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Lasin, Praphapan. Effect of anti-inflammatory treatment on depression, depressive symptoms, and adverse effects a systematic review and meta-analysis of randomized clinical trials JAMA Psychiatry Stone, D. Pelvic disruption in the polytraumatized patient: The foramen of Monro: Jenifer Lehker Designers: Hulburt, Tessa Comstock.

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Patrick M. Hector O. Daniel R. Philip F. Adam J. Allison E. Bruce H. Ziran Department of Orthopaedic Trauma, St. With an increase in minimally invasive approaches in fixation methods, knowledge of pelvic anatomy is vital to safe reduction and fixation of displaced fractures.

The purpose of this chapter is to review the salient features of the anatomy of the pelvis pertinent to the treatment of traumatic conditions. Pelvis is the Latin term for basin. The pelvic basin is divided by the pelvic rim into the true pelvis deep and the false pelvis superficial. The false pelvis consists of the sacral wing and iliac fossa covered by iliacus muscle.

The pelvic brim continues anteriorly to contain the pectineal eminence and becomes confluent with the superior pubic ramus. The deep pelvis is bordered by the quadrilateral surfaces, obturator membrane, rami, and sacrum. The deep pelvis contains the extra peritoneal visceral structures such as the bladder, vagina, terminal colon, rectum, and perineal and pelvic floor suspensory structures.

The floor of the pelvis or pelvic diaphragm is made up of the levator and coccygeus muscles and is pierced by the urethra, the rectum, and the vagina Fig. The false or superficial pelvis is delineated by the area above the iliopubic ridge.

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The true or deep pelvis is the volume within. The dashed lines represent the area of the anterior wall with femoral head underneath. This region is dangerous for screw placement.

The X represents the iliopectineal eminence. NF usually found in front of the sacro-iliac joint. L5 represents the approximate location of the course of the L5 nerve root as it coalesces with the lumbar plexus. The pelvic ring is comprised of the sacrum and three bones on each side that coalesce during adolescence to form the inominate bone of the adult pelvis. The sacrum connects to the ilium via an irregular joint, the iliosacral joint, which is technically an apophyseal joint.

The ilium becomes the pubis anteriorly and the ischium inferiorly. Anteriorly, the two pubic bones connect to one another via the symphysis and thus close the ring. Acetabulum The coalescence of the three bones, the ilium, ischium, and pubis, join to each other centrally to form the cotyloid or acetabular cavity.

Here, the anlage of the acetabulum develops in utero and as an infant. While not fully developed, alterations or abnormalities can result in conditions of the hip joint such as developmental dysplasia of the hip. The early blood supply to the femoral head traverses through the cotyloid fossa and ligamentum teres. While mostly a vestigial structure in adulthood, this ligament occupies the cotyloid fossa, which is a noncartilagenous, intra-articular portion of the acetabulum.

The cartilaginous portion of the acetabulum is a horseshoe-shaped surface that transfers load from Anatomy of the Pelvis 3 the inominate bone to the femur and lower extremity. Its mechanics and vectors of load have been well elucidated and described elsewhere by Olson and Vrahas. Iliac Wing and Inominate Bone The external iliac fossa is marked with two semicircular lines dividing it into three zones: Within the anterior section, the nutrient artery is found, located near the reflected head of the rectus femoris.

The crista glutea is the primary origin of the gluteus maximus and it is located along the border of the posterior superior iliac spine Fig. The shape of the iliac wing from above is s-shaped as it begins anteriorly with a slight medial oblique orientation.

By the time it becomes the posterior iliac spine, it is more sagittally oriented Fig. The iliac wing is full of hematopoetic and osteogenic marrow elements and is the primary source of autogenous bone graft. Along the crest there is a thickening along which many muscular structures attach. Along the outside are the lower extremity hip motors, while the abdominal anteriorly and paraspinal posteriorly muscles attach along the top.

Along the inner portions the iliacus and obturator internus and pelvic floor musculature attach. Figure 2 Outer table of the ilium and acetabulum. As noted in text, the ilium can be divided into three anatomic regions. The posterior section, is where the juntional attachments to the sacrum occur. The middle section is a relatively thin area that is mostly for muscle attachment.

The anterior segment has the thick anterior pillar of the anterior column. This bone is thick and strong and is primarily where external fixator pins are placed. Just anterior, in the area of the X is the reflected head attachment of the rectus muscle. OI and arrow: P and arrow: Figure 4 An inside out view of the obturator foramen.

This would be similar to the view from the sub-inguinal window of the ilio-inguinal approach. Anatomy of the Pelvis 5 There are both inner and outer cortices along most of the ilium, except in the most central portion, which thins to a unicortical shell, especially during older age. The posterior inner table, just lateral and anterior to the iliosacral joint contains a major nutrient artery, which is frequently a source of bleeding during surgery in this area.

The mechanics of bone and load transfer predicate that there is a strong buttress of bone emanating from the iliosacral joint towards the acetabulum. This structure is termed the sciatic buttress. Nearby structures include the coalescence of the lumbosacral plexus as well as the gluteal vasculature. These vessels are often the source of bleeding during injury and can be reinjured during surgical treatment.

Posteriorly, the posterior superior iliac spine is adjacent to the sacroiliac joint and outer ilium. The sciatic notch is the point at which the neurovascular structures exit the pelvis along with the piriformis muscle. The ischial spine is where the sacrospinous ligament, the gemellus superior, and the levator ani are inserted.

On the other side of the ischial spine is the lesser sciatic notch, which contains the obturator internus tendon. The pudendal vessels and nerves pass through this area, first exiting the pelvis and then re-entering it distally. The anterior-most border of the inominate bone begins with the anterosuperior iliac spine ASIS , which is the origin of the fascia lata, sartorius, and inguinal ligament.

Just medial to the AIIS pass the iliopsoas muscles, under which lies the illiopectineus eminence. Inferior to the AIIS is the indirect head of the rectus femoris and the acetabulum. The obturator foramen is bordered by the pubis superiorly, the ischium inferiorly, and the anterior horn of the acetabulum posteriorly.

Medially, the ischial and pubic rami join to form the symphyseal pubic junction. At its superior — lateral border, the obturator duct is found, which is occupied by obturator vessels and nerve. The foramen is almost circumferentially covered by obturator membrane, which is a thick fascial structure.

It is this membrane and the integrity of the inguinal ligament that prevents separation of rami fractures during reduction and fixation of symphyseal plating Fig. Sacrum The sacrum is quadrangular, pyramid-shaped, and forms, together with the last lumbar vertebra, the sacrovertebral angle or promontory.

The sacrum is generally wider proximally than distally and has an anterior concavity. The sacrum sits obliquely in the pelvis and is very difficult to interpret radiographically. The sacrum has several major cephalad body segments that can be used for fixation and then tapers in its caudad body segments to become the coccyx.

Alongside each vertebral body are the alar roots, which are homogenously connected laterally, contain the sacral foramen, and become the medial aspect of the iliosacral joint. Each foramen is itself obliquely oriented in the sacrum, headed in a posterior — superior — medial direction.

The central portion contains the terminal spinal canal and posteriorly is enclosed by confluent laminae that contain posterior foramen. Within this terminal canal are the individual nerve trunks of the filum terminale. The S1 ala is where the L5 nerve root lies and this area is of paramount importance when placing iliosacral screws. The superior ala can have various dysmorphisms and be concave or convex.

There can also be either a sacralization of the L5 vertebral body, where there is a bony confluence of the alar and vertebral structures, or there can be a lumbarization of the S1 body, wherein there is some separation of the alar and vertebral structures of S1 and S2. In the normal sacrum, the superior ala and iliosacral joint are important to visualize during the placement of percutaneous S1 screws since there can be a risk of injuring the L5 nerve root.

The entry point for fixation on the lateral ilium needs to lie inferior and posterior to the superior ala in order to minimize the chance of an in-out-in screw. The opacity seen on fluoroscopy is most likely the confluence of the sacral ala with the iliac cortex, as well as the subchondral bone of the iliosacral joint.

It is referred to as the alar slope or iliac cortical density. The orientations of the anterior and superior aspects of the sacrum are important as they are the main landmarks used for directing percutaneous screws into the S1 body. The joint itself has little to no motion due to the strong supporting ligaments anteriorly and posteriorly.

Anatomy of the Pelvis 7 which is the strongest ligament in human body. The anterior ligaments are mostly capsular and are usually the first to be disrupted with pelvic injury. There are also connections to the lumbar vertebrae via the iliolumbar ligaments going from the L5 transverse process to the iliac crest. These also make up part of the investing fascia covering the lumbar musculature.

The sacrotuberous ligament goes from the posterior iliac spines and sacrum to the ischial tuberosity. The sacrospinous ligament goes from the border of sacrum and coccyx in a plane deep to the sacrotuberous ligament and sciatic spine. This ligament divides the ischial area into two foramen: The superior region, or greater sciatic foramen, contains the piriformis muscle, superior glutei nerves, sciatic nerve, ischial vessels, and internal pudendal vessels and nerve.

The inferior region, or lesser sciatic foramen, contains the obturator internus muscle and internal pudenda vessels, which have crossed over the sacrospinous ligament after exiting the pelvis via the greater sciatic foramen to re-enter the pelvis via the lesser sciatic foramen. Lastly, the lateral sacrolumbar ligaments go from the L5 transverse apophysis down to the sacrum.

Put together, these ligaments help withstand rotational and transverse stresses and vertical shearing stresses. In the front, the symphysis pubis is connected via an interosseous ligament. The common iliac artery is rather short, beginning at around L4 and divides at around the L5— S1 junction into the external and internal arteries.

The internal iliac artery or hypogastric artery, branches to form the superior and inferior gluteal vessels, the obturator, the pudendal, and the coccygeal, as well as the sacral and vesicular vessels. The internal pudendal artery goes out from the pelvis underneath the piriformis and re-enters the pelvis through the minor sciatic notch and terminates as the dorsal artery of penis and clitoris and cavernous artery.

The external iliac branches just proximal to the inguinal ligament into the femoral artery. The femoral artery has three rami: The epigastric travels deep and then anastamoses with obturator vessels. When this connection is anomalously large, it is called the corona mortis, or crown of death Fig. Lumbar plexus consists of the first three lumbar anterior rami and a portion of the anterior ramus of the fourth lumbar nerve.

These are commonly contained along the psoas muscle. There are also short collateral rami, which include the hypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve. The terminal rami of the lumbar plexus are the femoral and obturator nerve.

The obturator nerve quickly divides into terminal rami surrounding the brevis muscle, and innervates the adductors and external obturator muscles. The femoral nerve receives contributions from the L2, L3, and L4 trunks. The main trunk of the femoral nerve continues along the psoas on its external border and then passes through the femoral arch. Its terminal branches include the external musculocutaneous, the internal musculocutaneous, the femoral, and the internal saphenous nerves.

The sacral plexus is made by the union of the lumbosacral trunk L5 anterior ramus with an L4 anasamotic ramus and the anterior rami of the first four sacral roots. The plexus will ultimately become the major element of the sciatic nerve posterior tibial and peroneal. There are other viscerally oriented branches that include the hemorrhoidal nerve, anus elevator nerve, and internal pudendal nerves.

The posterior branches relevant to orthopedic surgery are the superior gluteal nerve, branches to the external rotators, and inferior gluteal nerve. The sciatic nerve is a vital structure that is nearly always noted during posterior approaches to the acetabulum and pelvis. Because of the close proximity of the sciatic nerve and its major branch, the peroneal nerve, to the posterior portion of the acetabulum, fractures and dislocations in this area have a significant incidence of nerve injury.

The intimacy of vital soft tissue structures such as vessels, nerves, and viscera with the osseous anatomy presents a narrow window of safety for the operating surgeon. Miscalculation of a centimeter during dissection or placement of drills can cause severe hemorrhage or permanent nerve injury. The best strategy for preventing damage during surgery and limiting the damage of the initial injury is having detailed knowledge of every aspect of pelvic anatomy.

Computed tomographic evaluation of the internal structure of the lateral sacral mass in the upper sacra. Orthopaedics ; 22 Hoppenfeld S, de Boer P. Surgical Exposures in Orthopaedics, 3rd ed. Lippincott Williams and Wilkins, Letournel E, Judet R. Fractures of the Acetabulum, 2nd ed. Berlin, Heidelberg, New York: Springer-Verlag, Rohen JW, Yokochi C.

Color Atlas of Anatomy, 3rd ed. Igaku-Shoin, Philadelphia: Tile M. Fractures of the Pelvis and Acetabulum, 2nd ed. Zinghi GF. Fractures of the Pelvis and Acetabulum. Stuttgart, Germany: Thieme Verlag, Fluoroscopic imaging guides of the posterior pelvis pertaining to iliosacral screw placement. J Trauma ; 62 2: Douglas W. In combination with the strong ligaments, the pelvis represents the anatomical and functional link between the spine and the lower extremities.

During growth, the iliac, ischial, and pubic bones are connected by an inverse y-shaped epiphyseal junction, which is later fused into the osseous hemipelvis by a synostosis in adults. The pelvic ring is closed by the pubic symphysis anteriorly and by the strong sacroiliac ligaments posteriorly. The terminal line extends from the promontorium along the arcuatal and ileopectineal lines and ends at the upper pubic crest at the edge of the symphysis.

The symphysis consists of an interpubic disk, which is supported ventrocranially by the anterior pubic ligament and dorsocaudally by the arcuate 11 12 Fakler et al. Posteriorly, the sacroiliacal joints are supported by a strong sacroiliacal ligament complex, consisting of the anterior, interosseous, and posterior sacroiliac ligaments as well as the sacrospinous and sacrotuberous ligaments.

The biomechanical stability of the pelvic ring is essentially dependent on the integrity of this ligamentous complex. Apart from these biomechanical aspects, the pelvic ring functions as a protection for organs of the urogential and gastrointestinal tract as well as vascular and nervous structures.

In particular, the posterior presacral and paravesical venous plexus are relevant to surgical considerations, since traumatic injuries may cause severe hemorrhagic shock subsequent to venous mass bleeding. Furthermore, the proximity of the lumbosacral truncus and the sacral and coccygeal nervous plexus to the posterior pelvic ring and sacrum render these important neural structures particularly vulnerable to injuries affecting the posterior pelvic ring.

Accordingly, the close topographic relation of urogenital organs to the osseous pelvic ring implicates the high risk of associated vulnerability in case of pelvic ring disruption. Injuries of the vagina, the uterus, or the anorectum by blunt trauma are rare and more frequently associated with open pelvic fractures, for example, due to perineal impalement injuries.

The stability of the injured pelvic ring is evaluated based on radiological appearances, physical findings, and the knowledge of the mechanism of injury. The integrity of the biomechanically pivotal, axial load-transferring posterior pelvic ring complex represents the prime determinant for pelvic ring stability.

Thus, fracture patterns considered as fully stable type A do not involve posterior pelvic ring Classification of Pelvic Ring Injuries 13 Figure 1 Classification of stable pelvic ring injuries A type. Comparison of injury pattern and mechanism of injury as defined by the three standard classifications. Charts kindly provided by Mrs.

Classification of Pelvic Ring Injuries 15 elements. Such injuries are usually caused by low-energy trauma in combination with a lateral force vector, typically characterized by pubic rami fractures in elder patients with osteoporosis e. In contrast, unstable pelvic ring injuries require a high-energy mechanism of trauma, leading to a partial type B or complete type C disruption of posterior pelvic ring elements, including sacral fractures and sacroiliac ligament complex injuries.

As shown in Figure 2, the mechanism of injury leads to distinct injury patterns with defined archetypes of dislocation of the injured hemipelvis. The knowledge of the exact mechanism of injury and of the resulting force vector represents the basis for pelvic ring fracture classifications. In this regard, four distinct entities of pelvic ring injury patterns have to be differentiated, depending on the resulting force vector on the pelvic ring.

Anterior— posterior compression APC injuries Lateral compression LC injuries Vertical shear VS injuries Combined mechanical CM injuries These mechanisms of injury represent the fundamentals for modern classifications of pelvic fractures. Depending on the compressing force, an APC type injury may result in a stable fracture pattern without symphyseal diastasis ,2.

In these types of injuries there is no cephalad shift of the injured hemipelvis. The pathology to posterior elements in APC-type injuries depends on the impacting force. In contrast to the externally rotated hemipelvis resulting from APC-type forces, LC force vectors induce an internal rotation of the injured hemipelvis Figs.

Finally, high-velocity translational forces Fig. Lateral and anterior—posterior compression injuries often are associated with traffic accidents i. Vertical shear injuries usually result from high-velocity trauma by motorcycle accidents or falls from heights onto the lower limbs where the SI joint and sacrum are subjected to shear stress by massive axial loading.

These shearing injuries are both rotationally and vertically unstable. These mechanisms of injury provide the basis for classification of fractures of the pelvic ring. Figure 3 Classification of rotationally unstable pelvic ring injuries B type. Accurate classification systems should allow an adjusted treatment modality for specific pelvic ring injury patterns and therefore contribute to reduced mortality, particularly due to pelvic hemorrhagic —traumatic shock.

More than 50 different classification systems for pelvic fractures have been proposed and published since then. Most of the early classification systems are based on a purely descriptive nature and are therefore in large part not clinically relevant. The first clinically relevant systematic classification based on the mechanism of injury was introduced by Pennal and Sutherland in 2.

However, as a drawback, the early Pennal — Sutherland classification did not provide an estimate for the clinically important parameter of pelvic ring stability. In , Pennal and Tile 3 implemented the aspect of stability into the classification by incorporating the different conditions of partial and complete instability based on the mechanism of trauma.

Since then, the definition of pelvic ring instability has been based on the gradually decreasing osteoligamentous integrity of the posterior pelvic ring Figs. In contrast, a stable pelvic ring has been defined for all cases where the major axial load-transferring structures of the posterior pelvic ring are not affected Fig. For example, this is the case for low-energy APC or LC trauma leading to fractures of the anterior pelvic ring.

The classification by Young and Burgess 5 is based on the Pennal and Sutherland 2 classification system from In this classification, the direction of the force vector APC and LC was defined more subtly by quantifying the extent of force applied to the pelvic ring Figs. Type A: Stable Type B: Partial instability rotationally unstable Type C: They are most commonly caused by a low-energy trauma.

The subgroups are defined as: Type A1: Rim avulsion fractures of the iliac spine or tuberosity Type A2: Stable iliac wing fractures or minimally displaced fractures of the pelvic ring Type A3: Inferior transverse fractures of the sacrum or coccyx Rotationally unstable injuries of the B type Fig.

This leads to partial instability with respect to rotation, while vertical stability is maintained. Type B1: This type of injury is induced by an APC mechanism leading to symphyseal diastasis or obturator ring fractures of the anterior pelvic with partial anterior sacroiliac diastasis Type B1. This injury pattern is unstable with regard to external rotation, but the posterior sacroiliac ligaments remain partially intact, thus providing vertical stability.

Type B2: The subgroups of B2 type injuries are defined as: Type B2. Ipsilateral injury with two distinct injury patterns: Incomplete posterior iliac fracture. Recently, Pol Rommens et al. This critique is based on data from a large retrospective study of B-type injuries, where significantly higher complication and mortality rates were found in patients with B1-type injuries as opposed to the B2-type subsets 7.

Type B3: Combined bilateral B-type injuries Type B3. Bilateral B1-type injuries Type B3. Bilateral combination of B1- and B2-type injuries Type B3. Bilateral B2-type injuries The C-type Fig. Translational high-velocity forces lead to a 20 Fakler et al. Type C1: Unilateral injury Type C2: Unilateral C-type injury, contralateral B-type injury Type C3: In the revised classification, the pelvic ring and acetabulum were defined as bone segments No.

The detailed fracture patterns of stable A-type , partially unstable B-type , and completely unstable C-type fractures are depicted in Figures 1, 3, and 4. Similarly to the injury mechanisms defined by Tile, VS injuries represent a different entity in the Young and Burgess classification.

LC injuries occur by direct or indirect lateral impact and lead to internal rotation of the ipsilateral hemipelvis. The anterior pubic rami fractures are typically transverse and the degree of posterior pelvic involvement differentiates the subsets: Anterior transverse fracture patterns of the pubic rami combined with a lateral compression fracture of the ipsilateral sacrum, eventually involving neural foramina.

This injury is regarded as stable in most cases. LC II: Anterior transverse pelvic fracture patterns with internal rotation of the hemipelvis towards the midline. Posterior injury is typically represented by a crescent iliac wing fracture leaving a small fragment of the posterior ilium firmly attached to the intact posterior sacroiliac ligaments.

Stress load on anterior sacroiliac, sacrotuberous, and sacrospinous ligaments is rather relieved than increased. Consequently, this type of injury is vertically, but not rotationally stable. LC III: This type of fracture is associated with a high-energy trauma, that is, with high velocity or crush injuries. This type of injury is characterized by a diastasis of the symphysis or a vertical fracture pattern Classification of Pelvic Ring Injuries.

Depending on the integrity of the posterior pelvic ligamentous complex, the subgroups are defined as: APC I: Mild symphyseal diastasis ,2. Symphyseal ligaments are disrupted, whereas the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments are stretched, but intact.

This type of injury is generally judged as a rotationally and vertically stable fracture. APC II: The anterior sacroiliac, sacrotuberous, and sacrospinous ligaments are disrupted, resulting in rotational instability. On the other hand, the unaffected, strong posterior sacroiliac ligaments provide stability in the vertical plane.

Symphyseal diastasis or anterior vertical fracture pattern and complete separation of the hemipelvis. Anterior and posterior sacroiliac ligaments are completely disrupted, resulting in rotational and vertical instability. Nevertheless, this type of injury is differentiated from VS injuries by the lack of vertical displacement.

Additionally, the direction of the affecting vector anterior — posterior force differs from the respective vector in VS-type injuries translational force; Fig. VS type injuries result from massive axial loading. Anteriorly, the VS injury demonstrates a symphyseal diastasis or a vertical fracture pattern of one or both pubic rami. Posterior injury is characterized by a complete disruption of the sacroiliac joint with vertical displacement of the hemiplevis.

Occasionally, posterior injury occurs via vertical transsacral or transiliac fractures. As opposed to the Tile classification, unilateral or bilateral VS injuries are not further classified. CM injury includes a combination of fracture patterns due to different injuring force vectors.

Anterolateral compression with posterior and medial displacement of the hemipelvis represents a possible feature of this particular type of injury. Denis Classification of Vertical Sacral Fractures Vertical fractures of the sacrum associated with discontinuity of the pelvic ring are categorized into three groups depending on the location of the vertical fracture line in relation to the neural foramina Fig.

Type I: The fracture line runs lateral to the neural foramina. Nervous structures are generally are not affected. Type II: This type incorporates transforaminal fractures of the sacrum, frequently associated with lesions of sacral nerve roots ca. Type III: Central fractures of the sacrum involve the sacral spinal canal and are therefore associated with.

Figure 5 Denis classification of vertical sacrum fractures. Chart kindly provided by Mrs. An open pelvic fracture is defined by a communication to lesions of the integument or the gastrointestinal and urogenital tracts. Classification systems aimed at characterizing open pelvic fractures are associated with prognostic factors, with respect to mortality and morbidity.

Furthermore, these classifications should support management decisions and therapeutic modalities for these rare but very severe injuries. Jones Classification for Open Pelvic Fractures The Jones classification 8 of open pelvic fractures refers to pelvic ring stability and rectal injury. Based on a retrospective multicenter analysis, three distinct categories were differentiated: Class 1: Stable open pelvic ring fractures low mortality Class 2: More recently, the publication by Bircher and Hargrove 9 offered a more subtle and detailed classification of open pelvic fractures.

Subsets were defined by the primary skin lesion and associated soft tissue damage. Penetrating trauma, for example, by a bullet. Type A2: Type A3: Type C2: Type C3: Since this classification system is new 9 , its prognostic value needs to be corroborated in future prospective clinical trials.

Acute pelvic fractures: Causation and classification. J Am Acad Orthop Surg ; 4: Fractures of the Pelvis. Park Ridge, IL: American Academy of Orthopedic Surgeons, Pelvic disruption: Clin Orthop Relat Res ; Fracture and Dislocation Compendium. J Orthop Trauma ; 10 suppl 1: Pelvic fractures: Radiology ; Staged reconstruction of pelvic ring disruption: J Orthop Trauma ; Mortality, morbidity and functional outcome after open book and lateral compression lesions of the pelvic ring: Unfallchirurg ; Open pelvic fractures: Orthop Clin North Am ; Bircher M, Hargrove R.

Is it possible to classify open fractures of the pelvis? Eur J Trauma ; Pelvic ring disruptions: J Trauma ; Pelvic fracture in multiple trauma: Sacral fractures—an important problem: The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions.

Olson SA, Burgess A. Classification and initial management of patients with unstable pelvic ring injuries. Instr Course Lect ; Diagnosis of pelvic fractures in patients with acute pelvic trauma: Am J Roentgenol ; Pelvic fracture pattern does not always predict the need for urgent embolization.

Stahel PF, Ertel W. Pelvic ring injuries [German]. Unfallchirurgie, 2nd ed. Munich, Germany: Pelvic ring disruptions in emergency radiology. Eur J Radiol ; Tscherne H, Pohlemann T, eds. Pelvis and Acetabulum [German]. Springer, Classification, staging, urgency and indications in pelvic injuries [German].

Zentralbl Chir ; Philadelphia, PA: Classification of Pelvic Ring Injuries Fracture of the pelvis: Injuries of the pelvic girdle—the pathway to exact diagnosis: A European Perspective Axel P. In these patients, the cause of death is early exsanguination or the late sequelae of prolonged shock and mass transfusion. Acute management primarily focuses on the latter patient group, whereas management in patients without additional peripelvic soft-tissue trauma is addressed to the pelvic bone injury.

Open pelvic disruption represents an example. However, the appearance of a highly unstable life-threatening pelvic injury is usually even more inconspicuous when an intact soft tissue envelope is present. Only extended intrapelvic hemorrhage leads to recognizable variations of the external contour. The overall extent of the pelvic trauma is often only realized when a critical blood loss is reached.

Obvious clinical signs for pelvic injuries occur rarely. In polytraumatized patients who sustained high-energy trauma, pelvic injuries always have to be ruled out. Typical accident mechanisms likely to cause a pelvic injury are the following: High-speed road traffic accidents Side-impact automobile accident with the patient on the side of the impact Falls from great heights leading to a combination of side-impact Axial forces through the outstretched lower limb High-speed trauma in unprotected travellers, such as motorcyclists Roll-over-accidents If the patient is communicable, he has to be asked about pain in the pelvic region.

Pelvic stability is investigated by manual compression of the pelvic ring in anterior — posterior and lateral —medial directions. Stability testing should be performed carefully and gently as these measures can result in additional pelvic bleeding. The presence of a pelvic instability is often associated with a high risk of pelvic bleeding. Priority should be given to the treatment of the airway, breathing, and circulatory ABC problems.

Immediate antishock therapy by intravenous fluid administration is the primary treatment option in all patients with pelvic injuries. The benefit of prehospital intravenous fluids in severe trauma remains unproven. Prehospital intravenous access can be performed without causing a delay in transfer 6,7 , but the average volume of fluid preclinically infused is still questionable 8,9.

In the recent years, discussion arose if aggressive resuscitation with intravenous fluids may worsen the outcome in patients with hemorrhagic shock. A European Perspective Figure 1 29 Open pelvic fracture with a large groin wound and injury to the scrotum and penis. In a recent Cochrane review, there was no evidence from randomized controlled trials to support early or larger volume of intravenous fluid administration in uncontrolled hemorrhage.

The best fluid administration strategy in hemodynamic unstable trauma patients is still unknown Thus, in cases of clinically proven pelvic instability without noticeable gross hemorrhage, intravenous fluid is recommended because even closed unstable pelvic injuries may lead to loss of 2 to 5 L of blood 1,12 — In the presence of massive external bleeding, direct manual wound compression usually achieves a reduction or cessation of the bleeding Fig.

Reduction is performed in patients with highly unstable open book fractures external rotation injury who present with obvious deformities and instability on manual examination by traction, internal rotation, and lateral compression of the pelvis Fig. Reduction aims at decrease of the pelvic volume and probably assists in hemostasis.

Preclinically, military antishock trousers MAST have been used for reduction in pelvic and extremity fractures to increase venous return to the heart. Figure 2 Prehospital emergency stabilization of the pelvis can be performed by: A a single bed sling, B a pelvic sling Continued. A European Perspective 31 Figure 2 Continued C A pelvic belt that can be tied around the pelvis; D lateral compression of a bean bag at the pelvis.

In Europe, they do not appear to be of help due to extremely short rescue times. Additionally, complications like compartment syndromes, crush syndromes, or electrolyte deficits are not uncommon 17 — Alternatively, reduction of unstable pelvic fractures can be held by bean-bags, a bed sheet, or a pelvic sling tied around the pelvis 22 — 26 Fig.

In contrast to MAST, these new devices reduce the application time, are easier to apply, have a cost advantage 26 , and are clinically effective Biomechanical analyses supported their use, as reduction of open-book pelvic fractures was sufficient Even application of a simple bed sheet is reported to be effective After prehospital stabilization of the patient according to the ATLS guidelines, the transport of the injured patient should be as gentle as possible, preferably by physician-assisted rescue helicopter to a Level I trauma center with facilities for polytrauma treatment.

This is particularly true for hemodynamically unstable patients to enable life-saving emergency operations. Besides localization of pain, the clinical examination must investigate the degree of pelvic stability. In lateral compression injuries, the pelvic ring may be quite stable. In open-book injuries, a more severe rotational instability in the horizontal plane may occur with or without additional instability in the craniocaudal direction Fig.

The most severe instability is a combination of a rotational instability in the anterior — posterior and lateral directions and a craniocaudal instability. Repeated maneuvres of stability testing should be avoided as these could increase the danger of bleeding. Stability of the pelvis is graded as clinically stable or unstable.

While the mechanical pelvic instability is thus classified, the severity of additional hemorrhage, the blood loss, and the extent of the soft-tissue injuries remain difficult to assess. Immediate analysis of the primary hemoglobin concentration is performed from capillary, venous, and arterial whole blood by bedside hemoglobinometry photometry 27, The result is available within 40 seconds.

The vascular status is analyzed by palpation of the pulses of the lower extremities and inspection of capillary refill. An abnormous capillary refill is defined as more than three seconds. Additionally, in all suspected cases a Doppler examination of the foot pulses is performed.

Neurological screening of the lower extremities is essential and consists of an oriented sensory examination, testing of toe and foot extension, plantar flexion of the Acute Management of Pelvic Fractures: A European Perspective 33 Figure 3 Asymmetry of the right hemipelvis with internal rotation deformity and shortening of the leg indicating an acetabular fracture with hip dislocation or an unstable C-type injury of the right hemipelvis.

To avoid hypothermia during the diagnostic phase, a connective patient warming system is used 29, Primary radiological evaluation consists of at least an anterior — posterior pelvic X-ray Fig. Inlet and outlet views are no longer taken as these views can be reconstructed from the CT data set Fig.

Figure 4 Bleeding at the urethral orificium indicating injury to the urethra or bladder. Figure 5 Color difference of the right foot, indicating vascular injury of the right leg or pelvic region. A European Perspective 35 Figure 6 Stability testing of the pelvis is performed by assessment of rotational instability in the horizontal plane with external rotational stress A or lateral compression B.

Additionally, instability is assessed in the cranio-caudal direction C. Another advantage is that a conventional cystography is not further required for detecting and classification of bladder injuries 31, In suspected urethral lesions, a retrograde urethrogram should be performed with 20 mL iodine contrast medium as early as possible for classification of the urological injury Fig.

Indications for retrograde urethrography are: Type B: Type C: For emergency classification of these injuries and to facilitate the identification of life-threatening pelvic injuries, the following definitions have been shown to be useful, practicable, and of relevance as far as a prediction of mortality is concerned 34 Table 1: Simple pelvic fractures with little soft tissue injury and pure osteoligamentous instability.

Complex pelvic trauma: Pelvic fracture combined with a serious soft tissue lesion in the pelvic region 1. Fractures with pelvic and hemodynamic instability: Traumatic hemipelvectomy: A total or subtotal dislocation of one or both hemipelvises with complete disruption of the vascular and neural structures of the pelvis 37, A Stable A-type injuries not involving the pelvic ring, B rotational unstable B-type injury with partial disruption of the posterior pelvis, and C completely unstable C-type injuries with complete disruption of the posterior elements.

Reprinted from Ref. From Refs. Several treatment options are reported in the literature. The available treatment protocols for emergency hemostasis range between waiting for self-tamponade, MAST, spica casts, angiography, embolization, and emergency internal stabilization Table 2 1,4,18,19,21 — 26,39 — Self-Tamponade In the majority of patients with pelvic fractures without circulatory instability, the concept of retroperitoneal self-tamponade is valid In contrast, in unstable pelvic fractures, especially C-type fractures, frequently a disruption of all retroperitoneal muscle compartments 60 e.

Clinically, these cases often present as abdominal injuries. As the retroperitoneum is not a closed space, pressure induced tamponade is not of clinical importance MAST, military antishock trousers. Thus, the pelvis is immobilized, and systemic circulation is supported In contrast, access to the traumatized region is limited, and assessment and treatment of concomitant injuries will be impaired Fig.

Major complications such as compartment syndromes and impaired perfusion leading to amputations are reported particularly after long-term application 18,19,21, Figure 11 Pelvic injury with complete disruption of all retroperitoneal muscle compartments, clinically presenting as an abdominal compartment syndrome. Figure 12 Patient after application of the MAST with disadvantage of impaired access to the pelvis and lower extremities.

Prophylactic application of this device at the scene of the injury or in the emergency department has to be considered as biomechanical analyses showed positive effects on the stabilization of external rotation injuries of the pelvis 22, Therefore, the efficacy of angiographic embolization of pelvic vessels remains controversial.

Also, angiographic embolization has been reported to have severe complications. Several authors have reported on their experience with angiographic embolization of pelvic hemorrhage. Some of them are given below. Chaufour et al. All embolizations were effective and no complications were observed.

One patient died due to respiratory failure and myocardial dysfunction two hours after embolization. The time from injury to embolization decreased from 17 to Piotin et al. Prior to embolization the average PRBC was Agolini et al. All embolizations were successful, No deaths resulted from ongoing hemorrhage. Embolization was performed between 50 minutes and 19 hours after arrival of the patient.

The average time to perform angiography was 90 50 — minutes. Patients who were embolized within three hours of arrival had a significantly greater survival rate. No data was given for pelvic ring instability and hemodynamic instability. The authors concluded that embolization is effective, but only a small percentage of patients with pelvic fractures require embolization.

Perez et al. In eight patients the time until embolization was 5. During the clinical course, sepsis was common. The authors concluded that standardized parameters of a successful intervention are yet to be defined. Figure 13 Simple pelvic bed sheet tied around the pelvis prior to application of the emergency C-clamp for immediate stabilization of the pelvis. Hamill et al. The average time from injury to angiography was five hours 2.

The average amount of PRBC given before embolization was 14 2. The embolized patients were of older age and had a higher pelvic AIS. ISS was comparable in both groups. Velmahos et al. Thirteen patients first had laparotomies with unsuccessful control of the bleeding. In the remaining 17 patients, embolization was performed as the primary treatment for hemorrhage control.

The authors concluded that this concept seems to be useful in selected patients. Cook et al. In 23 of these, angiographic embolization was performed because of persistent hemodynamic instability systolic blood pressure ,90 mmHg. Vertical shear injuries were associated Acute Management of Pelvic Fractures: PRBC, packed red blood cells. No correlation was found between fracture morphology and arterial injury.

The average time to embolization was 3. Two complications were described: Five of these had a fracture which could have been stabilized by an external fixator. The authors recommended external pelvic fixation prior to fore pelvic angiography. Whereas the availability of interventional angiography is normally present in Level I trauma centers, the average time to intervention is reported as up to 17 hours 48,49,68,69,72 , but with a decrease to five hours during the last few years In summary Table 3 , the average time between admission and performed angiographic embolization was During this time, Ligation of Hypogastric Artery Due to the remarkable collateral supply within in the small pelvis, ligation of the hypogastric artery does not lead to satisfactory reduction in arterial bleeding 73 — Temporary Aortic Occlusion Occlusion of the aorta is a temporary measure to control disastrous massive hemorrhage, either as a direct cross clamping, or via percutaneous or open by inserted balloon catheter, which helps in regaining intraoperative access to the bleeding site External Fixation Pelvic emergent stabilization with an external fixator is the most widely accepted measure 45,47,50,51,55,57,59,79,80 due to relatively easy handling and the ready availability in trauma departments.

Application of an external fixator can only control blood loss by inducing hemorrhage control from the fracture site by direct pressure on bleeding vessels or by prevention of repeated insults to already clotted vessels. Additionally, the access to the patient, particularly for laparotomies, is reduced with almost every construction.

In a recent analysis, external fixation was shown to be helpful in the acute phase of resuscitation, whereas single treatment of unstable type-C injuries and type-B open-book injuries with symphyseal disruption showed a high rate of secondary displacement Pelvic C-Clamp Application of the pelvic C-clamp has the biomechanical advantage of direct and improved stabilization of the posterior pelvic ring compared to the external fixator, giving the basis for effective pelvic tamponade 15,82, Clinical series support these results 15,44,46,52, Disadvantages are their special indications not applicable in fractures of the ilium and transiliac fracture dislocations , potential injury to adjacent organs and the gluteal neurovascular structures, and overcompression with the risk of secondary nerve compression in sacral fractures, as well as pin tract infections in cases of prolonged application, and perforation into the small pelvis with the risk of additional organ damage.

Internal Fixation Definitive reduction and internal fixation is the procedure of choice for pelvic ring fixation as various biomechanical studies revealed a higher stability compared to external fixation 84 — The quality of the reduction is usually superior and normally there is no requirement for further acute measures.

In the acute management, symphyseal plating, anterior plating of the SI joint, and application of transiliosacral screws are feasible only when the patient is in a stable condition 4,87 — Direct Bleeding Control Direct surgical hemostasis is possible by vascular ligation, vascular clips clamps , and, rarely, by a vascular reconstruction of major vessels, and is the principal aim of every hemostasis in the pelvic region 46,54,74,83,90 — The more common venous bleedings from large ruptured venous plexus have the disadvantage of a time-consuming bleeding control with sometimes additional blood loss.

Therefore, in exsanguinating diffuse pelvic bleeding, especially major venous bleeding, pelvic tamponade is proposed under a condition of emergent posterior pelvic ring stabilization 46,54,74,83,91, Immediate posterior pelvic ring stabilization with the pelvic C-clamp or an external fixator provides the required mechanical stability to perform for pelvic tamponade, as fracture reduction leads to reduction of fracture hemmorrhage 60, The presacral and paravesical regions are packed from posterior to anterior using standard surgical tamponades.

Thus, pelvic hemorrhage can be controlled effectively during the primary resuscitation period 46, The average ISS was Parameters indicating severe hemorrhagic shock were a mean systolic blood pressure of 63 mmHg range: Traumatic shock was additionally indicated by a mean base deficit of During the first hour after admission, the mean amount of given units of blood was 7.

In six patients, pelvic C-clamp stabilization was performed in the emergency department within 30 minutes after admission. Primary operative treatment was indicated in 13 patients, all including pelvic tamponade. The remaining two patients were directly transferred to the ICU. Twelve of the 13 patients needed additional laparotomy due to concomitant intra-abdominal injury in 11 cases and severe retroperitoneal bleeding in four cases.

At the end of lapartotomy, external fixation of the anterior pelvic ring was performed in two patients. One patient without intra-abdominal injury had initial anterior SI-plating via anterolateral approach. For the 12 patients surviving the first six hours after admission, the mean amount of blood replacement with PRBC was No angiographic embolization was performed.

Overall mortality rate was The observed survival rate of these patients was doubled at Ertel et al. All patients were treated with immediate pelvic C-clamp followed by laparotomy and pelvic packing in persistent or massive hemorrhage. Hemorrhagic shock was indicated when blood lactate levels at admission were of 5.

In a further analysis, Ertel et al. The average ISS was 40 points, the average amount of transfused blood units was Ten patients had stable A-type pelvic fractures, 12 rotational unstable B-type injuries, and 19 C-type injuries. Emergency treatment consisted of nine crash thoracotomies, 23 crash laparotomies, nine aortic clampings to control hemorrhage hemorrhage control in one patient , and two pelvic C-clamp applications.

Effective angiographic embolization was performed in one patient. Therefore, an algorithm for pelvic injuries must fulfill the following criteria: Precision inclusion criteria. Oncologists, cancer researchers, and nutritionists are separated by divergent skills and professional disciplines that need to be bridged in order to advance preventative as well as treatment strategies.

While oncologists and cancer researchers may study the underlying pathogenesis of cancer, they are less likely to be conversant in the science of nutrition and dietetics. On the other hand, nutritionists and dietitians are less conversant with the detailed clinical background and science of oncology.

This book addresses this gap and brings each of these disciplines to bear on the processes inherent in the oxidative stress of cancer. This compact, diagnosis-speeding guide has virtually defined the field of dermatology for thousands of physicians, dermatology residents, and medical students across the globe. Spanning the entire spectrum of skin problems, it combines laser-precise color images of skin lesions with a concise summary outline of dermatologic disorders, along with the cutaneous signs of systemic disease.

A color-coded 4-part organization facilitates review at a glance and features helpful icons denoting the incidence and morbidity of disease. Trying to chart a course through the complex task of keeping patient records? Here's your lifeline! Medical Charting Demystified gives you the tools you need to prepare and update both computerized and written charts. You'll learn about chart components, what to write in a chart, and how to correct errors.

Medical Charting Demystified covers entering vital signs, assessments, test results, medications, procedures, patient care plans, and more. Details on the legal aspects of medical charting, including confidentiality, HIPAA, malpractice, and informed consent, are also included.

Hundreds of examples and illustrations make it easy to understand the material, and end-of-chapter quizzes and a final exam help reinforce learning. Simple enough for a beginner, but challenging enough for an advanced student, Medical Charting Demystified is your key to mastering this vital nursing skill.

Account Options Sign in. The first symposium of the working group on experimental urology of the German Society of Urology was held in Cologne in It was meant to be a platform to present and, in particular, to discuss experimental studies developing new diagnostic and therapeutic approaches, and to promote in novation in urology in Germany.

This plan was well received, and during the last 16 years both the number of participants from other European and overseas countries and the number and quality of presentations have been continuously increasing. At the most recent meeting, held in Aachen in , new data were presented on renal cell cancer, andrology, prostatic cancer and adenoma, bladder cancer, urinary diversion, urodynamics, renal pathophysiology, transplantation and the pathogenesis and treatment of urolithiasis.

The present book contains 44 of the papers given at the Aachen meeting, covering both basic and clinical research. It will be of eminent interest to all scientifically minded urologists, oncologists, neurophysiolo gists, endocrinologists, and pathologists because it is a synopsis of all the major scientific research currently being conducted in urology in Europe. There are no other books available which offer as comprehensive a cover age of recent experimental issues in urology.

The aim of the series Inves tigative Urology is to demonstrate the continuous development of research in urology and to encourage all colleagues interested in experimental urol ogy to continue their important activities and create new international co operation.

The War on Cancer set out to find, treat, and cure a disease. Left untouched were many of the things known to cause cancer, including tobacco, the workplace, radiation, or the global environment. Proof of how the world in which we live and work affects whether we get cancer was either overlooked or suppressed. This has been no accident.

The War on Cancer was run by leaders of industries that made cancer-causing products, and sometimes also profited from drugs and technologies for finding and treating the disease. Filled with compelling personalities and never-before-revealed information, The Secret History of the War on Cancer shows how we began fighting the wrong war, with the wrong weapons, against the wrong enemies-a legacy that persists to this day.

This is the gripping story of a major public health effort diverted and distorted for private gain. A portion of the profits from this book will go to support research on cancer prevention. Surviving Triple-Negative Breast Cancer: After her diagnosis of hormone-negative breast cancer, health journalist Patricia Prijatel did what any reporter would do: While she learned that important research on triple-negative breast cancer TNBC was emerging, she found a noticeable lack of resources on the disease, which differs from hormone-positive breast cancer in important ways, including prognosis and treatment options.

Triple-negative breast cancer disproportionately affects younger women and African-American women-and some forms of it can be more dangerous than other types of breast cancer. But there are many reasons to be hopeful, as Prijatel shows in this book. Surviving Triple-Negative Breast Cancer delivers research-based information on the biology of TNBC; the role of genetics, family history, and race; how to navigate treatment options; understanding a pathology report; and a plethora of strategies to reduce the risk of recurrence, including diet and lifestyle changes.

In clear, approachable language, Prijatel provides a fact-filled guide based on a vast array of scientific studies. Woven throughout the book are stories of women who have faced TNBC. These are mothers, wives, daughters, and sisters who went through a variety of medical treatments and then got on with life--one competes in triathlons, two had babies after being treated with chemo, one got remarried in her 50s, and one just celebrated the 30th birthday of the son she was nursing when she was diagnosed.

Writing with honesty and humor, Prijatel delivers an inspiring message--that TNBC is a disease to take seriously, with proper and occasionally aggressive treatment, but it is not automatically a killer. Most women diagnosed with the disease survive and go on to live full lives. Surviving Triple-Negative Breast Cancer is a roadmap for women who want to be empowered through their treatment and recovery.

Chief Complaint: Brain Tumor John Kerastas February 15, 2. At 57 years old, John Kerastas thought he was the poster child for fifty-year old healthiness: Then he discovered that he had a brain tumor the size of his wife's fist. His memoir chronicles the first year he spent addressing tumor-related health issues: He writes that his humor started out superficially light-hearted prior to the first operation; transmogrified into gallows humor after several subsequent operations; and leveled out as somewhat wry-ish after radiation and rehab.

This is a surprisingly upbeat and inspiring book for anybody interested in memoirs about people dealing with personal crises, for patients trudging through rehab, for caretakers helping victims of serious illnesses, or for anybody looking for an unexpected chuckle from an unlikely subject. Now, in addition to non-profit and charitable work, he spends his time blogging, speaking and writing about brain health, brain tumors and rehab.

You can follow his blog or view his presentations schedule at www. The Cancer Chronicles: When the woman he loved was diagnosed with a metastatic cancer, science writer George Johnson embarked on a journey to learn everything he could about the disease and the people who dedicate their lives to understanding and combating it. What he discovered is a revolution under way—an explosion of new ideas about what cancer really is and where it comes from.

In a provocative and intellectually vibrant exploration, he takes us on an adventure through the history and recent advances of cancer research that will challenge everything you thought you knew about the disease. We follow him as he combs through the realms of epidemiology, clinical trials, laboratory experiments, and scientific hypotheses—rooted in every discipline from evolutionary biology to game theory and physics.

Perhaps most fascinating of all is how cancer borrows natural processes involved in the healing of a wound or the unfolding of a human embryo and turns them, jujitsu-like, against the body. Throughout his pursuit, Johnson clarifies the human experience of cancer with elegiac grace, bearing witness to the punishing gauntlet of consultations, surgeries, targeted therapies, and other treatments.

He finds compassion, solace, and community among a vast network of patients and professionals committed to the fight and wrestles to comprehend the cruel randomness cancer metes out in his own family. For anyone whose life has been affected by cancer and has found themselves asking why?

In good company with the works of Atul Gawande, Siddhartha Mukherjee, and Abraham Verghese, The Cancer Chronicles is endlessly surprising and as radiant in its prose as it is authoritative in its eye-opening science. Handbook of Evidence-Based Radiation Oncology: Edition 2 Eric Hansen June 17, 3.

Building on the success of this book's first edition, Dr. Eric Hansen and Dr. Mack Roach have updated, revised, and expanded the Handbook of Evidence-based Radiation Oncology, a portable reference that utilizes evidence-based medicine as the basis for practical treatment recommendations and guidelines. Organized by body site, concise clinical chapters provide easy access to critical information.

Important "pearls" of epidemiology, anatomy, pathology, and clinical presentation are highlighted. Brief summaries of key trials and studies provide rationale for the recommendations. Practical guidelines for radiation techniques are described. Finally, complications and follow-up guidelines are outlined.

Updates from the first edition include brand new color figures and color contouring mini-atlases for head and neck, gastrointestinal, prostate, and gynecological tumors; redesigned tables for increased readability; new chapters on management of the neck and unknown primary, clinical radiobiology, and pediatric malignancies and benign conditions; and new appendices including the American College of Radiology guidelines for administration of IV contrast.

The Truth in Small Doses: Over the past half century, deaths from heart disease, stroke, and so many other killers have fallen dramatically. But cancer continues to kill with abandon. A decade ago, Clifton Leaf, a celebrated journalist and a cancer survivor himself, began to investigate why we had made such limited progress fighting this terrifying disease.

The Truth in Small Doses is that rare tale that will both outrage readers and inspire conversation and change. Bobblehead Dad: This is an inspirational account of a typical dad's extraordinary journey through several forgotten life lessons -- and the discovery of one life-changing gift. Jim Higley was a forty-year-old bobblehead. Just like those collectible figurines -- with an oversized head on a bouncy spring -- he had put on a smiling face and bobble through his hectic, overflowing days.

Higley's bobbling comes to a screeching halt with the diagnosis of cancer and a summer of healing. But this is not only a cancer story. This book gives the reader a front row seat in the author's discovery of illuminating parallels between the events of his childhood and adulthood, as he delves into his family history with rich, vivid detail. Through humorous and poignant memories, "Bobblehead Dad" unwraps lessons from the past -- revealing meaning in simple moments and the people who fill them -- including the surprise discovery of Higley's most important lesson, quietly waiting for over thirty years.

Written in an informal but eloquent voice, the book keeps readers laughing, crying and -- most importantly -- thinking about their own life journey. Higley's distinctive storytelling rhythm, combined with a knack for handling heavy topics with an embraceable voice, quickly draws readers into his experiences -- while launching them on their own journey of self-discovery and reflection.

The Definitive Guide to Prostate Cancer: The complete guide to coping with prostate cancer, with expert health advice for every man This comprehensive handbook gives men the vital information they need to effectively navigate every step of dealing with prostate cancer. A newly diagnosed cancer patient faces a mind-numbing array of treatment options, including medical therapies that carry serious side effects—and determining the right course of action is an overwhelming task.

In simple yet scientific terms, this book empowers readers with the tools they need to proactively fight cancer by making the most informed treatment decisions possible. With groundbreaking developments recently emerging in both conventional and holistic prostate cancer research, it is imperative that men fighting this disease have the absolute latest information.

Katz is uniquely positioned to guide readers through the new practices and breakthrough treatment options for every stage of the battle with cancer, from prevention to postdiagnosis. One in six men will be diagnosed with prostate cancer in his lifetime, and countless families will be affected by this widespread but ultimately curable disease. Armed with Dr.

Katz's expert guidance, patients will be equipped to actively participate in reclaiming their health and navigating this difficult diagnosis. A Memoir Geralyn Lucas April 1, 3. And there is one part of the diagnosis that no one will discuss with her: Trying to find herself while losing her vibrancy and her looks, Geralyn embarks on a road of self-acceptance that will inspire all women.

Although her story is explicitly about a period of time when she was driven by fear and uncertainty, Geralyn managed a transformation that will encourage all women under siege to discover their own courage and beauty. The important and outrageous lessons of Why I Wore Lipstick come fast and furious with the same gusto that Geralyn has learned to bring to every aspect of her life.

Compton August 9, 3. Significantly expanded, expertly and beautifully illustrated, The AJCC Cancer Staging Atlas, 2nd Edition, offers more than illustrations created exclusively for this new edition and is fully updated to reflect the concepts discussed in the 7th Edition of both the AJCC Cancer Staging Manual and its companion Handbook.

This Atlas illustrates the TNM classifications of all cancer sites and types included in the 7th Edition of the Manual and visually conceptualizes the TNM classifications and stage groupings. Specifically designed for simplicity and precision, the drawings have been verified through multi-disciplinary review to ensure accuracy and relevancy for clinical use. Every illustration provides detailed anatomic depictions to clarify critical structures and to allow the reader to instantly visualize the progressive extent of malignant disease.

In addition, nodal maps are included for each site, appropriate labeling has been incorporated to identify significant anatomic structures, and each illustration is accompanied by an explanatory legend. Expert Consult: Evidence-Based Practice of Palliative Medicine is the only book that uses a practical, question-and-answer approach to address evidence-based decision making in palliative medicine.

Nathan E. Goldstein and Dr. Sean Morrison equip you to evaluate the available evidence alongside of current practice guidelines, so you can provide optimal care for patients and families who are dealing with serious illness. Consult this title on your favorite e-reader with intuitive search tools and adjustable font sizes.

Elsevier eBooks provide instant portable access to your entire library, no matter what device you're using or where you're located. Build a context for best practices from high-quality evidence gathered by multiple leading authorities. Make informed decisions efficiently with treatment algorithms included throughout the book.

Rao January 6, 3. This book covers the entire subject of urinary tract stone disease from basic sciences to medical and surgical treatment of stones with the aim to cover the entire spectrum of this disease. The surgical management of stone disease has changed considerably in the last five years and our understanding of mechanism of stone disease has improved with some old concepts discarded and newer theories gaining ground.

The book is extensively illustrated with photographs, x-rays and line diagrams. Basic Radiation Oncology is an all-in-one book, encompassing the essential aspects of radiation physics, radiobiology, and clinical radiation oncology. A complete section is devoted to each of these fields. In the first two sections, concepts that are crucial in radiation physics and radiobiology are reviewed in depth.

The third section describes radiation treatment regimens appropriate for the main cancer sites and tumor types. The book has been designed to ensure that the reader will find it easy to use. Many "pearl boxes" are used to summarize the most information, and there are more than helpful illustrations, the majority of them in color. Basic Radiation Oncology will meet the need for a practical, up-to-date, bedside-oriented radiation oncology book.

It will be extremely useful for residents, fellows, and clinicians in the fields of radiation, medical, and surgical oncology, as well as for medical students, physicians, and medical physicists with an interest in clinical oncology. Cancer - it's a menacing word, and when we hear it from our own doctor, it can be terrifying. But there's hope. In this practical, comprehensive "field manual" from seasoned cancer fighters and renowned clinicians Francisco Contreras, MD and Daniel Kennedy, MC you will grab hold of 50 tangible tips, plans, and prescriptive measures for tackling cancer and finding renewed health.

Each of the 50 short, easy-to-digest chapters includes a concise explanation of the most effective and sought after cancer treatment in the realms of traditional medicine, natural medicine, emotional support and spiritual care. A succinct commentary is provided to help the reader understand potential benefits, and if it is a realistic treatment option or not.

Each chapter includes: Don't let a cancer diagnosis define your circumstances. Instead, develop a plan to identify, attack, and beat cancer. Medicine Hands: The field of oncology massage is maturing into a discipline with a deeper and deeper body of knowledge. The 3rd edition of Medicine Hands reflects this maturation.

Every chapter contains updated information and insights into massaging people affected by cancer. New chapters have been added to cover each stage of the cancer experience: These new chapters and organizational structure will make it easier for the reader to find the information needed to plan the massage session for a given client. This is the clinical framework around which the massage session is planned.

Causes, pathology, clinical features, diagnostic investigations, treatments and outcomes are all carefully explained and discussed, both for cancers in general and for the common cancers in individual countries. The reader will thereby be provided with an understanding of how and why people develop cancer, how the body reacts to cancer, what can be done to prevent the disease, and how the various cancers are best diagnosed and treated.

The book will serve as a sound basis for the more detailed or specific studies that may be needed in different areas of practice and in different countries. It will be invaluable for students of medicine, nurse oncologists, students of medical sciences and other health professionals in all parts of the world. Stay on top of the latest scientific and therapeutic advances with the new edition of Leibel and Phillips Textbook of Radiation Oncology.

Theodore L. Phillips, in collaboration with two new authors, Drs. Richard Hoppe and Mack Roach, offers a multidisciplinary look at the presentation of uniform treatment philosophies for cancer patients emphasizing the "treat for cure" philosophy. You can also explore the implementation of new imaging techniques to locate and treat tumors, new molecularly targeted therapies, and new types of treatment delivery.

Supplement your reading with online access to the complete contents of the book, a downloadable image library, and more at expertconsult. Gather step-by-step techniques for assessing and implementing radiotherapeutic options with this comprehensive, full-color, clinically oriented text. Review the basic principles behind the selection and application of radiation as a treatment modality, including radiobiology, radiation physics, immobilization and simulation, high dose rate, and more.

Use new imaging techniques to anatomically locate tumors before and during treatment. Apply multidisciplinary treatments with advice from experts in medical, surgical, and radiation oncology. Explore new treatment options such as proton therapy, which can facilitate precise tumor-targeting and reduce damage to healthy tissue and organs. Lee December 8, 3. This textbook is designed to help the busy radiation oncologist to accurately and confidently delineate tumor volumes for conformal radiation therapy including IMRT.

The book provides an atlas of clinical target volumes CTVs for commonly encountered cancers, with each chapter illustrating CTV delineation on a slice-by-slice basis, on planning CT images. Common anatomic variants for each tumor are represented in individual illustrations, with annotations highlighting differences in coverage.

The anatomy of each site and patterns of lymphatic drainage are discussed, and their influence on the design of CTVs is explained in detail. Utilization of other imaging modalities, including MRI, to delineate volumes is highlighted. Key details of simulation and planning are briefly reviewed.

Although the emphasis is on target volume delineation for conformal techniques, information is also provided on conventional radiation field setup and design when IMRT is not suitable. MRI of Rectal Cancer: Oncology in general has seen vast advancements over recent years. Improved und- standing of tumor biology, multidisciplinary team decisions and an individualized therapy are cornerstones of treatment planning for cancer patients today.

These dev- opments have challenged the imaging community with ever more specifc questions on tumor detection, staging and therapy control. Whereas this evolution applies to many tumor entities, rectal cancer takes an outstanding role, as it was the recognition of certain anatomical and pathological features of the disease, with the help of magnetic resonance imaging MRI , that induced radiology not only to aid in disease mana- ment, but in fact to be a powerful engine for new concepts in rectal cancer treatment.

The continuous improvement of highly specialized MRI and the groundbreaking scientifc contributions of radiologists all over the world have paved the way for s- stantial refnements of this technique during the last decade. Consequently, dedicated imaging protocols for routine diagnostic work-up of r- tal cancer patients are now available, which can guide multidisciplinary team de- sions and, in combination with optimized surgery and chemoradiotherapy, lead to longer survival and a better quality of life.

Besides the scientifc advances, the enduring clinical success of MRI in the feld of rectal cancer is highly contingent upon expertise. To this end, ongoing education and continuous training are vital. Smith June 21, 3. Detailed color illustrations and clinical photographs — accompanied by commentary from leading urologists—lead you step by step through each technique.

Know what to do and expect with comprehensive coverage of nearly every surgical procedure you might need to perform. Get a true-to-life view of each operation through illustrations, full-color photographs. Find answers fast thanks to a quick, clear, and easy-to-use format - ideal for residents as well as experienced surgeons. Master the latest techniques with new and revised chapters on laparoscopic urologic surgery, robotic-assisted laparoscopic prostatectomy, decision making in hypospadius surgery, Holmium: YAG laser treatment of benign prostatic disease, urethral sling for male and female incontinence, suture techniques, vascular surgery, and many other timely topics and recent advancements.

Get all the accuracy, expertise, and dependability you could ask for from new editors who are among the most important names in urology, for expert guidance and a fresh understanding of the subject. Avoid pitfalls and achieve the best outcomes thanks to a step-by-step approach to each procedure, complete with commentary, tips, and tricks of the trade from leading experts.

Mastering Communication with Seriously Ill Patients: Physicians who care for patients with life-threatening illnesses face daunting communication challenges. Patients and family members can react to difficult news with sadness, distress, anger, or denial. This book defines the specific communication tasks involved in talking with patients with life-threatening illnesses and their families.

Topics include delivering bad news, transition to palliative care, discussing goals of advance-care planning and do-not-resuscitate orders, existential and spiritual issues, family conferences, medical futility, and other conflicts at the end of life. Drs Anthony Back, Robert Arnold, and James Tulsky bring together empirical research as well as their own experience to provide a roadmap through difficult conversations about life-threatening issues.

The book offers both a theoretical framework and practical conversational tools that the practising physician and clinician can use to improve communication skills, increase satisfaction, and protect themselves from burnout. Brain Metastasis: A Multidisciplinary Approach Lawrence R. Kleinberg, MD August 19, 2.

New therapies and treatments targeted at brain metastasis are rapidly resulting in improved survival and quality of life for patients with this condition. A Multidisciplinary Approach conveys vital information about management strategies, outcomes, and techniques to enable oncologists to provide a full range of appropriate care and counseling to patients with metastatic spread to the brain.

Features of this uniquely accessible guide include: A timely discussion of exciting recent developments in aggressive care An emphasis on quality-of-life issues and palliative care Special chapters on radiosurgery for both brain metastasis and spinal tumors Full color insert of high-quality images This concise and comprehensive text provides a multidisciplinary information source for brain metastasis.

Edition 4 Stephen W. Leslie June 22, 1. Presented in a rigorous quick-hit question and answer style consisting of short clinical questions with concise answers Emphasis on distilling key facts and clinical pearls that are essential for exam success Questions on new technologies such as robotics and laparoscopic surgery, advances in cancer chemotherapy, medical urology, and complications related to new medicines such as Topamax High-quality of x-rays and imaging study pictures, including many new images more then in all.

Decision Making in Radiation Oncology: Volume 1 Jiade J. Lu November 22, 3. Decision Making in Radiation Oncology is a reference book designed to enable radiation oncologists, including those in training, to make diagnostic and treatment decisions effectively and efficiently.

Detailed guidelines are provided for multidisciplinary cancer management and radiation therapy techniques. In addition to the attention-riveting algorithms for diagnosis and treatment, strategies for the management of disease at individual stages are detailed for all the commonly diagnosed malignancies.

Moreover, radiation techniques, including treatment planning and delivery, are presented in an illustrative way. This groundbreaking publication is an essential tool for physicians in their daily clinical practice. The controversy over the use of primates in research admits of no easy answers. We have all benefited from the medical discoveries of primate research--vaccines for polio, rubella, and hepatitis B are just a few.

But we have also learned more in recent years about how intelligent apes and monkeys really are: And activists have also uncovered widespread and unnecessarily callous treatment of animals by researchers in , a Silver Spring lab was charged with 17 counts of animal cruelty. It is a complex issue, made more difficult by the combative stance of both researchers and animal activists.

In The Monkey Wars, Deborah Blum gives a human face to this often caustic debate--and an all-but-human face to the subjects of the struggle, the chimpanzees and monkeys themselves. Blum criss-crosses America to show us first hand the issues and personalities involved. She offers a wide-ranging, informative look at animal rights activists, now numbering some twelve million, from the moderate Animal Welfare Institute to the highly radical Animal Liberation Front a group destructive enough to be placed on the FBI's terrorist list.

And she interviews a wide variety of researchers, many forced to conduct their work protected by barbed wire and alarm systems, men and women for whom death threats and hate mail are common. She takes us to Roger Fouts's research center in Ellensburg, Washington, where we meet five chimpanzees trained in human sign language, and we visit LEMSIP, a research facility in New York State that has no barbed wire, no alarms--and no protesters chanting outside--because its director, Jan Moor-Jankowski, listens to activists with respect and treats his animals humanely.

And along the way, Blum offers us insights into the many side-issues involved: But if you listen hard, there really are people on both sides willing to accept and work within the complex middle. When they can be freely heard, then we will have progressed to another place, beyond this time of hostilities. Abeloff's Clinical Oncology E-Book: Edition 5 John E.

Niederhuber September 12, 3. Consult this title on your favorite e-reader, conduct rapid searches, and adjust font sizes for optimal readability. Select the most appropriate tests and imaging studies for cancer diagnosis and staging of each type of cancer, and manage your patients in the most effective way possible by using all of the latest techniques and approaches in oncology.

Enhance your understanding of complex concepts with a color art program that highlights key points and illustrates relevant scientific and clinical problems. Stay at the forefront of the latest developments in cancer pharmacology, oncology and healthcare policy, survivorship in cancer, and many other timely topics.

See how the most recent cancer research applies to practice through an increased emphasis on the relevance of new scientific discoveries and modalities within disease chapters. Streamline clinical decision making with abundant new treatment and diagnostic algorithms as well as concrete management recommendations. Niederhuber, James O. Armitage, and Michael B. Kastan as well as new editors James H.

Clinical Radiation Oncology. Quickly and effortlessly access the key information you need with the help of an even more user-friendly, streamlined format. Access the complete contents anytime, anywhere at Expert Consult, and test your mastery of the latest knowledge with online multiple-choice review questions.

Breast MRI: The comprehensive text is written by contributors from the top cancer centers in the world. Introductory chapters are devoted to diagnosis and cover the basics of performing breast MRI exams, setting up a breast MR program, and understanding clinical indications. Additional chapters discuss breast interventional procedures, including the surgeon's use of MR and MR-guided needle interventions.

A comprehensive diagnostic atlas completes the volume and addresses the spectrum of clinical situations, such as various carcinomas, special tumor types, and benign histologies. Radiologists, residents, and fellows will benefit from this guide's thorough examination of image interpretation, which highlights pitfalls that specialists must recognize. How We Do Harm: How We Do Harm exposes the underbelly of healthcare today—the overtreatment of the rich, the under treatment of the poor, the financial conflicts of interest that determine the care that physicians' provide, insurance companies that don't demand the best or even the least expensive care, and pharmaceutical companies concerned with selling drugs, regardless of whether they improve health or do harm.

Thyroid Cancer: The authors provide not only the The second edition of Thyroid Cancer: A Comp- most current review of their respective areas, but also their hensive Guide to Clinical Management marks the pub- own recommendations and approach. The reader is fo- cation of a markedly updated and expanded volume that warned that in many cases these approaches, albeit rooted covers all aspects of the etiology, pathogenesis, diag- sis, initial treatment, and long-term management of all in available data, may be empiric rather than based varieties of thyroid cancer.

Like the first edition, it will upon clear-cut results of well-controlled clinical t- als.

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