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Pelvic Ring Injuries Definitive Treatment
Steven A. Olson, MDRafael Neiman, MD
Created March 2004Revised 2007
Introduction
• Evaluation and Classification of Pelvic Ring Injuries (PRI)
• Acute Management of PRI
• Definitive Management of PRI
Introduction
• Definitive Treatment of PRI– Defining instability– The decision to operate– Preoperative planning– Selection of approach– Techniques of reduction and fixation– Biomechanics of fixation techniques– Outcomes in PRI
Instability
• As with any musculoskeletal articulation, stability relies on three factors, to variable degrees:– Bony Stability– Soft Tissue Stability
• Capsulo-ligamentous structures– Dynamic Stability
• Muscular structures-minimal contributor
Instability
• Bony and soft tissue stability– The 3 bones of the pelvic ring have no inherent
stability. Alone they cannot support the axial or appendicular skeleton
– However, the sacrum is the ‘keystone’ to the bony stability of the pelvic ring when ligamentous attachments are intact.
– Interosseous Sacroiliac ligaments are most important for posterior stability
Instability
• Multiple opinions exist for defining pelvic ring instability– Some use radiographic displacement, in
combination with physical exam, to define instability
– Most surgeons generally define it as the inability to sustain loads required for patient mobilization without significant displacement or deformation
Instability• Multiple opinions exist for defining pelvic ring
instability– Several classification systems address pelvic ring
injuries, some with focus on instability, others with focus on injury pattern:
• Tile• Bucholz• AO/OTA• Young and Burgess• Letournel
Instability
• Refer to section on Classification for details• For purposes of simplicity in defining
treatment options, the Bucholz classification will be used– Type I-Anterior injury with minimal posterior
involvement– Type II-rotationally unstable, vertically stable– Type III-rotationally and vertically unstable
Preoperative Planning
• A pelvic C-clamp/external fixator may be in place due to prior hemodynamic instability (refer to section on ‘acute management of pelvic ring injuries’). This will need removal for definitive treatment, often 5-7 days post-injury
Preoperative Planning
• Associated injuries are common and treatment must be coordinated with other teams– Trauma Surgery– Urology– Neurosurgery
• Combined injuries may require exploratory laparotomy
Preoperative Planning
• When an exploratory laparotomy is performed, this often gives the orthopaedist opportunity to stabilize the anterior pelvic ring– These opportunities should be used, as the
trauma patient may occasionally be unable to withstand future operations
Preoperative Planning
• Timing is important– within 24-48 hours, the fracture-dislocations
are most mobile and may allow the best reduction with closed techniques
– Routt has shown success with very early stabilization (at zero days post injury) with closed reduction and percutaneous pinning
The Decision to Operate-Indications
• Most PRI fall into Bucholz type I injury– Anterior disruption of
the pelvic ring with nondisplaced fracture of the sacrum or slight tearing of the anterior SI ligament.
– These are inherently stable
Bruce D. Browner, MDJ. Dean Cole, MD, Initial management of pelvic ring disruption. Instructional Course Lectures 1988, Volume 37:129
Non-Operative ManagementFractures amenable to non-operative
treatment include:• Lateral impaction type injuries with minimal
(< 1.5 cm) displacement• Pubic rami fractures with no posterior
displacement• Gapping of pubic symphysis < 2.5 cm• Operative treatment indicated rarely for
symptomatic delayed union or nonunion
Non-Operative Treatment• Bucholz type I injuries can be managed with bed to
chair mobilization and weight bearing as tolerated.• Weight bearing typically requires support with a
walker or crutches initially.• Serial radiographs are required after mobilization has
begun to monitor for subsequent displacement.• If displacement of the posterior ring > 1cm is noted
weight bearing should be stopped. Operative displacement could be considered for gross displacement.
The Decision to Operate -Indications
• Bucholz type II– Anterior pelvic ring
injury and complete tearing or avulsion of the anterior SI ligament complex with sparing of the posterosuperior SI ligament complex
Bruce D. Browner, MDJ. Dean Cole, MD, Initial management of pelvic ring disruption. Instructional Course Lectures 1988, Volume 37:129
The Decision to Operate -Indications
– Rotationally unstable injuries (typically external rotation injuries)
– Larger displacements anteriorly suggest further instability posteriorly
– These need operative fixation when gapped open > 2 - 2.5 cm
Techniques
• Bucholz II– Anterior fixation
options (anterior ring)• external fixation
(simple anterior frame constructs)
• internal symphyseal plating (single or double)
• ramus fixation
Techniques
• Symphyseal plating-incisions– Pfannenstiel if no incision has been made
• good visualization• good cosmesis• Avoid detaching rectus (although one side may be
torn at time of injury)– Use prior midline or paramedian approaches if
available
Techniques
• Symphyseal Plating– Reduction for
rotational displacement• Expose the lateral
portion of the pubic tubercles
• Use a Weber reduction clamp; avoid clamping through the foramen
Matta and Tornetta, CORR 329, pp129-140, 1996
Techniques
• Choice of anterior plating technique– Controversies exist– single plate
• 2 or 4 hole symphysis plate superiorly (6.5 mm screws)
• 6 hole plate anteriorly (3.5 or 4.5 mm screws)– dual plate
• combination of above, placed at right angles
Techniques
• Choice of plating technique-how to decide?– Single plate for open book injuries when stable
posteriorly or posterior fixation is planned– Tile recommends that dual plating should be reserved
for the unusual situation where the posterior injury cannot be addressed due to physiologic instability; the anterior construct can then better withstand superior-inferior and anterior-posterior forces
– A single plate and external fixation is also appropriate
Techniques
• When single anterior plating has failed, it can be from patient compliance, but may more likely be related to unrecognized or underestimated posterior injuries (Matta, Olson, Bucholz)
Techniques
• Pubic Ramus Fractures– ORIF if distracted over 1-1.5 cm – Or significantly rotated to impinge on vaginal
vault, bladder, or rectum (‘tilt fracture’)
Techniques
• Pubic Ramus Fractures– Rarely repaired in Bucholz type II fractures
• Matta series-over 84 percent treated nonoperatively, even in unstable injuries treated posteriorly (Bucholz III or Tile C)
The Decision to Operate -Indications
• Bucholz type III– Complete disruption posteriorly, to
include• SI joint dislocation• Sacral fracture• SI joint fracture dislocation (‘crescent
fracture’) – Variable anterior injury
• symphysis disruption• ramus fractures
The Decision to Operate -Indications
• Bucholz type III
Bruce D. Browner, MDJ. Dean Cole, MD, Initial management of pelvic ring disruption. Instructional Course Lectures 1988, Volume 37:129
The Decision to Operate -Indications
• Bucholz type III– These result in a multiplanar displacement of the
hemipelvis• Translation-posterior & superior• Rotation-external & flexion
– These injuries are completely unstable and require operative reduction and fixation; often they cannot be reduced by closed means due to interposing SI joint ligaments and capsule
Selection of Approach• Which portion of the PRI should be
approached first?– If rami fractured, repair posterior ring first
• anterior fixation only if rami fractures meet criteria– If symphysis disrupted, may plate anterior ring
first but must be anatomical (posterior reduction and fixation 1st may be more reliable)
Selection of Approach
• How should the posterior ring injury be approached?– Anterior (supine)– Posterior (prone)– Percutaneously– Combinations of above– External fixation is not definitive
Selection of Approach
• How should the posterior ring injury be approached?– other injuries may dictate the positioning of the
patient• severe pulmonary/thoracic trauma• unstable spine trauma• severe soft tissue injuries (abrasion/contusion)• associated degloving (I.e. Morel-Lavalle)
Selection of Approach• Supine position-Anterior Approach
– Indications• SI joint dislocation• SI joint fracture-dislocation (crescent)• Iliac wing fracture
– Contraindications• Sacral Fracture• Comminution/impaction of sacral ala
results in poor screw fixation
Techniques
• Anterior fixation of the SI joint dislocation– Advantages
• good visualization• good stability• soft tissue complications less common
– Disadvantages• more difficult approach• L5 nerve root at risk
Techniques
• Supine position-Anterior Approach– Fixation involves
anterior plating, using recon-type plates or dynamic compression plates placed at 90° to each other (at least three hole plate with one screw into the sacrum)
M Tile in Schatzker, Tile (eds). Rationale of Operative Fracture Care, Springer, Berlin, 1996, p221-270
Techniques
• Anterior fixation of the SI joint dislocation– Incision along iliac crest to beyond ASIS– Essentially the lateral window of the
ilioinguinal approach– Sweep away iliacus to approach SI joint– Can be used in conjunction with acetabular
ORIF
Selection of Approach• Prone position-Posterior approach
– Indications• SI joint dislocation• SI joint fracture dislocation (crescent)• Sacral fracture
– Contraindications• Soft tissue problems• Patient unable to tolerate prone position
Techniques• Prone position-Posterior
approach– Advantages
• good visualization and stability
• versatile• uncomplicated approach• Use of clamps for fracture
reduction– Disadvantages
• soft tissue injuries may be present and can occur
Techniques
• Prone position-Posterior approach– Vertical incision 1cm lateral to the posterior
iliac spine, from the crest to the sciatic notch– The G. maximus is incised and reflected
anterolaterally, allowing visualization to the sciatic notch
– A laminar spreader can be placed within the fracture to clear debris (Borrelli, Koval, and Helfet) if extraforaminal
Matta, Surgical Approaches to the Acetabulum
Matta, Surgical Approaches to the Acetabulum
Techniques
• Posterior reduction techniques (Matta and Tornetta)– A pointed reduction clamp is placed with one
point on the anterior sacral ala lateral to the S1 foramen and the other placed on the outer ilium.
– A Weber clamp can be used for cephalad displacement
Matta and Tornetta, CORR 329, pp129-140, 1996
Techniques
• Reduction of the posterior ring injury can be aided by initial reduction and plating of the anterior ring injury (if anterior injury is a symphysis disruption)– Reduction for rotational and vertical
displacement• an anchoring plate with a Jungbluth (AO) reduction
clamp can be effective for anterior reductions prior to symphyseal plating
Matta and Tornetta, CORR 329, pp129-140, 1996
Techniques
• Prone position-Posterior approach– Options for fixation
• SI screws– for SI joint fractures/dislocations
• Transiliac plates or rods
Techniques• Posterior fixation
– Posterior plating or transiliac rods can be placed
– these require a second approach on the contralateral side
Techniques• Posterior fixation
– Single or multiple iliosacral screws can be placed (2 preferred with threads into S1 superior portion)
– An anatomic ‘safe zone’ has been established
from Matta JM, Saucedo T: Clin Orthop 242:83, 1989; original by Zilbert
Techniques - Sacral Fixation• Between the S1 foramen and the superior margin of
the ala on the 40 degree cephalic (outlet) view• Between the neural canal and the anterior margin of
the body on the 40 degree caudad (inlet) view
Techniques• Percutaneous Techniques
of iliosacral screw fixation– Can be done with patient
either supine or prone– Less soft tissue dissection,
less risk of infection– Must have an acceptable
closed reduction in order to be successful
• Often Bucholz III cannot be reduced by closed means
Complication of Injury
• Pain• Deformity• Soft-tissue degloving lesions• Neurologic injury• Impotence
Complications of Treatment
• Infection• Neurologic Injury• Loss of reduction
Prevention of Complications
• Recognize soft-tissue injury• Avoid incisions through compromised tissue• Use appropriate fixation for the injury• Use care when placing implants
Closed Internal Degloving Injury• Traumatic separation - subcutaneous tissue from fascia• Fluid cavity develops with hematoma and necrotic fat• Degloving over trochanter is known as “Morel-Lavelle’ Lesion”
• Diagnosis Made On Physical Exam: Soft Fluctuant Area Over The Lesion Positive Fluid Wave Loss of Local Cutaneous Sensation
Pre-operative Considerations• Thorough surgical debridement of degloving injury prior to or at
time of fixation via surgical approach or via separate incision• Plan separate incisions carefully to avoid limiting surgical access
•Leave skin and subcutaneous tissue open
•May use delayed primary closure in some cases
Infection
• Serous drainage is common for several days post-operatively
• Bloody drainage or purulence is not normal.• Consider returning to OR for I&D when signs
of recurrent or abnormal drainage occur.• Antibiotic therapy should be guided by cultures
Hardware Placement Take Care To Avoid Injury to Neurovascular Structures
Several structures can be at risk during surgical fixation
L5/S1 nerve roots, sacral canal, branches of the internal iliac system.
Biomechanics
• Use fixation appropriate to the injury• Several investigators have compared the
previously discussed fixation options for structural rigidity
• Few outcome studies have been performed to directly compare methods, so much of the information is based on laboratory benchtop studies
Biomechanics
• Anterior fixation methods– External Fixation– Symphysis/Ramus plating
• Symphysis plating provides superior rigidity to internal and external rotation forces
• Neither provides sufficient rigidity for vertical instability/posterior injuries
Biomechanics
• Posterior fixation methods– Multiple studies have compared various
posterior stabilization procedures– Simonian found no significant difference for
single screw, double screw, plate, or transiliac bar with regards to load to failure in double limb stance models
Biomechanics• Posterior fixation
– Olson compared displacements following Bucholz III injuries in single limb, muscle- stabilized model
• single SI screw• multiple SI screws• SI plate• Transiliac plates and rods
– All constructs were stiffer than a single screw
Biomechanics• The most secure form of
fixation may be– two sacroiliac screws -or-– two anterior plates with an SI
screw• For bilateral dislocations
(‘grade IV’)– the above construct may be insufficient– a single plate or bar in addition to a single SI screw on each side may be most secure
Outcomes
• Functional outcomes are often assessed• The most common outcome is residual pain• The most significant influence on outcome
in PRI was neurologic injury
Outcomes
• Multiple studies have compared outcomes in varying injuries– Comparison of Tile A, B, and C or Injury
Severity Score (ISS) show no significant difference in outcome in some studies
– Similarly, fracture location did not significantly affect outcome in every study
Outcomes
• Often patients do not return to previous levels of employment or activity (return: 40% Cole et al, 75% Miranda et al, 67-83% Tornetta)
• Erectile dysfunction occurs in 20-80%
Outcomes
• Promising outcomes come from those with Bucholz II injuries who undergo ORIF and achieve a more anatomical reduction– Tornetta (1996) reports 96% have full
ambulation– 69% have no residual pain– 83% were able to resume their previous job– 0% had difficulty with sexual activity
Summary of Treatment
• Bucholz I - Nonoperative• Bucholz II - Operative treatment with
anterior or posterior ring stabilization• Bucholz III - Operative treatment with
posterior and possibly anterior ring fixation
Acknowledgment Pelvic Ring Injuries can be devastating, but with prompt
and thoughtful care, outcomes have been shown to improve.
Return to Pelvis Index
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