Treatment Of Unstable Pelvic Injuries Research Articles

Surgical considerations with the operative fixation of unstable paediatric pelvic ring injuries.

The operative treatment of unstable pelvic injuries in paediatrics is not frequently indicated. The detailed modes of pelvic ring failure, surgical techniques, fixation choices, and peri-operative difficulties are not well reported. From September 2010 to March 2016, 62 paediatric patients were admitted to an academic level I trauma center with the diagnosis of pelvic ring injury. Of them, 29 (17 males and 12 females) had operative fixation of unstable pelvic injuries. Their average age was 11.7 ± 4.4years. There were six Tile's B injuries and 23 type C injuries. The commonest modes of pelvic ring failure were pubic rami fractures anteriorly and ligamentous sacroiliac joint injuries posteriorly. The iliac apophysis was avulsed in nine patients. Supra-acetabular external fixators were frequently used for anterior fixation while iliosacral IS screws and lateral compression LC screws were commonly used posteriorly. Difficulties were encountered with open reduction and repair of avulsed iliac apophyses in two patients. The IS screws pierced the soft iliac wing in three patients. In two patients with open triradiate cartilage, the purchase of retrograde LC screws was weak due the small sized crescent fragment. The iliac apophysis needs to be repaired following reduction of the displaced hemipelvis. Anterior supra-acetabular external fixation is a good choice in paediatrics even with pubic symphysis diatasis as the pathology is commonly a pubic apophysis avulsion. IS screws might be inserted through plates to prevent piercing the soft iliac wing. Retrograde LC screws should be avoided in young children.

Treatment of unstable pelvic ring injuries with vertebropelvic transpedicular fixation

In the period from 2011 to 2013 in Botkin City Hospital 17 patients with unstable injuries of pelvic ring and lumbosacral junction were operated using the method of transpedicular vertebropelvic fixation. In the preoperative period a comprehensive instrumental examination, including X-rays and CT was performed in all patients. In 11 (64.7 %) patients neurological complications were detected, of which 4 (23.5%) - cauda equina syndrome (patients with transverse fractures of the sacrum). The follow- up of patients was 1.5 years In all cases the X-ray pattern after surgical treatment was regarded as satisfactory. During the observation period the necessary to remove the fixation devices didn’t appear. The regression rate of neurological symptoms in the postoperative period depend on the severity of the initial injury and the intensity of symptoms. In the group of patients with transverse fractures of the sacrum disorders of pelvic organs remained, caused by primary severe damage in the sacral canal zone. In the other groups there was a gradual regression of motor and sensory disorders in the year after surgery. The complications in the early postoperative period: 2 (11.8 %) cases of delayed healing of surgical wounds in the sacral region (secondary healing) and one (5.9%) case of postoperative wound infection that requested the secondary surgical treatment, rehabilitation and installation of the suction-irrigation system. The method of transpedicular vertebropelvic fixation is effective in the treatment of unstable pelvic injuries if braking-down of gemipelvis is necessary and also in the combined damage of low-lumbar spine.

Percutaneous iliosacral screwing in pelvic ring injury using three-dimensional fluoroscopy

BackgroundIliosacral screw fixation is a popular technique for treatment of unstable pelvic injuries involving the posterior ring. However, screw malposition may result in dangerous complications involving injury to adjacent neurovascular structures. This study was conducted in order to evaluate the results and efficacy of using three-dimensional fluoroscopy in the performance of iliosacral screw fixation. MethodsTwenty-nine patients (31 cases, two bilateral) who suffered injury to the pelvic ring requiring surgical treatment were included in this study. According to the Association for Osteosynthesis-Orthopaedic Trauma Association (AO-OTA) classification, there were 14 patients with type B, 13 patients with type C, and 2 patients with a bilateral sacral fracture. The mean age of patients was 39years. Once the guide pin had been inserted, its safety was confirmed using three-dimensional fluoroscopy; screw fixation was then performed. Eighteen patients underwent percutaneous iliosacral screw fixation and anterior fixation, while 11 patents underwent screw fixation only. Postoperative computed tomography (CT) was performed for evaluation of the screw position, including any invasion into the sacral foramen or canal and neurovascular injury. The perforation of the screw was divided according to the location (sacral zones I, II, and III) and the degree (grade 0, no perforation; grade 1, perforation <2mm; grade 2, perforation between 2 and 4mm; grade 3, perforation >4mm). ResultsThe mean operation time was 35.6min, and the mean radiation exposure time was 85.9s. For accurate location of the guide pin, one patient underwent three-dimensional reconstruction twice. None of the patients required reoperation or suffered any neurovascular injury. Although seven cases involved perforation, all were less than 2mm (grade 0: 24 cases, grade 1: 7 cases). ConclusionsWhen performing percutaneous iliosacral screw fixation in a patient with an unstable pelvic ring injury, use of three-dimensional fluoroscopy may allow for accurate location of the screw and result in fewer complications.

Surgical treatment of unstable pelvic injury with displaced sacral fractures.

Objective To evaluate the surgical technique and functional results of displaced sacral fractures. Methods From September 2000 to September 2007, thirty-three patients of pelvic injuries with sacral fractures treated with operation were assessed. There were 5 type-B pelvic fractures, and 28 type-C fractures, according to the AO/OTA classification system. Sacral fractures were classified by Denis classification into type- I , type- II, and type-III in 13, 11, and 9 cases, respectively. The patients with neurological injuries were find in 23 cases. Fractures of sacrum were fixed with tension band transiliac plate osteosynthe-sis in 1 case; pedicle rod-screw system placed to the iliac crest posterior to the pelvis for transversal fixation in 10; vertical distraction fixation through L_(4,5), L_5S_1, and bilateral iliac crest in 16; iliosacral screws fixation in 3; sacral bars fixation in 2; and combination of iliosacral screws and sacral bars in 1. Techniques for neural decompression with laminotomy and neurolysis of cauda equina nerve intraoperatively in 11 cases, and with delayed neurolysis and foraminotomy in 2. Results All patients were followed up on an average of 27.3 months. Clinical outcome was rated excellent in 17 cases, good in 7, fair in 2 and poor in 7, according to the Majeed functional evaluation. The satisfaction rate of clinical effect for sacral fractures of Denis type- I , type- II, and type-III was 92.3%, 72.7%, and 44.4%, respectively. For the neural decompression patients, neurological injuries from sacral fractures were recovered of excellent in 6 cases, good in 4 and no changes in 3. But for nonoperative group, the degree of recovery viewed excellent in 6 cases, good in 1, and no changes in 3. Complications of surgical treatment included: deep infection in 2 cases; unsatisfactory reduction and lumbosacral pains in 2; transient exacerbation of injured neural function in 4; and delayed sacral nerve injuries in 3. Conclusion Surgical treatment is important for improving reduction of sacral fractures; combination of anterior and posterior pelvic ring fixation enhance the strength of internal fixation effectively; early neural decompression could be helpful to recovery of the neural function. Key words: Sacrum ; Fractures ; bone ; Fracture fixation ; internal ; Treatment outcome ;