PelvicRingInjuries:

DefinitiveManagementJamesC.Krieg,MDHarborviewMedicalCenterSeattle,WARevised2009CreatedbyStevenA.Olson,MDin2004FirstrevisedbyRafaelNeiman,MDin2007SecondRevisionbyJamesC.Krieg,MDin2009GoalsDefinepelvicringinstabilityDecisionprocess:operateornot?Non-operativetreatmentPrinciplesofoperativetreatmentPreoperativeplanningSurgicalapproachesTechniquesofpelvicreductionandfixationBiomechanicsoffixationtechniquesOutcomesofpelvicringinjuryIntroduction:

PelvicRingStabilityStabilitydefinedasabilitytosupportphysiologicloadPhysiologicloadmaybesitting,sidelying,orstanding,asdictatedbypatientneedsIntroduction:

PelvicRingStabilityPosteriorringintegrityisimportantintransferringloadfromtorsotolowerextremitiesDefiningInstabilityLossofposteriorringintegrityoftenleadstoinstabilityLossofanteriorringintegritymaycontributetoinstability,andmaybeamarkertoposteriorringinjuryTileclassificationschemebasedoninstabilitypatternsIsitstable?Istheredeformity?DeformityonpresentationpredictsinstabilitlyIsitstable?Istheredeformity?Istheposteriorpelvicringintact?CTscanIsitstable?Istheredeformity?IstheposteriorpelvicringintactStressradiographsC-armimageinORIsitstable?Istheredeformity?IstheposteriorpelvicringintactStressradiographsAretherecluestosofttissueinjury?LStransverseprocessfxIschialspineavulsionLateralsacralavulsionDescribingInstabilityRefertopreviouslectureonClassificationTileClassificationAstableBpartiallystableCunstableOperativeIndicationsResuscitationSeepreviouslectureonAcuteManagementAssistinmobilizationJustasstabilizinglongboneshelpsinmobilizationofpolytraumapatientsPreventlongtermfunctionalimpairmentDeformityofpelvicringcanimpactfunctionNon-OperativeManagementLateralimpactiontypeinjurieswithminimal(<1.5cm)displacementPubicramifractureswithnoposteriordisplacementMinimalgappingofpubicsymphysisWithoutassociatedSIinjury2.5cmorless,assumingnomotionwithstressormobilizationThisnumberisnotabsolute,sootherevidenceofinstability(likeSIinjury)mustberuledoutNon-OperativeManagementX-raysarestaticpictureofdynamicsituationItmaybethatthedeformityisworsethanseenonX-raystakenStressradiographsmaybehelpfulPost-mobilizationradiographsshouldbetakeninallcasesofnon-operativetreatmentOtherevidenceofinstabilityshouldbesoughtLumbartransverseprocessfracturesAvulsionsofsacrotuberous/sacrospinousligamentsNon-OperativeTreatmentTileA(stable)injuriescangenerallybearweightastoleratedWalker/crutches/caneoftenhelpfulinearlymobilizationSerialradiographsfollowedduringhealingDisplacementrequiresreassessmentofstabilityandconsiderationgiventooperativetreatmentNon-OperativeTreatmentTileB(partiallystable)injuriescanbetreatednon-operativelyifdeformityisminimalWeightbearingshouldberestricted(toe-touchonly)onsideofposteriorringinjurySerialradiographsfollowedduringhealingDisplacementrequiresreassessmentofstabilityandconsiderationgiventooperativetreatmentNon-OperativeTreatmentFailureofnon-operativetreatmentmaybeduetodisplacementaftermobilizationExcessivepainwhichprecludesearlymobilizationmayalsobefailureofnon-operativetreatmentPrinciplesofOperativeTreatmentPosteriorringstructureisimportantGoalisrestorationofanatomyandenoughstabilitytomaintainreductionduringhealingMostinjuriesinvolvemultiplesitesofinjuryIngeneral,morepointsoffixationleadtogreaterstabilityThisdoesNOTmeanthatallsitesofinjuryneedfixationPrinciplesofOperativeTreatmentAnteriorringfixationmayprovidestructuralprotectionofposteriorfixationIfcombinedopenandpercutaneustechniquesareused,theopenportionisoftendonefirsttoaidinreductionofthepercutaneuslytreatedinjurySurgicalTreatment:

PreoperativePlanningConsiderpatientrelatedfactorsSurgicalclearance,resuscitationCoordinationofcareTraumasurgeon,intensivist,neurosurgeonSurgicalTreatment:

PreoperativePlanningConsiderpatientrelatedfactorsAssociatedinjuriesMayneedgeneralsurgeon,genitourinarysurgeon,gynecologist,plasticsurgeonPreoperativePlanningTimingofsurgeryReductionmaybeeasiestinfirst24-48hoursMayaidinpercutaneusreductionPatientsoftennotadequatelyresuscitatedinfirst24hoursPotentialforsurgical“secondaryhit”onpost-injurydays2-5MaybeasignificantissueinopenproceduresPreoperativePlanningIntraoperativeimagingRadiolucenttableFluoroscopyRadiologicTechnicianandSurgeonunderstandC-armviewsnecessaryPreoperativePlanningReductiontoolsTractionPelvicmanipulator(e.g.femoraldistractor)SpecializedclampsPreoperativePlanningImplantsneededExtra-longscrewsCannulatedscrews,oftenextra-longwithappropriateinstrumentsSpecializedplatesforcontourability(reconstructionplates)ExternalfixationPreoperativePlanningSurgicalapproachesplannedSofttissuesexaminedPatientpositioningplannedIsitsafetopronepatient?Equipment/paddingforsafepronepositioningSurgicalApproaches:

AnteriorPelvicRingPfannenstielExposureofsymphysispubisandpubicbonesAvoidtransectionofrectustendonsElevaterectussubperiosteallyrectussymphysiscephaladSurgicalApproaches:

AnteriorPelvicRingStoppaextensionExposessymphysistoSIjointalongpelvicbrimIliacfossaPelvicbrimPectinealeminenceSurgicalApproaches:

PosteriorPelvicRingAnteriorapproachIliacwindowoftheilioinguinalExposureofSIjointMTileinSchatzker,Tile(eds).RationaleofOperativeFractureCare,Springer,Berlin,1996,p221-270SurgicalApproaches:

PosteriorPelvicRingPosteriorapproachExposureofsacrumandposterioriliumSacralfracturesIliacfracturedislocationsoftheSIjoint(crescentfracture)SurgicalApproaches:

PosteriorPelvicRingPosteriorapproachParamedianincisionReductionandFixation:

SymphysisReductionwithclampWeberclamponpectinealeminencesMattaandTornetta,CORR329,pp129-140,1996ReductionandFixation:

SymphysisReductionwithclampJungbluthclampwithscrewsMattaandTornetta,CORR329,pp129-140,1996ReductionandFixation:

SymphysisPelvicreconstructionplateCommonly6holeplateVariabledirectionsofscrewsReductionandFixation:

RamusFracturesPelvicreconstructionplateMedullaryscrewfixationRetrogradeAntegradeReductionandFixation:

RamusFracturesPelvicreconstructionplateMedullaryscrewfixationRetrogradeAntegradeReductionandFixation:

RamusFracturesPelvicreconstructionplateMedullaryscrewfixationRetrogradeAntegradeReductionandFixation:

RamusFracturesAnteriorExternalFixationControlsrotationonlyPinsingluteusmediuspillarofiliumAlternativeplacementinAnteriorInferiorIliacSpineReductionandFixation:

SIJointDislocationAnteriorexposurefacilitatesreductionofdislocationIliacwindowofilioinguinalapproachPelvicbrimSIJointReductionandFixation:

SIJointDislocationClampappliedfromlateral,posterioriliumtoanteriorsacralalaReductionandFixation:

SIJointDislocationPlatingNeedmorethanoneplatetoavoidlinkagedisplacementCanbeusedintandemorwithSIscrewReductionandFixation:

SIJointDislocationSIscrewCannulatedforeaseofplacementPartiallythreadedforreductionFullythreadedforimprovedfixationKnowledgeofanatomyandimagingisessentialBeawareofsacraldysmorphismReductionandFixation:

SIJointFracture/Dislocation

“CrescentFracture”SIscrewIfcaudalsegmentisinthepathoffixationscrewOpportunityforpercutaneustreatmentReductionandFixation:

SIJointFracture/Dislocation

“CrescentFracture”SIscrewandplateAnteriorORIFiflargefragmentSupplementasneededwithSIscrewReductionandFixation:

SIJointFracture/Dislocation

“CrescentFracture”ORIFwithplatePosteriorapproachReductionandFixation:

SIJointFracture/Dislocation

“CrescentFracture”ORIFwithplatePosteriorapproachReduction:

SacralFractureIndirectreductionAnteriorringreductionReduction:

SacralFractureIndirectreductionAnteriorringreductionOpenreductionpubicrootReduction:

SacralFractureIndirectreductionAnteriorringreductionReduction:

SacralFractureIndirectreductionDistractorTractionReduction:

SacralFractureIndirectreductionDistractorTractionReduction:

SacralFractureDirectreductionPosteriorexposureClampapplicationPointedWeberclampsCandecompressaswellifneededReduction:

SacralFractureMattaandTornetta,CORR329,pp129-140,1996Fixation:

SacralFractureIliosacralscrewsUpper2sacralsegmentsFullythreadedscrewsKnowmorphology,anatomyFixation:

SacralFractureIliosacralscrewsUpper2sacralsegmentsFullythreadedscrewsKnowmorphology,anatomyFixation:

SacralFracturesLumbopelvicfixationVerticalcontrolCanbeusefulinunstableHorYtypesacralfractureTransiliacplatingBiomechanicsofPelvicFixation:

NoclinicalcomparisonstudiesexistExperimentalbiomechanicaldataexistIngeneral,itseemsthatmorepoints/planesoffixationprovidebetterstabilityHowmuchstabilityisenoughisinjurydependantBiomechanicsofPelvicFixation:

AnteriorFixationAnteriorplatingsuperiortoexternalfixationininternal/externalrotationNeithertechniqueveryeffectiveatcontrolofverticaldisplacementAnteriorfixationcan“protect”posteriorfixationfromfailureBiomechanicsofPelvicFixation:

AnteriorFixationTwoholesymphysealplateinadequateRetrogradepubicscrewhigherfailureratethanantegradeBiomechanicsofPelvicFixation:

PosteriorFixationOptionsincludesingleSIscrew,multipleSIscrews,doubleplatingofSIjoint,transiliacplateofsacralfracture,orplateplusSIscrewforsacralfractureorSIdislocationAnyoftheabovearemorestablethansingleSIscrewinunstableinjuriesBiomechanicsofPelvicFixat