12 Fractures of the Pelvis 239 12 Fractures of the Pelvis

M. Tile

tions, the results with simple treatment will be quite 12.1 different (Fig. 12.1). Therefore, in reading the litera- Introduction ture, we must be certain that we are not comparing apples with oranges or chalk with cheese. An under- In the past two decades, traumatic disruption of the standing of this injury is the key to logical decision pelvic ring has become a major focus of orthopedic making. interest, as has the care of polytraumatized patients. This injury forms part of the spectrum of polytrauma and must be considered a potentially lethal injury with mortality rates of 10%–20%. The stabilization 12.2 of the unstable pelvic ring in the acute resuscita- Understanding the Injury tion of multiply injured patients is now conventional wisdom. In order to better understand our proposed classi- With respect to the long-term results of pelvic fication and rationale of management, some knowl- trauma, conventional orthopedic wisdom held that edge of pelvic biomechanics is essential. surviving patients with disruptions of the pelvic ring The pelvis is a ring structure made up of two recovered well clinically from their musculoskeletal innominate bones and the sacrum. These bones have injury. However, the literature on pelvic trauma was no inherent stability, and the stability of the pelvic ring mostly concerned with life-threatening problems is thus due mainly to its surrounding soft tissues. and paid scant attention to the late musculoskeletal The stabilizing structures of the pelvic ring are the problems reported in a handful of articles published symphysis pubis, the posterior sacroiliac complex, prior to 1980. Despite the clinical impressions that and the pelvic floor. Although the anterior structures most patients do well, some authors have suggested are important, contributing 40% of the stiffness to the otherwise. ring (Hearn et al. 1991), the integrity of the posterior Holdsworth (1948) reported on 50 pelvic fractures sacroiliac complex is most important in maintaining and indicated that of the 27 patients with a sacroiliac pelvic ring stability (see Fig. 12.6). dislocation, 15 had significant pain and were unable to work, whereas those with a sacral or iliac fracture had more satisfactory results. Pennal and Suther- 12.2.1 land (1959), in a large, unpublished study of 359 Ring Structure of the Pelvis cases, further suggested that patients with unstable vertical shear injuries had many late complications. The pelvis is a true ring structure. It is self-evi- Slatis and Huittinen (1972) and Monahan and Taylor dent that if the ring is broken in one area and dis- (1975) both confirmed the significant percentage of placed, then there must be a fracture or dislocation late musculoskeletal problems. in another portion of the ring. Thus the vast litera- In reading the literature, the case mix for each ture describing anterior or posterior pelvic fractures series must be determined; otherwise the conclusions suggesting that they appear in isolation is mislead- may be erroneous. Pelvic fractures must be classified ing. Gertzbein and Chenoweth (1977), in a series of according to their degree of instability or severity. patients with undisplaced anterior pelvic fractures, If a series contains a large number of stable, incon- noted that a technetium polyphosphate bone scan sequential fractures, the overall results with simple of the posterior sacroiliac complex gave a positive treatment will be excellent, whereas if it contains a reading in every case, indicating the definite pres- high percentage of displaced, unstable pelvic disrup- ence of a posterior lesion (Fig. 12.2). This was further

12.2 Understanding the Injury

SCHA_12-Tile.indd 239 17.04.2005 14:27:56 Uhr 240 M. Tile

a b

c d

Fig. 12.1a–e. Pelvic fracture personality types. The management of a pelvic disruption depends on a clear evaluation of the personality of the fracture. The good personality types as noted in the drawing in a and the radiograph in b which demonstrates a relatively undisplaced stable fracture of the pelvis is different than the bad personality type as noted in the drawing in c and the radiographs in d and e. The anteroposterior radiograph (d) is that of a 21-year-old man who sustained a crush injury to the pelvis. The degree of instability was not recognized, and the patient was treated with bed rest while the extremities were attended. The ﬁ nal results (e) show severe shortening of the right hemipelvis with internal rotation. Note also the extremely high position of the right ischial tuberosity, which made sitting almost impossible (lower arrow). Marked shortening is indicated by the upper arrows above. Comparison of these two cases is like comparing apples to oranges or chalk to cheese e

12.2 Understanding the Injury

SCHA_12-Tile.indd 240 17.04.2005 14:27:57 Uhr 12 Fractures of the Pelvis 241

a b

Fig. 12.2. a Radiograph of a patient with an apparently undisplaced fracture of the inferior and superior pubic ramus on the right side (white arrow). No lesion is seen posteriorly. The deformity of the left hemipelvis represents a malunion of an old left acetabular fracture. b Technetium polyphosphate bone scan of the same patient clearly showing the increased uptake of the superior and inferior pubic ramus fracture anteriorly, but also a massively increased uptake at the right sacroiliac joint, indicating a posterior lesion (black arrow). (From Tile 1984; courtesy of Dr. S.D. Gertzbein)

confirmed in a study by Bucholz (1981), in which Of greater importance than the site of the poste- posterior lesions at autopsy were found in all patients rior lesion is the degree of displacement of the pos- with pelvic trauma even when the radiograph had terior sacroiliac complex. This can best be seen on revealed only an anterior lesion. the inlet radiograph showing posterior displacement of the so-called sacrogluteal line (Fig. 12.4) and is best confirmed by computed tomography (CT) scan. 12.2.2 Therefore, the posterior lesion, although present, may Anatomical Lesions be undisplaced and have intact posterior ligaments, often associated with a sacral crush, or may be dis- The anterior pelvic lesion may be a symphysis pubis placed with a major ligamentous disruption of the disruption or overlap, or pubic rami fractures unilat- posterior pelvic complex (Fig. 12.5). erally or bilaterally. A symphysis disruption may also occur in combination with pubic rami fractures. The posterior lesion may be a fracture of the 12.2.3 ilium, often in the coronal plane, a dislocation or Stability of the Pelvis fracture-dislocation of the sacroiliac joint, or a fracture through the sacrum (Fig. 12.3). The commonest The anatomical lesions are important for surgical lesion is a sacral fracture followed by a combined management, but the stability factor is more impor- injury, i.e., a fracture-dislocation of the sacroiliac tant for overall decision making in the management joint, usually with a portion of the ilium remaining of patients. attached to the main sacral fragment. Stability may be defined as the ability of the Sacral fractures, in turn, may be classified as lat- pelvis to withstand physiological forces without eral, medial, or through the foramina or as complex significant displacement. It is obvious that pelvic types (H types). stability is dependent not only on the bony struc-

12.2 Understanding the Injury

SCHA_12-Tile.indd 241 17.04.2005 14:27:58 Uhr 242 M. Tile

Fig. 12.4. The dotted line on the right represents the sacrogluteal line on the inlet view of the pelvis. Any break in the continuity of this line, as shown on the left, represents displacement of the posterior complex, an ominous prognostic indicator. (From Tile 1984)

Fig. 12.3a–c. Injuries to the posterior pelvic complex. The posterior injury may be a fracture through the ilium (a), a a pure dislocation of the sacroiliac joint (b, straight arrow), or a fracture through the sacrum (c, straight arrow). A common pattern is a fracture dislocation through the sacroiliac joint, as shown by the small curved arrows in b and c

Fig. 12.5a,b. The posterior lesion may be stable or unstable. a The impacted right sacrum is clearly seen (white arrow). There is at least 1 cm of overlap between the two fragments. This posterior lesion is stable and cannot be moved. b The left sacral lesion is grossly unstable (black arrows). As well as the displacement at the fracture, all soft tissues are disrupted. (From Tile 1984) b

12.2 Understanding the Injury

SCHA_12-Tile.indd 242 17.04.2005 14:27:58 Uhr 12 Fractures of the Pelvis 243

tures, but also on the strong ligamentous structures 12.2.3.1 binding together the three bones of the pelvis, i.e., Sacroiliac Complex the two innominate bones and the sacrum. If these ligamentous structures are removed, the pelvis The intricate posterior sacroiliac complex is a mas- falls into its three component parts. Moreover, sta- terly biomechanical structure able to withstand the bility is a spectrum: at one end of the spectrum is transference of the weight-bearing forces from the the intact pelvic ring, at the other end a completely spine to the lower extremities. The ligaments have unstable pelvis, an internal hemipelvectomy. In our a major role as posterior stabilizers, because the pelvic classification based on stability, the frac- sacrum, contrary to what is expected, does not form tures at the stable end are type A, at the unstable the shape of a keystone in a Roman arch, but is quite end type C, and those with partial stability in the the reverse. Therefore, the strong posterior sacroiliac middle type B. interosseous ligaments have been described as the The stability of the pelvic ring depends upon the strongest in the body, maintaining the sacrum in its integrity of the posterior weight-bearing sacroiliac normal position in the pelvic ring. Also, the iliolum- complex (Fig. 12.6) and the pelvic floor. The major bar ligaments join the transverse processes of L5 to ligaments are the sacroiliac, the sacrotuberous, and the iliac crest, and the intervening transverse fibers of the sacrospinous. the interosseous sacroiliac ligaments further enhance

Fig. 12.6a,b. The major posterior stabilizing structures of the pelvic ring, as seen from the anteroposterior (a) and posterior view (b). The anteroposterior view (a) indicates the sacrospinous ligament as a strong tri- a angular ligament lying anterior to the sacrotuberous ligament, a strong band extending from the lateral portion of the dorsum of the sacrum to the ischial tuberosity. These two ligaments form part of the pelvic fl oor, which is also supported by the pelvic fl oor muscles and fascia. The anterior sacroiliac ligament is fl at and not as strong as the posterior sacroiliac ligamentous structures noted in the drawing (b). The posterior sacroiliac ligament, the sacrotuberous ligaments, and the sacrospinous ligaments are the major posterior stabilizing structures of the pelvic ring, that is, the posterior tension band of the pelvis. The ipsilateral sacroiliac complex often shows a compression through the sacrum. The pelvic fl oor integrity is usually maintained by the implosion force, thereby buckling the ligaments on the pelvic b fl oor as noted. (From Tile 1984)

12.2 Understanding the Injury

SCHA_12-Tile.indd 243 17.04.2005 14:27:59 Uhr 244 M. Tile

the suspensory mechanism. The entire complex looks acting upon the pelvis, i.e., external rotation and ver- and functions like a suspension bridge (Fig. 12.7). tical shear. In this way, they supplement the posterior The anterior sacroiliac ligaments are flat and sacroiliac ligaments. strong and resist external rotation and shearing forces, although they do not have the strength of the posterior ligaments. 12.2.4 Types of Injurious Forces Acting on the Pelvis 12.2.3.2 Pelvic Floor Most forces acting on the pelvis are (a) external rotation, also called anteroposterior compression, (b) The pelvic floor, with its muscular layer covered by internal rotation (lateral compression), or (c) shear- investing fascia, also acts as a stabilizer of the pelvic ing or translational forces in the vertical plane. In ring. Two major ligaments also form part of the pelvic the complex high-energy trauma seen in our soci- floor, namely the sacrospinous and sacrotuberous. ety, some forces defy description, but, in general, the The strong sacrospinous ligament, with fibers above are the three major force vectors acting upon running transversely from the lateral edge of the the pelvic ring. sacrum to the ischial spine, resists external rotation of the pelvic ring (Fig. 12.8). The complex sacrotuberous ligament arises from most of the sacroiliac complex posterior to the sacrospinous ligament and extends to the ischial tuberosity. This strong ligament, positioned in the vertical plane, resists vertical shearing forces applied to the hemipelvis (Fig. 12.9). Therefore, these two supplementary ligaments, the sacrospinous and sacrotuberous, placed at 90° to each other, are well adapted to resist the two major forces

Fig. 12.8. The sacrospinous ligaments, joining the sacrum to the ischial spines, resist external rotatory forces (arrows). (From Tile 1984)

Fig. 12.7. The suspension bridge-like appearance of the ligaments binding the posterior sacroiliac complex. Note the vertical direction of the interosseous posterior sacroiliac ligaments, noted by Grant to be the strongest in the body, as well as the transverse component acting as the suspension, joining the Fig. 12.9. The sacrotuberous ligament, joining the sacrum to pillars, represented by the posterior superior or iliac spines, the ischial tuberosity, resists a shearing rotatory force (arrows). to the sacrum. (From Tile 1984) (From Tile 1984)

12.2 Understanding the Injury

SCHA_12-Tile.indd 244 17.04.2005 14:28:00 Uhr 12 Fractures of the Pelvis 245

External rotation forces occur with a direct blow The force of internal rotation or lateral compres- to the posterior superior spine or, more commonly, sion may be transmitted by a direct blow to the iliac by forced external rotation through the hip joints crest, often causing an upward rotation of the hemi- unilaterally or bilaterally. This force usually pro- pelvis or the so-called bucket-handle fracture, or duces an open book-type injury, i.e., the symphysis through the femoral head, often causing an ipsilateral pubis disrupts and, as further force is applied, the injury (Fig. 12.11). In this pattern, the anterior struc- sacrospinous ligament and the anterior ligaments tures, usually the rami, break and the hemipelvis of the sacroiliac joint may also open (Fig. 12.10). rotates internally. If the posterior ligaments remain Eventually, impingement of the posterior ilium on intact, the anterior sacrum will compress. If the pos- the sacrum occurs. At this point, the posterior sac- terior ligaments tear, stability is still maintained by roiliac ligaments still confer stability to the ring, the pelvic floor. and translation vertically or posteriorly is not pos- Shearing forces in the vertical plane cross the sible. main trabecular pattern of the posterior sacroiliac

b Fig. 12.10. a A direct blow to the posterior superior iliac spines will cause the symphysis pubis to spring open. b External rotation of the femora or direct compression against the anterior superior spines will also cause springing of the symphysis. (From Tile 1984)

a b Fig. 12.11. a A lateral compressive force directed against the iliac crest will cause the hemipelvis to rotate internally, crushing the anterior sacrum and displacing the anterior pubic rami. b Lateral compression injury may also be caused by a direct force against the greater trochanter. In that situation, the femoral head acts as a battering ram, dividing the pubic rami as shown, often through the anterior column of the acetabulum. The ipsilateral sacroiliac complex is also crushed in this injury. Note that the sacrospinous and sacrotuberous ligaments generally remain intact along with the pelvic ﬂ oor in this lateral compression- type injury. (From Tile 1995)

12.2 Understanding the Injury

SCHA_12-Tile.indd 245 17.04.2005 14:28:01 Uhr 246 M. Tile

complex, whereas a lateral compressive force causes impaction of the cancellous bone and usually allows 12.3 retention of the ligament integrity. However, external Classification rotation and lateral compression forces may be so great that they overcome the restraining effect of the ligament. Therefore, a completely unstable pelvic ring 12.3.1 may be caused by complex forces acting on the pelvis. Comprehensive Classification (from Tile 1988) The term “shear” is synonymous with these complex forces. Shearing forces cause marked displacement of 12.3.1.1 bone and gross disruption of the soft tissue struc- General Concepts tures (Fig. 12.12), including the pelvic floor. Continu- ation of these forces beyond the yield strength of the By combining the concepts of stability, force direc- soft tissues produces an unstable pelvic ring with tion, and pathoanatomy, a meaningful classification major anterior and posterior displacement. No finite may be developed to aid in patient management. No point is reached with these shearing forces; therefore, classification can answer all the questions regarding the entire hemipelvis may be avulsed from the body, a specific injury. Since the first edition of this book, occasionally resulting in a traumatic hindquarter and since our publication in The Journal of Bone amputation. and Joint Surgery in January 1988 (Tile 1988), refinements have been made to our original classification to allow acceptance as the comprehensive classifica- 12.2.5 tion of pelvic fractures. The basics of this classifica- Effect of Forces on Soft Tissue tion stem from the concepts of George Pennal, who developed a classification based on force direction. External rotation and shear forces tend to tear soft The Young-Burgess classification has retained those tissue; therefore, the injuries caused by these forces basic principles. With members of the AO group, we are usually major: tearing viscera and arteries and have expanded the concept to include stability as well causing traction injuries to nerves. Lateral compres- as force direction (Tile et al. 1988). sion forces (internal rotation) tend to puncture vis- All classifications should serve as guides to treat- cera and compress nerves (Dalal et al. 1989). ment and should allow centers to compare simi-

Fig. 12.12. A shearing force (arrows) crosses perpendicular to the main trabecular pattern of the posterior pelvic complex in the vertical plane. These forces cause marked displacement of bone and gross disruption of the soft tissues, resulting in major pelvic instability. (From Tile 1995)

12.2 Understanding the Injury

SCHA_12-Tile.indd 246 17.04.2005 14:28:03 Uhr 12 Fractures of the Pelvis 247

lar cases. The management of individual patients injury may be unstable in internal rotation or may be requires careful specific assessment, and the surgeon rigidly impacted, but neither is unstable in the verti- must be able to draw the fracture lines on a dry skel- cal plane unless a force which disrupts the posterior eton as well as determine the degree of soft tissue ligamentous structures is present. Also, it is self-evi- injury. dent that unstable pelvic injuries may be produced by The classification (Table 12.1) also follows the any force vector that overcomes the yield strength of A,B,C nomenclature of the comprehensive classifica- the soft tissues. tion (Müller et al. 1990), with increasing severity of As well, there is a tendency in the relevant litera- injury from A to C. It must also be remembered that ture, especially from European centers, to group all the types A, B, and C based on stability form a spec- type B injuries into one. Since the B1 external rotation trum rather than a rigid black and white concept. For type is vastly different from the B2 lateral compres- the purpose of this classification, the posterior pelvis sion, and has a different prognosis, these two types is located posterior to the acetabulum, and the ante- must be separated in any studies and reports. rior arch anterior to it. The fracture type is based on the posterior lesion, which is more important for stability, and the anterior lesions are denoted by modi- 12.3.2 fiers. Type A Stable Fractures (Table 12.2)

Table 12.1. Classification of pelvic ring disruption ( from In the type A injury, the pelvic ring is stable and Tile 2002) cannot, by definition, displace by physiological force. These injuries include type A1 avulsion fractures, Type A: stable pelvic ring injury which usually occur in adolescents and do not involve Type B: partially stable pelvic ring injury the pelvic ring. The type A2 fractures involve the iliac B1: Open book injury (AP compression, external rotation) wing or the anterior arch without a posterior injury, a B2: Latera; compression (internal rotation) rare occurrence. The type A3 fractures are transverse B3 : Bilateral injuries fractures of the sacrum and coccyx and should more correctly be considered spinal injuries. Type C: completely unstable (allows all degrees of translational displacement) 12.3.3 Stability is defined as the ability to withstand phys- Type B – Partially Stable Fractures (Table 12.2) iological forces without deformation. Therefore, at one end of the stability scale, the type A pelvic lesions 12.3.3.1 do not displace the ring, only involving the avulsions Open Book (Anteroposterior Compression) of the iliac wing or transverse sacral fractures, really Fractures (B1, B3.1) spinal injuries. In all these cases the pelvis remains intact. At the other end of the spectrum, the type C External rotatory forces applied to the pelvis usu- fractures are unstable, with complete disruption of ally cause a disruption of the symphysis pubis; how- the posterior arch, the pelvic floor, and usually the ever, they may also cause an avulsion fracture of anterior arch. The type B fractures retain some pos- the pubis adjacent to the symphysis or a fracture terior stability and are therefore partially stable; they through the pubic rami, the symphysis avulsion or cannot, by definition, translate vertically or posteri- disruption being more common. Since the force is a orly. continuum and may stop at any point, several pos- A and B types generally comprise about 70% of the sibilities exist. total fractures, even in trauma centers; the remainder First, an opening of the symphysis pubis less than are unstable type C (Pohlemann and Tscherne 1995). 2.5 cm permits stability to be retained in the pelvic The partially stable (type B) injuries are of two ring, a situation not dissimilar to that observed varieties: the open book or anteroposterior compres- during delivery of a baby. In the rare traumatic injury, sion injury, caused by external rotation, and the lat- the sacrospinous and anterior sacroiliac ligaments eral compression injury, caused by internal rotation. remain intact (Fig. 12.13). Therefore, a CT scan will It should be remembered that the open book injury show no opening of the sacroiliac joints. caused by an external rotatory force is unstable in Second, continuation of the external rotatory force external rotation, whereas the lateral compression will reach a finite end point when the “book” opens to

12.3 Classification

SCHA_12-Tile.indd 247 17.04.2005 14:28:04 Uhr 248 M. Tile

Table 12.2. Classification of pelvic ring disruption (from Tile 1988)

Comprehensive Classification Young and Burgess Classification

Type A: Stable pelvic ring injury No equivalent A1: Avulsion of the innominate bone No equivalent A2: Stable iliac wing fracture or stable minimally displaced ring fracture No equivalent A3: Transverse fractures of the sacrum and coccyx No equivalent Type B: Partially stable B1: Open-book injury APC 1, APC 11 B2: The lateral compression injury LC1, LC11, crescent fracture B3: Bilateral B injuries Windswept, complex Type C: Complete unstable C1: Unilateral APC 111, vertical shear C2: Bilateral, one side B, one side C Complex C3: Bilateral C lesions Complex

Fig. 12.13a,b. The ﬁ rst stage of an open book injury (type B1) is a disruption of the symphysis pubis only with no involvement of the sacroiliac joints (a). The patient in b, a hockey player who sustained a direct blow to the posterior sacroiliac area bilaterally, noted immediate pain anteriorly at the symphysis pubis. His radiograph indicates a symphysis pubis separation of 1.5 cm with no opening of the sacroiliac joints posteriorly. (From Tile 1995)

the extent that the posterior iliac spines abut upon the Therefore, this injury is unstable in external rotation, sacrum. In this particular circumstance, the sacrospi- but as long as the force does not continue beyond the nous ligaments and the anterior sacroiliac ligaments yield strength of the posterior ligaments, stability can are torn, but the strong posterior sacroiliac ligaments be returned to the pelvic ring by internal rotation. remain intact (Fig. 12.14). Occasionally, the poste- It is extremely important to realize that the exter- rior injury may be a fracture of the ilium or sacrum. nal rotatory force may in fact continue beyond the

12.3 Classification

SCHA_12-Tile.indd 248 17.04.2005 14:28:04 Uhr 12 Fractures of the Pelvis 249

Ultimately, with this type of force, a symphysis disruption as well as involvement of the pelvic soft tissues such as the vagina, the urethra, the bladder, or the rectum may occur. In the classification, the anterior lesion is designated by modifiers (Table 12.3). In the open book injury, typical varieties of open book fracture may occur with fractures anteriorly through the pubic rami unilaterally or bilaterally. These modifiers are descriptive of the injury, and are important for decision-making as well as clinical investigation.

Fig. 12.14a,b. The second stage of an open book injury. a Fig. 12.15. The presence of a symphysis disruption does not In this diagram note that the symphysis pubis has disrupted imply a stable conﬁ guration; in fact, most symphysis disrup- more than 2.5 cm. If that occurs, the sacrospinous ligaments tions are associated with unstable posterior lesions, as shown. tear or an equivalent avulsion of the adjacent sacrum or ischial Note the telltale avulsion fracture of the L5 transverse process, spine occurs, as well as an avulsion of the anterior sacroiliac indicating instability and posterior displacement of this frac- joints, causing a wide anterior opening of the sacroiliac joints. ture. (From Tile 1984) However, pelvic stability is maintained by the intact posterior ligamentous structures, indicated by the black lines. The endpoint is reached when the posterior iliac spines abut the sacrum. b A typical radiograph showing the disruption of the Table 12.3. Anterior pelvic qualifiers. The Qualifiers of the symphysis pubis and the markedly widened sacroiliac joints anterior arch lesions C1 to C9 are identical for all subgroups anteriorly (arrows). (From Tile 1984) of Types B and C (in part from Tile 2003) C1) Unilateral pubis / rami fx, ipsilateral C2) Unilateral pubis / rami fx, contralateral yield strength of the posterior ligament, causing C3) Bilateral pubis / rami fx a complete avulsion of the hemipelvis. This is no C4) Symphysis pubis disruption, m 2.5 cm longer an open book configuration but is now an C5) Symphysis pubis disruption, >2.5 cm unstable fracture of the worst variety (Fig. 12.15). In fact, as previously indicated, a complete trau- C6) Symphysis pubis disruption, locked matic hemipelvectomy may ensue. Therefore, the C7) Symphysis + ipsilateral pubis / rami fx (tilt) (yes) presence of a symphysis disruption does not always C8) Symphysis + contralateral pubis / rami fx imply an open book fracture. Careful assessment is C9) Symphysis + bilateral pubis / rami fx required to be certain that vertical instability is not also present. C10) No anterior lesion

12.3 Classification

SCHA_12-Tile.indd 249 17.04.2005 14:28:05 Uhr 250 M. Tile

12.3.4 Type B2.1 – Ipsilateral Fractures Partially Stable Fractures (Type B2) An internal rotation force applied to the ilium or, 12.3.4.1 more commonly, a direct blow to the greater trochan- Lateral Compression Fractures (Tables 12.1, 12.2, ter may cause a typical lateral compression or internal 12.4) rotation fracture of the hemipelvis. The superior and inferior rami break, and a crush may then occur ante- There are several types of lateral compression injury riorly at the sacroiliac joint or through the sacrum, depending upon the site of the anterior and posterior but, commonly, the posterior ligamentous structures lesion (Table 12.4). The anterior and posterior lesions do not disrupt (Fig. 12.16a). The entire hemipelvis may be on the same side or ipsilateral (type B2.1), may be forced across to the opposite side, thereby or they may be on opposite sides, producing the so- rupturing the bladder or blood vessels within the called bucket-handle type of injury (type B2.2). pelvis. The elastic recoil of the tissues may deceive the examiner, and the fracture may appear undisplaced in the radiograph. However, the radiographs in Fig. 12.16b,c show the bladder being drawn back Table 12.4. Lateral compression injury (from Tile 2003) into the fracture site by the recoiling pelvis. B2 Lateral compression injury If the bone is stronger than the ligaments, the posterior ligaments may disrupt, but stability may be B 2-1 Ipsilateral retained by an intact pelvic floor, not disrupted by the B 2-2 Contralateral type (bucket-handle) implosion force.

Fig. 12.16a–c. Lateral compression fracture, type B2.1: ipsilateral. The diagram (a) shows a typical ipsilateral type of lateral compression injury. Note the anterior crush to the sacrum and the overlap of the pubic rami. In this particular case there is posterior disruption, but stability is afforded by the crush in the sacrum and the intact pelvic ﬂ oor. The force necessary to produce this seemingly minimally displaced fracture is often underestimated because of the elastic recoil of the pelvis. This fracture, barely perceptible on the inlet radiograph (b, arrow), was obviously grossly displaced at the moment of injury, since the bladder was pulled back into it, as shown in the cystogram (c, arrow). (From Tile 1984)

b c

12.3 Classification

SCHA_12-Tile.indd 250 17.04.2005 14:28:06 Uhr 12 Fractures of the Pelvis 251

The anterior injury designated by the modifiers Type B2.2 – Contralateral: Bucket-Handle Injuries may be as follows (see Table 12.3): - Fractures of both rami. This is the most common The bucket-handle type of injury is usually caused injury, with a spike of bone possibly penetrating by a direct blow to the ilium. The anterior fracture the pelvic viscera. may be on the opposite side to the posterior lesion - Locked symphysis. This rare injury is a form of (contralateral type), or all four rami may fracture ipsilateral lateral compression type. As the hemi- anteriorly but the anterior displacement is on the pelvis internally rotates, the symphysis disrupts side opposite the posterior lesion. Another combina- and locks, making reduction extremely difficult tion might be a symphysis disruption with two rami (Fig. 12.17). fractures. - Tilt fracture. The tilt fracture consists of a sym- This injury has particular characteristics that physis disruption and a fracture of the superior may seem confusing. The affected hemipelvis rotates and/or the inferior pubic ramus, with possible anteriorly and superiorly like the handle of a bucket impingement of the bone into the vagina of young (Fig. 12.19). Therefore, even if the posterior structures females (Fig. 12.18). are relatively intact, the patient may have a major leg

Fig. 12.17a,b. Locked symphysis. a Diagram and b anteroposterior radiograph showing an unusual type of lateral compression injury where the symphysis becomes ﬁ rmly locked anteriorly. (From Tile 1984) b

a b

Fig. 12.18. a A variant of the type I injury often seen in young women. The lateral compressive force fractures the superior ramus, often through the anterior column of the acetabulum. Continuing lateral compression rotates the distal fragment through the symphysis pubis, thereby disrupting it. This distal fragment assumes a vertical position and may impinge on the perineum, as demonstrated in the anteroposterior radiograph (b). (From Tile 1984)

12.3 Classification

SCHA_12-Tile.indd 251 17.04.2005 14:28:06 Uhr 252 M. Tile

a b

c d

Fig. 12.19a–d. Type B2.2 lateral compression injury. The diagram (a) demonstrates a typical type B2.2 lateral compression injury, characterized by compression of the posterior sacroiliac complex associated with a straddle or butterﬂ y fracture of the four pubic rami anteriorly. The anteroposterior (b), inlet (c), and outlet (d) views of this 19-year-old woman show this classic lesion with upward rotation and impaction of the right hemipelvis. Even under general anesthesia, this hemipelvis could not be moved on the third day following injury, indicating severe posterior impaction

length discrepancy. Very often, the posterior struc- flexion forces but the posterior spinous ligament tures are firmly impacted, the deformity being clearly has ruptured. An excellent example of this is shown noted on physical examination. Reducing these frac- in Fig. 12.20a. The original radiograph of this 16- tures and thereby the leg length discrepancy requires year-old girl shows the internal rotation of the left derotation of the hemipelvis rather than pure trac- hemipelvis and the posterior impaction. All four tion in the vertical plane. rami are broken anteriorly and the leg length dis- With continued internal rotation, the posterior crepancy is seen. The CT scan (Fig. 12.20b) again structures may yield, producing some instability. shows the left hemipelvis to be internally rotated However, the anterior sacroiliac crush is usually so and the anterior portion of the sacroiliac joint stable that reduction is difficult, and some stability is crushed. Posteriorly, the arrow points to the avul- maintained by the intact pelvic floor and the sacro- sion of the posterior iliac apophysis (Fig. 12.20b,c). spinous and sacrotuberous ligaments. At surgery, the apophysis was clearly avulsed but This is akin to the situation with a vertebral frac- the posterior sacroiliac ligaments were completely ture, where the vertebral body may be crushed by intact. After posterior reduction of the fracture and

12.3 Classification

SCHA_12-Tile.indd 252 17.04.2005 14:28:07 Uhr 12 Fractures of the Pelvis 253

a b

c d

Fig. 12.20. a Anteroposterior radiograph of a 16-year-old girl with a type B2.2 bucket-handle fracture. The fracture involves all four pubic rami and the left sacroiliac joint. b Computed tomography (CT) clearly outlines the essential features of this fracture. Note the anterior crush of the sacrum, the internal rotation of the left hemipelvis, and, in this case, the avulsion of the iliac apophysis, which had not yet fused to the ilium (arrow). c Clinical appearance at surgery of this apophysis avulsion (outlined by the probe, arrow). d Appearance after reduction and ﬁ xation with two lag screws crossing the sacro- e iliac joint. e Postoperative radiographic appearance

12.3 Classification

SCHA_12-Tile.indd 253 17.04.2005 14:28:08 Uhr 254 M. Tile

fixation by two screws, the pelvis is anatomically Telltale radiographic signs of instability include reduced (Fig. 12.20d,e). avulsion of the transverse process of the L5 vertebra or of either attachment of the sacrospinous ligament Type B3 – Bilateral Partially Stable Injuries (Fig. 12.22). Greater than 1 cm of posterior or vertical translation is noted. The CT scan shows the radio- The B3 bilateral injuries may be the classical open graphic appearance of the unstable posterior com- book type (B3.1), or one side B1 and one side B2 plex better than the plain radiograph and should be (B3.2), or bilateral B2 (B3.3). obtained in all cases. A comparison of the CT scans (Fig. 12.23) shows clearly the difference between the impacted stable 12.3.5 posterior complex and the grossly unstable complex Type C – Unstable Fractures – of the vertical shear injury. Complete Disruption of the Posterior Arch (see Tables 12.1, 12.2)

An unstable pelvic disruption implies disruption of the posterior sacroiliac arch as well as a rupture of the pelvic floor, including the posterior structures as well as the sacrospinous and sacrotuberous ligaments (Fig. 12.21). The unstable injury may be unilateral (type C1), affecting one posterior iliac complex, or may be bilateral (type C2 or C3), affecting both. The unilateral lesions may be fractures of the ilium (type C1.1) through the sacroiliac joint, or either a pure dislocation or a fracture-dislocation with involved ilium or sacrum (type C1.2), or a fracture of the sacrum (type C.1.3). The bilateral types C2 include one side unstable (C) and one side partially stable (B), while the C3 a lesions include bilaterally unstable types.

Fig. 12.21. Unilateral unstable vertical shear fracture. Shear- Fig. 12.22a,b. Telltale signs of instability. a Avulsion of the ing forces cause massive disruption of the pelvic ring, includ- ischial spine (black arrow) and posterior displacement of the ing the pelvic ﬂ oor. Note the avulsion of the ischial spine and ilium (white arrow). b Avulsion of the sacral end of the sacro- the tip of the transverse process of L5, both signs of pelvic spinous ligament (black arrow) and the tip of the transverse instability. Note also the stretch of the lumbosacral plexus, process of L5 on the opposite side (white arrow) in this bilat- commonly injured in this pattern of injury. (From Tile 1984) eral injury. (From Tile 1984)

12.3 Classification

SCHA_12-Tile.indd 254 17.04.2005 14:28:08 Uhr 12 Fractures of the Pelvis 255

a b

Fig. 12.23. a CT scan showing marked disruption and instability of the left sacrum as a result of a shearing force. b CT scan showing impaction of the right sacrum from a lateral compression injury. This young woman sustained an acetabular fracture as well, conﬁ rming the mechanism of injury. Note the marked overriding of the sacral fragments on the fractured side as compared to the normal left side. Impaction was so rigid that no abnormal movement of the hemipelvis was detected on physical examination with image intensiﬁ cation. (From Tile 1984)

12.3.6 12.3.6.3 Unusual Types of Fracture Pelvic Disruptions Associated with Acetabular Fractures 12.3.6.1 Complex Fractures If a pelvic ring disruption is associated with an acetabular fracture, the prognosis will clearly change Many severe types of fracture dislocation of the pelvis and will be more dependent upon the acetabular defy precise classification because of the complex component than upon the pelvic ring disruption. forces causing the injury. In these cases, the pelvic These complex injuries are relatively common. CT ring may be disrupted in a very bizarre fashion. scanning of acetabular fractures has indicated a sig- Because of the high-energy forces involved, the pelvic nificant number of sacroiliac injuries and pelvic ring ring is usually unstable; since most are bilateral, most disruptions associated with acetabular fractures. In will fall into the C3 classification. the comprehensive classification, the pelvic ring component is classified separately from the acetabulum 12.3.6.2 (see Chap. 13). Bilateral Sacroiliac Dislocation with an Intact Anterior Arch

This unusual injury is usually caused by hyperflex- 12.4 ion of the legs (for example, two of our cases were Natural History in young women who were crushed in the hyper- flexed position under a horse that reared and fell In an attempt to further elucidate the incidence and backwards). In this particular situation, the anterior severity of the early and late musculoskeletal compli- complex remains intact but both sacroiliac joints dis- cations of this injury, we undertook a clinical study locate posteriorly (C3). in association with R. Lifeso, D. Dickinson, and R. McBroom (Dickinson et al. 1982). The purpose of this study was to place the management of this injury in perspective by determining which pelvic fractures

12.4 Natural History

SCHA_12-Tile.indd 255 17.04.2005 14:28:09 Uhr 256 M. Tile

Table 12.5. Comparison of series A and series B patientsa had the poorest prognosis. With the current trend to (from Tile 1984) internal fixation of the pelvis, a study of the natural Series A Series B history of this injury is even more important, in order (n=148) (n=100) to place that trend in perspective, for without knowledge of the natural history, logical decision-making 1. Age (range) 34.2 years 30.9 years becomes impossible. The results of our review of 248 (15–81) (14–85) cases are shown in Tables 12.5–12.9. 2. Sex In this study, every patient was recalled, personally Male 91 55 interviewed, examined, and radiographed using the Female 57 45 inlet, outlet, and anteroposterior views. The conclusions may be summarized as follows: 3. Injury types 1. Stable injuries gave few major long-term problems. Motor vehicle accidents 89 (60%) 81 Pain, if present, was usually mild or moderate. Fall 17 (11.5%) 11 2. By contrast, patients with unstable pelvic disrup- Crush 34 (23%) 4 tions had many problems at review. Approximately Miscellaneous 8 (5.5%) 4 30% of this group had continuing pain, including 3% with nonunion of the posterior complex and 4. Workmen’s Compensation 43 (29%) 5 Board 5% with malunion, defined as having a greater than 2.5-cm leg length discrepancy. In addition, 5% had 5. Associated injuries permanent nerve damage, and 3% continuing ure- CNS 31 (21%) 38 thral problems following urethral rupture. Chest 19 (13%) 15 Gastrointestinal 10 (6.6%) 20 Table 12.6. Factors resulting in unsatisfactory results (from Bladder 17 (11%) 8 Tile 1984) Urethra 6 (4%) 4 Series A: Series B: Nerve 12 (8%) 3 37/148 35/100 Musculoskeletal 63 (43%) 10 Pain 37 32 6. Follow-up average 60 mo 2 years Leg length discrepancy >2 cm 7 2 aIn Tables 12.5 and 12.6, series A is a group of 148 cases of Nonunion 5 3 pelvic fracture managed in Toronto teaching hospitals and in nonteaching hospitals in Ontario, retrospectively reviewed; Permanent nerve damage 9 3 series B consists of the first 100 cases of pelvic fracture treated Urethral symptoms 5 1 at the Sunnybrook Medical Center, Toronto, prospectively reviewed Deaths 17

Table 12.7. Pain (moderate and severe) (from Tile 1984)

Series A (n=148) Series B (n=100) No.NilModerateSevereNo.NilModerateSevere Incidence 53 (36%) – – – 35 – – – Location Posterior 47 (32%) – – – 32 – – – Anterior 6 (4%) 3 Severity Anteroposterior compression 23 14 8 1 6 3 3 Lateral compression 86 47 35 4 69 53 16 Unstable (shear) 9 4 2 3 25 9 13 3 Total 118a 65 45 8 100 65 32 3 aThirty cases with major acetabular involvement were not considered in this total

12.4 Natural History

SCHA_12-Tile.indd 256 17.04.2005 14:28:10 Uhr 12 Fractures of the Pelvis 257

The pain, when present, usually arose from the posterior sacroiliac joint area or from the lower 12.5 lumbar spine. CT has shown lumbar spine involve- Management of the Pelvic Disruption ment in significant numbers of patients with pelvic disruption. The pain in these cases was more severe, Management of a pelvic disruption depends on the and usually associated with an unreduced sacroiliac “personality” of the injury as well as that of the asso- dislocation or a nonunion. ciated injuries (see Fig. 12.1) and may be considered In summary, the natural history of pelvic trauma under the following four headings: assessment, resus- depends on the degree of violence, the type of injury, citation, provisional stabilization, and definitive sta- the method of treatment, and the presence or absence bilization, which, although considered separately, of complications such as a urethral tear, permanent form a continuum of care. nerve damage, malunion, malreduction of the sacroiliac joint, or nonunion. The unstable vertical shear injury results in a significant number of permanent 12.5.1 problems resulting in posterior pain. Assessment Therefore, it is obvious that most of our energies should be directed to the management of the unstable 12.5.1.1 vertical shear injury, especially if the sacroiliac joint General Assessment is dislocated or subluxated, since more stable injuries achieve good to excellent results when managed by It is beyond the scope of this chapter to detail the simple means, as will be described. general assessment of the polytraumatized patient. Suffice it to say that a polytraumatized patient with a pelvic fracture represents a therapeutic challenge to the treating surgeon because the mortality rate remains approximately 10%, and as high as 31% Table 12.8. Leg length discrepancy (malunion) (from Tile in the unstable pelvis (type C) (Pohlemann and 1984) Tscherne 1995). The necessity of a planned treatment protocol for the polytraumatized patient Amount Series A Series B (cm) (%) (%) cannot be overemphasized. The patient must have immediate appropriate treatment from the time of 06468 injury until stabilization in an appropriate inten- 0–1 19.5 19 sive care unit. The central theme of system man- 1–2 11.5 11 agement during resuscitation is simultaneous rather than sequential care. We recommend the treatment >2 5 2 protocol of the American College of Surgeons in

Table 12.9. Results by fracture type (from Tile 1984)

Series A Series B (n=148) (n=100) Total No. Satisfactory Unsatisfactory Total No. Satisfactory Unsatisfactory (n) % (n) % (n) % (n) % Anteroposterior 23 18 78 5 22 6 3 50 3 50 compression Lateral 114 79 69 35 31 69 53 77 16 23 compression Unstable (shear) 9 5 56 4 44 25 9 36 16 64

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 257 17.04.2005 14:28:10 Uhr 258 M. Tile

the Advanced Trauma Life Support (ATLS) Program compression of both anterior iliac spines. Lateral (Aprahamian et al. 1981). compression injuries are usually in an anatomical In the primary survey, problems involving the recoiled position unless they have been impacted. airway, bleeding (shock), and the central nervous Further internal rotation by compression of the iliac system have the highest priority. Immediate life- crests will displace the fracture. Finally, by apply- saving resuscitation, therefore, must be directed to ing one hand to the pelvic iliac crest and using the both the airway and the presence of shock. In pelvic other to apply traction to the leg, displacement in trauma, shock may be profound due to retroperito- the vertical plane can usually easily be diagnosed neal arterial or venous hemorrhage. (Fig. 12.24b). This maneuver may require two exam- The secondary survey following the primary resus- iners, one to apply traction and the other to pal- citation includes further examination of the airway, pate the iliac crests. If possible, these manipulations bleeding, the central nervous system, the digestive should be done under image intensification to verify system, the excretory system, and, finally, the frac- the type of displacement and whether displacement ture. For further study in the management of poly- in the vertical plane is present. trauma patients, we refer the reader to the excellent monograph on this subject by the American College of Surgeons mentioned above.

12.5.1.2 Specific Musculoskeletal Assessment

For the management of the musculoskeletal injury, assessment is directed to the determination of the stability of the pelvic ring.

Clinical Assessment

As in all areas of clinical medicine, an accurate a history is essential; patients who have sustained a high-energy injury from motor vehicle trauma or falls from a height are much more likely to have an unstable pelvic injury than are those who have sustained low-energy trauma. The physical examination is at least as important as the radiographs in determining pelvic stability. The essence of the physical examination is to inspect b the patient for major bruising or bleeding from the urethral meatus, vagina, or rectum. If these latter two Fig. 12.24. a Direct palpation of the iliac crest will reveal crep- areas are not carefully inspected, occult lacerations itus or abnormal motion, which, if present, is the best indica- may be overlooked, with dire consequences, since tor of instability of the pelvis. b With one arm controlling the injured hemipelvis and the second arm applying traction, the these lacerations always mean an open fracture of the amount of instability present can be determined. (From Tile pelvis. 1984) The pelvic area and the lower extremities should be examined with the patient undressed, so that displacement and limb shortening can be detected. In Radiographic Assessment the absence of a lower extremity fracture, rotatory deformity or limb shortening usually implies an Plain Radiographs. As a routine in the acute situ- unstable pelvic injury. ation, a single anteroposterior radiograph as com- Determination of pelvic stability can simply be monly used in most trauma centers is usually suffi- done by the physician applying his or her hands to cient to determine the presence or absence of pelvic the anterior superior spine and moving the affected ring instability. Although this radiograph will suffice hemipelvis (Fig. 12.24a). Open book injuries are in the acute injury during the resuscitative phase, a maximally externally rotated and can be closed by single anteroposterior radiograph may be mislead-

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 258 17.04.2005 14:28:10 Uhr 12 Fractures of the Pelvis 259

ing. Therefore, for accurate assessment of pelvic ring These views are now also used for radiographic displacement, an inlet and an outlet view should be control of iliosacral screw placement; therefore, added (Fig. 12.25). The inlet view, taken by directing knowledge of the skeletal landmarks is important. the X-ray beam 60° from the head to the midpelvis, is the best radiographic view to demonstrate posterior CT Scan. The CT scan is the best single investiga- displacement. The outlet view, taken by directing the tive tool for determining pelvic instability, since the X-ray beam from the foot of the patient to the sym- sacroiliac area is best visualized by this technique. physis at an angle of 45°, demonstrates superior or Stable impacted fractures of the sacrum can be inferior migration of the hemipelvis. clearly differentiated from grossly unstable ones by

a b

c d

Fig. 12.25a–e. With the standard anteroposterior radiograph, inlet and outlet views may be very helpful. The outlet view as shown on the skeleton (a) and the radiograph (b) is the best view for visualizing the sacrum, the sacroiliac joints, and the sacral foramina, caudad and cephalad displacement is seen as well. The inlet view, as noted in the skeleton (c) and radiograph (d) best delin- eates posterior displacement of the hemipelvis. e Note the different information obtained from the above views e compared to the anteroposterior view. (From Tile 1984)

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 259 17.04.2005 14:28:11 Uhr 260 M. Tile

this method (see Fig. 12.3). In pelvic ring trauma, 12.5.2 three-dimensional CT is helpful in assessing the Resuscitation overall injury pattern, but not nearly as much as in acetabular trauma. Hemorrhage in pelvic trauma may be life-threatening. The site of bleeding is determined by peritoneal 12.5.1.3 lavage, portable ultrasound, or CT. CT using contrast Diagnosis of Pelvic Instability may give a rapid picture of arterial bleeding, and is being advocated by some authors (Fig. 12.26). In the Careful clinical and radiographic assessment will resuscitative phase, control of hemorrhage must be allow the surgeon to determine the personality of the rapid and may be lifesaving. pelvic injury, i.e., whether the musculoskeletal injury Patients with an unstable pelvic disruption are at is more to the stable or to the unstable end of the much greater general risk than those with a stable stability scale. The completely unstable (type C) can pelvis. In our first prospective study of 100 patients, usually be diagnosed clinically by the lack of a firm 12 of the 15 mortalities were in this unstable group endpoint in rotation or traction. Radiographically, a (McMurtry et al. 1980). Their blood transfusion displacement or gap on plain X-ray or CT equivalent requirements were three times greater (15.5 units vs. to 1 cm and the presence of avulsion fractures of the 5.5 units), their injury severity score was 37 (vs. 29 in ischial spine or sacrum all suggest instability. those with a stable pelvis), and their overall complica- Patients with partially stable (type B) have a firm tion rate was three times higher. endpoint on palpation, be it external rotation (B1) Patients suffering this complication require mas- or internal rotation (B2). In the latter, the pelvis may sive fluid replacement, as outlined by the American be impacted in the internally rotated position (see College of Surgeons’ ATLS protocol. Early manage- Fig. 12.19). ment of shock should include the pneumatic anti-

Fig. 12.26a–c. A 70-year-old female struck by a car sustained an unstable C-type pelvic fracture. She was in shock, with no obvious source. a: Skeletal traction was applied to her right leg. b: A contrast-enhanced CT showed extravasation that correlated with angiographic ﬁ ndings indicating bleeding from the obturator artery. c: 9 h post-injury shows successful angiographic embolization of obturator artery. (Courtesy of b Dr. David Stephen). (From Tile 2003)

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 260 17.04.2005 14:28:11 Uhr 12 Fractures of the Pelvis 261

shock garment (PASG). The advantages and disad- small-bore artery such as the obturator or the supe- vantages of the PASG are listed in Table 12.10. In our rior gluteal arteries. Because of early diagnosis of opinion, the advantages outweigh the disadvantages, arterial bleeding, using advanced imaging (including the only notable disadvantage being restriction of contrast-enhanced CT), the overall use and effective- access to the abdomen. The garment must not be ness of embolization have increased. Earlier arterial precipitously released. During gradual release of the embolization for the right indication is desirable. garment, the blood pressure must be carefully moni- Embolization is of little value in hemodynamically tored. Any drop greater than 10 mmHg in the systolic unstable patients in extremis with massive bleeding blood pressure is a contraindication to further defla- from the major vessels of the internal iliac system, tion. Other guidelines of importance include inflation because the emboli cannot control this type of hem- of the legs prior to the abdominal portion and revers- orrhage, and the patient may die during the attempt. ing that order during deflation. In transfer situations, It is also, of course, of no value in venous or bony great care must be taken to prevent lengthy inflation bleeding. periods, which may cause compartment syndromes Small-bore artery bleeding may be assumed if, in the lower extremity. although the patient can be well controlled using the above methods of fluid replacement, PASG, and frac- Table 12.10. Pneumatic antishock garment (PSAG; from ture stabilization, he or she goes back into a shocked Tile 2003) P. 74 state each time the fluid is slowed down. A more precise diagnosis is made on contrast- Advantages Disadvantages enhanced CT (see Fig. 12.26) or definitively on angi- Simple Short-lasting volume effect ography. In those circumstances, after hemodynamic Rapid Compartment syndrome of lower stability has been achieved, the patient is moved to extremity the vascular suite, an arteriogram is performed, and Reversible Decreased access to abdomen if a small-bore artery is lacerated it is embolized with and lower extremity Gelfoam (Upjohn Pharmaceutical) or other embolic Accessible and available Decreased visibility of abdomen material. and lower extremities Direct surgical control is rarely indicated and is usually unsuccessful. However, urgent laparotomy Safe Fracture of lower extremity and packing the pelvis in patients in extremis are Decreases lung compliance becoming widely used, especially in Europe, and will be evaluated (Pohlemann et al. 1993; Ertel 2003). Fracture stabilization belongs in the resuscitative Open surgery is also indicated for open fractures. phase of management. There is a growing body of Very high mortality rates have been reported with evidence to suggest that the application of a simple open pelvic fractures (Richardson et al. 1982). How- anterior external frame will reduce retropelvic ever, the type of open pelvic injury, be it posterior venous and bony bleeding to the extent that other or peroneal, is of great prognostic significance, and intervention is rarely required. Therefore, pelvic sta- therefore all open pelvic fractures cannot be lumped bilization should be performed early. Pelvic clamps together. It must be recognized that some pelvic frac- which can be applied in the emergency room with tures are actually traumatic hemipelvectomies, and, direct skeletal fixation are now available and are rarely, completing the hemipelvectomy may be life- useful in the patient with an unstable pelvic ring and saving (Lipkowitz et al. 1982). severe bleeding (Ganz et al. 1991). It is hoped that this will reduce mortality by allowing the volume of the pelvis to decrease to its normal size, thereby restoring 12.5.3 the tamponade effect of the bony pelvis and helping Provisional Stabilization to stop the venous bleeding. The precise method for early fracture stabilization will be discussed in the Provisional stabilization is required only for those next section. fractures that potentially increase the volume of the The role of embolization of the pelvic vessels has pelvis, i.e., the wide open book injury (B1, B3.1) or largely been clarified, but its use varies greatly from the unstable pelvic fracture (C). It is rarely required institution to institution, depending on local circum- for lateral compression injuries (B2), which make up stances. In our trauma unit, we have narrowed its use a large percentage of the total number of pelvic dis- to those patients who are bleeding mainly from a ruptions.

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 261 17.04.2005 14:28:12 Uhr 262 M. Tile

12.5.3.1 and bony bleeding. An added beneficial effect is a External Fixation or Pelvic Clamp major reduction in pain and the ability to induce the upright position to better ventilate the patient in the Provisional fixation can be obtained by a pelvic clamp intensive care unit. Since such patients are usually or by an anterior external skeletal fixator. Whichever extremely ill, we believe that a simple configuration is used, it should be applied quickly. will suffice – two pins percutaneously placed in each The AO Pelvic Clamp (Fig. 12.27a,b; Ganz et al. ilium at approximately 45° to each other, one in the 1991, 2003) was designed to be used in the resuscita- anterior superior spine and one in the iliac tuber- tion room, to be applied quickly, to reduce the pelvic cle, joined by an anterior rectangular configuration volume, and to impart some stability to the pelvis, (Fig. 12.27). thereby reducing bleeding. This clamp is designed Recently, especially in older patients, there has to close the posterior aspect of the pelvic ring; there- been a trend towards the use of one pin in the supra- fore the concept is good, and in the right indication acetabular area (Fig. 12.27b). There is good bone in it has proved successful in the early resuscitation this area, but care must be taken to avoid penetra- phase of treatment. The anterior frame will reduce tion of the hip joint. The pin must be confirmed to be the volume of the pelvis, thereby reducing venous extra-articular on image intensification.

a c

Fig. 12.27a–d. External fi xation devices for the pelvis. a The AO pelvic clamp applied in the axis of the sacroiliac joints by hammering the spikes into the outer table of the ilium. b Note the clamp in place in a patient who had uncontrollable bleeding which stopped quickly following the application of the clamp. c Traditional fi xation device on the pelvic ring. In this case, only two pins were used at 45° to each other during the resuscitation of a critically injured patient. d The use of supraacetabular pins which must be inserted with image intensifi cation to avoid entering the hip joint d

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 262 17.04.2005 14:28:12 Uhr 12 Fractures of the Pelvis 263

Biomechanical studies performed in our labora- in the distal femur may be very helpful until defini- tory and elsewhere have shown that simple frames tive treatment is initiated. With the frame or clamp in can give good stability in the open book fracture place, 15–20 kg of traction will prevent the hemipel- (Fig. 12.28a, from Tile et al. 2003). However, in the vis from shortening (Fig. 12.29, Tile et al. 2003), thus unstable pelvic disruption, even the most elaborate facilitating secondary internal fixation. In the event frames cannot fully stabilize the pelvic ring if the that the patient is extremely ill and internal fixation patient is to be ambulated (Fig. 12.28b, from Tile et al. is undesirable or unsafe, this may become definitive 2003). In our opinion, sophisticated frames requiring and lead to a good outcome (Fig. 12.30). In most cases dissection to the anterior inferior spine are contrain- of unstable pelvic fractures, the frames or clamps dicated in the acute resuscitation period. They have should be applied rapidly and in such a way that they some biomechanical advantage, but this advantage is do not interfere with laparotomy. This is desirable in so slight that the added risk of the operative proce- almost all instances, unless it is certain that the life- dure is not worth taking. However, the supra-acetab- threatening hemorrhage is intraperitoneal. ular pin is usually inserted by closed percutaneous techniques, and is generally safe and effective. 12.5.3.3 Early Internal Fixation 12.5.3.2 Role of Skeletal Traction What is the role of internal fixation in the early resuscitative phase of treatment? Present literature reports Skeletal traction has its major indication in the early show increased complications (McGowan et al. 1987; phase of treatment, in stabilizing the unstable pelvis, Schied et al. 1991). However, early internal fixation in association with an external frame or clamp. may be indicated as follows: Since the frames or clamps cannot restore stability a) Anterior stabilization of the symphysis and medial to unstable type C fractures, a temporary traction pin rami. If the patient is undergoing laparotomy and

Antero-Posterior Compression Injury Unstable Vertical Shear Injury Newtons (Anterior Fixation) 2000 Newtons > 1960 Newtons 2 Plates

300 2 Plates + Trapezoidal Frame

Dwyer Vertical Loads Vertical 1000 Loads Vertical 200 Rectangular (5mm pins)

Double Cluster Frame Double Cluster 100 2 Plates Rectangular Frame 1 Plate Trapezoidal Frame Rectangular Trapezoidal 0 0 a 1 cm Displacement 1 cm Displacement b

Fig. 12.28. a Results of the biomechanical tests in the typical anteroposterior (open-book) type injury produced in the labora- tory by division of the symphysis pubis and anterior sacroiliac ligaments. The posterior tension band of the pelvis was intact. Of the external frames, the double-cluster frame was best, the trapezoidal the weakest. Because 1 kg equals approximately 10 N, both the rectangular and double-cluster frames gave suitable stable fi xation for this type of injury. b Graph demonstrates the biomechanical results of the unstable vertical shear injury produced by complete division of the symphysis pubis anteriorly of the sacrospinous and sacrotuberous ligaments. Note that the vertical axis is measured in hundreds of newtons, as compared with thousands in the stable confi guration. A 100-N load is equal to approximately 10 kg. From this graph, one can see that all forms of anterior fi xation fail under 20 kg of load when used to stabilize an unstable vertical shear type pelvic disruption. The best frame tested was one anchored on 5-mm pins with a rectangular confi guration and two side bars for triangulation. (From Tile 2002)

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 263 17.04.2005 14:28:13 Uhr 264 M. Tile

a symphysis disruption is present, plating will greatly simplify the further treatment. This is also true for medial rami fractures. Lateral rami fractures at this time are better treated by an external frame. If a urologic procedure has been performed, the urologist should use a suction drain and catheter, not a suprapubic tube, which is a risk factor for sepsis. Two plates at 90° to each other will give excellent stability to the unstable pelvis when combined with an external frame, and may be definitive care in some very sick patients. b) Posterior stabilization. Early posterior fixation is risky and should only be done in pelvic centers. However, with improved imaging and guidance Fig. 12.29. Unstable pelvic ring (Type C) in 19-year-old man. systems and using percutaneous minimally inva- Note the intramedullary nail in L femur and the external ﬁ x- sive techniques, many centers now proceed to fix ator. Traction was not used because transfer was contemplated, the posterior pelvis acutely, if the general state of but was delayed 6 weeks because of his medical state. Skeletal traction would have avoided this extreme deformity. (From the patient allows. Tile, Helfet, and Kellam 2003)

a b

c d

Fig. 12.30a–d. This 39-year-old patient sustained an unstable pelvic disruption with abdominal and head injuries. An external fi xator was applied as a life-saving measure, as was a skeletal traction pin in the left femur. Note the wide posterior gap at the sacroiliac joint in spite of the external fi xator and the traction. Attempts were made on three separate occasions to take this patient back for internal fi xation of the posterior sacroiliac complex, but he was so medically unstable that on two occasions he had cardiac arrests in the intensive care unit prior to surgical intervention. Because of that it was decided to continue his pelvic treatment. At 6 weeks there was massive callus in the left sacroiliac joint. Traction was continued for 8 weeks. The left sacroiliac joint healed with no shortening and a good outcome. b CT showing a wide opening of the sacroiliac joint

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 264 17.04.2005 14:28:13 Uhr 12 Fractures of the Pelvis 265

12.5.4 above (Fig. 12.27). The pins should remain in place for Definitive Stabilization approximately 6–8 weeks; the frame should then be loosened and radiographs taken under stress to see Definitive stabilization of the musculoskeletal injury whether healing has occurred and whether there is depends upon a precise diagnosis of the fracture con- stability across the symphysis. If healing is adequate, figuration. No matter what the configuration, if the the pins are removed at this stage. If not, the anterior pelvic ring is stable and undisplaced or minimally frame is reattached for a further 4-week period. With displaced, symptomatic treatment only is necessary. no vertical displacement possible, the patients may Patients with this injury may be mobilized quickly be quickly ambulated. Reduction is best obtained in and the pelvic fracture, i.e., the musculoskeletal the lateral position or in the supine position with injury, largely ignored. both legs fully internally rotated.

12.5.4.1 Internal Fixation. If the patient has a visceral injury Stable Fractures (Type A) necessitating a paramedian midline or Pfannenstiel incision, or if preferred by the surgeon to external Therefore, virtually all type A fracture can be man- fixation, internal fixation using a 4.5-mm plate will aged symptomatically with the following exceptions. restore stability. In this particular injury with partial Avulsion fractures (A1) of the iliac crest, especially stability, a single four-hole plate placed across the in young athletes, can be simply fixed with lag screws superior surface of the symphysis pubis will restore if widely displaced. Fractures of the iliac wing with stability. The type of plate will vary with the specific wide displacement (A2) may, with full informed con- injury: 3.5-mm low contact-dynamic compression sent, be fixed with standard techniques, especially in (LC-DC) plate or curved reconstruction, occasionally young women, as this injury can leave a malalign- 4.5 mm. This should be done immediately after the ment of the iliac crest. Transverse sacral fractures abdominal procedure prior to closure of the skin. In (A3) should be considered spinal injuries; therefore, this instance a double plate, recommended for sym- with wide displacement and a sacral plexus neurolog- physis fixation of unstable fractures, is unnecessary, ical deficit, reduction of the fracture with or without since the open book fracture is inherently stable. decompression is usually required. Spica or Sling. The patient with an open book fracture Open Book (Anteroposterior Compression) Fractures may also be treated with either a hip spica with both (Type B1, B3.1) legs internally rotated or in a pelvic sling. These two methods are better suited to children and adolescents This lesion may be unilateral or bilateral, but the than to adults, and we much prefer external fixation treatment is more dependent on the extent of the as definitive treatment for this fracture configuration. injury overall. The anterior disruption is indicated Nursing care with these options is difficult, and long in the classification by a modifier: α4 indicates a periods of bed rest are required, with the ensuing symphysis disruption of less than 2.5 cm, and α5 of complications; therefore this method is not recom- more than 2.5 cm. mended at this time. In the open book fracture, with the symphysis pubis open less than 2.5 cm (α4), no specific treat- Lateral Compression Fractures (Type B2) ment is indicated. Patients with this injury usually have no posterior disruption and have intact sacro- Lateral compression fractures are usually partially spinous ligaments (see Fig. 12.13). Therefore, the stable, and therefore surgical stabilization is rarely situation is somewhat akin to the stretching of the required; it is called for only if reduction is necessary symphysis pubis that takes place during pregnancy. to correct malalignment or leg length discrepancy. With simple symptomatic treatment, i.e., bed rest Since these injuries often result in an impacted pos- until comfortable, healing is usually adequate and terior complex, an intact pelvic floor, and hence a few patients complain of any symptoms. relatively stable pelvis, disimpaction and reduction If the symphysis pubis is open more than 2.5 cm (see should only be done if the clinical state of the patient Fig. 12.14), several options are available to the surgeon. warrants it. This will vary with the age of the patient, the general medical state, the degree of rotation of the External Fixation. We prefer stabilization of the pelvis hemipelvis, and the amount of leg length discrepancy. with a simple anterior external frame, as described In a young individual, a leg length discrepancy of

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 265 17.04.2005 14:28:14 Uhr 266 M. Tile

more than 2.5 cm or marked internal rotation which cannot be compensated by external rotation of the hip are indications to reduce the lateral compression injury. This is especially true in bucket-handle injuries. However, we must stress again that the vast majority of lateral compression injuries may be treated with bed rest alone and do not require any external or internal fixation (Fig. 12.31). If reduction is desirable for the above reasons, it may be effected manually with external rotation (Fig. 12.32a) or with the aid of external skeletal pins placed in the hemipelvis (Fig. 12.32b,c). By placing a handle on the cross-rod and applying an external rotation force, the bucket-handle fracture may be reduced by derotation externally and posteriorly, a allowing disimpaction of the posterior complex. In some instances, reduction is impossible and the surgeon must decide whether open reduction, the only remaining option, is necessary. Undue force applied to the pins may dislodge them from the bone; therefore, the major reduction force must be on the bone itself, not the pins. If external skeletal pins have been used to help with reduction, a simple rectangular anterior frame should be applied at the end of the maneuver to hold the hemipelvis in the external rotated position. In polytrauma patients, a simple external skeletal frame is indicated to relieve pain, to allow some movement in bed, and even the upright position, which in turn allows for easier nursing care. In this pattern, b good stability is obtained with the anterior frame. Internal fixation of a lateral compression injury is rarely indicated except in the atypical type with bony protrusion into the perineum, especially in women. In that particular case, a short Pfannenstiel incision will allow derotation of the superior ramus, and fixation with a threaded pin is ample (Fig. 12.33). The pin may be removed at 6 weeks in the stable configuration. Rarely, if deformity is great and cannot be reduced closed, open reduction and internal fixation are indicated. Warning: Pelvic slings are contraindicated in lateral compression and unstable vertical shear injuries since they will cause further major displacement (Fig. 12.34). c Fig. 12.31a–c. Stable lateral compression injury (type B2.2). 12.5.4.2 a Anteroposterior X-ray of a 16-year-old girl with a stable Unstable Fractures (Type C) lateral compression injury. Note the fracture in the left ilium (arrow) and all four pubic rami. b Cystogram of the same In unstable shear fractures, simple anterior frames patient showing a ruptured bladder. c Final result at 1 year was excellent. Treatment consisted of 8 weeks of complete bed will not be adequate for definitive management, as rest followed by ambulation with partial weight bearing for an attempt to ambulate the patient will often result in a further 4 weeks. Note that all fractures are healed and the redisplacement (Fig. 12.35). Therefore, the two options position is good

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 266 17.04.2005 14:28:14 Uhr 12 Fractures of the Pelvis 267

Fig. 12.33. a The original radiograph demonstrates the c rotated superior ramus of the left pubis through a disrupted symphysis pubis. b Since the posterior complex is stable, open Fig. 12.32. a Closed reduction of a lateral compression-type reduction and internal fi xation with a threaded Steinman pin injury is performed by external rotation of the hip with the restored stability. c Union occurred quickly, and the pin was knee fl exed and direct pressure on the hemipelvis, as shown. removed at 6 weeks. (From Tile 1984) b The type of leverage that can be obtained by placing handles on the crossbars of the external fi xation device to allow for both internal and external rotation of the unstable hemipelvis. c Diagrammatic representation on a CT scan indicating the type of direct leverage that can be obtained on the affected hemipelvis. (From Tile 1984)

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 267 17.04.2005 14:28:15 Uhr 268 M. Tile

a b

Fig. 12.34. a Pelvic slings are illogical in patients with lateral compression or unstable injuries, as they will recreate the original force and cause displacement. b Note the amount of persistent displacement and impingement on the bladder. Note also that neither the superior ramus nor the fracture through the sacrum is united. (From Tile 1984)

a b

c d

Fig. 12.35. a Anteroposterior cystogram showing an unstable fracture of the pelvic ring including a symphysis disruption and fracture through the left sacrum. Treatment consisted of a double-cluster frame. b The postreduction radiograph shows adequate position. c,d After ambulation, however, redisplacement occurred, as shown on the radiograph (c) and CT scan (d). Anterior frames do not afford sufﬁ cient stability to allow early ambulation in unstable pelvic ring disruptions. (Case courtesy of Dr. Ronald Rosenthal, Long Island, NY)

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 268 17.04.2005 14:28:15 Uhr 12 Fractures of the Pelvis 269

open to the surgeon are either the addition of femoral The traction must be maintained for 8–12 weeks supracondylar skeletal traction or internal fixation. and the patient monitored with anteroposterior and inlet radiographs as well as CT scans, where indicated. Skeletal Traction with External Fixation A major problem in the past has been too-early ambulation of these patients, who require a longer period Isolated, unstable shear injuries may be safely and of recumbency to allow for sound bony union. adequately managed by the addition of a supracondylar femoral traction pin to a pelvis stabilized with Open Reduction and Internal Fixation an anterior external frame (Fig. 12.36). In our clinical review, patients managed in this fashion, especially Internal fixation of the pelvis, especially the posterior those with fractures of the sacrum, fracture-disloca- sacroiliac complex, was virtually unreported prior to tions of the sacroiliac joint, or fractures of the ilium 1980, with almost no literature on this subject except had satisfactory long-term results. Redisplacement, if for sporadic case reports. There are reports of plating it occurred, was minimal and rarely clinically signifi- and wiring of the anterior symphysis complex but few cant. Internal fixation may be a preferred option, but of the posterior complex. The past two decades have in many instances this may be undesirable because brought a marked increase of internal fixation of the of the poor accessibility to a surgeon or center with pelvis. Clearly, for the right patient and with a knowl- expertise in pelvic surgery. In those circumstances, edgeable surgeon, the benefits outweigh the risks. since internal fixation of the posterior pelvic complex The indications are strong in the unstable ring, much is fraught with many complications, it is far safer less so in the stable types. We have seen from our for the general orthopedist to manage pelvic trauma, study of the natural history of pelvic fractures that especially isolated pelvic trauma, in this manner, than the stable injuries, which comprise approximately attempt ill-advised open reductions (Fig. 12.37). 70% of the total number of cases, have few indica-

a b

Fig. 12.36a–c. Unstable pelvic disruption treatment with external frame and traction. a Anteroposterior intravenous pyelogram of a 59-year-old man who sustained a grossly unstable pelvic ring disruption in a motor vehicle accident. The white arrow indicates the marked disruption of the left sacrum with posterior displacement of 2.5 cm, causing an injury to the lumbosacral nerve plexus. The two black arrows show the avulsion of the rectus abdominus muscle anteriorly through the symphysis. b Restoration of alignment was possible with an anterior frame and 30 lb (about 13.5 kg) of supracondylar traction on the left leg (broad arrows). Note the distraction of the left hip joint (black arrow). c Final result showing healing of all fractures and adequate restoration of the pelvic ring. The clinical result was good except for perma- c nent nerve damage in the left leg. (From Tile 1984)

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 269 17.04.2005 14:28:16 Uhr 270 M. Tile

a b

Fig. 12.37. Anterior posterior radiograph indicating an unstable left hemipelvis through a symphysis disruption and left sacroiliac disruption. Initial treatment with an external fi xator and traction showed an acceptable reduction. An attempt made at open reduction and internal fi xation using screw fi xation redisplaced the fracture with the resulting signifi cant rotational malunion and leg length discrepancy

tions for internal fixation. For unstable disruptions, Risks. The risks include the following: many patients can be safely and adequately managed 1. In general, early fracture stabilization is benefi- by external fixation and skeletal traction., but stable cial in the unstable pelvic injury, but prolonged internal fixation offers many advantages, as outlined surgery may bring its own problems in polytrau- in Tables 12.11 and 12.12. matized patients.

Table 12.11. Benefits of internal fixation (from Tile 2002)

Obtain and maintain anatomic reduction Fig. 12.38. a Results of the biomechanical testing show the Biomechanically more stable fixation superior stability afforded the pelvis by posterior fi xation in the unstable vertical shear injury. (Adapted from Tile 1984). Safer techniques b Graph indicates the main stiffness of the pelvis (in newton (minimally invasive, guidance systems, image intensification) meters) achieved with various forms of anterior fi xation, Early mobilization, shorter hospitalization, improve outcomes noted by the bars; namely, one inferior plate on the symphysis pubis, one superior plate on the symphysis pubis, two plates, and external fi xation. In each case, the anterior fi xation was Table 12.12. Risks of internal fixation (from Tile 2002) associated with anterior sacroiliac plates, lag screws, and transiliac (sacral bars). Note that no matter what form of posterior General effects of surgery fi xation was used, two plates across the symphysis (dark bars) Complications to nerve, vessel and viscera yielded the highest values of overall ring stiffness, stressing the importance of stable anterior fi xation in this model. (From Infection Hearn et al. 1991). c Schematic representation of displacement Failure of fixation transducers and target, aligned with three orthogonal sacroiliac axes. d Mean displacement, in micrometers per newton applied axial load (±SD), in the medial-lateral axis, corresponding to Benefits. The benefits of pelvic internal fixation are sacroiliac joint separation. Values are grouped by posterior as follows: fi xation, showing anterior fi xation within each group (n=8). e Mean anteroposterior displacement (±SD), in micrometers per 1. Anatomical reduction and stable fixation would unit of applied load, corresponding to interfragmentary shear reduce the risk of late malunion. in the direction of an axis aligned normal to the posterior 2. Internal fixation is more biomechanically more sacral surface. Values are grouped by posterior fi xation, show- stable (Fig. 12.38), allowing easier pain-free move- ing anterior fi xation within each group (n=8). f Mean vertical ment in the polytrauma patient. displacement (±SD), in micrometers per newton applied axial load, corresponding to shear displacements of the sacroiliac 3. Modern techniques of internal fixation include joint in the direction of the longitudinal axis of the sacrum. minimally invasive techniques, reducing the risk Values are grouped by posterior fi xation, showing anterior fi xa- of soft tissue complications. tion within each group (n=8). (From Hearn et al. 1991)

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 270 17.04.2005 14:28:16 Uhr 12 Fractures of the Pelvis 271

a b

d c

e f

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 271 17.04.2005 14:28:17 Uhr 272 M. Tile

Loss of tamponade and the possibility of massive to the artery during exposure of the fracture may hemorrhage because of clotting problems must result in massive hemorrhage. be recognized. The superior gluteal artery is com- 2. Sepsis. Posterior incisions in the acute trauma sit- monly injured during pelvic trauma, but the injury uation have resulted in an unacceptably high rate may be unrecognized because the artery may clot. of skin necrosis (Kellam et al. 1987). Even without With the massive blood transfusions required in posterior incisions, we have seen skin breakdown these patients, the clotting mechanism may be in many of our patients with severe unstable ver- defective on the fifth–tenth postoperative day tical shear injuries (Fig. 12.39). At surgery, the when surgical exploration is performed. Reinjury gluteus maximus muscle is often torn from its

c a

Fig. 12.39. a This 29-year-old man was struck by a motor vehicle, sustaining an unstable shear injury to the right hemipelvis. Note the marked displacement of the bladder by the pelvic hematoma and also the protrusion of the bladder through the symphysis on this intravenous pyelogram. b Application of an external skeletal fi xator restored only partial stability. Note the deformity of the right hemipelvis with the fi xator in place. c Stability was restored by dual plating of the symphysis pubis. d Ten days following injury, a large hematoma on the right sacroiliac joint spontaneously drained, indicating the marked soft tissue lesion of the posterior ligamentous complex. e The fi nal result was good, with sound healing of the right sacroiliac joint and no displacement of the pelvic ring. (From Tile 1984) e

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 272 17.04.2005 14:28:18 Uhr 12 Fractures of the Pelvis 273

insertion, leaving no underlying fascia to nour- for these patients. It must be remembered that in ish the skin. Skin breakdown has been frequent the most unstable types, internal fixation cannot despite meticulous technique, adequate nutrition, restore full stability, at most 1.5X body weight. and preoperative antibiotics (Fig. 12.39). Percuta- Great care must be taken when ambulating the neous techniques have improved the risks of soft patient and when weight bearing is allowed. Each tissue breakdown. case must be managed individually, according to 3. Complications to nerves, vessels, and viscera may circumstance. occur, and must be avoided to achieve satisfactory outcomes. Indications 4. Neurological damage is especially important, because of the ensuing impairment. We have now The general indications for internal fixation of the seen several cases of neurological damage caused pelvis are summarized in Table 12.13. by screws entering the first sacral foramen or the 1. Anterior internal fixation spinal canal. These injuries have occurred in patients a) Symphysis disruption. If the patient has a dis- previously neurologically normal (Fig. 12.40). The rupted symphysis pubis and the general sur- insertion of screws posteriorly across the sacroiliac geons, urologists, or trauma surgeons are pro- joint must be precise in order to avoid that com- ceeding with a laparotomy or exploration of the plication. In a recent series at our institution, only bladder, then plating the symphysis pubis in a one screw caused neurological damage (Cogley et reduced position will greatly simplify the man- al. 1998). Improved imaging techniques have made agement of the case. If the fracture pattern is a this complication less likely. stable open book variety, a short two- or four- 5. Failure of Fixation: improved understanding of hole plate can be placed on the superior sur- pelvic biomechanics has improved the outlook face of the symphysis pubis to restore stability.

a b

c d

Fig. 12.40. a Anteroposterior radiograph showing a fracture dislocation of the right hip and a dislocation of the left sacroiliac joint. b This is better seen on the CT scan. Treatment consisted of open reduction and internal fi xation of the right acetabular fracture, internal fi xation of the left sacroiliac joint, and an anterior frame. c Note the position of the screws. d Postoperative CT showing the tip of the screw in the fi rst sacral foramen (arrow)

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 273 17.04.2005 14:28:19 Uhr 274 M. Tile

Table 12.13. General indications for internal fixation of the approach can be used to fix both components pelvis of the fracture, as shown in Fig. 12.41. This case Indications for posterior fixation of pelvic ring disruption represents an unusual configuration of an open book injury with a massive symphysis disrup- Unstable sacroiliac complex with more than 1 cm of displacement, especially if through the tion, an anterior opening of the right sacroiliac joint, and an external rotation injury to the left sacroiliac joint ilium extending into the anterior column of the Open fractures with posterior (not perineal) wound acetabulum with major displacement. This frac- Unstable posterior complex associated with acetabular ture was approached through an ilioinguinal fractures incision and all components fixed as shown. Indications for anterior fixation of symphysis and pubic rami fractures Rami Fixation. Our recent biomechanics studies Disrupted symphysis pubis have shown that 40% of pelvic stability comes from the anterior pelvis; therefore, if early ambulation is to In unstable (Type C) pelvic disruption be instituted, fixation of widely displaced rami is bio- Symphysis open >2.5 cm mechanically more sound than external fixation. In Laparotomy being performed for visceral injury minimally displaced rami fractures, internal fixation Locked symphysis is not desirable, but several methods are available for the unstable rami. A standard anterior approach or Rami fractures a modified extraperitoneal Stoppa approach can be Associated with femoral artery or nerve injury used with standard methods of internal fixation. Per- Tilt fracture with ramus protruding into vagina cutaneous techniques have recently been developed Marked displacement (unstable Type C disruption) to fix these fractures retrograde from the symphysis (Routt et al. 1995); however, the technique has con- If the symphysis pubis disruption is part of an siderable risk of penetration of the hip and damage unstable pelvic ring pattern, then double plat- to the anterior vessels, and should only be done in ing to prevent displacement in the vertical and expert centers (see Fig. 12.50). anteroposterior planes is preferable (Fig. 12.39). When combined with an external frame, sta- 2. Posterior internal fixation. bility will be restored, as shown in Fig. 12.38; a) Malreduction of the posterior sacroiliac com- therefore, it may be used as definitive treatment plex. This is difficult to define, but greater than in some cases. This is especially true with dual 1 cm of displacement of the posterior sacroiliac plating, which is biomechanically superior to a complex, especially in pure sacroiliac disloca- single plate (Fig. 12.38). However, plates should tion, may be an indication for posterior internal not be used in the presence of fecal contamina- fixation. If posterior fracture with or without tion or the proposed use of a suprapubic tube; dislocation is noted, some displacement may be in that situation, external fixation is usually the acceptable because healing of the fracture may safer and preferred option. lead to a satisfactory outcome. b) Displaced fracture in the perineum (see However, there may be instances where the Fig. 12.18). In the atypical type of lateral com- fracture itself cannot be reduced, thus requir- pression injury, with rotation of the superior ing open reduction, as shown in Fig. 12.42. In pubic ramus through the symphysis into the this particular case, the patient was injured in perineum, i.e., the tilt fracture, a limited Pfan- a collision between a motor bike and a motor nenstiel approach, derotation of the fragment, vehicle. Note the external rotation of the left and fixation with a threaded pin will maintain hemipelvis. This unusual injury caused by an the fracture until healing has been completed, external rotatory force on the left hemipelvis usually a period of 6 weeks for this stable frac- has fractured the ilium and driven the iliac ture. portion of the sacroiliac joint anteriorly until c) Associated anterior acetabular fracture. If a it rested on the front of the sacrum. The lumbo- fracture of the anterior column of the acetabu- sacral plexus was injured but gradually recov- lum or a transverse fracture is associated with ered, except for the fifth nerve root, which was a symphysis disruption, a displaced sacroiliac permanently damaged. When seen at 6 months joint, or a fracture in the ilium, an ilioinguinal following injury, the left hemipelvis was exter-

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 274 17.04.2005 14:28:19 Uhr 12 Fractures of the Pelvis 275

a b

Fig. 12.41. a Anteroposterior radiograph demon- strating a left acetabular fracture associated with a pelvic ring disruption. Note the left acetabular fracture (long arrow) and the massive symphysis pubis disruption associated with a fracture of the left ilium and an anterior opening of the right sacroiliac joint, a variation of an open book fracture (short arrows). b The open right sacroiliac joint and left iliac fracture are best seen on the CT scan. c Open reduction and internal ﬁ xation were performed through an ilioinguinal approach with ﬁ xation as c shown. (From Tile 1984)

nally rotated 45° and the fracture dislocation in the upright position to improve chest venti- was not united. The patient had significant pain lation. If the pelvic fracture is so unstable that on sitting or standing. All four rami were frac- this becomes impossible, then open reduction tured anteriorly, the right ones not being united may aid in the post-trauma care of the patient. but the left being united. Utilizing two teams Since stabilization with an anterior external of surgeons with the patient in the right lateral frame will usually allow nursing in the upright position, the sacroiliac joint was approached position for the first few days with or without a from both the inside and the outside of the traction pin in the femur, when this position is pelvis. The fracture could not be reduced until often life-saving, this indication would be rela- the left anterior pubic rami fractures, which tive rather than absolute. were healed, were osteotomized. At that point, c) Open posterior fracture. In those uncommon the left hemipelvis could be reduced and held instances when the posterior sacroiliac com- with three anterior plates placed across the sac- plex is disrupted and the posterior skin has roiliac joint. One long anterior plate across the been lacerated from within, the same principles symphysis pubis and the rami fractures fixed applied to other open fractures can be applied the anterior complex. here. With the wound already open, the surgeon b) Polytrauma treatment. Current surgical wisdom should take the opportunity to stabilize the requires polytraumatized patients to be nursed posterior complex in a manner described later

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 275 17.04.2005 14:28:20 Uhr 276 M. Tile

a c Fig. 12.42. a Anteroposterior radiograph of an unstable pelvic ring disruption. The injury looks relatively innocuous; however, note that the left hemipelvis is externally rotated approximately 45° compared to the right. The left hemipelvis shows an iliac oblique view, the right an anteroposterior view. b This is more clearly seen on the CT scan. Note that the hemipelvis anterior to the iliac fracture has rotated externally and has compressed into the sacrum (arrow). The patient had a lumbosacral nerve plexus injury. c The pelvis failed to unite, and 7 months after the original injury, because of severe pain, a combined anterior and posterior approach was employed and resulted in reduction of the pelvis and ﬁ xation as shown. b Stability was restored and the ﬁ nal result is good

in this chapter. In those instances, the wound fixation of the pelvic ring and acetabulum. This may be left open and closed secondarily. requires careful decision-making and preoper- However, if the open wound is in the perineum, ative planning. The acetabular fracture cannot then all forms of internal fixation are usu- be reduced anatomically until the pelvic por- ally contraindicated. Both the rectum and the tion is reduced. vagina must be examined carefully for lacerations to rule out occult open fractures of the 12.5.4.3 pelvis. Open fractures into the perineum are Surgical Techniques dangerous injuries and result in a high mortality rate. Treatment for the open pelvic fracture General Aspects should include cleansing and careful débride- ment of the wound followed by open wound Timing. In general, we prefer to wait with pelvic care. The fracture should be stabilized in the open reduction until the patient’s general state has first instance with an external skeletal frame. improved, which is usually between the fifth and the Both bowel and bladder diversion with a colos- seventh post-trauma day. During this initial period, tomy and cystostomy are essential. Occasion- relative stability is maintained with the external fix- ally, minimal internal fixation, especially across ator and skeletal traction. the anterior arch or symphysis, may be very Exceptions to this rule are instances when a lapa- helpful; however, this requires much experience rotomy or bladder exploration has been carried out, and surgical judgment. so that the symphysis is already exposed; it should d) Associated posterior acetabular fractures. Trans- then be internally fixed primarily. Secondly, in the verse or posterior fractures of the acetabulum rare instance of a vascular injury to the femoral associated with pelvic ring disruption are also artery necessitating vascular repair, associated with a an indication in some instances for posterior pelvic factor, the incisions may be carefully planned

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 276 17.04.2005 14:28:20 Uhr 12 Fractures of the Pelvis 277

with the vascular surgeon to allow stabilization of the for pelvic open reduction and internal fixation. This anterior pubic rami. allows the surgeon to work around corners, especially As previously mentioned, a posterior open frac- necessary when working on anterior fixation of the ture may also be a rare indication for immediate open symphysis pubis in obese individuals. reduction and internal fixation. In centers with the facilities and expertise in Open methods: Anterior Pelvic Fixation percutaneous techniques and with better imaging and guidance systems, earlier surgery is now a pre- Symphysis Pubis Fixation ferred option, if the patient’s general state allows (see Fig. 12.50). Surgical Approach. If the abdomen is already open through a midline or paramedian incision, then the Antibiotics. Prophylactic antibiotics are routinely symphysis can be simply fixed through that approach. given for these major operative procedures. A first- If no incision has been made and the symphysis is generation cephalosporin is given intravenously just being approached primarily, the Pfannenstiel incision prior to surgery and continued for 48 h or longer if transversely offers excellent visualization (Fig. 12.43). necessary. In the acute case, the rectus abdominis muscle has usually been avulsed and dissection is easy. The sur- Antithrombotic Therapy. Recent epidemiological geon must stay on the skeletal plane to avoid injury studies (Geerts et al. 1990) have shown that 60% to the bladder and urethra. of patients with pelvic trauma develop deep-vein thrombosis. The specific balance between clots and Reduction. Reduction of the symphysis is usually further pelvic bleeding is delicate; suffice it to say that easy in the acute case. The medial aspect of the some form of therapy is indicated when the threat of obturator foramen should be exposed and the frac- further hemorrhage is appreciably over. ture reduction clamp inserted through the foramen (Fig. 12.43b). Reduction should be anatomical. Care Implants must be taken to avoid catching the bladder or urethra in the symphysis when closing the clamp. Plates. Because of the difficulty in contouring the standard plates in the several directions required, Internal Fixation. In the stable open book configura- we recommend the 3.5-mm and 4.5-mm reconstruction, a simple two- or four-hole 3.5-mm or 4.5-mm tion plates for pelvic fixation (see, e.g., Figs. 12.42, reconstruction plate applied to the superior surface 12.43). These plates can be contoured in two planes of the symphysis will afford excellent stability. An and are most useful. In general, the 3.5-mm plates external frame is not essential in this particular are used on most women and smaller men, and the injury. 4.5-mm plates on larger men. Preshaped reconstruc- In the symphysis disruption associated with an tion plates are available for the anterior column unstable pelvic disruption, we favor a double-plate fractures. technique (Fig. 12.43c). A two-hole plate, either a 3.5 or 4.5 mm, is fixed to the superior surface of Screws. The 3.5-mm fully threaded cancellous screws the symphysis and fixed with the appropriate-sized and the 6.5-mm fully threaded cancellous screws cancellous screws (Fig. 12.43d) immediately adja- are essential components of the fixation system, as cent to the symphysis pubis. To avoid displacement well as all the standard lag screws in the two sizes in the vertical plane, an anterior plate, usually a 3.5- (4.0 mm and 6.5 mm). Screws of exceptional length, mm reconstruction plate fixed with the appropriate up to 120 mm, are required in the pelvis. screws and applied anteriorly, will offer increased stability (see Fig. 12.38). Restoration of this ante- Instruments. Since reduction of the pelvic fragments is rior tension band will allow the previously inserted the most difficult part of the operation, special pelvic anterior frame to compress the posterior complex clamps are essential. These include the pointed frac- by externally rotating the hemipelvis at the time the ture reduction clamps and the large pelvic reduction clamps are closed. Good stability may be obtained clamps held in place with two screws (see Fig. 13.36). and the patient may assume the upright position. Other specialized pelvic reduction clamps are also In addition, if later fixation of the posterior injury available. We also find the flexible drills and taps is attempted, the position of the injury will be rela- as well as the universal screwdriver to be essential tively reduced.

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 277 17.04.2005 14:28:21 Uhr 278 M. Tile

e d

Fig. 12.43. a Open reduction of the symphysis pubis is done through a Pfannenstiel incision. b Deep dissection of the symphysis pubis. Usually, in a symphyseal disruption, the dissection is done by the injury; rarely, the rectus needs to be removed from the pubis. The bladder is retracted, as noted, and the inferior epigastric artery and the spermatic cord are protected. c A large fracture reduction clamp is inserted around the medial border of both obturator foramina. Closure of the clamp will easily restore the anatomy of the symphysis pubis. d Fixation is secured using two 4.5-mm DC plates placed at right angles to each other. e Fully threaded cancellous screws should be used to anchor the plates to the soft bone of the symphysis. (From Tile 1995)

Pubic Rami Fractures zation, preferably by internal fixation. Open reduction requires major dissection, possibly using an ilioingui- Given the increased knowledge of pelvic biomechan- nal approach or extraperitoneal Stoppa approach. If ics revealing that the anterior ring accounts for 40% of fractures of the pubic rami are grossly displaced and ring stability, fixation of rami fractures has been revis- unstable, the indications are stronger. Open fixation ited. If the rami fractures are not gapped, or unstable, may include plates and/or screws. the anterior ring can be maintained by external fixa- Retrograde percutaneous superior ramus screws tion. However, many centers have chosen to internally have now been introduced through the symphysis, fix the rami by open means (Hirvensalo et al. 1993) to but should only be used in expert hands and only for allow earlier rehabilitation. In unstable patterns, bio- very limited indications (see Fig. 12.49). The poten- mechanics dictate both anterior and posterior stabili- tial hazard of penetrating the hip joint and/or the

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 278 17.04.2005 14:28:21 Uhr 12 Fractures of the Pelvis 279

femoral artery may be potentially greater than the is aided by longitudinal traction and pointed fracture benefits; however, better imaging and guidance have clamps in the anterior superior spine of the ilium, increased the safety factor. pulling anteriorly. The reduction should be checked anteriorly at the greater sciatic notch. Posterior Pelvic Fixation Two two- or three-hole 3.5 or 4.5-mm plates held by the appropriate fully threaded cancellous screws The posterior sacroiliac complex may be approached afford excellent fixation (Fig. 12.44d,e). A rectangular anterior or posterior to the sacroiliac joint. Decision- external frame will supplement the posterior fixation making is as always based on fracture and patient fac- if no fixation is present at the symphysis. The wound tors, especially the state of the posterior soft tissues. should be drained and closed. Because the complication rate for posterior incisions If the patient is young and good stability has been through crushed skin is high, posterior surgery in attained, the upright position may be assumed, but this situation must be avoided. The posterior skin is weight bearing should be restricted until healing pro- often in a precarious state and spontaneously breaks gresses, a period of approximately 6 weeks. down even without surgery because of the avulsion of the underlying gluteus maximus fascia. In that situ- Posterior Fixation of the Sacroiliac Joint ation, an anterior approach to the sacroiliac joint is preferred, but only if the fracture pattern allows. As noted previously, the posterior approach to the Posterior pelvic fixation cannot be used in sacral sacroiliac joint is safe and straightforward, but the fractures, only sacroiliac dislocation or iliac fracture. risk of complications such as wound breakdown and Therefore, we favor the anterior approach for fixation nerve damage is significant, and it should therefore be of sacroiliac dislocations and some fracture disloca- approached with considerable caution. The indications tions, and the posterior approach for some iliac frac- include an unreduced sacral crush, sacroiliac disloca- tures and sacral crush. tion, and fracture-dislocation, especially the crescent Percutaneous techniques are becoming more prev- fracture pattern (Fig. 12.46). Since no clear indications alent and, with better radiographic or wand control, exist at this time for favoring either the anterior or the also safer. Skin problems may be avoided, but reduc- posterior approach to the sacroiliac joint, the surgeon’s tion remains a problem. choice of approach can often be guided by personal preference and the state of the soft tissues. Anterior Fixation of the Sacroiliac Joint Surgical Approach. The incision should be longitudinal just lateral to the posterior superior iliac spine over the Surgical Approach. A long incision is made from the belly of the gluteus maximus muscle (Fig. 12.45a). The posterior portion of the iliac crest to beyond the ante- subcutaneous border of any bone should always be rior superior spine. The iliac crest is exposed and avoided, especially in this area. The incision is opened the iliacus muscle swept by subperiosteal dissection to the posterior superior spine and iliac crest area. The posteriorly to expose the sacroiliac joint including gluteus maximus muscle, which is often avulsed, is the ala of the sacrum (Fig. 12.44a). If further exposure further dissected by the subperiosteal route to expose is required, the incision may be extended distally, as the superior gluteal notch. The sciatic nerve must be for the iliofemoral or Smith-Petersen approach to the protected as it exits through the notch. In the unstable hip joint. The greater sciatic notch should be clearly fracture for which this incision is indicated, the exam- exposed to protect the sciatic nerve. ining finger can be placed through the notch to explore The L5 nerve root exits from the intervertebral the anterior aspect of the sacrum (Fig. 12.45b). Ana- foramen between L5 and S1 and crosses the L5–S1 disc tomical reduction can be verified only by this maneu- to the ala of the sacrum, where it joins the S1 nerve ver. Image intensification is most desirable, especially root as it exits from the S1 foramen (Fig. 12.44b,c). if screws are to be used across the sacroiliac joint and These nerves are in jeopardy in this approach, and the sacral foramina are to be avoided. care must be taken not to injure them by pointed reduction clamps or by plates that are longer than Open Techniques of Posterior Fixation one screw on the sacral portion. This technique is not suitable for fractures of the Fractures of the Ilium: Screw and Plate Fixation. Pos- sacrum because of the proximity to the nerves; there- terior fractures of the ilium or fracture dislocations of fore, it can only be used in sacroiliac dislocations or the sacroiliac joint are best fixed with standard tech- fractures of the ilium. Reduction may be difficult and niques of open reduction of the fracture and primary

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 279 17.04.2005 14:28:22 Uhr 280 M. Tile

Fig. 12.44a–e. Anterior ﬁ xation of the sacroiliac joint. a Inci- sion just medial to the iliac crest. b Subperiosteal dissection of the iliacus muscle will expose the sacroiliac joint. Note the proximity of the L5 nerve root (arrow), which when joined by the S1 nerve exiting through the S1 foramen becomes the sciatic nerve, which leaves the pelvis through the greater sciatic notch, as shown. c Anatomical dissection showing the relation- ship of the L5 nerve root to the sacroiliac joint. The L5 nerve root (small white arrow) is seen crossing the ala of the sacrum and joining with the S1 nerve root exiting the ﬁ rst sacral foramen (broad white arrow). The sacroiliac joint is outlined by the black arrow. d Inlet view showing an unstable right hemipelvis with posterior displacement of the right sacroiliac joint and disruption of the symphysis. e Fixation of the right sacroiliac joint with two anterior plates and a single plate on the symphysis pubis e

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 280 17.04.2005 14:28:22 Uhr 12 Fractures of the Pelvis 281

a c

Thoracolumbar Sacrospinalis fascia Longissimus iliocostalis Fig. 12.45a–c. Posterior pelvic fi xation. Note that the surgical incision should be made either 1 cm medial Articular capsule or lateral to the posterior iliac spine and not directly over the subcutaneous border (a). Depending on the amount of exposure required pos- Square teriorly, the insertion of the gluteus periosteal maximus may be dissected from the elevator S 1 lateral aspect of the ilium into the greater sciatic notch with an elevator, as noted in the diagram. b Note also that the superior gluteal artery and nerve exit from the greater sciatic S 2 Glut. med. notch, and great care must be taken P. Sl. S when dissecting in that area. If exposure to the posterior aspect of the sacrum is required because of sacral Sup. glut. fracture, note the medial dissection Art. & nerve and the sacral fracture. Exposure of b Piriformis the posterior foramina may help with Glut. max. reduction. c Dissection should allow Sacrotuberous the palpating fi nger to explore the ligament with chewed anterior aspect of the joint to confi rm remains ofglut. max. orign reduction. (From Tile 1984)

internal fixation with lag screws across the fracture, technique of placement of these screws must be pre- followed by the application of a 4.5-mm or 3.5-mm cise; otherwise, damage to the cauda equina by pen- reconstruction plate, as a neutralization plate. Usu- etration of the spinal canal or to the S1 foramen will ally two plates or one plate and a derotation screw are be unacceptably common. If this technique is to be required to prevent displacement (Fig. 12.46). used, image intensification is essential in two planes as well as a lateral view of the sacrum (Fig. 12.47). Sacroiliac Dislocations: Screw Fixation. Screw fixa- The superior screw should be placed in the ala of tion across the sacroiliac joint affords excellent fixa- the sacrum and across into the area of the S1 body. tion. The screws can be used alone or through a small A 2-mm Kirschner wire should be inserted first and plate as a washer, especially in older individuals. The checked on the image intensifier to confirm the posi-

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 281 17.04.2005 14:28:23 Uhr 282 M. Tile

Fig. 12.46. a The use of lag screws to fi x a fracture of the ilium. b The use of plates to fi x the posterior ilium. c Anteroposterior radiograph showing a fracture through the ilium. d CT scan of the same patient. e A 4.5-mm reconstruction plate fi xing the anatomically reduced fracture in the coronal plane. Note the lag screw fi xation being used to compress this fracture. (From Tile 1984) e

tion. Across the sacroiliac joint, 6.5-mm cancellous position of the screw is critical. The drill and guide lag screws over washers (Fig. 12.47) or cannulated wire must be inserted under image intensification. screws should be used. The second screw, again using image intensification, In a sacroiliac dislocation, a length of 40–45 mm should be inserted distal to the S1 foramen. To avoid will suffice. However, for a sacral fracture or sacral the nerve within the foramen, the final screw can be nonunion, the screw must penetrate the S1 body to placed distal to the S1 foramen, although in this area cross the fracture line. In those circumstances, longer it is extremely difficult because of the thinness of the screws of 60–70 mm must be used, and therefore the bone. The foramen can be seen on the image intensi-

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 282 17.04.2005 14:28:24 Uhr 12 Fractures of the Pelvis 283

a b

d e

Fig. 12.47a–f. Fixation of sacroiliac dislocation by 6.5-mm cancellous bone screws (according to Matta). a Entry points of cancellous bone screws. b Insertion of the index ﬁ nger through the incisura ischiatica helps in aiming the drill. c X- ray controls of screw position. d,e Correct position of cancellous bone screws. f Drilling directions to be avoided (sacral foramina, spinal canal, great vessels) f

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 283 17.04.2005 14:28:25 Uhr 284 M. Tile

fier or may be seen directly by posterior disruption and terior approach, the use of sacral bars is safe and ade- dissection. Often two screws may be placed proximally quate. Since the device does not penetrate the sacrum, and one distally. It is essential that the surgeon embark- the neural elements are not at risk unless compression ing on this technique learn it in a manual skills labora- across the fracture is excessive and traps the nerve tory prior to inserting these screws into a patient. in the foramen. In all open approaches to sacral fractures, the fracture should be exposed, all fragments Sacral Fracture: Transiliac Bar Fixation. In the acute removed from the neural foramina, and the reduc- sacral crush requiring open reduction through a pos- tion as anatomical as possible, lining up the neural

a b

c d

Fig. 12.48a–g. Transiliac bar posterior ﬁ xation. a Two slightly curved, vertically placed incisions are made just lateral to the ୴୴ posterior superior spines. b After reduction of the fracture dislocation, Kirschner wires are placed across the sacroiliac joint as provisional stabilization. The posterior iliac crest in the region of the posterior spine is predrilled with a 0.25-inch (6.4-mm) drill bit to provide a gliding hole. c A second hole is predrilled for the second bar. The sacral bar is then inserted posterior to the sacrum and the sharp trocar point driven into the opposite posterior iliac spine. d A standard washer is used to prevent sinking of the sacral rod nut into the bone. Then the nuts are tightened, compressing the sacroiliac joint or the sacral fracture. e The two transiliac bars in place on a cadaveric specimen. The tips of the bars should of course be cut short so as not to interfere with the posterior soft tissues. f An anteroposterior radiograph of a case of pelvic disruption in a 32-year-old female, showing the two sacral bars stabilizing the posterior lesion and an anterior frame, the anterior lesion. g The ﬁ nal result after healing of the fracture and removal of the anterior frame. (From Tile 1995)

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 284 17.04.2005 14:28:27 Uhr 12 Fractures of the Pelvis 285

foramina. The insertion of two sacral bars will restore driven through until it hits the opposite posterior excellent stability to the posterior complex, as shown iliac spine. The sharp point on the sacral bar is driven in Fig. 12.48. The addition of the anterior frame or through the posterior spine until it emerges on the anterior fixation will complete the stabilization. outer table of the iliac crest. Washers and nuts are The incision on the side of injury is the same as inserted and the bars cut off flush at the nut. A second previously mentioned, just lateral to the posterior bar is inserted distally. An absolute contraindication superior iliac spine. The posterior spine is exposed, is a fracture in the posterior superior spine area. If a gliding hole made, and the threaded sacral bar none exists, good compression may be obtained for the sacral crush without fear of damaging the neural elements. We favor this approach for the acute sacral crush, where necessary. Newer transiliac bars have been developed but are not in general use (Gorczyca et al. 1994; Schied et al. 1991).

Iliosacral Screws. In experienced hands, iliosacral screws inserted as previously outlined offer excellent fixation for sacral fractures, if the anterior arch is controlled by either internal or external fixation.

Sacral Plates. Small sacral plates have been developed by the Hannover Group (Pohlemann et al. 1993), but their use has been limited. Other methods include plates across the entire posterior complex, acting as e a posterior tension band. Bilateral Sacroiliac Inju- ries. In bilateral injuries, the sacral bars cannot be used unless supplemented with screw fixation into the sacrum on at least one side to prevent posterior displacement of the entire complex.

Closed techniques

Anterior. Techniques have been recommended for percutaneous fixation of the symphysis (Mears and Rubash 1986) as well as the pubic rami (Routt et al 1995). Although percutaneous fixation of the symphysis is rarely done, rami fixation using retrograde percutaneous screws using real-time imaging f (Routtet al. 1995; Starr) or guidance wands (Kahler et al. 2001) is more frequently done in select centers (Fig. 12.49). Advantages include better stabilization of the unstable ring, with a minimal incision; the risks include damage to hip, femoral nerve, or blood vessels

Closed Percutaneous Iliosacral Screws. As previously stated, percutaneous techniques are becoming more common with more experienced pelvic surgeons, for the reasons given. Precise placement of the screw is essential to prevent neurological complications (McLaren 1995; Matta and Saucedo 1989), and reduction must be adequate (Fig 12.50). The patient may be in the supine position, another advantage in poly- g trauma care, and damage to soft tissues is minimal.

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 285 17.04.2005 14:28:28 Uhr 286 M. Tile

a b

e Fig. 12.49a-e. The patient is positioned supine and elevated on a soft lumbosacral support, usually a folded blanket. The contralateral thigh may obstruct screw placement in obese patients. The C-arm is placed on the side of injury. The obturator- outlet image is obtained by tilting the image intensiﬁ er approx. 30° toward the foot of the bed (outlet image) and then rotating it 30° toward the affected hip joint (obturator oblique image). This combination image demonstrates the safe zone for screw placement cephalad to the acetabulum. (b) This intraoperative image demonstrates the ideal starting point for the retrograde medullary screw. The inlet (c) and obturator-outlet (d) images guide drilling and screw placement. (e) The retrograde ramus screw is located medial to the acetabulum or in cases of lateral ramus fracture cephalad and beyond the acetabulum, exiting the lateral iliac cortical bone. (From Tile, Helfet, and Kellam 2003)

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 286 17.04.2005 14:28:29 Uhr 12 Fractures of the Pelvis 287

a b

Fig. 12.50. a The lateral sacral view: anatomic model. b A cross section of the pelvis at the upper level of the S1 vertebral body shows the safest path for a screw at this level between c the two dotted lines. Note the concavity of the sacral ala anteriorly. Screws should not cross any of the black boundaries, nor should they be aimed posteriorly, toward the spinal canal. c Case example: Anteroposterior pelvis radiograph showing a common iliac artery injury and an unstable left sacroiliac dislocation. d Anteroposterior pelvis radiograph showing the reduced left sacroiliac dislocation with callus formation seen at the inferior margin of the S1 joint 8 weeks postinjury. The external ﬁ xator is removed when callus is seen or after 3 months if there is no callus. (From Tile, Helfet and Kellam 2003)

12.5.4.4 12.5.4.5 Postoperative Care Complications

Postoperative care depends entirely on the quality Early Complications of the bone and the quality of the fixation. If the bone quality is good and fixation is stable anteriorly Complications of pelvic trauma occur as a result of and posteriorly, ambulation with crutches is possible. the injury pattern and/or the operative intervention. However, each case must be individually managed, The surgeon must ensure that the treatment modality and in some, a period of postoperative traction is chosen is safe. Prophylactic antibiotics are a necessity prudent and may prevent late displacement. to reduce the incidence of sepsis. Wounds must be kept

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 287 17.04.2005 14:28:32 Uhr 288 M. Tile

away from areas of skin and soft tissue crush to limit forgotten but should be managed concurrently with the incidence of wound necrosis. Fixation devices the other injuries. The trauma or orthopedic surgeon must be carefully placed to avoid penetration of the must carefully plan the early management to include great vessels or the neurological structures. During stabilization of the pelvic fracture. Knowledge of the surgery, neurological monitoring is desirable. fracture types as well as a careful assessment of the Pelvic vein thrombosis is common; therefore, anti- hemodynamic state of the patient, that is, the per- thrombotic prophylaxis is indicated. However, this is sonality of the injury, is essential for logical deci- extremely difficult in the immediate post-trauma sion-making. period because of the danger of further bleeding. Four possibilities exist: Therefore, anticoagulants should be used as soon as 1. Stable hemodynamics and a stable pelvic injury possible when the threat of bleeding has diminished, 2. Unstable hemodynamics and a stable pelvic often at 24 hours. injury 3. Stable hemodynamics and an unstable pelvic Late Complications injury 4. Unstable hemodynamics and an unstable pelvic Nonunion and Malunion. Since nonunion of the pelvis injury is not a rare event, occurring in 3% of cases, the above Each of the above scenarios requires a different techniques may prove valuable in the management of plan of management, as has been described. these difficult problems. The surgeon must be familiar The role of external skeletal fixation or a pelvic with all of the above techniques before embarking on clamp may be life-saving in provisional fixation of the management of a nonunion, especially in the mal- the unstable pelvic disruption in a hemodynamically reduced position. These complex problems require unstable patient. It should be applied quickly and individualization and careful preoperative planning. simply. External skeletal fixation may also be used Posterior iliac osteotomies may be required to cor- as definitive treatment in the stable open book (B1) rect vertical displacement. If major amounts of cor- fracture, in the occasional lateral compression injury rection are necessary (more than 2.5 cm), we favor (B2) which requires reduction by external rotation, a staged procedure. The first operative procedure or in a patient with polytrauma and in the unstable should include freeing up of the nonunion and correc- pelvic disruption (C) in association with supracon- tive osteotomies posteriorly or anteriorly, as required. dylar skeletal traction, or open reduction and inter- The patient should then be placed in supracondylar nal fixation. In the acute situation, skeletal traction skeletal traction with a weight of 30–40 lb (14–18 kg) should be maintained until secondary internal fixa- applied to the limb. With the patient awake, correction tion is completed. can be monitored radiographically. Problems with the The role of internal fixation is becoming clearer, sciatic nerve may be detected because the patient is and has clear benefits that will outweigh the risks in awake. At 2–3 weeks following the primary operation, carefully selected cases and in expert hands. Inter- a secondary procedure to stabilize the pelvis may be nal fixation does afford the advantage of excellent performed (Fig. 12.51). Occasionally, the large, double stability to the ring, thereby maintaining satisfactory cobra plate or a long, contoured DC plate may be help- reduction, resulting in easier nursing care. Therefore, ful for these difficult cases. the indications will widen with improved techniques, percutaneous or open, and improved guidance systems to improve safety. Anterior fixation of symphyseal disruption is desirable, and in some cases so is 12.6 rami fixation. Conclusions Using open techniques for posterior pelvic fixa- tions, we favor the anterior approach to the sacroiliac Disruption of the pelvic ring is a serious injury with joint for sacroiliac dislocations and iliac fractures, and a significant mortality. Early management is directed the posterior approach for sacral fractures and some to the essentials of polytrauma care. Complications fracture dislocations of the sacroiliac joint, especially of this injury are many, including massive hemor- is there is any soft tissue compromise. For sacral dis- rhage, rupture of a hollow viscus, especially bladder, ruptions, we favor the insertion of two transiliac bars urethra, and small bowel, and open wounds in the posteriorly or iliosacral screws. perineum. As the general aspects of the injury are Where possible, closed techniques are favored using dealt with, the musculoskeletal injury should not be percutaneous screw insertion (see Figs. 12.50, 12.51).

12.5 Management of the Pelvic Disruption

SCHA_12-Tile.indd 288 17.04.2005 14:28:33 Uhr 12 Fractures of the Pelvis 289

a b

c d Fig. 12.51. a Anteroposterior radiograph of a 35-year-old woman who sustained an unstable disruption of the pelvic ring 18 months prior to this radiograph. Note the marked internal rotation of the right hemipelvis as well as posterior displacement of greater than 2 cm. Note also the leg length discrepancy, as indicated by the position of the femoral heads. A major problem in these individuals with pelvic nonunion is their diffi culty in sitting because of the different planes of the ischial tuberosities (white arrows). Note also the nonunion of the left superior pubic ramus. b The nonunion is confi rmed on the CT scan. The fi brous tissue in the posterior nonunion site was divided and the patient placed in traction. c After 2 weeks in traction, note on the anteroposterior radiograph that the posterior displacement of the right hemipelvis has been corrected. At this time open reduction and internal fi xation through a posterior approach restored stability to the pelvis. d Note that three of the long lag screws cross the nonunion site and enter the body of the sacrum. A bone graft was placed around the nonunion, which subsequently healed. e e The appearance on the CT scan after healing

Above all, these fractures occur in very ill polytrau- on the injury than on the treatment (Schied et al. 1991; matized patients and are often extremely complex. Tornetta and Matta 1996). This is especially true if a Therefore, management must be individualized and nerve lesion is present, as it is in 40%–50% of unstable cannot be doctrinaire, since the outcome of this injury, (C) sacral fractures (Schied et al. 1991). The final result especially the sacral fracture, currently depends more in these patients may be disappointing.

12.6 Conclusions

SCHA_12-Tile.indd 289 17.04.2005 14:28:33 Uhr 290 J. Schatzker

Further study is thus still necessary, as are further Kahler DM, Mallik, Tadje J (2001) Computer-guided percuta- refinements of technique, which in the future will be neous iliosacral screw fixation of posterior pelvic ring dis- made, I believe, with percutaneous techniques. Also ruption compared to conventional technique. Presented at the Fifth North American Program on Computer-Assisted needed at this time is careful decision-making to be cer- Orthopedic Surgery, Pittsburgh, July 7, 2001 tain that patients are being helped with minimal risk. Kellam JF, McMurtry R, Paley D et al (1987) The unstable pelvic fracture: Operative treatment. Orthop Clin North America 18–25 References Lipkowitz G, Phillips T, Coren C, Spero C, Glassberg K, Velcek FT (1982) Hemipelvectomy: a lifesaving operation in severe open pelvic injury in childhood. J Trauma 25 (9):823–827 Aprahamian C, Carrico CJ, Collicott PE et al (1981) Advanced Matta J, Saucedo T (1989) Internal fixation of pelvic ring frac- trauma life support course. Committee on Trauma, Ameri- tures. Clin Orthop 242: 83–98 can College of Surgeons Park Ridge, IL McGowan S, Kellam JF, Tile M (1987) Unstable pelvic ring dis- Bucholz RW (1981) The pathological anatomy of Malgaigne ruptions – results of open reduction and internal fixation. fracture dislocations of the pelvis. J Bone Joint Surg Orthop Trans 11: 478 63A(l):400–404 McLaren AC (1995) In: Tile M (ed) Fractures of the pelvis and Cogley D, Stephen DJG, Kreder (1998) Functional outcomes acetabulum. Williams and Wilkins, Baltimore, p 150 of pelvic fractures treated by iliosacral screw fixation. Pre- McMurtry R, Walton D, Dickinson D, Kellam J, Tile M (1980) sented at the Canadian Orthopaedic Association annual Pelvic disruption in the polytraumatized patient: a manage- meeting, Ottawa, Canada, June 1998 ment protocol. Clin Orthop 151:22–30 Dalal SA, Burgess AR, Siegel JM, Young JW (1989) Pelvic frac- Mears DC, Rubash HE (1986) Pelvis and Acetabular Fractures. tures in multiple trauma. Classification by mechanism is key Thorofare, NJ to pattern of organ injuries, resuscitation requirements and Monahan PR, Taylor RG (1975) Dislocation and fracture dislo- outcome. J Trauma 29:981 cation of the pelvis. Injury 6(4):325–333 Ertel W (2003) General assessment and management of the Muller ME, Allgower M, Schneider R, Willenegger H (1990) polytrauma patient. In: Tile, M, Helfet D, Kellam, J (eds) Manual of internal fixation, 3rd edn. Springer, Berlin Hei- Fractures of the Pelvis and Acetabulum, 3rd ed, Lippincott delberg New York Williams and Williams pp. 61–79 Pennal GF, Sutherland GO (1959) The use of external fixation. Dickinson D, Lifeso R, McBroom R, Tile M (1982) Disruptions Paper presented at the Canadian Orthopaedic Association of the pelvic ring. J Bone Joint Surg 64B(5):635 Annual Meeting Ganz R, Krushell R, Jacob R, Kuffer J (1991) The anti-shock Pohlemann T, Bosch U, Gansslen A, Tscherne H (1993) The Han- pelvic clamp. Clin Orthop 267:71 nover experience in management of pelvic fractures. Clin Ganz R (2003) Surgical Techniques for Acetabular Fractures. Orthop 305:69–80 In:Tile, M, Helfet D, Kellam, J (eds) Fractures of the Pelvis Pohlemann, T, Gansslen A, Schellwald O et al (1996) Outcome and Acetabulum, 3rd ed.,Lippincott Williams & Williams, pp after pelvic ring injuries. Injury 27 (Suppl): B31-B 38 533–603 Pohlemann T, Tscherne H (1995) Fixation of sacral fractures. Geerts WH et al (1990) Venous thrombosis in trauma – a pro- Techniques in Orthopaedics 9:315 spective study. Orthop Trans 14: 271 Richardson JD, Harty J, Amin M et al (1982) Open pelvic frac- Gertzbein SD, Chenoweth DR (1977) Occult injuries of the tures. J Trauma 22(7):533–538 pelvic ring. Clin Orthop 128:202–207 Routt ML Jr., Simonian PT, Grujic L (1995) The retrograde Gorczyca J, Varga E, Woodside T, Hearn T, Powell J, Tile M (1994) medullary superior pubic ramus screw for the treatment of The strength of iliosacral lag screws and transiliac bars in anterior pelvic ring disruptions: a new technique. J Orthop the fixation of vertically unstable pelvic ring injuries with Trauma 9(1):35–44 sacral fractures. Presented at the Orthopaedic Trauma Meet- Schied DK, Kellam JF, Tile M (1991) Open reduction and inter- ing, Los Angeles nal fixation of pelvic ring fractures. J Orthop Trauma 5:226 Gorczyca, J, Hearn T, Tile M (2003) Biomechanics and methods Schopfer A, Hearn TC, D’Angelo D, Tile M (1994) Biomechanical of pelvic fixation. In: Tile, M, Helfet, Kellam J, (eds), Fractures comparison of fixation methods of vertically unstable pelvic of the Pelvis and Acetabulum, 3rd edn, Lippincott Williams ring disruption. Int Orthop 18 (2):96–101 & Williams, pp 116–129 Slatis P, Huittinen VM (1972) Double vertical fractures of the Helfet D, Beck M, Gautier E, Ellis T, Ganz R, Bartlett C, Sieben- pelvis: a report on 163 patients. Acta Chir Scand 138:799–807 rock K (2002) Surgical techniques for acetabular fractures Tile M (1984) Fractures of the pelvis and acetabulum, 1st edn. In: Tile M, Fractures of the Pelvis and Acetabulum. 3rd Williams and Wilkins, Baltimore edn.,Lippincott Williams & Williams, pp 533–603 Tile M (1988) Pelvic fractures: should they be fixed? J Bone Joint Hirvensalo S, Lindahl J, Partio E (1993) Technique for internal Surg. 70B:l fixation of pelvic fractures. Presented at SICOT Meeting, Tile M (1995) Fractures of the pelvis and acetabulum, 2nd edn. Seoul, Korea, August 29–Sepember 3 Williams and Wilkins, Baltimore Hearn TC et al (1991) Effects of ligamentous sectioning and Tile M (2003) Management of Pelvic Ring Injuries. In Tile, M, internal fixation of bending stiffness of the pelvic ring. In: Helfet D, Kellam J, Fractures of the Pelvis and Acetabulum, Proceedings of 13th International Conference on Biome- 3rd edn., Lippincott Williams and Williams, pp 168–202 chanics, Perth, W. Australia, 9–13 December, pp 518–520 Tornetta P 3rd, Matta JM (1996) Outcome of operatively Holdsworth FW (1948) Dislocation and fracture dislocations of treated unstable posterior pelvic ring disruptions. Clin the pelvis. J Bone Joint Surg 3OB:461–466 Orthop 329:186–193

1.1 Introduction

SCHA_12-Tile.indd 290 17.04.2005 14:28:34 Uhr