Lateral Compression Injuries Research Articles

High Rates of Sexual and Urinary Dysfunction After Surgically Treated Displaced Pelvic Ring Injuries

Pelvic ring injuries may be associated with genitourinary injury (GUI) and result in urinary or sexual dysfunction. We determined (1) incidence of new sexual and urinary dysfunction after surgically treated pelvic ring injuries, (2) association of sexual or urinary dysfunction to fracture type and GUI, and (3) incidence and association between new sexual and urinary dysfunction in male and female patients without GUI. We retrospectively studied 151 patients by postal questionnaire after pelvic reconstruction. Presence, type, and severity of new sexual dysfunction and urinary dysfunction were related to GUI and type of pelvic fracture using the Young and Burgess classification. Minimum followup was 1 year (median, 5 years; range, 1-12 years). New sexual dysfunction occurred in 61 of 143 (43%) and urinary dysfunction in 61 of 150 (41%) responding patients. Neither new sexual nor urinary dysfunction was associated with sex or GUI. In patients with no GUI, new sexual dysfunction was associated with chronologic age (odds ratio [OR], 1.04/year; 95% CI, 1.01-1.07) and pelvic fracture type. Lateral compression injury was less likely to result in new sexual or urinary dysfunction compared with AP type (sexual OR, 1.73; 95% CI, 0.67-4.47; urinary OR, 2.97; 95% CI, 1.15-7.66) and vertical shear type (sexual OR, 2.60; 95% CI, 1.02-6.64; urinary OR, 4.6; 95% CI, 1.81-11.73). Our data suggest new sexual and urinary dysfunction occur at relatively high rates after pelvic fracture in patients with or without GUI. We recommend early assessment and referral for specialist treatment. Level III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Persistent Impairment After Surgically Treated Lateral Compression Pelvic Injury

Recently, fixation of lateral compression (LC) pelvic fractures has been advocated to improve patient comfort and to allow earlier mobilization without loss of reduction, thus minimizing adverse systemic effects. However, the degree of acceptable deformity and persistence of disability are unclear. We determined if (1) injury pattern; (2) demographics; (3) final posterior displacement; (4) L5/S1 involvement; (5) associated injuries; and (6) time influence outcome measurements, sexual dysfunction, and pain. We retrospectively reviewed 119 patients with unstable LC injuries treated surgically between 2000 and 2010. There were 52 males and 67 females; mean age was 39 years with a mean body mass index of 27 kg/m(2). All patients underwent clinical examination and radiographic imaging for instability and accompanying injuries. We obtained Short Musculoskeletal Function Assessment (SMFA). The minimum followup was 12 months (mean, 33 months; range, 12-100 months). SMFA subscores were not affected by injury pattern and demographics. Posterior reduction was less than 5 mm with persistent displacement in 99 of 119 (83%). Displacement of 5 to 10 mm did not affect any SMFA subscore at any time interval. Patients with additional lower extremity injuries had worse SMFA scores. Function improved with time. A visual analog scale pain score of 4 or more at 6 months predicted pain and overall SMFA score at last followup. Unstable LC pelvic ring injuries result in persistent disability based on validated outcome measurements. Near anatomical reduction can be achieved and maintained. While our findings need to be confirmed in studies with high rates of followup, patients with unstable LC pelvic injuries should be counseled concerning the possibility of some degree of persistent disability. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Open reduction technique for overlapping and locked pubic symphysis

A locked pubic symphysis can occur following a lateral compression injury of the pelvic ring when one pubic bone becomes entrapped behind the contralateral pubis or obturator foramen. In selecting the treatment modality, it is important to know the mechanism of injury. We presented the use of an open reduction technique in the treatment of a locked pubic symphysis in which open reduction external fixation application failed in the emergency department.

Examination Under Anesthetic for Occult Pelvic Ring Instability

To describe the technique and results of stress examination with fluoroscopy under anesthesia (EUA) to determine stability and the need for operative stabilization of traumatic pelvic ring injuries. Retrospective chart and radiographic review. Level I trauma center. Skeletally mature patients with traumatic incomplete posterior pelvic ring injuries. Patients were consented for EUA if preoperative radiographs and computed tomographic scanning of the pelvis demonstrated an incomplete injury to the posterior pelvic ring (Orthopaedic Trauma Association [OTA] 61-B type injuries). Patients with nondisplaced anterior compression fractures of the sacral ala without internal rotation or a fracture line exiting the posterior cortex were excluded from this analysis. Similarly, skeletally immature patients or those with complete instability of the pelvic ring (OTA 61-C type injuries) were excluded. All patients meeting inclusion criteria were taken to the operating room, anesthetized, and placed in the supine position for stress examination (EUA) of the pelvic ring using intraoperative dynamic fluoroscopy. Examination consisted of a resting static film followed by internal rotation, external rotation, and push-pull maneuvers of both lower extremities. Each of these maneuvers was performed using the anteroposterior, inlet, and outlet projections, providing a total of 15 distinct images for each patient's examination. The preoperative classification of the pelvic ring injury was then accepted or redefined based on the amount of rotational and translational instability in the axial, coronal, and sagittal planes. The decision to proceed with anterior and/or posterior operative reduction and stabilization was subsequently based on the degree of pelvic ring instability noted during the EUA. A total of sixty-eight patients underwent an EUA of their pelvis by the senior author. Fifty males and 18 females with an average age of 35 years comprised the study group. In all, 37 anteroposterior compression (APC or OTA 61-B1) injuries and 31 lateral compression (LC or OTA 61-B2) injuries were evaluated. Of the 14 pelvic ring injuries initially classified as an APC-1, seven (50%) were deemed stable and treated nonsurgically, whereas seven (50%) were felt to have sufficient instability (an occult APC-2) to warrant treatment with anterior fixation based on EUA. Of the 23 injuries initially classified as an APC-2, all but one required surgical fixation: 13 (57%) were treated with anterior fixation alone (APC-2a), whereas nine (39%) were treated with anterior fixation and supplemental iliosacral screw placement (APC-2b) based on the degree of instability noted during the EUA. Of the 20 injuries initially classified as an LC-1, 13 (65%) were stable and treated nonsurgically (LC-1a), whereas seven (35%) were treated with anterior and/or posterior stabilization (LC-1b) based on the degree of instability noted during the EUA. The reported incidence of poor functional outcomes associated with pelvic fracture may be attributable, in part, to inadequate treatment of misdiagnosed injuries and chronic instability and/or malunion. Performing an examination under anesthesia with dynamic stress fluoroscopy as described in this series revealed occult instability in 50% of presumed APC-1 injuries, 39% of APC-2 injuries, and 37% of LC-1 injuries. We propose a modification to the Young-Burgess Classification system to reflect the dynamic component of pelvic ring instability disclosed on EUA as follows: APC-2a for those injuries requiring anterior only fixation, APC-2b for those injuries that may require treatment with anterior and posterior fixation, LC-1a for those injuries that are stable and do not require internal fixation, and LC-1b for those lateral compression injuries that may require treatment with internal fixation. We conclude that pelvic EUA merits further analysis as an important diagnostic tool that may provide additional information regarding instability of the pelvic ring.

Fracture of the pelvic ring: a retrospective review of 224 patients treated at a single institution

Pelvic ring fracture presents with a wide spectrum of clinical status and fracture type that requires multimodal treatment strategy. We report our experience in the treatment of 224 pelvic ring fractures in terms of clinical and radiological findings, mode of treatment, surgical data, and functional outcome at final follow-up. The study subjects were 140 men and 84 women (mean age 58 years, range 8–94). Surgery was conducted in 63 patients, while 161 were treated conservatively. The average follow-up period was 7.1 years (range 1–15). AO-Orthopaedic Trauma Association classification of fracture type, Injury Severity score rating, Rommens and Hessmann’s ambulatory and pain assessment, and radiographic studies were conducted. Conservative treatment was provided in 161 (73%) patients, including simple bed rest with definitive external fixation, skeletal traction, and/or pelvic sling. Of these, 148 patients achieved excellent/good results, but the remaining 13 cases complained of severe pain at the sacroiliac joints caused by malunion or fibrous union of the joint. All 63 (27%) patients who were treated surgically, using most frequently a combination of anterior extraperitoneal and Pfannenstiel approaches, showed excellent/good clinical and radiographic results. Treatment of unstable pelvic ring fracture should be urgent and based on biomechanical and anatomic reconstructive strategy, paying utmost care to associated injuries. A combination of open stabilization of posterior sacroiliac area and anterior fixation of pubic rami and symphysis pubis is recommended for unstable anteroposterior compression, lateral compression, vertical instability, and unilateral or bilateral posterior injuries to the pelvic ring.

Neuroinflammation in a Forceps Compression Model of Spinal Cord Injury

We sought to evaluate the neuroinflammatory response in a compression model of spinal cord injury (SCI). Because compression is a common mechanism of injury in human spinal cord trauma, such a model has clinical relevance. In this study we used forceps to induce lateral compression injury to the spinal cord, producing a moderate degree of injury as previously described in the contusion model (Basso et al., 1996).Post‐injury inflammation has been implicated in secondary degeneration but has not been characterized in this model. We evaluated the inflammatory response in the injured spinal cord using immunohistochemistry. We found that neutrophils are present within the lesion site by 1 day post injury (dpi) but do not persist past 3 dpi. T‐cells were present by 1 dpi, mainly in gray matter at the epicenter. They peaked in number at 7 dpi, but persisted to 42 dpi. A similar time course was observed for macrophage activation, although the response was more widespread at the impact site and extended further rostrocaudally. Overall, we confirm that forceps compression of the spinal cord produces a neuroinflammatory response similar to what has been described in human spinal cord trauma and in contusion models of experimental spinal cord trauma. Thus, forceps compression represents a clinically relevant experimental model for evaluating secondary injury.Grant Funding Source: MWU Biomedical Sciences program

Displacement After Simulated Pelvic Ring Injuries: A Cadaveric Model of Recoil

Determining pelvic ring stability after a fracture is vital to treatment decisions. Commonly used information includes the displacement seen on initial radiographs. Static imaging studies may misrepresent the maximal amount of traumatic displacement at injury. We hypothesized that postinjury radiographs do not reveal maximal displacement of pelvic ring fractures. We also sought to determine whether different injury patterns and varying severity of displacement lead to different amounts of passive recoil. In 15 cadaveric pelvic specimens, unilateral anteroposterior compression (n = 7) or lateral compression (n = 8) injury patterns were experimentally created. A motion-tracking system was used to record rotational deformity of each hemipelvis before, during, and after fracture creation. The absolute and relative magnitudes of pelvic displacement and recoil after force relaxation were determined. In the simulated AO/OTA Type 61-B1.1 patterns (open book, rotationally unstable), maximal symphyseal diastasis recoiled by 48% +/- 18% (p < 0.05). In the AO/OTA Type 61-C1.2 patterns (open book, completely unstable), diastasis passively recoiled by 44% +/- 7% (p < 0.05). Lateral compression injuries (AO/OTA Type 61-B2.2) had maximal hemipelvis rotation of 41 degrees +/- 7 degrees and subsequently recoiled by 80% to 8 degrees +/- 6 degrees (p < 0.001). In this cadaveric model of simulated pelvic injury, a significant magnitude of passive recoil occurred after removal of the deforming force. The amount of recoil varied based on different injury patterns. However, the degree of recoil among specimens with similar injury patterns was generally consistent. In a clinical scenario, this suggests that only a portion of the maximal displacement that occurs at the time of injury is seen on initial plain radiographs. Injury severity should not be minimized based on pelvic displacement seen on initial static radiographs and computed tomographic scans.

An unusual type of lateral compression injury of the pelvis tilt fracture with anterior displacement

Tilt fracture is the most unusual variant of pelvic lateral compression injury. The major problem was reported to be protrusion of the pubic ramus into the perineum by posterior–inferior displacement of the fragment. Tilt fragment with anterior and inferior displacement has not been reported in English speaking literature to our knowledge. Anterior tilt fragment can cause significant morbidity in terms of vascular injury, pelvic stability and acetabular fracture.

Isolated zone I vertical fracture of first sacral vertebra: a case report

Isolated sacral fractures which occur by shear forces on the pelvic ring are seen less commonly and they are commonly transversely oriented. A 29-year-old Turkish female patient, who sat in front seat in the car, was unrestrained, and another car hit them from right front side of their vehicle. Physical examination revealed considerable tenderness over the right superior gluteal region and excruciating pain during sacral and iliac compression. There was no clear fracture line in her plain radiographs. CT revealed incomplete, zone I fracture located on the superior and anterior part of the first sacral vertebra. Type 1 lateral compression pelvic fractures are relatively common and they include impacted sacral and ipsilateral rami fractures. Only a few cases, related with the isolated sacral fracture, have been reported in the literature. To our knowledge, no isolated vertical zone I fracture of the first sacral vertebra which occurred with the lateral compression injury has been described previously. Fracture of the sacrum should be suspected in the presence of sacral pain and tenderness.

Human neural precursor cells continue to proliferate and exhibit low cell death after transplantation to the injured rat spinal cord

During the last decade, the interest in stem and progenitor cells, and their applications in spinal cord injuries have steadily increased. However, little is known about proliferation and cell death mechanisms in these cells after transplantation to the spinal cord. The aim of the present project was to study cell turn-over, i.e. total cell number, with time course of proliferation and cell death, in human neural precursor cells (NPCs) after transplantation to the injured rat spinal cord. Immunodeficient rats were subjected to lateral clip compression injuries, transplanted with neurospheres of human forebrain-derived NPCs two weeks after lesion, and sacrificed after 6 h, 1, 3, 10, or 21 days. Cell death was assessed by quantifying human cells immunoreactive for active caspase-3 and calpain 1-dependent fodrin breakdown products (FBDP). The results showed that after an initial drop, the number of implanted cells increased over time after transplantation. Cell proliferation was substantial, with 34% of human cells being immunoreactive for proliferating cell nuclear antigen at 6 h, but which declined over the next few days. The fractions of caspase-3-, and FBDP-immunoreactive cells were remarkably low, together representing 18% of all human cells at 6 h, and rapidly decreasing the next few days. Our results show that already 10 days after spinal cord transplantation of human NPCs as intact neurospheres, the number of human cells exceeded the initially implanted, which was the result of marked cell proliferation in combination with a low rate of apoptotic and non-apoptotic cell death taking place early after transplantation.

Case Report: Locked Pubic Symphysis: An Open Reduction Technique

A locked pubic symphysis occasionally occurs after a lateral compression injury of the pelvic ring. One pubic bone becomes entrapped behind the contralateral pubis. Lateral compression pelvic injuries are well recognized, but a lateral compression pelvic injury resulting in a locked pubic symphysis is rare. We describe a locked pubic symphysis with greater than 4 cm overlap that was reduced with simple maneuvers and readily available instruments.

Distraction External Fixation in Lateral Compression Pelvic Fractures

To observe the results and describe the technique of closed reduction and placement of a two-pin supra-acetabular external fixator, followed by immediate weight bearing, in the treatment of displaced vertically stable lateral compression pelvic fractures. Prospective, consecutive. Regional trauma center. A consecutive series of fourteen patients with displaced, vertically stable lateral compression pelvic fractures who were transported to a regional trauma center. Surgical treatment with closed reduction and maintenance of the distraction force with a two-pin, single-bar, supra-acetabular external fixator, followed by immediate weight bearing. Healing rate and time, operative blood loss and time, quality of reduction, time to full weight-bearing, and incidence of complications, including neurovascular deficits, loss of reduction, nonunion, pin tract infections, and chronic pain. A symmetric reduction of both hemipelves was achieved in all fourteen patients. Time to healing averaged 8.2 weeks (seven to twelve weeks), and no fixator required removal before healing. There were no delayed unions or nonunions, and none of the fractures displaced significantly after initial reduction. Average surgical time was thirty-seven minutes (range, twenty-five to sixty minutes) with an estimated blood loss of less than fifty milliliters. Patients were allowed to bear full weight immediately and were able to do so without ambulatory assistive devices within an average of twelve days (range, three to eighteen days). Complications consisted of three minor pin tract infections, one temporary lateral femoral cutaneous nerve palsy, one late pin tract abscess, and one patient with chronic low-back pain. Treatment of type B lateral compression injuries of the pelvic ring with anterior distraction external fixation is a highly effective yet relatively simple and minimally invasive treatment method. Surgical time and blood loss are minimal, and patients can be effectively and rapidly mobilized. Based on our experience, we believe this method to be a valuable tool in the treatment of these fractures.

Damage Control Orthopaedics

In some groups of polytrauma patients, particularly those with chest injuries, head injuries, and those with mangled extremities, early total care of major bone fractures may be potentially harmful. Delaying all orthopaedic surgery, however, is also not always the best approach. In these situations, damage control orthopaedics, which emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered.

Lateral compression injuries in the pediatric elbow: Panner's disease and osteochondritis dissecans of the capitellum.

Lateral compression injuries of the elbow typically occur in throwing athletes and gymnasts. In the preadolescent and adolescent patient, these injuries predominantly include Panner's disease and osteochondritis dissecans. Panner's disease, an osteochondrosis of the capitellum, is a rare disorder that usually affects the dominant extremity in individuals younger than age 10 years. Symptomatic management of Panner's disease consisting of reduction of stressful activities of the elbow is usually sufficient to allow resolution. Although a prolonged period is required for healing, most patients demonstrate excellent long-term results. Osteochondritis dissecans of the capitellum typically occurs in adolescents and is associated with loose body formation. Panner's disease and osteochondritis dissecans likely represent a continuum of disordered endochondral ossification with presentation and prognosis dependent primarily on age at onset.

Relationship between throwing mechanics and elbow valgus in professional baseball pitchers

Valgus elbow stress leads to medial tension and lateral compression injuries in baseball pitchers of all ages. This study was undertaken to investigate the relationship between elbow stress in professional baseball pitchers and the kinematic parameters of pitching mechanics. This was done in an attempt to understand valgus extension overload better and in an effort to improve preventive and rehabilitative protocols. High-speed video data were collected on 40 professional pitchers in game situations during the 1998 and 1999 Cactus League season in Arizona, as part of Major League Baseball Spring Training. A multiple linear regression analysis was used to relate elbow valgus to kinematic parameters of pitching mechanics. The resulting analysis produced an adjusted multiple R2 value of 0.974, indicating that nearly 100% of the variance in valgus stress on the elbow was explained by the parameters in the regression equation. This ability to explain over 97% of the variance in valgus stress is significant. The parameters of pitching mechanics related to elbow valgus may be assessed and optimized, if necessary, in order to decrease the magnitude of elbow stress in pitching. (J Shoulder Elbow Surg 2002;11:151-155)

Unusual Dislocation of the Symphysis Pubis: A Case Report

The lateral compression injury of the pelvis is common in high-speed vehicle accidents, and symphysis pubis disruption can occur with external rotation or anterior compression injury. The most common injury of the symphysis pubis is diastasis. So far, four cases of the locked symphysis pubis have been reported, and two of these were treated by closed reduction. The current case involves a 26-year-old man who experienced a lateral compression force to his pelvis and knees, and suffered a symphysis pubis disruption (locked symphysis pubis, i.e., creeping of the left pubic body below the right pubic body), urethral rupture and bilateral knee dislocation. The locked symphysis pubis was successfully reduced with a closed maneuver.

Medial Collateral Ligament Reconstruction

Medial Collateral Ligament Reconstruction

Distraction external fixation in lateral compression pelvic fractures.

To observe the results and describe the technique of closed reduction and placement of a two-pin supra-acetabular external fixator, followed by immediate weight bearing, in the treatment of displaced vertically stable lateral compression pelvic fractures. Prospective, consecutive Regional trauma center A consecutive series of fourteen patients with displaced, vertically stable lateral compression pelvic fractures who were transported to a regional trauma center. Surgical treatment with closed reduction and maintenance of the distraction force with a two-pin, single-bar, supra-acetabular external fixator, followed by immediate weight bearing. Healing rate and time, operative blood loss and time, quality of reduction, time to full weight-bearing, and incidence of complications, including neurovascular deficits, loss of reduction, nonunion, pin tract infections, and chronic pain. A symmetric reduction of both hemipelves was achieved in all fourteen patients. Time to healing averaged 8.2 weeks (seven to twelve weeks), and no fixator required removal before healing. There were no delayed unions or nonunions, and none of the fractures displaced significantly after initial reduction. Average surgical time was thirty-seven minutes (range, twenty-five to sixty minutes) with an estimated blood loss of less than fifty milliliters. Patients were allowed to bear full weight immediately and were able to do so without ambulatory assistive devices within an average of twelve days (range, three to eighteen days). Complications consisted of three minor pin tract infections, one temporary lateral femoral cutaneous nerve palsy, one late pin tract abscess, and one patient with chronic low-back pain. Treatment of type B lateral compression injuries of the pelvic ring with anterior distraction external fixation is a highly effective yet relatively simple and minimally invasive treatment method. Surgical time and blood loss are minimal, and patients can be effectively and rapidly mobilized. Based on our experience, we believe this method to be a valuable tool in the treatment of these fractures.

Failure of reduction with an external fixator in the management of pelvic ring injuries

We reviewed 110 patients with an unstable fracture of the pelvic ring who had been treated with a trapezoidal external fixator after a mean follow-up of 4.1 years. There were eight open-book (type B1, B3-1) injuries, 62 lateral compression (type B2, B3-2) and 40 rotationally and vertically unstable (type C1-C3) injuries. The rate of complications was high with loss of reduction in 57%, malunion in 58%, nonunion in 5%, infection at the pin site in 24%, loosening of the pins in 2%, injury to the lateral femoral cutaneous nerve in 2%, and pressure sores in 3%. The external fixator failed to give and maintain a proper reduction in six of the eight open-book injuries, in 20 of the 62 lateral compression injuries, and in 38 of the 40 type-C injuries. Poor functional results were usually associated with failure of reduction and an unsatisfactory radiological appearance. In type-C injuries more than 10 mm of residual vertical displacement of the injury to the posterior pelvic ring was significantly related to poor outcome. In 14 patients in this unsatisfactory group poor functional results were also affected by associated nerve injuries. In lateral compression injuries the degree of displacement of fractures of the pubic rami caused by internal rotation of the hemipelvis was an important prognostic factor. External fixation may be useful in the acute phase of resuscitation but it is of limited value in the definitive treatment of an unstable type-C injury and in type-B open-book injuries. It is usually unnecessary in minimally displaced lateral compression injuries.

Failure of reduction with an external fixator in the management of injuries of the pelvic ring. Long-term evaluation of 110 patients.

We reviewed 110 patients with an unstable fracture of the pelvic ring who had been treated with a trapezoidal external fixator after a mean follow-up of 4.1 years. There were eight open-book (type B1, B3-1) injuries, 62 lateral compression (type B2, B3-2) and 40 rotationally and vertically unstable (type C1-C3) injuries. The rate of complications was high with loss of reduction in 57%, malunion in 58%, nonunion in 5%, infection at the pin site in 24%, loosening of the pins in 2%, injury to the lateral femoral cutaneous nerve in 2%, and pressure sores in 3%. The external fixator failed to give and maintain a proper reduction in six of the eight open-book injuries, in 20 of the 62 lateral compression injuries, and in 38 of the 40 type-C injuries. Poor functional results were usually associated with failure of reduction and an unsatisfactory radiological appearance. In type-C injuries more than 10 mm of residual vertical displacement of the injury to the posterior pelvic ring was significantly related to poor outcome. In 14 patients in this unsatisfactory group poor functional results were also affected by associated nerve injuries. In lateral compression injuries the degree of displacement of fractures of the pubic rami caused by internal rotation of the hemipelvis was an important prognostic factor. External fixation may be useful in the acute phase of resuscitation but it is of limited value in the definitive treatment of an unstable type-C injury and in type-B open-book injuries. It is usually unnecessary in minimally displaced lateral compression injuries.