Rami Fractures Research Articles

Entry Point Variation in the Osseous Fixation Pathway of the Anterior Column of the Pelvis-A Three-Dimensional Analysis.

Fractures of the superior pubic ramus can be treated with screw insertion into the osseous fixation pathway (OFP) of the anterior column (AC). The entry point determines whether the screw exits the OFP prematurely. This can be harmful when it enters the hip joint or damages soft tissues inside the lesser pelvis. The exact entry point varies between patients and can be difficult to ascertain on fluoroscopy during surgery. The aim of this study was to determine variation in the location of the entry point. A retrospective single center study was performed at a level 1 trauma center in the Netherlands. Nineteen adult patients were included with an undisplaced fracture of the superior pubic ramus on computer tomography (CT)-scan. Virtual three-dimensional (3D) models of the pelvises were created. Multiple screws were placed per AC and the models were superimposed. A total of 157 screws were placed, of which 109 did not exit the OFP prematurely. A universally reproducible entry point could not be identified. A typical crescent shaped region of entry points did exist and was located more laterally in females when compared to males. Three-dimensional virtual surgery planning can be helpful to identify the ideal entry points in each case.

The clinical characteristics and management of paediatric pelvic fractures: a changing landscape based on skeletal maturity

IntroductionPaediatric pelvic fractures (PPFs) are uncommon but signify serious trauma. A comprehensive multidisciplinary approach is needed due to a high number of associated injuries. This study aims to retrospectively analyse PPFs over a 5-year period and evaluate how advancing skeletal maturity changes fracture patterns and management plans.MethodsThe trauma database was retrospectively reviewed for pelvic fractures in patients aged ≤ 18 years. Radiographs and CT scans were used to classify pelvic injuries according to the modified Torode classification and determine the status of the triradiate cartilage (open: skeletally immature; closed: skeletally mature). Data collected also included the mechanism of injury, clinical and functional outcomes, and associated injuries. Logistic regression analysis was performed to identify risk factors for associated abdominal injuries.Results65 PPFs (2.8% of paediatric trauma admissions during the study period) were classified as type I (3.1%), type II (7.7%), type IIIa (32.3%), type IIIb (38.5%), type IV (18.5%) according to the modified Torode classification. The mean age was 13.41 ± 3.82. Skeletally immature children were more likely to be hit by a motor vehicle as a pedestrian (p < 0.001), be intubated (p = 0.009), acquire Torode type II (p = 0.047) and rami fractures (p = 0.037), and receive chest (p = 0.005) and head injuries (p = 0.046). Skeletally immature children were also less likely to acquire Torode type IV fractures (p = 0.018), receive surgical treatment for their pelvic injuries (p = 0.036), and had a faster time to full weight bearing (p = 0.013). Pelvis AIS score ≥ 4 (OR 5.3; 95% CI 1.3–22.6; p = 0.023) and a pedestrian accident (OR 4.9; 95% CI 1.2–20.7; p = 0.030) were risk factors for associated abdominal injuries. There was a strong association between a higher pelvic fracture grade and the proportion of patients with closed triradiate cartilage (p = 0.036), hospital length of stay (p = 0.034), mean pelvic AIS score (p = 0.039), a pelvis AIS score of ≥ 4 (p = 0.022), mean ISS (p = 0.003), an ISS score between 25 and 75 (p = 0.004), average time to FWB (p = 0.001), requirement of blood products (p = 0.015), and a motor vehicle accident (p = 0.037).ConclusionPPFs occurring in skeletally mature and immature patients are significantly different in terms of mechanism of injury, fracture severity, fracture pattern, and management strategy. There is a high rate of associated injuries, necessitating an integrated multidisciplinary approach in paediatric trauma centres.

Rami Comminution Is Associated With Displacement of Minimally Displaced Lateral Compression Type 1 Injuries on Lateral Stress Radiographs.

To determine whether displacement on lateral stress radiographs (LSRs) in patients with minimally displaced lateral compression type 1 pelvic ring injuries is associated with any demographic and/or injury characteristics. Retrospective comparative cohort. Urban level 1 trauma center. Ninety-three consecutive patients with minimally displaced lateral compression type 1 injuries. Displacement of pelvic ring injury on LSR (≥10 mm vs. &lt;10 mm). Demographic and injury characteristics (mechanism of injury, Nakatani rami classification, rami comminution, Denis zone, complete/incomplete sacral fracture, sacral comminution). 65.6% of patients (n = 61) had ≥10 mm of displacement on LSR. On univariate analysis, displacement was associated with increased age [median difference 11: confidence interval (CI), 2-23], female sex [proportional difference (PD): 25.1%, CI, 3.9%-44.4%], Nakatani classification (type I PD: 27.9%, type II PD: -19.5%), and rami comminution (PD: 55.6%, CI, 35.4%-71.3%). On multivariate analysis, displacement was only associated with rami comminution (odds ratio: 16.48, CI, 4.67-58.17). Displacement was not associated with energy of injury mechanism, sacral fracture Denis zone, complete sacral fracture, sacral comminution, or bilateral rami fractures. Although rami comminution was the only variable found to be independently associated with displacement ≥10 mm on LSR, no single variable perfectly predicted displacement. Future studies are needed to determine whether displacement on stress radiographs should change the management of these injuries. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mandibular Ramus Fractures: A Case Series Of Diversity In Rarity

Mandibular ramus fracture is the second least common fracture occurring in the mandible. The ramus is located at the congregation of the dentate and the non-dentate part of the mandible. It can get fractured in various patterns. Owing to the presence of the anatomical structures and the orientation of the fracture line, the treatment plan varies in each case. In this article, we have demonstrated a series of four distinct kinds of mandibular ramus fractures and its management with ORIF.

Emerging Options Using Osteobiologics Treatment for FFP Type IA Comminuted Stable Fragility Fractures Involving the Pubic Rami

Introduction: For many elderly patients who sustain a pubic rami fracture after a fall, the traditional treatment of extended bed rest and restricted mobility is often not practical. A classification for pubic rami fractures has been developed to recommend treatment. There is a technique to augment the biologic fracture environment using Calcium Phosphate through a minimally invasive procedure. In this study FFP Type Ia fractures were treated using Calcium phosphate. Methods: Our study, from January 1, 2018, to December 31, 2019, identified eighty-eight patients with FFP Type Ia fractures, who were treated with Calcium Phosphate. There were 9 males and 79 females, average ages were 78 and 86 respectively. Admission workup included pelvic x-rays as well as a CT scan. All received Calcium Phosphate for fracture fixation. They were followed in the outpatient clinic with pelvic radiographs at 3 weeks, 6 weeks, 6 months. 9 months and 1 year. Evidence of incorporation of the Calcium Phosphate in the fracture healing were documented. Results: There were no infections, no vascular, and no urological complications with this technique. All treated fractures went on to heal. Incorporation of the Calcium Phosphate was noted as early as 12 weeks. Residual presence of Calcium Phosphate was seen at 1 year and was consistent with the research literature. Conclusion: This new method of minimally invasive internal fixation using a bone biologic enhancement material provides an immediate improvement of post injury pain and an increase in immediate post treatment mobility. This treatment is applicable for all pelvic fragility fractures, including Type Ia who present with comminution. Risks with this treatment are low and benefits to the patient are high.

Novel Covert-Inferior Pelvic Approach with a Subpubic Plate for Anterior Pelvic Ring Fractures: Preliminary Results.

Anterior pelvic ring injuries can be treated via Pfannenstiel, modified Stoppa, or ilioinguinal approaches, but these require exposing the abdominal soft tissues and may damage pelvic organs. The scar on the abdominal wall is also unacceptable for some patients. The minimally invasive anterior pelvic ring internal fixator (INFIX) is not ideal for thin patients with easily irritated skin, and it is associated with complications such as femoral nerve palsy, vascular occlusion, and lateral femoral cutaneous nerve injury. In this study, we designed a new external pelvic approach for the treatment of an anterior pelvic ring fracture. We retrospectively reviewed 28 patients with 36 pubic ramus fractures that had been treated via the covert-inferior pelvic approach. All patients underwent a surgical procedure between August 2019 and January 2021. According to the Nakatani classification, there were 6 cases of type-I fracture, 25 cases of type-II fracture, and 5 cases of type-III fracture. Operative time, blood loss, and postoperative radiographic and computed tomographic (CT) findings were recorded. Patients were followed for fracture healing time, functional status, esthetic satisfaction, and complications. A total of 27 patients had follow-up for at least 12 months (range, 12 to 29 months). Postoperative radiographs and CT scans showed well-positioned plates and screws. The mean preoperative time was 9.4 ± 3.8 days, the mean operative time was 61.3 ± 22.67 minutes, the mean intraoperative blood loss was 63.6 ± 42.62 mL, the mean fracture healing time was 4.1 ± 1.6 months, and the mean Majeed score was 89.74 ± 8.07. There were no complications of nonunion, internal fixation failure, vascular injury, nerve palsy, or hernia. All of the patients were esthetically satisfied with the scar. The covert-inferior pelvic approach combined with a subpubic plate effectively fixed Nakatani type-I, II, and III fractures. The advantages of this method include rapid recovery after the surgical procedure, safety, simplicity, a short learning curve, no damage to abdominal soft tissue, no effect on pubic symphysis micromotion, and esthetic benefits. It may be another option for anterior pelvic ring fractures and can supplement other approaches. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

A biomechanical comparison of superior ramus plating versus intramedullary screw fixation for unstable lateral compression pelvic ring injuries,,,

IntroductionManagement of the anterior component of unstable lateral compression (LC) pelvic ring injuries remains controversial. Common internal fixation options include plating and superior pubic ramus screws. These constructs have been evaluated in anterior-posterior compression (APC) fracture patterns, but no study has compared the two for unstable LC patterns, which is the purpose of this study. MethodsA rotationally unstable LC pelvic ring injury was modeled in 10 fresh frozen cadaver specimens by creating a complete sacral fracture, disruption of posterior ligaments, and ipsilateral superior and inferior rami osteotomies. All specimens were repaired posteriorly with two fully threaded 7 mm cannulated transiliac-transsacral screws through the S1 and S2 corridors. The superior ramus was repaired with either a 3.5 mm pelvic reconstruction plate (n = 5) or a bicortical 5.5 mm cannulated retrograde superior ramus screw (n = 5). Specimens were loaded axially in single leg support for 1000 cycles at 400 N followed by an additional 3 cycles at 800 N. Displacement and angulation of the superior and inferior rami osteotomies were measured with a three-dimensional (3D) motion tracker. The two fixation methods were then compared with Mann-Whitney U-Tests. ResultsRetrograde superior ramus screw fixation had lower average displacement and angulation than plate fixation in all categories, with the motion at the inferior ramus at 800 N of loading showing a statistically significant difference in angulation. ConclusionAlthough management of the anterior ring in unstable LC injuries remains controversial, indications for fixation are becoming more defined over time. In this study, the 5.5 mm cannulated retrograde superior ramus screw significantly outperformed the 3.5 mm reconstruction plate in angulation of the inferior ramus fracture at 800 N. No other significance was found, however the ramus screw demonstrated lower average displacements and angulations in all categories for both the inferior and superior ramus fractures.

The lateral stress radiograph: an effective alternative to examination under anesthesia for identifying occult instability in minimally displaced lateral compression pelvic ring injuries.

The purpose of this study was to review the practice of utilizing lateral stress radiographs (LSRs) to identify occult instability (≥ 10mm of dynamic displacement on LSRs) of minimally displaced lateral compression type 1 (LC1) pelvic ring injuries and to evaluate for associations between instability and patient demographics, injury characteristics, and hospital course. A retrospective review of a prospective registry from 2018 to 2022 identified 151 patients with LC1 injuries. LSRs were obtained in 86.8% (131/151) of patients. Three (2.2%) patients were excluded for malrotation of LSRs, leaving 128 patients for analysis. The median maximum dynamic displacement on LSRs was 12.2mm (IQR: 5.9 to 17.3). Occult instability was present in 62.5% (80/128) of patients and was associated with older age (Median difference 11.0years, 95%CI 3.0 to 20.0), Nakatani type 1 rami fractures (73.7% vs. 47.9%, p = 0.001), and rami fracture comminution (Proportional difference 58.7%, 95%CI 42.8 to 71.3%), but not gender, high-energy mechanism, bilateral rami fractures, Denis classification, sacral fracture completeness, or sacral comminution. Patients with occult instability took longer to ambulate 15 feet and clear physical therapy (PT), were more likely to be unable to clear PT by hospital day 3 or by time of discharge, had longer hospital stays, and were more likely to require rehabilitation facilities. LSRs were obtained in a majority of patients. Occult instability was frequently present and associated with older age, comminuted distal pubic rami fractures, longer hospital stays, longer times to mobilize and clear PT, and an increased need for rehabilitation facilities.

GROIN PAIN - SOCCER

HISTORY:A 20 yo collegiate female soccer player presented with two weeks of insidious onset left groin pain. Pain was achy, without radiation, and intermittent. Pain with cutting and lateral ball dribbling/drills. No additional symptoms. She had decreased activity for a year due to the pandemic. Prior to preseason, she independently began a vigorous training program with hours of daily activity. She lost twenty pounds in two months and consuming about 1800 calories daily. Menses remained regular on oral contraceptives. PHYSICAL EXAMINATION: Inspection: Normal. Palpation: Nontender at all bony prominences and muscles of pelvis, hip, and lumbar spine. ROM: Full. Strength: Normal. Left groin pain with hip adduction and flexion. Neuro: Normal. Hip: Log roll, FABER, FADIR, Ober, Thomas, Ely’s, Scour all normal. Sacroiliac: normal including figure four, compression and thigh thrust. Lumbar : normal with negative straight leg raise. Single leg hop was nonpainful and nonantalgic gait with normal proprioception. DIFFERENTIAL DIAGNOSIS:1. Adductor Strain or Psoas Strain2. Pubic Rami Avulsion Fracture3. Sacral Ala Stress Fracture4. Femoral neck stress fracture5. Labral tear TEST AND RESULTS: AP Pelvis Xray: Sacroiliac joints, sacrum, lumbar spine, pelvis, and bilateral hips normal alignment without fracture. She completed one month of physical therapy with improvement initially, however, her pain then progressed to bilateral groin pain. MRI pelvis: symmetric transverse bilateral inferior pubic rami fractures. Nondisplaced with normal alignment. FINAL WORKING DIAGNOSIS:1)Bilateral Inferior Pubic Rami Transverse Stress Fractures2)Relative Energy Deficiency Syndrome TREATMENT AND OUTCOMES: Physical therapy and soccer were discontinued. Crutches provided. Calcium and vitamin D supplementation recommended. CBC, CMP, PTH, TSH, Ferritin, Vitamin D testing indicated iron deficiency anemia. Bone Density testing: normal. Referred to sports dietician•Repeat Pelvic AP xrays indicated interval progression of her stress fractures bilaterally, now radiographically present with evidence of callus formation at bilateral inferior pubic rami. No displacement. Plan: Slowly progress activity as tolerated over several months with repeat exam, lab work, and xrays to ensure healing and resolution.

Pelvic ring injuries after road and mountain bike accidents.

The purpose of this study was to compare patients with traumatic pelvic ring injuries sustained in road and mountain bicycling accidents to evaluate for differences in injury types and hospital courses. A retrospective review of 60 patients presenting with pelvic ring injuries after road (n = 46) and mountain (n = 14) bicycling accidents was performed to compare patient/injury characteristics and hospital course. LC1 injuries were the most common pelvic ring injury (n = 31, 51.7%), 38.7% (n = 12) of which were considered unstable, followed by isolated iliac wing (n = 11, 18.3%), pubic rami (n = 6, 10.0%), and sacral fractures (n = 6, 10.0%). Hospital admission was required for 41 (68.3%) patients. The median hospital LOS was 4days (IQR 2-9) and 12 (20%) patients received operative treatment. Patients in road versus mountain bicycling accidents were more likely to be older tobacco users and were similar in sex, body mass index, and injury severity score. Road bicycling resulted in more LC1 injuries (58.7% vs 28.6%, p = 0.04), while mountain bicycling resulted in more iliac wing fractures (42.9% vs. 10.9%, p = 0.01). Road cycling injuries required more days in the hospital to clear PT (median difference 2, CI 0-4, p = 0.04) and had longer hospital stays (median difference 2, CI 0-6, p = 0.02) but had no difference in the rate of admission, operative intervention, or discharge to rehabilitation facilities. The majority of pelvic ring injuries from road and mountain bicycling accidents were LC1 injuries that were frequently unstable and often required hospital admission and operative fixation.

Clinical Experience with the New EASY (Endoscopic Approach to the Symphysis) Preparation Technique for Injuries of the Anterior Pelvic Ring.

High-energy injuries of the anterior pelvic ring and especially disruptions of the pubic symphysis usually require surgical stabilization. There is a conflict between biomechanical stability and size in the surgical approach. We have previously presented a minimally invasive approach for symphyseal plating. Our current endoscopic surgical technique is presented step-by-step and is illustrated in a video. The results and courses of the first seven patients treated with the EASY preparation are presented. In all seven patients, the EASY preparation was successful. In four of the seven patients with an anterior pelvic ring injury, we performed a complete endoscopic plate osteosynthesis of the pubic symphysis. One patient gave consent only for endoscopic preparation, in one patient, we converted to open plate due to ventilation problems, and in one patient, the superior pubic rami fracture was stable. There were no surgical complications. The EASY is a feasible minimally invasive preparation technique to stabilize anterior pelvic ring injuries in the most biomechanically stable manner by performing plate osteosynthesis. However, further scientific monitoring is necessary to improve the technique and validate our data.

Biomechanical evaluation of locking versus nonlocking 2.0-mm malleable L-miniplate fixation of simulated caudal mandibular fractures in cats.

To evaluate the biomechanical properties of the mandibles of cats with experimentally created osteotomies simulating oblique ramus fractures, which were stabilized with malleable L-miniplates with either locking screws [locking construct (LC)] or nonlocking screws [nonlocking construct (NLC)], compared with those for intact mandibles. 20 mandibles from 10 adult cat cadavers. A block study design was adopted to allocate the mandibles of each cadaver to 2 of the 3 test groups (LC, NLC, or intact mandible). Mandibles within each cadaver were allocated systematically to a test group. For mandibles assigned to an LC and an NLC, a complete oblique osteotomy was performed from the mid rostral aspect of the ramus in a caudoventral direction. All mandibles were loaded in a single-load-to-failure test through cantilever bending. Load and actuator displacement were recorded simultaneously. Mode of failure and radiographic evidence of damage to tooth roots and the mandibular canal were evaluated. Biomechanical properties were compared among the groups. No iatrogenic tooth root damage was evident, but all mandibles with an LC and an NLC had evidence of screw invasion into the mandibular canal. Plated mandibles had significantly less stiffness and bending moment than intact mandibles. Stiffness was not significantly different between the LC and the NLC; the NLC had a greater bending moment at failure than the LC. The pre-yield stiffness of plated mandibles decreased when the number of screw holes overlapping the mandibular canal increased. The use of a malleable L-miniplate in a caudal mandibular fracture model is feasible. Both the LC and the NLC were inferior mechanically to intact mandibles. Type of construct used did not affect the construct stiffness significantly in tested mandibles.

Bilateral coronoidectomy associated with the use of acrylic resin for fixation of fractures in the mandible of a dog - Case Report

Mandibular fractures are relatively common in dogs, and damage to the temporomandibular joint (TMJ) can cause jaw immobility. A mixed breed dog with a history of escape and trauma of unknown origin and time of occurrence was treated at Animal Care Barueri Veterinary Clinic, in Barueri, São Paulo, due to which he returned home with lesions distributed throughout the body, mainly located in the face. The animal was sent for radiographs that showed a fracture in the mandibular symphysis, left mandibular ramus and bilateral mandibular coronoid processes. We then opted for bilateral coronoidectomy followed by fixation of the symphysis and mandibular ramus fractures. A curvilinear incision was made over each temporomandibular joint followed by exposure of the fragment of the coronoid processes which were then excised. The correction of symphysis and mandibular ramus fractures was performed by applying acrylic resin throughout the lower dental arch. Finally, an esophageal tube was passed for food and medication and external coaptation of the mouth and muzzle was made with Vetrap elastic bandage. The postoperative period was performed with enrofloxacin, tramadol hydrochloride, meloxicam dipyrone and tube fededing. After 60 days of post-surgical evaluation, no complications were observed and good outcome was reached with treatment.

Pelvic ring injuries after alpine ski and snowboard accidents.

The purpose of this study was to analyze the patient/injury characteristics and associated hospital course of patients sustaining traumatic pelvic ring injuries after alpine ski and snowboard accidents at a level one trauma center in the Rocky Mountain region. Patient/injury characteristics were obtained from patients presenting with pelvic ring injuries after alpine ski (n = 55) and snowboard (n = 9) accidents. Characteristics and outcomes analyzed included mechanism of injury, pelvic ring classification (Young-Burgess and Tile), hospital admission, physical therapy (PT) clearance, ambulation, length of stay, inpatient morphine milligram equivalents (MME), and discharges to rehabilitation facility. Snowboarders were more often younger, male, tobacco/substance users, and more likely to be injured by a fall from height than skiers. There were no differences in injury classification or hospital course outcomes between alpine sports. Most common injuries included lateral compression type 1 (LC1) injuries (37.5%), isolated pubic ramus fractures (31.3%), and isolated iliac wing fractures (15.6%). LC1 injuries were unstable in 50% of cases and associated with increased admissions (proportional difference: 47.5%, CI: 23.8-64.5%, p = 0.0002), longer time to PT clearance (median difference(MD): 1.0day, CI: 0-2.0, p = 0.03), longer LOS (MD: 2.0, CI: 0-2.0, p = 0.02), and increased inpatient MMEs (MD: 197.9 MME, CI: 30.0-420.0, p = 0.02), as compared to other pelvic ring injuries. The majority of pelvic ring injuries from alpine ski and snowboard accidents were LC1 injuries, half of which were unstable, resulting in longer hospital stays, time to PT clearance/ambulation, and opioid use.

Identifying safe corridors for anterior pelvic percutaneous instrumentation using computed tomography-based anatomical relationships

IntroductionPercutaneous anterior pelvic ring instrumentation is performed for retrograde screw fixation of ramus fractures, as well as for repair of pubic symphysis diastasis. The anatomic relationships of critical structures around the anterior pelvic ring, such as the spermatic cord and round ligament, have been described in only a few studies regarding the risk of iatrogenic injury during surgery. Our goal is to further describe these relationships, as well as provide radiographic information on safe corridors for percutaneous fixation. MethodsEighty (80) axial computed tomography scans of the abdomen, obtained for non traumatic diagnostic purposes and screened for prior abdominal trauma or procedures, were evaluated by 3 fellowship trained radiologists. Mid-symphyseal cuts were used to obtain several measurements relative to the spermatic cords (SC) or round ligaments (RL): inter-cord or inter-ligament distance, skin to cortex of symphysis distance (vertical), skin to cortex of symphysis distance (oblique), safe corridor distance (between SC/RL and femoral triangle), center safe angle (relative to bilateral ischia), maximal safe angle, and minimal safe angle. ResultsThere were 41 male and 39 female scans included in the final analysis. The average inter-cord distance was 50.2 mm, skin to cortex vertical distance of 43.0 mm, skin to cortex oblique distance of 83.5 mm, safe corridor distance 26.3 mm, center safe angle 19.3˚, maximal safe angle 32.3˚, and minimal safe angle 13.6˚. These were further broken down by range and gender in Table 1. Agreement between radiologists was high for these different measurements with the exception of the skin to cortex oblique distance in female patients and the maximal safe angle in female patients, due to absence of round ligament in a majority of the scans. The round ligament was only present at the mid-symphyseal level for our three reviewers in 37/39, 36/39, and 24/39 of female patient scans. ConclusionsWe have identified defined safe corridors for instrumentation of the anterior pelvic ring that can assist the surgeon in percutaneous application of fixation for fracture care.

Combined anterior and posterior ring fixation versus posterior ring fixation alone in the management of unstable Tile B and C pelvic ring injuries: A randomized controlled trial

PurposeCombined anterior and posterior ring (APR) fixation is classically performed in Tile B2 and C1 injuries to achieve superior biomechanical stability. However, the posterior ring (PR) is the main weight bearing portion that is responsible for weight transmission from the upper parts of the body to the lower limbs through the sacrum and the linea terminalis. It is hypothesized that isolated PR fixation can achieve comparable radiological and clinical outcomes to APR fixation. Therefore, we conducted this study to compare the two fixation principles in managing Tile B2 and C1 injuries. MethodsOur study included 20 patients with Tile B2 injuries and 20 patients with Tile C1 injuries. This study was a randomized control single-blinded study via computerized random numbers with a 1:1 allocation by using random block method. The study was performed at a level one trauma center. A total of 40 patients with Tile B2 and C1 injuries underwent combined APR or isolated PR fixation (Group A and B, respectively). Matta & Tornetta radiological principles and Majeed pelvic scoring system were used for the assessment of primary outcomes and postoperative complications. Secondary outcomes included operative time, amount of blood loss, intraoperative assessment of reduction, need of another operation, length of hospital stay, ability to weight bear postoperatively and pain control metrics. We used student t-test to compare the difference in means between two groups, and Chi-square test to compare proportions between two qualitative parameters. We set the confidence interval to 95% and the margin of error accepted to 5%. So, p ≤ 0.05 was considered statistically significant. ResultsThe mean follow-up duration was 18 months. The operative time (mean difference 0.575 h) and the intraoperative blood loss (mean difference 97.5 mL) were lower in Group B. Also, despite the higher frequency of rami displacement before union in the same group, there were no significant differences in terms of radiological outcome (excellent outcome with OR = 2.357), clinical outcome (excellent outcome with OR = 2.852) and postoperative complications assessment (OR = 1.556) at last follow-up. ConclusionThe authors concluded that isolated PR fixation could favorably manage Tile B2 and C1 pelvic ring injuries with Nakatani zone II pubic rami fractures and intact inguinal ligament. Its final radiological and clinical outcomes and postoperative complications were comparable to combined APR fixation, but with less morbidity (shorter operation time, lower amount of blood, and no records of postoperative wound infection).

Percutaneous screw fixation assisted by hollow pedicle finder for superior pubic ramus fractures

BackgroundPubic ramus fracture was an injury of anterior pelvic ring, the anterior pelvic ring plays an important role in maintaining the stability of the pelvis. The purpose of this study was to investigate the effect and indication of percutaneous retrograde pubic screw fixation assisted by hollow pedicle finder for pubic ramus fractures.MethodsThe clinical data of 68 patients with pubic ramus fracture treated with cannulated screw from March 2008 to March 2020 were retrospectively analyzed. According to the surgical methods, they were divided into traditional surgery group (32 cases in group A, with traditional retrograde pubic screw fixation) and modified surgery group (36 cases in group B, with percutaneous retrograde pubic screw fixation assisted by hollow open circuit device). Operation time, blood loss, incision length, screw length and complications were recorded and compared between the two groups. On the second day after surgery, the maximum fracture displacement over plain radiographs, entrance radiographs and exit radiographs of the pelvis was evaluated according to Matta criteria to evaluate the postoperative fracture reduction. Majeed score was used to evaluate the hip function at 12 months after surgery.ResultsThe operations were successfully completed in both groups. The operation time, blood loss and incision length in group B were significantly less than those in group A (P < 0.05). There was no significant difference in screw length between the two groups (t = 0.797, P = 0.431). All patients were followed up for 8–38 months (mean 21.8 months). There were no vascular and nerve injury, fracture of internal fixator, screw entry into joint cavity, fracture nonunion and other complications in both groups. The fracture healing time of the two groups was 23.1 ± 2.1 weeks in group A while 22.7 ± 2.1 weeks in group B, respectively, and there was no statistical difference in the fracture healing time between the two groups (P > 0.05). In group A, there were 3 cases of incision infection, 1 case of incision fat liquefaction and 2 cases of lower extremity deep venous thrombosis, and the complication rate was 18.8%. There was only 1 case of lower extremity deep vein thrombosis in group B, and the complication rate was 2.8%, which was significantly lower than that in group A. The fracture in one case after surgery was found to be displaced in group A and no fracture was found in group B. There was no significant difference between the two groups in Matta imaging evaluation on the next day after surgery and Majeed function evaluation at 12 months after surgery (P > 0.05).ConclusionPercutaneous retrograde pubic ramus screw fixation assisted by hollow pedicle finder is effective in the treatment of pelvic pubic ramus fracture. It has the advantages of less incision, shorter operation time, less blood loss and lower incidence of complications compared with traditional methods. However, correct surgical indications should be required when we apply this surgical method.

Epidemiology of Fragility Pubic Ramus Fractures in the United States.

IntroductionPrevious studies illustrate significant increases in pelvic fracture incidence; however, there is a paucity of information on the incidence of osteoporotic pelvic ring injuries based on large-scale examinations of geographically and ethnically diverse populations. This study addresses the epidemiology of osteoporotic pubic ramus fractures in the United States and details differences in incidence rates with respect to age, gender, and race.Materials and MethodsNational Electronic Injury Surveillance System (NEISS) data between 2002 and 2019 was gathered for individuals aged 60 and above presenting to U.S. emergency departments with ramus fractures. Incidence rates for ramus injuries were calculated using adjusted U.S. Census Bureau estimates of population. Fracture incidences were calculated for age, gender, and race strata.ResultsThe overall incidence rate of pubic ramus fractures in the United States between 2002 and 2019 was 13.47 per 1,000,000 people 60 years and older (95% confidence limit: 9.92-17.01). The incidence of pubic ramus fractures for females in the US was 21.71 (16.08-27.34). Rates of ramus fracture increased overall (P < .001) and for both genders between the ages of 60 and 100, though the rate increase was significantly greater in females than in males (P < .001). In terms of race, incidence was highest Asian females and lowest in Native American and Pacific Islander men.Discussion/Conclusion: As the first national study addressing the epidemiology of ramus injuries in the United States, this work reveals these injuries comprise a significant fracture risk in the elderly. In addition, it highlights gender and ethnic strata that are more susceptible to these injuries.

155 Fracture of Pubic Rami During Hip Fracture Fixation - a Rare Case of Traction Table Related Injury

Abstract Background Traction tables form the mainstay of closed reduction techniques for lower limb fracture and in particular hip fractures. They offer a versatile solution to continuous traction required in a variety of operations such as closed intramedullary femoral fixation and hip fixation. Counter traction on the table is provided by the perineal post, this has been associated with significant complications such as neuropraxia, erectile dysfunction, cutaneous necrosis, and urethral injuries. Case presentation We present a case of an elderly and co-morbid patient who was scheduled to undergo a hip fracture fixation using an intramedullary nail. Unfortunately, this was delayed by 3 weeks as the patient was unfit to undergo this procedure. She was placed onto the traction table and intra-operatively sustained a superior and inferior pubic rami fracture while attempting reduction on the traction table. Conclusions Closed reduction techniques using traction tables and perineal posts are not without morbidity. Risk factors such as osteoporosis and delayed fixation should be accounted for when managing this complex and often frail group of patients.

Consider Emergency Department Stress Examinations on Lateral Compression Type-1 Pelvic Ring Injuries with Complete Sacral Fractures: Commentary on an article by Graham J. DeKeyser, MD, et al.: "Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable".

Commentary A minimally displaced Young and Burgess lateral compression type-1 (LC1) pelvic fracture represents a spectrum of injury1, and treatment is controversial. Sembler Soles et al. promoted nonoperative treatment for all2, but others such as Sagi et al. have shown that some of these LC1 fractures may benefit from a surgical procedure despite their benign radiographic appearance3. This led Sagi et al. to publish their technique for examination under anesthesia (EUA) of these fractures to identify occult instability that is missed by static radiographic imaging3. However, there is concern about the unnecessary anesthetic and operative cost for fractures that are determined to be stable in the operating room (OR). Furthermore, as surgeons, we may be biased and may be more likely to fix the fractures in patients who go to the OR for an additional stress examination despite initial borderline stress examination findings. Other authors have investigated a stress examination without anesthesia. Parry et al. performed an anteroposterior pelvic radiographic examination with the patient lying on the injured side while awake in the OR prior to EUA in 20 patients and found this to reliably identify pelvic instability4. However, I have not adopted this into my practice outside the OR because of the concern for patient tolerance in the emergency room and the fact that an anteroposterior pelvic radiograph is not as sensitive as an inlet view to identify rotational displacement. In their study, DeKeyser et al. wanted to investigate if the stress examination could be performed outside the operating room with the patient awake. They present a commonsense approach to see if a rotational stress examination of an LC1 fracture in the emergency department (ED) can reliably be performed, can be tolerated by the patient, and can be trusted to direct treatment. There are 2 important things to remember about the study methods as surgeons consider adopting this protocol in their practice. First, only isolated LC1 fractures (anterior pelvic ring disruption with an ipsilateral compression sacral fracture) with <10-mm displacement on static imaging were included. Second, the rotational stress examination protocol was very specific, including how to account for magnification when measuring displacement. For those patients who had a positive stress examination and went to the OR, the rotational stress examination was repeated under anesthesia for comparison with the ED stress examination. The findings of this article are very enlightening and can help surgeons to avoid taking specific types of patients with an LC1 fracture to the operating room to perform a stress examination. All 70 patients who were enrolled tolerated the stress examination in the radiographic suite without complication. An important correlation was identified between the mechanism of injury and the rate of positive stress examination. Fifty-four percent of the patients enrolled sustained the pelvic fracture from a high-energy mechanism. As expected, high-energy fractures were significantly more likely to have positive ED stress examinations. Two (4%) of the patients who had a negative stress examination in the ED converted to the operative group because of an inability to walk after the initial stress examination. Of note, they had high-energy mechanisms of injury and bilateral fractures of the rami, but still had a negative intraoperative EUA. Both were able to mobilize after the surgical procedure. Forty-three of the patients who had a negative ED stress examination had clinical and radiographic healing with no further radiographic displacement at the 3-month follow-up, which is consistent with the findings by Whiting et al.5, and patients with a positive ED stress examination had a similar amount of displacement during the intraoperative comparison stress examination. No occult LC3 injuries were identified. Risk factors that were identified for a positive stress examination include a high-energy mechanism of injury, a complete sacral fracture, and bilateral, parasymphyseal, and comminuted rami fractures. Finally, DeKeyser et al. draw some important conclusions. First, the ED stress examination should only be considered for patients with LC1 injuries secondary to high-energy mechanisms with complete sacral fractures. Second, patients with low-energy, incomplete sacral fractures should be allowed to mobilize prior to considering a stress examination. Third, none of the positive stress examinations included instability with an external rotation stress; therefore, the external stress examination is likely unnecessary. In my practice, I already follow the nonoperative protocol for low-energy, incomplete sacral fractures, but I do plan on incorporating the ED internal rotation stress examination for minimally displaced (<10 mm of displacement) LC1 fractures involving a high-energy mechanism and a complete sacral fracture.