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Pelvic Ring Disruptions Pelvic Ring Disruptions
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James F. Kellam, M.D., F.R.C.S.(C.) Keith Mayo, M.D.
The pelvis is the key link between the axial skeleton and the major weight-bearing locomotive structures, the lower extremities. The forces resulting from activities such as sitting and ambulating are transferred through its bony structure to the spine. Major structures of the vascular, neurologic, genitourinary, and gastrointestinal systems pass through or across its ring. Because the extensive disruption that results from signicant injuries to this ring has important consequences for these associated structures, the potential for death and disability is high. Orthopaedic surgeons treating any multiply injured patient must understand and be prepared to deal with the consequences of major pelvic disruption.* In addition, even after treatment of the pelvic injury, residual deformity can create signicant problems in functional recovery.44, 60 Pain has been reported as a common problem after major pelvic disruptions. Holdsworth46 reported that 15 of 27 patients with sacroiliac joint dislocations were unable to return to work. His study concluded that displacement of the sacroiliac joint was a signicant cause of this disability. Peltier81 emphasized the posterior weight-bearing capacity of the sacroiliac area and its importance in mortality and morbidity from multiple injuries. Raf,87 Dunn and Morris,24 and Huittinen and Slatis47 have all conrmed that displacement through the weight-bearing arch of the pelvis, particularly if the sacroiliac joint is involved, can lead to long-term problems of pain and inability to pursue a functional lifestyle. A review by Tile112 showed a signicant difference between fractures that were classied as stable and those that were classied as unstable. The unstable group had a signicant increase over the stable group in the incidence of pain in the posterior sacroiliac region. Leg length discrepancy indicating a malunion was signicantly higher in the unstable group. Even nonunion of the pelvis was a problem, particularly in injuries that involved the sacroiliac joint. Patients in the series who had open anatomic
*See references 7, 21, 30, 35, 39, 60, 68, 71, 73, 76, 85, 86, 89, 90, 92, 104, 105.
reduction and stabilization of the pelvic ring appeared to do better. This subdivision of pelvic fractures into two groupsstable and unstableseems to be validated by other studies.11, 20, 28 Stable fractures usually do well and cause minimal disability. Patients with unstable fractures have more signicant problems, such as a higher mortality rate9, 21, 30, 66 and a higher rate of dysfunction secondary to pain, malunion, and occasionally, nonunion.43, 45 To minimize these problems, treatment of pelvic injuries should be based on an understanding of the anatomy and biomechanics of the pelvis, with particular regard to stability. These principles are applied by using a functional description of the injury so that the right treatment is used for the right injury. The goal is to restore the displaced pelvic ring to as close an anatomic position as possible with the minimum of complications.
ANATOMY
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The pelvis is a ring structure made up of three bones: the sacrum and two innominate bones. The innominate bone is formed from the fusion of three ossication centers: the ilium, the ischium, and the pubis (Fig. 361). These three centers coalesce at the triradiate cartilage of the acetabulum and, when fused, form the complete innominate bone. The innominate bones join the sacrum posteriorly at the two sacroiliac joints. Anteriorly, they are joined to one another at the pubic symphysis. The three bones and three joints composing the pelvic ring have no inherent stability without vital ligamentous structures.106 The strongest and most important ligamentous structures occur in the posterior aspect of the pelvis. These ligaments connect the sacrum to the innominate bones. The stability provided by the posterior ligaments must withstand the forces of weight bearing transmitted across the sacroiliac joints from the lower extremities to the spine. The symphysis acts as a strut during weight bearing to maintain the structure of the pelvic ring. The posterior
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Copyright 2003 Elsevier Science (USA). All rights reserved.
CHAPTER 36 Pelvic Ring Disruptions
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FIGURE 361. The bony architecture of the pelvis consists of the sacrum and the two innominate bones. Without their ligamentous attachments, these bones provide no inherent stability.
sacroiliac ligaments are divided into two components: short and long. The short posterior ligaments are oblique and run from the posterior ridge of the sacrum to the posterior superior and posterior inferior spines of the ilium. The long posterior ligaments are longitudinal bers that run from the lateral aspect of the sacrum to the posterior superior iliac spines and merge with the sacrotuberous ligament. The long ligaments cover the short ligaments. Anteriorly, the sacroiliac joint is covered by a at, strong ligamentous structure that runs from the ilium to the sacrum. This structure provides some stability, but less than that provided by the posterior ligaments (Fig. 362). The sacroiliac joint is made up of two parts. The inferior portion consists of the articular surface of the joint; the upper, more dorsal portion, between the posterior tuberosity of the ilium and the sacrum, contains the brous or ligamentous parts of the joint (interosseous ligaments). The anterior portion of this synovial joint is covered with articular cartilage on the sacral side and brocartilage on the iliac side. The joint itself has a small ridge on the sacral
side that provides minimal stability. In the upright position, the weight of the body pushes the sacrum down between the iliac wings and causes approximately 5 dorsoventral rotation.79 The innominate bones move backward and downward as the pubic rami swing upward.60 Precise reduction and reestablishment of the morphology of the sacroiliac joint may not be as important as for an extremity joint because tight contact between the articular surfaces never occurs in normal function119 (Fig. 363). The symphysis pubis consists of two opposed surfaces of hyaline cartilage. These surfaces are covered with brocartilage and surrounded by a thick band of brous tissue. The symphysis is reinforced inferiorly by muscle insertions and the arcuate ligament. The thickest portion of this brous joint is usually superior and anterior. In addition to the interosseous ligaments that span these joints, connecting ligaments join various portions of the pelvic ring. The sacrotuberous ligament is a strong band running from the posterolateral aspect of the sacrum and the dorsal aspect of the posterior iliac spine to the ischial tuberosity. Its medial border thickens to form a falciform tendon that blends with the obturator membrane at the ischial tuberosity. It also merges into the posterior origin of the gluteus maximus. This ligament, in association with its ipsilateral posterior sacroiliac ligaments, is especially important in maintaining vertical stability of the pelvis. The sacrospinous ligament is triangular. It runs from the lateral margins of the sacrum and coccyx and the sacrotuberous ligament to insert on the ischial spine. It divides the posterior column of the pelvis into the greater and lesser sciatic notches. The sacrospinous ligament may be important in maintaining rotational control of the pelvis if the posterior sacroiliac ligaments are intact (see Fig. 362). Several ligaments run from the spine to the pelvis. The iliolumbar ligaments secure the pelvis to the lumbar spine. They originate from the L4 and L5 transverse processes and insert on the posterior iliac crest. The lumbosacral
Posterosuperior iliac spine Posteroinferior iliac spine Post sacroiliac ligaments: short long
FIGURE 362. Ligamentous complexes of the pelvis. A, Posteriorly, the major ligaments noted in the region of the sacroiliac joint are the posterior sacroiliac ligaments, both long and short. These structures blend with the sacrospinous and the sacrotuberous ligaments. B, In cross section, the orientation of the very thick posterior interosseous sacroiliac ligaments can be noted.
Dorsum ilii Iliac crest
Posterosuperior iliac spine
Gluteal lines: posterior anterior inferior Greater sciatic foramen Tip of coccyx Sacrospinous ligament and ischial spine Lesser sciatic foramen Falciform edge
Capsule of hip joint
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Interosseous sacroiliac ligaments Greater trochanter Sacrotuberous ligament
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Ischial tuberosity Lesser trochanter
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Iliac crest Anterosuperior spine Posteroinferior spine Superior articular process
Posterosuperior spine Print Graphic Anteroinferior spine Iliopubic eminence Os pubis Presentation Body of pubis Inferior ramus of pubis Margin of obturator foramen Lateral sacral crest Greater sciatic notch Superior ramus of pubis Ischial spine Lesser sciatic notch Falciform crest Ischial tuberosity Ramus of ischium
Body
Cornua of sacrum and coccyx
Transverse process of coccyx
FIGURE 363. The sacroiliac joint. A, Iliac side of the sacroiliac joint, as well as the remainder of the innominate bone and the important bony landmarks. B, Sacral side. The two portions of the sacroiliac joint can best be appreciated on these views. The articular surface of the sacroiliac joint on the sacrum has a ridge and is covered by articular cartilage. The posterior portion is lled with ligamentous structures.
Tip of coccyx
ligaments run from the transverse process of L5 to the ala of the sacrum. They form a strong ridge anteriorly and abut the L5 root. If its ligamentous structures are intact, the pelvis is a stable ring. The posterior sacroiliac ligaments consist of the lumbosacral and iliolumbar ligaments, and they form a posterior tension band for the pelvis. The transversely placed ligaments, including the short posterior sacroiliac and the anterior sacroiliac along with the iliolumbar and sacrospinous ligaments, resist rotational forces. The vertically placed ligaments, including the long posterior sacroiliac, sacrotuberous, and lateral lumbosacral ligaments, may resist vertical shear or vertical migration. Holographic analysis of pelvic stability has shown that removal of the sacrotuberous or sacrospinous ligaments, or both, has no effect on patterns of pelvic deformation. However, if the sacroiliac interosseous ligaments are excised, the sacrum becomes wedged deeply into the pelvis on erect loading.119 These ligaments must act in unison to maintain pelvic stability. The intact pelvis forms two major anatomic areas. The false pelvis and the true pelvis are divided by the pelvic brim, or the iliopectineal line, which runs from the sacral promontory along the junction between the ilium and the ischium onto the pubic ramus. No major muscular structures cross the pelvic brim. Above the brim, the false pelvis (greater pelvis) is contained by the sacral ala and the iliac wings. It forms part of the abdominal cavity. The inner false pelvic surface is covered by the iliopsoas muscle. The true pelvis (lesser pelvis) is below the brim, and its lateral wall consists of the pubis, ischium, and a small triangular portion of the ilium. It includes the obturator foramen, which is covered by muscles and membrane and opens superiorly and medially for passage of the obturator nerve and vessels. The obturator internus takes its origin from the membrane and curves out through the lesser sciatic notch to attach to the proximal end of the femur. The obturator internus tendon is an important structure
because it serves as a guide to access the posterior column (Fig. 364). The piriformis originates from the lateral aspect of the sacrum and is key to understanding the sciatic nerve. Commonly, the sciatic nerve leaves the pelvis beneath the piriformis and enters the greater sciatic notch. Occasionally, the peroneal division leaves through or above the piriformis (Fig. 365). The oor of the true pelvis consists of the coccyx, the coccygeal and levator ani muscles, and the urethra, rectum, and vagina, which pass through them. The lumbosacral coccygeal plexus is made up of the anterior rami of T12 through S4, the most important of which are the L4 to S1 roots. The lumbar roots L4 and L5 enter the true pelvis from the false pelvis, whereas the sacral roots are part of the true pelvis. The L4 root runs between the L5 nerve and the sacroiliac joint and merges with L5 to form the lumbosacral trunk at the sacral promontory (12 mm from the joint line). The L5 root is 2 cm away from the sacroiliac joint as it exits the intervertebral foramen.3 The sacral roots pass through the sacral foramen and join the plexus. Numerous branches extend to the major muscles within the pelvis. The superior gluteal and inferior gluteal nerves leave ventral to the piriformis and exit the pelvis through the greater sciatic notch. Major blood vessels lie on the inner wall of the pelvis. The median sacral artery is situated on the anterior aspect of the midline of the sacrum. The superior rectal artery is a major branch lying midline and posterior. The common iliac divides and gives off the internal iliac, which runs over the pelvic brim. A branch of the internal iliac, the superior gluteal artery, crosses over the anteroinferior portion of the sacroiliac joint to exit the greater sciatic notch. As it sweeps around the notch, it lies directly on bone. The external iliac artery exits the pelvis anteriorly over the pelvic brim (pubic ramus). These arteries and associated veins can all be injured during pelvic disruption (Fig. 366).
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Iliacus Obturator nerve
Pelvic brim Print Graphic
Lumbosacral nerve plexus
True pelvis Presentation True pelvis
Obturator internus
Sacrospinous ligament
B
Sacrotuberous ligament
FIGURE 364. Internal aspect of the pelvis. A, The inner aspect of the pelvis consists of the true pelvis, which is below the pelvic brim or iliopectineal line, and the false pelvis above it. The sacrotuberous and sacrospinous ligaments are attached to their appropriate structures and form the basis of the pelvic oor. B, The major structures in the inner aspect of the pelvis are the lumbosacral plexus, which originates from the L5 and the sacral roots and leaves the pelvis through the greater sciatic notch as the sciatic nerve, and the superior gluteal artery. The obturator internus originates from the obturator membrane and loops out through the lesser sciatic notch. Note that no muscles cross the pelvic brim.
The major components of the genitourinary system involved in pelvic trauma are the bladder and urethra. The bladder is situated superior to the pelvic oor (i.e., coccygeal and levator ani muscles). These muscles arise in
continuity from the ischial spines, obturator membrane, and pubis and insert into the coccyx and anal coccygeal raphe. They form a musculature diaphragm with a gap anteriorly through which pass the urethra, vagina, rectum,
FIGURE 365. The outer aspect of the pelvis, as viewed posteriorly through the notch, shows how the piriformis originates from the inner aspect of the pelvis and attaches to the greater trochanter. Above this structure, the superior gluteal artery and vein lie very close to bone in the sciatic notch. This proximity to bone makes these vessels vulnerable to injury in pelvic disruptions. Below the piriformis, the sciatic nerve usually disappears and runs extremely close to the ischium.
Superior gluteal artery and vein Print Graphic
Piriformis Presentation Sciatic nerve
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and support ligaments. The fascia of the pelvic oor is loose and mobile. In males, the prostate lies between the bladder and pelvic oor and is invested by a dense fascial membrane. The urethra passes through the prostate and exits below the pelvic oor. Associated with passage of the urethra through the urogenital diaphragm are pudendal arteries and veins, the pudendal nerve (S2S4), and the autonomic nerves of the pelvis (S2S4), which are all responsible for the erectile mechanism in males. The junction between the prostate and the pelvic oor is strong, as is the membranous urethra. The weak link in this area is the urethra below the pelvic diaphragm in its bulbous portion. Colapinto has shown that when the bladder is pulled forcefully, the urethra ruptures in its bulbous portion, which is the most common site of urethral rupture below the pelvic oor.14 Occasionally, the membranous portion of the urethra ruptures at the upper surface of the pelvic oor. In females, the urethral injury is near the bladder neck. Urinary continence is dependent on the external (striated muscle) sphincter at the membranous urethra (midurethra in females) and the bladder neck (smooth muscle) in both males and females. An understanding of pelvic anatomy will help orthopaedic surgeons maintain a high degree of suspicion for recognizing retroperitoneal bleeding, as well as injuries involving the genitourinary or gastrointestinal systems.
PELVIC STABILITY
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz A stable pelvic injury can be dened as one that can withstand normal physiologic forces without abnormal deformation. Tile and Hearn,113 using a physiologic mechanical testing system, showed that with sitting or
standing, the symphysis is in tension and the posterior complex is compressed. In single stance, the symphysis is compressed and the posterior complex is distracted. For this action to occur, the pelvic ring must maintain its anatomic integrity through its ligamentous and bony components.113 Sequential sectioning of the ligaments of the pelvis can help dene the relative value of individual components of the entire spectrum of pelvic stability.113 If only the symphysis is sectioned, mechanical testing of the pelvis reveals a symphyseal diastasis no greater than 2.5 cm. Further opening is inhibited by the sacrospinous and anterior sacroiliac ligaments. If the symphysis and anterior sacroiliac ligaments are sectioned, more than 2.5 cm of external rotation (diastasis) is noted (Fig. 367). Abutment of the posterior iliac spines against the sacrum stops the pelvis from any further rotation. These investigators noted that absolute vertical instability or posterior displacement did not occur because the posterior longitudinal ligaments and sacrotuberous ligaments remained intact. Ghanayem and colleagues have demonstrated the secondary effect of the abdominal muscles on maintaining rotational stability.38 In this situation, the pelvis is rotationally unstable but vertically stable and can therefore be restored to its anatomic integrity by use of the intact posterior osseous ligamentous hinge. With sectioning of the symphysis, sacrospinous, sacrotuberous, and posterior sacroiliac ligaments, the pelvis becomes vertically, posteriorly, and rotationally unstable (Fig. 368). However, if the symphysis remains intact while the posterior ligaments are sectioned, little posterior instability occurs because the posterior bony complex is compressed.113 It must be kept in mind that some bone injuries produce instability equivalent to that caused by disruption of the posterior ligaments. Fractures through the iliac wing bypass the ligamentous structures and,
Common iliac artery Ureter External iliac artery External iliac vein Vas deferens Obturator nerve Presentation Superior vesical artery Bladder Rectum Symphysis pubis Internal iliac artery (hypogastric artery) S1 nerve S2 nerve Print Graphic Superior Inferior gluteal artery
Pelvic splanchnic nerves Lumbosacral artery
FIGURE 366. Internal aspect of the pelvis showing the great vessels and the lumbosacral plexus, as well as the pelvic oor, bladder, and rectum.
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Posterior hinge
Sacrospinal and sacrotuberal ligaments
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FIGURE 367. Pelvic stability. A, The intact ligamentous bony structures of the pelvis maintain its integrity with regard to stability. The posterior hinge, which consists of the posterior sacroiliac ligaments and the iliolumbar ligaments, is imperative for maintaining vertical stability. The sacrospinous ligament prevents rotation, and the sacrotuberous ligament prevents vertical migration. As long as those ligaments, the anterior sacroiliac ligament, and the symphysis are intact, the pelvis will remain stable. If, however, the anterior symphysis is separated or the sacrum is crushed posteriorly, as seen in B and C, the posterior hinge remains intact and the pelvis is usually stable vertically. The sacrospinous ligaments are intact, and rotatory abnormalities are thus prevented.
hence, are unstable unless they are impacted. A shear fracture, the result of violent force perpendicular to the bony trabeculae of the posterior ring, and fracturedislocation of the sacroiliac joint are other injuries that can produce equivalent degrees of instability (Fig. 369).
which causes external rotation of the hemipelvis. As a result of a posteriorly directed force, the pelvis springs open and hinges on the intact posterior ligaments. This force ruptures the pelvic oor and anterior sacroiliac ligaments. No vertical instability occurs because the posterior ligamentous complex is intact.
PATHOMECHANICS AND MECHANISMS OF PELVIC DISRUPTION Anteroposterior Force Pattern
Lateral Compression Force Pattern

The most common force pattern of pelvic fractures is lateral compression. The lateral compression force is commonly directed to the outer aspect of the iliac wing or pelvis and usually is parallel to the trabeculae of the sacrum. This injury creates compression or impaction of the cancellous bone of the sacrum. Depending on the area
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Pelvic disruptions can be caused by four different force patterns. The rst is the anteroposterior (AP) force pattern,
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Avulsion fracture ischial spine
Avulsion fracture L5 transverse process Presentation
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FIGURE 368. A, Division of the symphysis pubis will allow the pelvis to open to approximately 2.5 cm with no damage to any posterior ligamentous structures. B, Division of the anterior sacroiliac and sacrospinous ligaments, either by direct division of their bers (right) or by avulsion of the tip of the ischial spine (left), will allow the pelvis to rotate externally until the posterior superior iliac spines abut the sacrum. Note, however, that the posterior ligamentous structures (e.g., the posterior sacroiliac and iliolumbar ligaments) remain intact. Therefore, no displacement in the vertical plane is possible. C, Division of the posterior tension band ligaments, that is, the posterior sacroiliac, as well as the iliolumbar, depicted here on the left side, plus avulsion of the transverse process of L5 will cause complete instability of the hemipelvis. Note that posterior displacement is now possible.
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FIGURE 369. A shearing force (arrows) crosses perpendicular to the main trabecular pattern of the posterior pelvic complex in the vertical plane. These forces cause marked displacement of bone and gross disruption of soft tissues and result in major pelvic instability.
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applied through the femoral shafts and hips. The leg is caught and externally rotated and abducted, a mechanism that tends to tear the hemipelvis from the sacrum. In analyzing postmortem specimens from motor vehicle accidents, Bucholz11 has demonstrated that signicant disruption of the posterior structures can occur and lead to an unstable injury through the sacroiliac area. He has conrmed pathologically that unstable AP compression injuries involve complete disruption of the posterior supporting ligamentous structures.
Shear Force Pattern

FIGURE 3610. Lateral compressionunstable. In this mechanism, the force (arrow) is directed over the anterior aspect of the hemipelvis. The hemipelvis pivots around the anterior portion of the sacroiliac joint, thus compressing the sacrum or fracturing through the ilium (or both). Posteriorly, the posterior interosseous hinge is now disrupted and the pelvis is unstable in internal rotation. It may exhibit some degree of vertical instability. Vertical instability is limited by the intact sacrotuberous ligaments.
of impaction and the magnitude of this force, different lateral compression injuries are seen. If force is applied to the posterior aspect of the pelvis, a lateral compression impaction fracture into the sacrum results. It causes minimal soft tissue disruption because the posterior ligamentous structures relax as the hemipelvis is driven inward. Because the force of injury is essentially parallel to the ligament bers and trabeculae of the bone, it produces a very stable fracture conguration. In the second type of lateral compression, the force is directed over the anterior half of the iliac wing. This force tends to rotate the hemipelvis inward, with the pivot point being the anterior sacroiliac joint or anterior ala. Consequently, the anterior portion of the sacrum is crushed, and disruption of the posterior sacroiliac ligament complex follows.21, 124 This injury becomes more unstable as disruption of the posterior osseous ligamentous structures increases. However, the sacrospinous and sacrotuberous ligaments are intact, and most important, the pelvic oor remains intact, thereby limiting translational instability (Fig. 3610). This force can continue to push the hemipelvis across to the opposite side and compel the contralateral hemipelvis to externally rotate. This action produces a lateral compression injury on the side where the force has been applied and an external rotation injury on the contralateral side, with disruption of the anterior bers of the sacroiliac joint.124 The resulting anterior pelvic lesions may be any combination of ramus fractures or fracture-dislocations through the symphysis. Finally, a force applied over the greater trochanteric region also produces a lateral compression injury, usually associated with a transverse acetabular fracture.
Shear fractures are the result of high-energy forces usually applied perpendicular to the bony trabeculae; these forces lead to an unstable vertical fracture with a variable degree of translational instability. Avulsion injuries through the pelvic ligamentous attachments and the lumbar transverse processes may occur with this mechanism of disruption. If this injury disrupts the sacrospinous and the sacrotuberous ligaments, the involved hemipelvis becomes vertically unstable. The exact fracture pattern depends on both the amount of force applied and the bone strength in relation to the ligamentous structures. In an osteoporotic or elderly individual, bone strength is proportionately less than ligamentous strength and the bone, therefore, fails rst. Conversely, in a young person, in whom bone strength is relatively greater, ligamentous disruptions usually occur primarily. In conclusion, pelvic ring fractures occur when the pelvis is disrupted anteriorly and posteriorly.40 The mechanism of injury should be determined from the clinical history and fracture pattern, and then stability must be assessed. Classications and diagnostic tests are aimed at categorization of the stability to allow logical treatment decisions to be made.
CLASSIFICATION OF PELVIC DISRUPTIONS Anatomic Classications
Several anatomic classications have been proposed. Letournel and Judet58 suggested a classication based on the site of injury (Fig. 3611). Bucholz11 proposed a pathologic classication based on autopsy studies. Five sites of injury were characterized: (1) anterior vertical fractures dividing the obturator ring or adjacent bodies of the pubis, (2) transiliac fractures extending from the crest of the greater sciatic notch, (3) transsacral fractures either outside or inside the foramina, (4) pure separation of the symphysis, and (5) pure disruption of the sacroiliac joint.
External Rotation-Abduction Force Pattern

The third force, a common one in motorcycle accidents, is an external rotation-abduction force, which is usually
Mechanism-of-Injury Classication (Young and Burgess)

A classication by Young and Burgess124 based on the mechanism of injury alerts the surgeon to potential
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resuscitation problems associated with pelvic fractures. The classication has three major components. The rst is an AP compression injury,124 which is divided into three types. Type I, characterized by less than 2.5 cm of diastasis, consists of vertical fractures of one or both pubic rami or disruption of the symphysis. Because no posterior injury of signicance occurs, problems with resuscitation are minimal. An AP compression type II injury has greater than 2.5 cm of symphyseal diastasis with opening of the sacroiliac joints, but vertical stability is maintained. An AP compression type III injury is a complete disruption anteriorly and posteriorly, with signicant posterior diastasis and displacement of vertical pubic ramus fractures. This fracture is essentially completely unstable with signicant associated injuries. The second component in the Young and Burgess classication is a lateral compression injury.124 A lateral compression type I injury results from a posteriorly applied force that causes sacral impaction. It is stable. Patients with these injuries usually have minimal problems with resuscitation. A lateral compression type II injury follows an anteriorly directed force with resultant disruption of the posterior osseous/ligamentous structures but maintenance of vertical stability. It may be associated with an anterior sacral crush injury. These two injuries are often coupled with head injuries and intra-abdominal trauma. A lateral compression type III injury results from a laterally directed force that has continued to cross the pelvis to produce an external rotation injury to the contralateral hemipelvis, similar to the isolated injuries caused by the patient being crushed or rolled over. This injury component is isolated to the pelvis and has a minimum of signicant associated injuries. The nal component is a vertically unstable or shear injury and a combined mechanism injury leading to unstable fracture patterns with signicant retroperitoneal hemorrhage and major associated injuries21, 124 (Fig. 3612).
The Young and Burgess classication was developed to enable trauma surgeons to more adequately predict associated major injuries within the pelvis and abdomen and to allow resuscitative therapy to be carried out in a more logical and predictive fashion. AP injuries are associated with an increased incidence of pelvic vascular injuries and therefore an increased incidence of shock, sepsis, adult respiratory distress syndrome, and death. Lateral compression injuries carry a high incidence of associated brain and visceral injuries but a lesser incidence of pelvic vascular injuries and associated complications. Death caused by an AP injury is related to the combined effect of blood loss from pelvic vascular and visceral injuries, whereas death caused by a lateral compression injury is usually related to associated brain or severe intra-abdominal injury (or both). Vertical shear injuries tend to follow a pattern similar to that of lateral compression injuries with regard to associated injuries, pelvic vascular injuries, and death.21 The causes of each particular injury pattern are typically different. AP injuries usually occur in pedestrians and motorcyclists. Lateral compression injuries more commonly result from motor vehicle collisions and vertical shear injuries from falls. Therefore, with knowledge of the mechanism of injury and review of the initial AP radiographs, a logical approach to resuscitation and appropriate surgical decisions can be made regarding the cause and surgical management of hypovolemic shock.20, 21, 28
Comprehensive Pelvic Disruption Classication (Modied after Tile)

This classication combines both the mechanism of injury and the degree of pelvic stability and can be used as an aid in determining the prognosis and treatment options43, 112 (Fig. 3613). Determination of pelvic stability with regard to rotation, vertical and posterior displacement, the history and mechanism of injury, and assessment of soft tissue injuries allows a complete classication to be made (Table 361). Type A injuries preserve the bony and ligamentous integrity of the posterior complex of the pelvis and the pelvic oor. A type A1 injury consists of avulsion of the pelvic apophyses by a sudden muscular pull; these injuries are never unstable and usually require only symptomatic care. Type A2 injuries represent isolated iliac wing fractures. Because they have not violated the anterior or posterior osseous ligamentous hinge, they remain completely stable. This group also includes undisplaced low-energy pelvic ring injuries, which are usually seen in osteoporotic bone (Fig. 3614). A type A3 injury consists of fractures of the sacrum and coccyx that do not involve a pelvic ring injury (below S2). As has been shown by Denis22 and Kaehr48 and their colleagues, appropriate assessment of these sacral fractures may be necessary to determine the extent of neurologic compromise and whether decompression is required. If the sacral fracture extends into the S1 and S2 vertebrae and is associated with an anterior injury, it is classied more appropriately as a pelvic ring disruption.
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FIGURE 3611. The Letournel and Judet classication of pelvic fractures is anatomic. A, Iliac wing fractures; B, ilium fractures with extension to the sacroiliac joint; C, transsacral fractures; D, unilateral sacral fractures; E, sacroiliac joint fracture-dislocation; F acetabular fractures; G, pubic , ramus fractures; H, ischial fractures; I, pubic symphysis separation. It should be remembered that combinations of all of these injuries could occur.
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III
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B
I II III
C
FIGURE 3612. Young and Burgess classication. A, Lateral compression force. Type I: a posteriorly directed force causing a sacral crushing injury and horizontal pubic ramus fractures ipsilaterally. This injury is stable. Type II: a more anteriorly directed force causing horizontal pubic ramus fractures with an anterior sacral crushing injury and either disruption of the posterior sacroiliac joints or fractures through the iliac wing. This injury is ipsilateral. Type III: an anteriorly directed force that is continued and leads to a type I or type II ipsilateral fracture with an external rotation component to the contralateral side; the sacroiliac joint is opened posteriorly, and the sacrotuberous and spinous ligaments are disrupted. B, Anteroposterior (AP) compression fractures. Type I: an AP-directed force opening the pelvis but with the posterior ligamentous structures intact. This injury is stable. Type II: continuation of a type I fracture with disruption of the sacrospinous and potentially the sacrotuberous ligaments and an anterior sacroiliac joint opening. This fracture is rotationally unstable. Type III: a completely unstable or a vertical instability pattern with complete disruption of all ligamentous supporting structures. C, A vertically directed force or forces at right angles to the supporting structures of the pelvis leading to vertical fractures in the rami and disruption of all the ligamentous structures. This injury is equivalent to an AP type III or a completely unstable and rotationally unstable fracture. (AC, Redrawn from Young, J.W.R.; Burgess, A.R. Radiologic Management of Pelvic Ring Fractures. Baltimore, Munich, Urban & Schwarzenberg, 1987.)
Type B fractures are incomplete disruptions of the posterior arch that allow rotation of the hemipelvis (see Fig. 3613). A B1 injury is a unilateral external rotation or anterior compression (open-book) injury (Fig. 3615A). A variable degree of widening of the sacroiliac joint may be present (see Fig. 3615B). A type B3.1 injury is a bilateral external rotation injury with greater than 2.5 cm of symphyseal displacement. This injury is unstable in external rotation. The sacrotuberous ligament remains intact, as do most of the posterior ligaments, and no vertical instability occurs. If vertical instability is present, the injury is classied as a type C injury (see Fig. 3615C). Type B2 injuries are produced by lateral compression or internal rotation and are vertically stable (see Fig. 3613B). A type B2.1 injury represents an anterior crush or
compression fracture of the sacrum associated with fractures of the pubic rami. This injury is usually caused by a force directed over the posterior iliac wing; the force produces a sacral impaction injury and spares the ligaments (Fig. 3616). Unusual anterior arch injuries are a locked symphysis and a tilt fracture. A locked symphysis injury disrupts the symphysis rather than fracturing the rami as it drives one side of the symphysis behind the other (Fig. 3617B). A tilt fracture is an unusual variant of a lateral compression injury in which the superior pubic ramus is fractured near the iliopectineal eminence and through the ischial ramus; the fragment tilts inferiorly and anteriorly into the perineum and dislocates the symphysis. This injury is seen more commonly in females than males. The major problem with this fracture is its position within the perineum, especially in females, where the pubic
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SECTION III Pelvis
B1
Print Graphic
Presentation
B2
Incomplete partially stable lesion
C
Complete unstable lesion
FIGURE 3613. Modied Tile AO Muller classication. Pelvic ring injuries may be classied as stable or unstable depending on the integrity of the posterior arch. Stable lesions have an intact posterior arch (A), whereas unstable lesions can be divided into incompletely or rotationally unstable injuries with partial integrity of the arch or oor (B1, B2) or completely unstable injuries with no part of the oor or posterior arch intact (C). (AC, Redrawn from Muller, E., ed. Comprehensive Classication of Pelvis and Acetabulum Fractures. Bern, Switzerland, Maurice E. Muller Foundation, 1995.)
Posterior arch intact
Posterior arch disruption
ramus protrudes into the vagina and results in dyspareunia (see Fig. 3617C). A B2.2 injury is produced by a lateral compression force and involves a partial fracture/subluxation of the sacroiliac joint (see Fig. 3616) associated with contralateral anterior ramus fractures (Fig. 3618A), with four ramus fractures
TABLE 361
Classication of Pelvic Ring Disruptions
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TYPE ASTABLE, POSTERIOR ARCH INTACT A1Posterior arch intact, fracture of innominate bone (avulsion) A1.1Iliac spine A1.2Iliac crest A1.3Ischial tuberosity A2Posterior arch intact, fracture of innominate bone (direct blow) A2.1Iliac wing fractures A2.2Unilateral fracture of anterior arch A2.3Bifocal fracture of anterior arch A3Posterior arch intact, transverse fracture of sacrum caudal to S2 A3.1Sacrococcygeal dislocation A3.2Sacrum undisplaced A3.3Sacrum displaced TYPE BINCOMPLETE DISRUPTION OF POSTERIOR ARCH, PARTIALLY STABLE, ROTATION B1External rotation instability, open-book injury, unilateral B1.1Sacroiliac joint, anterior disruption B1.2Sacral fracture B2Incomplete disruption of posterior arch, unilateral, internal rotation (lateral compression) B2.1Anterior compression fracture, sacrum B2.2Partial sacroiliac joint fracture, subluxation B2.3Incomplete posterior iliac fracture B3Incomplete disruption of posterior arch, bilateral B3.1Bilateral open book B3.2Open book, lateral compression B3.3Bilateral lateral compression TYPE CCOMPLETE DISRUPTION OF POSTERIOR ARCH, UNSTABLE C1Complete disruption of posterior arch, unilateral C1.1Fracture through ilium C1.2Sacroiliac dislocation and/or fracture-dislocation C1.3Sacral fracture C2Bilateral injury, one side rotationally unstable, one side vertically unstable C3Bilateral injury, both sides completely unstable
at the front (see Fig. 3618B), or with two ramus injuries and a fracture-dislocation through the symphysis (see Fig 3618C). These vertically stable injuries are the equivalent of the Young and Burgess lateral compression type 2 injuries. Because the force of injury is applied in an oblique fashion across the pelvis, the involved portion of the pelvis acts like a bucket handle; as it is internally rotated, it tends to migrate superiorly, thereby leading to a leg length discrepancy and internal rotation deformity. The other (type B3) lesions are caused by combinations of anterior and external rotation (Fig. 3619). A type C injury is vertically, posteriorly, and rotationally unstable (see Fig. 3613C). In severe C1 injuries, all posterior structures are disrupted, including the sacrotuberous and sacrospinous ligaments. Further subdivision is based on the nature of the posterior lesion. C1.1 is an iliac fracture, C1.2 is a sacroiliac dislocation or fracture-dislocation, and C1.3 is a fracture through the sacrum (Fig. 3620). C2 injuries are bilateral disruptions in which one side is rotationally unstable (B types) and the other side is completely unstable (C types). C3 injuries represent bilateral, completely unstable disruptions (Fig. 3621).
ASSESSMENT OF PELVIC DISRUPTION Acute Management
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The prehospital phase starts with paramedics taught to recognize the potential for an unstable pelvic ring injury from the history, characteristics of the crash, and physical examination. Lower limb deformity without a long bone fracture and a mobile pelvic injury conrmed by manual compression of the pelvis are clues to a pelvic injury. If such injury is present in the prehospital situation, application of a stabilization splint such as a pneumatic antishock garment (PASG), vacuum splint, or the newer pelvic stabilization belts may be lifesaving.31 Emergency and trauma unit assessment of the patient must include evaluation of the immediate life-threatening problems associated with pelvic fractures (Fig. 3622). A
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FIGURE 3614. Modied Tile AO Mul ler classication. Type A: stable posterior arch with intact pelvic ring injuries. Group 1 represents avulsion fractures of the iliac spine (A1.1), iliac crest (A1.2), and ischial tuberosity (A1.3). Group 2 represents fractures of the innominate bone or injuries from direct blows: iliac wing (A2.1), unilateral anterior arch (A2.2), and bifocal anterior arch (A2.3). Group 3 represents transverse fractures of the sacrum caudal to S2: sacrococcygeal dislocation (A3.1), sacrum undisplaced (A3.2), and sacrum displaced (A3.3). (Redrawn from Muller, E., ed. Compre hensive Classication of Pelvis and Acetabulum Fractures. Bern, Switzerland, Maurice E. Muller Foundation, 1995.)
1.1
1.2
Avulsion fractures
1.3
Print Graphic
2.1
2.2
Innominate bone fractures
2.3
Presentation
3.1
3.2
Transverse sacral fractures
3.3
pelvic fracture is considered a signpost leading to other associated life-threatening injuries,20, 21, 30, 66 including major head, chest, and abdominal injuries and, most important, retroperitoneal vascular injuries caused by the pelvic fracture.9, 30, 35, 66, 78 A history of the injury may also give a clue regarding the energy absorbed. A low-energy pelvic injury is produced by a fall from a low height (<1 m), such as occurs with tripping, and is often seen in elderly, osteoporotic patients. High-energy injuries are usually caused by motor vehicle or motorcycle collisions or by falls from heights (>1 m). Low-energy injuries may be isolated, but high-energy injuries can be associated with other signicant problems, including hemorrhage in 75% of patients,66 urogenital injuries in 12%, and lumbosacral plexus injuries in about 8%.14, 66, 80 The likelihood of aortic rupture is eight times greater in high-energy pelvic fractures than in blunt trauma injury overall.74, 78 The mortality rate in the high-energy group is about 15% to 25%.21, 66 Sixty percent to 80% of patients with a high-energy pelvic fracture have other associated musculoskeletal injuries.66 Consequently, a planned method of simultaneous assessment and treatment of this acute injury is required. Such management is best handled by an interdisciplinary team that includes a general surgeon, an emergency department physician, an anesthesiologist, and an orthopaedic surgeon. Standardized resuscitation priorities must be established to ensure that the patient is stabilized. Priority should be given to the treatment of airway, breathing, and circulatory problems. It is important that the orthopaedic surgeon be involved in the primary resuscitation and care of these patients to provide input to the group on the severity and stability of the pelvic fracture, which can assist in decision making. Second, it is important that the pelvis
1.1
Through anterior SI joint
Print Graphic
Presentation
1.2
Sacral fracture
B3.1
FIGURE 3615. Modied Tile AO Muller classication. A, Type B: incomplete disruptions (external rotation). Injuries that disrupt the symphysis will also disrupt the anterior sacroiliac (SI) joint unilaterally (B1.1) or cause a fracture through the sacrum (B1.2). Bilateral disruptions of the SI joint from an external rotation force are classied in a separate group (B3.1) and then further subdivided according to SI joint or sacral involvement. These radiographs show external rotation of an unstable fracture classied by the Tile method as a B1 fracture. Illustration continued on following page
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SECTION III Pelvis
Print Graphic
Presentation
FIGURE 3615 Continued. B, Unilateral opening of the symphysis and SI joint. This injury can be adequately visualized on a radiograph (left) and computed tomography (CT) scan (right) of the pelvis. C, Anteroposterior radiograph showing a bilateral open-book injury of the pelvic ring. Displacement is less than 2.5 cm. This injury is stable and usually handled quite adequately by symptomatic treatment. D, Radiograph showing bilateral opening of the SI joints associated with wide diastasis of the pubic rami. In this interesting variant of the fracture, the pubic rami are also fractured. This injury resulted from a direct blow posteriorly over the sacrum; the patient was thrown into a wall and at that time probably fractured his pubic rami as they externally rotated. (A, Redrawn from Muller, E., ed. Comprehensive Classication of Pelvis and Acetabulum Fractures. Bern, Switzerland, Maurice E. Muller Foundation, 1995.)
be thoroughly assessed acutely so that any evidence of instability can be documented and appropriate treatment planned and instituted early rather than late. Once the airway and breathing are stabilized, care of the circulatory system (i.e., for hypovolemic shock) is mandatory. Most important is determination and control of the site of hemorrhage. Establishment of a minimum of two 14- to 16-gauge intravenous cannulas in the upper extremity is important. The use of lower extremity intravenous access in pelvic injuries may not be an efcient method of providing uid because of signicant pelvic vein disruption. An appropriate volume of uid resuscitation must be given, as determined by ascertaining the degree of blood loss based on the patients clinical condition4, 5 (Table 362). The replacement volume can be estimated from the principle that 3 mL of crystalloid must be given for each 1 mL of blood lost. A minimum of
2 L of crystalloid solution is given over a 20-minute period. If a good response is obtained, the crystalloid infusion can be maintained until type-specic, fully matched blood is available. However, in patients with a transient response or no response, a further 2 L of crystalloid is infused, and then type-specic or uncrossmatched universal-donor (group O negative) blood is given immediately. These latter two responses indicate ongoing blood loss, and bleeding control is urgently required. These patients require massive amounts of uid; consequently, it should be assumed that they would have a dilutional coagulopathy. Platelets and fresh frozen plasma should be ordered initially. As a rule of thumb, 2 to 3 U of fresh frozen plasma and 7 to 8 U of platelets will be required for every 5 L of volume replacement. Appropriate monitoring of the patients response to ongoing resuscitation is mandatory. Perfusion pressure can
CHAPTER 36 Pelvic Ring Disruptions TABLE 362
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Estimated Fluid and Blood Loss Based on the Patients Initial Clinical Findings*
Class I Blood loss (mL) Blood loss (% of blood volume) Pulse rate Blood pressure Pulse pressure (mm Hg) Respiratory rate Urine output (mL/hr) Central nervous system and mental status Fluid replacement (3:1 rule) Up to 750 Up to 15 <100 Normal Normal or increased 1420 >30 Slightly anxious Crystalloid Class II 7501500 1530 >100 Normal Decreased 2030 2030 Mildly anxious Crystalloid
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Class III 15002000 3040 >120 Decreased Decreased 3040 515 Anxious, confused Crystalloid and blood Class IV >2000 >40 >140 Decreased Decreased >35 Negligible Confused, lethargic Crystalloid and blood
*For a 70-kg man. The three-for-one rule is derived from the empirical observation that most patients in hemorrhagic shock require as much as 300 mL of electrolyte solution for each 100 mL of blood loss. Applied blindly, these guidelines can result in excessive or inadequate uid administration. For example, a patient with a crush injury to the extremity may have hypotension out of proportion to blood loss and require uids in excess of the 3:1 guidelines. In contrast, a patient whose ongoing blood loss is being replaced by blood transfusion requires less than 3:1 uids. The use of bolus therapy with careful monitoring of the patients response can moderate these extremes. Source: American College of Surgeons. Advanced Trauma Life Support Instructors Manual. Chicago, American College of Surgeons, 1989, 1993.
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2.1
Anterior sacral compression injury
Print Graphic
Presentation
2.2
Partial fracture subluxation of sacroiliac joint
2.3
Incomplete posterior iliac fracture
FIGURE 3616. Modied Tile AO Muller classication. Type B: incom plete disruptions (internal rotation). Internally directed or lateral compression forces cause anterior sacral compression injuries (B2.1), partial fracture-subluxations of the sacroiliac joint (B2.2), and incomplete posterior iliac wing fractures (B2.3). (Redrawn from Muller, E., ed. Comprehensive Classication of Pelvis and Acetabulum Fractures. Bern, Switzerland, Maurice E. Muller Foundation, 1995.)
be assessed by clinical signs of capillary rell, pulse volume, color, and temperature. More specic monitoring methods require a urinary catheter to assess urinary output (20 mL /hr) and an arterial line for direct arterial pressure measurements and determination of mean arterial pressure. Volume status can easily be assessed by these methods and can be conrmed by central venous pressure measurements. Monitoring of core body temperature is mandatory if major uid replacement is continued. Blood and crystalloid are usually at room temperature or may even be cooler. The use of large volumes during resuscitation cools the patient even further and thereby adds to the effect of hypovolemic shock and exposure in the eld. Warming of intravenous uid and blood is necessary to keep the core temperature at least in the range of 32C to 35C. A normal temperature of 37C is preferred. Lower temperatures lead to coagulation problems, ventricular brillation, higher surgical infection rates, and acid-base disturbances. A gastric tube should be inserted, but with the nasal route avoided if cribriform plate fractures are suspected. Catheterization of the bladder is used to decompress it before the minilaparotomy. Before catheterization in a male, assessment for evidence of blood at the urethral meatus, examination for scrotal hematomas, and evaluation of the prostate to make sure that it is palpable and in the appropriate position are mandatory. In females, a vaginal examination as well as inspection of the urethral meatus is performed. If any evidence of pelvic instability is noted in addition to any of the preceding ndings, urinary catheterization should not be undertaken because of potential urethral injuries. Lowe and associates reported that 57% of men with urologic injury secondary to a pelvic fracture had none of the classic signs.59 Urethrography is performed after the patient is hemodynamically normal. Physical signs of pelvic instability include deformity of a lower extremity without a long bone fracture, usually an ipsilateral leg length discrepancy involving shortening or
Print Graphic
Presentation
FIGURE 3617. Modied Tile AO Muller classication. Injuries to the pelvic ring caused by internal rotation forces lead to vertically stable injuries classied as B2.1 fractures. A, Anteroposterior pelvic radiograph showing ipsilateral pubic ramus and ischial ramus fractures with minor crushing of the posterior of the sacrum. This fracture is slightly displaced in internal rotation, and some displacement is seen through the pubic rami but minimal displacement, if any, posteriorly. This type of injury is a stable fracture vertically but a potentially unstable rotational injury. B, Another of the internally rotated ipsilateral group, a locked symphysis. This radiograph demonstrates a locked symphyseal injury with one pubic body displaced behind the other. C, An unusual variant of a lateral compression injurya tilt fracture. Notice how the superior pubic body has dislocated from the symphysis and been turned down into the perineum.
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Presentation
FIGURE 3618. Severe variant of an internally rotated, unstable fracturea contralateral type or bucket-handle type (B2.2). A, An internal rotation force crushed the sacrum as well as produced a fracture through the four rami anteriorly. Note how the computed tomographic (CT) scan of the hemipelvis on the right side demonstrates an internal rotation deformity of almost 45. B, An anteroposterior radiograph of the pelvis again demonstrates a different contralateral injury, with an injury posteriorly on one side and ramus fractures on the opposite side. Also note the internal rotation deformity of the pelvis, as well as elevation of the hip on one side. This variant is not true vertical instability but is a rotational phenomenon. C, Final variety of a contralateral injury. In this injury, the anterior component is a fracture through the pubic rami, on either one or both sides, with dislocation or fracture-dislocation of the symphysis. Again, the hemipelvis has been rotated internally. Note on the CT scan (right) how the sacral injury is a crushing injury on the right posterior aspect. The sacrum has been driven in and has crushed cancellous bone, and it is thus relatively stable posteriorly.
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3.2
3.3
FIGURE 3619. Modied Tile AO Muller classication. Type B3: incom plete disruption (bilateral). Bilateral incomplete disruptions are reprePresentation sented by bilateral open-book injuries (see Fig. 3615A, B3.1) and combination injuries consisting of open-book and internal rotation (B3.2) and bilateral internal rotation injuries (B3.3). (Redrawn from Muller, E., ed. Comprehensive Classication of Pelvis and Acetabulum Fractures. Bern, Switzerland, Maurice E. Muller Foundation, 1995.)
internal/external rotation (or both), depending on the injury. Massive ank or buttock contusions and swelling with hemorrhage are indicative of massive bleeding. Visual inspection of the posterior part of the pelvis is done when the patient is logrolled for examination of the back. Palpation of the posterior aspect of the pelvis may reveal a large hematoma, a gap through the disrupted fracture area, or dislocation of the sacroiliac joint. Similarly, palpation of the symphysis may lead to recognition of a gap. Signs of potential instability include an open pelvic fracture, scrotal hematomas, and neurologic injuries to the lumbosacral plexus. Evaluation of the spine with lateral radiographs is mandatory to exclude the presence of any fractures. In 85% of cases, these lms can rule out any signicant injury that may cause further neurologic deterioration. A chest radiograph is also helpful to determine the width of the mediastinum or the occurrence of a pulmonary contusion. An AP radiograph of the pelvis is mandatory in all patients who have a depressed level of consciousness, who fail to respond to uids when no intra-abdominal source of bleeding is noted, or who complain of pain or tenderness on examination of the pelvis.53 Once the patient is assessed and stabilization is started, the surgeon must be prepared to act efciently if ongoing pelvic bleeding is observed.30, 35, 66, 71, 116 The usual cause of ongoing pelvic bleeding is disruption of the posterior pelvic venous plexus. Bleeding of a large vessel such as the common, external, or internal iliac may also cause such bleeding. Injury to large vessels usually is associated with rapid, massive bleeding and loss of the distal pulse. The severity of the hemorrhage determines the appropriate management path. The ve areas of potential hemorrhage are external, thoracic, intraperitoneal, retroperitoneal, and extremity fractures. A standardized protocol involving the orthopaedic surgeon and trauma surgeon is necessary to distinguish an intraperitoneal from a retroperitoneal source of hemorrhage. In an acutely injured patient, abdominal examination is unreliable. Therefore, rapid determination of the presence of intra-abdominal blood by supraumbilical diagnostic peritoneal lavage, ultrasonography, or computed tomography (CT) is mandatory.73 Infraumbilical minilaparotomy is fraught with problems because the pelvic hematoma may track up through the anterior fascial planes and contaminate the specimen. The major aim of the orthopaedic surgeon in controlling pelvic bleeding is stabilization of the unstable pelvic injury.19, 35, 49, 66, 71, 73 Stabilization of the pelvic
injury prevents an increase in retroperitoneal volume, and therefore, decreases blood loss as tamponade of the bleeding vessels occurs. Stabilization of a disrupted pelvis can be handled in several ways. The oldest is the application of a PASG.35 This inatable garment is placed over the lower extremities and around the abdomen and inated until blood pressure is stabilized. The garment works by increasing peripheral vascular resistance. However, in this situation, the abdominal component of the trousers acts as a pneumatic splint and decreases continued motion of the pelvic fracture. This decrease in motion prevents any further disruption of the pelvic veins or the clots that have formed. At present, PASGs are recommended for the immediate stabilization of massive pelvic bleeding in the emergency department or for transport of the patient to a denitive care facility.4 Once the garment is applied in the emergency situation, it should not be removed until the patient is receiving uids in the operating room so that the bleeding can be controlled surgically. A PASG should not be used on a long-term basis unless the leg and abdominal components are alternately deated every 2 hours to allow perfusion of the muscle compartments and skin.35 Long-term use of these garments in hypotensive patients has led to the development of compartment syndromes and subsequent amputations.65
1.1
Through iliac wing
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1.2
Through sacroiliac joint Presentation
1.3
Through sacrum
FIGURE 3620. Modied Tile AO Muller classication. Type C: complete disruptions. Complete disruptions can be unilateral or bilateral. Unilateral disruptions occur through the iliac wing (C1.1), through the sacroiliac joint (C1.2), and through the sacrum (C1.3). Bilateral injuries are combinations of incomplete, complete, and totally complete injuries and are not shown in this gure. (Redrawn from Muller, E., ed. Comprehensive Classication of Pelvis and Acetabulum Fractures. Bern, Switzerland, Maurice E. Muller Foundation, 1995.)
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Presentation
FIGURE 3621. Type C injuries representing complete instability both vertically and rotationally. The injuries can occur through the sacrum, sacroiliac joint, or iliac wing. A, Inlet view (left) and computed tomography (CT) scan (right) of the pelvis. The inlet view demonstrates diastasis of the symphysis and a large gap through the sacrum anteriorly and posteriorly. Note how the hemipelvis has been displaced posteriorly in this view. The CT scan conrms the wide gap in the sacrum. This injury is an extra-articular sacral fracture and is unstable. Also note the slight widening on the left side of the sacroiliac joint. This widening may have been caused by an anteriorly or posteriorly directed force as the nal stage in an open-book or externally rotated injury. B, An anteroposterior (AP) radiograph of the pelvis (left) demonstrates two injuries: dislocation through the sacroiliac joint and a fracture-dislocation involving the iliac wing and sacrum on the right side. The double density marked by the arrow shows where the iliac fracture has occurred. Also note the widening of the sacroiliac joint on the right side as well as the left. On the left side note the marked displacement of the hemipelvis. A CT scan (right) conrms the ndings on the AP radiograph. A pure sacroiliac joint dislocation has occurred on the left side and a fracture-dislocation through the sacroiliac joint on the right side. C, Inlet view (left) of the pelvis demonstrating a fracture through the iliac wing. This view also shows some widening of the sacroiliac joint, but a CT scan (right) shows that most of this injury is through the iliac wing. The arrow indicates the anterior opening of the joint, but note that an opening does not appear to be present posteriorly and most of the structures are intact, thus giving stability. The instability in this fracture will occur through the iliac wing because the injury has bypassed the posterior interosseous ligamentous structures.
Other straightforward techniques can be used to control pelvic hemorrhage until the patient can be transferred to denitive care. The use of skeletal traction applied through the injured leg is effective in controlling venous bleeding. A traction pin is inserted into either the supracondylar region of the femur or the tibial tubercle, and 25 to 35 lb of traction is applied. This technique pulls
the displaced hemipelvis into a more anatomic position and stabilizes it so that the tamponade is more effective. Internal rotation of the lower extremities closes an anterior pelvic diastasis, particularly if the posterior ligamentous structures still have some continuity. This position can be maintained by tying the internally rotated legs together. Finally, any encircling device such as a sheet wrapped
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around the pelvis or a wide belt can be used to close the anterior diastasis until more denitive management can be undertaken. A beanbag positioning device or vacuum body splint is effective. It be can be applied to the anks of the patient to maintain access to the abdomen and groin. It is also useful as a splint for lower extremity injuries. Because it conforms to the patient, it provides a safe total-body splint to stabilize the spine and allow easy transport.31 A more efcient method of emergency pelvic stabilization is the application of specialized pelvic clamps.12, 36 These clamps can be applied by a trained physician in the emergency department. A pelvic C-clamp36 is applied to the posterior of the pelvis at the level of the sacroiliac joints. A pelvic stabilizer is applied to either the posterior or the anterior of the pelvis in the cancellous bone above the acetabulum.7, 9 Control of massive venous bleeding is an indication for the use of these devices. The standard method of controlling the hemipelvis is the application of an anterior external xation frame.50, 88, 90 The frame should be used in conjunction with traction on the involved leg to control vertical instability. Application of the frame requires operative
intervention, and it must be applied as quickly as possible (within 20 to 30 minutes). A hemodynamically stable patient does not require temporary stabilization unless it is thought that motion of the pelvic fracture may lead to recurrence of the hemorrhage. The timing of placement of acute pelvic stabilization devices should be a decision made in consultation with the general surgeon or the physician in charge of the resuscitation.72 Before placement of the xator, the pelvic AP radiograph should be assessed. This radiograph reveals several clues regarding the exact nature of the injury and the potential for ongoing bleeding. A lateral compression injury usually has a horizontal or buckle-type fracture across the rami with evidence of an anterior sacral crushing injury if one looks along the arcuate line between the sacral promontory and the iliopectineal line. A line drawn vertically through the midline of the sacrum can also reveal a signicant shift of the pelvis such as might occur in a lateral compression type 3 injury124 (Fig. 3623). An injury to the quadrilateral plate or a transverse acetabular fracture also indicates a lateral injury. An AP injury is usually recognized by the presence of vertical fractures through the rami that tend to be separated but
Hemodynamically Unstable Patient w/Pelvic Fracture

Identify/treat life-threatening hemorrhage
Apply Non-Invasive Pelvic Stabilization (if indicated)
Transfer
no
Definitive treatment promptly available?
yes
R/O Life Threatening Intra-Abdominal Hemorrhage absent present
Initial Skeletal Stabilization/Angiography
Initial Skeletal Stabilization/Laparotomy
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ICU Admission Further work-up & stabilization
no
Large expanding RPH?
yes
Angiography
Presentation
Angiography Repeat Angiography
yes
Remains Unstable? Excessive Transfusion Requirement?
no
Is Pelvic Fx OPEN?
yes No Colostomy Required no Buttock/Perineal Wound? yes
no
Definitive Pelvic fracture fixation
Definitive Pelvic fracture fixation
Serial I&D of wound Perform diverting colostomy within 48 hours of injury
FIGURE 3622. Algorithm for resuscitation after pelvic disruption. Abbreviations: C spine, cervical spine; ER, emergency room; Fx, fracture; IVs, intravenous lines; OR, operating room; PASG, pneumatic antishock garment; RPH, retroperitoneal hematoma; R/O, rule out.
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Presentation
FIGURE 3623. Emergency assessment of an anteroposterior pelvic radiograph. A, Lateral compression injuries that are stable are usually associated with horizontal fractures of the right superior pubic ramus or overlapped or compacted fractures, as seen in this gure. B, Combination lateral compression external rotation injury with translation of the hemipelvis past the midline, which is represented by the dotted line. Also seen is the opening of the sacroiliac joint. This fracture is more complex than that shown in A and may present an increased risk of hemorrhage. (A, B, Redrawn from Young, J.W.R.; Burgess, A.R. Radiologic Management of Pelvic Ring Fractures. Baltimore, Munich, Urban & Schwarzenberg, 1987.)
not vertically displaced. Fractures along the iliac wing or through the posterior acetabular region also indicate an AP compression injury. Posterior displacement of the hemipelvis can be inferred with the use of the second sacral arcuate line124 (Fig. 3624). Vertical displacement can be recognized by displacement greater than 1 cm through the posterior sacroiliac joint, by gaps occurring in the sacrum, by the impression that the pelvis itself has widened, or by an avulsion fracture through the sacrum. It should be remembered that lateral compression fractures are usually associated with major intra-abdominal and head injuries, as are vertical shear injuries. However, unstable AP compression injuries and completely unstable injuries
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Presentation
FIGURE 3624. Assessment of posterior displacement and anteroposterior compression injuries. The dashed line represents a second sacral arcuate line drawn through the second sacral foramen. It should line up with the iliopectineal line, but on the right side it does not, thus demonstrating that the hemipelvis is displaced posteriorly as well as externally.
have a far greater incidence of retroperitoneal hemorrhage than intra-abdominal bleeding. Decision making can be guided by the patients response to resuscitation.41 In the case of a negative test for intra-abdominal blood in a patient with ongoing hypovolemic shock (transient responder to uid) and major pelvic disruption, it is mandatory that angiography be performed before the external xator is applied. Angiography will demonstrate the site of bleeding and help determine the type of therapeutic embolization necessary. If the diagnostic peritoneal results are grossly positive (free ow of blood through the peritoneal catheter) and the patient responds only transiently, laparotomy is required to assess the intra-abdominal injury. After treatment of the intraabdominal cause of bleeding, ongoing hemorrhage should resolve with retroperitoneal packing of the pelvis and the application of an external xator. Attempts at pelvic packing will be of no value, however, unless the pelvis is immobilized. If the ndings on peritoneal lavage are positive (i.e., >100,000 red blood cells per cubic millimeter) and the patient is hemodynamically stable, the frame should be applied before laparotomy. The laparotomy can subsequently be performed and the intra-abdominal bleeding controlled. If bleeding continues, a dilutional coagulopathy must be ruled out or treated; if indicated, angiography can then be performed. A patient who fails to respond to appropriate uid resuscitation and has a negative test for intra-abdominal blood is, by denition, bleeding from a large-caliber vessel. The patient then requires angiography to determine the source and whether embolization can be used to stop the bleeding, which depends on the caliber of the bleeding vessel. Temporary balloon occlusion of large-caliber arteries may be lifesaving until denitive control can be achieved by surgery. If possible, a pelvic stabilization device should be applied before angiography.
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With a positive test for intra-abdominal blood in a patient who fails to respond, celiotomy is indicated, as well as the use of a pelvic stabilization device. If during celiotomy the retroperitoneal hematoma is expanding, packing of the presacral area and posterior aspect of the symphysis is carried out. For this technique to be effective, it is necessary to achieve reduction, which can be obtained by traction and manipulation of the pelvis by the C-clamp or xator, guided by nger palpation or visualization through the transperitoneal approach.84 If the patient remains hypotensive despite these methods, angiography must be performed immediately. Any clotted vessel seen during angiography should be treated by embolization to prevent delayed hemorrhage if the clot is dislodged or reabsorbed. In open pelvic fractures that are hemorrhaging through an open wound, packing of the area is mandatory to control the bleeding at the same time as the pelvis is acutely stabilized by the application of an external stabilization device. Diagnostic and therapeutic angiography in patients with pelvic hemorrhage is difcult even in experienced hands. Selective embolization is most effective in controlling bleeding from small-diameter vessels (i.e., 3 mm or less). Angiography may assist in localizing large-vessel bleeding, but only if time and hemodynamic stability permit.101 Compromising delays in resuscitation and treatment can occur if the angiography response time is slow or the angiographer is inexperienced. Arteriographic embolization is 100% successful in stopping bleeding and saving lives if done within 3 hours of injury.1 The radiology department must have the necessary equipment available to administer lifesaving procedures in the event of cardiopulmonary collapse when performing embolization in these high-risk patients.52 If the patient is stabilized and able to undergo a CT scan, it should be contrast enhanced. A patient with a positive contrast extravasation sign on a contrast-enhanced CT scan has a 40:1 likelihood of signicant arterial bleeding requiring embolization.110 Therefore, any patient who has a potential for arterial bleeding or is a transient responder must have a contrasted-enhanced CT scan early in care to document the potential for arterial bleeding. Such imaging may allow earlier control of the bleeding site. After the patient has been stabilized, further assessment of the other intraperitoneal pelvic structures must be carried out. If any indication of an unstable fracture is noted, urethrography should be performed in male patients.14, 71 This technique is accomplished by inserting a small catheter into the urethral meatus, inating the balloon, and injecting approximately 25 to 30 mL of a radiopaque dye to outline the urethra. If no leak is evident, a catheter is inserted. It is best to do the radiograph of the pelvis in an oblique plane (e.g., as in a Judet view of the full pelvis) to put the urethra into full relief. However, in most situations, this view is difcult to obtain, and a standard AP radiograph is satisfactory. After urethrography, a cystogram should be obtained by lling the bladder with 400 mL of dye and taking a radiograph. After evacuation of the dye, a postvoid view is taken to determine any occult extraperitoneal bladder rupture. If these investigations do not reveal a cause of the hematuria, an intravenous pyelogram should
be obtained. In female patients, urethrography is rarely helpful and usually omitted. A thorough physical examination, including a vaginal examination, is performed before the catheter is placed, and even then a vaginal injury may be missed in up to 50% of cases.83 A thorough neurologic examination is always required to evaluate injuries to the lumbosacral plexus. Therapeutic decision making and the medicolegal environment necessitate a baseline examination.30, 118 An open pelvic fracture further complicates assessment and diagnosis.83, 88, 89 The wound must be adequately evaluated. Wounds occurring in the anterior aspect of the pelvis or over the ank are relatively clean and can be treated like most open fractures. However, wounds that occur in the buttock and groin regions and any wound in the perineal region require exact assessment. Because they are usually contaminated by the contents of the rectum, any wounds that involve the rectum or the perineal or buttock regions must be debrided and an external xation device applied. Performance of a colostomy to divert the fecal stream should be given serious consideration for this group of open pelvic fractures. Other fractures that do not involve these areas but are clean can be debrided, and then appropriate xation can be instituted. Occasionally, in a hemodynamically stable patient, external xators are applied in the acute phase to facilitate care.112, 113 The frame adequately stabilizes the pelvic disruption to allow patient mobility and nursing care.90
Denitive Management
After stabilization of an acutely injured patient, the pelvic injury must be reassessed to determine denitive management. Appropriate evaluation is necessary to decide whether the injury requires operative intervention to decrease the chance of late pain, malunion, and nonunion.44, 46, 73, 84, 91, 104, 112 This assessment must include a determination of pelvic stability, the fracture pattern, and location, with emphasis on determining sacroiliac joint involvement and nerve injury, as well as an evaluation of the soft tissue components of the injury. HISTORY Assessment of the mechanism and the type of force that was applied to create the injury should be carried out. Direct crushing injuries cause serious soft tissue disruption, which leads to wound-healing problems. Indirectly applied force usually spares the soft tissue and does not lead to wound problems. Knowledge of the age and occupation of the patient and, most important, the patients expectations is necessary if the surgeon and the patient are to have a common treatment goal. PHYSICAL EXAMINATION Appropriate measurement of leg length discrepancies and evaluation of internal and external rotational abnormalities and open wounds are important. Of equal importance is the evaluation of soft tissue injuries (e.g., contusions,
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hemorrhage, and hematomas). After inspection, palpation of the areas of injury should be carried out to determine soft tissue disruption, bony gaps, and hematomas. Thorough assessment of soft tissues in the preoperative period helps prevent wound slough from the injudicious placement of incisions. Rotational instability can be assessed by pushing on the anterior superior iliac wings both internally and externally to determine whether the pelvis opens and closes. Push-pull evaluation of the leg can be used to detect any vertical migration of the pelvis. Conrmation can be obtained with radiographs or image intensication. This assessment is best done when the patient is initially examined; however, if the stability of the pelvis is at all in doubt, examination under anesthesia is mandatory.49
arcuate lines, along with a vertical line through the midline of the sacrum, is important to determine displacement. Leg length discrepancies can be noted by the level of the hip joints. INLET RADIOGRAPH The inlet view (Fig. 3626) is taken with the patient in the supine position. The tube is directed from the head toward the feet at 60.82 It is therefore perpendicular to the pelvic brim, and the radiographic view is a true inlet picture of the pelvis. On this view can be seen the pelvic brim, including the iliopectineal line, the pubic rami, the sacroiliac joints, and the ala and body of the sacrum, as well as the posterior tubercles. This view is useful for determining posterior displacement of the sacroiliac joint, sacrum, or iliac wing; internal rotation deformities of the ilium; and sacral impaction injuries. Inspection of the sacral ala, particularly along the arcuate line, demonstrates sacral crush injuries as a buckling through this line or a shortening of the sacrum on one side in comparison to the other. Ischial spine avulsions can also be seen on this view. OUTLET RADIOGRAPH The outlet view (Fig. 3627) is taken with the tube directed 45 to the long axis of the patient, but at the foot of the patient.82 The tube is directed toward the head. This radiograph is very useful for determining superior rotation of the hemipelvis, which is seen in the bucket-handle type of injury. Displacement or leg length discrepancy is determined from the level of the hip joints. Vertical migration can also be determined, and fractures through or near the sacral foramina are easily seen.
Radiographic Assessment
Before denitive treatment decisions are made, a complete radiographic assessment of the pelvis should be done, including AP, inlet, and outlet views and a CT scan. It is important to remember that the pelvis, in the supine position, lies 45 to 60 oblique to the long axis of the skeleton. Consequently, an AP radiograph is essentially an oblique radiograph of the pelvis. To appropriately determine displacement, it is mandatory to evaluate two radiographs taken at right angles, which has led to development of the inlet and outlet views by Pennal and Sutherland.28, 82 ANTEROPOSTERIOR RADIOGRAPH The AP radiograph (Fig. 3625) is very useful in providing an overview of the pelvic injury. Assessment of anterior ring lesions with regard to pubic ramus fractures and symphysis displacement is important. The sacroiliac joint, sacral and iliac fractures, and avulsion of the sacral spines, lateral margin of the sacrum, and L5 transverse process are seen in this view. Use of the sacral promontory and sacral
Computed Tomography
The use of CT has revolutionized assessment of the posterior osseous ligamentous structures of the pelvis. It
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Presentation
FIGURE 3625. A, For the anteroposterior (AP) projection, the beam is directed perpendicular to the midpelvis and the radiologic plate. B, Radiographic appearance of the pelvis in the AP plane.
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Presentation
FIGURE 3626. A, For the inlet projection, the beam is directed from the head to the midpelvis at an angle of 60 to the plate. B, Radiographic appearance in the inlet projection.
is mandatory for determining the exact nature of a posterior injury (Fig. 3628A). It reveals whether an injury through the sacrum is a crushing injury or a shearing injury with a large gap. Sacroiliac joint displacement is valuable in determining the stability of this posterior injury. Anterior opening of the joint with a closed posterior portion represents a rotationally unstable injury with intact posterior ligaments (type B). If the joint is open throughout its course, the posterior ligaments are disrupted and the injury is translationally unstable (type C). CT is also helpful in dening acetabular injuries. Many pubic ramus fractures that occur near the base of the anterior column enter the acetabulum, and appropriate assessment of these injuries is necessary. Advances in technology have shown that three-dimensional reconstructions of CT scans may
provide a more useful evaluation of the overall displacement of a pelvic fracture (see Fig. 3628B). Close scrutiny of the upper sacral vertebral bodies and lumbosacral junction must be done to assess the anatomic abnormalities in preparation for posterior stabilization and treatment of L5S1 facet joint injuries.
Examination under Anesthesia

If after all these investigations the true instability pattern of the pelvis is unclear, the physician should not hesitate to examine the patient under anesthesia within the rst 5 to 7 days after injury because the results may dictate major changes in the management of these patients.
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Presentation
FIGURE 3627. A, For the outlet projection, the beam is directed from the foot to the symphysis at an angle of 40 to the plate. B, Radiographic appearance in the outlet projection.
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DECISION MAKING
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz After a full assessment of the pelvic injury is complete, a decision can be made regarding appropriate treatment17 (Fig. 3629). The rst component to be considered is instability. Fractures that are stable include AP compression injuries with less than 2.5 cm of displacement (type B1.1) and lateral compression injuries with sacral impaction (type B2.1). Instability with symphysis disruption106, 113 of more than 2.5 cm is an indication for operative stabilization. Fractures and dislocations through the sacroiliac joint have a high incidence of sequelae such as long-term pain, discomfort, and nonunion.43, 44, 46, 49, 55, 93, 102, 105 To avoid these problems, operative stabilization of the pelvis is commonly indicated to ensure reduction and stability. Extra-articular sacroiliac joint fractures occurring through the iliac wing (C1.1) or sacrum in patients with isolated injuries can usually be managed by appropriate closed reduction and traction and the application of an external xator to control the rotatory abnormality50, 51 (Table 363). If closed reduction is unsuccessful, operative care is recommended. If associated injuries are present that require mobilization of the patient or if the patient wishes to accept the risks of operative treatment, surgical intervention can be carried out. Signicant displacement is dened as the following: 1. Leg length discrepancy of more than 1 to 1.5 cm. 2. Signicant internal rotation abnormality with no exter-
nal rotation of the lower extremity past neutral. Similarly, the lack of internal rotation in an external rotationtype fracture is signicant. Obviously, a tilt fracture leads to a signicant deformity, particularly in females, who may be subject to dyspareunia because of a displaced fragment near the vagina. If a stable fracture is signicantly displaced, intervention may be required. Treatment of associated injuries, particularly injuries to the acetabulum or long bones of the lower extremity, must also be considered when planning operative procedures. A femoral shaft fracture associated with a major pelvic disruption treated by traction may lead to signicant knee stiffness. This combination of a pelvic fracture and an ipsilateral femur fracture leads to a higher mortality rate than either injury does alone. The presence of multiple lower limb long bone fractures associated with an acetabular fracture is usually an indication for surgery to maximize functional rehabilitation.
REDUCTION AND FIXATION TECHNIQUES
Biomechanics of Pelvic Fixation

To make logical decisions regarding the stabilization of pelvic disruptions, knowledge of the mechanical stability
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Presentation
FIGURE 3628. The use of computed tomography (CT) for evaluation of the posterior structures of the pelvis is imperative. A, This series of CT scans demonstrates a shear fracture through the sacrum that is disrupting the bone and causing a large gap. Also note some fracturing in the posterior elements on the opposite side. CT can also be used for evaluating anterior lesions, particularly in the acetabulum and in iliac wing fractures. B, New advances in computer technology now allow three-dimensional reconstruction. The three-dimensional reconstruction of this pelvis demonstrates how well it will aid in determining the complete injury.
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pelvic fracture
resuscitation
reflow assess 1. stability clinical E.U.A. radiographs CT scan 2. displacement rotational axial 3. patient characteristics
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pelvis stable
pelvis stable displaced rotationally
pelvis rotationally unstable
Presentation
pelvis rotationally and vertically unstable
undisplaced
location of fracture symptomatic treatment if indicated O.R.I.F. closed reduction external fixation or O.R.I.F. especially if abdominal and urological operation done
extraarticular SI joint
SI joint
isolated polytrauma yes reduction in traction and external fixation (maybe O.R.I.F., if reduction not satisfactory) O.R.I.F.
FIGURE 3629. Algorithm for management of pelvic fractures. Abbreviations: E.U.A., examination under anesthesia; O.R.I.F open reduction and ., internal xation; SI, sacroiliac.
of different internal and external techniques is necessary. A mechanical study showed that in bilateral unstable posterior injuries, the anterior external xator frame does not afford enough stabilization to allow weight bearing.113 Mears and Rubash68 attempted to improve the mechanical stability of external xation by using pelvic transxation pins, but this technique led to insertional difculties and problems with nursing care. By adding another cluster of pins to the anterior inferior spine region, Mears and Rubash achieved increased stability.68 McBroom and Tile62 suspended a pelvis from the sacrum, which allowed full triplanar motion and showed that all existing external frames would stabilize the pelvic ring sufciently to allow mobilization of the patient if the posterior osseous ligamentous hinge remained intact. With disruption of this posterior hinge, unstable pelvic disruptions could not be stabilized with any of the existing external frames. The
best external frame design was a rectangular construct mounted on two to three 5-mm pins spaced 1 cm apart and inserted into the iliac crest.62 Using a similar model, McBroom and Tile showed that internal xation could signicantly increase the force resisted by the pelvic ring when compared with external xation.62 In stable injuries, failure was ultimately caused
TABLE 363
Indications for External Fixation
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
Resuscitation Rotationally unstable fractures Open-book fracture Bucket-handle fracture Adjunct to traction in unstable fractures (type C)
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
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by screw pull-out; therefore, in stable open-book fractures, anterior xation allowed early mobilization. However, in an unstable injury with a disrupted posterior hinge, anterior symphysis plates did not stabilize the pelvic ring. A moderate increase in stability could be achieved by anterior symphysis plating and a trapezoidal external frame. However, the only direct method of stabilizing this unstable pelvic ring injury was by posterior and anterior xation. The strongest available xation was achieved by two plates at right angles across the symphysis along with posterior screw xation or transiliac bar xation. From mechanical studies, it is recommended that for iliac wing fractures, open reduction and stable internal xation with interfragmental compression and neutralization plates be performed. For unilateral sacroiliac dislocation, direct xation across the joint with cancellous screws or anterior sacroiliac xation with plates failed at similar loads.109 Tile and Hearn showed that iliosacral lag screws have the best pull-out strength if they have a 32-mm thread length and are positioned in the sacral body.113 For unilateral sacral fractures, two transiliac bars should provide adequate xation. Posterior iliosacral screws that have purchase in the sacral body (S1) provide a suitable technique, but insertion may be complicated by neurologic or vascular injury. Pohlemann and colleagues84 achieved sacral xation with 3.5-mm plates. They tested osteosynthesis with the plate versus sacral rods and an internal spinal xator. The results showed that plates failed at 74%
of body weight and sacral rods failed at 85% of body weight. Albert and Miller2 described the use of a 4.5-mm reconstruction plate xed to the posterior tubercles and iliac wings. Mechanical testing showed that this construct failed at an average of 1000 N. Although these results are the best reported, they were done in plastic bone.50 If the anterior injury is easily amenable to surgery, plate xation of the symphysis is the best treatment. If it is not amenable to surgery and the anterior injury remains displaced and unstable, external xation to control the anterior injury may be helpful. In bilateral posterior unstable disruptions, xation of the displaced portion of the pelvis to the sacral body is necessary and can be accomplished only through posterior screw xation (Fig. 3630). The results of all mechanical studies are routinely reported in newtons. A newton is equal to 0.22 lb of force. Failure of posterior sacroiliac joint plating at 387 N is equal to failure at 85.14 lb of force, which is much less than the body weight of an average adult. Caution must be exercised in the postoperative period to not overly stress the internal xation construct by weight bearing or an upright position.
Symphyseal Reduction and Stabilization

Disruption of the symphysis is related to an AP or external rotation injury to the pelvis. Consequently, the principle of
ANTEROPOSTERIOR COMPRESSION INJURY Newtons 2000 1960 Newtons Two Plates Newtons 2000
UNSTABLE VERTICAL SHEAR INJURY
1960 Newtons Two Plates posterior fixation
VERTICAL LOAD
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1000
Dwyer
VERTICAL LOAD
1000 Double cluster posterior fixation Rectangular frame posterior fixation Plates 0 trapezoidal frame
Presentation
Mears frame Rectangular frame Slatis frame 0 1 cm
Double cluster frame Rectangular frame 1 cm DISPLACEMENT
DISPLACEMENT
FIGURE 3630. A, Results of mechanical testing on a vertically stable open-book injury produced by division of the symphysis pubis and the anterior sacroiliac ligaments. External frames gave adequate xation for this type of injury, but two plates across the symphysis provided better stability. B, Results of xation of an unstable vertical shear injury produced in the laboratory by division of the symphysis pubis, fracture of the ilium posteriorly, and division of the pelvic oor ligaments. All forms of anterior xation failed under a 20-kg load (1 kg = 10 N); posterior internal xation proved to be far superior. Internal stabilization of the unstable posterior injury and the symphysis pubis produced excellent stability of the pelvic ring. (A, B, Modied from Tile, M., ed. Fractures of the Pelvis and Acetabulum, 2nd ed. Baltimore, Williams & Wilkins, 1984.)
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reduction is to close the pelvic ring by internal rotation, which can be accomplished by closed manual pressure over the anterior superior iliac spines. However, this technique is relatively inefcient and is supplemented by internal rotation of the femurs by an assistant. Closed reduction can be accomplished through internal rotation of the femurs and their attachment to the hemipelvis. If the reduction is unacceptable, the patient is turned onto the uninvolved side so that gravity will assist in reduction of the upper portion of the hemipelvis. With these closed reductions, stabilization of the symphysis is external. APPLICATION OF EXTERNAL FIXATION TO THE PELVIS The external xator is a mainstay in the treatment of pelvic disruptions. Orthopaedic surgeons should become comfortable with and competent in efcient application of an external frame.123 During the resuscitation phase, this device may have to be applied quickly, in as little as 20 to 30 minutes. Important principles are the use of 5-mm pins with the threads buried into the thick anterior half of the iliac wing. These pins should be placed a minimum of 1 cm apart to increase their stability. It is mandatory to place two pins per side, but it may be advantageous to insert three in case one pin is not completely placed within the iliac crest. The standard rectangular frame is probably all that is needed in most situations. Rarely, a more rigid, multiplanar frame is required.68 With a small iliac crest or a fracture that may extend into the iliac crest, application of pins in the anterior inferior spine region of the pelvis may be necessary. Application of the frame requires consideration of the deformity and subsequent reduction technique. If the hemipelvis has migrated vertically, the rst reduction maneuver is traction through a distal femoral or proximal tibial traction pin and the application of 25 to 30 lb of traction. If traction greater than 30 lb is necessary, the pin must be placed into the distal part of the femur. Because the displacement is usually posterosuperior, it is helpful to apply traction in an anteriorly directed fashion with the hip in about 45 to 90 of exion. It is usually necessary to maintain this traction for 4 to 6 weeks to preserve vertical stability if posterior internal xation is not used. With the posterior deformity corrected, stab incisions for the pins must be placed through the skin in a rotationally reduced position. If a percutaneous method is to be used, it is advantageous to use transverse incisions angled across the iliac crest at 90 and directed toward the umbilicus. The most anterior pin is positioned 2 cm dorsal to the anterior superior iliac spine to avoid the lateral femoral cutaneous nerve. However, if a later iliac crest incision is planned, standard stab wounds parallel to the crest are preferred to avoid compromise of the incision by these wounds. The advantages of angled stab incisions are that they avoid long wounds that can decompress extraperitoneal hematomas and they are in the direction of any correction of displacement of the hemipelvis.
Regardless of whether a percutaneous closed or an open method is used, it is imperative to understand the anatomy of the iliac wing. The opening of the iliac wing is angled 45 oblique to the operating table or the oor, and the lateromedial are of the wings is also 45. The iliac crest has a lateral overhang. A model pelvis in the operating room helps the surgeon determine the exact pin orientation. A small guide such as a spinal needle can be placed along the iliac crest to act as a directional nder for the drill and the pin. Image intensication oriented in the plane of the crest helps guide pin placement. When placing the pins, it is important to start the pin just medial to the midline of the iliac crest. The pin should then be directed along the angle of the iliac crest. Drilling of the pins perpendicular to the long axis of the patient or to the oor will result in passage of the pins through the iliac crest and out its lateral aspect (Fig. 3631). After the crest is identied, a drill bit is directed in the appropriate orientation as determined by the guide. A drill hole that just perforates the iliac crest is made. The pin is inserted into the drill hole and seated with several gentle blows of a hammer. The size of the drill hole is determined by the system in use. Normally, for 5-mm pins, a 3.2- to 3.5-mm drill bit is required. Once the pin has been seated in the predrilled hole, it is gently turned by hand and allowed to seek its way between the inner and outer cortical tables of the hemipelvis while being directed toward the greater trochanter (Fig. 3632). The complete threads of the pin should be buried within the iliac bone. Once the pins have been placed into both hemipelves, they can be used cautiously as a handle to assist in reduction of the hemipelvis. If the patients condition permits, pin placement must be checked before leaving the operating room. The outlet view reveals whether the pin is out of the crest. The obturator oblique view is tangential to the crest and shows whether the pins are between the two tables. A combination of both views will provide excellent visualization of the iliac crest to guide insertion. After pin placement and verication, the frame can be constructed. Several basic principles should be observed. With a simple rectangular frame, the two crossbars should be joined together with bars or 6-mm Steinmann pins. With this connected double bar across the front, rotational control is enhanced. Care must be taken to apply the frame so that sufcient clearance is present in the abdominal region to allow for postoperative distention. If the frame does not allow enough clearance, it should be revised. Once the frame has been applied, an image intensier is brought into position with the patient on a radiolucent table. Closed reduction is carried out by methods described previously. Reduction can be conrmed on the AP, inlet, and outlet views by rotating the image intensier either 45 to the head or 45 to the feet. After anatomic reduction is obtained (i.e., with the symphysis closed as much as possible and no superior rotation through the symphysis), the frame is tightened. If a triangular and more complex frame is required (i.e., pins into the iliac crest and the region of the anterior inferior iliac spine), the lower pins are inserted through an
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Presentation
FIGURE 3631. Application of external xation to the pelvis. A, Landmarks are the iliac crest and the anterior superior iliac spine. B, The iliac wing is palpated to determine its orientation. It may also be determined by the use of an open technique or by spinal needles to outline both the inner and the outer aspects of the pelvis. C, Appropriate orientation of the iliac wing; note the pin orientation on an angle to the body. D, After insertion of the rst pin, the second and third pins are inserted freehand or with a guide device. E, The pins in place match the orientation of the iliac wing. F, The nal frame.
incision made between the anterior superior and anterior inferior spines to expose the interspinous bone. Care must be taken to protect the lateral cutaneous nerve to the thigh. The origins of the sartorius and rectus femoris between the
spines are removed. Pins are then placed in a similar manner through the anterior inferior spine into the thick bone above the acetabulum. This technique is best done under image intensication to avoid entering the hip joint
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frame construct uses one pin in each anterior inferior spine with a rectangular frame. This frame must allow at least 90 of hip exion so that the patient can sit.
Open Reduction of Symphyseal Disruptions

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Presentation
FIGURE 3632. Improper pin position. It can be seen from the pelvic radiograph that the pins have gone through the iliac wing and out the lateral aspect (arrow). Note that the orientation of these pins is far too perpendicular and, therefore, the direction of the iliac wing has been forgotten. These pins are inadequate for long-term use and would have to be replaced.
(Fig. 3633). Potential problems with this approach are the loss of tamponade as a result of stripping of tissue from the inner pelvic wall, exposure of the anterior aspect of the pelvis, and penetration of the hip joint. With two pins in the anterior inferior spine region and two in the iliac crest, the pin clusters are developed by using pin-to-bar clamps and a bar. The two pin clusters are connected by separate bars to form a triangle. The two triangular portions are then joined across the patients abdomen to complete the frame (Fig. 3634). A simpler
If open reductioninternal xation of a symphyseal disruption is necessary, a decision whether to use one or two plates must be made. If the posterior osseous ligament hinge is intact (a stable AP compression injury), the use of a single plate placed on the superior aspect of the pubic bodies and crossing the symphysis is adequate.49, 54, 107, 108 If the posterior osseous ligamentous hinge is disrupted and will not be stabilized internally, the use of a second plate (four holes or more) placed on the anterior pubic bodies is recommended. However, if posterior stabilization will be carried out, single-plate xation is satisfactory. A two-hole or greater, 3.5- or 4.5-mm plate is used to provide suitable stability. The symphysis cycles in tension and compression, depending on the patients position, and a four-hole or larger plate will limit this motion and thereby potentially lead to breakage of the plate. A two-hole plate allows such motion to occur, although failure of implant xation may result from screw loosening. Determination of plate size should be based on the plate that best ts the pubic bodies.54 OPEN REDUCTION AND INTERNAL FIXATION OF THE SYMPHYSIS: TECHNIQUE A Foley catheter is inserted for bladder decompression.49, 54 It may be instilled with uid intraoperatively to identify the bladder. The standard approach to the
FIGURE 3633. Technique of insertion of the double-cluster external xator. The iliac crest is exposed as shown in A from the anterior inferior iliac spine to a point 4 cm posterior to the anterior superior iliac spine. The 5-mm pelvic pins are inserted under direct vision, as indicated, and the double frame is assembled. This exposure may be avoided by the use of image intensication to guide percutaneous insertion of the pins (A, Redrawn from Mears, D.C. External Skeletal Fixation. Baltimore, Williams & Wilkins, 1983.)
X
X
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FIGURE 3634. Types of external frames. A, B, Trapezoidal (Slatis) frame, which was proposed to be able to control posterior instability. It is a good frame for stabilization of the pelvis because it allows the arms to be moved in an outward direction away from the abdomen for work on the abdomen. C, Double-cluster frame of Mears.
Presentation
symphysis is through the Pfannenstiel incision, which is usually located approximately 2 cm above the symphysis. The incision should extend from one external inguinal ring to the other. After the skin and subcutaneous tissues have been incised, the fascia over the rectus abdominis muscles and the external oblique muscle is identied. In males, the spermatic cord should be protected to prevent iatrogenic injury. In most cases of symphyseal disruption, the rectus abdominis is traumatically disrupted from one or both pubic bodies. Consequently, the exposure can be carried out very easily. However, if the rectus abdominis has not been torn off its insertion, the insertion of this muscle onto the pubic bodies must be elevated to access the symphysis. The inferior 8 to 10 cm of the linea alba is split down to the symphysis. The insertion of the recti onto the pubic bodies can be elevated to reveal the anterior aspect of the pubis and the medial aspect of the obturator foramen. Posteriorly, the space of Retzius is opened, with care taken to not damage the bladder. By remaining on the pubic bodies, the exposure can be extended laterally to expose the superior pubic rami to the iliopectineal eminence. This approach may be done through a midline abdominal
incision. Beware that the standard midline laparotomy incision does not extend the incision distally enough to expose the symphysis. An orthopaedic surgeon must be present if the trauma surgeon is making the incision so that the appropriate length is achieved (Fig 3635). Once the exposure has been completed, a pelvic reduction clamp can be applied to the anterior body of the symphysis through appropriate screw xation, or pointed reduction clamps can be placed through the obturator foramen anteriorly, and then reduction can be accomplished. If the reduction has any rotational component or displacement at the symphysis, a second clamp can be applied anteriorly or superiorly to control this aspect of the displacement (Fig. 3636). The appropriate plate is contoured and applied to the superior aspect of the pubic bodies. Palpation of the posterior aspect of the pubic body determines the orientation of the drill so that the screw can be placed through the full length of the pubic body. Usually, a 40- to 50-mm screw can be placed into the body of the pubis. If a second plate is required, it can be contoured along the anterior aspect of the pubic bodies and the screws placed in an anterior-to-posterior direction
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FIGURE 3635. Exposure of the symphysis and pubic body. A, A Pfannenstiel transverse skin incision made approximately 1 to 2 cm above the palpable symphysis and pubic body. This incision usually extends from one external ring to the other external ring. B, After subcutaneous dissection, the rectus sheath is identied from its outer borders. Note the spermatic cord. Care should be taken to avoid it, and retraction can be carried out once it is mobilized laterally. The rectus sheath is then divided just above the symphysis while making sure that a cuff of tissue is left anteriorly to attach it. C, Exposure is completed by subperiosteally taking away the prebladder fat. D, An alternative method whereby the linea alba is split along its bers down to the rectus and then pulled back to the obturator foramen with the use of a Hohmann retractor. E, This method allows exposure of the symphysis but maintains some attachments of the rectus to the pubic body.
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between the superiorly placed plate screws. These screws must not be left long to avoid erosion into the bladder. After xation has been achieved, the incisions are closed while making sure that the rectus abdominis is well apposed to its insertion, which may require complete muscle relaxation as well as exing of the table so that the muscles are brought together to facilitate reattachment. The external oblique aponeurosis must be repaired, and if the external ring has been entered, care must be taken to repair it anatomically so that an inguinal hernia does not develop. If a pubic ramus fracture requires exposure, it can be done by extending the surgical exposure along the pubic ramus. The reduction can be accomplished, and stabilization of the symphysis will usually control displacement of the pubic ramus. If the displacement is within the rst 4 cm lateral to the body of the pubis, the plate may be extended out onto this area to achieve plate xation. If an extensile approach is required for reduction and stabilization of a pubic ramus fracture, particularly at the root of the acetabulum, it is accomplished with an ilioinguinal anterior approach, as described by Letournel.58, 121 This approach allows adequate exposure of the whole anterior aspect of the pelvis and appropriate plate xation with a well-contoured 3.5-mm reconstruction plate (Figs. 3637 and 3638). An alternative approach is the modied Stoppa approach to the inner aspect of the pelvis.15, 45 With the patient in the spine position and the involved extremity draped free, a transverse incision is made 2 cm above the symphysis similar to the Pfannenstiel incision. The recti are split along the linea alba and sharply elevated from the pubic body and rami. The rectus and neurovascular structures are retracted laterally and anteriorly. With the surgeon standing on the opposite side of the table from the fracture, the vascular anastomoses between the inferior
epigastrics and the obturator vessels are ligated. Before elevation of the posterior iliacus, the iliolumbar artery is ligated. Full access is achieved by dividing the iliopectineal fascia superiorly and the obturator fascia inferiorly. This exposure will allow access to the sacroiliac joint by retracting the psoas and iliac vessels. Flexion of the ipsilateral leg facilitates the exposure by relaxing the psoas. The obturator nerve and vessel must be protected throughout this approach. The standard xation is plate osteosynthesis. Screws inserted at or lateral to the iliopectineal eminence will be in the hip joint. Retrograde intramedullary screw xation of ramus fractures has been developed by Routt.98, 108
Sacroiliac Joint Reduction and Fixation

Dislocations or fracture-dislocations through the sacroiliac joint can be reduced and stabilized either anteriorly or posteriorly.49, 61, 64, 99, 109 Advantages of the anterior approach include better visualization of the sacroiliac joint, which allows reduction under direct visualization.109 It is also easier to denude the articular cartilage of the sacroiliac joint to facilitate the insertion of a bone graft for potential fusion of this joint.49, 109 The disadvantage of this approach is the close relationship of the L4, L5, and lumbosacral trunk to the sacroiliac joint. The L4 nerve root runs between the L5 root and the sacroiliac joint and merges with the L5 root to form the lumbosacral trunk an average of 11.49 mm from the joint line at the level of the sacral promontory. It is at risk for a traction palsy if adequate exposure is not obtained and excessive retraction is necessary.3, 47 Advantages of the posterior approach are simplicity in exposing the iliac wing and sacroiliac joint and the ability
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FIGURE 3636. Reduction techniques for disruption of the symphysis pubis. A, Reduction using a pointed or serrated reduction clamp through the obturator foramen to hold the pelvis together. B, Use of pelvic reduction clamps applied to the anterior aspect of the pubic body on both sides of the symphysis and then closing the symphysis. This technique gives better control and allows for more rotational correction through the clamps themselves. (A, B, Redrawn from Schatzker, J.; Tile, M. Rationale of Operative Fracture Care. New York, Springer-Verlag, 1987, p. 165.)
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FIGURE 3637. Series of radiographs demonstrating an open-book (B1.3) injury that is unstable in external rotation and requires xation. A, Anteroposterior pelvic radiograph demonstrating the diastasis of the symphysis, which is unilateral on the left side. B, Inlet view conrming the opening of the symphysis, as well as the opening of the sacroiliac joint. C, Outlet view of the pelvis showing the diastasis of the symphysis, well as widening of the sacroiliac joint on the left side. D, Computed tomographic scan conrming the opening of the sacroiliac joint on the left side. Note that posterior subluxation has not occurred and that the posterior structures appear to be intact because of the absence of displacement in this area. It appears that the right hemipelvis has been hinged posteriorly. Note the normal right side. E, Postoperative radiograph showing plate xation of the symphysis. A ve-hole plate has been used. This injury could also have been treated with a two-hole plate. Inlet (F) and outlet (G) views of the pelvis during anatomic reduction and closure of the symphysis and sacroiliac joint.
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FIGURE 3638. Example of anterior xation showing the use of double plating of the symphysis in unstable fractures in which posterior xation may be contraindicated either because of poor posterior soft tissue or because of the patients condition. A, Anteroposterior radiograph of the pelvis of a man who was crushed between two pieces of heavy equipment. Note the diastasis of the symphysis with an associated fracture posteriorly (closed arrow). Also note a component of the sacrum left attached to the iliac wing (open arrow). B, Inlet view again showing the diastasis of the symphysis with a wide posterior gap and posterior displacement. C, Outlet view again showing the large gap and superior vertical migration of the hemipelvis on the right side (arrows). D, Computed tomographic scan conrming a shear fracture through the sacrum with the sacral side of the sacroiliac joint left intact. Note the widening of this injury and avulsion of the posterior tubercle indicative of complete disruption of the posterior ligaments. E, At the time of laparotomy, immediate internal xation of the symphysis was performed. Because of this mans condition, potential problems with returning to the operating room to stabilize the posterior injury were considered remote. Consequently, a double plate was applied across the anterior of the ring and supplemented by external xation. F, This man did improve, and posterior transiliac bar xation was used to close the sacral fracture and stabilize it. It should be noted that this is the only time that double-plate xation of the symphysis should be used for unstable posterior injuries when the potential for nonoperative treatment exists.
to reduce either sacral or sacroiliac fractures and fracturedislocations.64 The major disadvantage of this approach is that the patient must be turned prone or lateral, which may be difcult in a multiply injured patient. Because the screws can be placed into either the sacral ala or the body, precise reduction of the fracture and image intensication are required so that exact placement of the screws can be observed. Damage to the anterior vascular structures in front of the sacrum or to the cauda equina by inadvertent perforation with the screws must also be avoided. Posterior soft tissue crush injuries or signicant skin loss may also cause problems.49
Both techniques carry a risk for signicant complications, of which the surgeon must be well aware, but no denite proof has been presented that either approach is better. As long as appropriate precautions are taken, both approaches provide adequate reduction and stabilization of fractures or fracture-dislocations of the sacroiliac joint. The decision regarding which approach to use is determined by the characteristics of the soft tissue injury and the fracture. The anterior approach is indicated for sacroiliac joint dislocations and fracture-dislocations involving the ilium, for iliac wing fractures, and for associated anterior pelvic fractures that require xation.
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The anterior approach is not indicated for sacral fractures or when the risk of infection from an external xator pin, colostomy, suprapubic catheter, or overhanging abdominal pannus is high. The posterior approach is indicated for sacral fractures, fracture-dislocations involving the sacroiliac joint, and fractures of either the ilium or sacrum and the iliac wing. Contraindications to a posterior approach are crush or degloving injuries to the posterior skin or wounds that communicate with the perineum and ischiorectal area. For all internal xations of the pelvis, the use of an image intensier and a radiolucent operating table is mandatory. The C-arm is necessary to conrm reduction and screw placement. Familiarity with the three pelvic radiographic views is necessary. Patient size, bowel gas, and radiographic dye may hinder the ability to obtain quality radiographs and force a change in treatment or radiographic technique. ANTERIOR APPROACH TO THE SACROILIAC JOINT: EXPOSURE AND REDUCTION The patient is placed in the supine position on a radiolucent table. A small radiolucent roll is placed just lateral to the midline on the involved side to elevate the involved hemipelvis for easier manipulation109 (Fig. 3639). The involved leg is draped free so that it is available to assist in the reduction. This approach can also be performed with the patient in the lateral decubitus position. The incision starts approximately 6 cm behind the highest point of the iliac crest and is carried forward to just past the anterior superior iliac spine. Posteriorly, the muscles of the lateral abdominal wall are split in the direction of their bers to expose the posterior half of the iliac crest. The iliac fascia and the insertions of the external muscles of the abdomen onto the iliac crest are incised, and the iliacus muscle is then stripped off the internal iliac wing. The lateral femoral cutaneous nerve is located just medial to the anterior superior spine and must be protected in this approach. At this point, with exion and internal rotation of the hip to relax the psoas and iliacus, careful dissection along the iliac wing will bring the sacroiliac joint into view. Because the iliac wing usually displaces posteriorly, the sacrum is generally found anterior to the iliac wing. Care should be taken to avoid going through the iliacus onto the sacrum and damaging the L5 root. By following the displaced iliac wing, the articular cartilage of the sacroiliac joint can be identied, and by moving both superiorly and posteriorly, the sacral ala can be identied. Subperiosteal dissection is then carried along the ala. Care should be taken to gently retract the soft tissues medially, including the L4 and L5 roots. The L5 root normally lies 2 to 3 cm medial to the S1 joint in a small groove and then goes over the anterior aspect of the sacrum to drop into the pelvis. After the superior aspect of the sacral ala has been identied, dissection continues along the anterior aspect of the ala and the pelvic brim down inside the true pelvis to identify the notch. The surgeon must take care that the dissection remains subperiosteal and avoid injury to the superior gluteal artery. If bleeding does occur, packing of the area can usually control it. After the dislocation or fracture-
dislocation has been identied, the sacroiliac joint is denuded of cartilage on its sacral side and the subchondral plate roughened if fusion of the joint is desired. A small bone graft can be taken from the anterior iliac crest. The fracture or dislocation is then reduced. Reduction is best accomplished by placing boneholding forceps on the iliac wing through the interval between the anterior superior and anterior inferior iliac spines to grasp the hemipelvis and pull it forward. The use of 5-mm Schanz pins in the iliac crest is helpful to obtain the correct rotational position of the hemipelvis. By pulling the pelvis forward with the bone-holding clamp and rotating it with the Schanz pins, reduction is obtained at the level of the sacroiliac joint (Fig. 3640). By using an asymmetric pelvic reduction clamp, the sacroiliac joint can be reduced and stabilized provisionally. One arm of the clamp is placed on the posterior aspect of the iliac crest and the other on the anterior aspect of the sacral ala. The direction of force is such that the joint will be pushed anteriorly and closed down posteriorly. With a fracture through the iliac wing, this maneuver helps reduce the dislocation. Reduction may also be accomplished by placing one screw into the sacral ala and one into the iliac wing and then applying the pelvic reduction clamps. Provisional stabilization is achieved by placing a 3.2-mm Steinmann pin percutaneously through the iliac wing into the ala. Before reduction, this pin may be inserted through the ilium into the iliac side of the sacroiliac joint so that its position is conrmed under direct vision. A staple across the sacroiliac joint may also be used as a temporary stabilization device.57 A 3.5- or 4.5-mm three- or four-hole reconstruction plate is then contoured. One screw is placed into the sacral ala and directed parallel to the sacroiliac joint. The direction of the screw can be determined by placing a 1.6-mm Kirschner wire (K-wire) in the joint at the time of reduction. These screws are usually 30 to 40 mm long. The plate is attached to the iliac wing by fully threaded cancellous screws, which usually traverse the length of the posterior tubercle. The pelvic reduction clamp can then be removed and replaced by a second plate. Specialized plates have been developed for sacroiliac joint stabilization, but they do not allow incorporation of iliac wing fracture xation.109 At times, a small ridge may overgrow the sacroiliac joint on either the iliac or the sacral side. This ridge may make reduction and plate xation difcult and can be removed. A nal way of stabilizing the joint once reduction is achieved is by insertion of a percutaneous cancellous screw into the sacral body and neutralization with a three- or four-hole 3.5- or 4.5-mm anterior sacroiliac plate. After image intensication or plain radiographs conrm reduction, the wound is closed in the appropriate fashion (Figs. 3641 and 3642). POSTERIOR APPROACH TO THE SACROILIAC JOINT: EXPOSURE AND REDUCTION For a posterior approach to the sacroiliac joint, the patient must be placed either prone on bolsters or in the lateral decubitus position with the involved side up64, 100 (Fig. 3643). This approach is similar to that used for the insertion of transiliac bars. It is also wise to drape the
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FIGURE 3639. Anterior approach to the sacroiliac joint. A, With the patient in the supine position, an incision is made along the iliac crest, starting at the anterior superior iliac spine and extending back past the posterior tubercle and into the external oblique musculature. B, With dissection along the iliac wing, the iliopsoas muscle is reected medially. Note the orientation of the L5 root and its relationship to the sacroiliac joint. Full exposure reveals the iliac wing, as well as the sacrum and the sacroiliac joint. It can be appreciated that fractures through the iliac wing and into the sacroiliac joint can be treated with this exposure. C, Two-plate xation of the sacroiliac joint. One screw is placed in the sacrum, and one or two screws, depending on the size of the patient, are placed on the iliac side. A wire is inserted in the sacroiliac joint to show the orientation of the joint so that screws can be placed parallel to it. D, The orientation of the plate and screws, as well as the sacroiliac joint, can be seen. It is possible to lag the posterior tubercle of the iliac wing into the sacroiliac joint through the sacral screws.
involved leg free to facilitate the reduction through manipulation of this extremity. To commence, a longitudinal incision is made just adjacent to the posterior superior iliac spine, either medial or lateral, depending on whether the ilium or the sacrum is to be exposed. The incision is extended from just above
the upper margin of the iliac crest to 4 to 6 cm below the projected area of the posterior aspect of the sacral notch. The gluteal musculature as it inserts onto the posterior spine is then elevated sharply and, with subperiosteal dissection, is lifted off the outer aspect of the posterior wing of the ilium. Fractures in the iliac wing can easily be
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identied. The sacral notch is exposed by sharp reection of the insertion of the gluteus maximus bers from the lumbodorsal fascia, the erector spinae, and the multidus muscles. After the sacral notch is identied, the fascial origin of the piriformis must be taken down. Care must be taken to avoid damage to the superior gluteal artery. Once the piriformis has been released, it is relatively easy to identify the dislocation of the sacroiliac joint. With the use of a lamina spreader, the joint or fracture may be distracted and debrided. On completion of debridement of the joint or fracture, reduction is accomplished with the use of pointed reduction clamps, a femoral distractor, and pelvic reduction forceps. Palpation with the surgeons nger through the notch and along the anterior aspect of the sacroiliac joint allows appreciation of the reduction anteriorly. Palpation along the superior border of the sacral
ala and the iliac crest can also be carried out. Conrmation of the reduction by radiographs or image intensication is necessary (Fig. 3644). The reduction can then be maintained with the use of a clamp from the sacrum and a small unicortical drill hole into the posterior spine. It may also be maintained by placing a K-wire under image intensication into the sacral ala. If an iliac wing fracture is present, anatomic reduction of the fracture with interfragmental compression and plate xation usually allows anatomic reduction of the sacroiliac joint or at least facilitates it. After the fracture has been reduced, iliosacral screw xation must be undertaken. As an open procedure, the guide wire or drill starts on the outer aspects of the iliac crest and is kept cephalad to the dorsal S1 foramen and approximately 2.5 cm dorsal to a line from the
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FIGURE 3640. Reduction technique for sacroiliac dislocationanterior approach. A, Use of a pointed reduction clamp to apply traction and control rotation. B, A Schanz screw in the iliac crest to apply traction, produce translation, and control rotation. C, A pointed reduction clamp may be used to maintain reduction through a previously drilled hole in the sacrum and the iliac wing, or a large asymmetric pointed clamp may be placed onto the anterior aspect of the sacrum, just medial to the sacroiliac joint, and then passed over the posterior aspect of the iliac crest (not shown). D, Preinsertion of two screws on either side of the sacral iliac joint. The reduction may be performed with a Farabeuf clamp. E, F, Pelvic reduction clamp. G, Reduction may also be achieved indirectly by using a plate attached to the sacrum with one screw and, subsequently, using a second screw to pull the pelvis up and in. The at plate is inserted into the sacrum and xed. A gap is left under the sacroiliac joint but will be reduced when the iliac screw (arrow) is tightened. (AG, From Tile, M., ed. Fractures of the Pelvis and Acetabulum, 2nd ed. Baltimore, Williams & Wilkins, 1995.)
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FIGURE 3641. Series of radiographs showing a pure sacroiliac joint dislocation. This injury can be treated by anterior sacroiliac joint xation. A, An anteroposterior view of this pelvis shows that the sacroiliac joint has narrowed on the left side. The anterior lesion is a symphysis diastasis with a fracture through the pubic and ischial rami. B, Inlet view. Note the posterior displacement of the sacroiliac joint (arrow). Provisional stabilization was accomplished with an external xator. C, Note the continuing wide diastasis anteriorly, indicative of malrotation. Also note the vertical orientation of the external xation pin on the left side as it perforates both the inner and the outer cortices of the iliac wing; it does not obtain good purchase because it was drilled in the wrong direction. D, Pure sacroiliac joint dislocation. Note the arrow pointing to a small piece of bone in the joint. At the time of surgery, this dislocation represented complete avulsion of the articular cartilage of the sacroiliac joint. It was removed as a complete shell with a minor amount of bone in place. E, In a Pfannenstiel approach, the symphysis was rst reduced and plated. It was not necessary at this time to deal with the pubic rami fractures because they had soft tissue attachments and appeared to be adequately reduced at the time of symphyseal xation. Through an anterior approach, two plates were placed across the sacroiliac joint to stabilize the reduction. Because the articular cartilage was avulsed, further denuding of cartilage was not necessary, and primary fusion was probable. Note the position of the plates on the sacrum (i.e., approximately 1 to 2 cm inside the joint). The screws are directed posteriorly. Plates on the iliac side tend to diverge, so good bone purchase can be obtained with screw xation.
posterior superior to the posterior inferior spine (crista glutea) and 2.5 cm above the greater sciatic notch.75 The use of a specic point on the iliac wing demands that the sacroiliac joint be anatomically reduced or any implants started in this position will be malpositioned in the sacrum (Fig. 3645). With an anatomic reduction, the xation may be started in this position and placed into the sacral ala. AP and inlet views determine the AP position of the screw, the outlet view is used to determine the superoinferior position of the screw, and guide wire or drill bit placement is conrmed to be aimed into the sacral body (see Fig. 3644). At the time of drilling, it is very important to gently advance the drill in steps to ensure that the drill bit remains in bone. Three cortical barriers should be crossed (i.e., the outer iliac wing, the iliac side of the sacroiliac joint, and the sacroiliac joint subchondral bone). If a fourth cortical barrier is encountered, the drill bit is about to leave the sacrum, with potential danger either to the cauda equina or to the anteriorly placed neurologic and vascular structures. If the position of the drill or guide wire is not correct, it is withdrawn completely and redirected. A small two- or three-hole plate can be applied to the outer aspect of the iliac wing, or a washer can be used to prevent penetration of the screws. In sacroiliac
dislocations, cancellous screws with a 32-mm thread length and a 6.5- or 7.3-mm diameter are normally used (Fig. 3646). However, the surgeon should make sure that the threads cross into the sacral ala and are not in the sacroiliac joint and blocking interfragmental compression of the reduction. Mechanically, a screw with a 16-mm thread length may be stronger than a screw with a 32-mm thread length because the junction of the screw shaft and threads is further from the potentially mobile fracture site. Although screw position can be evaluated by direct visualization posteriorly and by palpation of the ala superiorly and anteriorly, it is mandatory that C-arm uoroscopy be used to conrm its safe position. A similar approach using the lateral position can combine both anterior and posterior exposures of the sacroiliac joint. By placing the patient in the lateral decubitus position and carrying the incision along the iliac crest to the posterior tubercle and then down as described previously, the surgeon can peel off the gluteal mass from the outer aspect of the pelvic ring. Then, by moving inside the posterior tubercle, the surgeon can identify the sacral ala and the sacroiliac joint by detaching the abdominal musculature and iliacus from their attachments to the inner aspect of the iliac crest. Reduction can be accom-
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plished under direct vision, and screws can be seen entering through the sacroiliac joint into the ala. This approach is probably best used for very difcult fractures or late fractures that require greater mobilization for reduction. PERCUTANEOUS ILIOSACRAL SCREW FIXATION UNDER FLUOROSCOPIC CONTROL Because of the potential for severe soft tissue complications with an open posterior exposure, the concept of limiting the amount of surgical dissection for reduction and xation has become popular. This practice has led to the development of percutaneous techniques for posterior pelvic stabilization.25, 64, 94, 99, 111 It is a technique that is suitable for stabilization of sacroiliac joint dislocations and sacral fractures. To use this method, the fracture must be reduced and the surgeon must understand the radio-
graphic anatomy of the sacrum, posterior iliac wing, and related soft tissues. Screw placement is critical to achieve maximal stability and avoid complications. The screw must start on the outer aspect of the iliac wing, cross the sacroiliac joint, follow the S1 pedicle mass into the body of S1, and remain completely in bone. Safe placement demands thorough understanding of sacral radiographic anatomy because this technique is performed completely percutaneously, with no options to guide or conrm screw placement by palpation or visualization. The S1 pedicle is bordered inferiorly by the S1 root canal and foramen. The pedicle is approximately 28 mm (width) by 28 mm (height) in cross section. The superior surface slopes downward in a posterior-to-anterior direction at an angle of 45, with a gutter for the L5 root located 2 cm medial to the sacroiliac joint.77 The internal iliac artery lies anterior to the ala and gives off its largest branch, the superior gluteal artery,
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FIGURE 3642. Radiographs representing a bilateral, posteriorly unstable injury. A, Anteroposterior (AP) radiograph demonstrating a dislocation of the sacroiliac joint on the left side. On the right side is a fracture-dislocation of the sacroiliac joint. The arrow shows the double density where the fracture line has overlapped. B, CT scan conrming the bilateral fractures and showing the fracture-dislocation on the right and the dislocation on the left. C, AP radiograph showing the bilateral anterior approaches to the sacroiliac joint. By using plate xation to reduce the iliac wing fracture, as well as lag screw xation into the posterior tubercle, the iliac wing was reduced and stabilized. A plate on the anterior portion stabilized the sacroiliac joint component. The anterior lesions were stabilized with the use of an external xator to maintain the reduction obtained. D, Final result at approximately 8 months after the injury. Note how the fractures have united. It appears that the sacroiliac has fused on the left side as well as on the right.
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C
FIGURE 3643. A, Posterior sacroiliac joint and sacral exposure. With the patient prone, exposure is initiated with a longitudinal incision centered over the posterior tubercle. This incision must be extended distally to traverse the origin of the piriformis or the area of the greater sciatic notch. B, The incision is carried down onto the posterior tubercle. The gluteus maximus is then reected off the iliac crest posterior spine and its attachment to the spinal muscles. C, With the gluteus maximus muscle reected laterally and inferiorly, the origin of the piriformis can be noted in the depth along the greater sciatic notch and must be detached. Detachment of the origin of the piriformis allows access to the posterior iliac crest, and if the dissection is carried medially, the sacrum may be exposed posteriorly for sacral reductions. Beware of the superior gluteal artery and its branches at the greater sciatic notch above the piriformis. With the piriformis detached from the notch, access to the inner aspect of the pelvis is obtained.
anterior to the sacroiliac joint.96 These three structures are at risk of injury if the drill bit, guide wire, or screw penetrates through the ala. The body of the sacrum joins both alae through the pedicles and is surrounded by the cauda equina posteriorly, the pelvic viscera anteriorly, the
L5S1 intervertebral disc superiorly, and the fused S1S2 disc space inferiorly. The S1 body has an anteriorly protruding bony prominence, the sacral promontory, that is anterior to the sacral ala (Fig. 3647). Screws aimed toward the promontory will not traverse the bony sacral
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FIGURE 3644. To make sure that the screw xation into the sacrum or sacral ala is placed safely, the use of image intensication is mandatory. On a radiolucent table, an image intensier is brought in so that anteroposterior 40 caudal and 40 cephalad views can be obtained. The screws can then be directed under direct radiographic control into the sacral ala and body superior to the S1 foramen and thereby avoid the cauda.
FIGURE 3645. Starting position for posterior screw xation of pelvic disruptions. A, The proper starting position is approximately 15 mm from the elevated attachment of the gluteus maximus muscles on a line drawn from the top of the greater sciatic notch on the iliac crest. B, Another similar location, found by starting approximately 2.5 cm (2 to 3 ngerbreadths) lateral to the posterior superior iliac spine and 2 ngerbreadths cranial to the greater sciatic notch. Both these starting positions require anatomic reduction of the disruption.
15 mm
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A B
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pedicular canal and may cause injury to the neurovascular structures that lie anterior to the pedicle/ala (Fig. 3648). More than half of the S1 root canal is lled by the S1 nerve root. It runs inferiorly and laterally to the anterior S1 foramen. Because of this inferior, sloping course, the posterior half of the body of S1 is not available for screw placement because the screw could traverse the S1 root canal. Only the middle portion of the S1 body is therefore left for screw placement near the upper S1 end-plate. For safe placement of the screws, only the sacral landmarks should be used; the iliac landmarks are important to conrm reduction. The sacral landmarks are identied by using four uoroscopic views of the pelvisthe AP, the inlet and outlet (tangential), and the lateral sacral views93, 94, 96, 111 (Fig. 3649). Indications This technique is indicated if the following criteria are met: 1. It can be performed within 5 days of injury. 2. Preoperatively, the pelvis has been placed in traction to correct displacement. Severe soft tissue injury, bowel injury, or a combination of both these injuries is a good indication because this technique avoids large exposure and the risk of infection. It is useful for sacroiliac dislocations, fracture-dislocations, and sacral fractures.
Contraindications This technique is contraindicated if the following are present: 1. Failure to reduce the fracture by closed means. 2. Failure to visualize the posterior and lateral sacral structures with a C-arm. 3. The presence of sacral dysmorphism95, 96 (transitional vertebra), which occurs in 30% to 40% of people. Sacral dysmorphism is recognized by c The upper part of the sacrum and iliac crests co-linear on the outlet view. c A residual disc between S1 and S2 on the outlet view. c Alar mammillary processes. c An abnormal upper sacral ala. c Iliac cortical density not co-planar with the alar slope. 4. Osteoporosis. Technique The percutaneous method is usually done with the patient in the supine position because of the ease of reduction and because simultaneous anterior xation can be achieved without changing the patients position. Prone positioning is necessary if open reduction of the sacrum is planned. It may also be the surgeons preference. The patient is placed supine on a radiolucent table and positioned to allow the C-arm full rotation so that inlet and outlet views can be obtained. A soft radiolucent support is placed under the
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FIGURE 3646. This man had a disruption of his left sacroiliac joint xed by posterior screw xation. A, This patient was struck from behind by a truck and suffered a displaced fracture through the sacroiliac joint and pubic rami anteriorly. B, Inlet view conrming posterior displacement at the sacroiliac joint on the left side. C, Anteroposterior view demonstrating posterior screw xation of the pelvis. Note how the screws have been placed across and into the body of the sacrum. Such placement is necessary for sacral fractures, but it also gains good purchase in sacroiliac joint dislocations. The screws are above the rst sacral foramen. D, Good screw placement is noted on the inlet view, which shows that reduction has been achieved and adequate xation has occurred with screws in the ala and body of the sacrum. E, Outlet view again conrming proper position of the screws.
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FIGURE 3647. Anatomy of the upper part of the sacrum (S1S2). A, This cross section through the sacrum demonstrates the promontory of S1 and the concavity of the sacral ala. Safe placement of screws is marked by the white area. B, From above the promontory the concavity of the ala can again be appreciated, as can the location of the posterior sacral wall. C, This diagram represents the course of the L5 root (arrow) going over the gutter of the sacral ala and descending in front of the sacroiliac joint and the course of the S1 root in a medial-to-lateral direction. One can see where the safe position is for screw placement. D, This diagram shows the area that must be taken into account for placement of a percutaneous screw from outside the iliac wing into the body of the sacrum. (A, B, D, From Tile, M., ed. Fractures of the Acetabulum and Pelvis, 2nd ed. Baltimore, Williams & Wilkins, 1995. C, Redrawn from Routt, M.L.C., Jr.; et al. J Orthop Trauma 10:173, 1996.)
patients lumbosacral spine to elevate the buttocks off the table and ensure that the lateral aspect of the ank is accessible so that the starting point for the screw is not compromised. The C-arm is used to visualize the lateral aspect of the sacrum. Ensuring that the radiographic images of the femoral heads and greater sciatic notches are superimposed checks this position. The body of S1 is centered in the uoroscopes screen. The AP view is now obtained by rotating the C-arm. To obtain the inlet view, the C-arm is then tilted so that the anterior cortex of S1 overlaps that of S2. If such visualization is not done, the concavity of the sacrum will not be appreciated and the screw may exit anteriorly. However, the posterior cortex of S1 is best seen if the anterior cortex of S1 is over the coccyx. This projection is needed to ensure that the screw does not exit posteriorly. The outlet view is obtained by rotating the C-arm 90 so that the pubic tubercles lie just
inferior to the S1 foramen and the symphysis overlies the midline of the sacrum.64 After complete radiographic visualization has been obtained, fracture reduction can be undertaken after induction of muscle-relaxing anesthesia. Closed reduction is usually possible within 2 to 5 days of the injury. Closed reduction requires knowledge of the displacement of the fracture. A completely unstable hemipelvis is displaced vertically and posteriorly and is externally rotated. However, depending on the mechanism of injury, the displacements may differ, so review of the history and radiographic studies is mandatory before reduction is attempted. The patient is prepared from the costal margins to the knees on both sides and down to the table on the involved side. The involved leg is prepared and draped free to allow manipulation. The rst displacement to be corrected is the axial malposition, which is accomplished by longitudinal
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skeletal traction through a traction pin inserted in the distal end of the femur. If the fracture is posteriorly displaced, the traction is directed upward to correct it. Rotational displacement is corrected by placing one or two Schanz screws into the involved iliac crest and using them to manipulate the hemipelvis into place. The external xator can be used to reduce this component as well. Posterior translational displacement is reduced by closing this gap with a ball-spiked pusher. These reduction maneuvers may require one or two assistants. Once the reduction is achieved, it is conrmed by C-arm visualization with the three views of the hemipelvis. Provisional xation is possible with a K-wire inserted into the ala or use of the pelvic resuscitation C-clamp.
The supercial skin location for screw insertion is 2 cm posterior to the intersection of a line from the femoral shaft and a line dropped from the anterior superior iliac spine. The guide wire or drill bit is placed through a stab wound down to the posterolateral aspect of the ilium. The AP view shows that this device is aimed into the S1 body and perpendicular to the sacroiliac joint. At this point, the C-arm is used to visualize the lateral part of the sacrum. The position of the drill bit or guide wire is conrmed to be in the middle of the S1 body. It is important to make sure that the screw is placed so that it is below the cortical projection of the sacral ala, which is seen only on the lateral view.94, 96, 111 If the position is correct, the drill bit or guide wire is advanced toward the body of S1. It is
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FIGURE 3648. Penetration of the ala with screw placement. Inlet (A) and outlet (B) views of the pelvis show that the screw appears to be intraosseous. C, A postoperative computed tomographic scan shows that the anterior cephalad screw is extraosseous. The patients left L5 nerve root was injured. D, E, A plastic model shows how this injury can occur. (AC, From Routt, M.L.C., Jr.; et al. J Orthop Trauma 10:175, 1996. D, E, From Tile, M., ed. Fractures of the Acetabulum and Pelvis, 2nd ed. Baltimore, Williams & Wilkins, 1995.)
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FIGURE 3649. Important radiographic landmarks for the insertion of percutaneous iliosacral screws. A, Cross section of the pelvis showing the sacral promontory and important aspects as visualized on a lateral sacral radiograph. The sacral promontory and the alar slope should be recognized in these views. B, Inlet view of the pelvis showing both the bony pelvis and the radiographic appearance of the anterior cortex of S1 and S2 superimposed. C, Inlet view of the bony pelvis and radiographic image showing that increasing the angle on the C-arm allows the anterior cortex of S2 to be visualized, but the posterior cortex of the sacral spinal canal is now seen. D, Outlet pelvic view and radiographic image showing the pubic tubercles just below the S1 foramen. (AD, From Tile, M., ed. Fractures of the Acetabulum and Pelvis, 2nd ed. Baltimore, Williams & Wilkins, 1995.)
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useful to halt insertion of the pin when the tip reaches the superior aspect of the lateral border of the rst sacral foramen on the outlet view. A true lateral view of the sacrum is obtained again to conrm that the tip of the pin is in the alar safe zone (pedicle). The progress of the drilling is watched on the three pelvic views. The drill bit or guide wire perforates three cortical barriers (outer part of the ilium, inner iliac side of the sacroiliac joint, and sacral side of the sacroiliac joint). If a fourth cortical barrier is encountered, insertion is stopped and the drill bit or guide wire is realigned because it is potentially about to leave the safe channel and injure a major structure. Any misdirected drill bits or guide wires must be completely removed and restarted to create a new tract. Once the position of the drill bit or guide wire is conrmed, the screw is inserted. A lag screw is used to x a sacroiliac dislocation so that any residual gap can be closed. In foraminal or body fractures of the sacrum, a fully threaded large-fragment screw can be used as a position screw to maintain the reduction but not overly reduce or compress the fracture for fear of injuring a nerve root. Screw head position is conrmed by over-rotating the anteroposteriorly positioned C-arm 20 to 30 toward the involved side. This view shows the outer cortex of the ilium so that the position of the screw head is conrmed to abut the cortex. Medial placement past midline is difcult because of superimposition of the opposite-side alar cortical slope. Care must be taken if the screw is inserted past the midline to avoid the risk of perforation of the anterior sacral surface. This procedure can be done with the patient in the prone or lateral position. It is imperative that this technique not be attempted if the pelvic bony landmarks cannot be visualized radiographically. If these problems occur, the percutaneous technique must be aborted (Fig. 3650). OPEN REDUCTION AND INTERNAL FIXATION OF UNSTABLE SACRAL FRACTURES Fractures through the sacrum are probably the most difcult to reduce and stabilize.47, 112 Open reduction of these fractures is usually handled posteriorly, and consequently, a good evaluation of the posterior soft tissues must be carried out. These unstable fractures must not be xed by open techniques until the skin and soft tissues are able to tolerate surgery. If possible, closed reduction should be performed and may allow the use of a percutaneous xation technique. The patient is then placed in the prone position, on bolsters, to allow the abdominal contents to be free and facilitate reduction. Three basic methods of stabilization can be used. The rst is the posterior iliosacral screw xation method described previously. The screw xation must enter the sacral body. The principle to remember is that if a lag screw technique is selected, the threads must not cross the fracture if compression is to be effective. If nerve root impingement is a possibility, a fully threaded position screw must be used to maintain the reduction. The approach to this area is no different from that described previously for posterior screw xation of the sacroiliac joint. However, the surgeon may move the incision medially to identify the fracture and use it as a guide for the reduction. The fracture can be opened with
a laminar spreader and the sacral roots visualized and decompressed if necessary. A femoral distractor applied to both posterior tubercles is very helpful in controlling and maintaining the reduction.63 Reduction is usually accomplished by traction to reduce vertical displacement and by direct manipulation with reduction clamps to correct anterior, posterior, and rotational displacement. The reduction is done by manually lifting and rotating the distractor to correct the AP and vertical displacement. Fine adjustments are made with the pointed reduction forceps and held in place for provisional xation.63, 83 The second method of xation indicated for a unilateral sacral fracture is the transiliac bar technique. This technique requires that one side of the pelvic ring be stable and that an intact posterior tubercle be present on both sides. The fracture is reduced and provisionally held by clamps. Transiliac bars, which are at least 6-mm fully threaded rods, are inserted from the outer aspect of the ipsilateral posterior tubercle to the contralateral tubercle. The rst bar should be inserted at the level of the L5S1 disc space from one tubercle to the other. It is passed posterior to the sacral lamina, not through the sacrum or under the lamina. To do so, a second incision is required on the opposite side. This incision can be small and used only to apply the washer and nuts. The bar is then suitably stabilized with a washer and two nuts at both ends of the rod. A second rod is placed in a similar fashion approximately 3 to 6 cm below the superior rod (S1S2 interspace) and parallel to it. Nuts are placed on the screws and tightened, with compression applied to the sacral fracture line. They usually slide because the bone has enough give, and the threads are shallow enough that they cannot achieve bony purchase (Fig. 3651). This technique produces a lag effect across the fracture. Overcompression of the fracture at the sacrum, particularly if it involves the foramen, should be avoided to prevent impingement of the sacral nerve roots. Once the rods have been xed, the double nuts are tightened against themselves and crimped to prevent them from backing off. The rods are then cut ush against the nuts, and the incisions are closed in layers. This method has provided suitable xation for stabilization of unilateral sacral disruptions (Fig. 3652). If bilateral unstable sacral disruptions are present, this technique is useful to handle one side, but one of the unstable disruptions must be xed to the sacrum to provide suitable stability for this system to obtain purchase. The third method of xation is the use of plate xation posteriorly. Through similar incisions on both sides, the posterior muscles can be elevated from the iliac wing, with their attachment to the gluteal muscles left intact. After these muscles have been incised at the level of the posterior aspect of the sacrum, subperiosteal dissection can be carried down to peel back the gluteal muscles attached to the posterior tubercle. A tunnel is then made under the tissues and muscles lying over the sacrum at the level of the S3 foramina. The spinous processes are removed. A plate specially designed by Mears and coworkers11, 67 (the double cobra plate) or 3.5- or 4.5-mm reconstruction plates that can be contoured to come across the posterior aspect of the sacrum and down both iliac wings are xed to the iliac crest. However, screws are not
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FIGURE 3650. Technique for insertion of percutaneous iliosacral screws. A, The prone position on a radiolucent table. Similarly, screw insertion may be accomplished with the patient in a supine position with access by the C-arm for all three views. B, Alignment of the guide wire or drill for placing a screw into the sacrum. Note that the alignment is behind the S2 cortex in the central portion of the body to avoid the pedicles and the promontory and is below the alar slope line. C, Inlet view with S1 and S2 superimposed to show the position of the guide pins in place and avoid penetration of the ala and the posterior cortex of the sacrum. The outlet view conrms the appropriate position in the S1 body to avoid the S1 foramen. D, Final placement of screws in the safe zone of the sacrum. (AD, From Tile, M., ed. Fractures of the Acetabulum and Pelvis, 2nd ed. Baltimore, Williams & Wilkins, 1995.)
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inserted into the sacrum. One screw should be placed down the posterior tubercles along the iliac wing to acquire good xation. By overcontouring the plate slightly and with xation through the posterior tubercles, the iliac wing components of the plate are made to compress the sacral fracture. Albert and Miller2 described a similar technique, but they undercut the inferior aspects of the posterior tubercles to allow the plate to be buried beneath the posterior spines to avoid any prominence of the xation (see Fig. 3651A and B). Pohlemann and colleagues described an additional plate technique that allows direct plate xation of the sacrum with small fragment plates.84 The operative
approach is through a single dorsal incision with the patient in a prone position. The important landmarks for the skin incision are the L4 and L5 spinous processes, the posterior iliac crests, and the upper gluteal cleft. Unilateral sacral fractures are approached through an incision midway between the sacral spines and the posterior iliac crest on the involved side. For bilateral sacral ala exposure, an incision slightly lateral to the sacral spines is used. Deep exposure of unilateral fractures is achieved by incising the lumbodorsal fascia close to the sacral spines and elevating the muscle from the sacrum. If a more extensile approach is needed, the complete erector spinae can be elevated by detaching its distal and lateral attachments to the sacrum
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C D
FIGURE 3651. Transiliac bar posterior xation. A, Through two slightly curved incisions made just lateral to the posterior spine, the gluteus muscles can be reected laterally and the sacral fracture exposed. Reduction is then accomplished. B, After a 6.4-mm drill bit is used to provide a gliding hole, a drill hole is placed through the posterior iliac spine or crest; a long drill bit can then make a hole in the opposite crest. The drill and rods are kept superior to the sacrum. C, After predrilling, the sacral rod is placed through the holes to stabilize the pelvis. D, Washers and nuts are then applied and tightened while watching the fracture so that overcompression does not occur.
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FIGURE 3652. A, Radiographs demonstrating a sacral fracture that is unstable. Note that on the anteroposterior radiograph, the left posterior aspect of the hemipelvis appears to be disrupted. Some translation and shortening of the hemipelvis, as well as rotation, appear to be present. B, In this view, disruption of the sacrum can be noted on the posterior aspect. Posterior displacement as well as rotation can be appreciated. C, Computed tomographic scan conrming the gap or shearing injury through the posterior aspect of the pelvis. Note how this fracture has been displaced posteriorly with a large bony fragment. D, E, Transiliac rod xation. A reasonable reduction has been performed posteriorly, although slight compression and medial translation of the pelvis have occurred. Because this injury is extra-articular, it is probably not signicant. The outlet view shows reasonable reduction and good xation.
and posterior iliac crest. For bilateral exposure, the unilateral approach can be performed on both sides. Reduction is accomplished as described previously (Fig. 3653). Screws placed laterally into the ala and medially into the sacral bone between the posterior foramina attach the posterior sacral plates as close to the sacroiliac joint as allowed by the attachments of the iliosacral ligaments. The lateral alar screws are safely placed if their orientation is parallel to the plane of the sacroiliac joint, as identied by a K-wire placed into the joint posteriorly. Plunging with the drill bit is dangerous because of the anteriorly placed internal iliac vessels and lumbosacral trunk. The S1 alar screw must not exit the superior surface of the ala. Palpation of this surface is possible between the L5 transverse process and the sacrum. The medial screw at S1 is placed directly inferior to the distal border of the L5S1 facet. Enough room is available to insert two 3.5-mm screws. The screw is oriented in the sagittal plane and parallel to the cranial sacral lamina for lateral fractures. For transforaminal fractures, the screw is angulated 20 laterally in the horizontal plane and parallel to the cranial sacral lamina in the sagittal and frontal planes. It is aimed at the sacral promontory, so it has an average length of 50 to 80 mm. For S2S4 medial screws, the entry point is along an imaginary vertical line through the foramina and in the midpoint between them. The direction of placement is perpendicular to the posterior sacral lamina. A more
medial direction would be dangerous because the screw would enter the central canal. The implants used are standard small-fragment plates that are cut to t. Each fracture line must be crossed by at least two plates, preferably at S1, S3, or S4. For transalar fractures, H-plates are used at the S1 and lower levels. If the fragmentation extends too far laterally for secure screw placement, the plate must extend onto the ilium. If a medial screw cannot be inserted, a dynamic compression plate must cross the midline to the opposite ala. Transforaminal fractures are stabilized in a similar manner. Two dynamic compression plates parallel to each other at S1 and S3 stabilize bilateral (zone 3) fractures. These plates cross the midline and are xed to the alar region. Supplemental thinner plates such as H-plates or one-third tubular plates may be added, depending on the fracture pattern. After posterior xation, anterior pelvic stabilization is necessary to supplement this tension bandtype xation. Such stabilization may be accomplished by symphyseal plating or anterior external xation based on the anterior injury. Another technique of sacral fracture xation is the use of a transiliac 4.5-mm reconstruction plate.2 The patient is in the prone position and three posterior incisions are made, a midline incision that dissects down to the spinous processes of S1 and S2 and two lateral incisions that begin at the posterior superior iliac spine and are directed obliquely in an inferolateral direction. The muscle and
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FIGURE 3653. Placement and technique of inserting plates for sacral xation. A, Orientation of the screws. The lateral screw is always parallel to the plane of the sacroiliac joint, and the medial screw is perpendicular to the dorsal sacral lamina. At S1, two orientations are possible. B, Placement of screws from the posterior aspect of the sacrum. C, Landmarks for the skin incision with the patient prone. D, Deep exposure showing the lumbar sacral fascia incised and the erector spinae completely elevated from the sacrum for an extensile approach. Small plates were used for xation of transforaminal fractures (E) and plates spanning from one ala to the other for xation of bilateral fractures (F). (AF, From Pohlemann, T.; Tscherne, H. Techn Orthop 9:315, 1994.)
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fascia are then split to expose the iliac wing. With a 4.5-mm drill bit, two holes are placed 0.5 cm apart, 1 cm lateral to the posterior superior iliac spine. A 4.5-mm reconstruction plate (with 10 to 11 holes) preoperatively templated is then chiseled through the iliac spine across the dorsum of the sacrum to the opposite side. The direction of the plate can be controlled through the midline incision. Similar holes are placed on the opposite posterior superior iliac spine. The ends of the plates are then contoured with an impactor and xed to the iliac wing with 6.5-mm cancellous screws (Fig. 3654). FIXATION OF THE ILIAC WING Occasionally, a markedly displaced iliac wing fracture requires internal xation, which can usually be accomplished through an anterior approach, as has been described for xation of the sacroiliac joint. Fixation is achieved by interfragmental compression and the application of neutralization plates. Normally, on the inner wall of the pelvis, the application of a plate should be just under the crest, where the bone is good and thick, and along the sciatic buttress. The use of a plate in the midportion of the iliac wing is unsuitable because the bone is very thin in this area. If it is necessary for a plate to span this area, a longer plate is required to get more screw xation and better stabilization. If a posterior approach is used, similar plates should be placed in the area of the thickest bone, which is
usually along the sciatic buttress and just below the iliac crest. Thick bone is also present posteriorly, where the tubercle is available for plate xation.
POSTOPERATIVE PLAN
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The postoperative plan for these patients is ideally one of early mobilization. However, such mobilization must be tempered by the ability to achieve stable xation of the fracture and the quality of bone. If bone quality is good and if suitable, stable xation is achieved in a rotationally unstable injury, the patient can be mobilized within 3 to 5 days on crutches, with full weight bearing on the uninvolved side. Partial weight bearing can be allowed between 3 and 6 weeks, with progression to full weight bearing by 6 weeks and off all aids by 3 months. However, for completely unstable fractures with stable xation, the patient should be mobilized from bed to a chair 5 to 10 days after surgery. Early weight bearing should be avoided until fracture healing is observed, and it may be necessary to avoid weight bearing for up to 3 months. If the xation is unstable because of fracture patterns or if good anterior xation cannot be achieved but the patient is not multiply injured, the use of postoperative traction to protect the xation for 4 to 6 weeks should be considered. Traction maintains length and takes some of
FIGURE 3654. Technique of transiliac plate xation for sacral fractures. A, Skin incisions. B, Placement of drill holes for insertion of the plate. C, Direction of plate insertion. D, Final conguration. (AD, From Albert, M.J.; et al. J Orthop Trauma 7:228, 1993.)
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the force off the xation, thereby decreasing the possibility of xation failure. However, this technique is useful only for an isolated pelvic fracture, which is uncommon. The use of external xation as a supplement to internal xation allows the patient to be in the upright position in bed or on a chair. Radiographic follow-up is usually done in the early postoperative phase before hospital discharge, at 6 weeks, and at 3 months. At 3 months, the healing is usually satisfactory to allow full weight bearing, and no further radiographs are necessary for 1 year. After this interval, radiographs are necessary only if indicated by patient complaints. Generally, removal of pelvic internal xation is not done. The only xation that usually causes problems is that placed just below or on the iliac crest or on the symphysis. Such xation may require removal if it causes symptoms; however, extensive exposure is required for this type of procedure.
pelvis. This type of injury pattern leads to signicant bony disruption and, more importantly, to severe soft tissue disruption and resultant disabilities and infection.8 Raffe and Christensen88 described 26 patients with open pelvic fractures. Disruption of the genitourinary system occurred in 12 and disruption of the gastrointestinal system in 7. Perry83 and Richardson and associates89 have emphasized the potential for major vessel disruption and resultant fatal hemorrhage as one of the most important early complications of this injury.
Assessment
Assessment of a patient with an open pelvic fracture must be meticulous. The best method of determining the extent of soft tissue damage is to describe the exact injury. Anteriorly or laterally directed wounds in the ank usually occur through muscle and do not involve rectal or genitourinary contamination. Wounds that occur in the perineum with extension into the rectum posteriorly and wounds that extend into the rectal or genitourinary region are contaminated by a rectal tear or have the potential for contamination at a later date.27 Faringer and colleagues32 attempted to delineate the location of the wound by dividing the pelvic region and upper part of the thighs into three distinct zones. Zone 1 is the perineum and extends from the lower anterior abdominal wall to posteriorly over the sacrum. Zone 2 is the medial aspect of the thigh from the anterior midline to the posterior midline. Zone 3 is the ank and posterolateral region of the buttock. A urethrogram and a cystogram reveal the genitourinary involvement. Rectal and vaginal examinations are mandatory in all patients with pelvic fractures. The presence of blood on either examination is an indication for visual inspection of that orice to rule out an open injury.76 Evaluation of neurologic status must also be undertaken immediately to determine which structures are not functioning.122 Finally, contamination of the wound from both external and internal (intestinal) sources must be determined. After evaluation of the soft tissue injuries, appropriate radiographic evaluation of the pelvic fracture must be undertaken.
GENITOURINARY INJURIES
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Management of genitourinary injuries requires a team approach. The urologist and orthopaedic surgeon need to have a protocol to handle these injuries effectively. Extraperitoneal bladder ruptures are usually managed nonoperatively unless the pelvic ring injury will require operative intervention. In this case, open bladder repair is recommended to prevent infection of the xation or persistent stula formation. This repair is usually performed as early as the patient is stable and is combined with pelvic fracture osteosynthesis. Treatment of urethral rupture is more controversial. Three options exist: immediate exploration and realignment over a catheter, primary urethroplasty, and suprapubic cystostomy drainage with delayed urethroplasty. Timing is dictated by the magnitude of the injury and complicating injuries to adjacent structures. The most important factor appears to be related to avoiding further surgical damage to the pelvic oor to keep the incidence of stricture and impotence low. Recent indirect open realignment procedures have been effective in early care with limited complications.56, 97 In women, urinary complaints were more frequent in patients with residual pelvic displacement (5 mm), as was dyspareunia. Other than a higher incidence of cesarean section in displaced pelvic fractures (5 mm), no difference in miscarriage or infertility was noted.18
Management
Management of these patients must be organized and meticulous because they can die early of hemorrhage. Rapid resuscitation with universal-donor blood and prompt noninvasive pelvic immobilization, such as with PASG trousers, in association with packing of the open wound, will help control major vessel bleeding.1, 19 These injuries represent internal traumatic hemipelvectomies and, in fact, conversion to an actual hemipelvectomy may be lifesaving in some patients. Once hemodynamic stabilization has occurred, appropriate debridement of the wounds is necessary. This procedure may involve consultation with general surgeons, urologists, and gynecologists so that the wounds can be explored adequately. If any wound enters the perineum (zone 1), especially if it has rectal involvement, a defunctioning colostomy must be
OPEN PELVIC FRACTURES
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz An open pelvic fracture is dened as any fracture of the pelvic ring in which the fracture site is or has the potential for bacterial contamination as a consequence of the injury. This concept includes a fracture site open to the external environment, as well as a fracture site communicating with a vaginal or rectal laceration. For this injury to occur, a massive amount of energy must be transferred to the
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performed.32 This intervention should probably be a loop colostomy placed in the area of the transverse colon so that it is well out of the way of any surgical access to the pelvis. Distal colonic washout should be undertaken so that the colon, from the colostomy site through to the rectum, is immediately cleansed (i.e., debrided). Broad-spectrum antibiotics, in particular those necessary to handle bowel contamination, should be started immediately and used prophylactically for 24 to 48 hours. One very serious injury that occurs to the soft tissues is shearing and avulsion of the skin and subcutaneous tissue from the underlying muscle. In a sense, the skin has become devascularized by the loss of its blood supply from the vessels from the underlying muscle. In these situations, a decision must be made regarding the extent of debride ment required. These avulsions can be massive, and determination of their extent is usually guided by an evaluation of the skin and subcutaneous bleeding. All tissue that is dead and thought to be potentially nonviable must be removed. If debridement is inadequate and a large quantity of devitalized soft tissue remains, sepsis may result and compromise the patients outcome. If the exact amount and extent of devitalized tissue are not initially evident, repetitive debridement is mandatory. In fractures with signicant contamination involving the perineum or rectum and in situations in which it is impossible to obtain a clean surgical wound, external xation should be used. Such xation provides a relatively stable pelvic ring so that the patient can be mobilized and repeated debridement can be performed. After the soft tissues have demonstrated viability and healing is progressing, denitive stabilization can then be carried out. If the wound does not involve the perineum and is not signicantly contaminated and if a clean surgical wound can be achieved, the use of primary internal xation to stabilize the fracture is possible; often, the open wound may allow reasonable access to these areas. This technique can also be supplemented by external xation. The use of minimal lag screw xation along with external xation may be the best method to obtain stability with this injury. If the urethra or bladder is involved and the abdomen has been opened, stabilization of the anterior injury can be done by internal xation if the fracture pattern is amenable. In females with an open fracture into the vagina, debridement of the open fracture, usually through the vagina, is all that is required. If the vaginal laceration is clean, it can be closed primarily. Any potentially contaminated vaginal wound should be left open to heal secondarily. Stabilization of the pelvis in the acute phase is best accomplished by external xation.
the nominal mortality rate of up to 50% can be reduced to 20%, a rate associated with a completely unstable pelvic ring injury (type C).8 Richardson and associates89 showed that with very aggressive surgical intervention, early colostomy, and extensive debridement, the treatment results of open pelvic fracture could be markedly improved.
COMPLICATIONS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Because of the systemic nature of the injury and the wide spectrum of methods of treatment required, complications of pelvic fractures are often frequent and severe. The polytrauma setting and the systemic nature of the injury make the patient susceptible to the development of adult respiratory distress syndrome, thromboembolic disease, pneumonia, and multiple organ failure.
Early Complications
INFECTION Postoperative infection can occur after either external or internal xation. Infection with the use of external xation devices usually occurs around the pin tracts. Pin tract infection can generally be managed adequately by appropriate release of the skin about the pins and changing dressings as required to maintain drainage from the pin tracts. Antibiotic coverage should be used if cultures are positive. Pin tract loosening is a potential problem when infection is present. The clamps around the pins must be released and the pins checked for stability within the bone. If a pin is loose, it is usually very difcult to reinsert because of the localized infection. Consequently, the xator may have to be removed, or alternative placement of the pins may be necessary. If the xator has been placed in the standard iliac crest position, it is usually safe to place these new pins between the anterior superior and anterior inferior iliac spines. Most pin tract infections resolve with removal of the pins and debridement of the pin tract itself. Postoperative infections after internal xation usually occur secondary to signicant soft tissue integrity or healing problems. These complications are common after a posterior approach in which an incision has been made through devitalized and nonviable skin and muscle. Very careful evaluation of the soft tissue injury must be undertaken. Even if this problem occurs anteriorly, the approach must be altered to operate and stabilize through viable soft tissue.49 If a postoperative infection does develop around the xation, the same treatment principles apply as for acute postoperative infections after internal xation. Incision and drainage plus debridement must begin early. The wound should be left open and the xation evaluated for stability. If it is solidly xed to bone, it can be left in place. If it is loose and not maintaining stability, it must be removed and supplemented or changed to an alternative. Pelvic osteomyelitis is a rare but disastrous complication. Repetitive debridement is the only treatment method. It
Follow-up Care
After the patient is hemodynamically stable and the pelvis has been stabilized, denitive fracture care can be undertaken. Further soft tissue treatment can be carried out, such as repair of the genitourinary system, and the colostomy can be closed at 6 to 12 weeks, after the soft tissue and rectal injuries have healed. With aggressive care of patients with pelvic fractures,
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may be necessary to excise major portions of the iliac crest to control the osteomyelitis. LOSS OF FIXATION Loss of xation often occurs when the expected degree of healing cannot be achieved during the early phase of pelvic xation. Honest assessment of the stability of the xation must be made at the end of any surgical intervention. The use of external xation or traction to supplement internal xation must always be considered. If the adequacy of the xation is uncertain, it is better to maintain the patient on bedrest with external xation or traction and to delay mobilization until internal bone union has occurred. Early mobilization with loss of reduction and xation may compromise the end result. Failure to attain reduction will probably not cause signicant problems unless the sacroiliac joint is involved. Therefore, all attempts to achieve anatomic reduction of the sacroiliac joint should be instituted. This necessity for anatomic reduction has led to the development of a technique for primary fusion of the sacroiliac joint to avoid any minor incongruencies in this area that may lead to long-term discomfort and pain.109 Routt and co-workers93 reported the complications associated with the percutaneous technique of insertion of an iliosacral lag screw. They evaluated 244 screws in 159 patients. Malreduction was noted in 19 of 159 patients. An inability to adequately image the posterior of the pelvis occurred in 18 patients because of obesity or residual intestinal contrast. Five screws were malpositioned because of failure to understand the value of the lateral sacral view. Fixation failure occurred in 7 patients. NEUROLOGIC INJURY Permanent nerve damage is a common disability after pelvic disruption, with an incidence of about 10% to 15% overall.122 In unstable, double vertical-type fractures, the incidence rises to 46%. Huittinen and Slatis,47 in their series of 85 patients, reported that a signicant number had L5 or S1 root involvement. These appeared to be traction injuries, but anatomic studies suggested that root avulsions may actually occur. Recent interest has led to the development of a classication of sacral fractures22 that may lead to a better understanding of the injury patterns and the injury site. Fractures through or medial to the foramina are associated with a high incidence of neurologic injury, as are transverse fractures of the sacrum with a kyphotic deformity. Reduction and stabilization of these pelvic injuries may improve recovery. Decompression of any sacral transverse fracture with a kyphotic deformity or any burst fracture of the sacrum that appears to compromise the root posteriorly may be of some value (see Chapter 35). However, the long-term results are disheartening. Causalgia resulting from injuries to the L5 or S1 root (or both) or to the sciatic nerve can be particularly difcult to manage, both acutely and on a long-term basis, because of an inability to control pain. The use of specic medications has not been a great help. However, it appears that early intervention with a lumbar sympathetic block to break the
pain cycle may be of some value. Consultation with pain management physicians should be carried out to determine an approach to alleviate some of the long-term disability. Lumbar sympathetic blocks may also help control chronic causalgia pain. If these blocks are effective, phenol or surgical obliteration of the sympathetic plexus may help. Iatrogenic nerve injury secondary to operative treatment may occur. Attempts to modify its incidence by nerve-monitoring techniques have not reliably decreased its incidence.42 The use of electromyographic monitoring techniques might be benecial.70, 120 Neurologic damage should be managed with an appropriate splint or brace, and surgical intervention should be carried out if indicated. Repair or decompression of the sciatic nerve has not to date been done with great success. Repair of the femoral nerve, which has a shorter travel route than the sciatic nerve, may be indicated if the nerve has been lacerated. THROMBOEMBOLISM Thromboembolic complications may occur more commonly in patients with a major pelvic disruption, especially those with associated lower extremity fractures.10, 13, 29, 37 Screening has not been successful in determining the at-risk group because most clots are located in the internal pelvic venous plexus, which is not amenable to standard screening methods. At the present time, it is suggested that some method of prophylaxis based on the patients overall clinical situation be considered. Many different protocols are used, but none has proved more effective than another or even better than no prophylaxis in the prevention of fatal pulmonary emboli.6, 33, 34, 117
Late Complications
PAIN Pain can develop from malunion, nonunion, or osteoarthritis of the sacroiliac joint. Some patients, despite having had anatomic reduction and adequate fracture union (or a fused sacroiliac joint), continue to complain of discomfort and pain. The pain is usually localized to the area of the sacroiliac joint. Evaluation of the lower lumbar spine must be carried out, initially and late, to ensure that no occult fractures are present in this area. Other causes of this pain include signicant soft tissue injury, particularly to the muscles and neurologic structures. MALUNION The incidence of a symptomatic deformity is about 5% in all major pelvic disruptions treated nonoperatively. Deformity can be avoided with appropriate assessment and recognition of pelvic displacement and the potential problems of pelvic instability. The major problem appears to occur with malunion in the region of the sacroiliac joint. These malunions cause leg length discrepancies, but unless the malunion occurs through the sacroiliac joint, pain is unlikely. However, leg length discrepancies with displacement of one hemipelvis more than 1 cm may lead to sitting
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problems. Patients usually experience pain in the sacroiliac joint or over the ischial tuberosities because these structures are at an unequal level and, therefore, subjected to excessive pressure. Occasionally, severely displaced lateral compression fractures (type B2) can result in an internal rotational deformity that leads to pelvic obliquity and leg length discrepancies. Patients present with pain, deformity, leg length discrepancy, and gait abnormalities. Careful evaluation of the patients functional and physical disability is mandatory, and the need for surgical treatment must be determined. Leg length discrepancy without pelvic symptoms can be handled by standard surgical techniques for limb equalization. However, if pelvic symptoms exist, especially pain or sitting problems, direct osteotomy of the malunion site is required. A malreduction of the sacroiliac joint that causes pain is usually treated by sacroiliac fusion. NONUNION Nonunion is an uncommon but well-recognized complication of vertically unstable pelvic disruptions. Pelvic pain and instability are the most common initial symptoms. Lateral compression injuries may lead to anterior ramus nonunion, which is usually relatively asymptomatic. Complete evaluation of the patients symptoms and bony pelvic abnormalities is mandatory. The principles of surgical treatment are stable pelvic ring xation and bone grafting of the nonunion. Most cases require stable xation both anteriorly and posteriorly, accompanied by osteotomy or takedown of the nonunion to allow correction of any signicant malposition.26
on the location of the posterior lesion and the ability to reduce it anatomically. Pure sacroiliac joint dislocations fared poorly if anatomic reduction was not achieved. Fractures of the iliac wing or associated fracture-dislocations of the wing and sacroiliac joint did very well because they were easily reduced and stabilized. Sacral fractures did poorly despite good reduction because functional outcome was related to the associated nerve injury. Cole and associates16 and Tornetta and Matta115 have also shown that although anatomic reduction plus stable internal xation is possible in completely unstable pelvic ring injuries and leads to excellent anatomic results, the nal functional outcome is usually determined by the associated soft tissue injury or other nonorthopaedic traumatic injuries. In the rotationally unstable group, the results of internal xation are much better, with up to 96% of patients having no pain on strenuous exercise.114 There is probably little disagreement that patients with unreduced sacroiliac joint injuries do not do well unless the injuries are reduced and stabilized, but it cannot be guaranteed that this result is as consistent as the results of operative treatment of sacroiliac joint fracture-dislocation or iliac wing fractures. Until a randomized prospective trial is conducted to determine which method of treatment of a sacral fracture, fracture-dislocation of the sacroiliac joint, and fracture of the iliac wing (crescent) is most effective, surgeons must treat the patients injury with prompt recognition of any problems, reduction of the displacement, and stabilization. If such treatment is not possible, referral to appropriate care is mandatory.
RESULTS
SUMMARY
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Treatment of pelvic ring injuries requires an in-depth understanding of the anatomy of the pelvis and the mechanisms of injury. With this understanding and precise clinical and radiographic evaluation of the injury, appropriate management can be chosen. A determination of pelvic stability is imperative; along with assessment of displacement, pelvic stability guides the surgeon in deciding the best form of treatment. Although surgical intervention to stabilize unstable fractures is usually the best method of achieving an intact pelvic ring and ensuring a good result, not all pelvic ring disruptions require stabilization. The complications of management of these injuries are formidable, but they can be lessened by appropriate evaluation.
REFERENCES 1. Agolini, S.F Shah, K.; Gaffe J.; et al. Arterial immobilization is a .; rapid and effective technique for controlling pelvic fracture hemorrhage. J Orthop Trauma 43:395399, 1997. 2. Albert, M.J.; Miller, M.E.; MacNaughton, M.; Hutton, W.C. Posterior pelvic xation using a transiliac 4.5 mm reconstruction plate: A clinical and biomechanical study. J Orthop Trauma 7:226232, 1993. 3. Altoona, D.; Tekdemir, I.; Ates, Y.; Elhan, A. Anatomy of the anterior sacroiliac joint with reference to lumbosacral nerves. Clin Orthop 376:236241, 2000. 4. American College of Surgeons. Advanced Trauma Life Support Manual. Chicago, American College of Surgeons, 1989.
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Although the techniques of internal xation of a disrupted pelvis are being rened, little proof has been presented that these techniques provide the patient any better result than closed reduction and stabilization by traction or external xation. Reimer and colleagues69, 90 showed that the functional outcome in unstable pelvic disruptions treated by closed reduction and external xation, as measured by the SF36, is no different from the result achieved with a stable pelvic ring fracture. This result was again demonstrated by Nepola and co-workers, who showed that functional outcomes using validated scores did not differ when related to residual vertical displacement.75 Scheid and co-workers,103, 104 in a review of unstable pelvic ring injuries treated by internal xation, found that 52% of patients experienced pain and a change in lifestyle. This percentage was similar to that reported by Kellam and associates51 for a similar group of patients from the same institution with the same surgeons. These results were correlated with the location of the fracture, with sacral fractures and pure sacroiliac dislocation having the worst results. Dujardin and colleagues reviewed two consecutive cohorts of patients with unstable pelvic ring injuries by using anatomic measures and the validated pelvic outcome score of Majeed.23 One group was treated by external xation and the other by internal xation based on protocol. The overall functional result depended
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SECTION III Pelvis randomized study of compression alone versus no prophylaxis. J Orthop Trauma 9:17, 1995. Fishmann, A.J.; Greeno, R.A.; Brooks, L.R.; Matta, J.M. Prevention of deep vein thrombosis and pulmonary embolism in acetabular and pelvic fracture surgery. Clin Orthop 305:133137, 1994. Flint, L.M.; Brown, A.; Richardson, J.D. Denitive control of bleeding from severe pelvic fractures. Ann Surg 189:709716, 1979. Ganz, R.; Krushell, R.J.; Jakob, R.P.; Kuffer, J. The antishock pelvic clamp. Clin Orthop 267:7178, 1991. Geertz, W.H.; Code, K.I.; Jay, R.M.; et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med 331:16011606, 1994. Ghanayem, A.J.; Wilbur, J.H.; Leiberman, J.M.; Mogta, A.O. The effect of laparotomy and external xator stabilization on pelvic volume in an unstable pelvic ring injury. J Trauma 38:396401, 1995. Gilliland, M.D.; Ward, R.E.; Barton, R.M.; et al. Factors affecting mortality in pelvic fractures. J Orthop Trauma 22:691693, 1982. Gokcen, E.C.; Burgess, A.R.; Siegel, J.H.; et al. Pelvic fracture mechanism of injury in vehicular trauma patients. J Trauma 36:789796, 1994. Gruen, G.S.; Leit, M.E.; Gruen, R.J.; Peitzman, A.B. The acute management of hemodynamically unstable multiple trauma patients with pelvic ring fractures. J Trauma 36:706713, 1994. Helfet, D.L.; Koval, K.J.; Hissa, E.A.; et al. Intraoperative somatosensory evoked potential monitoring during acute pelvic fracture surgery. J Orthop Trauma 9:2834, 1995. Helfet, D.L. Pelvic ring, the three types. In: Muller, M.E., ed. Comprehensive Classication of Pelvis and Acetabulum Fractures. Bern, Switzerland, Maurice E. Muller Foundation, 1995, p. 61. Henderson, R.C. The long-term results of nonoperatively treated major pelvic disruptions. J Orthop Trauma 3:4147, 1988. Hirvensalo, E.; Lindahl, J.; Bostman, O. A new approach to the internal xation of unstable pelvic fractures. Clin Orthop 297:28 32, 1993. Holdsworth, F Dislocation and fracture dislocation of the pelvis. .W. J Bone Joint Surg Br 30:461466, 1948. Huittinen, V.M.; Slatis, P. Fractures of the pelvis, trauma mechanism, types of injury and principles of treatment. Acta Chir Scand 138:563569, 1972. Kaehr, D.; Anderson, P.; Mayo, K.; et al. Classication of sacral fractures based on CT imaging. Paper presented at an Orthopaedic Trauma Association Meeting, Dallas, October 2728, 1988. Kellam, J.F McMurtry, R.Y.; Tile, M. The unstable pelvic fracture. .; Orthop Clin North Am 18:2541, 1987. Kellam, J.F The role of external xation in pelvic disruptions. Clin . Orthop 241:6682, 1989. Kellam, J.F Boyer, M.; Dean, R.; Tile, M. Results of external .; xation of the pelvis. Paper presented at the 12th International Congress on Hoffman External Fixation, Garmisch Partenkirchen Murnau, Bavaria, West Germany, October 910, 1986. Kiting, J.F Wearier, J.; Blackout, P.; et al. Early xation of the .; vertically unstable pelvis: The role of iliosacral screw xation in the management of the vertically unstable pelvis. J Trauma 13:107 113, 1999. Koury, H.I.; Peschiera, J.L.; Welling, R.E. Selective use of pelvic roentgenograms in blunt trauma patients. J Trauma 34:236237, 1993. Lange, R.H.; Hansen, S. Pelvic ring disruptions with symphysis pubis diastasis. Indications, techniques and application of anterior internal xation. Clin Orthop 201:130137, 1985. Latenser, B.A.; Gentilello, L.M.; Tarver, A.A.; et al. Improved outcome with early xation of skeletally unstable pelvic fractures. J Trauma 31:2831, 1991. Lee, J.; Abrahamson, B.S.; Harrington, T.G.; et al. Urologic complications of diastasis of the pubic symphysis: A trauma case report and review of world literature. J Trauma 48:133136, 2000. Leighton, R.K.; Waddell, J.P. Techniques for reduction and posterior xation through the anterior approach. Clin Orthop 329:115120, 1996. Letournel, E. Acetabular fractures: Classication and management. Clin Orthop 151:81106, 1980. Lowe, M.A.; Mason, J.T.; Luna G.K.; et al. Risk factors for urethral injuries in men with traumatic pelvic fractures. J Urol 140:506 507, 1988.
5. Anglen, J.O.; DiPasquale, T. The reliability of detecting screw penetration of the acetabulum by intraoperative auscultation. J Orthop Trauma 8:404408, 1994. 6. Asprinio, D.E.; Helfet, D.L.; Tile, M. Complications. In: Tile, M., ed. Fractures of the Pelvis and Acetabulum. Baltimore, Williams & Wilkins, 1984, pp. 243245. 7. Bone, L.B.; McNamara, K.; Shine, B.; Border, J. Mortality in multiple trauma patients with fractures. J Trauma 37:262264, 1994. 8. Brennerman, F .D.; Katyal, D.; Boulanger, B.R.; et al. Longterm outcomes in open pelvic fractures. J Trauma 42:773777, 1997. 9. Brown, J.J.; Greene, F McMillin, R.D. Vascular injuries associated .L.; with pelvic fractures. Am Surg 50:150154, 1984. 10. Browner, B.D., ed. Internal xation of pelvic ring disruptions. Techn Orthop, Vol. 9, 1994. 11. Bucholz, R.W. The pathological anatomy of the Malgaigne fracture dislocation of the pelvis. J Bone Joint Surg Am 63:400404, 1981. 12. Buckle, R.; Browner, B.D.; Morandi, M. A new external xation device for emergent reduction and stabilization of displaced pelvic fractures associated with massive hemorrhage. J Orthop Trauma 7:177178, 1993. 13. Buerger, P.M.; Peoples, J.B.; Lemmon, G.W.; McCarthy, M.C. Risk of pulmonary emboli in patients with pelvic fractures. Am Surg 59:505508, 1993. 14. Colapinto, V. Trauma to the pelvis: Urethral injury. Clin Orthop 151:4655, 1980. 15. Cole, J.D.; Bolhofner, B.R. Acetabular fracture xation via a modied Stoppa limited intrapelvic approach. Clin Orthop 305: 112123, 1994. 16. Cole, J.D.; Blum, D.A..; Ansel, L.J. Outcome after xation of unstable posterior ring injuries. Clin Orthop 329:160179, 1996. 17. Connolly, J.F Closed treatment of pelvic and lower extremity . fractures. Clin Orthop 240:115128, 1989. 18. Copeland, C.E.; Bosse, M.J.; McCarthy, M.L.; et al. Effect of trauma and pelvic fracture on female genitourinary, sexual and reproductive function. J Trauma 11(2):7381, 1997. 19. Cotler, H.B.; LaMont, J.G.; Hansen, S.T. Immediate spica cast for pelvic fractures. J Orthop Trauma 2:222228, 1988. 20. Cryer, H.M.; Miller, F Evers, M.; et al. Pelvic fracture classica.B.; tion: Correlation with hemorrhage. J Orthop Trauma 28:973980, 1988. 21. Delal, S.; Burgess, A.; Young, J.; et al. Pelvic fractures: Classication by force vector in relationship to associated injuries. Paper presented at an Orthopaedic Trauma Association Meeting, Dallas, October 2728, 1988. 22. Denis, F Davis, S.; Comfort, T. Sacral fractures: An important .; problem. Clin Orthop 227:6781, 1988. 23. Dujardin, F .H.; Hossenbaccus, M.; Duparc, F et al. Long-term .; functional prognosis of posterior injuries in high-energy pelvic disruptions. J Trauma 12(3):145150, discussion 150151, 1998. 24. Dunn, A.W.; Morris, H.D. Fractures and dislocations of the pelvis. J Bone Joint Surg Am 50:16391648, 1968. 25. Duwelius, P.J.; Van Allen, M.; Bray, T.J.; Nelson, D. Computed tomography guided xation of unstable posterior pelvic ring disruptions. J Orthop Trauma 6:420426, 1992. 26. Ebraheim, N.A.; Biyani, A.; Wong, F Nonunion of pelvic fractures. . J Trauma 44(1):202204, 1998. 27. Ebraheim, N.A.; Savolainen, E.R.; Rusin, J.R.; et al. Occult rectal perforation in a major pelvic fracture. J Orthop Trauma 2:340343, 1988. 28. Edeiken-Monroe, B.S.; Browner, B.D.; Jackson, H. The role of standard roentgenograms in the evaluation of instability of pelvic ring disruption. Clin Orthop 240:6376, 1989. 29. Ellison, M.; Timberlake, G.A.; Kerstein, M.D. Impotence following pelvic fracture. J Orthop Trauma 28:695696, 1988. 30. Evers, M.B.; Cryer, H.M.; Miller, F Pelvic fracture hemorrhage. .B. Arch Surg 124:422424, 1989. 31. Falcone, R.E., Thomas, B.W. Bean bag pelvic stabilization. Ann Emerg Med 28:458, 1996. 32. Faringer, P.D.; Mullins, R.J.; Feliciano, P.D.; et al. Selective fecal diversion in complex open pelvic fractures from blunt trauma. Arch Surg 129:958964, 1994. 33. Fisher, C.G.; Blachut, P.A.; Salvian, A.J.; et al. Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: A prospective,
34. 35. 36. 37. 38.
39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51.
52.
53. 54. 55. 56. 57. 58. 59.
CHAPTER 36 Pelvic Ring Disruptions 60. MacKenzie, E.J.; Cushing, B.M.; Jurkovich, G.J.; et al. Physical impairment and functional outcomes six months after severe lower extremity fractures. J Trauma 34:528539, 1993. 61. Matta, J.M.; Saucedo, T. Internal xation of pelvic ring fractures. Clin Orthop 242:8397, 1989. 62. McBroom, R.; Tile, M. Disruptions of the pelvic ring. Presented at the Canadian Orthopaedic Research Society Convention. Kingston, Ontario, Canada. June, 1982. 63. McCoy, G.F Johnstone, R.A.; Kenwright, K. Biomechanical aspects .; of pelvic and hip injuries in road trafc accidents. J Orthop Trauma 3:118123, 1989. 64. McLaren, A. Internal xation in fractures of the pelvis and acetabulum. In: Tile, M., ed. Fractures of the Pelvis and Acetabulum, 2nd ed. Baltimore, Williams & Wilkins, 1995, pp. 183189. 65. McLellan, B.A.; Phillips, J.P.; Hunter, G.A.; et al. Bilateral lower extremity amputations after prolonged application of the PASG. A case report. J Surg 30:5556, 1987. 66. McMurtry, R.Y.; Walton, D.; Dickinson, D.; et al. Pelvic disruption in the polytraumatized patient. A management protocol. Clin Orthop 151:2230, 1980. 67. Mears, D.C.; Capito, C.P.; Deleeuw, H. Posterior pelvic disruptions managed by the use of the double cobra plate. Instr Course Lect 37:143150, 1988. 68. Mears, D.C.; Rubash, H.E. Pelvic and Acetabular Fractures. Thorofare, NJ, Slack, 1986. 69. Miranda, M.A.; Riemer, B.L.; Buttereld, S.L.; Burke, C.J. Pelvic ring injuries: A long-term functional outcome study. Clin Orthop 329:152159, 1996. 70. Moed, B.R.; Hartman, M.J.; Ahmad, B.K.; et al. Evaluation of intraoperative nerve monitoring during insertion of an iliosacral implant in an animal model. J Bone Joint Surg Am 81:15291537, 1999. 71. Moreno, C.; Moore, E.E.; Rosenberger, A.; Cleveland, H.C. Hemorrhage associated with major pelvic fracture: A multispecialty challenge. J Trauma 26:987994, 1986. 72. Murr, P.C.; Moore, E.E.; Lipscomb, R.; Johnston, R.M. Abdominal trauma associated with pelvic fracture. J Trauma 20:919923, 1980. 73. Nallathambi, M.N.; Ferreiro, J.; Ivatury, R.R.; et al. The use of peritoneal lavage and urological studies in major fractures of the pelvisA reassessment. Br J Accident Surg 18:379383, 1987. 74. Nelson, D.W.; Duwelius, P.J. CT-guided xation of sacral fractures and sacroiliac joint disruptions. Radiology 180:527532, 1991. 75. Nepola, J.V.; Trenhaile, S.W.; Miranda, M.A.; et al. Vertical shear injuries: Is there a relationship between residual displacement and functional outcome? J Trauma 46:10241030, 1999. 76. Niemi, T.A.; Norton, L.W. Vaginal injuries in patients with pelvic fractures. J Trauma 25:547551, 1985. 77. Noojin, F .K.; Malkani, A.L.; Haikal, L.; et al. Cross-sectional geometry of the sacral ala for safe insertion of iliosacral lag screws: A computed tomography model. J Trauma 14:3135, 2000. 78. Ochsner, M.G.; Hoffman, A.P.; DiPasquale, D.; et al. Associated aortic rupture pelvic fracture: An alert for orthopedic and general surgeons. J Trauma 33:429434, 1992. 79. Oonishi, H.; Isha, H.; Hasegawa, T. Mechanical analysis of the human pelvis and its application to the articial hip joint by means of the three-dimensional nite element method. J Biomech 16:427444, 1983. 80. Pattimore, D.; Thomas, P.; Dave, S.H. Torso injury patterns and mechanisms in car crashes: An additional diagnostic tool. Injury 23:123126, 1992. 81. Peltier, L.F Complications associated with fractures of the pelvis. . J Bone Joint Surg Am 47:10601069, 1965. 82. Pennal, G.F Sutherland, G.O. Fractures of the Pelvis. Motion .; picture. Chicago, American Academy of Orthopaedic Surgeons Film Library, 1961. 83. Perry, J.F Pelvic open fractures. Clin Orthop 151:4145, 1980. . 84. Pohlemann, T.; Bosch, U.; Gansslen, A.; Tscherne, H. The Hannover experience in management of pelvic fractures. Clin Orthop 305:6980, 1994. 85. Poole, G.V.; Ward, E.F Causes of mortality in patients with pelvic . fractures. Orthopedics 17:691696, 1994. 86. Poole, G.V.; Ward, E.F Muakkassa, F .; et al. Pelvic fracture from .; .F major blunt trauma. Ann Surg 213:532539, 1991.
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87. Raf, L. Double vertical fractures of the pelvis. Acta Chir Scand 131:298305, 1966. 88. Raffe, J.; Christensen, M. Compound fractures of the pelvis. Am J Surg 132:282286, 1976. 89. Richardson, J.D.; Harty, J.; Amin, M. Open pelvic fractures. J Trauma 22:533538, 1982. 90. Riemer, B.L.; Buttereld, S.L.; Diamond, D.L.; et al. Acute mortality associated with injuries to the pelvic ring: The role of early patient mobilization and external xation. J Trauma 35:671677, 1993. 91. Robinson, D.; Hendel, D.; Halperin, N. An overlapping pubic dislocation treated by closed reduction: Case report and review of the literature. J Trauma 29:883885, 1989. 92. Rothenberg, D.A.; Fischer, R.P.; Strate, R.G. The mortality associated with pelvic fractures. Surgery 84:356361, 1978. 93. Routt, M.L.C.; Kregor, P.J.; Mayo, K. Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma 9:207214, 1995. 94. Routt, M.L.C.; Meier, M.C.; Kregor, P.J. Percutaneous iliosacral screws with the patient supine technique. Op Techn Orthop 3:3545, 1993. 95. Routt, M.L.; Nork, S.E.; Mills, W.J. Percutaneous xation of pelvic ring disruptions. Clin Orthop 375:1529, 2000. 96. Routt, M.L.C.; Simonian, P.T.; Agnew, S.G.; Mann, F Radio.A. graphic recognition of the sacral alar slope for optimal placement of iliosacral screws: A cadaveric and clinical study. J Orthop Trauma 10:171177, 1996. 97. Routt, M.L.; Simonian, P.T.; Defalco, A.J.; et al. Internal xation in pelvic fractures and primary repairs of associated genitourinary disruptions: A team approach. J Trauma 40:784790, 1996. 98. Routt, M.L.C.; Simonian, P.T.; Grujic, L. The retrograde medullary superior pubic ramus screw for the treatment of anterior pelvic ring disruptions: A new technique. J Orthop Trauma 9:3544, 1995. 99. Routt, M.L.C.; Simonian, P.T.; Inaba, J. Iliosacral screw xation of the disrupted sacroiliac joint. Techn Orthop 9:300314, 1994. 100. Ruedi, T.; von Hochstetter, A.H.C.; Schlumpf, R. Surgical Approaches for Internal Fixation. Berlin, Springer-Verlag, 1984, pp. 7783. 101. Saibel, E.A.; Maggisano, R.; Witchell, S.S. Angiography in the diagnosis and treatment of trauma. J Can Assoc Radiogr 34:218 227, 1983. 102. Schatzker, J.; Tile, M. Rationale of Operative Fracture Care. New York, Springer-Verlag, 1987, p. 165. 103. Scheid, D.K. Internal xation. In: Tile, M., ed. Fractures of the Pelvis and Acetabulum, 2nd ed. Baltimore, Williams & Wilkins, 1995, p. 197. 104. Scheid, D.K.; Kellam, J.F Tile, M. Open reduction and internal .; xation of pelvic ring fractures. J Orthop Trauma 5:226, 1991. 105. Semba, R.T.; Yasukawa, K.; Gustilo, R.B. Critical analysis of results of 53 Malgaigne fractures of the pelvis. J Trauma 23:535537, 1983. 106. Simonian, P.T.; Routt, M.L.C.; Harrington, R.M.; et al. Biomechanical simulation of the anteroposterior compression injury of the pelvis. Clin Orthop 309:245256, 1994. 107. Simonian, P.T.; Routt, M.L.C.; Harrington, R.M.; Tencer, A.F Box . plate xation of the symphysis pubis: Biomechanical evaluation of a new technique. J Orthop Trauma 8:483489, 1994. 108. Simonian, P.T.; Routt, M.L.C.; Harrington, R.M.; Tencer, A.F . Internal xation of the unstable anterior pelvic ring: A biomechanical comparison of standard plating techniques and the retrograde medullary superior pubic ramus screw. J Orthop Trauma 8:476 482, 1994. 109. Simpson, L.A.; Waddell, J.P.; Leighton, R.K.; et al. Anterior approach and stabilization of the disrupted sacroiliac joint. J Trauma 27:13321339, 1987. 110. Stephen, D.J.; Kreder, H.J.; Day, A.C.; et al. Early detection of arterial bleeding in acute pelvic trauma. J Trauma 47:638642, 1999. 111. Tile, M. Internal xation. In: Tile, M., ed. Fractures of the Pelvis and Acetabulum, 2nd ed. Baltimore, Williams & Wilkins, 1995, pp. 189193. 112. Tile, M. Pelvic ring fractures. Should they be xed? J Bone Joint Surg Br 70:112, 1988. 113. Tile, M.; Hearn, T. Biomechanics. In: Tile, M., ed. Fractures of the Pelvis and Acetabulum, 2nd ed. Baltimore, Williams & Wilkins, 1995, pp. 2236.
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SECTION III Pelvis 119. Vukicevic, S.; Marusic, A.; Stavljenic, A.; et al. Holographic analysis of the human pelvis. Spine 16:209214, 1991. 120. Webb, L.X.; de Araujo, W.; Donofrio, P.; et al. Electromyography monitoring for percutaneous placement of iliosacral screw. J Trauma 14:245254, 2000. 121. Weber, T.G.; Mast, J.W. The extended ilioinguinal approach for specic both column fractures. Clin Orthop 305:106111, 1994. 122. Weis, E.B. Subtle neurological injuries in pelvic fractures. J Trauma 24:983985, 1984. 123. Wild, J.J.; Hanson, G.W.; Tullos, H.S. Unstable fractures of the pelvis treated by external xation. J Bone Joint Surg Am 64:10101020, 1982. 124. Young, J.W.R.; Burgess, A.R. Radiological Management of Pelvic Ring Fractures. Baltimore, Urban & Schwarzenberg, 1987, pp. 22, 27, 41, 55.
114. Tornetta, P.; Dickson, K.; Matta, J.M. Outcome of rotationally unstable pelvic ring injuries treated operatively. Clin Orthop 329:147151, 1996. 115. Tornetta, P.; Matta, J.M. Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop 329:186193, 1996. 116. Trunkey, D.D.; Chapman, M.W.; Lim, R.C. Management of pelvic fractures and blunt traumatic injury. J Trauma 14:912923, 1974. 117. Velmahos, G.C.; Kern, J.; Chan, L.S.; et al. Prevention of venous thromboembolism after injury: An evidence-based reportPart I: Analysis of risk factors and evaluation of the role of vena caval lters. J Trauma 49:132139, 2000. 118. Vrahas, M.; Gordon, R.G.; Mears, D.C.; et al. Intraoperative somatosensory evoked potential monitoring of pelvic and acetabular fractures. J Orthop Trauma 6:5058, 1992.

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Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 36 Pelvic Ring Disruptions

Dorsum ilii Iliac crest

Posterosuperior iliac spine

Capsule of hip joint

Interosseous sacroiliac ligaments Greater trochanter Sacrotuberous ligament

Ischial tuberosity Lesser trochanter

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Iliac crest Anterosuperior spine Posteroinferior spine Superior articular process

Cornua of sacrum and coccyx

Transverse process of coccyx

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 36 Pelvic Ring Disruptions

Iliacus Obturator nerve

Pelvic brim Print Graphic

Lumbosacral nerve plexus

True pelvis Presentation True pelvis

Superior gluteal artery and vein Print Graphic

Piriformis Presentation Sciatic nerve

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Pelvic splanchnic nerves Lumbosacral artery

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 36 Pelvic Ring Disruptions

Iliolumbar ligament Posterior sacroiliac ligament Anterior sacroiliac ligament

Sacrospinal and sacrotuberal ligaments

PATHOMECHANICS AND MECHANISMS OF PELVIC DISRUPTION Anteroposterior Force Pattern

Lateral Compression Force Pattern

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Avulsion fracture ischial spine

Avulsion fracture L5 transverse process Presentation

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 36 Pelvic Ring Disruptions

Shear Force Pattern

CLASSIFICATION OF PELVIC DISRUPTIONS Anatomic Classications

External Rotation-Abduction Force Pattern

Mechanism-of-Injury Classication (Young and Burgess)

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Comprehensive Pelvic Disruption Classication (Modied after Tile)

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 36 Pelvic Ring Disruptions

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Posterior arch intact

Posterior arch disruption

Classication of Pelvic Ring Disruptions

ASSESSMENT OF PELVIC DISRUPTION Acute Management

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CHAPTER 36 Pelvic Ring Disruptions

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 36 Pelvic Ring Disruptions TABLE 362

Copyright 2003 Elsevier Science (USA). All rights reserved.

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 36 Pelvic Ring Disruptions

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis