Rami Fractures Research Articles

The truth behind the pubic rami fracture: identification of pelvic fragility fractures at a university teaching hospital

Older patients presenting on the acute medical take with pelvic fragility fractures (PFF) represent an increasing epidemic.[1][1] The most common pelvic fracture identified by plain X-ray is that of the pubic rami.[2][2] PFF are painful and despite optimal analgesia, many of these patients struggle

High-energy Lateral Compression Type 1 Injuries of the Pelvis: A Spectrum of Injury.

Lateral compression type 1 pelvic fractures comprise a spectrum of injuries of varying stability. The clinician should be cognizant of signs and symptoms of instability including complete sacral fractures, bilateral ramus fractures, displacement greater than 1 cm, high-energy mechanism, and inability to bear weight. Management of these injuries is controversial, but the clinician should consider examination under anesthesia and potentially surgical stabilization.

Mandibular Ramus Fractures: A Proposed Classification.

The purpose of this article was to study and devise a classification of fracture patterns of the mandibular ramus to facilitate management. Mandibular ramus fracture demographics in literature were reviewed along with evaluation of the patients diagnosed with mandibular ramus fractures who had reported to the emergency/outpatient clinic of our Institute in the last 5 years. Epidemiology of these ramus fractures was studied, and these ramus fractures were categorized into repetitive patterns on the basis of radiological observations in an effort to achieve a simplified classification. A total of 1372 trauma patients were diagnosed with mandibular fractures, of which an incidence of 2.4% was recorded for ramus fractures. These were predominantly in males and mainly due to road traffic accidents commonly in people driving two-wheeler vehicles (64%). Ramus fractures seldom occur in isolation. Five predictable fracture patterns were observed and accordingly classified as types I to V. Type I was the most common and type IV the least. Open reduction was done in 45.5% patients with non-compression plating systems. Satisfactory aesthetic and functional outcomes were achieved in all patients. The mandibular ramus fractures although rare need to be well understood and demarcated. The classification highlights the importance of this mandibular buttress and focuses on the importance of its technically and anatomically more complicated fracture treatment. Future studies are needed to compare the modalities of management.

88 The Truth Behind the Pubic Rami Fracture: Identification of Pelvic Fragility Fractures at A University Teaching Hospital

Abstract Introduction Older patients presenting with pelvic fragility fractures (PFF) is an increasing epidemic. The most common pelvic fracture identified by plain radiograph is pubic rami fracture. These fractures are painful and often require admission to hospital. However, despite optimal analgesia, many of these patients struggle to mobilise and may have fractures of the posterior pelvic ring, which are overlooked and not visible on plain radiograph imaging. We aimed to quantify the number of patients progressing to further pelvic imaging in the form of computed tomography (CT) or magnetic resonance imaging (MRI) and the presence of concurrent fractures. Methods Prospective screening of pelvic imaging in patients aged over 70 years was undertaken at Nottingham University Hospitals NHS Trust over an 8-month period from October 2018. Results 103 predominantly female (83%) patients were confirmed to have an acute fragility fracture of the pubic rami on plain radiograph. 19% of patients were discharged direct from the Emergency Department, 45% were admitted to Health Care of Older People (HCOP) teams, 30% to Trauma and Orthopaedic (T&O) teams and 6% to other specialities. 25% of the patients admitted underwent further pelvic imaging, which confirmed fragility fractures of the pubic rami in 88%, with 40% showing acetabular fractures and 68% showing sacral fractures of all types. A further 10 patients were diagnosed with pubic rami insufficiency fractures on further imaging, having had a normal initial radiograph, but had been admitted with poor mobility due to groin pain. In these 10 patients, 20% also had an acetabular fracture and 60% sacral fractures. Overall, 59% of patients with pubic rami fractures had an ipsilateral sacral fracture; a Type 1 Lateral Compression pelvic fracture by AO classification. Conclusions Pubic rami fractures are a significant problem in older people and often require admission to hospital. Further imaging confirms these fractures are complex, with co-existing fractures of the acetabulum and sacrum common. However despite this, only a quarter of patients admitted had further imaging. Where pelvic fractures are missed or severity not appreciated, appropriate pain control can be more difficult to achieve. With the potential for minimally invasive surgical options to aid pain management in sacral fractures, it may be prudent for all patients hospitalised with suspected or confirmed pelvic fracture to undergo further imaging.

Anterior subcutaneous internal fixation combined with posterior percutaneous iliosacral screw for treatment of unstable pelvic fractures

To assess the effectiveness of anterior subcutaneous internal fixation (INFIX) combined with posterior percutaneous iliosacral screw for the treatment of unstable pelvic fractures. Between August 2016 and November 2017, 19 cases of unstable pelvic fractures were treated with anterior subcutaneous INFIX combined with posterior percutaneous iliosacral screw. There were 14 males and 5 females, with an average age of 40.6 years (range, 17-69 years). Causes of injury included traffic accident injury in 11 cases, falling from height in 5 cases, bruise injury by heavy object in 3 cases. According to Tile classification, there were 2 cases of type B1, 6 cases of type B2, and 11 cases of type C. Anterior ring injuries included bilateral pubic ischial ramus fractures in 12 cases, unilateral pubic ischial ramus fractures in 5 cases, and symphysis pubis separation in 2 cases. Posterior ring injuries included sacroiliac ligament injuries in 2 cases, unilateral iliac bone fractures in 3 cases, unilateral sacral fractures in 11 cases, unilateral sacroiliac joint dislocation in 2 cases, and bilateral sacral fracture in 1 case. The intraoperative blood loss and operation time were recorded, and the fracture healing and postoperative complications were observed. Matta score was used to evaluate the reduction of fracture, and Majeed score was used to evaluate the postoperative function of patients. The operation time was 47-123 minutes (mean, 61.4 minutes) and the intraoperative blood loss was 50-115 mL (mean, 61.1 mL). One case had superficial infection at the site of screw implantation, and 1 case had unilateral cutaneous nerve stimulation, which were cured after corresponding treatment. There was no damage of urinary system, reproductive system, and intestine. All cases were followed up 12-25 months (mean, 18.1 months). All the fractures healed after operation, the average healing time was 9.5 weeks (range, 8-13 weeks); no nonunion, delayed healing, internal fixation loosening, fracture, and other situations occurred. Of the 2 patients with lumbosacral plexus injury before operation, 1 recovered completely and 1 had residual mild claudication. At last follow-up, the reduction of fracture was evaluated by Matta scoring standard, the results were excellent in 13 cases and good in 6 cases, with an excellent and good rate of 100%; the function was evaluated by Majeed scoring standard, the results were excellent in 15 cases and good in 4 cases, with an excellent and good rate of 100%. Minimally invasive pelvic stabilization by using anterior subcutaneous INFIX and posterior percutaneous iliosacral screw for treatment of unstable pelvic fractures, can achieve good fracture reduction and definitive stabilization with minimum complications and obtain excellent functional outcomes.

Minimal-invasive stabilization of anterior pelvic ring fractures with retrograde transpubic screws

BackgroundIn the vast majority of patients with pelvic ring lesions, there is a combination of fractures of the posterior and anterior pelvic ring. Anterior fractures are painful and contribute to loss of stability of the pelvic ring. For these reasons, stabilization of pubic rami fractures is recommended together with posterior pelvic ring fixation. Retrograde transpubic screw osteosynthesis enjoys increasing acceptance due to its minimal invasive technique and adequate stability. Patients and methodsWe retrospectively reviewed the results of 158 retrograde transpubic screw osteosyntheses in 128 patients with pelvic ring lesions including a pubic ramus fracture. Sixty-three patients suffered a high-energy injury, 65 a fragility fracture of the pelvis. ResultsOne hundred and forty-six screws (92.4%) were inserted through a percutaneous procedure. There were no vascular, neurological or urological complications. Fifty-nine screws (39%) yielded an excellent reduction with less than one cortical width of displacement. Slight secondary displacement was seen in 33 of these fractures (55.9%). Early surgical complications were seen in 16 screws (10.1%): suboptimal pathway in 10, local hematoma in 4 and local infection in 3. Early revision surgery was done in 7 screws (4.4%). Median follow-up was 27.6 weeks, 83 screws (52.5%) had a follow-up of more than 6 months. During follow-up, 7.6% of screws loosened. Operative revision was performed in 13%. 75 fractures (90.3%) with a follow-up of ≥ 6 months showed radiographic evidence of healing. There was no difference in the healing rate of high-energy and fragility fractures. Nonunion rate was not dependent on the quality of primary reduction, secondary displacement, or screw loosening. Infection (p 0.001) and surgery ≥ 6 months after trauma (p 0.02) more often led to nonunion. ConclusionRetrograde transpubic screw osteosynthesis is a reliable method for splinting pubic rami fractures in high and low energy pelvic trauma. Although a slight secondary fracture displacement is seen in most cases, it does not affect fracture healing. Retrograde transpubic screw is a adequate minimal-invasive osteosynthesis to stabilize the anterior pelvic ring, especially in fragility fracture of the pelvis. Delayed operation (> 6 months) and infection show higher rate of nonunion.

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.

Management of Mandible Fracture in 150 Children Across 7 Years in a US Tertiary Care Hospital.

Pediatric mandible fractures are the most common pediatric facial fracture requiring hospitalization, but data are lacking on management methods, outcomes, and complications. To analyze management methods, outcomes, and complications of pediatric mandible fractures at an urban academic tertiary care center. Single-institution cohort study conducted at 2 urban level 1 pediatric trauma centers including all patients aged 0 to 17 years diagnosed with mandible fractures between January 1, 2010, and December 31, 2016. Fractures were treated by multispecialty surgical teams. Data were analyzed between January 1, 2018, and March 1, 2018. Fracture distributions, mechanisms, treatment methods, complications, and follow-up. Of 150 patients with 310 total mandible fractures, the mean (SD) age was 12.8 (4.6) years; 108 (72.0%) were male; 107 (71.3%) were white; and 109 (72.7%) had 2 or more mandible fractures. There were 78 condylar or subcondylar fractures (60 patients), 75 ramus or angle fractures (69 patients), 69 body fractures (62 patients), 78 symphyseal or parasymphyseal fractures (76 patients), and 10 coronoid fractures (10 patients). The most common mechanisms of injury were assault and battery, motor vehicle collisions, falls or play, and sports-related mechanisms. Thirty-eight (25%) patients were treated with observation and a soft diet. Children 12 years and older were more likely to receive open reduction internal fixation (ORIF) (P = .02). Of 112 patients treated with surgery, 63 (56.2%) were treated with maxillomandibular fixation (MMF), 24 (21.4%) received ORIF, and 20 (17.9%) received both MMF and ORIF. Nonabsorbable plating was used in all but 1 of the ORIF procedures. Five of 44 (11.4%) patients receiving ORIF or ORIF and MMF had follow-up beyond 6 months, and 8 of the 44 (18.2%) had documented plating hardware removal; hardware was in place for a mean (SD) 180 (167) days. Sixty of the 150 patients (40.0%) had some form of follow-up, a mean (SD) 90 (113) days total after initial presentation. Thirteen patients experienced complications, for a total complication rate of 8.7%. Conservative management, using MMF and a soft diet, was favored for most operative pediatric mandible fractures. Open reduction internal fixation with titanium plating was less commonly used. Outcomes were favorable despite a lack of consistent follow-up. 4.

Morbidity and mortality following pelvic ramus fractures in an older Atlantic Canadian cohort

Pelvic ramus fractures in older patients are associated with substantial morbidity and mortality. There is a paucity of literature on fractures of the pelvis in this age group. The purpose of this study was to report mortality rates following such injuries. In addition, we aimed to describe and quantify the important resultant morbidity in this vulnerable population. We performed a retrospective chart review of all low-energy pelvic ramus fractures in patients more than age 60 years that occurred between January 2000 and December 2005. Data on survival, hospital length of stay, ambulatory status and place of residence were recorded. For comparison, we calculated the mortality rate for a surrogate age- and sex-matched group using Statistics Canada survival data for use as an uninjured control group. We identified 43 patients (32 women [74%]; mean age 79.4 yr) with isolated low-energy pelvic ramus fractures over the study period. The 1- and 5-year mortality rates were 16.3% (95% confidence interval [CI] 7.8%–30.3%) and 58.1% (95% CI 43.3%–71.6%), respectively, both significantly higher than the point estimates for the control group (6.6% and 31.3%, respectively). Following injury, 14/39 patients (36%) permanently required increased ambulatory aids, and 8 (20%) required a permanent increase in everyday level of care. The results suggest that there may be increased mortality and morbidity following low-energy pattern pelvic ramus fractures in an older population compared to age- and sex-matched uninjured control subjects.

Intra-Abdominal Solid Organ Injury Management in Pediatrics

Abdominal trauma is relatively uncommon in children but can leads to a significant morbidity and mortality in the pediatric population. The abdomen is the third most commonly injured anatomic region in children, after the head and the extremities. The abdomen is the most common site of initially unrecognized fatal injury in traumatized children. We are reporting a case of a child with multiple solid organ injury that was successfully treated non-operatively at our center. We presented a previously healthy 9-month-old girl, presented with fluctuating GCS secondary to motor vehicle accident with borderline hemodynamic stability. She was intubated, blood transfusion commenced and a single inotrope support started. She subsequently diagnosed with grade III liver injury, grade II splenic injury, right grade IV renal injury with large perinephric and retroperitoneal hematoma and moderate hemoperitoneum, a non-displaced left superior pubic rami fracture and cerebral edema on computed tomography (CT). She was admitted to pediatric intensive care unit (PICU). Her intra-abdominal injury injuries were successfully treated conservatively. She required a right chest tube on post trauma day 2, for right hemothorax. The chest tube was removed 3 days later following adequate drainage. She eventually was weaned off from ventilator on post trauma day 11. Feeding was commenced on day 7 of post trauma. She was discharge home well after 3 weeks post trauma with periodical follow up. Conclusion: Pediatric intra-abdominal solid organ injury is relatively uncommon, but a potential source of significant morbidity. Non-operative management is the standard of care for the majority of these injuries, which have shown successful rate more than 95%, although continued hemodynamic instability mandates operative intervention.

MON-410 Ectopic ACTH- Secreting Tumor Causing Rapidly Progressive Cushing’s Syndrome Remains an Elusive Localization Diagnosis

Background: 68Ga-DOTATATE PET-CT (DOTATATE-PET) has higher sensitivity and positive predictive value than other studies, reason for which it has become the imaging modality of choice for Neuroendocrine tumor (NET) localization, but data on ACTH-secreting NET is scarce. Case summary: 61 year old female with history of right hepatic lobe lipoma resection, T2DM (A1c 9.4%), HTN, and benign thyroid nodule that was evaluated for cushingoid features with facial and lower extremity edema, progressive generalized weakness, difficulty climbing stairs, 20 lbs weight loss and intermittent hypokalemia while on a diuretic plus three other antihypertensives over a six month period. ACTH-dependent hypercortisolism was confirmed with a non-suppressed ODST 11.27mcg/dL (normal <1.8), elevated 24 hr urine free cortisol 525 mcg/24h (RR 4.0-50.0, total volume 3.85 L, creatinine 0.92 g/24 hr), midnight salivary cortisol 1.13 mcg/dL(RR ≤0.09), and ACTH 122 pg/mL (RR 6-50). Additionally, plasma metanephrines were negative, aldosterone <1 ng/dl (RR ≤21) and renin activity 0.58 ng/mL/h (RR 0.25-5.82). Cushing’s disease was suspected since her 8am cortisol suppressed >50% after 8 mg dexamethasone (dexa) overnight (pre-dexa cortisol 33.78 mcg/dL, post-dexa cortisol 6.59 mcg/dL). However, MRI Sella did not show a pituitary adenoma and IPSS was compatible with Ectopic ACTH-secretion (EAS). CT chest, abdomen, pelvis with contrast did not reveal any frank lesion that could be the culprit of EAS. Octreoscan and FDG-PET were negative. DOTATATE-PET reported a mild focus of uptake on the medial aspect of the right upper lung lobe, thought to be a branching blood vessel since no anatomic lesion was seen on CT Chest that would correspond to the possible area of uptake. In the interim, she developed diffuse ecchymosis with worsening of her functional status, needing a walker and assistance with activities of daily living. She had several falls complicated by multiple lumbar compression fractures, rib, right pubic ramus and bilateral sacral insufficiency fractures for which she received reclast, a back brace and physical therapy. She was started on ketoconazole and titrated up, but due to rapid progression of her Cushing syndrome over five months without an identifiable source of EAS, the decision was made to proceed with bilateral adrenalectomy and perform surveillance imaging to identify growth of a possible occult NET. Conclusion: In our case, DOTATATE-PET did not help to localize an ACTH-secreting NET, suggesting that the sensitivity of this study might not be as good as reported for other types of NET. Therefore, Occult EAS remains a diagnostic challenge and clinicians may resort to bilateral adrenalectomy for permanent biochemical control and serial CT imaging to detect an incipient NET.

MON-501 A Hemangioma Causing Tumor Induced Osteomalacia

Introduction: TIO (Tumor induced osteomalcia) is a rare paraneoplastic syndrome due to ectopic production of FGF23 (Fibroblast growth factor 23) from a mesenchymal tumor that results in renal phosphate wasting and impaired calcitriol synthesis. We present a case of TIO from a benign hemangioma which is an uncommon occurrence. Clinical case: A 68-year-old female presented with a history of multiple fractures; right pelvic fracture 8 years ago, bilateral pubic rami fractures 3 months ago, left femoral neck fracture and left humeral shaft fracture 1 month ago due to trivial traumas. She also complained of chronic generalized muscle pain and severe fatigue that essentially made her bedbound. Her past medical history was significant for DM type II, hypertension, hyperlipidemia, osteoarthritis and chronic anemia. She was diagnosed with a right inferior parathyroid adenoma after noting high PTH of 281pg/ml [15-65] and increased uptake on a parathyroid scan. Following a right inferior parathyroidectomy, the PTH was 51pg/ml [15-65]. Current workup: Vitamin D 7.4pg/ml [30-80], Calcium 7.0mg/dl [8.6-10.2] (corrected calcium 8.0mg/dl), Phosphorous 1.4mg/dl [2.7-4.5], Magnesium 1.6mg/dl [1.7-2.6], Alkaline phosphatase 222U/l [35-104] , Creatinine 0.6mg/dl [0.5-1.2], PTH 214.4pg/ml [15-65] and normal transaminases. Whole body bone scan showed increased uptake in multiple foci in the bilateral ribs, sternum, both shoulders and left humerus. About 2 weeks following vitamin D and calcium supplementation, serum calcium normalized, vitamin D improved to 15pg/ml [30-80] and PTH trended down to normal limits at 52.4pg/ml [15-65]. But the phosphorous level was never >1.6mg/dl [2.7-4.5] despite vigorous IV and oral replacement. This raised concern for hypophosphatemic osteomalacia. Incidentally, as workup for back pain and acute on chronic anemia, a CT abdomen was done which showed a heterogeneously enhancing right pelvic mass measuring up to 7.5 cm extending into the spinal canal from approximately L4-5 level into the upper sacrum. MRI confirmed the presacral mass. A CT guided biopsy was done and final pathology reported hemangioma by STAT6 immunostain. 1,25 (OH)2 Vitamin D was 24 pg/ml [18-78] and an FGF23 level was very high at 3980 RU/mL [<=180] confirming our diagnosis of TIO. Although surgery would have been curative in TIO, this patient was tired of surgeries and decided to go with medical management. Calcitriol 0.25mcg bid, K-Phos Neutral 1 tablet four times a day at equal intervals throughout the awake hours was recommended. Conclusion: TIO is a rare disorder that is usually caused by benign mesenchymal tumors. Although rare, hemangiomas can cause TIO.

Preliminary application of 3D printing navigation template in the screw insertion of the suprapubic fracture

Objective To introduce the method of using hollow pull screw insertion for the suprapubic fracture with 3D printing navigation template and to evaluate its clinical effect. Methods From March 2016 to August 2017, eighteen cases of suprapubic ramus fractures treated with hollow lag screw fixation in the Department of Orthopedics of Yanan University Affiliated Hospital were retrospectively collected was collected.Before operation, the thin slice CT scan of pelvis was used to get raw data, and the mimics17.0 software was used to reconstruction the model, to design and make the personalized navigation template assisting the suprapubic fractures surgery.The navigation template was printed out pre-operatively, and the nail was inserted via the assisted by the template intra-operatively.After the operation, the fracture reduction was evaluated by Matta imaging scores and the pelvis function was evaluated by Majeed scores. Results All the operations were successfully completed.The Matta scores were excellent in 11 cases, good in 6 cases, and fair in 1 case.The Majeed scores were excellent in 13 cases, good in 3 cases, and fair in 2 cases. Conclusion 3D Printing navigation template assisted the placement of the hollow screw on the suprapubic fracture could provide personalized treatment, reduce the difficulty of operation and satisfy the clinical effect. Key words: 3D printing navigation template; suprapubic fracture; Retrospectively study

Phosphaturic Mesenchymal Heel Tumor Presenting with Tumor-Induced Osteomalacia

To help clinicians identify and treat patients with tumor-induced osteomalacia (TIO) resulting from a phosphaturic mesenchymal tumor, mixed connective tissue variant (PMTMCT). Describe the history, presentation, laboratory findings, diagnostic studies, treatment, and literature review. A 58-year-old female with no significant past medical history presents with ongoing multiple bone pain for years. She had a bone scan showing multiple focal areas of increased uptake involving bilateral ribs, distal right tibia, and left femoral neck, representing previously healed fractures. Her bilateral lower-extremity magnetic resonance imaging showed stress fractures of the anteromedial cortex, right tibia, and the left femoral neck. Phosphorus was noted to be 1.9 mg/dL (normal range, 2.0 to 4.0 mg/dL), and alkaline phosphatase was 179 U/L (normal range, 25 to 110 U/L). Tubular maximum re-absorption of phosphate to glomerular filtration rate ratio was 0.438, which was low. An outside physician initiated patient on teriparatide, which showed bone mineral density improvement after 1 year, and then the teriparatide was stopped. Later, she developed a nontraumatic pubic ramus fracture; teriparatide was resumed. While on teriparatide, she developed several new rib fractures. Due to declining phosphorus levels, further investigation led to an elevated fibroblast growth factor 23 (FGF-23) level of 243 RU/mL (normal, <50 RU/mL). TIO was strongly suspected, and a nuclear medicine positron emission tomography/computed tomography trunk with 68Ga-1,4,7,10-tetraazacyclododecane 1,4,7,10-tetraacetic acid tyrosine-3-octreotate (i.e., 68Ga-DOTATATE) showed a right heel soft-tissue nodule. Fine-needle aspiration biopsy was performed, confirming PMTMCT, positive for FGF-23 mRNA. After surgery, her symptoms resolved and her phosphorus normalized. TIO is a rare paraneoplastic syndrome characterized by bone pain, muscle weakness, and fractures associated with persistent hypophosphatemia. Clinicians now have new imaging tools to help identify and treat patients with PMTMCT.

Finite element analysis of anterior ring injuries in unstable pelvic fractures treated by different methods

To compare the biomechanical stability of different fixation methods for anterior ring injury of unstable pelvic fractures, and to provide reference for clinical treatment. An unstable pelvic fracture model (Tile C) with one side of the sacroiliac joint dislocation and the pubic rami fracture was constructed via three-dimensional finite element analysis. Five different fixation methods were used in the front, and the rear was fixed with sacroiliac screws. The von Mises stress and strain distributions of different combinations of fixation methods were analyzed under mimicking standing conditions. After being loaded with 500 N vertically, the maximum stress in the anterior fracture was 3.56 MPa in anterior pelvic external fixation (AEF) group, the total displacement and the vertical displacement of the Y axis at the sacroiliac joint and the fracture were not more than 1.5 mm. The maximum stress at fixation, the front of the fracture and sacroiliac joints in the anterior pelvic subcutaneous approach(APA) group and AEF, was significantly higher than anterior modified Stoppa approach(ASA) group, anterior pelvic Ilioinguinal approach (AIA) group, and canulated screw fixation(CSF) group. The total displacement and the vertical displacement of the Y axis at the sacroiliac joint and the fracture in APA group and AEF group were also greater than the other three groups. Anterior ring injury of unstable pelvic fractures can be significantly improved after the fixation of the implants in the five combined methods. However, overall biomechanical properties of ASA, AIA and CSF group are superior to APA and AEF group.

Unstable Pelvic Ring Injuries: How Soon Can Patients Safely Bear Weight?

To determine if time to weight bearing (WB) is associated with complications in operatively treated pelvic ring injuries. Retrospective cohort study. Academic Level I trauma hospital. Two hundred eighty-six patients with pelvic ring injuries treated operatively over a 10-year period [OTA/AO 61-B1-3, 61-C1-3; Young-Burgess lateral compression (LC) 1-3, anterior-posterior compression (APC) 1-3, and vertical shear] were included. Patients were stratified into early (≤8 weeks) and late (>8 weeks) time to full WB groups. Composite outcome of implant failure [broken screw(s)/plate(s), screw(s) loosening], revision surgery, and malunion. We identified 286 patients with a mean age of 39.9 years (range: 18-81 years) and an average follow-up of 1.2 years (1.0-9 years). There were 132 and 154 patients in the early and late WB groups, respectively. A total of 142 Young-Burgess LC-1, 48 LC-2, 23 LC-3, 10 APC-1, 45 APC-2, 8 APC-3, and 8 vertical shear injuries were noted. Complications were noted in 47 patients (16%). Complications included 18 implant failures, 16 malunions, and 13 patients who required revision operations for loss of reduction. Time to WB was not associated with composite complication rates (P = 0.24). APC-2, LC-3, and injuries with bilateral rami fractures were noted to have a higher complication rates independent of time to WB (P = 0.005, 0.03, and 0.03, respectively). No difference in implant failure, malunion, or early loss of reduction between operatively treated pelvic ring injuries allowed to WB as tolerated before 8 weeks compared with those who remained on protected WB protocol for any time greater than 8 weeks was noted. These data may provide information to support early WB protocols. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary Stabilization of Pubic Ramus Fractures in Elderly Patients With a Photodynamic Bone Stabilization System (IlluminOss).

Introduction:A photodynamic bone stabilization system (PBSS) is a percutaneous operating method that provides intramedullary stabilization. The purpose of the study was to assess the clinical and radiological outcome after treatment of pubic ramus fractures with the PBSS.Materials and Methods:In a retrospective study, patients with osteoporotic pubic ramus fractures were included. The patients were treated with the PBSS in a percutaneous method. In the routine follow-up examination, pain was measured with the visual analog scale (VAS) and the type of mobilization was verified. Computer tomography of the pelvis was carried out in the follow-up examination (mean of 7.5 months after surgery) to investigate bone healing.Results:A total of 32 patients (25 females and 7 males) were included in the study. The average hospital stay was 16.5 ± 7.9 days (range: 5-37 days) and the mean operation time was 116.8 ± 47.1 minutes (range: 33-255 minutes). Two cases of wound infections and 1 case of misplacement of the PBSS implant with revision surgery have been documented. The mean VAS score for pelvic/hip pain at the day of inpatient discharge was 4.4 ± 1.4 (range: 2-7). A total of 25 patients could attend the follow-up examination 7.5 ± 1.7 months (range: 6-14) after the procedure, reporting a mean VAS for pelvic/hip pain of 3.0 ± 2.2 (range: 0-8). A total of 11 patients could walk without an orthopedic walking device, 7 patients needed underarm crutches, 6 patients used a walker-rollator, and 1 patient was immobilized. Consolidated pubis ramus fractures were described in 24 (96%) cases.Discussion:The results of our study reveal adequate clinical and radiological outcomes after treatment of osteoporotic pubic ramus fractures with the PBSS. This is the first study investigating the outcome after treating pubic ramus fractures with the PBSS.Conclusion:Based on our findings, the PBSS is an alternative to known techniques for the stabilization of the pubic ramus.

Massive Hemorrhage Caused by a Non-Displaced Pubic Ramus Fracture from Low-Energy Trauma

Massive Hemorrhage Caused by a Non-Displaced Pubic Ramus Fracture from Low-Energy Trauma

Pubic Rami Fractures Fixation by Interlocking Intramedually Nail: First Clinical Experience

Background. Growing number of patients with pelvic fractures is associated with evolution of high-speed transport, high-rise construction and industrial production. The optimal surgical procedure for pubic rami fractures must ensure a stable fixation and simultaneously minimize the risk of postoperative complications. Our aim was to evaluate the efficiency of a new technique for pubic bones fixation by a titanium nail in patients with pelvic fractures.Material and Methods. The authors present the experience on treatment of 18 patients who underwent 25 surgeries for internal fixation of pubic rami fractures by a designed solid titanium nail. Mean age of patients was 40.16±10.35 years. Proposed surgical method provides for mandatory use of image intensifier during all stages of the procedure. With patient in a supine position the authors performed internal fixation of pubic bones by a retrograde nail inserted using a navigating handle through a skin incision of1 cm in the area of symphysis. After complete insertion into the bone the nail was interlocked proximally by two3.5 mm cortex screws through an additional skin incision of1.0 cm using a navigating handle and guiding sleeves. All pelvic ring fractures were classified according to AO/OTA classification and pubic fractures by Nakatani classification. Functional outcome was evaluated by Majeed score.Results. Bilateral fractures were diagnosed in 7 (38.8%) patients (floating pubic symphysis). 13 (72.2%) patients featured polytrauma with average ISS score of 25.1±7.8. 2 (11,1%) patients were diagnosed with open pelvic fractures, 3 (16.6%) patients had a concomitant acetabular fracture. The authors performed epicystostomy in two (11.1%) patients and laparotomy bringing out the drainages in 5 (27,8%) patients. Mean follow up was 7.8±6.2 months. Stable fixation was obtained in all patients. By the moment of the present publication x-ray healing of pubic bones was observed in 16 (64%) cases, in remaining 9 (36%) cases the follow up period was less than mean healing period (2 months). In 11 (68.8%) patients the functional outcome averaged 91±3.9 by Majeed score 6 months postoperatively, in 8 (50%) patients – 93.8±2.9 by Majeed score 12 months postoperatively and more. No complications like skin necrosis, secondary fragments displacement or infection were not observed.Conclusion. Preliminary results demonstrated the absence of wound infection and reliable fragments fixation. This technique can be applied in patients with stomas and drainages upon the anterior abdominal wall which extends the indication range for surgical treatment of anterior pelvic ring. High fixation properties of proposed nailing create conditions for early mobilization of the patients and for conducting the exercise therapy.

Relation Between Sacroilium and Other Pelvic Fractures Based on Real-World Automotive Accidents.

The study firstly aimed at looking whether sacroilium (SI) fractures could be sustained as unique pelvic injuries in side impact real world automotive accidents. Secondarily, the sacroilium fractures observed in conjunction with other pelvic fractures were analyzed to investigate the existence of injury association patterns. Two real world accident databases were searched for SI fractures. The occupants selected were front car passengers older than 16, involved in side, oblique or frontal impact, with AIS2+ pelvic injuries. In frontal impact, only the belted occupants were selected. The cases were sorted by the principal direction of force (dof) and the type of pelvic injury, namely SI, pubic rami, iliac wing, acetabulum, pubic symphysis, and sacrum injuries. The relation between SI and pubic rami injuries were investigated first. The first database is an accident database composed of cases collected in France by car manufacturers over a period of approximately 40 years. In total it contains approximately 28 000 occupants involved in all types of accident configurations. The occupant injuries, as well as the vehicle deformations, are described in detail. The second database gathered accident cases from 7 zones monitored in Great Britain over a period ranging from 1998 to 2005. All the cases collected include at least one towed away vehicle with at least one injured occupant. In total the database contains approximately 15 000 occupants. The occupant injuries are described in details and autopsy reports were screened when available. Results - In the French database, 39 occupants sustained SI fractures. Out of 39 SI fractures, 32 were associated with pubic rami fractures and 5 additional were associated with other pelvis ring fractures. In the UK database, 46 occupants sustained SI fractures. Out of 46 SI fractures, 34 were associated with pubic rami fractures and 8 additional were associated with other pelvis ring fractures. In side impact (dof 2, 3, 4, 8, 9 or 10 o'clock), in the cases where the side is known for both the SI fractures and pelvic ring injuries, both injuries were on the same side in 70% of the cases. Overall, out of 85 SI fractures cases, only one was clearly identified as occurring with no other pelvic injury and 3 with pelvic injuries other than pelvic ring injury. Conclusions - Overall, from the real world automotive accidents selected at any dof, SI fractures were observed to be associated with other pelvic ring fractures in 96% of the cases. On the reverse, in side impact (dof 2, 3, 4, 8, 9 or 10 o'clock in the LAB database), 89% of the pubic rami fractures occurred without any SI fractures. From a mechanical standing point, it suggests that the SI fractures is a structure more resistant than the rest of the pelvic ring. Overall, 70% of SI fractures were observed in various types of side impacts and 30% in frontal impacts.