Posterior Pelvic Injuries Research Articles

Combined Pelvic Ring Disruption and Acetabular Fracture

Combined pelvic ring disruptions and acetabular fractures are thought to be uncommon. Our objectives were to characterize concomitant injury patterns and to compare them with historically observed rates for each injury in isolation. Retrospective review comparing a study group with historical controls. Fracture patterns were compared with our institution's isolated injury patterns and with isolated injury patterns of other published series. Level I academic medical center. Between 1997 and 2001, 854 pelvic ring disruptions and 457 acetabular fractures were evaluated. Forty patients sustained combined injuries. None. Fracture patterns, Injury Severity Scores, and mortality rates. Our series of combined injuries included 5% posterior wall fractures. This was significantly different from the 30% incidence of posterior wall fractures among isolated acetabular fractures at our institution (P < 0.006). No posterior column or posterior column with associated posterior wall fractures occurred. Fifty-three percent of the patients sustained anterior-posterior compression pelvic ring injuries, exceeding our center's 19% norm for isolated pelvic ring injuries (P < 0.001). For combined injuries, the mean injury severity score was 27.9 and the overall mortality rate was 13%. Early death occurred in 19% of patients with combined anterior-posterior compression injuries and 6% with lateral compression injuries. Patients with combined pelvic and acetabular injuries have multiple system injuries and high Injury Severity Scores. Fracture patterns differ from those observed with isolated injuries. Posterior acetabular fractures are uncommon components. Anterior-posterior compression pelvic injuries seem much more frequent in cases of combined injuries than isolated injuries and are associated with high mortality rates. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Posterior iliac crescent fracture-dislocation: What morphological variations are amenable to iliosacral screw fixation?

ObjectivesPosterior iliac crescent fracture with associated sacroiliac joint disruption (PICFSID) is a type of traumatic posterior pelvic injury associated with instability. Posterior iliac fracture location and obliquity along with other details determine the treatment. Open reduction and internal fixation has been previously recommended for the majority of crescent fractures. Our objectives were to determine whether all crescents can be categorised according to the previously described Day crescent classification scheme, and to see which crescent types are amenable to percutaneous fixation. Patients and methodsWe identified 129 crescents in 128 patients during a 7-year time period. Of these, 100 patients met the inclusion criteria of at least 3 months of clinical and radiographic follow-up. There were 57 males and 43 females, with a mean age of 42 years and a mean injury severity score of 25.5. Treatment selection was based on fracture type and overall patient factors and consisted of non-operative management, pelvic external fixation, open reduction and internal fixation, and closed reduction and percutaneous iliosacral screw fixation. ResultsThere were 16 Type I, 47 Type II and 37 Type III crescent fractures. Twelve injuries could not be classified according to the Day scheme. Percutaneous iliosacral screw fixation was utilised in 60% of all crescents after either closed or open reduction of the PICFSID. ConclusionsThe majority of PICFSIDs are amenable to closed reduction and percutaneous iliosacral screw fixation. The Day classification for PCIFSID should be expanded to include variant injury patterns.

Surgical reduction and fixation techniques in the treatment of posterior pelvic injuries

Pelvis kiriklari, yuksek mortalite ve komplikasyon orani ile iliskili yaralanmalardir. Posteriyor pelvik yaralanma tedavisinde anteriyor veya posteriyor yaklasim ile acik reduksiyon veya kapali reduksiyon ile tespit yontemleri tanimlanmistir. Gunumuzde kapali reduksiyon, ozellikle kirik hematomunu bozmamasi, daha iyi ve hizli kaynama saglamasi ve daha az yara sorunu olmasi nedeniyle tercih edilmeye baslanmistir. Kapali reduksiyon yontemleri uygulanirken gereksinim duyulan temel arac, radiolusent bir travma masasi ve C-kollu bir floroskopidir. Erken cerrahi girisim de buyuk onem tasir. Cerrahi sirasinda floroskopi kontrolu altinda reduksiyon kalitesi degerlendirilmelidir. Bununla birlikte, posteriyor kesiye engel olan ciddi yumusak doku yaralanmalarinda, sakroiliyak eklem ayrilmalarinda, buyuk hilal seklinde kirik parcasi bulunan yaralanmalarda ve iliyak kanat kiriklari varliginda anteriyordan acik reduksiyon kullanilabilir. Diger yandan, posteriyordan acik reduksiyon ise, sakroiliyak eklem ayrilmalari, sakroiliyak kirikli cikiklar, ayrilmis transforaminal sakrum kiriklari ve Denis zon III sakral kiriklar icin tercih edilebilir. Reduksiyon cerrahisi sonrasinda tespit icin anteriyor veya posteriyor internal tespit yontemleri kullanilabilir. Hizli uygulanabilir bir yontem olmasina karsin, eksternal tespitin posteriyor yaralanmalarin tedavisinde etkisiz oldugu bildirilmistir. Gunumuzde posteriyordan acik cerrahi yaklasim, yara yeri sorunlari ve uzun iyilesme sureleri nedeni ile tercih edilmemektedir. Bu nedenle, morbidite ve mortaliteyi azaltmak ve anatomik reduksiyonu korumak amaci ile gelistirilen perkutan sakroiliyak vidalama yontemi tanimlanmistir. Politravmali hastalarda, erken tespit saglamasi ve az hasarli bir yontem olmasi nedeniyle perkutan teknik tercih edilmelidir. Sonuc olarak, gunumuzde artik az hasarli yontemler kullanilarak daha az kan kaybi, daha az enfeksiyon ve daha yuksek iyilesme oranlari elde etmek mumkundur.

Transiliac–Transsacral Screws for Posterior Pelvic Stabilization

Typical posterior pelvic fixation constructs use one or more large screws inserted from the lateral iliac cortex into the safe upper sacral ala or body. As a result of the deforming forces acting perpendicular to the implant axis, routine iliosacral screw fixation may not provide adequate stabilization, especially in certain unstable injuries. Longer iliosacral screws that traverse the entire upper sacrum and exit the contralateral iliac cortex may improve holding power and also stabilize concomitant contralateral posterior pelvic injuries. These transiliac-transsacral screws are reliably safe to insert using routine intraoperative fluoroscopy, and they provide durable fixation. These screws require careful preoperative planning and more precise technical attention during insertion because they pass through both sacral alar zones. Transiliac-transsacral screws may be particularly useful in the presence of osteoporosis, significant posterior pelvic instability including spinopelvic dissociation, patient obesity, anticipated noncompliant behavior, bilateral posterior pelvic injuries, and nonunion procedures.

Trans-sacroiliac joint with plate via the anterior approach in management of posterior pelvic injuries

To report the clinical experience in trans-sacroiliac joint with plate via the anterior approach in management of posterior pelvic injuries. The clinical data of 29 cases (30 sides) with pelvic injury, 16 being of type B, and 13 of type C according to the Tile classification; with the average displacement of the posterior ring injuries of 18 mm; undergoing trans-sacroiliac joint with plate via the anterior approach from January 2002 to June 2007 were analyzed retrospectively, among which 20 sides were fixed by two plates across the sacroiliac joint and 10 sides by single plate. The anterior pelvic injuries of 22 cases were fixed by plates too. Twenty-one cases were followed up for 35 months on average. The average operation time was 3 hours, and the average blood transfusion was 1200 ml. Reduction was excellent in 23 sides (77%), good in 6 sides (20%), and fair in 1 side (3%). Operative injury of lumbosacral trunk occurred in 3 sides (10%) and operative injury of lateral femoral cutaneous nerve occurred in 7 sides (23%). Intra-operative major hemorrhage occurred in 2 cases. The average outcome score according to the Majeed grading system was 93, and the function results all were excellent or good. Plating the sacroiliac joint through the anterior approach is an effective method for the management of sacroiliac dislocation or trans-iliac fracture dislocation, while the blood loss of the operation is obvious, and the risk of iatrogenic nerve injury is high.

Predictors of death in patients with life-threatening pelvic hemorrhage after successful transcatheter arterial embolization.

The purpose of this study was to determine predictors of death in patients with pelvic fracture whose pelvic arterial hemorrhage is controlled successfully by transcatheter arterial embolization (TAE). From January 1996 to December 2000, 61 patients with a pelvic fracture who had pelvic arterial hemorrhage were treated at our Level I trauma center according to a protocol that assigns a high priority to diagnostic and therapeutic angiography within the algorithm. Angiography is performed before laparotomy in patients with hemoperitoneum, who can be stabilized by fluid resuscitation, and otherwise afterward. External fixation was performed immediately after TAE in the angiography suite. Predictors of outcome were determined retrospectively by univariate and multivariate analysis using anatomic and physiologic parameters. Forty-eight patients survived and 13 died. TAE successfully controlled pelvic arterial hemorrhage in all patients. Predictors of death included posterior pelvic arterial injury and an elevated Acute Physiology and Chronic Health Evaluation II score (odds ratio, 15.6 and 23.9, respectively). Need for fluid requirements to achieve hemodynamic stability were higher in nonsurvivors than in survivors. Outcome did not correlate with the type of fracture or the Injury Severity Score. Application of angiography as a therapeutic intervention in patients with pelvic arterial bleeding may reduce the need for surgery, thereby avoiding or minimizing this additional trauma.

Computed tomography for the assessment of posterior pelvic injuries in patients with isolated fractures of the pubic rami in conventional radiography

To investigate the incidence of occult posterior injuries of the pelvic ring in patients with isolated fractures of the pubic rami, additional computed tomography (CT) was performed. Data from 70 patients were collected within a prolective study. Solitary fractures of the anterior pelvic ring based on conventional radiographic diagnosis were included. Spiral CT, slice thickness 5 mm, was carried out in all patients. In only 47% of cases was the diagnosis of isolated fractures of the pubic rami confirmed. A further 35 fractures of the sacrum and two partial disruptions of the sacroiliac joint were diagnosed using CT. All sacral fractures were incomplete, most were found at the anterior part of the bone. Furthermore, CT revealed three acetabular fractures. Dorsal injuries were significantly more frequent after high energy accidents. Clinical examination did not assist in the prediction of posterior injuries of the pelvic ring. There was no correlation between the extent of the anterior injuries in conventional x-ray and incidence of the posterior injuries in CT. None of the patients with dorsal injuries underwent operative treatment. In conclusion, CT is not required for the routine diagnosis of supposed isolated fractures of the pubic rami.

Late neurological symptoms after internal fixation of a pelvic fracture due to breakage of an iliosacral screw

Screw breakage is a well reported complication of vertebral and pelvic surgery [1]. Nerve root damage at the time of surgery by means of misplaced iliosacral screws is also documented in posterior pelvic injuries [2]. We report on the acute late onset of nerve root symptoms after breakage of an iliosacral screw.

Outcome after fixation of unstable posterior pelvic ring injuries.

Between June 1989 and May 1995, the authors surgically treated 64 patients with unstable posterior pelvic in juries. Fracture types included Tile Type C1 (75%), C2 (8%), and C3 (17%). There were 19 sacroiliac dislocations, 12 sacral fractures, 4 transiliac fractures, and 29 sacroiliac fracture dislocations. Average patient age was 32 years and Injury Severity Score was 27 points. Posterior fixation was accomplished by percutaneous iliosacral screw insertion in 53 patients (83%). Only pure transiliac fractures were treated without iliosacral screws. There were no iatrogenic nerve palsies. During the study, there was increased reliance on internal fixation of the anterior pelvic ring that aided in anatomic alignment of the pelvis for posterior fixation and resulted in decreased chronic pubic tenderness. The use of external fixation for definitive treatment was abandoned. Patients were observed for an average of 36 months (range, 5-74 months). Fifty-two patients were available for recent complete followup. Fifty-one patients (98%) healed their pelvic disruptions; there was 1 sacral nonunion. A 40-point pelvic outcome grading scale was developed based on physical examination, pain, radiographic analysis, and activity/work status. Scores obtained by this scale correlated closely with the Short Form-36 Health Survey scores. Patient functional outcome after posterior pelvic fracture was not associated with Injury Severity Score or fracture location.

Magnetic Resonance Imaging of Traumatic Posterior Urethral Defects and Pelvic Crush Injuries

A total of 18 patients 4 to 71 years old with complete occlusion of the prostatomembranous urethra from pelvic crush injury underwent magnetic resonance imaging (MRI) of the pelvis just before open urethroplasty. MRI studies included T2-weighted sagittal and coronal images as well as transaxial T1 and T2-weighted spin-echo images. Operative findings and erectile function were correlated with MRI findings. All patients underwent conventional cystography and retrograde urethrography. The mean interval from injury to operation was 5.5 months (range 3 to 12 months) and followup averaged 12 months (range 3 to 40 months).Posttraumatic pelvic anatomy can be distorted and imaging in all 3 planes was needed. The severity and direction of prostatourethral dislocation, and the length of the urethral defect could be accurately determined, which often is not possible with conventional radiographic studies. MRI also demonstrated injuries at many locations along the erectile pathway, including sacral and ischial fractures as well as fractures and avulsions of the cavernous bodies. Pelvic MRI can accurately define the pelvic anatomy after crush injury and, therefore, it can provide useful preoperative information that cannot be obtained by conventional radiographic studies. Our results correlating MRI findings of cavernous avulsion with clinical impotence require further study.

Neurologic Deficits in Major Pelvic Injuries

Nerve injury is a common complication of major pelvic injuries. Of 73 patients examined who suffered major pelvic injuries, 24 (33%) had resultant neurologic deficits. The extent of nerve injury is proportionate to the severity of the posterior pelvic bone injury. Sacroiliac dislocation and sacral fractures may be equally complicated by nerve injury. This study suggests that nerve recovery starts three months after injury and stops after two years. Complete recovery was not recorded in severe nerve injuries. Eighty percent of patients recovered from impotence. Nerve injury was found to affect the functional outcome of patients with pelvic injuries. For these reasons, injury should be considered and looked for in every case of pelvic injury.

Fixation device for pubic fractures

Wide separation of the pubic bones, combined with a posterior pelvic injury, is usually stabilized after reduction by external support using a pelvic sling, or by internal fixation using interpubic wires or plates. A rather unusual case is described in which neither method was applicable, and for which alternative fixation was devised.