Anterior Pelvic Ring Injuries Research Articles

Sacral fractures: issues, challenges, solutions

Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma.This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation.Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction.Herein, we present issues, challenges and solutions related to the management of sacral fractures.Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064

Posterior iliac screw rod for the treatment of unilateral unstable Denis I and II sacral fractures

Objective To explore the efficacy of posterior iliac screw rod for unilateral unstable Denis I and II sacral fractures. Methods Data of 50 patients with unilateral unstable Denis I, II sacral fractures treated from March 2016 to October 2018 were retrospectively analyzed. According to fixation methods, the patients were divided into posterior iliac screw rod group (Iliac screw rod group) and robot-assisted iliosacral screw group (Iliosacral screw group). There were 20 patients in the Iliac screw rod group, 13 males and 7 females, with an average age of 41.10±14.07 years (range, 22-76 years), and there were 5 cases of Denis type I and 15 cases of type II sacral fractures. All of them had anterior pelvic ring injuries, and according to pelvic Tile classification, there were 2 B1 type, 12 B2 type, 6 C1 type, and 3 cases of Gibbons grade II sacral nerve injuries. There were 30 patients in the Iliosacral screw group, 18 males and 12 females, with an average age of 44.70±13.35 years (range,16-78 years), and there were 6 cases of type I and 24 cases of type II sacral fractures. There were 2 cases of type B1, 20 cases of B2, 8 cases of C1 pelvic fractures, 4 cases combined with sacral nerve injuries including 3 cases of Gibbons grade II and 1 case of grade III. The patients’ age, operation time, amount of bleeding, times of fluoroscopy, postoperative Majeed score were compared by the independent t test. The quality of fracture reduction was compared by Chi-square test, and the postoperative Gibbons grade was compared by the rank sum test. Results All patients were followed up for 22.8 months (range, 12-40 months). In the Iliac screw rod group, the operation time was 41.40±7.30 min, intraoperative blood loss 105.00±61.94 ml, intraoperative times of fluoroscopy 19.10±7.33, and according to Mears and Velyvis valuation criterion, there were 9 cases of anatomical reduction, 10 cases of satisfactory reduction, and 1 case of unsatisfactory reduction, with the Majeed score of 84.25±8.29. There were 3 cases with Gibbons grade II sacral nerve injury, and 2 of them recovered to grade I. In the Iliosacral screw group, the operation time was 18.27±5.89 min, intraoperative blood loss 33.00±17.54 ml, intraoperative times of fluoroscopy 14.93±4.49, and according to Mears and Velyvis valuation criterion, there were 15 cases of anatomical reduction, 13 cases of satisfactory reduction and 2 cases of unsatisfactory reduction, with the Majeed score of 86.43±7.43. There were 3 cases with Gibbons grade II sacral nerve injury, and 2 of them recovered to grade I, and 1 case with grade III recovered to grade II postoperation. Compared to Iliosacral screw group, the Iliac screw rod group has longer operation time (t=-12.36, P<0.001), more blood loss (t=-6.04, P<0.001) and more intraoperative times of fluoroscopy (t=-2.50, P=0.016). There were no statistical differences for quality of fracture reduction (χ2=0.23, P=0.89), Majeed score (t=0.97, P=0.34), and the Gibbons grade (Z=-0.224, P=0.82) between the two groups. In the Iliac screw rod group, 1 patient had a unilateral superficial wound infection and 1 patient complained of discomfort because of the nail. In the Iliosacral screw group 1 patient had iatrogenic S1 neurological injury. Conclusion For the unstable sacral fractures, who are not suitable for iliosacral screw fixation, posterior iliac screw rod fixation is an effective alternative with similar clinical effect as robot assisted iliosacral screw fixation. Key words: Sacrum; Fractures, bone; Fracture fixation, internal; Surgical procedures, minimally invasive

Fixation of Anterior Pelvic Ring Injuries.

Treatment of anterior pelvic ring injuries involves both acute stabilization during the initial resuscitation and definitive fixation. Definitive management has evolved substantially over the past 40 years with improved patient mobilization and long-term outcomes. Although its use has recently declined, external fixation remains a favorable option in certain situations. Symphyseal plating is the preferred technique for stabilization of symphyseal diastasis because of superior stability and low morbidity. Ramus screws can be effective for simple ramus fractures but require a careful technique because of the proximity of neurovascular structures. The subcutaneous internal fixator provides a good option for obese patients in whom external fixation would be poorly tolerated. Regardless of fixation strategy, posterior ring reduction and stabilization is crucial.

The preserving insertion point of the rectus abdominisPfannenstiel approach for the treatment of anterior pelvic ring fractures

Objective To compare the clinical efficacy of the preserving insertion point of the rectus abdominis-Pfannenstiel approach with traditional Pfannenstiel approach in the treatment of pelvic anterior ring injuries. Methods A retrospective analysis was performed on 43 cases with pelvic anterior ring injuries treated from September 2008 to February 2016. Among them, 20 cases were treated with the preserving insertion point of the rectus abdominis-Pfannenstiel approach (modified approach group) including 14 males and 6 females, aged 18-58 years, with an average age of 36.9 years. According to Tile classification of pelvic fractures, there were 8 cases of B1 type, 4 cases of B2 type, 2 cases of B3 type, 4 cases of C1 type and 2 cases of C2 type. And 23 cases were treated with traditional Pfannenstiel approach (traditional approach group, 16 cases of males and 7 cases of females, aged 19-59 years, with an average age of 36.8 years). Tile classification of pelvic fractures: 9 cases of B1, 4 cases of B2, 3 cases of B3, 4 cases of C1 and 3 cases of C2). The operative time, intraoperative blood loss, postoperative hospital stay, postoperative reduction, postoperative functional and complications were compared between the two groups. Results 43 patients were followed up for 12-40 months, with an average of 20.5 months. All fractures healed in 8-20 weeks, with an average time of 10 weeks. Duration of anterior approach: 119.0±18.3 min in the modified approach group and 93.7±17.8 min in the traditional approach group (t=4.597, P 0.05). Complications: 2 cases of internal fixation loosening and 2 cases of coital pain occurred in the modified approach group after surgery, with a complication rate of 20.0% (4/20). Postoperatively, 1 case of superficial infection, 1 case of pulmonary infection, 1 case of internal fixation loosening, 1 case of screw broken and 4 cases of coital pain occurred in the traditional approach group, with a complication rate of 34.8% (8/23). Conclusion Both approaches can achieve satisfactory results in the treatment of anterior pelvic ring injury. The preserving insertion point of the rectus abdominis-Pfannenstiel approach for the treatment of anterior pelvic ring injuries has the advantages of less bleeding, faster recovery and shorter hospitalization time. Key words: Pelvis; Fractures, bone; Fracture fixation, internal

Complications following minimally invasive internal fixation for anterior pelvic ring injury: a Meta-analysis

Objective To summarize the complications and their incidences following Anterior Sub-cutaneous Internal Pelvic Fixation(ASIPF). Methods A comprehensive search was conducted of PubMed Library, Cochrane Library, Web of Science, SinoMed, Wanfang Data and China National Knowledge Internet for all articles addressing the postoperative complications of ASIPF published in English and Chinese from January 2009 to November 2018. A proportion Meta-analysis across the studies was performed for the complications after ASIPF (lateral femoral cutaneous nerve irritation, femoral nerve palsy, heterotopic ossification, infection and implant failure) using R software. Results This meta-analysis included 29 clinical studies involving a total of 825 patients. The complications following ASIPF were lateral femoral cutaneous nerve irritation, femoral nerve palsy, heterotopic ossification, infection and implant failure; their incidences were respectively 12% (95%CI: from 7% to 19%), 3% (95%CI: from 2% to 4%), 30% (95%CI: from 22% to 39%), 4% (95%CI: from 3% to 6%) and 4% (95%CI: from 3% to 6%). Conclusions Lateral femoral cutaneous nerve irritation and heterotopic ossification are common complications following minimally invasive internal fixation for anterior pelvic ring injury. High-quality clinical research is needed into the factors leading to the complications and into their preventive countermeasures. Key words: Pelvis; Fractures, bone; Fracture fixation, internal; Surgical procedures, minimally invasive; Complications

Robot-assisted Minimally-invasive Internal Fixation of Pelvic Ring Injuries: A Single-center Experience.

ObjectiveTo investigate the indications, surgical strategy and techniques, safety, and efficacy of robot‐assisted minimally‐invasive internal fixation of pelvic ring injuries.MethodsThe clinical data of 86 patients with anterior and posterior pelvic ring injuries who underwent robot‐assisted minimally‐invasive internal fixation were retrospectively analyzed. The patients included 57 men and 29 women aged between 22 and 75 years, with an average age of (40.2 ± 13.6) years. According to the Tile classification, there were 5 (5.8%) type A2, 48 (55.8%) type B, and 33 (38.4%) type C fractures. The surgical plans were formulated based on the injury type of the pelvic ring, the effectiveness of the reduction, and the integrity of the osseous channel. Posterior pelvic ring injuries were treated with robot‐assisted percutaneous cannulated screw fixation of the sacroiliac joint. Anterior pelvic ring injuries were treated with robot‐assisted percutaneous cannulated screw fixation of the pubic ramus, INFIX fixation, or a “hybrid” fixation. The surgical complications and the efficacy of the surgical treatments were analyzed.ResultsA total of 274 screws were inserted with robotic assistance, of which 262 screws were successfully inserted to a satisfactory position on the first attempt. The number of screws placed per person was 3.2 on average, and the average operation time was 175 min (35–280 min). Fluoroscopies were performed an average of 29.1 times (range, 9–63 times), and it took 6.1 s to place each screw. There were 13 unsatisfactory guiding needle placements during the surgeries, among 7 of which cutting or penetration of the cortex was re‐planned until satisfactory insertions; 1 penetrated the pubic cortex, causing hemorrhage of the “crown of death,” and was changed to “hybrid surgery”. The robot‐assisted surgical wounds all healed by primary intention with satisfactory position and precision of screw insertions. All patients were followed up for 3–6 months, with an average of 4.2 months. There were two postoperative fixation failures, in which both patients had separated symphysis pubes after hybrid surgery. The average Majeed score at the last follow‐up was 92.4 points.ConclusionsRobot‐assisted surgery is accurate and minimally invasive, with a high success rate for one‐time screw placement and satisfactory clinical results. The indications and surgical strategy should be rigorously selected, the level of surgical techniques mastered, and the operating procedures standardized, all of which may help to prevent surgical complications. Robot‐assisted surgery provides a novel modality for the minimally‐invasive treatment of pelvic ring injuries.

Complications Following Internal Fixator in the Treatment of Pelvic Fracture

The aim of this systematic review was to investigate the incidence of complications of the internal fixator in the treatment of anterior pelvic ring injury. The literature was comprehensively searched from 1980 to January 2017 to identify potential studies. Six studies involving 272 cases of anterior pelvic ring injury treated with the internal fixator were included in this meta-analysis. The rates of wound infection, heterotopic ossification, nerve paresthesia, pain, and fracture dislocation were 5.7%, 35.1%, 28.2%, 3.7%, and 3.0%, respectively. This new technique should be prudently used to treat pelvic fractures. [Orthopedics. 2019; 42(1):e7-e13.].

Minimally Invasive Endoscopic-Assisted Technique for Implant Removal After Pelvic Bridge Plating.

Subcutaneous internal plate fixation for anterior pelvic ring injuries has become more common, but implants require removal, usually by 12 weeks. The purpose of this article is to report a novel, minimally invasive, endoscopic-assisted technique for the removal of subcutaneous anterior pelvic plates safely and atraumatically without violating the underlying fascia.

High-Energy Pelvic Ring Disruptions with Complete Posterior Instability: Contemporary Reduction and Fixation Strategies.

* Accurate reduction and rigid internal fixation of anterior pelvic ring injuries enhances overall stability of the pelvic ring and augments posterior fixation constructs.* Closed reduction techniques can be highly effective for unstable pelvic ring disruptions and are preferable over open reduction methods.* Percutaneous iliosacral screw fixation is a generally safe and effective method of fixation of posterior pelvic ring injuries.* Multiple and longer (transiliac-transsacral) screws at both sacral segments are required to create a stronger screw construct for complete posterior pelvic disruptions.* Lumbopelvic fixation substantially augments iliosacral screw fixation and is particularly useful for comminuted transforaminal sacral fractures with associated vertical instability.

Minimally invasive treatment for anterior pelvic ring injuries with modified pedicle screw-rod fixation: a retrospective study

BackgroundPelvic ring injuries constitute only 2 to 8% of all fractures; however, they occur in 20% of polytrauma patients. High-energy pelvic fractures often result in mechanical instability of the pelvic ring. Successful treatment of unstable pelvic ring fractures remains a challenge for orthopedic surgeons. This study presents a novel internal fixation method for stabilizing unstable anterior pelvic ring fractures using a minimally invasive modified pedicle screw-rod fixation (MPSRF) technique.MethodsThis retrospective study included six patients with unstable pelvic ring injuries who underwent MPSRF, with or without posterior fixation. Intraoperative parameters such as blood loss, operative time, complications, and quality of reduction (Matta criteria) were recorded and evaluated by a blinded reviewer.ResultsIn the present clinical series, the mean operative times and mean blood loss for unilateral versus bilateral anterior ring fixations were 176.0 min versus 295.6 min, and 153.3 mL versus 550.0 mL, respectively. No iatrogenic neuropraxia of the lateral femoral cutaneous nerve or femoral nerve palsy occurred. The reduction quality, graded by the Matta criteria, was excellent in five patients and good in one patient.ConclusionsThere were no infections, delayed unions, nonunions, or loss of reductions during the follow-up period. Only one patient suffered from a broken rod at 4 months postoperatively. The modified technique represents a novel, minimally invasive procedure for the treatment of anterior pelvic ring fractures and offers a reliable and effective alternative to currently available surgical techniques.

Indications for Open Reduction Internal Fixation of Anterior Pelvic Ring Disruptions.

In acute trauma, pelvic ring instability can lead to hemorrhage and hemodynamic instability. Pelvic ring instability and displacement that is not stabilized may lead to chronic pain, sitting imbalance, and limb length inequality. Methods and timing of securing anterior pelvic ring injuries operatively is controversial and debatable. Many orthopaedic trauma surgeons would agree that acceptable methods to treat a disrupted anterior pelvic ring fracture include nonoperative care, external fixation, internal spanning fixators, intramedullary superior ramus screws, and open reduction internal fixation. We will review the indications for open reduction internal fixation fractures and disruptions of the anterior pelvic ring.

Robot-assisted percutaneous screw placement combined with pelvic internal fixator for minimally invasive treatment of unstable pelvic ring fractures.

PurposeThe purpose of this study was to investigate the safety and efficacy of the combination of robot‐assisted percutaneous screw placement and pelvic internal fixator (INFIX) for minimally invasive treatment of unstable anterior and posterior pelvic ring injuries.MethodsFrom September 2016 to June 2017, twenty‐four patients with unstable anterior and posterior pelvic ring injuries were treated with TiRobot‐assisted percutaneous sacroiliac cannulated screw fixation on the posterior pelvic ring combined with robot‐assisted pedicle screw placement in the anterior inferior iliac spine along with INFIX on the anterior pelvic ring. The results of the treatment, including surgery duration, fluoroscopy frequency, total drilling, amount of blood loss, fracture healing time, and postoperative functional outcomes were recorded and compared with another 21 similar patients who underwent conventional manual positioning surgery.ResultsThe TiRobot group incurred significantly shorter duration of surgery; less fluoroscopy frequency, intraoperative bleeding, and total drilling than in the conventional group (P < 0.05). Postoperative radiological follow‐up showed that all screws were in the safe area and no screw penetrated the cortex. All wounds healed by primary intention and no iatrogenic damage to the blood vessels, nerves, and organs occurred. Patients showed good tolerance to INFIX and reported no discomfort. The mean follow‐up duration was 5.4 months; the fractures were all healed, no loss of reduction occurred, and the mean Majeed score at the last follow‐up did not show any difference.ConclusionTiRobot‐assisted percutaneous screw placement combined with INFIX for the anterior and posterior pelvic ring injuries is accurate, safe, less invasive, and shows satisfactory efficacy, suggesting it is a better method for minimally invasive treatment of unstable pelvic ring fractures.

The Pelvic Bridge: A Subcutaneous Approach for Anterior Pelvic Fixation.

An alternative method to external fixation for the treatment of unstable anterior pelvic ring injuries, termed the pelvic bridge technique, provides equivalent results with fewer complications and is performed using occipital cervical rods subcutaneously, with fixation into the iliac wings and parasymphyseal bone. For preoperative planning, review the appropriate imaging, including radiographs and computed tomography (CT) scans, to mesh the findings on imaging to the clinical picture of the patient and ensure that the patient meets operative criteria and that none of the contraindications are present. Position the patient to facilitate anterior and posterior fixation. Make the incisions necessary to expose the osseous contour where fixation will be utilized. Carefully contour the plate-rod construct, which is necessary to minimize postoperative complications. Use care when inserting the rod as doing so will help to avoid neurovascular complications. To recreate pelvic stability, the pelvic ring needs to heal in as close to anatomic position as possible and there are multiple methods that help to obtain an adequate reduction. Multiple constructs may be used to stabilize the anterior pelvic ring, but the fundamental principle is to attach the 2 hemipelves to achieve stability, and the location where fixation can be achieved depends on the fracture pattern. Ensure meticulous closure to reduce the chance of infection and achieve appropriate soft-tissue coverage over hardware. Early mobilization is a fundamental goal of this procedure, but the time to full weight-bearing is dependent on fracture characteristics and healing. Anterior pelvic internal fixation (APIF) using the pelvic bridge technique has been demonstrated to have significantly fewer complications than APEF2.

Modified pedicle screw\u2013rod fixation as a minimally invasive treatment for anterior pelvic ring injuries: an initial case series

BackgroundUnstable pelvic ring injuries often involve high mortality and morbidity. This study was aimed to evaluate the modified minimally invasive pedicle screw–rod fixation for anterior pelvic ring injuries, in the respects of its feasibility, merits, and limitations.MethodsTwenty-three patients with unstable pelvic ring injuries underwent the modified anterior pedicle screw–rod fixation, with or without posterior fixation. The clinical outcomes were assessed using Majeed scores, and the quality of reduction was evaluated according to the criteria of Matta.ResultsMajeed scores showed that the clinical outcomes at postoperatively 1 year were excellent in 14 patients, good in 7, and fair in 2. One woman complained of persistent pain at the pubic tubercle during sexual intercourse. Iatrogenic neuropraxia of the unilateral lateral femoral cutaneous nerve occurred in 3 patients. Unilateral femoral nerve palsy occurred in 1 patient. The reduction was found to be excellent in 12 patients, good in 8, and fair in 3. Heterotopic ossification occurred in 8 patients, all being asymptomatic.ConclusionsThe modified pedicle screw–rod fixation with the minimally invasive technique offered an effective alternative for unstable anterior pelvic ring injuries.

CT characteristics of traumatic sacral fractures in association with pelvic ring injuries: correlation using the Young-Burgess classification system.

The purpose of the study is to determine the incidence of sacral fracture patterns on CT imaging of pelvic trauma patients with correlation with mechanism of injury and pelvic ring injury pattern using the Young-Burgess classification system. This is a retrospective review of all pelvic CTs with pelvic fractures performed at our level 1 trauma center during a 4-year period from July 2010 to June 2014. Sacral fractures were very common in pelvic trauma patients, being present in 60% of patients presenting to our institution with pelvic fractures. Longitudinal fractures were almost always associated with additional pelvic ring injuries. Denis zone 1 fractures had the highest association with lateral compression pelvic ring injuries. Denis zone 2 and 3 fractures were seen with increased frequency in AP compression and vertical shear injuries. A third of transverse sacral fractures occurred in isolation, with isolated transverse sacral fractures typically occurring in the low (S3-S5) sacrum. Almost half of combined transverse and longitudinal sacral fractures occurred without an additional pelvic fracture present. Sacral avulsions almost always occurred as part of a pelvic ring fracture pattern, most commonly in AP compression injuries. Coccyx fractures frequently occurred in isolation, but were commonly seen in vertical shear injuries when associated with a pelvic ring injury pattern. Avulsion fractures and longitudinal fractures of the sacrum are almost always associated with anterior pelvic ring injury. Conversely, transverse fractures of the lower sacrum and combined longitudinal and transverse sacral fractures are prone to occur in isolation.

The AOSpine Sacral Fracture Classification

Introduction Sacral fractures are complex and heterogeneous injuries that often include involvement of the lumbar spine and/or pelvis. Due to their complex nature, no comprehensive classification system has been accepted. Material and Methods The AOSpine Trauma Knowledge Forum partnered with orthopaedic traumatologists from AOTrauma to develop a straightforward, hierarchical classification system for sacral fractures. The classification was developed via a consensus process of clinical experts, and, prior to finalizing the classification system, a survey was sent to all members of AOSpine and AOTrauma asking for their input on key parts of the classification. Results The new AOSpine Sacral Classification is a hierarchical classification that follows the same structure as the subaxial and thoracolumbar classifications. First injuries are broadly divided into three types: Type A—Lower Sacro-coccygeal Injuries; Type B—Posterior Pelvic Injuries and Type C—Spino-Pelvic Injuries. Type A injuries have no impact on posterior pelvic or spinopelvic instability, however higher grade injuries may be associated with neurologic injuries. Type A injuries are divided into three subtypes; A1—Coccygeal or compression injuries as well as ligamentous avulsion fractures; A2—Non-displaced transverse fractures below the Sacroiliac (SI) joint, and A3—Displaced transverse fractures below the SI joint. Type B injuries are unilateral longitudinal sacral fractures in which the ipsilateral superior S1 facet is not discontinuous with medial portion of the sacrum. These injuries primarily impact posterior pelvic stability and have minimal impact on spino-pelvic stability. Type B injuries are divided into three subtypes based on the likelihood of neurologic injury, and while this is similar to the Denis classification, because B-type injuries exclude fractures with a transverse component, there is little risk of a neurologic injury with an injury medial to the foramen. The three sub-types of B injuries are: B1—Longitudinal fracture medial to the foramen; B2—Longitudinal fracture lateral to the foramen and B3—Longitudinal injury thought the foramen. Type C injuries are Injuries that result in spino-pelvic instability. They are divided into four subtypes: C0—Non displaced sacral U fracture (commonly seen in low energy insufficiency fractures); C1—Any unilateral B-subtype where the ipsilateral superior S1 facet is discontinuous with the medial portion of the sacrum; C2—Bilateral complete B type fracture without a transverse component, and C3—Displaced sacral U type fracture. In addition to the fracture morphology, the new classification also formally considers the neurologic status of the patient: Nx—The patient cannot be examined; N0—No neurological deficits; N1—Transient neurological injury; N2—Nerve root injury and N3—Cauda Equina Syndrome. Lastly there are four patient specific modifiers that may alter the treatment of these fractures: M1—Significant soft tissue injury; M2—Metabolic bone disease; M3—High-energy injury that may be associated with an anterior pelvic ring injury, acetabular fracture or vascular injury, and M4—Altered anatomy of the lumbosacral junction (may be due to a prior fusion or transitional anatomy). Conclusion The AOSpine sacral fracture classification is the first comprehensive sacral classification to consider posterior pelvic and spino-pelvic instability patterns, and validation studies are ongoing.

Radiographic diagnosis of sagittal plane rotational displacement in pelvic fractures: a cadaveric model and clinical case study

Our objective was to measure the sagittal plane rotational (flexion and extension) displacement of hemipelvis radiologically and analyze the ratio of flexion and extension displacement of unstable pelvic fractures. We used 8 cadaveric models to study the radiographic evidence of pelvic fractures in the sagittal plane. We performed pelvic osteotomy on 8 cadavers to simulate anterior and posterior pelvic ring injury. Radiological data were measured in the flexion and extension group under different angles (5°, 10°, 15°, 20°, and 25°). We retrospectively reviewed 164 patients who were diagnosed with a unilateral fracture of the pelvis. Pelvic ring displacement was identified and recorded radiographically in cadaveric models. The flexion and extension displacement of pelvic fractures was measured in terms of the vertical distance of fracture from the top of iliac crest to the pubic tubercle (CD) or from the top of iliac crest to the lowest point of ischial tuberosity (AB). Fifty-seven pelves showed flexion displacement and 15 showed extension displacement. Closed reduction including internal fixation and external fixation was successfully used in 141 cases (86.0%). The success rates of closed reduction in flexion and extension displacement groups were 77 and 73%, respectively, which were lower than in unstable pelvic ring fractures. The sagittal plane rotation (flexion and extension) displacement of pelvic fractures could be measured by special points and lines on the radiographs. Minimally invasive reduction should be based on clearly identified differences between the sagittal plane rotation and the vertical displacement of pelvic fractures.

Pelvic Ring Fractures in the Elderly

Pelvic ring fractures in elderly patients are usually associated with a low-energy trauma, which may hide the fact that these fractures are often a combination of anterior and posterior pelvic ring injuries with a potential significant instability with subsequent pain and immobility. Pelvic fractures in the geriatric population are associated with a high morbidity and mortality. The goals of any treatment are the restoration of mobility and independency as well as the prevention of future fractures. In order to accomplish these goals, an interdisciplinary approach is indispensable. This review is aimed to provide insight into the characteristics of geriatric pelvic ring injuries and into their diagnosis and therapy with the associated outcome.

Significance of clinical examination, CT and MRI scan in the diagnosis of posterior pelvic ring fractures

IntroductionPatients with a fracture in the anterior pelvic ring often simultaneously demonstrate pain in the posterior pelvic ring. The aim of the present prospective study was to assess the sensitivity of CT, MRI and clinical examination in the detection of fractures in the posterior pelvic ring in patients with fractures of the anterior pelvic ring diagnosed in conventional radiographs. MethodsSixty patients with radiographic signs of an anterior pelvic ring injury were included in this prospective analysis. Following a focused clinical examination of the posterior pelvis, all patients underwent both a CT and then a MRI scan of their pelvis. Two board certified radiologists evaluated the CT and MRI scans independently. To estimate the presence of osteoporosis the Hounsfield units of the vertebral body of L5 were measured in each case. ResultsFifty-three women and seven men, with a mean age of 74.7+/−15.6 years were included into the study. A fracture of the posterior pelvic ring was found in fourty-eight patients (80%) patients using MRI. Fractures of the posterior pelvic ring would have been missed in eight cases (17%), if only CT had been used. Eighty-five percent of the patients with a posterior fracture had an osteoporosis. The majority of the cases suffered from a low energy trauma. Thirty-eight patients (83%) with positive clinical signs at the posterior pelvic ring actually had a fracture of the posterior pelvic ring in the MRI. The clinical examination proved to be equally effective to CT in detecting posterior pelvic ring fractures. ConclusionThe significance of both, clinical examination and CT was confirmed in the detection of fractures in the posterior pelvic ring. MRI examination of the pelvis however, was found to be superior in detecting undislocated fractures in a cohort of patients with a high incidence of osteoporosis. Using MRI may be beneficial in select cases, especially when reduced bone density is suspected.

Clinical effect and complication of minimally invasive surgery in treatment of anterior and posterior pelvic ring injury

Objective To evaluate the clinical effects and complications of sacroiliac screw instrumentation combined either with external fixation or anterior column screw fixation for treatment of posterior pelvic ring injury combined with fractures of anterior pubic and ischiadic ramus.Methods A retrospective review was conducted on 91 patients with posterior pelvic ring injury combined with fractures of anterior pubic and ischiadic ramus treated between December 2007 and December 2012.There were 67 males and 24 females aged at 22-61 years (mean,37.8 years).All together,51 out of the patients were treated with sacroiliac screws combined with external fixation and 40 underwent sacroiliac screw fixation combined with anterior screw fixation.Comparative analysis of the two surgical treatments were made in aspect of postoperative complications,postoperative ambulation time,fracture healing,Majeed pelvic function score,and visual analogue scale (VAS).Results Eighty-eight patients were available for the mean 13.6 months of follow-up (range,12-26 months).Except for postoperative complications and fracture healing,postoperative ambulation time [(31.0 ± 6.2) d vs (41.9 ± 7.2) d],excellence rate in Majeed pelvic function score (95％ vs 73％) and VAS score[(1.1 ± 1.3) points vs (3.5 ±2.0) points]were significantly better in patients treated with anterior column screw than in patients undergoing external fixation (P ＜ 0.05).Conclusion Sacroiliac screw combined with anterior column screw as an alternative to treat posterior pelvic ring injury combined with fractures of anterior pubic and ischiadic ramus advantages in early ambulation,relief of the pain,and few complications. Key words: Pelvis; Fracture fixation; Anterior column screws