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Today we are honored to welcome Dr.

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Samir Ranga for a lecture entitled CT Evaluation

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of Pelvic Ring Injuries, patterns,

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classifications, and Approach.

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Dr. Ranga is a radiologist at University Hospital in Muscat,

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Oman with subspecialty interest in emergency radiology

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neuroimaging and MSK imaging.

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In 2018, he received the prestigious Lee Rogers Fellowship

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in radiology journalism from the A RRS.

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Dr. Ranga is a reviewer on the RSNA Educational Exhibit

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Review panel and serves on the social media

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and Digital Innovation Committee for Radiographics Journal.

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He has authored over 40 peer reviewed articles,

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six book chapters, and 30 plus educational exhibits

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and scientific presentations for R-S-N-A-A-R-R-S

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and ESRA seasoned speaker.

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He has delivered more than a hundred lectures at national

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and international conferences,

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and we are honored to have him here with us today.

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At the end of the lecture, please join Dr.

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Ranga in a q and a session

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where he will address questions you

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may have on today's topic.

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Please remember to use the q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

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Ranga, please take it from here.

1:36

Yeah, so good evening from muscato man.

1:39

Uh, it's 8:00 PM here.

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Uh, warm welcome to everyone, um, uh,

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who are joining from different time zone.

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Good morning, afternoon, good evening.

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Uh, thank you modality, uh, formally MRI online, um,

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for inviting me once again to speak at the NO conference.

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Uh, I started giving this no conference somewhere in 2020

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during the Covid time.

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Uh, this is my fifth

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or sixth, uh, uh, no conference, such warm

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and passionate people, and it's been my pleasure

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to be part of modality family.

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Uh, today we'll be discussing about one

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of my favorite topics, uh, is imaging

2:14

of pelvic ring injuries, uh, with emphasis on the role of CT

2:17

and how CT helps to identify, classify,

2:19

and differentiate different pelvic injuries.

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Uh, this talk, um, is all about how I do it, my approach

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to this important topic, um, of trauma imaging, uh,

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no disclosures, um, just an acknowledgement to some of the,

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um, uh, best, uh, medical illustrators I know.

2:36

And, uh, Dr. DeRio oal, Dr. Shaba Mara, and Dr.

2:39

Matt Skalski. Very famous, uh, on social media.

2:43

Uh, phenomenal guys

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and, uh, majority of all

2:46

of the illustrations you will see today in my talk

2:48

is prepared by one of them.

2:50

So thank you so much

2:51

and please follow them on all the social media, uh,

2:54

and they're doing some amazing work.

2:56

Um, I have been working at two of the,

2:59

the largest trauma centers in Oman since 2010,

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so it's almost 15 years,

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and I've seen probably more than like few thousand pan

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cities for Polytrauma

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and probably a few hundred, uh, uh, pelvic ring injuries.

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And, uh, what I'm going to discuss today is uh, uh,

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my reflection of what I learned in last 15 years, uh,

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working at two of this, uh, incredible trauma centers.

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So pelvic fractures, uh, can be divided into several types,

3:25

and one is, uh, one which involves the pelvic ring.

3:28

And this ring injuries can be divided again into high energy

3:31

trauma, which occurs in young people due

3:33

to motor vehicle collision or fall from height,

3:35

or it can occur in older population due

3:38

to low energy trauma like fall from the ground level, uh,

3:41

uh, which, which is a common injury in

3:43

that particular age group.

3:45

The pelvic fracture can involve ace,

3:47

which we are not going to look at today.

3:49

It can be a non ringing fracture,

3:50

which can involve the sacrum, iliac,

3:52

or pubic bone, not as a part of the ring,

3:54

or it can be a ian side of the muscle.

3:57

And the, uh, ligament test attachment is again, not

3:59

what we are going to do today.

4:01

So my today's talk is about pelvic leak injuries in high

4:05

energy trauma either due to motor vehicle collision

4:07

or fall from height, young population

4:09

with normal bone density.

4:11

And we are going to talk today from a bony

4:14

articular trauma perspective.

4:15

So orthopedic trauma perspective today, I'm not going

4:18

to talk about vascular lower urinary tract

4:20

or soft tissue injury, which are frequently associated

4:23

with these fractures or this injuries.

4:25

So as far as numbers are concerned, like majority

4:28

of the level valve trauma center, uh, pelvic fractures

4:31

or pelvic ring injuries, you will see somewhere,

4:33

anywhere from three to five to 10% of the patients.

4:36

Overall mortality, again, varies depending upon which type

4:39

of center you work, but it varies again from lower single

4:42

digit to all the way up to 45%.

4:44

And it all depends upon how unstable the pelvic fracture is.

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So as the fracture becomes more unstable, the possibility

4:50

of hemorrhage and associated to mortality increases

4:54

and open fractures has some of the worst injury,

4:56

one worst mortality all almost up to 45%.

5:01

Most of the death which occurs in pelvic uh,

5:03

trauma patients is due

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to pelvic vascular injuries and hemorrhage.

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And remember that when someone has unstable pelvic fracture,

5:09

it's likely that they have other injuries at that dorm,

5:11

head, chest, and anywhere else,

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which can also result in the, uh, in the death.

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So my learning objective

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for today is we will review the anatomy

5:20

and biomechanics of pelvic ring.

5:22

We will learn about what is the imaging appropriateness of

5:26

of uh, uh, uh, in pelvic trauma.

5:29

We will learn about the classification

5:31

and two most commonly used classification young Burgess

5:34

and the tile, A OO OT classification.

5:36

Then we'll look at the TT systematic search pattern

5:40

and checklist based approach.

5:41

We'll look for the binders

5:43

and pitfalls, uh, how they can, they can mask the injury

5:47

and how to unask those injuries.

5:49

Last but not least, we'll discuss about stability

5:51

and stability spectrum and

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what are the management implication?

5:54

Uh, case-based review, I don't think so.

5:55

We'll have a time, but if a time, we'll we'll go

5:57

through some of the cases as well.

5:59

So let's start with the anatomy and the biomechanics.

6:03

So as we know that the pelvic ring is formed

6:05

by the five bones,

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two paired bones in the front two pubic bone

6:09

and the side two uh, iliac bones.

6:11

And on the back one sacrum,

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this five bones are joint at three joints anteriorly,

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two pubic point joint at the pubic symphysis

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and posteriorly two saac, two iliac point joint

6:21

with the sacrum at two sacroiliac joints.

6:25

Arbitrary pelvic ring can be divided by hel spine

6:28

or stab into two component anterior ring, which consists

6:31

of pubic bone, pubic symphysis and pubic air mic

6:34

and posterior ring, which consists of iliac bone,

6:36

sacroiliac joint, and the sacrum.

6:39

The bones and the joints are inherently unstable

6:42

and which is reinforced by the ligaments,

6:44

which makes it relatively stable.

6:47

So the anterior ring overall provides relatively less

6:50

stability to the entire ring, only 15%.

6:53

The posterior ring provides almost 85% of the stability.

6:56

The pubic symphysis is reinforced by the SE cell ligament,

6:59

which is a part of the capsular reinforcement.

7:02

The posterior ring, which provides majority of the uh,

7:05

stability of the ring, uh, is primarily by the SI ligaments.

7:09

Si ligament can be divided into two types,

7:12

anterior sacroiliac ligament,

7:13

which are relatively weak ligament

7:15

and part of the capillary reinforcement.

7:17

The posterior ligament, which are the strongest ligament in

7:20

the human body, which makes almost up to 60 to 70%

7:24

of the total pelvic ring stability.

7:26

This posterior ligament can be further divided into entro

7:30

posterior si, long and short ligaments.

7:32

All of these ligaments cannot be discreetly

7:35

seen separately on imaging.

7:36

However, the injury can be indirectly implied

7:40

by looking at some of the other sides.

7:42

We have pelvic floor ligaments, which includes sacro tubes

7:44

and sacro spinous ligament.

7:45

And last but not least is the iliolumbar ligament.

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Let's try to look at this ligaments.

7:49

So this is a 3D anatomy.

7:51

We are looking at the pelvis from the front

7:53

and we can see that the two pubic bone at the pubic

7:56

symphysis and this phis is reinforced

7:58

by the phi and ligament.

8:00

The anterior part of the sacroiliac joint,

8:02

which is a reinforcement of the anterior capsule,

8:04

is the anterior scro ligament,

8:05

which is relatively a weak ligament.

8:08

The sacrospinous ligament extend from the lower

8:12

and the lateral anterior aspect of the sacrum

8:15

and goes to the hel spine, which is horizontally oriented

8:18

and which provides some stability, which is a part

8:20

of the pelvic floor ligament.

8:23

And last but not the least,

8:24

are the iliolumbar ligaments which extend from the

8:26

transverse processor of L four L five

8:29

and extend all the way to the IAC crust.

8:32

When you look at the transverse section of the pelvis,

8:36

the SI ligaments are arranged from front

8:38

to back in four layers.

8:40

The most anterior one is the anterior si ligament as I

8:44

as we saw in the coronal anterior 3D image.

8:47

And then the posterior si ligament has three component.

8:50

The first component is the inpro component,

8:52

which is the anterior most among three.

8:54

The second component is short posterior IL ligament.

8:58

And the third component is a long posterior IL ligament

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Outta three intros is the strongest ligament.

9:03

Again, these three ligaments cannot be seen separately.

9:06

However, the injury can be implied based on the widening

9:10

of the pubic widening of the sacroiliac chart.

9:13

Again, we are looking at the posterior view of the pelvis

9:16

and how these ligaments are arranged.

9:18

So you can see that from posteriorly.

9:21

You can see part of the the short si ligament which extend

9:25

from the sacrum to the iliac in a transverse manner.

9:28

We have this longitudinally extended posterior SI ligament,

9:32

the long part of it, and this ligament inferiorly is

9:35

continuous with the second part

9:38

of the pelvic floor ligament.

9:40

The first we saw is a sacro spinous ligament.

9:42

The second one is sacro tubus ligament.

9:44

Sacro tubus ligament arises from the posterior lateral

9:47

inferior aspect of the sacrum

9:49

and extend to the, uh, extend to the sacral,

9:52

the hel tuberosity.

9:54

And this ligament is continuous with the long part

9:57

of the posterior asci ligament.

9:58

So they make the single sheetlike ligament structure

10:02

how these ligaments help in the biomechanical stability.

10:05

So almost all of this ligament contributes variably

10:08

to the rotational or the external stability,

10:11

rotation, stability of the pelvis.

10:13

However, the vertical stability of the pelvis is primarily

10:16

by the posterior SI complex with little bit of uh, uh,

10:20

contribution from the pelvic floor

10:21

and the IAL lumbar ligaments.

10:24

The spine and pelvic work together as a single unit

10:27

and the lumbar spine L five joints at the sacrum at L five

10:32

S one, so the Lphi S one

10:35

and S two, the Lphi S one facet joint, sacroiliac joint

10:39

and all the ligaments, what we described makes

10:41

the spine or pelvic unit.

10:42

Some of the pelvic ring injuries can disrupt the spinal

10:45

or pelvic unit as well,

10:48

and that needs a different way of management compared

10:50

to the pelvic isolated pelvic ring injuries.

10:54

So when the ring is stable, when all the bones,

10:56

all the joints and all the ligaments

10:58

and muscles are intact, the pelvis helps in transmission

11:02

of the load from the weight from the upper body

11:06

to the lower limb.

11:07

It helps in the gait

11:09

and the smooth movement, painless movement

11:11

of the of the body.

11:12

It supports the vital structures which include blood

11:15

vessels, geral, urinary tract, gastrointestinal tract,

11:18

including the rectum as well as the nose and the now plexus.

11:25

The second part of my learning objective is

11:28

how we image the patients.

11:30

It's suspected polytrauma.

11:32

So we have two imaging modality,

11:33

one is x-rays and second is ct.

11:35

So radiograph, we do it in all patients.

11:38

It's part of a TLS protocol.

11:40

We do portable x-ray in the trauma bay.

11:42

Single pelvic x-ray is done P view in all these patients,

11:47

we do CT a, pretty much any patient who is stable enough

11:51

to be transferred to a ct.

11:54

Our x-rays help. So the x-rays help you

11:56

to detect the unstable fractures.

11:59

It's very good in detecting anterior ring injuries.

12:02

It helps to triage us

12:03

to further management whether the patient will go for CT

12:07

or IR or, or it also helps in CT protocol optimization.

12:11

Some places they use x-rays to do that

12:13

and it also helps which patient will need pelvic blinder if

12:17

it's already not in place for the pre-hospital care.

12:21

The disadvantage of pelvic x-rays is that we Ms. Good number

12:24

of posterior ring injury.

12:26

That means the iliac fracture, sacral fractures

12:28

and sacroiliac joint injuries.

12:30

In one study, they saw that almost up to more than half

12:34

of the sacral fractures were missed in, in, um, in a,

12:37

in a pelvic x-ray,

12:39

particularly in older patients who are osteopenic.

12:42

But as I said, the the pelvic uh,

12:45

x-rays are extremely good when it comes

12:47

to the anterior ring injuries

12:49

and all fractures

12:50

of pubic re all pubic diastasis can be very well seen on

12:53

the, on the x-rays, the when it's grossly unstable,

12:57

even posterior ring injuries can also be seen on x-ray.

13:02

So what are the signs

13:03

of features which suggest unstable fracture

13:06

patterns on radiograph?

13:07

So whenever you see displaced fracture, bilateral pubic

13:11

fracture or displaced fracture of sacrum

13:12

or iliac, it's a sign that this pelvic ring is unstable.

13:16

Whenever you see gross muscle mar alignment

13:18

of the pubic diastasis CCI joint

13:20

or vertical displacement of the hemi pelvis,

13:22

those are the signs that this pelvis is

13:24

potentially unstable.

13:26

Let's see some of the example. What do you see?

13:28

This is a deformed pelvis.

13:29

It doesn't look bilateral symmetrical.

13:31

You can see the displaced fracture

13:32

of the superior pubic Ramon left side,

13:34

inferior pubic Ramon left side.

13:36

There is a fracture of the inferior pubic reus anterior uh,

13:39

or posterior part of the CE tablum.

13:40

There is a fracture of the pubic CH ramus.

13:42

On the right side there is a fracture

13:44

of the pubic CH Ramon the left side.

13:45

So we can see there is a bilateral multiple pubic

13:49

fracture which are displaced and pelvis is deform.

13:51

So this is a sign of an unstable pelvic fracture.

13:56

How does this help in the drive eye of the patient?

13:58

So when you see an unstable injury like this,

14:01

if patient is hemodynamically stable,

14:04

they will go for the ct.

14:06

If the patient is hemodynamically unstable, they do fast.

14:09

If the fastest positive patient goes to the

14:12

or if the fastest is negative, patient goes to the IR.

14:15

For the transarterial embolization

14:18

and the angiographic, again, there are places,

14:21

as I told you, they help the, the x-rays are used to

14:25

optimize the CT protocol.

14:26

So when the pelvic ring looks in intake,

14:29

they do single phase portal venous imaging

14:32

of the pel of the pelvis.

14:33

However, when the pelvis looks unstable

14:35

or any fracture of the pelvis is seen,

14:37

they do multiphasic CT of the pelvis, the fractures

14:42

as seen on the on the x-rays as a part of the portable.

14:46

Her radiograph can also help us

14:48

to decide which patient will need a binder.

14:51

Any unstable pelvic injury you see on the pelvic radiograph,

14:55

the binder is placed in the trauma bay if it's already not

14:59

placed by the paramedics at the hos at the

15:02

pre-hospital care.

15:05

So which patient we should do ct?

15:07

Any patient who is stable enough who can be transferred

15:11

to the ct, CT should be done as a part

15:13

of the polytrauma protocol.

15:15

So all patients who are in hemodynamically stable will

15:17

undergo a ct.

15:19

All patients who initially presents with unstability

15:22

or hemodynamically unstable

15:24

but they respond to the volume responders

15:26

and which in the current era is almost three fourth

15:30

of the initial unstable patient will become stable

15:33

because of the excellent uh, uh, protocols

15:36

of the volume expansion.

15:37

They will undergo a ct.

15:40

CT is a gold standard to detect the fractures

15:42

to detect the instability CT ISS gold standard

15:44

to detect the vascular injuries as well

15:46

as soft tissue injuries like lower uterine

15:48

tract visal tract.

15:51

When it comes to polytrauma CT pelvis can be imaged in a

15:55

single phase multiphase or with a split bolus.

15:59

Uh, today I'm not going

16:00

to discuss about which is the best protocol.

16:02

I'll just tell you what we do.

16:04

At our institution, we do multiphasic CT in all patients.

16:08

So our protocol include non pon CT of the head and C spine.

16:12

We do arterial phase chest abdo pelvis,

16:15

and then we do venous phase abdominal pelvis.

16:18

So all pelvis in our patients undergo

16:21

by PHA examination arterial endo venous.

16:24

We do delayed phases based on the on-call radiologist, uh,

16:28

uh, interpretation of the artery and venous phase.

16:30

And CT cysto graphic can be done in certain um, a number

16:33

of these patients as well.

16:36

So once we have done the ct, why we have to learn about how

16:40

to classify these fractures

16:42

and which classification system to use.

16:44

So why to classify the pelvic fractures

16:47

to understand the mechanism of injury,

16:49

to detect which fractures are potentially

16:53

unstable based on the mechanism of morphologic

16:55

to guide the management,

16:56

whether this patient will undergo

16:58

conservative or surgical management.

17:00

It'll also anticipate the bleeding risk

17:02

and transfusion needs.

17:04

So more unstable the fracture,

17:05

more likely the patient will need the more transmission.

17:08

It'll predict the morbidity and mortality.

17:11

It'll help to triage the effectively

17:13

where the patient will go to ICU ward

17:16

or it'll go to the OT or ir.

17:18

It'll help in the resource planning

17:19

and it'll also standardize the communication

17:22

across the clinical team.

17:23

So when I say youngberg is a PC two, my, my trauma surgeons

17:28

or my trauma team also understand what I mean by APC two.

17:32

It also enables research, audit and outcome comparison.

17:35

So that's why we have to classify

17:37

whatever classification we use.

17:39

So most of the classifications

17:40

or all of the classifications are based on the imaging

17:44

and all of this classification came much

17:47

before the CT became a standard of care.

17:49

So these classifications are based on primarily the

17:52

radiographic interpretation.

17:54

However, we'll extrapolate this on the ct,

17:59

the common classifications which are used are young Burgess

18:02

and the tile O-A-O-T-A.

18:05

So the first people who came up

18:07

with this classification was the penal.

18:09

So most of this classification is based on the

18:12

work done by penal.

18:13

So young burque is also based on the penal work

18:15

and TY is also based on the penal.

18:17

However, they're slightly different.

18:19

So young burque is based on the mechanism.

18:21

Penal is also based on the mechanism.

18:23

T decided to go based on the stability in in in UH, and

18:28

and tile and penal published this

18:30

classification in eighties.

18:33

Later on the OA

18:34

and OTA came up

18:35

with this morphology based classification in 96,

18:38

which were later revised in 2007

18:40

and 2080 18, which is morphology stability

18:43

and mechanistic based.

18:45

So Youngberg is classification is mechanistic based

18:48

and where we decide about what is the primary vector

18:52

of the direction of the force or the injury.

18:54

And based on that there are four types of vector

18:58

enter posterior compression, lateral compression,

19:00

vertical share or combined.

19:02

And this, each of this vector can have three subclass based

19:06

on how, how severe the force is.

19:09

And so a PC will have a PC 1, 2, 3, lc will have lc 1, 2, 3

19:14

vertical share and combined do not have any subclass based

19:17

on the force because by and large vertical share

19:19

and combine are considered

19:21

as the most severe force involved in those patients.

19:26

Tile decided that rather than based on the

19:29

mechanism they will,

19:31

they will classify the fracture based on the stability.

19:34

So they divided the fracture into three classes, A, B,

19:37

and C, A when the pelvic ring is in intact

19:40

or the posterior ring is intact.

19:43

B, when the posterior ring is partially intact

19:46

and C is when both anterior

19:48

and posterior rings are completely disrupted.

19:51

So there is a total instability.

19:53

So A is a stable fracture, B is partially unstable

19:56

or partially stable fracture and C is unstable fracture.

20:01

So the traumatic forces as described

20:04

by panel were described in 1960s.

20:06

They're based on the biomechanical studies,

20:08

they were done on the ca and x-rays were taken

20:11

and they, they divide the fracture types into three

20:15

biomechanical types, A PC lc and vertical share later on.

20:20

Young pges also put a four type of uh,

20:23

force which is a combined which is a combination

20:25

of any three types of uh, forces used

20:28

by the panel which were the pure forces.

20:30

So the first force is the enter posterior compression force

20:34

where the force direction comes from the front to back.

20:38

It'll externally rotate the pelvis,

20:40

it'll distract the pelvis.

20:42

In the horizontal plan it'll open up the pelvis like a book.

20:46

So it's called open book fracture

20:48

and it'll result in the diastasis more than the fracture

20:52

and it'll result in the volume expansion of the pelvis.

20:57

It is most commonly occur when there is a head-on collision

21:00

type of a uh, uh, injury mechanism.

21:03

And what happens? So falls direction comes from front

21:06

to back which will result in external rotation

21:10

of the anterior ring.

21:11

External rotation of the posterior ring.

21:13

As the anterior ring is weaker compared

21:16

to the posterior ring, the first distraction happens

21:19

anteriorly and then progressively posterior

21:21

distraction also aus.

21:22

It'll open the pelvis like an open book from front to back

21:26

and it'll result primarily into pubic diastasis.

21:30

So pubic diastasis is the hallmark of this injury

21:33

and it'll ultimately result in the expansion of the volume.

21:36

So as I said it, the hallmark

21:38

of the A PC injury is pubic diastasis

21:42

with increasing force sacroiliac joint also dias uh,

21:46

become distracted from front to back.

21:50

So APC one which is only like the relatively mild force in

21:55

interop posterior direction pubic diastasis occur.

21:58

However, it is relatively mild

22:00

but side joint remains normal.

22:02

So this injury only involves the anterior ring

22:06

and it preserves the integrity of the posterior ring.

22:09

And so this injury is potentially considered rotationally

22:12

and vertically stable in a PC two other than pubic

22:17

symphysis, there is a partial disruption

22:19

of the posterior posteriorly.

22:20

There is variable disruption of the anterior SI joint

22:24

as well as the pure pelvic floor ligament which includes

22:27

sacro tubus and sacro spinous ligament.

22:31

The pubic symphysis diastasis is slightly more than a PC

22:34

one, which is like 25 to 40 mm

22:37

and anterior SI joint opens up and there is some distraction

22:41

or the avulsion injury of the pubic uh,

22:44

pelvic floor lit bits.

22:46

A PC three is the most severe form of the A PC injury

22:50

where the pubic diastasis is more severe

22:52

more than four centimeter.

22:54

The SI joint separates not only in the front

22:57

but also in the BL back.

22:59

So it's called global SI joint whitening

23:01

and all the ligaments of the pelvic uh, the pelvic floor

23:05

as well as the ileal lumbar ligaments are also disrupted.

23:09

So AP C one involves only the pubic ligament as diastasis

23:13

or injury AP C two apart from anterior there is some

23:18

involvement of the anterior SI

23:19

and the pelvic floor ligament In APC three there is

23:23

posterior SI ligament is also completely disrupted

23:28

in lateral compression.

23:29

The force direction is from side

23:31

to side which will internally record the pelvis

23:34

and so the pelvis just

23:36

has a crush injury impact on itself collide in within

23:40

pelvic will crumple.

23:42

It's like crumpling. The book

23:44

fractures are more common than diastasis

23:46

and pelvic volume reduces unlike an A PC

23:49

where pelvic volume increases.

23:51

So this is typically occur in T-bone collision

23:54

and particularly the guy

23:56

who is whose car is hit from the sun, the guy

23:59

who is hitting the scar might get the A PC injury

24:02

because for him it is different to back

24:04

but guy who is hit from the side

24:06

for him it is a side lc type of injury might occur.

24:10

So what happens the force direction comes from side

24:14

to side from one side or from both sides.

24:16

There is internal rotation of the pelvis.

24:19

The anterior ring is weaker so there is

24:21

where you see it first

24:22

and then the posterior will also internal rotate.

24:25

So you will see the sacral impaction fracture.

24:27

In the iliac fracture. The pelvis composes like a book.

24:31

There is a fracture is more commonly seen.

24:33

The diastasis and volume of the pelvis reduces.

24:37

So the hallmark of lateral compression injury includes

24:41

pubic fracture.

24:42

All lateral compression injuries have some form

24:45

of pubic fractures.

24:47

There is sacral impaction injury.

24:49

Almost all lateral compression injuries have iliac fracture

24:52

or the crescent fractures is a part of lc two fractures.

24:57

And then there is lc three also, which we'll learn later.

25:00

But fractures are more common compared to distraction.

25:03

So whenever I see any pubic REI fracture, any ral fracture,

25:07

any iliac fracture, I know that it is some form

25:10

of lateral compression injury.

25:13

So lateral compression type one

25:15

where you have the pubic REI fracture as well as sorry

25:19

as well as the impaction fracture of the sacrum.

25:24

In lc two you have lc one

25:27

plus you have a iliac fracture which extend

25:30

to the sacro iliac joints

25:32

and lc two where you have one hemi pelvis has a a type

25:36

of LC injury.

25:38

The other hemi pelvis has a PC type of injury.

25:41

So basically lc three is a type

25:43

of a combined injury in in youngberg is similar

25:47

to a combined injury

25:48

however it is classically described as a wind SW wind,

25:51

sweat, pelvis or lc three type of injury.

25:55

The vertical share is the most severe form

25:58

of injury like it is the force is perpendicular

26:01

to the long exs of the pelvis.

26:03

It's a distraction injury

26:05

as if you are just steering the entire textbook of the book.

26:08

And it can result in variable fractures

26:11

and diastasis volume expanding basically one hemi pelvis

26:16

moves in cranial cordal direction compared

26:19

to the other pelvis.

26:20

So the force direction is vertical cranial sheer injury

26:24

and it'll result in in the hemi pelvis

26:28

a move into cranial direction in relation

26:31

to the other hemi pelvis.

26:33

So the hallmark of the injury is one hemi pelvis most

26:38

in relation to the other hemi pelvis.

26:41

Now what are the disadvantage of this classification system?

26:45

Several disadvantage

26:46

but one of the most important disadvantage is

26:48

that this classification is based on the static imaging

26:52

which doesn't incorporate the elastic recoil

26:56

of the soft tissues body health.

26:58

And so most of our many

26:59

of this classification quite often underestimate the true

27:03

injury or the instability

27:05

because it is based on the static imaging.

27:09

Now we'll learn about how I approach the CT

27:13

and what is my search pattern

27:14

and the checklist, the search pattern

27:16

and checklist can be based on x-rays on the ct.

27:20

This is the extra search pattern which I'm not going

27:23

to go in detail.

27:24

And Rio Paul has done this amazing work.

27:27

Uh uh uh, I was one of the co-authors with radio pedia.

27:31

This poster is available free on radio pedia

27:34

2023 so please check it.

27:36

And he has produced some amazing uh,

27:38

checklist on the radiographs

27:40

today my talk is about CT search pattern in the checklist.

27:43

So we look at the similar pattern anterior ring,

27:46

we look at the pubic symphysis, we look at the pubic

27:50

and the acetabulum posterior ring,

27:53

we look at the sacroiliac joint sacral fractures

27:55

and iliac bone fractures observed in

27:58

that we look at the lumbar spine femur and everything else.

28:02

So anterior arch injury can involve pubic phis of pubic

28:07

posterior arch injury can involve SI joint

28:10

iliac bone or sacrum.

28:13

So let's see why the search pattern is important.

28:17

So search pattern is important

28:18

because as the biomechanics ring always breaks it to places.

28:23

So whenever you see anterior ring injury there has

28:26

to be a posterior ring injury and

28:29

whenever there is a posterior injury there has

28:31

to be anterior ring injury.

28:33

All of this injury occurs in a predictable pattern.

28:36

So a PC have a predictable pattern of AP anterior

28:40

as well as posterior injury.

28:42

Same way lateral compression vertical share also have a

28:44

predictable pattern of anterior and posterior injury.

28:47

So if you can identify correctly correct pattern

28:51

of anterior ring, you can extrapolate

28:54

or you can imagine what will be the posturing injury will be

28:58

stay away for lateral compression and vertical she.

29:00

And so it'll help you to reflectively

29:05

identify the entire spectrum

29:06

of injury if you identify one injury correctly

29:09

and let's try to do hardly see how I do it.

29:14

The normal pubic symphysis, what we look for, we look

29:17

for distance alignment, soft tissues and aversion.

29:20

What is the distance or distance is the maximum D distance

29:24

between the two pubic bone on axial and on coronal.

29:28

In adults it's less than six millimeter up to three

29:31

to six millimeters normal.

29:32

In women of childbearing age particularly

29:35

who have recently delivered or who postpartum

29:38

or who have had children will be slightly wider of eight

29:42

to 10 millimeter pediatric patient.

29:44

Up to 10 millimeter less than 10

29:46

years should be considered normal.

29:47

So that is one thing we look for is the distance.

29:50

Second thing we look for alignment.

29:52

So alignment we look for two places.

29:54

One is the on axial, we look

29:56

for the posterior smooth alignment

29:57

and on coronal we look for the cranial cordal alignment.

30:01

Subtle mal alignment

30:02

of one millimeter should be considered as a normal.

30:05

There is no like a perfect geometric alignment.

30:08

Okay, soft tissue we look for.

30:10

So soft tissue you have to look for peri anterior pub,

30:14

pre pubic and supra pubic supra Pubic is best seen on

30:17

sagittal if you do it, but

30:19

otherwise the exile images are fantastic to look

30:21

for pre pubic

30:22

and supra pubic soft tissue,

30:24

there should not be any soft tissue swelling other than the

30:28

anterior abdominal wall rectus muscle anti pubic plate.

30:32

UL injuries will look for the uls

30:34

of the pubic symphysis ligament which attaches to the edge

30:37

of the pubic bone on axi and the coronal images.

30:41

So same way on the sacroiliac joint we look for four things,

30:45

distance alignment, symmetry, soft tissue, and avulsions.

30:48

Again the only difference in the sacroiliac joint

30:50

because we have two sacroiliac joint, we can also look

30:53

for the symmetry and sacroiliac joint should be

30:55

bilateral symmetrical.

30:57

So what is the normal distance?

30:58

A normal distance is two to four millimeter.

31:01

Usually there is right to left symmetry.

31:04

Usually it should have a normal ap, A enter posterior

31:08

and cranial cordal alignment.

31:09

And posterior sacroiliac joint is slightly wider than the

31:13

anterior sacroiliac joint which is normal.

31:16

Anterior should not be wider than the posterior.

31:19

Posterior is slightly wider than

31:21

anterior, which can be normal.

31:22

Okay, and pediatric it is slightly wider up

31:25

to eight millimeters should be considered normal less

31:27

than 10 years of age.

31:29

Now let's see how the A PC injuries look on CT and x-rays.

31:33

So hallmark of a PC injury is pubic diastasis.

31:37

And then with increasing force you will see variable injury

31:41

of anterior SI joint

31:43

and then poster si joint pelvic volume increases

31:46

and diastasis are more common that fracture.

31:47

So as you can see in this patient,

31:50

pubic symphysis diastasis which is more than three

31:53

to six millimeter but less than 2.5 millimeters.

31:56

So as per our conventional panel classification

31:59

or YB classification, this should be type one.

32:03

And as you carefully look posteriorly both the sacroiliac

32:06

joints are looking symmetrical and normal.

32:10

What is happening in this patient again you can see

32:12

that there is a widening

32:14

of the pubic symphysis slightly more than probably 2.5.

32:17

However you can see posterior lead compared to the left.

32:21

The right sacroiliac joint is more wider, which suggests

32:23

that this patient has at least a PC two injury.

32:27

We cannot differentiate a PC two from three on radiograph

32:34

A PC three injury you can see

32:35

that the pubic diastasis is more than four centimeter

32:38

and you can see grass diastasis

32:40

of sacroiliac joint on right side compared to

32:42

that on the left side.

32:44

So this makes it APC three.

32:46

So APC one on radiograph on the ct you can see

32:49

that both the sacroiliac joint looks

32:52

symmetrical and well aligned.

32:54

There is mild widely as you go from front to back,

32:57

which is a normal finding,

32:59

but anterior sacro joints are less than two

33:01

to four millimeter and well aligned.

33:03

So this suggests that this patient has a PC one injury.

33:07

Now a PC one injury as I said the pubic

33:10

and five cell dias station is graded based on

33:13

2.5 centimeter or less.

33:15

2.5 to four or more than five to four differentiate APC one,

33:19

two, and three and which suggests

33:21

that there is potential ligamentous involvement

33:24

and which makes the pelvis stable or unstable.

33:27

So look at this thing. This patient has a gross instability

33:31

more than four centimeter.

33:32

The posterior size markedly widen.

33:35

So this is a PC three

33:37

and this patient probably the elastic recall did not work

33:40

that much but look at this patient, this patient

33:44

a the pubic symphysis is less than four centimeter,

33:47

however you can see

33:49

that the the SI joint is completely disrupted.

33:53

So that suggests that this patient,

33:55

the elastic recoil has brought back the pubic symphysis

33:59

partly to its normal uh uh, less than four centimeter,

34:02

but still the SI joint is completely vital.

34:05

So this suggests that the 2.54

34:08

and more than four works when the

34:12

IT does not work all the time

34:14

because elastic recoil can make the pubic PHIS look less

34:18

severe than what it is.

34:19

So you have to look at the SI joint in order to diagnose

34:24

or differentiate a PC one, two, and three

34:26

and we'll see how to do that.

34:27

So this is how the normal SI joint looks like.

34:30

And look at this APC one.

34:32

I told you this how the normal AP PC the side joint

34:34

looks like on APC one.

34:36

Look at this APC two ap,

34:37

this is the normal SI joint on

34:39

the left side in this patient.

34:40

However, on the right side there is a anterior divergent

34:44

or VHA SI joint which is a sign

34:48

of APC two injury compared to the fracture or the patient.

34:52

On these uh, the second image on the left side

34:55

where there is a diffuse parallel widening of the SI joint,

35:00

which suggests that this patient has a globally

35:03

unstable A PC type three injury.

35:05

So this is how we differentiate two from three on CT two

35:09

will have a anterior divergent V-shape injury while three

35:13

will have a diffuse parallel widening of the SI joint

35:18

lateral compression injury.

35:20

The hallmark of lateral compression injury is the pubic REI

35:24

fracture which happens in all patients with

35:26

with lc injuries, particular impact fracture.

35:29

Almost all patients iliac fracture happens.

35:32

Which particular type of iliac fracture,

35:34

which is the crescent fracture

35:36

and fractures are more common than distraction

35:39

or diastasis, unlike in a PC

35:41

where diastasis was more common compared to the fracture.

35:45

So let's see, what are the, what is the hallmark

35:46

of lateral compression?

35:48

So whenever you see pubic RAM fracture,

35:50

this patient has one pubic ramus,

35:53

two pubic ram per pubic ram.

35:55

So at least three pubic MI are fractured.

35:59

This patient must have a posterior ring injury until proven

36:03

otherwise because pelvic ring always breaks at two points.

36:06

So when you do a CT you will always see a posterior ring

36:10

injury which may or may not be determined on this x-ray

36:14

which is the limitation of the radiograph.

36:17

B. What are the, what is the hallmark

36:19

of the posterior injury in the sacral?

36:22

Uh, in the lc is the sacral impaction failure.

36:26

This subtle buckling, subtle impaction injury

36:29

of the sacral ella is the hallmark

36:32

of the lc one injury.

36:34

So lc one has two basic injury in anterior ring you will see

36:39

multiple pubic ramal fracture posteriorly.

36:42

You will see this impaction buckling type

36:45

of a sacred fracture.

36:48

Again this patient you can see superior pubic ramus

36:51

fracture, inferior pubic CMUs fracture

36:52

and left side also there is probably an inferior pubic CMUs

36:55

fracture At the same time there is a impaction fracture

36:59

of the sacral ella on the right side.

37:01

So this patient has lc one injury

37:03

with characteristic hallmark injury of the anterior ring

37:07

and the posterior room again the sacral injury

37:12

in lc one has a spectrum

37:14

with the mildest fracture is this impaction fracture which

37:17

only involves the anterior cortex

37:20

and only involve the sacral ella compared

37:23

to this fracture which is involving the entire sacrum from

37:26

the front to back

37:28

and it's involving more medial part of the fracture

37:30

and more lower part of the sacrum.

37:33

So the lc one is not a single injury

37:37

but a spectrum of injury.

37:39

This is a mild type of lc injury lc one injury.

37:42

This is a more severe type of lc one injury.

37:45

So that is one of another important teaching point is that

37:50

lc one is not a single injury but it's a injury spectrum

37:54

and in the same injury spectrum you can have a stable

37:57

injury, partially unstable injury

37:59

and completely unstable injury.

38:03

The one of the rare type of lc injury other than

38:08

pubic bone fracture is this injury which is called

38:11

locked pubic phis.

38:12

Where pubic phis overrides each other.

38:16

It can be seen along with pubic fracture

38:18

or an absence of pubic fracture.

38:20

So locking of the pubic phis is also one of the

38:25

injuries spectrum, rare

38:27

or uncommon injury spectrum

38:28

of the lateral compression injury.

38:30

When you look at the posteriorly you will see some other

38:32

type of L injury in this patient the iliac injury is seen.

38:38

So this was about LC one.

38:41

LC two is when you see the scent fracture

38:44

of the iliac bone, which is a hallmark of the lc two, how

38:49

to look for the crescent fracture.

38:50

So crescent fracture has this five criteria on axial what

38:54

to look for is iliac bone fracture there?

38:57

Yes, iliac bone fracture is there,

38:59

is iliac bone fracture transverse or obliquely oriented?

39:02

Yes, it is transverse or obliquely oriented.

39:05

Does this fracture interiorly extend to the SI joint?

39:09

Yes, it extend to the SI joint.

39:11

Does it cause some widening

39:13

of the SI joint interior to this part?

39:16

Yes it does. Cause does the posterior SI joint intake?

39:20

Yes it is. So when all

39:22

of this five criteria are met in variable combination,

39:26

you call this as a lateral compression type two IAC crest

39:31

injury on axial, what are the criteria on coronal?

39:34

Again, same question. Is iliac fracture there? Yes it is.

39:38

There is the fracture vertical obliquely oriented?

39:41

Yes, it is vertical obliquely oriented.

39:43

Does fracture extend to the SI joint? Yes it does extend.

39:46

Is the SI joint widened below the level of the fracture?

39:50

Yes it is. Is the side joint intact

39:52

above the lower level fracture?

39:54

Yes, it is intact.

39:55

So when all of this criteria are met in variable

39:57

combination, you call this a cent fracture,

40:01

lc two fracture again on x-ray.

40:04

Do you see IAC fracture?

40:05

Yes you we do see is it vertical or oblique oriented?

40:08

Yes it does. Does it extend to the SI joint? Yes.

40:11

It looks like the rest of the findings you may not be able

40:15

to see on x-ray

40:16

and that is why you have to do CT again.

40:20

Why we are, we are, we are saying that this is important

40:23

because lc two can potentially be an unstable fracture lc

40:28

two, just like lc one has a spectrum

40:30

of injury from relatively stable to unstable injury.

40:34

However, iliac bone fracture can be of multiple times

40:39

and lc two

40:40

or the crescent is only one of that type of a fracture.

40:44

So what are those? Lookalike fracture of the iliac bone

40:47

or iliac bone fracture suggests some form

40:50

of lateral compression injury.

40:52

So this fractures can be avulsion type which are not

40:56

typically lateral compression injury

40:57

but that can involve the avulsion of the A SIS or A IIS.

41:02

It can involve the avulsion of the IAC crest.

41:06

This fracture can involve the transversely, the IAC crest.

41:10

So this is called transverse IAC crest fracture.

41:13

Because the fracture line is more transversely oriented,

41:16

it can be single or multi fragmentary.

41:18

This is one of the non ring fracture, stable fracture.

41:23

This is another patient where the iliac fracture is there.

41:26

It is more vertically oriented

41:29

but it is not extending to the SI joint.

41:32

So this is not a cent fracture.

41:34

However this fracture is extending to the pelvic brim.

41:39

So this makes it a ring fracture,

41:42

potentially unstable fracture.

41:45

Again is it a vertical or a horizontal fracture?

41:48

It is vertical fracture. Does it extend to the pubic phi?

41:53

Does it extend to the sacroiliac joint? No it does not.

41:56

Does it extend to the pubic rim? No it does not.

41:59

So this makes it a vertical fracture part

42:02

of lateral compression injury

42:03

but not cent, not pelvic brim injury.

42:07

This is a fracture.

42:09

There is a multiple types of fracture,

42:12

multiple iliac fractures.

42:13

This is a transversely oriented fracture.

42:16

This is a vertically oriented fracture extended

42:18

to the pelvic brim.

42:20

This is uh, another obliquely oriented fracture

42:23

to the SI joint.

42:24

So this is a crescent fracture,

42:26

this is a pelvic brim fracture.

42:28

This is a transverse fracture of the iliac bone.

42:31

Other than that, this patient also has a characteristic lc

42:35

one injury which is the compression

42:37

or impaction injury of the sacral ella.

42:40

So this fractures,

42:42

multiple fractures can be present in the same patient

42:45

and the same fracture can have a variable severity

42:49

or the spectrum of the instability.

42:53

Lc three is a wind swept pelvis and any combination of lc

42:58

and a PC injury is called lc three injury.

43:01

So look at this fracture.

43:02

There is a, there is a a lc two type of I

43:07

to vein fracture or the crescent fracture on the

43:09

left hemi pelvis.

43:10

At the same time there is a anterior V-shape widening

43:14

of the sacroiliac joint on the right side which suggests

43:17

there is a APC two injury.

43:19

So lc two on left, APC two on right, this makes it lc three.

43:25

This is another patient lc one injury on the left side.

43:28

So you can see the iac, the the sacral

43:31

compression fracture which is going from front to back,

43:34

more severe type of lc one spectrum at the same time.

43:37

On the right hemi pelvis there is anterior divergent

43:40

widening which is APC two.

43:42

So LC one plus APC two is lc three.

43:46

Any combination of one pelvis lc,

43:48

other hemi pelvis A PC is lc three Injury

43:53

vertical share as I said is one

43:54

of the most surgery injury hallmark is cranial cordal

43:57

displacement of the one hemi pelvis

43:59

and this cranial cordal displacement occurs

44:01

through the pubic rami or pubic symphysis.

44:03

It can occur posteriorly through the sacrum iliac joint.

44:07

So the, the hallmark is the cranial cordal displacement

44:12

of one hemi pelvis

44:13

and in this patient the posterior ring is

44:15

disrupted through the sacrum.

44:17

The anterior ring is disrupted through the sacro

44:19

through the pubic rami with in impact techic symphysis.

44:24

This is another patient you can see bilateral

44:26

cranial cordal MA alignment.

44:28

So this hemi pelvis on the left side has more cran compared

44:32

to that on the sacrum.

44:34

So you can see that the cranial cordal alignment

44:36

of the sacrum and iliac bone is lost.

44:38

So this left he pelvis is cranial migrated.

44:40

The right he pelvis is also cranial migrated.

44:43

So this patient has bilateral vertical

44:45

shared type of an injury.

44:47

There is widening of the left sacroiliac joint which suggest

44:50

that there is some form of a PC injury.

44:52

There is a lateral compression type two

44:54

injury on the right side.

44:56

So this patient has bilateral vertical share.

44:59

Left-sided A PC right-sided lateral compression.

45:02

This is a combined injury mechanism

45:05

and that's why we do not sub classify combined

45:07

because combined automatically make it the most severe type

45:11

of a pelvic ring.

45:13

Again, another patient with combined injury you can see

45:15

pubic symphysis diastasis,

45:17

you can see cranial cordial malalignment of the pelvis.

45:20

You can see the pubic MI fracture.

45:21

On the right side you can see the crescent fracture.

45:24

On the right side you can see widening

45:26

of the sacro joint on the right side.

45:28

So patient has a variable A PC lc one, two

45:31

and vertical share injury.

45:32

This is a combined type of injury.

45:35

Now the next part of of my talk is about pelvic binder.

45:40

Why to use it and what are the disadvantage of using it?

45:44

So this is pelvic binder,

45:46

pelvic circumferential compression device.

45:51

It is a standard of care.

45:53

Pre-hospital care in many countries

45:56

in my country the pelvic binders are not placed as a part

46:00

of the pre-hospital care

46:02

but it is placed in the emergency room

46:05

after doing the first x-ray.

46:07

So we will always have a pre binder,

46:10

the post binder x-ray in our patients,

46:12

which will make our life relatively easier.

46:14

And I'll tell you why it basically what it does is

46:17

that any fracture which opens up the pelvis,

46:20

which is basically the volume expanding family,

46:23

which is the volume expanding family, all APCs one, two

46:26

and three and lateral compression type three.

46:28

These four fracture types are volume expanding family,

46:31

it reduces the open book, closes it

46:34

and makes rotationally unstable fracture

46:37

relatively stable fracture.

46:38

So it also stable.

46:40

So initially it was used primarily for a PC type of injury.

46:44

However we realize that it also helps in active bleed

46:48

by providing hemostasis.

46:50

It also helps by preventing further vascular

46:53

and soft tissue damage.

46:54

And so it can potentially help also in the lateral

46:59

compression and vertical share injury.

47:00

So currently the pelvic binder is placed pretty much in

47:05

any pelvic injury whether it's a PC lc or vertical.

47:09

She initially we thought that what lateral compression,

47:12

because it's already reducing the pelvic volume

47:16

and adding the pelvic binder might reduce the pelvic volume

47:19

further and may worsen the pelvic uh,

47:22

lateral compression injury.

47:23

However, it doesn't happen in real life.

47:25

So we are also using it in the lateral

47:28

compression type of injury.

47:29

What to look for when the patient has a pelvic binder

47:32

and CT to look for the position of the binder,

47:34

whether it's a correctly placed or not

47:36

and we'll learn how to look for it And we how to

47:39

the pelvic binder, because it closes the pelvic ring injury,

47:43

it will mask the severity of the A PC injury.

47:47

So a APC three might start looking like two

47:49

and two might start looking like one

47:51

and one might start looking like no AP PC at all.

47:55

So we have to understand how to unask this injuries.

47:58

So first of all, let's see how to look

48:01

for the correct binder position.

48:02

So for that you have to draw a line on the CT

48:06

or the x-ray from the top of the greater roc enterer,

48:10

which is the red line from the bottom

48:12

of the greater roc enterer, which is the green line.

48:14

And then you look at the binder buckle.

48:17

If the binder has a buckle, look for the buckle.

48:19

And then you look for the center of the buckle,

48:21

which is this blue line between this two spring.

48:24

This blue line should ideally between the red

48:28

and the green line when the binder is correctly placed.

48:31

So what does it mean in this patient?

48:33

The binder is slightly cran placed in the ideal position

48:37

and that is the information you can provide to your trauma t

48:41

that this binder is slightly mal position,

48:44

but that is what is for them to reflect

48:46

to putting the binder next time.

48:49

As I told you, the second big disadvantage for us that it,

48:53

it is a standard of care like it is,

48:55

there is no question about that binders sales lives.

48:58

So we will see more and more pelvic city with a binder.

49:01

So we have to learn that how to unmask the injury.

49:05

As I told you, APC one might look like normal

49:08

APC two might look like one and three might look like two.

49:11

So we how to look for certain indirect evidence of the

49:16

unstable injury on those patients with parents.

49:18

So what to look for hard signs and soft signs.

49:21

Hard signs include residual malalignment of pubic symphysis

49:24

and sacroiliac joint and avulsion at the site

49:27

of those ligaments.

49:29

The pub symphysis ligament si ligaments,

49:31

the pelvic floor ligament, iliolumbar ligament

49:33

and soft sign include rectus muscle, uls retroperitoneal,

49:37

pelvic hematoma, vascular injury,

49:38

and the lower urinary tract injury.

49:40

So this is an excellent uh, uh, uh, illustration prepared

49:43

by the preop pal and the, and the uh, uh, Dr.

49:48

Uba. And you can see that anterior we look

49:51

for the residual pubic symphysis, diastasis or MA alignment

49:54

and we look for peri pubic hematoma

49:58

or AULs of the, uh, of the pubic symphysis.

50:02

We also look for the UL injury

50:05

of the sacral tubera sacrospinous ligament at the sacral

50:08

attachment at the tal spines, uh, at the tal tuberosity

50:13

or we look for the uls injury of the iliolumbar ligament,

50:16

uh, as a transverse process.

50:18

L five fracture transverse process L four fracture

50:21

or we look for the SI joint diastasis

50:23

and uh, SI joint ligament as a.

50:26

So let's try to see how to unask the injury in this patient.

50:29

You can see there is bilateral asymmetry of the si.

50:32

There is subtle SI widely in this patient with the binder

50:35

and there is a, a sian injury

50:37

of the ints sacroiliac ligament.

50:40

So this suggests that this is a high grade A PC injury.

50:43

Again, this patient you can see there is a bilateral

50:46

asymmetry of the SI joint, right looks wider compared

50:49

to the left all the way from the front to back,

50:51

which suggests high grade SI joint injury.

50:54

This patient also has the, uh,

50:57

lower urinary tract injury suggested by extra

50:59

of the contrast, which suggests

51:01

that this patient has a highly unstable injury.

51:04

This patient has the injury at the attachment

51:06

of the sacral spinous ligament from sacral attachment side.

51:10

This patient has a big pelvic retroperitoneal hematoma.

51:13

Again, a sign of a grossly unstable injury.

51:16

This patient has an active contrast extravasation

51:19

with a large pelvic retroperitoneal hematoma.

51:22

Again, it suggests unstable injury irrespective whether you

51:25

see the dislocation or not.

51:27

This patient has a residual cranial cordal

51:29

and the transverse mal alignment or diastasis.

51:32

Also, this patient has a versions

51:34

of the pubic symphysis ligament.

51:36

This patient you can see peri pubic hematoma.

51:39

You can see why the hematoma of the,

51:42

of the rectus muscle at the attachment of the pubic bone

51:45

and the attach and the uh, hematoma of the inguinal canal,

51:49

hematoma of the pubic Plato.

51:52

Uh, there is a role for binder of imaging,

51:54

however, it's a controversial an examination.

51:57

Anesthesia can be performed once patient is stabilized.

52:00

So don't beat a hurry.

52:02

This should be done only when the

52:03

final stabilization is planned.

52:06

But the last part is the stability instability spectrum.

52:09

And what are the management implication?

52:11

So the stability and instability

52:13

of the pelvis is a dynamic concept.

52:16

What I mean is that pelvis is considered stable

52:20

if it does not deform on weight bearing or routine activity

52:24

or there is painless activity, painless movement

52:28

or painless weight bearing.

52:30

So when there is no pain

52:31

or deformity when patient starts walking

52:33

or when patient is weight bearing,

52:35

that is a considered as a stable pelvis.

52:38

Anything other than that is a unstable pelvis.

52:40

So basically the stability is uh,

52:44

not a radiological concept, it's a clinical concept.

52:47

Imaging can tell us,

52:50

tell the surgeons whether the pelvis is stable or unstable.

52:54

However, we have to remember that the CT

52:57

and x-ray based on which we determine the stability

53:00

or instability are static imaging modality

53:03

done without weight bearing.

53:04

And so it may overlook this instability when it's a subtle

53:09

or it'll underestimate the instability when it is severe.

53:14

And another thing is stability is not a binary concept.

53:17

So you don't have like stable patients

53:19

and unstable patients.

53:20

There's a lot of gray zone

53:22

between the stability and unstability.

53:26

The second thing, as I said is that each

53:29

fracture surplus can also have an instability spectrum.

53:33

So lc one is not a single fracture, it's a spectrum

53:36

of injury varying from stable

53:39

to unstable same way lc two is, uh,

53:43

is a spectrum varying from stable to unstable

53:46

and similarly APC one, two and three as well.

53:50

So in terms of biomechanics, we consider pelvis

53:53

as stable when posterior ring is intact.

53:55

Partially unstable when posterior ring is at least partially

53:58

disrupted and totally unstable when posterior ring is

54:02

completely disrupted.

54:05

As I already mentioned

54:06

that the pelvic instability is not a radiological

54:11

diagnosis, though we can infer instability based on direct

54:14

and indirect evidence by diastasis

54:16

of the pubic symphysis unstable fracture.

54:18

Astro seia joint all ligament is a sance vascular injuries.

54:23

The lower urinary tract injuries,

54:25

those are the radiological surrogate markers

54:28

of unstable pelvis.

54:30

However, we have to understand

54:32

that it's basically a clinical diagnosis.

54:34

And so there is a role for dynamic imaging,

54:37

which includes stress views or examination of anesthesia

54:40

or intraop fluoroscopy, which will give us an idea

54:44

to completely unask the injury when we underestimate

54:48

or we completely negate the injury.

54:51

So management, early goal

54:53

of management include bleeding controls.

54:55

So dynamic which includes the the resuscitation

54:59

and stabilization and final goal is

55:02

to provide mechanically stable pelvis.

55:04

So how to do that.

55:06

So for bleeding prevention

55:07

or bleeding control, this the concept is damage control

55:11

resuscitation, DCR, it can be done either by pelvic packing,

55:14

by laparotomy, by re boa or trans arterial embolization.

55:18

When we think that the pelvis is the culprit damage control

55:21

stabilization, which will also help introducing the, the,

55:24

the which will prevent the further hemorrhage includes

55:27

binder sheets, uh, external fixator,

55:29

the C clamps and the rescue screw.

55:32

Definite stabilization and reconstructions are based on the

55:36

biomechanical EO principles.

55:37

So it, when we, when we try

55:40

to look at the pelvis from a stability perspective,

55:42

the black and white concept is that APC one

55:45

and LC one are stable.

55:46

AP C two lc two are partially stable.

55:49

APC three, lc three and vertical shape share are the grossly

55:52

unstable our real life.

55:54

It's not true. APC one

55:56

and LC one has a spectrum which ranges from

56:00

stable two unstable injuries.

56:02

Same way APC two

56:03

and lc two have a range from partially

56:05

unstable to globally unstable.

56:07

And same way the APC three and bed. Why this happened?

56:11

Because the body has soft tissues

56:13

and soft tissues have elastic recoil.

56:16

So the actual violence which happens at the time

56:18

of injury will recoil back the bones, comes back

56:22

to its original position at least as much as possible.

56:25

The joints try to go back to its original position

56:28

because there is a inherent elastic recall the soft tissue.

56:31

And that is where when the A PC injuries,

56:36

they did the stress imaging, 50% of the A PC one

56:40

where a PC two injuries, 50%

56:43

of the APC two were almost 39%

56:47

of the APC two were APC three injuries.

56:49

And almost 37 to 60%

56:52

of the lc one injuries were unstable injury.

56:55

So these are the injuries which we consider as a stable

56:57

or very minimally unstable or partially unstable.

57:00

However, under stress imaging, this injuries turn out

57:03

to be much more severe than what it shows on imaging

57:07

because of the elastic record.

57:09

So remember that whatever you are seeing, showing

57:11

or writing in your report is underestimation

57:15

of the actual injury.

57:18

What are the principles, uh,

57:19

of the AO principle include anatomical reduction

57:22

to restore the shape, to fix the instability,

57:25

and to restore the weight bearing excess

57:27

of the, of the pelvis.

57:29

And so this is what we do.

57:31

So definitive reconstruction can be done anterior only,

57:34

posterior only circumferential,

57:35

anterior plus posterior or spinal or pelvic.

57:38

Where we try to do from L five to sacrum to pelvic,

57:42

definitely reconstruction can be done by closed.

57:45

Uh, uh, the definitive the the reduction can be done

57:49

by closed or open anterior or posterior.

57:51

Same way the reconstruct can be done

57:53

by percutaneous screw fixation plates and s screw fixation.

57:56

So these are the different ways it can be done.

57:58

So this is the, the first x-ray shows the spine

58:00

or pelvic type of reconstruction posteriorly.

58:03

And per the, the, the pubic phis,

58:05

they have done the plating.

58:07

This is an external fixation, which is a, which is a part

58:09

of the, the, not the permanent ins,

58:12

the permanent stabilization,

58:13

but the temporary stabilization anteriorly plating the

58:17

posteriorly plating,

58:19

anteriorly plating the laterally plating

58:21

posteriorly screw fixation.

58:23

And this is the, the, the spinal pelvic fixation

58:26

by putting the plates

58:27

and screws from the L four L five sacrum through SOH

58:30

as I joined to the pelvis.

58:33

So what we learned today is review the anatomy

58:36

and biomechanics of how the ligaments provide stability

58:41

to the bones

58:42

and joints, how to do imaging, how x-rays are useful

58:47

and when to do ct.

58:48

And how to do ct. We learned about two classification,

58:51

but primarily youngberg is classification.

58:55

We learn about CT systematic search pattern

58:59

and by learning that ring always breaks at two points, how

59:02

to predict the injury.

59:04

When you diagnose one injury, you can predict

59:08

or reflective identification

59:10

of the other injury based on the, on the mechanism

59:13

of injury, how binders can potentially mask the injury

59:17

and how to unask the engineering, how to say

59:19

that the binders are appropriately placed or not.

59:22

How to decide the stability, instability

59:24

and why stability in stability is not a binary concept,

59:28

but a spectrum and what does it mean

59:30

to the surgeon when they're managing it.

59:34

So this is all, um, I hope, uh, it was useful to you

59:38

and I would be happy to take, uh

59:41

any questions any one of you have.

59:43

Thank you so much.

59:45

Thank you so much, Dr. Ranga. Yes.

59:47

At this time, we will be opening the floor

59:49

for any questions from our audience,

59:50

and you may submit your questions

59:52

through the q and a feature.

59:54

And Dr. Ranga, I don't know if you see the, uh, q and A

59:58

Tool? I can

59:59

actually, yeah, yeah. So in excess, the recording.

60:03

Okay. So this, the first few are yours. Um, okay. Okay.

60:07

All unstable fractures are given binders

60:10

or only those with a PC up.

60:12

So Anisha, uh, well, it started with a PC injuries,

60:16

but currently we are pretty much putting this pelvic binder

60:20

in almost all pelvic fractures.

60:22

In fact, just like we put the cervical collar,

60:25

pelvic binder is placed in many places as a part

60:28

of the pre-hospital care.

60:30

So patient just comes with the cervical collar

60:32

that comes with the pelvic binder.

60:34

My hospital, where I work, it's not part

60:36

of the pre-hospital care.

60:37

So we put in some patients after they come to the ER

60:41

after the, in the trauma bay, they do the first x-ray.

60:44

And when the x-ray shows some form of stable

60:47

or unstable pelvic injury, any type of injury,

60:50

they could be pelvic binder, uh, studying for care.

60:54

Yeah. Thank you. Okay. Yeah, so far, uh,

60:58

Um, there's the QA feature that is very close.

61:01

Okay. Okay. I can, yeah. Uh, more, no, I don't see it.

61:07

Chat, uh, chat. I can see the chat. It's, uh, the q Okay.

61:12

Let me close the chat. Okay. Um, more.

61:16

Okay, let me go more, uh, yeah, qn. Okay, fine. Sorry.

61:20

Thanks. Yeah, thanks. I can see it now. No problem. Okay.

61:23

Is pubic re fracture seen in a PC also

61:26

as ligament fracture can?

61:27

Yes. So, uh, it's a good question.

61:29

So pubic re fracture can occur in a PC injuries.

61:34

It is correct, however, just to make

61:38

everyone's life relatively simpler

61:40

and show you the more of a, a rule-based teaching.

61:43

I told that the A PC is primary diastasis

61:46

of the pubic bone rather than the fractures.

61:48

Alternatively, pubic bend can also fracture when pubic bone

61:53

fracture in a PC injury.

61:54

The fractures have a slightly different pattern compared

61:58

to the fractures which you see in the

62:00

lateral compression fracture.

62:01

So those fractures have more of a diastasis,

62:04

they separate from each other rather than the segmental

62:08

or overlapping type of fractures.

62:10

What you typically see in the lateral compression, so

62:14

what I, what I say, that

62:16

whenever you see multiple fractures, bilateral fractures,

62:19

segmental fractures of the pubic re mi overlapping

62:23

of the fractures, uh, uh,

62:25

those fractures suggest lateral compression.

62:27

However, if I see a pubic bone fracture

62:30

or pubic re mi fracture with breast distraction

62:33

of the fracture fragment,

62:36

it is possibly an a PC injury.

62:38

Same way, vertical share also can have a fracture, um, uh,

62:43

of the pubic re mi.

62:45

However, in those patients,

62:46

the pubic cre mi fracture will have more

62:49

cranial cordal malalignment.

62:51

When you look at three types of fractures,

62:53

a PC vertical share

62:54

and the lateral compression,

62:55

lateral compression injuries are commonest injuries.

62:58

So statistically majority of the patients,

63:00

when you see a pubic bone fractures, pubic fractures,

63:04

it is actually lateral compression injuries.

63:06

AP C injuries are second commonest injury,

63:08

but the pubic ssis frac, uh, widening

63:11

or diastasis is much more common compared

63:13

to the pubic fracture.

63:15

And that, and the vertical share is,

63:17

is the least common type of fracture.

63:19

Um, and whenever you see cranial cordial mal alignment

63:21

of the posterior ring,

63:23

and then you see the anterior ring injury, you,

63:26

you look at the cranial cordial

63:27

mal alignment of the fracture.

63:29

Yes. So that is if patient go

63:33

to ct, why plan x-ray?

63:35

You still need it. Yeah, that's a, that's a good question.

63:38

Uh, um, well, uh, there is plenty

63:41

of literature in recent years

63:43

and people have come up with different protocols.

63:46

There are places where they have stopped doing

63:48

pelvic x-rays.

63:50

However, A TLS, uh, American trauma, uh, uh, uh,

63:54

society, uh, uh, uh, guidelines,

63:57

A TLS guidelines still suggest

63:59

that do pelvic x-rays in all patients.

64:02

As I said, pelvic x-rays help you to try the patients.

64:05

So patients who are moreally unstable, they will directly go

64:09

to IR or, or, uh, that helps sometimes in, in, uh,

64:13

diagnosing unstable fractures,

64:15

sometimes in CT protocol optimization.

64:18

But you're right, just like you, many people have questions.

64:21

There are, there are trauma centers

64:23

who have stopped doing it.

64:25

We are doing it. Um, it's very low cost, uh,

64:30

uh, examination.

64:31

It gives, um, uh, amazing information.

64:34

Um, uh, it's, it's one of my favorite examination, like, so,

64:38

so far we are doing it,

64:39

but, uh, uh, there are a few centers who don't do it.

64:42

Yes, but anyone who is following a TLS guidelines

64:44

as they're doing it, it's just like

64:46

for vi spine later radiograph, everyone does it.

64:48

The patient gets in the pan CT or,

64:51

or they do the chest radiograph though, they're going

64:53

to do the pan ct because those are the life threatening,

64:58

uh, checklist again.

65:00

Okay. So I'll, I'll come back to that probably at the end,

65:03

like, uh, so you can take a screenshot of that checklist

65:07

of the x-ray and the ct.

65:09

Uh, is is MRI, uh, helpful in pelvic trauma patient?

65:13

Um, well, uh, there is no straight answer.

65:16

Um, MRI has been done, um, uh,

65:20

in some centers, in some studies it does show

65:24

few more injuries than

65:25

what you can see on CT in high velocity injuries,

65:29

pelvic ring injuries, it shows ligamentous injuries, uh,

65:33

slightly better than CT people who have done it.

65:37

However, it is,

65:40

it does not add any further value than what CT provides.

65:44

So, um, um, uh, when,

65:46

when the CT looks grossly unstable, uh,

65:49

those patients are grossly unstable.

65:51

When CT looks completely normal in binder ct,

65:55

probably MRI might show some edema along the ligaments,

65:58

probably, which might suggest that this patient has a low

66:00

grade injury.

66:02

The pelvic MRI has definitely some role when it comes

66:05

to elderly patient with ground level fall

66:08

and low velocity injury.

66:10

So those are the patients when the, the sacral fracture is

66:14

so subtle, you don't see it on the x-ray and even on the CT

66:18

because of osteoporotic bone,

66:20

either you can do a dual source CT

66:22

or you can do an MRI, uh, David Drazin

66:25

and their, their group has, has, uh, uh, from that, uh,

66:28

Madeline Trauma Center have done this study on role

66:31

of dual source ct, which shows bone marrow edema

66:34

and the ligamentous levels in site edema.

66:37

Uh, as an alternative to mr,

66:39

they have some promising result,

66:41

but none of this is standard of care.

66:43

So the standard of care is x-rays in all patients,

66:46

ct in all patients who can undergo CT MR, MRI is

66:49

so far not in the algorithm.

66:52

Some role in, in patients who are elderly, uh,

66:55

with ground level fall, low velocity injury,

66:58

and, uh, subtle fractures, which can be overlooked.

67:03

Thank you. Um, what about the stress

67:06

or insufficiency fracture?

67:08

Absolutely, so those patients, uh, definitely we do

67:12

x-rays followed by ct.

67:13

So, uh, uh, well, uh, it all depends like, um, so

67:17

after x-ray, you can go to MR directly or you go to ct.

67:21

All of my patient undergoes ct, uh, uh, uh,

67:24

for several reasons, simply because like MR.

67:27

Service may not be available 24 7.

67:28

That's one of the reasons. And CT is easy to perform

67:31

as quick, so we do CT in all patients.

67:33

Um, and then Mr, in those patients who, who CT negative, uh,

67:38

uh, we can do that.

67:39

We have, we have the dual source, we do dual source, uh, um,

67:43

again, not one of the biggest fan of, uh, uh,

67:46

of dual source in diagnosing, uh, um, the, uh, uh, the,

67:50

the AL fractures, uh, uh, it just tell me where to look

67:54

for the fracture on the plain ct,

67:55

like all the no on the single, uh, source ct.

67:59

So, uh, yes, absolutely there is MRI has some role in,

68:02

in those patients, old age low velocity

68:05

and pediatric poly fractures.

68:06

Absolutely. I completely agree with that.

68:08

Uh, uh, it's, it's completely different, old age,

68:11

low velocity and pediatric pelvic fractures.

68:13

And, and, um, um, I just wanted to start

68:17

with something which is like a, a typical age group

68:20

and typical type of injuries I see in my daily practice.

68:23

Um, so, uh, I, I started

68:25

with this in the high velocity young patients, uh,

68:27

but we do have a very good number

68:29

of p pediatric pelvic fractures.

68:31

We do have a good number of, uh, elderly patients

68:34

with pelu fractures as well.

68:35

So, um, hopefully sometime, um, um,

68:38

in the future we, we'll talk about this.

68:41

Yes, all osteoporotic fractures

68:42

are completely different as well.

68:44

Uh, I, I, I completely agree with that.

68:46

So probably pretty much, uh, all the questions, uh, uh,

68:50

have been answered.

68:52

Um, and I just to quickly show you the,

68:55

the checklist which someone wanted to see.

68:58

So this is how the checklist looks like.

69:01

Uh, uh, this checklist, the radiographic checklist, um, is

69:05

as I told you, available on radio PIA 2023.

69:09

This was prepared by, uh, the prial, one

69:12

of the medical illustrators, which I was talking about.

69:15

And um, uh, this is our poster in 2023 Radio pedia.

69:20

I'm sure it's still there. Um, uh, uh,

69:22

and um, uh, there is a link also so you can just uh,

69:26

uh, take it from there.

69:28

Uh, for the ct, this is what we look for,

69:31

the anterior ring injury

69:33

and uh, pelvic symphysis, how we look for in pubic, uh,

69:36

and the secondary joint, how we look for,

69:38

so this is our CT search pattern in the checklist.

69:41

Um, um, um, if everything will go well, probably by October,

69:45

um, uh, our article on how

69:48

to look at the pelvic CT from the trauma protective,

69:50

what I talk about today, um,

69:53

will be there in the Radiographics as well.

69:55

So hopefully by October, uh, we will have this paper

69:58

as well, maybe article,

69:59

which will be helpful to you in your practice.

70:01

Yeah, thanks. Alright.

70:03

Thank you so much Dr. Ranga.

70:05

Thank you so much for sharing your lecture today

70:07

and taking the time to answer everyone's questions.

70:10

My pleasure. Thanks.

70:11

And thank you to all for participating in our noon

70:14

conference and asking such great questions.

70:16

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70:18

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70:20

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70:21

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70:26

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70:27

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70:30

where Dr. John Jacobson will deliver a lecture entitled

70:33

Ultrasound of Peripheral Nerve Entrapment.

70:35

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70:38

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70:39

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70:41

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