CT guided percutaneous fixation of sacroiliac fractures in trauma patients.

BACKGROUND: Open reduction and internal fixation of unstable pelvic fractures has been advocated to minimize complications and avoid further injury. We have recently performed CT guided percutaneous fixation of sacroiliac joints as an alternative to open repair. METHODS: From May 1, 1998 to April 30, 1999, our Level II trauma center admitted 76 patients with pelvic fractures, all due to blunt trauma. Twenty patients with unstable sacroiliac fracture-distractions underwent 22 percutaneous fixation procedures under general anesthesia in the radiology department by the third hospital day. Procedure times averaged 82 minutes. Localization with CT guidance was performed by the radiologist using 3-D images followed by percutaneous screw placement by the orthopaedic surgeon. RESULTS: There was minimal procedural blood loss and no post-procedural wound complications. There was one operative delay due to respiratory difficulties and one postoperative death unrelated to the pelvic fracture. All patients were mobilized on the first post-procedural day. CONCLUSION: CT guided fixation of unstable pelvic fractures minimizes blood loss during a short procedure with few subsequent complications and allows early mobilization of the patients.

Parathyroidectomy in chronic renal failure.

BACKGROUND: A subset of patients who are being maintained on dialysis for end-stage renal disease develop severely symptomatic secondary hyperparathyroidism that cannot be controlled medically. The relative merits of two alternative surgical approaches--subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation--have not been clearly elucidated. METHODS: The records of 77 patients who had renal failure and underwent parathyroid surgery between 1982 and 1993 were retrospectively reviewed. RESULTS: Fifty-three patients (69%) underwent subtotal parathyroidectomy and 24 (31%) underwent total resection with auto-transplantation into forearm musculature. The incidences of postoperative hypocalcemia and tetany were similar in both groups, as was the recurrence rate (7%) of clinically significant hyperparathyroidism. CONCLUSIONS: Subtotal parathyroidectomy can be performed without mortality or morbidity and provides good control of hyperparathyroidism secondary to chronic renal failure. Total parathyroidectomy with autotransplantation offers no additional advantage in this difficult patient population. Most patients will require postoperative intravenous calcium replacement. We observed a significant incidence of continued hyperparathyroidism following successful renal transplantation.

How much monitoring is needed for basilar skull fractures?

Basilar skull fractures account for approximately 19% of all skull fractures. There have been little data published concerning the need for intensive care monitoring in this injury. We retrospectively studied 259 patients admitted to our trauma center over an 8-year period with a diagnosis of basilar skull fracture. All patients were evaluated with cranial computed tomographic (CT) scans. These patients were admitted to the trauma service, and neurosurgical consultation was obtained in all cases. The diagnosis was made by clinical signs in 207 patients (80%), by CT scan in 47 (18%), and by plain films in 5 (2%). Ninety-two patients (group I) had intracranial pathology in addition to basilar skull fracture. Twenty-one patients in this group underwent craniotomy. In this group, the morbidity and mortality rates were 11% and 7%, respectively. Forty-four patients (group II) had no intracranial pathology and a Glasgow Coma Score (GCS) of less than 13. The morbidity was 2%, and the mortality was 2%. One hundred twenty-three patients (group III) had no intracranial pathology on CT scan and a GCS of 13 or greater. The complication rate in this group was 1%, and there was no neurologically related mortality. Patients who are admitted with a diagnosis of basilar skull fracture and who have a GCS of 13 or greater with no intracranial pathology on CT can be managed without intensive care monitoring.