Extra-articular Unstable Iliac Fractures: Associated Injuries, Fixation Strategies, and Outcomes

Damage-control orthopedics or early total care: What you need to know

ABSTRACT

Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.

Surgical management of iliac wing fractures: Proposal of a new classification system

INTRODUCTION

Isolated fractures of the iliac wing are a rare injury, usually occurring in high-energy trauma, and are associated with other non-musculoskeletal and soft tissue injuries that could compromise the patient's life. Surgical indications are unclear, and there is limited information on the most frequent fracture patterns.

METHODS

A descriptive multicenter case series study of isolated fractures of the iliac wing treated surgically in three referral trauma hospitals in Latin America. The different fracture patterns are described, the "iliac ring" concept is proposed, and a classification is made.

RESULTS

Twenty-eight patients were included; 24 were male, the median age was 31 years RIQ (24-46), the most frequent trauma mechanism was a traffic accident, and in 14 patients, the ISS >16. The most frequent associated injury was to the appendicular skeleton at another level in 13 patients. In the new classification, according to the number of fragments, 11 patients were classified as type A (1 fragment), ten patients as type B (two fragments), and seven patients as type C (three or more fragments). The most compromised anatomical area was the crest and anterosuperior iliac spines in 26 patients, followed by the fossa and anteroinferior iliac spine in 17 and 8 patients, respectively.

DISCUSSION

The patterns of isolated fractures of the iliac wing allow the identification of three types of fractures. Identifying these patterns can help the surgeon decide to perform surgery in these scenarios and choose the fixation technique according to the number and location of the fragments.

Minimally Invasive Percutaneous TightRope® System Fixation for an Unstable Posterior Pelvic Ring: Clinical Follow-up and Biomechanical Studies

Objective

To evaluate the mechanical stability and clinical efficacy of minimally invasive percutaneous TightRope® systems applied via gun‐shaped reduction forceps for unstable posterior pelvic ring fractures.

Materials and methods

This study consists of two parts: a clinical retrospective study and a randomized controlled biomechanical test. For the clinical study, a retrospective analysis of posterior pelvic ring fractures was performed between June 2015 and May 2020. Eighteen patients underwent surgery using two TightRope® systems to fix a broken posterior pelvic ring because of unstable AO type C1 and C2 pelvic ring fractures. The patients were followed up for at least 2 years, and all patients were evaluated using the Majeed scoring system and vertical displacement. In the biomechanical tests, six embalmed adult pelvic specimens were used. The fractures were subjected to TightRope®, IS screw, and TBP fixation in a randomized block design. The specimens were placed in a biomechanical testing machine in a standing neutral posture. A cyclic vertical load of up to 500 N was applied, and the displacement of the specimens was recorded by the testing machine. The ultimate load in each group of specimens was recorded. The displacement and ultimate load were compared and analyzed by statistical methods.

Results

At a mean follow‐up of 38.89 ± 8.72 months, the functional Majeed score was excellent in 14 patients and good in four patients. The final radiological examinations showed that the outcome was excellent in 14 patients and good in four patients. In these patients, no serious clinical complications were found. Weight‐bearing was delayed in four patients. In biomechanical tests, the displacement of the specimens fixed with TightRope® was significantly lower than that of the specimens fixed with TBP (P < 0.05) when the load ranged from 300 to 500 N. The displacement in the IS screw group was significantly lower than that in either the TBP or TightRope® group (P < 0.05) when the load ranged from 0 to 500 N. The ultimate load in the IS screw group (1798 ± 83.53 N) was significantly greater than that in the TBP group (1352 ± 74.41 N) (t = 9.78, P < 0.0001) and the TightRope® group (1347 ± 54.28 N) (t = 11.11, P < 0.0001). However, no significant difference was observed between the TightRope® and TBP groups (t = 0.13, P = 0.90).

Conclusion

Percutaneous posterior TightRope® system shows strong stability in mechanical experiments and shows good results in clinical follow‐up while this system has certain advantages in lower surgical requirements and lower risk of related nerve and vascular structural damage.