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PubMed2000

The lumbosacral nerves in relation to dorsal S1 screw placement and their locations on plain radiographs.

Seven adult cadaver lumbopelvises were harvested to study the anatomic relationship of the L4 and L5 nerves to S1 dorsal screw placement and the location of the L4, L5, and S1 nerves on plain radiographs. The mean lateral angle of S1 screw trajectory toward the L4 nerve was 31+/-8 degrees, and the mean screw trajectory length was 53+/-8 mm. The mean lateral angle of the screw trajectory toward the L5 nerve was 21+/-8 degrees, and the mean screw trajectory length was 38+/-4 mm. On both inlet and outlet radiographs, the lateral angle of the nerves increased from L4 to S1. The L4 nerve coursed over the middle third of the superior ala in the inlet view and the middle third of the lateral mass in the outlet view. The L5 nerve coursed over the inner third of the superior ala and inner third of the lateral mass. On the lateral view, the mean distances from the sacral promontory to the L4, L5, and S1 nerves along the anterior border of the sacrum were 4+/-7 mm, 12+/-5 mm, and 28+/-8 mm, respectively. This study suggests that S1 sacral screws be directed between 30 degrees and 40 degrees lateral to avoid compromising the lumbosacral trunk and sacroiliac joint.

Adult↗

PubMed2002

A level one trauma center's experience with the posterior approach to the pelvis.

A retrospective review of the experience at Los Angeles County and University of Southern California Medical Center was conducted as part of a multicenter study to evaluate the true complication rate of the posterior approach to the sacroiliac joint. Between 1995 and 1997, 35 patients underwent 42 approaches, representing all patients who underwent the posterior approach by a single staff surgeon at these medical centers. All patients underwent follow-up > or = 1 year postoperatively. (11%) neurologic complications were found postoperatively, all of which resolved prior to discharge. There was 1 (2.4%) wound complication. There was 1 gluteal flap for closure (open fracture) and 1 secondary wound closure. Five patients had prolonged wound drainage (> 5 days). There were no skin sloughs in the series and only 1 patient developed a deep wound infection. Contrary to reports by advocates of anterior approaches and closed reductions, the posterior approach allows anatomic reduction of posterior lesions with an acceptable complication rate.

Adolescent↗

PubMedDate not supplied

Orthopaedic management of ankylosing spondylitis.

Ankylosing spondylitis is an inflammatory disease of unknown etiology that affects an estimated 350,000 persons in the United States and 600,000 in Europe, primarily Caucasian males in the second through fourth decades of life. Worldwide, the prevalence is 0.9%. Genetic linkage to HLA-B27 has been established. Ankylosing spondylitis primarily affects the axial skeleton and is characterized by inflammation and fusion of the sacroiliac joints, spine, and hips. The resultant deformity leads to severe functional impairment in approximately 30% of patients. Orthopaedic management primarily involves correction of hip deformity through total hip arthroplasty and, less frequently, correction of spinal deformity with spine osteotomy. Closing wedge osteotomies have the lowest incidence of complications. Whether patients with ankylosing spondylitis are at increased risk for heterotopic ossification remains controversial, but comparison with age- and sex-matched counterparts suggests no dramatically higher risk. Because of the high rate of missed fractures and complications after minor trauma in patients with ankylosing spondylitis, plain radiographs are usually not sufficient for evaluation. Thorough patient assessment should include a comprehensive history, physical examination, and laboratory studies.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed2006

Nonsurgical management of acute and chronic low back pain.

A variety of nonsurgical treatment alternatives exists for acute and chronic low back pain. Patients should receive appropriate education about the favorable natural history of low back pain, basic body mechanics, and methods (eg, exercises, activity modification, behavioral modification) that can reduce symptoms. Nonprescription medication is efficacious for mild to moderate pain. Nonsteroidal anti-inflammatory drugs, alone or in combination with muscle relaxants, relieve pain and improve overall symptoms of acute low back pain. Exercise therapy has limited value for acute low back pain, but strong evidence supports exercise therapy in the management of chronic low back pain. Moderately strong evidence supports the use of manipulation in acute back pain. Evidence is weak for the use of epidural corticosteroid injections in patients with acute low back pain, strong for short-term relief of chronic low back pain, and limited for long-term relief of chronic low back pain. The use of facet injections in the management of acute low back pain is not supported by evidence, nor is the effectiveness of orthoses, traction, magnets, or acupuncture. Trigger point injections are not indicated for nonspecific acute or chronic low back pain, and sacroiliac joint injections are not indicated in the routine management of low back pain. Conflicting evidence exists regarding the use of transcutaneous electrical nerve stimulation.

Acute Disease↗

PubMed2002

Update on spondyloarthropathies.

Spondyloarthropathies are a cluster of interrelated and overlapping chronic inflammatory rheumatic diseases that primarily include ankylosing spondylitis, reactive arthritis, and the arthritis associated with psoriasis and inflammatory bowel diseases. The primary pathologic sites are the entheses (the sites of bony insertion of ligaments and tendons); the axial skeleton, including the sacroiliac joints; the limb joints; and some nonarticular structures, such as the gut, skin, eye, and aortic valve. Although spondyloarthropathies are not associated with rheumatoid factor, they show a strong association with HLA-B27; however, this association varies markedly among various spondyloarthropathies and among ethnic groups. The most widely used classification criterion, from the European Spondyloarthropathy Study Group, encompasses the currently recognized wider disease spectrum, with a sensitivity and specificity that generally exceed 85%. Spondyloarthropathies occur in genetically predisposed persons and are triggered by environmental factors, but the cellular and molecular mechanisms of inflammation are not yet fully understood. Chlamydial and many enterobacterial infections can trigger reactive arthritis, but an infectious trigger for ankylosing spondylitis has not yet been established. HLA-B27 itself is involved in enhancing genetic susceptibility, but the underlying molecular basis is still unknown; additional genes include the putative susceptibility genes for Crohn disease, ulcerative colitis, and psoriasis. A specific susceptibility gene for Crohn disease, NOD2, is located on chromosome 16q12, and one of the candidate genes for psoriasis, PSORS1, has been mapped to a 60-kb fragment on chromosome 6p, which is telomeric to the HLA-C locus. This paper reviews the efficacy of anti-tumor necrosis factor-alpha therapy and other therapeutic advances.

Arthritis, Psoriatic↗

PubMed1998

[A case of psoriatic arthritis associated with ankylosing spondylitis treated with bilateral total hip arthroplasty].

We report a case of a 40-year-old male with psoriatic arthritis associated with ankylosing spondylitis. At the age of 34, the patient suffered pain in his hips, knees, ankles, neck and low back 3 years after the onset of psoriasis vulgaris. The hip pain gradually became severe despite the medical treatment and physical therapy. On admission, the skin lesion of diffuse erythematous plaques with scales was observed on the trunk and extremities. Motion of the spine was markedly limited. We also noted limitation of motion in the bilateral hips and remarkable gait disturbance. In laboratory findings, rheumatoid factor and HLA-B 27 antigen were negative. Radiographs of the cervical spine showed typical bamboo spine as seen in ankylosing spondylitis. Obliteration of the sacroiliac joints and joint space narrowing in the hips with reactive sclerosis were revealed on the pelvic film. Bilateral cementless total hip arthroplasty with adductor tenotomy resulted in complete pain relief and a marked improvement in gait function 18 months after surgery. The appropriate reconstructive surgery was extremely helpful to increase daily activities of the patient in this case.

Adult↗

PubMed1999

Pelvic fracture urethral injuries: the unresolved controversy.

PURPOSE: The unresolved controversies about pelvic fracture urethral injuries and whether any conclusions can be reached to develop a treatment plan for this lesion are determined. MATERIALS AND METHODS: All data on pelvic fracture urethral injuries in the English literature for the last 50 years were critically analyzed. Studies were eligible only if data were complete and conclusive. RESULTS: The risk of urethral injury is influenced by the number of broken pubic rami as well as involvement of the sacroiliac joint. Depending on the magnitude of trauma, the membranous urethra is first stretched and then partially or completely ruptured at the bulbomembranous junction. Injuries to the prostatic urethra and bladder neck occur only in children. Injury to the female urethra usually is a partial tear of the anterior wall and rarely complete disruption of the proximal or distal urethra. Diagnosis depends on urethrography in men and on a high index of suspicion and urethroscopy in women. Of the 3 conventional treatment methods primary suturing of the disrupted urethral ends has the greatest complication rates of incontinence and impotence (21 and 56%, respectively). Primary realignment has double the incidence of impotence and half that of stricture compared to suprapubic cystostomy and delayed repair (36 versus 19 and 53 versus 97%, respectively, p <0.0001). CONCLUSIONS: In men surgical and endoscopic procedures do not compete but rather complement each other for treatment of different injuries under different circumstances, including indwelling catheter for urethral stretch injury, endoscopic stenting or suprapubic cystostomy for partial rupture, endoscopic realignment or suprapubic cystostomy for complete rupture with a minimal distraction defect and surgical realignment if the distraction defect is wide. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. In women treatment modalities are dictated by the level of urethral injury, including immediate retropubic realignment or suturing for proximal and transvaginal urethral advancement for distal injury.

Adult↗

PubMed1999

Diagnosis of intermittent vascular claudication in a patient with a diagnosis of sciatica.

BACKGROUND AND PURPOSE: The purpose of this case report is to illustrate the importance of medical screening to rule out medical problems that may mimic musculoskeletal symptoms. CASE DESCRIPTION: This case report describes a woman who was referred with a diagnosis of sciatica but who had signs and symptoms consistent with vascular stenosis. The patient complained of bilateral lower-extremity weakness with her pain intensity at a minimal level in the region of the left sacroiliac joint and left buttock. She also reported numbness in her left leg after walking, sensations of cold and then heat during walking, and cramps in her right calf muscle. She did not report any leg pain. A medical screening questionnaire revealed an extensive family history of heart disease. Examination of the lumbar spine and nervous system was negative. A diminished dorsalis pedis pulse was noted on the left side. Stationary cycling in lumbar flexion reproduced the patient's complaints of lower-extremity weakness and temporarily abolished her dorsalis pedis pulse on the left side. OUTCOMES: She was referred back to her physician with a request to rule out vascular disease. The patient was subsequently diagnosed, by a vascular specialist, with a "high-grade circumferential stenosis of the distal-most aorta at its bifurcation." DISCUSSION: This case report points out the importance of a thorough history, a medical screening questionnaire, and a comprehensive examination during the evaluation process to rule out medical problems that might mimic musculoskeletal symptoms.

Adult↗

PubMed1999

[Radiography of the lumbosacral spine--do the referrals conform to clinical recommendations?].

The aim of this study was to evaluate how referrals from Norwegian general practitioners for plain radiography of the lumbosacral spine conform to clinical recommendations. The clinical information given in 274 referral letters was compared with Norwegian and British recommendations. We also interviewed 99 of the patients about symptoms and prior radiographs, and performed a new comparison using all available information. Only 27% (43%) of the 274 referrals conformed to the Norwegian (British) recommendations, 36% (41%) did not conform, and 37% (16%) were considered uncertain, mainly because of lack of pertinent information in the referral letters. Of 143 referrals which were in disagreement with the Norwegian and/or the British recommendations, only four resulted in "important" findings (osteoporotic fractures in two patients, uncertain sacroiliac joint arthritis in one patient, and probably benign bony sclerosis in one patient). In the interview group, the proportion of non-conforming referrals decreased from 40% (47%) to 31% (29%) when the additional clinical information was considered. Nevertheless, we conclude that a substantial proportion of referrals for plain radiography of the lumbosacral spine do not conform to clinical recommendations. Referrals outside the advised criteria yield few relevant findings and could probably be cancelled.

Adult↗

PubMed1999

[A new type of iliac fracture caused by bone insufficiency].

BACKGROUND: The iliac bone is an uncommon localization for bone insufficiency fractures. We report a new type. CASE REPORT: A 51-year-old woman with post-menopause osteoporosis was seen for a fracture of the ischio-pubic branch of the iliac bone. X-ray also revealed an unknown fracture situated above the anterior superior iliac spine continuing cranially and medially towards the iliac crest. DISCUSSION: Three types of iliac fractures due to bone deficiency have been described. Type 1, (oblique iliac), the fracture is oblique beginning in the greater sciatic notch and extending a more or less into the iliac wing. Type 2 (superior medial iliac) involves the most medial part of the iliac wing, approximately parallel to the sacroiliac joint. In type 3 (supra-acetabular), the fracture is in a supra-acetabular localization. Our case suggests a fourth type should be individualized.

Alendronate↗

PubMedDate not supplied

[POEMS syndrome. Report of a case].

POEMS syndrome is a multisystem disorder with signs such as peripheral neuropathy, organomegaly, endocrinopathy, monoclonal protein, skin lesions, papilledema, and increased cerebrospinal fluid proteins, which can also evolve with renal and cardiac affection. It is considered a result of a plasma cell cyscrasia with the production of a monoclonal protein. A 46-year old man was seen as an outpatient referring progressive weakness of legs and arms, fever, impotence, inguinal and cervical lymphadenopathies, peripheral edema, hepatomegaly and skin hyperpigmentation. In laboratory test, platelet count was between 528 x 10(9)/L and 599 x 10(9)/L, creatinine clearance 27.2 ml/min, proteinuria 0.8 g/dl, IgA 455 mg/dl, T3 30 ng/100 ml, T4 2.6 vg/dl, T4F 0.5 ng/dl, TSH 12.4 vU/ml; testosterone 1.56 ng/ml. The electromyography showed a mixed sensitive-motor pattern. On the pelvis radiography, an osteosclerotic lesion on the left sacroiliac joint was identified. Bone biopsy of the site of the sclerotic lesion revealed plasma cell dyscrasia. The patient was treated with diuretics, digitalis and prednisone. Diagnosis of this disorder is difficult because of the multipathology it is necessary to establish differential diagnosis.

Diagnosis, Differential↗

PubMed1999

Modified continuous femoral three-in-one block for postoperative pain after total knee arthroplasty.

UNLABELLED: We prospectively studied the continuous "modified" femoral three-in-one block for postoperative pain after total knee arthroplasty. Sixty-two patients undergoing elective knee arthroplasty under spinal anesthesia with bupivacaine (B) and fentanyl were randomized to receive 0.2% B, 0.1% B, or placebo at 10 mL/h for 48 h after an initial bolus of 30 mL of the same solution via the femoral block catheter. The catheters were inserted under the fascia iliaca using a "double pop" technique and a peripheral nerve stimulator and were advanced 15-20 cm cranially. Venous plasma levels of B, desbutylbupivacaine, and 4-hydroxy B were measured daily for 3 days. All patients received patient-controlled analgesia with morphine and indomethacin suppositories for 48 h. Using computed tomography, we evaluated the catheter location for 20 patients. The catheter tips, located superior to the upper third of the sacroiliac joint in the psoas sheath, were labeled as ideally located. The group receiving 0.2% B had a larger block success rate, smaller morphine consumption in the immediate postoperative period (15 vs 22 mg) and during the first postoperative day (9 vs 18 mg), and achieved a greater range of motion in the immediate postoperative period (91 degrees +/- 10 degrees vs 80 degrees + 13 degrees ). Visual analog scores for pain during both rest and activity were low but similar between the groups. Forty percent of the catheters evaluated were ideally located. Ideal location and use of 0.2% B resulted in 100% success of blockade of all three nerves. The S1 root was blocked in up to 76% of patients. The plasma levels of B, 4-hydroxy B, and desbutylbupivacaine were below the toxic range during the infusion. We conclude that continuous fascia iliaca block with 0.2% B results in opioid-sparing and improved range of motion during the immediate postoperative period. Larger doses of bupivacaine may safely be used in the immediate postoperative period if needed. IMPLICATIONS: Continuous fascia iliaca block with 0.2% bupivacaine reduces opioid requirements and improves range of motion in the immediate postoperative period compared with a placebo and 0.1% bupivacaine. Plasma levels are below the toxic range with this dose. Only 40% of the catheters are positioned in the ideal location. With the smaller dose of bupivacaine, the success rate with this block is small.

Aged↗

PubMed1999

[Pneumatocyst of the sacrum. Apropos of a case].

We report a new case of asymptomatic pneumatocyst of the sacrum in a 45-year-old man with a history of lumbago. Pneumatocysts are rare benign osseous lesions filled with gas and always found in the subchondral bone of the sacral or iliac side of the sacroiliac joint. The diagnosis is made by CT scan. In the sacral location, the pneumatocyst is asymptomatic and surgical treatment is not justified.

Bone Cysts↗

PubMed2000

[The clinical history and physical examination in patients with chronic lumbar pain. Patient classification by a decision tree].

AIM: To analyze the correlation between clinical symptoms and physical examination signs in diagnostic groups of low back pain patients; making a spanning tree. MATERIAL AND METHOD: A prospective longitudinal study of 485 low back pain patients was carried. We assess the type of pain and its irradiation, evolution in time, duration of the episodes, timetable, intensity and morning stiffness. A complete physical examination with specific tests for sacroiliac joints and neurologic examination was carried. We carried out a study of absolute and relative frequencies; calculating the rates with the chi 2 Pearson test and having a confidence of 95%. RESULTS: We found a significant relation (p < 0.0001) between the type of pain and the diagnosis groups. Proximal irradiation with functional disorders (p < 0.01) and metabolic bone diseases (p < 0.0001); the radicular irradiation and the disorders by physical agents (p < 0.001). The flare-up back pain with disorders by physical agents and metabolic bone diseases (p < 0.001). The morning stiffness was exclusive in the inflammatory diseases. In the physical examination, was found a significant relation (p < 0.0001) between the different tests with the diagnostic groups. CONCLUSION: The history and the physical examination provide us symptoms and signs which let us direct towards the above diagnostic. The type of pain with its characteristics and the referred pain as a main symptoms, give us some information, which complemented with the physical examination tests, providing the base on which we support our diagnostic hypothesis, allow us the first classification of the patients; at the same time we understand as a low back pain patients suffer its problem.

Chi-Square Distribution↗

PubMed2000

Chiropractic management of mechanical neck and low-back pain: a retrospective, outcome-based analysis.

BACKGROUND: Evidence suggests that spinal manipulation is an effective treatment for mechanical neck and low-back pain (LBP). Treatment efficacy is important to establish for these symptoms because combined they account for a considerable amount of disability and substantial associated direct and indirect costs to society. OBJECTIVE: The purpose of this study was to examine the outcome of patients undergoing chiropractic treatment for mechanical neck or LBP. DESIGN AND SETTING: A retrospective, outcome-based analysis was done for patients seeking care at a private chiropractic practice over a 1-year period. A total of 512 files were reviewed, with 119 patients selected for inclusion. Patients were included if their chief symptom was uncomplicated mechanical neck or LBP. Diagnoses included cervical, lumbar, or sacroiliac joint sprain/strain (International Code of Diagnostics version 9 [ICD-9] code: 847.1, 847.3, 846.1, respectively), discogenic LBP (ICD-9: 722.1), and headaches (ICD-9: 784.0) because many patients with neck pain presented with concomitant headaches. Disability and pain were measured with the modified Oswestry scale (for the patients with LBP), Neck Disability Index, and an 11-box visual analogue pain scale before and after treatment. Treatment consisted of spinal manipulation, various soft-tissue techniques, home-care instructions, and ergonomic and return-to-activity advice, including rehabilitative exercises. Patients received an average of 12 treatments over a 4-week period. Statistical analysis was performed on pretreatment and posttreatment values for both disability and pain. Stratification was based on duration (acute/subacute, chronic, acute exacerbation of a chronic condition) and severity (mild, moderate, or severe) of symptoms. RESULTS: Statistically significant reductions in disability and pain scores were achieved in all groups. An average 52.5% and 52.9% reduction in pain and disability, respectively, was achieved in the low-back group. The chronic LBP group realized a less statistically significant reduction of pain and disability (19.7% and 19.8%, respectively) than the acute/subacute (66.8% and 62.5%) or the chronic/recurrent group (56. 5% and 63.4%). The differences were statistically significant. Patients with neck pain had an average 53.8% and 48.4% reduction in their pain and disability, respectively. Patients with concomitant neck pain and headaches had statistically significant higher pretreatment and posttreatment disability and pain scores than those with only neck pain. There was no statistically significant difference in outcomes between groups stratified according to pain intensity. CONCLUSIONS: Patients attending a private chiropractic clinic for treatment of mechanical neck pain or LBP had statistically significant reductions in their pain-related disability after treatment. These results indicate that chiropractic manipulation is beneficial for the treatment of mechanical neck pain and LBP. However, care must be taken when drawing conclusions from these outcomes. The study design does not account for the natural history of low back- or neck pain-related disability and therefore does not allow for claims of treatment efficacy. In addition, it has been suggested that patients presenting to medical doctors with these symptoms have significant overlying comorbidity when compared with patients presenting to a chiropractor.

Acute Disease↗

PubMedDate not supplied

The lumbar spine: imaging in rheumatic disease.

Seronegative inflammatory spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, Reiter syndrome, juvenile chronic arthritis and colitic arthritis. These diseases share some characteristics among which the most important is the presence of the histocompatibility antigen HLA B27; moreover the frequent overlapping of the various inflammation patterns have accounted for their classification in a single group. Diagnostic imaging can differentiate among the different forms only if the diagnostic algorithm, based on clinical history and laboratory findings is followed, considering the advantages and limitations of each method. In this respect, it should be kept in mind that the findings relative to the spine and sacroiliac joints allow to establish a definitive diagnosis.

Arthritis↗

PubMed2000

The genetics of spondyloarthropathies.

INTRODUCTION: Spondyloarthropathies are a heterogeneous group of rheumatic disorders that commonly present with axial skeleton or sacroiliac joints involvement. Ocular involvement like uveitis, iritis and conjunctivitis can be present in up to a third of the patients. Genetic factors play a part in the pathogenesis of spondyloarthropathies. Association with the HLA-B27 gene, especially that between ankylosing spondylitis and HLA-B27 antigenic positivity, is one of the strongest association seen between a disease and a Class I antigen. This paper aims to review the frequencies of HLA-B27 gene and its subtypes in different population groups, possible mechanisms leading to the development of joint inflammation and the risk it confers for development of spondyloarthropathies. METHODS: The MEDLINE database was searched using keywords: HLA-B27, spondyloarthropathy, molecular mimicry, arthritogenic peptides, reactive arthritis and ankylosing arthritis. Related articles for selected papers were also consulted. Books on HLA-B27 and spondyloarthropathy were obtained through the NUS Medical Library's LINC system. RESULTS: The genetic subtypes and susceptibility to development of disease vary in different population groups. Other HLA genes and non-HLA genes also play a part in the development of spondyloarthropathies, especially in those who are HLA-B27 negative. HLA-B27-positive relatives of spondyloarthritics have a higher risk of developing a similar condition. The presence of the HLA-B27 gene may serve as an aid to diagnosis or prognosis for clinicians. In juvenile arthritic patients, it is a poor prognostic factor, predicting for disease severity. It is also associated with poor outcomes for patients with anterior uveitis. However screening of asymptomatic individuals for the HLA-B27 gene is not recommended. CONCLUSION: The polygenic nature of the disease needs further elucidation and study.

Arthritis↗

PubMedDate not supplied

[Spiral computed tomography in the assessment of vascular lesions of the pelvis due to blunt trauma].

PURPOSE: We investigated the role of Helical Computed Tomography (CT) in the evaluation of low or high flow vascular injuries in patients with blunt pelvic trauma. MATERIAL AND METHODS: From May 1998 to December 1999, forty-nine patients (32 men and 17 women, ranging in age 14-59 years) with acute symptoms from blunt pelvic trauma were submitted to Computed Tomography (CT). A conventional radiography of the pelvis had been performed in all cases. CT was performed with a helical unit (thickness 8 mm, reconstruction interval 8 mm, pitch 1.5) after intravenous contrast agent (150-180 mL) rapid infusion (4-5 mL/s, 60 s acquisition delay from bolus starting) and using a power injector. A second spiral acquisition was performed in all cases from the iliac roofs to the inferior border of the pubic symphysis. Vascular hemorrhage was considered as low flow when the hematoma appeared as a focal homogeneous density area and as high flow when associated with contrast agent extravasation. Moreover, traumatic assessment included evaluation of the hematoma, of the leakage site and of the involved vessel. RESULTS: Radiologic examination of the pelvis revealed fractures in 35/49 patients (71.4%). Helical CT allowed us to identify low flow hemorrhage in 37 patients, affected with hematomas from fracture of the iliac wing or of the sacrum (14 cases), tear of the pelvic (3 cases) or extrapelvic (4 cases) muscular structures, or injury of the venous plexus (20 cases). In four patients two vascular injuries were detected. High flow hemorrhage was seen in 12 patients, who had Helical CT findings of contrast agent extravasation along the common iliac vein (3 cases), external iliac artery (3 cases), internal iliac artery (4 cases), internal pudendal artery (1 case), obturator artery (1 case), inferior epigastric artery (2 cases), superior gluteal artery (2 cases), inferior gluteal artery (1 case), cremasteric artery (1 case). In 6 patients with high flow hemorrhage, two vascular injuries were shown. In all these patients, an extraperitoneal hematoma was associated with the contrast agent extravasation. DISCUSSION AND CONCLUSIONS: Fractures of the pelvic ring generally result from severe trauma. Management of these injuries must include not only treatment of the skeletal trauma but also of the associated shock and complications. Major blood loss usually occurs as a result of bleeding from the branches of the internal iliac artery. With respect to pelvic plain radiography, CT provides superior detailing of fractures, position of fracture fragments and extent of diastasis of the sacroiliac joints and pubic symphysis. Moreover CT provides diagnostic information regarding the presence or absence of pelvic bleeding and can identify the site of bleeding. In our experience, Helical CT allows us to distinguish high flow hemorrhage, where vascular injuries must be treated first, from low flow hemorrhage which can be managed differently.

Adolescent↗