Early open reduction and internal fixation of the disrupted pelvic ring

Unstable pelvic ring disruptions in unstable patients

Management of the patient with a high-energy pelvic fracture requires a multidisciplinary team approach with coordination between the general surgery, orthopaedic surgery, neurosurgery, and urology teams. Resuscitation and initial evaluation efforts are critical in stabilization of the patient. An understanding of the complex nature of the pelvic anatomy and injury patterns, the associated injuries, and various treatment fixation constructs are necessary for a successful outcome. This review outlines the initial stabilization and definitive management for the spectrum of pelvic ring disruptions. Case examples illustrate the discussion.

Simple anterior pelvic external fixation

BACKGROUND

Unstable pelvic ring disruptions are often associated with significant morbidity and mortality, especially in patients with multiple injuries. Early pelvic fixation provides stability and should diminish ongoing hemorrhage. A simple anterior single-pin pelvic external fixator can be applied rapidly and accurately to stabilize pelvic ring injuries as a part of the initial patient resuscitation of such patients. Simple anterior pelvic external fixation (SAPEF) frames can be used as either temporary, definitive, or supplementary fixation depending on the pelvic injury pattern.

METHODS

Over a 32-month period, 41 patients with unstable pelvic ring disruptions were stabilized using a simple anterior pelvic external fixator. Eight patients had open pelvic ring injuries and 13 others had genitourinary system disruptions. Fluoroscopic imaging was used to insert all of the fixation pins into the iliac crest between the iliac cortical tables to a depth of at least 5 cm. Each patient had closed manipulative reduction of the pelvic ring using external methods before SAPEF application.

RESULTS

One patient died less than 24 hours after injury because of torrential hemorrhage. Clinical evaluations and serial radiographs, including postoperative computed tomographic scans, were available for the other 40 patients postoperatively. Seventy-five of the 80 (94%) pins were completely contained between the iliac cortical tables, according to the computed tomographic scans. The initial pelvic closed reductions were maintained until the fixators were removed in 37 of 40 patients (93%). Only one deep pin track infection developed, mandating early frame removal and intravenous antibiotic therapy.

CONCLUSION

Simple anterior pelvic external fixation can be applied rapidly using fluoroscopic guidance to direct accurate pin insertion and closed manipulative reduction of the pelvis. Depending on the specific pelvic ring injury pattern and clinical scenario, SAPEF can serve as a resuscitative temporary fixation device, as definitive pelvic treatment, or as a supplement for pelvic internal fixation implants.

Medium- and long-term results of open reduction and internal fixation for unstable pelvic ring fractures

Over a 10-year period, 74 patients with unstable pelvic injuries were treated with open reduction and internal fixation. Radiographic and clinical follow-up averaged 71 months (range: 38-141 months). Satisfactory (ie, good and very good) radiographic results were obtained in 90% of patients. Clinical results were superior in patients without associated injuries (P=.05-.001). Most of the complications in this series were due to associated injuries. Sepsis was mostly due to open pelvic injuries and malunion to either lack of patient cooperation or inadequate open reduction and internal fixation. Careful preoperative analysis of the nature of the pelvic injury and selection of the appropriate operative technique for open reduction and internal fixation result in a satisfactory outcome for the majority of operative patients.

Distraction external fixation in lateral compression pelvic fractures

OBJECTIVE

To observe the results and describe the technique of closed reduction and placement of a two-pin supra-acetabular external fixator, followed by immediate weight bearing, in the treatment of displaced vertically stable lateral compression pelvic fractures.

DESIGN

Prospective, consecutive

SETTING

Regional trauma center

PATIENTS

A consecutive series of fourteen patients with displaced, vertically stable lateral compression pelvic fractures who were transported to a regional trauma center.

INTERVENTION

Surgical treatment with closed reduction and maintenance of the distraction force with a two-pin, single-bar, supra-acetabular external fixator, followed by immediate weight bearing.

MAIN OUTCOME MEASUREMENTS

Healing rate and time, operative blood loss and time, quality of reduction, time to full weight-bearing, and incidence of complications, including neurovascular deficits, loss of reduction, nonunion, pin tract infections, and chronic pain.

RESULTS

A symmetric reduction of both hemipelves was achieved in all fourteen patients. Time to healing averaged 8.2 weeks (seven to twelve weeks), and no fixator required removal before healing. There were no delayed unions or nonunions, and none of the fractures displaced significantly after initial reduction. Average surgical time was thirty-seven minutes (range, twenty-five to sixty minutes) with an estimated blood loss of less than fifty milliliters. Patients were allowed to bear full weight immediately and were able to do so without ambulatory assistive devices within an average of twelve days (range, three to eighteen days). Complications consisted of three minor pin tract infections, one temporary lateral femoral cutaneous nerve palsy, one late pin tract abscess, and one patient with chronic low-back pain.

CONCLUSIONS

Treatment of type B lateral compression injuries of the pelvic ring with anterior distraction external fixation is a highly effective yet relatively simple and minimally invasive treatment method. Surgical time and blood loss are minimal, and patients can be effectively and rapidly mobilized. Based on our experience, we believe this method to be a valuable tool in the treatment of these fractures.

Reduction and fixation of sacroiliac joint dislocation by the combined use of S1 pedicle screws and the galveston technique

STUDY DESIGN

This retrospective study was designed to analyze the results of the treatment with S1 pedicle screws and the Galveston technique of seven patients with sacroiliac dislocation.

OBJECTIVES

To evaluate the effectiveness of the combined use of S1 pedicle screws and the Galveston technique for the treatment of sacroiliac dislocation.

SUMMARY OF BACKGROUND DATA

Although several procedures for internal fixation of sacroiliac dislocation have been reported, there have been no reports discussing surgical treatment of sacroiliac dislocation by the combined use of S1 pedicle screws and the Galveston technique.

METHODS

Seven patients with sacroiliac dislocation were treated with pedicle screws of S1 and iliac rod according to the Galveston technique. In the seven patients, the dislocation was associated with vertical displacement of the sacroiliac joint and rotational deformity of the pelvic ring. They were classified into Type-C pelvic disruption according to the Tile's classification. Three patients with disruption of the symphysis pubis underwent additional fixation of the symphysis using a dynamic compression plate. The remaining four patients were treated by the posterior procedure alone.

RESULTS

The vertical displacement was completely reduced in five patients, and the rotational deformity was completely corrected in four patients. The reduction was maintained at the time of the final follow-up evaluation. There were no perioperative complications with the exception of late infection in one patient.

CONCLUSIONS

The combined use of S1 pedicle screws and the Galveston technique provided immediate stability and sufficient reduction for sacroiliac dislocation in seven patients in this study. This hybrid internal fixation procedure is useful for reduction and fixation of sacroiliac dislocation associated with the vertical and rotational instability of the pelvic ring.

Management Guidelines for Hypotensive Pelvic Fracture Patients

Pelvic fractures are common in blunt trauma patients and are often associated with other system injuries. Most studies describe the type of pelvic fractures and classify them by the forces creating the injury. Mortality from these fractures is due most often to other system injuries or to hemorrhage. Mortality ranges from 5 to 20 per cent depending on complexity and number of systems injured. We studied 692 cases of pelvic fractures and analyzed the seriously ill patients. They were identified by blood pressure (BP) less than 90 systolic on presentation to the trauma room and having a complex pelvic fracture. The management of these patients was by a protocol used by a group of eight trauma surgeons. This group of 75 hypotensive pelvic fracture patients were analyzed to identify significant factors in their management that predicted mortality. Patients with base excess (BE) values ≤-5 were significantly more likely to die ( P < 0.05). Patients with BP ≤90 on leaving the trauma room had a significantly higher mortality ( P < 0.01). Injury Severity Score predicted mortality and can be useful as a tool for quality assurance and process improvement. The early operative intervention to fix associated fractures within 24 hours was not detrimental to patient outcome. Overall mortality in this very sick population was 14.7 per cent. Emergent angiography was used successfully on 14 patients. Seven patients died of continued bleeding. The most important management guidelines for these seriously injured, complex patients are: 1) resuscitate with BE used as a monitor; 2) keep patient blood volume as close to normal as possible; 3) use BP, BE, and ISS to evaluate management of these patients.

Percutaneous fixation of pelvic ring disruptions

Percutaneous pelvic fixation is possible because intraoperative fluoroscopic imaging and other technologies have been refined. Anterior and posterior unstable pelvic ring disruptions are amenable to percutaneous fixation after closed manipulation or open reduction. Stable and safe fixation is achieved only after an accurate reduction. Anterior pelvic external fixation remains the most common form of percutaneous pelvic fixation; however, percutaneously inserted medullary pubic ramus, transiliac, and iliosacral screws stabilize pelvic disruptions directly while diminishing operative blood loss and operative time. These percutaneous techniques do not decompress the pelvic hematoma allowing early definitive fixation without the risk of additional hemorrhage. Complications associated with open posterior pelvic surgical procedures are similarly avoided by using percutaneous techniques. A thorough knowledge of pelvic osseous anatomy, injury patterns, deformities, and their fluoroscopic correlations are mandatory for percutaneous pelvic fixation to be effective.

Comminuted fractures of the iliac wing

PURPOSE

Comminuted iliac fractures are uncommon and difficult to treat. The purpose of this study is to further delineate the fractures, to present a management protocol, and to evaluate the results of treatment.

DESIGN

Retrospective clinical study.

SETTING

Level one trauma center at Harborview Medical Center.

PATIENTS

During a sixty-eight-month period, 695 patients with pelvic ring disruptions were treated at a level one trauma center. Thirteen (1.9%) of these patients had a severely comminuted iliac fracture. All patients were men, ranging in age from twenty to eighty years (mean, 38 years). These patients were polytraumatized and had a mean Injury Severity Score of 23. Eleven of the thirteen patients had severe iliac and flank degloving injuries. Five patients had open fractures, one with fecal contamination requiring diverting colostomy. Six patients with clinical signs of hemodynamic instability had local arterial injuries associated with their fractures. All five patients with extension of the fracture into the greater sciatic notch were found to have a local arterial injury on angiography. One patient had a lumbosacral plexopathy on the fractured side. Four patients had traumatic brain injuries.

INTERVENTION

All thirteen patients were treated operatively. Routine pelvic external fixation was not possible because of the iliac comminution. Stable internal fixation was accomplished by an anterior iliac surgical exposure using lag screw and plate combinations. The open wounds and degloving injuries were treated with irrigation, debridement, and closed suction drainage.

MAIN OUTCOME MEASUREMENTS

Healing and stability of fixation were assessed clinically and on pelvic radiographs.

RESULTS

Comminuted iliac fractures were divided into two patient groups, according to associated pelvic ring disruption. Follow-up evaluations were available for all patients at a mean of eighteen months after injury. There were no deaths. All of the fractures healed clinically and radiographically. In one patient, fecal contamination caused a polymicrobial wound infection, and this patient had an associated delay in union of the fracture. Another patient with an open fracture developed a deep wound infection. Both infections responded to local management and antibiotics. There were no complications associated with the degloving injuries.

CONCLUSIONS

Comminuted iliac fractures occur in two distinct patterns and are associated with numerous local injuries that complicate management. Management protocols should include early open reduction and stable internal fixation. Traumatic open wounds should not be closed primarily. Primary closure with closed suction drainage is effective in the management of associated degloving injuries. Extension of the fracture into the greater sciatic notch warrants further evaluation with pelvic angiography.

Functional outcome of internal fixation for pelvic ring fractures

OBJECTIVE

Evaluation of the functional outcome after unstable pelvic ring fractures stabilized with internal fixation.

METHODS

Between January 1, 1990, and September 1, 1997, 37 patients were treated with internal fixation for unstable pelvic fracture. Demographic data, type of accident, Hospital Trauma Index-Injury Severity Score, and fracture type according to Tile classification were scored. One patient died the day after the accident from neurologic injury. A Short Form-36 health questionnaire and a form regarding functional result after pelvic trauma, adapted from Majeed et al., were returned by 31 of 36 patients (86%). Twenty-eight patients (78%) were seen for physical and radiologic examination.

RESULTS

Twenty-six men and 11 women, with an average age of 34.7 years (range, 15-66 years) were included. The mean Injury Severity Score reached 30.4 (range, 16-66). According to the Tile classification, there were 16 type B fractures and 21 type C fractures. Seven patients were treated with open reduction and internal fixation of the pubic arch, 10 patients were treated with a combination of anterior open reduction and internal fixation with additional external fixation to increase the stability of the posterior ring. Nineteen patients underwent internal fixation of both anterior and posterior arch. In the remaining case, percutaneous posterior screw fixation was combined with anterior external fixation, because of estimated infectious risk. The average follow-up time was 35.6 months. Patients scored 78.6 of 100 on the Majeed score. Remarkable was the reported change in sexual intercourse in 12 patients (40%). Only 12 patients (40%) did not have complaints when sitting. On the SF-36 scales physical and social functioning, role limitations due to physical problems and vitality were limited compared with the averages for the Dutch population. Patients treated with combined anterior and posterior internal fixation scored significantly better on both the Majeed score and on the categories physical functioning, pain, general health and social functioning compared with patients with similar fractures treated with a combination of anterior internal fixation with external fixation. At the physical examination, 11 of 28 patients (39%) did not have any abnormality. Nineteen patients (68%) were back at their original job, which was physically demanding in 9 cases. There was a suspicion of nonunion of the posterior arch in two patients, which could be confirmed with a computed tomographic scan.

CONCLUSION

In general, limitations in functioning are reported, even after long-term follow-up. In partially unstable fractures, solitary anterior fixation gives good results. In completely unstable fractures, patients treated with combined internal fixation anterior as well as posterior scored a better outcome compared with combined internal and external fixation. Therefore, this technique is recommended as treatment of first choice in completely unstable fractures.

Early fracture fixation may be "just fine" after head injury: no difference in central nervous system outcomes

BACKGROUND

Recent reports suggest that early fracture fixation worsens central nervous system (CNS) outcomes. We compared discharge Glasgow Coma Scale (GCS) scores, CNS complications, and mortality of severely injured adults with head injuries and pelvic/lower extremity fractures treated with early versus delayed fixation.

METHODS

Using trauma registry data, records meeting preselected inclusion criteria from the years 1991 to 1995 were examined. We identified 171 patients aged 14 to 65 years (mean age, 32.7 years) with head injuries and fractures who underwent early fixation (< or = 24 hours after admission) (n = 147) versus delayed fixation (> 24 hours after admission) (n = 24).

RESULTS

Patients were severely injured, with a mean admission GCS score of 9.1, Revised Trauma Score of 6.2, Injury Severity Score of 38, median intensive care unit length of stay of 16.5 days, and hospital length of stay of 23 days. No differences between groups were found by age, admission GCS score, Injury Severity Score, Revised Trauma Score, intensive care unit length of stay, hospital length of stay, shock, vasopressors, major nonorthopedic operative procedures, total intravenous fluids or blood products, or mortality rates. In survivors, no differences in discharge GCS scores or CNS complications were found.

CONCLUSION

We found no evidence to suggest that early fracture fixation negatively influences CNS outcomes or mortality.

Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing

OBJECTIVE

Presentation of a new triangular osteosynthesis technique that permits early weight-bearing in vertically unstable sacral fractures.

DESIGN

Retrospective evaluation of a consecutive series.

SETTING

Level I trauma center.

PATIENTS

Thirty-four patients, twenty-eight of whom were polytraumatized, all with vertically unstable sacral fractures. This group included eight women and twenty-six men, with a mean age of thirty-five years. Average time between trauma and definite operation was thirteen days (range 0 to 28 days).

INTERVENTIONS

All patients underwent triangular osteosynthesis using a combination of a vertical vertebropelvic distraction osteosynthesis (pedicle screw system) and a transverse fixation of the sacrum fracture with either iliosacral screws or transsacral plating. Immediate postoperative weight-bearing was permitted postoperatively.

RESULTS

Nineteen patients were treated with early progressive weight-bearing and advanced to full weight-bearing, on average, after twenty-three days (range 8 to 70 days). Three of the thirty-four patients (9 percent) experienced loosening of hardware, including two patients (6 percent) who required secondary intervention because of loss of the original reduction. Further complications included one pulmonary embolism (3 percent), one iatrogenic nerve lesion (3 percent), one wound necrosis (3 percent), and two local infections (6 percent).

CONCLUSIONS

Triangular osteosynthesis is a demanding procedure that can be performed on vertically unstable sacral fractures to allow early progressive weight-bearing with an acceptable complication rate.

Angiographic embolisation in pelvic fracture

Pelvic angiography is accepted in the control of haemorrhage due to pelvic fracture. The technique is reported to be effective in patients bleeding from small arterial branches of the internal iliac artery. Despite its widespread use, complications of the technique are scarcely reported. We reviewed all patients having undergone this intervention at our institution over a 10 year period. The technique was applicable in a minority of pelvic fracture cases. Sepsis was common in patients subsequently undergoing internal fixation of the pelvic fracture. Angiographic embolisation may be useful in controlling haemorrhage due to pelvic fracture. However, standardized parameters of a successful intervention are yet to be defined. Caution must be exercised when using this technique, particularly when proceeding to internal fixation of the pelvic ring.

Long-term functional prognosis of posterior injuries in high-energy pelvic disruption

OBJECTIVE

This study sought to identify the long-term functional results of various posterior pelvic lesions and to determine whether such injuries benefit from exact reduction.

DESIGN

Consecutive cohort of patients admitted for pelvic disruption between 1980 and 1990.

SETTING

University hospital.

PATIENTS

Eighty-eight pelvic fractures in eighty-eight patients were classified according to the instability and anatomy of the posterior injury. Simple fractures of the pubic rami, minimally displaced fractures with pubic diastasis of less than 2.5 centimeters, and fractures without other pelvic lesions (type B1 lesions, stage 1 in the Tile classification) were all excluded. Patients with sequelae of associated lesions that could render functional evaluation difficult were also excluded.

INTERVENTIONS

The initial status of the patient and the type of fracture determined the treatment. In the anteroposterior compression injuries group, an external fixator using the double-frame Hoffmann device was applied in twenty-eight cases to reduce a large external horizontal displacement, either immediately to control bleeding or later as definitive treatment when anterior internal fixation was not possible. Anterior internal fixation with a plate was used six times to repair a symphyseal disruption. In vertical shear injuries, tibial skeletal traction was used for six weeks as an attempt to stabilize vertical instability. In ten patients, traction alone was used. In other cases, traction was used in conjunction with an external fixator or internal pubic fixation. In impacted lateral compression injuries, simple bed rest for six weeks was used in cases of stable lesions. Skeletal traction was applied in ten patients of this group because of a potential vertical instability, particularly in cases with a comminuted sacral lesion.

MAIN OUTCOME MEASURES

Anatomic diagnosis and evaluation of the reduction were made using anteroposterior, inlet, and outlet radiographs of the pelvic ring. To assess reduction, vertical, anteroposterior, and rotatory displacement was measured. Functional results were qualified based on the injury pattern and the quality of the final reduction and were then quantified according to the grading proposed by Majeed.

RESULTS

Functional results varied according to injury anatomy, with fractures of the iliac wing and sacroiliac (SI) fracture-dislocations having the best prognosis. The quality of reduction did not affect the functional results. Conservative methods such as skeletal traction and external fixation generally gave satisfactory functional results. Conversely, however, pure SI lesions were associated with poor functional results, especially if reduction was not exact.

CONCLUSIONS

This study shows that when the posterior injury is a fracture of the iliac wing or a mixed fracture with SI propagation, a long-term satisfactory functional result can be obtained without an exact reduction even in cases of vertical instability. Simple methods are usually sufficient, and it seems unnecessary to propose more aggressive treatment. It is important, however, to recognize that SI fracture-dislocations (17 percent in this series) seem to be quite different from pure SI disruptions in terms of persistent pain. Moreover, it appears that exact reduction of pure SI lesions is critical for good functional results, something that is difficult to obtain with conservative procedures. Sacral fractures represent a special problem for the surgeon because of the frequency of fair results in which neurologic lesions whose pathophysiology is poorly known seem to be responsible.

Biomechanics of the Gazi type pelvis external skeletal fixator

External skeletal fixation is an alternative method of treatment to conventional therapy and open surgical procedures in pelvis fractures. The appropriate type of frame and the configuration of the connecting bars of these fixators are under investigation. In the Gazi type pelvis external fixator (GPEF) which has been developed, a 70 degree angulation is applied to the connecting bars of the anterior quadrangular frame. This configuration, which is expected to improve the stability of the posterior column of the pelvis, was evaluated biomechanically on a phantom with various types of pelvic fractures and separations. The results suggest that the GPEF effectively controls anterior column pelvis fractures such as unilateral pubic ramus fractures, unilateral ischium pubis rami fractures and symphysis pubis separations under vertical loads. The fixator is partially capable of stabilizing the posterior column; however, loads above 700 N cause separation at the fracture site. Further studies and clinical trials are essential to determine the GPEF's effectiveness in reducing blood loss and in providing stability at the posterior column.

Iliosacral screw fixation: early complications of the percutaneous technique

OBJECTIVE

To report on the early complications related to the percutaneous placement of iliosacral screws for the operative treatment of displaced posterior pelvic ring disruptions.

STUDY DESIGN

Prospective, consecutive.

SETTING

Level-one trauma center.

PATIENTS

One hundred seventy-seven consecutive patients with unstable pelvic ring fractures. One hundred two male and seventy-five female patients ranging in age from eleven to seventy-eight years (mean, thirty-two years).

INTERVENTIONS

Operative procedures were performed urgently according to the patient's clinical condition. Anterior pelvic reductions and fixations were performed by using internal and external fixation techniques. Accurate closed or open reductions of the posterior pelvic ring disruptions were accomplished by using a variety of surgical techniques dependent on the specific pattern of pelvic ring disruption. Closed manipulative reductions of the posterior pelvic ring were attempted for all patients. Open reductions were necessary in those patients with unacceptable closed manipulative reductions as assessed fluoroscopically at the time of operation (more than one centimeter in any field of fluoroscopic imaging).

MAIN OUTCOME MEASURES

Plain inlet and outlet radiographs were obtained postoperatively at six weeks, three months, and twelve months. A pelvic computed tomography scan was performed postoperatively to assess fracture or dislocation reduction and the implant safety. Annual follow-up pelvic radiographs were obtained. Residual pelvic deformities were quantified based on these imaging modalities.

RESULTS

There were no posterior pelvic infections. Minimal blood loss was associated with this technique. Complications occurred due to inadequate imaging, surgeon error, and fixation failure. Fluoroscopic imaging was inadequate due to obesity or abdominal contrast in eighteen patients. Five screws were misplaced due to surgeon error. One misplaced screw produced a transient L5 neuropraxia. Fixation failures related to either crandiocerebral trauma, delayed union, noncomplicance, and a deep anterior pelvic polymicrobial infection secondary to a urethral tear occurred in seven patients. There were two sacral nonunions that required debridement, bone grafting, and repeat fixation prior to healing.

CONCLUSIONS

Iliosacral screw fixation of the posterior pelvis is difficult. The surgeon must understand the variability of sacral anatomy. Quality triplanar fluoroscopic imaging of the accurately reduced posterior pelvic ring should allow for safe iliosacral screw insertions. Anticipated noncompliant patients or those with craniocerebral trauma may need supplementary posterior pelvic fixation. Low rates of infection, blood loss, and nonunion can be expected.

Biomechanics of pelvic fixation

This article reviews a series of biomechanical studies performed in the author's laboratory, evaluating the instabilities produced by the more common and problematic pelvic ring fracture patterns and the increasingly popular and newly developed modes of internal fixation. Topics that are discussed include the following: anteroposterior compression injuries and the disrupted sacroiliac joint; sacral fractures; anteroposterior compression injuries and symphyseal fixation; new symphyseal plate designs; unstable pubic rami fractures; unstable fractures of the iliac wing; and resuscitation fixator biomechanics.

Stabilization of pelvic ring disruptions

Pelvic ring disruptions are challenging management problems for the orthopedic surgeon. Early hemorrhage, permanent nerve injury, and late pain caused by residual pelvic deformity are some of the many complicating factors. A variety of treatment alternatives are available to stabilize the disrupted pelvic ring. Each technique has inherent advantages and problems.

Pseudoaneurysm of the superior gluteal arterial system: an unusual cause of pain after a pelvic fracture

This case report describes a complication after treatment of a rotationally unstable pelvic fracture: a pseudoaneurysm of the superior gluteal arterial system. The patient sustained an anterior-posterior compression pelvic fracture that was stabilized with anterior symphyseal plating and percutaneous iliosacral screw insertion. The etiology of the pseudoaneurysm was likely multifactorial, including the injury (anterior-posterior compression pelvic fracture), prolonged coagulation parameters during administration of warfarin, and the percutaneous insertion of an iliosacral lag screw. A pseudoaneurysm of the superior gluteal arterial system should be included in the differential diagnosis of unexplained pelvic or buttock pain after a pelvic fracture.

Open pelvic fractures. A multicenter retrospective analysis

A marked discrepancy exists in the reported mortality rates in patients with open pelvic fractures, ranging from 4.8% to 50%. A retrospective review of patients with open pelvic fractures was performed at three centers. Thirty-nine patients with open pelvic fractures were identified; the average age was 32. The average injury-severity score was 29 (13-75). There were 10 (26%) deaths. Factors that correlated with mortality and morbidity were instability of the pelvic fracture and the presence of a rectal injury. Delay in performing diverting colostomy correlated with a poor outcome. Previously described methods of treatment are still valid; however, there is a need for re-emphasis of early diverting colostomy in the patient with a rectal or perineal injury. A classification system for open pelvic fractures is proposed in this article.

Biomechanical comparison of posterior internal fixation techniques for unstable pelvic fractures

Early reduction and rigid fixation of unstable vertical shear pelvic fractures has been shown to decrease the incidence of late sequelae and facilitate early mobilization. The results of fixation of the posterior pelvic ring without anterior fixation are unknown. The purpose of this study was to perform a biomechanical comparison of the most frequently used techniques of posterior fixation for unstable pelvic sacroiliac dislocations in conjunction with ipsilateral rami fractures, i.e., an unstable vertical shear injury. The four methods of posterior fixation tested included sacroiliac (SI) screws, anterior SI plates, transiliac bars, and a combination of SI screws and transiliac bars. Six cadaveric pelvises were tested in axial compression and torsion on a biaxial servohydraulic testing machine. Compared to the intact pelvis, single posterior methods of fixation provided approximately 70-85% resistance to axial and torsional loading. By combining SI screws with transiliac bars, approximately 90% of intact pelvic stability was achieved. Our results suggest that rigid posterior fixation of sacroiliac dislocations alone may obviate the need for additional complex anterior surgical procedures to fix rami fractures.

Clinical and biomechanical aspects of external fixation of the pelvis

OBJECTIVE: The aim was to evaluate the mechanical stability of several traditional and modern external fixators in unstable pelvic ring disruption. DESIGN: In a laboratory study external and internal fixation techniques were tested in seven fresh and five embalmed human pelves with a disruption of the pubic symphysis and one sacroiliac joint (type C1.2 injury according to the Tile-AO classification). BACKGROUND: Stability provided by external fixation depends upon many factors, with the residual pelvic stability being the most important. METHODS: Simulating a single-leg stance, the load was applied quasi-statically to the acetabulum of the unstable hemipelvis. Device failure was defined as displacement >10 mm either at the symphysis pubis or the sacroiliac joint. RESULTS: The frame with the highest failure load (fresh versus embalmed specimens) was the Egbers configuration with the AO fixator (analysis of variance; P < 0.05). Failure was noted at 114.9 N versus 129.5 N. Augmentation of the Mono-Tube by additional internal posterior osteosynthesis gave the following results: sacral bars 325.4 N versus 217.8 N, plate fixation 294.3 N versus 215.8 N, lag screws 338.4 N versus 215.8 N. Failure loads of hybrid fixation of the Orthofix were as follows: sacral bars 257.9 N versus 213.9 N, plate fixation 333.5 N versus 245.3 N, lag screws 397.3 N versus 280.6 N. The differences between the two fixators were not statistically significant. CONCLUSIONS: No single external frame provided sufficient stability. The addition of a posterior internal fixation significantly increased failure loads and controlled the weight-bearing pelvic elements.

Outcome after fixation of unstable posterior pelvic ring injuries

Between June 1989 and May 1995, the authors surgically treated 64 patients with unstable posterior pelvic in juries. Fracture types included Tile Type C1 (75%), C2 (8%), and C3 (17%). There were 19 sacroiliac dislocations, 12 sacral fractures, 4 transiliac fractures, and 29 sacroiliac fracture dislocations. Average patient age was 32 years and Injury Severity Score was 27 points. Posterior fixation was accomplished by percutaneous iliosacral screw insertion in 53 patients (83%). Only pure transiliac fractures were treated without iliosacral screws. There were no iatrogenic nerve palsies. During the study, there was increased reliance on internal fixation of the anterior pelvic ring that aided in anatomic alignment of the pelvis for posterior fixation and resulted in decreased chronic pubic tenderness. The use of external fixation for definitive treatment was abandoned. Patients were observed for an average of 36 months (range, 5-74 months). Fifty-two patients were available for recent complete followup. Fifty-one patients (98%) healed their pelvic disruptions; there was 1 sacral nonunion. A 40-point pelvic outcome grading scale was developed based on physical examination, pain, radiographic analysis, and activity/work status. Scores obtained by this scale correlated closely with the Short Form-36 Health Survey scores. Patient functional outcome after posterior pelvic fracture was not associated with Injury Severity Score or fracture location.

The management of complex orthopedic injuries

As advancements are made in the prevention of automobile fatalities, an increase in the incidence of pelvic and lower extremity injuries has occurred. These remain the leading causes of impairment and loss of years of productive life. Pelvic trauma has a high initial mortality rate when severe. However, with early resuscitation and transport, more survivors arrive in our trauma centers harboring these injuries. Owing to early stabilization and mobilization of the traumatized patient, a decrease in complications in these patients has been noted. Both the trauma surgeon and the orthopedic trauma surgeon should work as a team and remain in continuous communication during the treatment of these patients. Open fractures are among the most difficult problems to manage; early and aggressive decisions can prevent a lifetime of complications and physical impairment. As previously stated, to obtain good outcomes, open fractures must be treated initially at the accident scene followed by timely transport to the trauma center for definitive care. It must be remembered that the golden time to prevent major complications is 6 hours. Intra-articular fractures of the lower extremity involve a major weight bearing joint. Post-traumatic arthritis and impairment develop in joints where joint congruity is not achieved. To preserve normal function, there should be articular congruity, stable fixation, axial alignment with the rest of the extremity, and restoration of full range of motion. Immediate stabilization of long bone fractures has many advantages in the multiply injured patient, such as improved long-term function, prevention of deep venous thrombosis and decubitus ulcer, decreased need for analgesia, and reduction in the incidence of adult respiratory distress syndrome and fat emboli. Patients with femoral shaft fractures should undergo immediate stabilization of the fracture within 24 hours of injury. We have presented a series of orthopedic injuries that have high mortality and high morbidity which, if not treated expediently, yield a high degree of impairment.

Internal fixation of unstable pelvic ring injuries

One hundred and seven unstable pelvic fractures were treated operatively. Reductions were graded by the maximal displacement measured on the 3 standard views of the pelvis. Criteria were: excellent 4 mm or less, good 5 to 10 mm, fair 10 to 20 mm, and poor more than 20 mm. Overall there were 72 excellent, 30 good, 4 fair, and 1 poor reduction. Ninety-five percent of all reductions were excellent or good. Open reduction and internal fixation within 21 days were associated with a higher percentage of excellent reductions than in reductions performed after 21 days (70% versus 55%). These differences were not statistically significant, however. Complications were infrequent using the techniques described.

Acute Pelvic Fractures: II. Principles of Management

The past two decades have seen many advances in pelvic-trauma surgery. Provisional fixation of unstable pelvic-ring disruptions and open-book fractures with a pelvic clamp or an external frame with a supracondylar pin has proved markedly beneficial in the resuscitative phase of management. In the completely unstable pelvis, external clamps and frames can act only as provisional fixation and should be combined with skeletal traction. The traction pin is usually used only until a definitive form of stabilization can be applied to keep the pelvic ring in a reduced position. If the patient is too ill to allow operative intervention, the traction pin can remain in place with the external frame as definitive treatment. Symphyseal disruptions and medial ramus fractures should be plated at the time of laparotomy. Lateral ramus fractures can usually be controlled with external frames. A role has been suggested for percutaneous retrograde fixation of the superior pubic ramus; however, the benefits to be gained may not be enough to outweigh the serious risks of penetrating the hip, and this technique should therefore be used only by surgeons trained in its performance. The techniques for posterior fixation are becoming more standardized, but all still carry significant risks, especially to neurologic structures.

Internal fixation for the transforaminal sacral fracture

The mechanical stability of alternate forms of internal fixation of the transforaminal sacral fracture were compared. A transforaminal sacral fracture was made in each of 6 fresh-frozen cadaveric pelvic specimens. Implants compared for fixation included: a single and 2 fully threaded iliosacral screws inserted through the posterior ilium and anchored into the first sacral vertebral body both with and without the addition of a posterior tension band plate; and 2 transiliac bars inserted through the posterior tubercles. The femora of each specimen were potted and fixed to the table of a materials tester. The pelvis was restrained only from flexing and extending, and a compressive load was applied through the lumbar spine, representing a standing loading condition. Flexion of the sacrum and displacement at the fracture site were measured during loading. Although creation of the injury increased motion considerably, there was no measurable increase in stability provided by any of the implants or combination of implants in this model when an anatomic reduction was obtained.

Functional outcome of patients with unstable pelvic ring fractures stabilized with open reduction and internal fixation

An unstable pelvic ring fracture represents a severe injury and is associated with high morbidity and mortality. Little data are available assessing the long-term functional limitations, including disability, in a patient with an unstable pelvic ring fracture. The purpose of this study was to describe the impairment and functional outcome (disability) for patients with unstable pelvic ring fractures managed with open reduction and internal fixation (ORIF). Disability was measured at a minimum of 1 year postinjury using the Sickness Impact Profile (SIP), a measure of the health-related quality of life as perceived by the patient. Of the 230 consecutive patients with a pelvic ring fracture, 54 had unstable fractures requiring ORIF; 48 patients were available at a 1 year follow-up. The follow-up roentgenograms confirmed an osseous union and an anatomic alignment of the pelvis. Thirty-seven (77%) of the patients had mild disability (total SIP < 10); 11 (23%) of the patients had moderate disability (SIP > 10) at 1 year. Of the patients who were employed preinjury, 76% were employed 1 year postinjury; 62% had returned to full time work and 14% had returned with job modification. Of the 7 patients who had been in school, 6 had returned full time and 1 student returned part time. Mean SIP scores for subcategories were: physical health = 6.8 +/- 9.4, psychosocial health = 7.4 +/- 12.7, work = 17.6 +/- 25.5, home management = 8.3 +/- 13.0, ambulation = 10.7 +/- 13.7, and mobility = 5.3 +/- 13.0. Despite the magnitude of the bony injuries, the majority of patients with unstable pelvic ring fractures managed with ORIF had mild disability 1 year postinjury; the majority of the patients had returned to work.

Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low-impact falls

OBJECTIVE

To determine the effect of the timing of fracture fixation and the physiologic status on admission of elderly patients with hip fractures from low impact falls on resource utilization and outcome.

METHODS

A 5-year retrospective review of 82 elderly (age > 65 years) patients with isolated low-impact hip fractures stratified into early (< 24 hours), intermediate (24 to 72 hours), and late (> 72 hours) operative fixation. Admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores, number of comorbidities, fracture type, complication rate, length of stay, discharge acuity, and mortality were calculated for each group.

RESULTS

Values are mean +/- SD. The mean admission APACHE II score of the entire group was 8.1 +/- 0.2, indicating that these patients were physiologically stable on arrival. The mean numbers of comorbidities or APACHE II were not significant between groups. No differences existed in the mean APACHE II scores for survivors and nonsurvivors (7.95 +/- 2.34 vs. 9.17 +/- 3.06, p = 0.2409). There were no differences in the mean APACHE II scores and predicted survival for each group. However, a significant decrease in actual survival was observed with late fixation (p < 0.001; Fisher's Exact Test). Patients who were fixed late also had a significantly higher infectious morbidity (p = 0.00469), length of stays (p = 0.0226), and total hospital cost (p = 0.0001), compared with those fixed early or immediate, despite having no difference in average acuity upon discharge (p = 0.3883).

CONCLUSIONS

Delay in fracture fixation, in elderly patients who are physiologically stable on admission, significantly increases morbidity and mortality and adversely affects resource utilization.

Percutaneous iliosacral screw fixation: early treatment for unstable posterior pelvic ring disruptions

OBJECTIVE

Open reduction and internal fixation of unstable posterior pelvic ring injury provides better bony stability and less long term morbidity than nonoperative treatment. However, open reduction and internal fixation of the posterior pelvis may involve substantial intraoperative blood loss, reported infection rates of 6 to 25%, and wound complications in 25%. Our hypothesis was that percutaneous cannulated iliosacral screws placed by fluoroscopic control would provide early, rapid, definitive stabilization with minimal blood loss, infection, and wound complications.

DESIGN

A retrospective medical record and radiographic study. MATERIALS, METHODS, MEASUREMENTS AND MAIN RESULTS: Twenty consecutive patients with an unstable posterior pelvic ring injury treated by percutaneous fixation (41 screws) under fluoroscopic guidance were reviewed. Average patient age was 34 years, trauma score was 14.4 +/- 3.3, and Injury Severity Score was 22.9 +/- 10.6. Mechanisms were motor vehicle collisions (11), falls (3), crush injury (3), and pedestrian/auto (3). Pelvic injuries were classified as Tile B (5) or Tile C (15). Associated injuries were present in 80%. Seventy-five percent of patients underwent pelvic fixation less than 72 hours after injury with closed percutaneous screw placement achieved in 60%, assisted by open reduction in 25% or aided by anterior external fixation in 15%. Mean operative time was 52 minutes for patients requiring percutaneous screws only (7 of 20 patients, 35%), whereas average blood loss was 233 mL for all cases (including open anterior and posterior procedures). No loss of fixation or wound complications occurred during 9.6 months follow-up.

CONCLUSIONS

Percutaneous iliosacral screw fixation for unstable posterior pelvic disruption provided early fixation with minimal operative time, minimal blood loss, and wound-related morbidity.

Effects of method of internal fixation of symphyseal disruptions on stability of the pelvic ring

This study tested different methods of internal fixation of a symphyseal disruption, in comparison with the mechanics of the intact pelvis. Unembalmed cadaveric pelves were tested in simulated bilateral stance in a servohydraulic materials-testing machine. Motion of the superior and inferior pubic symphysis, and at two levels of the posterior sacroiliac complex, was measured using high resolution displacement transducers. The fixations tested were (1) double plating (4.5 mm reconstruction plates), (2) wire loops around two 6.5 mm, fully threaded cancellous screws, and (3) an absorbable suture material (polydioxanone). Each pelvis was first tested intact, recording displacements in response to a cyclic axial load up to a maximum of 500 N applied through the proximal sacrum. The pubic symphysis was then sectioned and the sacrum fractured to produce an unstable pelvis (Tile C-type). Recordings were then repeated, following fixation of the sacral fracture with lag screws and sequential fixation of the symphysis with each of the test methods. The results from eight pelves revealed that internally fixed symphyseal motion was generally greater than intact, regardless of fixation method. The superior symphysis was usually compressed, while there was distraction inferiorly. Wiring resulted in significantly less symphyseal motion than the other methods (P < 0.02), provided four loops were used, reducing the separation inferiorly. There was no significant difference in sacral fracture motion between the three methods. The results indicate that in osteoporotic bone, as used in this study, symphyseal wiring is best able to oppose the tensile loads in the inferior symphysis that are associated with bilateral stance loading. These biomechanical findings must be interpreted within the broader context of surgical management of these complex injuries.

The effect of thread length and location on extraction strengths of iliosacral lag screws

Although iliosacral lag screws are an established technique for fixation of sacroiliac joint dislocation and sacral fractures, there is a paucity of data on the relative strength of fixation of screws in the sacral ala and body. The purpose of this study was to quantify and compare the extraction strength of cancellous screws in the sacral ala and body. Twelve fresh frozen cadaveric human pelves (mean age 76) were used to test the extraction strength of three groups of 7.0 mm cannulated cancellous screws: long-threaded in the sacral body, short-threaded in the body and short-threaded in the ala. The mean extraction strengths were 925, 374 and 71 newtons (or 92, 37, and 7 kg) respectively. The differences between the three groups were highly significant (all P < 0.0025). These data strongly recommend that the goal in iliosacral lag screw fixation should be to insert a long-threaded screw into the sacral body, if safely feasible. Fixation in the ala is inferior and should be avoided in the elderly.

Anterior square-plate fixation of sacroiliac disruption. 2-8 years follow-up of 23 consecutive cases

21 consecutive patients with 23 rotationally and vertically unstable sacroiliac joint disruptions were operated on through an anterior approach. Open reduction and internal fixation with a 2-hole square plate was performed. At follow-up after 5 (2-8) years, 18 patients were rated excellent or good and 3 patients poor. In all the cases the reduction of the SI-joints was maintained.

Operative fixation of unstable pelvic ring injuries in polytrauma patients

Sixteen polytraumatized patients with a variety of unstable pelvic ring fractures were treated with operative fixation. We have found that an aggressive approach with adequate early stabilization of the pelvis offers many advantages over conservative management particularly in polytraumatized patients.

Operative treatment of unstable pelvic fractures

Unstable pelvic fractures are serious injuries. Non-operative treatment gives poor early and late results. We report the results of operative treatment of 28 unstable pelvic fractures; eight were rotatory unstable and 20 were both rotatory and vertically unstable. The average age of the patients was 33 years. All the patients underwent operation according to a definite protocol for internal fixation. Mobilization was started within 2 weeks after the operation; the average hospital stay was 9.8 weeks. With an average follow-up of 19 months, there was no mortality. In 20 patients there was no discomfort, five patients had moderate back pain and four patients walked with a limp due to leg length inequality and back pain. Twenty patients returned to gainful employment. Complications included one deep wound infection, two superficial wound infections, one dislodgement of the external fixator, and residual interval rotatory deformity of the hemipelvis. We conclude that operative treatment of unstable pelvic fractures is safe and that the early and late results are much better than those treated by non-operative means.

Anterior and posterior internal fixation of vertical shear fractures of the pelvis

A laboratory study was undertaken to evaluate the effectiveness of alternative methods of fixation of unilateral vertical shear fractures of the pelvis. Prior to experimental testing, a biomechanical analysis was performed to estimate the forces that displace the hemipelvis in the presence of two different patterns of injury: an interforaminal sacral fracture and a disruption of the sacroiliac joint. These lesions were then experimentally created in five unembalmed human pelvises and sequentially fixed with an external Hoffmann frame alone, a Hoffmann frame with sacral bars, or sacral bars with either one or two bone plates placed across the symphysis pubis. Each pelvis/fixator system was mechanically tested by loading along the direction of the resultant muscle force predicted by the biomechanical analysis. During loading the proximal migration of the ilium was continuously recorded with a transducer. At intervals during loading, the three-dimensional displacement of the detached hemipelvis at the pubic symphysis was also measured using a stereophotographic technique. With both the sacral fracture and the sacroiliac disruption, the addition of posterior sacral rods substantially increased the strength and rigidity of fixation provided by the Hoffmann fixation frame alone (p less than 0.01). In specimens with a sacral fracture, the use of anterior plates with posterior rods restored 65-71% of the strength of the intact pelvis, in comparison with 46% observed with the combination of sacral rods with an anterior Hoffmann frame (p less than 0.01). All of the methods of fixation evaluated in this study were less successful in stabilizing the sacroiliac disruption.(ABSTRACT TRUNCATED AT 250 WORDS)

Pelvic ring injuries

Many problems may complicate the treatment of pelvic fractures. Thorough evaluation of the whole patient, all local structures, and the skeletal injury itself is essential. Continued bleeding due to unstable pelvic ring injuries is most effectively controlled by prompt anterior external fixation. Posterior shearing injuries are poorly stabilized by external fixation, and require additional treatment. Especially when significant deformity exists, or when the posterior injury is primarily ligamentous, open reduction and internal fixation are likely to be beneficial.

Blunt pelvic trauma

Blunt pelvic trauma results in significant morbidity and mortality from associated genitourinary, neurological, vascular, and visceral damage. Diagnosis begins in the ED with the initial trauma evaluation. Proper treatment using a multidisciplinary approach and cooperation between orthopedist, urologist, trauma surgeon, and emergency physician should minimize complications.