seeing the bladder or I think it's the bladder actually uh because it's well well defined, there is a possibility of a small disruption of the pubic symphysis, looking at this view and then I wonder if there is injury at the posterior, right, uh, psycho elect joint. Yes, there's something going on there, isn't there? Um, so, so what about the left? Say, quiet out joint there? Yeah, there may be an injury there as well. I can see, uh, I think there's a break in the line of the jail on the left as well. The sacrum is a very hard thing to interpret on a plain radiograph, isn't it? It's obscured, it's hidden. It's also not in a plane of the X ray because it's triangular and therefore you get overlapping lines. So it gets quite hard to see. But can you notice how the right hemipelvis looks different at the up trader Framan and the I call it the spine of the civic spine. So where you've got the greater notch meets a lesser notch, you can see much more of that than you can on the other side. So you're seeing less of an obturator frame and more of the spine. Now, I'm going to try and do this with my model, which means, okay, you're seeing it on the right side a bit more like this. Can you see that panels? Yeah. Does that make sense? So that means that the right hemipelvis is externally rotated. It's giving you an Iraq oblique view essentially of the right side. Yeah. Yeah, I agree. It's like an A B C type two, an ABC type injury. Yeah, I don't know which type it is but it's a bad one. Okay. Carry on. Next slide. Let's find out together because it's been a while. Is this a video press plate? No, it's not a video oh panel. Same slide. What you see at the present on the right? There's a crescent on the right. Yeah. Isn't that weird? But then we say that was a lateral compression type two. Mhm. So you'd expect it to be internally rotated, right? Yes, it's only rotated. So what's going on? Okay. I think there's a displacement of the eye like wing. So the A P of the X ray is giving us a false impression. That is an APC potentially. Whereas on the actual view of the CT, we're seeing a different pattern of injury. I think it's, it's actually more likely that when you have higher orders of energy imparted, they don't behave as per classification system. Do you know what I mean? And actually if you look at the left side joint, it looks like that might be a bit open to. Yeah. So you've got a high order high energy mechanism injury where once, once it's so broken, you can put it anywhere you like internally externally, vertically distantly. Yes. Okay. So it's like an L C too, but it's, it's not behave like you thought it would. And in fact, if you go back to the case that Hassan um described there with that medialization from the post crescent's there, it's gone. Medial look, it's an external rotation. Put back one slide. There we go. Can you see it's an external rotation, not internal rotation despite it being a crescent. Have I confused you? Uh Yes, I'm, I'm not sorry to say I can see that. Great. Okay. You're nodding. Yeah, next week. So the thing to understand here is that the more, the more energy that goes through, the less predictable things can behave. I, they much more unstable doesn't mean they're easy to fix. By the way, it just means they're unstable. All right. Carry on. Let's go to case four. I don't know what case four is another form of present involving the sacred elect joints. Right? So, um, that's a bit easy. So I won't pick on anyone for that. That was too simple. Yeah. Keep going, keep going. The same thing. Uh This whole affects that. Uh, then Hussein just had a little baby when he saw that. I know he did carry on. What's number case five? I wonder, I'm, I've, I wonder who's next. That's what I'm wondering. Is any volunteers? Hi. It's Jewish in here. I don't mind going. Oh, hey, Trisha, I'm sorry, how are you? All right. Hey, Tritium, what do we see here? Um So, um axial section through the Pelvis. Um I can see um, the, on the right side there's opening up of the S I joint, on the left side, there's a fracture through the sacrum. Um, so I think it's an APC on which side is on both sides because on the right it's open at the more open in the front of the S I joint on the back and on the left side. Mhm. It's only rotated on the left. I'll give you that for sure. Right. It's fractured and it's fallen out. Yeah. Or let's, let's think about this. The width of that sacred a lot is disproportionately big. It's bigger than you expect on the, on, on, on, on the left than on the right, isn't it? So that can happen because actually you're seeing it slightly higher up, I see. So you're seeing a more proximal slice, a more, more, more cranial uh slice, then you've come across it too soon. So it's come up. So I'm going to hazard a guess that on the left Hemi Pelvis, the right of the screen, the left hemi pelvis, it's gone vertical and on the, the, on the other side, it's actually externally rotated. So we've got a bilateral injury one involving high energy compression or vertical displacement and on the other side, it's gone externally rotated. So we got the two. So what's that? Make it uh Elsie three. Yeah. Bilateral. Yes. Or it's just a V S on, on, on one side, right? So, but you have to take it to theater like we used to do and screen the other side to make sure it's okay. Yeah, it keeps what you don't have is a marker normal. Oh, who's Kishon? Go on? Tell me what's going on here. Uh Wow. Um, same, same case. That's the same case. Okay. So, um, so here I can see on the right side the, uh, sorry, my child's crying in the background. Um, on the right side, the side joint has opened up as we saw in the previous, uh, scan on the left side, you can see the, again, you can see the, the sacred fracture and you can see uh like a post your column fracture as well. Well done. Yeah, that's why the slices so good because there's more to it, isn't it? There's something that you have to look at and you can also see that push your column has sort of internally rotated to. So there's a lot going on here to restore morphology and to restore it back to normal. So very, very well done, well done. Good. Next volunteer, a run out of volunteers. Yeah, this is why we got to do these in person. All right, I'm going to come back to said because he did so well at the last one. Okay, I'm back. Uh So uh yeah, main things here. Well, obviously, there's a right, very common in proximal femoral fracture fracture through the right uh super info uh pubic remi uh I mean, it's also a rotated view. I don't, I don't know if it's an intentional um uh have you. Uh okay. Well, no, that's brilliant said. But okay then how, where do you go to, to define a rotation? Um So you can, oh it's not rotate, is it there's um because they can look at the spine is process in the middle of the lumber spine. Um And you can look at the uh the so called foramina, which are actually quite equal. So actually, that's not good. I think there's a, I think sort of hidden by that line, whatever that artifact over is there's a crescent fracture through the right so called a low as well. Um So I think there's sort of an L C too tight pattern that I don't know if there's more on the other side. Well, is your, is your left hemi pelvis. So you've got this kind of ob trader view. Yeah, in the right lobe trader full on, aren't you? So, you know, that's one of the, of the pelvis has become internally rotated. You're seeing. Yeah. And on the other side, you're seeing the hijack missing like bleak, okay. So it is done this, it's wind sweat, it's that wind swept pelvis. So it's a L C three type pattern. It's a rollover injury. This is typically the pattern that you get when someone gets run over. Not great, right? And you can imagine that uh like the patient states pill, but the trucks gone over the Elvis over their midsection and it's just squashed one side natural compression and that's forced, or the trucks forced the other side open. So they come in like this. So, the spinous process, oh, my head's the spinous process and it goes like that. Does that make sense? Yes. Yes, it does. All right. So high energy open femur massive pelvic disruption, you know, massive massive blood loss, right? Hmm. Massive risk of what injuries. Where's that bladder? I mean, the cath seems to be sitting, I mean, you can't, it's off sent, well, it's off center from this view. So I wonder whether the there might be some bladder disruption as well, right? It's injury. So let's, let's work on that. So, it's bladder disruption. What else might you get? Um, so you've got bladder, you've got your, um, post venous plexus, which probably is, uh, probably bleeding quite a bit in this case. So the bind is very important. You've got your, um, your, your neurological structure the back. So your L5 is probably at risk there. Uh, a risk, a risk, uh, the entire lumber plexuses at risk, but entire sacred plexus and innovation of the bowel bladder, you know, uh, sexual function, etcetera. That's no, that's been entirely trashed by this mechanism. Okay. What else? We've got an open femur? So you can also have an open fracture of the pelvis itself as well. So one part would be assessing the urethra meatus, the anal, well, doing a pr examination to check if there's any fecal contamination that's connecting to the fracture, blood help, er, or mucosal tear. Yeah. Right. And actually there isn't, but let's say what's another injury? So what, so this is an L C three, the truck, you've seen truck wheels, right. They're enormous, aren't they? Yeah, it's going to hit your pelvis, are they, they're going to get other bits of you. So, what else might they be? Um, so, I mean, I'd also need to see the spine itself and I need to see the rest of the lower limb as well to see if there's open, commended fractures of those as well, which I imagine that one of them is injured as well. If they've been hit by that bigger truck, we're so orthopedic, aren't we? We've just thought about bones. Oh, right. Yes. Sorry. And the other, and there's properly soft intraabdominal injuries as well. Sorry. Yeah, intrapelvic, soft tissue as well. So, we digress um, abdominal injuries. So mesenteric tears and, you know, and giblet trauma is really, really, really, really common, you know. So there is a thing about contusional bowel wall injuries, not being evident straight away on a CT scan, but actually perforating late. Um I don't know for saying you're with me when this guy came in, but you might remember him. Uh I think, I think I do. Was it was, was this the one that was morbidly obese and really difficult to fix? Know that that would be, yeah, it was difficult to fix. Very difficult. That was the guy that was, the guy transferred. The one thing I was the one transferred from Colchester, the wall collapsed on him. Yeah. No. Yeah. Yeah, I know the one you mean? No, this guy got run over by something, I think it was something large but it was during COVID and there were lots of remote reviews, etcetera, but he had a, a bowel injury that wasn't picked up straight away and is extremely unwell. So he's an I T U too unwell to take two theatre, which is really annoying because you know, skeletal stability really helps people's unwell nous that he had a perforation and which was picked up late because of COVID and other circumstances. Um and he had a midline laparotomy before he got his pelvic pelvis fixed and he had a belly for the pass and a bladder injury h peritoneal. So uh very difficult cases. The warning mark there is every patient needs to be reviewed appropriately, but also bowel perforations can occur later. Third warning there is that these are incredibly high energy injuries, incredibly high energy injuries. Okay. Next slide, there's more than this when you get a mesenteric stranding or you know, not quite mesenteric ischemia. Do you get an interval scan at 48 hours or what is your protocol? Because I have seen it missed in other centers. Uh Local protocol is for a 48 hour interval scan. Yeah, but that doesn't mean it doesn't, you still can miss it because it can happen after 48 hours. But I guess it reduces your chances. The difficulty then is that between 0 to 48 hours everyone's going, well, there's an interval scan, you know, yet the basic cess is climbing. The patient's becoming more in atropic requirements, etcetera. Um So these can be missed the, where they're less missed if there's hemorrhage, they are morse more of this perforation sticking with you, uh campsite and then can you go back one just to the three D CT. So the funny thing is is that you can orientate this pelvis where it looks normal. Can you hear? See here? It, it looks, looks all right. Doesn't it said uh vaguely except for the fracture lines all over. Uh Yeah. Right. But don't be misled because the sacrum is pointing in the opposite direction, isn't it? It's pointing 45 degrees away from you. Yeah. So the fourth warning here is um X rays can conceal things and conceal the magnitude of an injury. All right. All right. Thanks. Seb, just crack on a few slides if that's alright is saying we'll go onto case seven. That's like that's the synopsis of the spectrum that you can get of um of L C type injuries. So we've gone from L C one at the start there or hang on. It was unstable Elsie to being a crescent and then we saw variations on the L C to where it's not only externally rotated, but it's internally rotated. And here we've seen quite a dramatic L C three. Uh Can you put on two K seven? Keep going. It's not very exciting. That's just boring operative pictures. Now, what is K seven, any other volunteers apart from seb condition? And Hassan and I'll have a go it, sorry if there's baby screaming in the background. But that's alright. Babies, babies can join in. Okay. Um So there's an ap of the pelvis, it's got a pelvic binder on and despite the binder, I can see a diastase of the pubic synthesis. All right. And what else can you, can you, if you look at the back, what you thinking? I mean, let's go back to write. I'm asking you, I'm kind of getting you slightly used to talking in terms of Judeh view. So Iraq Oblique or OP Trader Oblique. So, yeah, it's an operative view and then on the right, I've got more of an Iliac few. So the, so the pelvis is um sort of rotated to the patient's right. Um And the spine, it's not, you know, the sacrum and the spine is not, it's not dead ap view, but it's uh I think it's rotated left. So the pelvis I think is externally rotated on the right. Yeah. Great, great. So, now can you see how I'm talking about an APC injury? Not just being an anti Aeropostal compression, but an external rotation of, of 11 side. So very, very good next side. Yeah. Okay. So the, there's a S R J opening on the, on the right. You see that on both of Youse? Okay. Have you, has your slide moved on? Because mine hasn't, I've got an actual view of the pelvis at the moment. All right. That's amazing. Mine, mine's stuck. Yeah. Oh, there we go. Yeah. Yeah. For some reason I had to press play again on the screen. Great. So you got, you can see that that's open. And can you see what I'm talking about the back that on the actual view when you looked at the actual view, it, there seems to be an intacs posterior ligament structure. I it's not open at the back, it's open in the front. And that does that make sense? So if you'll say APC 12 or three uh to, yeah, I would agree with that. Two years. Uh Yeah. Keep going on slides. Oh, here's another one, Tom Sticker too with you because you've done so well, so far. Different case, I think. Where's the platter? Well, you can see the tip of the catheters right up in, in front of the top of this. A come in and uh probably L5. So he's had a bladder injury and it's, and it's been pulled off approximately. Okay. And so there's lots of contrast everywhere, isn't there? Like diffusely everywhere and can you see the contrast and ureters? Yeah, I can see it on the right. Yeah. And on the left. Yeah. So that, yeah, so the Euro to on the left looks like it's going down to the bottom of the pelvis can't really see the one on the right going down there. They, so what's your main concern and worry on this case? Uh, bladder rupture, right? Bladder rupture associated with an APC injury. So, APC injuries are associated with higher sort of bladder injury and abdominal injury because if you imagine it's a front loaded tearing mechanism. So that's, that's the worry of this. Yeah. Uh So what do we do if there's a bladder rupture? What, what's, what's both say that you should do? Uh MD tea with urology? Yeah. What, what? So first of all, you got to treat it like an open fracture, right? So you got antibiotic. Second is that you have a single pass of a catheter. Okay, see if that catheter goes in because you need a drain of bladder rupture too, right? Otherwise you just get urine pulling in the uh and then often if there's a single pass and ends up in the right place, they manage it non operatively, uh which can be a bit annoying when you're coming to do an operation because I'm just middle like around you in which isn't here. But yes, it's a urologically guided uh process. Now, if there's an intraperitoneal bladder rupture So intraperitoneal that actually defines being a laparotomy. So single past otherwise, it's going to require urologist to do a flexible cystoscopy and catheterization or also superpubic. Okay. So you turn to top and tail drain a bladder rupture if there is a significant one that has been managed with intervention. Great and well done. Interesting uh, ostomies. Yeah, if they're really bad. Yeah. Generally at that's the point though they've tried to repair it and you've got a catheter in uh Urethra Lee to protect the urethral hard about it and uh Superpubic to protect that as well. All right, thank you, Trecia. Good case. A oh, any volunteers for this smiley panda face? Can anyone see a panda face in the sacrum? I can. Yeah. Good, good. I think I'm gonna go to, I'm gonna pick names now, but all the names have disappeared. So, um oh, no. Hang on Daniel. What's I haven't heard from a Daniel Watts or uh Assam Ture Rajah. This is interesting. Daniel network only 39%. Okay. Very good. All right. I'm going to go for a Victoria Stoner because you're coming to the middle bits of your training. Mhm Maybe I'm not going to Victoria Stoner. All right, Tom, I was gonna put forward Ben Davis to do it. A great idea. Person answering. Nominate the next person to Tom. You're a genius. Go on and have a go at this and then uh, all right, go on. So this is an actual CT scan of the Pelvis. You can see that the S R J on the right looks abnormal both at the front also at the back, it looks like the ligaments in the back of gone. So I think it's an APC three. Yeah, this is really interesting. Go and talk to me a more bit of it. What sort of translation has that Iliac Crest in on that sacred uh was translated posteriorly? Okay. That's crazy. Huh? Not only has it, it's not opened, it's gone backwards. So one could say it's an APC 31 could also say it's kind of a multi directionally unstable. Yeah. So vertical shears don't just have to have a vertical component. They can also be post theory, but they also can go through the sacred I'll ac joint as well as an aid are fracture. Does that make sense? Yeah. Okay. Let's see. The next slide. Let's go on this Voyage of Discovery Tom. Yeah. So on the, on the, on the previous slide, you saw that it was largely married up and here, you know, it doesn't look like it's gone superior on this corona, love you. So it's more of a post theory of displacement. Okay. So, you know, it's behaving multi direction, but there's a, there's a translation to chase. So it's a very unstable fracture pan. All right. Keep going. And I think I fixed it. Yeah, this is a long time ago with an open reduction and the other side, look at that, the other side was also injured. Um, so, yeah, there, can you see how that's open, Tom? Yeah. All right. Got some screws. So, here we go. So, Tom nominate the next person. Yeah, Ben. Ben Davis, the real pelvic guy. I think Ben said in the chat he's on, call it, uh, Dan wants to call it Peterborough. Uh, what about, uh, Macias? Come on. Mhm. All right. Let's, let's flick onto this slide. Well done. Nothing nice. It's well done. Um Yeah, vertical shoes are pretty bad. Uh Keep going. Uh saying sorry, case nine uh go on nothing. Assess. What do we see? Do I get to say you're on mute? No, it's not. It's not drowning in. I can't hear you, sir. I don't think the mic is working. Uh Mike working. Yours is working loud and clear. Yeah. All right. Just talking through this. Then we can see that there's a disruption. You can't see my mouth. But if you could see it, it'll be pointing to the sacred A lar at the back on the left hand of the patient. So there's a sacred a lot fracture that's gone through there. So this is a vertical share. It's called north posterior superior, let's say, resulting in a synthesis disruption, but also an A LA fractures. The next size is saying, uh keep going. This is just how we fix it. Uh keep going. So looking at synthesis disruption. It's quite dramatic, isn't it? But it's an unstable injury and it came back easily so I can keep going to the end of that. Yeah. On a bit of a journey that, that left hemi pelvis. All right. Now, are you saying, could you go to the spinal pelvic fracture? Uh It's under SPD. So keep going there. We are. Oh, what I recall or to recognize is that spiner pelvic associations aren't always visible unless you go looking for them. What is the spine of pelvic association? A spinal pelvic association is when this pelvis has got an H or A you type or a white type fracture. But what that means is that there's a vertical component and a horizontal component. So the point, the constant fragment is a bit of the skeleton that still attached to the rest of the spine and often it's very small. It's like half of S one or a little bit of S one and S two. And you're looking for that vertical as demarcated by the, on the actual, by the longitudinal fracture here and the horizontal that you'll see on the sagittal plane. The problem with this is that a translation, yeah, deformity. And therefore that puts the quarter equina elements at risk. So this is a as at risk as having cord equina syndrome. All right. Next slide. And you can see on this poor chat that they're called elements, even though there's room, there's translation, massive amounts of translation posterity that puts them on detention. And what also you note is that the only bit of the sacrum to fix into is that half or three quarters of a body of S one. So this is where we start talking about in terms of fixation, triangular fix. But actually more for the patient, we talk about how it's unstable. Number one, it's unstable neurologically because it puts a neural elements at risk. If they're not already entrapped, often these patient's are high energy and therefore you don't know they've had a quarter of coiner injury until they wake up until they extubated and their bowels and bladder don't work and they can't feel their feet. Often L5 is preserved. But that's the significance of this, that they're picked up late. They're high energy injuries with very poor outcomes. Um So that's very important to bear in mind there, to population groups of spider pelvic association. There's sort of the high energy trauma, but it's also your frailty for fractures where this is a slowly occurring fatigue failure over time over, over months to, you know, a year or so. They come in on the medics, they've had difficulty mobilizing all of a sudden, they're in urinary retention or not. All of a sudden, they've got developing urinary retention and fecal incontinence and everyone's, you know, putting on the geriatric nappies and inco pads to keep the patient clean. But I haven't really looked for the cause. So when you get referred these as a regimen call, you know, and they think they think there's a remi fracture and there's a little bit more to the story. Get a CT, get a CT. Anyway, you might pick it up uh often at that point, it's too late. And actually, stabilization is just about treating a non union and allowing someone to weight bear and mobilize again. All right, next time, please say, oh, this is a good one. I could definitely do with a volunteer for this one. I can't volunteer. That hasn't here. Is this because you've got a predilection for the spine. Okay. Vested interest, vested interest to get it right. Correct. Um But what you, what you see here, man, what you see here. So cognitive fractures through the sacred body involving the the frame and on both sides with on the sagittal view, there is uh diseases as uh this disruption of the neurovascular elements highly likely here. So this is a very unstable type of sacred body faction. Okay. Yeah. And, and so what, what name, what the main culture are you going to give it? What type of pattern do you think it is? So it is a vertical and there's a transverse component isn't there. So this will probably look like uh hedge. Yeah. Yeah. And it's an H type fracture and there is posterior translation. Correct. So we're going to decompress it. That's a, that's a that's a, that's a degree level question, by the way, I'm sorry about that. So it depends on the on the time of injury. So, uh if we are looking at uh from a cardiac wanna point of view, yes. But again, it will be good to decompress because with the indirect reduction, we might get a good compression. If it's, if it's too late, then the by the nature of this injury, it's highly likely that there would be um thecal sac injury. So a lot of CSF and disruption. Yeah. So that's the problem with the surgical decompression. So, an open decompression is associated with a high risk of fecal sac disruption. CSF leak and wind breakdown. So actually, you probably want to decompress this by reduction. Um And the advantage of achieving a reduction is that a, you've decompressed it and be you increase your chances of union because this isn't a good place to get a non union. Is it, it'll be a bit of a problem. So that's why you, that's how you decompress it surgical reduction. And then that does your indirect decompression. That's actually a paper by Mr Chow. There we go. That's, that's his publication and the contribution to spine surgery. But this is a combined operation, right? It involves someone decompressing or fixing for a triangular fixation because it's high energy and involves most of S one and to the pelvis and pelvic fixation via S I screws to deal with the the vertical component. Okay. So that was uh one of my other cases. So I sound sticking with you. Yeah. Crack on Hussein. Let's go for this one. Okay. Go oh, hang on. I remember his name. Go on Hassan. What do you see there? So Corona views and there is a fracture to the suitable um on the left hand side um through the word that area, the press play, keep going didn't work. Maybe pressing play didn't work. Okay. Yeah. So that inter operative, I I suggest that the S I is opening up on the right hand side. Yeah, let's look at the next screenshot. Oh, and where's the femoral head feller had gone through the uh establish a fracture. So it's a transverse, that's the tablet fracture associated with an S I joint disruption. Okay. So the combined a transverse ashtabula fracture is often a sacroiliac and pelvic ring fracture. Okay. Um I think probably there, we've talked through all the elements and you've seen examples of all the elements of, of pelvic ring and um trauma and classification, etcetera. I'm not sure there's going to be enough time to talk about acetabular fractures as such because you know that that's an hour on its own um to a greater or lesser degree, probably for the next 15 minutes. I'm free to ask any questions if anyone's got any. Uh don't bother with the chat just, just put it on before my next meeting. So any questions from, from our talk so far? May I ask? And the last one, would you still use our binder in the emergency? Sorry. Yeah. Right. Great. Great question. So panel. So I'm not, I'm not being a pain, but I will be a pain. What's the purpose of a binder? Well, you want to reduce the potential space for a blood accumulate basically. Right. Right. So the purpose of a blinder is to say to everyone in the room that you've got a hemostatic agent on. Okay. So, you know, treat you treat, see before you treat d before you treat E and so you're going to be putting that binder on to stop hemorrhage. So if it's stopping hemorrhage, I don't really care what happens to the hip joint. Right? It's not, it's not a problem. That's it. Okay. Well, what, what is wise though? And you probably thought about it is to then say, well, on the CT scan is not a lot of hematoma. Okay. Number one, number two, they're stable. Number three, let's get the binder off in a controlled fashion. Yeah. Yeah. Yeah. Okay. So don't be scared to bind us. Binders are your friend. They, they save many more lives than they harm. Yeah. Any other questions? Have a good question if you don't mind. So, um may I, I have a question but it's not directly related to the cases. It's actually the, the x rays that I get a bit confused with the, uh, the various x rays that you take in pelvic mass tabular um fractures, you know, the iliac of league and the operator of league. Um If you could just give us a few words on, on those, please, I'd be very grateful. Sure. Um, they're very simple. Okay. They're just tilted views of the pelvis. All right. So, here you've got your A P and an AP is a front view of a patient lying on a gantry. Okay. Yeah. So actually it doesn't tell me very much apart from where that patient is on the gantry, they can have anterior pelvic tilt or post your pelvic tilt depending on a lumbosacral lumbosacral incidents. Yes, that's another spine term relevant to hip surgeons, isn't it? So, an A P is useful in that it tells you rough morphology. But actually let's talk about looking at an in look. So an inlet tells me, uh I'm just going to go full screen so I can see what you're seeing. Um Okay, it doesn't work, but an inlet tells me where the front border of the sacrum is. And that's from looking over S one and S two. So that means moving a gantry or the patient. So it's easy to move a gantry, isn't it? And you have to look that way. So it looks into the Pelvis hence inlet at the front border of the sacrum. So I know that I'm not coming into the pelvis with my screws. Uh Now an outlook is Axion. Ap of the sacred framer. Yeah. Looking at the front of the sacred frame. And so I'm making those, those frame and not look like little eyelets, but I'm making them look like holes and proper holes. So I can say where my superior, inferior relationship is. So, inlet, anterior, posterior outlook, superior, inferior. Okay, easy, peasy, lemon squeezy and then they're variations. Okay. You don't even know about those. Um You know, those are for me when I'm doing an operation. Now, Judeh views. Okay. Here's a Judeh view. Yeah, of that hemipelvis of this hemipelvis. Can you see that? Yeah, this is an Iraq oblique because I'm seeing the iliac on face. I'm seeing as much. So it's an ap of the iliac crest, think of it that way. Yeah. And what you can see is an outline here of the anterior wall elements. Yeah, particularly the anterior wall around the region of the A I I S. What I can see also is the sciatic notch and down to lesser. Yeah, down here. So what that tells me is what's happening in disruption of the posterior column. I'm looking at a posterior column in outline and I'm looking at the anterior wall elements in outline. Yeah, I can then tell more on it. But for you, that's what you want to know. Now, dude, a view of the ob trader like this looks at the obturator Framan in total. And it gives me an outline here of part of the posterior column, but also of the posterior wall outline and an outline of the anterior column, right? Okay. So there was a little nomenclature to remember it. But actually if you think about what you're looking at, yeah, I'm looking at issue. Um I'm looking at posterior wall here and I can see those quite clearly. I'm looking at in for your um I, I can see that quite clearly and I can see the anterior column and a bit more clarity. Okay. If I look at it, this, it's a sciatic notch can really see the outline of that down to the spine and I can see the anterior wall elements in outline. But it's just about thinking, it's just think of them as A P S of different sections. Yeah. Here, here's an ap at the top of the sacrum. Here's an a pre of the Sacral Framan. There's an ap of the ob trader Framan. There's an ap of the cardiac crest just about what you're looking at. Awesome. Great, thanks. Did that help? Probably. Possibly. Yeah. Absolutely. Yeah. Repetition. It helps. Hassan had a question, Hassan, what was your question? So, and let's a quick scenario of an unstable pelvis three o'clock in the morning, uh take a binder off to take a uh an X ray and the patient became, becomes unstable and I are cannot help. Would you put the binder on again and leave it until the morning or what would you advise how stable is unstable? Has that? So, becoming ongoing lee and stable. So this is your transient responder. Yeah. So you put the binder back on, don't you? If that they've taken the binder off, gives instability, put your binder back on. Yeah, then you do something okay. Then you have to have an act to turn off the tap. And what's that acts going to be? So usually you would speak to I R and if there's anything that I can embolize and there's often an act that you can do before, then to resuscitate them with blood. Right? So it's an incredibly fact that the vast majority of trauma patient's when they come in, even when they've had pack one are under resuscitated. Yeah. And they're still behind behind because there's a physiological response to trauma as well as a blood loss response, right? You know, they might have lost 22 liters of blood, but actually their bodies behaving like it's lost four liters. You know, there's a physiological response to trauma and then there's the actual amount that they blood. So if you put back the amount of blood that they lost back in their body, they'll still be behaving like they're depleted. And I don't know why that is, but it's a fact. So resuscitate and the things that you need our FFP and, and platelets cry precipitate. Yeah. And blood you need to stuff to form a clock. Sure. Perfect. Yeah. So you resuscitate and then get Ir sure. Yeah, there is no harm if you've got a patient that suddenly drops their pressure to put in the binder back on and filling them and then, then it depends on their response to that filling process. Yeah. And if they've now still dropping wolf, hang on. And I are saying we ain't going anywhere, we need to make a plan, that plan is to, to the theater to operate. Yeah, for packing. Okay. Now what usually happens is that that responder they get it filled, they then form a good clot and they stay like they're going to have a good clot and they stabilize and you can remove that binder at a later time. That's perfect. Thank you. Okay. Any other questions? No, lovely. That's awesome. Thank you, Joe. Thank you for taking the time to teach us. Um I know you're busy today and uh Mr Van Rensburg has also kind of made some space to teach us. We're lucky to have, you know, famous surgeons uh teach us on our training program. Uh So we'll take a five minute break, everyone unless anyone's got any questions and then we'll get Mr Van Rensburg uh set up. Oh,